a sort of naval cadet, appointed by the captain of a ship of war, to second the orders of the superior officers, and assist in the necessary business of the vessel, either aboard or ashore.

The number of midshipmen, like that of several other officers, is always in proportion to the size of the ship to which they belong. Thus a first-rate man of war has 24, and the inferior rates a suitable number in proportion. No person can be appointed lieutenant without having previously served two years in the royal navy in this capacity, or in that of mate, besides having been at least four years in actual service at sea, either in merchant-ships, or in the royal navy.

Midshipman is accordingly the station in which a young volunteer is trained in the several exercises necessary to attain a sufficient knowledge of the machinery, movements, and military operations of a ship, to qualify him for a sea-officer.

On his first entrance in a ship of war, every midshipman has several disadvantageous circumstances to encounter. These are partly occasioned by the nature of the sea-service; and partly by the mistaken prejudices of people in general respecting naval discipline, and the genius of sailors and their officers. No character, in their opinion, is more excellent than that of the common sailor, whom they generally suppose to be treated with great severity by his officers, drawing a comparison between them not very advantageous to the latter. The midshipman usually comes aboard tainted with these prejudices, especially if his education has been amongst the higher rank of people; and if the officers happen to answer his opinion, he conceives an early difficulty to the service, from a very partial and incompetent view of its operations. Blind-ed by these prepossessions, he is thrown off his guard, and very soon surprised to find, amongst those honest sailors, sailors, a crew of abandoned miscreants, ripe for any mischief or villainy. Perhaps, after a little observation, many of them will appear to him equally destitute of gratitude, shame, or justice, and only deterred from the commission of any crimes by the terror of severe punishment. He will discover, that the pernicious example of a few of the vilest in a ship of war are too often apt to poison the principles of the greatest number, especially if the reins of discipline are too much relaxed, so as to foster that idleness and dissipation, which engender sloth, diseases, and an utter profligacy of manners. If the midshipman, on many occasions, is obliged to mix with these, particularly in the exercises of extending or reducing the sails in the tops, he ought resolutely to guard against this contagion, with which the morals of his inferiors may be infected. He should, however, avail himself of their knowledge, and acquire their expertise in managing and fixing the sails and rigging, and never suffer himself to be excelled by an inferior. He will probably find a virtue in almost every private sailor, which is entirely unknown to many of his officers: that virtue is emulation, which is not indeed mentioned amongst their qualities by the gentlemen of terra firma, by whom their characters are often copiously described with very little judgment. There is hardly a common tar who is not envious of superior skill in his fellows, and jealous on all occasions to be outdone in what he considers as a branch of his duty: Nor is he more afraid of the dreadful consequences of whistling in a storm, than of being stigmatized with the opprobrious epithet of lubber. Fortified against this scandal, by a thorough knowledge of his business, the sailor will sometimes sneer in private at the execution of orders which to him appear awkward, improper, or unlike a seaman. Nay, he will perhaps be malicious enough to suppress his own judgment, and, by a punctual obedience to command, execute whatever is to be performed in a manner which he knows to be improper, in order to expose the person commanding to disgrace and ridicule. Little skilled in the method of the schools, he considers the officer who cons his lesson by rote as very ill qualified for his station, because particular situations might render it necessary for the said officer to assist at putting his own orders in practice. An ignorance in this practical knowledge will therefore necessarily be thought an unpardonable deficiency by those who are to follow his directions. Hence the midshipman who associates with these sailors in the tops, till he has acquired a competent skill in the service of extending or reducing the sails, &c. will be often entertained with a number of furious jeers, at the expense of his superiors. Hence also he will learn, that a timely application to those exercises can only prevent him from appearing in the same despicable point of view, which must certainly be a cruel mortification to a man of the smallest sensibility.

If the midshipman is not employed in these services, which are undoubtedly necessary to give him a clearer idea of the different parts of his occupation, a variety of other objects present themselves to his attention. Without presuming to dictate the studies which are most essential to his improvement, we could wish to recommend such as are most suitable to the bent of his inclination. Astronomy, geometry, and mechanics, which are in the first rank of science, are the materials which form the skilful pilot, and the superior mariner. The theory of navigation is entirely derived from the two former, and all the machinery and movements of a ship are founded upon the latter. The action of the wind upon the sails, and the resistance of the water at the stem, naturally dictate an inquiry into the property of solids and fluids: and the state of the ship, floating on the water, seems to direct his application to the study of hydrostatics and the effects of gravity. A proficiency in these branches of science will equally enlarge his views, with regard to the operations of naval war, as directed by the efforts of powder and the knowledge of projectiles. The most effectual method to excite his application to those studies is, perhaps, by looking round the navy, to observe the characters of individuals. By this inquiry he will probably discover, that the officer, who is eminently skilled in the sciences, will command universal respect and approbation; and that whoever is satisfied with the despicable ambition of shining the hero of an assembly, will be the object of universal contempt. The attention of the former will be engaged in those studies which are highly useful to himself in particular, and to the service in general. The employment of the latter is to acquire those superficial accomplishments that unbend the mind from every useful science, emasculate the judgment, and render the hero infinitely more dextrous at falling into his station in the dance than in the line of battle.

Unless the midshipman has an unconquerable aversion to the acquisition of those qualifications, which are so essential to his improvement, he will very rarely want opportunities of making a progress therein. Every step he advances in those meritorious employments will facilitate his accession to the next in order. If the dunces, who are his officers or mess-mates, are rattling the dice, roaring bad verses, hissing on the flute, or scraping discord from the fiddle, his attention to more noble studies will sweeten the hours of relaxation. He should recollect that no example from fools ought to influence his conduct, or seduce him from that laudable ambition which his honour and advantage are equally concerned to pursue.

