\ ~ z V % . V ^jr *+ - ■\ ^< 9* I \ % ■ ^c - - o "^ /**- - \ ji> c b 1 ttT %,' * a* te! "%>. .# " # \> -. \>* = %. .# : %,^ : & £ <3* ^ c ^- .^ f\ O. <. 4 Q,. ~ ,5 Q ><£^Y< &<* \ v rt> ^> Qi *'**< xV Q> ** V ■ V \\ , . o , "% <>, ^ \> u A SYNOPSIS OF THE VARIOUS KINDS OF DIFFICULT PARTURITION, WITH PRACTICAL REMARKS ON THE MANAGEMENT OF LABOURS. BY SAMUEL MERRIMAN, M. D. TEACHER OF MIBWIFERY; Physician -Accoucheur to the Middlesex Hospital, the Westminster General Dispensary, and the Parochial Infirmary of St. George, Hanover-Square. WITH NOTES AND ADDITIONS^ BY THOMAS C. JAMES, M. D. Professor of Midwifery in the University of Pennsylvania. «VW\A/WWW\v ^cs** PUBLISHED BY THOMAS DOBSON, AT THE STONE HOUSE, NO. 41, SOUTH SECOND STB,EET. William Fry, Printer. 1810. I of 7?^7 M$1 District of Pennsylvania, to wit: ******** BE IT REMEMBERED, that on the twenty- * SEAL. * nnitft day °f October, in the forty-first year of the % ' * independence of the United States of America, A. ******** D. 1816, Thomas Dobson, of the said district, hath deposited in this office the title of a book the right whereof he claims as proprietor, in the words following", to wit: " A Synopsis of the various kinds of Difficult Parturition, with Practical Remarks on the Management of Labours. By Samuel Merriman, M. D. Teacher of Midwifery; Physician-Accoucheur to the Middlesex Hospital, the Westminster General Dispen- sary, and the Parochial Infirmary of St. George, Hanover- Square. With Notes and Additions, by Thomas C. James, M. D. Professor of Midwifery in the University of Pennsylvania. Da spatium tenuemque moram, male cuncta ministrat Impetus. Statu Theb. Lib. x. The first American from the second London edition. In conformity to the act of the Congress of the United States 9 intituled, " An act for the encouragement of learning, by secu- ring the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned." And also to the act, entitled, "An act supplementary to an act, entitled * An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and pro- prietors of such copies during the times therein mentioned,' and extending the benefits thereof to the arts of designing, engrav- ing, and etching historical and other prints." D.CALDWELL, Clerk of the District of Pennsylvania* ADVERTISEMENT. IT has sometimes appeared to the Editor of this Compendium, that a person could not be more usefully, although at the same time, per- haps, more humbly employed, than in bringing before the cultivators of medical science in the new world, those practical works that have ob- tained deserved celebrity in the old. The high price of European publications, as well as their rarity in this country, prevent their obtaining any thing like a general circulation among us; and like the manuscripts of the early ages, they are frequently only to be met with in the libra- ries of the rich, or the cabinets of the curious. Even, of the little work, of which he thus en- deavours to facilitate a more extended know- ledge, he has, as yet, met with but one copy in this country, and that imported by a specific order. He, nevertheless, believes it to be so worthy of the attention of the student and young practitioner of the art that it was written to IV illustrate and explain, that he did not hesitate, by the addition of some notes, tables, and an appendix, to add to it, any authority, however trivial, that such improvements may be sup- posed to confer. A few plates explanatory of the figure and dimensions of the pelvis, both in its perfect and deformed state, have been also added, to which a reference may be occasion- ally made, with some advantage, by the student, in the perusal of the work. One recommendation, suggested by the com- pendious and concise nature of the work, was that, from its size, it may, without inconve- nience, be made the companion of the young practitioner to the bedside of the patient; and may thus afford useful hints and supply neces- sary information, at the very period when they may be most wanted by the attentive, although perhaps, inexperienced assistant of the opera- tions of nature. Philadelphia, Oct. 25, 1816. THE AUTHOR'S PREFACE. l\\V\AW\\V% ABOUT a year ago, I drew up, in a nosologi- cal form, a list of the various kinds of difficult labours, most commonly met with in practice. I was induced to do this, that I might be ena- bled to describe each kind more precisely in my Lectures; and I published the arrangement in a small pamphlet, for the use of those gentlemen who attended my Courses. Finding, however, that the book was often asked for, and sold at the booksellers, and being about to publish a new edition, I was desirous of endeavouring to render it somewhat more useful, by adding such remarks upon the ma- nagement of labours, as a pretty extensive practice in midwifery had taught me to approve. VI But I have attempted nothing more than to give a sketch of obstetrical practice, to form such a Compendium of Midwifery as might occasionally supply the place of a more volumi- nous work, in suggesting a hint or a caution, or in recalling to the mind an observation useful to the young practitioner. Thus this little book may serve the purpose of a Vade-Mecum, but will not supersede the perusal and study of more elaborate systems of midwifery. At the end I have inserted tables of accidents, unusual presentations, deaths, Sec. in labour and childbed. The first is collected from 1800 women, in my own practice; the third is taken from Dr. Bland's Calculations; the second and fourth are from French authors; and the fifth, taken from the London Bills of Mortality, de- monstrates how many more lives were formerly lost in child-bed, than are met with in modem practice. Oct. 13, 1814. \ CONTENTS. •WWW-VVXWV Class I. Eutocia simplex, or Natural Labour . 9 Class 2. Dystocia, or Difficult Labour . . 27 Order 1. Dystocia Diutina, or Lingering Labour . ib. 2. Dystocia Anenergica, or Powerless Labour 49 3. Dystocia Perversa, or Malfiosition of Head 54 4. Dystocia Amorfihica, or Deformity of Pelvis 64 Signs of a Dead Child . . . .66 5. Dystocia Obturatoria, or Obstruction in the Soft Parts .... 72 6. Dystocia Ectofiica, or Displacement of the Uterus 77 7. Dystocia Transversa, or Preternatural Presentations . . . • 81 a. Nates . 86 b. Inferior Extremities . . . 93 c. Superior Extremities . . .104 d. Back, Belly, and Sides . . . 119 e. Navel String 121 VU'l CONTENTS. Page Order 8. Dystocia Gemina, or Twin Children . 130 9. Dystocia Laceratoria, Ruptures or Lacerations . . . . 143 10. Dystocia Hemorrhagica^ or Hemorrha- ges 159 11. Dystocia Syncopalis, or Paintings and Palpitations . . . . 179 12. Dystocia Convulsiva, or Convulsions . 183 13. Dystocia Infafmnatoria, Inflammation or Fever 198 14. Dystocia Retentiva, or Retention of the Placenta 201 15. Dystocia Inversoria, or Inversion of the Uterus 212 Of the Use of Instruments in Midwifery . .213 Of the Fillet y Forceps, and Vectis . . . 218 Of the Perforator 229 Of the Cesarean Operation . . . . 239 Of inducing Prematura Labour .... 242 Tables 247 Appendix . . . » . • • .261 Plates and Explanations . . . . 289 LABOURS MAY BE DIVIDED INTO TWO CLASSES: * 1 . Eutocia — Natural L abour. t 2. Dystoci a — Difficult Labour. CLASS I.— EUTOCIA, COMPREHENDS ONLY ONE ORDER. I. Eutocia Simplex — Natural Labour.. Natural Labour. Smellie, Denman, Plenck, 8cc. Easy Labour. Cooper. Definition. — Natural labour is that, in which the vertex presents, the head descends ♦From E«, bene, and tik\u, pario, seu tokos, partus. t From 2vs, difficulter, and tokos, partus. B 10 readily into the pelvis, taking such a direc- tion as brings the occiput to emerge under the arch of the pubes. The labour termi- nates within twenty- four hours after its commencement. The placenta is expelled within one hour after the birth of the child. The whole process is passed through with- out danger to the mother. #£# Mr. Burns considers it as essential to natural labour that it shall not occur before the full term of nine months; he has therefore in his classification of labours, introduced premature labour ', as his second class. Mauriceau considered it not only essen- tial that the woman should have reached the full term of pregnancy, but likewise that the child should be born alive, in order to constitute natural labour.* * " Quatre conditions se doivent absolument rencontrer en I'accouchement pour pouvoir etre veritablement dit 11 Of the different Stages of Labour. Labour is divided into four stages or periods. 1. During the first stage, the head of the fetus passes through the superior aperture of the pel- vis, and the os uteri becomes dilated at least to the size of a crown piece. [This may therefore be termed the entrance of the head into the pelvis.] 2. The second stage produces that change in the position of the head, which turns the fore- head into the hollow of the sacrum, and brings the occiput to emerge under the arch of the pubes. [This may be termed the passage of the head through the pelvis.] 3. The third stage produces the expulsion of the child through the os externum. naturel: 1, qu'il arrive a terme; 2, qu'il soit prompt, et sans aucuns accidents considerables; 3, que Venfant soit vivxintj 4, qu'il vienne en bonne figure et situation. Mauriceau, torn. 1. p. 202. 12 4. The fourth stage is accomplished by the delivery of the placenta.* *£* Sometimes the os uteri becomes completely dilated during the first stage: at other times this is not accomplished till the second stage is nearly over. J* J The time at which the membranes rupture is very various. The longer they remain entire, the safer in general is the labour. That labour is the most truly na- tural, in which the liquor amnii (popularly called the waters) is not evacuated till the * Dr. Denman divides labour into three stages only. # The first includes the dilatation of the os uteri: the rupture of the membrane: the discharge of the waters. The second, the descent of the child: the dilatation of the external parts: the expulsion of the child. The third, the separation of the placenta: the expulsion or extrac- tion of the placenta." Denman? 8 Aphorisms, p. 3. Mr. Hogben divides labour into five stages. The first lasts from the commencement of labour till the child's 13 head of the child is just ready to pass into the world.* Of the precursory Symptoms of Labour. Labour is usually preceded by 1. A general and equal subsidence of the uterus and abdomen. head enters the brim of the pelvis. The second, is the time in which the face is passing into the lower pelvis, the face turning into the cavity of the sacrum. The third, the further advance of the head without the os externum. The fourth, the expulsion of the body and lower extremities of the child. The fifth, the discharge of the placenta and membranes. Ifogbcn's Obstetric Studies, p. 33. Dr. Romer of Zurich, makes four stages of labour. The first is known by the precursory pains: dolores prasagientes: the second by the preparatory pains: dolores prapar antes: the third by the true pains: dolores veriad partum: the fourth by the vehement forcing pains: dolores conquassantes. Homer Partus naturalis brevis Expositio. Got ting os, 1786. * « In easy natural labour, the waters are all along protruded before the child's head, in a regular forms 14 This is a favourable symptom, as it indicates that the pelvis is well formed, and that the parts are pro- perly disposed for labour. 2. A discharge of a glairy or mucous fluid from the vagina. When this discharge is tinged with blood it is popularly called a shew; but this appearance is frequently not perceived till the labour has made considerable progress. and the membranes do not break till they have dilated the os externum; by which time the head of the child is advanced pretty low in the pelvis, and the membranes being then stretched to their utmost degree of disten- sion, are burst in the time of a pain, by the force of the protruding waters; on which the child's head immediate- ly falls to the edge of the os externum, and in another pain or two, the occiput rises round the edge of the pubes, and a very trifling assistance brings it into the world; and indeed it seldom requires any, the same pain that breaks the membranes, being frequently sufficient to protrude the child also." Coofier's Compendium of Midwifery, 1766, fi. 87. 15 3. Frequent gripings or tenesmus. 4. A frequent urgency to make water. Occurrences during Labour. Pains. Rigors. Restlessness. Vomitings. Despondency. Profuse perspirations. Pains are of two kinds, spurious and true. Spurious pains are to be distinguished by their irregular recurrence; by affecting the belly more than the back or sides; by not producing any dilatation of the os uteri. Spurious pains are to be relieved, by aperients, if arising from costiveness or indigestion; by absorbents, if from superabundant aci- dity in the intestines; by opiates, if from spasm or fatigue; by bleeding, if from inflammation or fever. 16 True pains may be known by their recurring at regular intervals; by affecting the back and shooting round to the thighs; by producing a sensible opening or dilata- tion of the os uteri during each pain; by protruding the membranes, like a blad- der filled with water, through the os uteri. True pains are of two kinds, 1. Grinding \ rending, cutting pains,* when the os uteri first begins to open. 2. Bearing or forcing pains, f after the os internum is somewhat opened, and the bag of waters, or the head of the child, is forced through the circular mouth of the womb, producing its more complete *Or the pains of Dilatation, t Or the pains of Expulsion. 11 dilatation, and afterwards expelling child through the os externum. The restlessness and despondency which par- turient women experience, most commonly occur in the early stages, and are produced by nervous irritability during the continuance of the grinding pains: these symptoms are generally removed or relieved when the bearing pains come on.* Rigors or tkritimgs often happen during the dilatation of the os uteri; sometimes they ac- company every pain; more frequently they pre- vail most, when the os uteri first begins to dilate, and at the time when the dilatation is about to be folly accomplished. Not uncom- •G : . -. :t : -.:-:::.; = ; i-. :'. ;i :-..:: i -.:;.-. sir. t:_rir5 :•::_. ;:. :.::;:- _:.; _. •■■;.;-. :'r.e ~i'.:t7.. 'i i::er. :-... :e:;r:\es nearbr or quite exhausted, and are then to be looked c 18 monly they precede the passage of the head through the os externum, and terminate by producing a violent cramp in the lower extre- mities. Rigors or thrillings are generally esteemed favourable indications of labour; but they should be distinguished from those severe, distinct shivering fits which are the forerunners of fever, and consequently productive of danger.* It is frequently useful to give warm diluting drinks during these rigors, such as tea, thin gruel, weak broths, &c; but the custom of giving spiced caudle, warm beer, mulled wines, or spirits and water, is highly reprehensible, though very common among the lower ranks of society. * Shivering fits, the forerunners of fever, more com- monly happen in long and difficult, than in natural labours. 19 Vomiting is likewise looked upon as a veij favourable occurrence during labour, agreeably to an old adage often quoted in the lying-in chamber, " that sick labours are safe ones:' ? and inasmuch as it removes from the stomach improper food or drink, which are often, particu- larly among the lower ranks, the exciting causes of this symptom, it is beneficial. Vomiting is likewise sometimes useful by producing relaxation; thus it is often observed, that pains accompanied with vomiting occasion a greater and more rapid dilatation of the os uteri, than would be produced by the pains alone, without the vomiting. But vomiting ought to create alarm, if it occurs after a long continuance of labour, if the os uteri is completely dilated, if the pains are suspended, or have alto- gether ceased, 20 if the patient is feverish, if the fluid ejected be of a dingy, san- guineous, or blackish hue. Perspiration is a natural consequence of la- bour; but the degree of it depends upon various causes and peculiar constitutions. The relaxa- tion that natural perspiration produces in the system, doubtless tends to facilitate parturition; but artificial perspiration brought on by loading the patient with too many bed-clothes; by keep- ing the lying-in chamber too hot and close; or by giving heating liquors, exhausts the strength, and tends in every instance to delay the progress of the labour. Rules for the Management of Xatural Labour. 1. Natural labour requires but little assistance on the part of the accoucheur. He must recollect that the dilatation of the soft parts will be effected by the natural pains, assisted by the bag of waters gradually insinuating 21 itself through the os uteri and vagina, much more easily and more safely, than by any artificial means that he can employ; of course no attempts ought to be made by him to produce artificial dilatation. 2. During the first and second stages, the pa- tient may be allowed to sit, stand, kneel, or walk about, as her inclination may prompt her; if fatigued she should repose occasionally upon the bed or a couch, but it is not expedient during these two stages that she should remain very long at a time in a recumbent posture. 3. She should be supplied from time to time with mild bland nourishment in moderate quantities. Tea, coffee, gruel, barley water, milk and water, broths, &c. may safely be allowed. Beer, wine, or spirits, undiluted or diluted, should be forbidden: they are very rarely required even when the third 22 stage of labour is nearly terminated, but in the earlier periods, are almost always mani- festly injurious. The attendants in the lying-in chamber fre- quently object to toast and water, lemonade, oranges, and other subacid fruits, &c. but under many circumstances such articles are highly grateful to the patient, and may be indulged in without hazard. 4. Frequent opportunities should be afforded the patient of passing her water. * 5. If costive, the bowels should be opened by castor oil or other mild aperient, or by clysters. 6. It will be necessary for the practitioner to pass his finger occasionally per vaginam i * By the occasional absence of the practitioner. 23 in order to judge of the progress of the labour: but this should not be too often repeated, and great care must be taken not to rupture the membranes. 7. The spirits of the patient should be kept up by kind and cheerful conversation. All noisy discourse, all conversation on melancholy or unpleasant topics, should be checked. Particularly no mention should be made of unfortunate cases in mid- wifery. Reflections on the conduct and behaviour of other practitioners should be discouraged. 8. Towards the end of the second stage of labour the patient should be placed upon the bed properly made up and secured; and in the third stage, as soon as the head of the child begins to protrude through the os externum, the accoucheur should place his hand covered by a soft napkin in such 24 a manner as shall support the perinasum and guard it from laceration. 9. After the head has passed, it is best to wait for another pain or two to expel the shoulders, and not hastily to drag them into the world. 10. After the child has breathed freely and cried vigorously, a ligature may be made upon the navel string at a distance of one or two inches from the belly, and another an inch nearer to the placenta, and the funis should be divided with a pair of scissors between the two ligatures. This operation should never be performed under the bed-clothes. A surgeon-accoucheur not long since included one of the little fingers of the child in the ligature which he had made upon the funis, and cut off the first joint with his scissors. This acci- 25 dent could not have happened had he brought the part to be divided into view. 11. After the child is born, secondary pains come on to separate the placenta; these usually occur in less than twenty minutes, and the placenta is thrown by them into the vagina, from whence it is easily extracted by the accoucheur. 12. Before the practitioner quits his patient he should 1. lay his hand upon the abdomen, to satis- fy himself that the whole contents of the uterus are expelled; 2. feel her pulse, that he may not leave her in a state of faintness; 3. examine that the funis of the child is properly secured. Labours of the class Eutccia do not often last so long as twenty -four hours, especially if 26 the woman has already borne a child. Of the last 200 women that I have attended in natural labour, 64 were delivered within 6 hours: here were no first children. 