example of the labors. The subject, therefore, embraces so wide a field of discussion and detail, that it will be requisite to treat it according to the nature of the several causes that happen to interfere with the usual process of childbirth; whence I shall endeavor to describe the different sorts of preternatural labor according to the circumstances that make them what they are, and point out the modes of treatment most suitable to their several natures.

Perhaps it matters not which kind of preternatural labor is here first treated of, for there is no natural order or method of their occurrence; each one might be the subject of a separate monograph. Yet I have chosen to commence with the account of presentations of the shoulder, in which the operation of Turning is generally considered to be inevitable as a part of the treatment; and since that operation is not unfrequently resorted to in other kinds of preternatural labor, I deem it of some advantage to take an early opportunity of describing it in this connection.

I have already said that, in order to constitute a natural labor, one of the extremities of the foetal ovoid ought to present at the opening; and I have treated of the pelvic presentations as being natural; and I have supposed that the knee and footling cases are but accidents or deviations of the natural pelvic presentation.

In presentations of the head, there is also, I said, a liability to deviations, by which the head glances off from the brim of the pelvis, whereupon it is either turned upwards into the venter of the ilium, or rises above the top of the pubis.

In a case where the direction of the uterus is very oblique, so as to allow the fundus to fall far down into the right flank of the patient, the child, if pressed by the contractions of the fundus, might be pushed towards the left side of the brim of the pelvis in such a manner as to make it doubtful whether the head would enter the strait, or slide upwards on the left side of the womb. For the most part, it fortunately happens, even in the very greatest lateral obliquity of the womb, that the head is not deflected, but enters the strait; but in a few examples it is found to rise upwards, instead of engaging. When this takes place, it must almost inevitably happen for the shoulder to fall into the cavity from which the head was turned away, and as the shoulder is a projecting part, it is very likely to maintain the position in which it is once ensconced. The shoulder, therefore, when the head glances off, descends or engages in the superior strait, and is pushed downwards by the uterine contractions as far as it can possibly be urged, and there it stops. The strait being now jammed full of a mass, composed of the shoulder, arm, neck, throat, and part of the thorax of the child;

so that no additional portions of the child can be pressed into it, a total arrest of the progress takes place, and the woman, after vain struggles, protracted according to the strength of her constitution, sinks at last, without the possibility of rescue from death except by the skilful aid of the obstetrician, or by the happy event of what is called a spontaneous evolution.

There can scarcely be any need for me to enlarge upon the imprac ticability of delivery here except by art; for even could the shoulder be pushed down as low as the vulva, it would happen, at last, that the head would be again brought to the strait from which it had been turned off, but it would be accompanied by the child's body, either of which, alone, is sufficient to fill the plane and the excavation, so that the two together could by no means pass through. The remedy is either to push the shoulder out of the way, and to bring the child's feet down so as to deliver it footling, or to restore the head to its proper place. There is, even where the operation is impracticable, an exceptional escape from death under these circumstances by the very rare occurrence of what is called spontaneous evolution of the foetus, to be hereafter described.

I ought to remark that while the shoulder presentation is a deviation or accident occurring in an original head presentation, so it may happen that, instead of the shoulder, the hand or elbow may come down; but in fact they are mere circumstances of a shoulder case; and when they are advanced to a certain degree, it is the shoulder, after all, that fills the strait and the excavation, and which constitutes the presenta tion. The hand and arm are merely prolapsed, and their prolapsion adds nothing to the difficulty of the case; indeed, their prolapsion serves as a means of guiding us in our diagnosis, and does not at all oppose the successful treatment of the labor. In the management of a pelvic presentation, I should, in general, prefer that the feet should not prolapse; in a shoulder presentation, it would be rather a favorable circumstance for the arm to prolapse.

CASE. Some months since I was in attendance in a labor case, in which, though the os uteri was very much dilated, and completely dilatable and distended with the bag of waters, I could not with the index finger touch the presentation. The patient was very much flexed, which relaxed the abdominal integuments. Upon placing my hand over the right iliacus muscle, I distinctly felt the orbicular mass of the child's head under my palm. Introducing the fingers, again, I waited until a pain came on. As soon as the bag of waters became tense from the pain, I pressed with my left hand, the head out of the right

iliac fossa towards the chasm of the superior strait. I then ruptured the ovum, and exhorting the woman to "bear down, bear down," I had the pleasure to perceive the head driven quite into the excavation, and to find it born after a few minutes. Doubtless, I prevented the shoulder from coming to the os uteri by pushing the head to it.

Fig. 88.

Two Shoulder Presentations.-Two Positions for each Shoulder. As there are two shoulders, a right and a left one, there must be a set of positions for each shoulder; but in determining what is the position of the shoulder, it is also necessary to determine the situation of the child's head. In speaking of natural labor with the vertex in the first position, I endeavored to explain the causes which give a greater number of first positions. The same reasons operate to produce, in shoulder presentations, a greater proportion of instances in which the head is to the left side of the pelvis, than those in which it is to the right side. Now if the right shoulder presents at the strait and the head is to the left, as in Fig. 88, the face of the child, and its toes and feet, will look towards the mother's back; but if the same shoulder presents, and the head is to the right side of the pelvis, the face and front of the child must look

towards the mother's front: so of the left shoulder in the first position, the face will look in front, and in the second position it will look towards the mother's back. By speaking, therefore, of the positions of the two shoulders separately, we get a better and less complex idea of this sort of labor than we should have were we to enumerate a set of positions without such a division.