**Midwifery**

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

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

From all the passages in Scripture where midwives are mentioned, it is plain, that women were the only practitioners of this art among the Hebrews. Among the Greeks also women assisted at labours. Phanaret, the mother of Socrates was a midwife. Plato speaks at large of midwives, explains their functions, regulates their duty, and remarks that they had at Athens the right of proposing or making marriages. Hippocrates makes mention of midwives, as well as Aristotle, Galen, and Aetius. This last even frequently quotes a woman called Apsepsia, who was probably a midwife. They were called among the Greeks Μαμα, or Ιαροπαιας; that is to say, mamma, or grand-mamma.

We are still better acquainted with the customs of the Romans, and know that they employed women only. This may be deduced from the comedies of Plautus and Terence alone. We there see that they are women only who are called to assist persons in labour. Besides, Pliny, in his Natural History, frequently speaks of midwives and their duties; and names two, Satira and Salpe, who had apparently the greatest reputation. Women were also employed after the fall of the empire; and it is certain, that, till lately, all civilized nations have employed women only as midwives. This appears even from their names in many different languages, which are all feminine. There were, however, especially in great cities, surgeons who applied themselves to the art of midwifery, and made it their peculiar study. They were sent for in difficult cases, where the midwives found their incapacity; and then the surgeon endeavoured to deliver the woman by having recourse to instruments useful in those cases, as by crotchetts, crow-bills, &c.; but as these cases happened but seldom, women remained in possession of this business. It is certain, according to Afruc, that Maria Theresa wife of Lewis XIV. employed women only in her labours; and the example of the queen determined the conduct of the princesses and court-ladies, and likewise of the other ladies of the city. The same author tells us, that he has been assured, that the epoch of the employment of men-midwives goes no farther back than the first lying-in of Madam de la Valiere in 1663. As she desired it might be kept a profound secret, she sent for Julian Clement a surgeon of reputation. He was conducted with the greatest secrecy into a house where the lady was, with her face covered with a hood; and where it is said the king was concealed in the curtains of the bed. The same surgeon was employed in the subsequent labours of the same lady; and as he was very successful with her, men-midwives afterwards came into repute, and the princesses made use of surgeons on similar occasions; and as soon as this became fashionable, the name of accoucheur was invented to signify this class of surgeons. Foreign countries soon adopted the custom, and likewise the name of accoucheur, though they had no such term in their own language; but in Britain they have more generally been called men-midwives.

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

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

The art of midwifery seems not to have been so soon improved as that of physic. Hippocrates, though an excellent physician, seems to have been a very bad midwife. He was acquainted with no other kind of natural labour than that in which the head presents; and condemns fooling labour as fatal both to mother and child: he would have the children in such cases turned, so that the head may present: but, says he, if the arm, or leg, or both, of a living child present, they must, as soon as discovered, be returned into the womb, and the child brought into the passage with its head downwards. For this purpose he advises to roll the woman on the bed to shake her, and make her jump: he proposes the same expedients to procure the child's delivery; and if they do not succeed, he advises to extract it with crotchetts, and, whatever happens, to dismember it.

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

But however common this opinion was, it was never universally received; and several physicians of character rose up, who, without suffering themselves to be dazzled with the common prejudices, or seduced by the authority of Hippocrates or Galen, recommended and approved of footling delivery. The question then was a long time undecided; and even in 1657, Rive- rius, a physician of reputation, condemned footling labour. Mauriceau also remarks, in the first edition of his book, on the disorders of pregnant women, printed in 1664, that many authors were still of opinion, that when the child presented with its feet, it should be turned to make it come with its head foremost; but after having observed that it is difficult, if not impossible, to execute this, he concludes, "it is much better to extract the child by its feet when they present, than to run the hazard of doing worse by turning it."

All practitioners, however, are now of the same opinion; and the knowledge of midwifery has been so much increased within this century, that it seems to have nearly attained its ultimate perfection, and its operations reduced almost to a geometrical certainty: And this, says Astruc, is not surprising; for, after all, the art of midwifery is reduced to the following mechanical problem, "An extensible cavity of a certain capacity being given, to pass a flexible body of a given length and thickness through an opening dilatable to a certain degree." This might be resolved geometrically, if the different degrees of elasticity of the womb, and strength and weakness of the child, the greater or lesser disposition of the blood to inflammation, and the greater or lesser degree of irritability of the nerves, did not occasion that uncertainty which physical facts constantly produce in all physico-mathematical questions.

Chap. I. Of Pregnancy.

At the time of conception, and for some time after, the parts which form the small foetus are so blended together, that one cannot be distinguished from another. The whole mass is then called an ovum. This ovum consists of four membranes; the placenta, or after-birth; the funis umbilicalis or navel-string, leading to the child; and the surrounding watery fluid in which it floats. Before the child acquires a distinct and regular form, it is called embryo, and afterwards retains the name of fetus till its birth. For the increase and nutrition of the fetus, see the article Generation.

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

The gravid uterus is of different sizes in different women; and must vary according to the bulk of the fetus and involucra. The situation will also vary according to the increase of its contents and the position of the body. For the first two or three months, the cavity of the fundus is triangular as before impregnation; but as the uterus stretches, it gradually acquires a more rounded form. In general, the uterus never rises directly upwards, but inclines a little obliquely, most commonly to the right side; its position is never, however, so oblique, as to prove the sole cause either of preventing or retarding delivery: its increase of bulk does not seem to arise merely from distention, but to depend on the same cause as the extension of the skin in a growing child. This is proved from some late instances of extra-uterine foetuses, where the uterus, though there were no contents, was nearly of the same size, from the additional quantity of nourishment transmitted, as if the ovum had been contained within its cavity.

