^*_*9___sS2?W ^:3i■__££««» ii: w
 
 
AN
ABRIDGMENT
o_
MR. HEATH'S TRANSLATION
OF
    BAUDELOCQUE'S

MIDWIFERY.
WITH NOTES,
BY WILLIAM Pf, DEWEES, M. D.
   Lecturer on Midwifery in Philadelphia.
vABRA/?,
c

PHILADELPHIA:
Fublished by Thomas Dobson, at the Stone House, No. 4J,
              South Second Street.
             Fry and Kammerer, Printers.
                    1811. 
ANNEX   '
     'v_rv^rea>l
      District of Pennsylvania, to wit:
  *#*#*#*    BE IT REMEMBERED, that on  the twentieth
  * c  ,  *  day of November, in the thirty -first year of the indepen-
  * Seal  *  dence  of the  United States of America, A. D  1807,
  *******  Thomas  Dobson, of the said district hath deposited in this
office, the title of a book, the right whereof he claims as proprietor, in
the words following, to wit:

    " An Abridgment of Mr. Heath's Translation of Baudelocque's
      "Midwifery; with Notes, by William P. Dewees, M. D. Lec-
      "turer on Midwifery in Philadelphia."

  In conformity to the act of the  congress of the United States, inti-
tuled, "An act for the encouragement of learning, by securing the
copies of  maps, charts, and books, to the authors and proprietors of
such copies during the times therein mentioned." And also to the act,
entitled " An act supplementary to an Act, entitled, "An act for the
encouragement of learning, by securing the copies of maps, charts,
and books, to the authors and proprietors of such copies during the
times therein mentioned,"  and extending the benefits thereof to the
arts of designing, engraving, and etching historical and other prints."

                                 D. CALDWELL,
                         Clerk of the District of Pennsylvania 
APOLOGY.
In offering an abridged edition of Baudelocque's
Midwifery to the public, I have been influenced but
by the desire of extending the best system on  this
subject I believe this or any other country is in pos-
session of. I have used Mr. Heath's translation of
this work, as it is the only one extant; and by com-
paring it pretty extensively with the original, find it
at least faithful, if not elegant.
   The mode I have almost exclusively pursued, has
been, to retain, wherever compatible with the design,
either whole paragraphs, or such portions of them, as
best suited the object of the abridgment; where this
has not been adhered to, I have condensed in as small
a compass as I was capable, the meaning of the au-
thor.  At other times, I have left out entire chapters,
from an opinion, they were either useless or unneces-
sary, to the intended form of the work; thus, I have
omitted his considerations on the use of the Lever, as
it is merely a critique upon a number of  gentlemen's
mode  of using it;  and though  it must  be acknow-
ledged he has done this in the most masterly manner,
yet it does not add a particle to the student's know-
ledge; I consider myself in this the more excusable,
as he has given in another place the cases in which he
judged it proper to employ this instrument, and direc-
tion for  its application.  I may urge a similar reason
for the omission of the chapter on  the section of the
pubes. In this our author has so fully demonstrated
its inutility, and so completely triumphed over its ad-
vocates, that it is now no longer considered  as a re-
source of the art. It would have, therefore, been more 
IV
\
 than idle, to have given a description of an operation  /
 never to be performed; or even to have detailed the  *
 reasons by which he gained this victory.  It may be
 proper, however, in this place, to  state, that  it has
 been almost exclusively the honour of Baudelocque,
 first to call in question the propriety of this cruel ope-
 ration, and next to demonstrate, in the most satisfac-
 tory manner, its inutility, or rather insufficiency for
 the object proposed.
   I have made some other omissions of a minor kind,
 but none, I trust,  to injure the work, or mislead the
 student; on the contrary, I am of opinion it can well
 bear this pruning, and all that is useful  be retained.
 Unnecessary repetition, useless detail,  and tedious
 minuteness, are the  frequent faults of  our author;
 these I have endeavoured to obviate.
  With a view to an extensive circulation of this truly
 valuable work, cheapness has  been  regarded;  to in-
 sure this, the work  is condensed into one volume,
 which  will bring it to a moderate price.
  A number of engravings have also been omitted
in this edition, as it is conceived they administer  no-
thing to the student's information, while they very
considerably augment expense.
  I have occasionally added notes, but not in  suffi-
cient number, I trust, to materially enhance the price
of the work.  They could easily, and perhaps advan-
tageously, have been extended, but powerful motives
withheld me. For readers kindly disposed, they may
be found enough, and for the fastidious  perhaps  too
many.
                           W. P. DEVVEES.
  Philadelphia, 20th November,  1807. 
\
)

/ 
\
Haiein.
V 
TO  INSTRUMENT  MAKERS.
      THE forceps delineated in plate VII. are reduced
\    to a third of the size of the original.  They differ a
    little from these expressly mentioned in this work:
    1st. Jn not having the thread running round the edges
    of the internal face of the  forceps.  2d. In having the
    internal  edges of  the openings in  the blades made
    nearly as thin as the  external or superior and inferior
    edges; by which means more room is  allowed for
    the head to accommodate itself when seized  by the
    instrument.  This is considered as a great improve
    ment;  for in the common way of making these in-
    struments, the blades are pierced in the middle, where
    they are of considerable thickness, and this thickness
    is allowed  to remain, and consequently diminishes
    the  space between the blades when fixed.  Now by
    taking down these edges, and making them nearly
    as thin as the external or superior and inferior edges,
    much room is gained. 3dly. The slide at the top of
    the  female branch, which was intended to secure the
>    pivot of the ma1: branch, is omitted as useless. 
ADVERTISEMENT,
                MR.  EBERLE,

          No. II, North Sixth-Street.
  Made the improvement just spoken of; he work.
ed \w Paris under the direction of Baudelocque him-
se;  ctnd is considered particularly fortunate in mak-
ing his Midwifery Instruments.
 Directions for placing the Plates.
Plate    I. to face page 21
       II.             S7
      III.             38
      IV.             51
       V.             52
      VI.             70
     VII. to face the Advertisement, p. v 
CONTENTS.
                       PART I.
                                                 OPAGE.
   F those Parts of Anatomy, Physiology, and other
  Sciences, relative to Midwifery      -      -      -  1
Of the Parts of the Woman concerned in  Delivery        2
Of the Female Pelvis, considered with respect to Deli-
  very     -      -      -      -      -             3
Of the Os Ilium      -      -      -      -      -    4
Of the Os Ischium       ....      7
OftheOs Pubis      -      -      -      -      -    8
Of the Union of the Ilium, Ischium, and Pubis; of the
  common Parts which result from that  Union;  and of
  the natural Dimensions of the Os Innominatum in
  Adults      -       -      -      -      -      -   10
Of the Os Sacrum       -       -     -      -      -   11
Of the Coccyx       -       -      -      -      -    13
Of the Union of the Bones of the Pelvis      .      -   14
Of the Separation of the Bones of the Pelvis in Labour   22
Of the Division of the Pelvis, and of its natural Dimen-
  sions      -       -       -       -       -      -    33
Of the Deformities  of the Pelvis, considered with re-
  spect to Delivery       ....       39
Of the Soft Parts connected with the Pelvis     -     -   53
Of the Examination necessary to discover whether the
  Pelvis is well or ill formed   ,  -      -      -     60
Of the Parts of the Woman concerned in Generation and
  Delivery       -                                   72
Of the Uterus                                       75
Of the Parts dependent on the Uterus       -      .77
Of the changes which Pregnancy produces in the Vo-
  lume, Figure, and Structure of the Uterus      -     82
Of the Action of the Uterus      -       -       -      88
Of the Descent or Prolapsus of the Uterus, of its Retro-
  version, and Anteversion     -      -       -      -   93
Of the Obliquity of the Uterus      ...   104
Of the Menses     -     -      -       -      -     115
Of Generation              -      -      -          li« 
viii                 CONTENTS.
12!
123
125
Of Conception      -
Of Pregnancy     -
Of Touching      -
Of the Foetus         -   ♦   -      -      -      -  134
Of the Attitude and Situation of the Foetus in Utero     138
Division of the Child       -       -       -       -     140
Of the Secundines, or After-birth, and particularly of the
  Placenta      -      .       -      -       -       144
Of the Membranes    -     -       -      -       -   148
Of the Umbilical Cord    -      -      -      -     149
Of the waters of the Amnion     -     -      -     -  151
Of the manner in which the Child  is nourished during
  Pregnancy      -       -       -       -       -154
Of the Circulation of the Blood in the Foetus           156
Division of Labour, of its Causes, its Signs, &c.     -    159
Of the common Determining  Causes of Labour      -  161
Of the natural efficient Causes of Labour    -      -   162
Of the Causes accessory to the action of the Uterus     164
Of some of the principal Phenomena of Labour      -  165
Of Labour Pains      -      -      -       -      -   ib.
Of the Dilatation of the Neck of the Uterus     -   -  167
Of the Mucus tinged with Blood, which drains from the
  Vagina       -       -      -      -      -      -  168
Of the Gathering of the Waters     -      -       -   169
Exposition of the preceding  Phenomena,  and of some
  others, according to the order in which they generally
  happen       -       -      -      -      -      -  170
Of the Phenomena of the last  Period of Labour       -   172
                     PART  II.

OF Natural or Unassisted Labour, and the various Kinds
  of it      -      -      -      -      -      -    175
Of the first general Species of Natural Labour, or that in
  which the Child presents the Head       -       -     176
Distinguishing Signs of the Vertex, and of its different
  Positions      -       -      -      -      -     -  ib.
Of the Mechanism of Natural Labour, where the Child
  presents the Crown of the Plead in the First Position  179
Of the Mechanism of Natural Labour, Avhere the Child
  presents the Crown of the Head in the Second Position  182
Of the Mechanism of Natural Labour, where the Crown
  *>f the  Head presents in the Third Position       -     183 
                     CONTENTS.                  ix

Of the Mechanism of Natural Labour, where the Crown
  of the Head presents in the Fourth Position.      -   184
Of the Mechanism of Natural Labour, where the Child
  presents the Crown of the Head in the Fifth Position  186
Of the Mechanism of Natural Labour, where the Crown
  of the Head presents in the Sixth Position      -     187
Of the Second general Species of Natural Labour, or that
  in which the Child presents the Feet      -      -  188
Of the Signs which indicate that the Child presents the
  Feet      -       -      -       -      -      -    189
Of the Mechanism of Natural Labour, where the Child
  presents the Feet in the First Position      -      - 190
Of the Mechanism'of Natural Labour, where the Child
  presents the Feet in the Second Position     -     - 193
Of the Mechanism of Natural Labour, where the child
  presents the Feet in the Third Position      -      -  ib.
Of the Mechanism of Natural Labour, where the Child
  presents the Feet in the Fourth Position     -     - 195
Of the Third general Species of Natural Labour, or that
  in which the Child presents the Knees      -      - 197
Of the Fourth general Species of Natural Labour, or that
  in which the Child presents the Breech      -     - 198
Of the Mechanism of Natural Labour, where the Child
  presents the Breech in the First Position     -     - 199
Of the Mechanism of Natural Labour, where the Child
  presents the Breech in the Second Position    -    - 200
Of the Mechanism of Natural Labour, where the Child
  presents the Breech in the Third and Fourth Positions  ib.
Of the Management of the Woman during Labour     201
Of the Treatment which the State of the Woman gene-
  rally requires in the First Period of Labour    -    -202
Of the Situation of the Woman during Labour      -    206
Of preparing the Parts of the Woman for Delivery     208
Of quickening lingering Pains       -                 209
Of opening the Membranes       -       -        -    211
Of what is necessary to be done after the Membranes are
  open      -       -      -       -      -      -    213
Particular Precautions relative to each Position of the
  Head, or to other  Circumstances which sometimes
  render Natural Labour a little more difficult    -     216
Of the Management of the new-born Child      -      219
Qf the usual Method of treating a  new-born healthy
  Child      -       -      -      -      -       -    ib.
Of the Treatment of a Child born in a Morbid State     220
Sequel of the Treatment of healthy Children      -    225
                               b 
x                  CONTENTS.                       )

Of the Manner of dressing new-born Children      -   226  j
Of delivering the After-birth, and the Regimen to be ob-
  served in the Month      -                        228  \
Of Deliverance      -      -      -      "      -   ib.  ;
Of the unassisted Delivery of the Placenta       -      229  ^
Of the Signs which indicate the Time when we ought to
  cooperate in delivering the Placenta, and the Method
  of doing it in the most usual Cases      -       -    231
Of accidental Circumstances which oblige us to deliver       «
  the Placenta sooner or later, and to vary the Mode of
  Operating       -       -      -       -      -    233   ,
Of the Method of delivering  the Placenta in case of
  Flooding      -      -      -       -       -      234
Of Obstacles to delivering the Placenta, arising from an
  Atony of the Uterus, and from a natural or spasmodic
  Contraction of its Neck     -                      235
Of Obstacles to Deliverance, proceeding from preterna-
  tural Adhesions of the Placenta; and of what must be
  done in those Cases       -                         236
Of the retention of a  portion of the Placenta, and of
  Clots of blood in the Uterus; and the precautions ne-
  cessary in  those Cases     -      -      -      -  241
Of Deliverance when the Placenta is encysted      -    243
Of Deliverance in those Cases where the  Placenta is at-
  tached to the Neck of the Uterus       -      -    244
Of Deliverance after an Abortion    ...  248
Of Deliverance after the Birth of Twins      -      - 252
Of what is to be done  immediately after Deliverance,
  during the Time the Woman must  remain on the
  couch      -       -       -       -       -        254
Of putting the Woman to bed       ...   255
Of the principal Phenomena which manifest themselves
  in  the. Month      -      -      -      -      -  257
Of the Regimen for Women in the Month       -    - 263
                     PART  III.

Labours of the second Order, commonly called preterna-
  tural       -       -      . ■      .       _       .   266
Of the Causes which may render Labour preternatural    ib.
Of Hemorrhage, considered with respect to the necessi-
  ty of immediate Delivery      ...     269
Of Convulsions, considered particularly with  respect to
  Labour and Delivery      -                       276 
                      CONTENTS.                   xi

x "Of  Syncopes,  of the Exhaustment of the Woman's
    Strength, and other Causes stated in Par. 1079;  and
    particularly of the exit of the Umbilical Cord        287
  Of the Signs, in general, which show that a Labour will
    be preternatural; of the Indications presented by that
    Kind of Labour; and some general Precepts relative
    to it      -       -      -      -       -          291
  Of the proper Situation for the  Woman in a preternatu-
    ral Labour       -       -       -       -      -     292
  General Precepts relative to preternatural Labour      294
  Of  the general Indications, in those Labours where the
    Child presents the Feet    -                       300
  Of  the different Species of Labour, in which the Child
    presents the Feet      ...      -      308
  Labours in which the Child presents the Knees.  Of the
    Causes which render a Labour, in which the Child pre-
    sents the Knees, difficult, or preternatural       -    317
  Of  the Characteristic Signs of the several Species of La-
    bour in which the Child presents the Knees, and the
    Indications they present relatively to the Mode of ope-
    rating       -      -       -     -      -      -318
  Of  Labours in  which the Child presents the Breech  ,  321
  Of  the Causes which may render those Labours where
    the Child presents the Breech, difficult, or preternatu-
    ral: the essential  Differences of those  Labours, and
    their distinguishing Signs       -             -     ib.
  Indications in  those Labours where the Child  presents
    the Breech       ....       -    322
  Of  the Signs which characterize the different Species of
    Labour, in which the Child presents the  Breech, and
    the Method of bringing down the Feet in those Cases 325
  Labours in which the Child presents the Crown of the
    Head at the  Orifice of tire Uterus       -       -    328
  Of  the Causes  which may render those Labours rn which
    the Child  presents the Crown of the  Head, difficult or
    preternatural, and the Indications they prescribe     329
  Of bad Situations of the Child's Head in  general, and par-
    ticularly of that which it is sometimes forced to take as
    it advances in the Pelvis       -     -       -      330
  Of the Indications in those Labours in which the Child
    presents the Crown of the  Head, when complicated
    with circumstances that  render them difficult     -  333
  Of the Method of turning the Child to bring it by the
    Feet, when  it presents the Crown of the Head. Gene-
    ral Rules       -----     336 
CONTENTS.
Of the distinguishing Sigus of the first, second, and third
  Species of preternatural Labour, in which the Child
  presents the Crown of the Head, and the manner of
  turning the Child in those Cases      -    _  -       340
Of the Signs of the fourth, fifth, and sixth Species of La-
  bour, where the Child presents the Crown of the Head,
  and the Method of operating in all those Cases     -   343
Labours in which the Child presents the Face      -     346
Of the Causes,  Signs, and  Differences of Labours  in
  which the Child presents the Face, and the Indications
  they prescribe      -      -      -       -       -   lb.
Methods of operating in the different Species of Labour
  in which the Child presents the Face, when it can  be
  done with the Hand alone       -                    349
Labours in which the Child presents the Fore Part of the
  Neck, commonly called the Throat       -      -     351
Labours in which the Child presents the Breast    -    353
Of the Causes, Signs, and  Differences of Labours  in
  which the Child presents the Breast       -       -    ib.
Labours in which the Child presents the Belly      -   354
Labours in which the Child presents the Fore Part of
  the Thighs, and of the Pelvis;  their Causes, Signs,
  Differences, and the Mode of operating in them    -  355
Labours in which the Child presents the different regions
  of its posterior surface to the orifice of the uterus     356
Labours  in which the Child presents the occipital Re-
  gion at the Orifice of the Uterus. Of the Causes and
  distinguishing Signs of those Labours, and their Indi-
  cations      -   .    -       -       -       -         35?
Labours  in which  the Child presents the  Back of the
  Neck,  commonly called the Nape.  Of their Causes,
  Signs, Differences, and general Indications      -   358
Labours in which the Child presents the Back. Of their
  Causes, Signs, Differences, and Indications      -    359
Labours in which the Child presents the Loins. Of their
  Causes, Signs, Differences, and Indications      -    360
Labours  in which the Child presents the lateral Regions
  of its  Surface       -       -       -       -      -  361
Labours in which the Child presents the right or left Side
  of the  Head. Of their Causes, Signs, Differences, and
  Indications      -       -      -       -       -362
Method of operating  in the  first and second Species,
  where the Child presents one of the Sides of the head  364
Labours in which the Child presents one of the Sides of
  the Neck       -      -       -      .             p,pq 
                    CONTENTS.                  xiii

Of the Indications  presented by these Labours, and the
  Mode of operating in them      -      -       -    371
Labours in  which the Child presents one of the shoul-
  ders. Of their Causes, Signs, Differences, and Indica-
  tions       -              -      -       -      -   ib.
Method of operating when the Child presents the shoul-
  der      -       -       -       -       -       "    373
Labours in  which the Child's Hand presents first       376
Labours in  which the Child presents one of its Sides.  Of
  their Causes, Signs, Differences, and Indications     388
Labours in which the Child presents one of the Hips at
  the orifice of the Uterus. Of their Causes, Signs, Dif-
  ferences, and Indications       ...     389
Labours of the  third Order, or Laborious       -      - 390
Of the Forceps, and their general Mode of acting       391
                     PART  IV.

Of the Causes which make the Use of Instruments ne-
  cessary in the Practice of Midwifery, particularly the
  Forceps and Lever      -      -      -       -    412
Of the Locked Head      -       -      -       -    414
Of the Causes, Signs, and Accidents of the Locked Head 419
Indications in the Locked Head, considered exclusively
  of the Accidents which are the Consequence of it     426
Circumstances in which the Head may stop in the Pas-
  sage without being locked, and the difference between
  those two states      ----- 429
General Rules concerning the Use of the Forceps      436
Of the Application of the Forceps in that  Position in
  which the Occiput answers to the Arch of the Pubes,
  and the Forehead to the Sacrum; and also  in that in
  which the Occiput is against the latter, and the Fore-
  head opposite the Arch of the Pubes       -      - 440
Method of using the Forceps in that Position of the Head,
  in which  the  Occiput answers to the left Foramen
  Ovale, and the Forehead to the right Sacro-iliac Sym-
  physis;  and in that  where the Forehead is  behind the
  left Foramen Ovale, and the Occiput opposite the right
  Sacro-iliac Symphysis      -       -       -        444
Method of using the Forceps, l.in that Position in which
  the Occiput answers to the right Foramen Ovale, and
  the Forehead to the left Sacro-ischiatic  Notch; 2. in
  that in which the Occiput is  placed opposite the said 
xiv
CONTENTS.
   Notch, and the Forehead behind the  right Foramen
   Ovale; 3. when the Crown of the Head is situated ex-
   actly across at the inferior Strait       -       -       447
 Causes which ought to determine us to use the Forceps,
   while the Head is still  above the superior Strait; and
   general Rules to be observed in it       -       -     450
 Method of using the Forceps in that Position of the Head
   in which the Occiput rests on the Top of the Symphy-
   sis of the Pubes, and the Forehead against the Sacro-
   vertebral Angle; and in that where the Occiput answers
   to the said Angle, and the Forehead to  the Pubes      452
 Method of using the  Forceps when  the  Head, retained
   above the superior  Strait, presents  the Occiput at the
   left Side, and the Forehead at the right: and also when
   the Forehead answers to the left Side, and  the Occiput
   to the right      -      -      -       -           456
 Method of using the  Forceps when the  Head present-
   ing the Vertex, is wedged in the superior Strait      459
 Method of using  the  Forceps, when the  Head is locked
   lengthwise between the Pubes  and the Sacrum, supe-
   riorly       -       -       -       -      -      -   ib.
 Method of using the Forceps when the head is wedged
   transversely in  the superior Strait      -       -     461
 Method of using the Forceps and the Lever, when the
   Child presents the Face       -       -       -       463
 Method of using the Forceps and the Lever in that Posi-
   tion of the Face, in  which the Forehead answers to the
   Pubes, and the  Chin to the Sacrum; as well as in that
   in which the Forehead is against  the  latter, and the
   Chin towards the former       -                     464
Method of using the Forceps and  Lever in the transverse
   Position of the Face, in which the Forehead answers to
   the left side of the  Pelvis, and  the Chin to the right
   Side;  and in that in which the Forehead is towards the
  right  Side, and  the  Chin to the  left      -       -     470
Method of applying the Forceps, when the Head is re-
   tained by its Base in that Position in which the Occiput
  answers to the Pubes, and the Face to the Sacrum; and
   in that where the Occiput is against the latter, and the
   Face towards the Pubes      -                       473
Method of using the Forceps, when the Head is retained
  in a transverse Position, after the Exit of the Trunk   477
Of the use of the Lever       -       -       .      .  479
Method of using the  Lever in that Position of the Ver-
   tex in which the Occiput answers  to the Pubes of the 
CONTENTS.
xv
  Mother, and the Face to the Sacrum; and in that where
  the Occiput is against the latter, and the Face behind
  the Pubes      -      -      -                   481
Method of using the Lever in all Cases where the"Child's
  Head is placed diagonally or transversely at the infe-
  rior Strait      -      -      -      -       -     483
Labours which  cannot be terminated without the Appli-
  cation of some cutting Instrument to the Body of the
  Child      -       -       -       -       -       -  485
Signs by which we usually judge whether the Child be
  living or dead      _      _       -                487
Of the Application of Crotchets, and other Instruments of
  that Kind, to  the Head      -       -      -       - 495
Of the retention of the Child's Head after the Trunk is
  torn from it, and the method of extracting it      -  499
Of the Beheading the Child, or the Separation  of the
  Head from the Trunk; and of several other Cases
  which require the Application of Cutting Instruments
  to the Trunk itself       -       -      -      -     503
Of the vitious Conformation of the soft Parts of the Wo-
  man, which  constitute what is commonly called the
  Passage, considered as a Cause of laborious Labour   509
Indications presented  by a Deformity of the Pelvis, rela-
   tive to Delivery      -      -      -      -       -*4
A succinct Analysis of Delivery by the  Feet; of the Use
   of the Forceps, Crotchets  and Perce-cranes, in Cases
   of Deformity of the Pelvis       -      -      -     516
 A succinct Analysis of the Cesarean Operation      -  518
 Of premature Delivery, proposed on account of a Defor-
   mity of the Pelvis,  with a View of avoiding the Cesa-
   rean Operation      ----- 522
 Of  Regimen, considered as a Means of preventing  the
   Difficulties of Labour, which proceed from a Deform-
   ity of the  Pelvis      ...       -      527
 Of the Cesarean Operation       -      -       -      528
 Of the Causes which  require  the Cesarean Operation; the
   Preparations necessary for  it; the proper Time to per-
   form it; and the Instruments and other requisite Ap-
   paratus      -       -      -       "       "        5o°
 Of  the Part where the  external Incision ought to be
   made       -      -      -            .  "      -  534
 Method of performing the Cesarean Operation      -  541
 Of the proper  Treatment after the Cesarean Operation   546
 Of the Causes of the Rupture of the Uterus, and the prin*
   cipal Accidents attending it      _              -    5 52 
 xvi                 CONTENTS.

 Signs ofa Rupture of the Uterus      -               557
 Of the Indications presented by a Rupture of the Uterus 560
 Of Compound Pregnancy, its Signs, and the Indications
  it presents relative to Delivery      -               566
 Of the Signs ofa Pregnancy composed of several Children 568
 Of the Indications presented by Twins relative to Deli-
  very      -       -      -       -       -       -569
 Of false Pregnancy, its Signs, and curative Indications   575
 Of the Signs which characterize a false Pregnancy       578
 Of the Mechanism by which the Substances which con-
  stitute the different Species of false Pregnancy are ex-
  pelled; and the Assistance they require from Surgery 581
Of the Causes of Abortion,  and its Symptoms            583
Indications in Cases of Abortion       -       -      -   585 
A SYSTEM
         OF

MIDWIFERY.
                  PART I.

Of those Parts of Anatomy, Physiology, and other
         Sciences, relative to Midwifery.

  1. JYliDwiFERY is the art of facilitating the exit
of the  child, and all its  appurtenances, from the
womb of its mother.
  2. This operation, which is entirely mechanical,
and subject to the laws of motion, is most frequently
performed by the natural force of the organs of the
woman; but no other function of the animal econo-
my requires the concurrence of so many powers, or
is so laborious and painful. The facility of its exe-
cution always depends on the union of many causes;
and the failure of any one of them may render it
difficult, often dangerous, to both mother and child,
and even impossible without assistance.
  3. If the office of the accoucheur is in some mea-
sure reduced to that  of  a mere spectator,  in those
cases where this function is performed according
to the intentions of Nature, there are others  in
which his assistance is absolutely necessary. Some-
times it is  proper to moderate  the action of the
natural  powers,  which would expel the child too 
 2             Of the Parts, &c.

 suddenly;  sometimes to augment this action, or
 supply the want of it; to weaken the resistance of the
 parts which form the passage, to render it pervious
 to the child; or to open it another issue, &c. But what
 a fund of knowledge is necessary to  enable us to
 distinguish between the  boundaries of Art and Na-
 ture!  to know when  to  let that provident mother
 act, or to assist her seasonably! We ought to be ac-
 quainted, in every possible respect, with the parts
 of the woman concerned in delivery; the mechanism
 of that important function, the manner in which it
 is performed, the requisite  conditions for it, the
 causes which may render it difficult, or obstruct it;
 and the indications which each of them prescribes.
If some parts of this knowledge may be acquired
by study and meditation, there are others which
can only  be the fruit of practice.
 Of the Parts of the woman concerned in Delivery.

  4. Among the great number of parts concerned
in delivery, some serve to expel the child, and others
merely form the canal destined for its passage; which
permits us  to divide them into active and passive.
The former comprehends the uterus, the abdominal
muscles, &c; the latter the pelvis, and the soft parts
which cover it, both within and without. 
Of the Female Pelvis, &c.

  Of the Female Pelvis, considered with respect to
                    Delivery.

  5. Th e pelvis, considered without the soft parts
which cover  it on all sides, is a kind of irregular
bony  cavity, situated below the spine, of which it
forms the basis, and above the inferior extremities
with  which it is articulated.  The facility of de-
livery always depends on the more or less favoura-
ble proportion which the dimensions  of the pelvis
bear to those of the child's head, and from thence
arise  the greatest obstacles to  oppose  it.
   6.  The pelvis in an adult is formed but of four
bones; viz. the ossa ilia or innominata, which consti-
tute the sides and the fore part; the sacrum and coc-
cyx, which form the back part: but  we observe a
greater number in the foetus,  and in infancy; each
os ilium being  then  composed of three parts—the
ilium (properly so called) the  ischium, and  the pu-
bes; the sacrum of five, called false vertebrae; and
the coccyx of three, as it likewise is in the adult.
   7.  Most of these bony pieces are soft and flexi-
ble in the foetus, some of them being still in a man-
ner cartilaginous; and the edges of the others are
found incrusted with a similar substance. It is some
time  before they acquire that  solidity which consti-
tutes the essence of bone. This disposition is not
peculiar to the bones of the pelvis, at the time of
birth, when the man,  if I  may be  allowed the  ex-
pression, is no more than sketched; for  Nature fol-
lows the same course in the development  of all
the parts which are to form the frame  of the edifice.
Those who have thought they discovered disposi-
tions favourable to delivery, in the mustiplicity of
bones which form the pelvis  of the  foetus, in the 
4     Of the Bones of the Pelvis, separately.
manner of their connexion, and in the little solidity
which results from the whole, and who have advanc-
ed  that those bones undergo the same changes of
figure in the course of labour  as  those of the cra-
nium,  have  deceived  themselves;  and we  may
be assured that their opinion is as little consonant
to reason as to experience.*
                  Of the Os Ilium.

   8. The os ilium is the largest of the three pieces
 which  compose the os innominatum  in the foetus;
 it is placed at the side of the pelvis, and is com-
 monly cailed the hip bone. Its form is nearly trian-
 gular-; we observe  two faces in  it, one  of  which
 forms part of the inside of the pelvis, the  other the
 outside; three edges, viz.  the  superior,  the ante-
 rior, and the posterior; as well as three angles.
   9.  A  kind of angle, or line, pretty sharp  in the
 posterior two thirds of its extent, and a little round-
 ed in the rest of its length, cuts the internal face of
 the ilium a little obliquely, from above downwards,
 and from behind forwards, and divides it  into two
 parts.  The superior,  which is larger, and a little
 concave, forms the iliac fossa:  the  other,  which is
 inferior, presents behind a sort of tuberosity,  to
 which is attached a great number of tendinous and
 ligamentous  fibres;  and a little forwarder  a cartHa*

  * " In the fatus, says a modern accoucheur, the pelvis is
  soft and flexible, which facilitates the different attitudes it
  takes m the uterus, and favours  delivery by the breech, and
  teet: in both cases, the pieces of which it is composed per-
  form by their flexibility what the bones of the  head do in
« a natural birth." M. D. Leurie, nouv. ed. § 8. 
      Of the Bona of the Pelvis, separately.     5

ginou^ articular impression which has some resem-
blance to a crescent. The rest of the internal face
of the ilium makes part of the brim and cavity of
the pelvis and describes a  very small portion of a
circle.
   10. The external face of the ilium, more irregular
still than the internal, is so little important  to the
accoucheur,  that I shall dispense  with describing
it. It is covered by the glutei  muscles which are
attached to it,
   11. The superior edge of the ilium, which is call-
ed the crista, is turned nearly  like the italic S. It is
cartilaginous in infancy; of an irregular thickness
in the adult; and about seven  or eight inches long
in a woman of the middle size. It is divided into
two lips, and an interstice, to  determine more ex-
actly the insertions of certain muscles, which will
be mentioned in the sequel. The internal lip forms
a kind of angle more or less  obtuse, at about the
posterior  third  of its length, where is inserted a
ligament,  attached at the other end to the  trans-
verse apophysis of the last vertebra. See § 42.
   12. The  anterior edge of  the ilium  is  much
shorter than  the  superior.   An apophysis  which
rises in  the  middle of it, and which anatomists
call the anterior inferior spine of the ilium, makes
two superficial notches, one  of which only gives
passage to a few nervous cords, but the other serves
as a pulley to the tendons of the psoas and  iliacus
muscles.  The meeting of the anterior with the su-
perior edge forms almost a right angle,  which is
called the anterior superior spine of the ilium, to
distinguish it from the other  apophysis mentioned
above. They serve for the insertion of several mus-
cles.
   13. We see nearly the same disposition  in the 
 6     Of the Bones of the Pelvis, separately.

 posterior edge of the ilium; a bony projection makes
 two notches in it, of which the largest only forms
 the summit of one more considerable, placed at the
 side of the pelvis, and a little backward, called the
 sacro-ischiatic notcjh.  The union of this edge with
 the superior forms another angle, called the poste-
 rior superior spine of the ilium.
   14. The meeting of the anterior edge of the ilium
 with the posterior forms an  angle  much thicker,
 and more obtuse, than the preceding; on  which
 account some anatomists have regarded it as the
 basis of this bone.  We observe three cartilaginous
 impressions in it, which have  no resemblance to
 each other. One, pretty  large, a little concave, and
 whose  superior edge describes  a kind of crescent,
 forms nearly a third of  the acetabulum, which re-
 ceives  the head of the os femoris; and it is by the
 two others  that the ilium is united,  and as it were
 soldered, to the ischium  and pubes, as will be seen
 in the sequel.  The cartilage which covers the ace-
tabular portion is extremely thin, very smooth, and
continually moistened during life by a mucous li-
quor, known by  the name of synovia. Those which
cover the  other two facettes are of a different na-
ture: similar to the cartilage which  every  where
unites  epiphyses to the  bodies of  bones, they are
only found in infancy; and  insensibly change  into
bone, in proportion as the subject advances towards
adult age. 
      Of the Bones of the Pelvis, separately.     7


               Of the Os Ischium.

   15. The os ischium is situated almost perpen-
dicularly  under the ilium. As  its irregular  figure
renders the division of it in some sort arbitrary, I
shall  distinguish three parts in it, of which one
forms the body, and the others the extremities.
   16.  The first is triangular:  one  of its faces re-
gards the  inside of the pelvis; the second, the out-
side; and  it is on the third, called the tuberosity of
the ischium, that the body rests when we sit. Of
the angles of the body of the  ischium,  two form the
edges of  the tuberosity,  internally and externally,
and which anatomists call the lips of the tuberosity;
the other  is of a semilunar form, and makes part of
the foramen ovale.
   17.  A  long apophysis,  a little  flatted,  pretty
broad  at  its origin,  and narrower at its extremity,
terminates the os ischium forwards, and  is consid-
ered as the branch of it. One of the  edges of this
apophysis  contributes to the  formation of the fora-
men ovale; and the other to that of the arch of the
pubes, or  the great notch at the fore part  of the pel-
vis. Its point is joined to a production of  the os pu-
bis, by means of a cartilage  which  always ossifies
before the age of puberty.
   18. The posterior extremity of the os ischium,
more voluminous  than its body, presents a  sort of
irregular  mass, on which however we may distin-
guish five faces of an unequal breadth; with a much
greater number of edges and angles,  which I shall
not undertake to describe.  Of these faces, three are
cartilaginous,  and destined  to  the same uses  as
those on the inferior angle of the ilium;  that is to
say, one of them makes part of the acetabulum, and 
8     Of the Bones of the Pelvis, separately.

the two others  serve for the union of the  ischium
with the pubes and ilium; the fourth regards the in-
side of the pelvis, and  the fifth the outside. This
last seems to send out an apophysis backward, and
a little obliquely downward, pretty sharp, and of
the length of five or six lines,* which is called the
ischiatic spine.
                Of the Os Pubis.

   19.  The os pubis, commonly called  the  share
bone,  with its fellow, form  the anterior part  of
the pelvis:  the body of this bone is almost triangu-
lar in the middle,  flatted  towards the  place  of its
union with that of the other side, and  pretty thick
at the  other extremity  which makes  part of the
acetabulum.
   20. The superior face of the os pubis,  broad be-
hind, narrow before, and  a little concave between
its extremities, serves for a channel to the crural
vessels at their exit from the abdomen. The  inter-
nal and external faces present some little difference;
they are broad before, and narrow towards the ace-
tabular extremity.  The superior and internal angle
of the body of the  os pubis is sharp and makes part
of the  brim of the pelvis. The external angle  is
rounded, and the inferior semilunar; this  last forms
a portion of the foramen ovale.
  21. The large extremity of the os pubis, which
I shall call acetabular, presents two  little  faces
somewhat lengthened, by which it is united to the
illium and ischium, by means  of a cartilage which
* A line is the twelfth of an inch. 
      Of the Bones of the Pelvis, separately.     9

ossifies insensibly, and in time totally disappears.
We remark also at this extremity another facette,
much more extensive, a little concave, and  cover-
ed  with a layer  of cartilage extremely  thin, by
Which the os pubis concurs with the  ilium and is-
chium to form the acetabulum.
  22. The anterior extremity of the os pubis pre-
sents a  cartilaginous and ligamentous impression,
fifteen or eighteen  lines long,  and  about  six  in
breadth, which serves  for the union of this bone
with  its  fellow.  The  direction of  this  articular
impression is almost vertical when the pelvis rests
on the tuberosities of the ischia and the point of the
coccyx;  but its inferior extremity is  more  or less
inclined backward when the subject is  standing.
The middle, of its  internal  edge only is covered
with a very smooth cartilage, as are  all the extre-
mities of bones joined by a moveable articulation.
  23. This ligamento-cartilaginous impression, and
the superior face of the body of the os pubis, form
at their union almost a  right angle; which is called
the angle of the pubes.  Above,  and a little on one
side of this  angle, appears  a kind of tuberosity,
sometimes even  a sort of spine,  more or less sa-
lient, which  serves  for the insertion of the rectus
muscle, as well as the pyramidal,  and the external
and inferior portion of the abdominal ring.
  24.  A production about seven or  eight lines in
length, pretty broad and flat superiorly, but narrow-
er  at its point, descends from the anterior extre-
mity of the  body of the os pubis, and passes com-
monly for the branch of that  bone. It  is, as it were,
twisted  from the  inside of the pelvis outwards,  in
                        B 
10     Of the Bones of the Pelvis, separately.

such a manner that one of its edges is almost ante-
rior, and the other  posterior:  the posterior makes
part of the foramen ovale; the anterior, part of the
arch of the pubes.
  25.  The branch  of the pubes does not descend
perpendicularly  to  the  horizon;  it constantly in-
clines  towards the foramen ovale, and much more
in women than in men:  which renders the arch of
the  pubes much wider in them at its upper part,
and favours delivery as  much as a contrary dispo-
sition would obstruct  it.
 Of the Union of the Ilium,  Ischium and Pubes; of
   the common Parts which result from that Union;
   and of the natural Dimensions of the  Os Innomi-
   natum in Adults.

   26.  These three bony pieces, destined  to form
 but one after infancy, are united in that t arly age
 by a pretty thick  cartilage, but  of a different na-
 ture from  those  which form part of the sacro-
 iliac symphyses,  and that of the pubes; for it is in
 its nature to ossify, which it always does:  whereas
 the latter never do but by accident, and that is ex-
 ceedingly rare.  This junction of the ilium, ischium
 and pubes, is made near the middle of the acetabu-
 lum, and always  with so much regularity, that  after
 some time it can scarcely be distinguished; unless
 it be above the cavity, where we see a line more or
 less salient, which anatomists call linea ilio-pectinea,
 because it  is formed by the union of  the ilium and
pubes.
   27. It often happens, in children affected by the
 rickets  before the age in which this  consolidation 
       Of the Bones of the Pelvis, separately.   11

 is perfect,  that the three pieces which form the ace-
 tabulum are pushed inwards by  the head of the
femur, which narrows  the  entrance of the pelvis,
 and renders it so irregular as  often afterwards to
 cause the greatest obstacles to delivery.
   28. The junction  of the branch of the pubes with
 that of the os ischium, is likewise made by a carti-
 lage  which ossifies after some  years. By the con-
 nexion of these  two bones, is formed that great
 oval aperture which  we see on each side of the fore-
 part of the pelvis, as well as the notch in the ante-
 rior edge of the acetabulum.
   29. The os innominatum,  in a woman of the or-
 dinary size, is about six inches broad, from the an-
 terior superior spine to the posterior superior. Its
 height is nearly six inches and  a half, taken from
 the anterior spine to the bottom of  the tuberosity
 of the ischium; and an inch  more,  if taken from the
 middle of the crista of the  ilium.  The  knowledge
 of this height may serve to determine the depth of
 the cavity of  the pelvis laterally, from the superior
 to the inferior strait.
               Of the Os Sacrum.

  30. The sacrum represents a kind of inverted
pyramid, flatted, and a little bent inwards.  We are
to consider in it, the base, the point, the faces, and
edges.              '
  31. The base of the sacrum being broader be-
fore than  behind,  pretty much resembles the sec-
tion of a cone. In the  middle of it, we  see a carti-
laginous impression of an oblong figure, and cut
very  obliquely from before  backwards, by which 
12   Of the Bones of the Pelvis, separately.
 the sacrum is articulated  with the body of the last
 lumbar vertebra.  Two little masses, which are also
 articular, seem to be fixed on the posterior edge of
 this impression, near its extremities, and with them
 form channels which lodge the filth pair of lumbar
 nerves, at their exit from the  vertebral canal: these
 apophyses unite themselves to similar ones  of the
 aforesaid vertebra, %.s we shall see hereafter.
   32. The point of the sacrum presents also a car-
 tilaginous facette, transversely obiong; but much
 smaller than that of the base, and inclined in a con-
 trary direction; and with that the coccyx is united.
   33. The anterior face of the sacrum describes a
 curve of the depth of about half an inch. We  ob-
 serve in  it. four transverse lines, resulting from the
 consolidation of the five pieces' which constituted
 this  bone in early infancy. These lines terminate at
 each side in as many holes,  which pierce the  thick-
 ness of the bone very obliquely, and whose  use is
 to give passage  to the sacral nerves. These holes
 communicate with a canal, whose  apertures may
 be seen  on the  posterior  face of the sacrum: they
 are not all of the same size; and some of them are
 lengthened in form of a groove, towards the  edges
 of the bone: they are called the sacral holes.
  34.  The posterior face is convex,  and rough with
 a great number of tubercles, of which some answer
 to the spinous apophyses of the vertebrae, and others
 to the  oblique and transverse  eminences. We see
 in it  also eight holes, placed in two rows, whose
use is to give passage to some nervous fibres and
blood vessels. Above and below the spinous tuber-
cles are two other  apertures, nearly  of a triangular
figure, of which  one forms the beginning, and  the
other the end of the sacral canal.  From the extre-
mity of this  canal  descend  two little productions, 
      Of the Bones' of the Pelvis, separately.    13

in the shape of a bodkin, which unite by means of
a ligament with the superior and posterior part of
the coccyx.
   35. Each edge of the sacrum presents superiorly
a large  cartilaginous  impression, perfectly similar
to that  of the  os. ilium, with which it is joined.
These articular impressions, nearly of a semilunar
figure, are cut obliquely from above  downwards,
from without inwards, and from  before backwards;
so that their'anterior edge and their superior extre-
mity are farther from a line  which would  divide
the sacrum vertically into  two equal parts,  than
their posterior  edge and  their inferior extremity:
whence  we see that the sacrum is fixed  between
the ossa ilia, after the manner of a  double wedge,
with the base above and before. There is nothing
very remarkable in the rest of the edges of the sa-
crum, unless it be a little notch in their inferior ex-
tremity.  The length  of this bone is usually from
four inches to four and  a half; its greatest breadth
four inches; and its thickness, taken from  the mid-
dle of its base  anteriorly, to the extremity  of the
spiny tubercle of its first false vertebra, is two in-
ches and  a half.  This  last dimension varies  so
little, that I have not found a difference of a  line in
been thirty and forty pelves, the greater part of
which were deformed;  which is as we  shall  see
hereafter, very important to be known.
                 Of the Coccyx.

  36.  The  coccyx is usually  formed  of three
pieces, which altogether produce nearly the figure
of a pyramid, twelve  or  fourteen  lines long and 
 14             Of the Union of the

 sometimes more, a  little bent forward, and bound
 by its base to the point of the sacrum.  I  shall say
 no more of these three pieces than what is neces-
 sary to  show their  connexions  with  each other,
 and with the sacrum.  The breadth and thickness
 of the coccyx diminish insensibly from the top of
 the  first piece to the extremity of the last;  we may
 consider in each of them a base, a point, two faces,
 and two  edges.  The base of  the first  presents  an
 oblong facette, covered with a ligamento-cartilagi-
 nous substance,  by which it is united to the extre-
 mity of the sacrum;  and, at the sides and back part
 of this substance, two  longish tubercles, in which
 are  inserted as  many  ligaments.  The  point  is
 rounded, and covered by an articular cartilage, like
 a little flatted head: it is received  into a superficial
 cavity which is observed in the base of the second
 piece, and forms with it a kind of articulation,
 whose emotions, though limited, are preserved a
 longer time than  those of the whole of the coccyx
 on the sacrum. We  find nearly the same  relation,
 the same reciprocity of figure, between the point
 of the second piece and  the base of the third; con-
 sequently the same kind of connexion.  This third
 piece is longer and  narrower  than  the  preceding,
 and  terminates in a sort of  tuberosity, like the last
phalanges of the fingers.
     Of the Union of the Bones of the Pelvis.

  37. The ossa pubis are joined together by means
of a substance which has always been described by
the  name  of cartilage, though it differs as much
from that as from a ligament.  According  to some 
Bones of the Pelvis.             15
 anatomists, each os pubis is covered by its own car-
 tilage: their junction is not a true synchondrosis, but
 a close articulation,  which only admits of insensible
 motions.
   38. By carefully examining this symphysis, we
 observe that each os pubis is really  covered by a
 cartilage  at its  anterior  extremity; that this carti-
 lage is thicker before than behind, and  in its supe-
 rior and  inferior parts than in the  middle  of  its
 length; that these bones, thus covered, are bound
 together by means of a substance which seems li-
 gamentous, and whose fibres  which  are  mostly
 transverse,  go from  one  to the other; that these fi-
 bres are so disposed, that the  deepest are the shor-
 test, and the most superficial the longest; that they
 leave  between one another a kind of meshes filled
 with reddish corpuscles,  very like those which are
 seen about the  moveable articulations, and which
 are commonly supposed to be synovial glands. We
 observe, farther, that this fibrous and ligamentous
 substance does  not occupy the  whole thickness of
 the symphysis, and does not bind the bones together
 through the whole extent of the surfaces presented
 by their anterior extremities;  but that there exists
 a  true articulation,  of the  species known  by the
 name  of arthrodia.  If we open this  symphysis to-
 wards the inside of the pelvis, after a cellular tissue,
 very thin and loose,  which we meet  with first, we
 discover a capsular  membrane, whose  most appa-
 rent fibres are transversal; afterwards two  cartilagi-
 nous facettes, smooth, polished, and moist, from
 six to eight lines long, and two broad,  of a figure
 a little semilunar, lightly convex on one bone, and
 concave on the other.  These facettes comprehend
 nearly the middle third of the length of  the sym-
physis, and the posterior third of  its thickness 
16            Of the Union of the
This symphysis then presents in one third of its ex-
tent, or thereabouts, a true articulation; and, in the
rest, a syneurosis and synchondrosis at the same time.
   39. This compound and articular substance, be-
ing detached from the bones, forms a kind of wedge,
whose  base constitutes  the anterior part of the
symphysis, and its edge the posterior; so that these
bones seem to touch towards the inside of the pel-
vis, and appear separated to  the distance of several
lines without.  The base  of  this kind of wedge  is
generally from four to six lines broad, towards the
middle  of the length of the symphysis, and from
eight to ten in the inferior and superior parts; while
the edge, at most, does  not exceed one  line. Its
thickness, taken according to that of the bones,  is
greater  above  than  below; where  this substance,
become thinner, forms what is called the triangular
ligament.
  40. This first means of union was not sufficient
to give these bones the firmness necessary for the
free exercise of the functions to which the pelvis  is
destined; it is covered and fortified in all parts, but
especially before, by  bundles of ligamentous and
aponeurotic fibres. Independently of the thick and
very strong ligamentous structure which forms the
forepart of the symphysis, we observe bundles of
tendinous fibres, which  decussate  each  other  a
thousand  ways,  some of which arise from the in-
terior graciles and the external obturators, and others
from the external portions of the inguinal  rings.  I
shall remark,  too, that  the  triangular expansion
which terminates the symphysis inferiorly, and which
forms the top of the arch of the pubes, seems to have
other uses than that of binding the bones together.
  41. The os sacrum is engaged like a wedge be-
tween the posterior parts of the  ossa innominata, to 
               Bones of the Pelvis.            17

 which it is united. Although some anatomists pre-
 tend that this union  is like that of the  ossa pubis,
 yet we may observe a great difference between them;
 for here each articular facette is covered by a true
 cartilaginous layer, and we see on each side ine-
 qualities which are mutually received; but we see
 nothing of that kind in  the junction of the pubes.
 These articular cartilages have not the same thick-
 ness on each bone; that which belongs to the sacrum
 being nearly throughout one line thick, and that of
 the os ilium being extremely thin.  They are whitish,
 streaked as it were in many places and moistened
 with a small quantity of synovia.  We cannot disco-
 ver, in any  part of these articular surfaces, any
 transverse fibres which go from one bone to the
 other,  as is observed in the connexion  of the ossa
pubis: so that these articulations, which I shall often
 mention by the name of sacro-iliac  symphyses, de-
 rive all their strength  from the great  number  of
 ligaments which surrounds them.
   42.  Most of these ligaments are very short, and
 do not extend beyond the edges of the articular
facettes: there are others longer, to be seen above,
 below, and behind these symphyses.
   43.  The former may be called the anterior sacro-
 iliac ligaments: they are disposed like bands which
 pass transversely from the anterior edge of the ar-
 ticuLir facette of the os ilium to the edge of that of
 the sacrum, and the greater part are very thin. The
 strongest and thickest of these ligamentous bands
 are before the summit of the sacro sciatic notch, and
 at the bottom of the sacro-iliac symphysis; we must
 likewise add a capsular membrane.
   44. The most remarkable superior ligaments are
 two on each side. One descends from  the inferior
 edges of the transverse apophyses of the last lumbar
                       C 
18            Of the Union of the
 vertebra to the  superior edges of the articular fa-
 cettes of the sacrum and ilium, spreading itself over
 the top of the symphysis; and the other goes from the
 points of those same apophyses to the angle  made
 inwards  by the crista of the  ilium, from  whence
 they advance a little forward,  and form a  kind  of
 small falx  above the iliac fossa.
   45.  The inferior ligaments, one  on  each side,
 known by  the  name of sacro-ischiatic,  arise from
 some of the inequalities of the posterior part of the
 sacrum, the coccyx,  and even of the ilia: they are
 broad  and  thin  backwards, but they narrow and
 thicken as they advance forward. Towards the mid-
 dle of the  ischiatic notch, these ligaments divide
 themselves into two branches, the shorter of which
 terminates  in the spine of the ischium, and the longer
 in the internal lip of its tuberosity: this latter ad-
 vances towards the pubes, and  in its course  forms a
 kind of falx, which has caused it to be called the fal-
 ciform ligament. These two ligamentous branches
 leave between  them a kind of  triangular space,
 through which pass some nerves, and the tendon  of
 the internal obturator.
   46.  The posterior ligaments,  more  numerous
 and shorter, but much stronger and tighter, than
 these last,  go from the os ilium  to the tubercles  of
 the sacrum, which by their situation resemble the
 oblique apophyses of the second, third,  and fourth
 false vertebra,  of which this  bone was originally
 formed.
   47. The sacrum is not only  articulated with the
ilia, but also with the spine and coccyx. It is joined
 to the spine in three different places:  1. It is united
by that cartilaginous impression transversely ob-
long, which we  see in the middle of its  basis, to a
similar impression in the body of the last  lumbar 
Bones of the Pelvis.             19
vertebra, by means of an elastic substance; 2, and
3, by two little articular masses which are fixed in
the posterior edge of that first impression, and which
answer to similar substances in the vertebra before
mentioned.
   48.  The elastic substance which unites the mid-
dle of the base of the sacrum to the spine, is entirely
similar in its nature to that seen between the bodies
of all the vertebrae. It is very thick before, and thin
behind; which renders the angle necessarily result-
ing from the disposition of the articular facettes of
these two parts more obtuse. This sacro-vertebral
junction is surrounded by an infinity of ligaments,
some without, and others concealed within the spi-
nal canal.
   49.  All  motion is  not prohibited  in this kind of
junction; but, as it only depends on the compres-
sion of the intermediate substance,  it can be but
very small. If the pelvis executes a  larger motion
on  the trunk, we must regard it as  one composed
of those which take place between each of the lum-
bar vertebras, and between the lower ones of the
back.*
   50.  The motion which is permitted between the
body of the last lumbar vertebra and  the base of the
sacrum, is  never extensive enough to make any al-
teration in the degree of acuteness of the angle which
results from their junction; but the convexity of the
lumbar column may be augmented or diminished, by
means of the compound motion just mentioned, ac-

  * It would be an error  to believe, as some have done, that
the projection formed by the union of the sacrum with the last
lumbar vertebra, maybe augmented or diminished by that mo-
tion; and that error might contribute to deprive women of a
means which generally relieves those troublesome pains in
the back which so frequently torment them during labour. 
20             Of the Union, &c.
 cording as the trunk is bent backward or forward,
 or by raising or lowering the breech when the wo-
 man lies on her back;  which merits particular at-
 tention in the practice  of midwifery. We may by
 this means make a favourable change in the direc-
 tion of the axis of the pelvis, relatively to that of the
 trunk, to that of the uterus; and in the direction of
 the expulsive forces of the latter,  which may be
 rendered more or less  efficacious, according to cir-
 cumstances, by  making the woman preserve a pro-
 per attitude.
  51.  The junction of the  coccyx with the sacrum
 is entirely similar to that called sacro-vertebral, with
 respect to the medium which constitutes it: it per-
 mits that appendix to move, and yield  to the pres-
 sure it undergoes in different circumstances.  This
mobility, which is extreme in youth, diminishes in-
sensibly, and in time is  entirely lost.  If it diminishes
considerably,  or  is lost before the time in which a
woman becomes sterile, it produces in some cases,
but very rarely,  an obstacle to delivery.
  52.  The pelvis has connexions with  the inferior
extremities, which are  not so important for the ac-
coucheur  to  know as  some have endeavoured to
persuade us.  Any fault in them cannot disturb the
natural  course of labour, when the pelvis is well
formed; and  in  general they are a consequence of
the deformity of that. These articulations are enar-
throses, which permit motion in every direction. 
 
 
         Explanation of the First Plate.

  This figure presents a well formed pelvis, whose
parts are all reduced to about half their natural size.
  A, A, A, A, The ossa ilia, properly so called.
  a, a, The iliac fossa.
  b, b, b, b, The angle which divides transversely,
and obliquely from behind forward, the internal face
of the os ilium into two parts, and which makes part
of the brim of the pelvis.
  c, c, c, c, The cristae of the ossa ilia.
  e, e, The anterior superior spines of the ossa ilia.
  f, f, The angle formed by the internal lip of the
crista of the ilium towards the extremity of its an-
terior two  thirds, and to which is attached a liga-
ment  inserted at the  other end in the  transverse
apophysis of the last lumbar vertebra.
  g, g, The inferior  angle of the os ilium which
makes part of the acetabulum.
  B, B, The os ischium.
  h, h, The tuberosities of the os ischium.
  i, i, The branches of the os ischium.
  k, k, The posterior part of the os ischium, which
makes part of the acetabulum.
  C, C, The body of the os pubis.
  1, 1, The angle of the os pubis.
  m,  m, The  posterior extremity of the os pubis,
which makes part  of the acetabulum.
  n, n, The descending branch of the os pubis,
which unites with  that of the ischium.
  D, D, D, The os sacrum.
  1, 2, 3, 4, The anterior sacral holes.
  o, o, o, The  base of the sacrum.
  p, p, The sides of the sacrum.
  q, The point of the sacrum. 
22       Of the Separation of the Bones.
   E, The coccyx.
   F, The last lumbar vertebra.
   r, r, The transverse apophyses of that vertebra.
   s, s, The ligament which goes from the transverse
apophysis of the last vertebra to the angle of the
internal lip of the crista of the os  ilium,  indicated
by the letters f, f.
   t, t, Another ligament which descends from those
same apophyses to the superior edge of the sacro-
iliac symphyses.
   G, G, The femur, or thigh bone.
   V, V, The head of the femur received in the
acetabulum.
   u, u,  The foramina ovalia.

