of it, it would present another example of the process in which one head is keyed by another. There is less danger in this case than in the former, because the trunk of the child would not form an insuperable obstacle to the passage of a hand, whereby to displace the keying head.

It has happened to me, on different occasions, to find the woman becoming so much fatigued, so much worn out indeed, by the protracted efforts of a twin labor, that I felt obliged at the last to give the assistance of my forceps both for the first and second child.

A labor with twins is one in which there may be either one or two placentae. It sometimes happens that both the children are contained. in a single chorion, but each child must have its own amnion; if there are two chorions, there will be two placenta, and those placenta will be situated in different and opposite parts of the uterus. A labor in which there are two separate placenta, and in which the first placenta is detached and discharged with the child, is one in which the placental superficies is likely to bleed, for there cannot be immediate condensation of the placental superficies of such a womb.

A twin labor, in which there is a single chorion and a single amnion, is one which could scarcely fail to give birth to a monster, for there is nothing to prevent the fusion of the parts of twins contained within the same amniotic sac, whereas such fusion of parts is impossible in two separate amnia. Chang and Eng must have existed in a single amnion; so did Ritâ-Christina. The same must have been the case with Dr. Pfeiffer's double-headed infant, to which I refer the Student, and with my specimens of omphalodyms contained in the museum of Jefferson Medical College.

One never has charge of a twin labor without feeling some anxiety with regard to hemorrhage likely to follow the birth of the first child, and no accoucheur should dare to leave the woman until she be safely delivered of the second. As a general rule, the same contractility of the uterus which expels the first child, after a slight pause resumes its operation for the expulsion of the second, just as happens as to the expulsion of the after-birth in a unipara labor; and we may, therefore, expect that within the hour the presenting part of the second child shall descend through the os uteri into the vagina. I think I have never waited so long as an hour. When the membranes have already been ruptured, I have found the child to descend earlier than that, and when they had not already given way, I have ruptured the ovum within twenty minutes. As my own experience in this parti cular has been fortunate, I venture, upon that ground, to advise the medical Student to follow the same course. Some persons prefer to

wait longer, and I admit, if the patient be carefully observed, if there be no signs of hemorrhage or faintness, or other urgent motive for interfering, one might feel himself justified in waiting longer than I have indicated. Let him always make the diagnosis as to the presentation before he proceeds to rupture the ovum, and should he find a cross birth, a possible event, let him hasten to pass his hand high up on the side of the ovum, penetrate it there, and seize the feet to turn and deliver.

Whenever hemorrhage is suspected to have begun, or is known to have commenced, there should be no hesitation in rupturing the membranes; the discharge of the second sac fulfils Louise Bourgeois's commandment to let the water off in order that the womb may condense itself. The accoucheur, under such circumstances, would act according to the indication: if the hemorrhage is sudden and startling, he would turn and deliver, provided the head is above the superior strait; he would seize and extract it with the forceps, provided it were in the excavation.

As soon as the second child is born, pressure should be made upon the hypogastrium to promote a tonic contraction of the uterus; the lately over-distended, but now relaxed belly should be sustained by a proper binder and compress, and the placenta or placentas should be carefully extracted.

In triplet labors the same causes of slowness of parturition exist as in the twin case; the expulsive power is even more decomposed, since it is communicated through three bodies; there is the advantage, however, that triplets are smaller than twins, and the distension of the cervix uteri, the vagina and the external organs, is not so great as in unipara or twin labors, in consequence of which the last pains are less distressing. I was called in consultation to a lady in labor, however, who gave birth to triplets, the sum of whose weights was twenty-one pounds and a half; they were fine children; the mother had nearly lost her life from an exhausting hemorrhage, which followed the birth of the last child. The superficies of the placenta, required for the aëration and support of three such children, must have been vast, and a most powerful contraction of the uterine globe would be required to constringe the uterine orifices after such a labor.

I have never seen a case in which four children were delivered at one birth.

Preternatural labors may be terminated with the hand alone, or by means of instruments. The simplest midwifery instrument is the fillet, which consists of a ribbon of silk or linen. The fillet is now chiefly employed as a means of drawing down the buttock, in cases of breech

labor, where the pains are incapable of completing the delivery. A very good fillet may be made of a linen roller some three inches. wide and twenty-eight or thirty inches in length. It is not always a very easy matter to apply it-and there is great difficulty to get it adjusted except when the breech is quite low in the excavation and completely out of the circle of the os uteri. Previously to making any attempt to use it, it should be prepared, by drawing it through the hand filled with a good quantity of lard-or else it may be soaked in thick flaxseed tea, or in white of eggs. Without this precaution, it will not pass over the thigh of the child, or it will rub the surfaces so as to cause excoriation.

