II. TREATMENT OF NATURAL LABOUR…

II. TREATMENT OF NATURAL LABOUR

State of the bowels.--Form and size of the uterus.--True and spurious pains.--Treatment of spurious pains.--Management of the first stage.-- Examination.--Position of patient during labour.--Prognosis as to the duration of labour.--Diet during labour.--Supporting the perineum.-- Treatment of perineal laceration.--Cord round the child's neck.--Birth of the child, and ligature of the cord.--Importance of ascertaining that the uterus is contracted after labour.--Management of the placenta.--Twins.--Treatment after labour.--Lactation.--Milk-fever and abscess.--Excoriated nipples.--Diet during lactation.--Management of lochia.--After-pains.

This is a subject of great extent as well as importance, because it comprehends the whole mass of rules for the management of a woman, not only just previous to and during, but also after, her confinement. On nothing does the course of a natural labour depend so much, as upon the careful removal of every source of irritation which may tend in any way to derange or interrupt the regular progress of that series of changes or phenomena which constitutes the great process of normal parturition. It will be necessary that the reader should have made himself thoroughly master of the subjects discussed in the last chapter, before commencing those of the present one. With each change there mentioned, the state of the system and its functions should be carefully watched, and every slight deviation from the natural course of things checked by appropriate dietetic or medical treatment. Hence, therefore, the more a woman can follow her usual avocations, and take that degree of exercise to which she has been accustomed at other times, the better; for by so doing the circulation is equalized, the digestion is kept in full activity, and the tone and general strength of the system maintained.

It would almost seem, by rendering a woman more capable of moving about during the last weeks of pregnancy (which has already been shown to be produced by the sinking of the fundus, enabling the respiration to act more freely,) that Nature intended she should use exercise at this period, and thus prepare her, by increased health and strength, for a process which requires so much suffering and exertion.

Her hours should be regular and early, her meals light and moderate, and by agreeable and cheerful occupation she should fit herself, both in body and mind, to meet the coming trial.

State of the bowels. Attention to the state of the bowels is of first importance, and must never be neglected. It is a subject nevertheless upon which women are remarkably careless, and they will frequently, when not attended to, allow labour to come on with their bowels in a very loaded and highly improper condition.

There is, perhaps, no one circumstance which is found to exert such a prejudicial influence on the course of a natural labour, in so many different ways, as deranged and constipated bowels. Where the contents are of an unhealthy character, the irritation which they produce in the intestinal canal is quickly transmitted to the uterus, and tends not a little to pervert and derange the due and healthy action of this organ: hence arises one of the most fertile sources of spurious pains, a subject which will shortly come under our consideration. Where the bowels are loaded, in consequence of the pressure upon the ascending cava, considerable obstruction to the free return of blood from the pelvic viscera is produced, the vessels of which become considerably engorged. No organ feels these effects more than the uterus: from the immensely dilated condition of its veins, a state of local plethora is engendered, which, from the congested state of the uterine parietes, considerably interferes with the free and regular action of its fibres, and not unfrequently predisposes to hæmorrhage.

Moreover, the rectum being distended with fæces, diminishes proportionally the capacity of the pelvis, and prevents the ready descent of the head into it; occasionally it forms, at the beginning of labour, a solid cylinder of indurated fæces, so hard, as, at the first touch, almost to induce the suspicion of a projecting sacrum. As a measure of common cleanliness, the bowels ought always to be attended to before labour, for, besides the more serious effects now enumerated, the labour may be rendered exceedingly filthy for the patient, and not less disgusting for the practitioner; for, as the sphincter ani loses all power of contraction when the head advances deeper into the pelvis, it follows that whatever fæcal matter may have been lodging in the rectum will now be unconsciously pressed out.

Hence, therefore, for the last few days of pregnancy, the bowels should be regularly opened (unless they are so spontaneously, which is seldom the case) by castor oil or other mild laxatives: and if labour has already commenced before this measure has been taken, and if, therefore, there is not sufficient time for the operation of the medicine, an enema should be given.[66] In Germany it is a rule to throw up some chamomile infusion at the commencement of every labour, by which means the process is rendered more cleanly than is frequently the case in this country; and also, for the reasons already given, the early stage is less apt to be tedious from spurious and ineffective pains.

Form and size of the uterus. The more regular the first precursory pains are, the more symmetrical and uniform will be the shape of the uterus; and again, on the other hand, the more uniform its shape, the more regularly and effectively will it act.

It is these slight but early contractions, which, although they produce little or no effect upon the os uteri, exert a very important influence over the first half of labour; for it is by their action, in great measure, that the form of the uterus is determined, as also the correct position of the child. Hence, therefore, some practitioners lay considerable stress on ascertaining the precise form of the abdomen as a means of determining what sort of labour the patient will have.

In a woman pregnant for the first time, and in a state of perfect health, the uterus is of an oval or rather elliptical form at the beginning of labour: when seen in profile, the abdomen presents nearly a uniform degree of convexity. In this state the child lies with its long axis parallel to that of the uterus, that is, with its head or inferior extremity turned towards the brim of the pelvis; and if the fundus has already sunk in the manner above-mentioned, the practitioner may very confidently prognosticate that the head presents, even before making an examination per vaginam.

In a perfectly healthy primipara there is scarcely any inclination of the uterus either to one side or forwards, its median line corresponding with that of the abdomen: whereas, in the multipara, the axis of the uterus is seldom straight, inclining more or less to one side, or, from the greater relaxation of the abdominal parietes, being somewhat pendulous. The size of the uterus should also be taken into consideration, especially in first pregnancies; a large uterus shows that either its parietes are gorged with too much blood, or that its cavity is distended with an unusual quantity of liquor amnii, or that the child is very large, or that there are twins. Whatever may be the cause of the distension, it interferes with the regular and effective contractions of the uterus, and tends to make the labour (at least the first part of it) tedious. A moderate sized uterus is much more capable of active exertion, for its fibres not being put so much upon the stretch are enabled to contract better.

True and false pains. If the patient is already beginning to suffer pains, it is of great importance to ascertain whether they be genuine or spurious; upon the correct diagnosis of which, the favourable or unfavourable course of the labour not unfrequently in great measure depends.

A genuine labour pain comes on at tolerably regular intervals, rises gradually to a certain degree of intensity, remains at that point for a few seconds, and then subsides as gradually; the body and the fundus of the uterus increase in hardness, and the os uteri in tenseness, in proportion as the pain rises, and vice versâ; the pain is seated in the back and loins, and is of a dull aching character: but with the spurious pains it is quite the reverse; they come on and go off suddenly and irregularly, the pain is in the abdomen, and produces a sharp twinging sensation, and the hardness of the uterus and tenseness of its mouth bear no proportion to the pain.

Spurious labour pains are the early contractions of the uterus perverted and rendered irregular, spasmodic, and painful by irritation, congestion, or inflammatory action; they sometimes come on several days before actual labour commences, and if not recognised and removed, may expose the patient to considerable suffering and exhaustion. Derangement of the stomach and bowels is one of the most frequent causes of spurious pains, for by the irritation which is thus produced, the uterus is almost sure to sympathize, and to have its action more or less disordered. This may arise from unhealthy irritating contents of the bowels producing spasmodic, griping, and colicky pains, or from diarrhoea with tenesmus arising from exposure to cold, or from irritation caused by the pressure of the gravid womb. Spurious labour pains of this character also frequently occur in patients who are accustomed to indulge in the luxuries of the table, or in the lower classes, who are addicted to the use of spirituous liquors. Constipation has been already mentioned as a cause of this condition. The state of plethora, congestion, or inflammation, acting as a cause of spurious pains, may arise from various sources: it is frequently observed in strong healthy young women, especially those pregnant for the first time; the pains do not assume the proper character of genuine labour pains, and exhaust the patient by continued but useless suffering. The os uteri probably dilates somewhat, but its edge remains thin and tense, and the pains appear to have no effect in dilating it any farther. The mucous secretion of the vagina is not of the character described at the beginning of labour in the preceding chapter. The pulse is strong and more or less excited, and the flushed face, and generally increased heat of skin indicate the condition upon which those symptoms depend. The inflammatory form of spurious labour pains is not unfrequently of the rheumatic character, a condition which has not been much noticed in this country, but which is capable of exerting a very considerable influence upon the course and progress of the labour. It is usually produced by exposure to cold and the other common causes of rheumatism in other parts of the body, and is generally accompanied with more or less derangement of the stomach and bowels. In this state each contraction of the uterine fibres is attended with much suffering, although the contraction itself may be so slight as to produce little or no effect upon the os uteri. Most of these conditions, in a severe degree, form that species of dystocia which arises from a faulty state of the expelling powers, for the farther consideration of which we must refer to our chapter upon that subject. In a minor degree they produce these slight derangements of uterine action, which we are now considering under the name of spurious pains.

Treatment of spurious pains. The indications of treatment depend in great measure upon the cause; and we cannot impress it too strongly on the young practitioner, as a rule never to be lost sight of, that, whatever is wrong in the state of the circulation or of the bowels must be first rectified before having recourse to opiates. Where the stomach is much deranged at the beginning of labour, nature frequently induces spontaneous vomiting, with considerable relief to the patient, and mitigation of the pains; if not a gentle emetic may be administered. Where the bowels are loaded, the treatment already mentioned must be put into practice, after which [Symbol: minim] xx of Liquor Opii Sedativus and of antimonial wine in peppermint water, or gr x of Dover's powder may be given. When there is diarrhoea with a good deal of griping and tenesmus, a dose of castor oil with Liquor Opii Sedativus in any aromatic water may be administered; and if the labour be not yet commenced, gr v of Pil. Hydr. and Dover's powder may be also given at night. If there be a plethoric or even inflammatory condition, the lancet will be of the greatest service; it reduces the temperature of the body, relaxes the soft parts, brings on copious secretion of mucus, and by relieving the congested state of the uterine parietes, enables the fibres to contract with more regularity and effect. In the rheumatic form, laxatives followed by diaphoretics, the warm bath, and even venesection will be necessary.

By thus treating the spurious pains according to their cause, they will usually subside readily enough, and be either followed immediately by pains of a more genuine and effective character, or leave the patient perfectly free for several hours, or perhaps even days. It is by inattention to, or ignorance of, these conditions, that patients have been allowed to remain for several days in suffering, during which they have been treated as if they had been in natural labour, until at length they have become so exhausted that, when labour really made its appearance, they were incapable of undergoing the exertions which this process demands.

Management of the first stage. The preparatory pains of labour, which form the first stage, do not require that the patient should take to her bed at this early period; and this is especially the case in primiparæ, where the first stage is usually somewhat tedious. Until nearly the end of the first stage, she ought rather to be induced to suppose that actual labour has scarcely yet commenced, and that she may still sit up or walk about the room as best suits her feelings, taking care at the same time that every thing is in readiness against the moment when it shall become necessary for her to lie down. A nurse who understands her business will of course duly arrange all these matters, but it behoves the accoucheur, nevertheless, to pay attention to these little details, and to see that every thing is properly prepared: that the bed is ready, and guarded either by several folds of sheeting, or by a leather for the purpose, to prevent the blood and other discharges during labour from soaking into the bedding beneath; this must be done either on the right side or at the foot of the bed, in order that the patient may be better within the reach of the accoucheur: that the patient should be partially undressed, and covered with her dressing-gown: that all the linen should be well aired: that there should be towels, napkins, hot and cold water in readiness, and also a bottle of vinegar, and one of spirit in the room, in case of hemorrhage, suspended animation in the child, &c. &c. These and many other arrangements of less importance are by no means beneath his attention, and require but a moment's glance to assure him that every thing is properly prepared.

By encouraging the patient to sit up as long as she can, or even to move about occasionally, the pains are rendered more tolerable as well as more effective; the time passes more agreeably and quickly; and by the time that it has become necessary for her to lie down, the labour has made so much progress that the rest of its course seems to be much quicker than was at first expected. On the contrary, where the practitioner at an early period of the first stage, informs her that she must stay up no longer, that she must go to bed and remain lying on her left side, her mind is solely occupied with her pains, which become wearying and irksome; the time passes heavily away; she becomes impatient and therefore dispirited; and is much disappointed, that, after remaining in this state for some time, the termination of the labour appears to be as far off as ever. Nothing eases the pains of the first stage, or increases their effect, so much as frequent change of position and moving about; when, however, they are severe or of long continuance, and the patient becomes fatigued, she will require rest, and this opportunity, afforded by her lying down, should be seized for the purpose of making an examination.

Examination. The manner in which this operation should be proposed to the patient cannot be too delicate: it should, as Dr. Dewees has justly observed, always if possible be done by means of a third person, such as the nurse or any elderly female friend who happens to be present. If the accoucheur has proposed it with that degree of gentleness and good feeling which it ought to behove every one to show under such circumstances, he will rarely, if ever, experience the slightest unwillingness to accede to his request: the better the patient's rank in life is, the more docile will she prove at these times, and the more resolute to undergo whatever she is told it is necessary to submit to. The object of an examination is to determine whether the child presents rightly, whether the labour is far advanced, and to form some degree of prognosis as to its course and duration, &c.: these are points which are of such importance as well as interest to ascertain, that the dread which a patient feels at undergoing an operation so repugnant to her feelings is generally merged more or less in the intense anxiety to know if all is right.

An examination at an early period of labour is important in many respects. We ascertain the condition of the vagina, whether it be soft, cool, relaxed, and well lubricated with mucus, as described at the beginning of the last chapter; whether the os uteri be dilated; whether its edge be thin and tense, or already becoming soft, cushiony, and yielding; whether the membranes are ruptured; whether the presentation be a natural one, and whether the pelvis be rightly formed. In cases where the umbilical cord is prolapsed, it is particularly desirable to ascertain the existence of this displacement as early in labour as possible.

It is usually directed to examine during a pain, because at this moment we feel the os uteri tense, and therefore more distinct to the finger; but it is far better to examine during the interval between the pain: the os uteri being now relaxed, admits the finger more easily; the membranes being loose are not so liable to be ruptured; and, from their not being distended, we shall feel the presenting part more distinctly.

Wherever the os uteri is nearly or fully dilated, or from its condition and the effect which the pains have upon it shows a disposition to dilate with rapidity, the patient should go to bed, as we cannot be sure when the membranes may rupture, more especially in primiparæ, in whom this usually takes place early. It is equally desirable, also, in those who have already had children, that the patient should be upon her bed at this moment; because, if the pains be strong, and the os uteri yielding, the head is apt to follow the discharge of the liquor amnii, and sudden expulsion of the child might result at a moment when the patient is unprepared for such an occurrence.

The accoucheur should always examine when the membranes give way, because not only will he be able to feel the presenting part now more distinctly, but if the cord has prolapsed, a coil of it will come down into the vagina and cannot escape his notice; in fact, if there is any thing unusual about the presentation, he will be now able to distinguish it with greater certainty. In women who have had large families, the head remains very high in the pelvis until this moment, so that it is frequently extremely difficult to reach it and to ascertain its position: the same is observed with presentations of the nates and of the shoulder, which seldom descend into the pelvis until the liquor amnii escapes.

Position of the patient during labour. The position which the patient should take during the actual process of labour has been a subject of considerable discussion, and even at the present day varies exceedingly in different countries. In the earliest periods of history, women appear to have been delivered in a sitting posture, as is described in the first chapter of Exodus: this mode was revived in comparatively modern times; thus Ambrose Paré, in 1573, speaks of a labour chair with an inclined back, which he preferred to a common bed. Labour chairs were brought into very general use upon the Continent in the beginning of the last century by Hendrick van Deventer of Dort in Holland, and although they have been in great measure discontinued in modern times, there are still some districts of Germany where they continue to be used. It is a species of chaise percée furnished with straps, cushions, &c. by which the patient can fix her extremities, and thus enable the abdominal muscles to act with the greatest power. This is the very reason which renders labour chairs objectionable. The presenting part of the child is forced through the soft passage with great violence, before they have had time to yield and to dilate sufficiently; hence it has been noticed that lacerations of the perineum are of very frequent occurrence in those countries where labour chairs have been in general use. In some remote parts of Ireland, and also of Germany, the patient sits upon the knees of another person, and this office of substitute for a labour chair is usually performed by her husband. Labour chairs, as far as we are acquainted with their history, were never used in this country, nor have they been used for the last century in France, where the patients are usually delivered in the supine posture, on a small bed upon the floor, which has not inaptly been termed lit de misére. A modification of the labour chair is the labour cushion first used by Nuger, and afterwards by the late Professor von Siebold of Berlin and Professor Carus of Dresden; it is a species of mattress, with a hollow beneath the nates of the patient for receiving the discharges which take place during the labour. The patient is compelled to lie upon her back during the greater part of labour, and thus maintain the same posture for some time, which must necessarily become irksome and even painful to her. In this country and in Germany the patient is delivered upon a common bed, prepared for the purpose as above mentioned: in England she is placed upon her left side, the nates projecting to the edge of the bed, for the greater convenience of the accoucheur: in Germany, except in Vienna and Heidelberg, where the English midwifery has in great measure been introduced by Boer and Naegelé, the patient is delivered upon her back.[67] In former times the supine posture was also used in this country, but for about a century the position on the left side has been preferred; the patient lies more comfortably to her own feelings; her face is turned from the practitioner who sits behind her, and who, from this posture, is able to examine or to perform any other necessary manipulation without her feelings being annoyed by seeing what is going forward. It is decidedly the easiest position during the last moments of tremendous suffering and exertion; when the presenting part is passing she is not able to exert an undue degree of violence, and from the knees being kept together, there is less danger of the perineum being torn. The left side seems moreover to be the natural position for a woman at the moment of parturition, for if accidental circumstances have occurred, such as sudden labour, &c. by which she is deprived of all assistance at this moment, she will almost invariably be found upon the ground lying on her side supporting herself with one hand. In some cases she will remain during these moments upon her knees, into which posture she has gradually dropped from that of standing: in by far the majority of cases she will take the position upon her side, as above mentioned.

So long as the os uteri is not fully dilated, the patient is not involuntarily compelled to strain and bear down: hence it is important to caution patients, more especially primiparæ, not to be induced by an ignorant nurse or friend to exert themselves improperly during the first stage of labour, for not only is the process of dilatation considerably impeded, and much exhaustion produced, but frequently severe febrile or inflammatory action excited, which may lead to serious results after labour. All attempts to accelerate the course of a natural labour, especially the first stage, either on the part of the patient by premature straining, or on the part of the practitioner by attempts to dilate the os uteri and passages, or by giving her stimuli, &c. cannot be too strictly forbidden. It is a mode of practice which has long since been strongly condemned by the highest authorities in midwifery, except in Scotland, and which may very easily lead to most mischievous results. Quick rapid labours are by no means desirable, for they are seldom safe; nor is it possible to limit this or that stage (especially the first) to any given duration of time.

No conscientious practitioner, who has clear and enlarged views of the process and mechanism of natural labour, would feel himself justified in interfering with its course, merely because some portion of it has extended beyond a certain fixed period; but would rather guide his conduct by the habit and strength of the individual, and by the effects which the labour has upon her. We have before stated, that no two labours are alike; we may also add, that no two individuals are similarly affected by the same degree and duration of labour, nor indeed are any two labours exactly alike in the same person: hence it will be evident, that what to one patient would prove a protracted and exhausting labour, to another would be nothing more than a perfectly regular labour, natural both in its character and progress. Among other injurious effects which premature efforts on the part of the patient will have, is, that the membranes are liable to give way too soon--this is by all means to be avoided, for nothing is so likely to render the first stage protracted as the occurrence of this accident; the course of the labour frequently undergoes an immediate change; the pains lose their regular and effective character; the os uteri remains thin, tense, and unyielding, and the process of dilatation is greatly retarded.

Prognosis as to the duration of labour. There are few subjects upon which an accoucheur is so frequently importuned, or about which it is so difficult to give a decided opinion, as the probable duration of labour. It is natural enough that both she and her friends should be anxious to know how long this process of suffering is likely to last: nothing, however, is more hazardous than a prognosis in these cases; and we would warn our junior brethren to be cautious how they commit themselves by venturing an opinion, which the result of the labour may prove to have been founded upon guess-work or ignorance. The character of the labour during the second stage, is frequently very different to that of the first, so that the mode in which the labour commences is by no means a criterion for its latter part. A labour which has commenced briskly and regularly, and with every promise of a rapid progress and termination, frequently becomes exceedingly lingering during the second stage, so that the expelling powers may, perhaps, even fail altogether in making the head pass through the os externum; whereas, on the other hand, a labour, the first stage of which has been slow and protracted, frequently experiences a complete alteration of character, and advances with a degree of quickness and energy, which could scarcely have been anticipated from the manner in which it commenced. In primiparæ, especially, it is particularly difficult to foretell, with any thing like certainty, the duration of labour: hence it is, that unguarded assertions in this respect are not only liable to disappoint the patient, but destroy her confidence in the practitioner.

Wigand's views. The celebrated Wigand of Hamburgh considered that the form of the vagina would frequently furnish the means of a pretty certain prognosis, as to the duration of labour: thus, if it were wide and yielding throughout its whole length, the labour would be quick, both at its beginning and termination; if, on the other hand, it were small, rigid, and contracted throughout, the labour might be expected to be of a very opposite character. If on examination the vagina is found roomy and well dilated at its upper part, but contracted and rigid near the os externum, the labour will be probably quick and easy during the first half, but slow and difficult afterwards; on the contrary, where the os externum is yielding and wide, but the upper portion of the vagina narrow, the labour may be expected to be slow at first, but to be brisk and active afterwards. We have already stated, that the course of labour varies in every possible way; in some cases the same peculiar character of labour shows itself through two or three successive generations: hence it has been observed, that very tedious or very violent and rapid labours sometimes seems to be hereditary; the mother, daughters, and grand-daughters, being all remarkable for their lingering or rapid labours.

