tions, the posterior fontanel may be in the fifth position, that is to say, the occiput of the child may be directed to the left sacro-iliac junction, and its forehead to the right acetabulum; but the cardinal point on the pelvis is the left acetabulum, from which we count the first, second, third, fourth, fifth, and sixth positions. Care should be used to avoid confounding the terms presentation and position. A vertex presentation is one in which the head presents in flexion. A face presentation is one in which the head presents in extension. There are six positions of the vertex presentation: 1st. Vertex to the left acetabulum. 2d. Vertex to the right acetabulum. 4th. Vertex to the right sacro-iliac junction. 1st. The chin to the right side of the pelvis. There are four positions of the pelvic presentation: 1st. Sacrum to the left acetabulum. 2d. Sacrum to the right acetabulum. 4th. Sacrum to the promontory. In the shoulder presentations there are four positions-two positions for each shoulder. First RIGHT-SHOULDER-position; the head is in the left iliac fossa, the face looking backwards. Second RIGHT-SHOULDER-position; the head is in the right iliac fossa, the face looking forwards. First LEFT-SHOULDER-position; the head to the left, looking forwards. Second LEFT-SHOULDER-position; the head to the right, looking backwards. These being the principal presentations, with their several positions, I shall enter into fuller details of them when I come to treat of the special labors in which they require to be managed by the accoucheur. CHAPTER IV. THE EXTERNAL ORGANS. The THE word Pudenda expresses the idea of those parts of the reproductive apparatus that appear upon the outer surface of the pelvis. The expression mons, or mons veneris, refers to the elevation or fleshy prominence lying upon the ossa pubis, which, because they project to the front, are called shear bone or shear bones. mons becomes still more prominent than it would be from the mere advance of the horizontal or body-portion of the pubis, in consequence of a quantity of adipose substance that lies below the skin. there, and which, together with a quantity of hair that covers the whole surface, has caused it to receive in ancient times the appellation of mons. The skin and cellular tissue found in this region, the great abundance of hair-follicles and numerous sebaceous glands disposed there, render the mons subject to attacks of diseases of various kinds, such as abscess, folliculitis, &c., and it might well be supposed that furuncular inflammation affecting so dense and resisting a texture must give rise to very severe pain. I must say, however, that during a practice of little short of half a century, and a large clientage among sick women, I have never been called to treat any abscess or other inflammation of the mons; whence I suppose the cases to be rare. The symphysis of the pubis is about one inch and a half or perhaps in general rather more in length, and it is only the upper portion of the symphyseal aspect of the bone that is covered or concealed by the lower portion of the mons veneris; the lower two-thirds of the bone being invested with tissues that are covered with mucous membrane lying inside of the vulva or genital fissure. The skin or derm there. fore that covers the mons passes downwards on either side of the symphysis leaving the genital fissure or sulcus bordered on the right and left by the labia majora, or greater lips of the pudenda. These labia are covered with ordinary cutis on their exterior surfaces, but are lined with mucous membrane on their inner aspects; passing downwards and backwards, they are at length lost or disappear in the perineum. As in the human lip, the outer skin gradually and insensibly changes into mucous membrane, the line of demarcation between them being undiscoverable. Like the mons, the dermal surface of the labia major is covered with hairs and supplied with numerous sebaceous glandules. They have a store of adipose cells, though a less copious one than the mons above them. The arcolar tissue lying betwixt the dermal and mucous surfaces of the labia is very loose and distensible, and yields quite readily to an injecting or lacerating force. Hence it happens that women attacked with dropsy, or those who are much infiltrated with oedema gravidarum, are commonly found to complain of great distension, and sometimes of very painful hardness of these labia. They are found, on occasions, to swell to the size of a stout man's arm, and now and then are observed to be so firm and solid that they feel excessively hard and will not yield except to long-continued. pressure. The student who reads this paragraph ought to understand that when a pregnant woman has her legs distended enormously with the serum of an oedema gravidæ, she is very likely, at the same time, to have oedema labii majoris, which she will not complain of on account of her delicacy of sentiment. It is truly a matter of slight concern provided the oedema be slight; but not so when the legs are swollen so as to look more like an elephant's limb than like a woman's ankle. I advise him under such circumstances to inquire about it, and if she admits that she is very much swollen and has some pain in the part, to insist upon examining by touch. If a woman having both the labia very much swollen, should fall into labor, it is to be expected that the powerful efforts of the womb will push the child's head against the distended labia, and, by repeated efforts of the pressure, squeeze the serum out of the areolar cells or meshes, until at last they yield enough to let the child be born. I may even inform the student that this good success is to be generally looked for, though not always. Such a state of the woman's health is not always the most favorable to an easy parturition, and it now and then happens that he may be called upon to expedite the birth by using his forceps; in which