ment of the pubis, compel it to descend far below the crown of the arch, to extend and be born.

Such a form of the arch is precisely equivalent to a preternaturally long symphysis pubis. The easiest labor, cæteris paribus, is that in which the symphysis pubis is the shortest-that in fact, in which the symphysis is but a narrow bar under which the head has an early opportunity to be extended in the third act of the mechanism of the head in the labor. In all cases where the arch is very narrow, and the head is compelled to descend very low previous to commencing its act of extension, the distress of the patient and her hazard are considerably augmented by the necessity of thrusting the perineum so much further down previous to commencing its act of extension. I have seen such labors in which the woman made the most desperate efforts at expulsion, and have been compelled, in consequence of this species of deformity, to exert all my strength and dexterity to extract the foetal head with the forceps.

The obstetrical properties of the pelvis depend mainly upon the conformation of the anterior aspect of the sacrum: where its curve is too great, the point of the coccyx interferes with the antero-posterior diameter of the inferior strait, and where the curve is too small, that most important act in the mechanism, the rotation of the head, is rendered difficult, if not indeed impossible. I speak, from painful experience, of the difficulties I have encountered from this cause, in cases in which, having found the spontaneous rotation not possible, I have been compelled to effect it by locking the child's head in the blades of the forceps, and then, with a difficulty, and cautiousness, and slowness, and doubt, calculated to impress my mind with a senti ment not very different from one of horror, and after protracted efforts, finally crowned by success as to the mother at least-and sometimes, both for the mother and child-have thanked God for their escape.

CASE. On the 5th of January, 1849, I delivered a lady of her seventh child. It was the fifth forceps operation required in her case. The child's head measured, in its occipito-mental diameter, six inches; its occipito-frontal was 5ths, and its bi-parietal 4ths. There was no rotation. The left-hand blade of my forceps was applied upon the occipital region, and the right-hand blade upon the frontal region. After the most exhausting efforts on my part, and unspeakable suffering on hers, the child was delivered with its vertex to the left tuber ischii, and its forehead to the right. To-day, January 9, the mother and child appear to be in perfect health.

Fig. 117.

Notwithstanding I have already spoken of cases of labor rendered preternatural by prolapsion of the bladder, more properly to be called vaginal vesicocele, to which I refer the Student, I annex a drawing (Fig. 117), to show the mode in which the over-distended bladder may get beneath the head so as to prevent its descent. Fatal consequences might ensue from a mistake in the diagnosis of this case, of which the remedy is to be found in the use of the catheter.

In a former part of this book, is an account of a case that occurred to me in consultation with Dr. Bicknell-that of a woman in whom a large mass of intestinal convolutions had fal len down below the uterus and filled the cavity of the pelvis, occupying the recto-vaginal cul-de-sac, and distending it to an enormous size. This cause converted an otherwise perfectly healthy labor into a preternatural one. I think it probable that the woman would ultimately have fallen into a state of exhaustion, or that she would have developed inflammation in the mass of half strangulated intestinal convolutions, had not the cause of difficulty been ascertained, and the labor brought to a rapid conclusion by the return of the prolapsed bowel into the cavity of the abdomen. It is proper to cite the example in this connection, were it merely to indicate the possibility of such an occurrence, and the necessity of interference.

Many cases are mentioned of labors rendered preternatural by the engagement of a firm tumor, consisting of altered ovary occupying a considerable part of the excavation of the pelvis, and so preventing the descent and passage of the head. The rule of action, under such circumstances should be to endeavor by all the means in one's power to return the tumor above the strait; and, as such a tumor must necessarily be behind the uterus, attempts to push it out of the way would be far more likely to succeed, were the patient placed on the knees, the top of the breast being pressed upon the same plane on which the knees rest: the pelvis being thus elevated, the uterus would by gravitation be drawn far upwards out of the pelvis, leaving a more ample space for the reposition of the tumor; and the patient placed in this position is completely deprived of the tenesmic, or bearing-down power, a slight exertion of which would be sufficient, in almost any case, to contravene the efforts of the practitioner. In all such cases, then, I advise the Student to cause his patient to be placed in the position

above indicated, and with the hand in the vagina or one or two fingers in the rectum, endeavor to displace the tumor upwards.

It has been recommended, where displacement of the tumor up wards proves to be impossible, to endeavor to reduce its magnitude by puncturing it with a trocar, or incising it with a bistoury through the posterior wall of the vagina. I do not feel at liberty to recommend such an operation-one which could only be legitimately per formed, upon mature consultation with the most acute and able practitioners of the vicinity. They alone should feel themselves vested with the authority to act under such terrible circumstances. Dr. Lever recites a case in which he punctured such a tumor through the vagina. The woman recovered happily, and at a subsequent period was delivered of a child by a Mr. Newth, surgeon.