Diet during labour. The diet of the patient during labour should be simple and unirritating; if every thing is going on naturally and briskly, some gruel or tea, with or without a little biscuit or bread and butter, will be quite sufficient; but if the process is becoming tedious and exhausting, some beef-tea, broth, or any other mild nourishment of this sort will be required to support the strength.

During the first stage of labour there is no need for the practitioner to be constantly in the room, nor even during the early part of the second, unless the pains are very violent and protrusive; for, by taking frequent opportunities of quitting the patient for a few minutes, she is left more free from restraint, and the presence of the practitioner becomes less irksome when it is really necessary; whereas, if he continues at the bed-side, she is justified in expecting that the labour must be advancing rapidly to demand so unremitting an attendance, and, therefore, becomes disappointed and impatient to find that his presence has been of so little use to her. The conversation should be light and cheerful, and every means taken to encourage her and keep up her spirits.

Supporting the perineum. As the head approaches the os externum our attention must be directed to giving the perineum such a degree of support, as shall secure it from any serious degree of laceration during its passage. The greatest danger of ruptured perineum is in primiparæ, for the soft parts never having been subjected to such a degree of dilatation before, do not yield so readily as in multiparæ. The anterior margin of the perineum, called frænulum, is, we believe almost invariably ruptured in every first case; but the laceration ought not to extend farther. The more gradual the advance of the head is through the os externum, the better will be the dilatation of the soft parts: hence therefore, when the pains are violent, and the head is thrust with great force against the perineum, it will be desirable to restrain it in some degree, until the parts shall have had sufficient time to yield; on the other hand, where the pains are more gradual, the perineum and os externum may receive the whole dilating force of the head, and every succeeding pain will show that a progressive advance is taking place.

The increasing thinness of the perineum itself, and the frænulum becoming tense during the height of a pain, may be looked upon as warnings that the expulsion of the head is not far distant, and now the support of the hand will be needed to prevent laceration; for this purpose the position on the left side is peculiarly convenient, besides having the additional advantage of relaxing the external parts more completely. If the pains be violent, and the impulse to strain very considerable, we must desire the patient to lie as passive as she can, and do her best not to bear down, for otherwise the head is sometimes driven through the os externum with a single effort, and the mischief done in spite of all our care.

The support of the perineum has been variously directed by different authors; we prefer using the left hand, because then we have the right at liberty for any manipulations which may be necessary, such as examining if the cord be round the child's neck, &c. &c. It is awkward at first, because it requires the hand to be considerably twisted, and makes the wrist ache a good deal; but a very little practice soon conquers this slight difficulty, and the superiority of the mode will then be apparent. As our object is not merely to support the perineum, but to direct the head as much forwards under the pubic arch as possible, in order that the anterior portions of the os externum should undergo their share of dilatation, and thus in some measure spare the perineum, the chief pressure should be applied near to the sphincter ani, gradually diminishing it up to the frænulum perinei in front: for this purpose the left hand protected by a napkin (partly for the sake of cleanliness and partly for the purpose of having a firmer hold upon the parts, and preventing it slipping) should now be applied with the palm in the vicinity of the sphincter ani, so that the tips of the fingers should project somewhat beyond the frænulum; the whole should be laid as flat and close to the part as possible. In order that we may be sure of the hand being applied exactly along the raphe of the perineum, we should guide it by the examining finger of the right hand, bearing in mind, that when we place this against the posterior margin of the os externum, and bring the middle finger of the left hand in contact with it, we shall hold the left hand in the desired direction.

It is desirable also to hold the examining finger of the right hand against the frænulum perinei when a pain comes on, because then we know exactly when the tension of the perineum is becoming such as to endanger its integrity, and when the head is about to pass out. Until this moment the frænulum is seldom on the stretch, although the rest of the perineum is: hence we need not apply our support until now, and thus give the parts the full benefit of the dilating force, which the head exerts upon them, until the very last instant. To relax them still farther, the patient's knees ought not to be separated by a pillow or cushion placed between them, as is usually done, although it must be confessed that in some cases she is relieved by it.

In applying the left hand to support the perineum, it should be placed somewhat more backward than the spot which we intend to support: for by this means we are enabled to push the soft parts somewhat forwards, and thus relax them. By this means, also, we not only direct the head against the other parts of the os externum but avoid the danger of its perforating the perineum. When the moment of greatest distension arrives, the process cannot be too slow; we must therefore desire the patient not to bear down, and endeavour, if possible, to make the head remain in the state of crowning until the next pain comes on: the os externum having been held for some moments at its utmost dilatation, permits the head to pass with greater ease and safety. As the globe of the head passes forwards and emerges through the os externum, we feel the posterior portions of the perineum become soft and lax, while the forehead, followed by the face, and lastly the chin glide over the anterior margin of it.

The passage of the head is not the only moment of danger to the perineum, for laceration is even still more liable to be produced during the expulsion of the shoulders; any slight rupture of the anterior edge is now apt to be converted into a considerable laceration, unless the support be continued until the thorax be expelled. We have already stated that the frænulum perinei is generally torn through in the first labour; but the laceration ought not, if possible, to extend farther, because serious injury may be produced either to the vagina, or even to the sphincter rectum. To say, however, that laceration of the perineum need never happen, would be preposterous; because cases every now and then occur, where, from the contracted and unyielding state of the os externum, and from the size of the child, it is nearly impossible that the perineum can escape without injury; fortunately, although considerable lacerations are by no means uncommon, they are seldom observed to extend into the sphincter ani, the direction of the rent being usually to one side. Under the ordinary circumstances of perineal laceration, little more than mere attention to cleanliness is required; for the parts contract so astonishingly after labour, that what was a wide rent of an inch and a half long, in a couple of days will be scarcely more than two or three lines in length. Rest, great cleanliness, and gentle-relaxed bowels, constitute the chief treatment.

Treatment of perineal laceration. Where, however, the laceration extends into the rectum, the case becomes exceedingly troublesome and difficult to cure, and the patient is liable to be rendered a miserable object for life; for the action of the sphincter being entirely destroyed, she is unable to retain fæces or flatus in the rectum; besides which, from the injury to the posterior wall of the vagina, prolapsus uteri is an almost certain consequence. In these cases the slightest movement of the thighs upon each other alters the position of the lips of the wound, and thus tears it open afresh, so that at length the edges of the wound become callous and refuse to heal. A great deal in these cases depends upon the patience and good conduct of the patient herself; for if she have the resolution to lie perfectly still for at least a week, she will have every chance of a perfect cure. If there be much swelling of the edges, and a disposition to slough, a warm poultice of chamomile flowers should be applied, and the bowels kept in a nearly liquid state by gentle and repeated doses of salines, in order to prevent distension of the rectum when the evacuation is passing; she should preserve the supine posture, and have her knees confined together by a piece of tape, as is done with patients after the operation of lithotomy. Straps of adhesive plaster are seldom or never of any use, but if the rent be very severe a suture or two may be required. The great fault in applying these means for bringing the edges of the wound together is the attempting to unite them throughout their whole length; for by so doing the tension of the parts is increased, and therefore there is less disposition to unite; and even if we succeed in effecting complete union of the whole wound, the perineum is so contracted and unyielding from the cicatrisation, that it can scarcely escape a repetition of the injury in succeeding labours. It is, therefore, much better that we should content ourselves with uniting merely the posterior half of the laceration; the parts heal much more readily, and the os externum is left of a sufficient size to escape all danger of laceration on future occasions.

Where the edges have become callous and refused to unite, they require to be pared and brought together again; this, however, does not always succeed, and the case becomes very difficult and protracted: under these circumstances, the treatment adopted by Dr. Dieffenbach, of Berlin, is well worthy of attention. Having pared off the callous edges of the wound, he brings them into the closest opposition by transfixing them with needles in several places, as is done for the operation of hare-lip; and in order to isolate the wound as much as possible from the surrounding parts, and prevent any tension, he makes a free incision through the integuments, parallel with the wound, at a little distance from it, and nearly of the same length; by this means, every cause which might tend to separate the edges is removed; whilst the parallel cuts, being fresh incised wounds, soon close by granulation.[68]

It sometimes, although rarely, happens that the perineum, instead of being torn from before backwards, is perforated through its centre by the head, so that the child is not born through the os externum, but through a lacerated opening in the body of the perineum. This accident may arise from a variety of circumstances: the direction of the pelvic outlet may be faulty, or the inclined plane formed by the lower part of the sacrum, by the sacro-sciatic ligaments, &c. may be insufficient to guide the head forwards under the pubic arch; or the perineum may be unusually broad; in which cases the power of the uterus being directed against the centre of it, the head becomes enveloped in a bag of protruded perineum; and if the pains are violent, and the head not properly supported, it at length bursts its way through the centre without even injuring the frænulum. The treatment of this form of ruptured perineum is the same as that of the more common species; the bowels must be kept open, and a fomentation of chamomile flowers applied to the wound, which, from the gradual contraction of the surrounding parts after labour, diminishes remarkably, so that in the course of a short time it will have entirely or nearly closed.[69]

Besides the above-mentioned advantages in supporting the perineum, we may mention another which is not generally noticed, and which is sometimes of considerable service. In cases where the head has completely descended upon the perineum, and begins to protrude somewhat through the os externum, the pains occasionally fail at this moment, the labour becomes very lingering, while the advance of the head and state of the parts show that two or three active pains would bring the child into the world; firm pressure applied at the lower end of the sacrum, in a direction forwards, materially adds to the effect of each pain in bringing the head through the os externum, and seems also to excite the patient to make a more powerful effort with the abdominal muscles. On several occasions we have thus assisted the expulsion of the head, when otherwise the labour would have been very protracted, or would have even required the forceps to disengage it. Madame La Chappelle is the only authority in midwifery, as far as we know, that has noticed this fact.

Cord round the child's neck. As soon as the head is born, we must examine whether the cord be twisted round the child's neck; and here the advantage of supporting the perineum with the left hand becomes evident: it is ready to support the shoulders when they begin to pass, while the right hand is at liberty to perform any manipulations which may be necessary. If it be important to support the head during its passage over the perineum, still more so will it be to support the shoulders; for if a small laceration has already been produced, it is invariably converted into a wide rent at this moment, if great care be not taken: indeed, we are justified in saying that most of the cases of severe perineal rupture are produced by the shoulders, not by the head.

Passage of the shoulders. If the pains cease for a time, or the child be large, the shoulders do not pass immediately: in this position the face swells and grows purple from the pressure upon the neck, although it does not necessarily result from the cord being round it; if, however, we find that this is the case, we can in most instances loosen it somewhat by the finger, and as the shoulders advance, slip it first over one and then the other: we must recollect that the shoulder, which is forwards, passes out first, and that, therefore, we must slip the cord over it first.

It is seldom necessary to assist the shoulders by applying any extractive force to the head, for in the course of a minute or two the uterus generally resumes its activity and expels it: on the other hand, when the shoulders pass through the os externum, the right hand should be in readiness to prevent the body of the child from being born too rapidly: the uterus can scarcely be emptied of its contents too gradually, for by this means it contracts equably, powerfully, and permanently, and throws off the placenta without difficulty; whereas, if suddenly evacuated, it frequently becomes powerless for a time, or if contraction does take place, it is so irregular and incomplete as to endanger partial separation, retention of the placenta, and hæmorrhage.[70] If, however, the cord be twisted exceedingly tight round the child's neck, and imbedded so deeply into the skin, as to render it impossible to push the coil over the shoulder, it may become necessary to divide it in order to let the child pass, in which case the practitioner must seize the divided ends as well as he can, and apply a ligature the instant the child is born. We believe that this is rarely, if ever, necessary; for in proportion as the child advances, so does the fundus descend, and thus relieves, in some measure, the tension to which the cord is exposed. This subject, however, belongs rather to the third species of dystocia, to which we must therefore refer.

Birth of the child and ligature of the cord. As soon as the child is born, we must place it in such a position as will enable it to breathe with ease. The sudden exposure to the external air is generally sufficient to excite respiration; if not, a gentle pat on the nates, or blowing suddenly in the face, will usually succeed: if, however, the child still remains insensible, recourse must be had to those means which are recommended under the head of Asphyxia neonatorum. The cord should not be tied until it has ceased to beat, for unless the circulation be well established in its new course, the breathing is apt to stop, and the child relapse into insensibility: the cord should be tied about three inches distant from the umbilicus; it should be applied tightly, because otherwise it is apt to become loose, as the cord grows flaccid. In tying the ligature, one hand should be supported against the other to prevent giving the cord any jerk in case the ligature breaks; we are able also by this means to tie it more firmly.

The cord should be divided at some little distance from the ligature, so as to prevent all chance of its slipping off, and it should be done with a pair of blunt scissors, by which means the vessels of the cord are so bruised as to be rendered nearly impervious. There is no need to apply two ligatures; in fact it is better not, for, as Dr. Dewees justly observes, "the evacuation from the open extremity of the cord will yield two or three ounces of blood, which favours the contraction of the uterus and expulsion of the placenta." It has been recommended, in case of twins, to apply a second ligature, to prevent all chance of the second child bleeding through the cord of the first. There is, however, no connexion between the two placentæ, although they usually form what appears to be one mass. We only know of one case where the umbilical arteries of one cord anastomosed with those of the other, an anormality of very rare occurrence: still, however, it is better to apply a second ligature upon the cord, where we find that twins are present, as a precaution: and also to prevent it being said, in case the second child is still-born, that it had died from no ligature having been applied upon the placental extremity of the cord. It has been questioned whether it was really necessary to tie the cord before separating the child from the mother, from the well known fact that nothing of the sort is required in animals; and that, in cases of rapid labour, where the child has been unexpectedly dashed upon the floor and the cord broken, no hæmorrhage has resulted. This arises from the bruised and lacerated condition of the cord under these circumstances: animals not only bite the cord, but also draw it through their teeth several times, so as to contuse the vessels for a considerable extent; whereas, if it was merely divided with a sharp instrument, there is no doubt but that the new-born animal would quickly bleed to death.[71]

Importance of ascertaining that the uterus is contracted. As soon as the child is separated from its mother and removed, or even sooner, if this process has gone on slowly, we ascertain if the uterus has contracted: this we shall know by its feeling like a large hard ball behind the symphysis pubis: if there be one rule more important than another, it is this, for without it we cannot be certain of the patient's safety for a single minute: so long as we feel the fundus to be hard, we know that the uterus is contracting, and that it will expel the placenta quickly, and ensure the patient against hæmorrhage; but if it be soft and relaxed, she cannot be considered safe even if their be no hæmorrhage; for the placenta may have been separated, and may be lying across the os uteri, or the os uteri itself may be contracted, or blocked up with coagula, so as to prevent the blood from escaping; it therefore collects in the cavity of the uterus in large quantities, to the imminent danger of the patient. Even where the uterus has contracted, the patient is not permanently safe, for it may again relax and grow soft, and hæmorrhage come on.

Management of the placenta. The placenta sometimes follows the child immediately, and occasionally is expelled by the same pain; usually, however, a few minutes intervene, during which time the uterus remains more or less in a state of inaction; it then begins to contract, and the dull and peculiar pains which characterize the separation of the placenta are now felt. The interval after the birth of the child varies considerably, and depends in many cases on the degree of rapidity with which the uterus has been emptied: hence in some cases we feel the fundus hard almost immediately, whereas, in others some considerable period elapses before it resumes its state of activity, a period which, if any separation of the placenta has already taken place, will be attended with the greatest danger. The occurrence of pains indicates fresh contractions, and therefore we should now examine to ascertain if the placenta has been detached. As a general rule it may be stated, that if we can reach the insertion of the cord with our finger we may presume that the placenta is ready to be expelled; if not, that it is still partially or wholly attached to the uterus. So long as this latter is the case, the less we meddle with the cord the better, for by pulling at it we only excite the os uteri to contract, and thus seriously impede its removal.

Where some time has elapsed without any symptoms of contraction coming on, we may excite the uterus by circular friction of the abdomen, fanning the face, or by sprinkling a little water upon it, &c.: if, however, the uterus is hard and yet the placenta not within reach, we may pull slightly at the cord, pressing it at the same time back with the fore-finger into the hollow of the sacrum; we thus bring it down in the direction of the pelvic axis, and generally succeed in moving it into the vagina. No violent effort should be made, as this would probably tear it off from its insertion into the placenta, but, by keeping a gentle pressure upon it, the placenta will slowly pass through the os uteri, and then come away without farther difficulty. Following the axis of the vagina, we now guide it downwards and forwards; and when it approaches the os externum, it should be seized with the finger and thumb, and rotated several times: the membranes are thus twisted into a rope, and are less liable to be torn in separating from the uterus. The uterus being now completely emptied, contracts into a hard ball of about the size of a child's head. If, however (whether before or after the expulsion of the placenta) the uterus grows soft and swells, if the patient becomes pale and restless, and complains of faintness, sickness, load at the præcordia, darkness before the eyes, &c. we may be sure that hæmorrhage is going on. We refer to the chapter upon uterine hæmorrhage for the measures to be adopted.

Twins. Where there are twins, the above rules for ensuring the safe expulsion of the placenta require to be still more strictly observed: the uterus has been more distended, the mass of placenta is larger, and is attached to a much greater extent of surface than where there has been only one child: hence there is not only a greater liability to hæmorrhage, but if it does take place, will probably be much more dangerous. We cannot be too cautious how we extract the placentæ of twins: from the size of the mass, the uterus remains larger, and therefore less contracted: hence, if we venture to pull at the cord before being able to reach the placenta with our finger, we shall feel it yield; but this is not from the placentæ being detached and coming away, but from the fundus itself being pulled down with it--a state which would rapidly pass into inversion if the force were continued. In order to detach the mass more equally, we should twist the two cords together; by so doing there is less danger of their giving way. The same rotating movement should be used when the placentæ approach the os externum; the two bags of membranes are thus twisted together, and come away entire: if this be not attended to, the membranes are torn, portions of them are left adherent to the uterus, and come away some days afterwards in a half putrid state producing a fetid discharge, and sometimes considerable fever.

Treatment after labour. As soon as the placenta is expelled, the soiled and wetted sheet should be removed and a warm napkin applied to the external parts: the patient should remain thus for half an hour or more, and enjoy a little rest, or even a short sleep: by this time the nurse will have washed and dressed the child, and be ready to attend to the mother. The external parts should be sponged with warm water, her linen changed, and a broad bandage pinned firmly round the abdomen to give it the necessary degree of support. Where there has been great abdominal distension and more than one child, it is sometimes advisable to apply the bandage immediately after the birth of the first, in order to assist the uterus in expelling the second, and in contracting afterwards. The bandage, therefore, should be gradually tightened as the abdomen diminishes in size: without this precaution the removal of so much pressure from the abdominal circulation will be sometimes attended with alarming faintings. A similar effect may be produced by the patient incautiously sitting up in bed to take any refreshment which may be offered to her at this moment; she should be warned, more especially if she be a primipara, not to raise herself from the horizontal posture for a few hours after labour; at any rate, not until the bandage has been properly applied: from inattention to this point, cases have occurred where, on the patient's sitting up immediately after labour, she has fallen back in a faint from which she never recovered; in other cases it has been attended by profuse hæmorrhage, which has instantly proved fatal. "The influence of position," says Dr. Meigs, "in determining the momentum of blood in the vessels is well known to the Profession, but there are few cases where it is of more consequence to pay a profound regard to this influence than in the parturient woman. A uterus may be a good deal relaxed or atonic, and yet not bleed, if the woman lie still with the head low; whereas, upon sitting up suddenly, such is the rush of blood down the column of the aorta, the hypogastric and the uterine and spermatic arteries, that the resistance afforded by a feeble contraction is instantly overthrown, and volumes of blood escape with an almost unrestrained impetuosity: the vessels of the brain under such circumstances become rapidly drained, and the patient falls back in a state of syncope, which now and then proves immediately fatal." (Philadelphia Practice of Midwifery, by Charles D. Meigs, M. D. p. 192.) Even if all these directions have been strictly obeyed, if every thing has gone well, and the uterus is firmly contracted, we are not sure of its remaining so: after the lapse of many hours it may again relax, and flooding come on, its power of contraction being impaired either by the exhaustion of the previous labour, the warmth of the bed, &c. It will, therefore, be desirable to adopt such measures, as will ensure the patient against this occurrence: in most cases it will be sufficient to keep the room moderately cool, and ensure a due degree of ventilation; but where the uterus has shown a disposition to relax, we know of nothing which guards the patient so effectually against hæmorrhage after labour, and enables us to leave her with so much confidence, as putting the child to her breast. The sympathetic connexion between the breast and the uterus is now well known; nor are there any means so certain of producing permanent uterine contraction as this natural act: it is a duty which nature instinctively prompts the mother to perform, not only for the preservation of her child, but for the safety of herself. We, therefore, make it a rule, whenever the patient intends to suckle her child (a duty which is performed more frequently now than it was a few years ago,) to have it put to the breast before quitting the house: the first excitement of the mother's feelings towards her offspring is a favourable moment for the performance of this act, the erectile tissue of the nipple becomes turgid, the child takes the breast with ease, and the effect upon the uterus is not less certain than complete; even if the child sucks fairly well for only five minutes we feel satisfied, for we cannot call to mind a single case of hæmorrhage after the effects of this operation.

Lactation. When the wet clothing has been removed, and fresh linen substituted, the patient should be left to enjoy perfect quiet both of body and mind, in order that she may have some sleep, for "the refreshment of sleep seems to be the most powerful natural means of inducing full contraction of the uterus."[72] After this, the child should be placed at her side, in order that it may enjoy the warmth of her body, and make another trial of taking the breast. That new-born animals are not able to maintain a sufficient degree of warmth, is seen by the care with which a bird shelters her young beneath her wings, and by the manner in which kittens, puppies, &c. crawl close to the mother's abdomen to enjoy that degree of heat which of themselves they are unable to produce. Dr. Edwards has shown that the animal heat of a new-born infant is several degrees below that of the adult: the mother's breast is, therefore, the natural place for it, where it can not only enjoy the necessary warmth, but take that nourishment which has been destined for its support at this early period. A child is capable of sucking the moment it is born; indeed, we would say, better at this moment than later, for the power of instinct in it is fully as great as in other animals; whereas, if not put to the breast soon after birth, but fed instead, it quickly loses it. A vigorous healthy child immediately seeks its mother's breast, and if it does not find it, sucks at every thing which touches its mouth, even its own little hand or finger when presented to it: so strong is this instinct, that, on more than one occasion, we have known the child suck at the finger of the medical attendant when the head had only just cleared the os externum.

