mos mag sé grmest 12 va de heat to me we cant we are asse is sure the de its a grand purst. If after we are brock se font down the dead. are sty where we were at first, and can open 1 Premiere LA.. ~—Ïse oper tes that is certainly the best method of managing des very s deformite vars set this premature late. a is founded as these that darng prestansy. the bead of the child is Cocreasing in 1 ze. to the time of delivery : so that if we take the their gradual increase of size, it is pretty plais, that one in the early months of pregnancy would pass with ease through a peiris that would not receive it at a later period; and in this way, by considering the case in all its parts, comparing the diameter of the pelva with the size of the head at diferent periods of the pregnancy, we shall be able to calculate the time when we may bring on premature labour, fixing either the seventh month, seventh and a haif, or eighth month, but never later; for if we do, the head will be too much ossified to submit to the pressure it must sustain, with that ease which is necessary to the delivery being perfectly safe. It may indeed be brought as early as five or six months, but the child then cannot be expected to live; and if it be produced later than eight months and a half, the labour will be as difficult as that at nine months.

The first step towards bringing on premature labour is to carry up a male catheter through the vagina to the os uteri, and to introduce it with care, in such a manner, as that the point of the catheter shall be in contact with the sides of the uterus, using a gentle pressure only. When the extremity of the catheter is against the membranes, but clear of the child, the instrument is to be thrust forward, so as to break the membranes; and in this the catheter is preferable to a rod of silver, since as soon as the catheter enters we know the object for which we introduce it is gained; for while the instrument is still in our hand, we shall feel the waters passing off more or less; while if a solid rod be employed, it may be necessary to introduce it a second time. In puncturing or breaking the membranes, it is also preferable to get the instrument some way up the side of the uterus, instead of breaking them immediately upon the os uteri, because in the latter way the child is most frequently born dead; which depends on the different effect with regard to the flowing off of the waters, produced by the mode of puncturing or breaking the membranes.

The breaking the membranes at the side only allows a partial escape of the waters, quite sufficient to produce a disposition to contract in the uterus, without permitting any injurious effect to arise from pressure; while on the other hand, when they are broken in the front, the whole of the waters flow away, the uterus contracts very strongly round the child, and the circulation generally suffers, and is either partially or completely interrupted. Delivery, by bringing on the action of the uterus prematurely, is for many reasons very estimable: a month or two before delivery naturally produced, the head is not only smaller, but more compressible; there is a less

of the cae same size, che beng of eight #vas formin and me sher seven, ste that 2 WITH #Dis have the acvastage in passing SATEL & SATO pers It is ech for my determine the time wim should apply afera perses: but where the distance be tween the pubes and steric is ander three, yet a but three actes, eight months may be allowed; where the datance is two and three quarters, se ven met is, and so on. Yet when a child is born at serer mods it wil rarely suck, and requires the atmos attention to be reared. By these meats, then, we may be able to save both lives; by the Cesarean section we certainly lose oue ide; and by doing nothing we lose both.

Preternatural Labour.- We now proceed to a consideration of the third class of labours to which we have divided our subject, and which are ge Denky decum rated preternatural, or births; including all presentations bit those of the bead. This class is naturally, therefore, dv. sible into presentations of the lower and presenta tions of the upper extremities: and to this subdivision we shall adbere.

We know little of the cause of preternatural presentation: perhaps it depends on a peculiarity of form, either in the uterus or pelvis. It is said to arise from accidents, because there are more instances of it in the lower walks of life; that is very true; and there are more aquiline noses ameg the poor people than among the rich; and more noses of every kind, because the truth is, there are more individuals in one class than in the other; preternatural births are most likely the effects of peculiarity of shape in the parts. In this kind of labour sometimes the lower extremities presest, and sometimes the upper. We shall treat of each presentation.

Presentation of the lower Extremities-Now this division of labours is capable of being finished by the powers of nature alone: and the only consequen would be upon the child, to whom such delivery is not always safe, for when the feet present, and the child is gradually expelled, the child in figure forms a cone, which all along increases to the shoulders, and the head is born last of all; the ma vel string would be born long before the shoul ders were disengaged, the effect of which would be that the circulation would be interrupted the cord, and perhaps suspended; for pressing the navel-string before birth, is the same as pressing the throat after it; each produces death. After this observation, we have only to remark that when the cord comes down by the navel passing through, a portion of the cord should be drawe slack after it, that it may not be stretched by the child's passing under the pubes.