      Symphyses of the Bones of the Pelvis.
   H, The symphyses of the ossa pubis.
   I, I, The sacro-iliac symphyses.
   K, The sacro-vertebral symphysis.
   Of the Separation of the Bones of the Pelvis in
                    Labour.

   53. However  firmly the ossa innominata and
the sacrum are united together—however nume-
rous the means which nature has employed to give
this assemblage the stability necessary for the free
exercise of the motions of the trunk and inferior
extremities, of which it is in some sort the centre—
their symphyses may nevertheless be relaxed and
weakened  to such a degree, as to allow an apparent
mobility; they may yield to the impulse of exter-
nal agents; even by the efforts of labour  they may
extend, or tear, and permit the bones to  separate; 
         Of the Separation of the Bones.      23

which in either case might seem necessarily to pro-
cure a greater capacity in the pelvis, and give an
easier passage to the child. Such in fact is the opin-
ion of the greater part of those who have  written
on  the art of midwifery for these two  thousand
years. The divine wisdom, which presides over all
things, appeared to  them equally wonderful in this
separation, and in  the solidity which it was like-
wise necessary to give to the symphyses of the pel-
vis; and without this  double advantage, according
to those authors, the  woman could not have trans-
ported herself from place to place so conveniently
and safely, nor bring  forth children so easily.
   54. All authors have not however had the same
idea of the separation of the bones of the pelvis.  If
some, zealous admirers of the resources  of nature,
entirely occupied in the preservation of the mother
and child, have found nothing  in it but an effect
worthy of her providence; others have regarded it as
a morbific state, and  many have even contested its
possibility.
   55. Such has been  in all ages the variety of opi-
nions on this point.  It is very certain that the bones
of the pelvis may separate in labour, but that does
not happen so often as has been thought; and ex-
perience demonstrates that this separation, far from
being common, is very rarely met with, and is not
more usual after a laborious, than after an easy la-
bour; nor in a distorted pelvis, than in one well form-
ed. I have sought for it twenty  times in all these
cases,  by opening the bodies, and  have scarcely
met with one which could remove all doubt of its
existence.
   56. The infiltration of serum into the  ligamen-
tous tissue of the symphyses, must be regarded as
the most usual predisposing cause of the separation 
 24       Of the Separation of the Bones..

 of the bones of the pelvis, and whatever may occa-
 sion that infiltration will become the remote cause.
 The  pressure  which the  uterus, loaded with the
 produce of the conception, exerts  during several
 months on the trunks of the vessels which are dis-
 tributed to these symphyses, and on those which re-
 turn  the blood from the inferior extremities can-
 not alone produce this  effect; and, for  it to take
 place, we must likewise admit a peculiar alteration
 in the fluids, to render them fitter for it.  This pres-
 sure is nearly the same in all women who have the
pelvis well formed; and yet the relaxation of the
 symphyses does not exist in all of them at the time
 of labour. It is also more  considerable  in women
 pregnant of several children,  as  well as in those
 who have a narrow pelvis; and nevertheless the re-
 laxation is not more frequent in those cases than in
 others. In examining the bodies of several woman
 who had the pelvis singularly deformed, I found
 the symphyses as  firm and tight  as  in the natural
 state, although they died in childbed; and there was
 in several of them a considerable collection of fluid
 through the whole extent of the inferior extremities,
 and of the pudendum. Whatever may be the remote
 cause of the relaxation of the symphyses, that acci-
 dent is not less the most usual predisposing cause
 of the separation of the  bones  of the pelvis; and it
 was acknowledged to be  such in the time of Severin
 Pineau.—See his Opusc. d'Anat. et de Physiolog.
  57.  Though the relaxation of the symphyses, pro-
 duced by the infiltration of serum into their  liga-
mentous tissue, is generally regarded as the predis-
posing cause of the separation of the bones of the
pelvis, the swelling of the cartilages  which make a
part of those symphyses  cannot be looked upon as
the immediate cause of it. Whatever  relaxation 
         Of the Separation of the Bones.       25

may affect the ligaments, the cartilages which in-
crust the  extremities of the ossa pubis, as well as
the avXicxAzr facettes of the ossa ilia and the sacrum,
are no thicker: therefore they cannot act as so many
wedges placed between those bones, as  the roots
of ivy do which grow and extend themselves in the
clefts of rocks: or like wedges of dry wood drove
into holes bored in them, in order to separate large
masses from them.* The structure of the symphy-
ses, better known at present, no longer admits those
ingenious comparisons; and the explication of the
phenomena is  not less  clear no that account.  The
wedge which separates the bones of the pelvis does
not act between the extremities of those bones, but
in the circle formed by their assemblage in the pel-
vis itself; it is  the uterus charged with the produce
of conception  in  the latter periods of pregnancy,
and the child's head forced down by the  action of
the uterus and of the abdominal muscles in time of
labour.  However considerable this separation may
be on some occasions, we may presently  place the
bones again in their natural contact, and render the
symphyses as close, though not so solid, as they were
originally; which could not be done if the cartilages
were  tumefied, as some have published. The error
of many authors concerning the greater capacity in
the pelvis, and a greater breath of hips, even in wo-
men who have had but one child, is a consequence
of the former; and could only arise from the idea
which was entertained, that the cartilages which
make part of the symphyses swell during pregnancy.
   58. The separation of the bones  of the pelvis,

  * See Memoiresde l'Academie Royale de Chirurgie, torn.
iv- Dissertation sur I'Ecartement des Os du Bassin, par  M
Louis.
                       D 
26       Of the Separation of the Bones.
which sometimes happens in labour, is not always
the effect ofa relaxation and stretching of the liga-
mentous tissue of the symphyses. Little disposed to
yield thus, in some  cases in which the  obstacles
which obstruct the passage of the child are very
great,  and the efforts which tend to expel it very
strong and lasting, the  symphyses tear, and permit
the bones to separate much farther than they could
have done by a simple relaxation. If the passage on
that account becomes freer,  the consequences of it
are also much more disagreeable: being the same as
those which have often been observed after the sec-
tion of the symphysis of the pubes, I  shall take no-
tice of them when I come to treat of that new ope-
ration, and shall  relate some examples of the rup-
ture in question. That the  word rupture,  which
I use here, may not be a cause of error, I must
add, that it is not the symphysis of the pubes, pro-
perly speaking, which tears, for no effort can break
the ligamentous substance which unites those bones
to each other; the symphysis detaches itself from
one of them, and leaves the bone naked.
   59. The natural efforts of labour are not the only
ones, which may conduce to this disunion  of the
ossa pubis: it has taken place in instrumental delive-
ries, to which those efforts seemed  to contribute
nothing; and it has sometimes  been found in con-
sequence of an external percussion,  or of a fall.
   60. Being deceived in the principle of this sepa-
ration, they  necessarily erred in the consequences
deduced from it. It has been so firmly believed to
take place in all labour,, that it was thought to be
absolutely necessary, and that without it many wo-
men could not be delivered but with extreme diffi-
culty. " It would be in vain," says Severin Pineau,
" that  the neck  of the uterus and  the  other soft 
         Of the Separation of the Bones.      27

" parts should dilate to give a passage to the child,
" if the bones could not separate:"—" otherwise
" (adds Pare) the child could not pass through so
u narrow a way."
   61. Having thus mistaken the necessity and pre-
tended advantages  of this separation,  the  natural
resistance of the symphyses, and, above all, the dry-
ness and rigidity necessarily induced in them by
age, were consequently reckoned among the causes
of laborious  and dffiicult labours. Obstacles have
been attributed to the state of these symphyses,
which merely depended on the resistance of the
neck of the uterus,  and of the external parts; and it
has been recommended to moisten and relax them
by the use of baths, cataplasms, liniments,  fomen-
tations, &c.   But what can be expected from such
methods, when delivery is obstructed by a  narrow
pelvis?
   62.  Will any one venture to assert that  he has
once by such means obtained the effect he  expect-
ed,  and  that  he  has thus assisted  labours which
could not otherwise have been terminated but by the
Cesarean operation, as has been so often published?
I should have dispensed with demonstrating the fal-
lacy which  has prevailed on this point, if it had
not led some practitioners into a very serious conse-
quence;* but the interests of humanity, and the
honour of the art,  oblige me to  expose it, and if
possible endeavour to dissipate it. In order to ap-
preciate  all  these means,  and fix  the degree of
confidence to be placed in them, supposing that
they could effect the relaxation of the symphyses of
the pelvis, it is necessary to determine what degree

       * See the Chapter on the Section of the pubis. 
28      Of the Separation of the Bones.

of amplitude can be given to that cavity, by the
separation of the bones which constitute it.
   63. The ossa pubis cannot separate without aug-
menting the circumference of the pelvis. That is a
fact so certain, that the smallest doubt of it would
be a proof of ignorance. But how much will its di-
ameter be increased? If the circumference were per-
fectly circular, every possible diameter would par-
take a third of that augmentation; but as the entrance
of the pelvis is in general the more elliptic as it devi-
ates more from the natural state, it follows that its
different diameters cannot increase in the same pro-
portion, and that there is, as I may say, none but
the transversal which can become larger.
   64. The augmentation of the antero-posterior dia-
meter is reduced almost to zero, when the  separa-
tion is moderate; and repeated experiments  have
demonstrated that the ossa pubis must separate at
least an inch to procure two lines in that direction;
while the transverse diameter shall be increased six
lines, and often more.
   65. The pelvis being larger in most women than
is necessary for delivery, the separation of the bones
could be of no advantage to them, nor render their
delivery  more easy. Far from  regarding it,  with
some ancient authors, as  a benefaction  of  nature,
we ought to consider it as an additional source of
inconveniences in those women who are subjeet to
it; for on one  side we see that a pelvis too large
exposes  the woman to a number  of accidents,*
and, on the other, that there are some which inevi-
tably accompany the separation, and the mobility of
the bones which form that cavity. Far from favour-
ing delivery in all these cases, it could not but ren-
"SeeNos. 86,87, 
Of the Separation of the Bones.       29-
der it more tedious and painful to the woman, as
experience has convinced  me.f If we ought to ex-
pect any real advantage from it, considering it only
with respect to the passage of the child, it could
only be in those women who have  the pelvis de-
formed; and where the defect which rendered de-
livery impossible did not  exceed  two lines at the
most, since the separation of an inch cannot pro-
cure an augmentation of more than two lines in the
small diameter of the superior strait (see par. 64,)
which is  almost always that which occasions the
greatest obstacles to the exit of the child. If from
a  separation of an  inch,  which  has  never taken
place between  the ossa pubis without a rupture of
their symphyses, we  are not to expect an augmen-
tation of more than two lines, in the direction of the
little diameter  of the superior strait, what  can we
obtain from a separation always much less, and so
little apparent  in most women that we may doubt
its existence? The examination  of a great number
of women who have died in childbed has  proved
to me that it is excessively rare for the separation in

   t A woman of a good habit, and of the middle age, who
had  been delivered of her  first child so quickly  that  I
could scarcely reach her in time, though not far off, in the
latter months of her pregnancy, felt acute pains in'the sym-
physes of the pelvis, which made her walk with uncertainty
and difficulty, and even lamely. These pains,  supportable
then, became so troublesome and violent during labour, and
especially  while  she endeavoured to bear down and assist
her delivery, that nothing could engage her to repeat it, nor
to alter 1>he attitude which she had mechanically taken, to
relax all the muscles that are  attached to the pelvis: which
rendered the labour longer and more painful than the preced-
ing, although the child was much smaller than the former. 
 30       Of the Separation of the Boner.

 question to amount to two lines; and I never found
 it exceed that but once.*
   66\ But supposing, which is impossible, that art
 could procure a separation of an inch between the
 ossa pubis without dividing their symphyses, what
 practitioner would dare to affirm, without fear of
 being deceived, that the volume of the child's head
 did  hot exceed the  little diameter of the  superior
 strait by more than two lines?  If it is difficult to
 estimate justly the degree  of opening in the pelvis,
 it is much more difficult to judge still of the size of
 the child's head;  and it is only by taking the mean
 between the largest and smallest, that we usually
 establish the relation of its dimensions to  those  of
 the pelvis;  but a  thereabouts in the case supposed,
 cannot  supply  the place of that  precision which
 would be necessary.
   67. We  see clearly  by these reflections  what we
 ought to think  of the  means proposed by Severin
 Pineau, with a view of favouring the amplification
 of the pelvis; as well as of those accoucheurs who
 boast of having delivered  women by those means,
 who must otherwise have  undergone the Cesarean
 operation.
   68. The proscription of the  section of the sym-
physis of the pubes, though performed several times
 within these ten years with all the success its  au-
 thor could desire, seems an inevitable consequence
 of those same reflections; that operation being the
 fruit of an opinion too hastily embraced by persons of
 science, but too credulous concerning the pretend-
 ed advantages of  the spontaneous separation of the
 ossa pubis.—See the sequel of this work.

  * The relaxation  of the symphyses  of the pubes was so
 great, that we could  separate them fourteen  lines, and put
 them again in contact. The pelvis was of the largest size.
 and the body entirely putrid. 
Of the Separation of the Bones.       31
   69. If I have clearly demonstrated the inutility of
the most usual separation of the bones of the pelvis
in labour, how often has experience shown the dan-
ger of it! Even if it were in the power of art to pro-
em e this separation without cutting the symphysis
of the pubes, if that separation could in  some cases
destroy the obstacle  which obstructed  the exit of
the child—have the consequences of a spontaneous
separation always been so fortunate as to authorize
us to give it the preference to other means equally
fit to procure that  effect, and almost always exempt
from inconveniences either to the  mother or  the
child?
   70. When this  separation has been  made sud-
denly, severe pains in the parts divided, an impos-
sibility of walking, and sometimes even of moving
the inferior extremities, inflammation,  fever,   ab-
scesses, caries, and lastly death itself, have gene-
rally been the mournful effects of it.  When it only
proceeds from a relaxation of the symphyses,  the
consequences are much less severe, it is true; since
a painful and tottering  walk is the only symptom
attending it.
   71. If the relaxed symphyses at length grow firm
again, if the bones of the pelvis recover their former
stability, if the lameness goes entirely off in some
women—how often, on the contrary, have we  not
observed an inability to walk,  or even to move  the
legs without violent pain,  continue for years  af-
terwards!
  72. We should be in the wrong if we were to sup-
pose that such a state of weakness and pain always
denotes great disorders in the junction of the bones
of the pelvis. I am convinced that those accidents
may be the consequence of a very small  separation,
and of the slightest movement between the ossa in- 
3 2.       Of the Separation of the Bones.

nominata. A woman to whom I  was called had kept
her bed ten months, a prey to  the most excrucia-
ting pains in the junction of the ossa pubis, and of
one of the ilia with the sacrum, whenever she  at-
tempted to  move the inferior extremities, though
we could  not  discover  the  least  separation of  the
symphyses;  we could only find a  small degree of
mobility in that of the pubes.  The aceklent had
been first felt in the time of labour,  and the mid-
wife was accused of having luxated the bones. The
lameness which results  from the  relaxation of  the
symphyses  of the pelvis is not  always  so painful;
if  the  woman suffers pain  at  first whenever  she
attempts to walk, it lessens  gradually,  because  the
parts  which constitute the symphyses  accustom
themselves to  the dragging occasioned by the mo-
bility of the bones.
   73. According to these observations, the separa-
tion of the bones of the pelvis will appear to  be an
unnecessary accident, and  sometimes a very seri-
ous one;  since it  may influence  the  subsequent
symptoms, and even affect the  life of the woman,
or render  her existence a long  time  burthensome.
Topical astringents, aromatic fumigations, the cold
bath,  even  almost freezing, are the most proper
means, in case of relaxation, to restore the lost tone
to the symphyses;  but they cannot be  used in  the
first periods, for fear of suppressing the evacuation
of the lochia. In the mean time we must prescribe
rest; and fix the bones of the  pelvis by a proper
bandage, if the case require it.  * The indications

  * A few turns of a bandage rolled tight on the pelvis were
sufficient, in  a woman who had been delivered eighteen or
twenty days, to enable  her to walk into her chamber, though
before she could not move in her bed  without great pain: No
other means were used but that bandage. Another woman, 
         Of the Zfivision of the Pelvis, &c.      33

are very different,  and much  more  urgent, when
the symphyses are  ruptured: we must prevent in-
flammation  and  its consequences,  open the  ab-
scesses when  fit,  and treat the  caries  (which is
sometimes the consequence) properly, &c. We are
fortunate when the woman escapes even  so.
  Of the Division of the Pelvis, and of its natural
                   Dimensions.

  74. A Ridge, rarely circular, often elliptic, and
sometimes of another figure, but always  more  or
less inclined forward, divides the cavity of the pel-
vis into two parts; of which one forms the upper
and the other the lower part.
  75. The upper part of the pelvis, which the French
call the great bason, is very wide at the sides, and
quite open before.  Its breadth, taken from the an-
terior superior spine of one ilium to that of the other,
is usually eight or  nine inches, and its depth from
three to "four.  We see in the back part  of it the
projection of the lumbar vertebrae, and at  the sides
the iliac fossae.  The knowledge  of this part is not
the least interesting with respect to delivery.
  76.  The  lower  part called by the French  the
little bason, forms  a kind of canal,  whose entrance
and outlet are somewhat narrower than the middle;

who had been delivered nine months, having used topical as-
tringents and  aromatic fumigations without success,  could
not recover the faculty of walking but by the use of cold baths
almost freezing, f
  t I can bear testimony myself in favour of the use of the
bandage, a patient of mine being unable to move  without it.
She was eventually cured by a continuance of it.  W. P. D.
                         E 
 3 4          Of the Division of the Pelvis,

 which has caused it to be distinguished into the su-
 perior strait, the inferior strait, and an excavation.
   77. The superior strait is that ridge mentioned
 in par. 74; it is a kind of circle which forms  the
 entrance  of the  canal. (See the  second plate).  Its
 form is not constantly the same, as I have already
 remarked; its inclination or obliquity from behind
 forward,  which an accoucheur of the first rank  has
 fixed at from thirty-five to forty degrees  (see  M.
 Levret,) cannot be exactly known, because it  va-
 ries a little in every subject.
   78.  To determine  the extent of the  superior
 Strait more exactly, it is necessary to  take notice
 of its several diameters. The smallest whose length
 is in general about four inches,  extends from  the
 middle of the projection of the sacrum to the supe-
 rior and internal part of the symphysis of the pubes.
 The longest extends from one side of the  strait to
 the  other, and is usually an inch longer than  the
 preceding. The others are the two oblique diame-
 ters: they are of a middle length between  the two
 former; they extend diagonally from  each acetabu-
 lum  to the sacro-iliac junction  of the opposite side.
 The two former cut the pelvis at right angles and
 the two latter divide those angles into acute ones.
  79. The  respective  length  of these  diameters,
 considered relatively to delivery, is not what I have
just  indicated; the soft parts within the  pelvis cau-
 sing some changes in them, if they all equally lose
 of their length on account of  the thickness of  the
neck of the uterus, which is not much  when it is
entirely developed, being then not thicker than three
or four folds of paper, it is not  the same with re-
spect to the muscles.  The long or transverse dia-
meter is almost the  only one which the psoae dimi-
nish  in their passage: they diminish it more or lest". 
          and of its natural Dimensions.        35

in different subjects,  according to their bigness,
and according as  the pelvis is more or less of an
elliptical figure; but always so much as to make this
diameter appear, at the first cast of the eye, shorter
than the oblique. If these muscles take a little from
the posterior extremities of the oblique  diameter,
yet that does not hinder them from being the  lon-
gest; and we ought to consider them as such in re-
spect to delivery, except in some deformed pelves.
  80. The inferior strait, in general smaller, and ofa
more irregular figure, than the superior, is not, like
that, entirely formed of bony parts; its edge, which
three large and deep notches render unequal, being
completed behind and at the sides by the sacro-is-
chiatic ligaments, and forming before a kind of cir-
cular notch, called the arch of the pubes.  (See the
third plate.) We are also to remark as many dia-
meters in it as in the superior strait, and their length
is commonly about four inches.  Although the
transverse, or that  which extends from one ischium
to the other, be often a little longer than that which
goes from  before  backward, it must however be
reckoned the smallest with respect to delivery, be-
cause the latter augments in proportion as the point
of the coccyx recedes  from the pubes. It is  very
useful to bear in mind, that the great diameter of
the inferior strait is parallel to the smallest of the
superior, and that it crosses the longest of that strait
at an angle more or less  acute. This observation,
important for the explication of some of the pheno-
mena of common  labour, becomes infinitely more
so in the management  of difficult labours; and by
taking advantage of it, in many cases, the  finger
alone, well directed, will dispel obstacles which
would have been difficult to overcome with instru- 
 36      Of the Division of the Pelvis, &c.

 ments, or which could not be overcome by those
 means without exposing the child to great inconve-
 niences, as I shall remark in the sequel.
   81. The middle part of the pelvis is a little larger
 from before backwards than the straits; and this dis-
 position, which proceeds from the curve  of the sa-
 crum, is as favourable to delivery, as the  excess or
 defect of that same curve would be contrary to it.
 On one  side it diminishes the numerous  and  long
 continued frictions which the child's head must ne-
 cessarily undergo, if the pelvis were of  the same
 breadth  in all its parts; and on the other, it is not
 less useful in preventing the effects of a  long and
 forcible  pressure on the sacral nerves, which a flat
 form  of the sacrum would have rendered inevitable
 during the whole passage of the head.
   82. The  cavity of the pelvis is not equally deep
 in every part; it is commonly from four to five in-
 ches deep behind, three and an half or thereabouts
 at the sides, and at most eighteen lines before.
   83. The arch of the pubes does not merit less to
 be well  understood than the parts I have just de-
 scribed,  since its form and dimensions may equally
 influence the mechanism  of labour. This  arch,
 rounded at its superior part, and only from fifteen
 to twenty lines  broad, augments  insensibly as it
 descends; so that its  sides are more than three in-
 ches and an half apart  at the  bottom, even four in-
 ches,  if we take the line which is looked on as the
 transverse diameter of the inferior strait, for its base:
 its height is about two inches.
   84. The axis of the pelvis is difficult to determine,
 because the same line cannot traverse the centres of
 the two straits: and, besides, any axis that  could be
assigned would not be the same in every subject,
 nor in every attitude of the body. 
 

 
        Explanation of the Second Plate.      31

  The axis of the superior strait seems to be almost
as much  inclined from before backwards, as the
strait itself is in the contrary direction: one of its ex-
tremities passes under the  umbilicus, and the other
towards the middle and inferior part of the sacrum.
The axis  of the inferior strait must be considered,
relative to delivery, as passing through the centre
of the opening of the vagina dilated by the child's
head: its  direction is  then so much inclined from
behind forward, that its superior extremity traver-
ses the lower part of the first false vertebra of the
sacrum, and crosses that of the other strait at a very
obtuse angles
        Explanation of the Second Plate.

  This  figure represents the entrance or superior
strait of a well-formed pelvis, reduced to the half
of its natural dimensions.
  a, a, The iliac fossa.
  b, The sacro-vertebral angle, or the projection of
the sacrum.
  c, The last lumbar vertebra.
  d, d, The lateral parts of the base of the sacrum.
  e, e, The sacro-iliac symphyses.
  f, f, The parts over the acetabula.
  g, The symphysis of the pubes.
  The lines indicate the different diameters of the
superior strait.
  A, B,  The antero-posterior or little diameter.
  C, D,  The transverse or great diameter.
  E, F,  Oblique diameter,  which extends from the
left acetabulum to the right sacro-iliac junction. 
 38      Explanation of the Third Plate.

   G, H, Oblique  diameter,  which goes from the
 right acetabulum to the left sacro-iliac symphysis.


         Explanation of the  Third Plate.
   This figure represents the inferior straitofa well-
 formed pelvis, reduced to the half of its natural size.
   a, a, The external  faces of the ossa ilia.
   b, b, The anterior superior spines of the ossa ilia.
   c, c, The anterior inferior spines of the ossa ilia.
   d, d, The acetabula.
   e, e, The foramina ovale, with the obturator liga-
 ments.
   f, f, The ischiatic tuberosities.
   g, g, The ossa pubis.
   h, h,  The branches of the os pubis and ischium
 united.
   i, i, The sacrum.
   k, The coccyx.
   1, 1, The sacro-ischiatic ligaments.
   m, The symphysis  of the pubes.
   n, n, The arch of the pubes.
   The lines indicate the diameters of the  inferior
strait.
   A, A, The antero-posterior or great diameter.
   B, B, The transverse or little diameter.
   C C, D D,  Oblique diameters. 
 
 
Deformities of the Pelvis.          39
Of the Deformities of the Pelvis, considered with
              respect to Delivery.

  85. The different states in which the dimensions
of the pelvis vary so much from those I have just
described, as to disturb the natural order of labour,
and render it more or less difficult, ought to be ac-
counted so many deformities, if we consider them
relative to that function: they all consist in the ex-
cess or defect of size in that cavity.
  These principal faults may affect all parts of the
pelvis, or  one alone; and often one of these faults is
the consequence of another, or arises from the same
cause. Their shades are so numerous,  that it would
be in vain to expect to distinguish them all by the
touch. I shall speak here only of those most essen-
tial to be known.
   86. It seems at first sight that a delivery should
be the more fortunate, as  the pelvis  is of a larger
size; because  the child's head must  undergo less
friction in its passage, fewer efforts are required to
expel it, and the labour is  less painful. Although
this be generally true, as to delivery, strictly speak-
ing,  yet  experience  has but too often taught that
this slender advantage is dearly paid for by lasting
inconveniences, either before or after delivery; so
that  we cannot regard the most spacious pelvis as
the  greatest indulgence of  nature, relative to this
important function. Women who enjoy a conform-
ation so favourable in appearance, are more exposed
than others to the effects of obliquity  of the uterus,
and to its descent; especially in time of labour, when
 that viscus, already charged with the weight of the
 child, is entirely subjected to the expulsive force of
 the abdominal muscles. Feebly retained by its liga- 
40         Deformities of the Pelvis.
 ments,  in  women who have already had  several
 children, the uterus is habitually lower and descends
 lower still in the subsequent pregnancies, till it be
 sufficiently developed to rest on the margin of the
pelvis; which does not take place till after the first
 four or  five months. Before that time it gravitates
 strongly on the extremity of the  rectum,  and as
 well by  its weight as volume impedes the discharge
 of the faces and urine, as well as the free course of
 the blood in the veins which pass through the pel-
 vis; which is often the cause of very important ac-
 cidents. If they partly vanish towards the middle of
 pregnancy, they sometimes re-appear at the latter
 end,  because the child's head engages early in the
pelvis; and acts, as it increases,  on  the same parts,
 as the totalitv of the uterus did before. If we add to
 these accidents those which may result from a too
 sudden  and too easy delivery, it  will not appear sur-
prising that I should reckon an excess of amplitude
in the pelvis among the faults in the conformation
of that cavity.
  87. It is indeed  easy to prevent some of these
accidents, and  to remedy others; but there are some
to which we can apply no remedy. We may remedy
the descent of the uterus, and the accidents which
depend on it, by means of a proper pessary; we may
also keep that twem in its natural position, when it has
taken an unfavourable one. We may prevent it from
prolapsing in time of labour, by keeping the woman
in a horizontal position;  by recommending  to  her
not to make the most of her pains, that is to say,
not to bear down at all; by supporting the edge of
the orifice  till  the head has cleared it; and taking
care that it be not dragged along by the child's
shoulders, in extracting  the trunk.
  88. When the neck of the uterus, charged  with 
            Deformities of the Pelvis.         41

the child's head, is so far prolapsed that the head
appears entirely without the pelvis, we must begin
by extracting the child, with all possible precautions
not to aggravate the evil already existing; and then
the uterus, diminishing in volume, will easily return.
When things are less advanced, we begin by push-
ing back what is prolapsed, and proceed as directed
above; that is to say, we are to support the neck of
the uterus till the child be disengaged from it.
   89. The  accidents which have no other remote
cause than the  too great capacity of the pelvis, are
in  general much less troublesome, and more easy
to avoid, than those which arise from the narrowness
or defect of size of that canal; this last fault being
capable of affecting the lives of both  mother and
child, by obstructing delivery, or rendering it ex-
tremely difficult.
   90. The narrowness of the pelvis, considered with
respect to delivery, ought to be distinguished  into
relative and absolute.  The former arises from the
extraordinary size  of the  child's head,  or from its
bad position; the latter from the bad conformation
of the pelvis itself.  To  fix a just estimate of the va-
rious degrees of both these species, and determine
the consequences they might produce, it would be
necessary to know exactly, a priori, the  extent  of
the pelvis affected by them, as well as the volume
and  solidity of the head  which must pass through
it. As it  is impossible  to appreciate the size of the
latter, I shall suppose it constantly to be three in*
ches six  lines in diameter, from one parietal protu-
 berance to the other,  in  order to establish some
 general data.
   91. Absolute narrowness, the  only species  of
which I shall speak here, is rarely found in all parts
of the pelvis at the same time;  in general it affects 
12          Deformities of the Pelvis.

but one of the straits, and in that case the other is
pretty commonly of the natural size, and sometimes
a little larger than usual. This fault is more frequent
in the  superior  strait than in the inferior; and we
observe that it almost always affects the strait in its
small diameter, and very rarely in the  transversal;
and sometimes it only affects one side.  We remark
the contrary in the inferior strait; for there it is gene-
rally caused by the approximation of the tuberosities
of the ischia.
  92. It is easy to determine why the superior strait
is oftener  deformed than the inferior;, and why it is
almost always between the pubes and sacrum that it
is defective respecting delivery. If we consider the
direction  of the forces  which act on the pelvis in
rickety children, in whom the bones are at the same
time softer and more loosely connected  than in the
natural  state, we shall see that the greater part of
those forces tend to carry the base of the sacrum
forward, and the ossa pubis backward. Whether the
child be standing or sitting,  if we attend to the di-
rection  of the spinal column we shall  see that the
weight of the body must insensibly push the base
of the sacrum towards the pubes; and that it  acts in
the same manner on the inner parts of the acetabula.
which serve as a. fulcrum to the inferior extremities,
when the child is standing or walking. The ossa pu-
bis, particularly in these latter cases must be pushed
towards the sacrum; but in such a manner, how-
ever, that their posterior extremities often approach
a little nearer to the projection of the base of that
bone than their anterior extremities, or the symphy-
sis. If the superior strait does not  constantly pre-
sent the same figure in deformed  pelves;  if it is
sometimes larger on one side than the other; if one
of the  acetabula is nearer to the sacrum, while the 
            Deformities of the Pelvis.         43

other approaches less; if the symphyses of the pubes
is removed in many cases, fiom a line which would
divide  the body into two equal parts—it is because
the rickets has not equally  affected  all the bones of
the pelvis, nor equally hurt all their junctions; and
because the attitude which the child tak.es in walk-
ing or  sitting  may change  a little the direction of
the compressing powers which I have just mention-
ed. The weight of the body may also equally hurt
the form of the inferior strait, but variously, accord-
ing to  the most usual attitude of the child, and the
direction taken by the spinal column. For example,
if it sits much, the sacrum will be more curved, and
the strait more contracted from before backwards;
in this attitude if it inclines habitually to one side,
one of the ischiatic tuberosities will be thrown in-
wards, the os ilium will be more elevated,  &c.  The
action  of the muscles which are attached to the
pelvis, the pressure of clothes, and that which the
arms of the nurse exert on this part, contribute also
something to the deformities in question, but much
less than the weight of the  trunk: whence we see of
what importance it is to  keep rickety children in
bed, and leave them at liberty; instead of obliging
them to walk, to sit up, or have them constantly
in the  arms, as is done almost every  where.
   93.  The deviations of nature do not present fewer
varieties in the dimensions of the pelvis, than in the
contour of its straits. If the diameter of some, consi-
dered  from the pubes to the middle of the projection
of the  sacrum, is only defective a few lines; in others
the defect is of several  inches, so as scarcely to leave
one between those two bones. The intermediate de-
grees  are more frequently  found than these two ex-
tremes;  and the latter of them is never so great in
the inferior strait as in the superior. I have  seen 
44         Deformities of the Pelvis.

pelves in which the distance from the pubes to the
sacrum, superiorly, was but from six to eight lines.
I have one in which it is only between three and
four lines from the back of trie right acetabulum to
the projection of the sacrum; and in another, which
is likewise in my collection, that projection is four-
teen lines distant from the  symphysis of the pubes.
There are no examples of the inferior strait  being
ever so contracted: that related by M. Herbiniaux,
a surgeon of Brussels, Observation VII. being con-
tradicted by the fact itself;  since the woman was in
her sixth labour, and he delivered her by means of
the lever. To assert that, in such a case, the sinus
formed by the branches of the ossa pubis and  the
tuberosities of the ischia, was but  half an inch  wide,
is displaying more than ignorance.—See the  work
of that surgeon, p. 264, &c.
   94. If we compare the dimensions of a child's
head  with  those of a  well formed pelvis, we shall
see clearly that the latter might  have some inches
less in its circumference, and yet be large  enough
for an easy delivery: a common-sized head, when it
passes through that canal, presenting a circumfer-
ence of no more than ten inches  and a quarter, or
ten and  a half, only requires a passage of that size.
Proceeding on this principle, we must  fix the first
degree of narrowness of the pelvis at something less
than three inches and a half for each diameter, but
especially for the smallest,  as well of the  superior
as of the inferior strait; and the other degrees, from
that, down to the one I mentioned in the preceding
paragraph.
   95. The difficulty of delivery, all things besides
being well disposed, and  the child's head of the
usual solidity, is in general so much the  greater,
as the narrowness of the pelvis is more considerable, 
            Deformities of the Pelvis.         45

When this vicious conformation leaves an opening
of but three inches and a quarter, delivery becomes
so much the more tedious and  painful, in propor-
tion as  the  frictions which the child's head must.
undergo in passing through the pelv ware more nu-
merous and strong. If the obstacles are more con-
siderable when the pelvis has  but three inches in
the little diameter, yet  they are not even then al-
ways insurmountable by the  natural agents of de-
livery; and the woman may still be delivered with-
out help, notwithstanding the apparent dispropor-
tion which exists  between  the  diameter of the
child's head and that of the pelvis: the woman may
enjoy the same advantage even when the  little di-
ameter  is  but two inches and three quarters,  as
I  have  seen several times. These natural labours
ought only to be considered  as exceptions to the
rule: the uncommon suppleness of the bones of the
child's cranium having favoured the lengthening of
the head, and the change necessary  for its passage.
   96. Examples still more extraordinary  come to
the  support of these;  and show us that nature is
sometimes able, by new deviations, to prevent the
disagreeable consequences which might arise from
a deformity of the pelvis: a suppleness of the cra-
nium, greater still than that I have just mentioned,
having  procured to some  women the good fortune
to be delivered without  help, and with as much
facility  and success, although their pelvis had but
two inches and a half in  the little diameter of its
entrance. M.  Solayres observed, in  a case of this
kind, that the head was lengthened in such a man.
ner, that its longest diameter  was eight inches all
but two lines; that  which goes from  one parietal
protuberance to the other, being reduced to two
inches five or six lines. I have seen similar changes 
 46         Deformities of the Pelvis.

 in the form of the head, and the respective length
 of its diameters at the instant of birth,  where the
 woman  was equally deformed; the great diameter
 being seven inches, and the transverse thickness of
 the cranium two  inches six or seven lines. These
 children were in good health, and the day after their
 births their heads wanted vety little of being of the
 dimensions usual at that time. The history of the
 section of the pubes furnishes us with more convinc-
 ing proofs of the possibility of a natural delivery,
 in cases  where the pelvis has but two inches and a
 half in the little diameter of the brim. The woman
 who was cut by  M. de  Matthiis, the 17th April,
 1785, was delivered successfully, and without
 much difficulty of her first  child nine years before,
 although her pelvis had but that diameter.*
   97. When the pelvis is so much contracted as to
 have less than two inches and a half in the little
 diameter, a child at full  time cannot pass it.  The
 Cesarean operation, the section of the pubes, and
 premature delivery,  have  been recommended in
 these cases; but the first  is  the only  one which sur-
 gery has authorised: we shall see in the sequel what
 we ought to think of the second; and of premature
 delivery, which the laws  proscribe entirely.
   98. Though the woman  may sometimes be de-
 livered naturally, when the  contracted pelvis has no
 more than two inches and an half in the little di-
 ameter, it is not always without danger to her  and
 to the child. On one side, the soft parts which  line
 the pelvis being subjected to a strong pressure, even
to a kind of contusion, inflame, become painful, and
are threatened  in the  sequel with suppuration  and
gangrene. On the other side, the bones of the child's
* See the article on the section of the pubes. 
Deformities of the Pelvis.         47
   cranium riding one over the  other, or  being frac-
   tured and depressed, compress or wound the brain,
   which causes it to become plethoric, and produces
   internal extravasations,  which are generally mor-
   tal.—See the chapter on the locked head, and the
   manner of using the forceps.
     99. The obstacles which are produced by a defor-
.   rnity of the pelvis, and the accidents which result
   from it, show themselves sooner or later, according
   as it is  the superior or inferior strait which is viti-
   ated. When they are both so,  those obstacles mani-
   fest themselves as soon as labour begins; and very
   often the expulsive powers are so exhausted by ex-
   erting themselves against the obstacles produced by
   the superior strait, that the head stops there; or else,
   having been pushed into the  cavity  of the pelvis,
   and not being able to  advance any farther, remains
   fixed, till the exhausted, or only weakened,  forces
   of the woman be sufficiently  recruited  to expel it,
   unless  art come seasonably to  her aid. The head
   cannot clear the  first strait without lengthening
   from the occiput to the chin, and diminishing in thick-
   ness  from one parietal protuberance to the other;
   and without the parietal bones crossing each other
   at their superior edges, as well as the other bones of
   the cranium; nor without producing a tumefaction
   in that part of the teguments of the cranium  which
   answers to the void of the pelvis, and an engorge-
   ment of the brain; and, lastly, without strongly com-
   pressing and bruising the soft parts which line the
   strait.  Being got into the cavity of the pelvis, and
   finding itself in a larger space than the strait which
   it had just cleared, the child's head is restored more
   or less to its natural state, according as it sojourns
   there a longer or a shorter time; and  departs in the
   same degree  from the form it had acquired in the 
48         Deformities of the Pelvis.
first period, and which is still necessary to enable
it to pass the inferior strait. The symptoms which
had manifested themselves, as I  may say, with  the
first pains, sometimes disappear, more or less, dur-
ing the stay of the head in the excavation; but re-
appear, and increase anew, when the labour comes
on  again with force.
  100. When the superior strait alone is contract-
ed,  the child's head at first advances with great diffi-
culty;  but as  soon as the parietal protuberances
have cleared the strait, the other parts of the pelvis
being relatively or absolutely larger, the head pas-
ses  them with so much ease, that frequently  a few
pains suffice to terminate the delivery.
  101. We observe the contrary when the  inferior
strait is vitiated, if the first is of the usual size. The
head descends easily into the lower part of the pel-
vis, but can proceed no farther till it overcome  the
obstacles which obstruct its course, and render it
as difficult as laborious. The symptoms which I
have just mentioned in paragraphs 98 and 99, mani-
fest themselves later  in this than in the preceding
case.
  102. The accoucheur who has not yet by long
practice enabled himself to form a just estimate of
the  powers of nature, may easily deceive himself in
these cases; and, in the first, judge a  delivery to
be impossible which is ready to  terminate; and, in
the  second, declare that  to be easy which is just
going to be opposed by difficulties that art alone can
surmount, or  which  at least render it extremely
tedious and painful.  I shall not here collect obser-
vations to give more force to these truths:  authors
might have furnished a great number of them, if
they had mentioned all the errors they have  com-
mitted in  such cases.  More than forty  persons 
Deformities of the Pelvis.          4&
were tvkiiesses to the disagreeable consequences of
a mistake of this kind, in a woman whose pelvis I
have long had. by  me. The operator having pro-
nounced that the woman would be speedily deliver-
ed, on account of the facility with which the child's
hsad had engaged with the first pains—and attri-
buting the obstacles which soon after obstructed its
passage to another cause, and not to the narrowness
of the inferior strait, which had not been noticed—
waked two days in perfect security; and then, by
a more blind temerity than  the  former, used  a
crotchet on a child whose  life might by other means
have been preserved. The superior strait of the pel-
vis, divested of all its coverings, presented a cir-
cumference of fourteen inches,  in a circular  form,
while the inferior strait had but nine;  the distance
from the point of the sacrum to the symphysis of
the pubes, as well as the interval between the ischi-
atic tuberosities, was but three inches. The cavity
of this pelvis diminished insensibly in breadth from
one strait to the other, and was as regular as possi-
ble in its contour.
   103.  The middle part,  or excavation,  of the pel-
vis, is  much seldomer defective than the straits;
and, when it exists, must arise from some exostosis,
or from the sacrums describing a straight line in
its anterior part, instead of being curved as usual.
This defect in the cavity  can produce  no other ef-
fects than those  which have just been described.
  A straight and fiat form of the sacrum, in general,
produces fewer  obstacles  to delivery than the too
great curve of that bone.  The  former fault  com-
monly  only affects the cavity of the pelvis;  which
cannot hinder the passage of the child, if the canal
be otherwise well disposed: whereas the latter, or
too great curve of the sacrum,  generally injures the 
50          Deformities of the Pelvis.

two straits, and contracts them from before back-
ward, at the same time that it diminishes the depth
of the pelvis posteriorly, and the respective height
of the arch of the pubes. The child's head, after
having  with difficulty cleared the first strait,  in
these cases, cannot pass the  other; because it is
stopped in its course by the inferior part of the sa-
crum, before the occiput is low enough to engage
under the arch,
   104. A too great length in the symphysis of the
pubes, a want of elevation or breadth in the arch of
those bones, the length and wrong direction of the
ischiatic spines, as well as a consolidation of the
coccyx with the point of the sacrum, may also render
labour difficult, in the same manner as is  done by
the excessive curve and shortness of the sacrum.
Besides that these latter faults are very rare, if we
except the consolidation of the coccyx, I must ob-
serve that they are scarcely ever met with alone,
and that they are generally  the consequence of a
bad conformation of the rest of the pelvis.
   105. If the intimate consolidation of the three
pieces which constitute the coccyx, or of the coccyx,
with the sacrum, be more common than the other
faults,  yet it cannot obstruct delivery so often as
has been thought; and, if it sometimes does, it is
only in women who have also a narrow pelvis. Those
who have  assured us that, in all cases,  the point of
the coccyx is pushed back half an inch or even an
inch, by the child's head, knew not the relation be-
tween the  dimensions of that head, and those of the
inferior strait, in most women; for they might have
seen that  the diameter,  measured  from  the  ex-
tremity of that appendix to the inferior edge of the
symphyses of the pubes, was absolutely greater than
that which the head presents in that direction, when 
 
 
        Explanation of the Fourth Plate.       51

it disengages from the pelvis.—See the mechanism
of natural labour.
   We cannot  then recommend the precept  laid
down by some, on account of the consolidation of
the coccyx with the sacrum,* without exposing the
greater part of those who practise Midwifery to
the  abuse of it; generally this  consolidation has
been blamed for what was merely the effect of the
resistance of the external parts.
        Explanation of the Fourth Plate.

  This  figure  represents  a  deformed pelvis, of
which all the parts are reduced to half their natural
size.
  a, a, The ossa ilia.
  b, b, The ossa pubis.
  c, c, The ossa ischia.
  d, d, d, The last lumbar vertebra.
  e, The projection of the sacrum.
  f, f, The sacro-iliac symphyses.
  g, The symphysis of the pubes.
  h, h, The foramina ovalia.
  i, i, The  branches of the ossa pubis and ischia-,
which form the  anterior arch of the pelvis.
  k, k, The acetabula.
  The lines indicate the diameters of the superior
strait of this pelvis.
  A,  A, The antero-posterior diameter; its natural
length is fourteen  or fifteen lines.
  B,  B, The transverse diameter; its natural length
is four inches ten  lines.

  fj This precept advises pushing back the coccyx, when the
head, though low down, cannot disengage itself easily. 
52       Explanation of the Fifth Plate.

  C, C, The distance from the projection of the
sacrum, to that point of the margin which answers
to the left acetabulum, thirteen lines.
  D, D, The distance from the same point' of the
sacrum, to that of the margin which answers to the
right acetabulum, twenty lines.
  I have  another pelvis, which  has an  opening of
between three and four lines only in  the direction
of this last line, and an inch and an half from the
middle of the projection of the sacrum to the sym-
physis of the pubes.
  The inferior strait in both these pelves is very
large.
         Explanation of the Fifth Plate.

   This figure represents  a deformed pelvis,,  in
which the parts are reduced to half their natural
size.
   a, a, The ossa ilia.
   b, b, The ossa pubis.
   c, c, The ossa ischia.
   d, d, d, The last lumbar -vertebra*
   e, The projection of the sacrum*
   f, f, The sacroiliac symphyses.
   g, The symphysis of the pubes*
   h, h, The foramina ovblia, seen obliquely.
   i, i, The  arch of  the pubes, seen  in  the  same
manner.
   k, k, The acetabula.                        •._■_!
   The lines indicate the different dimensions' of
the superior strait.                        e:
   A,  A, From the pubes to the  projection of the
sacrum, in the natural state of this-pelvis, two hi
ches two lines. 
 
 
Of the Soft Parts, fcte.           5S
  B, B,  The transverse  diameter,  three  inches
eight lines.
  C, C, From the middle and left side of the pro-
jection of the sacrum,  to that part of the margin
which answers to the acetabulum of the same side,
between six and seven lines.
  D, D, From the  middle and right side of the
projection of the sacrum, to that part  of the margin
which  answers to the  right acetabulum, one inch
two lines.
  This pelvis was taken from the cabinet of M.
Riel. The subject was a woman of twenty-seven
years.
   Of the Soft Parts connected with the Pelvis.

   1(6. The accoucheur would have but an imper-
fect knowledge of the pelvis, if, after having studied
it in the skeleton, he should not consider it in con-
junction with the soft parts which surround it on all
sides; since some of these latter cause great changes
in its form  and dimensions; and  it is only by a
knowledge of the situation, the connexion, and uses
of others, the change of place, and the constraint or
compression  which they suffer during  pregnancy,
that he can explain the greater part of the pheno-
mena which  occur in that  period,  and during
labour.
   107. The pelvis, making part of the  abdominal
cavity, is bounded superiorly by  the  diaphragm,
which separates that cavity from the breast; behind,
by the spinal column, the quadrati muscles, and
others; before, and at the sides, by the  abdominal
muscles, &x. These latter have too much influence 
54              Of the Soft Parts
 on the mechanism of labour, for us not to take h&-
 tice, at least, of their principal attachments, and the
 relation which they have to each other.
    108. Of these muscles, which are ten in number,
 eight are attached to the breast, and to the superior
 edge of the pelvis; that is  to say, the oblique, the
 transverse, and the recti. The two oblique and the
 transverse, on each side, extend from the last true
 ribs, and from all the false ones, to the crista of the
 ossa  innominata, forming  three distinct planes by
 the direction of their fibres:  those of the external
 plane descending more or  less obliquely from be-
 hind forwards; those of the second ascending from
 before backwards; and the  fibres of the third going
 transversely,  in the manner of a girdle.  Each of
 these muscles terminates in a  broad aponeurosis at
 its anterior part. The aponeurosis of the  external
 oblique, passing from the anterior superior spine of
 the ilium to the angle of the pubes, forms Pouparfs
 ligament, and the inguinal ring; that of the internal
 oblique divides into two layers, one of which unites
 itself intimately to the aponeurosis of the former,
 and the other to that of the transverse muscle. In
 the sheath formed  by this  partition are found the
 recti  muscles, at least the superior  two thirds of
 their  length.  These muscles  descend  in parallel
 lines from the anterior and inferior part of the breast
 to  the anterior  extremity  of the body of the  ossa
pubis.  They are thinner  and broader above than
 below.  Their inferior extremity is applied imme-
 diately to the peritoneum, and is covered externally
 by the pyramidal muscles;  which ascend from the
 angles of the ossa pubis to the tinea alba.
   109. The linea alba is the space which separates
 the recti muscles; it is a kind of band, formed by
 the junction of the aponeuroses of the oblique and 
connected with the Pelvis.          5 5
transverse muscles of each side; but whose fibres
are so crossed and interwoven, that those of the ex-
ternal oblique muscle of the right side, for example,
seem continued  with those of the internal oblique
of the left side, &c. This band  is broader above
the umbilicus  than  below, and extends from the
bottom of the sternum to  the top of the symphysis
of the pubes. Its breadth constantly augments in the
course of pregnancy, in proportion as the volume
of the abdomen is developed; towards the end of it,
the recti  muscles are considerably separated from
each other, especially at the height of the umbilicus;
and sometimes the umbilical ring is singularly open.
We observe  also that the linea alba  is then very
thin;  and that its separated  fibres leave in many
places considerable meshes, which have sometimes
given birth to  certain hernias. The abdominal mus-
cles, independently of their uses relative to the mo-
tions of the breast on the pelvis, and of the pelvis
on the breast, exert their action  on the viscera of
the abdomen, and especially on the uterus in time
of labour,  to  which that action singularly contri-
butes.
   110. In order to mark the place which nature has
designed to each of the viscera of the abdomen, of
which I shall here only enumerate the  names, it is
proper to recollect the names of the different regions
of that cavity.  We reckon three principal ones: viz.
one superior, called the epigastric; one middle, the
umbilical; and  one inferior, the hypogastric: we may
estimate the extent of them by drawing two trans-
verse lines from one side of the abdomen to the other,
at two fingers' breadth above and below the umbi-
licus. Each of these regions is subdivided into three
others; one middle, which is called the principal 
56             Of the Soft Parts
 region; and two lateral,  known by the names  of
 hypochondres, lumbar and iliac regions.
   111. The stomach, the liver, the spleen, the duo-
 denum, and the pancreas, occupy the first of these
 principal  regions; the greater part of the small in-
 testines, the colon, almost the whole of the omentum,
 the kidneys, and their dependencies, are situated in
 the second.  The other contains the cacum;  a por-
 tion of the ilion and of the colon; some of the parts
 qf generation; and others which, having a more im-
 mediate relation to the pelvis, require a particular
 detail.
   112. We find two muscles at each side  of the
pelvis internally; the iliacus and the psoas. The for-
 mer, whose fibres  are as it were radiated, covers
 the iliac fossa; and the other descends from the  la-
 teral part  of the lumbar column, over the side of
 the superior strait and above the acetabulum,  where
 they join and unite themselves strictly, to be  in-
 serted together into the little trochanter: the  psoas,
 in this course, narrows at the entrance of the pelvis
 a  little transversely,  as I  have already observed.
 We sometimes meet with a third muscle, psoas
parvus; it lies along the internal edge of the  psoas,
 and  is terminated  by a flat tendon  at the  posterior
 extremity of the eminence, called ilio-pectineus.
   113.  Behind, and in the substance of the psoa
 muscles, are found the nerves which form the obtu-
 rator and  the crural, as well as other branches fur-
nished by the three first pair of lumbar nerves, es-
pecially by the  first;  which,  following a different
course, are lost in the teguments of the groins, and
parts adjacent. I think  it is to the distension and
stretching which these subaltern  branches and their
ramifications undergo, by the augmentation of the
volume of the  belly,  that  we are to attribute  the 
Connected with the Pelvis.          57
troublesome pains which women feel about  the
pubes, in the groins, and in the small of the  back,
in the latter periods of gestation; especially when
they  are standing still, or  kneeling, &c.  So also
We must attribute to  the compression which  the
crural and obturator nerves suffer before their exit
from the abdomen, that weakness of the inferior ex-
tremities, which makes most pregnant women so
apt to fall on their knees, or the breech, and makes
their gait so unsteady; for  these accidents cannot
depend entirely on the alteration of the centre of
gravity during pregnancy.  We know that the ob-
turator and the crural nerves are formed by the
union of several cords which are derived from the
second, third, and fourth pair of lumbar nerves; that
the obturator goes out of the pelvis at the posterior
and superior  part of the foramen ovale, to be dis-
tributed to the muscles of the inside of the  thigh;
that the crural passes out under the ligamentum
Fallopii, where it divides into  a great number of
branches, some of which go as far as the foot.
   114. Before the last  lumbar vertebra,  and  fre-
quently before the fourth,  we remark the bifurca-
tion of the aorta, and of the vena cava inferior;  and
soon after the division of each of these branches,
known by the name of primitive iliac arteries  and
veins, into two others. One of these latter goes to
the inferior extremities, along the internal edge of
the psoas muscle;  and  the second descends into the
pelvis, to rise again at the side of the bladder  and
umbilicus, forming a curve from which arise the ob-
turator vessels, the glutei, the sciatica, and the pu-
dica communia.  The first of the two branches of
the  primitive iliac arteries, is called the external
iliac, or crural; the second, the internal iliac, or hy-
pogastric. The veins are distinguished by the same
names.
                        H 
58             Of the Soft Parts
  115. The rectum is not the part least remarkable
among those I propose to mention.  Its situation at
the  left  side of the projection of the sacrum,  and
that of the Roman S of the colon, of which it is the
continuation, as  well  as  the volume which it ac-
quires by the accumulation  and retention of the
excrements, produce effects which have often been
attributed to causes which  had nothing to do with
them; such as a lateral obliquity  of the uterus, &c.
This  intestine is  bound  to the  sacrum by a very
loose  cellular tissue, in which we mark the sacral
and hamorrhoidal vessels,  the  extremity  of  the
great  sympathetic  nerves, and especially the sacral
nerves.
  116.  These latter, to the number of five pair,
pass out of the canal of the os sacrum, through the
holes  which have already been remarked in its in-
terior face. The three first  pairs, with a cord from
the two last lumbares,  are almost entirely employ-
ed  in forming the sciatic nerves, which are distri-
buted through the whole extent  of the inferior ex-
tremities, after passing out of the pelvis at the ischi-
atic notch. The fourth and fifth pairs go only to the
parts  within the  pelvis, to some  of the muscles
which surround  it,  and to the  external parts of
generation.
  117.  It is to the compression  which the child's
head, on certain occasions,  exerts on these nervous
cords at their exit from  the sacral holes, that we
must  attribute the painful cramps, and the convul-
sive trembling, of the inferior extremities,  which
sometimes so cruelly  torment women in time of
labour;  as well as the  sensation  of numbness and
weakness which they often feel in those parts.
  118. At the sides of the pelvis, and behind, are
found the two pyramidal  muscles of the thighs, the 
connected With the Pelvis.         $9
sacro-ischiatic ligaments,  and  the  ischio-coccygei
muscles. A little forwarder are the levatores ani,
which embrace  the  neck  of the bladder by their
anterior  edge, and the extremity of the rectum by
their lower parts. Lastly we find here the  internal
obturator muscles.
   119. Behind the ossa pubis is the urinary bladder,
with the canal of the urethra.  Towards the  latter
end of gestation it is almost always found entirely
above those bones; and the urethra  then becomes
parallel to their symphysis.
   120. In the middle of the pelvis is  situated the
uterus and its dependencies, of which  I shall speak
presently; and the whole  is covered by the peri-
tonaum.
   121. A great number of muscles, of which some
belong to the thighs and  legs,  others  to the back,
loins, and arms, are  attached to the outside of the
pelvis. These muscles, and much more those of the
abdomen, by  acting on the pelvis, and drawing  it
sometimes to one side and sometimes  to the other,
according to  circumstances, may change the direc-
tion of its axis a little, relative  to that  of the body;
and may in another manner also affect the mechan-
ism of delivery.
   122. The teguments and the cellular membrane,
more or less  loaded with fat, according to the lusti-
ness of  the woman, form a common covering to
the  hard and soft parts which  we have comprised
under the name  of pelvis.  But  this  covering is not
equally thick in  all parts,  because the  subcutaneous
cellular  membrane is  closer in some  parts than in
others, and cannot admit  there the same  quantity
of adipose juices.  We  observe, for example, that
the cellular membrane is always pretty thin behind,
in the places which answer to the spiny tubercles of 
60         Examination of the Pelvis.

the false vertebra of the sacrum, whatever may be
the lustiness of the subject. We know that the tegu-
ments present several large openings on the out-
side of the pelvis, as the anus and the vulva, as well
as plaits in form of furrows at the groins and under
the nates. These plaits are  more or less profound
or superficial, according as  the thighs are bent or
extended. In an extreme flexion of these extremi-
ties the plaits of the nates are effaced; and  if we
then separate the knees, as most women do  when
the head is ready to be delivered, the perinaum be-
comes extremely tight; which renders the develop-
ment of that part more difficult,  as well as that of
the vulva; and retards delivery,  at the same time
exposing the fourchette and the perinaum itself to
be more  torn. We see, according to this observa-
tion, that we ought  at that moment to keep the
Woman's thighs, at  most,  moderately  bent and
separated, &c.
Of the Examination necessary to discover whether
         the Pelvis is well or ill formed.