It has been, and even still is, a very general practice not to apply the child to the breast until the second or third day, upon the plea that there is no milk: a more erroneous and mischievous plan of treatment could not be devised, for it is a fruitful source of much injury as well of suffering both to the mother and her child. The child should be put to the breast, "whether there be signs of milk or not." (White, on Lying-in Women.) There is always more or less thin watery fluid called colostrum which is admirably adapted to form the first nourishment of the infant; it is slightly purgative, and, therefore, well fitted to unload the bowels of the viscid green mucus, called meconium, which fills them. The colostrum has been variously described by authors; some speak of it as a thin watery fluid, others as a thick creamy milk: this difference depends in great measure upon the interval between the birth of the child and its application to the breast: where this has taken place early, as we have just recommended, the colostrum has almost always the thin watery appearance above mentioned; whereas, if some period of time has been allowed to pass before the child is applied, the breast begins to secrete a fluid containing a larger proportion of caseous matter, or, in other words a more perfect milk, which not being drawn off, the watery part of it is absorbed, leaving the thicker portion to be removed by the process of sucking. Instead of giving the child this bland and natural fluid when in a state best fitted for its delicate digestive organs, it is but too frequently the practice to make it swallow some soft sugar, or a tea-spoonful of castor oil, and follow this up with a little gruel. The effects of such treatment upon a stomach which has never yet received food may be easily imagined; the digestive function becomes deranged, pain is excited, acid is secreted, gas is disengaged, flatulence, diarrhoea, &c. are the result, with all those manifestations of gastric irritation, such as strophulus, aphthæ, colic, &c. from which new-born children are made to suffer so severely.

Besides the above advantages in applying the child thus early to the breast, there are others of even greater importance which require to be mentioned. The breast is not yet distended; it is soft and conical, and therefore in a most favourable condition for being drawn; the child can seize the nipple and draw it out with ease, and by thus straightening the lactiferous tubes it commands a ready flow of their contents. By the gentle irritation of sucking, an earlier secretion of milk is excited, and being drawn off as fast as it is formed, the breast is never distended by an accumulation of milk. On the other hand, where some time has elapsed before putting the child to the breast, it will have in great measure lost the instinctive desire to suck; the breasts have become distended and painful; instead of being soft and conical, they are now hard and flattened, the nipple is shortened, or even sunken in; and if the child does succeed in drawing it out, it is at the expense of severe suffering to the mother. The process of sucking in this state of the breast is very difficult; a considerable effort is required to elongate the nipple, and the thin delicate skin which covers it is abraded; excoriations and deep fissures round the base of it are produced, and each application of the child is one of absolute torture. In many cases, partly from having been fed, and partly from the difficulty it meets with, the child refuses the breast altogether; in others, the suffering is so severe as to oblige the mother to discontinue the attempt. The breasts now increase in size and hardness, producing great pain from their weight and tension; hard painful knots from the distended tubes and vessels are felt in different parts, and the pain and dragging extends to the axillæ, the glands of which are also swollen and painful.

Milk fever and abscess. By this time, or even earlier, the patient will in all probability have been attacked with a smart shivering fit followed by a hot and then a sweating stage, and accompanied with headach and febrile excitement of the circulation. This is the febris lactea, or milk fever, an affection which, at one time, was very generally supposed to be necessary for establishing the secretion of milk: experience, however, has shown that it chiefly results from neglect in not putting the child to the breast sufficiently early; the secreted milk has been in part absorbed into the system, fever has been induced, and the patient has been relieved by the natural crisis of a sweating stage. The febrile excitement will be considerably moderated, and the tension of the breasts relieved, by the action of saline laxatives: the shoulders which are usually kept warm for the purpose of promoting the secretion of milk, should now be clothed more lightly; the relief, however, is but too frequently partial, the breasts still remain large and painful; the process of suckling is just as difficult as before, and the indurated spots increase in hardness, sensibility, and extent; throbbing and darting pain is felt in the part, the skin over it becomes hot and red, and at length presents that shining glazy look which but too surely indicates the formation of matter beneath, a circumstance which is still farther proved by the oedematous feel of the part, or by the presence of actual fluctuation.[73]

Where the breast is capable of being drawn, whether by the child or by artificial means, the application of a cold evaporating lotion, and the frequent exhibition of saline laxatives, will generally suffice to check the determination of blood to the breast, and diminish the secretion of milk; but where these means fail to reduce its size and hardness, it should be frequently rubbed with volatile liniment, and then enveloped in a hot linseed-meal poultice: this may be advantageously made with Goulard, and changed every two or three hours, keeping up a brisk action upon the bowels, as before-mentioned.[74]

If there be much febrile excitement of the circulation, bleeding may be sometimes required: we have rarely, however, found it necessary, having been almost always able to exert a sufficient effect by means of nitre with small doses of Vin. Antimonii and Sp. Æth. Nitr. Leeches seldom give more that temporary relief, and that only when applied in large quantities; in which case so much irritation and inflammation is produced by their bites as not unfrequently to counteract the benefit arising from the loss of blood. The patient should preserve the horizontal posture, or at least have the breast well supported by a soft handkerchief, as otherwise its weight will produce much painful dragging. It is not always easy to detect the fluctuation, particularly when it is seated deep beneath the fascia, which invests the mammary gland; but wherever it is tolerably distinct, especially in the upper parts of the gland, the abscess should be let out early, otherwise it will burrow through a large extent of the breast, and destroy a considerable portion of the gland; whereas, if it be felt below the nipple, it may be allowed to approach nearer to the surface and point, by which means it will not be necessary to make the incision so large or so deep, a point which is worthy of attention, as otherwise considerable-sized milk tubes and even blood-vessels may be divided. Dr. Burns has mentioned a case of fatal hæmorrhage from this cause. In either case, whether the opening has been made artificially or spontaneously, the breast should be constantly enveloped in a hot poultice of linseed meal: if this be made with boiling water it forms a gelatinous mass, which retains its heat for a very considerable time, and not only acts as a fomentation, but gives great relief by softening the indurated portions and diminishing the tension. If the patient can bear it, the breast ought to be drawn by a glass for that purpose: this is much better than the breast-pump, being simple and easy of application. Where little or no milk comes, it is useless to persevere, as we should only expose the patient to much unnecessary pain, and the breast to a good deal of irritation.

It rarely happens that the breast recovers so far as to enable the mother to nurse with it, and she will therefore be obliged to nourish the child entirely from the other, which generally bears the double duty without inconvenience: in some cases, however, there has been so much fever, and the process of inflammation and its consequences has been so long, that it is neither possible nor advisable to keep up or recall the secretions. In succeeding labours great attention must be paid to a breast which has been thus injured, and every disposition to distension and accumulation of milk carefully watched.

By the time a mammary abscess has been fairly opened, the strength of the patient is considerably lowered, not only from the quantity of discharge, but also from the nature of the previous symptoms and treatment; her food should now be more nutritious, she should take a little wine or porter; and if the appetite be delicate, two pills, consisting of equal parts of Extr. Gentianæ and Extr. Hyoscyami should be given night and morning; she will thus be enabled to sleep better, and the general irritability arising from her state of weakness will be relieved. If, however, the appetite fail entirely, and she has a pale flabby tongue, or if it is brown and dry in the centre; if the bowels are deranged, and she has a disposition to profuse perspiration, with much pain in the front or summit of the head, and other signs of debility, the Hydr. c. Cretâ and Dover's powder should be given at night followed by a rhubarb and manna draught the next morning, and if these have acted sufficiently, she may be put upon the use of quinine and sulphuric acid with Tinct. of Hyoscyamus two or three times during the day.

Excoriated nipples. When the nipples are merely excoriated, or there are fissures in them, they should be bathed with tepid Lotio Plumbi or a solution of Zinci Sulph. in rose water, which must be carefully washed off before applying the child to them. If they are too tender to permit being drawn by the child, they should be covered by the shield, to which is attached a cow's udder or some form of artificial nipple, through which the child can draw the milk without pain to the mother; the udder should be kept very clean, and there should be one or two spare ones soaking in water, in order that they may be changed from time to time. Excoriation of the nipples frequently arise from the extreme thinness of the skin which covers them, and from their unnatural softness. Whatever renders the nipples soft and tender, makes the operation of sucking difficult, because the child can draw them out too easily: we should rather be careful to have them firm, and less sensitive of irritation, just as they would be if they had not always been covered by the dress from the earliest childhood, and thus rendered perfectly unfit to perform the office designed them by nature. The best means of attaining this end is to expose them frequently to the air during the latter months of pregnancy, and by dabbing them occasionally with cold water mixed with a little lavender water or eau de Cologne. (Boer.)[75]

It is important that the child should be suckled at regular intervals of about three hours during the day; and if this be done the last thing at night, and the first thing in the morning, there will be no need of giving it the breast during the night. With a little perseverance on the part of the mother, the child soon learns not to require the breast at this time, which ensures her a good night, and spares her much trouble and annoyance. Those mothers who are obliged to suckle their children at all hours of the night to pacify their screaming, have brought the trouble upon their own heads, for if, instead of dosing the children with castor oil, and feeding them for the first day or two after birth, they had put them to the breast at once, the derangement of stomach and bowels which is the cause of this restlessness would have been avoided.

Diet during lactation. Attention should be also paid to the diet of the mother, for upon this subject much erroneous opinion prevails. If she be strong and healthy, her food should be entirely farinaceous for the first three or four days, using gruel, tapioca, farinaceous powder, arrow root, &c. with a due admixture of milk; if there are no symptoms to forbid it, an egg may now be taken in the morning, and she may gradually proceed from chicken, &c. to the stronger meats, as her general condition and appetite point out. Where she is naturally delicate, or has been weakened by a sickly pregnancy, &c. it will be advisable to allow her chicken broth, and weak beef-tea from an earlier period.

"Serious mischief is frequently done by the mother attempting to remedy every temporary diminution of milk, by increasing the quantity of her food, or by imagining that some stimulating drink will answer this valuable end. Owing to some trifling disturbance in the system of a temporary kind, the secretion of milk may be for the moment suspended or diminished. An attempt is made to recall it by an increase of food, by which a slight inconvenience is converted into a permanent derangement of the system, or a fever of even a dangerous character may be generated; or owing to a false theory, or imperfect observation, it has been supposed that certain liquors have a control over the secretion of milk, and hence the too free use of certain combinations, into which ardent or fermented spirits too largely enter. We must not, however, be supposed to deny the influence of certain solid as well as fluid substances upon the secretion of milk, for we well know, that unless the body be properly supported, there must soon be a diminution of milk. We only mean to insist that it is the nutritious, and not the stimulating part of the diet, which is subservient to the plentiful and healthful formation of this fluid. In proof of this we need only observe, that we have often been consulted upon the subject of the failure of milk, where an anxious mother herself, or a hireling nurse, was concerned, and had been informed by them that they had tried every thing with a hope of improving it, such as rich food, porter, ale, beer, &c. without success, or it was followed, perhaps, by a diminution of it. In such cases we have often succeeded in producing a plentiful supply of milk, by adopting the opposite plan of treatment, for it must be borne in mind, as an important truth, that this failure proceeds more frequently from an over, than from an under, quantity of food or of drink. It is a fact well-known to all who have paid attention to the consequences of arterial excitement, that when it amounts to even moderate fever, the milk almost immediately diminishes in quantity; and also when this action is diminished by suitable remedies (provided it has not continued too long,) that the secretion of milk again becomes more abundant. Upon this principle we have frequently prescribed evacuants and abstinence to promote the secretion of milk." (Dewees, on Children.)

Where the mother does not intend to nurse her child, a different plan of treatment must be adopted: the shoulders should be lightly covered, cold evaporating lotions applied to the breasts, and the bowels freely opened by saline laxatives, her diet must be abstemious until the fulness of the breasts subsides, and she ought not to take much fluid: where there is a disposition to febrile action, an antimonial may be advantageously combined with the salines. In most instances the milk is thus checked without any inconvenience, but every now and then much illness and suffering is produced before this can be effected. Wherever, therefore, it is possible for the patient to suckle, the practitioner should urge the importance of it in the strongest terms.

"A very serious evil from a woman neglecting this imperious duty is the probability of her becoming more frequently pregnant than the constitution of most females can sustain without permanent injury. A woman who suckles her children has generally an interval of a year and a half or two years between each confinement; but she who without an adequate cause for the omission does not nurse, must expect to bear a child every twelve months, and must reconcile her mind to a shattered constitution and early old age." (Conquest's Outlines.)

Management of the lochia. The management of the lochia constitutes also an important part of the treatment of a natural labour, for the patient's health will be materially affected by any alteration either in its quantity or quality. The lochia usually continues to be a sanguineous discharge for about three days, becoming paler, thin, watery, and of a brownish hue, and gradually disappears: a free lochial discharge for the first forty-eight hours, at least, is one of the greatest safeguards against the different forms of puerperal fever and inflammation which are so justly dreaded by the practitioner, and nothing tends to ensure this desirable object so much as the early application of the child to the breast. It may seem paradoxical to assert, that what prevents hæmorrhage after labour should promote the lochial discharge: we do not attempt to explain why such is the case, but merely mention it as a fact repeatedly observed. As the lochia is secreted from the internal surface of the uterus, it will continue to accumulate in this cavity and that of the vagina so long as the patient remains in the horizontal posture, the direction of the vagina preventing its spontaneous escape: it will, therefore, be desirable to favour its discharge by occasionally altering the position of the patient, and thus prevent its becoming offensive, which it would readily do from the temperature at which it is kept by the surrounding parts, from being in contact with the external air, and from its muco-sanguineous character. In the same way it frequently happens that small coagula of blood lodge in the uterus and rapidly grow putrid. In either case much irritation and fever are produced by their presence in the passages, and serious symptoms would soon result if they were allowed to continue there. Hence we make it a rule, that whenever the patient requires to evacuate the bladder, she should do it by kneeling: by this means the position of the vagina is altered, and the accumulated discharges and coagula readily drain away and produce the greatest relief. Wherever the patient complains of abdominal pain, and the lochia has become scanty and somewhat offensive, it will be advisable to wash out the vagina with a warm water injection: for the farther treatment of these symptoms, we must refer the reader to the chapter on PUERPERAL FEVER.

After-pains. When coagula have remained or formed in the uterus after labour, these irritate it by their presence, and excite it to contract: pains therefore of a crampy spasmodic character are produced, which have received the name of after-pains. Women who have already borne children are more liable to them than primiparæ. They vary considerably in degree: in some cases they are scarcely sufficient to excite attention; in others they rise to great intensity, and may even be mistaken for inflammation; indeed, they occasionally pass into this condition. During these pains the uterus is evidently in a state of contraction, for the fundus feels hard, and for the moment it is more or less painful to the touch: the patient has also pain in the back like a labour pain.

After-pains do not only arise from coagula in the cavity of the uterus irritating it to contraction, but also from little plugs of coagulated blood, which fill the sinuses opening upon the internal surface of the uterus. After awhile they excite contractions, by which they are squeezed out and come away in the discharges: this fact was first pointed out by Dr. Burton in 1751. Having to introduce his hand into the uterus for the purpose of removing a portion of the placenta, he felt several of these little oblong fibrinous masses exuding from the orifices of the uterine sinuses, whenever he at all stretched the uterus by opening his hand; these proved to be so many fibrinous casts of the above vessels, the blood having been retained and coagulated in them, when the uterus contracted after the birth of the child. When the uterus has been slowly emptied during labour, it contracts gradually and uniformly, and forces the blood from its numerous sinuses into the rest of the circulation; but where its contents have been suddenly removed, the contraction is unequal, and a portion of the blood is retained, which coagulates as described. This fact affords an additional argument in favour of putting the child early to the breast: the active contraction of the uterus, which is thereby induced, effectually expels the coagula from its sinuses: hence we see that where a patient suckles shortly after labour, she seldom (cæteris paribus) has severe after-pains; but where this has been delayed until the second or third day, the first application of the child to the breast is sure to induce a sharp attack; the truth of the old adage, that "the child brings after-pains," is thus verified.

After-pains must be looked upon as an important agent in preventing those attacks of inflammation and fever which arise from the retention of putrid coagula and lochia: they ought not therefore to be checked, unless their severity is such as really demands it: hence the custom of giving an opiate after every labour cannot be too strongly reprobated, for by this means those uterine contractions are suspended, by which nature would have rid herself of the offending cause: nor do we consider ourselves justified in giving an opiate where after-pains are severe, until by change of posture, &c. we are satisfied that no accumulation exists in the passages. "Wherefore," says Burton, "we must not be too forward in giving strong opiates and other internal medicines, which may take them off while this grumous blood is lodged within these sinuses. I doubt not but those patients who die from the eighth to the fourteenth day, whose uterus has been inflamed with the symptoms above-mentioned, have been injured by the too free use of opiates." (Essay towards a complete new System of Midwifery, by J. Burton, M. D. p. 342.) We do not deny that a mild sedative is frequently of great benefit after labour: it calms the irritability of the system and procures sleep: these effects will be much better obtained by a little extract of hyoscyamus, lettuce, or hop. Where an opiate is really necessary, twenty minims of Liq. Opii Sed. in any aromatic water will be as good a form as any.[76]

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III. MECHANISM OF PARTURITION

Cranial presentations--first and second positions.--Face presentations--first and second positions.--Nates presentations.

If we were asked to point out the basis on which the principles of practical midwifery should be founded, we would answer, on an accurate knowledge of the manner in which the child presents, and passes through the pelvis and soft parts during labour. In confirmation of this remark, we may observe, that almost every great improvement in midwifery practice which has taken place during the last century, has resulted from farther investigation into this difficult field of inquiry, and from the gradual addition of new facts to our knowledge respecting this interesting process.

Unless a practitioner be thoroughly acquainted with every step in the mechanism of a natural labour, how can he be expected to understand and detect with certainty any deviation from its usual course, still less make use of those means which may be required under the particular circumstances of the case; and yet, strange to say, there are few subjects which, generally speaking, have excited so little attention, and upon which such incorrect opinions have prevailed even up to the present time. The investigation is confessedly one of considerable difficulty, and as it was more easy to calculate how the head ought to pass in this or that position through the pelvis than to ascertain how it really did pass, ingenuity has been taxed, and theories have been invented, and positions of the child without number have been described, which have never existed in nature, and which have only added to the difficulty and perplexity of the subject.

We consider that to form an accurate diagnosis in these cases, requires the highest perfection of the tactus eruditus, which can only be acquired by long practice and patient observation: and it is chiefly from this circumstance that we can explain why such gross errors and vague notions should have existed about a process of every day occurrence, and why, with but few exceptions, they should have been transmitted from one author to another even up to the present time. In the last century, when it was so much the fashion to resolve every physiological process into a mathematical problem, it was scarcely deemed necessary to spend much time in actual observation and examination; the proportions between the head and pelvis were ascertained, their angles were measured, and their curves determined, and from these data it was inferred, what must be the course which nature would follow; few attempted the slow but surer method of ascertaining by patient research the real facts connected with the process of parturition.

When the long axis of the child's body corresponds with that of the uterus, the child (provided the passages are normal) can be born in that position: it matters little, as far as the labour is concerned, which extremity of the child presents, so long as this is the case; but where the long axis of its body does not correspond with that of the uterus, the child must evidently lie more or less across, and will present with the arm or shoulder, a position in which it cannot be born. In stating this, we wish it to be understood, that we merely refer to the full grown living foetus, and not to one which is premature, or which has been some time dead in the uterus, as these follow no rule whatever, hence the positions of the child at the commencement of labour resolve themselves into two divisions, viz. where the median line of the child's body is parallel with that of the uterus, and where it is not; the first we shall call natural, the second faulty, presentations of the child. A description of the natural presentations will form the contents of the present chapter.

The reader will almost anticipate us when we state, that the natural presentations consist of two classes, those where the cephalic, and those where the pelvic end of the child presents; in the first case, it will be a presentation of the cranium or of the face; in the second, of the nates, knees, or feet.[77]

Cranial presentations. The presentation of the cranium, (or vertex, as it has been improperly called,) is of by far the most frequent occurrence; thus, for instance, of 4042 children which were born in the lying-in hospital, at Heidelberg, 3834 presented with the head; of these the 3795 with the cranium, and 39 with the face: in either case, whether it be a presentation of the cranium or of the face, it will be either with the right or the left side more or less foremost; the former, from its greater frequency, has been called the first position of the cranium or face, the latter the second position.

First cranial position. It will be recollected we have stated, that the os uteri at the end of pregnancy is turned obliquely backwards, corresponding to the upper part of the hollow of the sacrum. If we examine during the first stage of labour, when it is just dilated sufficiently to allow the finger to pass, we shall feel the sagittal suture of the head running across it, dividing it into two unequal portions, the os uteri itself corresponding nearly to the middle of this suture. If the os uteri be sufficiently dilated to let us trace its course, we shall find that it corresponds more or less to the direction of the right oblique diameter, viz. that it runs from the right and backwards, obliquely forwards, and to the left. If we follow it with our finger in this last-mentioned direction, we come to a spot where it divides into or meets two other sutures; these are the right and left lambdoidal sutures, and beyond them is the hard convex occiput, the point where they meet being the posterior or occipital fontanelle. If we trace our finger along the suture in the other direction, viz. backwards and to the right, we shall come to a four cornered space, where four sutures meet at right angles to each other; these are the sagittal, the frontal, and right and left coronal sutures; the open space itself is the great or anterior fontanelle.