76 ', 12 hours: among these were 11 first labours. 46 18 hours: among these were 14 do. 14 24 hours: among these were 7 do. 200 32 *#* Should any circumstances arise during the process of parturition that make it more painful, slower, or more difficult than ordinary; that place the mother's life in danger; or that render artificial assistance necessary; such labour must be reckoned as belonging to the class DYSTOCIA. 27 CLASS II.— DYSTOCIA. COMPREHENDS FIFTEEN ORDERS, Order 1. Dystocia Diutina — Lingering Labour. Natural Labour, No. 3. Lingering Labour. Smel- lie. Slow and Painful Labour. Watts. Lingering and Perplexing Labour. Cooper. Tedious Labour. Burns, Class IV. Difficult (but Natural) Labour. Hogben. Dystocia Protracta. Young's Nosology, CI. V. Order 17, $ 6. Definition. — Labour in which the head presents as in Eutocia; which terminates without danger to the mother; which is effected principally by the natural pains; but which occupies a space of time exceeding twenty. four hours. 28 Dystocia Diutina, is usually attributable to one or more of the following causes. a. original or accidental weakness of habit in the mother, producing inert, or irre- gular or partial action of the uterus. Dystocia a Debilitate. Sauvages, O. 22, § 1. Tedious Labour. Order 1. Burns. b. a rigid and undilateable state of the os uteri, and other parts concerned in the process of parturition. Dyst. ab Angustid. Sauvages, § 4. Tedious Labour. Order 2. Burns. c. small size of the pelvis, or a very slight degree of distortion. D. ab Angustid. Sauvages. d. the size of the fetus being unusually large, or the bones of the head not easily compressible. 29 e. monstrous formation of the fetus. D. a Mole Foetus. Sauvages, § 5. Laborious labour from increased bulk of the infant. Hamilton - f. extreme distention of the uterus, from an excessive quantity of the liquor amnii. g. extraordinary thickness of the mem- branes (chorion and amnion.) h. too early an evacuation of the liquor amnii. i. sudden and violent affections of the mind. D. a. Pathemate. Sauvages, § 3. k. the fetus being dead. D. a Fcetu mortuo. Sauvages, § 6, 1. The funis umbilicalis being naturally too 30 short, or accidentally shortened by being twisted round the child. The method of managing women in lingering labour must in a great measure depend upon the cause of the difficulty. 1. In treating difficult labours arising from the first cause enumerated (a), it will be neces- sary to allow a great deal of time for the parts to develope themselves. The patient's strength must be supported; and this will be best effect- ed by mild nourishment, as gruel, arrow root, panada, chocolate or cocoa, beef tea, veal broth, &c. If the pulse requires it, add a little wine. Open the bowels by clysters. Avoid fatiguing the patient. Be careful not to keep her too hot, or much oppressed by the weight of the bed- clothes. — Change her posture occasionally. — Encourage her by a cheerful unembarrassed manner. Promise a safe delivery, but avoid 31 fixing any period for the duration of the labour. Medicine does not seem capable of doing much good, in such cases: yet sometimes it may be expedient to amuse the patient by giving a few drops of liq. vol. corn, cervi, — spir, ammon. comp. — spir. Athens sulphur — or sp. lavend. comp, in camphor julep, or aq. menth. virid. If there be a want of rest, from «ix to mxx* of tinct. opii. may be given with great advan- tage. Much larger doses of opium, namely to the extent of 6, 8, 10 grains of extr. opii. have been recommended in this kind of slow labour with a view to relax spasm, and render the uterine action more perfect; f but such hercu- * Minims, or drops. t From repeated trials of the effects of the Secalc Cornuturri) or Spurred Rye, the editor does not hesitate 32 lean doses can very rarely be necessary, and would not always be safe. 2. In labours of the next kind (b) our great resource is to allow time. The grinding pains will frequently last for 12, 18, 24, and 36 hours: while these continue, speak of them as only preparatory pains, not as the real pains of labour. If the teasing irksomeness of the pains pre- vents the patient from getting rest, give at discretion a dose of laudanum. to confirm the report of Drs. Stearns and Prescott, that in these cases it may be exhibited with great advantage after a sufficient dilatation of the soft parts concerned in parturition has taken place. To render the uterine action more perfect therefore, it may be given in the dose of 9j. finely powdered, and suspended in a little molasses and water — and this dose may even be repeat- ed, should it fail in rendering the contractions of the uterus energetic in the course of half an hour — but the editor has never found it necessary to exhibit a third dose. — Ed. 33 Let the patient keep pretty much in an erect posture, but be careful not to overfatigue her. Avoid whatever is likely to produce fever. Let her diet be spare and simple. Her drink should be tea, or toast and water, or milk and water, or barley water. Avoid cordials and stimulants. Pay great attention to the state of the blad- der, that it may not become over distended. Open the bowels by clysters, or by castor oil, or by salts dissolved in emulsion or gruel.* * In cases of lingering labour, especially if the pains had become suspended, Mauriceau was partial to the practice of giving an infusion of two drachms of senna in a small quantity of water, acidulated with the juice of a Seville orange: after this had been taken about two hours, he threw up a stimulating clyster. And from the combined effect of these remedies he frequently experi- enced great advantage. It has been thought that the griping quality of the senna and orange juice, was the cause of stimulating the uterus to fresh exertions by 34 Fomentations to the abdomen have been re- commended; but I have not experienced any marked advantage from them. Sitting over the steam of warm water is sometimes beneficial. Some practitioners are fond of introducing lard or pomatum in order to induce relaxation; but this never does good unless the rigidity is confined to the vagina or external parts; it may then be frequently used with advantage. Gardien and other French accoucheurs, in- ject mucilaginous liquids, (as injus. althcea vel lint) into the vagina; and where there is a want of the natural mucus, and much heat and sore- sympathy with the bowels. I have several times tried Mauriceau's remedy with good effect; but a solution of salts or castor oil are, according to my experience, equally useful. The practice of giving aperients by the mouth, is often of use during labour, especially in women habitually costive. 35 ness in the parts, this may probably be a useful practice. Rueff, who published in 1554, recom- mends to introduce a composition of oil and the whites of eggs. In cases of great rigidity, particularly if there be any tendency to inflammation, the abstraction of blood is frequently beneficial. This practice has been carried to a great extent in America, where women have been bled to the amount of 20, 30, 40, 50 or more ounces at a time, for the purpose of producing general relaxation, and consequently a more speedy dilatation of the os uteri and the external organs. But it may be doubted whether patients in general would recover w r ell after so great a loss of blood. An accoucheur at Paris lately professed to teach a secret, by which all women, even the most deformed, might be easily delivered. His method was to give an emetic to the parturient woman, and he expected that the violent strain- 36 ing to vomit would greatly contribute to force the infant through the pelvis. It was soon found that this method was altogether inefficacious in cases of distortion; he was therefore compelled to restrict the practice to cases of slow labour, where the pelvis was well formed; but even in these cases, this plan does not seem to have been productive of much advantage,* and is, I believe, at present, seldom employed. Upon the principle of producing relaxation, the use of the warm bath has been recommend- ed. This was tried by Dr. Smith in America, but excessive haemorrhage was so often found to be the consequence, that this practice was abandoned. Gardien considers that this acci- dent might be prevented, by having recourse * See Gardien Traite d'AccouchemenS) torn. ii. p. 273 —1807. 37 to bleeding before the bath was used; but he does not appear to speak experimentally. Upon the same principle of inducing relax- ation and consequent dilatation of the os uteri, clysters of tobacco were recommended in Ame- rica, but the alarming symptoms which followed in the single case where tobacco was thus em- ployed, will, I trust, prevent a repetition of this experiment.* 3. The treatment of dystocia dintina arising from either of the causes marked (c) (d) (e) must be nearly the same. Much must be trust- ed to time. If care be taken to avoid all causes of fever and inflammation, and to prevent the * See M An Essay on the Means of lessening Pain, and facilitating' certain Cases of difficult Parturition. By TV. P. Dewees, M. Z>." 1806, And the Medical and Physical Journal, vol. xviii. 38 patient from exhausting her strength by unavail- ing strainings, the labour may be suffered to proceed for very many hours without danger; and at length the head of the fetus may be squeezed through the pelvis, very much elon- gated and compressed: yet the child may be born living, and the mother may have a favour- able recovery. 4. Dystocia diutina has very often been as- cribed to one or other of the causes marked (f) and (g), but frequently without sufficient reason. When an excessive quantity of the liquor amnii, or an extreme thickness of the mem- branes is really the cause of a slow labour, the obvious remedy is to rupture the membranes: but this requires very great caution; for if rup- turing the membranes does not produce manifest advantage, it almost always occasions great in- convenience, increases the distress of the patient, 39 and not uncommonly places her or the child in a state of danger. It may be safely laid down as a rule, (which will admit of very few exceptions) that the membranes should not be artificially ruptured, 1. while the head of the fetus, or a large portion of it, is above the brim of the pelvis. 2. while the os uteri is undilated, or in a state of rigidity. 3. while the perinaeum is thick and firm, or rigid. These rules are especially to be observed, if the woman is in labour of her first child. 5. The membranes sometimes rupture spon- taneously (h) without previous notice, or any 40 explicable cause. When this happens, the waters usually escape from the uterus, in small quantities at a time, keeping the woman con- stantly wet and uncomfortable. This is called the dribbling of the waters: and no uterine action comes on till nearly the whole of the liquor amnii is discharged; so that frequently 24, 48, or more hours elapse, before any true labour pains are felt. When labour actually takes place, it often terminates as safely as if this accident had not happened: but commonly the pains are more severe and cutting. Very little can be done on the part of the practitioner, except observing the rules, thai are applicable to the case of rigidity of the soft parts (b). It is right to examine per vaginam early after the waters have begun to drain away, in order that he may be satisfied whether the fetus presents properly: if not, the patient should be frequently visited, and a strict injunction should be given to the attendants to send for the 41 accoucheur, as soon as the pains of labour commence. It has been proposed to introduce a finger within the os uteri, and lift up the head of the child, so as to allow a more expeditious dis- charge of the waters: but this could not often prove beneficial. 6. Practitioners of all ages have agreed that the action of the uterus is very much influenced by the mental powers (i). Evidences of this are to be found in many medical records; and the fact is presented to our view in many oc- currences of common life. It is therefore to be considered of importance, that the mind of the parturient woman should be kept as easy and tranquil as possible. 7. The death of the fetus (k) is not necessa- rily a cause of lingering labour. The affection of the mother, of whatever nature it might be, F 42 which occasioned the death of the child, may possibly retard the labour, otherwise it will ter- minate favourably, unless the size of the fetus is increased by putrefaction.* 8. Shortness of the navel string (1) will sel- dom be a cause of lingering labour, till the head is about to pass through the external parts: it may then be an impediment to the birth by occasioning the head to be retracted after each pain. We are not however always to conclude, that the retraction of the head is produced by shortness of the funis; for the resilition of the * " When a child after death becomes putrid, and thence enormously swelled by the included and rarefied air, the birth will be impeded, but the difficulty will arise not from the death of the child, but from its in- creased bulk." Bland's Description of the Lever. 43 parts, especially in first labours, occasions a greater or less degree of retraction of the head. The delay in the labour which shortness of the funis occasions, is generally soon overcome. Changing the position of the woman sometimes facilitates the birth. It has been recommended, after the head is born, if the birth of the shoulders is prevented, by the navel string being twisted round the neck of the child, to introduce a pair of scissors, divide the funis, and thus set the parts at liberty. This operation may sometimes be expedient; great care being taken to guard against doing mischief: but it is proper to remark that Dr. Denman relates a case of the death of the infant from dividing the funis under these circum- stances.* Introduction to Midwifery^ p, 288, 4to. edit. 44 Besides the causes of difficult parturition above enumerated, it sometimes happens that incautious practitioners occasion lingering la- bours, by mismanaging the different stages, and thus interrupting the natural progress of the labour: and this may be effected, by the injurious practice of giving cordials and strong drinks, under a false idea of supporting the patient's strength; by keeping the room too hot and close; by letting the patient remain too long in bed; by allowing too much company, who fatigue the patient by their noise and talking; by urging the woman to exert herself in bearing down before the parts are well dilated; by injudicious and unavailing attempts to give assistance; by prematurely rupturing the membranes; 45 by suffering the bladder to become over distended;* by not timely opening the bowels. Whenever from any such cause the progress of the labour is impeded or suspended, it becomes the practitioner to retrace his steps, and endeavour to place his patient in the same state that she would have been in, had he not indiscreetly admitted of such injurious practice. The rules already laid down for the treatment of dystocia diutina, when occurring from natu- ral causes, will be applicable to the cases, which are rendered difficult by artificial causes. Instances of dystocia diutina, including first and all other labours, probably occur as often as once in 30 cases: but it is very difficult to * This forms " Complicated Labour." Class 7. Order 6. Burns, 46 form an exact average. They are much more common with first children than with others.* From what has been remarked respecting this order of labours, it is apparent: * Among the last 120 women that I have attended in their first labours-— 95 were cases of eutocia; 56 being delivered within 12 hours. 39 in between 12 and 24 hours. £5 were cases of dystocia diutina. 9 were delivered in between 24 and 30 hours. 9 30 and 40 2 40 and 50 2 50 and 60 2 60 and 70 1 70 and 80 All the above women recovered perfectly from the state of child-bed, and two only of the children lost their lives during the labour. In one of the cases where the child died, the mother was only 20 hours in labour: in the other case, the woman was 68 hours in labour. Six others of the children were dead born, but had evidently been dead several days before the labours came on. 47 that many causes may produce dystocia diutina; that in all such cases much delay must necessarily take place; that frequently very little progress will be made, though the labour may have lasted for several hours; that sometimes many days will elapse be- fore the termination of the labour; yet it may at length terminate safely both to the mother and the child, without arti- ficial assistance.* * Mr. Burns, in his " Principles of Midwifery/' first edit. p. 242, quotes from Dr. Breen's Tables of Labours at the Dublin Lying-in Hospital: 172 cases of slow labour in women with their first children. 91 in women m ho had formerly borne children. In the first class 34 were from 30 to 40 hours in labour. 103 40 .. 50 do. 24 70 . . 80 do. 12 90 . l(>0 do. And 121 of the children were born alive. In 48 It must however be remembered, that all women are not equally capable of undergoing such long continued sufferings as sometimes occur in this order of labours. Occasionally it will be found, that cases of dystocia diutina will be so long protracted as to bring the patient into a state of exhaustion which deprives her of the power of further exertion: when this happens the case no longer belongs to the order dystocia diutina> but comes under the next order. In the second class 28 were from 30 to 40 hours in labour. 48 40 . . 50 do. 6 50 . . 60 do. 9 70 . . 80 do. And 66 of the children were born alive. No mention is made of any death among the women, it may be presumed therefore that they all recovered. 49 Order 2. Dystocia Anenergica — Powerless Labour. Difficult and Perilous Labour. Cooper. Laborious Labour. Order 2. Hamilton. Laborious, or Instrumental Labour. Burns. Definition. — Labour of long but indefinite con- tinuance, in which the pains becoming weak and inefficacious, or being entirely- suspended, and the patient exhausted by her sufferings, it becomes necessary to afford artificial assistance to terminate the labour. D. Diutina and D. Anenergica may be distin- guished from each other by the following symptoms: c so Favourable Symptoms constituting Dystocia Diutina. 1. A regular recurrence of uterine action. 2. Perceptible progress in the labour, how- ever slow. 3. The patient's strength being unim- paired. 4. Her mind being tranquil. 5. A disposition to quiet sleep in the in- tervals of her pains. 6. The absence of fever or inflammation. 7. The vagina and os uteri feeling cool and moist. 8. The patient possessing the power of voiding her urine. While these symptoms are present, the labour may be safely trusted to nature. Unfavourable Symptoms indicating Dystocia Anenergica. 1. Severe shivering fits unconnected with 51 dilatation of the os uteri, or of the passage of the head through the os externum. — See p. 18. 2. Frequent or constant vomitings after the os uteri is dilated. 3. The accession of fever. 4. Great restlessness or jactitation. 5. A disturbed and anxious mind. 6. The want of true uterine action, though there may be irregular and unproductive pains, and this happening after many hours of labour.* . * Here the use of the Secale Cornutum, or Spurred Rye, has been often resorted to by the editor, with the happiest effects. He has been for some time past, in the habit of giving it in these cases, after the soft parts have been sufficiently dilated, in the dose of £j. finely powdered (as mentioned in a preceding note) and sus- pended in molasses and water. Its effects in increasing the uterine contractions are generally observable within half an hour; and he has seldom found it necessary to repeat the dose. A second 52 7. Heat and soreness in the vagina and os uteri. 8. Offensive discharges from the uterus. 9. Violent and continual pain and soreness, or tenderness of the belly. 10. Low muttering delirium. 11. A quick and weak, or low sinking pulse. 