off, or the other danger of a too early detachment of the placenta. It

is easy to draw a considerable loop of it downwards, by pulling at the yielding portion, as in Fig. 86. As soon as the feet are delivered and extended, they, as well as the body, should be wrapped in a napkin, in order that the skin may not suffer any injury, and also for the purpose of enabling the accoucheur to hold it more firmly, which he could not otherwise do on account of the viscous nature of the substances that adhere to it soon after it emerges.

First Position.-In the first position of the breech, the child's left hip should rotate to the left towards the pubis, so as to allow the sacrum to glide down along the left ischium, and the right hip to fall

Fig. 86.

Fig. 87.

into the hollow of the sacrum. Fig. 87 shows this pelvic presentation in situ before rotation, while Fig. 85, above, exhibits the appearance after the rotation has taken place. But after the hips are fully delivered, they recover the obliquity of their former situation, and the body continues to descend so, until the shoulders, entering into the pelvis in an oblique direction, come to rotate as did the hips; the left shoulder advancing to the pubis, as the hip did, and the right one falling back into the hollow of the sacrum. In Fig. 86, the right shoulder has come to the pubis and the left to the sacrum. When the shoulders do not come down well, a finger should be passed up so far as to reach above the one that is nearest, to depress it by drawing it downwards with the finger,

which commonly suffices to cause the arm to escape. But if the arm does not descend readily, let the finger be slid along its upper surface to a spot as near as may be to the bend of the elbow, and then the elbow may be drawn downwards with considerable force, and without any danger of fracturing the os humeri. One arm having escaped, there

will be little difficulty or delay in getting the other down, especially if care be taken to move the body, rotating it in a line of direction opposite to or away from that part where the arm is detained.

As soon as the arms are delivered, an examination should be made in order to learn how the head is situated. If the face is found in the hollow of the sacrum, and the chin well down towards the fourchette, it is well. The child's body ought now to be raised upwards on the practitioner's arm, to a height sufficient to enable the longest axis of the head to become parallel with the axis of the vagina, and the patient should be urgently exhorted to bear down and force the child's head out of the passage; for at this time the head is not in the womb, but in the vagina, and for its expulsion there is required rather the effort of the abdominal muscles than that of the uterus, which doubtless does, in many instances, partially close its orifice above the vertex, in this stage of a footling or breech case. If the patient therefore does not make a very great effort of bearing down, or expulsion, the head must remain in the passage; during all which time the child is exposed to the risk of perishing by asphyxia. It is true that the pressure of the head upon the parts tends to produce a violent tenesmus, which compels the woman to strain very much; but it is also true that in some instances she will not make the smallest effort, unless urged or commanded in the most earnest or even vehement manner by the physi cian. Should the Student make the grave mistake of waiting for a pain, he might lose the child. Let him not forget what I have above said, viz., that the child's head is out of the womb and in the vagina, and that the action of the womb has nothing further to do with it; for the expulsion of the head is now to be effected by a tenesmic, and not by a womb-contraction.

Some aid may be given at this critical moment by drawing the child downwards; but the attendant should always carefully reflect, while employing any extractive force, that the child's neck will not bear a great deal of pulling, without the most destructive effects on the spinal marrow. Certain it is that the infant in the birth will not safely bear more force applied to its neck than one after the birth, a reflection. that ought to regulate the physician always, who should remember that the infant will not safely bear a more violent pull by the neck in this situation, than it would if dressed and lying in its mother's arms. Such a reflection would be a very useful one for the occasion.

If all his exhortations should fail of causing the woman to assist him by bearing down, let him endeavor to preserve the child from suffocation by passing two of his fingers upwards until they reach the two maxillary bones, and cover the nose; by doing this, the backs of the

fingers, pressing the perineum backwards, serve to keep an open communication with the air, and the child can breathe very well until the tenesmus comes on. I have kept a child alive in this way, breathing and sometimes crying, for twenty or twenty-five minutes before the birth of the head, and thereby saved many a life that must have been lost but for this care. At last the head descends and escapes from the vulva very suddenly, after which, the placenta having been duly attended to, the delivery is complete; whereupon the patient may be put to bed.

Second Position.-The rule for managing this case is the same as that for the first position. Here the sacrum of the child is to the right acetabulum of the mother; the right hip to her left acetabulum, and the left one to her right sacro-iliac symphysis. As the presenting part descends, the right hip comes to the pubis, and the left falls into the curve of the sacrum.

Third Position.-Here the sacrum of the child lies behind the pubal symphysis-its right trochanter to the left ischium, and its left trochanter to the right ischial plane. In any such case, there will be rotation, converting it into one of the first or one of the second position, as accident may determine. It requires no further observation in this place.

