were delivered, and gave birth to 13,933 children. Of these children, 7177 were males and 6756 females, whilst the still-born, including those born putrid, amounted to 968. Of the 13,748 women delivered, 4535, or one-third, were primiparous, 233 had twins, 1 had triplets, and 163 died in childbirth from puerperal and other causes. From these latter, however, it is right to deduct 17 who were admitted into the hospital in a dying state, leaving a balance of 146 deaths from all causes, or 1 in 94. But of these it would appear that 70 deaths were due to puerperal epidemic disease, which subtracted, would reduce the mortality to 76, or 1 in 180, and of these it is further to be observed that 40 died of other than puerperal diseases, such as apoplexy, bronchitis, pneumonia, phthisis, &c., leaving a total of 36 deaths only which originated in labour, or 1 in every 381

of those delivered.

From the same source we learn that the greatest number of monthly deliveries was respectively in the following order :-May, March, June, April, July, August, February, November, December, September, October, and January, whilst inversely as regards mortality, the fewest deaths occurred during the month of May, and the greatest during December, the May series for the seven years presenting the least amount of mortality and the greatest number of deliveries, whilst the December gave the smallest number of deliveries and the greatest amount of mortality. Taking the series of months during the seven years in the order of their salubrity, commencing with the most healthy and terminating with the most fatal, we find them to run thus:-May, June, September, October, August, March, January, November, April, July, February, and December.

It is worthy of remark that the general fact thus indicated as to the salubrity of different seasons in regard to parturient females accords very strikingly with that which has been observed elsewhere, and the reader will find an interesting exemplification of it in a note published in the appendix to Dr. Ferguson's essay on Puerperal Fever. From it we learn that the most injurious months in l'aris are respectively, November, October, and February; in Geneva, January, March, and November; in Aberdeen, October, December, and November; in Edinburgh, November, December, January; and in London, January, March, February, December, and May. As a general rule, the cold months are the most fatal, and it is surmised that this increased mortality is partly due to the want of ventilation. Nothing, it is remarked, will induce the patients in winter to allow a window or door to be opened; hence the whole ward is hot and close; while in the month of July every door and window admits fresh air day and night.

We shall next proceed to give an outline of the practice pursued in the 13,748 deliveries recorded and tabulated in the work, premising that the arrangement of labour into four classes-Natural, Preternatural, Difficult, and Anomalous, as proposed by Denman, has been adopted throughout, each, however, having certain subdivisions, to which we shall refer in the progress of our analysis.

I. NATURAL LABOUR.-This is understood to signify labour where the head presents and the delivery is completed within twenty-four hours. It is divided into purely natural labour and varieties of natural labour, the latter being subdivided into face, face to pubes, and arm-with-head cases.

Commencing, then, with purely natural labour, we have to express our approval of the careful manner in which the duties to be discharged in the management of these cases are laid down; the necessity of investigating the state of the os uteri, that of the membranes, the presentation and its relative position, the condition of the pelvic strait, that of the soft parts in the pelvis, their surfaces and secretions, the state of the bladder and rectum, the existence of morbid growths and tumours, are successively indicated as points for careful investigation. Upon this subject, however, we have no time to enlarge, and passing over the management of the first and second stages of natural labour with the single observation that we object altogether to the practice of puncturing the membranes in the first stage, as recommended by our authors in certain exceptional cases, we proceed to the consideration of the treatment recommended in the third or placental stage of labour.

We believe, notwithstanding the difference of opinion which exists, that the practice recommended by our authors is essentially the best-viz., the fundus uteri having been

steadily compressed manually, and thus followed down during the descent and birth of the child, and the charge of maintaining its contraction having been intrusted to the midwife, whilst the necessary attentions are paid to the child on its birth, the medical attendant resumes the charge of maintaining uterine contraction until after the expulsion of the placenta. We believe this practice is better than the ordinary plan of applying the binder immediately after the birth of the child. We concur with our authors in thinking, that by this means the liability to hæmorrhage is lessened, the state of the uterus as to flaccidity, distension, or contraction, is more certainly determined; the detention of clots within the uterus prevented, and the abdominal parietes generally better supported. As compared, moreover, with the immediate application of the binder, we conceive that it has the advantage that it obviates the chance of overlooking insidious or internal hæmorrhage, and that it thus does away with the necessity and consequent delay of having to undo the bandage, and seek for and restore the contraction of the uterus in cases in which internal hæmorrhage has occurred.