12. Clammy sweats. In proportion to the number and severity of these symptoms will be the danger of the scruple has been sometimes exhibited at the interval of half an hour, but he has never gone beyond this. Given to this extent, he has never witnessed any unpleasant consequences resulting either to mother or child — and he believes that in cautious and prudent hands, it may, in certain cases, obviate the necessity of having recourse to the application of instruments, generally so abhor- rent to female delicacy, as well as irksome and unplea- sant to the practitioner.— Ed. 53 patient, and unless artificial aid be timely afford- ed, both mother and child will perish. The assistance to be afforded will generally be that of the forceps or vectis; for, unless in cases of distorted pelvis, the head of the fetus will have sunk low enough to allow the ear to be felt, before the strength of the patient becomes quite exhausted. 54 Order 3. Dystocia Perversa — Labour, the Head presenting in a wrong Direction. Natural- Labour, No. 2. Smellie. Variety of Natural Labour. Denman. Preternatural Labour. Class 3. Order 5. Burns, The French writers on midwifery enumerate more than twenty kinds of malposition of the head, but it is sufficient for all useful purposes to resolve them into three: a. The forehead turned towards the pubes. b. the face presenting. c. the position of the head altered, by the descent of the hand or arm with the head into the pelvis. 55 1. The most common of all the wrong pre- sentations of the head, is that of the forehead towards the pubes (a), divided by M. Gardien into three species: — Position fronto-cotylo'idienne gauche.* fronto cotyloidienne droit e.\ frontO'pubienne.% Tuaite d'Accouchemens, torn. ii. p. 307. This kind of presentation is seldom discover- ed at the first examination. The accoucheur having ascertained that the head is the present- ing part, feels little solicitude about its exact position. The labour, however, being much more severe, or continuing longer than he had expected, because in this position the bones of the fetal head do not readily adapt themselves • Or the anterior fontanelle to the left acetabulum, t Or the ant. fontanelle to the right acetabulum. \ Or the ant. font, to the symphysis pubis. 56 to the shape of the pelvis, he is induced to make a more accurate examination, and then discovers the wrong position by the following indica- tions: — The presenting part is not so conical to. wards the arch of the pubes. The bones do not ride one over the other. The scalp does not form into a cushion. The hollow of the sacrum is not so com- pletely filled up by the head. The anterior fontanelle is to be felt towards the symphysis pubis.* * The anterior fontanelle in these presentations, is readily distinguished by its four angles, and a suture proceeding from each angle — the posterior fontanelle having but three angles, and a suture proceeding from each angle. If the anterior fontanelle is readily felt upon an examination per vaginam, we may expect that the head 57 The sagittal suture inclines towards the back of the pelvis. This kind of labour is not in general very- unmanageable. The head may be longer than ordinary in passing through the pelvis; but if this be well formed, and the pains are strong, it will be at length excluded, and in the majority of cases the child will be born alive. It is necessary to pay particular attention, to prevent a laceration of the permasum: for the external parts are excessively stretched when the head passes in this direction. Even women, who have borne many children, have had the perinaeum lacerated, under the circumstances of this kind of presentation.* is inclined to take an unfavourable position or that of the forehead towards the pubes. — Ed. * This presentation may be rectified and the progress of the labour accelerated, by applying the fingers to the H 58 2. The presentation of the face (b), may be known by the general inequality of the present- ing part, and by the distinction of the eyes, nose, mouth, and chin. When the face is the presenting part, the most favourable, and according to Dr. Den- man the most usual position, is with the chin towards the symphysis pubis. The management of this case must in a great measure be left to nature and time, which will side of the forehead, and carefully pressing the anterior fontanelle from the acetabulum which it approaches to the sacro-iliac symphysis of the same side of the pelvis —by which operation the occiput is ultimately brought under the arch of the pubis — and the dangers and diffi- culties above enumerated, obviated. In the progress of the foetal head through the pelvis, this malposition is sometimes rectified by nature herself, without the> assistance of art. — Ed. 59 gradually effect the delivery: but the bones of the face not being capable of compression, do not yield to the form of the pelvis, and therefore very often many hours elapse with but little perceptible progress. The children are usually born alive, but the features of the face are amazingly distorted, and do not recover their proper appearance sometimes for many days. We have been directed, to get a finger into the mouth of the child, and to press down the chin upon the breast, or in any other manner, to endeavour to alter the position of the head. There is, however, but little probability of doing good by this manoeuvre, and some hazard of doing mischief. It has been strongly recommended, among others by Smellie, Burton, and Cooper, to turn and deliver footling in face cases : and this prac- tice was enjoined upon the supposition that the life of the child would be sacrificed, unless the 60 labour was quickly terminated: but experience has shown in this and many other points of practice, that the safety of the child is not always commensurate with the quickness of the labour. 3. Independent of the awkwardness of posi- tion, which the head may assume from the cir- cumstance of the hand or arm descending with it into the pelvis (c), there will be so much increase in the bulk of the part, as to render its passage slow and difficult. Yet, if the case be not interrupted by mismanagement, it will terminate favourably; for this complication of presentation seldom happens but in a wide pelvis. There will be some difference in the diffi- culty of the labour, according to the manner in which the superior extremity enters the pelvis. If it be only the fingers or hand coming down 61 in a flattened shape, by the side of the head, the difficulty will not be very great. If the elbow be the part, with the fore- arm bent back upon the humerus, the difficulty will be increased. And it will be still more perplexing, if the hand and arm have descended before the head, the head resting upon the arm, at the bend of die elbow. Occasionally it will be practicable, by means of the operator's fingers, to prevent the hand or arm from descending below the brim of the pelvis, till the head has sunk so low as to be clear of the impediment: but in attempting this, care must be taken, not to make the case more embarrassing by drawing the arm down lower, or forcing the head above the brim of the pelvis; for this might convert the case into a truly pre- ternatural labour, and render the turning of the child necessary. The arm of the child is often very much bruised and tumefied in consequence of this 62 position, and it is sometimes difficult to persuade the attendants that it is not fractured or dis- located. I have not, however, known an in- stance, in which the arm did not recover itself in a few days. The rules laid down for the management of labours of the order dystocia diutina, are applicable to those of dystocia perversa. In both, the labours are painful, difficult, and slow: yet in both, the efforts of nature are usually sufficient to effect the delivery without artificial assistance, or at least, with that assistance, which a single finger may give. Care must be taken to preserve the patient from fever, to keep her spirits calm and undis- turbed, and to husband her strength; she should not be permitted to fatigue herself in vain attempts to force the child forwards, before the parts are properly prepared to let it pass; nor ©ught she to be kept too much in bed, lest she 63 be weakened by profuse perspirations under a load of bed clothes. Her bowels must be occa- sionally relieved, by laxative medicines or clys- ters, and the urine must not be suffered to accumulate in the bladder.* Under such treat- ment the process of parturition may continue for a long time without hazard. If, however, the favourable symptoms of labour before enumerated (p. 50) gradually dis- appear, and those which are unfavourable begin, we must consider this order of labours to be .degenerating into dystocia anenergica, and must adopt such measures, to insure our patients from danger, as the nature of the case may require. * Perhaps there is a particular tendency to suppres- sion of urine in face presentations; at least I have found this inconvenience to happen in several labours of this nature to which I have been called. 64 Order 4. Dystocia Amorphica — Labour render •- ed difficult from Deformity in the Bones of the Pelvis. Dystocia ab Angustia. Sauvages, CI. 7, O. 26, § 4. Dystocia Amorphica. Young, CI. 5, O. 77, § 4. Laborious or Instrumental Labour. CI. 5. Burns. Impracticable Labour. CI. 6. Burns. Distortions of the pelvis may arise — from rachitis in infancy. from malacosteon in more advanced life. from exostosis. from fracture or dislocation of the bones of the pelvis. From whichever of the above causes the deformity proceeds, the capacity of the pelvis 65 will be so much intrenched upon, as to oppose an impediment to the passage of the child, not only in first but in all future labours. Yet sometimes the efforts of the uterus will be sufficient to force the child with the head much compressed through the deformed pelvis. Much in such cases will depend upon the small- ness and compressibility of the head, and the strength of the pains. It becomes us to be exceedingly cautious not to suppose upon light and insufficient grounds that the distortion is too great to allow the child to pass without the intervention of instruments; and particularly when there is a question about employing the perforator, an instrument always incompatible with the life of the child, we ought to weigh every circumstance very carefully in our minds, and if possible procure the opinion of some other experienced practitioner, before we i 66 determine upon having recourse to it. The ex- istence of a human being depends upon our decision, we ought not therefore to decide but with the greatest deliberation and wariness: Nulla unquam de fnorte hominis cunctatU longa est. Juvenal, sat. 6. The reluctance, which every well-regulated mind must feel, at employing the perforator even in cases of the greatest necessity, while the infant is yet living, naturally occasions a wish to delay the operation, till there are some indications of the child's death; and these indi- cations are sought for, in certain symptoms, which most writers on midwifery have been careful to enumerate. These symptoms may be divided into two classes; the first are useful in proving that the fetus has been dead in utero for several days or even weeks. 67 These symptoms are: Severe shivering fits on the part of the mother, followed by a sense of coldness in the abdomen; a feeling as of a lump, or dead weight, in the uterus; a subsidence of the abdomen; a want of motion in the child; a flaccid state of the breasts; a recession of the milk. But this is not what is commonly wanted. The object is to ascertain whether the child, which was known to be living when the labour commenced, has afterwards lost its life from the violence of the pains, or the severity of the labour. And this is to be judged of from the second class of symptoms, which are however more or less fallacious. I shall enumerate seve- 68 ral of these, and offer some comments upon them as I proceed: 1. " If the woman be four days in labour, the child scarce escapes." This is given upon very indifferent authority, that of Culpeper, and is never to be relied upon in cases of well-formed pelvis; but when the pelvis is much distorted, a labour of less than four days continuance is often destructive of the child. 2. An evacuation of the meconium during the labour. Viardel considers this as a decisive proof of the child's death, but very improperly; since in nates presentations, a discharge of the meconium always happens, yet in the majority of cases the child is born alive. Many authors have refuted this opinion of ViardeL 69 Others have supposed, that when the meco- nium is discharged in presentations of the head, a pretty certain proof of the child's death is obtained, but many instances to the contrary have occurred. 3. A fetor, and an ill appearance of the discharges from the uterus. These symptoms are not wholly to be de- pended upon; but when they accompany others, are not to be disregarded. 4. A want of pulsation in the navel string. The proof here is conclusive, but opportuni- ties of examining the navel string are compara- tively rare.* * I do not consider this symptom so entirely conclu- sive as it appears to our author. — I have known a tern- 70 5. An edematous or emphysematous feel of the scalp, with the bones of the cranium separated and loose. These may likewise be considered as conclu- sive proofs of the child's death. 6. A want of motion in the child is often re- lied upon, and ought to be enquired about in all doubtful cases, because if the mo- tions of the child are really felt, it cannot be dead. But very often the mother does not feel the child to move for many hours together during labour, and yet it is often porary suspension of the pulsation in the funis, where the child was born alive; and a case occurred to me where the pulsation had ceased for a considerable time, the child being apparently still-born, where neverthe- less, upon having recourse to the proper means of resus- citation, the pulsation returned — the child recovered — lived between one and two days, and once took the breast. — Ed. 71 born strong and healthy; want of motion therefore, in the child, cannot alone be considered as proving the child's death: but, joined with other symptoms, it will materially assist the practitioner in forming his opinion. [A deformed pelvis is said, by the most intelligent travellers, to be unknown among the female aborigines of our continent — and it is a very happy circumstance, that it is a very rare occurrence among the women born and educated in the United States. This will be readily understood by the medical reader. Children and women in this country, are not subjected to so many causes producing Rachitis and Malacosteon: such as scanty and bad food, sedentary confinement in crowded manufactories, and other debilitating processes so com- mon in Europe. — Hence the propriety of pausing and reflecting, before ever having recourse to the operation of Embryulcia, the necessity of which must be so ex- ceedingly rare in our happy country.]— Ed. Order 5. Dystocia Obturatoria — Obstructed Labour. Dystocia ab Angustia. Sauvages, § 4. Dystocia Amorphica. Young, §4. Definition, — Labour rendered difficult, by a mechanical obstruction in the soft parts, to the passage of the child. a. by the presence of the hymen, or by a cohesion of the labia, or of the vagina. b. by a polypous, steatomatous, or other tumour growing from the organs of generation, and obstructing the passage. c. by a diseased ovarium, intrenching upon the capacity of the pelvis. 73 d. by a protrusion of the bladder into the vagina. e. by a portion of intestine or omentum, forming a hernia in the vagina. 1. All the species of this order of labour are of very rare occurrence. Those of the first kind (a) will not probably occasion much embarrass- ment to the accoucheur; the action of the uterus will alone be sufficient, in most cases, to over- come the difficulty.* Should it, however, be found necessary to do more, an incision must • Fui ego adTOcatus ad raulierem parturientera. cui ragina adeo erat angusta, utnec ego, nee G05te:rix du-i:i minimi apicem potuerimus vaginae immnere, maritus a triennio, quo ipsi matrimonio erat junctus, nunquam more solito coitum exercere cum ilia potuit. Interim tamen spatio 18 horarum dolores parturiuonis vaginam adeo dilatabant, ut partus sine omni ruptura vaginae, vel genitalium finiretur. PUnck Elrmer.:z ArtU Obaeirici*, p. 113, K 74 be made through the obstruction; very great care being taken not to wound or injure any contiguous part. I have met with one instance only of the pre- sence of the hymen during parturition. 2. Tumours growing from the organs of generation (b) are sometimes so small and compressible as to occasion little or no impedi- ment to the passage of the child. But, occasion- ally, they have been found to occupy so large a space as to render delivery impossible without the intervention of art. Should the case be such as to allow the diffi- culty to be overcome by employing the forceps or vectis, there could be no hesitation in having recourse to either of these instruments. But if there be no chance of succeeding with any instrument, short of using the perforator, it would be right to pause, and to consider *3 whether to remove the tumour, or to diminish the size of the child, would be most likely to be attended with ultimate advantage; and so much will then depend upon the size, situation, and nature of the tumour, that it is impossible to lay down exact rules upon the subject.* 3. Cases of diseased ovarium, intrenching upon the capacity of the pelvis, have been mentioned by several writers on midwifery, f Should the ovarian tumour be occasioned by an accumulation of fluid, it would probably be better practice to puncture the tumour and evacuate its contents, than to diminish the size of the child's head. * See " Two Cases of Tumours in the Pelvis, ifc. by P. P. Drew, M. D." in the Edinburgh Medical and Sur- gical Journal, vol. i. p. 20. 1805. t Denman's Midwifery, 4to. p. 324. — Baudelocque\ Midwifery, § 1963. — Medico-Chirurgical Transactions, vols. ii. and iii. 76 It is however of the utmost consequence to be well assured that the tumour is ovarian, and not a protrusion of the vesica urinaria into the vagina (d)*, which may he always ascertained by passing a catheter; nor a hernia of the intes- tines (e), which will be relieved by procuring stools. * See " Hamilton* s Select Cases in Midwifery** p. 9. 1795; and a very instructive paper by Mr. Christian, in the Edinburgh Medical Journal, vol. ix. p. 281. 77 Order 6. Dystocia Ectopica — Difficult Labour from Displacement of the Uterus. Uterus Obliquatus. Deventer. Hysteroloxia Anterior — Lateralis— -Poste- rior. Sauvages. Hysteroloxia Lateralis. (Imperfecta). < Antica— — Postica — (Perfecta), Plcnck. Most authors enumerate three species of obliquity of the uterus. a. The os uteri inclined towards one or the other side of the pelvis. b. The os uteri tilted up backwards, so as almost to reach the projection of the sacrum. 78 c. The os uteri projected forwards, above the symphysis pubis. 1. The lateral obliquity* of the uterus (a) can scarcely prove a cause of difficult labour; an erect posture will, if the pelvis be well formed, speedily rectify this displacement. [Or laying on the opposite side to the obliquity.] 2. The os uteri, tilted backwards towards the projection of the sacrum (b), is not a very unusual occurrence in women with wide pelves, and it almost always occasions a slow labour. Young practitioners are apt to be embarrass- ed, when thev find the uterus thus situated: for upon an examination per vaginam, the pelvis at first seems to be filled up by the head of the child making a rapid advance towards delivery. A more accurate examination, however, shows that the part, in contact with the finger, is not the naked head of the child, but the anterior 79 surface of the uterus spread over ir. And the os uteri scarcely at all dilated, will with some difficulty be discovered towards the projection of the sacrum, almost beyond the reach of the finger. This kind of difficult labour is best reliered by time and patience. It has been thought advantageous for the patient to take her pains, lying on her back. The method proposed by some authors, of insinuating a finger into the os uteri, and drawing it towards the centre of the pelvis, is liable to many objections. 3. The os uteri projected above the sym- phy sis pubis is a very rare occurrence. Dev enter describes this situation of the uterus, but he does not seem to have had a very correct idea of the case. Since his time many authors have denied the possibility of such an occurrence; but there are several cases upon record which prove the fact. It is a retroversion of the uterus 80 continuing to the full period of pregnancy.