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B. HISTORY OF EXTERNAL MANIPULATIONS IN OBSTETRIC PRACTICE.

It is evident, then, that external manipulations—massage and expression—should have played an important part in the history of midwifery among primitive people at all times. First of all, it was their only help; the only way in which they could force labor was the expression of the unwilling fetus from the womb. The vis a tergo was their only resort; and secondly, if properly applied, the methods are unexcelled and correct, both upon mechanical and physiological principles. I have in my former writings minutely described the obstetric practice of people, savage and civilized, in all ages, so that I need not here dwell at length upon the history of these manipulations.

There is hardly a people, ancient or modern, that do not in some way resort to massage and expression in labor, even if it be a natural and easy one. An obstacle or irregularity of any kind they always sought to overcome by these methods. Hippocrates, in his writings, says: "If you put a fruit-stone into a narrow-neck flask, you may find it impossible to bring it out crosswise; and even so it is with a child when it lies across the mouth of the womb.'' In the case of plethoric young women, venesection was performed often without effect. Sternutatories were given, and the nose held fast when they began to take effect. If this did not suffice, a still rougher mode of practice was adopted: the patient was laid on her back in bed, while the shoulders and upper part of the body were bound fast, and the end of the bed next her head was then raised and allowed to fall with a jerk, which was supposed to aid in the expulsion. Or four women seized each an arm or a leg, and thus jerked the patient up and down as she lay in bed. If a malposition existed, this same succussion was used with the feet high, so as to shake the child into the roomy portions of the womb.

In Greece, when a woman was in labor, she seated herself upon a tripod, the nurse seized her from behind around the middle of the body, and rubbed and pressed upon the abdomen with both hands. The ancient Arabian physicians, among them Rhazes, recommend massage, firm rubbing of the abdomen in childbirth; and even now all the Arab tribes of Caucasian origin, on the banks of the Caspian Sea, have nurses to massage the abdomen and the lumbar region. Common

as the practice is in Asia, resorted to in all ages for various diseases, it was equally used in labor cases for the double purpose of increasing the force of the uterine contractions, and of causing the expulsion of the ovum by pressure.

Modern means of communication, as well as medical schools, are rapidly doing away with these primitive customs, which were frequently practiced in more remote regions of our own States in the early parts of this century. Many of our older physicians tell of their early labor cases in the farm-houses of Virginia, Ohio or Georgia, where the patient was delivered upon the lap of her husband, whose encircling arms exercised a steady pressure upon the descending uterus; even now expression is occasionally practiced in this way.

Among our Indians, at least such of them as are not yielding to the civilizing influence of the agency physician or the army surgeon, massage and expression are common, whether the parturient occupies the kneeling, sitting, recumbent, or semi-recumbent position; malpositions are corrected, and labor hastened by the hands of an assistant, who kneads the loins and abdomen, and exercises pressure by the palm of the hands placed upon the uterine globe. Among the natives of Mexico, of Central and South America, it is still common practice. At the time of the Incas, the exit of the child was hastened by the firm compression by an assistant's arms, which closely encircled the waist of the sufferer. Among the Calmucks, the parturient squats down upon her buttocks at the foot of her bed, and braces herself against a pole that descends obliquely from the top of the hut, very similar to the practice now in use among the Mexicans, and the assistant clasps her in her arms, and, when labor begins, seats herself upon the ground, takes the patient upon her knees, and presses and kneads the abdomen from above downward. If the strength of the patient begins to fail, she is placed upon two boxes, and a strong man, standing behind her, compresses the abdomen with all the strength of his arms. Among the Tartars the nurses hang the woman up by the arms, and compress the abdomen with bandages; sometimes they place a heavy weight on the abdomen.

In the East Indies, they knead the back and loins—shampoo. In the seventeenth century, massage was practiced in

Siam in difficult labors. Hureau de Villeneuve has described this practice under the name of Cong-fou. He says that its object is to lessen pain, and explains it by reflex action. The manipulation consists essentially of light rubbing, touching, delicate pressure, tickling, and friction with the ends of the fingers. In this the nurse must be methodical. The manipulations must be made during the pain, and not only upon the abdomen, but also upon the perineum, the groins, the hypochondrium, and over the diaphragm. Among the Japanese, Ambouk is a kneading of the body, with the object of expelling the child. They also have a practice called Seitaz or version, in which, by external manipulation, they pretend to rectify malpresentations.

The Malays put hot bricks upon the woman's abdomen, and press upon the bricks with all their force. The Negritas clasp the trunk of a bamboo and press against it. In New Caledonia, they use violent pressure and blows of the fist in hard labor. In Senegal, some one sits upon the patient's abdomen. In Old Calabar, the woman is put in a sitting posture, and the nurse compresses the abdomen with the hands anointed with oil. Among the negroes of New Guinea, the parents or friends of the woman assist her by beating or kicking her in the stomach. In Kabylie, no manipulations seem used in ordinary labor, but, what is rare among other people, traction upon the parts already expelled is made; if, however, labor is slow, an assistant butts the patient in the abdomen. She places her head upon the pregnant womb, and clasping her hands behind the patient's back, presses first upon the back, then upon the abdomen to hasten the expulsion of the child. Some of our own Indians strap a pillow of some kind to the abdomen, and lie flat upon the ground, thus to express the fetus; others press the abdomen upon a staff firmly planted in the ground; but, as I have already stated, by far the most common methods are massage of the back, of the loins, and abdomen, to increase the uterine contraction, and the pressure upon the abdomen by the encircling arms, or by the hands laid upon the uterine globe to express the fetus.