CASE. A few years ago, I was engaged to attend a young woman in her first childbirth. When she fell in labor, I discovered that the breech presented. Her residence was about three-fourths of a mile from my house. I was very much inclined to send for my forceps, for fear that when the head should come at last to occupy the vagina, I might be unable speedily to deliver it: but as she was exceedingly delicate and timid, and her friends anxious, I deferred sending for them lest needless alarm should be the consequence of bringing them to the house. The labor proceeded favorably until the shoulders were free, and then, notwithstanding the head took the most favorable position, I found no exhortation or entreaties sufficient to make the woman bear down, and the child soon became threatened with asphyxia, which I obviated by admitting the air freely to its mouth and nostrils, by pressing off the perineum, as before explained. The child cried from within the vagina, and I felt a hope that the forceps, which I now sent for, would arrive in time for its succor. The instruments were placed in my hands in the shortest time possible. In two minutes after I received them they were applied, and the head withdrawn, but it was

too late to resuscitate the child. I have never since failed to order my forceps to be placed within my reach in any case of footling or breech labor, and I feel well assured that the consequence of this care has been the saving of several lives that must have been lost but for this precaution. I have lost but few children in pelvic presentation of late years. It is my invariable custom to order a forceps to be got in readiness as soon as I ascertain that the presentation is not one of the head; and I feel well assured that such a precaution, if generally observed, would preserve many a life that would be lost, either by delay in the delivery of the head, or by pernicious attempts to extract by pulling at the neck, to which the temptation is so strong in moments of great anxiety for both parent and offspring.

It is so unpleasant an event in the practice of Midwifery to lose a child in the operation, that the accoucheur ought to take all the precautions possible to free himself from reproach, which he shall scarcely escape, in consequence of the utter ignorance of the nature of parturition even in what is called educated or good society.

CASE. On the 11th of September, 1848, I visited a primipara lady in labor, at 7 A. M. She had been in sharp pain from 10 P. M., nine hours. The os uteri was not so large as the end of a finger. Upon ausculting and examining by palpation, I determined a pelvic presentation. At 12 M., I thought the labor would continue until morning, so slow was the dilatation; but at 5 the membranes gave way, and all the liquor amnii came off, the os uteri being still rigid and irritable. The bands of the upper os uteri were more tense and unyielding than those of the os tincæ proper. The child was still in health, as ascertained by the regular action of the heart. I had announced all the hazard for the child early in the day. My forceps was at hand; at 8 P. M. the head was thrust into the vagina, and, as I failed to deliver it with my hands, I applied the forceps and speedily drew out the head. The child was quite dead. There was no motion of the heart. When I drew down the feet, I found there was no vital tension in the limbs. Now I feel sure that this child perished by asphyxia from the unmitigated pressure of its placenta against the head consequent to the discharge of the waters. It perished of course before the operation. How could I, by any careful obstetrical measure, have saved it? I regretted, upon finding it dead, that I had not repeated my auscultations, after the rupture of the ovum. Had I done so, I should have been able to announce the loss of the child long before the midwifery operation became possible. I do not suppose that I am blamed by its friends, but a young accoucheur would feel

less uncomfortable in such a case for having announced his prognosis. Hence, let the Student remember to auscult often towards the close of pelvic labors.

Fourth Position. In those cases in which the sacrum of the child is directed towards the mother's back, it is highly desirable so to conduct the labor as to effect a complete rotation of the child before the head begins to get fairly into the excavation. If this change does not take place spontaneously, or by the skilful interference of the accoucheur, it must happen, at the last and most important stage, that the chin will be to the pubis, and then there will be some difficulty in obtaining the requisite dip of the head or its due flexion. It is exceedingly dangerous for the child to be so situated, but happily there is a method by which it may be hopefully assisted.

As soon as the shoulders are fairly freed from the vulva, the edge of the perineum tends to compress the neck of the child, and force it upwards against the arch of the pubis. In some cases, the perineum is so strong or elastic as to exert a considerable power in this way; and it is clear that, if it be not counteracted, the chin may be lodged upon the top of the symphysis of the pubis, which will wholly prevent the flexion of the head from taking place. For, if the perineum should press strongly on the nucha, it would push the front of the neck or throat hard against the symphysis, so as to prevent the chin from coming down. Under such circumstances, the child speedily perishes. The indication is to push the perineum back again, or carry the child far back towards the coccyx, and afford space enough to let the chin descend, either spontaneously, or by pulling it down, after introducing the fore and middle fingers of the right hand into the mouth. As soon as the chin is well brought down, the woman should use all her power to assist in the expulsion of the head. I have found that the best attitude for the mother, in this kind of delivery, is that which is advised for forceps operations, to wit, that in which she is placed on her back with her hips brought quite over the edge of the bed, the feet being supported by two assistants; so that, when the shoulders are delivered, the child may be supported almost in a vertical posture, as if standing, by the left hand of the accoucheur, while his right hand aids in the delivery of the head. I am sure that much greater command of the labor may be had in this position of the patient than in any other that can be devised.

But, as I have already observed, we should always endeavor to manage the case so as to get the face into the hollow of the sacrum,