  123. No one can be acquainted with certain fun- •
damental truths of the art of Midwifery, without
knowing all the importance of this examination:
but its difficulties are only perceived by those ob-
liged to make these researches; and a frequent ex-
ercise on the dead body can alone smoothen a part
of the obstacles we meet with in  it.
  124. If accoucheurs had applied themselves more
to these examinations; if they had earnestly demon-
strated all the necessity of it, with respect to de-
formed women; and if those  women had submitted 
           Examination of the. Pelvis.         61

 to it before they engaged in marriage, we should
 probably still have been ignorant of those sad re-
 sources of our art, which have had so many victims
 for a few mothers and children which they have
 saved from certain destruction. What woman would
 have purchased the title of mother so dear, if she
 had been assured that in becoming pregnant  she
 could have no resource but in the Cesarean opera-
 tion, or in the section of the pubes? what woman
 would have consented to the sacrifice  of her child,
 to save her from these operations? and who would
 have wished to taste the  sweets of hymen at that
 price?
   125. In whatever point of view we place this ob-
 ject, it will appear equally important:  whether  the
 question be of a young woman,  whose external  de-
 formity gives occasion to fear concerning the state
 of the pelvis; or of a married woman ready to lie in,
 or whose labour is begun—the accoucheur  be-
 comes, in some sort, the arbiter of her destiny; and
 his decision may affect the life of one or of several
 individuals. The more distressing the consequences
 of such an  examination may prove,  the  more
 care and skill we  ought to exert in making it.  All
 who practise the art of  Midwifery have  not  the
 knowledge necessary to estimate the degree of de-
 fect  in the  form and dimensions of the  pelvis. It
 cannot be determined by  inspecting the spinal col-
 umn; nor by the irregularity of the inferior extremi-
 ties,  and the gait of the  woman; nor by the time
 at which the deformities of all these parts were
 manifested.  On one side, the cause of these defor-
 mities does not always affect the form  of the pelvis
 so as to render delivery impossible, or even diffi-
cult;  and, on the other side, we have seen these
deformities manifest themselves in infancy, disap- 
62         Examination of the Pelvis.

pear in youth, and  the pelvis alone retain the im-
pressions of the rickets which had produced them:
so that many crooked women  may  be delivered
naturally; while others, who enjoy the finest exter-
nal proportions, cannot have the same good fortune,
the narrowness of the pelvis producing obstacles in-
surmountable by the common agents of delivery.
There is no rock on which these external appearan-
ces,  favourable or unfavourable, have not thrown
the  unskilful practitioner. His  security,  in  some
cases where he had persuaded himself that the pel-
vis was well formed, has suffered some women and
and children to perish in the continued exertion of
impotent efforts, who could not possibly have been
saved but by the forceps, or the Cesarean operation;
while the disadvantageous opinion which he had
conceived of that cavity, in other cases, has led him
to employ those means in circumstances that only re-
required a little dexterity on his part. It is not only
the forceps which have been abused in these latter
cases, but the Cesarean operation, and much more
still the section of the pubes: alarming truths, which
it gives me pain to  mention.—A few years ago I
preserved  a  woman from  the Cesarean operation,
the diameter of whose pelvis had been estimated at
only  one inch and a quarter by the accoucheur she
had  employed:  we  waited four  hours  for the fa-
vourable moment  to operate; the apparatus was
prepared; the woman was ready to place herself on
the couch; twelve or fifteen persons, as well phy-
sicians as surgeons, were going to be witnesses of
this afflicting scene; when  touching the  woman for
the first time, I declared strenuously that she would
be delivered naturally, and without difficulty;  as
actually happened  two hours afterwards, and the
child was strong and healthy. 
            Examination of the Pelvis.        63

   126. The consideration of the  external form of
the pelvis may be  very useful to  us in the exami-
nation which I am going to describe: for the nega-
tive signs of a good conformation are so many indi-
cations of a bad one; and both the one and the other
have, besides, external marks which enable us to
judge of the cavity and internal form of the pelvis.
The  roundness  of the hips; their quality, as  well
in height as in breadth; the convexity of the pubes;
the superficial depression  of the superior and  pos-
terior part of the sacrum;  an extent of four or five
inches from the  centre of that depression to the ex-
tremity of the coccyx; a thickness of seven  or eight
inches in women moderately lusty, from the point
of the spiny tubercle of the last lumbar vertebra to
the middle of the  mons veneris; and  a distance of
eight or  nine  inches between the anterior superior
spines of the ossa ilia; characterize a good conforma-
tion.  An irregularity of the hips, whether  in their
roundness or elevation; a distance  much smaller
than that which  I  have assigned  between  the  su-
perior anterior spines of the ossa  ilia; a too high or
too flat form of the pubes; too deep a fall in the small
of the back; a great convexity of the sacrum behind;
an  inflection of the  lumbar column  to one side or
the other, &c. denote a bad conformation.
   127. The superior strait is contracted between
the fore and back parts, whenever the pubes is less
salient than common, and the posterior and the su-
perior parts of the sacrum  more sunk in. The in-
ferior strait is also contracted in that direction, when
the point of the  sacrum and the coccyx are carried
inwards;  and  it  is larger,  when  that  appendix is
thrown backwards or outwards.
   128. When the  first  of  these straits is  vitiated
transversely, the region of the pubes is salient, in- 
64        Examination of the Pelvis.

stead of being flattened, as in the preceding case;
the anterior part of the pelvis forms an obtuse angle,
and not that circular figure Which characterizes a
good conformation; and often one of the groins ap-
pears more sunk in than the other. If it  is more
difficult to form a judgment of a narrowness which
affects but one side of this strait, so also it gives
less obstruction to delivery than that which I have
just mentioned.
   129.  But these general notions  are still insuffi-
cient, and cannot enable us to determine the  de-
gree of opening which a deformed pelvis  presents
interiorly. However experienced we may be, the
application of the hands externally will never in-
form us sufficiently to determine the choice of the
means proper to  be used for terminating the de-
livery in difficult cases. If we cannot any other way
acquire a knowledge  of all the  diameters with a
mathematical  precision, at least  we  come  near
enough to prevent our committing any capital mis-
takes. It is easy, especially, to determine the length
of that diameter of the superior strait which goes
from the pubes to the sacrum, the  only one which
is generally defective respecting  delivery.  Many
instruments are used  for measuring it,  which are
so many kinds of compasses, some of which are
developed within the pelvis, and some withbut;  I
prefer one of these latter, which I callcompas d/epais-
seur (calipers,) not only because its application  is
more easy, but also because there is nothing in it
painful or fatiguing to the woman; and because it
may be applied at all times, and on all kinds of sub-
jects; and because the result of it has appeared to
me more certain.
   130. To determine how much the superior strait
is defective inlhe aforesaid diameter, and measure 
Examination of the Pelvis.         65
it by means of these compasses, we take the thick-
ness of the woman from the middle of the mons vene-
ris to the centre of the depression of the base of the
sacrum posteriorly,  by applying one  of the points
of the instrument before, against the symphyses of
the pubes; and the other behind, a little under the
spine of the last lumbar vertebra;* and deduct three
inches from that thickness, in women who are thin,
for the base of the sacrum and the anterior extremi-
ties of the ossa pubis: the thickness of these latter
being at  most but six lines, and that of the base of
the sacrum two inches and a half;  and so constantly
so, that  I have not found a difference of a line in
about five and thirty pelves, distorted and contract-
ed in all manner of  ways, and in all possible de-
grees. This  subtraction of three inches from the
external thickness of the pelvis, in  the said direction,
is also sufficient where the lustiness is moderate;
and we mav add one or two lines more when it is
excessive,  "because the fat  which forms the  mons
veneris easily shrinks under the lenticular extremity
of the leg of the compasses. The result of this pro-
cedure is so  exact, that the pelvis, measured with
the common compasses after opening the body, was
not above a line over  or  under my estimation in
any one  of my experiments. A greater  precision,
if we could  obtain it, would be useless; since the
choice of the most proper methods for terminating
the delivery in a given case, cannot depend on a
line more or less in the diameter of the pelvis. Ac-
cording  to these data, the knowledge of this diame-
ter is  easily  obtained. It is four  inches, when  the
external thickness of the pelvis measures seven; it is
but three, when the latter  only measures six; and
* See the Sixth Plate,
        I 
 66         Examination of the Pelvis.

 but two, when it does not exceed five, &c. I suppose
 the woman to  be thin, as most of those are who
 have been rickety.
   131. The compasses whose branches  are deve-
 loped within the pelvis, have often presented a re-
 sult not very exact; and more than once the error
 has been of several lines over or under the product
 they had given, as well because it is difficult to keep
 one of the branches on the centre of the projection
 of the base of the sacrum, while the other is placed
 behind the pubes; as because the soft Darts  which
 line the pelvis obstruct their development: their
 use, besides, is  always  accompanied with pain,
 which excites the action of those same parts. We
 cannot make use of them  in young girls, concern-
 ing whom their doubtful  parents may consult us
 before marriage; nor even in married women, ex-
 cept in time of  labour.
   132. The fore finger likewise introduced into the
 vagina, and properly directed, may  equally serve to
 make known the length of the little diameter  of the
 superior strait;  and the knowledge of it is the more
 easy to obtain, as the pelvis is  more contracted.
 We advance the extremity of this finger to  the
 middle of the most  projecting part of the base of
 the sacrum, near its junction with the body of the
 last lumbar vertebra; and,  by raising the wrist, we
 apply the radial edge of the same finger to the in-
 ferior edge  of the symphysis of the pubes. We  mark
 on that finger,  with the nail of the fore finger of
 the other hand, the point  immediately under the
 symphysis;  then,  withdrawing  from  the vagina,
 we measure  the  length  from  that  point to  its
 extremity. This measure,  which is that of the line
 which  descends obliquely  from the middle of the
projection  of the sacrum  to the inferior edge of 
Examination of the Pelvis.         67
the symphysis of the pubes,  is commonly half an
inch longer than the diameter of the superior strait,
measured from the same point of the sacrum to the
top of the said symphysis. An accoucheur well vers-
ed in these examinations, cannot be deceived by
this method above a line or two, at most, whatever
may be the form or the degree of opening in the
pelvis; which cannot lead him  into the commission
of any capital faults in practice.
   133.  We cannot come near the same  precision
in the estimation of the other diameters, except that
of the inferior strait which goes from the pubis to
the coccyx; but we may estimate them well enough
not  to  be grossly deceived in the choice of the
methods  to be  employed for terminating the de-
livery.  Though the external dimensions of the pel-
vis cannot demonstrate  the  transverse diameter of
the superior strait, and though the finger introduc-
ed into the vagina cannot measure that  diameter,
we may judge of its length  with respect to delivery
by that of the former. When that which goes from
the pubes to the sacrum is so small that great obsta-
cles  result  from it, it is excessively rare for the
other to be so at the  same time; and more rare still
for the latter to be defective when the former is of
the requisite  length.  If we  measure the  transverse
diameter from one iliac notch to the other,  that is
to say, between the most distant points  of the su-
perior  strait,  we shall never find it less than four
inches, whatever may be the length of the diameter
 which  goes from before backward; but this  trans-
 verse line,  the  most extensive  which we can find
 in the  superior strait, must not be looked on as the
 diameter of that strait. Far from passing through
 the centre of that opening, we observe that  it in a
 manner touches the  sacrum, in  the greater part of 
68         Examination of the Pelvis.
deformed pelves, and that in many it passes under*
the projection of the base of that bone. If the trans-
verse diameter were to be  measured from one side
of the superior strait to the other, at equal distances
from the projection of the sacrum and the symphysis
of the pubes, it would be always shorter than what
I have  assigned, but nevertheless always greater
than the anteroposterior diameter.
   134. We discover the extent of the diameters of
the inferior strait, within a very trifle, by feeling ex-
ternally till we can clearly  distinguish the ischiatic
tuberosities, the point of the coccyx, and the inferior
edge of the  symphyses of  the pubes. Though it is
easy to  distinguish these two latter points while the
subject is standing, and to judge  of their distance,
it is not so with the former, on account of the great
number of muscles  which are attached to them,
and the direction of those muscles: but we discover
the tuberosities in question, we render them some-
what more salient, and evidently more palpable, by
giving the thighs of the subject an extreme flexion.
If then  we want to estimate the distance from one
of these tuberosities to the other, the woman must
be sitting, or, as it is vulgarly called, squat; that is
to say, in such an attitude that the legs and thighs
may be bent. It is  by the distance between the
fingers  which touch the ischiatic  tuberosities^ that
we judge of  that between them;  but the diameter
which  we propose to measure thus, is always two
or three lines shorter than the external measure-
ment;  and sometimes five or six lines, when the
bones are very thick.
   135.  As often as the condition of the subject to
be examined permits us to pass the finger into the
vagina, we ought to do it; we might even introduce
the whole hand into it, if necessary, and circum- 
Examination of the Pelvis.        69
stances  were sufficiently favourable to permit  it;
as, for example, in time of labour. This procedure
conducts us more surely still to the knowledge of
the pelvis,  since it  enables us  to discover things
which cannot be perceived by simply examining
the outside of this  part; such as exostoses, which
sometimes  affect it, he. By thus examining the in-
side of this canal, when by long practice we  have
acquired the habit of it, we may discover the length
of its  different diameters  within a few lines; and
especially that of the  small diameter of the  supe-
rior strait,  as I have already explained.  In the  same
manner we may measure the distance of the coccyx
from  the symphyses of the pubes, by keeping the
radial edge of the finger against the inferior edge
of the latter, and its extremity against the point of
the former, which we are to push back as much as
possible.
   136.  The depth of the pelvis behind may be mea-
sured by the length of the sacrum; at the sides, by
taking half the height of the ossa ilia from the  ante-
rior superior spine to the tuberosity of the ischium;
and before, by the  extent of the symphysis of the
pubes.
   137.  It is not more difficult to find the elevation
or height of the arch of the pubes, by deducting the
length of the symphyses from the depth of the sides
of the pelvis. For example, if the former is eighteen
lines, and the lateral depth of the pelvis is three in-
ches and an half, the height of the arch will be two
inches.  Lastly,  the breadth  of this  arch may be
known  by  means of the finger applied transversely
in the vagina; or by feeling externally  at the  sides,
and along the labia  pudendi. The distance between
the tuberosities of the ischia also demonstrates this
breadth very well. 
Explanation of the sixth Plate.
   This plate represents a  vertical  section of the
pelvis, reduced to about half its natural dimensions,
with the pelvi-meter of M.  Contouli, and my cali-
pers.

   Fig. I. A, A, A, A, The four last lumbar ver-
tebra.
   B,  B, B, The os sacrum.
   C,  C, The coccyx.
   d, d, Surface resulting from the  section of the
symphyses of the pubes.
   E, The left iliac fossa.
   F,  The left side of the superior strait.
   G, The sacro-ischiatic ligament.
   H, The tuberosity of the  ischium.
   i, i, The entrance of the  vagina.
   K, One of the labia pudendi.
   L,  The anus.
   M, The mons veneris.
   N, The left natis.

   Fig. II. The calipers which  I use for measuring
the antero-posterior diameter of the superior strait.
   a, a, The  branches of the calipers.
   B, The hinge which unites the two branches.
   c,  c, Lenticular buttons which  terminate the
branches.
   d,  A graduated scale, nine inches long, intended
to demonstrate the thickness of the body comprised
between the  branches.*

   * This scale is contained in a  deep groove cut lengthwise
in the branch of the calipers, from the letter e to the hinf-e 
Efr.l.
Plate T_.
 
 
         Explanation of the sixth Plate.       71

  e, The place where the scale is united by a kind
of hinge.
  f, A little screw, with a flat head, intended to fix
the scale, while we calculate the thickness of the
body comprised between the branches.

  Fig. III. The pelvi-meter of M. Contouli deve-
loped in the pelvis.
  A, A, The first branch, whose square, B, is appli-
ed to the projection of the sacrum.
  C, C, A kind  of hooks,  intended to keep the
first branch  in  its place while we  introduce and
develop the second.
  This branch has a dove-tailed groove, in which
the body of the second branch is lodged and moved.
  d, d,  The second branch of the  instrument,
whose square, e, is placed against the symphyses of
the pubes.
  F, A scale, four inches long, graduated on the
branch d, d, and  intended to show the degree of
opening from the pubes to the sacrum.
  Note, We have not confined ourselves  scru-
pulously to the geometrical proportions  of these
two instruments; but we have reduced them here,
as  well  as the pelvis,  to about half their natural
size.

B; and passes through a mortise made in the other branch.
under the letter/. 
72        Female Parts of Generation.
 Of the Parts of the Woman concerned in Generation
                  and Delivery.

   138.  These may be divided into external and
 internal: the external are the mons veneris, the labia
 pudendi, the sinus  called the  vulva, the nympha,
 the clitoris, the urethra, the orifice of the vagina, the
 hymen in virgins, the caruncula myrtiformes, the
fourchette, and the fossa navidfdaris. The internal
 parts are, the  uterus, and its dependencies; that  is
 to say, the ligaments, the fallopian tubes, the ovaria,
 and the vagina.
   139. The mons veneris is that region covered with
 hair,  situated  at the bottom of the hypogastrium,
 and before the pelvis.  The  teguments below this
 part divide into two columns, which run in parallel
 lines  towards  the anus, and form the labia pudendi.
   140.  These are firmer and thicker in virgins and
 young women, than in others. Their internal face
 is always moist, of a bright  red in the former; and,
 on the contrary, pale in those  who have  had chil-
 dren. Their external face is  covered  with hair  at
 the age of puberty. The labia pudendi, in their natu-
 ral state, have only a very narrow chink between
 them; but, when we separate  them,  we discover a
 sinus called the vulva in  which are found the other
 external parts of generation.
   141.  The most obvious of these are the nympha;
 which are two bodies narrow  and close at their ori-
 gin,  but  separate as they recede backwards, so  as
 nearly to represent a pair of compasses moderately
 extended. They serve  to direct the urine  down-
 wards, and also serve to augment the entrance of the
 vagina when the head of the child is about to pass  it.
   142.  Above the nympha a semilunar fold is per- 
Unimpregnated Uterus.          73
ceived which hoods the clitoris; this part is extreme-
ly sensible, and supposed to be the seat of venereal
pleasure—the clitoris is attached to the anterior part
of the symphysis pubes, by a ligament which is called
suspensor; it has vessels of every kind.
  143.  On separating the nympha we discover the
urinary passage; this is the extremity of the urethra,
it is shorter in women than  in men, although  its
structure differs very little from it. It passes under
the symphysis of'thepubes, and rises obliquely back-
ward to the bladder. Its direction is altered by preg-
nancy,  so that at the latter periods, it rises almost
perpendicular behind the symphysis, and sometimes
even a little curved over it.
  144.  Below the orifice of the urethra is found the
entrance of the vagina. This opening is bordered by
the caruncula myrtiformes in women, and in virgins
by the hymen.  A little below the hymen we find a
semilunar fold called  the fourchette, this for  the
most part is destroyed by labour. Between these
two we remark the fossa navicularis.
  145.  The perinaum is the space between the vul-
va and  anus.  It is  about two  fingers in breadth, in
the natural state, but capable  of great extension in
the time of labour. A kind of  seam called the raphe
runs through its whole extent.
                 Of the Uterus.

  146. The uterus is the organ in which the im-
portant work of generation is almost always perform-
ed.  This fleshy, vascular, and membranous viscus,
                     K 
74           Unimpregnated Uterus.

is  situated in the pelvis,  between the rectum and
bladder, with both of which  it has connexions.
   147.  Its figure is very like a flatted pear, of the
length of two inches and a half, qr thereabouts; its
breadth is from eighteen to twenty-four lines, and
its thickness ten or twelve only.
   148.  It is distinguished into fundus, bpoTy, and
neck. The fundus comprehends all that part abpve
the insertion of the fallopian tubes; the body is im-
mediately below it, and extends to the riarrqw^st
part of this organ, where the neck commences; this
latter terminates in the vatrina, forming a kind of
large  nipple, which has some  resemblance tq the
mouth of a tench. The uterus, considered external-
ly, presents two faces,  both  a  little convex:  three
edges, one of which forms the fundus, and the other
two the sides: lastly,  three angles;  that is tq say,
two superior and lateral, where the fallopian tubes
enter; and one inferior, which projects into the va-
gina, and is called the os tineas  Excepting tfyis last
part, the uterus is covered by the peritonaumthrough
its  whole extent; and  this membrane adheres to it
so closely, that it seems to enter its very structure;
though it  only envelops it in its duplicature, as we
observe with respect to the  other viscera.
   149.  When the uterus is unimpregnated, we can-
not absolutely determine what  is the order and ar-
rangement of its fibres, they are so inextricably in-
terwoven. It would be as difficult also to know their
nature, if their common properties with muscles
had not often manifested it in time of labour. These
fibres are paler and much closer in the neck of the
uterus  than  in its other parts, where they appear
softer, redder, and of a looser texture.
   1'50.  On  opening the uterus longitudinally,  we
discover its cavity; and may estimate the thickness 
             llhimpregnated Uterus.           75

of its parietes, which in general is but three or four
lines: its stibstance appears spongy, and as it were
diploicdl, in the fundus, arid through the whole ex-
tent of its body; b'Ut denser and closer in the Deck,
properly so called: which doubtless arises from the
distribution of the Vessels which pervade it, and
which the knife divides transversely.
   151. Although the cavity of the body and that of
the neck of the uterus are but one, it is the custom
to distinguish them from each other, and to describe
them separately.  That of the body is of a triangu-
lar figure, and would scarcely contain a bean: it
terminates above and at the sides by two very small
orifices, which form the beginning of the fallopian
tubes; and  below  by another, larger, which is called
the internal orifice of the uterus.
   152.  This cavity is lined by a very thin mem-
bra'ne, which adheres  as strongly to the substance
of the uterus, as the peritonaum which covers it
exteriorly.
   153. This membrane is so porous, that it appears,
as it were, reticular. The most considerable of these
openings  lead  to winding cavities,  called uterine
sinuses; and others to folliculi or glands, which fur-
nish that mucous and glairy humour with which the
internal surface of the uterus is  continually lined;
and the least of all are only the extremities  of ab-
sorbing or exhaling vessels. These latter are equally
distributed throughout; but the first are more nu-
merous at the fundus, and the second towards the
neck.
   154.  The cavity of the neck  of the uterus is a
kind of canal about an inch long, and a little larger
in the middle  than towards its extremities.  It is
lined by the  same membrane as  the cavity of the
body of the  uterus. The neck of the uterus opens 
76           Unimpi'egnated Uterus.
 into the vagina by a little transverse chink, called
 the external orifice of the uterus; and it is this chink
 which gives the projecting portion of the neck of
 the uterus the figure of a tench's mouth.
   155. The os tinea seems about four or five lines
 long before, and a little more, backward; its thick- <
 ness is about eight or ten transversely, and from
 six to eight from the anterior to the posterior part,.
 in which direction  it is a little  flatted. The chink
 is not exactly at its extremity, but a little backward;
 which makes its anterior lip appear thicker than the
 other.
   156. Pregnancy and delivery commonly so efface
 these characters, that the os tinea is entirely differ-
 ent in  women who have had children. In them,  it
 is generally thicker and rounder; and the edge of
 its orifice, then almost always open, is found more
 or less unequal, and sometimes even, as it were fes-
 tooned.
   157. The arteries  which are distributed to the
 uterus, come  from the spermatic and hypogastric.
 It is at the sides that they penetrate its  substance,
 from whence their branches go backward and for-
 ward, making an infinite number  of  convolutions
 round  themselves, forming a  great number of are-
 ola and anastomosing with each other; that is to say,
 the spermatics with those which come from the hy-
 pogastric, and those of the right side with those of
 the left. Some of them terminate in the veins which
 accompany them; and others  in a particular kind of
 vessels, known by the name of sinuses. The sinuses
 form, as it  were, so  many reservoirs,  where the
 blood  deposited by the arteries is re-absorbed by
 the veins, which return it into the circulating mass.
  158.  We cannot doubt of  the existence of lym-
phatic  vessels in the uterus;  but their source and 
         Parts dependent on the Uterus.       77

their course are not so well known as those of the
former. They are so numerous and so large in the
latter periods of pregnancy, that we might be almost
tempted to believe, says Mr. Cruikshank, that the
uterus  is nothing but a composition  of absorbent
vessels. This learned English  anatomist divides
them into two planes, one of which accompanies the
hypogastric vessels, and the other  the spermatic.—
See Cruikshank, Anatomy of the Absorbent Vessels
of the Human Body.
   159.  The  nerves of the uterus are derived from
the venal plexus, and the hypogastric, from the great
intercostal, and the sacral nerves. Considering these
numerous sources, and the communication of these
nerves,  we ought not  to be surprised at the extra-
ordinary sympathy of this  organ  with all parts  of
the body, and at the variety of symptoms produced
by the  diseases which affect it.
      Of the Parts dependent on the Uterus.

   160. The parts dependent on the uterus, are its
ligaments, the fallopian tubes, the  ovaria, and the
vagina.
   161.  There are four principal  ligaments, two
broad, and two round; the two former, are folds of
the peritonaum which seem t9 divide the pelvis
transversely, and contain the uterus between them,
they unite at the sides of this organ, and form as
it were two  wings~at their superior edge the fal-
lopian tubes are enveloped, and at their inferior the
ovaria—their use is to fix the uterus in the centre
of the pelvis.
   162. Through the cellular membrane which con- 
78       Parts dependent on the Uterus.
 nects these two folds of the peritonaum, the differ-
 ent blood vessels, and lymphatics run.
    163.  We there also  remark two cords, one on
 each side, called the round ligaments, which descend
 from the superior angles of the uterus, before  and
 a little below the beginning of the tubes. These lig-
 aments bend towards the pubes, and pass out through
 the rings in the oblique rrtuseles: they divide  into
 many branches; and, forming a kind  of crow-foot,
 lose themselves in  the  cellular membrane, and in
 the teguments round about the groins.
    164. Besides the four ligaments just mentioned,
 there are two others; one called the anterior round
 ligament, and the other the posterior round liga-
 ment—they are also folds or  duplications of the
 peritonaum; their use the  same as the broad liga-
 ments.
    165. The fallopian tubes are two conduits which
 take a winding course; they are about three or four
 inches in length, and their name sufficiently describes
 their figure. They  are  so narrow at the end next
 the uterus, that their orifices will scarcely admit a
 very small bodkin; but they enlarge insensibly as
 far as their middle, where  they narrow a little, and
 then dilate again: they terminate in a kind of expan-
 sion,  which is  bordered by a  fleshy fringe. This
 extremity is loose and floating in the cavity of the
 pelvis.
    166.  The structure of the  tubes appears to be
 absolutely the same as that of the uterus; like that
 they are enveloped by the peritonaum; we find in
 them several orders of fibres; and they are capable
, of extension  and contraction.  One of the  fleshy
 fringes  which border the  expansion of the tube, is
 attached to the ovarium; the others seem destined
 to dilate it, and apply it strictly to that body, in or- 
Parts dependent on the Uterus.       79
der to receive  from it what the woman furnishes
for generation.
   167.  The  ovaria are two whitish bodies, nearly
of the size and figure of a large bean. They are
placed loosely in the posterior pinions of the broad
ligaments; and are attached by a kind of ligamentous
cord to the superior and lateral parts of the uterus,
behind the origin of the tubes. These bodies are
larger  in the prime of  life than in advanced age,
when they in some measure wither and dry up.
They are a little plump during the time the woman
is fruitful; and, according to some  authors, are
marked with as  many  cicatrices as  she  has  had
children.
   168.  We know not perfectly either the structure
or use of the  ovaria: we only know that they are ne-
cessary for generation; and that to deprive animals
of them* is sufficient to take away from them the fa-
culty of propagation.
   169.  The  tubes, the ovaria, and the ligaments of
the uterus, are supplied by the spermatic vessels,
which form by their division, in women as in men,
a kind of body like a vine, from whence the differ-
ent branches  go to their destination.
   170-  The  vagina is a membranous canal, natu-
rally narrow  in virgins,  and always so short,  that
we may easily touch the neck of the  uterus with
the extremity of the finger; but its dimensions vary
according to circumstances.  It may  be  stretched
to the length  of more than half a foot, and widened
so as to contain the head of a child:  but it soon re-
turns to its natural state when the causes of its al-
teration cease to act; which proves that its texure
is very elastic.
   171.  The anterior part of the vagina  is much
shorter than the posterior,  because that canal is a 
80       Parts dependent on the Uterus.
 little curved towards the pubes, and its two extre-
 mities are,  as  it were, cut with  a slope.  One of
 them embraces the  neck of the uterus, about five
 or six lines above the external orifice; from whence
 the internal membrane of that canal seems to be
 reflected over the os tinea, and continued into the
 uterus itself. The  other extremity  of the vagina
 forms the entrance of it; it is surrounded by a very
 considerable vascular plexus; and embraced by two
 fleshy bands, which mount  from the sphincter ani
 to the clitoris, called constrictor muscles.  The  ple-
 thora and swelling of the former, joined to the con-
 traction of these latter, narrow  the entrance of the
 vagina more or less, and often in a very remarkable
 manner.
   172. The structure of the vagina is not yet very
 well known.  Some  give it a fleshy coat, composed
 of two orders of fibres; that is to  say, longitudinal
 and circular. Others, without  more reason, allow
 it only two membranes; of which the internal, much
 more extensive and of a closer texture than the
 other, forms an  infinite number of folds or wrinkles,
 which singularly diminish the capacity of that canal:
 while the external is merely cellular.  It is those
 folds in  the  former,  and which nature  has placed
there as in reserve for  the time of labour,  which
permit the vagina to lengthen and enlarge as occa-
 sion requires.
   173. Between the two membranes of the vagina,
 and chiefly towards its  inferior extremity, run con-
 siderable blood-vessels; and there  we find  a great
number of glands, which secrete  the  mucous li-
 quor which always lines the inside of that canal.
   174. The vagina is not insulated in the midst of
the pelvis: it has very close connexions, by means
 of the cellular membrane, with the canal of the ure- 
           Parts dependent on the Uterus.        81

  thra, with the lower part of the fundus of the blad-
  der, and with the rectum,.
    175. Its vessels arise from the pudica communia,
  which likewise sends some to the external parts of
  generation; and its nerves come from most of the
  sources which supply the uterus.—See .$ 159.
    176. The augmentation of the uterus is scarcely
  sensible from one month to another at the begin-
  ning of pregnancy: but it becomes so large in the
„t sequel, that it is difficult to conceive how it can be
  effected. Until the third month, the uterus in most
  women continues  small  enough  to  be  contained
  within the cavity of the pelvis; and it is not generally
  till the  fourth that its fundus rises sufficiently above
  the superior strait, to be manifestly felt by applying
  the hand  to the  hypogastric region.  In the  fifth
  month  it mounts to within two fingers' breadth of
  the umbilicus, and is as much above it at the end of
  the sixth. In the seventh, it enters  the  epigastric
  region, and occupies a great part of it in the eighth;
  but  is  often  found below it  at  the  end of  the
  ninth.
    177.  Although the uterus increases  in every di-
  rection during pregnancy, in proportion to the aug-
  mentation of the produce  of conception;  yet all its
 diameters do not increase in the same  proportion in
 every period, whether in respect to themsel e  », or
 to the fktus. The longitudinal axis of this viscus in-
  creases much more from the  third  to  the sixth
 month,  than from that to the ninth: while the other
 dimensions  augment much less in the first periods
 than in  the latter; when the cavity evidently grows
 rounder in all parts, without however entirely losing
 that oval figure which  appears  natural to it.  This
 cavity, relatively to the foetus, is  very large in  the
 two first months, and very small in the latter.
                        L 
82
Gravid Uterus.
  Of the Changes which Pregnancy produces in the
   Volume, Figure, and Structure of the Uterus.

   178. The fibres of the fundus of the uterus yield
 more readily than those of the neck until the sixth
 month of pregnancy, and hence afford  all the neces-
 sary room to the ovum until this period;  then the
 fibres of the neck begin to develop, and contribute
 with those of the fundus, to the necessary enlarge-
 ment for the foetus, and its appurtenances. From
 this time all the fibres unfold equally,  and continue
 to do so until towards the latter period of pregnancy;
 the dilatation now is made almost exclusively  at
 the expense of the fibres of the neck, because those
 of the fundus begin to make resistance,  and the
 equilibrium in the reaction of these parts no longer
 exists.
   179. As soon as this equilibrium is destroyed,
 the fibres  of the body and fundus begin to make
 efforts to expel  the contents of the uterus.  This  is
 manifest to the  touch, as the membranes when felt
 through the os tinea are found alternately  relaxed
 and tense.
   180. The fibres of the neck at this time sustain,
 not only this action of the body and fundus\ but also
 the weight and influence of the contents of the ute-
 rus, which obliges thenrto unfold  so  rapidly, that
the neck is effaced completely in two months. If the
uterus enlarges still more after this period, it is en-
tirely at the expense of the fibres of the neck, which
 so arrange themselves as not to  be thicker some-
times at the orifice, than two or three folds of com-
mon paiper. 
Gravid Uterus.
83
   181. It is by this mechanism that the dilatation
of the orifice of the uterus is effected, and labour
pains manifest themselves, and it is from  these
changes almost invariably taking place, and in the
order mentioned, that nine months is the usual pe-
riod of gestation, as it requires that period for the
most part for these circumstances to obtain.
   182. Whenever the fibres of the fundus, and body
of the uterus, too  strongly resist development in the
first periods of gestation, delivery takes place before
the proper time, and quite as naturally as at the
end of the ninth month; because those of the neck
are forced to unfold prematurely, and cannot sup-
port the reaction of the others beyond a certain
time. On the contrary, labour happens later in those
women where the neck of the uterus does not un-
fold at the  time intended  by nature;  either be-
cause the  fibres of the superior parts are  more
extensive  and less irritable than usual, or because
the neck is affected by a scirrhous hardness.
   183. This double assertion is not, as some may
imagine, merely  the fruit of speculation, intended
to square  with an established theory; but  a  truth
which experience and observation have many  times
demonstrated.  I  have met with a  great many  of
these cases where premature delivery has been en-
tirely owing to the feeble organization, either natu-
ral  or accidental,  of the neck of the  uterus.
   184.  When  we  compare the uterus at  the ap-
proach of labour with  what it  was  before  preg-
nancy, we see that its extension is less the  effect
of a simple development, than a kind of generation,
or rather of increase, which does not always take
place without injuring the original parts. Accord-
ing to M. Levret, the solid mass of  the uterus  in
its natural state, or in a state of vacuity, is about 
84
Gravid Uterus.
 four cubic inches and a half, and at the latter end
 of gestation fifty-one inches; so that, says he, the
 proportion of the smallest uterus to the largest  is
 nearly as 9 to 102, or as  1 to llf. *
   185. The uterus does  not, in fact,  extend after
 the manner  of the bladder:  if its parietes do not
 preserve all their natural thickness while it acquires
 a larger capacity, at least they lose so little of it, that
 many authors have thought it remains the same  in
 all periods. Indeed, while those have advanced that
 the  uterus in developing loses nothing of its thick-
 ness, others have maintained that that thickness di-
 minishes insensibly from the first period of gestation
 to that of labour; and some, of an absolutely con-
 trary opinion, assure us that, far from diminishing,
 it augments in the same proportions as the uterine
 cavity becomes larger.
   186.  Such a variety of sentiments on a matter of
 fact, may have arisen  from the part of  the uterus
 that has been examined, and from the time at which
 they have endeavoured to estimate its thickness. It
 is moreover certain that the parietes of  the uterus
 do not present the same thickness in all  women at
 the latter end of gestation, nor in the same woman
 at the end of every pregnancy;  for,  independently
 of the differences which may be looked on as indi-
 vidual, there are accidental ones, which depend on
 the smaller or greater degree of dilatation, in each
 pregnancy, and on the quantity of fluid determined
 to the uterus, to nourish and develop its substance.
   187. To judge of the thickness of the parietes of
 the uterus, at the  latter end of pregnancy, we ought
 to examine that  vise us in  the state of  its greatest
dilatation, that is to say,  before the  waters  of  the
amnion are evacuated; for that thickness  augments

     * L'Art des Accouchcmens, tvoisieme edit. 390. 
Gravid Uterus.
85
 in proportion as it  contracts,  and its  cavity  di-
 minishes, immediately  after delivery—we  ought
 to examine it in all parts, because there are  some
 where it is constantly thicker, and others  where
 it  is  always thinner, than its natural state. The
 place where the placenta is attached, is always that
 where the thickness of the parietes of the uterus is
 the most considerable; and the vicinity of the ori-
 fice that where it is least. If it does not augment
 in the former during pregnancy, at least we may be
 sure it remains such as it was in every part before
 impregnation; it is the only part where it seems to
 preserve the same state.  It diminishes in the rest,
 and very manifestly  in the neck, so that the edge
 of the orifice is often no  thicker than two or  three
 folds of writing paper.
   188. If it is demonstrated that the parietes of the
 uterus preserve the thickness which they have at the
 end of pregnancy only by the influx  of fluids; that
 their vessels dilate; in one word, that they become
 more  spongy and humid; why not admit that the
 place  where the placenta is attached  developes
 itself as much as the  others,  if not  more?
   189. Those who are acquainted with the texture
 of the uterus, and the extraordinary resistance which
 in its natural state it  opposes to any dilating force,
 cannot, without astonishment, see  it yield in preg-
 nancy, and permit the foetus to be  freely evolved in
 it: the more we consider it, the more wonderful the
 operations of nature will appear in this part of her
 work.
   190. The fibres of the uterus not only unfold and
 lengthen during pregnancy, but they also become
 softer, more spongy, and redder; so that  at last we
recognize in them all the  appearances of muscular
fibres: like  them too they are extremely irritable
and capable of contraction. 
86
Gravid Uterus.
   191. The vessels of the uterus are not exempted
from the effects of pregnancy. Bound to the fibres
which they supply, and extended by them in their
development, their numerous windings are effaced;
and being less pressed by the fibres which surround
them, some of them are dilated to a surprising de-
gree.
   192. If that dilatation  is not observed in all the
regions of the uterus where there are sensible ves-
sels, at least we observe it constantly in the  parts
occupied  by the placenta: there  all  accoucheurs
know that many of the sinuses mentioned in par.
158 become large  enough to receive the end of the
little finger, and the others a moderate-sized quill.
It is not only the sanguine vessels which are deve-
loped to that degree during pregnancy: the lym-
phatic vessels are much more so, in proportion to
their primitive diameters; since, according to Mr.
Cruikshank, they become as large as a goose-quill;
and besides appear so numerous, that  the uterus
seems to be nothing but a mass of those vessels.
   193. In proportion as the uterus is developed, as
its texture becomes  softer and  more spongy, the
arteries being straighter and less pressed, give less
resistance to the course of the blood; the motion of
that fluid becomes freer in them;  they then receive
a  greater quantity  in  a given time; they  transmit
more  into  the  sinuses or reservoirs which com-
municate  with the placenta, and  deposit there the
portion of blood destined to vivify the foetus and all
its dependencies.
   194. If these first phenomena are so many natu-
ral effects of the development of the uterus during
pregnancy, its contraction at the moment of delive-
ry produces others not less interesting,  since they
furnish us with useful reflections in practice. 
Gravid Uterus.
87
  195.  In  proportion as the cavity of this viscus
diminishes, the vessels fold and become convoluted
as they were before impregnation; they suffer a com-
pression not only so much the stronger, as the  ac-
tion of the uterus  on the  contained body is more
powerful, and as that body gives a greater resist-
ance; but also as it approaches nearer to its natural
state.
  196.  During this time the blood flows with more
difficulty through  the  arteries, and  passes more
slowly into the sinuses; the sinuses receive a smaller
quantity of it in a given time than before, and trans-
mit less into the parts indicated into par.  193.
  197.  The  blood passes with so much  difficulty
in the  arteries of the uterus when the labour be-
comes strong and lasting after the evacuation of the
waters  of the amnion, that all communication seems
to be intercepted between that kind of vessels  and
the sinuses in which they partly terminate; and be-
tween the sinuses themselves and those of the placen-
ta:  so that the child can be no longer vivified by the
blood of the mother, nor is there any considerable
flooding to be feared if the placenta should be de-
tached; and if any existed before, it will from  that
time be suspended. The closing and contraction of
the uterus after the exit of the child, and  still more
after delivering the afterbirth, produce  the same
phenomena.
   198. It  is on these observations that is. founded
the  precept which will immortalize the celebrated
Puzos  and the rational practice which he wisely
substituted to the blind and murderous routine fol-
lowed by most  accoucheurs before his time, in ca-
ses of violent flooding.* They serve equally for the

* Voyez l'Ouvrage de Puzos, Memoire sur les Pertes de Sang. 
88            Action of the Uterus.
base of an  enlightened  theory on the  origin and
natural cessation of the sanguine and serous lochia,
and for the explication of several other effects which
I shall speak of in the sequel.
           Of the Action of the Uterus.

   199.  The  uterus, very sensible and very irrita-
ble, in common with all muscles, enjoys two modes
of action—a tonic action, or elasticity, which is equal
and constant; and a spasmodic contraction, which
is sudden and momentary.  By the former, when it
is distended it constantly endeavours to restore it-
self to its original state; but it is by the latter that
it acquires the force necessary  to overcome the ob-
stacles to that restoration, and to deliver itself of
the bodies which encumber and incommode it.
   200. The tonic action of the uterus, or its elasti-
city, subsists after death, and seems to continue as
long as the heat of the subject. The  expulsion of
the foetus and its dependencies,  after the death of
the woman, seems to confirm  this truth;* and it is
likewise  proved by the contraction of the  uterus,
which takes place as quickly  and strongly as after
the most common labour, when we extract its con-

  * Many authors, assure us, that some women have been"
spontaneously delivered after their death; I shall dispense
with quoting  them. M. Levret adds to their testimony, by
saying that he is convinced of it from his own experience; but
I do not make myself responsible for any of these facts.^

  \ Harvey mentions the same fact, but with a view to prove
the agency of the child in its own delivery.    W. P. D.' 
Action of the Uterus.             89
tents at the instant life ceases.*  If we have a right
to conclude, from these observations, that the tonic
action of the uterus continues some time after the
cessation of life,  experience equally proves that it
may be so weak after delivery as to appear in some
measure destroyed.  As the parietes of the uterus
then remain soft, and without apparent action, it is
usual to express that state by the name of atony. I
must observe, with the surgeon of Dijon, whom I
have just  quoted, that the atony in question is not
an absolute loss  of tone  in  the uterus; but only a
diminution of its action, and of its irritability and
sensibility; a state of weariness,  of exhaustment; or,
in one word, of syncope, to make use of the expres-
sion of the aforesaid surgeon.
   201. In this state the  irritability and sensibility
of the  uterus are sometimes so  weakened, that it
will without difficulty bear the presence of the hand;
and even stimulating liquors injected into it cannot
force it to contract. This  case, often melancholy for
the woman, is at  the same  time one  of the most
deplorable for the  operator, whom  unreasonable
people consider  as  accountable for all events; for,
notwithstanding  his  utmost care and activity, he

   * M. Le Roux, surgeon, of Dijon,  perceived, in delivering
 a woman who had been dead about a quarter of an hour, that
the uterus contracted in proportion as he disengaged the child
 from it; and was as firm and solid as if the woman had been
 living. When he  proceeded to  extract the afterbirth, the
 neck of that viscus, he says, obstructed the introduction of the
 hand so much, as to give him some doubts of the reality of
 the woman's death. (Voyez Traite  des Pertes, observ. xiii.
 p. 25.)__In opening the body of the woman, whom I had de-
 livered  in the same manner immediately after her death, I
 found the uterus strictly contracted on the placenta, which I
 had not thought necessary to extract after the child, 
90            Action of the Uterus.
has almost always the mortification to see the woman
sink under the haemorrhage.
  202. The atony of the uterus, considered in this
sense, may affect all parts qf that viscus, or only one.
Sometimes it takes  place in the fundus and body
only, while the  neck enjoys its full tone: at other
times the neck alone is attacked by it, while the
other parts contract and close as usual. It  may be
in a greater or less degree; and manifest itself at the
instant of delivery, or some hours, or even days, af-
terwards; it may go off and reappear a number of
times, like  a syncope, properly so called: so that it
is not sufficient that the uterus be contracted in the
first  moments, as  almost always happens after de-
livery, for the  woman  to  be secure against an
haemorrhage, and for  the accoucheur to dismiss
all fear.
  203. The  remote  cause of atony may be, a bad
constitution in the woman; an haemorrhage from the
uterus itself, which sometimes precedes or accom-
panies labour; an extreme dilatation, when the ute-
rus contains much water, or several children. It may
be the effect of strong and long continued labour
pains, because the forces of the uterus n.ay be ex-
hausted, as well as those of other organs; and a sink-
ing always  succeeds  every  species of immoderate
action. Lastly,  it is  never  more to be feared than
after those deliveries  which the vulgar regard as the
most fortunate,  because they are the quickest and
least painful. In this  sort of cases, the uterus being
evacuated suddenly, and without any efforts,  the
child is,  as it were, washed out by  the current of
the waters; and the uterus falls into a kind  of tor-
por and  relaxation,  which  for a time  suspend its
contractile  faculties.
   204. This state of uterine syncope is more or less 
Action of the Uterus.             91
troublesome and dangerous, as it continues a longer
or shorter time; as it affects all the parts of the  ute-
rus, or only one; and as the placenta preserves more
or less of its connexions with that viscus. The atony
whose remote cause is an haemorrhage which has
preceded labour, is more dangerous than that which
arises from the quick and too sndden evacuation of
the contents of the uterus. In this latter case there
is nothing alarming while the placenta is not detach-
ed in any part; but it may have consequences equal-
ly dangerous, if that body should separate before
the forces of the uterus be  sufficiently restored. An
atony of the neck only  is not so alarming as that
which affects the fundus and body of the uterus; be-
cause  the placenta is most commonly attached to
the latter,  and more open orifices are  found there
than in the  former, &c.
  205. An  haemorrhage is the only  accident which
can essentially arise from  an atony of the uterus;
but it cannot take place unless the placenta be de-
tached, either totally or in part.  The  quantity of
blood  which a woman loses in a given time,  is in
proportion to the degree of atony, to the quantity
of the placenta separated from the uterus, and to the
momentum  of the blood, often augmented by the
labour pains which have  preceded it.*  The  hae-
morrhage is not always apparent: the blood some-
times is retained in the uterus; and may so far dilate

  * A woman lost before my eyes, and in presence of at least
thirty-five of my pupils, more than four pounds of blood in
the short space of three or four minutes, notwithstanding the
promptitude with which she was assisted: the coagulum col-
lected from  the bed, and put into the scale, weighed  more
than three pounds. The woman  was able to be carried home;
and was so, contrary to my wish, some hours afterwards,  with-
out the least inconvenience. 
92            Action of the Uterus.
it, as to give it nearly the capacity it had before the
exit of the child.*
   206.  A concealed hemorrhage  is more usual
when only the body and fundus  of the uterus  are
affected by an atony, than when it takes place in all
parts of it. The closing of the neck, in the former
case, is sufficient to retain the blood in the cavity;
whereas, in the latter, a congestion cannot be form-
ed, unless some foreign body mechanically stops
up the vagina.
   The state  of weakness and relaxation which we
call atony, disposes the uterus to be inverted, if we
attempt to extract the placenta, when it still adheres,
before the uterus  be contracted, and reduced to a
kind of globe, a little firm to the touch; as also if
the woman exerts strong efforts to expel it, while
that viscus is soft and inactive.
   The indication  presented by  an  atony  of  the
uterus consists in rousing the faculties which are,
as it were, asleep—in augmenting the sensibility and
irritability of that viscus: this is done by frictions
on the hypogastric  region; by applying hot cloths
to it, and  sometimes cold liquors, either aqueous or
spirituous; and by injecting them into the cavity of
the uterus. A flooding which arises from this state
of atony requires no other treatment; and cannot
be stopped but by the restoration of the faculties in
question.
   207. The  spasmodic contraction of the uterus is
a much more powerful action than its elasticity: it
is produced by an irritating cause unknown to  us;
and, unlike that of most of the muscles, is not sub-

  * In the woman whom I mentioned  in one of the  former
observations, though at the seventh day of her lying-in, the
extravasation of blood in the uterus was so considerable, that
\\?> fundus rose above the umbilicus. 
           Deplacement of the Uterus.         93

jected to the will: no woman can augment its force,
or diminish  it;  accelerate its return, or retard it;
though  strong passions of the mind may call it into
action, or stop its progress.
  208.  All parts of the uterus contract at the same
time, no one remaining at rest while the others act:
but  this contraction is not equally strong in every
part; for if it were, delivery could not advance. If
it is  stronger, in what is commonly called the fundus
than in its neck, it is because the fibres are not equal-
ly disposed, nor equally numerous in those two parts:
each fasciculus, taken separately, seems to act with
the same degree of force.
  Of the Descent or Prolapsus of the Uterus, of its
          Retroversion, and Anteversion.