When the feet or breech have presented, there is plenty of time to turn the occiput to the pubes long before the head is down. Whether one frat or the breech presents, it is better to let it come so, than to go up, and bring down either one of both feet; because in breech presentations, the parts are gradually and well dilated before the cord is likely to be compressed; therefore it is safer; besides the inferior extremities in breech cases lie upon the sides of the abdomen, by which they protect the navel-string lying between the two from any pressure whatever. So that we see all breech cases should be left unturned; and we may ascertain the breech from the head, by feb ing the parts of generation, as well as various depressions without that uniform defined resistant

which is given by the head. When the breech presents, the meconium will generally come away by the pressure squeezing it out of the abdomen. Suppose that in a breech presentation any aecident happen to the woman, needing immediate delivery, it has been said that the forceps may be applied; but from frequent trials we can say that they are of no use; they are not calculated to hold such parts, and always slip off. Another plan recommended, is to get a handkerchief between the thighs and the body: this is an exceeding good purchase, but in the living subject we can scarcely do it, we cannot get it between the legs and the body. If neither of these plans succeed, there is only one remaining; this is the carrying up the blunt hook, and so placing it over the thighs; this certainly commands the delivery, and where small equally applied force is sufficient, it will be both successful and safe; but as it is self-evident that iron must be always stronger than bone, there will be a great risk of breaking the thigh bones by this instrument. Yet the woman is not to die to save the child's thigh-bone from the risk of be ing broken; and it is certainly better to have to treat a child with its thigh broke, than one whose brains have been all scooped out. We should however be careful never to employ the least unnecessary force.

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The feet being born and the breech passed, the part which next presents is the umbilicus; and as the body afterwards passes further down the cord will be both pressed and dragged, and if a cylindrical yielding cavity be dragged, the cavity of that cylinder is diminished in its calibre, and the tube will ultimately be obliterated; so that the best practice will be, as soon as a part of the umbilicus can be felt, to pass up the finger and bring down sufficient to prevent its stretching in the progress of the expulsion; and as soon as the head is in the pelvis, to bend the face down, bringing it forward upon the breast of the infant, and opposite the os externum, by which means the child will commence breathing; and if the navel-string only pulsates up to that time when breathing commences, the child is safe in all that regards suffocation; and as to the head remaining within the os externum, it is of no consequence whatever. If the child's head cannot be brought through, we may pull, drawing it with caution. Some practitioners will pull the child very hard, which is quite improper; not that it is any material object to the woman, but to the child, the force being applied with the hopes of the child's being born alive; but is it very likely that its life will be saved, after a leg or an arm is pulled off, or after the body is pulled so hard as nearly to be separated from the head?

Presentation of the upper Extremities. The other division of this class of labours, is that in which the upper extremities present. This is now and then an original presentation, but sometimes it is artificial. It may he called original, if felt before the membranes be broken in the absence of a pain. It may be called artificial, when the hand being felt by the practitioner, perhaps with some other part, it is drawn down though the os uteri, and the position of the presentation varied; though it originally was a head presentation, it may be made a shoulder presentation. When the hands are at the os uteri, they are easily distinguished from the feet, by the thumb not being in the same line with the fingers; while in the foot we distinguish the toes and heel. The shoulder has been mistaken for the back, and it is a mistake

easily made in practice. In distinguishing, we should recollect the superior extremities have the scapula behind them, while at the breech we feel the organs of generation. We may here lay down a rule which is of the greatest consequence, and applies to all kinds of practice in midwifery; that is, that the shoulders and arm will never pass together: the labour may continue, but if that presentation be not altered, the woman will be worn out and die. We must return an upper extremity; and never regard it as a matter of choice, but as a rule of practice, which must always be adopted. We must turn, because it is a presentation that cannot be delivered. This altering the position of the child, in utero, is called the art of turning, which art, in modern science, is attributed to Ambrose Parée, though it is mentioned as far back as the time of Celsus, who says it is sometimes necessary; he does not, however, say whether it were ever done on a living child. Ambrose Parée's words are, "that in all cases where the upper extremities present, you must turn and bring down the feet; and if the midwife cannot do it herself, she must send for a surgeon who can."