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

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

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

The appendages of the uterus suffer very little change during pregnancy, except the ligamenta lata, which diminish in breadth as the uterus enlarges, and at full time are almost entirely obliterated.

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

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

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

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

Chap. II. Spurious Gravidity.

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

Scirrhouss, polypous, or farcomatous tumours in or about the uterus or pelvis; dropsy or venosity of the uterus or tubes; fleatoma or dropsy of the ovaria, and ventral conception, are the common causes of such fallacious appearances. In many of these cases the menes disappear; nausea, retchings, and other symptoms of breeding, ensue; flatus in the bowels will be mistaken for the motion of the child; and in the advanced stages of the disease, from the pressure of the swelling, on the adjacent parts. Tumefaction and hardness of the mamma supervene, and sometimes a viscid or serous fluid distills from the nipple; circumstances that strongly confirm the woman in her opinion, till time, or the dreadful consequences that often ensue, at last convince her of her fatal mistake.

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

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

Chap. III. Superfetation.

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

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

**Chap. IV. Extra-uterine Fœtuses, or ventral Conception.**

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

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

**Chap. V. Monsters.**

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

**Chap. VI. Diseases of Pregnancy.**

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cough, dyspnea, vomiting, difficulty or incontinency of urine, occasioned by the prelure of the bulky uterus on the stomach, liver, diaphragm, &c.—Complaints that can only be alleviated by frequent small bleedings, a light spare diet, and open belly. The patient should be placed in an easy posture, something between sitting and lying; and when the uterus rises high, a moderate degree of pressure from the superior part downwards, may in some cases prove useful. But this must be used with great caution; for dreadful are the effects of violent pressure, or tight lacing, during pregnancy. It frequently kills both mother and child, and ought to be guarded from the earliest months.

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

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

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

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

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

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

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

1. Convulsions at an early period of pregnancy chiefly happen to young women of a plethoric sanguine habit; and can therefore only be removed or palliated by a free and bold use of the lancet, by an open belly, cool regimen, and spare diet. After plentiful evacuations, if the stomach be loaded with acrid saburra or putrid bile, a gentle puke may be of use: but such remedies, on those occasions, must be employed with great caution. Instead of a plethoric, if the patient is of a nervous habit, a very necessary and important distinction, the intentions of cure will essentially vary. For here opiates in large doses and frequently repeated, emollient glysters, stupes applied to the legs, the femicupium, and every other means to soothe the nerves and remove spasmodic stricture, will prove the most effectual remedies. If insensible or comatous, opium, musk, and other antispasmodics, should be exhibited by way of glyster, and the patient ought to be roufed by epispastic and stimulating cataplams applied to the legs and hams. Convulsions succeeding profuse evacuations, are generally mortal. The vis vitae, in such circumstances, must be supported, by replenishing the vessels with the utmost speed: this is to be done by pouring in nourishing fluids as fast as possible by the mouth, and by glyster; warm applications should also be made to the stomach and feet, and nervous cordials given internally along with opium.

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

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

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

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

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

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

Chap. VII. Floodings.

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

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

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

I. Those that affect the general system: as, 1. External accidents changing the state of the circulation. 2. Changes in the circulation from internal causes: 3. Debility. 4. Plethora.

II. Those that affect the uterus and placenta: as, 1. Direct affections. 2. Stimuli communicated from an affection of other parts.

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

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

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

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

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

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

Chap. VIII. Abortion, or Miscarriage,

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

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

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

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

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

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

I. To whatever interrupts the regular circulation between the uterus and placenta.

II. To every cause that excites the spasmodic contraction of the uterus, or other afflicting powers.

III. To whatever occasions the extinction of life in the fetus.

Amongst the first are:

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

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

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

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

1. Diseases peculiar to itself. 2. Diseases communicated by the parents. 3. External accidents happening to the mother; or, 4. Accidents incident to the fetus in utero. 5. Diseases of placenta or tunis. 6. Knots and circumvolutions of the chord. 7. Too weak an adhesion of placenta or chorion to the uterus; and, 8. Every force that tends to weaken or destroy this attachment.

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

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

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

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

**Chap. IX. Regimen during Pregnancy.**

Women, when pregnant, should live a regular temperate life; moderation in eating and drinking should now be very carefully observed, and every thing that has any tendency to disagree with the stomach should be avoided; otherwise the manner of life should be much as usual. If complaints do occur, these should be treated as at other times; only guarding against such things as, by violent operation, may endanger miscarriage. If the woman has formerly been subject to this accident, the cause should be carefully considered, and suitable remedies applied; if plethoric, for instance, she should be blooded, live sparingly, and keep quiet, till she gets beyond the dangerous period. If she be weak, delicate, and nervous, bark, light aromatic bitters, mineral waters, and the cold bath (if able to bear it), will prove the best prophylactic remedies. The cold bath has, in many cases, cured the most obstinate florid albus, and sometimes even sterility itself; and, in relaxed habits disposed to miscarriage, when every other means has failed, the cold bath has done considerable service: the practice may safely be continued for some months after conception, when it has been early begun, or when the patient has been accustomed to it. Such a shock will, however, act very differently on different systems: hence, it is an expedient by no means to be indiscriminately used in the pregnant state.

