nesia, or castor oil, may be beneficially administered where there is sufficient time for the alvine operation to take place before the delivery of the child. Aperient doses are useful in some labors, because it cannot be doubted that the constitutional disorder brought on by the pain. and fatigue of labor, must, in some measure, extend to the digestive organs; nothing, indeed, is more common than to meet with parturient patients who vomit very much; while water-brash, heartburn, and sour eructations are also exceedingly common, and often quite distressing.

As to the exhibition of purgative medicines to women in labor, it ought to be understood that, in the selection of the article, care should be taken to provide one not likely to operate violently; which would be objectionable, as to the trouble it might give during the parturient process, and the inconvenience experienced by alvine operations soon after the birth of the child. For my own part, though I prefer, in general, that such a patient should not have a dejection until the third day, I commonly advise a dose of castor oil where I have to fear a long and reluctant dilatation of the cervix. I administer the drug in such cases, because I seem to have observed that the operation of it tends to suspend the power of the cervix and os uteri, or relax the sphinctorian force of the retentive fibres of the uterus, just as it does that of the sphincter ani muscles. It excites also the expulsive faculty of the womb, as it does that of the colon and rectum, and abdominal muscles.

CASE. This day, September 2d, 1848, I found an os uteri not bigger than a swan's quill, though the waters had gone off full fourteen hours, and the woman had had sharp pains for eight hours. I gave her a tablespoonful of oil, and in three hours the child's head had passed through the dilated os into the vagina.

The foregoing remarks show not only that medicines of an aperient kind are frequently indicated in obstinate and protracted labors, but they ought to show that care is required as to the exhibition of food to such patients: some food is wanted, particularly for those whose pains are of so lingering a kind as to allow the process to remain unfinished for many hours. For the most part, tea, bread, or gruel, sago, &c., are found to suit the patient best. The fittest drinks are gum-water, toast-water, lemonade, cold water, and such like articles; the object being to sustain the system by means of nutriment and drink while under severe effort, at the same time carefully avoiding to call the force in the direction of the digestive organs by overtasking them. The whole powers of the economy should, therefore, be hus

banded and preserved as much as possible in their normal condition, in order that they may be directed and determined towards the womb and its auxiliary organs. In the case of a very slow labor, which should be unattended with constitutional symptoms, or any evidences of gastric disorder, a light broth, or even some small portions of very digestible meat, might, upon due reflection, be allowed to the patient.

Decubitus.-The attitude of the patient exercises, in many cases, a notable influence on the progress of labor. It is the almost universal custom in this country and in England, to direct the woman to lie upon her left side, with the knees drawn up; a posture which is highly convenient to the practitioner, and productive of the least possible exposure. But where the labor proceeds slowly, the heat and the pressure occasioned by lying still in the same position, become injurious. The woman ought, therefore, to be directed to turn on her back, or even on the opposite side, or to rise and sit in an easy chair, from time to time. I do not recommend that she should be too much urged upon this point; and I note, that the influence of custom is so great, that a proposition to turn on the back is not unfrequently received with something like astonishment and aversion by the by. standers, who seem to regard that attitude as, at the least, indelicate. Hence, it is proper to assign reasons for the request.

Where the retardation arises from an improper direction of the expulsive forces, it is of the highest importance to direct the patient as to her attitude. For example, if a lateral segment of the os uteri can be felt towards the middle of the pelvis, and the other one is either out of reach of the finger, or very high up on the side of the ischium, the fundus uteri is directed to one side of the abdomen, giving more or less obliquity to the long axis of the womb, and of course an oblique line of direction to its forces, which are decomposed and so, partially nullified. A change of position to the back, or the opposite side, will bring the plane of the orifice to its proper place in the pelvis.

CASE.-On Sunday, November 30th, 1828, I was sent for to visit Mrs. C., whom I found lying upon her right side. The pains seemed so expulsive, that, when I arrived, I expected to receive the child immediately, for she bore down like one in the last throes of labor. I requested her to turn upon the left side, because that position was the most convenient for me. She did so. The pains now became inefficient and partook, in appearance, of the character of the grinding pains. I found that the uterus had obliqued far down to the left side,

as soon as she turned over, which interfered with the due exercise of its power. She was again placed on the right side, which brought the womb into its proper line of direction, and the labor ended, after three or four pains. Similar consequences follow from an anterior obliquity of the axis of the uterus; but, in this case, the anterior segment, or lip of the womb, seems to hold the head as in a sling or pouch-the anterior portion of the cervix being stretched across the head, far behind the middle of the pelvis, while the posterior edge of the circle either cannot be felt at all, or is found high up towards the promontory of the sacrum. It is evident that, in such a state of things, a good deal of power must be lost in pushing away the anterior part of the cervix, a power that should be determined in the proper direction. To do this we may draw the os uteri forwards towards the symphysis, and retain it there by the fingers; but there are in many cases a rudeness and violence in this plan, which will be easily appreciated by such as shall make the attempt, and who, moreover, will often find that they cannot retain it in the desirable place, without giving pain, and exerting so much force as to expose the os uteri to contusion or to rupture. If the woman lies on her back, the fundus uteri will retire towards the spine, bringing its axis into the proper range; and of course the plane of the os uteri will take its proper station; if this precaution be taken, the child will, in some instances, be delivered much sooner than if it should be omitted.