To make use of the fillet, let it be passed over the thigh that is nearest the pubis, as in Fig. 97. Roll up four or five inches of one of the ends of the ribbon into a roller, which may be passed into the vagina, and pushed with one or two fingers, between the belly of the child and the front of the thigh which is in contact with the belly. The point of the finger will carry the little ball or roller across the groin either inwards or outwards, as the case may be, and when it has got free from the pressure of the surfaces of contact, the roller or ball at the end may be brought out at the ostium vaginæ, and the remaining portion passed upwards, so as to get the fillet arranged to allow the two free ends to be tied.

The drawing, Fig. 97, shows the appear

Fig. 97..

ance of the fillet, when rightly placed, and the mode of operating with it.

The efficacy of its action would be greatly enhanced by placing it upon the groin that is farthest from the pubal arch-but that is a feat of dexterity that can rarely be performed.

In drawing downwards, one should act only during a pain, or coincidently with a tenesmic effort of the patient, and it should never be forgotten, that the neck of the thigh bone is a very frangible thing in the unborn foetus. This caution is necessary to prevent a fracture or dislocation of the hip-joint. The mere remembrance that such an accident might happen, would prevent any prudent person from exerting undue force with the fillet.

Notwithstanding the reasonable dread of doing mischief by violent and untimely tractions, it is true that great assistance may, by this simple implement, be given to the woman in a breech labor.

The fillet is also applied, on some occasions, to the wrist in prolapsion of the hand, in order, by means of it, to keep the hand down at the side, when we turn to deliver in shoulder cases. I have never found it necessary to take any such precaution; as I have always thought that I could bring down the arm, in case it should be lifted alongside of the head, and I have not chosen to embarrass myself with the string.

The fillet is also by some writers recommended as a means of securing one foot that has been brought out at the vulva, in turning, while the hand is passed upwards again to seek for the other foot. I do not think it necessary. Indeed, when I have got one foot down, I care not much to bring down the other; for, if it be left in the womb, we have rather an advantage by it; since, in such a delivery, we have the benefit of both the footling and breech labor.

Fig. 98.

Turning. The Student has learned that the most natural labor, one in which the vertex presents in the first position, may suddenly become a preternatural one in consequence of the coming on of hemorrhage, a series of bad fainting fits, convulsions, &c. &c., any of which might establish the indication to proceed at once to the delivery. Fig. 98 serves to show the situation of the child presenting in the first position of the vertex. It may be that this child's head had, in a good measure, occupied the circle of the os uteri before the accident occurred which established the indication to deliver by turning. If the head had wholly escaped from the circle, the indication to deliver by turning must have been considered wholly set aside in favor of a forceps operation; for when the head has once escaped from the os into the vagina, it cannot be thrust into the womb again, because the cervix uteri will by that time have contracted around the neck of the infant. Hence the rule of practice is to turn and deliver if the head be still in the womb; but if it be in the vagina, we are to extract it by the forceps. In fact, if it be

wholly in the vagina, it is below the superior strait; but to attempt to return the head through the superior strait and through a contracted os uteri also, is a thing too preposterous to be thought of.

Fig. 99.

The drawing above mentioned, Fig. 98, will show the Student what he will have to do if he makes up his mind to turn. It will show him, namely, that he will be obliged to thrust the head out of the plane of the superior strait, which it now occupies, to let his hand pass upwards in exploration: he will see, by inspecting the figure, that he must seek for the feet in the right posterior upper part of the womb, and as he must push the head, therefore, upwards and to the left, and not upwards and to the right, and must grasp the feet with the palmar, and not with the dorsal surface of the hand, which hand shall he use? Let him look at the figure, and he will see that, in this labor, he must use the left hand, and, carrying that hand upwards, according to the directions given in my article on Turning, at page 416, he will find the feet, one

Fig. 100.

or both, as in the figure, and grasping them firmly with the thumb and fingers, he will draw them downwards towards the os uteri, assisting his left hand, inside, by means of the right one pressed upon the fundus of the womb, outside. In this way, drawing the feet downwards, he keeps the head above the plane of the superior strait by means of his wrist and palm. This is a precaution he must by no means overlook, lest the head, urged downwards by the force of the contractions, should become engaged in the pelvis together with the foot, as seems about to happen in the drawing annexed, Fig. 100. If, through forgetfulness of this duty, or want of proper dexterity, he should permit this accident to happen, he would procure for himself superabounding vexations, for his patient a great increase of pain and hazard, and for the

child an almost certain death. Let him never forget, therefore, while drawing down the foot, that he must keep the head up if possible.