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

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

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

**Labours.**

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

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

**Chap. X. Natural Labour.**

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

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

Spurious pains are to be carefully distinguished from those of genuine labour. The former arise from the stretching of the uterus and its pressure on the neighbouring parts, or from coliciveness; and are to be distinguished from the latter by the following symptoms: They are most troublesome towards the evening, increase in the night, and abate through the day; they are more trifling and irregular than true uterine pains; the uterine orifice is not affected; and there is no increased flow of mucus from the parts.

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

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

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

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

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

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

This is also the work of nature, and seldom requires more force to bring it along than if it lay entirely loose within the cavity of the uterus. Thus, in pulling, no greater force should be employed than is just sufficient to put the funis on the stretch: for if it is already separated, no violence is necessary to extract it; and if the adhesion is very firm, all violent efforts are improper, and often followed with most dangerous consequences. Its advancing is known by the contraction of the uterus, and shifting of the abdominal tumour, and by the lengthening of the cord. By the spontaneous contraction of the uterus, this separation is effected; the expulsion will be slower or more expeditious, ditious, according to the state and condition of the woman, according to the number of children she has born, and according to the duration or violence of the labour; it is easier and sooner separated in a first birth, when the woman is in good health, and when the labour has been properly managed. In most cases, this separation is accomplished within half an hour after the delivery of the child. It adheres most firmly after premature births, when the woman has been sickly during pregnancy, where the labour has been tedious and difficult, or when hasty attempts have been made to extract it. A finger, or finger and thumb, guided by the funis, and introduced within the vagina, to bring down the edge, will remove any difficulty occasioned by the centre or bulky part passing the uterine or vaginal orifice.

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

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

Though bad consequences sometimes follow from the retention of the placenta, yet it is much to be questioned, if these are not less to be dreaded than the dangerous floodings, convulsions, delirium, inflammation of the uterus, fever, &c., that may be induced from the preposterous practice of passing the hand to make the extraction; and would it not in general be better to confine the practice of introducing the hand, to cases of uterine hemorrhages only? Where the adhesion is so firm as to require force, or where its place of attachment is out of the reach of the finger, by which, for the most part, the edge may be brought down, is it not by far the safest and the most rational practice universally to trust to nature? Should the mouth or body of the uterus become constricted before the separation is effected, no matter; little is to be dreaded: it will afterwards kindly dilate; and the separation and expulsion will spontaneously be accomplished with as much safety as in other animals, where no force is ever used. Let every candid practitioner acknowledge, that for one instance where the retention of the placenta has been attended with dangerous consequences, a precipitate or forcible extraction has proved fatal to hundreds.

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

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

**Chap. XI. Laborious or difficult labour.**

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

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

I. On the mother. II. On the child. III. On the secundines.

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

(1.) Debility in the mother, arising, a From disease, viz. 1. Flooding. 2. Epileptic fits. 3. Crampish spasms. 4. Lowness and faintness. 5. Inflammatory diathesis. 6. Colic. 7. Nauseating sickness and vomiting. 8. Hectic or consumptive habit. b From passions of the mind. c From mismanagement in time of labour.

(2.) Local complaints in the parts, or their neighbourhood, viz. a In the bones, occasioning narrowness and distortion. b In the soft parts, viz. 1. Dryness and contraction of the vagina. 2. Thickness and rigidity of the os tineæ. 3. Scirrhouss or polypous tumours about these parts. 4. Accumulated faeces in the intestines. 5. Stone in the urethra. 6. Prolapsus of the uterus, vagina, and rectum.

7. Ob- 7. Obliquity of the uterus.

II. Difficulties also arise on the part of the child, viz: 1. From the bulk and ossification of the head. 2. The situation in which the head presents. 3. Large broad shoulders, or their transverse descent through the pelvis.

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

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

I. Debility in the mother, arising from a disease. This may appear under various forms; as,

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

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

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

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

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

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

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

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

7thly, Nauseating sickness, with vomiting.—When these symptoms occur, warm water or chamomile-tea must be drunk freely. Sickness and vomiting happen in some degree in the easiest labours. Sometimes they proceed from a disordered state of the stomach; but in general are to be accounted for from the well-known... known sympathy of the womb with the stomach; and accompany the stretching of the os uteri only.

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

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

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

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

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

a. Narrowness or distortion of the bones of the pelvis. Where there is any material defect in this cavity, a superficial knowledge of the form and structure of the parts will enable us to judge. If, from the figure of the woman's body, there is reason to suspect a faulty pelvis; if the spine is twisted, the legs crooked, the breast-bone raised, or the chest narrow; whether the pelvis be affected or not, she will require a particular management; for the constitution of such women is weak and feeble, and they cannot be much confined to bed on account of their breathing. We can never be absolutely certain of a distortion of the pelvis, (except when the distortion is confined to the inferior aperture), till the uterine orifice is considerably dilated. After this time, if the pains are strong and forcible, and the head of the child makes no advance, a narrow pelvis or large head is to be suspected. The pelvis may be faulty at the brim, bottom, or in the cavity or capacity. The first of these, which most frequently occurs, is the most difficult to be discovered. The second can be readily perceived by the touch: for we can feel the defects in the shape of the os sacrum and coccyx, in the position of the ilchia, and in the bending of the pubes; and where the distortion is so general, that the whole cavity of the pelvis is affected, the shape of the woman's body, the slow progress of the labour, and the state of the parts to the touch, will afford sufficient information.

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

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

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

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

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

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

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

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

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

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

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

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

1st, The bulk or ossification of the head.

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

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

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

The unfavourable position of the head may be referred to two kinds, which include a considerable variety.