* Of this case I have known two instances. 4. Another kind of displacement of the uterus has been spoken of by authors, f but I have never known an instance of it. d. The os and cervix uteri sunk without the os externum during labour. * See " Cautions to Women, respecting the State of Pregnancy, &c. By S. H. Jackson, M. D." p. 59, 1798. —Also, U A Dissertation on the Retroversion of the Womb" By the Author of this " Synopsis" f Medical Museum, vol. i. p. 227. 1763. — Memoirs of the Medical Society of London, vol. i. p. 213.— .Medical and PhysicalJournal, vol. i. p. 154. 81 Order 7. Dystocia Transversa — Preternatural Labour. Dystocia a Foetus Situ. Sauvages, § 7. Perversa. Young, § 3. Unnatural Labour. Bland. Preternatural Labour. Smellie. Denman. Burns. Accouchement contre Nature. Baudelocque. Gar- dien. ————— Manuel. Capuron. Definition. — Labour in which any part of the child presents, except the head.* * M. M. Baudelocque, Gardien, Cafiuron, and other French practitioners, do not consider the labour to be preternatural, though the nates, the feet, &c. present, 82 Authors have enumerated a great variety of preternatural presentations, but they may be all resolved into the following: — a. Presentations of the nates, or of either hip, or of the loins. b. Presentations of the inferior extremities, c. superior extremities. d. back, belly, or sides. e. funis umbilicalis. Preternatural labours can only be known by an examination per vaginam. If upon such an examination it should be ascertained that the os uteri is considerably provided that it terminates without the extraordinary assistance of the accoucheur. Unless his assistance is required, it is still according to them unassisted (or natural) labour. 83 dilated, and the child cannot be felt, this affords reason to suspect that the presentation is preter- natural. Should the liquor amnu be discharged and the child be out of reach of the finger, the probability of a preternatural position is greater. Should the membranes be found hanging down in the vagina, not of the usual globular form, but rather conical and small in diameter, this likewise is a presumptive proof of a cross birth; especially if the part presenting through the membranes " be smaller, feci lighter, or give less resistance when touched, than the bulky heavy head." These, however, are but probable signs; we cannot positively ascertain the fact, but by accu- rately examining the presenting part. Whenever there are presumptive signs of a preternatural presentation, it becomes our duty to be very watchful of our patient, that we may 84 be prepared to give the necessary assistance if it should be required; and when we have fully satisfied ourselves that the child is coming in a wrong direction, we ought to inform some of the patient's friends of the circumstance; but it is best to conceal it from herself as long as possible. There is sometimes much difficulty in ascer- taining what the presenting part is. Yet it is often of the greatest importance not to make a mistake, particularly in the presentation of the extremities. The hazard of a mistake is greatest when only one extremity presents. The following rules -will in general enable us to form a correct opinion: — The head is known by its globular form, and hardness. by the sutures and fontanelles. 85 The face, by the inequality of its surface. by the eyes, nose, mouth and chin. The nates, by the softness, pulpiness, and globular shape. by the cleft between the buttocks. by the parts of generation. by the evacuation of the meconium. The foot, by its thickness, by the heel, by the great toe. by the shortness of the toes, by the ends of the toes forming nearly an even line. The hand, by its flatness. by the length of the fingers. by the unevenness of the ends of the fingers. by the thumb bending into the palm of the hand. 86 The elbow has sometimes been mistaken for the knee or the heel; it may be distinguished by being more pointed than either of these parts. The shoulder may be known by the clavicle and scapula; but generally when the shoulder presents, the arm is found in the vagina. 1. Of the presentation of the nates (a). In early labour, this presentation is not always easily distinguishable from that of the head, on account of the globular feel of both parts. Labours of this kind were formerly very much dreaded, as it was supposed that there was not room for the child in this doubled position to pass through the pelvis. Hence the older accoucheurs attempted to turn the child, and bring the head to present. Afterwards, upon the authority of Ambrose Pare, it became the prac- 87 tice to push up the nates, and bring clown the feet, thus converting the case into a feet presen- tation.* Burton strongly recommends this prac- tice, and Smellie too often adopted it, but it is never necessary except in cases of distorted pelvis. The nates may enter the pelvis in various directions; sometimes one hip only descends through the superior aperture, sometimes the * Partus naturalis et facilis is demum censetur, quo in caput infans prodit, aquarum effluxus sine mora sequu- tus; difficilior est quo in pedes prodeunte foetu fit: reliqui wanes difficilimi. Itaque obstetrices monendae sunt, ut quoties neutro commemoratarum partium prodire infan- tem cognoverint, sed vel in dorso, vel in ventrem, vel In pedes manusque simul, vel in porrectum brachium, vel quavis alia denique contra naturam forma, ipsum conver- tant et in pedes trahant: cui operi perficiundo si ipsae non sufficiant, chirurgum exercitatum accersant. Parai de Horn. General, cap. 15. This seems to be the first positive injunction to turn and deliver footling in preternatural labours. 88 child lies with its face towards the mother's belly, and at other times it is turned towards her back, and this is the most favourable po- sition. The first stage of labour in nates presenta- tions is frequently very slow, for though the nates and thighs do not take up so much room as the head, yet either they do not readily adapt themselves to the shape of the pelvis, or the action of the uterus is slower or less regular, in consequence of the awkward position of the fetus. No means, however, can with propriety be employed to hasten the progress of the labour; and by degrees the dilatation of the parts is effected, and the nates are forced lower and lower into the pelvis, till at length they protrude through the os externum. As soon as this has happened, the case becomes precisely the same as a footling presentation, and is to be managed exactly in the same way. For 89 further rules for the management of nates presentations, see the next section, p. 97. The danger to the mother in nates presenta- tions is not great; the danger to the child is considerable: but if the case be well managed, the life of the child need not be so often lost as has been supposed. Paul Portal, who was a celebrated accou- cheur at Paris from 1664 to 1682, says, that 80 out of 100 children, presenting in this man- ner, will be born alive. Portal gives very judi- cious directions for the management of this kind of labour; but his instructions were disregarded by subsequent practitioners and writers. His words are, "In such a case as this, you must not be impatient, for though the labour proceeds very slowly, yet it is not much more difficult than a M 90 natural birth: whence it is that our mid wives say by way of proverb, that where the buttocks can pass, the head will follow of course. The position of the child in this case is doubled, with his thighs upon the belly, and the passage being once opened for the buttocks by the reiterated pains, the head follows without much trouble.' >* I cannot help contrasting these judicious directions with those of our countryman, Dr. John Burton, of York, the cotemporary and rival of Smellie; who says, $ 89, " When the buttocks come foremost, it sometimes happens (though very rarely) that it may be brought in this pos- ture, if the child chance to be very small, and the passage large: but yet this is very accidental; for though we may discover the passage to be large, yet we cannot so easily judge of the child's * « Complete Practice of Men and Women Midwives f Vc. by Paul Portal, Sworn Surgeon, and Man-midwife in Pari*," p. 23. .91 bulk, and therefore we should attempt to bring it forth by the feet, as directed, } 88." The 88th section runs thus, " When the buttocks come foremost, the more it is suffered to advance, the more dangerous and difficult will be the labour: therefore as soon as the operator per- ceives, by the softness and fleshiness of the parts, what part presents, he must immediately thrust up against the buttocks with all his strength, but without committing violence to the child's os coccygis, or its parts of generation, which are often in this case swelled; and as he thrusts up, he must endeavour to turn the child with its belly towards the os uteri, and then search for the feet."* Were this rough and barbarous recommen- dation of Burton generally followed, the most • « New and Complete System of Midwifery, by John Burton, M. D." 1752. 92 lamentable consequences, both to mother and child, could not fail of being often experienced* Many writers on midwifery recommend, in nates presentations, when the buttocks do not readily pass through the pelvis, to insinuate a finger on each side, as high as to the groins of the child, and thus to assist the delivery. This mode of practice is very seldom necessary, and not always safe. It has likewise been recommended, when the groins are beyond the reach of the finger, to introduce a blunt hook, by which to extract the child: but though in the course of my practice I have attended very many cases of nates presen- tations, I have never yet found it necessary to have recourse to this expedient.* ♦Notwithstanding what our author says here, and although it may not be often necessary to have recourse 93 2. Of presentations of the inferior extre- mities (b). This is the most simple, and probably the safest to the mother, of all the preternatural positions: but the hazard to the child is con- siderable, particularly if it be a first labour. The danger to the child arises principally from the compression of the navel string between its own head and the parts of the mother, as the child passes through the pelvis. The great object of the accoucheur, then, is to prevent this compression; and this is to to any artificial aid in breech presentations, yet such cases do sometimes occur, and when they do, the blunt hook is the proper instrument to employ. In careful and judicious hands, if properly made, it may be used with- out injury to the child or mother. It should generally be applied to the groin which is nearest the sacrum of the mother. — Ed. 94 be effected, by getting the head of the child through the pelvis, with all proper expedition, as soon as the body of the child is born. In order for this, it is not necessary to hasten the delivery of the body of the child: on the contrary, it is desirable, that the delivery of the body should be effected slowly; for thus the parts of the mother will become more dilated and spacious, and of course there will be less resistance opposed to the passage of the head. But if attempts are very early made to reach the feet, and to expedite the delivery by draw- ing them down, and afterwards to extract the body rapidly, it will probably be found, when the head comes to occupy the pelvis, that the soft parts of the mother will be too rigid to let the bulky head pass through them; and thus so much delay will take place, as to destroy the child. 95 If, therefore, at the beginning of the labour, the membranes should be entire, let great care be taken not to rupture them, till all the dilata- tion that can be effected by the pressure of the bag of waters is produced. Or if the membranes should be ruptured, and the feet are felt naked in the vagina, let no hasty attempt be made to extract by them: it will be better to leave the case entirely to nature, till the nates have passed through the os exter- num; by which time the parts will be dilated as much as circumstances will allow. But when the nates are born, the attention of the accoucheur is demanded. In order that the head of the child may pass conveniently through the pelvis, it is necessary, that it be so inclined, as for the forehead to occupy the hollow of the sacrum, after the head has passed through the superior aperture. The 9% long diameter of the head must, therefore, first, be in the direction of the long (or transverse)* diameter of the pelvis, and afterwards the fore- head will fall into the hollow of the sacrum. It becomes us then, carefully to attend to the position of the child; and this is ascertained by examining the feet. If the toes are turned towards either sacro-iliac synchondrosis, the child is already in a right direction: for when the forehead has passed through the superior aperture of the pelvis, it will naturally slide into the hollow of the sacrum, and the passage of the head through the pelvis will be much facilitated. But if the toes point to the symphysis pubis \ or belly of the mother, the head will come in an unfavourable position: it will not readily adapt itself to the shape of the pelvis: probably * Or more properly the oblique. 97 in passing, the chin will hitch upon the ossa pubis, and it will be difficult to extricate it from this untoward situation. To guard against this accident, it will be proper, as soon as the nates* have passed through the os externum, to take hold of both thighs with a warm napkin; and, when the next pain comes on, to give such an inclination to the body of the child, by guiding it with the hands, as will direct the face towards the mother's spine. There is no difficulty in effecting this turn, if it be done prudently and cautiously. Much force is not required; nor is it necessary that the child's belly be turned quite round to thw * The following rules are applicable, as well to cases where the nates is the presenting part, as where the feet first come down. N 9$ mother's back: an inclination towards the back is all that is wanted. During the pain, which, with the assistance of the accoucheur, produces this turn of the child, it is probable that the whole of the body- will be expelled, and nothing will remain in the pelvis but the child's head, with the arms extended on each side above it. It has been a question much discussed, whether it be best in preternatural cases to finish the delivery, leaving the arms thus ex- tended on each side of the head, or to draw them down by manual assistance, before any attempt is made to bring the head into the world. It has been given as a reason for not bringing down the arms, that while they are in this situation, the os uteri is prevented from con* tracting round the neck of the child, and thus $9 impeding the passage of the head. But if the early part of the labour has been permitted to proceed sufficiently slow, to allow the os uteri to become properly dilated, such a contraction is little to be dreaded; and the arms need not be suffered to remain for this purpose. I believe, that a contraction of the os uteri round the neck of the child, never takes place after the os uteri f has once been completely dilated. Another reason given for not bringing down the arms, is, that while they are thus extended above the head, the navel string is secured from pressure: but I do not understand how the pressure can be diminished, by having the bulk of the parts passing through the pelvis increased. A far better reason for not bringing down the arms, is, the danger of dislocating or fracturing them; and, if the practitioner will be so heedless and imprudent, as to use undue force and vio- lence in extracting them, this danger will be 100 imminent: but if the attempt be cautiously and judiciously made, no hazard need attend this operation. The operation consists in passing the finger over the shoulder of the child as far as to the bend of the elbow, which is then to be gently depressed, and the fore arm commonly passes through the vagina without much difficulty. One arm being brought down, the extraction of the second becomes more easy. In proportion to the rigidity of the soft parts will be the difficulty of the extraction: should it be found that the operator's finger can not reach the bend of the elbow, or does not readily dis- lodge the arm, it will be better to defer the attempt, or to give it up altogether, rather than to do injury to the infant. With first children, it will require some care to guard against a laceration of the perineum, as the arm passes. 101 When the labour has proceeded so far, that only the head remains to be born, we are to extract this with all the speed that circum- stances will admit; for if it remains long in this position, the compression upon the funis will be so great, as speedily to cause the child's death. It is of importance to get a finger of the left hand introduced into the child's mouth. This serves two valuable purposes: — 1st. By this means we have it in our power to depress the chin, which alters the position of the head, and adapts it more commodiously to the pelvis, 2dly. By opening the mouth of the child, it will sometimes happen, that a portion of air will make its way into the lungs sufficient to distend them, and partially establish the function of 102 respiration: by which the life of the child may be somewhat prolonged. If the finger be properly passed into the child's mouth, the arm and hand of the opera- tor serve to support the body of the infant in such a direction as tends to facilitate the expul- sion of the head. The fore finger of the left hand being insi- nuated into the mouth of the child, the fore and middle fingers of the right hand should be passed over the nape of the neck, one finger resting on each shoulder; and now a moderate extracting force may be employed to bring forth the head. This will sometimes be more conve- niently done, if the woman be turned upon her back, and if the operator stands while making the extraction. It is desirable that this attempt be made during a natural pain, and that the operator cease 103 from his attempt as soon as the pain goes off: but if the case be urgent, the extraction must be made without waiting for the natural pains. The necessity for hastening the extraction of the head, as has been already remarked, is to preserve the life of the child; but so long as a pulsation is to be felt in the navel string, the child's life is in no danger. It has happened not uncommonly, that the eager desire of the operator to save the life of the child has defeated its own purpose; for if he is led to use too much force, he may thereby strain the child's neck, and thus injure it; or, if he keep the parts constantly upon the stretch, he will so completely compress the funis, as entirely to interrupt the circulation through it, and of course produce the death of the child: whereas, if he were to desist occasionally from dragging, the pressure on the funis would be 104 diminished, and the circulation might be pre- served.* 3, Of presentations of the superior ex- tremities (c). There are no presentations more dangerous, or more difficult to manage, than those of the superior extremities; for whether the part pre- senting be the hand, the elbow, the shoulder, or both hands, it is clearly impossible that a full-grown fetus should pass through the pelvis, unless this position be altered. It was the practice of the ancients to endea- vour to push back the arm, and bring the head into the pelvis; but this method could seldom * Add to this, that by too hasty and injudicious ex- ertion, of the practitioner, the danger of lacerating the perinaeum is increased.— E» f 105 succeed, and it was, after a time, laid aside, principally upon the authority of Ambrose Pare, who directed that the feet should be sought for, and brought down, in all preternatural presen- tations. It seems now universally agreed, that the preferable mode is to turn and deliver footling; for though it is sometimes practicable to return the arm, and bring the head to present, yet the chance of success in this way is very trifling.