For after pains opium is recommended, but we should prefer giving a full dose of castor oil, either with or without turpentine, when they are troublesome. We believe, however, that when care has been taken to maintain the contraction of the uterus in the manner described, they will seldom be severe, and when they do occur under such circumstances they will generally be found to be occasioned by a clot which is expelled under the action of the purgative. We hold that the employment of opium, after labour, should be as much restricted as possible, tending, as it frequently does, to constipate the bowels, disorder the secretions, impair the appetite, and disturb the sensorium. Of the sequelae of natural labour one of the most troublesome is sore nipples, for which a variety of applications are proposed, the favourite being a wash composed of borax, chalk, and diluted spirits. Sometimes gutta percha collodion was used so as to form a kind of flexible shield round the nipple, and sometimes weak citrine ointment; but as it is stated that every kind of unguent and lotion was used with occasionally little or no success, we venture to recommend a formula which we have employed with the greatest advantage-viz., a solution of tannic acid in glycerine, in the proportion of a scruple of the former to a drachm of the latter. With cleanliness and a frequent application of this lotion by means of a camel's hair pencil, we have seldom failed to cure the most troublesome affections of this kind.

Varieties of Natural Labour.-These comprise cases in which the head presents, and delivery is accomplished within twenty-four hours; it is subdivided, as already intimated, into face presentations, face to pubes, and arm-with-head cases.

The rule of practice in face presentations was to leave them as much as possible to nature, and no attempt was ever made to rectify them or to change them from face to vertex presentations. The chief care was to guard the perineum during the preternatural distension it had to undergo, so as to avert the consequent liability to rupture. Thus treated, of 40 cases in 31 the labour terminated naturally.

Face to pubes cases were treated much in the same manner, and were left entirely to nature unless delay compelled interference. Though often tried, it was not found that these positions could be rectified by manipulation, and, as in face presentations, the great point aimed at was to guard the perineum from rupture, and under this treatment of 33 cases 20 were terminated by the natural efforts within twenty-four hours.

Arm-with-head cases were not of frequent occurrence, amounting only to 16 in the 13,748 deliveries. In these cases when the arm descended before the head, which was always discovered early, when circumstances permitted, efforts were made to support it while the head descended, but never in the first stage of labour. When these efforts were not successful, and this was found to be generally the case, the labour was allowed to proceed until a delay occurred demanding interference.

II. PRETERNATURAL LABOUR.-This, we need scarcely observe, comprises all cases in which any other part than the head of the foetus presents, and is divisible into two varieties-1st, cases in which some part of one or both inferior extremities presents; and 2nd, those in which some part of the superior extremities presents. Breech, foot, and knee presentations constitute the former; shoulder, arm, elbow, and hand, the latter.

As a general rule, it is observed that these cases require manual assistance, and adverting to them in the order of sequence above stated, it is very justly insisted upon that the diagnosis of breech cases requires much care and consideration. They may, for instance, be mistaken for cases in which the shoulder, the face, or even the occiput, when the scalp is much swollen, presents, and hence, whenever a doubt exists, great care, it is insisted upon, should be taken lest in the necessary examinations some injury should be inflicted upon the child. We will not, however, enter upon the diagnosis of these cases, as we believe it to be generally well understood, and we do not find any information given which is not to be found in our ordinary text books.

As to treatment, the following appears to have been the practice generally pursued. The patient having been placed in the same position as in natural labor, the position of the breech relatively to the pelvis was first ascertained, and if found to be presenting in the first or second position-i. e., with the back of the child to the right or left acetabulum, no interference was deemed necessary beyond attention to the perineum while the nates were passing through the vulva. This was carefully guarded whilst the breech passed, and when the feet of the child came to touch the posterior fourchette, their too sudden egress was prevented by the hand of the attendant which was unoccupied. Pursuing the practice that is usually adopted until the arms are delivered, an important rule is laid down for the purpose of averting the mal-position of the head, which often results from traction of the body of the child-viz., the separation of the chin from the sternum, and the consequent substitution of the occipito-mental for the occipito-bregmatic position of the head in the pelvis. To obviate this difficulty and the consequent locking of the head, the following practice was pursued with one or two fingers of the right hand against the occipital bone, the child's occiput was pressed upwards so as to cause the chin to descend lower into the pelvis. By this means the mouth of the child was brought within reach, into which the finger of the left hand was inserted, and by simultaneously depressing this and elevating the occiput, the occipito-bregmatic was made the opposing diameter, instead of the occipito-mental. Reduced to this position the delivery was readily effected by traction, solely upon the shoulders by the right hand.