1. When the fontanella, or open of the head, presents instead of the vertex.

2. Face-cases.

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

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

1. With the chin to the pubes.

2. To the facrum.

3. To either side.

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

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

III. Lastly, From the secundines, difficulty and dan- ger sometimes arise.

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

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

3dly, The funis umbilicalis too long. The funis may be faulty from its too great length, or the con- trary: thus the extraordinary length, by forming cir- cumvolutions round the child's neck or body, some- times proves the cause of protracting the labour. But as this can only happen when the chord is of an un- common length, there is generally enough left to ad- mit of the exit of the child with safety; and it is time enough, in general, after the child is born, to slip the noose over the shoulders or head: there is seldom oc- casion to divide the chord in the birth, a practice that may be attended with trouble and hazard.

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

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

An inconvenience, at least fully as bad as the for- mer, may arise from the too great length of the fu- nis, though it may depend on other circumstances: viz.

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

5thly, Placenta attached towards the cervix or os uteri. This case is truly melancholy; for, if the de- livery is not speedily accomplished, the effusion from the uterine vessels will be so copious and profuse, that the unfortunate woman must, in a very short time, perish. On this occasion the delivery must be con- ducted in the best manner the judgment and skill of the operator can direct, and with as much expedition as the safety of the mother will admit.

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

Method of Delivery by Instruments.

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

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

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

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

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

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

Use of the Forceps.

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

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

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

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

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

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

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

I. The smooth part of the cranium, II. The face, presenting.

The head may present,

1st, Naturally, when low advanced in the pelvis, with the vertex to the pubes, and the forehead or face in the hollow of the sacrum. Or, 2ndly, When higher in the pelvis, the vertex may present with the face laterally, the ears to the pubes and sacrum. Or, 3rdly, The fontanel may present with the face to the pubes, and vertex to the sacrum; or with the vertex to the pubes, and face to the sacrum.

1. When the head presents naturally. The woman in this case must be placed on her back across the bed, properly supported; the accoucheur, seated before or in a kneeling posture, after gradually lubricating the perineum and vagina, must proceed gently to stretch the parts, by passing the hand in a conical manner through the os externum vaginae, pushing it forwards by the side of the child's head, till it advances as far as an ear, if possible; along this hand he is to guide a blade of the forceps, which with the other hand he introduces in the direction of the line of the pelvis, holding the handle backwards towards the perineum, and keeping the clam closely applied to the child's head. This must be insinuated very gradually by a kind of wriggling motion, pushing it on till the blade is applied along the side of the head over the ear: he must then gently withdraw the first hand from the pelvis, with which he must secure the handle of the blade of the forceps already introduced, till the other blade be passed along the other hand, in the same slow cautious manner: the handles must then be brought opposite to each other, carefully locked, and left them slip in extracting, properly secured by tying a fillet or garter round them; but this must be looked during the remission of pulling, to prevent the brain from being injured by the pressure. The extraction must be made by very slow and gentle degrees, and with one hand only, while the other is employed to guard the perineum: the motion in pulling, should be from blade to blade; the accoucheur must rest from time to time, and, if the pains are not gone, should always in his efforts only co-operate with those of nature. The child and mother will suffer less by going on in this gradual manner than by precipitating the birth, which can never be done but at the risk of destroying both. If, in making the extraction, the forceps slip, they must be cautiously withdrawn blade by blade, and again introduced in the same manner. When the tumour of the perineum forms, and the vertex begins to protrude at the os externum, the accoucheur must rise from his feet, raise the handle gently upwards, and, by a half-round turn, bring the hind-head from under the symphysial or arch of the pubes; remembering carefully to guard the perineum from laceration and its consequences, to which it is now so greatly exposed.

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

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

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

3. The fontanella may present with the face to the pubes. This is the most common of the fontanel cases; though sometimes the face is lateral in the pelvis, sometimes diagonal, and sometimes it is turned to the sacrum. The true position is ascertained by the direction of the fontanel, and that of the ear. Here, as in other laborious births, nature should be intrusted as long as we dare. The head does not always descend mechanically through the capacity of the pelvis, as some practitioners have supposed; nor will the deviation from its ordinary mode of descent always of itself influence the delivery, at least very rarely in such a manner as to require extraordinary assistance. In whatever manner the head presents, when it is situated high in the pelvis, the delivery cannot be effected without difficulty and hazard: in such circumstances, the application of the forceps will frequently baffle the utmost efforts of the accoucheur, and the consequences of such attempts may prove fatal to mother and child.

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

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

II. Face presenting.—Of laborious births, face-cases, as we have already observed, are the most difficult and the most dangerous. From its length, roughness, and inequality, the face must occasion greater pain; and from the solidity of the bones, it must yield to the propelling force with much more difficulty, than the smooth moveable body of the cranium. Face-cases are the most troublesome that occur in the practice of midwifery, and in which the most expert practitioners may be foiled in their attempts; and these attempts, if too early exerted, will be followed in many instances with fatal consequences. Whatever way the face presents, it should be allowed to advance as low as possible in the pelvis; by which means, the access will be more easy, and the position, for the application of instruments, more favourable. In this awkward situation, much mischief may be done by rashness; whereas, if time be allowed, and Difficult the patient be properly supported, the delivery will generally end well.

The face may present with, 1. The chin to the pubes. 2. To the sacrum. 3. Laterally.

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

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

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

1. In the first case, previous to the introduction of the forceps, the chin, if possible, should be advanced below the pubes. 2. In the second, the chin should be advanced to the inferior part of the sacrum. And, 3. In the third, the chin should be as low as the under-part of the tuber ischii: and although in general the head is to be extracted as it presents, if the operator meets with considerable resistance, it must be gently pushed up and turned with the chin, either laterally, below the pubes, or into the hollow of the sacrum, according to the particular circumstances of the case, and in a direction best accommodated to the form and diameter of the pelvis.