When we meet with patients who allow themselves to be violently agitated by the pains of labor, so as to require actually to be held, at a period when the perineum is in danger of rupture (and women are now and then so distressed as to lose all command of themselves), the best attitude is the one on the back, with the knees drawn up; in this position they are kept much stiller and quieter than when on the side. I had a woman under my care in November, 1833, who was so violent that two or three women could not keep her still; when I caused her to assume the dorsal position, she became passive enough.

To Assist the Flexion and Rotation.-I have spoken, in another place, of the dip of the occipito frontal diameter of the fœtal head. The nearer to the middle of the excavation we find the posterior fontanel, the greater is the dip; therefore in the conduct of labors, we may exert a most beneficial influence, by increasing the dip of the occipito-frontal diameter, which brings the posterior fontanel down towards the axis of the excavation; not down to the axis, indeed, but yet not far off from it. The vertex must always, at first, be towards one of the lateral pelvic walls; but where the posterior

fontanel is found quite up towards the side of the pelvis, and the anterior fontanel is at the same time within reach of the finger, we may feel assured the dip has not taken place, and the retardation of the labor may be attributed to that cause, for the chin has somewhat departed from the breast. Could we, under such circumstances, get the vertex more down towards the centre of the pelvis, the pains would be more successful. Now, the edges of the parietal bones overriding the edge of the occipital bone, form a ledge, which gives a good purchase for two fingers, which, when applied upon that ledge, can generally draw the vertex downwards to the required position. Whenever this operation is to be attempted, it should be tried during the absence of the pains; and when the vertex is once pulled downwards, it ought to be retained in its place until a new pain comes on and enables the operator to secure whatever advantage he has gained. Should the head be placed, by this gentle method, in the desired attitude, it is as easy to conceive, as it is indeed common to witness the increased facilities it affords for the delivery.

In this case it is useful to make the womb take an oblique position in the belly. For example, suppose the vertex to be to the left and unable to dip; it is clear that if the woman should lie upon her left side, the fundus of the womb would be thrust down towards the left side, and that the vertex would have less difficulty in dipping. If it should not fall down there, it ought to be pressed down with a gentle hand.

I have always found it much easier to pull the vertex down than to push the forehead up; because, the finger acting upon the ledge above described, acts upon the longer end of the lever, of which the atlas represents the fulcrum: whereas, in an attempt to push up the forehead, so situated, the lever we use is very short-its real extremity would be the chin; but we cannot reach the chin. Moreover, when we attempt any strong force, the bones of the os frontis are so yielding, that they readily indent, and we are obliged to desist for fear of contusing the brain; the fingers, in fact, being applied near the upper edge of the os frontis, where the ossification is as yet incomplete. The same objection does not hold as regards the posterior edges of the parietalia and os occipitis, which are very firm before birth.

The labor may be retarded by the failure of the head to undergo rotation. It is sometimes very difficult, at the bedside, to learn why the head does not rotate in a patient, who in another labor meets with no such difficulty. I am aware that it frequently arises from failure of the dip above spoken of; but I wish now to speak of a case in which the head has sunk very low, where the dip is good, yet the

rotation fails: I have on many occasions, after much doubt and auxiety, found that it could be fully accounted for by referring to the grasp of the cervix uteri, which actually bound and held the head so firmly, that it was unable to execute its pivot motion. The remedy in such cases, is patience; for as soon as all resistance of the cervix is over in consequence of the fatigue of the parts, or the acquisition of perfect dilatability, the pains will push the head down, and the inclined planes of the pelvis will make it execute its spiral or rotatory movement in the most rapid manner.

In all the cases where rotation fails for want of the requisite dip or approach of the chin to the breast, let that want be supplied by pulling down the vertex as directed, and if such gentle measures will not succeed we have the powerful resource of half the hand, which may be introduced into the vagina, and sometimes within the cervix; and which taking the head in its palm and fingers, can place the vertex wherever it may be desirable to fix it. It should be remembered, however, that a vectis is very rarely, but yet sometimes imperatively demanded for the management of such a case.

Vaginal Vesicocele.-Labors are rendered slow, painful, and even ineffectual, by vaginal vesicocele. The bladder of urine in these instances, instead of maintaining its place in front of the womb, appears to fall down below the top of the arch of the pubis, making a soft, elastic, and painful tumor there. Sometimes the depressed bladder is directed to one side of the pelvis, as in the following instance, which explains the circumstances of such a case better, perhaps, than could be done by a long dissertation.

CASE.-Mrs. B.'s labor, since yesterday morning. about 15th to 20th.

September 8th, 1848, 12 M. In labor
Expected her confinement last month,

She recovered from her last menstrua November 10th, 1847, and has not seen since that date. If we adopt Prof. Nægèle's method of calculation, and go back to October 10th, September 10th, and August 10th, which is three months, and then add to August 10th seven days, we should look for the accouchement on the 17th August. In fact, on that day she had a considerable show,-which was repeated for many days, inducing her to keep her chamber, which she has not since left. Her pains are now frequent and attended with violent tenesmus or bearing down. By the Touch I find the os uteri very high and scarcely to be reached-open to the size of a ten cent piece, very thick and hard; the head presents; the membranes unruptured.