or one hundred drops of laudanum. We should also not forget that patience ought to work her perfect work, and no more; the accoucheur must be the sole judge of how far patience ought to go.

I should think that there can never be the least use in attempting to return the arm. The arm must be returned by the version of the child: it goes upwards into the womb as the head rises and the breech descends. It would always be prudent to secure it by a noose, for the purpose of preventing its going too high within the cavity, where its presence might cause some embarrassment in the delivery of the head.

P. Cosgreave, Esq., in the Lancet of 1828-9, p. 298, informs us that he has at no time lost a child in an arm presentation. His method is to push up the arm during the absence of the pain, and return it into the womb and hold it there; after which the spontaneous evolution takes place, and the infant is born by the spontaneous powers of the womb. Mr. C. must certainly be regarded as a very lucky practitioner, to have met only with cases in which he could restore the arm to the cavity in this way, or in other words turn the child without searching for the feet. I am not aware of the number of his cases. I cannot, therefore, judge of the comparative

success.

Some persons have imagined that in the conduct of some of these dreadful cases of shoulder presentation, great facility in delivering the woman is obtained by amputating the arm, or wrenching or twisting it off by sheer brute force. Indeed, I am aware of an instance in which the doctor tore off in utero the arm of a child which was afterwards born alive, with the end of the humerus projecting below the ragged and torn edges of the wound. The arm was hidden, but afterwards discovered. The people interested, were made to believe that the lost arm had been destroyed by absorption.

Such a course of proceeding is to the last degree unjustifiable. Unjustifiable before the outraged family, and equally so as bringing unmerited discredit upon the whole profession of physic. If in any case it were deemed necessary to remove the prolapsed arm, it ought not to be done without any antecedent announcement of the purpose, and its motives. For my own part, I cannot understand what are the motives that should leave an accoucheur to do so barbarous an act.

The extirpation cannot be deemed needful to provide space within a pelvis, since the arm of a fœtus can never fill up a pelvis so as to prevent the introduction of the accoucheur's hand for exploration and version. Whenever it is done, it is done with a view to make space within soft parts, but those soft parts will dilate in due time and under

wise treatment. My clear opinion is that the amputation of the arm in shoulder presentations is a mala-praxis, and that it ought to be discountenanced and protested against.

Spontaneous Evolution of the Foetus.-It has happened that the operator, being unable to turn the child, has abandoned any further and useless attempts to deliver. In such instances, the woman has sometimes delivered herself by what is called spontaneous evolution of the foetus.

It is very important for the Student to understand clearly what is meant by spontaneous evolution of the child; and it will not be difficult for him to do so, if he will bear in mind the facts: 1st, that there is a superior strait; and, 2d, that the child's head and its body cannot be within the plane of that strait at the same time.

Now when the shoulder is presenting, and the arm, fallen down, allows the shoulder to be thrust or drawn quite out underneath the triangular ligament of the pubis, it happens that the side of the child's neck lies against the inner aspect of the symphysis of the pubis. But, if the side of the neck is pressed against the wall of the symphysis, the head of the child will lie upon, and even project over and beyond the horizontal part of the pubal bone, making a hard orbicular tumor that may be felt there with a hand laid on the hypogaster.

Now, things being situated as above, let the Student conceive that the trunk of the child's body, still contained in the womb, is thrust by the continued contractions more and more downwards, the head still resting upon or above the brim. The effect of this downward thrusting force will be to push the shoulder farther and farther out beyond the crown of the arch, and the head more and more over the top of the bone, leaving a space in which to thrust the trunk of the child. If it be a left shoulder case in the second position, the third rib will come out at the vulva, then the fourth, fifth, sixth, seventh, and so on until all the left side of the thorax is pushed out; after which follow the left flank, the left ischium, and trochanter; upon the escape of which the left thigh and leg are delivered, followed imme diately by the right thigh and leg, then the right arm, whereupon nothing remains but the head, which is speedily born.

Such is a spontaneous evolution. It differs from Version or Turning in this—that in turning, the head goes up to the fundus, while the buttock comes into the passage. Here the head is held close to the plane of the strait by the shoulder which has got under the arch, and even projects beyond it, so that the head is, as it were, tied fast to the brim so that it cannot rise.

Here I repeat the figure of the double-headed foetus, which I already have given at page 223, Fig. 63. Let the Student see in this figure a case in which evolution was indispensable.

For example, suppose the right head to have presented, and to be delivered. That head would be held close to the vulva, outside by the left head and body—the left head and body could not possibly be in the plane of the strait at the same time. It would be impossible to deliver by Turning-for the delivered head ties the undelivered one to the plane of the superior strait. Of course, then, it only remains that the undelivered head shall be forced over the horizontal ramus of the pubis to allow the trunk to descend by evolution, as I have described that process in the shoulder case. As soon as the trunk is born, the remaining head may be brought away.