Use of the Scissors, Crotchet, and Blunt Hook.

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

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

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

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

We judge of the form and size of the pelvis by the external make and form of the woman; by the progress of the labour; by the touch. When the fault is at the inferior aperture, the touch is pretty decisive; e.g., if a bump is felt in the os sacrum instead of a concavity; if the coccyx is angulated; if the symphysis pubis projects inwards in form of an acute angle; if the tuberosities of the ischia approach too near each other; or if the one tuber be higher than the other; such appearances are infallible marks of a distorted pelvis. But when the narrowness is confined to the brim, this is only to be discovered by the introduction of the hand within the pelvis: the projection of the lumbar vertebrae over the sacrum, is a species of narrow pelvis, that most frequently occurs in practice. In this case, the child's head, by the pressure it sustains between pubes and sacrum, is moulded into a conical or sugar-loaf form, the parietal bones are squeezed together, overlapping one another, and will be felt to the touch when the labour is advanced, like an acute ridge, something in the form of a sow's back. Instead of the complicated instrumental apparatus invented by the ancients, such as screws, hooks, &c., for fixing in, laying hold of, and extracting the head, as it presented, an operation in many cases difficult and dangerous, when the head was bulky or the pelvis narrow, as the woman frequently lost her life in the attempt; the practice of diminishing the size of the head, by opening the cranium and evacuating the brain, previous to the extraction, is a modern improvement, and an important one: the instruments for this purpose consist simply of a pair of long scissors, a sharp curved crochet, and a blunt hook: these are preferable to every other, whether of ancient or modern construction.

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

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

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

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

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

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

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

Chap. XII. Preternatural Labour.

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

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

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

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

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

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

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

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

1/3, If the pains be more slack and trifling than ordinary.

2/3, If the membranes be protruded in a long form like a gut, or the finger of a glove.

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

4/3, If the presenting part through the membranes be smaller, feels lighter, and gives less resistance than the bulky ponderous head.

5/3, Lastly, after the rupture of the membranes, if the meconium of the child be passed along with the waters, it is a sign that the breech presents, or that the child is dead.

Preternatural labours are difficult or hazardous, according to,

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

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

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

4. When complicated with plurality of children; the prolapsus of the funis umbilicalis; the limbs of the child entangled with the chord; profuse and violent floodings from the attachment of the placenta towards the cervix uteri, &c.

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

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

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

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

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

In this case, the patient must be placed on her back, properly supported; the hand of the accoucheur must be cautiously introduced; the parts of the woman must be gently stretched; the feet of the child must be laid hold of, and brought as low in the vagina as possible; a soft warm cloth must be wrapped round them, and the extraction must be performed in a slow, cautious manner, making large motions in a circular or lateral direction, resting from time to time, if the pains are gone; and if not, always waiting for the natural efforts. When advanced as far as the breech, the body, if not already in a proper direction, must be pushed up, and gently turned with the face towards the mother's back; and to make sure that the face turns with the body, or to prevent the chin, vertex, or shoulders from catching on the pubes, or angle of the sacrum, an extraordinary quarter-turn more must be made: this must be reversed previous to the extraction; and the difficulty arising from the obstruction of the shoulders must be removed in the following manner. While the breast and legs of the child are supported over the palm and forearm of the one hand of the accoucheur, which he draws towards one side, he must introduce two fingers of the other hand at the opposite side into the vagina, over the back-part of the shoulder, as far as the elbow, and endeavour in the most gentle manner to bring down the arm, always remembering, in his movements, to humour the natural motions of the joint: he must then shift hands, when the other arm is to be relieved in the same manner: both arms being brought down, the woman must now rest a little, when a pain or two generally follows, and the head is also forced along. But should the woman be much exhausted, and if the head does not quickly advance, the child may be lost from delay. The extraction of the head in preternatural labours, is often the most difficult and the most dangerous part of the delivery; the cause of resistance, when it does not advance, is chiefly owing to its confinement between the angle of the sacrum and pubes, when the bulky part of the head is detained at the brim; whether the resistance be here or towards the inferior aperture of the pelvis, if the head does not advance in a pain or two, the extraction must be made in this manner: Chap. XII.

Midwifery.

Preternatural Labour: While the right hand of the accoucheur supports the body of the child below, with two fingers pressing on either shoulder, the left hand and fingers must in the same manner be placed over the back of the neck, and pulling gently in the direction from pubes to sacrum, he must thus endeavour to bring it along; but, should the pelvis be narrow, or the child's head of a large size, or the face be laterally or anteriorly placed in the pelvis, or, what rarely happens, the os uteri contracted round the neck of the child; in either of these cases, the accoucheur will sometimes meet with the utmost difficulty. When the above method therefore fails, he must introduce two fingers of the right-hand into the child's mouth, while those of the left-hand are expanded over the shoulders, as already directed; and in this way he must endeavour to relieve it, pulling from pubes to sacrum, alternately raising and depressing the head till it advances low down, so that the face descends from the hollow of the sacrum, when the accoucheur must rise from his feet, and bring the hind-head from under the pubes with a half-round turn, imitating that of a natural labour.

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

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

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

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

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

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

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

1st, Anteriorly. 2nd, Laterally. Or, 3rd, Posteriorly.