* The established practice, then, is for the operator to pass his hand into the uterus, to take hold of the feet, and bring them without the os * Guitlemeau, however, the pupil of Pare^ directs the operator first to try to bring the head into the pelvis, and if he cannot succeed in this, to seek for the feet; and Bracken speaks of this operation as very easy; but he is mistaken. 106 externum; thus converting the presentation of the arm into a presentation of the feet. Though the necessity of effecting this altera- tion in the position of the fetus is generally subscribed to, and though it is by all admitted, that the turning should be accomplished as speedily as possible; yet it is not always in our power to proceed to the operation, as soon as the nature of the case is ascertained. A variety of circumstances may be present* in this kind of preternatural position, which will occasion embarrassment to the operator, and add more or less to the difficulty and danger of the case. It is not my intention to enumerate every possible difficulty; but I shall offer a few observations on the method ©f proceeding in four different cases, which will be sufficient to enable the young practitioner to regulate his method of management in all others. 107 1st. If it should be ascertained, before the membranes are ruptured and the waters dis- charged, that the arm is the presenting part, it will be right not to attempt to introduce the hand, till the os uteri is sufficiently dilated, to allow the hand to pass with ease into the uterus. For till the membranes are ruptured, no danger exists, and the dilatation of the parts is more easily and conveniently effected by the bag of waters, than by any other means. As soon as the os uteri is sufficiently dilated, (and the more complete the dilatation cf this part the more safe will be the delivery), the operator must dilate the external parts artifi- cially, till they oppose no further resistance to the introduction of his hand. Then slowly car- rying his hand through the vagina, to the os uteri, he must gently insinuate it through this part in the absence of a pain. He must, now, rupture the membranes by pressing a finger firmly against them; when his hand will 108 immediately come in contact with the body or limbs of the child. He is then to pass his hand forwards till he reaches the feet, -which he should draw down along the belly, not over the back of the child\ and proceeding slowly he will find, that as the feet are brought lower, the present- ing arm will be retracted; and when the nates are brought to occupy the hollow of the sacrum, the arm will be drawn completely within the uterus. The case now becomes precisely simi- lar to a feet presentation, and is to be managed accordingly. This is the easiest and safest case of turning, for the uterus is kept distended all the time by the liquor amnii, which, after the membranes are ruptured, is prevented from passing off by the operator's hand plugging up the vagina and os externum. So that the efforts of the accou- cheur to turn, are not impeded by the contrac- tion of the uterus upon the body of the child. 109 In all cases therefore where it is known, or suspected, that the arm is the presenting part, and the membranes remain entire, it becomes us to watch the patient with great assiduity, in order that we may take our own opportunity for turning, before the waters are evacuated. 2. Sometimes it will be found, that the arm is lying in the vagina, or without the os exter- num, the liquor amnii having been some time discharged, the os uteri nearly or quite dilated, and the patient either quite free from pains, or having pains seldom occurring. Here is another case in which it is advisable to proceed without delay to deliver by turning the child: but the turning will not be so easily effected in this, as in the former case, because the uterus will be in a state of contraction on the body of the child. There will therefore be greater difficulty in passing up the hand to reach the feet. Still if there be only the passive contraction of the 110 uterus,* the delivery may be effected without much trouble. The hand is to be passed cautiously through the os externum, care being taken to have this part sufficiently dilated. It must then be in- sinuated in the most gentle manner through the os uteri, and slowly conducted over the surface of the child, till it reaches the feet. These are then to be slowly drawn down into the vagina, * By passive contraction, I mean that contraction of the uterus, which always takes place, in consequence of the discharge of the waters, and which may be consi- dered " as the exercise of that inherent disposition, by which efforts are made by the uterus to recover its primitive size and situation, when any cause of disten- tion is removed:" this passive contraction admits of different degrees of intensity. By active contraction, I mean the occurrence of strong muscular action, whether regular as in labour pains, or irregular as in spasm. See jDcnman't Introduction to Midwifery, 4to. p. 440, Ill and finally without the os externum. Should uterine action be excited during the time that the hand is in the uterus, it must be kept in a flattened form close upon the body of the child; or may be a little withdrawn while the pain continues; and when the pain has subsided the hand may again be cautiously carried forwards. It is generally more difficult in this than in the former case to lay hold of both the feet; we must sometimes therefore be content with one only, but the turning is always much more safely and easily accomplished, when we can command both feet, than when we have only been able to reach one, 3. Again, it may happen, that a superior extremity presents, the liquor amnii is e vacua* ted, and the os uteri but little dilated, perhaps very firm and rigid. In this case it will probably be found necessary to wait with patience till the paru become more relaxed or dilated: for as 112 there would of course be great resistance to the introduction of the hand, it is probable that the attempt to force it into the uterus would excite inordinate or spasmodic action, and a laceration of the uterus or other serious mischief might ensue. By allowing time, however, the rigidity would diminish, the parts would dilate (slowly and untowardly indeed for want of the mechanical, or wedge-like, action of the bag of waters); yet at length there would be so much of softness and dilatability, as to authorise the practitioner to proceed to the operation, which must be slowly and cautiously performed, as before described. 4. Or it may happen that the waters have been early evacuated, the os uteri more or less dilated, the pains recurring often, and very strong and forcing. To attempt the turning under such circumstances would probably be 115 unavailing, and might be attended with great hazard to the mother. Here then nothing remains but to watch the patient attentively, and either to wait till the uterus having ex- hausted its strength in its fruitless endeavours to expel the child, becomes torpid, and incapa- ble of further exertion; or to lessen the vigour of the system by bleeding, or other depleting means, or to diminish the uterine action by a large dose of laudanum. This is the method recommended by Dr. Hamilton of Edinburgh, who speaks of it as attended with the most obvious good effects.* The dose that he gives is eighty drops. When from either of these plans the action ©f the uterus becomes suspended, the earliest * " Select Cases in Midwifery^ ifc. By James Hamii- (Qn,jun. MD." p. 102. 1795. P 114 opportunity is to be taken of proceeding to deliver. I am well aware that some practitioners object to delay in either of these last cases, upon the following grounds. First, They say that where the child is thus placed and there are strong pains, much danger is incurred of rupturing the uterus; for that frequently this accident happens from the head or one of the limbs of the child forming a pro- tuberance, against which the uterus is so forcibly pressed, that at length its fibres give way, and a laceration ensues. Now it is contended that the danger of this occurrence can be prevented by one method only, viz. changing the posture of the child, which must therefore be effected at all hazards. That the danger of a rupture of the uterus under such circumstances is very great, I shall 115 not attempt to deny; but how will it be dimi- nished by the means proposed? Will there be less hazard in the efforts of the operator to push forward his hand in opposition to the powerful resistance of the uterus? Nay, is not the attempt to introduce the hand likely to excite the uterus to still more inordinate action, and consequently to increase rather than to diminish the danger? — I doubt not that an appeal to facts will prove, that the danger of a rupture is at least as great from the persevering attempts of the operator, as from the untoward position of the child. Secondly. It is argued, that if the uterus be not ruptured by its own powerful action, yet that the labour pains will by degrees force the arm, shoulder, breast, and perhaps the head of the child so firmly into the pelvis, as to render it impossible to pass the hand into the uterus, after the pains become suspended.* * Dr. Hamilton^ in his " Select Cases" gives an in- 116 In the practice of midwifery, as in other branches of the art of healing, we have some- times only a choice of difficulties, and much must of necessity be left to the discretion and judgment of the practitioner in each individual case that he attends. I am not disposed to think ■ lightly of the hazard that attends having the fetus, thus preternaturally presenting, wedged into the pelvis; yet I am strongly inclined to believe, that there is less danger in this, than in forcing the hand into the rigid, unyielding uterus, in a state of active contraction. Upon the whole, therefore, I am of opinion, that there is a greater probability of doing good by delay, than in persisting to introduce the hand, when the uterus opposes so obstinate a resistance. I have not attempted to lay down any rules stance of this, and has subjoined some very judicious remarks upon the subject. 117 for the position of the patient while the operator is endeavouring to turn the child; because that position which gives him the most free use of his hand and arm is to be preferred, and under some circumstances one position, under others a different position, will be found most conve- nient. I generally make the attempt first, with my patient lying in the usual way on her left side, very near the edge of the bed, and use my light hand. Sometimes I have found, that while she was thus placed, I have been able to operate best with my left hand; or if I have preferred using my right hand,' I have been obliged to place my patient on her right side. Some prac- titioners very much recommend, that the patient shall be placed on her elbows and knees, and I have occasionally adopted this posture with ad- vantage, Smellie was an advocate for placing the woman on her back, with the breech raised higher than her shoulders, but I am not aware that any particular advantage results from this position during the operation of turning; but 118 when the body of the child is brought into the world, I have sometimes thought, that I have facilitated the passage of the head through the pelvis, by placing my patient on her back. It would be wrong to finish this chapter upon arm -presentations, without adverting to a curi- ous phenomenon, first accurately noticed by Dr. Denman, and since by other authors. It has occasionally happened, in these presenta- tions, that the labour pains have had the effect of forcing the nates or feet so low into the pelvis, that they have been precipitated through the os externum, and thus the turning of the child has been produced without the interference of the operator. In one or two such cases, the children have even been born alive. This has been called " the spontaneous evolution" of the child. * * See Denman's Midwifery^ p. 446. 119 The knowledge of this curious fact may, under some circumstances of extreme resist- ance to the passage of the hand into the uterus, reconcile us to the delay which I have above recommended; but we should never allow it to operate upon our minds, so as to induce us to neglect the proper means and proper time of turning when we have it in our power. 4. Of presentations of the back, belly, or sides (d). Each of these presentations is stated in the report from the Maison d' Accouchemens to have occurred once in 5,833 labours. Dr. Bland takes no notice, in his " Calcula- tions of Accidents, &c. in consequence of Parturition," of these presentations. Dr. Denman says, " I do not mention the marks by which back, belly, or sides, might be 120 distinguished, because these, properly speak- ing, never constitute the presenting part; that is, though they may sometimes be feit, they never advance foremost into the pelvis, in the com- mencement, at least, of a labour." Introduction to Midwifery, p. 423. In the practice of my uncle Dr. Merriman, and in my own practice, amounting together to very near 20,000 labours, no instance has occurred of either of these presentations except in one or two cases where the mother had not completed her seventh month of utero- gestation, and in these the children passed doubled through the pelvis. I have however been informed of a very skilful practitioner in the country who has twice met with a presentation of the back. In such a case it is probable that in the course of the labour the presentation would be 121 changed for that of the nates. If no alteration in the position took place spontaneously, the introduction of the hand would be necessary to bring down the feet. 5. Of presentations of the funis umbili- calis (e). Preternatural Labour. Order 6. Burns. Dystocia a Secundinis elapsis. Sauvages, § 8. This kind of presentation appears to have been much misunderstood formerly. It was supposed, when the funis came through the os uteri into the vagina, or without the os ex- ternum, that the child lay across the pelvis, the belly being over the os uteri; and this is the representation of the position given in Smellie's plates. This however is seldom or never the case. When the funis presents, there will be 122 found beyond it, either the head, the nates, or one of the extremities. This is always a case of difficulty, not on account of danger to the mother, but because there is a great probability of losing the child. Attention must be paid to the pulsation in the funis. If no pulsation is to be felt, the child is already dead; and the case is to be managed precisely as if the navel string were not pro- lapsed.* Should there however be a pulsation, we arc assured that the child is yet alive; and it becomes * The death of the child in prolapsion of the funis has been attributed to a congelation of the blood, from ex- posure to cold; but it is beyond a doubt, that its death is always occasioned, by compression of the funis between the child and the parts of the mother. It is to remove the funis from the effects of this compression that the assistance of the accoucheur is required. f- 123 us to consider in what way we can best proceed so as to preserve its life. Three expedients for this purpose have been recommended. First, To let the labour advance till the head of the child is within reach of the forceps, and then to hasten the delivery by means of this instrument. Secondly, To remove the navel string out of the way of compression. Thirdly, To hasten delivery by turning the child and bringing it by the feet. The first method probably possesses but little advantage beyond what may be gained by trust. ing the case entirely to nature. In some rare instances, where the mother has had children before, where the pelvis is very wide, the fetus 124 small, and the pains, strong and quick, the child has passed alive without extraordinary assist- ance. But the probability of this being effected is so remote, that it would be wrong to trust to it, did any other means of affording assistance present themselves. Should it however be found impossible to remove the funis out of the way of compression, or should the child's head have sunk too low into the. cavity of the pelvis, or should any other circumstance be present so as to render it hazardous to attempt turning, the application of the forceps might be admissible as the only remaining resource. The second method would be the most eligible could it always be put in practice; but the means of effecting a reduction of the pro- lapsed funis are not very easy. It has been proposed to carry it upon the points of the fingers, or upon a forked piece of cane or whalebone, through the os uteri, and above the bead of the child, so as to pre rem the funis from being pressed upon, as the head descends through the pelvis. But this expedient has been often found to fail; for upon withdraw, ing the fingers, or the forked stick, the funis nsuallv qnfc. 225 applying the lever or forceps; but I shall make a few general remarks, premising, that it will be proper first to introduce a catheter into the bladder, in order that we may be sure it con- tains no urine, and to clear the rectum by throwing up a clyster. Having then placed the patient in the position most favourable for our purpose, which will commonly be on her left side, the nates being brought very near to the edge of the bed,* we are to pass the fore finger of the right hand to the child's ear: then taking the handle of the forceps in the left hand, we are to introduce the point of the blade into the vagina, and making the finger of the right hand our guide, are with great caution to carry forward the blade to the * These directions apply only to the short English forceps — the best form of which, is that which is now commonly termed here, Haighton's Forceps En. 2F 226 child's ear, over which it is to be passed, and gently insinuated beyond it, till the claw of the forceps is brought quite to, or within the os externum. The first blade being thus applied, is to be kept in its place by the fourth and little lingers of the operator's left hand, while with his right hand he introduces the second blade of the forceps over the opposite ear of the child. But as he will not be able to feel the opposite ear, he must be guided in some measure, in introducing the second blade, by the position of the first. Both blades being introduced, the claws are to be brought together and locked, care being taken not to entangle any of the hair, or soft parts, in the lock.* * We should be particular in introducing the blades 227 If, on endeavouring to lock the forceps, it should be found that they do not readily come together, they have not been properly intro- duced: no force or violence, therefore, should be used to bring them together; but the second blade should be withdrawn, and introduced afresh. When the forceps are locked, if the handles are in contact with each other through their whole length, they are not properly applied; for the bulk of the head is usually too great to allow the handles to touch each other, if the head is properly included within the bows of the forceps. If the handles are very far apart, the points in the direction of the axis of the pelvis, which is to be considered as an imaginary line, drawn from the centre of the superior strait, to about the middle of the peri- naeum, — Ed. ■2-28 of the blades probably rest upon the ears; at all events, the head is not properly embraced by the forceps; and, in attempting to act with them, they will slip. When acting with the forceps, the force at first used should be ven moderate, but is to be increased as occasion may require: yet if the head advances at all, however slowly, with the force first applied, it need not be increased; for as Dr. Den man has ven- truly observed, " a small degree of force continued for a long time, will in general be equivalent to a greater force hastily exerted, and with infinitely less detriment either to moiher or child."