We do not observe any direction for the management of breech cases when the foœtal abdomen is directed forwards, beyond those generally enforced. The principal point insisted upon is the necessity of rotating the sacrum forwards just as the breech is being born; and this rule would appear to be the more necessary, inasmuch as our authors inform us, that although the peculiar changes in the presentation described by Naegelè as occurring naturally were looked for, yet that they had not the good fortune of seeing them. We presume this refers to the supposed spontaneous rotation of the body, as of the head of the foetus, when presenting in an anterior position; and inasmuch as this has been much insisted upon by some writers of late, it may be well to bear in mind that clinical observations do not support the accuracy of the rule.

For assisting the delivery of the breech when unusually protracted, the finger in the first place, and the blunt hook in the second, were exclusively resorted to. Never was the fillet employed, and when it happened that the head became impacted in the pro gress of the birth, the forceps were invariably tried before resorting to the perforator and crotchet.

In presentation of the superior extremities three indications are insisted upon :-the first being an early diagnosis, the second to turn and deliver at the proper period, and the third to eviscerate when turning is impossible. The general diagnosis of these cases need not be dwelt upon; but a circumstance is stated which may be usefully quoted-viz., that when the woman is at full term, it is often easy to diagnose a cross birth by the peculiar shape of the abdomen, which is neither so high nor so prominent as when the long axis of the child is directed from above downwards. In this case the uterine tumour is broader and flatter, not reaching much higher than the umbilicus, the fundus uteri being transversely long and straight, instead of being rounded, as it is ordinarily.

In connexion with presentations of the upper extremity, we find that foetal evolution occurred twice; the first instance having been a male which was born at the sixth

month, dead and putrid-and the second a female at the seventh month, which was also born dead. The description of the process of spontaneous evolution, as given by the late Dr. Douglas, was found to be strictly correct. The arm protruded, and the shoulder having become fixed under the pubic arch, remained in that situation until the breech of the child was born; the arch of the pubes having been the fulcrum upon which the body of the child was made to turn. All the uterine efforts would appear to have been expended in forcing the inferior portion of the trunk into the pelvis until the nates were expelled beyond the vulva.

III. DIFFICULT LABOUR.-This class of labours is divided into tedious and instrumental deliveries, which we shall treat of in the order in which they appear in the volume. Tedious Labour is described as labour at full term, in which the head presents, and the child is delivered without the assistance of instruments after the expiration of twenty-four hours. It is treated of under two heads-the first comprising those cases in which the cause of delay originates in the first stage of labour, and the second those in which it originates in the second.

Delay occurring in the first stage of labour, although less important than delay originating in the second, is yet regarded as serious, inasmuch as a lengthened first stage has always a tendency to render the second tedious. Hypersecretion of the liquor amnii, rigidity of the uterine tissue surrounding the os uteri, nervous irritability and despondency, inertia from constitutional disease, and want of power, the origin of which could not be traced, were found to be its most frequent causes; and puncturing the membranes, venesection and tartar emetic, the administration of chloroform or opium, and frictions of the abdomen, were respectively found to be the most successful means of treating it.

Delay in the second stage of labour was regarded as a matter of infinitely more importance than that in the first. It was often induced, first, by inertia occasioned by a prolonged first stage, especially if the membranes had been early ruptured; secondly, by nervous irritability; thirdly, by over-distension of the urinary bladder; fourthly, by simple rigidity of the soft parts of the pelvis, unconnected with that of the os uteri, in which case emollient enemata were found most useful; fifthly, by enormous distension of the bowels from flatus; sixth, by pendulous states of the uterus and abdominal parietes, for which the application of the binder was found useful; and seventhly, by vaginal bands and cicatrices, which, if not overcome by the uterine efforts, were divided by the scalpel. The majority of these cases, however, are treated of under the head of instrumental labours, to which we shall next proceed.

Instrumental Deliveries.-These comprise all cases in which the labour, either long or short, necessitated the employment of instruments. It is important to remark that during the mastership of Dr. Shekleton the vectis was never resorted to, and hence this variety of labour is divided into Forceps Deliveries and Crotchet Deliveries.

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Forceps Deliveries.—With regard to these cases the following circumstances were considered to render the application of the forceps necessary :-first, absolute or impending danger to the mother's life; secondly, the likelihood of injury to the mother's structures; and, thirdly, the threatened failure of the foetal circulation. Time, it may be remarked, was never taken so much into consideration when deciding upon employment of the forceps, as the existing state of the woman's constitution and that of the child's circulation. These furnished the chief indications for their use, and whenever the case was doubtful, it was deemed the safest practice to complete delivery by their aid.