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

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

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

The practice of helping forward the breech, by passing the blunt-hook under the ham, is now entirely laid aside: this can never be done with safety, till the breech be so low advanced, that the hand of the accoucheur can be used, which may be employed with more advantage as well as safety. In the former class of preternatural labours, it is advisable to trust to nature in many cases, as the birth will often be accomplished without manual assistance; but when the child lies across, no force of pain can make it advance in that position; and, without proper assistance, both the mother and child would perish.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CLASS III.

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

In order to effect the reduction of the arm, different instruments have been invented; but the hand of the accoucheur is preferable to every thing of this kind, whether of ancient or modern invention. This, conducted by the arm that protrudes, must be introduced through the vagina into the uterus, as far as the shoulder of the child, which, if the accoucheur can raise up, he will generally succeed in reducing the arm. Should this method fail, he must attempt to push up the fore-arm at the elbow; but, in bending it, must be very cautious, to avoid overstraining or dislocating the joint. In whatever manner the reduction is accomplished, if any method proves successful, the arm must be retained till the head, by the force of natural pain, enters the pelvis, and prevents its return; otherwise the arm will descend, as often as it is reduced.

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

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

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

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

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

CLASS IV.

When the membranes remain entire, till the soft parts are so much dilated, that the hand will readily find admittance; or when the hand can be passed within the cavity of the uterus, immediately after the rupture of the membranes, so that part of the water may be retained; the delivery may be accomplished, in the most trouble-free preternatural cases, with the greatest safety and expedition. But when the waters have been long evacuated, and the uterus closely contracted round the body of the child, the case will prove laborious to the operator, painful and dangerous to the mother and child.

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

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

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

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

Soon after attempting to stretch the parts, should the labour-pains come on, the waters begin to be collected, and the uterine hemorrhage diminish, the accoucheur must then withdraw his hand, and manage the delivery according to circumstances. And if, for instance, the child presents naturally, the delivery must be trusted to nature; otherwise, if the flooding continues, or the child presents across, the accoucheur must persist in his work, going on slowly, and with the utmost delicacy, till he be able to reach the feet, to bring them down, and deliver; always remembering, during this process, that the strength of the woman, by proper nourishment, be supported.

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

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

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

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

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

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

Besides our former division of labours, plurality of children, monsters, extra-uterine fetuses, and the Caesarean operation, are parts of the subject that yet remain to be considered.

Chap. XIII. Plurality of Children.

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

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

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

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

It very rarely happens, when the first birth is preternatural, that the second membranes are ruptured in making the extraction. Should this prove the case, the limbs of the children may be confounded, so that a leg and an arm, or three legs, or arms of different children, may present; which, however, will make little difference in the mode of delivery: the accoucheur will endeavour to lay hold of the foot or feet most readily within his reach, and will be cautious in bringing them down, to make sure they belong to the same body.

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

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

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

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

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

**Chap. XIV. Monsters.**

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

Chap. XV. Caesarean Operation.

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

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

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

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

I. Bad conformation of the bones of the pelvis. When the hand of the operator cannot be introduced within the pelvis; or, in other words, when its largest diameter does not exceed one inch, or one inch and a half, this conformation is perhaps the only one which renders the Caesarean operation absolutely necessary: happily, however, such a structure very seldom occurs in practice; and when it does, the accoucheur will readily discover it, by attending to the following circumstances, and to the common marks of a narrow pelvis. Wherever the capacity of the pelvis is so strait as not to admit any part of the child's head to enter, nor two fingers of the accoucheur's hand to conduct proper instruments to tear, break down, and extract the child piece-meal; in this case, recourse must be had to the Caesarean section: an expedient, though dreadful and hazardous, that will give the woman and child the only chance of life; and which, if timely and prudently conducted, notwithstanding of the many instances wherein it has failed, may be performed with some probability of success.

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

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

Elisabeth Clerk, aged 30, had been married for several years, became pregnant, and miscarried in the third month; the expulsion of the abortion occasioned so severe a stress, as actually to lacerate the perineum. Some time after her recovery, she was irregular, afterwards had one shew of the menes, again conceived, and the child, as she imagined, arrived at full time. She was attacked on Monday the 3d of January 1774, about midnight, with labour-pains, which went on slowly, gradually increasing till Saturday the 15th, when she was brought from the country to the Royal Infirmary here. Upon examination, the pelvis seemed considerably distorted; but the body was otherwise well shaped, though of small size; the os externum vaginae was entirely shut up, nor could any vestige of vagina be observed, nor any appearance of labia pudendorum: instead of this, there was a small aperture at the superior part of the vulva, immediately under the mons veneris, probably about the middle anterior part of the symphysis pubis. This aperture (which had a small process on the superior part, somewhat resembling the clitoris) was no larger than just to allow the introduction of a finger; the meatus urinarius lay concealed within it: a consultation of surgeons was called, and the Caesarian section was determined on. Having had no stool, nor voided any urine for two days, an injection was attempted to be thrown up; but it did not pass, nor was it possible to push the female catheter into the bladder. Mr William Chalmers was the operator in this case. At six in the evening, he made an incision on the left side of the abdomen in the ordinary way, through the integuments, till the peritoneum was exposed; two small arteries sprung, which were soon stopped by a slight compression: the wound was then continued through the peritoneum into the cavity of the abdomen, when the bladder appeared, slightly inflamed, much distended, reaching with its fundus near as far as the scrobiculus cordis: another unsuccessful attempt was made to pass the female catheter; at length a male catheter was procured, which was, after some difficulty, introduced into the bladder, and the urine evacuated to the quantity of above four pounds, high-funnelled and fetid. This occasioned a necessary interruption for a few minutes, between making the opening into the abdomen and uterus; the bladder collapsing, the uterus, which before lay concealed, now came in view, through which an incision was made, and a stout male child was extracted alive; and immediately afterwards the secundines. The uterus contracted rapidly. After cleansing the wound, the lips were brought together by the quill-suture, and dressed dressed superficially. The patient supported the operation with surprising courage and resolution; nor was there more than five or six ounces of blood lost on the occasion.