I saw, in consultation with Dr. Beesley, of this city, a lady in whom a large heterologue mass seemed to spring from the left semi-circumference of the brim of the pelvis and iliac fossa, overhanging appa rently nearly one-half of the plane of the superior strait. When labor came on, and the bag of waters was formed, the vaginal cervix became farciminal or cylindrical, so that, having got beneath the overhanging mass, it lifted it upwards and turned it over to the left side, permitting the head to fall into the excavation, whence it was soon happily expelled. After the birth of the child, the tumor resumed its former position, and the woman recovered.

An interesting account of tumors obstructing labor, by Dr. S. C. W. Lever, may be found in Guy's Hospital Reports, 1843, vol. i. p. 26.

Laceration of the Womb and Vagina.-It appears to me probable that most lacerations, or ruptures, as they are called, commence in the posterior wall of the vagina, nigh to the cervix uteri, where the vaginal wall consists merely of the mucous body and vaginal cellular tela, resting on a basement of peritoneum: the tube is so thin at this place that it is surprising to witness its power to resist, in certain labors where women, to the expulsive powers of the uterus, add all the force they are capable of exerting by means of their adjutory muscles. When the tissue becomes still thinner, as in being distended by a very large head, one would think that a fissure a line in length might prove the beginning of a laceration in which the rest of the vagina and the whole vaginal cervix would give way like a bit of torn linen. In any such case, if the head or presenting part should escape beyond the tube of the vagina or wall of the uterus, the pain will be greatly exaggerated and the uterus make haste to expel its burden into the peritoneal sac.

Upon the expulsion of the child and the contents of the uterus into the belly, the labor-throes cease, and a great calm immediately follows the accident, which is suspected to take place merely upon such a sudden and extraordinary cessation of the process, but which is known to have taken place, on discovering that the presenting part can no longer be detected, in consequence of its having escaped from the cavity which contained it.

Upon discovering even the smallest commencement of a laceration of the vagina or cervix uteri, the earliest precautions should be taken to insure delivery per vias naturales, and the prevention of the escape of the child into the peritoneal sac. This should be done, where it is practicable and convenient, by seizing the head, if it be the head, in the forceps; by bringing down the feet, if it be a breech; by turning and delivering, if it be a shoulder case; or a case of face presentation, or a departure of the chin, or any condition, indeed, in which the operation of version would be most likely to rescue the woman from the dangers by which she is surrounded.

Should the laceration have permitted the child to escape into the peritoneal sac, let the attendant lose no time, but bare his arm, and resolutely, with his hand passed through the rent, explore the abdomen in search of the feet, which he should immediately withdraw through the opening of the laceration. But if this be not done at once; if some hours should have elapsed subsequent to the occurrence of the accident; if the woman be already much exhausted by hemorrhage, by constitutional shock and irritation, the question will arise as to the properest manner of fulfilling the indication, which must ever be to extract the child. The hemorrhage will now have been stayed: were it not so, the woman would be already dead. To pass the hand through the rent, should it be in the vagina, would be to set the hemorrhage on foot again. It will be impossible afterwards to pass the hand through the rent in the uterus, because the uterus, being now contracted, will have reduced the size of the rent in proportion to the condensation of the organ. The child having passed through while the uterus was yet undiminished in size, can never be returned through a contracted rent, and the question arises as to the mode in which the indication is to be carried out.

I am convinced that, should I be called to the conduct of such a case, I should feel bound by my conscience to recommend delivery by gastrotomy. I cannot think that a clean incised wound along the linea alba, sufficient in length to permit the extraction of the child from the peritoneal sac, however exceptionable in itself merely considered, can be held in the least degree objectionable when compared

with the delay, the fatigue, the contusion, and the renewal of the suspended hemorrhage, that would inevitably attend an attempt to extract per vias naturales. I express this opinion here, upon a most vivid recollection of the distress which I occasioned to an unfortunate woman, who in consequence of a laceration affecting the posterior wall of the vagina and the vaginal cervix, drove her child into the cavity of the belly. As the head could be Touched, and as the child was dead-nearly twenty hours having elapsed since its escape from the uterus-I made use of the perforator, and then, seizing the head through the opening, with my embryotomy forceps, I used all the force which it was possible for me to employ in drawing it away through the natural passages. The unfortunate woman, who bore the rude operation with the greatest constancy and courage, lingered many hours after its close. The events of this case, which, peradventure, might have had a happier conclusion by means of the gastrotomy operation, have impressed me, more than a thousand arguments could do, with a deep conviction of the cruelty of such a mode of delivery; and I repeat here, in the most distinct terms, my decided preference for a delivery by means of an incision through the linea alba. The brilliant success of my fellow-townsman, Professor John Neill, in curing such a case by gastrotomy, only causes me the more to lament that I did not insist, in my case, on the same method of treatment.