  209. If the uterus, in a state of vacuity, descends
by the smallest impulse from the abdominal viscera,
it does it in a much more remarkable manner during
the first months of gestation; as well because it pre-
sents a greater surface to those same viscera, which
renders their impulsion stronger, as  because its
weight becomes specifically greater. It not only de-
scends farther at every impulse it receives, to rise
again afterwards;  but in general we find it habitu-
ally lower in these first periods of gestation than it
was before; and we observe that its fundus is almost
always inclined  backward, and its orifice turned
forward.
  210.  The accidents which arise from this first
species of deplacement, are in proportion to its ex-
tent, and the volume of the uterus relatively to the
capacity of the pelvis.  A sensation of heaviness at 
 94        Deplacement of the Uterus.

 the fundament; painful draggings about the groins,
 the umbilicus, and the loins, are the only ones which
 accompany the first degree of precipitation  of the
 uterus: a sensation of weakness, lowness, and faint-
 ness supervenes,  if the uterus descends farther; and
 the woman insensibly falls into a marasmus, if some
 remedy be not applied. I have seen several, in whom
 the return of health and flesh  has been produced
 merely by the application of a pessary.
   211. If the effects of a precipitation of the uterus
 are limited to a few slight inconveniences in the first
 months of gestation, it is not always so in the sequel.
 The uterus increasing more and more, and remain-
 ing so low, may compress the neck of the bladder,
 the urethra, and the rectum, in the same manner as
 a wedge strongly pressed into the middle of the
pelvis; which must occasion a retention of urine, a
 constipation,  and other accidents which will arise
 from those, as well as from the  pressure which the
 uterus itself must exert on the  other circumambi-
 ent parts.
   212. It is not only in those cases where the  ute-
 rus is thus developed in the midst of the pelvis, that
 it occasions a retention of urine; the same accident
 may happen if the uterus, less voluminous, descends
 so far as to engage itself very forward in the exter-
 nal parts,  and show itself without. This case, more
 easy to distinguish than the former, and in appear-
 ance more severe, since the descent of the uterus
 is  greater, is not however  so  troublesome  with
 respect to the retention of urine. When that symp-
 tom proceeds from such a degree  of precipitation
 of the uterus, it manifests itself all at once; and it
 is often the first effort of the woman to make water
 that forces it so low. In the other case, the retention
 of urine comes on slowlv, and it is  verv rare that it 
Deplacement of the Uterus.         95
takes place before the fourth  month of pregnancy.
At first the woman only finds a little difficulty in
making water; and greater obstacles succeed, by
insensible degrees, till the retention becomes com-
plete.
   213.  The course of the urine is quickly restored,
in the former case, by pushing up the uterus in the
pelvis, and supporting it so with the finger. Even
that assistance in many circumstances would not
be necessary, if the woman would lie on her back,
and keep the breech raised, whenever she feels an
inclination to make water.
   214.  We cannot so easily prevent or remedy it
in the latter case. For it to cease, the body of the
uterus must rise towards the middle of the belly,
and be so far developed that it cannot descend again
into the pelvis; which generally does not take place
till after the fifth month of pregnancy, and some-
times later. In the mean time, we may favour the
discharge of urine by removing the body of the
uterus from the urethra and  neck  of the  bladder,
with  a  finger  introduced pretty high behind, and
a little on one side of, the symphyses of the pubis;
or we may draw it off with the catheter as often as
occasion requires.
   215.  The mobility which the uterus preserves in
the midst of the pelvis, in the first periods of im-
pregnation, notwithstanding  the augmentation of
its volume, and the inclination  which it takes in
sinking a little, expose it to another species of de-
placement, less known and more rare than the pro-
lapsus;  but whose consequences have hitherto ap-
peared  more disagreeable. In this new species of
deplacement, the uterus seems to be laid lengthwise,
between the pubes and sacrum; but so that its fun-
dus sometimes remains a little higher than its ori- 
96         Deplacement of the Uterus.
 fice, and sometimes much lower, or appears on the
 same line which constitutes so many degrees neces-
 sary to be observed in practice.
   216. The retroversion is that deplacement in which
 the fundus of the uterus is turned towards the sacrum,
 and the orifice towards the pubes; and the antever-
 sion, that in which the fundus is carried behind the
pubes, and the orifice  before the sacrum. Both  one
 and the other may be more or less complete; but yet
 it seems, from the structure and connexions of the
 parts, as well as from  observation, that the antever-
 sion cannot become so considerable as the retrover-
 sion: it is besides more rare and less troublesome.
   217. The uterus may be inverted in either of these
 ways, while unimpregnated, and in the first three or
 four months of pregnancy. After the fourth month,
 its volume is generally so great that it cannot suffer
 such a deplacement; because its height  at that time,
 in most women, exceeds the breadth of the pelvis,
 taken from pubis to sacrum. One of the observations
 of Smellie seems nevertheless to prove, that this in-
 version in some cases may  take  place later, if he
really found it in the woman who is the subject of
it; since she  was  advanced in her pregnancy  five
months.*
   218.  This  inversion may take place slowly or
 suddenly; and the determining causes are then  dh\
ferent. In the former case, we may observe its pro-
gress from day to day, or from week to week,  and
it arrives insensibly at its highest degree; in  the lat-
ter it  becomes  complete  in  less than an hour,  and
often in an instant.
  219. When it takes place slowly, it seems to de-
pend on the slight but continued pressure of the
* Smeljie, trad. Frani;. 
Deplacement of the Uterus.         97
floating abdominal viscera on the fundus of the ute-
rus; either on its anterior or posterior part, accord-
ing to the species of obliquity  it has taken; so that
this pressure sometimes occasions  the anteversion,
and sometimes the  retroversion. It is by the same
mechanism that both kinds take place suddenly; but
that requires a stronger impulse, and that impulse
may be given by the action of the abdominal mus-
cles, or by external agents. The  uterus  has  been
sometimes inverted by straining to vomit, at stool,
or even to make water; and this inversion has often
been determined by a fall, a blow, or a strong com-
pression of the  belly. Some of the accidents pro-
duced bythisdeplacement soon add to its first causes,
and render it more  considerable, as I shall have oc-
casion to remark in par. 225.
   220. The accidents which proceed from the retro-
version and anteversion of the uterus, depend much
less on the degree or extent of the deplacement that
viscus has undergone, than on its volume relatively '
to the capacity of the pelvis. When a healthy uterus
and perfectly empty, is inverted in a pelvis of the na-
tural size, whether  its fundus be turned towards the
sacrum or towards the pubis, the woman feels nothing
but a troublesome weight on the fundament, painful
draggings in the groins, the fore part of the thighs,
and  the loins;  and  a sort of uneasiness  about the
neck of the bladder, and rectum, which excites fre-
quently an inclination to make water and to go  to
stool.  These symptoms augment in proportion  to
the  efforts the woman makes to overcome the ob-
stacles which oppose the  evacuation of the urine
and faces.  If the former with a great deal of pain
be established,  it is sustained with difficulty, and
appears often  interrupted.
   221. These accidents are manifested the moment
                       N 
98         Deplacement of the Uterus.
the uterus is inverted, when it is plethoric and tume-
fied, or when its volume is augmented by pregnan-
cy; because  it then acts with more force on the
neighbouring parts, and is itself more incommoded.
If the painful draggings which we have just men-
tioned are not more troublesome in the latter case
than in the  former, the weight on  the fundament
and on the neck of the bladder is greater; the  un-
easy sensations in the bladder and rectum are strong-
er; the difficulty of making water and going to stool
is more considerable: and, according as the uterus
is more or less voluminous relatively to the cavity
of the pelvis, there is a complete or partial retention
of urine, and an absolute constipation.
   222.  The  accidents increase to this degree in a
very short time;  and are very quickly aggravated
by new ones, when the uterus is completely invert-
ed in the third  or fourth month of pregnancy:  be-
cause its length from the fundus to the orifice equals,
and even surpasses, the distance from the pubes to
the sacrum;  which causes it to compress strongly
the neck of the bladder, the urethra, and the rectum,
from the  moment of its inversion, and to be itself
wedged in a  very uneasy manner in the cavity of
the pelvis.  Though the progress of these accidents
is rapid in this case, it  may  be very slow in that
where the inversion of the uterus takes place gradu-
ally, and at a less advanced period of gestation.
  223. Let us suppose it to take place before the
second month,  and to be complete.  The accidents
at first will be limited to those stated in par. 220,
because the uterus is still small at that period; but
as it is developed daily, notwithstanding its deplace-
ment, and as it successively requires a greater space,
it will at length more strongly compress the neck
of the bladder, and the rectum, till they both become 
Deplacement of the Uterus.         99
so far effaced as no longer to permit the discharge
of urine, or of the most liquid faces. It may happen,
in these circumstances, that the catheter cannot
penetrate the bladder, and it may be equally impos-
sible to administer clysters.
   224.  The uterus, already, as it were, wedged in
the middle of the pelvis, when the accidents are in-
creased to  this pitch, is wedged much more strong-
ly in it  in the  sequel, if we do not speedily effect
the reduction. Continuing to be developed, because
its contents continue to increase, and not being able
to do it according to  the  order in which that de-
velopment is made in the  common state of preg-
nancy, it moulds itself to the form of the cavity of
the  pelvis,  extending  itself towards those  parts
where  it finds the  least resistance. The  augmen-
tation of its  volume,  in this latter  period,  does
not only depend on the farther development of the
produce  of conception; it  proceeds also from the
tumefaction  of its  substance, which becomes full
and  inflamed.  As  the  space which the uterus then
occupies is greater than the superior strait;  as  it
completely fills  that space, and even finds  itself
compressed  there;  the  reduction of it becomes ex-
tremely difficult, and may even be impossible; be-
cause the length of its diameters exceed those of the
superior strait.*

  * In one of the interesting observations of Dr. Hunter, in-
serted in the fourth and fifth volumes of the Medical Obser-*
vations of London, we find that the uterus could not be redu-
ced; that the woman, very weak  when that physician saw her
for the first time, died the next day; and, on opening the body,
the uterus was found  so wedged in the pelvis, on all sides,
that it could not be disengaged  from it, till the symphysis of
the pubes  was divided, and  the bones considerably separated.
The parts designed and engraved, in all the necessary views,
are not the least valuable of those which formed the beautiful
collection  of Dr. Hunter. 
100        Deplacement of the Uterus.
   225.  The retention  of urine, and constipation,
 which we have hitherto considered only as accidents
 proceeding from the deplacement of the uterus, soon
 become, as it were, additional causes which concur
 with the others so as to render it more considerable,
 and also to oppose its reduction; but it  is only in
 that species called retroversion. The bladder cannot
 be greatly distended, and rise into the cavity of the
 abdomen, without bringing the neck  of the  uterus
 forward, and drawing it towards the upper part of
 the pubis, nor without acting on the body of the vis-
 cus, already depressed towards the sacrum, at least
 with a force equal to the weight of the urine it con-
 tains;  and that weight may amount to more than ten
 or twelve pounds in some cases. The faces, retain-
 ed and accumulated in the upper part of the rectum,
 above that portion of the  canal which is obliterated
 by the fundus of  the uterus, act in the same manner,
 and press that part lower  and lower. Add to that,
 the  impulse which  those faces receive every mo-
 ment from the intestinal action; and the efforts, often
 involuntary, which the woman exerts to make water,
 or go  to stool.
   226. These causes do not act so unfavourably in
 the case of anteversion;  for they seem rather to con-
 cur  in restoring  the uterus to its natural position
 than in removing it farther  from it; which may be
 easily  perceived by the  slightest attention to what
 is stated in the preceding  paragraph.
   227. Although the  abovementioned  accidents
 are so  many symptoms of those deplacements of the
 uterus called retroversion and anteversion,  they can-
 not however serve to establish the diagnostic of
 them;  because there  is not one of them which may
-not depend on another cause. It is only by the touch 
Deplacement of the Uterus.        101
that we  can certainly discover these deplacements,
and judge of the extent of each species: at a lit-
tle distance from  the entrance of the vagina, the
finger meets with a pretty solid  body,  in form of
a  tumour, which  fills the cavity of the pelvis:  it
is that of the uterus, which presents its anterior or
posterior surface  to  the touch,  according as it  is
found in a state of anteversion or retroversion, but
always covered by the vagina. In the latter the fun-
dus  resting against the sacrum, the orifice answers
to the pubes; in the former, the orifice is backward,
and it is the fundus which depresses the neck of the
bladder. In either  case, if we pass the finger into the
anus, to a convenient height, we find a tumour form-
ed by the fundus or neck of the uterus, which de-
presses the intestine; and the catheter introduced
into the bladder,  when it can penetrate it, demon-
strates the same thing.
   228. The essential indication,  in all these  cases,
is to replace the uterus in its natural situation, and
to keep it in that state. Though  we meet with few
obstacles to this reduction when  the deplacement is
recent, and the volume of the  uterus still  small,
they are very  great, and  sometimes insurmount-
able, when it has existed several days or weeks,
and the  voluminous uterus is wedged tight  in the
cavity of the pelvis.* Though the  principal indi-
cation consists in replacing the  uterus,  as I have
just stated, the accidents which  arise from its in-
version sometimes present more pressing indica-
tions, and require  a treatment which becomes pre-
paratory to the reduction, and   without  which in
many cases it could not be obtained.

  * See the case already quoted in the  London Medical Ob-
servations. 
 102        Deplacement of the Uterus.

   229. We begin, in  these  cases, by  evacuating
 the urine, if possible to do it, either by  insinuating
 the finger along and on one side of the symphysis of
 the pubes, to remove the  bod}  of the uterus from
 the urethra and neck of the bladder, or by introdu-
 cing a catheter. We must also evacuate the faces,
 if clysters can penetrate and  soften what are  accu-
 mulated and hardened in  the upper part of the rec-
 tum, and the Roman S of the colon.  We must have
 recourse to bleeding, and repeat it as often as the
 inflammatory state of the  parts require; we are to
 use fomentations and baths, and not to  proceed to
 the reduction of the uterus till we have prepared it
 in that manner. Though it has appeared impossible,
 in some cases, before the use of these  means,  it has
 been  easily performed afterwards, and  even in a
 manner spontaneously.
   230.  The  position of the woman which seems
 most advantageous, when we proceed  to the reduc-
 tion of  the uterus,  is that in which  the  abdominal
 viscera  make the least pressure  on it.  Therefore it
 has been recommended to place the  woman on her
 knees and elbows, so that the pelvis may be higher
 than the belly and  breast. Though this position is
 good  in some cases, it cannot be looked upon as
 essentially necessary in all. But it  is very neces-
 sary that the woman should not make  any pressure
 downwards while  we are employed  in replacing
 the uterus.*

  * Whenever attempts are made to reduce the retroverted
uterus, it is next to impossible for the woman to desist from
forcing downwards; and thus by the pressure made upon the
uterus by the abdominal viscera, it is prevented from ascend-
ing, and our efforts are thus counteracted.  I have therefore
made it a rule, in cases where symptoms required the reduc-
tion, to take off all resistance by bleeding my  patient ad deli- 
Deplacement of the Uterus.        10S
   231. Reducing the  uterus, is raising the fundus
to its natural situation. To effect this, it  is recom-
mended by some to introduce the fingers into the
vagina, and by others to introduce them into the
rectum. It is impossible to ascertain the quantity of
force necessary for the reduction;  sometimes very
little is  required, and at others a great deal.  The
fear of producing abortion ought not to prevent our
making an attempt, as this is not  a necessary con-
sequence, even where a great deal of force has been
employed.
   232. The reduction of the uterus is so important
for the preservation of the woman, that Dr. Hunter,
instructed  by  experience that  it could not  be ac-
complished, in some cases, without first diminish-
ing its volume, has recommended to evacuate the
waters of the amnion,  which are always abundant in
the  first months  of  pregnancy,  by  a  puncture
through the vagina.^ This puncture which is no
                           t
quium. When a  state of faint is induced, I have her laid on
her back on a bed, with her knees bent towards the abdomen;
the parts having  previously to the  bleeding been well lubri-
cated with hogslard, that immediate advantage may be taken
of the relaxation; I then introduce my hand in a state of su-
pination along the internal face of the perinaum towards the
hollow of the sacrum, and thus make the extremities of my
fingers carry along with them, the forced down fundus, until
it is placed above the projection of the  sacrum—I then in-
troduce a common pessary, and leave my patient to rest; I
recommend rest  upon the bed for two or three days, draw off
the urine for that period with the catheter, and have the bowels
opened by mild injections.
  It is to be remembered, that, the urine and faces are dis-
charged previously if possible, to any attempt at reduction—
the success of this method has been invariable with me.
                                     W. P. D.
  t This practice I trust is never necessary, even in the most
desperate cases, as I  believe no case of this kind can occur
where, the practice I have just ventured to recommend will
not succeed. At least, Dr. Hunter's method should not be had
recourse to, until the other has failed.         W. P. D. 
104       Deplacement of the Uterus.

way dangerous in itself, has not yet been practised
with that view; because the case for which Hunter
recommended it, did not occur a second time  in
the course of his practice. I  do not  see that any
thing better could be done in so deplorable a cir-
cumstance.*
  233. The uterus being  reduced, must be main-
tained in its natural situation. A proper position
on the part of the  woman, and an attention not to
press downwards either to make water, or to go to
stool, have sometimes sufficed  for that purpose; but
the application of a pessary seems indispensable in
most cases.
  234. The accidents which arise directly or indi-
rectly from these deplacements of the uterus do not
always cease immediately on the  reductions being
made; and often afterwards present new indications
which must not be neglected:  I shall only mention
the retention of urine, as an example. It,depended
at first on the pressure exerted by the uterus on the
neck of the bladder;  but, after the reduction, it may
be continued  by the inflammation of that  part,  or
by an atony of the bladder in consequence of its ex-
treme dilatation. The  surgeon must  endeavour to
discover the cause and treat it accordingly.
          Of the Obliquity of the Uterus.

  235. The  authors who have spoken of the obli-
quity of the uterus, have  established four  general
kinds of it:—1. An inclination forwards; 2. Back-

  * See the Observations of Dr. Hunter in the London Medi-
cal Observations, vols. iv. and v. 
Obliquity of the Uterus.         105
wards; 3. To the right side;  and,  4.  To the left.
One of the most celebrated has divided them into
others;*  and indeed  they might be multiplied ad
infinitum. After the right lateral obliquity, the an-
terior is  the most common; that of the left side is
prettv  rare;  and we may doubt  the possibility of a
posterior obliquity, which M. Levret and his fol-
lowers only admit when the lumbar vertebra are
curved in a  direction contrary to  their natural
state;! that is  to say, when their assemblage de-
scribes a concavity forwards, instead of that con-
vexity, which has hitherto appeared to me so much
the greater, as  the woman was more deformed.
   236. If it was believed, at first, that the obliquity
of the  uterus was an effect of its bad conformation,
of the relaxation of some of its ligaments, and the
contraction  of others; of certain tumours of the
neighbouring parts, or of the  habit which many
women are  in  of sleeping only on one side; most
authors,  especially since M. Levret, attribute it to
the attachment of the placenta  to some other part
than the fundus of the uterus. The most common
cause  of a deviation  of  the uterus, says that cele-
brated accoucheur, depends on that part of  that
organ  on which the placenta is implanted; for if it
is not  fixed on the fundus, or  on the orifice, it al-
ways draws that viscus to the side next which it is
attached. The most common cause after this, con-
tines M. Levret, is the original or accidental bad
conformation of the uterus, or of some of its parts,
or even of those in its neighbourhood 4

   * M. Levret l'Art des accouchemens, edit, troisieme, sect.
283, et suiv. sect. 638.
  f L'Art des accouchemens, edit, troisieme, sect. 635.
   t Ibid. sect. 633, 634.
                        O 
106         Obliquity of the Uterus.
  237. The obliquity of the uterus seems to  be a
necessary consequence of the roundness it acquires
in developing; of the figure and situation of some
of the surrounding parts, of the mobility of others,
and of the changes which their functions determine
in them every instant: but what is the cause which
obliges it to incline to one side rather than on the
other? If the obliquity were caused by the implan-
tation of the placenta in any other part  but the
centre of the fundus uteri, it would constantly take
place on  the side where that mass is found.  But we
often find it on the opposite side; and M. Levret
himself furnishes a proof of it in the second case
which he relates from M. Buzan:  we there see that
the  uterus was very much inclined to the right side,
though  the placenta was attached to the  left, and
very near the orifice. The uterus  is almost always
inclined  to the right side; and the placenta is not
oftener attached to the right lateral  part of that
viscus, than to the rest of its surface.
  238. It would  be easy to  prove that this mass
cannot in any case oppose the development of that
portion of the uterus to which it adheres, and does
not by that means force the uterus to take an ob-
lique form, as is asserted by M.  Levret,  nor even
any other form than it would  have acquired in de-
veloping, if the placenta had struck its roots in the
middle of the fundus. All authors agree  that the
place where the placenta is engrafted is thicker than
other parts; but  they add that the uterus, in that
same part, is softer, more spongy, and more humid.
M.  Levret has not a different opinion of  it; for he
expresses himself thus, sect. 279:  " When the pla-
" centa attaches itself to the fundus of the uterus, that
" part of it preserves a  great deal of thickness,
" no: withstanding its prodigious extension at the
u latter end of pregnancy." 
Obliquity of the Uterus.         107
  239. The anterior obliquity is caused by the di-
rection of the axis of the pelvis; the  inclination of
the superior strait in a well-formed pelvis is  gene-
rally estimated from 35 to 40°;  and the axis of this
strait is inclined nearly as much, but in a contrary
direction, as it descends  from  the umbilicus to  a
little above the point of the sacrum; the uterus can-
not therefore rise through it but by inclining for-
ward, and resting against the abdominal  muscles;
the support it finds from these,  will  be in propor-
tion as they have been more or less weakened by
former pregnancies. Therefore  we  may  observe,
that this species of obliquity is, caeteris paribus,
greater each  pregnancy.
  240. It will perhaps appear more difficult to as-
sign the true cause of lateral obliquities.  I am in-
clined to think they are determined by the relation
of the uterus to the rectum, and the Roman S of the
colon; by the anterior convexity of the lumbar co-
lumn, and the situation which the small intestines
take relatively to the uterus,  which lifts them up, in
proportion as it advances in the  abdominal cavity.
  241. The  relation of the uterus,  developed and
rounded in its body in the second or third  month of
pregnancy, with the rectum,  which forms a sort of
winding column along the sacrum, is such that those
two parts cannot touch but by convex surfaces, and
consequently by  very few points, like two  balls.
Now, if we allow the uterus the mobility which  it
really enjoys in the midst of the  pelvis, we shall be
forced to agree that the centre of its  posterior con-
vexity cannot remain  constantly against  the con-
vexity of the anterior surface of the rectum, which
on each side  offers its planes so  much the  more in-
clined, as it is then, though momentarily,  more di-
lated by the faces. This salient  point of the poste-
rior part of the uterus will  then  turn away, and 
108          Obliquity of the Uterus.
place itself on one  of the  sides of the  intestine;
Which cannot take place without removing the mid-
dle of the fundus from the axis of the pelvis, and in-
clining  it towards one of the lateral parts.  If  the
rectum  descended in a right line from the  middle
of the projection of  the sacrum  to the point of  the
coccyx, the space being  equal  on each  side,  the
uterus would be equally subject  to incline to either,
and  we should not  see the right lateral  obliquity
oftener  than the  left; but being placed on the left
side of the base of that bone, and leaving its curve
less free on that side than on  the right, the  poste-
rior convexity of the uterus is almost always direc-
ted towards the latter, and the centre of its fundus
inclines that way preferably. This first degree of
obliquity, which depends entirely on the relation of
the form of the body of the uterus to that of the
intestine, during its stay in the pelvis, is easily dis-
covered by the touch, in  most women,  after the
second or third month of gestation; the  orifice of
the uterus being from that time lightly turned to the
left side of the vagina, and much more manifestly
from the third to  the fourth month.
  242. The accumulation  of faces  in  the rectum
and the  extremity of the Roman S of the colon, and
the direction of the course they must take to pass
out, are additional determining causes of  the right
lateral obliquity of the uterus; since they press that
viscus from left to right, and with so much the more
force as that which expels them  is itself greater.
  243. These causes  acting almost  always in the
same manner; and not being able to act otherwise,
at least without a vicious conformation, a transpo-
sition of the Roman S of the colon, and of  the supe-
rior extremity of  the rectum—we ought not to  be
surprised that the fundus of the uterus inclines so 
Obliquity of the Uterus.         109
often to  the  right side,  and so rarely to the left.
Every attentive observer may in fact remark, that?
the right lateral obliquity is so frequent, and the 1
left so rare, that perhaps we should.be far from es-
tablishing  the due proportion of one to the other,
by saying that the latter  is scarcely met with once,  ;
where the former is an hundred times.  As the left
lateral obliquity cannot depend on the same mecha-
nism, nor on the attachment of the placenta to the
side of the uterus, what  must then be the determi-
ning cause of it"? We can only attribute it to the
concurrence  of some of  the accessory causes here-
aftermentioned
   2 +4 The fundus of the uterus, already a little in-
clined, as observed in par. 241, cannot afterwards
rise in the abdominal cavity, but in an oblique di-
rection: so that the small intestines are obliged to
give  way to  it, and go  towards the left side; to
which, according to the disposition of the  mesen-
tery, they  seem to have  a more natural inclination.
   245. The  convexity of the lumbar column very
much favours the lateral obliquity; and might de-
termine  it, exclusively of any other cause, if it did
not  already  exist,  in a  slight degree, before the
uterus is raised  above  the superior strait.  That
viscus growing rounder and rounder, without losing
any  of its mobility,  in  proportion as its contents
augment, cannot rest on that column, which offers
it, on each side, spaces much better  adapted  to its
figure. Supposing then  that it has risen above the
superior strait, till the  fifth month of pregnancy,
without  turning away its axis from the axis of that
strait, it would still be forced to change its  direc
tion, and incline to one  side;  because the greatest
convexity of its posterior part, which  would then
answer to that of the second and third lumbar ver- 
110          Obliquity of the Uterus.
 tebra, could  not rest on  that point:  it is in  this
 manner that the left lateral obliquity must happen,
 when no other cause determines it accidentally.
   246. It is by examining and feeling the belly of
 the  woman that we form a  certain judgment of
 the species of obliquity which exists, and of its ex-
 tent,  though it is sometimes  apparent to the sight.
 Experience also proves that we may, at will, change
 the situation of the fundus of the uterus, by causing
 the woman to take a different position,  while the
 neck of that viscus remains fixed against  the same
 point of the pelvis; unless, by means of the finger
 passed into its orifice, we draw it to another part.
   247. The obliquity of the uterus is in general of
 much less  consequence than is  commonly said.
 There is in fact, no accoucheur a  little in  vogue,
 who must   not have  observed, a thousand times,
 that the greatest obliquity of the  uterus  does  not
 constantly  disturb the mechanism of labour,  nor
 always render it  more tedious.  I have assisted a
 great number of  women who have been delivered
 in a few  pains, though the uterus was so inclined
 forward, that the belly, like a wallet,  fell  down to
 the knees wrhen they were standing.
   248.  When the obliquity  is considerable,  the
 neck of the uterus, commonly appliedVigainst some
 part of the sides of the pelvis,  opens with much
 more difficulty than if it answered to the centre of
 the cavity,  because the forces which tend  to open
 it are then directed in such a manner as to be partly
 lost on the  side of the pelvis; which renders the la-
 bour longer and more laborious.
  249. In this case, if the membranes break early,
 if the action of the auxiliary powers is pretty strong,
and the pelvis large, the child's head presents itself
to  the vulva, covered by a portion of the  uterus, 
Obliquity of the Uterus.          Ill
which it has extended and forced to descend be-
fore it, while the orifice  is carried farther and far-
ther backward;  which produces much  greater ac-
cidents, if the  accoucheur does not prevent them
in time; by checking those efforts which depend on
the will of the woman, by pushing back the child's
head a little in the  interval of the pains, and by
drawing the orifice of the uterus under it, and to-
wards the  centre of the  pelvis, and maintaining it
in that situation. The two  following cases appear
to me very fit to demonstrate the disagreeable con-
sequences of obliquity of the uterus in such circum-
stances, and the  salutary  effects  of the conduct
which I recommend. One of these cases is extrac-
ted  from a memoir on the obliquity of the uterus,
which  was communicated  to the Royal Academy
of Surgery by  M. Bavaii, surgeon-accoucheur in
the states of Brabant;* the other happened under
myT own care.
  Case I. A  woman of the village of Grimberg,
near Brussels, pregnant of her first child, not being
able to have M. Bavaii at  the beginning  of  her
labour, had  recourse to a midwife  who kept  her
standing, and made her bear down, whenever a pain
came, during three days and  two nights; so that the
child's head appeared at the vulva, enveloped in the
anterior part  of the uterus, when this surgeon was
sent for again. This portion of the uterus, which
was like a  cap  on  the child's head, was, says  he,
inflamed; and the orifice, which he could not dis-
cover  without a great deal  of trouble, answered to
the superior part of  the sacrum, and was not open

  *  This memoir is nothing but an abusive criticism of what
the first  edition of this work contains on the obliquity of the
uterus, and only displays the ignorance of its author. 
112         Obliquity of the Uterus.
farther than the breadth of a sixpence: the waters
had been drained off some days. Recourse was had
to bleeding, clysters, and emollient  fomentations;
and M. Bavaii, being scarcely able to  keep back the
child's head, and prevent it from clearing the vulva
enveloped in the portion of the uterus which cover-
ed  it, thought of laying the  woman so  that the
breech might be higher than the shoulders; and not-
withstanding that, continues he, a gangrene came
on, and the woman expired. Proceeding to open the
body in presence of M. Le Botte, sworn surgeon
of the Abbey  of  Grimberg, they observed that the
placenta was attached  to the  middle and inferior
part of the anterior paries  of the uterus; that the
pelvis was well formed, and very spacious; that the
orifice of the uterus answered to the nape of the
child's neck, the head having  come out enveloped
in a portion of that viscus, which was gangrened
and separated from the rest.  This case, in which I
have in some measure preserved the expressions of
the author, presents in a clear and alarming man-
ner, the melancholy effects of an obliquity of the
uterus, when the woman is left to herself, or com-
mitted to the hands of blind and temerarious igno-
rance. The following, on the contrary, demonstrates
what  we  may expect  from the assistance of art,
when well directed.  I have chosen it  from among
many which have fallen within my own observation,
because it is impossible that any one can  be more
similar to that of M. Bavaii.
   Case II. Towards the end of  the  year 1773, a
woman, robust and well made, and  Tvho had al-
ready had several children, presented herself to be
delivered in presence of my pupils; and by her ob-
stinacy procured them  an opportunity of observing
perfectly the effects of obliquity of the uterus, when 
             Obliquity of the Uterus.         113

it is not corrected seasonably, as well as what may
be expected from the timely application of the pre-
cepts of the  art. The uterus in this  woman was
manifestly inclined to the right side, and forward,
so far, that its orifice, turned backward, was  diffi-
cultly discovered by the touch. The waters broke
away, and her pains  were strong and frequent: the
child presented well. Nothing could convince this
woman of the necessity of remaining in a horizontal
position, and of supporting the presence of the finger;
she went on, sometimes sitting and sometimes stand-
ing, giving herself up inconsiderately to the most vio-
lent efforts, whenever she felt a pain; so that, after
twelve or fifteen hours' labour, the  child's head ap-
peared to occupy the lower part of the pelvis, co-
vered by the anterior and inferior part of the uterus,
so much that it might be perceived in that state by
separating the labia,  and opening the entrance of
the vagina  a little.  The  finger  passed over the
whole spherical portion which presented itself in
that manner, without finding the orifice, which was
then thrown  more backward, and as high as at the
beginning: it was necessary to  insinuate the finger
almost to the base of the sacrum, to touch its ante-
rior edge. The  portion  of the uterus  pushed for-
ward,  and forming  under  the child's head a kind
of cap which covered it entirely—more  apparent
still to the view in course of labour, because  it ap-
proached nearer and nearer to the entrance of the
vagina—was smooth, shining, tense,  wonderfully-
injected, and covered with an admirable network
of vessels. It became so  extremely sensible, that
the woman could not bear the slightest touch on it;
and the whole abdomen, threatened with  the same
inflammation, was so  painful that  her clothes be-
came  troublesome.  She was in a  high fever, and
                        P 
114         Obliquity of the Uterus.
   her  ideas began to be  deranged,  notwithstanding
   several bleedings; when a fortunate incident ren-
   dered  her sufficiently docile to listen to the advice
   which she had rejected for eight and forty hours, and
   to suffer the treatment which we would have put in
   practice from the beginning. Intimidated by the
   unexpected appearance of two men of the law, dres-
   sed  in their robes, she laid  herself  on the bed:  I
   raised up the  belly with one  hand, to diminish the
   obliquity of the uterus; while with two  fingers of
   the other, after having pushed back the child's head
   a very little, I was able to hook the anterior edge
   of the  orifice,  to bring it towards the centre of the
   pelvis, where I kept it during a few pains; and then
   permitting the  woman  to bear  down  with  the
   little strength  she had left, she was delivered in the
   space  of a quarter of an hour.  Her child  was
   healthy, and the subsequent  symptoms were very
   simple.  If this case were not sufficient to confirm
   the utility of this practice, I  could support it with
   many others.
     250. In women who  have the pelvis rather nar-
   row, the head, thus covered by a portion of the neck
   of the  uterus,  does not descend so  low as in others;
   but  in all, as the efforts which tend  to push the head
   forward act perpendicularly on the portion of the
1   uterus which  covers  it, that portion is distended,
   inflames, and tears,  if we  do not  prevent  those
   effects by correcting the obliquity of the uterus; and,
   if that  be not sufficient, by bringing the orifice to
   the centre of the pelvis, and keeping it there till the
   head be engaged in it; as I have just recommended.
     251. To prevent these effects we must then lay
   the woman on the side opposite to the deviation of
   the fundus, in order  that the uterus, charged with
   the wreight of the child, may incline that way; and 
Of the Menses.
115
to this precaution we mayr sometimes be obliged to
join that of pressing the belly to that side with one
hand.  We must moreover, in an extreme anterior
obliquity, recommend to the  woman not to bear
down; because  those efforts would become con-
trary to the end proposed, and would only augment
the obliquity.  If the orifice, by means of these pre-
cautions, does not approach the centre of the pelvis,
after waiting a proper time, we must bring it thither
with the finger during the absence of the pains, and
keep it there till it be sufficiently open to allow the
membranes with the waters to  engage in it like a
wedge. I can assert with confidence that the length
of labour,  in  many cases,  proceeds from the want
of this favourable relation of the orifice of the uterus
to the pelvis; and that the most certain means of ac-
celerating the labour, and sparing the woman a great
number  of useless and fatiguing pains, consists in
establishing that relation, in the manner I have just
recommended. There is nothing to be feared from
this procedure: it cannot produce a rent, nor inflam-
mation of the neck of the uterus, nor flooding, &c.
                 Of the Menses.

  252. The uterus, before the age of puberty, re-
ceives  no more blood than is necessary for its nu-
trition and growth; but, from that age to forty-five
or fifty years it suffers a periodical sanguine plethora,
which is followed by a depletion more or less abun-
dant, known by the name of menses.
  253. Almost all women are subject to this evacu-
tion; the derangement or suppression of which, ex- 
116
Of the Menses.
cept during the time of gestation, or giving suck,
seldom fails to injure their health.
  254. The first and last appearance of the menses
are  sooner or later, according to the constitution of
the  woman, her manner of life,  the country  she
inhabits, and an infinity of other circumstances. In
our temperate climate, this evacuation begins about
the  twelfth or fourteenth year, and ceases between
the  forty-fifth and fiftieth.
  255. It is not, however, extremely  uncommon
to meet with women who have had their menses
sooner, or in whom they have  ceased later.  In some
they appear even from infancy, and in others they
have continued to an extreme age.
  256. In a well constituted woman, the duration
of this evacuation,  and its periods, are almost in-
variable; but there are differences in each individual.
In some women the blood flows during  six or eight
days, in others only three or four, or even  less. So
there are some who menstruate every twenty-seven,
eight, nine, or thirty days; and others twice a month;
and many only every six weeks or two months,  and
even  seldomer. But there are very few who,  like
her mentioned by Deventer, have this  evacuation
only during their pregnancy.*
  257. It is impossible to know the exact quantity
of blood  each woman loses every month,  because
the  quantity is not the same in all, and because a
great number of circumstances may make it vary: it
is generally estimated at from three to four ounces.
  258. As it is more easy to judge of the nature of
this blood, we may affirm that it has not those nox-

   * Deventer, sur l'Art des Accouchemens, chap, xv.t

  t A case of this kind came under my notice in the year  179-1
at Abington.                            W. P. D. 
Of the Menses.             117
lous qualities which some have attributed to it. If
it does not always appear so pure as that drawn from
other parts  of the body, it is because it is mixed
with the humours of the vagina, or is corrupted by
its continuance in that canal, or in the cloths which
receive  it.
  259.  The menses do not always come red at first;
sometimes they begin by a discharge of serum, and
finish in the same manner. Often also, in girls, they
are preceded by acute pains, which, on account of
their seat and nature, might make one think they
are similar to those which succeed delivery, which
are commonly called after-pains. The cause of both
seems to be the same: all these pains depend on the
fulness of the blood in the sinuses of the uterus, and
the difficulty which it finds to escape.
   260.  The source of the blood of the menses is at
present well known:  we know that it distils from
those openings which we observe in the whole  ex-
tent of the cavity of the  uterus, in the neck, and
perhaps from  the vagina. If there still remain any
doubts on this subject, it is about what kind of ves-
sels furnish it; for some maintain that it comes from
the arteries,  and others assure us it is  discharged
from the uterine sinuses or veins. For my own part,
I think it comes from the uterine sinuses.*
   261.  We know not  the cause of the periodical
return  of the menses.  Most authors, by attributing
 it to a plethora of the uterus,  have left us as much
 to seek as those who have ascribed  it to another
 cause;  since they have not determined what causes

   * The sentiments of later physiologists on this subject arc
 very different from that of our author; most are now of opin-
 ion, it is a secretion from the membrane immediately lining
 the uterus.                               W. P. D. 
118             Of the Menses.
that plethora, nor  why it returns constantly at the
same period.
  262. If this evacuation is an astonishing phenome-
non, it  is not less so to see it stop suddenly never
to return, whether at the natural epoch, or  earlier,
without  injuring  the woman's  health; while  its
smallest derangement, before that period, sometimes
occasions such an  infinity of accidents.
  263.  The cessation of the menses unfortunately
does not always happen  thus. They most frequent-
ly become very irregular before they arrive at that
period: sometimes they  are  excessive, and  some-
times flow in so small a quantity as scarcely to mark
the linen: they often appear twice a month, and then
stop for six  weeks or more.
  264.  The time  of the cessation of the menses is
often justly called the critical time of women; for a
very great number, overwhelmed by the infirmities
which then attack them, ever after drag on a mise-
rable and languishing life. That epoch is also in
some women that of the return of their health, which
the continual vicissitudes of this evacuation had con-
stantly deranged.
  265.  The sterility of women who are  entirely
deprived  of their  menses, the suppression  of that
evacuation during pregnancy and giving suck, suf-
ficiently declare that it is not a depuration, but mere-
ly a depletion, and that that blood had a much more
precious destination. It is indeed so necessary  for
the development of the foetus during pregnancy, and
for  the  secretion of milk after delivery, that the
menses in those two states have always been looked
upon as an unnatural evacuation. 
Of Generation.
  266. This general operation of nature, by which
any individual produces its like, is called generation.
This  act, in  animals, always requires the union of
the two sexes, and cannot be performed without it;
excepting some few who singly enjoy the power of
reproducing themselves.
  267.  But this reproduction, is it only the deve-
lopment ofa preexisting animal? And does it come
from  the father or the mother, or is it formed of
the principles furnished by both? In the latter case,
what  are those principles, and how are they united?
—These are questions impossible  to resolve, or at
least on which I shall risk no conjecture.
   268.  Neither shall I lose time in  analysing the
different systems established concerning generation;
but shall content myself with mentioning them very
briefly.  They may be reduced to two principal ones;
that of the mixture of the two seeds, and that of
eggs.
   269.  The first was that of the ancients, who ima-
gined that a woman discharges a prolific liquor in
coition, like that of a  man. This  system, though
generally adopted, had its detractors; and some even
among  the ancients maintained that  the liquor in
question was no more than an humour secreted by
the glands of the vagina: in fact, if it came from the
ovaria,  how  could it  escape  during pregnancy?
To judge only by the sensation of pleasure,  and
that kind of orgasm which a woman feels in the re-
gion of the fallopian tubes, at the moment she gives
herself up to the pleasures of hymen, it seems proba-
ble that some fluid flows from the ovaria towards the
uterus; for that sensation cannot be excited by the 
120
Of Generation.
 liquor which  the woman emits without, since it is
 felt by the greater number independently of that ap-
 parent emission.
   270. M. de Buffon has only embellished this first
 system. According to that learned naturalist, the
 man and woman furnish equally what is necessary
 for generation. Their seed, says he, is nothing but
 an assemblage of organical particles, extracted from
 all parts of the body, of which they form, as it were,
 so many epitomes. These organical particles, which
 he calls living and active, because of their continual
 motion, are so shaped and formed, that they cannot
 unite and assimilate but with the particles sent from
 the same parts of the other sex; that is to say, that
 the particles furnished by the eyes of the man,  can-
 not be caught and united  but by those furnished
 by the eyes of the woman; and so of the rest.
  271. The formation of the parts of generation, so
 different in the two sexes, not being explicable by
 this  ingenious  system, the author's invention has
 supplied it, by supposing that the particles sent from
 one sex only, formed the basis of the whole edifice;
 and that it  turned out a boy or a girl, as those par-
ticles belonged to the man or the woman.
  272. The system of the ancients, mentioned above,
 maintained itself in full vigour till the discovery- of
the vesicula with which the ovaria of women are re-
plenished at the age of puberty^: that discovery im-
 mediately  excited the attention of physiologists. It
now began to  be believed that man and all other
animals come from eggs; and that all the difference
between viviparous and the oviparous consisted in
this—that the one, having hatched their eggs within,
deposit their young alive; whereas the others hatch
them after they are laid.
  273. According to this system, adopted by the 
Of Conception.              121
greater part of the moderns, the fecundated egg de-
scends into the uterus by means of the fallopian tubes;
but has any one seen it? We may be allowed to doubt
it, as well from the structure of the tubes, and the
relation of the caliber of their internal extremity to
the bigness of those little spherical bodies which we
take for eggs; as from the  numerous experiments
of a philosopher who is the wonder of his age.*
   274. The partisans of this system, though agreed
on the admission  of eggs, are nevertheless divided
concerning  the mode of their vivification.  Some
have thought that the foetus was ready formed in the
egg, and only wanted to be excited by the seminal
power of the male; others, on the  contrary, that
those eggs were only a kind of nests  destined to re-
ceive one of the little animalcula  which have been
supposed to be discovered  in the  semen by the help
of a microscope.
   275.  The insufficiency of all these systems, and
all these  hypotheses, for explaining the surprising
phenomena of generation, shews but too plainly the
depth of that abyss, where the reason of man often
wanders,  for  want  of knowing the  bounds which
nature has prescribed to his intelligence and his re-
searches.
                 Of Conception.

  276.  The union of the principles furnished by
both sexes for the purpose of generation, in the hu-
man species, is called conception. If this union is
not always performed in one of the ovaria, it will

              * The Baron De Haller.
                        Q 
122              Of Conception.
 be agreed, at least, that it is performed there some-
 times: since the remains offoetuses, and evenfcetuses
 entire, have been found in them.
   277. Those that have been found in the tubes
 prove that conception may take place in them, or,
 at least, that those conduits may serve to transmit
 the body, which is the produce of it, to  the uterus.
 Children which have been found in the cavity of the
 abdomen after the rupture of the tube,  or of the
 membrane of the ovarium, furnish evident proofs of
 the place where conception is performed; and those
 which have  been developed in that cavity, and had
 got thither  without any injury to the tube, prove
 much less that it may be performed  in them, than
 that it then had taken  place in the ovarium.
   278. Admitting that it takes place constantly in
 the ovarium, and that  the ovarium is the  first habi-
 tation of man, and that the tube is. only destined to
 transport the fecundated egg into the uterus—ought
 we not to be surprised that so many  eggs get into
 that viscus;  and  that the  tube, whose extremity is
 so large, and whose internal  orifice  is so narrow,
 lets so few of them fall into the cavity of the belly?
   279.  Though some women know, as we  may
 say, the very moment  of conception, by the inter-
 nal movements which they feel, the greater  part
 never suspect that they  have conceived till after
 the suppression of the menses. It would  be  a desi-
 rable  thing however, in many cases,  to have a cer-
 tain knowledge of that state earlier, that  we might
 not attribute the disorders which frequently accom-
 pany the beginning of pregnancy to other causes;
 nor employ  medicines not only useless,  but some-
times pernicious. 
Of Pregnancy.
  280. The state of a woman who has conceived
is  expressed  by the  word pregnancy; that state
lasts from the first instant of conception to that of,
the exit of the body which is the result of it.
  281. We may distinguish two general species of
pregnancy, relatively to the  nature of the produce
of conception; viz. a true, and a false. The first is
formed by one or several children; and the second
by a mole, which sometimes is of a kind  of fleshy
substance, and sometimes vesicular, &c.  We may
also give the name of false pregnancy to those collec-
tions of blood, of water, and glairy humour, which
are formed in the uterus, as well as to the  tympany
of that viscus; because they are always accompanied
by some of the rational symptoms of common preg-
nancy; because, like that, they occasion a develop-
ment of the belly, and may keep the  most skilful
accoucheur a long  time in the greatest uncertainty
concerning the true state of the woman.
  282.  A true pregnancy  has received  different
denominations, according to the place occupied by
the child.  It is called  an uterine  pregnancy when-
ever the child is contained in the uterus; a tubal, an
ovarial, or an abdominal pregnancy, when  the child
is found in one of the tubes, the ovaria, or in  the
cavity of the  abdomen. These three latter species
are also comprised in the generical name of extra-
uterine pregnancy.
  283. An uterine pregnancy is generally formed
by one child,  but sometimes by several; which  has
caused it to be distinguished into simple and com-
pound. We may also call it a compound pregnancy,
when the child is accompanied by a mole, and when 
124              Of Pregnancy.
there is already an extra-uterine pregnancy exist-
ing;  which  is not without  example, though  we
rarely meet with it.
  284. These different species of pregnancy have
some signs common to them all, and others which
are peculiar to each of them.  The former  are, the
disgust which the  woman feels for certain things,
strange longings, a spitting, nausea and  vomiting,
a suppression of the menses, a swelling and tension
of the breasts, &c.
  285. These symptoms, which are called rational
signs of pregnancy, characterize it however  in  a
very uncertain manner; and will appear very equi-
vocal, if we recollect that they have been often ob-
served in consequence of a simple  suppression of
the menses.  The suppression of the menses is not a
more certain sign of pregnancy,  as  their presence
is not always a negative proof of it; some women
being regular during the first two or three months
of gestation, others having ceased to be so a long
time before  conception, and some few being so
only during pregnancy.
   286. Though the greater part of these symptoms
united, or separate, offer us at most but  probabili-
ties concerning the state of the woman who expe-
riences them; the particular signs which I am now
going to describe, enable us to discover it from the
first months, and  to judge of its species, its  dif-
ferent  periods, &c. It  is by touching that we dis-
cover all these things. 
Of Touching.
  287. Touching, considered relatively to the art
of midwifery, is not confined to the introduction of
the finger into  the vagina, but comprehends also
the application  of the hand to the abdomen of the
woman. It is by the former we discover the state of
the neck of  the uterus, its situation, &c; but it is
by the latter that we must judge of the volume of that
viscus, of the height of its fundus, its obliquity, Sec.
  288. Touching is one  of the most difficult and
most essential parts of the art of midwifery. If De-
venter and Puzos, who have given some important
precepts on  this subject, have left us much to wish
for,  it was  because they  knew, as  well as  many
others, that  in this article nothing  can supply the
want of practice.
  289. Opportunities of  practising it occur fre-
quently, especially in great cities, where women are
more numerous, and  where persons of both sexes
dedicate themselves solely to the profession of mid-
wifery.  A wish to dissipate doubts often determines
women to submit to it; while at other times these
researches concern the honour, the health and even
the lives of  several individuals. Sometimes it is  a
woman who fears she has become  pregnant in an
illicit commerce, who wishes to withdraw herself
in time from the public eye, to secure  her reputa-
tion, who implores information  from  our know-
ledge, as soon as her  suspicions commence; some-
times a woman whose pregnancy still doubtful, is
complicated with accidents, or accompanied by  a
disease foreign  to it, who, not daring to employ the
remedies her state  seems  to require,  desires us to
remove  her uncertainty; at other times a woman 
126
Of Touching.
guilty of crimes which merit the extremest rigour,
declares herself pregnant when she hears sentence
of death pronounced upon her; lastly, the judges
may require our decision on the state of a woman
accused of concealment of birth, and infanticide.
  290. It is  by touching that we discover certain
affections of the hidden parts of generation; that we
judge of the size of the pelvis,  and of its deformi-
ties; it is by that we discover  pregnancy, its dif-
ferent periods, and the approaches  of labour; that
we distinguish the  true pains from false, the part
of the child which  presents, its  volume, the  turns
it makes in descending, &c.
  291. To touch with advantage in most cases, and
especially in discovering a doubtful pregnancy, in
the first periods, we must begin by habituating our-
selves to judge skilfully by this means of the natu-
ral  state of the uterus; for it is the negative signs of
that state which conduct us to the knowledge of the
others.
  292. In order to that, we should begin by touch-
ing dead bodies, where we may rectify our know-
ledge,  and correct our errors; and then touch
women not pregnant, in great number, and in dif-
ferent attitudes, to enable us to judge more exactly
of the volume of the uterus, of the  figure and situ-
ation of its neck, and of its weight and mobility.
  293. We  ought before  we  touch, especially if
precision is requisite, to put the abdominal muscles
in a  state  of relaxation; evacuate  the  water and
faces; to anoint the finger  well  we mean to touch
with, that it may pass the more readily, as well as to
protect it from any virus that may  exist in the va-
gina. We must employ the forefinger; but we ought
to learn to touch with both right and left. 
Of Touching.              127
  294. We separate the labia with the extremity of
the finger, pass it  into the vagina, until we meet
with the os tinea. We examine this part and ascer-
tain its length, thickness, density, and the state of
its  orifice—we agitate the uterus to determine its
weight and mobility, and we endeavour to form an
idea of its length by placing the other hand on the
abdomen.  With a view to this object, we place the
finger behind the os tinea, and raise up the  uterus
a little,  while we search for its fundus yust below the
navel with the other hand; we shall know the uterus
by its being round and solid; and estimate its length
by determining in the mind the distance between
the finger and the hand.
   295.  It is  generally recommended not to touch
until after the third month with the expectation of
determining a pregnancy, as it is imagined that we
cannot  discover it sooner;  but when we  combine
other circumstances with the information derived
from touching, we may be enabled to form a judg-
ment, that will not lead us into any material error.
   296.  In touching our chief  attention should be
directed to the changes produced on the body of
the uterus, until the seventh month, and after this,
to the neck; from an attention to the successive de-
velopment of these parts, we determine a pregnancy,
and its  period. But as these changes may take place
from a cause foreign to pregnancy, we cannot, strictly
speaking, say that there is  any certain sign of it,
except  the motions of the child.
    297.  These  motions are of two kinds: one de-
pends on the muscular action of the child's limbs;
the other is a rolling motion, in which it is entirely
passive. In one it moves itself in the uterus, and in
the other it is moved in the midst of that viscus. 
128               Of Touching.
   298. In the former kind it is sometimes the head,
and sometimes the arms or legs,  which it  moves.
These motions  take place as soon as the muscles
have acquired a sufficient force to produce them;
but the mother  is not commonly  sensible of them
till she is gone about half her  time. Before that
epoch  these motions are too weak, and the limbs
too imperfect, to strike forcibly against the parietes
of the uterus, which a pretty large quantity of water
then keeps distant from them in almost all parts.
   299. Delicate and  nervous women can however
distinguish these motions sooner, as those of a con-
trary constitution  do not  perceive them till much
later.  I have known several  who assured me they
constantly felt the child  move at  three months,
others  a little  sooner; but many when they drew
near the period of four months.  I  have seen others
who could not perceive these motions till after the
fifth, the sixth, and even the seventh month. In one
of these women, whatever we could do, and not-
withstanding the very manifest rolling with which
we agitated the child in the uterus, its motions did
not become sensible to the mother, nor to  the ac-
coucheur  who examined her, till the period of seven
months, two months before its birth:* whence we
see that we must not always take the time when
those motions are first felt for the period of four
months and a  half.

  * The birth of this child will not appear premature, when
we observe that it was very strong, and weighed seven pounds
and an half, or thereabouts.
  I was several times in  consultation concerning a woman
whose pregnancy appeared doubtful to her till the last mo-
ment, as well as  to the physician who had the care of her
health;  because the motions of the child  could not in any
way be perceived and nothing we could do, even  at eight 
Of Touching.               129
  300. The rolling of the foetus in the uterus is in-
dependent of its muscular action;  it exists after
death, as before; it even seems, in that case, more
troublesome  to  the woman, who complains that a
kind of ball seems to her to fall to the side on which
she lies.  This species of motion depends on that of
the uterus, and of the woman, and may  be excited
by the accoucheur.
  301. This rolling commences, as I may say, with
pregnancy; but  it is  so weak in the first periods, on
account of the extreme lightness of the foetus, that
the accoucheur cannot discover it; and, notwith-
standing the strictest inquisition, it cannot  be per-
ceived till towards the third,  or even the fourth
month.  After that period it is  easy to discover  it,
provided that we be prepared for it, by being ac-
customed to  seek it in women farther advanced in
pregnancy.
  302. To excite  and distinguish this filing,  we
advance the finger introduced into the vagina to the
body of the uterus, near the base of its neck, or as
high as  possible, either before or behind;  and  we
apply the other  hand over the pubis, in order to fix
the fundus: we  then  agitate it upward and down-
ward with the finger  and with the hand, till we dis-
tinguish the movement in question; observing how-
ever not to mistake the motion of the  uterus, for
that of the child contained in it.

months and an half, could excite them: this child, which was
as strong as usual,  was nevertheless born healthy. M. Levret
used to quote, in his private lectures, a case of a  woman who
felt no motion of the child in two successive pregnancies.f
  t  I knew a case where the motions of the child were never
perceived, yet this child was born alive and healthy.
                                     W. P. D.
                        R 
130
Of Touching.
   303. The woman ought to be standing during all
 these researches, for an horizontal position would
 augment the difficulties; the body of the child then
 receding from the  neck of the uterus, in proportion
 as the woman's  breast is lowered relatively to the
pelvis.  Every person will comprehend this rolling
 motion, and the advantage of keeping  the woman
 standing while  we endeavour to  excite and disco-
 ver it, by considering that after the first months the
foetus is specifically heavier than the water which
 then surrounds it in great quantity, and that it must
 consequently occupy the lowest  part of the cavity
 of the uterus, and  fall on it again if we remove it
 by any kind of agitation.
   304. This rolling motion characterizes  a  true
 pregnancy as certainly as the movements arising
 from the muscular force of the child; for a child is
 the only solid body which can be surrounded by a
 fluid in thrfuterus, and be moved in it in this man-
 ner: but this rolling, in which the child is absolutely
 passive, does not,  like them, demonstrate  whether
 the child be living or dead.
   305. We have then, before the motions of the
 child are felt, nothing to  prove  a true pregnancy
 but conjectures more or  less founded;  the force of
 which augments in proportion as  we can unite a
 greater number of these rational symptoms, which
 have caused doubts  concerning the  state of the
 woman.
   306. The signs  which touching discovers to us,
 and  on which these conjectures are founded, must
 always be deduced from the state of the uterus. In
 the first two months of pregnancy the body of that
 viscus grows rounder, and seems to sink a little  in
 the pelvis,  which  carries  its  orifice  forward  and
 downward, sometimes also backward and towards 
Of Touching.              131
the coccyx. The belly of the woman changes so
little at that time,  that the  vulgar  even think it
flattens, instead of growing bigger. If it swells, that
swelling cannot be referred solely to the  augmen-
tation of the uterus, but to an inflation of the intes-
tines.  This inflation  ceases  afterwards;  and  the
belly appears  no  bigger at six months than it is
sometimes accidentally at two.*
   307. In the third month, the fundus of the uterus,
more voluminous,  begins to force  the  intestines
upward, and to lift up the hypogastric region; be-
cause it is  then  manifestly above the edge of the
^s pubis. It is then the hand  begins to discover it
easily, by pressing on the aforesaid region.
   308.  When this development is caused by preg-
nancy, it is observed only in the body of the uterus,
and the neck  has no  share in it: the kind of giobe
felt by the  finger introduced  into the vagina,  and
which may be distinguished by the  other hand ap-
plied externally above the pubes, is regular in its
surface, and has a sort of suppleness. This body,
developed  by  a plethora of its substance, and affec-
ted by a chronical  disease, is  less regular, often
unequal, and  hard in certain  parts. The neck is
more or less affected  by the same causes, and  also
altered in its figure.
   309. If  touching  still  leaves the  accoucheur,
whom a proper experience has not enabled to dis-
tinguish all these shades, in doubt  concerning the
state ofa woman who supposes herself three months
gone, he can have no doubt after the period of from
three to four months. At this latter period, the

   * La Motte and some others look upon a woman as having
pretty certainly  a false conception or mole, if her abdomen
swells at the second month.                 W. P. D. 
 132              Of Touching.

fundus  of the uterus rises the breadth of several
 fingers above the superior strait. It rises to within an
 inch or two of the umbilicus in the course of the
 fifth; and the neck, receding farther and farther from
 the vulva, is carried backward and higher. The hy-
 pogastric region is then salient,  rounded,  and tight.
   310.  In the sixth month the uterus rises above
 the umbilicus,  which seems less sunk in; the neck
 begins  to  enlarge at its basis, and  seems a little
 softer than before.
   311.  In the seventh, the neck grows still shorter,
 and becomes less  accessible to the touch, because
 it recedes from the vulva in proportion as it is de-
 veloped:  the  umbilicus  is more salient:  and  the
fundus of the  uterus, raised very high above that
 cicatrix, occupies  a part  of the  epigastric region.
   312.  At the end of the eighth month, the uterus
 approaches so near to the  pit of the stomach,  in
 most women, that it is  difficult to judge  exactly
 how far it  extends. Its neck is almost always effaced;
 and its orifice so far off, that the finger can scarcely
 reach it; and, to do it, we are often obliged to carry
 it as high as the sacro iliac symphyses, right or left.
   313.  In order to reach so far,  we must proceed
 in the following manner:—The woman being stand-
 ing, leaning a little backward, and resting her back
 against  something solid,  we place the hand open
 between the thighs, and  introduce  the fore finger
 into the vagina;  so that the radial edge of the mid-
 dle finger may lie along the perinaum and  coccyx,
 and the thumb against the pubis; so that these two
 fingers and  the  thumb are at length very distant
 from each other. By proceeding thus we have ad-
 vantages which cannot be obtained any other way;
 because the middle  finger pressing upon the  ex-
 ternal parts of  the perinaum and  coccyx, forces 
Of Touching.           *  133
them upward, and diminishes so much of the depth
of the pelvis; which permits the extremity of the
forefinger to approach much nearer to the superior
strait than if the hand  were placed in any  other
manner.
  ■314. In the last period of pregnancy the neck of
the uterus is  completely developed, and the edge of
its orifice grows very thin in some women,  while
in others it seems  to become  thicker.  This kind
of increase, in that case, arises from an cedematous
swelling which may be observed in the  whole ex-
tent of the puuendum, and which spreads far in the
cellular tissue of the vagina and neck of the uterus.
   315.  It is  rare for labour to be many days dis-
tant when the edge of the orifice is very thin and
soft; whereas it is often a month or six weeks oft'
when this circle is  hard and thick, whatever may
be the diameter or  degree of its opening. In fact,
has not every accoucheur  often found  the internal
orifice of the uterus large enough to permit him to
touch  the membranes with his  finger,  at  seven
months and a half,  and  even sooner, although the
woman has  not been delivered till the  usual time?
But there is  no example of labour's being so far off
when it is thin and soft.
   316. The  state of the membranes at the orifice of
the uterus instructs us much  more  certainly con-
cerning the period of labour.  We ought always to
look upon it as very near, when the  membranes
tighten and  relax  alternately.  We may form the
same opinion when the  body  of the uterus  grows
hard suddenly, and  then softens  and relaxes;  and
especially when this alternate tension  and relaxa-
tion are remarked in the edge of its orifice.
   317. Though all the symptoms constantly  an-
nounce the approach of labour, they do not so cer-
tainly indicate the period of the ninth month; and. 
134              Of the Foetus.
to judge of that, we must also attend to the time of
the suppression of the menses, and to that of  the
first motions of the child; to the volume of the ute-
rus; to the size and hardness of the head, which we
distinguish by the touch,  &c.
   318. The elevation of the fundus of the uterus
above the entrance of the pelvis,  as I have assigned
it in par. 309, 310, 311, and  312, cannot serve to
determine the periods of pregnancy stated in  the
same paragraphs, but in a woman big with her first
child. I must remark that the fundus is a little lower,
at each of those periods, in a woman who has already
been pregnant several times; and I must  add that
the situation of the child may cause the same differ-
ence, it being less elevated when it is placed across
than when well situated. We observe likewise that
the neck of the uterus in its development,  in a first
pregnancy, changes the form of its inferior part but
little, while its base enlarges; and  its orifice  does
not open till the development  is complete. But it
opens much sooner in the subsequent pregnancies,
and the os tinea remains thicker in the latter months;
so that experience is necessary, not to be deceived
in  these signs.
                 Of the Foetus.