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The nature of these presentations may vary so much that it may be necessary to mention some circumstances. Suppose a case in which the waters are not yet discharged, and the labour is going on very naturally, but by examination through the membranes between the pains, we find that an arm or shoulder presents, yet we may, perhaps, not know exactly the parts; in such case we should not be absent from the woman upon any account at the time of the membranes breaking, for it will make all the difference in the world, as relates to that labour. We must ascertain the exact position of the child, and we must then proceed to turning. The question now is, what time in the progress of the labour is most proper for this operation? Bourdelois says, when the membranes are broken, and the os uteri dilated. Dr. Hunter is of the same opinion. Dr. Clarke differs from them both, and justly; for he found that if we delay turning till the waters have come away, and the os uteri is quite dilated, we allow it to remain to the increasing the difficulty of the operation. we take it when the os uteri will admit the finger and knuckles, it is the better time, because we then turn the child as if in a bucket of water; and this gives us so clear an advantage that it needs no explanation. This then is the most convenient period, and we should begin by dilating the os externum, previously intimating our design to the patient, cautioning her not to be in the least frightened at what we are going to say; we may then inform her "that the child does not lie quite right, but it may soon be set right, and with little trouble." It being then agreed upon, the woman is to be laid close to the edge of the bed; and we roll up the sleeve of our shirt, and pin it, anoint the hand and fore arm, and dilate by forming our hand into a cone, first going gradually through the os externum, taking our time, and being very gentle; but we should not pass on dilating beyond the vagina, until our hand passes easily through; if we do, we feel the inconvenience of it afterwards, by the contraction of those parts: having got our hand through the vagina, we may let it remain a while, and should a pain come on, it may waste itself on our hand. We should then gently begin again to dilate, till we get our hand into the uterus, when we turn the child gradually round, bringing the head to its proper situation.

There is no difficulty if we once get our hand

up through the os uteri, that being dilated suffi. ciently, without the membranes being broken. But suppose another labour, where the membranes are broken without the os uteri being dilated. We have here much more to do, and less chance for doing it well than we had in the other example; we must go on, and have to turn the child too, under the increased difficulty of the contraction of the uterus, which will not indeed be violent, but quite enough to render the turning difficult. But if we be able to manage the most easy case, and the most difficult, we shall be equal to all the subordinate or intermediate degrees of difficulty that may be met with in turning.

To give an example of the greatest degree of difficulty, suppose a case, where the waters have been lost twenty-four hours, two days, or even three. What we have to do in overcoming the contraction of the uterus is not altogether a matter of difficulty as to skill, so much as it is as to time and management. With a view to lessen the difficulty, opium has been given, but great caution is required in its exhibition; since the woman has been known to die from the use of opiates, she has been drained to death by uterine hemorrhages.

The last cirumstance necessary to notice with regard to preternatural labours, is that all the other parts being brought down, the head sometimes cannot be got through well. We may here use a moderate force, by pulling with the body, remembering that our object in using force is to save the life of the child. Besides, why should we use a force too great, when we may always deliver with the forceps? though where violence is unavoidable, it is best to open the head.

To employ that force which, without violence, may assist in bringing away the head, a good method is to make a sort of loop, by bringing a handkerchief loosely round the neck; when letting the ends down upon the breast, we tie them rather low on the breast, so that there may be plenty of room to place our hand within it to pull by; and if we succeed, we must mind, that in bringing down the head, we depress the sides of the head, so as to bring it into the hollow of the sacrum. If it will not come by any means, we must then open it; when we have extracted the brain, we should introduce the blunt hook, and it is used with the most effect when seconded by the pulling of the body.

In some instances it happens that the head is entirely separated from the body, when various means have been recommended for bringing it away. The only sure method, however, is to open it; and when we have dilated it by the opening of the perforator, we should introduce the crotchet, before we withdraw the perforator, in order to have the head always secure from slipping, as it otherwise would do. The difficulty is, that whenever we touch it we have a smooth slippery surface, which we cannot keep, unless we always have an instrument within the hole we have made. It will roll over the upper aperture of the pelvis. We must recollect always to keep one hand in the vagina, while any operation is going on, for the extraction of any body which may be within the uterus, and in order to guard the instruments.