* * In acting with the forceps, to prevent them from slipping, it is very necessary to act from handle to han- dle, through the whole process of extraction; but this, and other requisite rules, can only be satisfactorily ex- plained to the student, in their application on tne ma- chine. — Ed. 2*29 It is unnecessary to appear very adroit, or to yse great t xptdition in introducing the forceps: it is much better to introduce them slowly and . , than hastily and dangerous!] . The introduction and action n irh the lever, subjected to very much the same rules as those of the forceps. Equal care i=> to be taken not to be precipitate in having recourse to it, not to do mischief in introducing it, and not to bruise the mother, or otherwise to injure her. while acting with it. Of the Cases requiring the Use of the Perfo- rator. The cases which require the perforator are those, where the pelvis is so small at the brim : that the child's head cannot pass through it. Other causes do indeed sometimes render the perforator necessary; but the legitimate cause 230 for using this instrument, is distortion of the pelvis. Cases of distortion of the pelvis frequently occur, yet it is sometimes very difficult to as- certain whether the distortion is really so great as to prevent the head from passing through it undiminished; and under such circumstances it becomes us to be extremely careful not rashly to determine upon having recourse to the per- forator. Various means have been recommended for accurately measuring the dimensions of the pelvis; and the ingenuity of foreign accoucheurs has produced a number of different instruments, called pelvimeters, which are supposed to ascer- tain this point with great precision. But there is probably much more of inaccu- racy in this mode of admeasurement on the living body, than at first sight may appear; and 231 certainly the inferences drawn from such ad- measurements, and the modes of practice re- commended, are most grossly unscientific and perilous. Thus we are taught by Stein, Plenck, and others: — " 1. That if the straight or conjugate diame- ter of the pelvis amounts to four French inches,* the labour will be easy, and should be left to nature. "2, If this diameter amounts to 3| inches, the labour will be slow, but the child may be born alive:" they consider this as a fit case for the vectis. * The French inch is divided into twelve lines, and it measures about one line, or the twelfth of an inch more than the English. Four French inches, therefore, make rather more than four inches and a quarter English, 232 "3. If to 3§ inches, the child," they say, " will be dead if the case is left to nature; but it may be born alive if the forceps are applied in time. " 4. If only to 3 1 inches, the labour cannot be effected by the pains; and if the forceps are used, the child will be dead;" therefore they recommend to have " recourse to the division of the symphysis pubis, if the child be living; and to the perforator, if it be dead. " 5. If the conjugate diameter only amounts to 3 inches, 2|, 2§, 2 J inches, neither the natural pains, nor the forceps, will effect the delivery; therefore, if the child be living, the Cesarean operation is to be performed; if dead, the perforator is to be employed. " 6. If this diameter amounts only to 2 inches, it is probable," they say, " that even if the child be dead, the perforator cannot be used;" here 233 then they make no hesitation of recommending the Cesarean section if the child be alive. " 7. If the dimensions of the pelvis are as small as 1| or If inch, the child, whether living or dead, cannot pass, and the mother must undergo the Cesarean section." Even admitting that these admeasurements could be accurately ascertained, the practice recommended is, to say the least of it, hasty and injudicious; but many instances might be adduced of the inaccuracy of pelvimeters in ascertaining the dimensions of the pelvis. Dr. Osbcrn, who took great pains in investi- gating the best method of procedure in cases of distorted pelvis, considers that a fetus at full maturity cannot pass aiive, if the dimensions of the pelvis, from the pubes to the projection of the sacrum, be only 2| inches; but as it has been ascertained by Dr. Hamilton^ that children 2G 234 have been born living, though the pelvis in this diameter was " manifestly under three inches;" it is necessary that practitioners of midwifery- should be very much upon their guard against being deceived in their estimate of the actual dimensions. In England [and also in the United States,] we are more in the habit of examining the size of the pelvis by our fingers, than by pelvime- ters; and though we are not able, with so much appearance of precision, to state the actual amount of inches and lines, yet perhaps we may judge equally well, whether the case can be terminated without the use of the perforator.* * " Although the sacrum may project so much, or advance into the pelvis so far, as to reach within two or three inches of the pubes. and consequently the entrance into that cavity would be only of that diameter, if the bones were directly opposite to each other; yet the pubes being placed something lower than the greatest 235 In many cases, however, it will be difficult to determine whether the distortion is so great, as to render the delivery of an entire child impossible; and if there is this difficulty, it be- comes us to wait, as long as the safety of the woman will admit, before we proceed to the operation of cephalotomia. In other cases the projection of the sacrum, and opposed to a par: of that bone that diverges backward, the real distance between them may be much more considerable than to the touch it may seem to be. Whence it happens, that in cases where the projection of the sacrum has occasioned ex- ceeding great difficulty in the beginning of the labour, opposing an almost insuperable bar to the entrance of the head of the child into the pelvis, by directing it too far over the pubes; yet when that direction has been altered by the crotchet, or by any other means, and the head brought into the line of the cemre of the pelvis, the conclusion of the labour has been frequently effect- ed with very little exertion or force." — B:z'.:.'i 0:i~r. vatioiu on Human and Co mfi a r mtivc Perturiiiz-^, p \ 5th section. The whole of this section deserves the very attentive perusal of every practitioner of midwifery. 236 distortion will be so very considerable, as must satisfy us, upon the first examination, of the impossibility of effecting the birth without di- minishing the child;* but even in this case, a considerable space of time should be allowed to elapse before we proceed to the operation; and generally it will be right to have a consul- tation with some other accoucheur, before the perforator is employed, particularly if it be a first child; f 1. Because the operation, by being delayed, will be more easily and safely performed. * These cases, as we have heretofore observed, are of extremely rare occurrence in natives of the United States. — Ed. t At the close of this volume, are added two plates of deformed pelvis, to illustrate the different directions in which the pelves may be contracted in its dimensions See PL IV. and V.— Ed, . :ause we shall have the comfort of knowing or belie \ing that we did not introduce the instrument while the child was yet livir Because it is our duty to let the patient and her friends be as well convinced of the necessity for the operation, as we are. Now ire form our judgment of the necessity, from examining the dimensions of the pelvis: they can only judge, from the undue length and severity of the labour, and even then may still require the sanction of a deliberate consultation. When it is at length determined upon to proceed to this operation, moderate caution will enable the operator to perform it without danger of injuring the mother. He must take care to have the os uteri sufficiendy dikfe-fl , and most let his finger be the guide to the point of the perforator, till it reaches the head of the child. After he has made an incision through the scalp, he must guard the instrument from 238 slipping till he has drilled through the cranium,* and enlarged the aperture, by drawing asunder the handles of the instrument. It will often be advantageous, after the per- foration is made, to allow some hours to elapse before an attempt is made to separate the bones of the cranium. But respecting the propriety of this, the practitioner must judge for himself, founding his opinion upon the state of the pa- tient and the length of time that the labour has already lasted. * It will be best, when practicable, which is often the case, to perforate at one of the fontaneiles or sutures Ed. 259 Of the Cesarean Operation. This operation has been so generally unsuc- cessful in England,- that we can have but little inducement to recommend it. It is supposed that the Cesarean operation is more successfully performed upon the continent than in this island, and it is certainly more frequently employed there. Since the year 1750 there have been about 20 or 22 instances of this operation in England, and only two of the mothers recovered; nine of the children, however, were born alive. 31. Baudelocgue, in his " Memoir upon the * This observation will, as I believe, also apply to the result of this operation in the United States — En. 240 Cesarean Operation," has collected accounts of 73 operations: thirty-one of the women re- covered, and twenty. seven of the children were born alive; but many of these operations were most rashly resolved upon, since it cannot be doubted, that some of the women would have been delivered with no more than the ordinary assistance, had the cases been left to nature; and others might have been delivered by art without having their lives placed in such imminent peril.* * It is impossible to read without horror of the shame- ful ignorance shown by some of the operators who per- formed and advised these operations. In many cases there was no distortion of the pelvis !!! in some, the body of the child was born, and the operation was performed to set the head at liberty! in one case the head was sunk so low in the pelvis, that when the abdomen and uterus were opened, and the body of the child brought through the wound, it required all the strength of a very power- ful man, standing on the bed, to drag at the body, while another was forcing the head back with his hand in the vagina, to get the child's head back through the superior 241 I cannot for a moment doubt, that wherever the perforator can be employed, it is a much safer mode of delivery for the mother, than the Cesarean section; yet I must admit, if any cre- dit is to be given to medical records, that cases have occasionally been met with, which pre- sented so great a distortion of the pelvis, as to preclude the possibility of using the perforator, and in which, of course, the only possible chance of saving either the mother or child, lay in this operation; but such instances are extremely rare. aperture or brim, beyond which it had passed into the cavity of the pelvis!!! 2 H 242 On inducing Premature Labour, as a Means of preventing the JVecessity of having Recourse to the Perforator, As there is a paper of mine upon this subject, in the third volume of " The Medico- Chirur- gical Transactions,"* I shall not now enlarge upon it; but shall content myself with extract- ing, from that paper, the rules, limitations, and cautions, which ought, I think, to guide us in adopting this mode of practice. " 1. As the primary object is to preserve the life of the child, the operation should never be undertaken, till seven complete months of utero- gestation have elapsed; and if the pelvis of the mother be not too much contracted to allow of * See also a paper by the Editor. Eclectic Repertory, Vol. I. p. 105, et seq. — Ed. it, the delay of another fortnight will give a greater chance to the child of surviving the birth. " 2. The practice should never be adopted, till experience has decidedly proved, that the mother is incapable of bearing a full-grown fetus alive. " 3. It is sometimes necessary to have re- course to the perforator in a first labour, though there may be no considerable distortion of the pelvis; therefore the use of this instrument in a former labour is not alone to be considered as a justification of the practice. " 4. The operation ought not to be perform- ed when the patient is labouring under any dangerous disease. "5. If upon examination, before the opera- tion is performed, it should be discovered that 244 the presentation is preternatural, it might be advisable to defer it for a few days, as it is pos- sible that a spontaneous alteration of the child's position may take place; particularly if the pre- sentation be of the superior extremities. " 6. The utmost care should be taken to guard against an attack of shivering and fever, which seems to be no unusual consequence of this attempt to induce uterine action, and has often proved destructive to the child, as well as alarming with regard to the mother. The pecu- liar circumstances under which the operation is performed, and the habit of body of the patient, will determine the accoucheur either to adopt a strictly antiphlogistic plan, or to exhibit opiates, or antispasmodics and tonics. "7. In order to give every possible chance for preserving the life of the child, it will be prudent to have a wet nurse in readiness, that 245 the child may have a plentiful supply of breast- milk from the very hour of its birth. " Lastly, A regard to his own character should determine the accoucheur, not to perforin this operation unless some other respectable practitioner has seen the patient, and has acknowledged the operation as advisable" TABLES. Various tables have, upon different occasions, been published, of the accidents, extraordinary incidents, deaths, &c. that have occurred during labour; and it is probable that much benefit would result, and certainly some instruction would be gained, by correct statements of this kind. For some time past I have endeavoured to keep a very correct account of the kinds of labours that I have attended; and, since the commencement of my register, have delivered upwards of 1800 women. The result of these labours will be seen in the following table: the number, however, is not sufficiently great to draw very correct averages. It should be men- tioned, that this list does not include any patients of the charities to which I belong. £49 In 1559 cases, the child presented' "^- 75 or 1 in 24, though V'^a. 20 or 1 in 90, the iovt\ vcrsa > a * 4 or 1 in 450, the fac< > b - 4 or 1 in 450, thenar > c - 42 or I in 43, the nate:'^ r6a > a - 23 or 1 in 78, the low< > b - 7 or 1 in 257, the sup > c - 8 or 1 in 225, the fun > € - 1 or 1 in 1 800, the h? toria > a - 22 or 1 in 82, the pati^ zwa » a - 1 or 1 in 1800, the pa > b - 1 or 1 in 1 800, the xfitoria^ c. 1 or 1 in 1 800, a lar£- j d - 8 or 1 in 225, the pla^ zVa > a * 4 or 1 in 150, thepla > 6 - 12 or 1 in 150, there a — ; — > c « 2 or 1 in 900, there ^iva. 6 or 1 in 300, the pla™'"^- In 12 cas In 7 cas 9 of the a viz. 20, or 1 i 8, or 1 i 5 ofth€ £49 TABLE Of the Number of Accidents, Deaths, &c. in 1800 Labours. 1800 labours produced 1813 children: viz. 929 boys, 884 girls. In 1559 cases, the child presented properly, and the labour was over in less than 24 hours, - constituting Eutocia 75 or 1 in 24, though the children presented properly, the labour lasted more than 24 hours - Dystocia Diutina 20 or 1 in 90, the forehead was turned towards the pubes --_--.. . Perversa 4 or 1 in 450, the face presented --------.-_ 4 or 1 in 450, the hand or arm came down with the head ....... ■ 42 or 1 in 43, the nates or one hip presented ......... 7 23 or 1 in 78, the lower extremities presented ----..... 7 or 1 in 257, the superior extremities presented ........ 8 or 1 in 225, the funis presented - .......... 1 or 1 in 1800, the hymen was unruptured . . . -» Obturatoria, 22 or 1 in 82, the patient was delivered of twins ........ q 1 or 1 in 1800, the patient was delivered of triplets ........ _ 1 or 1 in 1800, the uterus ruptured Laceratoria 1 or 1 in 1 800, a large blood-vessel in the abdomen burst or 1 in 225, the placenta separated within the uterus Hemorrhagica 4 or I in 150, the placenta was attached over the os uteri ....... 12 or 1 in 1 50, there was flooding after delivery .- - - - • - - - 2 or 1 in 900, there were convulsions during labour Convulsiva 6 or 1 in 300, the placenta was preternaturally adhering - Rcten In 12 cases, or 1 in 15,0, the forceps or the lever were used.* In 7 cases, or 1 in 257, the perforator was ernployed.t 9 of the above women, or 1 in 200, died in the month of child-bed: viz. 3 of puerperal fever. 1 suddenly, on the 5th day after delivery, without any known cause. 1 in convulsions, 18 hours after delivery. 1 of phthisis pulmonalis, 12 hours after delivery. 1 broke a blood-vessel in the abdomen, and soon expired undelivered. 1 of rupture of the uterus. 1 of peripneumonia notha. 20, or 1 in 90, had, in a greater and slighter degree, peritonitis pucrperalis. 8, or 1 in 225, had the oedema lacteum. 5 of the children, or 1 in 363, had the rectum imperforate; the operation was performed on all; 2 died in less than 3 days; 1 lived 6 months; the other 2 are still alive— one six, the other three years old. * In 2 cases, on account of Dystocia Convulsiva. 2 Perversa, a. 8 Anencrgica- t In all these cases the pelvis was distorted. 21 250 • TABLt As published by Madame Bo'win % onec (See her " Memon Number of children born - 12,751 10,003, 1,213, or 1 in 10 4, or 1 in 3,188 1) or I in 12,751 2, or 1 in 6,375 1, or 1 in 12,751 1, or 1 in 12,751 40, or 1 in 319 20 or 1 in 638 1, or 1 in 12,751 22, or 1 in 579 17, or 1 in 750 181, or 1 in 70 3, or 1 in 4,251 6, or 1 in 2,125 or 1 in 4,251 3, or 1 in 4,251 2, or 1 in 6,375 85, or 1 in 150 58, or 1 in 58 2, or 1 in 4,251 1, or 1 in 12,751 3» or I in 4,251 3, or 1 in 4,251 3, or 1 in 4,251 20, or 1 in 637 18, or 1 in 708 2, or 1 in 6,375 * Query, is this correct? Sratllie, in his plates , gives a delineatioi 251 Table of the Number of Accidents or Deaths which happen in consequence of Parturition; taken from the Midwifery Reports of the JVestminster General Dispensary. By Ro- bert Bland, M. D. Of 1897 women delivered under the care of the Dispensary, 53 (or 1 in 30) had unnatural labours: in 18 of these (or 1 in 105) the children present- ed by their feet; in 36 (or 1 in 52) the breech presented; in 8 the arms presented; and in £ 9* (or 1 in 1 the funis. 5210.) 17 women (or 1 in 111) had laborious labours; in f8 of these (or 1 in 236) the heads of the chil- dren were lessened; in 80 8 * In all these nine cases the children were turned. ]■ T«o of these women have since been delivered of full- sized 2K 250 TABLE OF PRESENTATIONS; As published by Madame Boivin, one of the Superintendants of the Hospice de la Maternite, at Paris. (See her " Memorial de VArt des Accouchement 1812.) Number of children born 12,751 10,003, 1,213, or 1 in 10 4, or 1 in 3,188 l,or 1 in 12,751 2, or 1 in 6,375 1, or 1 in 12,751 l,or 1 in 12,751 40, or 1 in 319 20, or 1 in 638 1, or 1 in 12,751 22, or 1 in 579 17, or 1 in 750 181,orlin 70 3, or 1 in 4,251 6, or 1 in 2,125 3, or 1 in 4,251 3, or 1 in 4,25 1 2, or 1 in 6,375 85, or 1 in 150 58, or 1 in 58 2, or 1 in 4,251 1, or 1 in 12,751 3, or I in 4,251 3, or 1 in 4,251 3, or 1 in 4,25 1 20, or 1 in 637 18, or 1 in 708 2, or 1 in 6,375 Kind of Presentation. the vertex; occiput towards the left groin. the vertex; occiput towards the right groin. the vertex; occiput resting on the symphysis pubis. the occiput. the left side of the head. the right side of the head. the head and hand. the forehead to the left of the pubes. the forehead to the right of the pubes. the face, with the chin to the sacrum. the face, with the chin to the right side of the pelvis. the face, with the chin to the left side of the pelvis. the nates, with the face towards the right sacro-iliac synchondrosis, the nates, with the face towards the mother's back. the nates, with the face towards the mother's belly. the right hip. the loins. the back. the feet, the toes turned to the right of the pelvis. the feet, the toes turned to the left of the pelvis. the feet, the toes to the mother's back. the knees. the navel string and belly* the loins. the back. the right arm. the left arm. the right breast. • <** is thiscorrecU S.n.He, h his plat e„ *. a Nation of the same kind f P re 8 e n tatio n; but I never knew a single pMctitioner who had men were seized with mania, but reco- vered in about three months. In I woman a suppuration took place, soon after labour, from the vagina into the bladder and rectum. This patient recovered, but the urine and stools continue to pass through the wounds. Of 1 woman the perinaeum was lacerated to the sphincter ani. A suture was attempted, but without effect; she recovered, but is troubled with prolapsus uteri. 5 had large and painful swellings of the legs and thighs, but recovered. 