  319. The rudiments of the foetus appear at first
only as a mucilaginous *,eloud, in the midst  of a
little bladder filled with a clear transparent water;
nor is it till after some weeks that it is so far sketch-
ed as that.
  320. The illustrious Haller assures us that he
has observed nothing of  the kind in sheep before
the seventeenth day; and that it was not till the 
Of the Foetus.             135
nineteenth that he distinguished a mucous fcetus, of
the size of a -mill worm,  bent like a crescent:*
which  made him suppose that the human foetus is
not formed earlier.  The  observations I have made
in practice coincide with that sentiment.
   321. I have carefully examined many embryos no
bigger than an ant: they were bent forward, as M.
De Haller says, and enveloped in a mucous cloud.
They appeared to the  naked eye to have more re-
semblance to that little bone of the ear called mal-
leolus, than to any thing else; having, like that, one
end very thick, and the other extremely slender.
Among the women who produced  these embryos,
some thought themselves a month gone only, and
others five weeks; some  of them were of the num-
ber of those who are generally able to tell the mo-
ment when they conceive.
   322. I  have seen a greater number  of foetuses
about the size of a wasp. Their head formed more
than half their mass; the eyes and mouth were very
plain;  the hands and feet seemed attached immedi-
ately to the trunk, the arms, thighs, and legs being
scarcely visible. Some were of six weeks and others
 of seven,  according to the account  of the woman
 who conceived them.
   323. All these foetuses, as well those of a month
 as those of six weeks, were contained in a kind  of
 eapsula, as it were, spongy, or covered with a very
 thick  down externally.  Those of the former were
 nearly of the size ofa middling hen's egg, and those
 of the others bigger.
    324. These species  of eggs are composed of two
 membranes:  one  external and thicker, on the sur^

   * It is more than probable that this crescent form of em-
 bryos was produced from  the action of the alcohol in which
 they were generally examined,            . W. P. © 
136
Of the Foetus.
 face of which rises the down already mentioned; that
 is the chorion: the other internal, thin, and trans-
 parent,  through which we may  see the body of the
foetus in the midst of the limpid waters it contains;
 that is the amnion.
   325.  These membranes adhere less together at
 the beginning of  pregnancy  than the external does
 to the uterus; on which account, in abortions that
 happen  in the first periods, we often see those mem-
 branes separate from each other, and come away at
 different times. The chorion in those cases frequently
 tears at the orifice of the uterus; and the amnion con-
 taining  the waters and foetus immediately escapes,
 while the former  is not expelled till some time af-
 terwards.
   326.  In  this case the woman discharges only a
 kind of membranous egg, without the least down
 upon it; and when the downy membrane  comes
 away, if it be not  examined attentively, it is  usually
 taken for a clot of blood, because it is covered by
 a layer of that fluid.
   327.  It is doubtless observations  of  that sort
 which have made some believe that the egg is not
 downy at first, and that the lanuginous spot does not
 appear till  it has acquired the size of a hen's egg,
 and the foetus becomes as large  as a bee.
   328.  The development of  the foetus is so  slow at
 the beginning, and so rapid afterwards, that nature
 seems to have no difficulty but  in the  arrangement
 of its first lineaments. As soon as it is sketched, its
 increase is so sensible, from  one month to another,
 and even from fortnight to fortnight, that it  is diffi-
 cult to conceive how such great and wonderful dif-
 ferences could be the work of so short a time.
   329. These differences are not howeverabsolutely
 the same in every individual. We observe,  for ex-
 ample, as much variety in the length,  bigness, and 
Of the Foetus.
137
weight ofa certain number of foetuses of five months,
all proportions being observed, as in a like number
at full time: some are longer,  bigger, and heavier;
others shorter, thinner, and lighter; so that we can-
not exactly determine how far pregnancy was ad-
vanced by the dimensions and weight of the child,
as some authors have asserted.
  330.  The usual length of a child at nine months
is from eighteen to twenty inches, and the two ex-
tremes from sixteen to twenty-two or twenty-three.
Their medium weight,  according to the tables of
Ro'ederer,  is from  six pounds to seven and a half.
I have seen two of  nine pounds three quarters, one
of twelve, and another of thirteen pounds: the latter
had several teeth well advanced, and others ready
to cut; its bulk was so great, that I can scarcely^ be-
lieve there ever were any born of twenty-five pounds,
or even fifteen, as we hear related by the good wo-
men.* I have seen some also at full time who weigh-
ed but five pounds, others but four and a half, and
several of three pounds three quarters. These latter
seem more common than those of nine pounds, and
grow to as great a size after their  birth.
  331.  According  to these observations, we must
conclude  that there are children  of eight months
larger and heavier than others of nine, and vice ver-
sa: notwithstanding that, an experienced accoucheur
will not judge them to be of the same term. There
are always marks of immaturity in the exterior of a

  * Instances have frequently occurred in this country, of
children weighing more than fifteen pounds; I have seen I
think several, two I am certain of, as I carefully  weighed
them. The circumference of the head of one, was eighteen
inches and an half—round the shoulders twenty-one inches,
and the length from the summit of the head, to extremity of
the big toe twenty seven inches.              W. P. D.
                        S 
 138          Attitude of the Foetus.

foetus of eight months, though bigger than anothei
 at full time, which we  see not  in the latter, and
 which would be too tedious to describe here.
          Of the Attitude and Situation of the F'cetus in Utero.

            332.  The foetus is always bent forward, having
          the head inclined on  the breast, the  arms bent, the
          thighs and legs in the most perfect flexion, the knees
          separated, the heels near together, and placed against
          the breech.
            333.  The foetus thus folded forms pretty nearly
          an oval body, whose greatest diameter is ten inches,
          or thereabouts; and its smallest, which extends from
          one shoulder to the other, from four inches and a
          half to six inches at most.
            334.  We must not however be  contented with
          these  general ideas of the child; we  ought to make
          ourselves acquainted with the structure and dimen-
4         sions  of its principal parts, and  the motions they
          are susceptible  of; we ought by the touch to be able
          to distinguish the different parts  it  may present at
          the time of labour.
            335. An accoucheur who has long been regarded
          as the most celebrated in his profession,* has advan-
          ced, that in the natural order, after the fourth month
          of gestation,  the child is generally placed with the
          head above, the breech below, and the belly forward:
          while in the latter months we find the contrary; that
          is to say, with the head downward, the breech above,
          and the  back under the anterior part of the uterus.
          Such  was the idea of the ancients  on the position
* M. Levret, sect. 426, et suiw 
Attitude of the Foetus.          139
of the child, and  such is at present the opinion of
most moderns. If there is no inconvenience, as some
have  said, in admitting the movement which they
call the summerset, I  think there is much less in
rejecting it.
   336.  We find materials to combat the common
opinion on this  subject, even in the arguments of
its partisans. By reflecting on the  position  which
they give to the child till it makes the summerset,
as well as that  they assign it afterwards,, we shall
see, first, that it is the most inconvenient it can take,
and the most difficult for it to preserve two moments
together, if by chance it should exist one: secondly,
that  it is  contrary to the relation and structure of
its parts, as well as to the laws of gravitation.
  337.  First, The extreme smallness  of the child
in the two first months, when compared to the cavity
of the uterus; secondly^ the quantity of water which
surrounds it, and the mobility it enjoys in it; thirdly,
the weight of the head over the rest of the body;
fourthly the bent form it is in, forbids us to believe
it  can remain months in a sitting posture on the
lower part of the uterus.  Beside,  the summerset is
said to take place at about the seventh month, a pe-
riod when we shall find the great diameter  of the
child, (that is from head to breech) larger than any
of the transverse diameters of the uterus, consequent-
ly cannot pass  through  them to effect the change
spoken of.
   338. The strongest arguments we can use against
the summerset are  founded in  observation. The
opening of dead bodies has a thousand times de-
monstrated that  the child's head almost always oc-
cupies the inferior part of the cavity of the uterus;
and it is generally  the head  which presents  to the
orifice in cases of  premature delivery,  at whatever 
140           Division of the Child.
period of gestation it happens. If we have sometimes
found the child placed differently, either in opening
dead bodies, or in abortions, the proportion of these
cases  to those where the head  presents, is nearly
the same as what we observe at  full time.
   339.  Therefore both  reason and experience join
to prove, that there is  no such summerset as has
been supposed; that the  situation of the child varies
continually in the first periods of pregnancy; and
that it becomes fixed and constant in proportion to
its augmentation,  except in those cases where the
uterus contains an extraordinary quantity of water.
              Division of the Child.

  340.  The surface of the child, considered rela-
tively to our object, might  be  divided  into thirty-
four regions, which however I shall reduce to twen-
ty-three.
  341.  Of all the principal parts of the child, con-
sidered  with respect to labour, the head must be al-
lowed to be not only the most  solid, but also the
most voluminous. If the breast, in its natural state,
appears larger in some directions, its structure is
such that it always accommodates itself more easily
to the mould of the pelvis. A similarity of structure
obtains  in the head by means of sutures, &c. by
which the head is  enabled to mould  itself to the
figure of the pelvis  in some difficult labours. But it
must be  observed  that when it diminishes in one
direction, it almost always  augments in another.
  342.  Although  the child's head, at  the moment
of  birth,  be somewhat of an oval figure, we may 
Division of the Child.           141
however distinguish in it five regions, two extremi-
ties, four diameters, and two circumferences.
  343. Of the five regions of the head, two form
the summit and base, the three others the sides and
the face.
  344. One of its extremities is superior and pos-
terior; we call that the occipital, or vertex: the other
is anterior and inferior, which is the chin. The first
is thicker and rounder, the second  narrower and
longer.
  345. The largest diameter of the head, the length
of which is usually five inches and a quarter, passes
obliquely from the symphysis of the chin to the pos-
terior extremity of the sagittal suture; the middle
diameter,  which  is about an inch shorter, extends
from the middle of the forehead to the top  of the
occiput; the third  passes from the summit  of the
head to the base of the cranium; and the fourth from
one parietal protuberance to the  other. The length
of these latter is pretty constantly three inches and
from four to  six lines.  It is proper to remark, that
the breadth of the head is less below the ears than
in the part indicated for the fourth or transverse di-
ameter;*  although many persons, without  giving
themselves the trouble to examine it, maintain the
contrary.
   346.  The  largest circumference of the head is
nearly from thirteen inches and a half to fourteen or

  * I shall hereafter call the first of these diameters oblique;
the second, longitudinal; the third, perpendicular;  and the
fourth,  transversal.  Although  the longitudinal diameter,
which might also be called antero-posterior, is not the largest,
as I have just observed, I give notice that that is the diameter
 I shall mean whenever in future I shall make use of the terms
great or large diameter: and when I say little diameter, I shall
always mean the transverse. 
142           Division of the Child.
fifteen inches; the other is only ten or eleven. The
latter passes transversely over the middle of the
summit and base of the cranium, as well as over the
parietal protuberances: the first, over the two fonta-
nelles, the face, the chin, the occipital foramen, and
the tubercle of the same bone; in a word, over the
extremities of the oblique and longitudinal diame-
ters, and over those of one of the two small diame-
ters.
   347. When  the head lengthens in labour, it is
always in the direction of the oblique diameter;  so
that the point of the cone which it then represents,
is above the posterior angle of the parietal bones:
but it cannot undergo this lengthening without di-
minishing  in thickness from one side to the other,
and often from the summit to the base.
   348. These changes have limits however, which
cannot without manifest injury be exceeded, they
differ in different individuals, according as the head
may be more or less ossified; the breadth of the su-
tures, or width of the fontanelles; they cannot there-
fore be precisely estimated.  In some the  cranium
may lengthen with ease and safety, six or eight lines;
while in others the slightest change is injurious.
   349. The  most  remarkable sutures in the foetus
are the coronal; the sagittal, which extends to the
root of the nose; the lambdoidal; and  the temporal,
or squamous.
   350. The  most considerable fontanelle is at the
union of the coronal with the sagittal suture: it ia
called the bregma, or anterior fontanelle; its figure
is nearly that of a lozenge.  It was long believed,
and is still believed by some, to have a pulsation;
but nothing of the kind exists in it before birth.
   351. The place where the sagittal and lambdoidal
sutures join, is also called afontanelle; though there 
Division of the Child.           143
is  scarcely ever any membranous space in it, as in
the former. This fontanelle, which in the  course of
this work will always be called the posterior fonta-
nelle, differs also from the preceding, in being form-
ed  of only three bony angles, and in being only as
it were the point of union of three branches of su-
tures: while the anterior is composed of four angles,
and as many sutures terminate in it; which makes
them easily distinguishable by the touch.*
   352. The articulation of the head with  the trunk,
its  natural situation, and motions, are not less neces-
sary to be known. The first is a species  of gingly-
mus, which permits but very small motions, either
forward, backward, or on the sides: if the head ex-
ecutes greater, they depend on the combined motion
of all the cervical vertebra.
   353. These motions are freer in  the foetus  than
in the adult; but they have their limits, which can-
not be exceeded without  danger to the  child; the
pivot-like motion especially, which  depends almost
entirely on the twisting  of the  neck, cannot  with
safety be made to exceed a quarter of a circle. The
natural situation of the head of the  foetus is  such,
that the chin is lower than the occiput, which makes

   * We sometimes, though very rarely, meet with a fourth
angle in the posterior fontanelle, because  the  occiput is then
divided into two; and in that case there are likewise four
branches of sutures which terminate in  this fontanelle. Not-
withstanding that, it differs so much from the  former, that it
is almost impossible to be deceived in it, even when we cannot
touch them both, to compare them.f

   11 have seen two instances in the same family, where there
were three complete fontanelles in the course of the sagittal
suture,the additional one was between the two common ones,
that is, in the middle of the parietal bones.     W. P. D. 
.144             Of the Placenta.
the axis of the trunk pass a little before the poste-
rior fontanelle.
   354.  The  composition and motions of the trunk
and extremities, are also essential  to be known, as
they have their direction and limits also.  As  the
head cannot with safety be made to  rotate more than
a quarter of a circle, when we suppose the body the
fixed part  in  the pelvis, so also, the trunk cannot
be  made to exceed this without injury, when  the
head is  supposed to be the fixed part.
   353.  The  fundamental principles of midwifery
may be  perceived, by comparing the principles thus
far established between the pelvis of the mother, and
the child to be born. We learn from them  that de-
livery can only be effected, by having the  occiput
behind one of the acetabula, and the forehead before
one of the sacro-iliac symphyses of the other  side. It
must descend so, that the occiput  may turn under
the arch of the pubes, and the forehead into  the hol-
low of the sacrum; while the  shoulders are to make
similar turns, through the different  straits. In those
cases where the feet, knees or breech  present,  the
shoulders and head must  present their largest di-
ameters to the largest diameters of the pelvis, &c.
Of the Secundines, or Afterbirth, and particularly
                of the Placenta.

  356.  These  substances, although called  secun-
dines, are formed before the foetus, at least before it
is visible, if we except the umbilical cord, which is
a production of the hypogastric vessels of the foetus.
It is evident these  parts have important functions
to fulfil, since they are sometimes found without a 
Of the Placenta.             145
foetus, but never a foetus without them. From  the
 order of their development, it would seem, that they
 are nourished Solely by fluids transmitted  to  them
 by the uterus, at least in the  beginning of pregnan-
 cy.  Under the name of secundines or afterbirth are
 comprehended the placenta, the membranes,  and
 the umbilical cord; and we might add the waters to
 them.
   357. The secundines, in the first months of gesta-
 tion, are not such as we find them at the end: after
 several weeks, they are nothing but a kind of mem-
 branous bladder, on which we can scarcely perceive
 a rising down; but which in a short time is so covered
 with it, that the  membranes no longer appear with-
 out separating the tufts of that down.—See par. 323.
    358. This down is collected in a determined space
 and forms the placenta;* at the full time of delivery
 it occupies about a fourth of the chorion.
    359. The placenta is a spongy  and vascular mass,
 thick in the middle, and thin at its edge: it is seven

   * Our author appears to be in error here; the down,  as he
 terms it, which is the  spongy chorion, and which the  ovum
 brings with it from the ovarium, cannot collect  In a given
 point as he supposes, but only becomes more developed and
 extended by  an increase of vessels, and an augmentation of
 circulation. The point of the ovum where this takes place is
 always that where the funis umbilicalis is inserted, and conse-
 quently opposite the belly of the child;  which in the very early
 periods of gestation is found almost in contact with the  inter-
 nal face of the amnion, owing to the extreme shortness  of the
 cord—in the  more advanced periods  of pregnancy, if  we do
 not find the placenta occupying but a portion of the  chorion,
 it is not because the spongy or flocculent part of it has col-
 lected itself into a given space, but because the membranes
 have been extended beyond the vascular plexus called  the
 placenta. This is a wise provision of nature; for had the after-
  birth occupied the whole surface of  the uterus, few women
  would escape a fatal hxmorrhagy, when it became separated
           *                               W. P. D
                          T 
146             Of the Placenta.
or eight inches in diameter, and twelve or fifteen
lines thick in the centre, at full time. These dimen-
sions however vary a little, according to the consti-
tution of the woman, the strength of the child, and
the  part of the uterus on which the placenta is, as
it were, grafted.
  360. The placenta is always formed of several
lobes,  united by a cellular membrane,  so  fine and
delicate, that the  least force will tear it.  Merely
folding up this mass will separate  its lobes, and
make its external surface appear very unequal, and
deeply furrowed; whereas in its natural state we only
discover very superficial convoluted furrows, cover-
ed by a thin layer of cellular  membrane, and which
have a kind of resemblance to the anfractuosities of
the brain.
  361. It is now pretty well proved by  experiment,
that  certain eminences observed on the  external
face  of the placenta do not reach the uterine sinuses;
the connexion between these bodies  is by means of
cellular membrane, in such a manner that,  the ute-
rine  blood is deposited in it,  from the sinuses, to be
absorbed by the umbilical veins; consequently there
is no necessity  for an anastomosis of  their vessels.
  362. The internal surface of the placenta is lined
byr the chorion and amnion; and is nothing, it would
seem, but an expansion of the cellular tissue of the
former of these membranes. Whence it  follows, that
the placenta cannot be separated from it.
  363. On  some one portion on the internal face
of the  placenta we find an admirable plexus of ar-
teries and veins; which serves as a base to  the um-
bilical  cord, of whose vessels it is only a ramifica-
tion. The veins unite eventually in  one trunk and
form the umbilical vein. The  arteries are a continu-
ation of the primitive iliacs of the foetus. When they
arrive at the placenta they divide into very minute 
Of the Placenta.             147
branches, and anastomose with the veins. If one of
the umbilical arteries be injected, the whole plexus
becomes filled. The veins have no valves, but they
are found most generally in the arteries.
   364. When there are twins or triplets,  we some-
times find as many placentas as there are children;
at other times, and which is the most frequent, they
are united through a certain extent of their edges,
and seem to form but one mass; but, notwithstand-
ing this connexion, there is scarcely any communi-
cation between their vessels, which may have great
advantages.
   365.  Twins have however almost always some-
thing common to both, in those cases where there
is a placenta for each; for they are enveloped in the
same chorion, which unites the  two masses of pla-
centa so strictly, that we cannot extract one without
the other.*
   366. The placenta may attach itself indifferently
on any part of the internal surface of the uterus. It
generally  occupies the middle regions;  rarely the
middle of the fundus, so  as for its centre to answer
to the centre of that; and more  rarely fills the infe-
rior part,  or the orifice.
   367. No sign can inform  us before delivery what
place the placenta occupies,  unless it be on the neck
of the uterus, or at least in its vicinity, and that the
finger can discover it;  but it is  easy to judge of it
after the exit of the child, by following the cord into
the orifice of the uterus,  and observing whether it
descends from the posterior or anterior part, or from
one  of the sides.  It is not  till the placenta is deli-
vered that we can estunate how far it was removed
from the orifice, by attending to the distance from

     * See the article on twins, at the end of this work. 
148           Of the Membranes.
the opening of the membranes to the centre of the
internal surface of that mass. As that opening con-
stantly answers to the orifice of the uterus, and as
this latter is diametrically opposite to the fundus,
whenever it shall  be equidistant from all points of
the circumference of the placenta, we may affirm
that its centre answered to the centre of the fundus
uteri; the nearer it approaches to the edge of the pla-
centa, the farther that was removed from the fun-
dus, &c.
   368. Whatever may be the strength of the adhe-
sion of the placenta to the uterus, it is only attached
to it by a very fine  cellular membrane,  which is
commonly very easily destroyed.  We see nothing
like that mutual reception which some talk of; and
the firmer or weaker adhesion does not depend on
the eminences  of  the one being more strongly or
feebly engaged in the sinuses of the other.
               Of the Membranes.

   369. The bag in which the child is contained is
composed of two  membranes. The outer one or
chorion is cellular externally, and especially near the
placenta, by which it is attached to the uterus. It
does not form a sheath for the placenta, but passes
under it; for on the external face of the placenta we
find nothing but an extremely fine membranouslayer
covering the anfractuosities mentioned in par. 360.
The inner membrane or amnion is a very thin trans-
parent membrane throughout  its  whole extent. It
is united to the chorion by a fine cellular tissue, but
its connexion  with it however is less strict at the
placenta than elsewhere. These membranes are con- 
             Of the Umbilical Cord.          149

tinued over the umbilical cord. From the extreme
tenuity  sometimes of these membranes abortions
have  happened; as  they have not been sufficiently
strong,  to bear the weight of fluid which presses on
them.
   370.  Some anatomists make mention of another
membrane,  which might be regarded as the pro-
duce of conception, if it existed really, and sepa-
rately from the two former,  in every period of preg-
nancy: it is called decidua. We may see its situation
and connexions, as well with the uterus as with the
other membranes, in the  tables  of Dr.  William
Hunter, the first who has mentioned it. This mem-
brane,  decidua, does  not seem to exist manifestly
but in the first months of pregnancy, and is more
considerable towards the lower part of the uterus
than in any other part. It identifies itself so with the
chorion in the latter periods, that  we can no longer
find it separate from that.  I cannot admit it at any
period  as a particular  membrane, but only as a layer
 of the chorion.
             Of the Umbilical Cord.

  371. The umbilical cord is known to all, but its
structure is not equally so.  It is formed of two ar-
teries, and one vein, whose diameter is larger than
those of the arteries. This structure is not however
always the same, since we have seen many  cords
with only one artery.
  372.  These  vessels, whose origin is already
known, according to par.  363.  wind round each
other,  like the twigs which form the handle of a
basket: sometimes the arteries creep round the vein, 
150          Of the Umbilical Cord.
like ivy found a tree; and sometimes the vein does
the same round the arteries.  This vein often folds
itself into a kind of loops of different lengths, or
forms itself into a species of knots, subject to be-
come varicous.  These vessels are closely bound by
the cellular tissue of the  chorion, and  send off no
branch in the whole length of the cord.
   373.  They divide and  subdivide on the internal
face of the placenta, to form the plexus mentioned
in par. 363; and they separate  from each other at
the posterior part of the umbilical ring. The vein
ascends along the great falx of the peritonaum, to-
wards the scissure of the liver, to enter the sinus of
the vena porta; and the arteries descend towards
the lateral parts of the fundus of the bladder, from
whence they make a turn towards the iliac arteries,
of which they are almost always a continuation.
   374.  The umbilical vein, as  it approaches the
sinus of the vena porta, sometimes divides into two
branches,  one of which, known by the name of the
venous canal, is inserted into the vena cava inferior.
When this bifurcation does not take place, the ve-
nous canal rises from the sinus of the  vena porta;
and that is what we find most frequently.
   375. Another kind of cord rises from the top of
the bladder towards the umbilicus of the foetus,
where it terminates; that is the urachus; it is almost
always ligamentous throughout, and has no cavity,
at whatever period we examine it.
   376. We discover  no nerves in  the cord,  any
more than in the placenta and membranes; therefore
those parts are insensible.
   377. The chorion and amnion furnish a common
sheath to the three umbilical vessels; and  the skin
of the foetus advances about a finger's breadth on
the cord, but growing thinner and thinner. It is al- 
          Of the Waters of the Amnion.      151

ways at the place where the skin terminates that
the cord falls off from the umbilicus, at whatever
distance from it, it be tied and cut.
  378.  The  length of the cord varies very much,
but it  is commonly from  twenty  to  twenty-two
inches:  the two extremes which I have  seen, have
been  from six to forty-eight  inches.   There has
since  been seen another cord of fifty-seven inches,
forming seven turns round the child's neck.*
  379.  The cord from its. great length, sometimes
gets tied into one or  more knots. These  do not pre-
vent the ordinary development of the foetus nor oc-
casion its death as has been imagined by some.
  380.  There may when the head is delivered, an
inconvenience arise from the  cord being too short,
either naturally,  or  from its being  several times
twisted  round the neck of the child, such as a swel-
ling, and lividity  of the child's face, from the com-
pression the jugular vessels  suffer, from the cord
being tightly drawn; and also a dragging, or sepa-
ration of the placenta, and even  a rupture  of the
cord itself.
          Of the Waters of the Amnion.

  381. The  waters contained in the cavity of the
amnion are usually clear, and without any disagree-
able odour; sometimes they are whitish, milky, and
full of flakes of a matter which appears like cheese.

  *  M. L*Heritier, master in surgery, was a witness of the:
fact  at the Hotel-Dieu of Paris. 
152        Of the Waters of the Amnion*
In some women they are muddy, thick  like broth;
sometimes they are greenish, brownish,  or grayish,
and of an  odour singularly fetid.*
   382. In the natural state, these waters have all
the characters of the liquors of the pericardium, the
pleura, and the peritonaum; being, like this  latter,
lymphatic, and a little  greasy to  the touch.  They
exude  from  the  membranes by a mechanism ex-
actly similar  to that by which the liquor of the pe-
ricardium  is supplied.f
   383. The  saffron  colour,  which  agreeably to
Holler, has been  discovered in the waters of preg-
nant  women  who have taken  much of this drug;
and their property, according to Levret of whiten-

   * They were  found grayish, and of a consistence like mud,
in a woman  who was delivered in my amphitheatre; and they
exhaled an  odour so strong and disagreeable, that  no one
eould remain near the bed.
   t From the experiments of Vauquelin and Buniva, these
substances  would appear very different; their  analysis fur-
bishes the following component parts of the liquor amnii, via.
               98.8 water.
                   } Albumen
                     Muriat of Soda
                     Phosphat of lime, lime

              100.0
   While the liquors of the pericardium, pleura, peritonaum,
Sec. would seem to  be nothing but serum; which from the
experiments of the gentlemen just mentioned,  was found to
consist almost entirely of albumen, a little soda, and a small
proportion of water or serosity. It has been asserted that, the
liquor amnii when exposed  to heat would like serum coagu-
late; this from the experiments just alluded to, appears to be
a mistake.  From the above analysis it seems that the liquor
amnii contains but the third part of 1.2 parts of albumen,  a
quantity far too small to give it the power or property of co-
agulating, since, serum loses this quality when  diluted  with
six quantities of water.                    W. P.  D. 
Of the  Waters of the Amnion.        15£
 ing copper in women who have used mercury du-
 ring their pregnancy, demonstrate that the liquor of
 the amnios is furnished by the uterine vessels.*
   384. Although  the source of  the  waters of the
 amnion is not dried up at any period of pregnancy,
 they are  less abundant, relatively to the volume  of
 the foetus, in the latter months than at the begin-
 ning: but their absolute quantity is  greater at the
 approach of labour than at any other time.
   385. Nothing is more various than the absolute
 quantity  of this fluid:  some women scarcely dis-
 charge a pint or even half a pint, in time of labour,
 while others discharge many quarts.

   * These proofs of the mother furnishing the liquor amnii
 are very equivocal indeed, and too much caution cannot  be
 exercised  in adopting them. Since our author wrote, many
 experiments have been made, w hich  very much call in ques-
 tion the received opinions of that time; this has especially been
 the case with mercury.  The experiments of Doctor Physick
 on this subject are conclusive as far  as respects the observa-
 tion of M. Levret; he found, that, neither by gold, nor copper,
 nor any other test, could the presence of mercury be detected
 in the serum of the blood, or salivaof people who were profuse-
 ly salivated. These experiments were repeated, and varied in
 every possible way almost, without either the serum or saliva
 furnishing the smallest proof of the presence of mercury.
  Besides, were it admitted that mercury did enter the circu-
 latory system, and the liquor amnii of a salivated woman would
 whiten copper, and give the most unequivocal evidence of its
 presence in this fluid, would it prove  this liquor to be the im-
 mediate product of the mother? by no means—\\iefatus with-
 out doubt from its  earliest formation  derives its nourishment
or fluids from the mother; and eventually red blood passes to
it, and such red blood with little variation as circulated in the
mother's vessels. If then the serum of the mother's blood
 contained mercury, the  serum  of the foetal  blood must also
contain it, consequently when the thinner parts of this blood
were eliminated from the foetus to form the liquor amnii, they
 might, without doubt, carry with them a portion of mercury
within  the amnio*-.                        W. P. D.
                          u 
154          Nutrition of the Foetus.
  386.  They are one  of  the  instruments which
nature uses to effect the dilatation of the uterus in
pregnancy, and the opening of its orifice in labour.
These waters, on account  of their lymphatic qua-
lity, have appeared fit for the nutrition of the foetus;
besides,  they  facilitate  its  motions,  render  them
less troublesome and painful to the mother, and
likewise  diminish the  too violent  impression  of
external  bodies on the child. Lastly, a modern au-
thor regards them as one of the agents of  the first
inspiration, and thinks they serve to cool the  blood
of the foetus,  which is difficult enough  to compre-
hend.*
   Of the Manner in which the Child is nourished
               during Pregnancy.

   387. Though all  physiologists  agree that the
child draws its nourishment from the mother, they
are not agreed concerning the nature of the fluids it
receives from her, nor on the manner in which she
transmits  them  to  it. Some think  they are  only
white fluids, and others that it is blood.
   388. It  is more certain that the foetus receives its
nourishment by the umbilical cord; and the proof
of it is so  clear, that no one would dare contest it:
but the same variety of opinions exists concerning
the nature of the fluids transmitted  to it by that
canal.
   389. The difficulty of passing the thinnest injec-
tions from the vessels of the uterus into those of
the placenta, and vice versa; the  milky humour

          * M. David, Traite stir la Nutrition, 
Nutrition of the Foetus.          155
which we have seen draining from the cotyledons
which supply the place of a placenta in ruminating
animals, as well as the extreme delicacy of the ves-
sels of the embryo in the first periods—have  made
the greater  part of physiologists believe that the
child  receives  none  but  white juices  from  its
mother.
   390.  According to this opinion,  it is  the foetus
which forms its own blood, as we see in a chicken.
Admitting that the  blood  which circulates in the
vessels of the foetus,  among which we reckon those
of the placenta, is formed in that manner;  whence
comes that abundance of blood which fills the ves-
sels of the placenta,  in the first periods of  preg-
nancy, when the foetus is nothing but a tender and
delicate jelly, scarcely apparent to the sight; as well
as that  with which  we find that mass so filled  in
those cases where we give it the name of mole?  It
is without doubt such observations as these which
have  made  some believe that the placenta is the
organ of sanguification for the foetus; and others,
that the mother transmits the blood to it ready pre-
pared.
   391.  We cannot reasonably deny the passage  of
the blood from the  sinuses of the uterus into the
cells of the placenta.  That which fills them before
the embryo  is,  as it  were,  sketched, and in  those
cases  where no embryo exists, as well as the  flood-
ings which succeed a separation of that mass from
the uterus in every period of gestation, demonstrate
it clearly.  But  we may be allowed to doubt its ar-
rival  at the foetus in the first periods of  its forma-
tion; because of the great disproportion which must
exist  at that time between the roots of the umbili-
cal vein and the volume of the red globules. It is
in the placenta  itself that these veiny roots take up 
156         Circulation of the Fostus.
the fluids necessary for the foetus, and not in the
sinuses of the uterus.  If at first they absorb nothing
but white and thin juices, they afterwards take  up
the blood itself,  mixed  with those  same  nutri-
tious fluids; in the same manner as the pudica and
splenica take up the blood  extravasated in the  ca-
vernous texture of the penis and the spleen.
   392. It is very true, that the blood of the mother
does  not pass immediately from the arteries of  the
uterus into the umbilical veins; and that that of the
foetus, brought back again by the arteries which ac-
company those veins, does  not go directly into  the
veins of the uterus.  There is no anastomosis  be-
tween those two kinds of vessels; but there are  ca-
vities into which the  blood  is poured from both.
   393. These reservoirs are the uterine sinuses, con-
tiguous  to  the cellular cavities  of  the  placenta,
which I have mentioned above. The arteries of  the
uterus pour their blood into them, as  the umbilical
arteries do on the side of the placenta, where they
are mingled, and taken up again by the veins of  the
same name; the one  to return it into the general
mass of humours  of the woman, the other to con-
duct  it to the foetus.
   Of the Circulation of the Blood in the Foetus.

   394. The blood taken up from the cells of the
placenta  by the roots  of the  umbilical vein, is
poured into the sinus of the vena porta, where it is
mixed with what that vein has received from other
parts; and from thence it passes into the vena cava
inferior, as well by the venous canal, as by the he-
patic veins;  to be transmitted into the left auricle of 
               Circulation of the Foetus.         157

   the heart, along with the blood which returns from
   the inferior extremities, and from some parts of the
   breast and abdomen: while the right auricle receives
.*  from the vena cava superior what returns fr<?m the
   head and the superior extremities.
      395. The left auricle pressing the blood which it
   has  received from the vena cava inferior, and by
   means of the foramen ovale and the pulmonary veins,
   forces it into the left ventricle; as the action of the
   right auricle  forces  into the right  ventricle the
   blood it has received from the vena  cava superior:
   and those two ventricles distribute  it anew  to all
   parts of the body, and even to the placenta.
      396. The left ventricle distributes it to all parts
   without exception, even to the lungs; since there is
   no part which does not receive its arteries from the
   aorta and its principal branches: but  the right ven-
   tricle in the adult distributes it only to the lungs.
      397. In the foetus the blood propelled by the con-
   traction of the right ventricle, is immediately divided
   into three columns; of those columns the two smal-
   lest go to the lungs, while the principal one is trans-
   mitted  into the aorta inferior by the arterial canal,
   and communicates to the blood which has been pro-
   pelled thither by the action of the left ventricle all
   the force which it has itself received  from the con-
   traction of the right ventricle: so that the fluid cir-
   culates through the aorta, and all its divisions, by
   the united force of the two ventricles.
      398.  The  course of the blood  carried  by the
   aorta inferior of the foetus, extends at least as far as
   the  cavernous  tissue of the placenta; since a part
   of that fluid is brought thither by the umbilical ar-
   teries. These, after transmitting a part of it  into the
   veins of the same name, by means of the immedi-
   ate  communications  which  exist  between them. 
158         Circulation of the Foetus.
 pour the rest into the cells of the placenta, and the
 cavities contiguous to the uterine  sinuses; there it
 is mixed with the blood of the mother, and repairs
 the losses it has suffered by circulating through the
foetus; it undergoes a new elaboration; then returns
 to the child, loaded afresh with nutritious particles.
   399. The circulation of the blood from the ute-
 rus to the placenta, from that to the foetus, and vice
 versa, is performed thus till the time of labour;  but
 it then undergoes surprising changes, some of which
 depend on the contraction and closing of the uterus,
 and the others on the respiration which is establish-
 ed in the child as soon as it is delivered.
   400. In  consequence of the contractions of the
 uterus, its vessels suffer some compression, which
 not only diminishes their diameter, but retards the
 circulation within them; so that the sinuses of the
 uterus, and  cells of the placenta,  receive and trans-
 mit less blood in a given time.
   401. The retardment of the motion of  the blood
 in the uterine arteries is in proportion to the con-
 traction, and diminution of the uterus itself; so that
 in the beginning of labour it is much less, than when
 the labour is fully confirmed, and after the expul-
 sion of the placenta. This is proved by the diminu-
 tion of floodings during pain, their cessation after
 delivery, &c.
   402. The effect of this contraction is not confined
 to the vascular system of the uterus itself, but ex-
 tends to the placenta and child. The placenta pressed
 between the child's body and uterus so as to oblite-
 rate many of its  cells after the  evacuation of the
 waters, does not receive as much  blood  as before,
 either from mother or child.  That of the mother
 passes with difficulty into the sinuses of the uterus,
 and is again taken up by the corresponding veins; 
               Division of Labour.           159

while that of the child instead of being pursued into
the cells of the placenta, is returned to it by means
of the umbilical veins without receiving a new mix-
ture of the mother's blood.
   403. This action becomes sometimes soyiolent,
as entirely to destroy the circulation between mother
and child; to this must be attributed the extravasa-
tions and congestions which are sometimes observed
in a child, when a long series of efforts has been ne-
cessary to deliver it; hence the tumid and livid face
of these children; their being nearly and sometimes
quite apoplectic or dead; and hence the necessity in
cases where there is still a little life, of immediately
cutting the  cord and depleting freely from it.
   404. In general very little blood flows from the
two extremities of the cord, cut near the umbilicus,
as, for the most part the child respires immediately
after its escape from the uterus, and the  uterus al-
most as suddenly contracts. The almost immediate
cessation of circulation in the umbilical arteries aa
soon as the child is born, is one of those surprising
phenomena which has never been satisfactorily  ac-
counted for.  Experience teaches us it depends on
respiration, since the blood flows freely until this
function is  well established.
  Division of Labour, of its Causes, its Signs, &c.

  405. The general division of pregnancy into true
and false, as well as custom, requires that we should
distinguish labour, properly so called, from the ex-
pulsion of a mole, or any other body which might
be the produce of conception.
  406.  When we consider the great disproportion 
160           Division of Labour.
 we meet with between different foetuses at the same
 period of pregnancy, we cannot but agree that some
 may be  born, with a probability of living,  sooner.
 and others later, according to the strength and con-
 stitution of each; but in general  that probability is
 greater,  as their birth approaches nearer to the time
 of their perfect  maturity; and we do not look upon
 them as  viable till the period of seven months com-
 plete.
   407. The causes which determine the birth ofa
 child before the time fixed by nature, may also in-
 fluence the probability' of its living. One of seven
 months, for example, which comes naturally, is more
 likely to live than one of eight, vyhose birth is owing
 to a violent or accidental cause.
   408. The most usual epoch of labour  is the end
 of the ninth month of gestation,  but it is not inva-
 riable. The child may be born  sooner, or a little
 later. Some women are delivered naturally at seven
 or eight months; and others have carried their chil-
 dren  beyond  the ninth, without any reason  to sus-
 pect an error in their  calculation, or that they had
 violated their  conjugal faith.
  409. The exit of the child has  received different
 denominations, according to the period of pregnan-
 cy in which it happens, or the mode of its  opera-
 tion.  It is called a miscarriage, before the seventh
 month; delivery  before the time, from that epoch to
 eight months  and a half; and delivery at full time,
 when it  happens in the  latter part of the ninth
 month.
  410. In respect to the mode of their operation,
labours are called natural, preternatural, or  labori-
ous, &c.  These scholastic distinctions being arbi-
trary, I shall divide them into three principal orders:
 1. Those which are performed naturally,  or with- 
Determining Causes of Labour.      16i
®ut assistance.  2. Those which require the help of
art, but which may be performed by the hand alone.
3. Those which  cannot be terminated but by the
help of instruments, or in which it is useful to em-
ploy them.
  411. If in these latter cases the action of the or-
gans of the woman is not sufficient to perform  the
expulsion of the foetus, at least it begins the labour:
on which account all labours have some causes com-
mon, and some particular; which may be again dis-
tinguished into determining, and efficient.
  412. The common causes of which we shall pre-
sently  treat, are sufficient to effect deliveries of the
first order. As to the particular causes, being differ-
ent not only in  each order, but in each species of
labour, I shall not mention them till I come to treat
of those labours to which they relate.
   Of the common determining Causes of Labour.

   413. The common determining causes of labour
are, every thing capable of exciting the contraction
of the uterus, in order to disencumber itself of its
burden. Some are accidental, and produce abortion,
or premature labour; the others appear natural, be-
cause they almost always act at the  same period,
and rarely before the end of the ninth month.
   414. Naturalists have formed different opinions
concerning these  latter; some attributing them to
the foetus, and others to the uterus itself. The former
have thought that the child, excited by the want of
nourishment, the necessity of respiration, the trou-
blesome  weight of the  meconium in the intestinal
canal, &c. endeavours to get out, and overcome the
                       X 
162      Determining Causes of Labour.

obstacles  which oppose  its passage.  Others have
imagined  that the uterus was excited to contraction
only by the acrimony of the waters of the amnion,
or by the  violent distention which it suffers at  the
latter end of pregnancy. But these opinions have
been so completely refuted, that it is scarcely worth
while to take notice of them.   *
   415. It  can neither be the necessity of respiration,
nor the want of nourishment, which causes the foetus
to solicit its expulsion, when it has been some time
dead: nor can it be the stimulus of the waters of the
amnion  on the parietes of the uterus (even  if they
were as acrimonious as  some have asserted),  nor
the violent distension of the  fibres of that  organ,
that provoke  the efforts of labour, when it comes
on prematurely; since the waters are not in  imme-
diate  contact  with  the uterus,  and it is not in this
case distended to its greatest degree.
   416. The true determining cause of labour at full
time certainly resides in the uterus: this cause seems
to me to act  constantly during the whole time of
gestation,  though its effects are not usually sensible
till the end of the ninth month. The distended ute-
rine fibres continually endeavour to expel the bodies
which affect them disagreeably. If they are not able
to compass it in the first periods, it is because they
are not all equally solicited to it; and  because,  not
being all developed at the same time, the  action of
some is counterbalanced by the natural resistance
of others. 
     Of the natural efficient Causes of Labour.

  417.  The vulgar suppose that the child is the
principal agent of its birth; that it opens the parts
of the woman  by repeated efforts,  and thus sur-
mounts the obstacles which oppose its exit.
  418.  The expulsion of the child is a function en-
tirely dependent on the strength of the organs of the
woman.  Two kinds of action concur in it; that of
the uterus, and that of the muscles which surround
the abdominal cavity.  The former is the principal,
the latter is only accessory.
  419.  The  contractions of the uterus are always
very weak  at the  beginning of labour, but augment
insensibly, and become very strong.  Those of the
first periods are called  preparative; and those of the
latter, determining or  expulsive. But instead  of
the word contraction, which is only understood by
those who have  studied the art, pain is generally
made use of.
  420. The pains, and calms, present great variety
in different labours; they are sometimes shorter, and
sometimes longer,  no  two  individuals presenting
the same phenomena, nor even the same individual
is not held always alike in her different labours.
  421.  The  effect of the contraction of the uterus
is, to diminish its cavity in every direction. If the
child, pressed on all sides, is forced out  of it, it
is because  the resistance it meets with is not equal
in all its parts; it  always escapes at the place where
there is the least.
  422.  If that place is almost always the orifice of->
the uterus, it is because its fibres are fewer in its
vicinity than  in all other parts; because it is diame-
trically opposite to the centre,  which serves as  a 
 164       Efficient Causes of Labour.

fulcrum to all its fibres; because it is at the inferior
 part, and over the cavity of the pelvis, where it is
 no way fortified by the surrounding  parts, as all
 other parts of the uterus are; and,  lastly, because
 all the efforts of labour are  directed towards  that
 point.
   423. When the orifice cannot open, if all parts
 of the uterus resist equally, nature exhausts herself
 in vain, and labour at length ceases: but if any part
 of that organ is weaker than the rest, it tears; and
 the child passes, either partly or totally, into the
 cavity of the abdomen.—See the article on the rup-
 ture of the uterus.
 Of the Causes accessory to the Action of the Uterus.

   424. The  diaphragm and  abdominal muscles
 have an important share in the expulsion of the
foetus. The efforts which the woman makes to re-
 lieve herself in the moment of pain call these parts
 into action, and are nearly the same as those made
 to expel the urine and faces. In the first periods of
 labour, these efforts are subject to the will, but are
 no longer so, at the last moments.
   425. By these efforts, the abdominal muscles and
 the diaphragm not only contribute to the expulsion
 of the foetus, but  becoming in some measure con-
 tiguous to the  uterus, which they press, either me-
 diately or immediately, on  all sides, they serve for
 a support to it; and  in many cases secure  it from
 rupture,  which  without that support  would  be
 much more frequent than it is.
   426. These  muscles never act more efficaciously
 on the uterus, and the other abdominal viscera, than 
Phenomena of Labour.          165
when the bones to which they are attached are fixed
and  immoveable:  therefore  the contraction  of a
great number of other muscles becomes equally
necessary in labour; but these latter only coope-
rate  with the former in a very indirect manner.
   427.  While the sterno-mastoidei muscles, the
scaleni, the pectorales, major and minor, the serrati,
and  others, fix the thorax, and prevent its obedi-
ence to the abdominal muscles, the greater part of
those destined to move the thighs and legs do the
same by the pelvis.
  Of some of the principal Phenomena of Labour.

  428. I think  it is proper to explain some of
the principal phenomena of labour; such  as the
pains, the dilatation of the orifice of the uterus, the
discharge of mucus tinged with blood, and the for-
mation of what is  vulgarly  called the gathering of
the waters;  before I  indicate the  order  in which
they manifest themselves, as well as several others
which will be mentioned in the sequel.
               Of Labour Pains.

  429. The pains are the first sensible phenomena
of labour; it is they which announce it, and no wo-
man can  bring forth a child without them.
  430. They appear to be the immediate effect of
the contraction of the uterus; but that action must
have passed through many degrees to become sen- 
 166          Phenomena of Labour.

 sible. In the beginning, that contraction is so slight,
 that it merely produces an internal sensation like
 that of a tenesmus.
   431. The violence of the labour pains is always
 in proportion  to the force of the contractions which
 cause  them.  They are so  slight  in the beginning
 of labour, that they seem only like a gentle  prick-
 ing. If they are sharper towards  the end, it is be-
 cause the contraction of the uterus is stronger, its
 fibres are more  stretched, and  become more  sen-
 sible, and they act on a  body which gives them a
 greater resistance. The violence which the edge of
 the orifice  then  undergoes is  but an accessory
 cause.
  432. The labour pains do not always manifest
 themselves  in the same  manner.  Sometimes they
 begin at the loins, and shoot downward; sometimes
 they are felt at the navel, or other parts of the ab-
 domen, from whence they pass to the small of the
 back, where they torment exceedingly. The best
 are those which are directed towards the  orifice of
 the uterus, or  the fundament.
  433. These pains of the back sometimes  mani-
 fest themselves from the beginning of labour, at
 other times a  little later; but they rarely continue
 to the end.
  434. It  has  been attempted  in all ages, to calm
 this sort of pains. Bleeding and emollient clysters
 have sometimes succeeded; but  in general  those
 means  have been employed in  vain, at least with
 respect  to alleviating  those pains. What  seems
 most likely to  relieve them is, to lift the woman up
a little,  during each pain,  by  means  of a napkin
rolled up and passed under the loins. 
             Phenomena of Labour.          167


   Of the Dilatation of the Neck of the Uterus.
  435. The orifice of the uterus is almost always
a little open before the epoch of labour.  We see
the reason of it by following, step  by step, the or-
der of the  development  of that viscus, and by at-
tending to all that passes at its orifice in the latter
periods  of gestation.
  436. The cause of this first degree of dilatation
being well known, must  throw the greatest light
upon that which takes place in time of labour; and
show us that it is not immediately and entirely the
effect of that species of wedge which the substances
subjected to the contractions of the uterus present
to its orifice.
  437. Although in many cases, where the waters
drain off prematurely, no part of the child can en-
gage in the orifice of the uterus,  yet it does not
fail to open, in the same manner as if the bag for-
med by the protrusion of the membranes were en-
tire; from whence we see that the action of that
organ is alone sufficient to effect  the dilatation  of
its neck.  But it will perform  it so much the more
easily as the uterus is more distended, and as the
body it contains is more solid.
   438.  We must however allow,  that the concur-
rence of all these causes renders  the dilatation of
the  orifice  more easy,  and that  it  then requires
fewer pains to effect it;  for independently of the
force which  the membranes  distended  by the
waters exert in the orifice, when  they can engage
in it like a wedge, the soft  and gradual pressure
which -they continually make on all the neighbour-
ing  parts, determines a repletion in them, which
favours  their  development,  and  renders it less
painful. 
168         Phenomena of Labour.
  439. In general, it requires more time and labour
to open the orifice of the uterus the breadth of a
halfcrown,  than to obtain all the rest of the dilata-
tion  necessary for delivery. Young practitioners
ought  never to lose sight  of  this remark,  when
forming their prognostic on the duration of labour,
that  they may not expose women to be delivered
alone, by supposing the time still far off, when very
near.
  440. Besides, the progress of this dilatation is not
the same in all women, nor in all the labours of the
same woman.  Sometimes the orifice is more open
at the beginning  of labour, than at others  after
twelve or fifteen hours of strong pains; which de-
pends  on  certain  circumstances,  which  practice
soon makes us acquainted with.
  Of the Mucus, tinged with Blood, which drains
               from the Vagina.

  441. The  parts of the woman are  more than
Usually moist towards the latter periods of preg-
nancy, and during labour; for  the most part there
is a discharge more or  less abundant of a mucous
serosity.  This  is  sometimes  tinged with  blood,
owing most probably to a rupture of some of  the
small vessels of the placenta or chorion.  This is
generally looked upon as a presage of a speedy de-
livery; but this  is not always the case. 
Phenomena of Labour,           169
         Of the Gathering of the Waters.
  442. In proportion as the orifice of the uterus is
dilated, the membranes are  protruded through it,
and form a tumour in the vagina, which is tense in
time of a pain: this is what is called the gathering
of the waters.
  443. This tumour assumes various shapes agree-
ably to the situation of the mouth of the uterus; its
degree  of dilatation; or laxity of the  membranes
themselves; sometimes, circular, oblong, or  ex-
tended  like a pudding.  The portion of the mem-
branes which forms this tumour bursts from  the
impulse  of the waters pushed forward  by the con-
tractions of the uterus.  The  time of this rupturing
is however  very various, sometimes happening at
the very commencement of  labour or even before;
at other times not until the labour is well advanced
or nearly finished.
  444. When the membranes are delicate they burst
at the  beginning of labour,  which sometimes ren-
ders it more tedious; not because it produces a dry
labour, but because one of the causes which ought
to cooperate  in  the  dilatation  of the  orifice fails
before it is effected.*  If the membranes  do  not

  * I am disposed to believe the reason labours are more
tedious where the membranes prematurely give way, is  to
the uterus being unpreparedly thrown into contractions before
the body and fundus have exerted their influence on the fibres
of the neck, so as to  dispose them to yield, and not to the
loss of the waters as a mechanical agent. For we see many
instances  of the most perfect dilatation happen when the
membranes are  not protruded beyond the  orifice of the
uterus, and on the other hand, we see speedy delivery take
place where the quantity of water escaped has been small and
insufficient to excite  the uterus to contraction, or where it
has been abundant, but the uterus thrown into a state of tor-
por by the sudden depletion of the liquor amnii.  W. P.  D.
                        Y 
170          Phenomena of Labour.
burst until  the labour is at its height,  the  waters
escape  with a considerable jet, and the uterus is
thrown into a state of inactivity for a short time;
it however  presently recovers, and now acts with
increased force.
  445. The membranes do not always burst spon-
taneously;  and  if we did  not  tear them in these
cases, we should see the child sometimes born in
its involucra, and bringing the placenta with it.
Exposition of the preceding Phenomena, and of some
  others, according to  the Order in which they ge-
  nerally happen.

  446. Labour  is almost always announced by
sensible alterations in the animal economy; but they
are,  as I  may say, different  in  each  individual.
These symptoms  are presently succeeded by slight
pains in the loins, accompanied by a hardness of the
uterine globe, and a kind of internal tightness which
the woman can scarcely express.
  447. Touching discovers to us that, at the instant
of these pains, the orifice of the uterus contracts a
little, that its edge stiffens, and that the membranes
which cover it are more or less distended. All these
symptoms augment in the course of labour, except
the first;  for the orifice afterwards, far from  con-
tracting,  is obliged to enlarge at every pain.
  448. In the second period of labour the pains
become stronger and  more frequent;  the orifice of
the uterus enlarges, its edge  develops, and often
becomes extremely thin; the tumour formed by the
membranes becomes more  considerable;  and at
every pain the child's head seems to  go higher, so 
Phenomena of Labour.          171
that it is never farther from the finger that at this
moment.  The woman feels a weight below, which
invires her to  make some gentle efforts, like those
caused by a tenesmus; and the neck of the uterus
seems to descend a little, because the  whole body
of it is pushed towards the pelvis byr the action of
the abdominal muscles.
   449. After  the  pain, things return  to the same
state they were in  before;  the edge of the orifice
slackens, the membranes become flaccid, the child's
head descends again, driving away the waters to the
sides, and applies itself to the membranes.
   450. In the third period of labour, which is that
of its greatest  force and violence, the pains succeed
each other more rapidly;  they are sharper and long-
er; the woman is  more forcibly  excited to assist
them, and she supports them better than before. If
the calm  which succeeds each  pain is shorter, at
least it is quieter and more perfect; and is not com-
monly troubled by any of those uneasinesses which
the first pains often leave behind. The orifice of the
uterus augments so much, that it almost equals the
whole breadth of the pelvis.
   451.  The  glandular follicles scattered  through
the whole substance of the vagina and neck of the
uterus, at this time discharge a greater quantity of
mucus; and this is the time when that humour be-
gins to colour more or less with the blood which
escapes from the little ruptured vessels: so that it is
the period of labour when some women mark the
most, and in which the greater part begin to do it.
   452. At this epoch  likewise a great number of
other symptoms appear,  and the former acquire
more force and intensity.  The pulse becomes more
hard and  frequent,  but it is almost always irregular;
the face grows red, the eyes inflame, and the heat 
172          Phenomena of Labour.
extends to all parts; and the disorder of the whole
frame becomes so general,  that  all its functions
seem deranged.
  453.  The rupture of the  membranes comes
seasonably to calm this universal agitation, by the
relaxation which the evacuation of the waters pro-
duces: but this repose is usually of short duration;
still stronger pains soon disturb it, and give birth
to new phenomena, which announce the termination
of labour.
  Of the Phenomena of the last Period of Labour.