Dr. Pfeiffer, who showed me the specimen, delivered the woman, as I found

Fig. 89.

upon inquiry, by compelling the evolution of the body of the foetus. Here is a repetition of the figure of Dr. Rohrer's case, given at p.

Fig. 90.

225. Let the Student observe that such a vast fluctuating tumor on the vertex of the child could never be the really presenting part; that it must necessarily deviate, and go up in the iliac fossa, allowing the true head to present, and making that, of course, a face presentation. I say, of course, for the head would be of course in extension. Well -the labor going on-the head is born in face presentation-giving the face the appearance of suggillation-of which I have made a good representation in the figure; but the head being born, the tumor, larger than the head, remains above the strait, in the same way as the second head of the double-headed foetus of Dr. Pfeiffer's did. Here, then, is a case in which evolution is indispensable, and Dr. Rohrer informed me that this was what he brought about-after doing which he was enabled, with very violent force of traction, to pull away the caput succedaneum-as you see it in the figure.

CASE. I was called, some time since, by a friend of mine to assist him in a case of difficult and alarming labor. The woman, small, feeble, and highly nervous, was the mother of several children.

The doctor, finding the labor very slow, had administered a dose of ergot, which had brought on a most violent ergotism; to that degree, indeed, that I had great reason to fear she might speedily die from the mere excess of pain and irritation, if not from laceration of the womb, which appeared to me imminent. I have rarely witnessed a wilder expression of agony than hers.

I found the left shoulder down, in the second position. The indication was to turn and deliver by the feet-which I was requested to attempt. Protesting beforehand that I deemed success impossible, I reluctantly consented to make an attempt. With great difficulty I passed my right hand through the os uteri; but it was completely pinioned and held fast and immovable by the muscular contraction, and I was but too happy to extract it without having caused a laceration of the cervix. The waters had long gone off. The child was dead. I concluded it was impossible to turn, and I felt equally convinced that she would die before evolution could take place spontaneously.

I opened the thorax at the axilla, and broke up the tissues within both pleural cavities. Then, by means of the crotchet, I drew down rib after rib, the flank, the hip, and the buttock, so that I got the left thigh and leg down; then the other extremity, which completed the evolution. The arms came down, and I delivered the head. The woman recovered happily.

I relate the case, in order that the Student, reading it, may have a

clearer idea of what is meant by evolution in contradistinction to turning of the child.

Hemorrhagic Labor.-Labors are also rendered preternatural by the occurrence of hemorrhage from the womb; for, although it is very common, and not unfavorable for the parturient woman to have an issue of blood during some part of the process of childbirth, it is not either safe or natural for her to lose so much blood as to give to the flow the character or title of hemorrhagic. quantity lost antecedently to the birth of the child an ounce, and it is commonly even less than that. therefore, of a show of blood need not, and does not excite any alarm or even surprise, unless it goes beyond the ordinary amount. But where the effusion becomes excessive, great alarm is felt, and there is more or less real danger according to the cause of the hemorrhage.

In general, the does not exceed The occurrence,

I have already expressed my opinion of the mode of connection. between the placenta and the womb; and the Student will have seen that I do not admit that any very large vessels pass from each to the other, interchangeably Hence, when blood escapes from the uterus, it may be, perhaps, in consequence of a hemorrhagic nisus or sanguine determination, like that which sometimes causes the effusion of blood from the Schneiderian membrane, in those cases of epistaxis that come on spontaneously, or in the floodings of ordinary pure menorrhagia. We often see very copious outpourings of blood in epistaxis, where we can have no reason to suspect any rupture of ves sels or solution of continuity in the membrane. The same thing takes place in the pulmonary hemorrhage, and in hæmatemesis. But as the womb, from its very constitution, is prone to the hemorrhagic affection, it is more liable than any of the organs to losses of blood, without the suspicion of rupture of its tissues. Nevertheless, there is reason for believing that, in some cases of profuse bleeding, the delicate tissue of the uterine veins has been ruptured.

The gravid womb, a vacuum plenum, is filled with the ovum, which is really connected with the containing organ only at the placental superficies. All other points of the ovum, except the placental portion thereof, adhere so slightly as to be capable of most easy detachment. The placenta itself may commonly be separated with great facility from the surface on which it sits. When the chorion is detached from the womb, very little or even no blood escapes; but when the placenta is torn off, the womb generally, not always, bleeds freely. The separation leaves exposed many patulous openings that lead directly into the large veins and sinuses of the uterus. Hence, large