105 therefore of these (or 1 in 18) had preter- natural or laborious births, or suffered in consequence of labour. Of this number of cases 43 (or 1 in 44) were attended with particular difficulty or danger; and 7 only (or 1 in 270) died. The remaining 62 105 254 were delivered and recovered with little more than the common assistance; and 1792 had natural labours, not attended with any particular accidents. 1897 255 Table of Presentations at the Maison dWccouchemens. There have been admitted into the Lying-in Hospital at Paris (Maison d'Accouchemens), between the 9th of Dec. 1799, and the 31st of May, 1809, 17,308 women, who gave birth to 17,499 children: 189 of them have been delivered of twins, and two only of three children. The proportion of twin cases to single births is I to 91. Two thousand of these women were affected after- wards with illness, or some serious accident; 700 died out of the 2000. Of the 17>499 births, 16,286 were presentations of the vertex to the cs- uteri. No. Proportions. 215 were presentations of the feet - 1 to 81 ! 296 the breech - - 1 . — 59$ 59 the Lee - - 1 — . 296| 52 one of the shoulders . 1 — — 336-1 4 the side of the thorax . 1 __ 4374| 4 the hip - - 1 — 4374^ 4 the left side of the head . 1 — — 4374J 4 the knees : - 1 — 4 374| 4 the head, an arm, and the cord - 1 43741 3 the belly .... - 1 ... 5833 3 the back .... . 1 5833 3 the loins .... - 1 — . 5833 256 I the occipital region - - - 1 — 17499 I the side, with the right hand - 1 — 17499 1 the right hand and left foot - - 1 — 17499 1 the head and the feet - - - 1 — 17499 2 the head, the hand, and forearm - 1 — 8749J 37 the head and umbilical cord - 1 — 473 Of this great number of women 230 were delivered by art; the rest were natural births, being in proportion of 1 to 76 J. 161 were delivered by the hand alone, the children heing brought by the feet; 49 were delivered by the forceps, either on account of the small dimensions of the pelvis, the falling down of the umbilical cord, or the wrong position of the head, when the woman was exhausted, or her life was in danger by convulsions, &c; 13 were extracted by the crotchet after perforation of the head, on account of mal-conformation of the pelvis: in these instances, the death of the child was first ascer- tained. The Cesarian operation was performed in two cases, the diameter of the pelvis being only one inch six lines from sacrum to pubes. In one, the section of the symphysis pubis was per- formed, the diameter of the pelvis from sacrum to pubis being only two inches and a quarter. Gastrotomy was performed once, the fetus being extra-uterine: the child weighed 8lb. 2 oz. 257 Table of the average Number of Deaths in Child -bed in London , taken from the Bills of Mortality. 4 pears er iding in 1660 — 1 in 36. 10 - - 1670 39. 10 - - 1680 49. 10 - - 1690 47. 10 - - 1700 65. 10 - 1710 67. 10 - 1720 72. 10 - 1730 73. 10 - 1740 70. 10 - 1750 74. 10 - 1760 81. 10 - 1770 72. 10 - 1780 92. 10 - 1790 107. 10 - 1800 113. 10 - 1810 106. 3 - - 1813 116. 258 Table of the average number of Deaths in Child-Bed in Philadelphia, taken from the Bills of Mortality. — Ed. The population of the city of Philadelphia and its suburbs, within the bills of mortality, may be estimated at 100,000. The average number of deaths in child- bed solely, and also in child-bed and puerperal fever jointly, taken from the said bills for nine years, is as follows:— For 1 year ending Jan. 2, 1808 — 1 in 170 1 in 107 1 - - 1, 1809—1 in 567 I in 378 .1 - - 1, 1810—1 in 2004 1 in 400* 1 - - 1, 1811—1 in 2036 1 in I56f 1 1, 1812—1 in 477 1 in 265 1 - - 1, 1813—1 in 600 1 in 257 1 - - 1, 1814—1 in 408 1 in 272 1 - - 1, 1815—1 in 296 1 in 254$ 1 - . 1, 1816—1 in 291 I in 204 The average number of deaths in child-bed, exclu- sive of puerperal fever, for 9 years, is 1 in 418. The average number of deaths in child-bed, and puerperal fever jointly, for 9 years, is 1 in 219. * In this year, but 1 woman is stated to have died in parturition, and 4 of puerperal fever — the total number of deaths being 2004. •\ In this year, but 1 woman is stated to have died in child-bed, and 12 of puerperal fever — the total number of deaths being 2036. $ In this year, but 1 woman Is stated to have died of puerperal fe- ver, and 6 in child-bed-. 259 The folio A& is taken from an abstract of the Registry, kept at the Lying-in Hospital in Dublin, from the 8th December, 1757, to the 31st December, 1814, or 57 years, during which period, 78,000 women were delivered in the Institution: — Proportion of Males and Females born, about 10 males, to 9 females. Children dying in the Hospital, about 1 to 16. Children still-born, about 1 to 18. Women having twins (and more) about 1 to 57. — — — — — Women dying in child-bed, about 1 to 93. — — — — — Women having 3 and 4 children, about 1 to 3545. wx vw v-w v-vfe Abstract from the Registry, kept at the Lying-in Ward of the Philadelphia Aims-House, from the year 1797, to 1815 inclusive, or 19 years. — Ed. Proportion of Males to Females born, about 10 males to 8 females. • Children dying in the ward, about 1 to 18, Children still-born, about 1 to 11. — — - — — Women having twins, about 1 to 52.* Women dying in child-bed, about 1 to 97. • A different average was stated in p. 140 of this Synopsis, but that was taken from the result of 5 years onbj t in which twin cases had rery r«re!«- occurred. APPENDIX BY THE EDITOR. APPENDIX, Explaining the Mechanism of Parturition, hi which the Vertex is the presenting- part. vwvwvww-*- As it appears to be of considerable importance that the young practitioner should have correct ideas of the mechanism of parturition, or the mode in which the head presents at, and progresses through, the pelv*i3, and as without this preparatory knowledge, it is impossible to apply the forceps properly, when their aid becomes necessary, except by mere chance; we shall attempt here briefly to explain this subject, referring for fuller information than would be con- sistent with the conciseness of this Synopsis, to the writings of Baudelocque, Gardien, and to the improv- ed edition of Burns, published by the editor of this work. 264 The presentation of the vertex or crown of the head, as has been already explained in the commence- ment of this work, is recognised by the presence of a round solid tumour, upon which several sutures and fontanelles are to be traced. But even when the vertex presents, the sutures and fontanelles do not always correspond to the same point; this then has induced practitioners of midwifery to distinguish the different positions of the vertex, according to the manner in which this part presents at the superior strait or brim of the pelvis, and which is ascertained by the relative situa- tion of the fontanelles, and the direction of the su- tures. Although it may be asserted that there is no point of the pelvis, to which the posterior fontanelle, which we should always take for our guide, may not cor- respond; yet we may nevertheless, with Baudelocque and Gardien, confine the number, for the purposes of practice, to six principal ones. Indeed a sufficiently accurate idea of natural parturition might be given by describing a lesser number of positions. But, to explain fully those cases where the intervention and aid of art is required, it becomes necessary to admit them. 265 For properly to apply the forceps, and advantage- ously to act with them, the accurate knowledge of these different relations of the fcetal head with the pelvis, as well as its progress through the different stages of the labour until delivered, is supposed to be well understood. Let us then for the moment consider the circum- ference of the brim or superior strait of the pelvis as divided into two segments or semi-circumferences, one anterior and the other posterior. In the three first positions the posterior fontanelle answers to one of what we may venture to term the cardinal points of the anterior semi-circumference. [These presen- tations being included under the terms Eutocia Si?n- pkxy p. 9, Dystocia Diuthia, p. 27, and Dystocia Anenergica, p. 49, of this Synopsis.] In the three last positions the same posterior fon- tanelle answers to one of the diametrically opposite points of the posterior semi-circumference of the pelvis. [These three are included under the term Dystocia Perversa of this work, vid. p. 54.] If we observe the direction that the head pursues in each of these positions, when it is expelled by the efforts of nature alone, we shall find that in each of 266 them it offers some peculiarities, which it is of im- portance to understand. The mechanism of these different species of labour ought to be studied with the greater attention by the young practitioner, as it is this knowledge which is to guide him in all his operations in those cases where malposition of the head occurs. [Refer to p. 54, et seq. of this Sy- nopsis.] EUTOCIA, Including thejirst, second^ and third Positions, FIRST POSITION. In this position, (at the commencement of labour) the posterior fontanelle answers to the left acetabu- lum. The back of the infant is situated towards the anterior and left lateral portion of the uterus and pelvis: the face and the breast answering to their posterior and right lateral portions. The feet and breech are towards the fundus uteri. At the commencement of labour it is frequently only the middle portion of the sagittal suture which presents at the centre of the superior strait; whilst both the fontanelles remain as yet, out of the reach of the finger in the common examination. We cannot. 267 therefore, at this period, accurately determine the precise position of the head. For although we may ascertain that the sagittal suture is directed from the left acetabulum to the right sacro-iliac symphysis, we are as yet ignorant whether the posterior fonta- nels is situated in the anterior or posterior segment of the pelvis, and of consequence, whether the ver- tex presents in the first or the fourth position. The same difficulty presents in discriminating between the second and the fifth position, and between the third and the sixth, whilst we can only reach the sagittal suture. In the first period of labour, it is commonly one of the parietal bones which presents. As the labour advances, the middle portion of the sagittal suture retires from the centre of the pelvis, to give place to one of the fontanelles; and it is the posterior fonta- nelle that most frequently presents. When the waters have been discharged, the first contractions of the uterus tend, in the natural pro- gress of labour, to bend the head upon the breast. Whilst this is taking place, the posterior fontanelle approaches nearer and nearer to the centre of the pelvis. The head thus bent, continues to progress through the cavity passing from before, backwards, 2M 268 in order to accommodate itself to the axis of the su- perior strait; and thus it continues to descend, until checked by the sacrum, the coccix, and the peri- neum. Whilst the head descends into the cavity of the pelvis in a diagonal direction, one of the parietal protuberances passes before the left sacro-iliac sym- physis, and the other behind the right acetabulum. In this position it is the right parietal bone which answers to the arch of the pubis. One of the branches of the lambdoidal suture answers to the left branch of the pubis, and the other is directed towards the left ischiatic notch. This has often been mistaken for the sagittal suture: and in consequence of its di- rection, which is from before, backwards, it has been supposed that the head had already performed its movement of rotation, by which the posterior fonta- nelle is ultimately brought under the arch of the pubis. The head having arrived at the bottom of the pel- vis, can no longer follow its first direction, being checked by the sacrum and coccix. But the contrac- tions of the uterus continuing to act upon it, force the occiput, as it were, to revolve from behind, for- 269 wards upon the inclined plane which the left side of the pelvis offers, in order to advance towards the svmphysis of the pubis; whilst, at the same time, the face turns into the hollow of the sacrum, revolving, as it were, from before, backwards upon the inclined plane which the other side of the pelvis presents. If the fingers are placed upon the posterior fontanelle, whilst the head retains its lateral position, it may sometimes be perceived to perform this movement on its axis during a strong pain. Whilst the occiput approaches the arch of the pu- bis, the trunk remains stationary in the cavity of the uterus. This pivot-like motion of the occiput, depends solely upon the twisting of the neck: and this rota- tion being performed, the posterior fontanelle is situ- ated towards the centre of the arch of the pubis, and the anterior towards the sacrum. The sagittal suture is parallel to the great diameter of the inferior strait; the branches of the lambdoidal suture answering to each side of the pelvis. The chin, which, until this period, had remained constantly applied to the breast, now begins to recede from it. The occiput dilates the external parts, and 270 engages under the arch of the pubis, under which it revolves, in rising and approaching towards the ab- domen of the mother. Whilst the occiput thus pro- gresses, the nape of the neck, which may be consi- dered as the centre of motion, revolves under the inferior edge of the arch of the pubis. In this motion the occiput passes over but a small space, whilst the chin, in describing a curve, pro- gresses from the sacrum to the inferior commissure of the labia* The expulsive forces bear upon the forehead and upon the face during this period of labour, and oblige the chin to recede from the breast. The neck is sufficiently long to allow the head to be delivered without the trunk's advancing. If the head in its passage does not accommodate itself to the curved line above described, but descends directly in the axis of the superior strait, every effort bears upon the perinaeum, which is then in danger of rupturing in its centre. If we do not succeed in obliging the head to fol- low the direction above described by applying pres- sure from behind forwards, and from the perinaeum upwards, the only means to prevent the laceration of 271 this part, is to apply the forceps, in order to direct the head forward, and thus oblige the chin to recede from the breast. Scarcely is the head delivered, when the face turns towards the right thigh of the woman, to which it answered in the commencement of labour; for it only turns into the hollow of the sacrum, in conse- quence of the twisting of the neck, and resumes the first position as soon as the neck is restored to its former situation. When the head is completely delivered, the shoul- ders, which had entered the superior strait diago- nally, as well as the head, turn, one towards the pu- bis, and the other towards the sacrum. The left shoulder which is towards the sacrum, approaches the vulva, and begins to be engaged there, whilst the right shoulder remains applied behind the sym- physis of the pubis until the other appears externally; which indicates, that when it is proper to assist in extricating the shoulders, we should act principally upon that which is placed posteriorly. Such is the progress of nature in this species of parturition, as every one may convince himself, if he will trace it step by step through the course of the 272 labour. And in this observation he will be able to distinguish three different movements. In the first period, the head bends itself towards the breast, and progresses through the cavity of the pelvis. In the second, it performs a motion, which brings its long diameter in the direction of pubis and sacrum. In the third, the chin quits the breast, and the occiput turns backwards in disengaging itself from under the pubis. The head ought to present its greatest diameters to the greatest diameters of the straits; but as it regards the superior strait, it does not pre- sent, as is commonly supposed, its smallest diameter to the smallest of that strfit. Its smallest diameter is directed from one sacro-iliac symphysis, to the opposite acetabulum. The portion of the head which passes between the pubis and the sacrum, is still less than that which is termed its small diameter. This species of labour would always be the most advantageous, if the laws of nature were invariably carried into effect; but in proportion as nature varies from the line that has been delineated, the labour be- comes more and more difficult, and often indeed, impossible, without the aid of ark 273 SECOND POSITION. In this position the posterior fontanelle is placed behind the right acetabulum, and the anterior is situ- ated before the left sacro-iliac symphysis, so that the back of the child answers to the anterior and right lateral portions of the uterus and of the pelvis; whilst the face, the breast, and the knees, are situated to. wards their posterior and left lateral portions. The mechanism of labour in this position is per- fectly similar to that of the preceding. As in that, if the expulsive forces are directed in such a manner, as to apply the chin of the infant more and more to the breast, the occiput progresses during the first period through the depth of the cavity of the pelvis. In the second period, the occiput slides from behind forwards, upon the inclined plane, which is presented by the right side of the pelvis, in order to place itself under the arch of the pubis; whilst at the same time, the face turns into the hollow of the sacrum. In the third period, the expulsive forces oblige the chin to recede from the breast; the occiput dilates the vulva as it turns upwards towards the pubis. This move- ment of the occiput is but inconsiderable; it only makes a slight turn, whilst the nape of the neck re- volves under the superior part of the arch of the pu- 274 bis. In order that this flexion of the head backwards may take place, it is necessary that the face should pass over a curve, which in its course, extends along the whole length of the sacrum, to the anterior edge of the perinseum. As soon as the head is delivered, the face turns towards the left thigh, to which it primarily answer- ed; the left shoulder turns towards the pubis, and the right towards the sacrum. This latter alone ad- vances, until it appears at the vulva. The relative proportions of the diameters of the child, with those of the pelvis, are really the same in this position as in the former. The occiput and the face have not a larger space to traverse in the posi- tion where the posterior fontanelle is situated to- wards the right acetabulum, than in that where it is placed behind the left. Hence it would appear, that one of these positions ought to be as favourable as the other, to the expulsion of the child. But there are, notwithstanding, greater difficulties experienced in that where the occiput is to the right; because the rectum^ which is placed on the leftside of the sacrum, prevents the forehead from turning so readily into the hollow of that bone. 275 THIRD POSITION. In this position the posterior fontanelle is imme- diately behind the symphysis pubis, and the anterior before the projection of the sacrum. The back of the infant is towards the anterior, and its abdomen to- wards the posterior portion of the uterus. For a long time this was considered as the most common and the most advantageous position, but both of these suppositions are incorrect; for, experience on the contrary, proves, that it is very rare; so much so, indeed, that many practitioners who have never met with it, have absolutely called its existence in ques- tion.