The other division of this class of labours is that in which the upper extremities pre sent. This is now and then an original presentation ; but sometimes it is artifi cial. It may be called original if felt be. fbre the membranes be broken, in the ab sence of a pain. It may be called artificial when the hand being felt by the practi tioner, perhaps with some other part, is drawn down through the os uteri and the position of the presentation varied ; though it originally was a head presen tation, it may be made a shoulder pre sentation. When the hands are at the os uteri, they are easily distinguished from the feet by the thumb not being in the Slime line with the fingers ; while in the foot we distinguish the toes and heel. The shoulder has been mistaken for the back, and it is a mistake easily made in prac tice. In distinguishing, we should recol lect the superior extremities have the scapula behind them, while at the breech we feel the organs of generation. We may here lay down a rule, which is of the greatest consequence, and applies to all kinds of practice in midwifery : that is, that the shoulders and arms will never pass together the labour may continue, but if that presentation be not altered, the woman will be worn out and die. We must return an upper extremity; and ne ver regard it as a matter of choice, but as a rule of practice which must always be adopted. We must turn, because it is a presentation that cannot be delivered. This altering the position of the child, in utero, is called the art of turning, which art, in modern science, is attributed to Ambrose Paree, though it is mentioned as far back as the time of Celsus, who says it is sometimes necessary; he does not. however, say whether it were ever done on a living child. Ambrose Paree's words are, " that in all cases where the upper extremities present, you must turn and bring down the feet ; and if the midwife cannot do it herself, she must send for a surgeon who can." The nature of these presentations may vary so much, that it may be necessary to mention some circumstances. Suppose a case in which the waters are not yet dis charged, and the labour is going on very naturally, but by examination through the membranes between the pains, we find that an arm or &shoulder presents, yet we may, perhaps, not know exactly the parts; in such case, we should not be absent from the woman, upon any account, at the time of the metibmnes breaking, for it will make all the difference in the world as far as relates to that labour. We must ascertain the exact position of the child, and we must then proceed to turning. The question now is, what time in the progress of the labour is most proper for this operation ? Bourde lois says, when the membranes are broken, and the os uteri dilated. Dr. Hunter is of the same opi nion. Dr.Clarke differs from them both, and justly ; for he found, that if we delay turning till the waters have come away, and the os uteri is quite dilated, we allow it to remain to the increasing the difficul ty of the operation. If we take it when the os uteri will admit the fingers and knuckles, it is the better time,because we then turn the child as if in a bucket of water ; and this gives us so clear an advan tage that it needs no explanation. This then is the most convenient period, and we should begin bydilsting the os eater num, previously intimating our design to the patient, cautioning her not to be in the least frightened at what we are going to say ; we may then inform her " that the child does not lie quite right, but it may soon be set right, and with little trouble.' It being then agreed upon, the woman is to be laid close to the edge of the bed; and we roll up the sleeve of our shirt and pin it, anoint the hand and fore-arm, and dilate by forming our hand into a cone, first going gradually through the os ex.
ternum, taking our tame, and being very gentle ; but we should not pass on dilating beyond the vagina, until our hand passes easily through; if we do, we shall feel the inconvenience of it afterwards, by the con traction of those parts : having got our hand through the vagina, we may let it remain awhile, and should a pain come on, it may waste itself on our hand. We should then gently begin again to dilate till we get our hand into the uterus ; when we turn the child gradually round, bringing the head to its proper situation.
There is no difficulty if we once get our hand up through the os uteri, that being dilated sufficiently, without the mem branes being broken. But suppose ano ther labour, where the membranes are broken without the os uteri being dilated. We have here much more to do, and less chance for doing it well than we had in the other example : we must go on, and have to turn the child too, under the in creased difficulty of the contraction of the uterus, which will not, indeed, be violent, but quite enough to render the turning difficult. But if we be able to manage the most easy case, and the most difficult, we should be equal to all the subordinate or intermediate degrees of difficulty that may be met with in turning.
To give an example of the greatest de gree of difficulty, suppose a case where the waters have been lost twenty.four hours, two days, or even three. What we have to do in overcoming the con traction of the uterus, is not altogether a matter of difficulty as to skill, so much as it is as to time and management. With a view to lessen the difficulty, opium has been given: but great caution is required in its exhibition; since a woman has been known to die from the use of opiates ; she has been drained to death by uterine hientorrhages.
The last circumstance necessary to no tice with regard to preternatural labour is, that all the other parts being brought down, the head sometimes cannot be got through well. We may here use a mo derate force, by pulling with the body, re membering that our object in using force is to save the life of the child. Besides, why should we use a force too great when we may always deliver with the forceps Though where violence is unavoidable, it is best to open the head.
To employ that force which, without violence, may assist in bringing away the head, a good method is to. make asort of loop, by bringing a handkerchief loosely round the neck ; when letting the ends down upon the breast, we tie them ra ther low on the breast, so that there may be plenty of room to place our hand with in it to pull by, and if we succeed we must mind, that in bringing down the head, we depress the sides of the head so as to bring it into the hollow of the sacrum. If it will not come by any means, we must then open it : when we have ex tracted the brain we should introduce the blunt hook, and it is used with the most effect when seconded by the pulling of the body, In some instances it happens that the head is entirely separated from the body, when various means have been recom mended for bringing it away. The only sure method, however, is to open it; and when we have dilated it by expanding the perforator, we should introduce the crotchet before we withdraw the perfora tor, in order to have the head always se cure, from slipping, as it otherwise would do. The difficulty is, that whenever we touch it we have a smooth slippery sur face, which we cannot keep unless we have an instrument within the hole we have made. It will roll over the upper aperture of the pelvis. We must recol lect always to keep one hand in the vagi na, while any operation is going on, for the extraction of any body which may be within the uterus, and in order to guard the instruments.