  454.  The  uterus, applied immediately to the
child's body,  after the  evacuation of  the  waters,
contracts more briskly than before.  The head en-
gages in the orifice,  and approaches the vulva  at
every pain; so that, when all things are well dispos-
ed,  the delivery is terminated in a veryT little time.
  455. As soon as the head is completely in the ca-
vity of the pelvis,  many  women complain of a want
to go to stool; and some, for fear of discharging
their excrements on  the bed, dare not give them-
selves up to the efforts which they exerted before
with so much success, and to which they are then
so strongly excited; which more or less retards their
delivery.
  456. But this sensation is very often illusive: and
if we were to permit all women who feel it to place
themselves on the close stool, we should have the
mortification to see some of them delivered in that
attitude; which might have disagreeable consequen-
ces, either to themselves or their children.
  457. When this sensation is felt, if the perinaum 
Phenomena of Labour.          173
yields easily, we see it stretch at every pain, on the
child's head, which pushes it outward.  The vulva
dilates in the same  manner, and delivery is soon
terminated. But when it is thick and solid, and all
the parts resist, as usually happens in a first labour,
delivery is often several hours distant still.
   458. In this latter case,  though  the perinaum
distends, and is forced outward during  every pain,
it  shrinks  immediately afterwards;  and the head,
which was visible at the vulva, recedes,  and returns
again into the pelvis. These effects are  repeated in
the same order, till the parietal protuberances have
passed below the anterior part of the tuberosities of
the ischia: then the perinaum remains distended;
and the head, which appears almost entirely enve-
loped in it, no longer remounts after the pain.
   459.  Accoucheurs generally attribute the return
of the head, after each pain, to the twisting of the
umbilical cord round the child's neck, and have pro-
posed divers means for facilitating delivery in  that
case. It will perhaps appear surprising that I should
rise up against so many authorities,  and assign no
other cause  for this effect but the elasticity of the
perinaum, and of the bones  of the cranium:  but
reason and experience join to prove  that it depends
on no other.
   460.  When the head is so far descended as not
to return  again after the pain,  the perinaum, then
much distended and very thin, not being able alone
to sustain the united efforts of the uterus and the
abdominal muscles, is in the utmost  danger of tear-
ing. To prevent this accident, we ought to direct
the  woman  to suspend or moderate those efforts
which depend on her will;  while the  accoucheur
supports  the perinaum with the palm of one hand,
in order to counterbalance the rest,  till  the external 
174          Phenomena of Labour.

parts be sufficiently dilated for the passage of the
child.
  461. At the moment when the greatest breadth
of the  head presents to the vulva, the  caruncula
myrtiformes disappear, the nympha diminish, and
the fourchette commonly tears.  To this, the most
painful moment of labour, succeeds a calm, till then
unknown to the woman; and that calm, joined  to
the joy of being a mother, renders this instant in-
expressibly agreeable.
  462. But new pains would soon come, and dis-
turb this delicious moment, if the accoucheur should
abandon the expulsion of the child's trunk, and of
the placenta, to nature alone; for the spontaneous
exit of either could not be accomplished without a
great number of contractions of the uterus.
  463. In  many women these  pains are repeated
during the first days of lying in. They are then ex-
cited by the presence of clots which are formed  in
the uterus, or by the fulness of  the vessels of that
organ;  they are called after pains. If the first labour
is in general the longest and most painful, women
are in some measure recompensed by the absence of
these pains, which are much less common after the
first, than  after succeeding labours. 
PART  II.
Of Natural or Unassisted Labour, and the various
                  Kinds of it.

  464. If  we comprehend in the class of natural
labours all  those in which the women might be de-
livered without help, we may divide them into four
general species, each of which may be subdivided
into particular ones. 1. Those where the child pre-
sents  the head.  2.  Where it comes  by the feet.
3. Where it presents the  knees. 4. Those in which
it presents  the breech.
  465. A  natural delivery always depends on the
concurrence of several causes, some of which de-
pend on the mother, and some on the child. It may
be more or less  easy  or difficult, as  these causes
concur in a greater or smaller number; or according
to the number that are wanting.
   466. A  good conformation of the pelvis, a suffi-
cient  degree of strength, a favourable situation of
the uterus,  a suppleness of its neck, and of the parts
which form the pudendum,  are, on the side of the
woman, the conditions requisite for a natural deli-
very.
   467. On the part of the child, its volume must
not surpass the extent of the openings  of the pelvis,
and it must present to the orifice of the uterus, one
of the parts indicated in par.  464; that is to say, the
head, the feet, the knees, or the  breech. 
176            Unassisted Labour.
Of the frst general Species of Natural Labour, or
    that in which the Child presents the Head.

  468. By this generical term, ofa child presenting
the head, I give notice that I mean only that region
of it called the vertex; intending to speak of the
others in another place.
  469.  This first general species of labour, which
is the most natural in all respects, has in itself es-
sential differences, relatively in which the head may
present to the Superior strait.  Among the various
positions which the region of the vertex is suscepti-
ble  of, I  shall distinguish but  six, which will con-
stitute so many particular species of labour.
Distinguishing Signs of the Vertex, and of its Dif-
                ferent Positions.

   470. A round tumour, ofa certain extent, and
pretty solid, on which we may distinguish several
sutures and fontanelles, characterizes the vertex, or
the superior part of the head.
   471. It is the direction of the sutures, and the
situation of the fontanelles, with respect to the pel-
vis, which enable us to judge of the position in which
the vertex or crown of the head presents. It  is of-
ten sufficient for that purpose to touch either of the
fontanelles.
   472. In the first position, the sagittal suture cuts
the pelvis obliquely  from left to right, and from be-
fore backward. The posterior fontanelle is situated
behind the left acetabulum, and the anterior before
the right sacro-iliac  symphysis. 
Unassisted Labour.
177
   473. In  the  second position, the sagittal suture
 also traverses the pelvis diagonally, but passes from
 the  right acetabulum to the left sacro-iliac symphy-
 sis;  so that  the anterior fontanelle is before the lat-
 ter,  and the posterior behind the former.
   474. In  the third position, the posterior fonta-
 nelle answers to  the symphysis of the pubes,  the
 anterior to  the  sacrum, and  the sagittal suture is
 parallel to the small diameter of the superior strait.
   475. In the fourth position, this suture is direct-
 ed as in the first;  with  this difference, that the ante-
 rior fontanelle answers to the left  acetabulum,  and
 the posterior to the right sacro-iliac symphysis.
   476. In  the fifth, the sagittal suture is likewise
 directed obliquely with respect to the pelvis;  the
 anterior fontanelle being  situated behind the right
 acetabulum, and the posterior behind the left sacro-
 iliac symphysis.
   477. Lastly,  in the  sixth  position, the  anterior
fontanelle is behind the symphysis of the pubes,  and
 the  posterior before the sacrum; the sagittal suture
 being directed as  in the third position.
   478. Some of  these positions are not met with
 so frequently as others. It has appeared to me that
 the  proportion of the  first to the second,  was as
 seven or eight to one; and to the fourth and fifth, as
 eighty, or  even an hundred to one: as to the third
 and sixth positions, theyrare excessively rare; though
 most accoucheurs have thought, and still think, that
 the third is  the most natural and usual.
   479.  These  six  positions  not being  equally
 favourable to the  exit of the  child, may  be distin-
 guished into good and  bad. For the head to be well
 situated, it  must present diagonally to the superior
 strait, and in such a manner  that the occiput may
 turn under  the arch of the pubes, as soon as it is de- 
178
Unassisted Labour.
scended into the cavity of the pelvis. The two first
positions are  the best; the third may also pass for
such, when the pelvis is of the natural size. The
others,  and especially the sixth, would often justly
merit the title of bad positions, if the dimensions of
the child's head were not pretty constantly much
smaller than those of the pelvis of the woman: for
notwithstanding this favourable relation of the head
to the pelvis, yet it cannot disengage from it in all
these cases without a great deal of trouble;  as  we
shall see in the sequel.      ,
   480.  The best positions of the head with respect
to the superior strait, are not so with respect to the
inferior; for it cannot take a more favourable one at
the latter, than that where the occiput answers to the
arch of the pubes. The head may also engage in the
pelvis in such a  manner as to meet the greatest ob-
stacles to its progress, though it had at first present-
ed in the most advantageous position at the  supe-
rior  strait;  which depends on the concurrence  of
several  causes,  whose presence adds so considera-
bly to the natural difficulties of labour, that we are
often obliged to lend our assistance to terminate it.
  481,  It is necessary then, for the easy perfor-
mance of this function, that the  head, besides the
conditions  already stated,  should  follow a deter-
mined course: but different, in some respects, in
each of the six positions which I have established. 
Unassisted Labour.            119
Of the Mechanism of Natural Labour,  where the
   Child presents the Crown of the Head in the first
   Position.
   482. When we consider the position of the head
which constitutes  this species of labour, it is easy
to figure to ourselves the situation of the trunk and
other parts of the child in the  uterus; and to see
that the back, and hind part of the head,  answer to
the anterior and left lateral  part of that viscus; the
face, the breast, and the knees, to the posterior and
right lateral part; the feet and breech being situated
towards the fundus.
   483. In  the natural order, the first contractions
of the  uterus bend the head on the anterior part of
the trunk,  till the chin rests against the upper part
of the  breast.  During this time the posterior fon-
tanelle approaches more or less to the centre of the
pelvis; and the  head  in that state of flexion conti-
nues to descend in the direction of  the axis of the
superior strait,  till stopped by the inferior part of
the sacrum, coccyx, and perinaum: one of  the pa-
rietal protuberances passing before  the left sacro-
iliac symphysis,  the other behind the right acetabu-
lum.
   484. The touch discovers to us that a little more
than the  posterior and superior fourth of the right
parietal bone then answers to the arch of the pubes;
that the right branch  of the lambdoidal suture an-
swers to the left limb of that arch; and that the other
branch of  that  suture is towards the left ischiatic
notch.
   485. The head cannot remain long in  that state;
pressed by new  efforts, and  not being able to follow
its former  direction, it passes forward along the in- 
180            Unassisted Labour.
clined plane offered it by the sacrum, the coccyx,
the perinaum, and sides of the pelvis; but in such
a manner that, in descending thus, the occiput turns
by a pivot-like motion under the arch of the pubes,
with which it has a strong relation, both in its form
and dimensions.
   486. This pivot-like motion, by which  the occi-
put turns under the pubes, depends entirely on the
twisting of the child's neck:  we may estimate it at
about the sixth or eighth  of a circle.  It is very ne-
cessary to observe that, during  this motion of the
head, the trunk executes nothing of the kind in the
uterus. After this rotatory motion, we find the pos-
terior fontanelle towards  the  middle of the arch of
the pubes; from  whence  the  sagittal suture goes
backwards, rising obliquely towards the projection
of the sacrum under which the anterior fontanelle is
then situated. Each branch of the lambdoidal suture
crosses the common branch of the ischium  and pubis
of the same  side; and the nape of the neck rests
against the inferior edge of the symphysis pubes.
   487. The  chin, which  had been applied to the
breast, begins at this period of labour to recede from
it; and the occiput engages under the pubes, dila-
ting the vulva, and rising up before the mons vene-
ris; or, which is the same thing, turning backward,
if we  speak only with respect to the child.
   488. In this last period  the head describes almost
a quarter of a circle, turning round the inferior edge
of the pubes, like a wheel round its axle-tree. In
this movement, the centre of which is the nape of
the child's neck,  the occiput  passes through a very
small space in rising towards the pubes of the mo-
ther; while the chin describes a very extensive durve
behind, passing successively  over  every point of a
line which would divide  the sacrum,  coccyx, and
perinaum, longitudinally into two equal parts. 
Unassisted Labour.
181
  489.  In this species of labour, the shoulders,
which had engaged obliquely in the superior strait,
present themselves differently at  the inferior.  The
right shoulder turns towards the pubes, and the left
towards the sacrum; so that their  greatest breadth
becomes  parallel to that  of this strait.  After this
change, the left shoulder  continues to advance to-
wards the  bottom of the vulva,  where it appears
before the right has disengaged from under the
pubes.
  490.  The shoulders being delivered, the  rest of
the trunk comes along with the greatest facility, on
account of its conical and lengthened form.
  491.  By following step by step the course I  have
just traced from observation, it will appear, 1. That
in  all periods of labour  the  head  presents its
smallest diameters to the pelvis, and that it passes
through it presenting only its  smallest circumfer-
ence. 2.  That it executes three  different motions
in this passage: that of flexion forward, in the first
period: the pivot-like,  or rotatory motion,  in the
second; and, lastly, that of flexion backward, at the
time it  disengages from under the pubes.*
   492. Nature cannot deviate from this course,
but  the  delivery must in consequence become
longer  and more difficult;  and  often impossible
without assistance.

  * The student's attention is begged to these truths.
                                       W. P. D. 
182
Unassisted Labour.
 Of the Mechanism of Natural Labour,  where the
   Child presents the Crown of the head in the Se-
   cond Position.
   493. This position of the head, whose characters
 are described in par. 472, will appear as favourable
 to the exit of the  child as the first,  if we  only at-
 tend to the relation of the dimensions of the head to
 those of the pelvis.
   494. Nature however often finds obstacles in this
 second position, which she very rarely meets with
 in the first: the right lateral obliquity of the uterus,
 which is  much more  frequent  than the left;  the
 situation of the rectum with respect to the  sacrum,
 and the hardened faces which it often contains—
 appear to  be the principal sources of them.  The
 first of these causes obliges the head, as it  engages
 in the pelvis, to follow that disadvantageous course
 indicated  in par. 950; and the second obstructs the
 rotatory motion by which the occiput must turn
 under the pubes in the last period: the rectum, on
 the left side of which  the forehead is then placed,
 hindering it from passing  freely into the hollow of
 the sacrum.
   495. The mechanism of delivery in this position,
 when the  uterus has not deviated,  and all  other
 things are well disposed, is  entirely similar to that
 of the first position. The occiput descends in  the
 same  manner into  the cavity of the pelvis; and af-
terwards turns  under the arch of the pubes, and
disengages itself by turning on the inferior part of
the symphysis,  while the chin describes  backward
a very long curved line, as stated in par. 488.
  496. As soon as the  head is delivered,  the  left
shoulder presently places itself under  the pubes; 
Unassisted Labour.
183
and the right goes towards the sacrum, to advance
in the order indicated in par:* 489.
 Of the Mechanism of Natural Labour, where the
   Crown of the Head presents in the Third Po-
   sition.

   491. Most accoucheurs, even at this day, ima-
 gine that the head generally presents in this posi-
 tion, see par. 473.
   498. This third position will perhaps appear less
 advantageous than the two preceding,  because the
 longitudinal diameter of the head is parallel to the
 smallest diameter of the superior strait; but if we
 recollect that this latter is  generall)* four inches in
 extent, and that the diameter of the head in ques-
 tion scarcely ever advances foremost,  we shall see
 that delivery may sometimes be as easy in this case
 as in the former.
   499. When the uterus is not inclined to either
 side, the head engages in the  pelvis according to
 the usual laws; the occiput descends behind  the
 symphysis of the pubes, while the chin rises towards
 the breast; so that the head only presents its height,
 or perpendicular diameter, to the small diameter of
 the superior strait.
   500. As soon as the vertex is arrived  at the in-
 ferior part of the sacrum, we find the occiput placed
 under  the arch  of the pubes to which it naturally
 answers in this  position; and the head disengages
 as in the two former (see par. 487, and 488.) After
 that is disengaged, the shoulders present at the infe-
 rior strait, as stated in par. 489; but sometimes it
is  the  right shoulder  which goes backward, and 
184            Unassisted Labour.

sometimes the  left: whereas in the other positions
their course is almost constant.
 Of the Mechanism of natural Labour,  where the
   Crown of the Head presents in the Fourth Posi-
   tion.

   501. In this species of labour, the position of the
 head (see par. 474) is such, that  its delivery be-
 comes exceedingly difficult when the pelvis is not
 extremely large, relatively to the  volume of the
 head; because the face turns gradually upward, and
 presents the forehead to the arch  of  the pubes.
 When every thing is in the natural order, the  occi-
put  descends into  the  pelvis, passing  before the
 right sacro-iliac symphysis, till the posterior and su-
 perior part of the right parietal  bone rests on the
 lower part of the sacrum. At this time, the head
 being  obliged to turn  on its pivot, the  occiput
 passes into the curve of the sacrum; and the fore-
 head sliding along the inclined plane of the left side
 of the pelvis, goes under the pubes.
   502. It sometimes however happens, but unfortu-
 nately for the women too seldom, that the head in its
 descent approaches  to the second position; so  that
the occiput turns forward instead of going into the
curve of the sacrum.
   503. These examples of the fourth position re-
duced, as  it were, spontaneously to the second, and
from that to the most usual one at the  inferior
strait, indicate what we ought to do, in order to
save the woman from the difficulties of this species
of labour; for, by attempting  it  early, the accou-
cheur may always determine the head to take that
favourable direction. 
Unassisted Labour.            185
   504. The forehead being placed under the pubes,
 as stated in par. 501, we find the anterior fontanelle
 at the middle of the arch, and the  posterior above
 the point of the sacrum.  While this latter continues
 to advance forward along the coccyx and perinaum,
 the forehead,  placed opposite the arch of the pubes,
 and not being able to engage in it as  the occiput
 does in the former positions, is obliged to remount
 behind the symphysis, against the  inferior edge of
 which the anterior fontanelle is then strongly pres-
 sed, till the posterior appear at the bottom of the
 vulva.
   505. At that instant the anterior edge of the peri-
 naum,much more distended than in the former po-
 sitions, not being able to remain on the summit of
 the inclined and  slippery  plane of the occipital re-
 gion, retires backward towards the  child's neck.
 There it becomes the centre  of motion on which
 the head must turn, in disengaging from the pelvis.
   506. In this fourth species of labour the  occiput,
 as soon as  it is delivered, turns backward on the
perinaum, or towards the anus of the woman, while
 the face disengages from under the pubes,  and the
 chin describes a curved line, of the same extent as
 that it describes backward, in the three former posi-
 tions, before it appears at the bottom  of the vulva;
 but in a contrary direction. The chin scarcely ap-
 pears  without,  before the face turns  half round
 towards the mother's left thigh,  as if to look at the
 groin of that side. During this time the left shoulder
 places itself under the pubes, and  the right  goes
 towards the sacrum, to disengage first.
                      2 A 
186
Unassisted Labour.
Of the Mechanism of Natural Labour,  where the
  Child presents  the  Crown of the Head in the
  Fifth Position.

  507. The relation of the dimensions of the head
of the foetus to those of the pelvis of the  mother, in
the position which constitutes this species of labour
(see par. 475,) being absolutely the same as in the
preceding, the mechanism by which the expulsion
of the child is performed must, cateris paribus, be
also perfectly the  same.
  508. The occiput descends first into the cavity of
the pelvis, passing before the left sacro-iliac symphy-
sis, as it does before the right in the fourth position.
It afterwards turns towards the middle of the sacrum;
while the forehead, sliding along  the right side of
the pelvis, places itself under the pubes: after which
the whole passes  in the order stated in par. 504 and
following;  except that, when the face is delivered,
it turns obliquely  towards the right groin;  the right
shoulder slides under the pubes, and the left towards
the sacrum, in order to follow the course which has
been already assigned them.
   509. Sometimes the occiput, instead of turning
towards  the sacrum, gradually approaches the left
acetabulum, in  proportion as the head descends in
the pelvis; so that this fifth position is insensibly
reduced to the first. If the efforts of nature do not
always reduce  the head to this advantageous posi-
tion, in this species, at least they point out the course
we ought to make it take,  in order to procure the
woman this often inestimable advantage.
   510. Sometimes also this species of labour, often
difficult in itself,  on account of the tendency of the
face to place itself under the pubes, in proportion 
Unassisted Labour.
187
as the head descends in the pelvis, becomes much
more so, from accidental circumstances, and espe-
cially from a left lateral obliquity of the fundus uteri.
Of the Mechanism of Natural Labour, where the
 Crown of the Head presents in the Sixth Position.

  511. This species of labour is the most rarely
met with of any, where the crown of the head pre-
sents;  the cause of which no doubt is, that the back
of the  head being round, and very slippery, cannot,
on account  of the mobility which the child enjoys
till after the evacuation of the waters, remain against
the projection of  the last lumbar vertebra, which
offers  it, on  each side, spaces better adapted to its
figure.
  512. Though this species of labour, in which the
face comes upward, is allowed by all accoucheurs
to be the least favourable of the six, it is also very
happily the least common.  Its difficulties depend
much  less on the presentation of  the length of the
head parallel to the entrance of the pelvis, as some
perhaps may think, than on the inevitable presence
of the face under the pubes in the last period.
  513. In the sixth position of the  head, when the
pelvis  is well formed, the occiput descends before
the sacrum, as it does before the sacro-iliac symphy-
ses in  the fourth and fifth positions. The posterior
fontanelle, which we always take for a guide, passes
successively over every point of the curved line
mentioned in par. 488, to present itself at the mid-
dle of the crescent formed by the lower part of the
vulva, when the perinaum is  much distended. At
this instant the anterior edge of the perinaum retires 
188
Unassisted Labour.
towards the anus of the woman and the neck of the
child, as observed in par. 505; the occiput immedi-
ately begins to turn back  the same  way; and the
face disengages from under the pubes, according to
the course indicated in par. 506.
   514.  As soon  as the chin is delivered, the face
turns  towards one of the woman's groins; but in-
differently towards the right or the  left, without
our being able to assign a particular reason for it.
   515. The shoulders soon afterwards present their
greatest breadth to the length  of the vulva; one
of them turning towards the pubes the other towards
the sacrum; in order to  disengage as in the five
formerspecies of labour which I have just described.
Of the Second general Species of Natural Labour,
   or that in which the Child presents the Feet.

  516. Although experience has frequently prov-
ed that a woman might be delivered without help,
of a child presenting the feet, it is still customary
to class this sort of labours among those called pre-
ternatural, and to treat them as  such. I  shall not
examine scrupulously  whether it be right or not;
considering here purely and simply as natural, those
labours where the  child presents the feet:  I reserve
to myself the liberty of treating their particular in-
dications, according to circumstances in another
place. 
Unassisted Labour.
189
Of the Signs which indicate that the Child presents
                   the Feet.

  517.  Those  labours where the child presents
the feet, come on in the  same manner as the pre-
ceding, and are accompanied by the same pheno-
mena, till the opening of the  membranes.
  518.  It is generally so easy  to  distinguish the
feet, that I  think we  may dispense with a descrip-
tion of their characters; but it is not always so easy
to discover their true position, and judge by that
of the position  of the trunk and head of the child
in the uterus; because of the extreme mobility of
the legs and thighs, and even  of the feet. Indeed we
need not trouble ourselves much  about it, before
these latter, and even the breech,  appear without;
since the greatest difficulties of labour, in these cases
proceed only from the volume of the shoulders and
head, or from the manner in which those parts pre-
sent at the superior strait.
   519. Relatively to  these latter parts we shall dis-
tinguish four principal positions, to which all others
may be referred. These  four positions will consti-
tute so many species of labour.
   520.  In  the first position of the feet, the  heels
answer  to the left side of the pelvis,  and  a  little
forward; the toes to the  right side, and backward,
nearly opposite the sacro-iliac symphysis. Above that
symphysis are placed the  breast and face: while the
back is  situated under the anterior and left lateral
part of the uterus.
   521. In the second position the heels are towards
the right side of the pelvis, and the toes to the left,
and a little  backward. The  trunk and head are so
situated, that the breast and face answer to that part 
190            Unassisted Labour.
of the uterus which is over the left sacro-iliac sym-
physis, and the back to the anterior and right lateral
part of that viscus.
  522. In the third position, the heels are turned
towards the pubes, and the toes to the sacrum. The
child's back is under the anterior part of the uterus,
and its breast answers to the lumbar column of the
mother.
  523. The  fourth position is exactly the reverse
of the third: the child's back and heels are towards
the posterior part of the uterus; while the toes, the
face, and breast, are under its anterior part.
 Of the Mechanism of Natural Labour,  where the
   Child presents the Feet in the First Position.

   524. In this position, as well as in the other three,
the feet cannot descend but as they are pushed down
by the breech, against winch they are placed. They
sometimes advance with difficulty, because the legs,
crossing one another casually in the pelvis, produce
considerable obstacles to their descent. When they
are without, the breech soon appears at the vulva,
where it almost alwayrs  presents diagonally; the left
hip,  in this  first position,  answering to the  right
limb  of the  arch of the pubes, and the right hip to
the left sacro-ischiatic ligament. The breech con-
tinues to advance  in that direction, rising a little
towards the mons veneris, in proportion as the trunk
disengages;  because it is forced to bend a  little to
one side,  to accommodate itself to  the curve of the
pelvis.
   525. While things go on thus  with respect to
the trunk, before our eyes,  whether in this first po- 
Unassisted Labour.
191
sition of the feet, or in the three others, the child's
arms are raised towards the lateral regions  of the
head; following a course which it is easy to form an
idea of, if we recollect their natural situation at the
sides of the breast.
   526.  When the armpits  arrive at the superior
strait, the trunk would be stopped, and cease to de-
scend, because of the projection of the arms, if the
shoulders,  though placed according to  one  of the
largest diameters of the pelvis, were not as moveable
as we find  them to be, and could not diminish their
breadth; but, by means of these favourable disposi-
tions, they accommodate themselves to the figure
of the pelvis, and engage in it, by the efforts of the
uterus,  and of the auxiliary  powers.
   527.  The head soon  after  presents at the same
strait; and in such a manner that the occiput is over
the left acetabulum, and the face over the right sa-
cro-iliac symphysis.
   528.  The chin, naturally resting on the  breast,
almost  always engages before the occiput, so as to
be very low by the time the latter reaches the edge
of the strait; which  detaining it a little longer fa-
vours the descent of the former.
   529. If the head engages diagonally in the supe-
rior strait, it does not fail soon to change its direc-
tion. It has scarcely cleared that strait, before it de-
scribes a rotatory motion, similar to that mentioned
in par. 484; by means of which the forehead turns
towards the middle of the sacrum, whose curve is
better adapted tQ its  round figure, and offers it a
larger space. After this motion,  the face lies along
the coccyx and perinaum; the nape of the neck being
placed  against the inferior  edge of the  symp/isis of
the pubes,  behind which the  occiput is in some
measure concealed. 
192
Unassisted Labour.
   530. The chin being then very near the vulva,
 appears at the first or second pain: then follow the
 mouth, the nose, the forehead, the anterior fonta-
 nelle, and  the  vertex; all  which pass successively
 before the fourchette, or anterior edge of the peri-
 naum; while the nape of the neck only turns a little
 on the inferior edge of the  symphysis  of the pubes,
 as on its axis.          ;
   531. In this last period of labour, the action of
 the abdominal  muscles, is almost always subject to
 the will of the woman,' and to the exertion of which
 she is then so powerfully excited^ appears to be all
 that is necessary for the expulsion of the head; the
 contractions of the uterus assisting very little at that
 time. This remark ought  to induce the woman to
 bear down with all her strength; and the accoucheur
 not to pull  inconsiderately at the  child's  trunk,  to
 finish the extraction of the head; as is too often done,
 in the mistaken and dangerous idea, that we cannot
 deliver the head too  soon.
   532.  Though the child's  arms,  stopped by the
 elbows  at the  brim  of the pelvis, rise towards the
 sides of the  head; and, in proportion as the trunk
 and  shoulders  descend,  become  almost parallel to
 the neck—those parts are scarcely delivered, and
 the head advanced into the cavity of the pelvis, be-
fore  the arms disengage of themselves.
   533.  By carefully observing the progress of the
 child in this first species of  labour, we see with how
 much wisdom nature has directed all its motions—
 that  the largest diameter of the breech, the shoul-
 ders, and the head, may not  present parallel to the
 smallest diameters of the pelvis; and that the head,
 especially,  may traverse that canal by offering it
 only the smallest of its two circumferences. 
Unassisted Labour.            193
Of the Mechanism of Natural Labour,  where the
   Child presents the Feet in the Second Position.

   534. We cannot recollect the characters of the
position of the feet which constitute this  species of
labour, without remarking the same relation of di-
mensions between the foetus and the pelvis of the
mother, as in the preceding position, and  without
being convinced that the mechanism of the expul-
sion of the child must be the same in both cases.
   535. In fact, the feet descend in this position as
in the  first;  the breech traverses the pelvis in a dia-
gonal direction; the shoulders engage in it in the
same manner, and their breadth  becomes after-
wards  parallel to the  length of the vulva; the head
presents its  greatest extent according to one of the
oblique diameters of the superior strait, but so that
the occiput answers to the right acetabulum, and the
face to the  left sacro-iliac junction; as soon as the
head has cleared the strait, the face turns towards
the middle of the sacrum, and continues to advance
along the curve of that bone, the coccyx and peri-
naum;  while the nape or back of the neck seems to
turn to the  inferior edge of the  symphysis of the
pubes,  as on its axis.—See par. 530, and  following.
Of the Mechanism of Natural Labour, where the
  Child presents the Feet in the Third Position.

  536. The  position of the feet which character-
izes this species of labour, has always  passed for
the most favourable of the four which  I  have as-
signed them: and will still appear so to those who
                       2B 
194
Unassisted Labour.
only pay attention to the relation of the diameters
of the breast and shoulders of the child to those of
the superior strait; especially in those women who
have  the pelvis a little contracted from pubes to sa-
crum: but we shall think very differently, if we con-
sider the relation of the dimensions of the head to
that same strait.
   537. The feet and trunk of the child  may be de-
livered, in this species of labour, preserving their
primitive position with respect to the woman; that
is to say, with the back turned directly towards the
pubes. But it would  be an error, when we see those
parts  descend thus, if we were to imagine that the
head  continues in the same position; that the face
remains exactly  underneath; and that  the child's
forehead passes before  the  lumbar column of the
woman. The round form and mobility of the head
demonstrate, at  least, that it is difficult for it to de-
scend in that manner, and pass over the angle form-
ed  by the  union of the base of the sacrum  with
the last lumbar vertebra, as it descends into the
pelvis.
  538. Although the child's back sometimes dis-
engages directly from under the pubes,  experience
proves that the forehead  almost  always  turns away
from the lumbar column, and places itself on one
side of it; so that the  head presents diagonally at the
superior strait,  as in the first or second position, to
clear that strait, as well as the rest of the pelvis, in
the manner described in par. 528. and following. 
Unassisted Labour.
195
Of the Mechanism of Natural Labour, where the
  Child presents the Feet in the Fourth Position.

  539. The fourth position of the feet is generally
regarded as the least favourable; because, the child's
face coming upward, it was falsely imagined  that
the chin must be hitched on the edge of the pubes,
and so obstruct the progress of the head. If facts
have sometimes lent their support to this opinion,
they have much oftener demonstrated that the fear
of that accident was ill-founded, and that the  pre-
cautions  recommended to prevent it had only ser-
ved to favour  it.
   540. It is however certain, that delivery is  per-
formed  with  somewhat  more difficulty  in  this
fourth position, than in the three others; because
the face does not find the same space to disengage
itself from under the pubes in the latter period of
labour, as it finds towards the sacrum in the  other
cases.
   541. When we let nature act without constraint,
and do not, under pretence of assisting her perform
any manoeuvre capable of disturbing her course, the
child's trunk  generally changes its direction  as it
descends; the breast turns from under the pubes;
and the  breech, as well as the shoulders, engage
obliquely in the openings of the pelvis, pretty nearly
in the same manner  as in the first positions of the
feet.
   542. Independently of  these usual changes, the
chin  generally turns from over the symphysis of the
pubes, before" it reaches it;  because the occiput, on
account  of its roundness, and the extreme mobility
of the head, cannot descend exactly along the mid-
dle of the convexity of the lumbar column, to stop 
196            Unassisted Labour.
and be fixed above the sacro-vertebral angle. If it
does not place itself constantly on one of the sides
of this column, at least it does so almost always; so
that the base of the cranium presents diagonally  at
the entrance of the pelvis, but so that the  face an-
swers to one of the acetabula, and the occiput to the
sacro-iliac symphysis on the opposite side.
   543. The head having placed itself thus, engages
in the pelvis, and  passes  through it according  to
the same laws as in the three former species of this
kind of labour. The forehead engages in the same
manner before the occiput; but instead of descend-
ing backward towards one of the sacro-iliac sym-
physis, and  turning afterwards towards the middle
of the sacrum, it passes down behind one of the
acetabula, to place itself presently under the arch of
the pubes.
   544. After this  rotatory motion, the posterior
part of the  child's neck rests on the anterior edge
of the perinaum, or the posterior part of the vulva;
and that edge then becomes a kind of axis, on which
the head turns backward as it disengages from the
pelvis; in the same manner as it describes a quarter
of a circle round the symphysis of the pubes, in the
three former positions, but in a contrary direction.
 See par. 530.
   545. While the child's head describes this quar-
 ter of a circle backward, the posterior part of the
 neck turns  more and more towards the anus of the
 woman; and we see the chin, the nose, the forehead,
 the bregma, and  vertex, disengage  successively
 from  under the pubes.  But  the expulsion of the
 head is performed with more difficulty than in those
 cases where the face is turned towards the sacrum;
 because the arch of the pubes is narrower, in its su-
 perior  part, than the forehead  and vertex of the
 child. 
Unassisted Labour.            197
Of the third general Species of Natural Labour, or
    that in which the Child presents the Knees.

   546. If  we call to mind the respective dimen-
sions oftheycerwand the pelvic of the mother, and
the mechanism of those labours which make the sub-
ject of the preceding article, it will not appear sur-
prising that I reckon here, among natural labours,
those where the child presents  the  knees; because
it will be seen that it  may be  performed by the
powers of the mother alone. If in the sequel I con-
sider them otherwise, it is because there frequently
occur circumstances which render  them preterna-
tural; that is to say, impossible without assistance.
   547. The child almost always offers but one knee
to the orifice of  the  uterus; the other remaining
placed, and as it were  butted, against the margin
of the pelvis, so as to obstruct delivery; or at least
to render it very tedious and painful, unless we take
care to prevent its difficulties.
   548. It is not easy to know the knee by the touch,
when it presents  singly to the orifice of the uterus;
because at first the finger can go over only so small
an extent of it, that we cannot distinguish it from
other parts:  but  it is not so when  the two knees
present together.  The parallelism of two similar
tumours sufficiently denote them in the latter case;
so that we are not obliged, as in the former, to have
recourse to signs, which are then beyond the reach
of the finger, when the membranes are just opened.
   549. It is sufficient for the understanding the me-
chanism of the different species  of natural labour,
where the child comes presenting the knees, to dis-
tinguish four principal positions, as we have done
with respect to the feet; because all others we can
 meet with have a perfect resemblance to those. 
198
Unassisted Labour.
   550. In the first species, the child's legs, always
bent when the knees engage in the pelvis, are to-
wards  the mother's left side, and the thighs towards
the right.
   551. In the second, the thighs answer to the left
side of the pelvis, and the legs to the right.
   552. In the third species, the anterior part of the
thighs is turned towards the sacrum of the mother,
and the legs are under the pubes.
   553. We observe the contrary in the fourth spe-
cies; the child's thighs  being behind the  pubes of
the mother, and the legs placed against the sacrum.
   554. In each of these cases, the situation of the
child  writh respect to the  uterus is absolutely the
same  as in the position of the preceding general
species,  indicated by the  same numerical name.
The mechanism of these two kinds of labour is
also perfectly similar; for which the preceding ar-
ticle may be consulted.
Of the Fourth general Species of Natural Labour,
  or that in which the  Child presents the Breech.

  555. A pretty large tumour, in which we dis-
cover neither the hardness of the head, nor the soft-
ness of the belly, is the first sign of the presence of
the breech.  A deep  furrow, in which  we find the
anus and the  parts of  generation, puts us out of
doubt. The discharge  of the meconium, as soon as
the membranes are opened, may make us presume
that the child  presents the  breech; but we cannot
be certain of it without the signs above stated.
  556. Though it  is almost always difficult to dis-
tinguish  this part  perfectly before the opening of 
Unassisted Labour.
199
the membranes, it  is  almost impossible to mis-
take it afterwards; and  not to  discover also its si-
tuation with respect to the pelvis, with the greatest
precision.
   557. We might multiply the positions which the
child's breech may take at the orifice of the uterus,
beyond what we have done for the feet and knees;
but I shall distinguish only four principal ones, as
I have done for them.
Of the Mechanism of Natural Labour, where the
   Child presents the Breech in the First Position.

   558. In this species  of labour, the breech pre-
sents at the entrance of the pelvis; so that the child's
back is towards the mother's left side, and a little
forward.  But, in  proportion  as  it  descends,  its
greatest breadth becomes parallel to the antero-pos-
terior diameter of the inferior strait;* the left hip
placing itself a little obliquely under the pubes, and
the right  before the sacrum.  The  right hip at  first
makes more way than the other, continuing to ad-
vance  along the slope  of the sacrum, coccyx, and
perinaum; while the left only  turns on the inferior
edge of the symphysis of the pubes, as I have ob-
served before with respect  to the  occiput.—See
par. 488.
   559. We first see  the right hip appear  at the
vulva; and afterwards the breech disengages, rising
a little towards the mons veneris: and the  child's
trunk, as  it is delivered, bends a little in the same

  * That is, the diameter running from the inferior edge of
the Symphysis pubes to the point of the coccyx. W.  P. D 
200
Unassisted Labour.
direction. When the breech is sufficiently descend-
ed, the feet,  which  were extended towards the
child's breast,  disengage of themselves;  and the
rest of the labour  goes on as in the first position
of the feet.—See par. 525, and following.
Of the Mechanism of Natural Labour, where the
   Child presents the Breech in the Second Position.

   560. In  the  second position of the breech, its
greatest breadth is also parallel to one of the oblique
diameters of the entrance of the pelvis; but so that
the child's  back is towards the  right  side of the
uterus, and  a little forward.  The breech engages
byr the same mechanism as in the first position, and
advances in the same  manner; except that the right
hip, instead of the left, places itself under the arch
of the pubes. The left hip being turned toward the
sacrum,  continues to  descend along the curve of
that bone and the perinaum, while  the right hip
only turns a little under the symphysis of the pubes.
The child's trunk disengages, bending lightly to-
wards the pubes; and when  the feet are without,
every thing goes on as if they had presented in the
second position.—See par. 535.
Of the Mechanism of Natural Labour, where the
  Child presents the  Breech in  the  Third  and
  Fourth Positions.

  561. In  the third species of labour,  where the
child presents the  breech, it is phced  so that the
back is upward and the belly downward. It is seldom 
          Management during Labour.       201

that it descends in that position; and more  seldom
still that the forehead does not afterwards turn away
from  the  projection formed by  the  base  of the
sacrum; which makes the head present diagonally
at the superior strait, and place itself as in those
labours where the feet present in the first or second
position.
  562. Things go on nearly in the same manner in
the fourth position of the breech,  where the child's
belly is upwards, and the  back towards the poste-
rior part of the uterus.  If its breadth, from  one hip
to the other, is at first placed transversely, with re-
spect to the superior strait,  it becomes insensibly
parallel to one of its oblique diameters, and after-
wards to the largest diameter of the inferior strait;
so that the length of the head presents in the same
manner to both:  but with this difference,  however,
that the occiput is underneath, and the face answers
to one of the acetabula;  whereas in  the  former
positions the face is underneath,  and the  occiput
towards one of the acetabula.
Of the Management of the Woman during Labour.

  563. The greater  part  of women, if left en-
tirely to themselves during labour, would never-
theless be delivered without help: this truth, found-
ed in nature, has no need of new proofs. But those
same women, if assisted  seasonably, would they
not be delivered with more  ease and safety? That
is what I shall now proceed to investigate.
  564. Among those labours which are terminated
without help, some take place so precipitately, that
the great and sudden depletion of the uterus some-
times becomes the source of several  mortal acci-
                       2C 
202       Management during Labour.

dents, or at least extremely dangerous; and others
are so tedious and  laborious, that their  conse-
quences are not less dreadful:  whence  we see that
it may be as  salutary to check the progress of the
former, as to accelerate that of the latter.
  365. Though nature would, sooner or later, sur-
mount some of the obstacles to delivery, there are
many others under which the woman  would infal-
libly sink, if we were not to come to her assistance.
  566. The accoucheur ought then, in none of these
cases, to content himself with being a mere spec-
tator. That patience, which  is recommended by
some as his principal virtue, ought to have its limits;
an excess of confidence in the secret resources of
nature, which some people boast of with a sort of
assurance, being  not less condemnable than the
inconsiderate manoeuvres of  those ignorant men,
in whom rashness supplies the place of knowledge.
Of the Treatment which the State of Women gene-
  rally requires in the First Period of Labour.

  567. Women, almost always uncertain concern-
ing the period of their pregnancy, often mistake for
the beginning  of  labour, pains  which  are very
foreign to it; but whose progress is sometimes such,
that women who have had several children, may be
deceived by them.
  568. The accoucheur, after having observed the
effect of these pains a little while, ought to endea-
vour  to distinguish their true character, and dis-
cover their cause; in order to favour the true labour
pains, or  administer  proper remedies  for those
which are foreign to it, lest they should bring it on
prematurely, as frequently happens. 
          Management during Labour.      203

  569. Touching  alone  can enable us to distin-
guish these two species of pains with certainty;
for they are sometimes extremely similar in  their
manner of attack,  and their progress; but always
very different in their causes.
  570. A hardness of the uterine globe, a stiffness
of the edge of its orifice, and a distension of the
membranes during the pain, as well as a slackness
and relaxation of all those parts  in proportion as it
goes off, invariably characterize the pains of labour;
because, like them, those symptoms are inseparable
from a contraction of the  uterus.
  571. The effects of false pains are on the con-
trary very various, both on account  of the diver-
sity of their causes, their  complication, and  the
parts which are the seat of them. Sometimes these
pains are caused by a plethora, either universal or
partial;  sometimes by indigested or putrid matter
in the first passages, by a stone in the kidneys, ure-
ters,  or in the bladder; and sometimes from several
of these  causes together.  We never observe any of
the effects mentioned in the preceding paragraph,
during the action of these false pains, at least unless
they  have excited contractions of the uterus, and
true labour pains.
   572. After having perfectly recognised the char-
acter of the true pains, whose frequent return, and
augmentation, constitute what  is  usually  called
labour; the accoucheur must endeavour to discover
 whether the woman be at her full time or not; that
 he may  not forward an accidental labour, which he
 might have put off, if he had sought its true cause.
 In order to which, he must recal to mind the char-
 acteristic signs of the different periods of pregnancy
 —See the article  on touching. 
204       Management during Labour.
  513. When these pains are not felt till the time
of the perfect maturity of the foetus, we must attend
to their frequency and intensity; to the size of the
orifice of the uterus, and to the hardness of its edge;
in order to estimate nearly what will  be the dura-
tion of the labour, and the time when  it will termi-
nate.  We must  not forget, in order to form a just
prognostic, that the first labour is in general longer
than others, and that the dilatation of the orifice of
the uterus is never slower than at the beginning of
labour.— See par. 439.
  574. We  ought  also  to inform ourselves, by
touching, whether the pelvis be well formed or not,
especially in a first labour; and how the orifice of
the  uterus is situated, and  whether the fundus is
oblique, as well as  what part of the child presents,
and its position; in order to prescribe early that situ-
ation  which is best adapted  to the  state  of the
woman.
  575. All women should  not be  treated  in the
same manner during the course of labour, because
the  circumstances  of it may be different; what is
useful to some, may be pernicious to others. We
ought not, for example, to give any thing but broth
to those whose labour is strong, or ready to termi-
nate, if they stand in need of any aliment; but we
may allow more solid nourishment to those whose
labour is but beginning, especially  if it be  not
likely to  terminate soon, in order to support their
strength.
  576. We ought not to be less cautious concern-
ing the drink we allow to a woman in labour, than
about the nature of her aliment. All heating things,
such as  wine, mulled with spices,  or spirituous
liquors, so much in use among the common people,
are to  be avoided, except by some few, who may 
Management during Labour.       205
have need of a cordial. The most convenient drinks
are barley-water, gruel,  weak  lemonade, or any
other diluting liquor.  Many women  prefer wine
and  water; but it is apt to produce acidities, and
often provokes vomiting, to which there is already
but  too  much  disposition, especially when it is
drunk hot.
   577. Glysters should not be neglected:  one is
sufficient to evacuate the  gross excrement which
might add something to the natural difficulties of
labour; but it will be necessary to repeat them when
the  labour is  tedious, when  the pains are  felt
towards the loins, and when there is any heat in the
bowels. A decoction of some emollient plant, or of
linseed, is preferable to plain water.
   578. Bleeding at the  arm is not less useful in
many  cases.  By diminishing the  plethora in some
women, it augments the  force and energy of the
contractions  of the  uterus, while it mollifies  and
relaxes the soft parts which form the passage. It is
particularly salutary to those women who complain
of pains in the head, and a sensation of heaviness
in the limbs; to those who have  the eyes red, the
face inflamed, the superficial vessels puffed up; or
who are threatened with convulsions, haemorrhage,
inflammation of the uterus, &c.
   579. Baths,  demi-baths, emollient fomentations,
and moist fumigations, may be employed with suc-
 cess.  These means  are  never more  useful than
 when time has taken from the parts concerned  in
 delivery, the natural suppleness of youth, so neces-
 sary for a facility in this  operation.  But we must
 by no means have recourse to them, and especi-
 ally to the warm bath, when a sanguine plethora
 predominates,  till we have first  diminished it by
 one or  two bleedings. For so much as they are 
206         Situation during Labour.

beneficial  in some  circumstances, so much  they
become pernicious  in  this latter,  whether to the
mother, or to the child.
  Of the Situation of the Woman during Labour.

  580. The; situation of the  woman is not always
arbitrary: it must be varied according to circum-
stances, and the period of labour. When it is but
just begun, and  is not complicated with any acci-
dent, and every thing relative to delivery is in good
order, the woman may choose the situation which
appears most convenient to herself.
  581. Women  threatened with  a  descent of the
uterus,  or an haemorrhage;  those  who are very
weak, or in whom the uterus is situated obliquely,
ought to lie down from the beginning of labour to
the end.  In cases of great forward obliquity, they
must be laid on the back; in lateral obliquities, on
one side, but on that which is opposite to the de-
viation, in order to bring the axis of the uterus
nearly parallel to that of the pelvis.
  582. Although the situation in which women are
usually placed, in the last period of labour, is often
not less important than that at the beginning, yet
it is not the same in all nations. Reason, and conve-
nience to the women, are almost always less con-
sulted than custom. In some countries, as in Flan-
ders, Holland, Spain, he. the women have chairs
made on purpose.  Almost all over  England, they
place  themselves on a bed,  and lie on their side,
with the breech  turned  towards the accoucheur;
the legs and thighs being half bent, and their knees
separated by a pillow. 
Situation during Labour.         207
  583. In some of our  provinces the women are
delivered kneeling on a cushion,t with the elbows
resting on a chair: in others they keep themselves
standing, or sit on the knees of some person who
supports them.  But of all these  positions, none  is
more convenient than  that  adopted  among us.
Ro'ederer confesses that the  best chairs are much
less convenient than the little bed used in France.*
This bed is constructed in the following manner:
   If we have  not  the common bedstead of the
breadth  of from two feet and an half to three feet
at most, and covered with its straw mattress, we take
a lit de sangles,* on which  we smoothly lay one  or
two mattresses. Under the middle of them we put a
cushion  of hair, or straw, to keep them from sink-
ing, and to support the woman's loins. This bed is
to be furnished with pillows and sheets, and blankets
according to the season.
   584.  But it is better to double the uppermost
mattress, so that it may cover but one half of the
length of the bedstead, than to spread it over the
 whole: as the woman may then be placed on it much
 more commodiously for delivery. In the former case
 they are laid flat, with the  breech often sunk into
 the bed,  notwithstanding  the  precaution  of the
 cushion; so that the perinaum and vulva are hid.
 In the  latter, the lower part of the  trunk being
 placed on the end of the folded  mattress, all those

   * Ro'ederer practised midwifery in a nation where the chair
 was very much in fashion.
   * Lit de Sangles is a little bedstead without any transverse
 pieces at the ends; the feet of which cross each other at their
 centres, and are pinned together; so that, when the bed is off,
 the sides of the bedstead may be brought close to each other,
 and the feet are then almost parallel. It is a kind of bedstead
 in frequent use among the poorer people and servants in Paris. 
208          Of preparing the Parts.
parts are  entirely free, and are much more easily
developed:  the woman is not obliged,  as in the
former case, to raise the breech, resting on the heels
and  shoulders, at every pain, till the child be ex-
pelled.
   585. It is customary to place a cross board at the
foot of this  bed, to sustain the woman's feet in time
of a  pain, and favour her efforts: but this precaution
is useless,  as  we always find more hands than we
want, to give the woman every necessary support.*
Of preparing the Parts of the woman for Delivery.

   586. Most midwives are still in the  pernicious
habit of placing the woman on the bed  as soon as
the pains are a little frequent and strong, in order
to begin betimes what they call the preparation; or,
to speak more intelligibly, the dilatation of the parts.
This they often do without  knowing whether  the
woman  be in labour or not, and  sometimes even

  * The mode usually pursued here, is to have the patient's
bed made in the common way, with the addition of a folded
blanket in the middle  of it, and under the lower sheet; then
we separate the sheets by rolling the bed clothes from one
side nearly to the other. The foot of the bed is then well beaten
to make it firm, over which part another folded blanket is
spread; the patient is then for the most part placed on her left
side, her knees a little bent, her hips placed near the edge of
the bed, while her feet are firmly pressed against the bed post.
A pillow rolled tight and tied, in the advanced period of labour
is placed between her knees; a sheet or blanket according to
the weather is thrown over her; her head is raised by pillows.
The advantage arising from this mode is, that when the labour
is finished, the patient after having the wet things taken from
about her, is easily drawn up in the bed, without fatigue or
even disturbance.                           W. P. D. 
            Of quickening the Pains.         209

without being sure that  she  is with child; which
indeed 1 should scarcely believe, if I had not been
several times a witness of it.
  587. These manoeuvres, which they entitle pre-
paratory dilatations, often  produce an effect quite
contrary to what theyr expect from them: for by de-
priving the parts which they handle so incautiously,
of the mucus which nature furnishes at that time
abundantly, for no other purpose than to relax them,
they irritate and dry them so much, that they seldom
fail to inflame and  become extremely painful.
  588. It is  sometimes necessary to prepare these
parts for delivery,  and even to begin those prepa-
rations during the  latter periods of pregnancy; but
then we  must proceed in a very different manner.
Warm baths, or demi-baths, emollient vapours, and
the repeated application of fat or mucilaginous sub-
stances, may be advantageously employed. Emol-
lient injections, such as the mucilage of marsh mal-
lows, or of linseed, would not be less useful; but
there is something so disgusting in them, that few
women will  submit to their use, except in acci-
dental circumstances which are more severe than
those that accompany a labour which is merely long
and laborious.
         Of quickening Lingering Pains.

  589. Nothing is less regular than the progress
of labour pains: sometimes they augment suddenly;
sometimes they diminish, slacken, and even go en-
tirely off for a time;  which may depend on a variety
of causes, each of which presents a particular indi-
cation.
                     2D 
210         Of quickening the Pains.
  590. Many persons, without regard to those differ-
ent indications, always  prescribe irritating reme-
dies, in order to quicken  the  pains.  Some  give
decoction  of senna in glysters, others in draughts;
and Mauriceau added to this beverage the juice of
a sour orange.  Others again prescribe ipecacuanha,
to excite  vomiting;  and some to keep the woman
standing or walking about, which is quite as impru-
dent: for there  is as much ignorance in dragging the
woman  thus about the chamber, when she is worn
out with fatigue, as in tormenting her with active
medicines. Time is almost always the best remedy
in these cases.
  591. When the tardiness of labour proceeds only
from the weakness or exhaustment of the woman,
rest, good restoratives, a little wine, or other things
of that kind, will be found most beneficial. On the
contrary, when it depends on a stiffness of the fibres
of the uterus,  or an  engorgement, or inflammation
of that  viscus, bleeding, warm baths, emollient fo-
mentations, and diluting drinks, are the only things
capable  of quickening the pains.  But if the slowness
of the labour is only  the effect of the premature or
continual draining off of the waters, as  has  been
already  mentioned, we must wait till they be com-
pletely evacuated; or else accelerate their issue byr
tearing  the membranes anew in a more favourable
part, and  raising  the child's head a little with the
end of the finger; which may be easily done, and
without the smallest inconvenience, notwithstanding
the fears which some have endeavoured to excite
concerning the consequences of this procedure. 
Of opening the Membranes.
  592.  Though the premature opening of the
membranes often renders labour more tedious, and
in some respects more laborious; the same incon-
veniences sometimes also arise from their not open-
ing in proper time:  whence  we see that it would
not be less useful to open them in  the latter  case,
than to keep them whole in the former, if we could.
  593. Except in cases of flooding, or convulsions,*
we  ought never to open the membranes before the
orifice of the uterus be entirely prepared for delivery;
that is to say, till it be larger than a crown piece, and
its  edge so soft and thin, that it may be easily ex-
tended farther. The  labour ought  moreover to be
in its full force; which  supposes the pains to be
strong and frequent.
  594.  The  manner of opening the membranes is
in general very simple. We advance the end of the
finger to the middle of the orifice of the uterus, and
wait till the membranes are forced through it, and
become very tense, which can only be during a pain;
by pushing the finger then, it passes through them.
If we do not  succeed the first time, we must wait
for  another pain, and try again.
  595. This method does not always succeed: either
because the membranes are of a very strong or of a
very loose texture;  or because their thickest and
most cellular part is nearest the finger; or because
the child's head is already  so engaged, that the
waters cannot pass under it,  to distend the bag suf-
ficiently.  '
   596. When the membranes present their thickest
part at the orifice of the uterus, or are so strong that
*See par. 794 and 813. 
212        Of opening the Membranes.

we cannot tear them  by the method recommended
above, we must begin by weakening them in one
point, by scratching them  with the end  of the nail;
and afterwards we may succeed more easily. If this
also fail, we may open them with the point of a pair
of common  scissars, which may  be  introduced
covered with,a little  ball  of wax, if necessary, in
order to conduct them more safely.  I must remark
that this case is exceedingly rare; and still more rare,
when it does happen, for the pouch formed by the
membranes not to be near enough to the vulva to be
seen, and consequently opened without fear: so that
we may dispense with the aforesaid precaution.
  597. When the pouch remains very slack during
the pain, either because the membranes are of a very
soft and  loose texture, or because the head, being
very low,  hinders the waters from descending suf-
ficiently to fill and distend it,  it must be torn by
pincing the membranes, between  the ends  of two
fingers.
  598. Whether we  use the finger only in opening
the pouch, by scratching the membranes to weaken
them, or otherwise; or whether we use  scissars, or
any other instrument;, we  ought to take great care
not to act upon the  child's head,  by mistaking a
tumour of the hairy  scalp, which frequently rises
in laborious cases, for the pouch in question. We
must, with the same care, avoid applying an instru-
ment,  or  the  nail, to the  uterus, which sometimes
still  covers the head, though  it is very low in the
pelvis. It is so much the more  easy for  persons not
exceedingly skilful to be deceived in this latter case,
because the orifice of the uterus is concealed back-
ward; and that portion of it which covers the child's
head, becomes at length, and especially during the
pain, as smooth and  as tense as the membranes.—
See par. 249.  and the observations relating to it. 
General Precautions.          213
Of what is necessary to be done after the Membranes
                   are open.