The mode of applying this instrument need not be dwelt upon; but it is important to remark that, as a general rule, the patient was first brought into a state of complete anæsthesia. Any attempt to apply the forceps in a state of partial anesthesia was found to be not only difficult, but dangerous. They were first attempted to be applied in an obliquely lateral position, and if the effort at extraction failed, they were then withdrawn, and reapplied in an antero-posterior direction. Should this mode of application also prove abortive, another attempt was made in the direction in which they had originally been applied; and it is remarked that by persevering in this plan of

proceeding many lives were saved, which would otherwise have been sacrificed to the crotchet. Contrary to general directions, it was by no means felt necessary to feel the ear before resorting to their use-indeed, it was seldom or ever sought for, except for the purpose of determining the position of the foetal head; and in many cases they were employed when the head had only barely entered the pelvic cavity. Once applied, the only movement permitted was traction in one direction-viz., that of the curve of the pelvis, in which the head was placed. No seesawing or twisting movement was allowed, and it is said, that when the one steady direction by traction was maintained at intervals, the forceps never failed to complete delivery, if by any possible means the presentation could be moved through the pelvic space.

Thus employed, we may conclude the subject by observing, that of the 13,748 women delivered-irrespectively of twins--200 were delivered by the forceps. Of the children so born, 118 were males, and 82 females; 17 of the former were still-born, and 12 of the latter, whilst of the 200 subjects of forceps delivery 11 died.

Craniotomy Cases.-The circumstances which were considered to require the use of the perforator and crotchet were, first, pelvic deformity more or less; and second, disproportion between the foetal head and the pelvic space; third, mal-position and consequent impaction of the foetal head; fourth, bands or cicatrices in the vagina from former labours; fifth, great rigidity of the soft parts which did not yield to treatment; sixth, apoplexy of the mother; seventh, excessive action of the mother's heart; ninth, hæmorrhage; tenth, rupture of the uterus and inability to complete delivery after

version.

The general rule as regards the employment of craniotomy would appear to be the following. When the diminution of space at the brim was such as to prevent the entrance of a full-sized fœtal head, as judged of by the readiness with which the sacrovertebral angle could be reached by the examining finger, and the os uteri being sufficiently dilated, craniotomy was resorted to as soon as it was found that the pains made no impression upon the presentation, and more especially when it had been ascertained that the woman had been previously delivered by means of the crotchet.

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On the other hand, should the head have entered and become impacted in the pelvis, the forceps were first introduced; and if the attempt to adjust them failed, the operation of lessening the head was undertaken without hesitation. The same Course adopted when attempts at extraction failed after the forceps had been adjusted—when the action of the foetal heart was known to have ceased, when imminent danger occurred to the mother at any stage of labour from any cause-when delivery was impracticable by other methods, and when fibrous or bony tumours obstructed the pelvic cavity. Of 130 mothers who were the subjects of craniotomy, 104 recovered and 26 died.

IV. ANOMALOUS OR COMPLICATED LABOUR.-This class comprehends the following varieties: first, Plurality of children; second, Prolapsus of funis; third, Hæmorrhage; fourth, Convulsions; fifth, Rupture of uterus, vagina, or both; sixth, Inversion of the uterus; seventh, Premature labour; eighth, Retained placenta; ninth, Labial thrombus, &c. We shall very briefly touch upon the practice pursued in these cases in the order here stated.

A. Plural Births. Various circumstances are referred to as affording diagnostic evidence of twin cases, but all are regarded as more or less equivocal. The stethoscope would appear to be the most reliable when by its means a distinct.foetal cardiac sound is heard at opposite or distant parts of the gravid uterus. It was, however, considered but of little importance to have discovered the existence of twins before labour, inasmuch as the treatment up to the birth of the first child was precisely the same as though it were a simple case. But when the first child was born pressure was immediately made by the hand over the fundus uteri, and everything was done to accelerate the birth of the second. Hence, after a short interval, the membranes were punctured, and the fundus uteri gently rubbed. By this means uterine action was for the most part quickly restored, and the second child was speedily expelled. If, however, inertia of the uterus supervened, ergot was exhibited, and if this failed, either the forceps were applied if the head were below, or turning resorted to if above the pelvic brim.