That part of the head which lies lowest or deepest in the pelvis, and which the finger first touches upon when introduced along the vagina, is the right parietal protuberance; and if the os uteri be sufficiently dilated, we distinguish it by its hard and conical feel. In primiparæ, where the head usually is deep in the pelvis at the commencement of labour, and where the anterior and inferior segment of the uterus is closely stretched over it, the parietal protuberance may be felt through this part. Hence, then, the first position of the cranium, (or more correctly speaking, parietal bone,) is marked by the following characters: the sagittal suture crosses the os uteri, and runs parallel with the right oblique diameter of the pelvis: the vertex is therefore turned towards the upper part of the hollow of the sacrum, the posterior fontanelle forwards and to the left: the right perietal protuberance, therefore, is necessarily that part which is deepest in the pelvis; and the perpendicular diameter of the head, instead of corresponding to the axis of the pelvic brim, runs in an oblique direction upwards and forwards.

If the head at this early stage of labour be high up in the pelvis, viz. has scarcely entered the brim, as is frequently the case in multiparæ, the sagittal suture approaches in its direction to that of the transverse diameter, or to one between the transverse and oblique diameters, the posterior fontanelle corresponding to about the left acetabulum. The higher the head is in the pelvis, the nearer does its greater diameter correspond to the transverse one of the pelvis: the more oblique also is its perpendicular diameter, from which reason the right ear at this time can usually be felt without difficulty behind the pubic bones. Sometimes both fontanelles can be reached with equal ease; most frequently the posterior one is lowest, but occasionally the reverse is the case, and it is the anterior fontanelle, without, however, at all influencing the progress of the labour.

As the head advances through the brim and begins to enter the cavity of the pelvis, the sagittal suture corresponds more closely with the right oblique diameter, so that now the posterior fontanelle is turned towards the left foramen ovale, and as it approaches the outlet of the pelvis, the occiput advances still more forwards, although the head entirely quits its oblique position. At this stage of the labour, the fontanelles can usually be again reached with equal facility, and we find the anterior one corresponding to the right sacro-iliac synchondrosis, the occiput is completely behind the left descending ramus of the pubes, the right lambdoidal suture running parallel with it. Owing to this slight change in the position of the head, the occiput having advanced somewhat forwards, we no longer feel the right parietal protuberance to be lowest and in the centre of the pelvis, but the finger now touches upon the posterior and superior quarter of the right parietal bone, for this is the part of the head which first comes under the pubic arch, and first enters the external passages.

If there be but little liquor amnii, or the membranes have been ruptured prematurely: if the head be firmly pressed against the os uteri, and we examine when it is not more than two-thirds dilated, we feel a puffy oedematous swelling upon that part of the head which corresponds to the os uteri. This will therefore be found to be situated upon the sagittal suture, nearly equidistant from the anterior and posterior fontanelles; it arises from the circulation in the scalp being obstructed by the pressure of the os uteri upon the head. If the remaining portion of the labour be rapidly completed, this will be the situation of the swelling with which the cranium is born; if, however, it follows a more gradual course, and the head passes slowly through the os uteri into the vagina, as it thus advances deeper into the pelvis, and alters its position more or less, the swelling upon the sagittal suture disappears in part, and forms on that portion of the head which is advancing under the pubic arch, and is now tightly encircled by the external passage: we shall, therefore, find that this second swelling is situated upon the posterior and superior quarter of the right parietal bone, and this is precisely the situation of the swelling of the head, which the child is usually born with.

From these facts we may deduce the following simple law respecting the mechanism of parturition, where the head presents: viz. that the head enters, passes through, and emerges from, the pelvis obliquely; and this is the case not only as to its transverse diameter, but also as to the axis of its brim; the side of the head being always lowest or deepest in the pelvis. This shows the beautiful mechanism of the process, for, on account of its oblique position, there is no moment during the whole labour at which the greatest breadth (still less length) of the head is occupying any of the pelvic diameters; even at the last, when the head is passing under the pubic arch, the complete obliquity of its position, in order that it should take up the least possible room, is very remarkable; for the ring of soft parts, by which the head is now encircled, passes obliquely across it, running close behind the left, and before the right parietal protuberance. The head never advances with the occiput, forwards, under the pubic arch, as is stated in works on midwifery, still less with the sagittal suture parallel to the antero-posterior diameter of the pelvis; for the direction of the right lambdoidal suture, as also of the posterior fontanelle, and the position of the cranial swelling, or caput succedaneum, as it has been called, completely prove the inaccuracy of such a theory, the sagittal suture crosses the left labium at an acute angle, the right lambdoidal suture being parallel with the left descending ramus of the ischium.

Not less incorrect is the theory (for we can call it nothing else) of the head presenting with the vertex, and turning with its long diameter, from the oblique, into the antero-posterior or conjugate diameter, and the face into the hollow of the sacrum, for it is disproved by all the above-mentioned facts, which careful examination during labour puts us in possession of. When the head is born, the face looks backwards and to the right, viz. to the back part of the mother's right thigh, for the shoulders are by this time passing through the pelvis in its left oblique diameter, the right shoulder being forwards and to the right, and lowest in the pelvis: it is also that which is first expelled.

Such is the manner in which the head presents in the first or most common position: a slight modification of it is occasionally observed during the early stages of labour, without influencing the favourable character of its progress: the head at first is in the left oblique diameter of the pelvis, the occiput towards the left sacro-iliac synchondrosis, the anterior fontanelle towards the right acetabulum; but as the labour advances, the head turns, so that the occiput corresponds to the left acetabulum, the anterior fontanelle being turned towards the right sacro-iliac synchondrosis, the sagittal suture running parallel with the right oblique diameter of the pelvis. This peculiar commencement of the labour is probably not detected so frequently as it really occurs, owing to its changing into the common position at so early a period.

Second position of the cranium. The other or second position of the cranium is, where the left side of the head presents. It is, in fact, merely the reverse of the one just described: the sagittal suture crosses the os uteri at the beginning of labour, as in the former case, only now the posterior fontanelle is turned to the right instead of to the left; it is the left parietal protuberance which is deepest in the pelvis, and which the finger first touches upon. As the labour advances, and the head approaches the pelvic outlet, it is the posterior and superior quarter of the left parietal bone which first enters the vagina and protrudes through the os externum, and upon which the swelling of the scalp or caput succedaneum is situated.

The chief peculiarity is, that the change, which we noticed in the first position as an occasional occurrence at the beginning of labour, is in this case the regular commencement of it. In the second cranial position, the head at the beginning of labour, with very few exceptions, is always with its long diameter parallel with the right oblique diameter of the pelvis, the posterior fontanelle turned towards the right sacro-iliac synchondrosis, the anterior one towards the left foramen ovale. During the early periods of labour, when the head is passing through the brim, both fontanelles may be reached; and, generally speaking, the posterior one with greater ease, from its being usually somewhat the lower; but as labour advances, and the head has fairly engaged in the pelvic cavity, they may both be reached with equal ease, the anterior fontanelle still corresponding to the left foramen ovale, or rather to the descending ramus of the left pubic bone. "As soon as the head experiences the resistance which the inferior part of the pelvic cavity opposes to it, or, in other words, the oblique surface which is formed by the lower end of the sacrum, the os coccygis, the ischiadic ligaments, &c. by which it is compelled to move from its position backwards in a direction forward, it turns by degrees with its greater diameter into the left oblique diameter of the pelvic cavity, viz. the posterior fontanelle is directed to the right foramen ovale, and as the head approaches nearer and nearer to the inferior aperture, it is the posterior and superior quarter of the left parietal bone which is felt in the cavity of the pelvis opposite to the pubic arch, so that when the point of the finger is introduced under and almost perpendicular to the symphysis pubis, it touches nearly the middle of the posterior and superior quarter of the left parietal bone: and this is precisely the part, as the head advances farther, which first distends the labia, with which the head first enters the external passages, and the spot upon which the swelling of the integuments forms itself." (Naegelé, Mechanism of Parturition, transl.)

The manner in which this change in the position of the head takes place, varies a good deal in different labours: in primiparæ it usually takes place slowly, and requires several pains before it is completed; as the pain comes on, the posterior fontanelle, which was backwards and to the right, now advances more forward and comes more within reach; the anterior fontanelle, which was towards the left foramen ovale, retreats, so that when the pain has reached its maximum the head will for a moment be felt in the transverse diameter of the pelvis, and again resumes its former position as the pain goes off: with the recurrence of each pain there is a repetition of this screw-like motion, but by degrees the head not only passes from the right oblique into the transverse diameter, but from the transverse into the left oblique, so that at length the anterior fontanelle corresponds to the left sacro-iliac synchondrosis, and the posterior one to the right foramen ovale.

In women who have already had children, the whole change is frequently effected during one pain, so that the head, which but a few minutes previously was presenting in what is called the third position of the German schools, will now be found to be in the second.

It is to the celebrated Naegelé of Heidelberg that we are indebted for having first pointed out the uniform occurrence of this change in the second position. From his extensive and accurate observations, confirmed since by ourselves, as well as by many others, the head presents with the occiput originally forwards and to the right very rarely, but passes into this position during the course of labour. No one has ever described the mechanism of parturition so minutely and correctly; and the value of his investigations is the more enhanced, when we recollect what erroneous notions have prevailed upon this important subject up to the present time. "In the former part of my practice," says this distinguished obstetrician, "not knowing that the head made this turn, I always concluded that my examinations in the early part of labour were incorrect, and was very uneasy that I did not find it all exactly as the books described, and attributed my want of success in ascertaining the position to my own awkwardness. At length in a private case, in which I was much interested, I again felt what I thought was the anterior fontanelle towards the left foramen ovale; and circumstances occurring which rendered it necessary to apply the forceps and terminate the labour, I found that the head had been actually in the position which I imagined I had felt. Since this time I have, in many cases, sat by the bed-side during the whole labour, with my finger upon the head, and thus come at the truth." (MS. Lectures.)

The very circumstance of this change in the position of the occiput from the sacro-iliac synchondrosis to the foramen ovale of the same side, is of itself quite sufficient to mislead; nor is it to be wondered at that it should have been so long unnoticed, when we recollect how difficult the examination is at this early stage of labour, and how few give themselves the trouble to attain that degree of dexterity and tact, which, even under the most favourable circumstances, is required for this species of investigation.

The diagnosis of the sutures and fontanelles may be rendered more difficult by other circumstances: when there is a large quantity of liquor amnii between the head and membranes, it renders the diagnosis exceedingly obscure in the early part of labour. In some cases the cranial bones are remarkably thin and yielding, and communicate a sensation to the finger as if it were touching a fontanelle; in others, the sutures run an irregular course, and form ossa triquetra, &c. which may easily mislead. We may also notice the changes, already mentioned, which are produced by the death of the child, and the various congenital anormalities of hydrocephalus, acephalus, &c. &c. In some cases the sagittal suture is continued backwards through the occipital bone, dividing it into two equal portions, and thus making the posterior fontanelle four cornered, and not to be distinguished from the anterior. Nor is it always easy to distinguish the posterior from the anterior fontanelle under more normal and favourable circumstances; for it would be hazardous to conclude that it is the posterior fontanelle merely because we feel three sutures meeting together, as it may possibly be the anterior one, and we are not able to reach the sagittal suture beyond. In this case we may ascertain which it is by the following rule: if it be the posterior fontanelle in the first position we shall feel a suture running more or less forwards (the right lambdoidal,) but none backwards; but if it be the anterior fontanelle forwards and to the left, we shall also feel a suture (the right coronal) running backwards. Lastly, in the second cranial position the face when born turns to the posterior surface of the mother's left thigh.

Such are the two positions in which the head presents during labour, and such is the manner in which it passes through the pelvis and external passages. Slight deviations do occasionally take place, the chief of which is, that the head in the second position does not always make the quarter of a turn as above described, but comes out with the anterior fontanelle forwards and to the left: this is by no means of common occurrence, and, as far as we have observed, increases the difficulty of labour very little.

Face presentations. The face, like the cranium, may present in two ways, either with its right or left side forwards. The former is the most frequent occurrence, and bears a striking analogy to the first cranial position; indeed, we cannot too strongly impress upon the minds of our readers the advantages of accurately knowing the different features of the two cranial positions just described; for by this means the positions of the face will be rendered much more simple and easy of comprehension. Whether the right or the left side of the face presents (first or second facial position,) the root of the nose crosses the os uteri exactly in the same manner as the sagittal suture does in the two cranial positions; the chin is turned to the right acetabulum, and as the face descends through the pelvis during the progress of the labour, the chin moves somewhat more forwards, as the occiput does in the cranial positions.

At an early stage of labour the right eye and zygoma is that part of the face which is lowest in the pelvis, and which the finger first touches upon during examination, precisely as it was the right parietal protuberance in the first cranial position; and as in this case the caput succedaneum was situated upon the posterior and superior quarter of the right parietal bone, so here the livid bruise-like swelling, which the face brings with it into the world, is situated upon the right cheek, this part being the first which presses through the os externum; the chin passes under the right branch of the pubic arch, as the occiput in the first cranial position does under the left, the face during the whole process preserving a strictly oblique position, both as to the transverse diameter and axis of the pelvis.[78]

Second position of the face. The second position of the face is merely the reverse of the first: it is now the left side which is turned forwards, the left eye and zygomatic process being those parts which are lowest in the pelvis; the chin is turned to the left side and somewhat forward, and advances towards the left foramen ovale during the farther progress of the labour. As the face approaches the inferior aperture of the pelvis, it is the left cheek which first enters the os externum, and upon which the swelling is situated: likewise the chin passes beneath the left branch of the pubic arch.

It has been supposed by some authors, and we think correctly that the majority (if not all) of face presentations are originally cranial presentations: if this be the case, we can easily understand why the right side of the face presents more frequently than the left, for if the head in the first cranial position moves round upon its transverse diameter, and thus allows the face to turn downwards, we shall immediately have a first position of the face. We are the more inclined to adopt this opinion, not only from the greater number of cases where the right side of the face presents, but also from our having more than once met with cases where so long as the head of the child was moveable above the brim, the presentation was midway between one of the cranium, and of the face. On one side of the pelvis we could feel the anterior fontanelle; on the other we could, with some difficulty, reach the orbital process of the frontal bone: as the pains increased, and the head advanced lower, the side of the face came more within reach; so that by the time it had fairly entered the cavity of the pelvis, it had become a complete presentation of the face.[79]

We distinguish the face by the bridge of the nose, which from its crossing the os uteri may be detected at a very early period of labour: it is far better than the eye, for not only is this liable to mislead us in our examination, but it may also receive injury from the finger. Nor is the malar bone a guide, for this might easily be mistaken for the tuberosity of the ischium, or even for the shoulder. The nose not only tells us that the face is presenting but also in which position, for at one end we shall feel the soft cushiony extremity of it, at the other we shall reach the broad hard expanse of the forehead.

It was not until nearly the end of the last century that presentations of the face ceased to be accounted unnatural, and impossible to be terminated by natural means. Although the fact had been pointed out by Portal so early as 1685, that these presentations were very little removed from the usual one, it seems to have excited but little attention until the time of Deleurye in 1770. "I have," says Portal, "delivered several women whose children came with the face foremost, and always without any great difficulty, it being only observed, that in such cases no violence must be used, but nature be left to its own course; which done, there is no danger either of mother or child." (Portal's Midwifery, transl. obs. 66:) La Motte in 1721, although so accurate an observer, could not divest himself of the general opinion that these were unfavourable positions, even although the face was usually expelled by the natural efforts, after he had fruitlessly endeavoured to rectify it, and although he himself confesses never to have "seen any that had not done well."

Giffard has recorded two cases of face presentation (Cases in Midwifery, 1734, p. 59, 443.,) both of which he delivered by his extractor, which was one of the early forms of midwifery forceps; and in both, although the labour had lasted some time, the child was alive. He describes the position of the face in the second case, the chin being turned towards the right side. The only practical observation which he makes is, that turning is very difficult where the "waters are gone off, and the uterus closely envelopes the child." This is probably given as an explanation for his deviating from the usual practice of turning in these cases. Deleurye in supporting Portal's views observes, "one daily sees similar labours terminate naturally: it is true they are somewhat longer, but they terminate without the aid of art." (Traité des Accouchemens, 1770, § 736.)

Lastly, the celebrated Boer of Vienna (1793) placed the matter in a still more decided point of view when he asserted, that "face presentations being merely a rare form of natural labour, should be left to be completed by the natural efforts, since neither the mothers nor their children were exposed to any more danger in this form of labour than they were in the most usual forms of all." Having charge of the great lying-in hospital of Vienna, Boer had ample means of ascertaining the most accurate results on all points of practical midwifery, and his observations on labours where the face presented, are, therefore, peculiarly interesting, and tend strongly to contradict the prevailing opinion respecting the difficulty and danger of these presentations.

"Of eighty cases of face presentations which have occurred during a period of some years, and which I have myself observed and noted down, there were three, or at the most four, where the children were born dead. None of the patients suffered in the slightest degree from any of these labours; and, except one case, all were left entirely to nature: in one case only, on account of the weakness of the pains and doubtful character of the symptoms, I deemed it necessary to terminate the labour by the forceps." (Boer's Natürliche Geburtshülfe, erstes buch, p. 137.) In spite of this valuable practical fact, supported by experience on so great a scale, the opinion that face presentations were preternatural, continued to prevail upon the Continent, being supported by the authority of Baudelocque and Osiander. A similarly unfavourable opinion was entertained by Dr. Smellie in this country, although Dr. W. Hunter, in his lectures delivered prior to the publication of his plates on the gravid uterus (and, therefore, at an early date,) states, "in this case I do not turn the head round in order to deliver, but nineteen times in twenty leave it to itself to come as it will." (W. Hunter, MS. Lectures.)

Dr. R. W. Johnson, who dedicated his New System of Midwifery, &c. to Dr. W. Hunter and others, in 1769, and probably attended his lectures, expresses a similar opinion, and says, that in these cases "nature herself will do the work." (p. 267.) Dr. Alexander Hamilton, in 1784, also speaks favourably of these presentations. "The head will, however, in most cases, advance in that position by the force of the natural pains, though the delivery will be more slow or painful." (Outlines of the Theory and Practice of Midwifery.)

Farther experience has shown that, so long as the pelvis is of the natural size, the head can be born in this position without peculiar difficulty, the soft parts usually require a little more dilatation than where the cranium presents, and, therefore, this stage of the labour is generally somewhat slower. Although presentations of the face are not so favourable for the child as those of the cranium, they stand next to them in point of safety. Where the cranium presents, a slight misproportion between the head and pelvis produces little or no increase of difficulty to the passage of the child; but under similar circumstances, where the face presents, the difficulty may become very serious, for if the labour is prolonged, "the brain and vessels of the neck," observes Smellie, "will be so much compressed and obstructed as to destroy the child." (Explanation to table 25.) A similar view has been given by Dr. Denman, and still more recently by Professor Chaussier, of Paris, and Professor Naegelé; the two latter authorities examined the brain in several still-born children where the face had presented, and invariably found the cerebral vessels gorged with blood.

The presenting side of the face when born is frightfully distorted by the livid swelling above-mentioned; the mouth is pulled to one side and upwards; the angle of the eye is drawn downwards, and the corresponding ala of the nose scarcely discernible amid the purple mass of tumefaction: the less this is meddled with the better, for in the course of a day or two the parts will have returned to their condition; whereas, if friction or hot poultices, &c., be used, ulceration may be the result, and produce considerable disfigurement.[80]

Nates presentations. "After the presentations of the cranium those of the nates are the most frequent in point of occurrence, and also the most natural," says the celebrated Boer, in the work already quoted. Under the term nates presentations, we include those of the knees and feet, as these latter presentations can only be looked upon as modifications of the former. Professor Naegelé, jun., in his new edition of the admirable essay upon the mechanism of labour, published by his father, in Meckel's Archiv. für die Physiologie, has very properly brought these different positions under one head, viz. "positions of the pelvic extremity of the child:" as, however, we possess no word in English to express this, we shall attain the same object by considering knee and footling births as mere modifications of breech presentations.

"As regards the relative situation of the limbs to the body of the child, the position is the same as in the two genera of head presentations above described, viz. the knees are usually drawn up to the abdomen, the feet close to the nates, so that not unfrequently they may both be felt together at the beginning of labour, and afterwards descend into the pelvis and are born together. Sometimes the feet (or perhaps only one foot) are felt higher above the brim than the nates; in which case, as the nates descend they rise, and are turned upon the abdomen and breast of the child, and descend with these parts as labour advances. Frequently it is the reverse: the feet are somewhat lower than the nates; they are felt in the os uteri at the beginning of labour, and descend before them as labour advances. It is rare that the knees come down before the nates during the farther progress of labour, and it is not probable that they are ever found alone in the os uteri at the commencement of it." (H. F. Naegelé, Mechanismus der Geburt, 1838, p. 57.)

The nates may present in two ways, either with the back of the child forwards, or with its abdomen forwards: of these the former occurs most frequently; thus of 161 cases which were accurately ascertained at the lying-in hospital of Heidelburg, 121 were observed with the back of the child forwards, and 40 with it backwards: in either of these positions the transverse diameter of the child's pelvis always corresponds to one or other of the oblique diameters.

"Labours with the nates or feet presenting, follow certain laws quite as much as those where the head presents, only that one more frequently sees deviations from them, both with respect to the manner in which the child presents at the time of labour, and its passage through the pelvis; but where, under a proper state of the other requisites for healthy parturition, no prejudicial result occurs." (Naegelé, on the Mechanism of Parturition, transl. § 19. p. 128.) "In every case, whether the nates have at first a completely transverse or oblique direction, they will be always found, on pressing lower into the superior aperture of the pelvis, to have taken an oblique position; and that ischium, which is directed anteriorly, to stand lowest. They pass through the entrance cavity and outlet of the pelvis in this position, which is oblique, both as to its transverse diameter as well as to its axis."