  599.  The woman can never be examined by
touching more seasonably than  immediately after
the opening of the membranes;  whether to certify
ourselves concerning the position of the child, if we
have not been able to discover it before; or to ob-
serve whether  the head  engages in  a  favourable
manner, or not:  in order to let nature act, or pre-
vent her being exposed to fruitless efforts, accord-
ing to circumstances.
   600. As it is  necessary to excite  some women
to bear down with all their strength, to accelerate
their delivery; so it is not less advantageous to en-
gage those who are subject to a descent of the ute-
rus, an hernia, spitting of blood, &c. to moderate
those same efforts.
   601. To hinder the  descent of the uterus, when
there  is any reason to fear it,  it is  not sufficient
 merely to engage the woman not to bear down: the
 accoucheur must likewise support the edge of the
 orifice of the uterus during each pain, that it may
 not be pushed out by the child's head; which is apt
 to happen when the edge is rigid. We  must likewise
 be careful not to suffer  it to be dragged along by
 the shoulders, in delivering the  trunk.
   602. When there is  an hernial tumour, we must
 endeavour to reduce  it;  and prevent its return by
 a convenient pressure,  either with the ends  of the
 fingers, or a suitable compress. It were to be wished
 that we could exert a like pressure when the hernia
 cannot be reduced, to prevent a new portion of in-
 testine from insinuating itself into the tumour, and
 endangering a strangulation: as I saw  in a woman 
214           General Precautions.
who had had a large epiplomphalocele nine years, and
who for two days had in vain exerted the most vio-
lent efforts for delivery.
  603.  When the woman is much troubled with
pains  in the small of the back, a folded napkin may
be passed under the loins, with which two assistants
may raise her up, and support that part during each
pain.  This precaution,  besides that it diminishes
the intenshy  of those pains,  is often necessary in
the last moments of labour, to favour the exit of the
child. Indeed it can hardly be dispensed  with in
those  women who are laid flat, who have the breech
sunk  and  hid in the bed, and who want strength or
courage to raise it up during the last pains, by sup-
porting themselves on the heels and shoulders.
  604. When the woman is attacked by the cramp
in the legs and thighs,  which is often less support-
able than the most violent labour pains, we must
endeavour to relieve  her, either by dry frictions on
the part affected, or otherwise, according to circum-
stances; and by changing the direction of the child's
head a little with respect to the sacral nerves, which
it always compresses more on one side than the
other.
  605. When the child's head begins to press against
the external parts, it is sometimes proper to prepare
them, that they-may  not be injured  in the last mo-
ments. Besides fat substances, such as  lard,  &c.
which wTe are  to apply often, we  may introduce two
fingers into the vagina, to enlarge it by degrees, as
well  as  the vulva, either by separating the fingers
in different directions successively, or by pressing
downward against the perinaum. But this is only to
be done in the interval of the pains; contenting our-
selves, during their action, with supporting the peri-
naum with the palm of the hand, in order to prevent 
General Precautions.          215
its tearing, and  hinder the head  from being deli-
vered too suddenly.
  606.  These preparations are never more neces-
sary than in a first labour. If they are omitted then,
we  are commonly freed from the necessity of using
them afterwards; because the perinaum being torn,
never unites perfectly, nor do the other parts ever
recover their natural tone.
  607.  When the posterior extremity of the head
is engaged in the vulva, as in a  kind of crown, if
the fourchette is not too much distended, we may
permit  the woman to indulge her inclination to bear
down;  and during that time, without however dis-
continuing to support the perinaum, we may favour
the exit of the  head, by pressing against it under-
neath,  and near the anus of the woman, as it were
to  oblige it to ascend towards the mons veneris.
  s 608. The head being almost delivered, we finish
 its  disengagement by  raising it more  and more
 towards the pubes; or by insinuating one of the fore
 fingers under one of the sides of the lower jaw. We
 then turn the face towards one of the woman's thighs,
 but observing  that it be towards that to which it
 tends of itself. Afterwards we examine the situation
 of the  shoulders with respect to  the inferior strait:
 and push one of them towards the sacrum, and bring
 the other under the pubes, if they are not placed so
 naturally. We then deliver them, as well as the rest
 of the  body, by pulling gently and cautiously at the
 head; while the mother, on her side, does what she
 can to expel it.
    609. We must never attempt  to pull with any
 considerable force at the head and neck of the child,
  with a view to  extract the trunk, when the breadth
  of the shoulders obstructs it progress; for nothing
  can be more dangerons than  such efforts. In that 
216         Particular Precautions.
case, we must introduce the fore finger of each hand
into the axilla, in order to pull with them, after the
manner of hooks; and, if that be not sufficient, we
apply lacs, or the blunt hooks which terminate  the
handles of the French forceps, or some other similar
instrument:  but these  cases are so extraordinary,
that an accoucheur in great practice, and properly
skilled, would not perhaps meet with it four times
in his life.
   610.  When  the shoulders do not  come along
easily, we must always begin by making them take
the situation above mentioned; for even the smallest
cannot be delivered transversely without extreme
difficulty; as is  very easy to comprehend.
 Particular Precautions relative to each Position ^f
   the Head, or to other Circumstances which some-
   times render Natural Labour a little more difficult.

   611.  Circumstances,  which  would  be too
 long to detail here, may add to the natural difficul-
 ties of labour, by obstructing more or less the pivot-
 like motion, by which the occiput or forehead place
 themselves opposite to the arch of the pubes, when
 the head has engaged diagonally in the cavity of the
pelvis. We may then prevent  some difficulties to
 the woman, by seasonably favouring this rotatory
 motion; and may often shorten the work of nature
 considerably, supposing her able to  accomplish it.
   612.  When the head presents in the third posi-
 tion, which is not very frequent, if the brim of the
pelvis is a little narrow from pubis  to sacrum, we
 ought to advance the hand, or some of the  fingers
 only,  to the entrance of the uterus, to turn away the 
             Particular Precautions.         217

occiput from over the symphysis of the pubes, and
direct it towards one of the acetabula: which is gene-
rally pretty easily executed at the time of the open-
ing of the membranes. This precaution may spare the
woman the pains of a much longer labour than when
the head presents in the first or second position; and
which, after all, might sometimes be fruitless.
   613. In the fourth and fifth positions of the head,
we ought  also to endeavour to bring the occiput
towards one of the acetabula; that it may afterwards
turn under the arch of the pubes, instead of going
towards the curve of the sacrum. By thus directing
the back of the head, in proportion as it engages in
either of these positions, we often not only favour the
efforts of nature,  which tend to  make it take that
course; but sometimes also we, as it were, prescribe
Jaws to her: and the facility of the delivery is the
work of art.
   614. It  were to be wished that we could in the
same manner change the sixth position of the head,
and reduce it to one of the two first; but we must
not hope to accomplish  that, even if we  pass the
hand into  the uterus at the instant of opening the
membranes; on account of the difficulty of making
 the child's body turn in the same direction as  the
 head: still less can we do it when the waters have
 been a long time  evacuated, and the head is already
 in the cavity of the pelvis: we could not at this time
 carry the  face downward,  but  by making it pass
 round half the circumference of the pefvis; and that
 motion, which would be entirely at the expense of
 the neck, the trunk being  fixed, and closely em-
 braced by the uterus, would be of the most danger-
 ous consequence to the child.
    615. In the best positions, as well as in the others,
 the head sometimes engages in such a manner, that
                       2E 
218          Particular Precautions.
the forehead descends more than the occiput, so that
the head presents the whole length of its greatest
diameter to the inferior strait; which generally pro-
duces  insurmountable obstacles to its exit.  It is
easy to prevent these obstacles, by changing  the
situation of the uterus betimes, and by supporting
the fore part of the head a little, to oblige the occi-
put to descend.  I shall treat more amply in  the
sequel of what must be done in this circumstance.
See par. 950.  to par. 956. inclusively.
   616. It is very common to see a child come with
the umbilical cord twisted round its neck; and this
disposition, though it does not produce those obsta-
cles to the  exit of the head, which have been com-
monly attributed to it, yet requires some precautions
on the part of the accoucheur: but they do not be-
come necessary till the head is without; that, in dis-
engaging the trunk, the umbilicus, already stretched,
may riot be torn, nor the placenta dragged along at
the same time.
   617.  Some authors have recommended, in  order
to avoid tearing the umbilicus, as well as to facilitate
the delivery of the trunk, and hinder the placenta
from  being dragged along  with it, to untwist the
cord, by making it pass as many times over the head
as there are turns on the neck; or else to keep the
head on one side against the vulva, and deliver the
trunk by bending  it  as it comes along. But  if we
find any difficulty in obeying  these precepts, we
must cut the cord, and especially when the child's
face is  swelled, or livid, in order to  prevent the
effects of a longer strangulation.
   618. I shall in the  sequel detail the particular in-
dications presented by the other species of natural
labour; as well as the various circumstances which,
by complicating them,  often render them preter-
natural. 
            Management of the Child.        219


    Of the Management of the new-born Child.

  619.  The child must be treated  differently,
according to its state and condition at the time of
birth.
 Of the usual Method of treating a new-born healthy
                     Child.

   620. As soon as the child is born we lay it trans-
 versely, between its mother's legs, and so near to
 her that the cord may not be  stretched;  and then
 turn it on one of its sides, that the blood and waters
 which drain from the  uterus may not fall into its
 mouth.
   621. Some accoucheurs are accustomed to leave
 the child  in that state several  minutes,  and even
longer, without meddling with the cord; only taking
 care to lift up the coverings  a little, that it may
breathe: while many others scarcely give themselves
 time to tie and cut the cord, before they remove it
from its mother.
   622. In fact, we ought to leave it as short a time
 as possible under the clothes; because there  it can
only respire a moist and impure air, always too much
rarefied, and often infected with animal  vapours
 which rise from  excrements and urine which the
 woman discharges involuntarily in the last moments
 of labour;  very different from that pure and tempe-
rate air, which its delicate organs require.
   623. A  ligature made about  two inches from the
umbilicus is all that is necessary; two have  been em-
ployed, but the second is useless, nay even hurtful 
220        Management of the Child.

sometimes, as it prevents an important depletion
from the placenta. This ligature ought never to be
applied until the pulsation has completely ceased in
the cord. The best ligature we can use,  is  a part of
a skein of fine thread;  and  passing it once round
the cord and tying, is sufficient.
Of the Treatment ofa Child born in a Morbid State.

  624.  Some children  are born in a state of apo-
plexy; others in a state  of asphixy,  or  apparently
dead; and some come so weak, that we scarcely dare
flatter ourselves we shall be able to revive them.
  625.  The section of the cord, on account of the
depletion it procures, is the most efficacious assist-
ance we can give to those born in a state of apoplexy;
and it would not be less dangerous, to those children,
to leave the cord whole than to tie  it.
  626. The vital powers are sometimes so weaken-
ed in these cases, that it  is with difficulty we obtain
a few drops of blood, by the section of the umbili-
cal cord; which cannot be sufficient to save the life
of the child.  We must then endeavour  to procure
a greater discharge by pressing the belly gently, and
alternately. We often cannot obtain the discharge
necessary to unload the vessels of the  brain,  and
make the tumefaction and lividity of the face dis-
appear, without plunging the child up to the arm-
pits  into a bath more than warm, and rendered
stimulant by the addition of some spirituous liquor,
as wine, brandy, or even vinegar.
  627. By this means we awaken the irritability of
the heart, ready to be extinguished, excite its con-
tractions, and quicken them so far, that we soon see 
            Management of the Child.         221

its pulsations reappear, those of the arteries of the
cord, and  of the  carotids, though they had ceased
for some minutes; and the blood which fell by drops
from the umbilical arteries, presently flows by starts,
and to a considerable distance.  I have  observed all
these effects in children who were born in a state of
the most complete asphixy,  and had been already
abandoned as dead, after a few fruitless attempts.
One of these children gave but very uncertain signs
of life  half an hour after its birth, and did not shew
any positive ones till more than half an  hour; for we
cannot regard as such, the oscillations excited by
the heat and activity of the bath.
   628. Having brought these children into a  free
and temperate air, whether we keep  them in the
bath I have just prescribed,  or not, as may be
thought proper,  their mouths must  be cleansed
from the slime which often  fills them;* and then
we procure them a kind of artificial respiration, by
blowing repeatedly into  their  mouths  while  we
close the nostrils with the finger and thumb, and as
often  pressing their breasts, but very  cautiously.
We may also irritate the  membrane of the nose
with a feather, or bring a little volatile  alkali  near
it; or  rub the regions of the temples,  spine, and
heart, with cloths dipped in some spirituous liquor.
   629. These latter means must be used still more

   * Many children may be saved I  am convinced from ex-
 perience by a proper attention to this circumstance: the best
 mode of freeing them from the mucus, &c. which obstructs
the passage of air to the lungs, is to suspend  them by the
 heels with the mouth downwards; a great quantity by this
 means is sometimes discharged.  It however is occasionally
 too tenacious to flow out in this way; when  this is the  case
 we pass a piece of fine dry rag over, one of our fingers, and
 introduce it to the back part of the mouth; the mucus adheres
 to the rag and is withdrawn with it.            W. P. D. 
222         Management of the Child.
 liberally to children born pale and discoloured, with
 the  limbs flaccid, and  who appear  to  be in  that
 middle state between life and death,  known by the
 name of asphixy, than to those in an apoplexy.
   630. Dry frictions with hot cloths, on the whole
 length of the spine, and blowing the smoke of paper
 into the anus, must not be neglected. Brushing the
 soles of the feet, the palms of the hands,  and the
 back, swiftly, but lightly, with a flesh brush, is per-
 haps the most efficacious means of awakening the
 principle of life in this sort of children. We may
 advantageously pour one or two drops  of volatile
 alkali,  mixed with a tea-spoonful of water, into
 their mouths.  If that cannot be got, we  may put a
 bruised onion or garlick under their nose. Some
 children, to whom these means had been adminis-
 tered too sparingly, or who perhaps  had been de-
 prived of them  because they  were thought dead,
 have been taken alive several hours  afterwards
 from under  the clothes,  where  they  had been
 already, as it  were,  buried; which makes it pro-
 bable that many others might have been  saved, had
 the proper means been diligently used.
  631.  It is  generally thought necessary to keep
 children, born so  weak as to give little  hope of
living,  some time close to the mother, and without
cutting the umbilical cord.  This  precaution is not
only  useless, but may be hurtful to the child. The
circulation of  the  blood from the vessels of  the
 uterus, into those of the placenta, and  vice versa,
no longer going on, and  that  in the cord being
almost extinguished, the child  cannot be revivified
 by the mother,  as some have thought. She  can
 communicate but very little heat to it, which may
 be much more easily and certainly procured another
 way: the child, by this pretended help, is deprived 
           Management of the Child.        223

of that which would be more real and  efficacious,
and which cannot be administered till it be removed
from the mother.
  632. As soon as the pulsation ceases in the cord,
it ought to be cut: the ligature is that instant use-
less, because there is no blood flows. After taking
the child from under the clothes, it must be kept
warm, and treated as directed in par. 626, and fol-
lowing.  We  may  also bathe  it in warm water,
mixed with wine; but  it must never  be plunged
into brandy alone, or into strong wines, &c. I have
seen  children  who  have narrowly  escaped  being
victims to the credulity of their parents concerning
the virtues of these baths: some have been threat-
ened  with  convulsions,  and others have been taken
out with the face tumefied and livid, and as in a
state  of apoplexy.
   633. After natural labours which have been dif-
ficult and very long, whether on account of the nar-
rowness of the straits of the pelvis, or the resistance
of the soft parts, children are born with  a tumour
more  or less  voluminous,  and commonly  pretty
 soft,  on the top of the head and a little backward;
the cranium itself is lengthened, or undergoes other
 changes which make it appear deformed; sometimes
 also the bones  are  depressed in certain  places,  or
 even fractured, and the fragments sunk in on the
 brain.
   634. When  the  tumour  of the hairy scalp is
 merely cedematous, it  dissipates easily  in a short
 time: it is sufficient to foment it with wine,  with
 salt  and water, or any vulnerary infusion. This
 tumour is more difficultly resolved when it is san-
 guine; and especially when  the  blood is extrava-
 sated under the pericranium,  or under the tegu-
 ments, and is there coagulated, as I have  often seen: 
224         Management of the Child.
we are  sometimes obliged to open this species of
tumour.* If the consequences of it are simple when
the blood is onlyr extravasated under the teguments,
it is not so when these tumours are seated  on the
cranium itself, and the  bones are  found bare after
the incision; which is the most usual case.
   635.  The people  imagine that  the accoucheur
ought to press and mould the child's head, to res-
tore it its natural form, which it seems to have lost
in delivery;  and many matrons are still of the same
opinion. Though such pressure, methodically made,
is no way dangerous to the child, yet I  think it is
better to proscribe it entirely;  for the head soon
recovers its  natural form of itself.  It is only when
there is a fracture, with depression, that we need
pay any attention to  it; but then it is much less  on
account of the deformity of  the head, than  of the
accidents which depend qn the fracture and depres-
sion of  the bones. This case requires the aid of a
skilful surgeon,  and  not of a  midwife.
  636. After a preternatural  and laborious labour,
the accoucheur  has sometimes a fracture or luxa-
tion to reduce; because he cannot always, notwith-
standing the most exact precautions, free the child
from those  accidents:  he ought therefore  to  ex-
amine it well before  he leaves it to the nurse.

  * This I conceive can never be necessary, unless suppura-
tion has  been added  to extravasation, as all the instances
which I have seen, and  they are not  few, the effused fluids
have been sooner or later taken up by the absorbents; and in
a case where I ventured to open one of these tumours, I had
a troublesome sore to deal with for months.    W. P. D. 
Management of the Child.         225
   Sequel of the Treatment of Healthy Children.

   637. After having attended to the pressing in-
dications respecting the mother, having delivered the
afterbirth,  and put her  into a condition tq  pass a
few  seconds on the couch, the accoucheur must
ago in attend to the child. He ought to preside at
the dressing, in order to  forbid  every thing that
may be  hurtful; and  should prescribe the method
of managing the child in the first periods.
   638. Almost all children are covered with a
greasy viscous slime, which must be removed, not
only for the sake of cleanliness, but also to facilitate
the transpiration,  which it greatly  obstructs.*  It
must be carefully cleansed from  the armpits, the
folds of the groins,  and the parts of generation
in girls, where  this slime  is more  abundant, and
more apt to corrupt, and produce excoriations.
   639. In order to cleanse the skin easily, and free
itfrom this glutinous slime, we must begin by moist-
ening it with a little oil or butter, to render it more
fluid and less viscous; afterwards it  may be  wiped
off lightly with soft linen. If we do not first moisten
it thus, being obliged to rub harder, we irritate and
inflame the skin, so that it becomes, as it were, ery-
sipelatous in those places.  The child is afterwards
to be washed with warm water, and a little wine; or
it may be bathed,  if thought proper; but we ought
never, at this early period, to plunge  it into  cold
water, because the effects of it might  be very dis-
agreeable.

  * This substance has been analysed by Vauquelin and Bu-
niva and found most to resemble fat; they have not discovered
any thing which readily unites with it.         W. P. D.
                       2F 
226           Of dressing the Child.
   Of the Manner of dressing Newborn Children.

   640.  Every nation has a different method of
clothing and dressing a newborn child; but there
cannot be any thing contrived more contrary to the
intentions of nature, than the dress so long since
adopted among us, and unhappily too much known
in most of our provinces.
   641.  Of all the parts which compose this dress,
none appears more necessary than the little bandage
which is put round the child's  belly; whether to
support the end of the cord till it fall off,  or pre-
vent an umbilical hernia, till the ring be sufficiently
contracted to oppose it by itself.
   642.  At first this bandage must be made of three
compresses; that  is to say,  two of a few inches
square,  and another long enough to go round the
body. In the middle of one of the former we make
a hole large enough to receive the cord, and slit it
downward from that hole, so that it may have two
ends.  We anoint  this compress,  near the hole, on
bodi sides, with a little butter, that it may not stick
to the umbilicus, nor to the cord; and that  we may
change  it, when needful,  without pulling and tear-
ing the vessels, before  the  time of their  perfect
obliteration.  This compress being placed  on the
belly, we pass the cord into the notch, turning it
upward and towards the  left side, and then cross
the two ends underneath;  so that the skin of the
belly, which advances on the cord, may not appear,
nor the umbilicus be stretched. We place the second
compress over  the first;  and secure  all with the
third, with  which we make a circular round the
body, moderately  tight. 
Of dressing the Child.          227
  643. Although the cord falls of by the fourth or
fifth day, and the umbilicus is usually cicatrised by
the eighth at farthest, it is very useful  to continue
this little  bandage a few weeks  longer. But the
first compress  may be  made a  little smaller and
thicker, in order that  the  pressure may be made
more exactly' on  the umbilical ring, and the pro-
posed  views be  accomplished:  but  it must  no
longer be  opened in the middle as at first.
  644. The child ought to be dressed as simply as
possible, and wrapped up no more than the season
and cleanliness require. The head ought  to  be
covered only with a biggin and cap; the breast and
arms with a little shirt, and  waist-coat;  the rest of
the body,  from the arm-pits to the feet,  first with a
linen cloth, and then with one of cotton or woollen,
the surplus of which may be turned up before, arid
the whole  secured with pins and not with bands.
  645. The choice of  air  proper  for a newborn
child is not less important than that of its aliments,
and other  things  which surround  it.  Its chamber
ought to be in an airy situation, and not too close,
that the air may preserve the necessary salubrity.
It ought also to be as far as  possible from  noise,
that the child may sleep quietly, and not be awaked
with a start. It  is not less essential that it should be
laid opposite the light; which is the most effectual
way to preserve it from squinting.
  646. The child may do without nourishment the
first day; but it is not proper to continue that severe
regimen longer. In the mean time, it may be made
to swallow from  time to time a few spoonfuls of
water, sweetened with sugar or honey,  in order to
dilute the  meconium, and favour its evacuation.
  647. No  aliment is fitter for  a child than  its
mother's milk. Though the breasts do not  swell 
228        Delivery of the Afterbirth.

till the second or third day after delivery, we ought
not thence to conclude that the milk does not begin
to secrete  in them before that epoch, or that the
child has no need of nourishment till then; as many
have unfortunately imagined.  The mother ought
to give it the nipple as soon as possible; but a nurse
should not do it till later.
   648. It is not more advantageous to habituate a
child to suck only at certain hours of the day, than
to give it the  breast every time it  wakes or  cries.
It ought to be suckled  when  it is  hungry;  a little
attention will enable the nurse to  distinguish the
cries excited by  that sensation, from those caused
by pain or other  uneasiness.
Of delivering the Afterbirth, and the Regimen to
            be observed in the Month.

  649. Delivering the afterbirth, and the regi-
men to be observed by lying-in  women, form two.
articles not less essential than the  preceding: the
least fault in one, or the smallest inexactitude in the
other, may equally become the source of a crowd
of ills and disagreeable accidents.
                 Of Deliverance.

  650. By the word deliverance has long been un-
derstood the exit  of  the placenta, and the mem-
branes.  It would almost  always be the work of
nature, if we were to  give  her time to perform it;
and it must be confessed that in most cases we con- 
Delivery of the Afterbirth.        229
tribute very little to it, though the people imagine
the contrary, and regard our ministry in this article
as the sheet-anchor of the woman.
   651. The powers of nature are however limited;
and in delivering the afterbirth, as well as the child,
art is sometimes absolutely necessary.
   652.  Two  very opposite opinions  have been
built on these fundamental truths. Some have pre-
tended that we ought always to commit  the ex-
pulsion of the placenta to nature; and others, that
we cannot extract it too speedily: the latter scarcely
gave themselves time to tie and cut the cord, before
they introduced the hand into the uterus to finish
the delivery; while the former patiently waited the
expulsion of the afterbirth, though  in some cases
nature alone could  not perform it.
   653. These precepts, too general on both sides,
have  often  been fatal to the woman. There are
cases, without doubt, and I shall distinguish them
carefully, where the accoucheur is obliged to deli-
ver the placenta instantly; and others where circum-
stances require that he should abandon it almost
entirely to nature:  but,  in  all, he may cooperate
usefully, by seizing the favourable moment for it.
    Of the unassisted Delivery of the Placenta.

  654. The deliverance which is performed with-
out help comprehends two periods, that of the de-
tachment of the placenta, and that of its expulsion.
The uterus is the principal agent  of  this double
operation; its action alone forces  the  placenta to 
230        Delivery of the Afterbirth.
 detach itself; but standing in need of help to disen-
 cumber itself entirely of it, the contraction of the
 abdominal muscles comes to its assistance.
   655. The repeated efforts of  the uterus to expel
 the foetus, usually destroy the adhesions of the pla-
 centa, since we almost always find it at the orifice,
 immediately after the exit of the child.
   656. As the orifice of the uterus generally closes,
 as  soon  as the child has passed  it,   the pla-
 centa is shut up for a few minutes: but that viscus,
 still  very much irritated, not being able to bear this
 now foreign body, presently contracts to expel it,
 and forces its orifice to reopen to give it a passage;
 the  woman also,  stimulated  by  the uneasiness
 caused by the placenta engaged  in the  vagina, soon
 makes some efforts to accelerate her deliverance.
   651. The placenta always brings the membranes
 away with it, unless their union  with the uterus be
 very strict.  In that case they tear, and the portion
 retained does not separate till some time afterwards,
 when it comes away with the lochia: but the uterus
 does not always support its presence till that time,
 without accidents.
   658. Nature  always follows this course in deli-
 vering the placenta, but not always with an equal
pace; some  women expelling it  very quickly, and
others very slowly.  The delivery of the placenta is
in general  so much the quicker, as  the  expulsion
of the child has been slower, as  the uterus is more
irritable, and as it  preserves more force and less
capacity immediately after the delivery of the child;
and vice versa. 
Delivery of the Afterbirth.         261
 Of the  Signs which indicate  the  Time when we
   ought  to  cooperate  in delivering the Placenta,
   and the Method of  doing it in the most usual
   Cases.

   659. We  ought never, in the  natural order, to
 attempt  delivering the placenta, till it  be detached,
 and the  uterus endeavours to expel it. A return of
 the pains announces that instant; the hardness and
 small size of the uterine globe, which may be felt
 above the os pubis, the softness of the edge of its
 orifice, the dilatation of  it, and the presence of a
 body which  begins to  engage  in  the  vagina, con-
 firm it.
   660. We favour the deliverance, by suffering the
placenta to empty itself by  the umbilical vein; by
 frictions on  the  hypogastric region, to  excite or
 maintain the action of  the  uterus; and by pulling
 the umbilical cord.
   661. When  we pull  the cord, in order to bring
 away the placenta, we ought to direct our forces in
 such a manner, as to make it descend  according to
 the axis of the pelvis,  which it often will not do
 without  a particular precaution; either on account
 of the natural curve of the pelvis, or because of the
 situation of the woman, whose breech is more or
less sunk in  the  bed. This precaution consists in
 forming a kind of pulley for the  umbilical cord,
 with the extremities of the  fingers introduced into
 the vagina.
   662.  For this  purpose, the  accoucheur having
 taken the cord wrapped in a dry cloth in one hand,
must  pull it  horizontally, while he  carries three
fingers of the other hand united behind the os pubis,
as far as the  entrance of the neck of the uterus, to 
232        Delivery of the Afterbirth.
push the  base of the  cord  strongly  backward,
making it describe an elbow in that direction, in the
same manner as if it were passed round a pulley.
   663.  By  operating thus,  although the  cord be
pulled in an horizontal direction, or nearly so, it is
made to act upon the placenta as if it passed through
the space between the  anus and the point of the
coccyx, and consequently nearly according to the
axis of the superior strait.
   664. This precaution is sometimes so necessary,
that without it we might experience great difficulty
in extracting the placenta; which might induce us
to suppose it veryr voluminous, when it is only of
the usual  size;  or  imagine it very adherent, when
entirely detached;  and  consequently  make  the
accoucheur  pursue a conduct quite different from
what the circumstance would require.
   665. When the  placenta is  descended into the
vagina,  we merely draw it towards us,  by raising
the hand which holds  the extremity of the cord.
As soon as the  mass appears without, we take hold
of it with the right hand, and  support it with the
left placed transversely, under  the vulva; we then
turn it five or six  times round, in order to collect
the membranes, and twist them like a cord.
   666. No procedure is better calculated than  this
latter to bring away all the membranes, and prevent
the accidents which have  often been the conse-
quence of the retention of some of their fragments
in the uterus.
   667. Whenever  we find any difficulty in extract-
ing the placenta by  pulling the cord, we must
search for the cause, by advancing a finger far  into
the orifice of the uterus.  It is  also very proper to
continue the frictions which  I have recommended,
on the hypogastric region, to solicit the expulsive 
           Delivery of the Afterbirth.        233

action of the  uterus more powerfully; and if the
accoucheur cannot perform them himself,  he must
examine that region, from time to time, to inform
himself of the degree of contraction and hardness
of the globe of the uterus, that he may avoid drag-
ging down the fundus, and inverting it.
Of Accidental Circumstances which  oblige us  to
  deliver the Placenta sooner or later, and to vary
  the Mode of Operating.

  668. Of all the accidents which may oblige us
to deliver the placenta before  the  union of all the
signs indicated above, none is more  urgent than a
flooding; because the uterus, then weakened by the
loss of blood,  wants force to expel it, and  its pre-
sence increases the haemorrhage.
  669. The haemorrhage may be  either apparent,
or concealed.  In the  first case a stream of blood
flows from the vagina; in the  second, that fluid  is
extravasated in the uterus, whose orifice is stopped
up by the placenta, so that its parietes become dis-
tended and its cavity filled.
  670. This concealed haemorrhage is never more
to be dreaded, than  after a labour preceded  by a
copious flooding, and especially if it be  terminated
suddenly; because the placenta being detached, and
ceasing almost all at once to  be supported by the
child, presents itself at the orifice, before the uterus
is sufficiently  contracted to check the  impulse  of
the blood.  This  accident may  also happen after the
placenta is delivered,  if  we  should  stop up the
                      2G 
234        Delivery of the After-birth.
vagina, without any other  precaution, in order  to
oppose the flow of blood, continued by an atony of
the uterus.—See  par. 727 and following.
   671. Frequent syncopes  and convulsions ought
also to determine us to extract the placenta, and
other foreign bodies which are the cause of them.
 Of the Method of delivering the Placenta in case of
                    Flooding.

   672. When the cord is whole, and sufficiently
 strong, it must be pulled with the usual precautions,
 while an assistant solicits  the  expulsive action of
 the uterus, by proper frictions on the belly. If the
placenta resists these united efforts, we must intro-
 duce the hand cautiously into the uterus, to extract
 it. We must  do the same when the weakness of
 the cord, or any other cause prevents our using it.
   673. When the placenta is not entirely detached,
 we must search for the part where it is  already
 separated  from the uterus;  and,  insinuating  the
 fingers behind it, destroy the rest of its adhesions,
just  as  we  separate two  sheets  of paper stuck
 together.  During  this time  we are to take great
 care to fix the uterus, by pressing on the belly with
 the other hand (see par. 685,) and  neglect none of
 the means usually employed in flooding cases. 
Delivery of the After-birth.        235
 Of Obstacles to delivering the Placenta, arising from
   an atony of the  Uterus, and from a natural or
   spasmodic Contraction of its neck.

   674. Though an atony  of the uterus obliges us
 to deliver the woman  instantly, when it is accom-
 panied by a violent flooding, it prescribes a very
 different conduct when there  is no  haemorrhage;
 for then we ought to do nothing which may occa-
 sion a separation of the placenta, till the uterus
 recover from its  insensibility, and be in a state to
 contract itself.
   675. The spasmodic contraction of the neck of
 the uterus generally produces no more than a mo-
 mentary obstacle to deliverance. It rarely gives any
 trouble, unless it become  universal,  or is accom-
 panied  by  any  other  accident.  The  particular
 species of complication must then determine the
 choice of the methods to be pursued.
  676. When there are no obstacles to deliverance
 but what depend on the natural contraction of the
 neck of the uterus,  it must be  deferred as long as
that state  requires.  The delay is never very long
after a birth at full  time; but, after abortions, it is
generally so much the longer, as the pregnancy was
less advanced. 
236        Delivery of the Afterbirth.
Of Obstacles to Deliverance, proceeding from pre-
  ternatural Adhesions of the Placenta; and of what
  must be done in those Cases.

  611. The  union of the placenta with the uterus
may be so close and strong, as to resist not only the
efforts of that viscus, seconded by those which we
can exert on the cord, but even the immediate ac-
tion of the hand; at least, unless we risk expqsing
the woman to accidents a thousand times more dan-
gerous than those  we would free her from by de-
livering her.
  678. This union, however strict it may be,  is
never formed otherwise than by means of a cellular
membrane more or less dense; and we never see
any thing of  those  uterine crista which  some ac-
coucheurs have  talked of, and which they suppose
shoot deeply  into anfractuosities of the placenta;
which at least may secure us against any fear  of
tearing them,  in endeavouring to detach the latter.
   679. In general  these adhesions are not equally
strict in all parts. For the most part only a few lobes
are thus  identified as it were with the substance  of
the uterus; but these may be found at any part of
the placenta.
   680.  When the placenta is partly detached the
operation of  separation  is easier;  but it presents
more pressing indications, as an haemorrhagy ne-
cessarily attends it. It is not always necessary  to
introduce the hand, when the connexion between
the placenta  and uterus may be a little more strict
than  ordinary, as this difficulty for the most part
may  be  overcome by acting as stated in par.  662.
When it adheres to the anterior part of the uterus,
we gain the  advantage spoken  of in par.  662  by 
           Delivery of the Afterbirth.        237

placing the fingers before the cord; and when it is
fixed to the posterior part, we place the fingers be-
hind the cord; when it may be at the sides, we place
our fingers agreeably to the rule just laid down.
   681. The  precaution  of  forming a pulley  with
the fingers, for the umbilical cord, to change the
direction of the forces applied to its extremity, is
never more necessary than when it is inserted in the
lower part of the placenta. The reasons assigned for
it by the celebrated M. Levret are so clear, that I
cannot do better  than recommend the  reader  to
consult him on the subject.* " It very often hap-
" pens," says he, " in this case,  that the placenta
" appears to adhere very strictly, when we puil the
" cord in the usual manner, because  it no more
" tends  to separate any part of its circumference,
" than we could slide a paper towards  us, cut in
" form of a battledore, and applied wet on a plane
u parallel to its surfaces; for we should sooner tear
" off the handle of the paper, than separate it whole:
" whereas, if we lift up the handle to detach it, it
" easily quits the plane on which  it is applied."
   682.  When the adhesions of the placenta resist
the well-directed efforts which can be  exerted on
the umbilical cord, or when the cord is so weak that
 we cannot make use of it, many accoucheurs, even
among the moderns, think  it better to abandon the
 deliverance to time, and the efforts of nature, than
 to convey the hand into the uterus to perform it.
 This  counsel, which  we are sometimes obliged to
 follow, would be veryr prudent if we had nothing to
 fear from the retention of the placenta:  but how

   * M. Levret, Suite des Observations sur la Cause et les
 Accidens des plusieurs Accouchemens Labourieux, page 139,
 4"ic edition. 
238        Delivery of the Afterbirth.
 many women have been victims to the accidents
 which seem inseparable from  the putrefaction  of
 that body (see par. 693), or from its presence only
 in the uterus!
   683.  We must then introduce the hand, to try
 at least to deliver the woman, and shield her from
 those accidents. This precept, authorised by the
 greater part of practitioners, becomes of the great-
 est importance, when the presence of the placenta,
 already detached in some part, occasions a copious
 flooding. '
   684. It is always advantageous to preserve the
 cord, whether we propose to deliver the woman im-
 mediately,  or from prudence or necessity abandon
 the placenta to the efforts of nature. In the former
 case, it serves at least to direct the fingers to the
 mass; and,  in the  latter, to shake it from time to
 t'me, and even extract it, when the natural efforts
 s' all have destroyed its adhesions.
  685. As often as we pass the hand into the uterus,
 to detach the placenta from it, we ought to begin
 by fixing that viscus with the other hand applied to
the hypogastric region; otherwise we should succeed
 with difficulty, and not without some risk of injuring
the uterus.
  686. We easily  find the placenta while the cord
 adheres to it, because it serves for a guide; but we
are obliged to seek for it  when  the cord  is torn
away. We  then discover it  by the following signs:
 1. The internal face of the placenta is covered with
 vascular rays, very sensible to the touch.  2.  The
 woman can scarcely distinguish  the presence of the
fingers when they touch that body. 3. The region
 of the uterus is softer, and twice or thrice as thick
as any other part, comprehending the thickness of
 the placenta which is attached to it. 
Delivery of the Afterbirth.        239
  687. As it is very rare that the placenta is not al-
ready detached in some part, when we introduce the
hand into the uterus, we must endeavour to discover
that  part; in order to continue the separation from
that point to that which is farthest from it. But,
when the placenta still adheres in all parts, we must
begin the separation where it appears most conve-
nient and easy.
  688.  When it is  found already separated from
the uterus in some part of its circumference the ends
of the fingers  must be insinuated under it, and the
hand advanced gently between those two parts, as
directed in par.  672.
   689.  When the mass  is united to  the  uterus
through the whole extent of its circumference, and
is detached  in the middle, we must pull the umbili-
cal cord,  to enable  us to grasp the detached part
with the  ends of all the fingers; which is not difii-
cult to  do,  because it  presents itself, as it  were,
forming a projection more or less  salient from the
uterus.  If this method does not succeed, we must
endeavour to separate a part of the edge of the pla-
centa, in  order  to  insinuate the  hand under it; or
we may pierce it with the end  of the finger, near
the base of the cord, and  finish its separation from
the uterus by  passing the finger all round behind
it. I have succeeded by this means in a case of that
sort, after I had tried other ways in vain.
   690.  Before we endeavour to extract the placen-
ta, we must carefully observe whether it be entirely
detached; for, being of a fungous nature, and easily
torn, the adhering portion might remain in the ute-
rus, and  cause  the  same accidents as if the whole
were retained.
   691. There are  however some cases, where far
from persisting to extract the whole of the placenta, 
240        Delivery of the Afterbirth.
 prudence requires that we should leave a portion of
 it to nature.  Smellie gives us an  example of this
 sort in his excellent work; where we find he thought
 it better to follow this method, than to risk tearing
 the  uterus by endeavouring to detach a portion of
 the placenta which appeared to him to be scirrhous.
 I have twice met with the same thing; and, in one
 of those cases, the portion  of the placenta which I
 left  in the uterus, with a perfect knowledge of the
 cause, was  not expelled till six weeks afterwards.
 It was  then  about  the  size of a  walnut, and so
 withered, that we could tear it without soiling the
 fingers.
   692. If the  adhesions of the placenta are so strict
 as to form in a manner one and the same body with
 the uterus, we must act as  Smellie did, on account
 of a portion of it which appeared to him identified
 with that viscus, and as I have done myself; that is
 to say, abandon it for a time to the efforts of nature.
 The union of the placenta may relax, or  dissolve;
 and it will then present itself readily to the hand of
 the accoucheur.
   693.  We must not however conceal how dan-
 gerous the consequences of this circumstance, hap-
 pily very rare, may be; especially if we do not pay
 it  the strictest attention. The putrefaction of the
placenta, almost always inseparable from its reten-
 tion in the uterus, may become the source of a mul-
 titude of accidents;  among which  a foetor of the
 lochia,  suffocation of the uterus, syncopes, a slow
 fever, and insomnia, are the slightest.
   694.  Accoucheurs have hitherto applied them-
 selves more to provoke the expulsion of the pla-
 centa, than to  prevent or moderate the effects of its
 retention; without considering whether nature were
 disposed to get rid of it, or whether there might not 
           delivery of the Afterbirth.        241

be more inconvenience in extracting it, or provoking
its expulsion, than in leaving it. Of all the remedies
to which empiricism, rather than rational practice^
has attributed the power of expelling the afterbirth,
none  are more dangerous than the greater part of
those known by the name of emmenagogues. They
inflame the mass of blood, instead of calming the
irregular motion by which it is then too often agi^
tated, &c
  695. Antiphlogistics and antiseptics ought rather
to be employedj according to circumstances. Great
advantages may likewise be derived from emollient^
detersive, and antiseptic injections, repeated several
times a-day.  They relax the adhesions of the pla-
centa, wash away the putrid matter which drains
from  it, and prevent the accidents which might be
the effect of its absorption.
  696. We must then touch the woman from time
to time, to examine if the placenta be not detached;
in order to extract it, either by gently pulling the
Cord, if it has been preserved, or otherwise; that it
mav no longer corrupt the lochia, or retain them in
the' uterus, by stopping its orifice; and that health
may be more quickly restored.
Of the Retention of a Portion of the Placenta, and
  of Clots of Blood in the Uterus; and the Precau-
  tions necessary in those Cases.

  697. The extraction of a portion of the plaeenta,
or of a clot formed  in  the  uterus, must be con-
sidered as a part of the deliverance; since the pre-
sence of such foreign bodies may cause the same
accidents as the retention of the whole of the pk«
centA-
                      2H 
242        Delivery of the Afterbirth.
  698. It is not always from the placenta itself that
those portions  are detached  which remain  in the
uterus, and oblige us to pass the hand into it. They
are sometimes a species of cotyledons, little masses
distinct from the principal one; and which form, as
it were, so many little islands on the membranes;
which makes it much more difficult  to discover
them.
  699.  We may discover whether any part of the
placenta is left  in the uterus,  by  collecting  and
putting together all  which is extracted;  but we
cannot discover the existence of cotyledons, or those
little  masses I  have just mentioned, but by intro-
ducing the hand into that viscus. The tearing of the
placenta always  makes us presume the presence of
the former, and  we may search for it immediately:
whereas the  traces which  the  others leave on the
membranes,  are exceedingly  equivocal; so that we
can have no certain signs of their existence, either
immediately  after deliverance, or in the sequel;  be-
cause the accidents they produce may proceed from
another cause.
  700.  The  retention of these  portions of the pla-
centa is no otherwise alarming, than as it becomes
the cause of other accidents, of which the most to
be  feared is an haemorrhage.  That may manifest
itself sooner or later; I have seen it not appear till
the tenth day after delivery.  When it  is abundant,
as it was in that case, it requires us to pass the hand
into the uterus to extract the foreign body from it.
   701.  When  there are no  other  accidents  but
what are the consequence of the putrid dissolution
of the retained portion ol the placenta, we must have
recourse to the injections indicated in par. 695, and
vary  them according to circumstances.
   702.  If we were certain of the existence of these 
            Delivery of the Afterbirth.        243

portions of the placenta at the time of the deliver-
ance, it would be better to extract them immedi-
ately, than to wait till succeeding accidents oblige
us to it: but if we are not called till some time after-
wards,  there must be very great accidents, to de-
termine us to take the same method: because nature
alone almost always delivers herself of these foreign
bodies; and we have only to guard against the ef-
fects of their putrefaction, during their stay in the
uterus.
   Of Deliverance when the Placenta is encysted.

  703. The placenta is said  to be encysted, when
it is contained in a cell making part of the cavity of
the  uterus;  but  which  nevertheless sometimes
appears  as  distinct,  as  that  of the  body of that
viscus, in its natural state,  is from the cavity of its
neck.
  704. When the cavity of the uterus is thus divi-
ded, the  placenta is sometimes found in one cell,
and  sometimes in the other;  or each of them con-
tains  a part of it, according to the  place  of its
attachment. Thence we find placentas completely
encysted, and others only in  part.
  705. In  whatever  manner  the placenta may be
encysted, the deliverance is generally performed in
the usual way; it is only a little more difficult,
because  nature has to overcome not only the resis-
tance of the neck  of the  uterus,  but that of the
entrance of the cyst also.
   706. If we cannot  perform it  in the usual way,
that is to say, by pulling methodically at the um-
bilical cord, while an assistant endeavours to solicit 
244        Delivery of the Afterbirth.
the expulsive action of the uterus, we must advance
the hand to the entrance of the cyst, dilate it pro-
perly, detach the placenta, and  extract it, as has
been already directed, whether we can make use of
the umbilical cord or not,
Of Deliverance in those Cases where the Placenta
      is attached to the Neck of the Uterus.

  707. We no.longer fear now, as in the  time of
Deventer, being charged with advancing a paradox,
in declaring that the placenta is sometimes attached
to the neck of the uterus, and covers its  orifice.
Real practitioners are agreed on the certainty of
this fact; because there are none who have not seve-
ral times met with it.
  708. When the placenta presents first, a flooding
before delivery seems to be essential to it; but  it
may manifest itself sooner or later, according to
circumstances,  Sometimes  it appears as early as
the sixth  month, sometimes not till the  ninth, or
even till the approach of labour; but generally from
the seventh to the eighth month, It is always slight,
and may be stopped by the usual remedies when
it begins early;  but it soon appears again,  and
becomes so much the more abundant, as the  woman
approaches nearer to the end of her pregnancy; so
that it is never  more excessive than during the
course of labour,
  709. We cannot discover whether the orifice  of
the uterus be the seat of the placenta or not, with-
out passing the finger into it.  Instead of the very
gmooth membranes which are usually felt,  we then
find a soft and fungous substance;  all other signs 
Delivery of the Afterbirth,        245
are uncertain, and exceedingly equivocal. But these
examinations ought to be made with the  greatest
care,  because they may become hurtful; for the
finger may detach a salutary clot, which opposed,
or at least moderated, the haemorrhage.
   710. As the choice of the best methods to be
pursued  in this  case depends less  on the place
where the placenta is situated than on the violence
of the haemorrhage which proceeds from its sepa-
ration, we need not trouble ourselves at the begin-
ning with endeavours to discover its  seat.
   711. When the haemorrhage is slight, or even
moderate, we prescribe the most exact repose; and
keep  the woman as  much as possible in an  hori-
zontal position:  we bleed her,  if circumstances
require it;  that is to say, if she appears plethoric;
we give her none but the most cooling and incras-
sating drinks, and aliments of the same nature.  If
the haemorrhage continue notwithstanding these
precautions, and become more considerable, cloths
dipped in vinegar and cold water may be applied to
the belly; and we may introduce a kind of tent or
pessary of fine tow or lint, moistened with the same
liquor, into the vagina, or even into the neck of the
uterus, if  it  be sufficiently open. If the flooding
resists all these methods, and endangers the woman's
life,  we must excite the labour pains, and deliver
her.
   712. If this last resource is salutary to the mother,
and preserves her life, we ought  not to dissemble
how dangerous it is to the child.  It runs so much
the more risk, as it is then farther from the period
of its maturity, and as the neck  of  the uterus is
naturally less disposed to give it a passage. But of
two  evils  we must choose the  least;  though  the
child is endangered by this premature delivery, its 
246        Delivery of the Afterbirth.
loss is inevitable if we neglect it, and that of the
mother is not iess so. We must not even defer it
too long, in the hope that pains will come on, and
the labour take place naturally, or that an hour's
delay will  produce  more  favourable  dispositions;
for that hope is perfidious:  and an  instant  often
decides the fate of two individuals, who might have
been preserved  by acting  with  a little more  cele-
rity, and less timidity.
   713. Since  we must then have recourse to  deli-
very, we ought to perform it in the surest and gen-
tlest manner  possible.  The  method of  Puzos*
cannot in this case  have those advantages which
have been generally  found in it when the source of
the haemorrhage is farther off. In those cases the
flooding ceases or diminishes after the evacuation
of the waters, in proportion to the strength of the
pains, and the diminution of the cavity of the uterus;
so that the  labour may sometimes be allowed to go
on naturally, without danger  to the  woman. But
when the placenta  is attached to the  neck of the
uterus, if the  haemorrhage is suspended for a mo-
ment when the waters are evacuated, it soon appears
again; and becomes so much the more abundant, as
the orifice of the uterus  dilates farther, and as the
violence of the labour increases. I have met  with
but one case, where the flooding has entirely ceased
after the evacuation  of the waters, out of at  least
five-and-twenty where the placenta was attached to

  * Puzos advised, in case of violent flooding, to excite the
labour pains by dilating the neck of the uterus, and opening
the membranes___See his excellent observations on uterine
haemorrhages at the end of his work. 
            Delivery of the Afterbirth.        247

the neck of the uterus; but this single case cannot
establish a rule.*
   714. If in this case we should determine to eva-
cuate the waters of the amnion  before the state of
the neck of the uterus will permit us to deliver the
woman, and if as much benefit could result from it
as in other flooding cases, it might be more advan-
tageous to do it  by passing a trocar through the
placenta, than by making a hole in it with the finger:
but I am far from proposing  this method, as well
because its  application  might produce  inconve-
niences, as because the  evacuation  of the waters
then cannot be of any utility.
   715. When  the orifice of the uterus is properly
disposed for delivery, we detach the placenta from
one side of it;  and always, when we can discover
it, from that side where its edge approaches nearest
to the orifice. We tear the membranes at the edge
of the ma*s, then search for  the child's feet, and
 extract it as in common cases.
    716. Some practitioners prefer piercing the pla-
 centa in the middle, and  passing the hand through
 it to turn the child;  but this  method is  more diffi-
 cult,  and  less certain, than that  which  I propose.
 Those practitioners almost expose the placenta to a
 total separation by acting thus; and tear some of the
 principal roots of the umbilical cord. Besides, the
 child being obliged to  descend  through the pla-

   * A midwife had extracted the placenta some hours before
 I was called, and had not been able to turn the child, whose
 arm was engaged below the head. The uterus, irritated  by
 the manoeuvres of the midwife, was strongly contracted on the
 child, and discharged but a few drops of blood. Astonished',
 after the extraction of the child, to see the cord was torn oft"
 hear the umbilicus, and more surprised still not to find the
 afterbirth  in the uterus, I  discovered that it  had been ex-
 tracted a long time before my arrival, and carefully concealed' 
 248        Delivery of the Afterbirth.

 centa, seldom fails to bring it along with its shoul-
 ders: which augments the difficulties, by adding
 the volume of that mass to  that of the shoulders;
 and occasions some other inconveniences.
   717.  When the placenta still preserves a part of
 its adhesions to the uterus,  after the exit  of the
 child, we ought to wait till the  action of that viscus
 has destroyed them, before we extract it; unless a
 continuance or renev/al of the haemorrhage obliges
 us to deliver the woman sooner.  In all these cases, as
 well as in those where the placenta is attached in the
 neighbourhood of the orifice, the whole of the mem-
 branes  seldom come  away,  without  the greatest
 attention; because  they detach themselves  circu-
 larly  from the placenta, if their adhesions resist
 ever so little.  VVe must then take all  possible care
 that they may not be left behind, lest  their stay in
 the uterus should be the cause of troublesome acci-
 dents; and the accoucheur should be taxed with inat-
 tention  and unskilfulness,  when they are seen to
 come away afterwards, in the form of a portion of
the afterbirth. In order to extract the whole of them,
 we must take hold of them close to the placenta, as
 soon as that is  without, and pull them cautiously;
 while with the other hand  we solicit  the uterus to
 expel them by frictions on the hypogastric region.
        Of Deliverance after an Abortion.

  718. Cases in which we may be obliged to com-
mit the deliverance to nature, and  confess the im-
potence of art to effect it, are never more frequent
than after abortions; since we  then have scarcely
any of those resources,  which  we  meet with after
i birth at full time. 
Delivery of the Afterbirth.        249
   719. The difficulties of delivering the placenta,
 in these cases, generally increase in an inverse pro-
 portion to the term of gestation: they are so much
 the  greater as that is less advanced, and diminish
 in proportion as the abortion or delivery approaches
 nearer to the period of nine months.
   720. Before the third month, nature finds fewer
 difficulties in freeing herself from the  whole pro-
 duce of conception at once,  than in expelling the
 afterbirth separately; but after that period  we ob-
 serve the contrary.  Experience teaches us, more-
 over, that it is very rare that those deliveries are
 not  performed according to the intentions of nature,
 when  the accoucheur  does not disturb her course
 by seeking to assist her; for it is as rare to see the
foetus precede  the exit of its  involucra, before the
 third month, as to see it  come enveloped  in them
 after the fourth.
   721. According to  this  natural indication, we
 ought never  to open the membranes with a view of
 abridging the labour of an abortion, however tedi-
 ous  it may be, when it takes place before the  third
 month; as we ought never to  fail to do it after that
 epoch, if  the membranes do not tear of themselves,
 as soon as the orifice of  the  uterus is  sufficiently
 dilated to give a passage to its contents.
   722. In the former case, if the membranes should
 open spontaneously, or otherwise,  before the orifice
 of the uterus be sufficiently large  to expel its  con-
 tents entire,  they discharge the waters and foetus,
 which is still very small: they afterwards collapse,
 and  cannot be  expelled  but by a much  longer
 labour, and which  is often retarded  several days;
 because by that evacuation the uterus loses a part
 of the sensibility and irritability  it had acquired,
 and  which were necessary for the farther progress
                       2 J 
250        Delivery of the Afterbirth.
of its  contractions; and  because its orifice closes
during that state of rest.
  723. If we were near the woman at the time the
membranes open, we ought to introduce one or two
fingers into the orifice of  the uterus, to hinder it
from closing, and favour its farther dilatation, till
it be sufficient for the deliverance; which would
then take place without any more trouble, and in a
very short time,  but when we  are  not  called till
after the  discharge  of the waters, we  must wait
patiently, unless a flooding oblige us to act.
  724. But how can we  deliver the woman in this
latter case? The umbilical cord, brought along by
the foetus, is torn  off; and is besides so slender, that
it could not be used in extracting the placenta. The
external  parts of the woman, and the entrance of
the vagina, are so close, that the  hand could  not
penetrate it without force, and exciting a great deal
of pain; the neck of the uterus, scarcely at  all dila-
ted, will admit at most but a single finger, which,
far from serving to extract any portion of the pla-
centa that might be engaged in it,  could only push
it back again towards the fundus.
  125. When all things are in a state so little favour-
able to deliverance,  if the  flooding is not  violent,
the accoucheur must  content himself with soli-
citing the action of the uterus  briskly, and endea-
vouring to make it contract with sufficient  energy
to  finish  the detachment and  expulsion  of  the
placenta. By this means he may often obtain from
nature, in a quarter or half an hour, what he could
not have obtained otherwise without a great deal of
time and trouble.
  726. When a portion of the placenta is engaged
in the  neck  of the uterus, so as to project a little
into the  vagina,  we may take hold of it with two 
           Delivery of the Afterbirth.        251

fingers, in order to loosen and bring along the rest:
but it must be done cautiously, lest we tear it; which
would but retard the complete deliverance.
  121.  Though we may temporise thus, or confine
ourselves to these feeble succours, when the flood-
ing is moderate, we must act very differently when
it is so  considerable as to put the woman's life in
sudden danger. If we  cannot extract the placenta
immediately, we must, without delay, stop up the
passage, and  hinder the blood from flowing; and by
that means cause the formation ofa coagulum, which,
by exactly filling the cavity of the uterus, may stop
the mouths of the gaping vessels, and check the vio-
lence of the haemorrhage. For this purpose we may
introduce a piece of agarick  into the neck of the
uterus;  or, if we  can, a plug of very fine tow, or
lint, moistened with vinegar and water, with which
the vagina  may be entirely filled; we must take care
to support this plug properly, till the uterus, irri-
tated by its presence, by that of the coagulum,  and
the afterbirth,  contract with sufficient force to de-
liver itself of them all.
  728.  This method, whose utility has often been
proved by experience in cases of abortion, as well
as in those of inveterate or habitual haemorrhage,
might have very disagreeable consequences  if we
were to employ  it without any other precaution,
after a delivery at full time:  because there might
then be an internal extravasation capable of destroy-
ing the woman, as we see in one of the observations
of La Motte;* the cavity of the uterus then  being
too vast, and its parietes giving  too little resistance
to the influx  of blood.  If we should be obliged to
plug up the vagina in the latter case, as I have done
* Observation 386, nouv. edit. 
252        Delivery of tfte Afterbirth.

several times writh success, we must, while we sup-
port the plug with one hand, oppose the develop-
ment of the uterus, by pressing on the hypogastric
region with the other, and grasping, as it were, the
body of that organ with all the fingers.
  729.  When the placenta of an abortive foetus,
which we cannot extract, putrefies in the uterus, and
produces any of the accidents stated in par. 693, we
must have  recourse to the injections prescribed in
par.  695; but,  if nothing of that kind happen, we
need not be uneasy about it. Some  women, after
retaining it several months without being at all in-
commoded  by it, have at length discharged it,
withered and reduced to almost nothing.
     Of Deliverance after the Birth of Twins.

  730. The connexion which twins almost always
have by means of their involucra, shows us of what
importance it is, not to undertake to extract  the
placenta till after the birth of the last; though some
observations  seem  to authorize the contrary prac-
tice.
  731.  Each twin  having sometimes its involucra
very distinct, and perfectly separate, and the placen-
ta of one being only placed close to that of the other,
we might without the least inconvenience,  immedi-
ately after the exit  of the first child, extract its af-
terbirth, and do the same with regard to the second:
but how can we  discover this case, which is besides
extremely rare, before we proceed to the deliverance?
As  no signs can enlighten us on this point; and as
it much oftener  happens that there is but  one pla-
centa for the twins—or that the two masses  are so 
           Delivery of the Afterbirth.        253

bound together by means of the chorion which en-
velops the two, children, that we could not extract
one without detaching the other at the same time,
which might be equally dangerous to the. mother
and the second child—we ought never to attempt
it till  after the exit of the  latter. I only except the
case where the afterbirth of the first child presents
itself, as it were, to the hand of the accoucheur.
  732. Since then we ought not to extract the plu->
centa  till after the exit-of the last child, except in
those  cases where nature points out a different
mode, by pushing the placenta of the first to the
entrance of the vagina, perhaps it would not be use-
less in the mean time to tie the cord which descends
from  that mass, as some have recommended: but
we must untie it again at the time of its extraction,
in order to empty the common afterbirth, and  by
that means favour its deliverance.
   133.  We begin by pulling both cords, and pro-
ceed  as if there had been but one child. If the pla-
centa, more voluminous than in the latter case, does
not yield to these efforts, we may act on only one
of the cords, in order to bring down the two masses,
one after the other; and if we still  meet with the
same  difficulty, we may introduce two fingers into
the neck  of the  uterus, and endeavour to bring it
along edgewise. 
 254       Management after Delivery.