Being laid in bed, she complained of sickness, and had a slight fit of vomiting; but, by means of an anodyne, these symptoms soon abated: she was affected with universal coldness over her body, which also abated on the application of warm irons to the feet: she then became easy, and slept for four or five hours. Next morning, the 16th, about two o'clock, she complained of considerable pain in the opposite side, for which she was bled; and an injection was given, but without effect; for the pain increased, stretching from the right side to the scrobiculus cordis; nor did fomentations seem to relieve her; her pulse became frequent, she was hot, and complained of drought. At 7 A.M. the injection was repeated, but with no better success; and eight ounces more of blood were taken from the arm; a third injection still failed to evacuate any faeces; the drought increased; and the pulse rose to 128 strokes in a minute. At 11 A.M. the pulse became fuller; and the respiration much oppressed. No stool nor urine passed since the operation. At 12 she was bled again, when the stitches appeared less than formerly. She now took a solution of sal Glauber, manna and cr. tart. at short intervals; she vomited a little after the last dose, had a soft stool, and voided a small quantity of urine. At 3 P.M. her pulse was 136, and she had another stool, when thin faeces were evacuated; she was then ordered two spoonfuls of a cordial anodyne mixture every second hour: the vomiting now abated; the pulse became smaller and more frequent; she passed urine freely; but the pain and oppresed breathing increased. At seven P.M. her pulse rose to 142, and became weak and fluttering; she called for bread, and swallowed a little with some difficulty; her drought was intense; the dyspnea still increased. She was now much oppresed, and began to toss; the pulse sunk and became imperceptible; she complained of faintness, but on belching wind her breathing was relieved, and the pulse returned, growing fuller and stronger: the pain of the side till increasing, 12 ounces of blood, very fizzy, were taken away; and two glisters of warm water with oil were injected without effect: at 8 P.M. the pulse became less frequent and smaller; she complained much of the pain towards the scrobiculus cordis; her breathing was much oppresed; her belly was tense, and swelled as big as before the operation; her pulse was now small and feeble; she looked ghastly; and expired a little after eight, 26 hours after the operation.

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

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

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

II. Constriction, callosity, tumours, &c. about the vagina or os tineae. The vagina and os tineae are often affected with constrictions from cicatrices, with callosities and tumours; but it is seldom, if ever, necessary to perform the Cesarean section on this account. Tumours in the vagina may generally be removed with safety, even after the commencement of labour, and delivery happily succeed; or it may be sometimes practicable for the accoucheur to pass his hand by the side of the tumour, to turn the child, and deliver. With regard to constrictions in the vagina, and callosities in the os uteri, there are many instances, where, at the commencement of labour, it was impossible to introduce a finger into the vagina; yet the parts have dilated as labour increased, and the delivery terminated happily. At other times, the dilatation has begun during pregnancy, and been completed before delivery. There is a history, for instance, in the Memoire de l'Acad. des Sciences, 1712, of a woman whose vagina was no larger than to admit a common writing-quill; she had been married at 16, and conceived 11 years after; towards the fifth month of her pregnancy, the vagina began to dilate, and continued to do so till full time, when she was safely delivered. Guilemeau dilated, and La Mott extirpated callosities in the vagina and os tineae, when the children were successfully expelled. expelled by the force of natural labour.

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

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

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

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

III. Lacerated uterus is another cause for which this operation has been recommended. The uterus may be ruptured from violence in making the delivery; or such an accident may happen naturally, either from the cross presentation of the child in time of pregnancy, or in time of labour, when the pelvis is narrow: these cases are generally fatal; and it is very seldom, if ever, that the life of the mother can be saved by the Caesarian section, after the fetus escapes through the torn uterus into the cavity of the abdomen; because it often happens, that inflammation and sphacelus has affected the parts of the uterus that sustained the pressure previous to the rupture; or, if otherwise, convulsions or other fatal symptoms soon ensue, from the quantity of blood, waters, &c. poured into the cavity of the abdomen.

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

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

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

1. At what time must it be performed? 2. Would it not have the appearance of inhumanity to have recourse to this expedient immediately after the uterus bursts, when the woman is seemingly ready to expire, although it be the only time when there is a chance of saving the child? 3. In most cases where this accident happens, should the Caesarean section be made, is it not highly improbable that the mother will survive so terrible a laceration? 4. For if it be done with a view to save the mother, in what manner is the extravasated blood, &c. to be evacuated from the cavity of the abdomen?

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

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

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

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

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

Most women feel pain and violent motion at the time of ordinary delivery in these cases of ventral conception; if therefore the operation be ever necessary, now is the proper time to perform it. But in general, as the separation of extra-uterine fetuses from their involucra, may occasion immediate death in many cases, from the vast hemorrhage that might ensue from the non-contractile power of the parts to which they adhere; unless they point outwardly, or excite the most violent symptoms, they ought universally to be left to nature.

V. Herniae of the uterus are seldom or never sufficient to induce us to perform the Caesarian section, as the uterus is very rarely influenced in such a manner, that the orifice cannot be reached, and the delivery successfully made. Many instances are to be found among surgical authors, where deliveries, under such circumstances, have been happily performed, without having recourse to so hazardous an expedient. Thus Mauricen mentions a case, where the uterus, in a ventral hernia, was pushed along with the intestines above the hernia. Chap. XV.