Thus, if in the first species the left ischium were either originally directed more or less forward, (which is usually the case,) or had taken this direction in passing through the superior aperture, the nates descend in this direction into the pelvic cavity, with the left ischium during the whole time standing lowest; and this is the part, during the farther progress of the nates, which first passes between the labia as the os externum dilates. As they advance, and while the left ischium, which is directed forwards and always somewhat to the right, comes completely under the pubic arch and presses against it, the other ischium, which is situated in the opposite direction, and which has to make a much greater circuit, passes forwards over the strongly distended perineum, so that, when the pelvis is born, the abdomen of the child will be directed to the inner and posterior surface of the mother's right thigh.

"The rest of the trunk follows in this position, and as the breast approaches the inferior aperture of the pelvis, the shoulders press through its superior aperture in the direction of the left oblique diameter; and during its passage (viz. the breast) through the pelvic outlet, the arms and elbows which were pressed against it are born at the some moment. But whilst the shoulders are descending in the above-mentioned oblique position, the head, which during the whole progress of the labour rests with its chin upon the breast, presses into the superior aperture in the direction of the right oblique diameter, (viz. with the forehead corresponding to the right sacro-iliac synchondrosis,) and then into the cavity of the pelvis in the same direction, or one more approaching the conjugate diameter. After this, it presses through the external passage and the labia, in such a manner, that whilst the occiput rests against the os pubis, the point of the chin, followed by the rest of the face, sweeps over the perineum as the head turns on its lateral axis from below upwards.

"But it is sometimes the right ischium, which, in this chief division, is either originally turned forwards, or in the process of time assumes this direction. In this case the child passes through the pelvis in the same manner as before, only with the difference, that the surface of the body takes of course a different position with respect to the pelvic parietes, viz. its anterior surface, which in the former case corresponded to the right side of the pelvis, will be directed to the left, and the head will press through the superior aperture of the pelvis, in the direction of the left oblique diameter (the forehead passing before the left sacro-iliac synchondrosis.)"

"As in positions of the cranium, the swelling of the integuments is chiefly met with on that parietal bone which during the passage of the head, is situated lowest, and on that spot with which it enters the external passage, so in this case the livid coloured swelling appears on that part which, directed forwards, was situated lowest during the passage of the nates, and with which the nates were born.

"In the second chief position, viz. with the anterior surface of the child corresponding to the anterior abdominal parietes of the mother, it is chiefly the left ischium which is either originally situated forwards, or takes this direction as the nates sink through the superior aperture of the pelvis, which latter preserve this oblique direction during the farther progress of the labour, both whilst pressing into the pelvic cavity, and when entering the external passages.

"If the ischia be already born, the anterior surface of the child turns itself to the right and backwards, either immediately, or as the rest of the trunk advances; but the manner in which the head in this case presses through the entrance cavity and outlet of the pelvis, is the same as has already been described." (Naegelé, op. cit. p. 128, 130.)

It appears to be a law in nates presentations, that whatever may be the direction of the child (first or second position) at the beginning of labour, it will always, if not interfered with, be found with its anterior surface turned towards one or other of the sacro-iliac synchondroses, when the thorax or the shoulders are beginning to pass through the outlet of the pelvis. When the nates have once passed the os externum, the position of the child frequently varies a good deal, the abdomen turning first to one side and then to the other. This is especially the case in the second position, where it is more or less forwards; nevertheless, as labour advances, it will almost invariably turn obliquely backwards, and be born in this position. Dr. Collins is, as far as we know, the only English author who has distinctly noticed this fact. "It is very desirable," he observes, "the child should be delivered in this position (viz. the back of the child towards the mother's abdomen,) as it renders the getting away of the head much less difficult; yet where there has been no interference by the attendant in the previous part of the labour, he will rarely find it necessary to alter subsequently the child's position, the breech naturally making the turn above alluded to in its passage." (Practical Treatise on Midwifery, by Robert Collins, M. D. p. 41.)

It sometimes, although rarely, happens in these presentations, that the head does not rest with the chin upon the breast, but the occiput is pressed against the nape of the neck, as in presentations of the face. The passage of the trunk through the pelvis follows, as above-mentioned, as far as the head: this enters the brim with the occiput in advance, and vertex towards one or other ilium. As it advances through the brim into the cavity of the pelvis, it gradually turns more and more backwards, so that when the body is born, the vertex is turned towards the hollow of the sacrum, and the under surface of the lower jaw behind the symphysis pubis.

The diagnosis of nates presentations is not difficult. The pointed and more or less moveable coccyx, bounded at its broader end by the hard uneven sacrum, and in the contrary direction by the anus, will scarcely admit of a mistake. The tuberosities of the ischia may easily be mistaken, for the malar bone of a face presentation, or even a shoulder, can scarcely be distinguished from them, and the external organs of generation become too much swollen and pressed together to give any certain diagnosis; nor indeed can they be examined in this state without considerable risk of injury. The direction of the sacrum, like that of the forehead in face cases, points out the exact position of the child.

Presentations of the nates, although perfectly natural as far as labour is concerned, are far more dangerous for the child than those of the face, for when the head enters the pelvis, if every thing be not favourable for its passing rapidly through it, the cord is so long compressed that the child is almost certainly lost.

The natural position of the foetus in utero is admirably adapted for its safe passage through the pelvis under these circumstances, and is what we ought to maintain, as far as possible, during labour. The legs are turned upon the abdomen, the arms are crossed upon the breast, the chin rests upon it, the head being bent forwards, so that the whole forms an oval mass. So long as the child advances gradually, the fundus presses firmly upon the head, and keeps the chin close upon the breast; the head therefore enters the pelvis in the most favourable position possible, and the uterus, not having been suddenly emptied of a part of its contents, continues to act briskly, and presses the head so rapidly through the pelvis, that the child is born without having suffered from any serious pressure upon the cord. As however the body of the child diminishes from its pelvis up to the axillæ, it is very apt to be rapidly expelled as soon as the nates have passed the os externum; and if not, it is but too frequently assisted, as it is called, at the very moment when it ought rather to be supported and prevented from advancing too suddenly. When this is the case, the fundus ceases to press upon the head, the chin quits the breast, and as a space is thus left between them, the arms slip into it, and then turn upwards, so that the head not only enters the pelvis in a most unfavourable position, but, to make matters still worse, it has an arm on each side of it: at this critical moment the uterus, from having been suddenly emptied, ceases to contract, and the head remains so long in the pelvis that the child has no chance of escaping with its life.

Where the child has descended gradually, and the arms have advanced with the breast into the pelvis, if the cord be considerably upon the stretch, a portion should be pulled gently down in order to relax it, and we should endeavour as far as possible to guide that part of it which is within reach towards one of the sacro-iliac synchondroses, being less liable there to suffer from pressure. One or two fingers should be introduced to bring down the arms, which are now coming into the lower part of the hollow of the sacrum: they should be hooked down by the bend of the arm, in order to prevent the humeri from sticking across the passage. When this has been effected, the shoulders follow as the head descends through the pelvis. The body of the child should now be wrapped in warm flannel, and two fingers passed up towards the face: the lower jaw must not be trusted to in bringing the head through the pelvic outlet and os externum, for it may easily be broken: the fingers should be applied one on each side the nose, and the chin depressed as much upon the breast as possible, by which means the head will come in a much more favourable direction, and pass readily.

In no case is so much mischief done by impatient interference as in presentations of the lower end of the child. This is still more so in footling cases, for here the soft parts are not so well dilated as in nates presentations, where the child comes double: hence the fact, that presentations of the feet are easier to the mother but more dangerous to the child. In either case, the passage of the head through the pelvis must ever be attended with considerable hazard, for if it be delayed beyond a short time, the child's death is certain. "The more gradually the nates and body of the child are expelled, the quicker will its head pass through the pelvis, and the better will be its chance of being born alive." (Obstet. Memorand. 2d ed.) Hence, therefore, if the pains are slow at this moment, it will be desirable to rouse them with a dose of ergot; and if the child gives a convulsive twitch, the forceps ought instantly to be applied. The result of Professor Busch's practice in the lying-in hospital at Berlin shows, that by the timely use of the forceps a large majority of children may be saved. For the same purpose, the nurse should be instructed to have a warm bath in readiness, with some spirit, &c. for resuscitating the child the moment it is born.

The numbers which we subjoin are taken from the cases in the Dublin Lying-in-Hospital, under the late Dr. Joseph Clark and Dr. Collins, from the private practice quoted in Dr. Merriman's Synopsis, and from the General Lying-in-Hospital.

Of 71,578 labours, the nates presented once in every 78 cases, and the feet once in every 108-1/2. Of the nates cases the child was born dead in the proportion of 1 to 3·8, and in the footling births 1 to 2·8.

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I. THE FORCEPS

Description of the straight and curved forceps.--Mode of action.-- Indications.--Rules for applying the forceps.--History of the forceps.

Before describing the various species of dystocia, or faulty labour, it will be necessary to consider the different means with which the increasing experience of years has furnished us, of giving artificial assistance in such cases. These may be brought under two heads, first, where delivery can be effected with safety to the mother and her child; secondly, where this can only be effected at the expense of the infant's life. Under the first head come the forceps, turning, the Cæsarean operation, and artificial premature labour; under the second are craniotomy or perforation, and embryotomy.

Of these the forceps is by far the simplest and safest means of artificial delivery, and is therefore an operation which should always be had recourse to in preference to any of the others wherever it is possible.

The forceps is the simplest imitation of nature, for in fact it is nothing more than a pair of artificial hands introduced one on each side the head. It is impossible to define any precise limits of pelvic contraction, within which the forceps can, or beyond which it cannot, be safely applied, for the difference in the size and hardness of the child's head, and in the condition of the soft parts, will greatly modify the degree of resistance to the progress of the labour: hence the attempt to fix the exact degree of contraction beyond which the forceps becomes inapplicable is quite impracticable, as in some cases we might be led to make a trial of it where it would be quite improper, and in others have recourse to the perforator where a cautious application of the forceps would have been attended with success. For the farther consideration of this subject we must refer to the chapter on DYSTOCIA PELVICA.

The forceps consists of three parts--the blades, the lock, and the handles.

The blades of the present forceps are not solid, but are merely elongated bows of polished metal, by which they are not only rendered much lighter, but allow the most prominent parts of the head to project between them, and thereby take up no additional room when introduced into the pelvis. In the simplest form, viz. the straight forceps, the blades have only one curvature for adapting them to the convexity of the head. The degree of curve varies a good deal in different instruments: the greater the curve the more firmly will the blades hold, because they act more or less as blunt hooks, and do not require much pressure upon the head for the purpose, but on the other hand, they are more difficult to introduce; whereas, blades which are slightly curved can be applied with greater ease, but require much more pressure upon the head in order to hold fast.

It has been a general rule with almost every modification of forceps, that the greatest distance between their blades should not be less than two inches and a half, for as this is the breadth of the basis cranii in the foetal head, it would be impossible to compress the head beyond this extent. The form of the head curvature will determine the situation of the point where the blades are most distant from each other: in some forceps it is about one-third the length of the blades from their extremities; in some it is nearly equidistant; whereas, in others it is nearer to the lock; the medium between these extremes is the best. The extremities of the blades ought to be at least half an inch apart: in this country they are usually somewhat more; on the Continent they are much less, being rarely more than one or two lines asunder. The fenestræ, or open spaces in the blades, should be wide and ample, for not only are the projecting parts of the head allowed to protrude between them, but the pressure of the blades is diffused over a larger extent of surface: this is remarkably seen in the forceps of the late Dr. Hopkins and that of Professor Davis, both of which are extensively used. It is also important that the edge at the extremities of the blades should be well rounded and not too thin; it is thus less liable to catch against corrugations either of the vagina or foetal scalp. The greatest breadth of the fenestræ is generally towards the extremities of the blades; in some, their edges are parallel; whereas, in those of Drs. Orme and Lowder the greatest breadth is near the lock: upon the whole, an oval shaped fenestra is the best, for it can be easily introduced, and has the advantages of a wide blade.

In 1751 and the following year another curve was given to the blades of the forceps by the celebrated M. Levret of Paris, and by the equally distinguished Dr. Smellie of London, by which the instrument was adapted to the curve formed by the axes of the brim, cavity, and outlet of the pelvis, and by which the head could be seized much higher in the pelvis than by the straight forceps. Each have an equal claim to the merit of having invented this "pelvic curvature," as it has been called: the priority of the invention is perhaps due to Levret; but as he made a secret of it for some years, it is impossible to ascertain the precise fact. The pelvic curve, as it is called,[81] is especially adapted to the long forceps, which thus becomes an instrument of very considerable power. Numerous modifications of these curved forceps have since been made, but they are merely varieties of the original ones invented by Smellie and Levret, which have become the national instruments of their respective countries.

Perhaps the greatest improvements in the blades of modern times is seen in the forceps of Dr. Hopkins, above alluded to: the head curvature forms an elongated oval, admirably adapted to the form of the foetal head when considerably compressed during a difficult labour; and from the great breadth of the fenestræ, the pressure of the blades is applied over a large extent of surface; the pelvic curve is but slight, being greater on the posterior edge of fenestræ than on the anterior; the blades themselves are thin, their inner surface flat to ensure a firmer hold, their outer surface slightly rounded in order to be introduced with greater ease; and for a similar reason the edges of their extremities are somewhat thicker and carefully rounded in a peculiar manner.

The lock of the modern English forceps consists of two deep grooves, into which the shank of each blade mutually fits, so that the two blades are fixed upon each other merely by the pressure exerted upon the handles. In former times the blades were united together by a pivot, which could screw and unscrew at pleasure. This was abandoned by Chapman, who published the first work in English on operative midwifery.[82] He found that the forceps held better without the pivot than with it; and from what we have brought forward elsewhere (Med. Gaz. Jan. 8, 1831,) there can be little doubt that he invented the lock which is now generally used in this country. Chapman's forceps was adopted in France prior to this improvement in its lock, especially by Gregoire, and has retained the original pivot lock which now forms one of the most distinguishing marks between the French and English forceps. Although the pivot forms by far the firmest lock, for the blades can never slip from each other, still the difficulty in locking, and also in separating, the blades at a moment's notice, render it much inferior to the English lock. An ingenious modification was invented by the late Professor Von Siebold of Berlin, but the most perfect lock is that of Professor Brüninghausen of Würzburg, first introduced by ourselves into this country, and commonly known among the instrument-makers under the name of Professor Naegelé's forceps. The shank of one blade has a semicircular indentation, which at the moment of locking fits into a fixed pivot in the other: this, therefore, combines the advantages of the French and English locks. We can safely affirm, from extensive experience for many years, that there is even less difficulty in locking it than with the English lock: the blades are capable of instant separation, and yet when locked, the firmness of their union is equal to that of a pivot joint.

The handles of the English forceps are pieces of wood or ivory fixed upon each shank below the lock, flat upon the inside, convex externally and furnished with a depression or groove at the lower end for fixing a ligature round them. These handles were probably first introduced by Dr. Smellie, who seems to have borrowed the idea from the forceps of M. Mesnard, for the earlier English forceps, viz. of Giffard and Chapman, terminated in blunt hooks, those of the former being curved inwards, those of the latter outwards, a form of handle which has been retained in the French forceps up to the present time.

There are two pieces of forceps, the long and the short forceps; the former for cases where the head is still high in the pelvis, the latter when it is at the pelvic outlet and approaching the os externum; the former with few exceptions being curved, the latter straight.[83]

The forceps act in three ways, 1. by mere pulling; 2. as a species of double lever, by moving the handles from side to side; and 3. by compressing the head, thus still farther disposing it to elongate and adapt itself to the passage through which it has to be expelled.

The blades should always, if possible, be applied one on each side of the head, the position of which must be determined by the direction of the fontanelles and sutures, not by feeling for the ear, as is usually recommended in this country. The ear can seldom be reached without causing a good deal of pain, even under the most favourable circumstances; in cases, therefore, where the head is so impacted as to be incapable of advancing by the natural powers, it cannot surely be justifiable to force up the finger between the head and the pelvis to ascertain this point, the more so, as the soft parts soon become swollen and more or less inflamed, and, therefore, little able to bear such rude treatment. No operation requires such an intimate acquaintance with the mechanism of parturition as that for applying the forceps: it is simple and generally perfectly easy when the precise position of the head and its relations to the pelvis are accurately known; on the other hand, it is not less injurious and painful to the patient than difficult and unsatisfactory to the practitioner.

The most usual circumstances under which the forceps is applied, are where the head is already deep in the pelvis and approaching the os externum; in such cases it is generally required not so much for the purpose of overcoming an unusual degree of resistance, as for assisting the natural powers, which are becoming exhausted: the head is near the os externum, and therefore easily reached; and from there being little or no impaction present, the blades are applied without difficulty.

The application of the forceps when the head is at the upper part of the pelvis, and where the greater portion of it has not yet passed the brim, is rarely practised in this country, because as the necessity for performing the operation at this stage arises in most instances from contraction of the brim, the perforator has usually been preferred, wherever the expelling powers have proved incapable of overcoming the resistance to the passage of the head. The circumstance also of this condition requiring the long forceps has been another source of objection, from the much greater power which this instrument is capable of exerting, and from its being therefore more liable than the short forceps to prove mischievous in the hands of the inexperienced.

Cases however do occur where there is but a very slight want of proportion between the head and pelvis, where the obstacle is easily overcome, and where, but for the application of the forceps, the labour would either have been protracted to a dangerous degree, or have required the use of the perforator.[84] "On the whole," says Dr. Burns, "I would give it as my opinion that a well instructed practitioner, who has already had some experience in the use of the short forceps, is warranted to make a cautious, steady, but gentle attempt to apply and act with the long forceps in a case where he is not quite decided that the perforator is indispensable, and where the head is higher than admits the application of the short forceps." (Principles of Midwifery, 9th ed. p. 493.)

In applying the forceps, whether short or long, there are two conditions which, cæteris paribus, are requisite in every case; first, that the os uteri shall be fully dilated; secondly, that the pains are within the bounds of what are commonly known as moderate pains. In the first case it will be very difficult and frequently quite impossible to pass the blades between the head and os uteri when only partly dilated; it will be difficult to avoid injuring its edge more or less, and if we do succeed in applying and locking the forceps, on making an extractive effort we shall find that the uterus descends with the head as we draw it down.

In the second place we ought never to apply the forceps whilst the pains are violent, for not only do they render its application difficult and even dangerous, but we are adding still farther to the force (already too great) with which the head is pressed against the pelvis. Where the head remains immoveable under violent exertions of the uterus, it is not a case for the forceps but for the perforator; nor does it admit of much delay, for it endangers much injury of the soft parts or even rupture of the uterus.

It is exceedingly difficult to assign any precise limits of pelvic contraction, within which the forceps can, and beyond which they cannot be applied, for the size and hardness of the foetal head, the nature of the pains, and the condition of the patient must also be taken into account in every instance; hence, we frequently meet with cases where the pelvis is scarcely if at all contracted, and yet where the labour has been terminated with the greatest difficulty by means of the forceps; whereas, in others where we know the pelvis to be more or less deformed, the child has been delivered by the natural powers. This subject will be still farther considered under DYSTOCIA PELVICA.

The general indications for the use of the forceps are two: 1. They are indicated in all labours which are difficult or impossible to complete, either from deficiency in the expelling powers, or from misproportion between the head and pelvis, or from the arm coming down with the head. 2. They are indicated by circumstances or accidental causes, which render labour dangerous for the mother or child, and where the danger can only be removed by hastening labour, as in cases of hæmorrhage, convulsions, syncope, alarming debility, faulty condition of the organs of respiration, danger of suffocation, obstinate vomiting, unusually severe pains in nervous irritable habits, hemorrhoids which have burst, hernia, retention of urine, determination of blood to the head, prolapsus of the cord, (in certain cases,) inflammation of the uterus, &c. (Naegelé, MS. Lectures.)

We have already stated that an intimate acquaintance with the mechanism of parturition is of the greatest importance in applying the forceps. Knowing that the head always presents in one of the two oblique diameters of the pelvis, and that the blades are applied on each side of the head, it follows that the forceps must always be applied in the contrary oblique diameter of the pelvis to that in which the head is. Before speaking of the operation itself, we must first consider what position of the patient will be the most convenient. In this country no alteration is made in her position, beyond bringing her close to the side of the bed, with the nates projecting as much as possible over the edge, for the greater convenience of the operator; unless this be attended to, it will be difficult to depress the handle of the upper blade sufficiently when introducing it. Upon the continent, and also in America, where the long forceps is more generally used, the patient is usually delivered on her back; she is placed in a half-sitting posture upon the edge of the bed, her back supported by pillows, &c., her feet resting on two chairs, between which the operator stands or sits, and applies the forceps in this position. This, in many respects, is the most convenient posture for him, but the very preparation which it requires cannot but be alarming to the patient, who is obliged to be a witness of all his manipulations; whereas, when she lies upon her left side, she is aware of little or no preparation being made, and if any slight exposure happens to be necessary, viz. at the moment of locking, it can be done without her knowledge.[85]

The simplest case for applying the forceps is, where the head has already descended nearly to the os externum, and has begun to press upon the perineum: it is for this that the straight forceps is chiefly intended; and as this is the instrument which is generally used, we shall describe its application first.