I think that the form of the foetus, and the capacity of the womb, are such as to make it unnecessary to establish more than two positions for each shoulder: for example, for the right shoulder a first position, or that in which the head is to the left, looking backwards, and a second, in which the head is to the right, and looking front: for the left shoulder a first position, wherein the head is to the left, looking front, and a second, in which it is to the right, looking towards the back of the mother. This will, I think, be quite sufficient; and gives us four positions for the shoulders, hand, or elbow. It is not to be denied that the head might be in front, looking to the left, or looking to the right side of the mother, giving us in the former case a right shoulder, and in the latter a left one, in the strait; but it is needless

to enumerate such a position, as the contractions of the womb and abdominal muscles would soon turn it into one of the attitudes I have before pointed out.

Diagnosis.-The signs by which a shoulder at the strait may be diagnosed are, 1. The want of the regular form of the bag of waters which, in all preternatural presentations, is without that proper convex shape that we notice in favorable instances of natural labor: whenever the membranes pass down into the vagina, shaped almost like an intestine, or in a cylindrical form, there is good reason to think there is something untoward in the posture of the infant. 2. The spinous process of the scapula; the clavicle; the round-shaped shoulder; the axilla; the ribs; the arm, distinguishable by its size from the thigh, are evidences that a shoulder presents; but should the attendant retain any doubts, let him never omit to remove those doubts by the introduction of half his hand into the vagina, whereby he will be able freely to examine the nature of the presenting part, and learn its true position: no person is excusable for mistaking the diagnosis who knows he can command so infallible a method of making a correct one. The diagnosis can always be made in good time-that is, as soon as the dilatation will admit; and until then nothing can be done to aid the labor.

Turning. Having ascertained that a shoulder is at the strait, there remains but one determination for the practitioner, and that is to put it away and bring another part of the child to present. This necessity, and the hazard in which, consequently, both the mother and child are involved, should be plainly and seriously laid before those who have the best right to know her case; namely, her husband or parents, or such near relative or friend as may seem to be, for the time, in loco parentis for her. The necessity for interference ought also to be explained to the sufferer herself, but in the gentlest and most cheering manner possible. If it be within the bounds of possibility to do so in good time, a medical brother ought to be invited, in order that his counsel may be taken, and particularly that the friends, and the patient also, may have no doubt left in their minds as to the propriety of the operation, nor claim the least right afterwards to find fault with the physician, should any untoward event follow the plan he had recom mended. The act of turning to deliver by the feet is fraught with danger, for there is danger of uterine laceration, or of fatal contusions of the parts of the mother, and of failure to succeed in effecting the version, and great danger of destroying the life of the child in the act

of turning. In early times, our ancestors, who did not understand the mechanism of labor, used to wait, after pushing the shoulder back into the body, in hopes the head might descend. For example, here is the doctrine of Thomas Rainald, to be found at fol. lxv. of his "Woman's Booke:" "And yf so be that it appears and comes forth first the shoulders, as in the XI figure, then muste ye fayre and softlye thruste it backe again by the shoulders till suche tyme as the head come forwarde." It may be that those old practitioners of the days of Queen Elizabeth may have sometimes succeeded, by pushing up the presenting shoulder, in getting the head at last to come to the strait again; but such an event appears to me in any case most improbable.

But no operation can be performed while the os uteri is so closed as to refuse admittance to the hand. It cannot and must not be forced. The mouth of the womb must be dilated or dilatable before any operation is lawful; it must be dilated or sufficiently yielding to allow the hand to pass upwards into the uterine cavity; of this degree of dilatability the obstetrician is the only judge. He must never run the risk of tearing or inflaming such an important organ, since its laceration by his hand would be much increased by the following birth of the child, and place the woman in danger of sudden death; or he might contuse the parts so much as to establish a highly dangerous inflammation in them. So important is it to judge aright concerning the time to be chosen for the exploration of the womb, that it is thought to be the most responsible duty of the physician in the whole case. If he proceed too soon, the most lamentable consequences are apt to ensue; and if he defer the procedure too long, the difficulties and dangers are greatly enhanced by the delay, while the patient also suffers useless and pernicious pain. The bladder and rectum should be evacuated before the operation. The position should be carefully ascertained; this can be done by the introduction of the hand, if necessary, into the vagina; and if it be certain that the left shoulder presents with the head on the left side of the womb, then he must make choice of that hand which can most conveniently be employed in the operation. The rule is to use that hand whose palm, when open in the cavity of the womb, would look towards the face or breast or belly of the child, which, in this instance, would be the right hand; for it is clear that if the left hand were used, it would not apply the palm to the front of the infant, whether it were carried up before or behind the child's body.

Although some accoucheurs prefer the lateral decubitus, the best. position for the patient is that on the back, with the end of the sacrum brought quite over the edge of the bed, the feet and knees being pro