Disorders subsequent to Delivery.-Most of the diseases consequent upon pregnancy arise after delivery, and not during labour. We shall first observe that,

Quietude and a horizontal position should be strictly enjoined as a matter of the greatest moment. And for this reason it is obvious that as

the patient should not be moved early, she ought never to be delivered in her clothes: this, bow. ever, is a plan often proposed by the lower order of people to save inconvenience and expense; lat it never should be assented to by the practitioner, as it is a very dangerous experiment to raise the patient to an erect posture, at a time when she may remain perfectly safe in an horizontal posi. tion. There are many instances of the fatal effects of neglecting such a precaution.

A woman after delivery should remain perfectly at rest for at least two hours, and then should by no means be raised upright, but be very gently lifted just enough to allow the drawing away off the clothes; which if they give trouble must be cut away with scissars, to prevent the risk of exhausting the patient by over exertion.

Fainting.-Fainting after delivery frequently happens, and may arise from many causes, most of which are of little consequence; it is always an unpleasant occurrence, and sometimes dangerous. It may be merely the effect of fatigue; a wornas is just able to bring the child into the world, and after making perhaps the last exertion she is capable of, sinks into a faint. Frequently she wil fall into an hysterical paroxysm, which will easily be perceived by her laughing, crying, sobbing, &c. which characterizes hysteria. If the fainting proceed from either of the above causes, volatile alkali rouses the patient, and nothing more is necessary; neither should any apprehension be felt for her safety.

Fainting may be the consequence of the great agitation of mind which the patient has suffered from fear of the approaching pains, and, as she thinks, dangers. In such cases nourishing things should be administered, as a small quantity of good broth, with a table spoonful of wine in it, or some volatile alkali.

Whenever there is reason to suspect that the fainting arises from loss of blood, the practitioner should never leave it to probability, but instantly examine the truth of his suspicions, not only on the surface lying next to him, but the upper part of the further thigh, as the blood will sometimes run over the side of the thigh that is farthest off; when the practitioner, not perceiving any dis charge from that part whence it is generally ob served to flow, has not the least idea of his patient's situation. When upon examination it is found that hemorrhage has taken place, the placenta being got away, it is to be treated in the commen way by acids, &c.

In some rare instances it has happened, that inmediately after delivery the patient has sunk into a permanent syncope, from which she never has recovered, dying without a groan. When there is reason to suspect the approach of such a state, the patient should be made to swallow a large dose of volatile alkali; it can do no harm, and is generally highly beneficial, let the fainting origin ate from whatever cause; the spiritus ammosiæ comp. and tinct. lavendula may also be adminis tered; and hartshorn should always be kept in a lying-in room.

After delivery it is advisable to apply a certain degree of pressure to the parts. This circumstance has been variously received and very gene rally misunderstood. A certain degree of pres sure is useful, but if that pressure be too great, it will occasion worse consequences than the want of pressure altogether. The pressure required is more properly speaking a support, and is of the same kind as we like to feel from a waistcoat in

winter. The intention to be had in view in making it is just the same as after tapping in dropsy, and pressure judiciously applied in both cases will often prevent fainting.

Suppression of Urinc.-In the country it often happens that a practitioner does not see his patient any more after leaving her safely delivered. In such cases, it will be necessary for him to leave general directions with the attendants, the most material of which is, that the nurse shali send for him, if, upon trying, the patient finds herself unable to make water, at the distance of eighteen or twenty hours after delivery. If the patient be neglected, the bladder swells to an enormous size, and at last bursts, in which case death is inevitable.

When the practitioner has been sent for, he must not be satisfied with the patient's telling him that she has since made water, and that a little escapes frequently; all this amounts to nothing, and must not excuse a moment's delay in the introduction of the catheter. It will generally be necessary to draw off the water once or twice a day; but from distance of residence, this will sometimes be impossible. In such a case it is not very difficult to teach the nurse how to perform this operation, by showing her the parts, and pointing out the little orifice, at the same time tel ing her the instrument must be passed up carefully and slowly till the water flows from the other end of the tube.