Mode of applying the forceps. Having ascertained that the rectum and bladder are empty, examined the position of the head, and warmed and greased the blades, we proceed to introduce the upper or lower blade first, according as its lock is directed forwards: this precaution is for the purpose of preventing the locks being turned away from each other when brought together after the introduction of the second blade. The trochanter major will guide us as to the precise position of the patient's pelvis, and is especially useful in pointing out the direction of the left oblique diameter, in which the forceps (on account of the first position of the head being in the right oblique diameter) should be most frequently applied: in this case, we pass the upper blade, as it were, beneath the trochanter, and the lower one in the opposite direction.[86]

Let us suppose that the head is in the first position, with its sagittal suture parallel with the right oblique diameter of the pelvis, and that in accordance with the above rule, the upper blade is to be introduced first. Having passed one or two fingers up to the head, we guide the blade along them, depressing the handle so as to make the extremity of the blade lie closely upon the head, neither allowing the point alone to impinge upon the head, nor vice versâ, to protrude against the vagina. The extremity of the blade, therefore, must be our guide for the direction in which we hold the handle: we must carefully insinuate this by a gentle vibratory motion between the head and passage which surrounds it: the convexity of the head will show the course which it has to take, nor is there any need of passing the finger farther; for when once the extremity of the blade is fairly engaged between the head and passage, it will almost guide itself, and needs little more than to be pushed on gently, the handle gradually rising according to the curve of the blade. The shank or handle should, therefore, be held lightly like a pen, by which means the operator will possess much more feeling with his instrument, than if he grasped it with his whole hand. As the blade advances, he should keep his eye on the general form of the pelvis, the curve of the loins, the situation of the trochanter and symphysis pubis, and thus gain a more accurate idea of the course which the instrument must take. This will, in great measure, depend upon the situation of the head: if it be quite down upon the perineum, the blade should be pointed towards the promontory of the sacrum, and the handle turned downwards and forwards; if it be still in the cavity of the pelvis, and only beginning to engage in the outlet, the blade must be directed upwards towards the centre of the brim, and the handle turned directly downwards. Having passed the blade to its full extent, we must press the handle backwards against the perineum, to allow sufficient room for the introduction of the second blade, and give it to an assistant or the nurse, with the caution to hold it steadily and firmly, especially during the pains, when it is apt to slip into the hollow of the sacrum if held carelessly.

As we have passed the upper blade behind the right acetabulum or foramen ovale, so now we must introduce the other in the opposite direction, viz. before the left sacro-iliac synchondrosis: and, as the blades being exactly opposite to each other is essential to the easy locking of the instrument, it will be necessary to guide the course of the second blade, not so much by the form of the pelvis, as by the direction of the first blade. It must, therefore, pass up, so that when introduced to its full extent, the inner surface of its handle shall correspond precisely to that of the first blade. The easy or difficult locking of the blades is a proof of their having been correctly or incorrectly introduced. If, therefore, on bringing the locks together we find that they do not correspond, that the inner surfaces of the handles are not parallel, but form an angle with each other, we must endeavour to rectify this, by withdrawing, to a short extent, that blade which deviates most from the proper direction, and pass it up again more correctly. All attempts to twist the handles so as to correspond with each other, are bad and cannot fail to put the patient to much suffering.

When we are about to lock the blades, we cannot be too careful in preventing the soft parts from being pinched between them, for it causes most intolerable pain, and frequently makes the patient give such an involuntary start, as to run the risk of altering the position of the instrument.

The whole process of introducing and fixing the forceps should be conducted in as gentle and gradual a manner as possible: no attempt should be made to proceed with the operation during a pain; and in no case is force either necessary or justifiable.

Every thing being now prepared for the extraction, we must endeavour to make this resemble as far as possible the natural expulsion. When a pain, therefore, comes on, we should grasp the handle firmly, and pull gently, at the same time giving them a rotatory motion. The direction of the handles, as before said, will depend upon the situation of the head in the pelvis: if it be at the outlet, it will point downwards and forwards; if in the cavity, nearly directly downwards. If the head makes but little or no advance with one or two efforts, it will be advisable to tie the handles firmly together, and thus keep up a continued pressure upon it, and dispose it the more to elongate and adapt itself to the passages. As it advances and begins to press upon the perineum, we must be more than ever cautious not to hurry the expulsion, and give the soft parts time to dilate sufficiently. At this period it is desirable to make the extractive effort not so much forwards as the direction of the handles would seem to indicate: we thus avoid pressing too severely upon the urethra and neck of the bladder, which might otherwise suffer, and assist the dilatation of the perineum. When the head is on the point of passing the os externum, all farther extractive efforts should cease; the perineum must be supported in the usual manner, and the head should be expelled if possible by the patient herself.[87]

In applying the curved forceps we must bear in mind another rule in addition to the one above-mentioned for selecting the first blade, viz. the pelvic curvature must correspond with that of the sacrum. As with the straight, so also with the curved forceps, the extremity of the blade will be our best guide as to the direction in which we should hold the handle at the moment of introduction; it must be directed more or less forwards in proportion to the degree of the pelvic curvature of the blade. If, for instance, it be the upper blade which is to be introduced first, we pass it obliquely over the lower thigh or nates of the mother, making it glide closely round the convexity of the head, between it and the pelvis, without impinging either on the one or the other. As the position of the head is still more distinctly oblique at this earlier period of its progress through the pelvis, so will the blades require a more oblique direction, and also (as in the former case) they must be introduced in the contrary oblique diameter to that in which the head is.

As the blade passes up between the head and pelvis, so does the handle gradually make a sweep backwards, until at length it approaches to the edge of the perineum. During the process of introduction, one or two fingers should press against the posterior edge of the blade to guide it up to the brim of the pelvis, and prevent its slipping too far backwards towards the hollow of the sacrum.

The second blade will be guided in its direction by that of the first: it must be introduced so that the inner surface of its handle corresponds exactly with that of the first. The locking must be performed under the same precautions as with the straight forceps: the more so, as in some cases it has to take place just within the os externum, and therefore requires the most careful attention to prevent the soft parts from being caught and pinched between the blades when they are brought together. In extracting the head we must bear in mind the part of the pelvis in which it is impacted, and make our effort in the direction of its axis; we must also recollect the curved form of the instrument, and that we must not pull in the direction in which the handles point, but rather hold them firmly with one hand, and, by pressing against the middle of the forceps with the other, guide the head downwards and backwards into the cavity of the pelvis. We shall thus make our extractive effort in the direction of the upper portion of the blades, or that part which has the chief hold upon the head: hence, therefore, as it descends, the handles are directed more and more forwards, so that when it has reached the perineum, the handles will not only point forwards, but considerably upwards. Whilst extracting we should, as with the straight forceps, slowly move the handles from side to side, and even make them describe a circle: we thus not only use the forceps as a simple extracting instrument, but make it act as a lever in every direction, and greatly facilitate the advance of the head, even under circumstances of considerable impaction. It is in these cases where keeping up a continued pressure upon the head by tying the handles tightly together, and tightening it after every successive effort, has such excellent effects in diminishing the degree with which it is wedged against the pelvis and soft parts, and in disposing it by gradual elongation to assume a form which is better adapted for advancing through the passages.

The slow and gradual pressure of the forceps thus exerted upon the head of a living foetus will have a very different result to that of the experiments by Baudelocque and others, in attempting to compress the head of a dead foetus by the application of a sudden and powerful force. Even if we were capable of effecting no greater diminution of its lateral diameter than a quarter, or at the most, three-eighths of an inch, as stated by Dr. Burns, we should, in most cases of impacted head, where the forceps is justifiable, find it quite sufficient to remove the obstructing causes.

The forceps is also occasionally required in presentations of the face and nates. In the first case we must pass up the blades on each side of the face, and along the side of the head, having previously ascertained to which side of the pelvis the chin is turned. In nates cases, the blades should also be passed up along the sides of the child's pelvis, and here the advantages of a broad fenestra will be very evident, for otherwise our hold will not be firm enough without exerting an improper degree of pressure.

Cases every now and then occur, where from convulsions, &c., it is desirable to apply the forceps whilst the patient is lying upon her back, as is practised upon the continent. "The patient is placed across the bed, propped up in a half-sitting posture, by pillows, &c., her pelvis resting upon the edge, her feet on two chairs, the knees supported by assistants. Two, and generally three fingers are passed, if possible, up to the os uteri, on the side where the blade is to be introduced: the index finger, is held a little behind the middle finger, so that this last, by projecting somewhat, forms a species of ledge upon which the blade slides, and which acts as a fulcrum to it. The handle is held at first nearly perpendicular; but as the blade advances, it gradually approaches the horizontal direction, being guided by the pelvic curve of the instrument. The middle finger, along the ulnar surface of which the convex edge of the blade slides, prevents its extremity from passing too far backwards, and directs it in the axis of the pelvis. When introduced to the full extent, the handle is inclined obliquely downwards, and is now grasped by an assistant passing his hand below the patient's thigh. The other blade is introduced in the same way on the opposite side of the pelvis; and the locking, extraction, &c., conducted much in the same manner as in England." (British and Foreign Med. Rev. vol. iii. April 1837, p. 419.)

History of the forceps. We have already mentioned some historical points connected with the improvements of the present French and English forceps; it will now be unnecessary to enter more fully into the history of this instrument. The earliest trace of the midwifery forceps which we possess is under the form of a secret in the hands of an English family, named Chamberlen. As to when and by whom it was first invented, this must probably remain for ever unknown; and at any rate there is no more reason to suppose that Dr. Hugh Chamberlen was the inventor than his father or brothers were. He was compelled to quit England on account of being involved in the political troubles of the time, and went to Paris in the beginning of the year 1770, and evidently had then been some time in possession of the secret. He returned to London, in August of the same year, having in vain attempted to sell it to the French government, after having entirely failed in a case of difficult labour which he had asserted he could deliver in a few minutes, although Mauriceau had stated that the Cæsarean operation would be required. Dr. H. Chamberlen published in 1772, a translation of Mauriceau's work, which had appeared four years previously, and in his preface he publicly alludes to this secret, and says, "My father, brothers, and myself (though none else in Europe, as I know) have, by God's blessing and our industry, attained to, and long practised a way to deliver women in this case without any prejudice to them or their infants: though all others (being obliged, for want of such an expedient, to use the common way) do or must endanger, if not destroy, one or both, with hooks." He thus apologizes for not having divulged this secret: "there being my father and two brothers living, that practice this art, I cannot esteem it my own to dispose of, nor publish it without injury to them."

Whether a work, entitled Midwife's Practice, by Hugh Chamberlen, 1665, was by the translator of Mauriceau's work, or by his father, must now remain a matter of doubt: it was, however, in all probability by the latter, from what the translator says in his preface, viz. "I designed a small manual to that purpose, but meeting some time after in France, with this treatise of Mauriceau, I changed my resolution into that of translating him." On account of his being attached to the party of James II. he was again obliged to quit England, in 1688, and crossed over to Amsterdam, where he settled, and in five years after succeeded in selling his secret to three Dutch practitioners, viz. Roger Roonhuysen, Cornelius Bökelman, and Frederick Ruysch, the celebrated anatomist. In their hands, and in those of their successors, it remained a profound secret until 1753, when it was purchased by two Dutch physicians, Jacob de Visscher and Hugo van de Poll, for the purpose of making it generally known. It turned out to be a flat bar of iron, somewhat curved at each end: this lever was stated to have been received from Roonhuysen, one of the original purchasers of the Chamberlen secret; but there is no reason to suppose that any such instrument had been communicated by Chamberlen either to him or the others, as we have distinct evidence that both Ruysch and Bökelman possessed forceps, the blades of which united at their lower end by means of a hinge and pin. It is known also that Roonhuysen used a double instrument consisting of two blades. The above-mentioned flat bar of iron, commonly called Roonhuysen's lever, was, without doubt, invented after his time, by Plaatman, who received the Chamberlen secret from him. (Edin. Med. and Surg. Journal, Oct., 1833.)

Not many years ago a collection of obstetric instruments were found at Woodham, Mortimer Hall, near Mildon, in Essex, which formerly belonged to Dr. Peter Chamberlen, who, having purchased this estate "some time previous to 1683," was, in all probability, one of the brothers alluded to by Dr. Hugh Chamberlen, in his preface to the translation of Mauriceau's work. This collection, (now in the possession of the Medico-Chirurgical Society, of London,) contains several forceps, two of which appear to have been used in actual practice: these differ from each other only in size, and present a great improvement upon the instrument possessed by Hugh Chamberlen, at Amsterdam. The blades are fenestrated and remarkably well formed: the locks are the same as of a common pair of scissors, except that in one case the pivot is riveted into one lock, which passes through a hole in the other when the blades are brought together. In the smaller forceps there is merely a hole in each lock through which a cord is passed, and then wound round the shanks of the blades to fasten them together, an improvement in which Dr. Peter Chamberlen had evidently anticipated Chapman, in making the first approach to the present English lock.

The earliest professors of the forceps, besides the Chamberlens, were Drinkwater, who commenced practice at Brentford, in 1668, and died in 1728; Giffard, who has given cases where he used his extractor as early as 1726; and Chapman, who possessed a similar instrument about the same time. These forceps correspond very nearly with the above-mentioned ones of Dr. Peter Chamberlen; and as it is well known that from those of Giffard and Chapman, the forceps of the present day are descended, we cannot consider ourselves so much indebted to Dr. Hugh Chamberlen for these instruments, to which his bear so distant a resemblance, as to his relations, who, from living together in England, had doubtless assisted each other by their mutual inventions, and thus brought the instrument to that state of improvement in which it was found as above-mentioned.

For more detailed information respecting the history of the forceps we may refer our readers to Mulder's Historia Forcipum, &c., particularly, the German translation by Schlegel, to a similar work brought down to the present time, by Professor Edward von Siebold, to our own lectures on this subject, published in the London Med. and Surg. Journal, for March 28, 1835, vol. vii., and to the two papers already alluded to in the London Med. Gazette, Jan. 8, 1831, and Edinburgh Med. and Surg. Journal, October, 1833. [Also, Researches on Operative Midwifery, &c. By FLEETWOOD CHURCHILL, M. D., essay iv. on the Forceps. Dublin, 1841.--ED.]

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II. TURNING

Turning.--Indications.--Circumstances most favourable for this operation.--Rules for finding the feet.--Extraction with the feet foremost.--Turning with the nates foremost.--Turning with the head foremost.--History of turning.

Turning is that operation in midwifery where the feet, which had not presented at the time of labour, are artificially brought down into the os uteri and vagina, and in this manner the child delivered. (Naegelé, MS. Lectures.)

Besides turning with the feet foremost as now described it has also been proposed, as being safer for the child, to bring down the nates or the head, but these operations, especially the former, have scarcely ever been practised, and in most cases are impracticable.

Turning, in the strict sense of the word, is that operation, by which, without danger to the mother or her child, the position of the latter is changed, either for the purpose of rendering the labour more favourable, or for adapting the position of the child for delivering it artificially.

The delivery of the child with the feet foremost, by means of the hand alone, may be looked upon as a second stage of the operation; where, however, the turning has been undertaken on account of malposition of the child, it has been very properly recommended by Deleurye, (Traité des Accouchemens, 1770,) Boer, (Naturliche Geburtshülfe, 1810,) Wigand, (Geburt des Menschen, 1820,) and other high authorities in midwifery, that as the position is now converted into a natural one, (viz. of the feet,) it should be left as much as possible to the natural expelling powers; hence, therefore, under these circumstances, artificial extraction of the child with the feet foremost can scarcely be said to exist, the operation itself being confined to changing the position of the child.

Where, however, the circumstances of the case require that labour should be hastened in order to avert the impending danger, the extraction of the child with the feet foremost, by means of the hand alone, becomes a distinct operation.

The artificially changing the child's position into a presentation of the feet is indicated in cases where, on account of malposition of the child, the labour cannot be completed, or at least without great difficulty.

Indications. The artificially delivering the child with the hand alone, or the extraction of it with the feet foremost (which of course presumes that it has presented with the feet, either originally or has been brought into that position by interference of art,) is indicated in all cases where the labour requires to be artificially terminated either on account of insufficiency of the expelling powers, or from the occurrence of dangerous symptoms. Under this head, on the part of the mother, are violent floodings, especially under certain circumstances, convulsions with total loss of consciousness, great debility, faintings, danger of suffocation from difficulty of breathing, violent and irrepressible vomiting, rupture of the uterus, death of the patient, &c.;--on the part of the child, prolapsus of the cord under certain circumstances. (Naegelé, Lehrbuch der Geburtshülfe, §§ 394, 395. 3d edit.) Hence, therefore, the general indications of turning are the same as those of the forceps, it being indicated in all those cases where nature is unable to expel the foetus, or which demand a hasty delivery of the child, but which cannot be attained by the application of the forceps.

Turning is an operation which is far inferior to that of the forceps, both as regards the safety of the mother and her child, and also the ease with which it is performed. Whenever the circumstances under which it is undertaken are unfavourable, it not only becomes a very difficult operation, but also one of considerable danger: for the child especially is this the case, as the very circumstance of its being born with the feet foremost shows that it is necessarily exposed to the same dangers as those already mentioned in nates presentations, in addition to those of the first part of the operation, viz. the changing its position.

The most favourable moment for undertaking the operation of turning is when the os uteri is fully dilated and the membranes are still unruptured. In this state, the vagina and os uteri are most capable of admitting the hand, and the uterus, from being filled with liquor amnii, is prevented contracting upon the child, the position of which is changed with great ease and safety; but when the os uteri is only partially dilated, its edge thin and rigid, the membranes ruptured, and the liquor amnii drained off for some hours, it becomes a matter of great difficulty and danger either to introduce the hand into the uterus under such circumstances, or to attempt changing the child's position: the os uteri tightly encircles the presenting part, and the uterus contracts upon the child itself so as to render it nearly, if not altogether immoveable.

The os uteri ought always if possible to be fully dilated: this however is not so essential as with the forceps, for when once it has reached the size of a crown piece, it mostly yields easily to the introduction of the hand. Where turning is indicated in malposition of the child we may safely await its full dilatation so long as the membranes remain unruptured. Where the membranes have been ruptured some hours and the os uteri hard, thin, and rigid, it will be impossible to turn until, either spontaneously or by proper treatment, it becomes soft, cushiony, and dilatable.

In cases which require turning as a means of hastening labour, as for instance in flooding from placenta prævia and other causes, the hæmorrhage is seldom so severe as to demand it without at the same time rendering the os uteri so relaxed as to present little or no obstruction to the hand. Where convulsions indicate turning, the bleeding and other depleting measures, which are necessary to control them, will have a similar effect in preparing the os uteri for this purpose.

In ordinary cases of turning there will be no need to change the patient's position, as it will be just as easy to perform it as she lies upon her left side, merely bringing her pelvis nearer to the side of the bed in order to reach her with greater facility. Where, however, from the position of the child or from the state of the uterus, the introduction of the hand and searching for the feet will probably be attended with considerable difficulty, it may be advisable to place her across the bed, sitting upon its edge, her back supported by pillows, her feet resting on two chairs, in the same way as it is used by the Continental practitioners for applying the forceps; or if it be really a case of very unusual difficulty, it will be better to put her upon her knees and elbows, for in this position we gain the upper and anterior parts of the uterus with greater ease.

In choosing which is the best hand for performing the operation, the practitioner must not only be guided by the position of the child, but also by the hand with which he possesses most strength and dexterity: many always use the left hand for turning when the patient lies upon her left side; for our own part we have always used the right, and have never failed except in one or two cases of great difficulty, where we judged it more prudent to put the patient on her knees and elbows than risk any injury by using too much force. In introducing the hand into the vagina as the patient lies on her left side, the right is moreover preferable, as we can pass it more completely in the axis of the vagina, than we can the left.[88]

The directions which are usually given to introduce one hand or the other according to the child's position, are not practical, because cases occur where it is impossible to ascertain this point without passing the hand into the uterus, as in placenta prævia, and occasionally in shoulder presentations; and it would be by no means justifiable to make the patient undergo the suffering from a repetition of this operation, merely because the position of the child is such as is stated in books to require the left hand instead of the right.

Having evacuated the bladder and rectum, and greased the fore-arm and back of the hand, we should gently insinuate the four fingers, one after the other, into the os externum: the whole hand must be contracted into the form of a cone; the thumb will pass up easily along the palm; the passage of the knuckles is the most difficult, for as the os externum is the narrowest part of the vagina, and the hand is widest across the knuckles, it follows that this is the point of the greatest resistance and suffering, and that, when once this is overcome, our hand will advance with greater ease both to ourselves and to our patient. This part of the operation can scarcely be conducted too gradually or gently, for if we give the soft parts sufficient time to yield, it is scarcely credible what an extent of dilatation may be effected by a comparatively moderate degree of pain; the os externum is also the most sensitive part of the vagina, and serious nervous affections may even be provoked by the intolerable agony arising from a rude and hasty attempt to force the hand through it. We must not advance the hand merely by pushing it onwards, but endeavour to insinuate it by a writhing movement, alternately straightening and gently bending the knuckles, so as to make the vagina gradually ride over this projecting part as the hand advances.

In passing the os uteri the same precautions must be observed, particularly when the os uteri is not fully dilated; at the same time we must fix the uterus itself with the other hand, and rather press the fundus downwards against the hand which is now advancing through the os uteri. In every case of turning we should bear in mind the necessity of duly supporting the uterus with the other hand; for we thus not only enable the hand to pass the os uteri with greater ease, but we prevent in great measure the liability there must be to laceration of the vagina from the uterus, in all cases where the turning is at all difficult. "In those cases (says Professor Naegelé) where artificial dilatation of the os uteri is required to let the hand pass, it should be done in the following manner:--during an interval of the pains, we introduce, according to the degree of dilatation, first two, then three, and lastly four fingers; and by gently turning them and gradually expanding them we endeavour to dilate it sufficiently to let the hand pass. This must only be done under circumstances of absolute necessity and always with the greatest caution--in fact, only in those cases where the danger consequent upon artificial dilatation of the os uteri is evidently less than that, to avert, which we are compelled to turn before it is sufficiently yielding or dilated." (Lehrbuch der Geburtshülfe, p. 212. 3tte ausgabe.) This observation from so high an authority evidently applies to those cases where the os uteri is not only soft and yielding, but also nearly dilated; the forcible dilatation of the os uteri is justly deprecated by Madame la Chapelle: "I never attempt to produce this forced dilatation, not even in cases of hæmorrhage. But we may frequently promote the dilatation of the passages in a remarkable manner by moistening and relaxing them and diminishing their state of excitement, viz. by the steams of hot water, tepid injections, and more particularly by warm baths and bleeding." (p. 49.) Her diagnosis of the condition in which the os uteri will yield to the introduction of the hand is well worthy of attention. "If the inactive uterus be unable to expel the child, or to make the head clear its orifice although considerably dilated, if, in this state of affairs, the membranes give way, we can feel the os uteri retract, from being no longer pressed upon. How different is this state of passive contraction to the rigidity of an orifice which has not yet been dilated: in this case, although the os uteri is contracted and even thick, it is soft, supple, and easily dilatable; there is no feeling of tightness or resistance; it is little else than a membranous sac, and the head has not descended sufficiently to press upon it; or if the head does not present, it is some part of the child, as for instance the shoulder, which is unable to advance and act upon the os uteri: in this case operate without fear--in the other wait." (Pratique des Accouchemens, p. 86.)