* Those who have imagined that the occiput constantly answered to the pelvis from the very com- mencement of labour, have only been induced to think so, from observing it disengage itself in this direction from the inferior strait. A regular exami- nation through the whole progress, would have taught them, that, although the occiput is expelled from under the pubis, it nevertheless enters the superior strait diagonally, as in the first or second position. * So rare is this position, that in 12,183 cases of presentations of the crown of the head, of which an accurate register was kept in l'Hospice tie la Maternite at Paris, it occurred but four times. Vide Bandelocqut Art des Acoouchemer.s. Vol. II. 2N 276 But when the occiput at the commencement of labour, does present at the superior strait in the third position, the forehead, which is placed immediately before the upper part of the sacrum, will probably be turned towards one or other sacro-iliac symphysis by the projection of the sacrum, by which operation, the third position will be converted into the first or second. But as the rectum lies on the left side of the sacrum, and presents an obstacle to the forehead on that side, it will more readily be turned to the right sacro-iliac symphysis, the occiput at the same time approaching the left acetabulum, thus constituting the first position heretofore described. It is, nevertheless, a possible, although an ex- tremely rare case, for the occiput to pass through the superior strait directly behind the symphysis pu- bis. Here then, as the long diameter of the head is opposed to the small diameter of the strait, the diffi- culty which is experienced by the head in its passage must be greater. Nevertheless, if no obliquity ex- ists, parturition may ultimately be accomplished; be- cause, in a well formed pelvis, the short diameter of the strait is four inches, and the long diameter of the head is no greater. Besides, if the head engages favourably, it only presents its height, or its perpen- dicular diameter, because the chin rises towards the 277 breast of the infant, which facilitates the expulsion of the head. There are but two periods to be taken notice of in the progress of this species of labour: the face re- mains towards the perinaeum for some time after the delivery of the head; it does not turn to one or other of the thighs, until after the shoulders, which had entered the strait diagonally, have presented at the inferior strait, one being towards the pubis, and the other towards the sacrum; but they turn indifferently to one or the other side of the pelvis, because the head has not been obliged to perform the pivot-like motion. Of course, it is not in our power previously to designate which shoulder will turn towards the pubis. In the three next positions of the vertex that re- main to be explained, the posterior fontanelle an- swers to one of, what we have ventured to call, the cardinal points of the posterior semi-circumference of the pelvis, and which, in this Synopsis, are classed under the title of " Dystocia Perversa, or labour in which the head p'.estnts in a wrong direction," vide p. 54, et seq. 278 FOURTH POSITION. In this position, the anterior fontanelle is behind the left acetabulum, and the posterior before the right sacro-iliac symphysis, and the course of the* sagittal suture is obliquely, from the former to the latter point. The back of the infant is to the right posterior portion, and its breast, &c. towards the left anterior portion of the uterus. [This is what by Gar- dien is termed Position fronto-cotyloidienne gauche. Vide Synopsis, p. 55.] Although at the commencement of labour, the posterior fontanelle is placed towards the right sacro- iliac symphysis, the face does not always come out under the arch of the pubis. We sometimes observe, that the occiput approaches the right acetabulum, in proportion as the head advances in the pelvis. When the spontaneous conversion of the fourth to the second position takes place, it is to be considered as extremely favourable for the patient. From hence an inference has been drawn, that when the practitioner meets with this position, he ought, at the commence- ment of labour, to facilitate its progress, and lessen the suffering of the female, when the face is turned towards the symphysis of the pubis, by making an effort to disengage it from that part, and bring the 279 occiput, during the pains, rather forward towards the pubis, than towards the sacrum. If the membranes have not been ruptured, it is impossible to touch the head during the existence of a pain. This conversion cannot be accomplished without risk, except we act at the instant of the discharge of the waters. When nature spontaneously produces this conversion in the fourth and fifth position, the same change of relative situation takes place in the trunk. We ought not, therefore, to attempt producing it by art, unless the child is sufficiently moveable, to permit the trunk to undergo the same changes in situation as the occi- put; unless this were the case, the neck would suffer a twisting, which would amount to the third of a circle. It may be important to recollect the possibi- lity of this conversion, in those cases in which we are obliged to apply the forceps, because the mode of proceeding will be different if that has taken place. We should, therefore, before applying the forceps, endeavour to ascertain whether or no the face is to- wards the pubis. If the change of position, of which we have just spoken, has not taken place, the deliver}' of the head becomes more difficult, because, in the second pe- riod, the face turns towards the symphysis of the pubis. This part is disengaged with more diffi- 280 ficulty from under the arch of the pubis, than the occiput; for the arch has less breadth in its superior part, than the forehead and the face of the infant. The form of the occiput, on the contrary, accom- modates itself very well to the arch of the pubis, under which it turns, whilst the face disengages it- self behind. If in this position, the contractions of the uterus are directed in such a manner, as to bear upon the occiput, it descends into the pelvis, passing before the right sacro-iliac symphysis. When the head reaches the sacrum, it can no longer follow its first direction. The contractions of the uterus oblige it to perform a pivot-like motion, which turns the occiput into the hollow of the sacrum, descending along the inclined plane of the right side; whilst at the same time, the forehead places itself under the pubis, slid- ing along the inclined plane, which the left side of the pelvis offers. At the end of this second period, the anterior fontanelle is situated behind the pubis, and the posterior towards the sacrum. In the last period, the forehead cannot engage under the arch of the pubis, as the occiput does in the three preceding positions; it is obliged to ascend behind the symphysis, to the internal surface of 281 which it remains applied, whilst the posterior fon- tanelle passes over the length of the sacrum, the coc- cix and the perinaeum, to arrive -t the bottom of the vulva. At this moment, the edge of the peri- neum is considerably stretched, and runs a greater risk of laceration than in the preceding positions. The perinaeum not being capable of remaining sta- tionary upon the inclined plane which the occiput offers, retires suddenly towards the base of the neck of the infant. The posterior edge of the perinaeum becomes then the point of support, or axis, upon which the nape of the neck revolves, whilst the occiput turns backwards towards the anus of the woman: In proportion as the head turns backwards, upon the perinaeum, the face disengages from under the pubis. We observe suc- cessively appear, the forehead, the orbits, the nose, the mouth and the chin. As soon as the chin appears externally, the face turns towards the left thigh, to which it primarily answered. The left shoulder pre- sents afterwards, towards the pubis, and the right towards the sacrum. That which is posterior, disen- gages the first, the other remaining stationary. 282 FIFTH POSITION: (Or position fronto-cotyloidienne droite, vid. Synop, p. 55.) In this position, the anterior fontanelle is behind the right acetabulum, and the posterior before the left sacro-iliac symphysis. The back of the infant is towards the left and posterior part of the uterus; its breast and abdomen is towards the right and anterior part. It is not unfrequently the case, that the efforts of nature alone, are competent to convert this posi- tion into the first, the occiput gradually approaching towards the left acetabulum, in proportion as it de- scends into the pelvis. All the observations that have been made on the preceding position, with res- pect to attempting, by the aid of art, what nature herself sometimes performs, are equally applicable to this position. The relations of the dimensions of the head of the child with those of the pelvis, are absolutely the same in this position, as in the preceding; the face turns equally upwards. Hence the mechanism of this species of labour, is in every respect, similar to that of the preceding position. If every thing is in 283 the natural order, the occiput descends into the pel- vis, passing before the left sacro-iliac symphysis. In the second period it turns towards the sacrum, at the same time that the forehead turns towards the symphysis pubis. The presence of the rectum on the left side of the pelvis, renders this rotation more difficult, by preventing the occiput from turning freely into the hollow of the sacrum. This position is one of those, in which it is most essential to eva- cuate the rectum by an enema. As soon as the face is disengaged from under the pubis, it turns to the right groin. The right shoulder is afterwards directed towards the pubis, and the left towards the sacrum. The latter alone advances, until it appears at the vulva. SIXTH POSITION: (Or position fronto-pubienne) vid. Synop. p. 55.) In this position, the anterior fontanelle is behind the pubis. The sagittal suture is parallel to the small- est diameter of the superior strait. The occiput and the back of the infant is towards the sacrum. • o 284 This position is the least favourable of all those which the occiput can take. Not only does the head present its length to the smallest diameter of the su- perior strait, but also the face is anterior, as it re- gards the pelvis, as in the two preceding positions. Fortunately, it is the most rare of all.* The round- ed form of the head, with difficulty, permits it to re- main fixed during labour, against the projection of the sacrum, so that even supposing it should answer to this part of the sacrum at the commencement of the labour, it would soon turn to one of its sides, which would be better accommodated to its figure. When we happen to see the face disengage itself from under the pubis towards the end of labour, we are not thence to suppose, that the head engaged in that way in the superior strait. Although in the two preceding positions, the head traverses this strait in a diagonal situation, the face, which, in the first pe- riod, was placed towards one or other of the aceta- bula, turns by a pivot-like motion towards the arch of the pubis, from under which it is delivered. * So extremely rare is this position, that of 12,183 cases, in which the vertex presented at I'Hospice de la Maternite at Paris, and of which an accurate register was kept, this position occurred but once. VicL Baudelocque Art des Accouchemens, vol. ii. 285 We can distinguish but two periods in this posi- tion. If the expulsive forces of the uterus act upon the occiput, as occurs in the natural order, it pro- gresses through the pelvis before the sacrum. Whilst the forehead is applied against the internal surface of the symphysis of the pubis, the occiput which ought to be delivered first, considerably distends the perinseum, passing over a curve line which extends from the hollow of the sacrum, to the lower edge of the vulva. At this instant the perinseum retires backwards, and passes under the nape of the neck, which revolves above it, whilst the occiput turns backwards towards the anus of the woman. As soon as the occiput begins to turn backwards, the different parts of the face, which until then had been retained in the interior of the pelvis, successively disengage themselves from under the pubis, in the order which has already been pointed out. When the chin appears externally, the face re- mains some time stationary: afterwards it turns to- wards one of the woman's groins, but only at the same instant that one of the shoulders presents to- wards the pubis, and the other towards the sacrum. This position also, is one of those, in which it is un- certain, which of the shoulders may present towards the pubis; and whes the change of position is pro- 286 cured by the aid of art, it is indifferent which we bring there. These divisions of the presentations of the vertex, or crown of the head, originated, as we believe, with the experienced Baudelocque — and on this subject, he very judiciously observes, that the head may, without doubt, present at the superior strait, in a manner different from those described. The poste- rior fontanelle, which, as we have before observed, we should always take for our guide, may sometimes correspond to the intermediate spaces between those six points; so that we might, perhaps, distinguish six other positions, which might be again subdivided into as many more. This distinction, he remarks, would not only be useless and superfluous, but might confuse the ideas. There is not, in fact, any of these middle positions, which may not be referred to one of the six first; and each of them ought therefore properly, to be designated by the name of that to which it approaches the nearest, as the mechanism of delivery in it is exactly the same. These intermediate positions therefore, ought to be referred to the three first, as often as the poste- rior fontanelle answers to any point of the anterior semi-circumference of the pelvis; because that fonta- 287 nclle turns gradually towards the symphysis of the pubis, under which the occiput is ultimately situated. The head, continues Baudelocque, sometimes fol- lows this direction, even though the fontanelle in question, be placed opposite one of the sacro-iliac symphyses at the commencement of labour: but, when it is more backward, and answers to some point in the posterior third of the superior strait, all those positions ought to be referred to the three latter, that is to say, to the fourth, fifth, or sixth; be- cause the occiput constantly turns in descending, towards the sacrum, and the forehead under the pubes. EXPLANATION OF THE PLATES. wvwwvwvw EXPLANATION OF PLATE I. This figure presents a well formed pelvis, whose parts are all reduced to about half their natural size. A, A, A, A, The ossa ilia, properly so called. a, a, The iliac fossae. b, b, b, b, The angle which divides transversely, and obliquely from behind forward, the internal sur- face of the os ilium into two parts, and which makes part of the brim of the pelvis, called linea ileo- pectinea. c, c, c, c, The crista of the ossa ilia. e, e, The anterior superior spines of the ossa ilia. f, f, The angle formed by the internal lip of the crista of the ilium, and to which is attached a liga- ment inserted at the other end in the transverse apophysis of the last lumbar vertebra. g, g, The inferior angle of the os ilium which makes part of the acetabulum. B, B, The os ischium. 290 h, h, The tuberosities of the os ischium. i, i, The branches of the os ischium. k, k, The posterior part of the os ischium, which makes part of the acetabulum. C, C, The body of the os pubis. 1. 1, The angle of the os pubis. m, m, The posterior extremity of the os pubis, which makes part of the acetabulum. n, n j The descending branch of the os pubis, which unites with that of the ischium. D, D, D, The os sacrum. 1.2, 3, 4, The anterior sacral holes, o, o, o, The base of the sacrum. p, p, The sides of the sacrum. • q, The point of the sacrum. E, The coccyx. F, The last lumbar vertebra. r, r, The transverse apophyses of that vertebra, s, s,The ligament which goes from the transverse apophysis of the last vertebra to the angle of the in- ternal lip of the crista of the os ilium, indicated by the letters f, f. t, t, Another ligament which descends from those same apophyses to the superior edge of the sacro-iliac symphyses. G, G, The femur t or thigh bone. 291 V, V, The head of the femur received in the aceta* bulum. u, u, The foramina ovalia. Symphyses of the Bones of the Pelvis. H, The symphyses of the ossa pubis. I, I, The sacro-iliac symphyses. K, The sacro-vertebral symphysis. 2F 292 EXPLANATION OF PLATE II. This figure represents the entrance or superior strait of a well-formed pelvis, reduced to the half of its natural dimensions. a, a, The iliac fosses, b, The sacro-vertebral angle, or the projection of the sacrum, c, The last lumbar vertebra, d, d, The lateral parts of the base of the sacrum, e, e, The sacro-iliac symphyses. f, f, The parts over the acetabula, g, The symphysis of the pubes. The lines indicate the different diameters of the superior strait, A, B, The antero-posterior or little diameter. C, D, The transverse or great diameter. E, F, Oblique diameter, which extends from the left acetabulum to the right sacro-iliac junction. G, H, Oblique diameter, which goes from the right acetabulum to the left sacro-iliac symphysis. The oblique diameters may be considered as the greatest in the living subject; and it is in this direc- tion that the long diameter of the fcetal head gene- rally descends. 293 EXPLANATION OF PLATE III. This figure represents the inferior strait of a well-formed pelvis, reduced to the half of its natural size. a, a, The external surfaces of the ossa ilia. b, b, The anterior superior spines of the ossa ilia. c, c, The anterior inferior spines of the ossa ilia. d, d, The acetabula. e, e, The foramina ovalia with the obturator liga- ments. f, f, The ischiatic tuberosities. g, g, The ossa pubis. h, h, The branches of the os pubis and ischium united. i, i, The sacrum. k, The coccyx. 1, 1, The sacro-ischiatic ligaments. m, The symphysis of the pubes. n, n, The arch of the pubes. The lines indicate the diameters of the inferior strait. A, A, The anteroposterior or great diameter. B, B, The transverse or little diameter. C C, D D, Oblique diameters. 294 EXPLANATION OF PLATE IV. This figure represents a deformed pelvis, of which all the parts are reduced to half their natural size. a, a, The ossa ilia. b, b, The ossa pubis. c, c, The ossa ischia. d, d, d, The last lumbar vertebra. e, The projection of the sacrum. f, f, The sacro-iliac symphyses. g, The symphysis of the pubes. h, h, The foramina ovalia. i, i, The branches of the ossa pubis and ischia, which form the anterior arch of the pelvis. k, k, The ace tabula. The lines indicate the diameters of the superior strait of this pelvis. A, A, The antero-posterior diameter; its natural length is fourteen or fifteen lines.* In Elizabeth Sherwood's case, Dr. Osborne states, that this dia- meter did not exceed 3-4ths of an inch. Vid. Os- borne's Essays, p. 1 89. The child in this case, was delivered by embryulcia and the crochet: the wo- * A line is the 12th part of an inch, as has heretofore been explained. t— ' I 295 man recovered. In Mary Rhodes's case, this diame- ter measured only 7-8thsof an inch. Here the Cesa- rian section was performed — she expired five hours afterwards. Vide Lond. Med. Observations and Enquiries, vol. iv. A. D. 1771. B, B, The transverse diameter; its natural length is four inches ten lines. C, C, The distance from the projection of the sacrum, to that point of the margin which answers to the left acetabulum, thirteen lines. D, D, The distance from the same point of the sacrum, to that of the margin which answers to the right acetabulum, twenty lines. Baudelocque, from whose work these plates are taken, observes, that he has another pelvis, which has an opening of between three and four lines only in the direction of this last line, and an inch and an half from the middle of the projection of the sacrum to the symphysis of the pubes. The inferior strait in both these pelves is very large. 295 EXPLANATION OF PLATE V. This figure represents a deformed pelvis, in which the parts are reduced to half their natural size. a, a, The ossa ilia. b, b, The ossa pubis. c, c, The ossa ischia. d, d, d, The last lumbar vertebras. e, The projection of the sacrum. f, f, The sacroiliac symphyses. g, The symphysis of the pubes. h, h, The foramina ovalia, seen obliquely. i, i, The arch of the pubes, seen in the same man- ner. k, k, The acetabula. The lines indicate the different dimensions of the superior strait. A, A, From the pubes to the projection of the sacrum, in the natural state of iKispehis, two inches two lines. B, B, The transverse diameter, three inches eight lines. C, C, From the middle and left side of the projec- tion of the sacrum, to that part of the margin which answers to the acetabulum of the same side, between six and seven lines. 3 Fd 297 D, D, From the middle and right side of the pro- iection of the sacrum, to that part of the margin which answers to the right acetabulum, one inch two lines. 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