instead of letting the chin come to the pubis. If, therefore, the breech sink into the excavation in this unfavorable manner, we should, by pressure with two or three fingers, endeavor to force that hip which is nearest the front towards the symphysis, and if we succeed in ef fecting its delivery in that position, we should, with a proper degree of force, continue to turn the forward hip more and more round, so as to bring the child's spine at least as far in front as the ramus of the ischium or pubis; so that, when the shoulders begin to enter, they may enter obliquely, and that, after they have passed down, the head may also enter obliquely, or at least transversely. For example, let the sacrum be towards the mother's back, the child's right hip will be on the right ischium of the mother. We might try to get the right hip towards the ramus of the ischium, then towards the ramus of the pubis, and, as it advances, cause it to emerge just under the arch. When fully emerged, the hip should be turned more and more round to the left of the mother, so as to let the right shoulder enter the brim at the left acetabulum, afterwards to escape under the arch, in doing which the child's chin will enter near the left sacro-iliac symphysis, or at least near the left ischial plane, and at last slide into the hollow of the sacrum, as in the second position of the breech.

Where, in consequence of the grasping force of the womb holding the child's body tight during a pain, this desirable rotation cannot be gently effected, we ought to watch for an opportunity, during the absence of a pain, to push the child's body upwards again as far as we conveniently can, and then draw it downwards, endeavoring, while pulling it downwards, to twist or rotate it in the manner that is required, and above recommended.

If, on the other hand, we endeavor to bring the left hip to the pubis, we shall also get the left shoulder there; and at last, compelling the face to enter at the right sacro-iliac symphysis, we shall terminate the labor as in the first position of the breech.

CASE. I shall here relate a case taken from my record book, which may serve to show the Student what a great rotation may be effected by the hand of the practitioner, in cases of the fourth position. Tuesday, October 5th, 1830. Mrs. J., a young woman in her first pregnancy, sent for me at eight o'clock P. M. The waters had come off at five o'clock P. M. The os uteri, at my arrival, was almost com. pletely opened. I touched the breech and feet; the toes were towards the left acetabulum. At a quarter before nine o'clock, I disengaged the right foot, and then the left one. At nine, the arms were both delivered, the left one escaping first along the perineum, and the right

one under the pubis. I could not effect any further rotation, and was sorry to find the chin immediately behind the symphysis pubis. I then turned the child's body on its axis, and pulling the chin well downwards pressed the face with two fingers, on its right side, and with great ease turned it into the hollow of the sacrum. I next made a channel by passing up two fingers to the superior maxilla, so as to admit air freely to the nose, and the infant breathed; there was a total cessation of pulsation in the cord. The child breathed and cried at least twenty minutes before the head was extracted, which I could not effect until I carried its body upwards towards the mother's abdomen, and rolled her over on her right side, which gave me far better power to aid her with my right hand. The infant was born living, and did well. Let the Student remark that I turned the woman on her right side at the close of this labor. I wish that, in any case where he encounters delay or difficulty, yet not to such an extent as to demand the forceps, he would, at the last moment, turn his patient upon her right side, so as to enable him to make use of his right hand in assisting to make the head roll out under the crown of the arch. The fingers of the right hand are stronger and more apt than those of the left, and in these cases, where expedition in the operation is so essential to safety, it is desirable to obtain even this not inconsiderable facility and advantage.

was seized with

CASE.-On Thursday, July 14th, 1836, Mrs. labor pains, which came on with a rupture of the membranes. At six o'clock, I made an examination, and found the left foot in the vagina, accompanied by the umbilical cord, which pulsated. The toes were directed to the pubis. I could reach the breech of the child, but the right foot was so high up that I could not touch it. In a short time the left foot came quite down; and in order to rotate the body I drew moderately upon the foot, which caused the left hip rapidly to approach the pubis. I could not even yet get at the right foot, wherefore I permitted the child to descend with that limb pressed upwards against the belly; the left hip came under the centre of the arch, and, as soon as I could command it, I turned it more and more round, so that when the arms were delivered I found the face in the sacrum, soon after which the head was expelled. I immediately ascertained that there was a second child; pains came on, and in fifteen minutes after the first one was born, I broke the membranes of the second, which presented the nates and the right foot. The foot prolapsed, but the other limb was pressed against the child's belly, so that I could not get it; the sacrum was to the right acetabulum. When the

shoulders were delivered, I found the child's face rather transversely directed towards the left ischium. I brought it into the hollow of the sacrum, soon after which it was also expelled. Both children were well.

