PARTU 
firil children, it will require feme care to guard againft a 
laceration of the perinseum, as the arm paffes. 
When the labour has proceeded fo far, that only the 
head remains to be born, we are to extract this with all 
the Speed that circumftances will admit; for little reli¬ 
ance is to be placed on the uterine efforts, folely, to ef¬ 
fect the expulfion of the head; and, if it remains long 
in the pelvis after the body is born, the compreflion upon 
the funis will be fo great, as fpeedily to caufe the child’s 
death. The extraction of the head will fometimes be 
more conveniently made, if the woman be turned upon 
her back, and if the operator Stand while uling his ef¬ 
forts. 
It is defirable that this attempt be made during a na¬ 
tural pain, and that the operator ceafe from his attempt 
as foon as the pain goes off; but, if the cafe be urgent, 
the extraction muff be made without waiting for the na¬ 
tural pains. 
One foot may prefent in the fame variety of directions 
as both feet. Where one foot prefents naturally, if the 
pains be regular and Strong, the cafe is attended with 
lefs pain to the mother and lefs danger to the child, than 
where under Similar circumftances both feet prefent. It 
is lefs painful to the mother, becaufe the child is formed 
into the Shape of a cone, and the apex paffes iirft through 
the pelvis, by which the parts are gradually prepared, 
and not fuddenly forced open ; and, it is lefs dangerous 
for the child, becaufe, the one leg being folded along the 
belly and breaft, the umbilical cord is protected from 
compression. From thefe circumftances a very erroneous 
inference has been deduced by fome celebrated authors ; 
viz. that in cafes where it is neceffary to perform the 
operation Styled turning, one Soot Should be brought 
down in preference to both. But, as on fuch occafions 
the operator cannot be aSlifted by pains, it is obvious 
that he could not have a fufficient hold of the child by a 
fingle foot. With the exceptions juft Stated, the pheno¬ 
mena where one foot prefents are the fame with thofe 
which occur in cafes where both feet are in the paffage. 
When the knees prefent, all the inconveniences of foot¬ 
ling cafes take place, with this additional danger to the 
child, that, if the legs be croffed, one or both may be 
fraCtured before the knees be expelled. The manage¬ 
ment of knee-prefentations muft depend on the advance 
which thefe parts have made at the time affiftance is pro¬ 
cured. If they be Still at the brim of the pelvis, the feet 
Should be hooked down ; but, if they be fairly within the 
cavity of the pelvis, or in the vagina, they muft be al¬ 
lowed to protrude without the parts until the feet be 
expelled. 
Breech-cafes occur more frequently than footling ones. 
It has been calculated that they happen once in 52 cafes 
of labour. 
The breech may prefent in the fame variety of posi¬ 
tions as the feet; viz. with the belly of the child to the 
back, to the belly, or to the fide, of the mother. Cer¬ 
tain advantages and difadvantages attend each of thofe 
pofitions. 
When the belly is to the back of the mother, the 
thigh bones, being Straight, pafs with difficulty along the 
curved line of the facrum ; after that obstacle is fur- 
mounted, the largeft part of the child is applied to the 
fmalleft diameter at the brim of the pelvis; and, after 
the body is delivered, the head is Situated in fuch a di¬ 
rection that it cannot enter the brim ; for the Sinciput 
is oppofite to the promontory of the facrum, and the 
occiput to the fymphyfis pubis. 
If the belly of the child be to the belly of the mother, 
then the thigh-bones pafs very readily along the bones 
of the pubes, while the fpine, bending, accommodates it- 
felf admirably to the hollow of the facrum, consequently 
at firft the labour proceeds fpeedily and fafely ; but, after 
the breech has palled through the cavity of the pelvis, it 
js applied with its largeft diameter to the Shorteft diameter 
Yol. XVIII. No. 1274.. 
R I T I O N. 685 
at the outlet, and after it has at laft overcome the refin¬ 
ance occasioned by that circumftance, and the body is 
expelled, the face, being towards the fymphyfis pubis, 
fubjefts the patient to all the pain, and the child to all 
the dangers, already enumerated. 
When the belly of the child is placed towards the fide 
of the mother in breech-cafes, then the fame advantages 
attend the Situation which have been enumerated under 
the firft footling-cafe ; for the largeft part of the child 
is uniformly applied to the largeft aperture of the pelvis. 
Befides this, the child incurs lefs hazard in this pofition 
than where the feet originally prefent; for the legs being 
folded on the belly protect the funis umbilicalis from 
compression. 
Breech-cafes, where the pains are powerful, are to be 
left entirely to nature, taking care tofupport the peri¬ 
nseum till the infant be expelled. It is then highly im¬ 
portant that the navel-ftring be immediately taken off 
the ftretch, and the child accommodated to the paffage on 
the fame principle as footling-cafes. 
Labours of this kind were formerly very much dreaded, 
as it was fuppofed that there was not room for the child 
in this doubled pofition to pafs through the pelvis. 
Hence fome of the older accoucheurs attempted to turn 
the child, and bring the head to prefent; others, among 
the reft Celfus, recommend to bring down the feet. 
Dr. John Burton, of York, the cotemporary and rival 
of Smellie fays, “ When the buttocks come foremoft, the 
more it is buffered to advance, the more dangerous and 
difficult will be the labour : therefore as foon as the ope¬ 
rator perceives, by the foftnefs and fleShinefs of the parts, 
what part prefents, he muft immediately thru ft up again SI 
the buttocks with all his Strength, but without commit¬ 
ting violence to the child’s os coccygis, or its parts of 
eneration, which are often in this cafe Swelled ; and, as 
e thrufts up, he muft endeavour to turn the child with 
its belly towards the os uteri, and then fearch for the 
feet.” 
Smellie was too fond of this puShing up ; indeed it 
was the doCtrine of the day ; and Dr. Hunter, in the 
early part of his practice, ufed to follow the fame plan, 
in breech-prefentations; but, from a conviction of its 
impropriety, he afterwards difeontinued it. “ When I 
firft began practice (fays he), I followed the old dodtrines 
in breech-prefentation, although I did not like them, 
but yet dared not broach new ones, till I got myfelf a 
little fettled in life: at this time I loft the child in almoft 
all the breech-cafes, but, Since I have left thefe cafes to 
nature, I always fucceed.” Hunter’s LeCtures, MS. 1768. 
3. Presentations of the Upper Extremities. 
The mod natural pofition of the child, at the begin¬ 
ning of labour, is, as we have already feen, with the 
head placed at the brim of the pelvis, the face towards 
the facro-iliac fynchondrofis of one fide, and the occiput 
towards the groin of the oppofite fide. But there are 
many deviations from this natural pofition. 
Although the head be applied to the brim of the 
pelvis, it may be forced with the Sinciput towards the 
promontory of the facrum, and the occiput towards the 
fymphyfis pubis. In this Situation the largeft diameter 
of the head Is oppofed to the fmalleft of the pelvis ; con- 
fequently the head remains firmly fixed in that pofition ; 
for, as the finciput cannot advance a point beyond the 
promontory of the facrum, the occiput is forced juft fo 
much below the brim at the pubis as to wedge the head 
firmly between the facrum and pubis. By the long- 
continued preffure the foft parts become much fwelled, * 
and at laft the head is found fo immoveably fixed, that 
it can neither be made to recede, nor can it advance in 
the fame direction. This constitutes what has been 
Styled the caput incuncatum, or, as it is called by French 
practitioners, la tete enclaves . This cafe moll commonly 
is the effeft of mifmanagement 5 for, if a very little pref- 
8 M fure 