case the student may find the most serious embarrassments in his operation. To lock the forceps upon the child's head, the part just above the junctura or lock must be pushed back towards the axis of the lower strait; but how can he push the junctura backwards against a perineum that has become by this infiltration as hard as a board? The infiltration of the labia does always affect the perineum more or less, and I assure the student that I have been completely foiled in my attempts to adjust the forceps by this very cause. I remember par ticularly the case of a poor Irish woman thus affected, in whom neither Dr. Dewees nor I could succeed in applying the instrument, and in which by that great teacher's advice I was led to deliver the dead child by embryulcia. These remarks I now make for the purpose of persuading the midwifery Student to consider what ought to be done in cases of labial oedema of pregnancy, and advising him to insist upon his privilege to examine the patient, and, if proper, to let the serum escape by means of punctures in the labium. Such an operation gives very little pain, and is not followed by any evil consequence. It ought not to be omitted where the part is greatly distended, and somewhat painful. It is better to do it before the patient falls in labor, though it is very well to perform it even while she is so, provided the swelling should in any considerable degree seem to oppose the delivery, which it sometimes is known to do. If a sharp-pointed lancet held betwixt the finger and the thumb is allowed to project about one sixteenth of an inch, and the swollen labium is turned well outwards, the point may, by several rapid blows, be struck through the mucous membrane into the areolar tissue of the labium, whereupon the serum immediately begins to exude from the punctures, and continues to flow out until the part is quite collapsed and softened again. The youngest beginner in practice need not hesitate to take this step. Labial Thrombus is an accident that happens mostly to women in labor, though women in other circumstances might be affected with it. During the great distension and strain to which the genitals are exposed in parturition, a branch of the ischiatic or pudic artery may be ruptured, whereupon a rapid extravasation takes place, and the blood is forced into the meshes of the cellular tela of the labium, or even lacerates it and occasions great cavities to be formed that are filled with fluid or with clotted blood. When a labium thus becomes injured during the process of childbirth it is not always discovered by the complaints of the woman, who is generally incapable of discriminating between one kind of pain and another in the superabounding sources of agony with which she is surrounded. The discovery is, for the most part, made by the medical attendant, while touching for the diagnosis. or prognosis. If, indeed, a woman goes into labor without having any abnormity of the labia, and becomes affected with considerable and very tense swelling of one of them, the prima facie inference should be that thrombus of the labium has occurred, and it should at once be investigated. When the blood vessel gives way in the labium the extravasation is not always of necessity very great, but sometimes a great many ounces are driven hastily and with great injection-force among the loose internal textures of the part, which become black and swollen to the size of a man's arm. If the extravasation should continue, there is reason to apprehend that not the labium only, but the areolar tissue inside of the pelvis, might become infiltrated, so as to dissect the internal structures to a dangerous extent. Any such risk as this can be obviated only by permitting the hemorrhage to have a free outlet by opening the labium by a free incision. It is very reasonable to make such an aperture, were it but to let out the fluid blood or serum and allow of the coagula to be turned out with a finger passed into the cavities. Hence, when an incision is made, it ought to be large enough to admit of the introduction of the finger. I have turned out many ounces of coagulated and fluid blood and serum by such an incision, and the evacuation has allowed the distended lip to collapse immediately. A child could not be born in such circumstances without rupturing the swollen labium, and adding greatly to the mischief. I do not suppose that all the cases of thrombus are due to laceration of a pudic or ischiatic artery; it is very probable that those instances in particular, that occur during or subsequently to deliveries with forceps are caused by rupture of one of the bulbs of the vestibule, to be hereafter described. The bulbs are excessively vascular, and so much exposed to injury by the blades of the instrument that one has more occasion for surprise at their exemption than at their injury in the operation. Thrombus of the labium is, for the most part, discovered after the conclusion of the labor and not before, because most of the accidents of rupture do take place while the child is passing through the external organs. I conclude, also, that post-partum thrombus is a less serious matter than that which happens before the head comes to press the external parts strongly outwards. But, in either case, the blood should have an outlet by means of the incision, which should be made on the mucous and not on the external aspect of the labium. I wish here to be understood as advising the incision only in such in stances as may, without question, require it. In very slight degrees of extravasation the removal of the infiltration may be safely left to the absorptive powers of the parts. Abscess of the Labium, like abscess in any other part, may be treated by antiphlogistic methods, provided suppuration has not taken place already. I believe that physicians will very rarely have any. thing else to do in labial abscess beyond the exhibition of emollient |