It is so easy a matter, in general, to cause the body to rotate during its transit through the pelvis, that it very rarely happens, if the physician is called early, that the face at last is found towards the pubis.

With regard to the presentations of the feet and knees, I do not feel that it is necessary for me to enlarge upon them before I close this chapter, inasmuch as the footling case is a mere accident happening in a pelvic presentation, and which, moreover, can never prevent it from being at last a pelvic presentation-for all footling and knee cases are certainly breech presentations. I may remark, however, that the knee presentation is found to be embarrassing from the tendency there is to a sort of arrest, in consequence of the knees abutting against the sides or parietes of the pelvis, which is sufficient to prevent the descent of the child's nates, so that they, being thereby thrust over to the opposite side, cannot enter the excavation. Hence, where the knee presents it is advisable to convert it into a footling case, which can be done by pushing the whole presentation upwards, during the absence of pain, in order to gain space enough to bring down the feet.

The Student will perceive, if he refers to the axis of the womb and that of the vagina, that in a knee case, in which the child's back is towards the left front of the mother, the thighs would be very greatly extended, or bent backwards, before they could emerge from the external organs; an extension that must be very difficult to effect where the legs are bent up on the back of the thighs-for in such circumstances the rectus femoris, and indeed the whole quadriceps muscle must be put excessively on the stretch. It is a good rule, therefore, in knee presentations, to get the feet down as soon as it can be pru dently done; whereas, in the well defined breech cases, the feet ought not to be brought down, except for some valid and well-understood

cause.

In order to distinguish the feet from the hands, for which they are sometimes mistaken, it is only necessary to give attention to the sensations imparted by the operation of Touching. The even range of the ends of the toes, and their shortness, compared with the length of the fingers; the closeness of the great toe to the one next to it, in contrast with the wide separation of the thumb from the forefinger; the ankle and the heel, are marks that might be supposed sufficiently prominent to guard us against even the danger of mistake; yet very

great attention is in some instances required to enable us to aver positively that the presenting part is, or is not, the foot.

As the footling is but a deviation from the breech presentation, its positions are like the original four-namely, the heels to the left acetabulum; the heels to the right acetabulum; the heels to the pubis; and lastly the heels to the sacrum. As the treatment is precisely the same as in presentations of the nates, I shall not detain the reader by any further remarks upon the management of them.

CHAPTER XIII.

OF PRETERNATURAL LABOR.

ANY labor that cannot be brought to a safe conclusion by the natural powers of the system might properly be denominated a preternatural labor; and, as the causes that might prevent the accomplishment of the parturition, save by the intervention of our art, are very numerous, it follows that there are a great many kinds of preternatural labor.

Causes. A labor may be accidentally changed from a natural to a preternatural one; or it may possess a preternatural character from the very beginning, and be unavoidably so. Thus, a woman may have brought her child almost into the world without any appearance of disorder, or danger, or uncommon distress, and be then suddenly attacked with convulsions, apoplexy, hemorrhage or laceration of the womb, &c. &c., either of which occurrences completely changes the character of the labor. Or she may, in consequence of disease or accident, be found incapable of bringing her child into the light with out surgical aid; as, where the passages are closed by stricture, or by some fibrous tumor, or by a deformity of the bones of the pelvis. Lastly, the labor may be preternatural because there presents at the strait some portion of the child which cannot pass through it, but must be put aside in order to let some other part advance, before the labor can be brought to a close. For example, if the arm or shoulder should present, it is necessary to put them out of the way and bring the head back to the opening, or else the feet must be brought there, the child being for that purpose turned quite over; for have we not learned that one or the other of the extremities of the foetal ovoid must advance, in order to admit of the escape of the child?

It appears from the above that the causes which constitute preter. natural labor are very various; and it is reasonable to infer that the medical and obstetric treatment of the several cases will be founded upon the peculiar and distinguishing character of each individual