If the membranes be not yet ruptured we should use the greatest caution to preserve them uninjured: the hand must be gently insinuated between them and the uterus, and should be passed either until the feet are felt, or at least, until it has gained the upper half of the uterus. Now, and not till now, ought they to be ruptured. As this is done at the side of the uterus little or no liquor amnii escapes, for the torn membranes are pressed closely against the uterine parietes, and the vagina is completely closed by the presence of the arm in it acting as a plug; the uterus is unable to contract upon the child on account of the fluid which surrounds it, and the hand, therefore, passes up with great facility. The uterus is not diminished by the loss of its liquor amnii; its contractile power is, therefore, not increased. When the hand has broken the membranes it can move about in perfect freedom: if the feet have not as yet been reached they will now be easily found, and the position of the child will be changed without difficulty.

The importance of passing in the hand without rupturing the membranes was first shown by Peu in 1694.[89] But it excited little or no notice at the time, not even by La Motte, who paid so much attention to improving the operation of turning. Dr. Smellie appears to have been the first after Peu who recommended this mode of practice, although he makes no mention of his name. "Then introducing one hand into the vagina we insinuate it in a flattened form within the os internum, and push up between the membranes and the uterus as far as the middle of the womb: having thus obtained admission, we break the membranes by grasping and squeezing them with our fingers, slide our hand within them without moving the arm lower down, then turn and deliver as formerly directed." (Treatise on the Theory and Practice of Midwifery, vol. i. p. 327. 4th edit.) In 1770, Deleurye again pointed out the value of this mode of introducing the hand, and expressly directs us "introduire la main dans la matrice sans percer la poche des eaux, détacher les membranes des parois de ce viscère, et les percer à l'endroit où l'on juge que les pieds peuvent le plus naturellement se trouver."[90] Dr. Hamilton, of Edinburgh, five years afterwards recommended the same method, and in nearly the same terms. Little notice, however, has been taken of it since, either in this country or upon the Continent, and the old objectionable mode of rupturing the membranes at the os uteri is still taught even by the most modern authors. The celebrated Boer also added his testimony in favour of Deleurye's mode of practice,[91] and it has still farther been confirmed by Professor Naegelé.

Turning under these circumstances is an easy operation, and a very different affair compared with its performance in cases in which the membranes have been some time previously ruptured, and the uterus drained of liquor amnii: the hand is passed up with difficulty, the feet are quickly found, and the child moved round with a degree of facility which is scarcely credible. Where, however, the uterus is irritable and closely contracted upon the child, the liquor amnii having long since escaped, where the os uteri is not more than two-thirds dilated, its edge thin, hard, and tight, as is especially seen in a neglected case of arm or shoulder presentation, every step of the operation is attended with the greatest difficulty, and in fact is neither possible nor justifiable, until by bleeding to fainting, by the warm bath and opiates, we have succeeded in producing such a degree of relaxation as to enable us to introduce the hand. "Blood-letting is the only remedy with which we are acquainted that has any decided control over the contracted uterus. It is one almost certain of rendering turning practicable under such circumstances, if carried to the extent it should be. A small bleeding in such cases is of no possible advantage, for unless the practitioner means to carry the bleeding to its proper limits, which is a disposition to, or the actual state of syncope, he had better not employ it." (Dewees' Compendious System of Midwifery, § 629.) "The vagina is never so soft, so dilatable, and capable of admitting the hand as during the presence of an active hæmorrhage, and this is equally the case in primiparæ as in those who have had several children: and it is a mistaken kindness in the medical attendant, who in order to spare his patient's sufferings, under these circumstances delays to introduce his hand until the hæmorrhage shall have ceased. The moment this is the case, the vagina regains more vitality, sensibility and power of contraction, the hand now experiences much more opposition, and excites far greater pain than during the state of syncope." (Wigand, Geburt des Menschen, vol. ii. p. 428.)

When once a powerful impression has been made upon the system by an active bleeding, opiates, which before it, would have only tended to render the patient feverish, are now of great value: they relax the spasmodic action of the uterus, allay the general excitement and irritability, and induce sleep and perspiration. As with bleeding in these cases, they must be given in decided doses: a grain of hydrochlorate of morphia given at once, or in two doses quickly repeated, and at the same time from half a drachm to a drachm of Liquor Opii Sedativus thrown into the rectum with a little thin starch or gruel, will rarely or never fail to produce the desired effect. The opiate by the mouth may be advantageously combined with James's powder, and thus assist its diaphoretic action. The warm bath will also prove a valuable remedy.

"If the arm or funis of the child presents and is prolapsed into the vagina, we must not try to push back these parts into the uterus again, but we must endeavour to pass our hand along the inner surface of the presenting arm; or if it be the cord, we must guide it so as to press the cord as little as possible: if however a coil of it has passed out of the vagina and is still beating, we had better carry it upon the hand with which we are about to turn the child." (Boer, op. cit. vol. iii. p. 5. 1817.) For farther information on this head we must refer to the observations on Malposition of the Child.

If the head or nates be occupying the brim of the pelvis it will be necessary to raise them gently and press them to one side: this however is usually effected by the very act of passing up the hand, and seldom produces any difficulty, unless these parts have already advanced deeper into the pelvis; in which case, as turning under these circumstances can only be undertaken with a view to hasten labour, it will become a matter of consideration whether we shall not be able to attain this object better by the aid of the forceps.

Although it ought ever to be considered as a rule that turning must not be attempted whilst the pains are violent, the introduction of the hand into the uterus always excites it more or less to contraction: the degree of pressure and impediment which it will produce to the progress of the hand will in a great measure depend upon the quantity of liquor amnii which it contains. Where the uterus has been drained of the fluid, every contraction will be felt in its full force by the operator: his hand is firmly jammed against the child, and if it happens to be caught in a constrained posture at the moment, is liable to be attacked with a severe fit of cramp, which benumbs and renders it powerless. Wherever we find that the hand is tightly squeezed during a pain, we should lay it flat with the palm upon the child, and hold it perfectly still: in this posture it will bear a powerful contraction without inconveniencing ourselves or injuring the uterus; and by letting it be quite flaccid and motionless we shall not provoke the uterus to farther exertions. Attempting to turn during the pain would not only be useless, but we should exhaust the strength of our hand which cannot be spared too much; we should torture the patient unnecessarily, and run no small risk of rupturing the uterus.

In letting the pressure of our hand be upon the child during a pain, instead of against the uterus, we must select any part rather than its abdomen, for pressure here seems to act as injuriously as pressure upon the umbilical cord.

Rules for finding the feet. In searching for the feet we must endeavour to gain the anterior surface of the child, for (unless its position be greatly distorted) they are usually turned upon the abdomen: in arm presentations the position of the hand will also guide us, the palm of it being mostly turned in the same direction as the abdomen, and therefore points to the situation of the feet; the rule also, as above given by Boer, of passing the hand along the inside of the presenting arm, is well worthy of recollection, for this can scarcely fail to guide us to the anterior part of the child. Where, either from the pressure of the uterus or other circumstances, it is difficult to distinguish the precise position of the child, it will be better to follow Dr. Denman's simple rule, that the hand "must be conducted into the uterus, on that side of the pelvis where it can be done with most convenience, because that will lead most easily to the feet of the child." The soft abdomen, the curved position of the child, and its extremities crossed in front are so many reasons why there should be more room in this direction.

During all this time the other hand placed externally will be of great service, not only in supporting the uterus, but in fixing the child and rendering the different parts of it more attainable. Where the feet are at some distance, we frequently come first to an arm or thigh, which soon leads us to the elbow or knee; if the introduction of the hand has been attended with some difficulty, it will not be very easy to distinguish these joints from each other, without bearing in mind the following diagnostic points:--the knee present two rounded prominences (condyles of the femur) with a depression between them, whereas, the elbow presents also two rounded prominences, but with a sharp projection (olecranon) between.

If the foot is not easily reached, there will be no need of forcing up the hand farther to gain it: it will be much better and safer to hook the finger into the bend of the knee and hold by it for a pain or two: this will generally be sufficient to bring it within reach; or during an interval of the pains, the leg may be gently disengaged and brought down. Not unfrequently we can only feel the toes with the extremities of our fingers, and therefore cannot maintain a sufficient hold upon the foot so as to bring it down: here again the same rule will be applicable, for by keeping but a slight hold upon it during a pain, it will be found to have approached nearer when the pain has gone off; in fact our first attempt to move the child must be done in this cautious manner, and we shall effect our object with greater certainty by merely holding the feet still during the pain, not allowing them to recede from that position in which we had placed them during the intervals, than by using considerable efforts to bring them to the os uteri. By the time we have got one foot fairly within grasp, the other is seldom very distant and should always be brought down if possible: by bringing down both feet we cause the hips of the child to enter the brim of the pelvis more equally; whereas, if one leg only is brought down, the pelvis of the child comes more or less awry, and the ischium of the other side is apt to lodge against the brim of its mother's pelvis.[92] This practice has been recommended on the grounds that, by bring down only one leg, we make the presentation rather resemble a breech case, which is known to be more favourable for reasons already mentioned, and that by having the other leg turned upon the abdomen it will protect the cord from undue pressure. As far as the abdomen is concerned this may possibly be the case, but the pressure of the head upon the cord, which is the real source of danger to the child in turning, can in no wise be influenced by this position.

In bringing down the feet it must be done with the articulation, that is, the child must be turned forwards; at the same time the hand upon the abdomen, externally, will be of great service in assisting us to move the child, and in preventing the change of its position from taking place in too sudden and violent a manner, a circumstance which is apt to paralyze the uterus considerably, and even produce alarming symptoms from the shock it occasions.

Extraction. When once we have brought the feet into the vagina, the first part of the operation, viz. the changing the position of the child, is completed: it has now become a presentation of the feet, and as such ought to be treated, unless some source of danger be present which requires that the delivery should be hastened. The value of this practice in footling cases was first pointed out by Deleurye,[93] and particularly applied to the second act of turning by Wigand. "I have made it," says he, "a strict rule in turning, from the moment that I have brought a foot of the child as far into the vagina as I can without force, to do nothing beyond patiently waiting for the return of the pains, even if this did not take place for many hours, and leaving the rest of the labour entirely to nature. I have found by doing so that when the pains at length began to expel the child, they did it with so much force and activity as was not even seen in the most natural case of head presentation." (Geburt des Menschen, vol. ii. p. 130.)

As the feet descend towards the os uteri, the presenting part, particularly if the arm has been prolapsed into the vagina, begins to recede, the hand externally will assist in moving the child round, and we should perform this step of the operation so gradually as to be assured that the presenting part has quitted the pelvis before the feet have entered. Without attention to this point, the child may easily be fixed across the upper part of the pelvis, or even the body brought down, while the head is wedged into the cavitas iliaca of the ilium, and produce a serious obstacle to its farther advance. This is a sort of mishap which can rarely happen except to young practitioners. If the process be slowly and carefully conducted, we doubt much if it be ever necessary to disengage the presenting part as has been so frequently recommended: the uterus in fact will move the child round with very little assistance on our part, and we shall find that after every pain the advance of the feet and recession of the part has increased considerably. From our own observations we would say that in all difficult cases, of turning especially, it is desirable for the patient to have several pains between the moment of gaining the feet and bringing them fairly into the vagina: very little force is required to bring them down, and the uterus does not appear to suffer; but where the position of the child has been rapidly changed, its contractile power seems to be injured, and it is ill able to make those exertions during the last stage, which will be required of it in order to save the child's life.

Not less necessary is it that we should proceed with the second stage as cautiously as possible: the grand principle is the same, viz. to conduct the expulsion as gradually as possible: there is no use whatever in hurrying this part of the operation, for if the child be alive, we place it in imminent danger of its life; and if it be dead, as will easily be known by the cord not pulsating, we are putting the mother to a great deal of suffering for no reason. Now that it has become a footling case, it must be managed according to rules already given for this species of presentation: the uterus must be emptied as slowly as possible, the anterior part of the child must be directed more or less backward, and the funis guided into the vicinity of one or other sacro-iliac synchondroses. By retarding the advance of the child, we resist the action of the uterus somewhat, and thus excite it to contract more actively, the head enters the pelvis in the most favourable position, and as the pains are still brisk, it passes through so quickly as to subject the child to little or no danger by pressing upon the cord. Where however the passage of the head through the pelvis threatens to be delayed, we would strongly recommend the application of the forceps in order to terminate the delivery before the child has begun to suffer: it is to this mode of practice that Professor Busch, of Berlin, attributes the extraordinary success of turning in his hands; of forty-four cases where turning was deemed necessary only three children are stated to have lost their lives from the effects of the operation, a result which is by far the most favourable known.

Turning with the nates foremost. It has been proposed by several authors of the last century to turn the child with the breech foremost, as being a less dangerous operation for it than the common one of bringing down the feet. Levret has distinctly proposed this mode (L'Art des Accouchemens, § 767,) and Smellie on more than one occasion has alluded to bringing down the nates. Dr. W. Hunter has also recommended turning with the breech foremost: still more recently has this mode of practice been confirmed by W. J. Schmitt, of Vienna,[94] also by some other continental authors; but the difficulty in bringing down a part of the child's body, upon which we can exert so little hold, will always be very considerable, wherever the circumstances under which the operation is undertaken is at all unfavourable. Schmitt recommends that as soon as we reach the nates we should apply the hand flat upon them; while in order to turn the child, active pressure is kept up from without by the other hand: when once we have succeeded in moving the breech somewhat downwards, its farther descent is very easy.

A still more recent modification of turning the child in arm and shoulder presentations has been proposed by Dr. v. Deutsch, of Dorpat: it consists in raising the presenting part, and at the same time turning the child upon its long axis, as the hand placed in the axilla carries the shoulder to the upper parts of the uterus, after which, as the hand descends, it brings the feet along with it into the vagina.

Turning with the head foremost. In former times, as the head was considered the only natural presentation of the child, every deviation of its position from this was looked upon as unnatural, and, therefore, the operation of turning only applied to bringing down the head, which had not presented: as, however, the difficulties already mentioned, in turning with the nates, would apply still more forcibly to bringing down the head, it is plain that this mode of turning would rarely be practicable. "Were it practicable at all times," says Dr. Smellie, vol. i. book iii. chap. iv. sect. iv. number v., "to bring the head into the right position, a great deal of fatigue would be saved to the operator, much pain to the woman, and imminent danger to the child: he, therefore, ought to attempt this method, and may succeed when he is called before the membranes are broke, and feels by the touch that the face, ear, or any of the upper parts present." Still, however, he confesses that the usual method of turning by the feet is the safest. In his first volume of cases, (collection 16, number 6, case 5,) he has given a description of this mode of turning. Dr. Spence also turned with the head foremost, as is shown by his thirty-second case, where the hand and cord were prolapsed into the vagina. "I introduced my hand into the vagina, and in the intervals between the pains reduced both the arm and the cord: but as I found they were like to return again upon my withdrawing my hand, I therefore continued to support them till such time as, by the strength of the pains, the child's head was so far forced down as to prevent any danger of their returning, the happy consequence of which, was, that she was delivered of a live child in about half an hour after: both mother and child did well." (Spence's System of Midwifery, p. 465.) Dr. Merriman has recorded a similar case in his own practice: "The arm was returned at two o'clock; there was afterwards no occurrence of pain till six, after which, they became very strong, and between eight and nine the child was born. This was the only infant that Mrs. R. has seen alive out of six." (Synopsis of Difficult Parturition, 1838, p. 250.) Still more recently turning with the head foremost has been tried by Dr. Michaelis, of Kiel, (Neue Zeitschrift für Geburtskunde, vol. iv. 1836.) When once the faulty position has been altered, the liquor amnii is allowed to drain off, the uterus contracts and presses the head down into the pelvis, and the child is born without farther difficulty.

History of turning. Turning, as it is generally practised at the present day, viz. changing the position of a living child so that the feet are brought down foremost into the vagina, was unknown to the ancients. There is little doubt, however, that if they could have been induced to have looked upon presentations of the nates and feet as natural labours, they would have been in possession of this valuable means of effecting artificial delivery; as it is, we meet with detached allusions to it in their writings, although applying only to cases where the child is dead. In the writings of Aspasia and Philumenus, which, but for the quotations of Oetius, would have been entirely lost to us, we find directions for turning the child. Thus, Philumenus states, "Si caput foetûs locum obstruxerit ita ut prodire nequeat infans in pedes vertatur atque educatur." At a still later period, Celsus gave similar directions, but to all appearance they also merely apply to a dead child. "Medici vero propositum est, ut infantem manu dirigat, vel in caput vel etiam in pedes si forte aliter compositus est;" and again he says, "Sed in pedes quoque conversus infans, non difficulter extrahitur. Quibus apprehensis per ipsas manus commode educitur." (Celsus, de Medicinâ, lib. vii. cap. 29.)

From this time the whole subject seemed to sink into oblivion, until Pierre Franco, in his work on surgery[95] proposed the extraction of the child with the feet foremost: this was put into practice by the celebrated French surgeon, Ambrose Paré, (Ambr. Paræus, Opera Chirurgia, 1594,) who, nevertheless, recommended turning with the head foremost, where it was possible. His work was afterwards translated into Latin by Guillemeau, who, although he still adhered to the old plan of bringing down the head, showed the value of Paré's mode of turning in hæmorrhages and convulsions. To Francis Mauriceau, a man of great learning and experience, we are indebted for this operation being greatly improved, by means of his valuable work, in 1668; but it is Philip Peu, in 1694, and William Manquest de la Motte, in 1721, to whom the merit is due of having pointed out the value of two great laws in turning--the one of not rupturing the membranes as already mentioned, the other of not attempting to push back the arm which presents.[96]

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III. CÆSAREAN OPERATION

Indications.--Different modes of performing the operation.--History of the Cæsarean operation.

The next operation in Midwifery for delivering the full-grown foetus alive is that of Hysterotomy, commonly called the Cæsarean operation, viz. where the foetus is extracted through an artificial opening made through the parietes of the abdomen and uterus.

The indications for performing the operation are so different in this country to what they are elsewhere that they require especial mention: in England the operation is never performed upon the living subject except where the child cannot be delivered by the natural passage; under these circumstances it is scarcely undertaken in this country for the purpose of saving the child's life, but merely that of the mother, it being considered preferable to deliver the child by perforation or embryotomy, even when known to be alive, than to expose the mother to so much suffering and danger.

On the Continent and also in America, it has not been considered in so dangerous a light as in this country, still less as an operation almost certainly fatal to the mother: therefore, besides being indicated as a means for preserving the mother's life, it is performed for the purpose of saving the child's life in cases where, by using the perforator, the child might be brought through the natural passages. The results of the Cæsarean operation have been so unfavourable, and the character of the process so frightful, as to have rendered it a measure of peculiar dread to practitioners, and in different times and countries the strongest feelings have been excited against it. By many of the celebrated authors of former times, viz. Ambrose Paré, Guillemeau, Dionis, &c. it was looked upon as altogether unjustifiable, and a similar opinion was entertained by many of our own countrymen at a much more recent period, (Dr. W. Hunter, Dr. Osborn, &c.)

There is no doubt that in England it has been peculiarly unsuccessful. Dr. Merriman has collected the results of 26 cases of Cæsarean operation: of these only 2 mothers and 11 children survived; thus out of 52 lives only 13 were saved. On the Continent it has been far more successful. Klein has collected with the greatest care 116 well authenticated cases, of which 90 terminated favourably; and Dr. Hull, in his Defence of the Cæsarean Operation, has recorded 112 cases, of which 69 were successful. M. Simon has not only collected a number of cases which were favourable, to the number of 70 or 72, but which were performed on a few women, "some of them having submitted to it three or four times, others five or six, and even as far as seven times, which if they were all true, would superabundantly prove that it is not essentially mortal." (Baudelocque, transl. by Heath, § 2095.)

During the last fifteen or twenty years the operation has become remarkably successful in the hands of the German practitioners, so that there has been scarcely a journal of late from that part of the Continent which has not contained favourable cases of it. One of the most interesting instances of later years is that recorded by Dr. Michaelis, of Kiel, where the patient, a diminutive and very deformed woman, was operated upon four times:[97] the second operation was performed by the celebrated Wiedemann, and is stated to have been completed in less than five minutes, and without any extraordinary suffering on the part of the patient, who complained most when sutures were made for bringing the lips of the wound together. The uterus became adherent to the anterior wall of the abdomen, so that in the fourth operation the abdominal cavity was not even opened, the incision being made through the common cicatrix into the uterus.