Effusion of Blood into the cellular Membrane of the Labia Pudendi.-This is an accident which now and then happens after delivery. It is merely a mechanical effect of pressure, and very rarely occurs. In one case where the parts had been previously much strained, the swelling was first observed by the patient's finding herself unable to close her thighs together. This blood, if left to itself, will first coagulate round the orifice of the bleeding vessel, and afterwards the whole quantity of effused blood becomes fixed. There are two ways by which the parts may get rid of this blood, if its quantity be considerable, either by the skin sloughing off, by which part of the blood may escape, or by the part inflaming and suppurating. When the latter circumstance happens, and it is determined to open it, the orifice made cannot be too small, so that the matter be allowed to escape; for the constitutional weakness at such a time as this will give a tendency to gangrene in any part which is divided. Cold is the only application that is to be at all regarded. It has been recommended to cut and scarify the part, but this is objectionable, because should the artery continue to bleed after the openings are made, the situation of the patient at once becomes serious, for we must necessarily be perfectly ignorant where the ruptured vessel is, and consequently as perfectly unable to stop it. Should it ulcerate, the treatment should be the same as that of an ulcer in any other part of the body.

Lochial Discharge. By this is meant that discharge which follows the expulsion of the placenta, continues for several days, and diminishes in proportion as the uterus contracts. A short time after delivery the vessels which before poured out red blood will, from the womb having contracted to a certain degree, only ooze forth serum. When small pieces of the maternal part of the placenta remain with fragments of the membranes, &c. and mix with the lochial discharge, they constitute what the nurses call the green waters; and these discharges generally subside in six or eight days, more or less. They will, however, often be reproduced by very slight causes; such as sitting

upright, endeavouring to walk, eating stimulating food, or indeed any thing which may increase the action of the heart and arteries. In a strong woman of tense fibre the discharge will be of shorter duration than in a weak woman of lax fibre; if a woman be quiet it will not continue so long as if she be restless. Where the quantity is profuse, and it flows for too long a period, the constitution becomes weakened, and it is necessary to give bark with the vitriolic acid, or the conserve of roses.

Lacerated Perinaum. — The intermediate part of the body situated between the vagina and rectum is called perinæum; and from its peculiar situation is very liable to accident from the violence of pressure in labour; this will sometimes happen with the most careful practitioner; it will now and then give way in a trifling degree, and is in such cases of no further consequence than from its leaving the parts a little sore and weak for a few days. The only laceration of consequence is that from before backwards to the rectum, by which the os externum and rectum are laid into one, and the sphincter ani consequently torn asunder. This accident is, however, extremely rare, and may always be prevented by supporting that part of the perinæum with the hand.

In case of an actual laceration of the perinæum, the first step is to empty the bowels by a brisk purge; after the medicine has operated, the parts should be perfectly cleansed from all fœculent matter, and then the thighs should be bandaged together, by which there is a probability of the parts uniting by the first intention, and in some cases this has succeeded. Should this fail, the only chance is not to allow the parts to heal except by uniting with each other. If considerable inflammation takes place, it must be reduced by the use of fomentations and cataplasms, and of cooling laxative medicines; and if the pain is violent, opiates may be given. When suppuration occurs, bark must be administered. The dressings may be superficial.

After-Pains.-Every woman who has been in labour is subject to what are called after-pains, though they do not always occur equally. They come on at regular intervals, and are more or less violent. These pains are very rarely felt after a first lying-in; and they are less when the labour has been retarded, allowing the uterus to contract gradually behind the body of the child, than where the expulsion of the child has been hastened; the uterus then contracting suddenly but not perfectly. In consequence of these pains, and the fatigue which the woman has sustained throughout the labour, it is a very general and excellent practice to give an opiate of from twenty to thirty drops of laudanum, and afterwards to repeat it in such a diminished quantity as shall allay the irritation, but not the contraction of the uterus.

An after-pain will perhaps come on an hour after delivery, by which a large coagulum may be expelled; and after that others, by which smaller coagula will be separated; and then an after-pain as violent as any of the rest, to throw off one of the smallest possible size. To some women these are very distressing, and are borne with less patience than the labour pains, as the latter they know are for a good purpose, while the pains after delivery afford no such consolation, and yet are some. times as violent as the worst pains of labour can be. These pains may be moderated by warm applications to the abdomen, and by small doses of laudanum.

General Treatment of Women after Delivery,