There is every reason to suppose that the chief cause of its want of success in this country has been the delay in performing it. "In France and some other nations upon the European Continent," says Dr. Hull, "the Cæsarean Operation has been and continues to be performed where British practitioners do not think it indicated; it is also had recourse to early, before the strength of the mother has been exhausted by the long continuance and frequent repetition of tormenting, though unavailing pains, and before her life is endangered by the accession of inflammation of the abdominal cavity. From this view of the matter we may reasonably expect that recoveries will be more frequent in France than in England and Scotland, where the reverse practice obtains. And it is from such cases as these, in which it is employed in France, that the value of the operation ought to be appreciated. Who could be sanguine in his expectation of a recovery under such circumstances as it has generally been resorted to in this country, namely, where the female has laboured for years under malacosteon (mollities ossium,) a disease hitherto in itself incurable; where she has been brought into imminent danger by previous inflammation of the intestines or other contents of the abdominal cavity, or been exhausted by labour of a week's continuance or even longer." (Hull's Defence of the Cæsarean Operation.)[98]

The difficulty of deciding upon the operation according to the indications of the Continental practitioners, is much more perplexing than according to that which is followed in this country: the question here is, can the child under any circumstances be made to pass per vias naturales with safety to the mother? The impossibility of effecting this object is the sole guide for our decision. In using the operation as a means for preserving also the life of the child, we must not only feel certain that the child is alive, but that it is also capable of supporting life, before we can conscientiously undertake the operation upon such indications. This uncertainty as to the life or death of the child greatly increases the difficulty of deciding. Under circumstances where there is reason to believe that, although the child may be alive, it is nevertheless unable to prolong its existence for any time, and the pelvis so narrow that it can only be brought through the natural passage piecemeal, we are certainly not authorized in putting an adult and otherwise healthy mother into such imminent danger of her life for the sake of a child which is too weak to support existence. Circumstances may nevertheless occur where the pelvis is so narrow that the child cannot be brought even piecemeal through the natural passage: in this case, even if the child be dead, the operation becomes unavoidable.

Under the above-mentioned circumstances, it is the duty of the surgeon to perform the operation; and he can do it with the more confidence from the knowledge of many cases upon record where it has succeeded even under very unfavourable circumstances, and where it has been performed very awkwardly: moreover, it seems highly probable that the unfavourable results of this operation cannot often be attributed to the operation itself, but to other circumstances. Not unfrequently the uterus has been so bruised, irritated, and injured by the violent and repeated attempts to deliver by turning or the forceps, and the patient so exhausted, and brought into such a spasmodic and feverish state by the fruitless pains and vehement efforts, together with the anxiety and restlessness which must occur under such circumstances, that it is impossible for the operation to prove successful. Here it is an important rule that we should decide as soon as possible, whether she can be delivered by the natural passages or not: we should allow of no useless or forcible attempts to deliver her; and if these have been made, we should carefully examine whether the passages, &c. have been injured, and proceed to the operation without delay. Moreover, the patient can the more easily make up her mind to the operation, as she will suffer far less than from the fruitless efforts and attempts to deliver her by the natural passages. (Richter, Anfangsgründe der Wundarztneikunst, band vii. chap. 5.)

Although it is so important that we should lose no time, still nevertheless it does not appear desirable to operate before labour has commenced to any extent; for unless the os uteri has undergone a certain degree of dilatation, it will not afford a sufficiently free exit for liquor amnii, blood, lochia, which, by stagnating in the uterus after the operation, would soon become irritating and putrid, in which case they would be apt to drain through the wound into the abdominal cavity and create much mischief.[99]

Different modes of operating. The incision has been recommended to be made in different ways by different authors; but the highest authorities, as also later experience, combine in favour of that in the linea alba. Richter states, that one great advantage from making it in this direction is, that when the uterus contracts and sinks down into the pelvis, the incision in it still corresponds with that through the abdominal parietes, and therefore admits of a free discharge of pus, &c. through the external wound; whereas, if it have been made to one side, viz. at the outer edge of the rectus abdominis muscle, as recommended by Levret for the purpose of avoiding the placenta, the wound in the uterus when contracted ceases to correspond with it, and the discharge escapes into the abdominal cavity. Besides this the abdomen is usually more distended at the linea alba; the uterus here lies immediately beneath the integuments; the intestines are usually pressed towards each side; and therefore when the incision is made on one side they frequently protrude, a circumstance which rarely happens when it is made in the linea alba, except perhaps towards the end of the operation. In the linea alba we have only to cut through the external integuments in order to reach the uterus, while at the side, we have to cut through considerable layers of muscle.

Previous to operating, the rectum and the bladder should be emptied, particularly the latter, because it is desirable to carry the incision of the abdominal integuments, for reasons just given, as near as possible to the symphysis pubis (viz. an inch and a half,) which otherwise would endanger the safety of the bladder. The experience of later years proves decidedly that three intelligent assistants are necessary, "two to prevent the protrusion of the intestines, and a third to remove the placenta and foetus." (Neue Zeitschrift für Geburtskunde, band iii. heft 1. 1835.) We are convinced, that the success of the operation depends more upon carefully preventing the slightest protrusion of any portion of the intestines, and excluding all access of the external air than upon any other cause, for by this means alone can we save the patient from the dangerous peritonitis which is so apt to follow. The two assistants, whose duty it is to support the abdominal parietes and keep the edges of the wound closely pressed against the uterus, should be furnished with napkins or sponges soaked in oil in order instantly to cover any coil of intestine which may protrude, and press it back as quickly as possible; it is to this that the great success of the Cæsarean operation in later years is chiefly owing.

The incision in point of length varies from five to six, seven, or more inches, beginning at about two to four inches below the navel, and terminating at rather less than that distance above the symphysis pubis. The peritoneum is usually divided with a bistoury and director, and the wound through the uterus made an inch or two shorter than that of the abdominal integuments. If, on dividing the uterine parietes, the placenta presents, it must be separated, and removed as quickly as possible to one side, the membranes ruptured, and the child extracted; after which the uterus rapidly contracts, and thus prevents all fear of hæmorrhage: for this reason the sooner the child is removed the better, as otherwise the uterus is apt to contract upon a portion of it when passing through the wound, and thus retain it. It is desirable to remove the membranes as far as possible, especially from the os uteri, to allow of a free discharge from the uterus per vaginam. No sutures are needed for the uterine incision: the contractions of the organ not only diminish its length, but generally bring its edges into sufficiently close contact.

Some discrepancy of opinion has existed respecting the treatment of the external wound: sutures are of course the most secure means of retaining the edges in apposition, but they produce great suffering, and, from taking up a good deal of time, delay the closing of the abdominal wound more or less; whereas, straps of sticking plaster are applied much quicker and without any suffering to the patient. To do this most effectually it will be advisable to arrange them under the loins previous to the operation: they should be from five to six feet long, and the ends may be rolled up until wanted; the wound can thus be instantly closed and in the most secure manner. Where the operator finds it necessary to use sutures, he must avoid puncturing the peritoneum as far as possible: the lower inch of the wound should be left open to allow any matter to drain out, and the whole dressed according to the common rules of surgery. The patient should be placed upon her side with the knees bent to relax the abdominal parietes. A grain of the hydrochlorate of morphia has been given in these cases with the best effects, having procured sleep and allayed the disposition to spasmodic coughing and vomiting, which so frequently exists after the operation.

One of the greatest triumphs of modern surgery is the performance of this dangerous operation four times successively on the same patient. The first operation was performed in June 1826, the woman being then in her twenty-ninth year, the second in January 1830, the third in March 1832, and the fourth on the 27th June, 1836. The second operation was performed by Wiedemann, of Kiel, and scarcely lasted five minutes; nor does it appear that the patient's sufferings were very great, for the application of sutures on this occasion elicited more complaint than all the operations put together.[100]

History. Although the early records of the Cæsarean operation are not very distinct, still we possess sufficient data to pronounce it of very considerable antiquity. The earliest mention of it shows that it was at first used merely for the purpose of saving the child by extracting it from the womb of its dead mother, a law having been made by Numa Pompilius, the second king of Rome, forbidding the body of any female far advanced in pregnancy to be buried until the operation had been performed.

The mythology of the ancients refers to two cases of an exceedingly remote period where a living child was taken from the dead body of its mother: these were the birth of Bacchus and Æsculapius; but as these traditions are so enveloped in allegory and mystery, it is difficult to come to any other conclusion than a mere inference of the fact: one circumstance, however, connected with the birth of Bacchus is curious, viz. that his mother Semele died in the seventh month of her pregnancy.

The oldest authentic record is the case of Georgius, a celebrated orator born at Leontium in Sicily, B. C. 508. Scipio Africanus, who lived about 200 years later, is said to have been born in a similar manner. There is no reason to suppose that Julius Cæsar was born by this operation, or still less that it derived its name from him, for at the age of thirty, he speaks of his mother Aurelia as being still alive, which is very improbable if she had undergone such a mode of delivery. We would rather prefer the explanation of Professor Naegelé, viz. that one of the Julian family at Rome had been delivered ex cæso matris utero, and had been named Cæsar from this circumstance, so that the name was derived from the operation, not the operation from the name.

"The earliest account of it in any medical work is that in the Chirurgia Guidonis de Cauliaco, published about the middle of the fourteenth century. Here, however, the practise is only spoken of as proper after the death of the mother." (Cooper's Surg. Dict.) Among the Jews, however, it appears to have been performed on the living mother at a very early period; a description of it is given in the Mischnejoth, "which is the oldest book of this people, and supposed to have been published 140 years before the birth of our Saviour, or, according to some, even antecedently to this period. In the Talmud of the Jews, also, their next book in point of antiquity, the Cæsarean operation is mentioned in such terms as to render it extremely probable that it was resorted to before the commencement of the Christian era. In the Mischnejoth there is the following passage, 'In the case of twins, neither the first child which shall be brought into the world by the cut in the abdomen, nor the second, can receive the rights of primogeniture, either as regards the office of priest or succession to property.' In a publication called the Nidda, an appendix to the Talmud, there is the following remarkable direction: 'It is not necessary for women to observe the days of purification after the removal of the child through the parietes of the abdomen.'" (Introduction to the Study and Practice of Midwifery, by W. Campbell, M. D. p. 260.)

The first authentic operation upon a living woman in later times was the celebrated one by Jacob Nufer, upon his own wife, in 1500, after which, owing to its fatal character and the strong feeling against it, it was performed but rarely: still, however, sufficient evidence existed to mark its occasional success and urge its repetition in similar cases; and from what we have already stated, the history of the last twenty years shows that its results have rapidly become more and more favourable, so that in the present day it can be no longer looked upon as an operation of such extreme danger and almost certain fatality, as it was in former times.[101]

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IV. ARTIFICIAL PREMATURE LABOUR

History of the operation.--Period of pregnancy most favourable for performing it.--Description of the operation.

Perhaps the greatest improvement in operative midwifery since the invention and gradual improvement of the forceps is the induction of artificial premature labour for the purpose of delivering a woman of a living child, under circumstances of pelvic contraction, where either the one must have been exposed to the dangers and sufferings of the Cæsarean operation, or the other to the certainty of death by perforation, or at least where the labour must have been so severe and protracted as to have more or less endangered the lives of both. It consists in inducing labour artificially, at such a period of pregnancy that the child has attained a sufficient degree of development to support its existence after birth, and yet is still so small, and the bones of its head so soft, as to be capable of passing through the contracted pelvis of its mother.

History. Few improvements have met with more violent opposition, or have been more unjustly stigmatized or misrepresented, than artificial premature labour, and it redounds, not a little, to the credit of the English practitioners that they have not only had the merit of its first invention, but with very trifling exceptions, have been the great means of bringing it into general practice and repute.

To the late Dr. Denman we are under especial obligations in this respect; for, although himself not the inventor of this operation, he, nevertheless, was one of the first who widely recommended it to the profession, and actively promoted it by the powerful support of his name and writings. "A great number of instances," says he, "have occurred to my own observation of women so formed that it was not possible for them to bring forth a living child at the termination of nine months, who have been blessed with living children, by the accidental coming on of labour when they were only seven months advanced in their pregnancy. But the first account of any artificial method of bringing on premature labour was given me by Dr. C. Kelly. He informed me that about the year 1756 there was a consultation of the most eminent men in London, at that time, to consider of the moral rectitude and advantages which might be expected from this practice, which met with their general approbation. The first case in which it was deemed necessary and proper, fell under the care of the late Dr. Macauley, and it terminated successfully.[102] Dr. Kelly informed me he himself had practised it, and among other instances mentioned that the operation had been performed three times on the same woman, and twice the children had been born living." (Denman's Introduction to the Practice of Midwifery, 2d ed. vol. ii. p. 174.) Since this the observations of Mr. Barlow, Dr. Merriman, Mr. Marshall, Drs. J. Clarke, Ramsbotham, &c. &c., have afforded an ample body of evidence in its favour, and have, we trust, tended not a little to diminish the frequency of perforation. On the Continent it experienced a very different reception, being regarded as immoral, barbarous, and unjustifiably endangering the life of the mother and her child. In France, although at first successfully adopted by a few practitioners, (Sue,) its farther progress was completely stopped by the powerful opposition of Baudelocque, and by the plausible though erroneous objections which he made against it. A similar course was pursued by Gardien and Capuron, and even by the celebrated Madame la Chapelle, all of whom have taken a singularly incorrect view of it and assign it a totally different object to that which is intended: the very name which they have given to it of Avortement artificiel, plainly shows how little they have understood of its real character.

Among his objections, Baudelocque states, that "the neck of the uterus at seven months has seldom begun to open; it is still very thick and firm. The pains, or the contractions of that viscus, cannot then be procured but by a mechanical irritation pretty strong and long continued; but those pains, being contrary to the intentions of nature, often cease the instant we leave off exciting them in that manner. If we break the membranes before the orifice of the uterus be sufficiently open for the passage of the child, and the action of that viscus strong enough to expel it, the pains will go off in the same manner for a time, and the labour afterwards will be very long and fatiguing; the child deprived of the waters which protected it from the action of the uterus, being then immediately pressed upon by that organ, will be a victim to its action before things be favourably disposed for its exit, and the fruit of so much labour and anxiety will be lost. Premature delivery obtained in this manner is always so unfavourable to the child, that I think it ought never to be permitted except in those cases of violent hæmorrhage which leave no chance for the woman's life without delivery; the nature of the accident also disposes the parts properly for it." (Baudelocque, transl. by Heath, § 1986, 1987.) All this plainly shows that Baudelocque did not rightly understand the real objects and nature of artificial premature labour, to which, in fact, his objections do not apply, but to the accouchement forcé of the French practitioners, where, on account of the sudden accession of dangerous symptoms, such as hæmorrhage, convulsions, &c. &c., the os uteri was rapidly and violently dilated by the hand, which was then passed into the uterus, the feet seized, and the child forcibly delivered, an operation which is now rarely performed in Germany and never in this country.

The celebrated Carl Wenzel, of Frankfort, was the first in Germany who declared himself in favour of the operation. Kraus and Weidemann followed, the former two having performed it with complete success. The favourable results also in the hands of English practitioners and its increasing reputation quickly silenced the virulent abuse which was levelled at it by Stein, jun., and some other German authorities; the celebrated Elias von Siebold, of Berlin, who had first opposed it, candidly confessed his error and became one of its earliest supporters. Increasing experience showed that it could scarcely be looked upon as a dangerous operation for the mother, and that in by far the majority of instances it was also successful as regarded the child. Professor Kilian, in his work on operative midwifery, has collected the results of no less than 161 cases of artificial premature labour. (Operative Geburtshülfe, erster band, p. 298.) Of these, 72 occurred in England, 79 in Germany, 7 in Italy, and 3 in Holland: of these cases, 115 children were born alive and 46 dead; of the 115 living children, 73 continued alive and healthy; 8 of the mothers died after the operation, but of these, 5 were evidently from diseases which had nothing to do with the operation.

The most unfavourable circumstances under which the operation can be undertaken are, where the child presents with the arm or shoulder: here it will require turning, which, in many cases, owing to the faulty form and inclination of the pelvis, cannot be effected without considerable difficulty, and greatly diminishing the chances of the child being born alive. With this exception we cannot see why it should not be as favourable as labour at the full term of pregnancy; it is far less dangerous than other species of premature labour, for the hæmorrhages, which are so apt to attend them, are never known to occur here.

This mode of delivery has not only been proposed in cases of contracted pelvis: "There is another situation," says Dr. Denman, "in which I have proposed and tried with success the method of bringing on premature labour. Some women who readily conceive, proceed regularly in their pregnancy till they approach the full period, when, without any apparently adequate cause, they have been repeatedly seized with rigour and the child has instantly died, though it may not have been expelled for some weeks afterwards. In two cases of this kind, I have proposed to bring on premature labour, when I was certain the child was living, and have succeeded in preserving the children without hazard to the mothers." (Introduction to the Practice of Midwifery, 2d ed. vol. ii. p. 180.)

Period for performing the operation. Although under the head of PREMATURE EXPULSION we have stated that a foetus is capable of maintaining its existence if born after the twenty-eighth week of pregnancy, we must not be supposed to recommend the artificial induction of premature labour at so early a period as this. "Experience has shown that it was not necessary to induce labour at so early a period as was first imagined, on account of the very great difference which even one or two weeks are found to make in the hardness of the foetal skull. Thus, for instance, in cases where the antero-posterior diameter was only three inches, six weeks before the full term of utero-gestation were found sufficient, and where it was three inches and a half, fourteen days made sufficient difference." (Naegelé, MS. Lectures.) Still, however, as it is so difficult to be quite sure of the data upon which we have made our reckoning, it will be safer to fix the operation a week or two earlier; and if we lose a little time by failing in our first endeavours to induce uterine action, it will be of so much the less consequence: hence, therefore, as a general rule, the most eligible time will be between the thirty-fourth and thirty-sixth week; and if the deformity be very considerable, we may commence operations as early as the thirty-second week or two months before the full term, short of which it will seldom either be justifiable or necessary. On the other hand, where the state of the cervix and the history of her pregnancy combine to make our reckoning nearly a matter of certainty, the later we can safely delay the operation the better, for by so doing the process resembles more a natural labour, and the chances in favour of the child are much increased.

Operation. The original mode of artificially inducing premature labour was merely by puncturing the membranes and allowing the liquor amnii to escape; the more gradually this is done the better, for by this means the uterus is not entirely drained of its fluid contents, and is, therefore, prevented contracting immediately upon the child; the value of this precaution was pointed out by the late Dr. Hugh Ley, and also by Wenzel. A considerable interval may elapse between puncturing the membranes and the first contractions of the uterus, generally varying from forty to eighty hours: it should be performed while the patient is in the horizontal posture, in order to prevent the escape of too much liquor amnii. A moderately curved male catheter, open at its point and carrying a strong stilet sharpened at the end, is the best and simplest instrument for the purpose: on passing it up to the membranes, the stilet should be protruded, but to a short extent, to avoid injuring the child; and as soon as the liquor amnii runs from the other end, the instrument should be withdrawn, and the patient desired to remain quiet. A dose of opium has been usually given after the operation by the English practitioners, but its utility appears rather questionable: a brisk purge of calomel and jalap, some hours previously, is much more important; uterine action comes on much more regularly and effectively, and there will be much less chance of those rigours occurring which some practitioners, although erroneously, have supposed, were connected with the death of the child.

The practice of dilating the os uteri first, as recommended by Brüninghausen, Kluge, and others, has, as far as we know, never been attempted in this country, and resembles much too closely the accouchement forcé of the French authors ever to be permitted.

The simplicity of the operation of tapping the membranes has rather led practitioners to overlook a still greater improvement, viz. the inducing uterine action first: this was proposed by Dr. Hamilton to be effected by passing up a catheter, and separating the membranes from the uterus to a considerable distance above the os uteri. The operation certainly succeeds in some cases; but our own experience goes to prove, that in the majority it is not sufficient by itself to provoke uterine contraction, and in order to ensure success we must combine with it other means.

The plan of treatment which we have found most certain is first to clear out the bowels by a full dose of calomel and colocynth, then to give the patient a warm bath, in which she may remain twenty or more minutes, after which the abdomen should be well rubbed with stimulating liniment as she lies in bed, and the secale cornutum given in doses of a scruple of the powder in cold water, repeated every half hour for five or six times. Contractions of the uterus rarely fail to follow, and although they generally require the secale to be renewed after a few hours, they will be found to have effected several very important changes preparatory to actual labour;--the abdomen has sunk, the fundus is lower, the cervix is shorter or has disappeared, and not unfrequently we feel the head has already passed the brim and is now in the cavity of the pelvis; the vagina and os uteri are lubricated with a copious secretion of remarkably pure and albuminous mucus; and in these cases especially, we frequently meet with those little lumps of inspissated mucus which were formerly called the ovula Nabothi. All these precursory changes are so many preparations of nature for a natural labour, and contribute not a little to the successful termination of the case, advantages which cannot be enjoyed where the membranes have been previously ruptured. If, however, we do not succeed in producing more than a slight dilatation of the os uteri, if the repeated exhibition of the ergot only produce vomiting, or constant pains which have no other effect beyond preventing rest and inducing exhaustion, the separation of the membranes from the uterus, as proposed by Dr. Hamilton, will now have the best effects: even if this fail and we are compelled to puncture the membranes, it will now be performed under so much more favourable circumstances, from labour having already commenced to a certain extent.

A warm bath and the other usual means for recovering the child should be in readiness. In most cases the secretion of milk follows as after labour at the full term, which is a great advantage; for the thin watery secretion of this early period is much better adapted to the weak digestive organs of the premature child. It is frequently a matter of some difficulty under these circumstances to make a child take the breast at first, and this is the chief reason why their digestive organs so soon become deranged. "In case no milk be present, a good substitute may be made by beating up fresh eggs and milk, boiling them over a gentle fire and straining off the thin fluid." (Reisinger, die künstliche Frühgeburt.)

One great encouragement in cases requiring this operation is the fact that in every successive pregnancy the uterus is more easily excited to premature action; and in some cases where it has been induced several times, it has at length, as it were, got so completely into the habit of retaining its contents only up to a certain period, that labour has come on spontaneously exactly at the time at which in the former pregnancies it had been artificially induced.[103] We have already alluded to this circumstance in the chapter on PREMATURE EXPULSION OF THE FOETUS.[104]

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