 Of what is to be done immediately after Deliverance,
   during the Time the Woman must remain on the
   Couch.

   734. As soon as the placenta is delivered, whether
 that operation has been performed spontaneously or
 not, the accoucheur ought to inform  himself, by
 touching, whether the placenta has not drawn down
 and  inverted the fundus of the uterus, or whether
 the whole of that viscus be not descended too  low;
 that, in the latter case, he may raise it up;  and, in
 the former, reduce the inverted part immediately.
   735. When,  in this respect, every thing is in the
 natural order, it will suffice to rub the abdomen with
 the hand, and repeat it now and then, to excite and
 maintain the  spring or tonic action of the uterus, to
 favour its  depletion, and prevent the formation of
 clots, which  often become the source of many ac-
 cidents.
   736.  As the woman ought to remain some time
 on the couch where she has been delivered, either
 to rest herself a little, or  because it would  be  im-
prudent, and even dangerous in some cases, to move
her immediately (as in those when  the delivery has
been preceded  or followed by an haemorrhage, by
syncopes, or any other accident; as  also when there
is any reason to fear they may happen),  she must
be kept clean by substituting dry clothes for those
which are wetted.*
   737.  She must be kept at first as much as pos-
 sible in a horizontal position; she may draw her legs

  * The inconveniences here spoken of, are obviated by hav-
ing the patient pl&ced as recommended in note to par. 585.
                                       W. P. D. 
          Putting the Woman to Bed.       255

up and down; she must be covered according to the
season, and be enjoined silence, and the most exact
repose.
  738. It is not  less  necessary to keep the mind
quiet, than the body: experience  proves that every
thing which affects it strongly, may have disagree-
able consequences.  How many women have been
victims of an impulse  of joy, of immoderate anger,
or other similar passions, immediately after delivery!
  739. If the  woman is  thirsty, we may give her
some of those drinks,, mentioned in par. 516, or a
little broth, if necessary. But we ought to proscribe
entirely the use of spirituous liquors  and heating
potions,  which are indiscreetly taken by the lower
class of people, whether  with a design to raise the
spirits, or prevent afterpains.
  740. Before we remove the woman, we must take
every thing from  her that has been moistened with
sweat, or with the  waters  and blood which have
drained from the uterus. This is what the nurses
call  putting the  woman  to bed. Though the ac-
coucheur is rarely admitted to this toilette, and still
more rarely obliged to put his hand to it; it is how-
ever proper that he should know in what it consists,
and be acquainted with its advantages and abuses.
         Of putting the Woman to Bed.

  741. Nothing is indifferent in the time of lying-
in; at that time things the most simple in appearance
sometimes becomes very pernicious: and women are
often  victims of a vain advantage which they en-
deavour to procure for the time to come; or at least
of their ignorance, or of that of their nurses. Those 
256       Putting the Woman to Bed.
 women will perhaps be obliged to me for attending
 to their first adjustment; then it will be of little im-
 portance  that some accoucheurs reproach me for
.haying entered into these details.
%  742. Every nation has, as I may say, its particu-
 lar  manner  of dressing and  managing lying-in
 women: the same method perhaps cannot pass every
 where for the best. I shall speak only of that which
 is in use among us; but I must premise that fortune
 has  caused as many varieties in it, as she has  esta-
 blished different conditions among women.
   743. After removing every thing wet from the
 woman, she has a short shift open before put  upon
 her; this shift reaches no lower than the waist, that
 it may not be soiled with the lochia.  Over this shift
 a bed gown with long sleeves is put. A bandage is
 then placed round the abdomen, the utility of which
 has  been demonstrated by Smellie.
   744. Experience, which had confirmed its ad-
 vantages to me before I knew the precepts of Smel-
 lie, has since taught me that it may be made useful
 in some cases of flooding after delivery, by making
 a pressure on the abdominal vessels, and moderating
 the course of the blood towards the uterus. At other
iimes it opposes the dilatation and puffing  up of the
 intestinal canal; it prevents hernias, by resisting the
 impulsion of the floating parts.  Lastly, I have re-
 marked that, at the same period after  delivery, those
 women who had not had the belly gently confined
 in the first days had the uterus more voluminous and
 plethoric than others.
   745. It seems to me, according to these obser-
 vations, that this bandage ought not to be omitted;
 and that in some cases, it should be applied imme-
 diately after deliverance.
   746. The  bandage for the belly  is made in the 
             Subsequent Symptoms.         251

following manner:—We first apply a very soft nap-
kin, folded in a square or triangular form, to the
hypogastric region; then apply another over it, fold-
ed lengthwise, which must go round the belly. It
should not be very strict at first; but we may after-
wards tighten it by degrees, in proportion as the
volume of the uterus diminishes.
  747.  A kerchief on the neck, a cloth round the
loins and thighs of the  woman, after the manner of
a petticoat, and a soft napkin applied to the vulva,
must finish her adjustment. We then transport her
to the bed, and prescribe a regimen according to her
condition.
  748.  It would be difficult to  fix the method of
treating women in the month, or even to establish
general precepts on the subject, without first making
known  the  principal  phenomena which manifest
themselves after  delivery, and their differences rela-
tively to the  various circumstances which may hap-
pen. I shall state them very briefly.
Of the principal Phenomena which  manifest them-
               selves in the Month.

  749. The symptoms subsequent to delivery have
been distinguished into natural and accidental. The
former present us with  an infinite variety,  depen-
dent on  the  constitution of each individual; the
latter are sometimes the effect of a  predisposition
to disease, which labour has only called into action;
and sometimes they depend on the bad habit of the
subject, the unskilfulness of the accoucheur, the
neglect of a proper regimen, or on some unforeseen
events.  I shall only speak of the usual subsequent
symptoms.
                     2K 
258          Subsequent Symptoms.
  750. A kind of faintness, or  lassitude, like that
which is felt after violent exercise, soon succeeds
to the agitation excited by labour:  but the pulse
quickly revives, a warmth is diffused through the
body, the skin becomes moist,  a salutary perspira-
tion breaks forth, the limbs recover their former
liberty, the order of the functions is re-established:
and a perfect calm succeeding to this violent effort
of nature, permits  the  woman to  enjoy peaceably
the happiness of being a mother.
  751. During the  first days there  is a copious dis-
charge at the vulva. At first, of pure blood, whose
colour and consistence  begin to weaken sooner or
later, and diminish insensibly; so that, in about
twenty-four hours,  it is commonly nothing but a
reddish serum, which soon after changes again. It
becomes in a short  time thicker and whiter, and, as
it were, purulent; which has caused it to be called
puriform lochia,  while the two  former species are
named sanguine and serous.
  152. The duration and quantity of these different
species of lochia likewise depend on a great num-
ber of different circumstances, which I shall not
mention in this place. The sanguine lochia some-
times flow during the first two days, with or with-
out pain; which depends on the state of the uterus,
and the  nature  of the  blood, which  sometimes
passes fluid, and sometimes in clots.
  753. If we were less acquainted  with the mecha-
nism by which these  first lochia stop, it would be
matter of  astonishment that  all  women  do not
perish by an haemorrhage  soon after delivery; so
great is the diameter  of the vessels,  at that time,
which transmit  the blood  to the  uterus (see par.
400). Though this evacuation seldom  continues
beyond the two first  days, it is very common for 
              Subsequent Symptoms.          259
                                    i
the blood to reappear from time to time during the
first weeks, and even the whole month; which pro-
ceeds  from the weakness  of  the uterine  vessels,
and the preternatural size which some  of them still
retain.
   754. The source of these different kinds of dis-
charge sometimes seems to dry up from the second
to the  third day, but for twenty-four hours only, or
thereabouts. The lochia seem  then to return into
the blood, and be translated to the breasts; and a
crisis,  more or less violent, is  produced,  which is
called  the milk fever.*
   755. This crisis is announced by shooting pains
in the breasts: a swelling  and tension soon  after
succeed; and their volume  insensibly augments, to
that degree in some women, that the skin seems to
be in  danger of bursting.   The engorgement often
extends to the  axilla, and  sometimes renders res-
piration difficult and laborious. The pulse during
this time becomes strong and quick, the head grows
heavy, the  face red, the woman  suffers a kind of
universal lassitude, and feels pricking pains all over
the body.
   756. A sweat more or less abundant, and whose
sour smell  sufficiently denotes its milky nature, at
length always restores a calm.  It often continues

  * I am convinced that this milk fever is in great measure,
if not altogether, of artificial origin. It never occurs to pa-
tients who strictly follow my directions after  delivery. It is
the product of improper regimen. W hen women, who are not
predisposed  to fever, are kept quiet, from all stimulating
drinks,  from animal food and broths, who have cool and dilu-
ting drinks, as water, toast  water,  balm tea, 8cc.  who have
fresh air freely admitted into their chambers, who have fre-
quent changes of cloths, who have their bowels freely opened
on the second or third day, never have this milk fever as it is
termed.                                 "'• * • D- 
260         Treatment in the Month.

twenty-four hours, or even longer, with very short
intervals.  We ought to do nothing that may dis-
turb it; and it might be equally disadvantageous to
endeavour to  provoke it by loading the woman with
blankets,  or  by giving her those heating potions,
against the use of which  I have  already explained
my self.  All we ought to  do is, to favour this eva-
cuation when we find nature disposed  to it.
   757. The suppression  of the lochia,, during this
crisis, is so natural a consequence of it, that  we
ought never to be uneasy about  it. The discharge
returns of itself when the  sweats become less abun-
dant; and the lochia then resemble a milky or puru-
lent matter, which afterwards acquires more or less
bonsistence.
   758. At the end of the  fourth day the swelling of
the breasts usually begins to lessen;  as they now
empty  themselves by the nipples.  Women who
suckle are seldom attacked by the milk fever which
I have just described; because they transmit to  the
child from time to time the redundant fluid which
causes it.  They sweat less abundantly than other
women; their breasts do not swell so much:  the
lochia flow not  so long;  and  if that evacuation is
suspended on the third  day,  it  often afterwards
returns in very small quantity. 
Treatment in the Month.         261
    Of the Regimen for Women in the Month.

  759. Regimen extends not only to the aliments,
but to every thing which relates to the non naturals,
whose  influence on the animal economy is never
mere sensibly felt than at this time.
  760. Nothing is of greater importance than the
quality of the air: the example of epidemics, which
so often exert their fury in large hospitals, where
poverty crowds so many women together, proves
how important it is that that fluid should be pure,
and  free from corruption. An air too hot, or too
cold, is not less hurtful to women newly delivered,
than that  which is loaded with the heterogeneous
particles I have just mentioned. It is very essen-
tial that the chamber they  are  in should be well
situated, and capable of being well opened, in order
to renew  the air from  time to time,  and warm or
cool it, as occasion may require.
   761.  The  woman ought to receive no  more
visits on the  first days than are absolutely  indis-
pensable. She ought to be lightly covered  in bed,
except it  be in winter; having more  regard to the
season and the habits  of the woman, than to the
puerperal  state.  The  curtains of the  bed ought
never to  be close, unless while the  windows and
doors are opened to renew the air.
   762. The chamber ought to be as far as possible
from noise, and no more talking allowed in it than
necessary, that the woman may rest quietly, and not
be waked with a start,  nor incommoded by the
noise and shaking of carriages,  which is too much
the case in great cities. The chamber ought more-
over to have but  little  light by day, and only one
candle at night, which should be kept from the eyes
of the woman. 
s
262        Treatment in the Month.

   163. We ought not to oblige women newly deli-
vered to  continue constantly in the same position,
and remain on the back the first twenty-four hours,
as is but too often recommended to them: nothing
being  more capable  of  relieving  them after  the
fatigue of labour, than the liberty of moving their
limbs, and changing their attitude,  they ought not
to be hindered from doing it, except after a flood-
ing, or when there is some reason to fear that acci-
dent.  If nothing of that kind is to be dreaded, they
may lie sometimes on  one side and sometimes on
the other; or even sit  up a little, if their strength
will permit it.
   764. Strong passions being not less to be feared
in the puerperal state,  than  immoderate motion of
the body, we ought to inspire her with none but
what are gentle and agreeable, and keep every thing
from  her that  may cause any agitation. I have
known some who have been victims of an impulse
of joy; and  others struck  with  an apoplexy and
mortal convulsions by a fright; and  some who have
sunk in a few minutes under the regret of seeing
the child carried away by the nurse they had pro-
vided for it.
   765. Nothing is more conformable to the inten-
tions of Nature, than to favour the  evacuations by
which she endeavours to rid  herself of the milky
humour with which she is overloaded.  To  excite
or maintain that of the bowels, we may order an
emollient glyster every day, or  even two, if  the
woman should  be troubled with the  cholic.  We
ought not to dispense with them, except at the time
of the crisis and copious sweats which I have already
mentioned.  They may   be  continued  after  this
epoch, and now and then rendered  more  laxative,
by the addition of three or four ounces of honey, 
Treatment in the Month.        263
or of mel mercurialis, or something more active, if
the case require it.
   766. The discharge of urine, and the moisture of
the skin, may be kept up by drinking plentifully of
barley water,  or a decoction of dog grass with a
little liquorice; a light  infusion of  the flowers of
linden, camomile, matricaria, elder, or other things
of that kind. Common water, almost cold, with a
little  syrup  of capillaire, or  of marshmallows,
ought to be the ordinary drink of those who cannot
take the others.
   767. These drinks also favour the discharge of
the lochia, and are almost always sufficient to  recal
them when they are suppressed; an engorgement,
an erithismos, or an inflammation of the uterus being
generally the cause  of that suppression.
   768. We are very rarely obliged to have recourse
to infusions of mugwort, rue, saffron, &c. nor to
any of those heating potions still so frequently given
to the wives of the common people, abandoned to
the care of  a nurse, or of one of their neighbours:
hot wine with spices is not less dangerous. When
the suppression of the lochia arises from one of the
causes indicated above,  emollients and diluents are
the only proper remedies.
   769. Those drinks and heating potions are  how-
ever useful in some  cases where there is more weak-
ness than astriction in the vessels of the uterus: but
as it often happens, when we prescribe a light infu-
sion, that the women substitute a strong decoction
of the plants ordered them, of which  I have several
times been a witness, the accoucheur ought to ex-
plain himself clearly on  this subject, and determine
the quantity proper for a quart of drink.
   770.  The quantity and  nature of the aliments
which a woman  newly delivered ought to  take. 
264         Treatment in the Month,
 must be determined by circumstances.  According
 to some, we cannot keep women who do not suckle
 to too strict a diet; but that little alteration need be
 made in the way of living of those who perform that
 important  duty.  Such  vague precepts  may be
 equally pernicious in both cases.
   771. We are often obliged to allow a free diet to
 the former, arid keep the latter very strictly; because
 their habits have been different, &c. I  have  often
 thought it necessary to prescribe food to  some
 women, accustomed to eat  much, in order to calm
 symptoms, which in others would have required
 abstinence.
  772. When nothing  extraordinary happens after
 delivery, we may without fear allow the woitiah two
 little basons of broth a day, or even three; with rice,
 or otherwise: or a little soup with a crust of bread.
 Though it is necessary to deprive her of the broth
 during the continuance of the milk fever,  we may
 afterwards add a little chicken or other solid  food,
 and a little good wine mixed with water, according
 to her  taste.
  773. The day of the milk fever  we  must keep
 the patient to thin gruel, and make her drink abun-
 dantly; in order to furnish a proper  vehicle for the
 milky  humour, and restore  the serum to the blood,
 which  it has been deprived of by the sweats which
 break out at that time.
  774. Some women are scarcely delivered before
 they apply cloths dipped in wine and oil to the vulva,
 to allay the pain and irritation which  they suffer in
 that part; afterwards, they lay aside the oil, and use
 only the wine, in which some of them boil roses,
 and  even things more astringent.   These latter
lotions are never more usefully employed than by
women subject to a relaxation of the vagina, a de- 
Treatment in the Month.         265
scent of the uterus, or in  whom the symphyses of
the pelvis,  softened during  pregnancy,  retain too
much mobility after delivery:,  but  we ought to be
careful not to employ them inconsiderately at the
beginning.   Emollient,  softening,  and relaxing
lotions are the only ones proper at that time.
   775. These latter are commonly made of  milk
with a little chervil boiled in it.  Or we  may  sub-
stitute a decoction of marshmallows, agrimony, or
barley.
   776. In many cases, it is not less useful to foment
the belly, during the first days, with flannels wrung
out of hot water, milk, or  a  decoction of emollient
plants; in order to keep it soft, and favour the de-
pletion of the uterus, which  some degree of erithis-
mos renders more difficult in many women.
   777. The sal de duobus is too frequently given to
women in the month, to be passed over  in silence.
It seems consecrated to their use, and every matron
thinks herself at  liberty to prescribe it,  as soon as
the milk fever is over. It is not however an indif-
ferent  medicine: many women are not able to bear
it, even in a small dose. Though there may be a few
cases where it is really indicated, there are a much
greater number where we may do  without it.
   778. It  is also  custom, rather than reason and
the good  of the woman,  which  has fixed the time
for changing the shift and other  parts of the lying;
in dress: except the cloths that receive  the lochia,
which are changed often,  that  favour is not granted
to the woman till  the seventh, or  ninth day.  But
why should she be left thus, as it were, immersed
in excrement, when no state can require more care
and cleanliness than the puerperal?
   779. I am of opinion  that women may change
their linen much sooner, and as  often as it is moist
                      2L 
266         Treatment in the Month.
with sweat, or otherwise; provided that what is sub-
stituted be very dry, and properly warmed. They
may also  from the first days be carefully moved
into their little bed, while their own is made, and
the sheets changed if necessary. But they ought to
avoid walking as long as possible, and never attempt
it  in  the first eight or ten days, even after an easy
labour.  By observing this precaution, they will be
less exposed  to a relaxation of the vagina, a descent
of the uterus and  other inconveniences which are
the consequence of those. 
PART  III.
  Labours of the second Order, commonly called
                 Preternatural.

  780.  It is pretty generally agreed to call those
labours preternatural, in which the child presents
any other part but the crown of the head to the ori-
fice of the uterus; because it was falsely imagined
that in that case it could not be born without assist-
ance.  I have already observed that among those
parts  there are several, as the feet, the knees, and
the breech, whose presence not only does not always
render the labour essentially preternatural, but not
always more difficult, or more subject to accidents,
than that where the child presents the crown of the
head.
      Of the Cases which may render Labour
                 Preternatural.

  781. Alabour may be essentially preternatural,
or become so accidentally. In the first case, it is al-
ways the bad situation of the child which is the cause
of it; in the second, a variety of circumstances may
complicate it, which I consider  as  so  manyr acci-
dents.
  782. In order to have a just idea of what is to be 
268      Causes of Preternatural Labour.
here understood by a bad position of the child, we
must recollect what has been already said of its di-
mensions, and of those of the woman's pelvis; and
remember that it cannot be born without presenting
to the orifice of the uterus one of the extremities of
its largest diameter, or of the oval figure in which
it is naturally folded. Its situation is then essentially
bad, whenever it does not present the crown of the
head, the feet, the knees, or the breech. If there are
cases where  the- child may be born without help,
though  it presents neither of these  parts, they can
only be considered as exceptions to the general rule,
and  cannot  happen except when the child is very
small relatively to  the pelvis of the mother..
  783. When several parts present  successively to
thei orifice of the uterus, if at any time we find the
head there, we  ought instantly to pierce the mem-
branes,  and  discharge the waters.
  784.  Among the causes of preternatural labours
in general, none is more justly so called, than a de-
formity of the pelvis. It. seems indeed rather to be-
long to the third order of labours than to the second;
since in that case the hand alone is seldom sufficient
to deliver the woman; except the deformity be very
slight.  Therefore I shall not enter fully into the dis-
cussion of it, till I come to the fourth part  of the
work..
  785.  The accidents which do not permit us to
abandon the labour to nature,  either  because  it
would endanger the life  of the  mother, or  of the
child, and often both; or because it absolutely can-
not be performed without help, are an haemqrrhage,
convulsions, and frequent faintings  or syncopes; an
exhaustment of the woman's strength, a lingering or
cessation of the pains,  the existence of an irreduci-
ble hernia, with a disposition to strangulation; some 
Of Flooding.               269
times the obliquity of the uterus, or the contraction
of its neck round that of the child; at other times
the presence of several children, who reciprocally
prevent each other's exit; the issue of the umbilical
cord; its shortness, and its being twisted round the
child's neck, if we adopt the common opinion  on
that subject;  and many other causes besides, which
will be stated in the latter part of the work.
Of Hamorrhage, considered with respect to the Ne-
          cessity of immediate Delivery.

  786. The haemorrhage known by the name^ of
flooding,  may endanger the lives of both mother
and child during pregnancy and labour; it is always
the consequence of an accidental separation of a
portion of the placenta from the uterus, and may
happen at any period of pregnancy.
  787. This species of haemorrhage is not always
apparent; for the blood, instead  of being shed with-
out, is sometimes extravasated behind the placenta,
and retained there by  the strong adhesions of its
edge to the uterus, sometimes by those of the mem-
branes, and sometimes by the natural contraction of
the neck of the uterus itself, which is not yet open at
the time when the extravasation takes place;  which
establishes two species of uterine haemorrhage, one
apparent, the other concealed.
  788. Though the structure of the uterus, and the
resistance which its parietes oppose to the agents of
its  development,  seem to favour the opinion that
much blood cannot be  extravasated behind the pla-
centa, experience does not coincide with that opin-
ion, but  has several times proved to me that this 
270
Of Flooding.
 sort of extravasation might become so considerable
 as manifestly to affect the  strength of the woman
 and the life of the child.* Besides, the dyke, which

   * There was an extravasation of this kind in Madame de
 * * * *, after being bled in the arm, which had occasioned fre-
 quent syncopes; and the symptoms, stated in par. 790 and 791,
 appeared almost immediately. The pains continued during
 three weeks, becoming stronger  every day; and this lady was
 delivered ofa dead child, at the period of eight months. There
 were behind the placenta two clots of blackish blood, solid, and
 in a manner  dried, of the size ofa duck's egg each.
   In another woman, the coagulum, which covered two thirds
 of the placenta, was as large as the placenta itself; and in a
 third I estimated it at four or five porringers: they were each
 of them delivered of a dead child, after having suffered most
 of the symptoms described in the paragraphs indicated.  The
 extravasation became more considerable, and the consequen-
 ces of it were more fatal in another woman, which the limits
 of this work will not permit me to relate  at large.  This
 woman, after a long walk, felt  some dull pains towards the
fundus of the uterus, and the loins, which continued all night,
 and  which she compared to those which had been used to
 precede  the  menses. Having got up the  next day as usual,
 great and frequent faintings, and the fear of a violent flooding,
 upon seeing a little watery blood appear, obliged her to go to
 bed  again a few hours afterwards: it was about ten o'clock in
 the  morning. Her weakness and exhaustment, the syncopes
 which were continually repeated, and the paleness and altera-
 tion of her countenance, not being accountable from the small
 quantity of blood she had evacuated, for there appeared scarcely
 a porringer full, besides a few cloths slightly tinged with it,
 made me suspect an  internal extravasation: the rapid aug-
 mentation of the volume of the uterus since the evening, by
 the  account of the woman and the family, strengthened that
 suspicion, and new symptoms soon confirmed it. About seven
 months advanced in her pregnancy, and scarcely showing it
 before this accident, the uterus was so developed, as to make
 any  one, at first sight, suppose her at full time, and pregnant
 of two children rather than one.  The expulsive action of the
 uterus manifested itself about the time  of my arrival, and the
 orifice began to dilate. It was scarcely open before the pains,
 though weak, expelled a quantity of clots black and soft,  more
 than the  crown of a man's hat could hold.  The blood continu- 
Of Flooding.
271
retains  the blood thus, must  be broke  through
sooner  or later; the haemorrhage then becomes ap-
parent, and a fresh loss of blood which the vessels
pour out plentifully, increases the  danger  which
already existed from the former.
   789. It is not only in the species of accidental
capsula which I have just mentioned, that extrava-
sations of blood may be formed during pregnancy;
they may also take place in the cavity of the mem-
branes which envelop the child: but from a different
source. M. Levret relates an example of it, from a
rupture of the umbilical cord;* and de la  Motte,
whom  we cannot suspect either of falsehood or ig-
norance,  assures us that he has seen the blood flow
through the meshes of the coats of the vein, which
makes part of the cord, in a place where it was be-

ing to flow afterwards, the danger augmenting, and the little
hope of preserving the woman by deferring the delivery, de-
termined me to perform it. I executed it in presence of two
surgeons,  who were sent for before me:  but it was without
success; the child having scarcely survived it an instant, and
the woman having died five hours afterwards, in a paroxysm
of syncopes and hysterics, which nothing could  prevent or
moderate.t

   f I can add my testimony in favour of what our author has
just advanced on the subject of internal haemorrhagy. I was
called to a poor woman whom I found  dead  on  my arrival
from this  kind of flooding, joined,to an apparent  one; as the
latter had not been sufficiently abundant to procure death; and
 as it was asserted by the midwife and women that, she became
 larger after the  external discharge, which had been by some
 means or other arrested, I suspected an internal haemorrhagy;
 leave was obtained to inspect the body,  and my suspicions
 were verified. I shall elsewhere give this case in detail.
                                          W. P. D.

   * Levret, Suite des Observ. sur la Cause de plusieurs Ac-
 couchemens Laborieux, obs. 35me, page 199, edit. 4me. 
272
Of Flooding.
come varicous.*  From me testimony of my own
senses,  I can assert that the cord may be ruptured
or torn partially before the birth of the child, and
shed a great deal of blood into the cavity of the
membranes.
   790.  The diagnostic  of these extravasations  is
not so easy as that of common floodings; the latter
cannot  be  mistaken; but the former may.remain a
longtime doubtful, unless it increase very suddenly.
A dull  deep-seated pain, accompanied by a sensa-
tion of weight in the place where the extravasation
is made, manifests itself almost at the instant of its
commencement, and augments insensibly with it.
The region of the uterus under which this collection
is formed,  rises in proportion to its quantity.
  791. The extravasation cannot become consider-
able enough to produce such changes in the volume
of the uterus, without strongly exciting its expul-
sive action: nor is it long before pains are felt simi-
lar to those of labour, and labour is soon the conse-
quence  of them. Those pains which are signs of the
contractions of the uterus, driving the blood forward,
we see clots come out as soon as the orifice is suffi-
ciently open, if  the  extravasation has been made
behind the placenta; but not ti'i the  opening of the
membranes,  when the  collection has been formed
within their  cavity:  in the latter  case, the waters
which precede the clots are tinged with red.f

  * Ohserv. 249, nouv. edit, tome ii. page 725.
  f The  concealed haemorrhage'may take  place some hours
after labour  has begun, as appeared in the case I alluded to
in last note; pain or the contractions of the  uterus  were sus-
pended most probably after this discharge happened, as the
patient said she was now free from pain and wished to be al-
lowed to sleep.                           W. P. D. 
Of Flooding.
273
  792. The necessity of delivery, without any regard
to the period of gestation, when the flux of blood is
so copious as to endanger the lives of the mother
and child, has  been acknowledged for  two centu-
ries back; and the precept is so much considered as
a law among us, that  we could not act otherwise
without being taxed with ignorance. This practice,
founded on the theory of the cessation of floodings
after delivery,  is confirmed by a  great number of
observations. A long and too fatal experience  has
equally proved, that an hour's, and  even a moment's
delay has in many cases cost the lives of both
mother and child.
  793. Though  we cannot dispense with delivery,
it is not less important to proceed to it in the gen-
tlest and most advantageous manner. The conduct
to be pursued must be guided by the  intensity of
the flooding, and the time when it manifests itself
with  violence. Sometimes it begins and becomes
abundant, while the neck of the  uterus retains all
its natural thickness and firmness, and the orifice,
scarcely  begun to  open,  will with difficulty  admit
the finger; at other times, it does not happen till
later, when the parts are already prepared for deli-
very, or  when the labour is begun, and even consi-
derably advanced.
   794. In the former case, whatever abundance of
blood the woman may lose, nothing could justify
the conduct of the accoucheur who should persist
in endeavouring to deliver without delay. He ought
to content himself with checking or moderating the
haemorrhage by the application of cold and stimula-
ting liquors to the belly and thighs  of the woman; and
especially by stopping up the vagina, and the neck
 of the uterus if he can.  If he obtains no advantage
 by these means,  he must excite  the labour pains,
                       2M 
274
Of Flooding.
by gently stretching the edge of the orifice of the
uterus, and making  strong frictions on the  belly,
either with the hand, or with a  hot napkin. If the
flooding  continues notwithstanding these  aids,  he
must open the membranes, that the uterus may
close on the child; and continue to excite the pains
till the labour be  well established.
  795. When the flooding diminishes in proportion
as the pains augment, we may leave the expulsion of
the child to the care of Nature; but if it continues so
long as to weaken the woman, the child ought to be
extracted. We may then gradually dilate the neck of
the uterus, by introducing the fingers successively,
and remove the child's head, if that presents, and
turn it and bring  it by the feet.
  796.  When the  pressing danger which  arises
from the  flooding does not  appear till the child's
head occupies the cavity of the pelvis, we ought to
prefer the forceps: supposing the  accoucheur has
them at hand; for the accident is  too serious  to
allow him time to send for them. Otherwise he may
still  push back the head, though pretty far advan-
ced,  and  search  for the  feet.  See  par.  959, and
following.
  797. The danger  being the same in all cases of
violent  flooding,  whether the blood flows  freely
without, or is extravasated  within, we must pro-
ceed in this manner; because the open or ruptured
vessels cannot cease to pour out the blood, till  the
contraction of the uterus shall have determined a
sufficient change  in their direction  and diameters,
to hinder it from  passing easily through them. See
par.  400 and  following. The precept of immediate
delivery in case of a violent haemorrhage from  the
nose, or mouth, cannot be so generalh- admitted at
all periods of gestation, as in those of flooding; even 
Of Flooding.   '             275
if it should be  certain that the strong pressure  of
the uterus on the abdominal vessels was the deter-
mining cause of that haemorrhage, but I do not hesi-
tate to recommend it,  when that accident happens
during the efforts of/labour; for it would be as un-
skilful to expose the woman to a long continuance
of those efforts, or not to deliver her, as to suffer her
to sink under a common flooding.*

  * There are few cases of disease occurring during preg-
nancy or labour that are so alarming in their appearance, and
seriousin their consequences as Haemorrhagy. Ourauthorlays
down in a  very judicious manner all he knew on the subject
of this disease, but was not in possession of one of the most
powerful  remedies yet  discovered for the  suppression of
haemorrhagy; I mean the acetate nf lead. Its general certainty
in this accident is now so well established, that it would be
loss of time to dwell on it; we shall therefore, without hesi-
tation  recommend this  remedy wherever  the  necessity
exists. I have uniformly however made it a  rule where the
pulse was tense, and  the  disease in its  commencement, to
diminish its vigour by blood-letting from the arm  before its
exhibition; and in employing the bleeding, I usually recom-
mend the  blood to  be taken pretty suddenly  away, by which
means we induce a disposition to syncofie without a great loss
of blood; and if the patient be not too much weakened, to have
her bowels opened by an injection. The  acetate of lead may
then be given with freedom and certainty, from three grains
to ten every half hour until its object is obtained. It will per-
haps  surprise when  this remedy is recommended in such
quantity and in such quick succession, but I have no  hesita-
tion in declaring I have not only found it safe in such quanti-
ties, but necessary; and with respect to the frequency of its
exhibition, I believe if it does not produce the desired effect
in half an hour, that that dose will not do it in  a longer period.
It is always to be combined with a small quantity of opium, a
fourth or fifth of a grain will in general be sufficient. I have
in some cases found, where opium has disagreed,  joining a
grain of the powdered  Capsicum, has been useful; this how-
ever is only to be used where the system is prostrated, from
the long continuance or excess of the discharge. By employ-
ing this remedy we  sometimes obtain, if nothing moic,  an 
276
Of Convulsions.
Of Convulsions, considered particularly with respect
             to Labour and Delivery.

   798. There is no woman who may not be seized
with convulsions during pregnancy and labour, the
causes of them are so numerous; but there are some
women in whom they seem so  to  depend on that
state, that they are repeated every time they become
pregnant or are in labour.*
   799. In some cases, the convulsions are constitu-
tional, and we know no more of their cause, than of
the means of curing them  without return.  They
attack during pregnancy, as  in the natural  state,
and each paroxysm leaves no other consequences
than what they did before the woman was pregnant.
In  other cases,  the convulsions are only sympto-

important truce, more especially at the latter periods of preg-
nancy, and when the placenta is not attached over or very near
the mouth of the uterus; time is given by this means to  the
uterus to dilate, and if farther exigencies require delivery, it
is in a better condition for  this object. In addition to this I
have seen a very alarming haemorrhagy suppressed, by a
stream of cold water let fall from a considerable height on the
belly of the patient. It is important where the discharge is
serious, to keep the feet and legs warm by flannels, bottles of
warm water, &c. I have succeeded frequently in considerable
discharges in the early months of pregnancy, by having a
strong  solution of the acetate thrown up the vagina; say a
drachm to a pint of water.
  I have met with some cases where the sugar of lead has
produced no effect when given by the mouth, and where it
has produced an almost instantaneous one, when 9j, to a gill
of cold water with 5j- of Tinct. Thebiac has been given as an
enema.                                   W. P. D.
  * I never have known them recur a second time in the same
woman in subsequent pregnancies, except they were strictly
epileptic and constitutional; I do not consider these therefore
strictly puerperal convulsions.                W. P. D. 
Of Convulsions.             211
matic or accidental, and the remote causes of them
aye not so impenetrable as those of the former.
   800. This species of convulsions may depend on
great and sudden emotions of the  mind, on  a san-
guine plethora, or on an excessive flooding, on a
fulness of the prima via, on an extreme sensibility
of the uterine fibres, a violent distention of the edge
of the orifice of the uterus, and of  the parts  which
form the entrance of the pudendum, on a rupture of
the body of the uterus, and, according to some au-
thors, on the  excessive dilatation  of the cavity of
that viscus,  which however is not  founded on any
incontestable fact.
   801. As the time of labour is that period of preg-
nancy when these causes are united in the greatest
number, it is also that  when women are oftenest
seized with convulsions.  The uterine fibre  is not,
in fact, so sensible, nor so irritable, in any period of
pregnancy, as in  that of labour: those two proper-
ties, inherent  in  the muscular fibre,  seem at that
time to increase  in proportion to  the  force which
the uterus must  exert  to  overcome the obstacles
which oppose the expulsion  of the child. It is the
time when the blood is driven with the greatest im-
petuosity towards the brain, because it is that when
the uterus, closely embraced by the abdominal mus-
cles, makes the strongest pressure on the inferior
aorta: it is the time when that fluid is most rarefied,
that in which there is the greatest disturbance and
agitation in the animal economy, on account of the
violence and frequency of the pains,  &c. From the
state of perturbation  which we  observe in most
women when the force of labour  is  at its greatest
height, especially in a first labour,  to a state of con-
vulsions, the passage is short and  rapid. 
278             Of Convulsions.
   802. The concurrence of all these causes is not
necessary to  produce convulsions; a single one is
sufficient. As all those which I have mentioned may
act separately, and at different periods of pregnancy,
the woman may be  attacked by convulsions at any
time of it. There are cases in which the convulsion
adds to the cause which produced it, so that a first
paroxysm  brings on a second, &c. and  there are
others where the cause seems to be extinguished
with its  effect, so that the convulsion  appears no
more.
   803. As there are cases where the convulsion is
only  momentary,  so there  are others  where it
becomes periodical, and in which the paroxysm is
very long. M. Levret mentions a woman  in whom
this paroxysm was repeated every day at  the same
hour, and towards the latter end of pregnancy lasted
eighteen hours out of four and twenty.* I have de-
livered one, who suffered  convulsions periodically
every month, during three successive pregnancies:
theyr seized her at the time when the menses used
to appear, and attacked her twelve successive days
in each  month of the first pregnancy, augmenting
at each paroxysm, till they lasted three hours  and
an half towards the  middle of the day, and three
hours and an half in the evening.  They returned
also periodically in  the two next pregnancies,  but
they lasted a shorter time, and were not so strong;
because we found the way to calm, and even pre-
vent them.f Convulsions of a different kind were
so  exactly periodical for  four days,  in  another
woman, that there was not a minute's difference in
the commencement and duration of each paroxysm.

  * Levret, Essai sur l'Abus ties Regies generates, Sec. p. 15.
  t See the note on par. 809. 
Of Convulsions.             219
  804. All convulsions are not of the same nature,
nor affect the same organs, nor equally disturb the
harmony of the functions. Sometimes they present
a frightful spectacle; agitating all the muscles, even
those reservoirs, or organs, which we look on as so
many hollow muscles. At other times, the counte-
nance  is tranquil during the  paroxysm, and  the
convulsion affects only the  large muscles, as those
of the trunk and extremities.
  805. In the former case, the eye of the spectator
can scarcely follow the motion of the woman's eyes,
the  agitation  of the muscles of the face, the neck,
the  trunk and extremities; the jaws are locked, and
she grinds her teeth; the  mouth is  covered with
froth, and the nostrils throw it out  likewise; respi-
ration is quick, irregular and loud; sometimes  also
there is an  ejection of the urine and faces. A stiff-
ness of the body and limbs succeed this convulsive
agitation, and the woman remains immoveable  du-
ring a longer or shorter time.  The  respiration,
though more tranquil then, continues loud; the  face
remains swelled and  very red; the jugular veins
appear very large, and the pulsation of the carotids
is very strong. Sometimes the understanding does
not return  for several hours, and even days, after
these convulsions; and the loss of memory, sight,
and of hearing, continues still longer. I have seen
women who  had  no remembrance of their preg-
nancy more than a week after the convulsions, hav-
ing been delivered in one of the fits;  in others the
light has made no impression on the eye, nor could
the  ear be affected by any sounds,  during three or
four days.
  806. When the convulsion affects only the mus-
cles which  serve for the animal  functions, and espe-
cially the  large  muscles,  it  scarcely causes  the 
280             Of Convulsions.
slightest alteration in the woman's countenance. If
her colour heightens a little during the paroxysm,
she soon grows pale again; if she loses her under-
standing,  it presently  returns,  or, if it  does not
return, the state in  which she remains after the fit
rather resembles natural  sleep than that  comatose
state just mentioned; and when she revives she will
often continue the conversation which the convul-
sion had interrupted.
   807.  These different species of convulsions are
not equally troublesome, nor do they equally disturb
the progress of  gestation, and the mechanism of
labour, nor do they require the same treatment. It is
very rare that they do not bring on the pains of la-
bour, at whatever period of pregnancy they happen,
when they are of the species described in  par.  805;
but theyr bring them on the more certainly, as preg-
nancy is farther  advanced. Whatever method we
may take against these  convulsions, we cannot save
all the women who are seized with them, and some
must sink under them. It is not the same with those
described in par. 806;  they rarely disturb the pro-
gress of gestation, or happen in the course of labour,
however frequent they  may have been before. De-
livery took place but fifteen days before the usual
time, in the woman who is the subject of M. Lev-
refs observation; and in her whom I have mentioned
in the note on par. 809, it wanted but three or four
days of the period  of the tenth  revolution of the
menses,  when she was delivered of her  first child.
Yet the convulsions in the latter  were constantly
excessively strong;  and in several of the paroxysms
in which I saw her in the eighth month, the trunk
was so bent backward, that her head and feet resting
on the bed, touched each other; which was repeated 
Of Convulsions.             281
 more than ten times during the paroxysm, and with
 a rapidity which the eye could not follow.
   808. Though convulsions sometimes attack with-
 out  any precursive symptoms, they are generally
 preceded by a lassitude and a starting of the limbs,
 oppression and anxiety, a heaviness or pains in the
 head, giddiness and singing in the ears, even a sud-
 den  blindness and  deafness;  the mind  seems dis-
 turbed, and the eye becomes wild, &c. Though
 these symptoms in some women only denote a ner-
 vous affection, or an hysterical state, they are almost
 always indications  of a sanguine plethora;  and in
 either case we may prevent the consequences.
   809. In some of these  cases, we may usefully
 employ the warm  bath, antispasmodics, and  anti-
 hysterics, either to prevent or calm the  violence of
the convulsions: but nothing can supply the place of
 bleeding in those  who have signs  of  a sanguine
 plethora, or when the convulsions have caused an
 engorgement of the brain. Authors are not perfectly
 agreed on the part where we ought to open the vein;
 some advise bleeding in the foot, others in the neck,
 but the greater part in the arm: it would be of great
 importance to fix the opinion of young practitioners
 on this point. 1 have seen convulsions  of the  kind
 described in par. 805, yield to nothing but bleeding
 in the neck, after several bleedings in the foot; those
 mentioned in par.  806, appear after a  bleeding in
 the foot,  and be constantly removed by  bleeding at
 the arm.* There are circumstances in which evacu-

  * The woman who is the subject of this observation, had
 convulsions of this species at the instant of a bleeding in the
 foot, which a suppression of the menses, some years before
 marriage, had seemed  to require. Being attacked with con-
 vulsions in the first month  of pregnancy, eight or ten drops
 of the mineral anodyne liquor of Hoffman, taken in a spoonful
                      2N 
282               Of Convulsions.
ants  are exclusively  indicated: but I cannot state
them here.*

of orange flower water, rendered the fit longer by half than it
had been the evening before; and a similar dose administered
the next day, prolonged it as much more: so that from three
quarters of an hour, which it was at first, it was lengthened
to an  hour and three quarters, and afterwards to  three hours
and an  half, both morning and evening; which continued in
that manner, during twelve days of each month, till the end
of pregnancy; notwithstanding the use of the warm bath four
hours each day without interruption; diluting drinks,  &c.
   The second and third pregnancies would have been equally
stormy, had she not been bled at the arm.  The  convulsions
appeared at the same periods, and seemed to follow the same
course: but eighteen times taking away a single porringer of
blood  stopped their progress. If it was deferred  twenty-four
hours after the first attack in each month, the convulsions be-
came  very  strong; done at the instant of its commencement,
the paroxysm went off; at the time when the precursive symp-
toms announced it, it  was prevented; so that it had constantly
the same success, whether it was employed with a curative or
a preventive intention.
  Bleeding at the arm was not less salutary in the same woman,
since  the third pregnancy, on account of convulsions proceed-
ing from a  suppression of the menses. Recourse  was not had
to it till after the trial of many other methods which had aug-
mented them, and they ceased immediately after that bleed-
ing: it had the same success two following months. The con-
vulsions have not appeared since, the menses having  been
regular.
  * I  am much pleased with the stress our author lays upon
the use of the lancet in this truly formidable disease, as I am
well persuaded in nine cases out of ten in this country, it is
the only remedy to be depended upon. I cannot agree with him
as to  the importance  of the part from  whence  the blood is
drawn, provided an equal quantity in a given time  can be
taken. I am persuaded this noble remedy has failed in many
instances, and in some done harm, from an inattention to the
time employed in drawing the blood; if the orifice be small,
and the blood  only trickle down, it  will almost  certainly do
harm, by allowing the blood vessels gradually to contract on
their  contents, and thus  fail in  diminishing their vigour; it 
Of Convulsions.               283
   810. Although the danger which arises from con-
vulsions is as great in many cases, as that which pro-
ceeds from  an excessive flooding, yet we ought not
to endeavour to bring on labour, as in the latter cir-
cumstance;  because it would not  be attended with
the same  success. Besides that  convulsions do not
always essentially depend  on pregnancy, and that
they often have other remote causes, which delivery
cannot remove, the efforts necessary to overcome
the obstacles which might oppose  it,  would not fail
to aggravate  them and  render  their consequences

should therefore be an invariable rule, to draw the blood from
a large orifice, and a large vein; on this account, I have some-
times preferred the  jugular, and in  others have  set two
streams going, one from each arm.—I have no doubt but the
mischievous effect of bleeding in the foot, as mentioned by
our author, may be  accounted for in the way we have sug-
gested, and the relief obtained by bleeding from the arm, was
entirely owing to the sudden abstraction  of the blood.
  With respect to the  quantity drawn,  I have but one rule,
bleed as long as the convulsions continue  frequent and power-
ful, and the determination to the head evident, by the swelling
and lividity of the face, projection of the eyes, and almost com-
plete suffocation. I  have in more instances than one, taken,
with  the  happiest effect, an hundred  ounces in a few hours.
The first bleeding especially should  always be large where
the case is violent and  threatening:  Two important  objects
are almost always answered in this way, first a cessation or
diminution of the convulsions, and secondly, a relaxation of
the mouth of the womb, that enables us to turn, if the disease
happens just before, or at the commencement of labour.
  This remedy, like many others, must be employed prompt-
ly, if good be expected from it; it is too late, when effusion
has taken place in the brain. I had not long since an oppor-
tunity of seeing the head of an unfortunate woman who died
from this kind of convulsion. The longitudinal sinus of the
dura mater, was estimated to contain between two and three
ounces of blood; the posterior left ventricle was filled with a
bloody serum; the rests appeared healthy, as did the other
parts of the brain.                           W. P. D. 
284             Of Convulsions.
still more grievous.  I except however those cases
where they happen during the course of labour, and
at a time when the parts of the woman are already
well disposed for the passage of the  child. When
these natural dispositions do not exist, the violence
which must be exerted to solicit the expulsive ac-
tion of the uterus, to dilate  its neck, and introduce
the hand into it,  to turn  the child and extract it,
would it not be a new cause of convulsions, which
would  increase the former, as well  as the danger
resulting from it?  Will it be said that we may cut
the neck of the uterus, in order to penetrate it more
easily, as several accoucheurs have practised? This
proposition, in such cases, could only pass for the
effect of a fit of insanity.
  811. Those who have attributed the convulsions
to an excessive  distention of the uterine fibres in
the last  periods of pregnancy, of course knew no
better  mode of calming them, than to perform the
delivery; and  some have thought that evacuating
the waters of the amnion would be sufficient to re-
store and properly relax those same fibres. Without
admitting their opinion on the cause of convulsions,
I allow that this practice has sometimes had the de-
sired success; that there are really cases where it is
proper to evacuate the waters of the amnion, others
where we ought to extract the child, and even cut
the neck of the uterus: but those casas are rare, and
never are met with before the efforts of Nature have
already begun the labour.
   812. By attentively observing what passes in cases
of convulsions, we remark that they do not always
interrupt the  course of  the labour pains, whether
they had excited those pains, or the pains had pre-
ceded them. All authors relate examples of women
who have  been delivered without help after several 
Of Convulsions.             285
fits of strong convulsions, and others while  they
were actually convulsed, whether there were lucid
intervals between, or that the loss of understanding
was permanent. The progress of labour in most of
these  cases  seems even more rapid than in others,
since  we have  often found the child between  its
mother's thighs, though an instant before we could
discover no  disposition for delivery.
   813. The result of these observations is, that we
ought not to be in haste to deliver,  when Nature
seems disposed to perform it herself, whatever may
be the nature and force of the convulsions; that we
ought never to attempt it in any case, if the labour
is not already begun, because Nature, notwithstand-
ing the disorder in her functions, can perform in a
short time, what we could not obtain but with abun-
dance of efforts and danger, besides that a calm may
be restored,  notwithstanding the number of convul-
sions which have taken place; that while we wait
the favourable moment  for operating, we should
only employ those means which we could use after
delivery if the convulsions should continue; lastly,
that we may in many cases accuse  those practition-
ers of too much precipitation, who have conducted
themselves  differently, instead of giving them credit
for the success they flatter themselves they have
obtained.
   814. The convulsions which only happen during
labour, having often no other cause than the excess
of pain, the extreme sensibility which the fibres of
the uterus then acquire,  the stretching which those
of the neck of that viscus suffer when it opens with
difficulty, as well as the  external parts; the volume
of the blood, augmented by the heat excited by con-
tinued efforts; the engorgement of the vessels of the
brain, &c.  seem to require different aids, and call 
286              Of Convulsions.
for less delay in the delivery. If they continue, with
loss of understanding, after a copious bleeding, we
may open the membranes, in order to diminish the
volume of the uterus, relax its fibres,  calm the ex-
cess of its sensibility and irritability, which are then
accidentally excited to that degree; and much more
to weaken the pressure which that viscus exerts on
the inferior aorta, and thus recal the blood in greater
quantity into the vessels of the  abdomen, and  the
lower  extremities. If the convulsions subsist with
the same  force  after the administration  of these
succours,  we may  perform the delivery,  unless it
appears disposed to take place speedily.
  814.  There are cases in which we cannot  dis-
pense  with  turning  the child and extracting it by
the feet; because it presents in such a manner,  that
it cannot be born without help, nor  be extracted
any other way; we ought then to proceed to  it im-
mediately after the evacuation of the waters, whether
the convulsions subsist or not. There are other cases,
where  it would be better to extract it  with the  for-
ceps,  if we  could procure them in time, and the
distance of  the head ought not  to be a motive for
excluding that instrument, except when the hand,
obliged to direct it in this pressing circumstance, is
not sufficiently experienced.  There  are  some in
which  the head is so engaged at the time when the
danger of deferring delivery appears, that there is
no longer any option between those two methods,
the application of the forceps being  the only  one
indicated; except when the child is dead, for then
we may substitute the crotchet. Lastly, there  are
some  where we are obliged to cut the edge  of the
orifice of the uterus, the fibres of which cannot ex-
tend beyond what they have done before, nor tear;
whether because they are too dry and too  rigid, as 
          Causes of Preternatural Labour.      287

we observe particularly in women advanced in age
when they are in labour of their first child,* or be-
cause that part of the uterus is hard and scirrhous.
But these cases are very different from those for
which I have rejected even the idea of such an ope-
ration.
Of Syncopes, of the Exhaustment of the  Woman's
   Strength, and other  Causes stated in Par. 785,
   and particularly of  the Exit of the  Umbilical
   Cord.

   815. Syncopes, orfaintings, if frequently repeat-
ed in the course of labour, although we may not be
able precisely to determine the cause of them,f as

  * M. Dubosc, professor in the College of Surgery of Tou-
louse, communicated to the  Royal Academy of Surgery, in
1781, one of the most interesting observations on this subject.
We there remark that the preservation of the woman was
the fruit of the section of the edge of the orifice of the uterus.
This woman, being about forty years old, and big of her first
child, had been in strong labour three days, and suffered con-
vulsions from the second;  her person could  not be known,
says M. Dubosc, and was frightfully pale; her pulse weak and
almost extinct, as well as her voice; her eyes, hollow and dull,
appeared dying, a clammy sweat covered her whole body, and
her extremities were cold; she was senseless, and could not
swallow a single drop; the edge of the orifice of  the uterus,
open the breadth of a crown, was hard, tight, and in a manner
callous. Delivery was performed spontaneously three or four
minutes after the section of that part: the child was dead, but
the mother immediately grew calm, and the subsequent symp-
toms  were mild.
   t One of those women who were delivered  in my theatre,
for the instruction of my pupils, in 1774, after  violent convul-
sive agitations on the part  of  her child, at the beginning of
labour, suffered frequent faintings, followed by an abundant 
288      Causes of Preternatural Labour.
well as a general weakness or exhaustment, which
deprives the  woman of the power of exerting suf-
ficient efforts to expel  the child, ought to engage
us to deliver her, in order to prevent consequences
often very disagreeable.
   816. That procedure is a thousand times prefer-
able to  the useless attempts which are made  to
quicken lingering pains, after a labour so long and
So  severe,  that  the uterus  scarcely retains the
power of contracting, or  is in a state more or less
disposed to inflammation.
  817. An  irreducible hernia sometimes obliges us
to deliver, as the efforts of labour may force more
of the intestine down,  and thus become  strangu-
lated*
  818. The obliquity  of  the uterus alone, rarely
obliges us to deliver, as  the bad direction of the
uterus is easily obviated.  The young practitioner's

vomiting and a copious diarrhoea,  for two hours;  and died
about fifteen hours afterwards, in a third paroxysm of syncopes,
before she was delivered. On opening her body, we found a
stone, of the size of a small walnut, in the gall-bladder; and
the omentum collected in the form of a cord, strongly adher-
ing to the inferior and right lateral part of the uterus, so that
the stomach and the arch of the colon were dragged by It in a
singular manner.
  * I was a witness of the fatal consequences of such an acci-
dent, towards the middle of November 1774. A loop of intes-
tine, in the efforts of labour, had insinuated itself through a
mass of the omentum, about the size of a hen's egg, which for
nine  years had  formed  an  umbilical hernia, and was  there
strangulated.  The woman already suffered the  symptoms of
strangulation, when I was called; and those symptoms, much
more than the apparent impossibility of her being delivered
alone, determined me to deliver her.  But we could not effect
the reduction, not of the omentum, which had always appeared
irreducible, but of the portion of intestine newly come out,
and it was not thought proper to  attempt the  operation; so
that the woman died the third day after delivery. 
Causes of Preternatural Labour.      289
  attention should however be directed to this condi-
  tion of the uterus, we therefore recommend him to
  the chapter on this subject.
     819. Still more rarely does the contraction of the
  neck of the uterus on that of the child, render deli-
  very impossible without help. The circle which con-
  stitutes the internal orifice more frequently contracts
  than the external circle; we can do but little in these
»  cases, as the hand cannot pass the head of the child,
  when  the latter is in the pelvis, to dilate  the neck,
  nor can we without great inconvenience push the
  head back to search for the  feet; and if the forceps
  are applied, the  shoulders will pass with great diffi-
  culty.  When  it  is the internal orifice that contracts,
  the  inconveniences  are not  so  great, as the head
  has not descended so low, and may always be push-
  ed back, and which allows the hand to pass under
  the uterine circle, to dilate it.*
     820. The exit  of the umbilical  cord, brought
  along by the current of the  waters at the time the
  membranes open, has always  been considered as
  an accident very dangerous to the child; as well on
  account of the contact of the air,  which cools the

     * I have been a witness of this  circumstance but once; but
  I could quote several examples, which persons capable of
  forming a good judgment have communicated to me. The
  opening of the body of the woman, in some of these cases, has
  demonstrated that the contraction of the neck of the uterus
  alone obstructed delivery. In that case of which I was a wit-
  ness, the child's head had occupied the bottom of the pelvis
  for sixty hours; it had been crushed with the forceps, and the
   crotchet, which was used afterwards, had only brought away
   some pieces of it.  Instructed by the examples which had
   been communicated to me, and finding the volume of the head
   sufficiently diminished, I advanced my hand by the side of
   the  base of the  cranium, to dilate the neck of the uterus; I
   then turned the bodv of the child, and brought down the feet.
                           20 
290      Causes of Preternatural Labour.
cord, and diminishes the motion of the blood in it;
as of the compression which afterwards intercepts
the course of that fluid through it.*
   821. This accident is, without doubt, dangerous;
but the precept of delivering instantly, by turning
the child, would  not be less so, if we  were to give
it indiscriminately for all cases where the cord falls
down thus:  for many a child has perished while it
was extracted by the feet, which might have been
born living, notwithstanding the exit of the cord, if
the delivery had been left to Nature.
   822. We ought then to attempt  nothing till  we
have well examined the course Nature is likely to
take, and the effects the umbilical cord suffers; for
often,  after the  discharge of the  waters, which
brought it out, the expulsion of the child is quicker
than its extraction could be; by following the too
general precept we should, in all those cases, add a
long compression of the cord,  to the danger some-
times inseparable from turning the child, and bring-
ing it by the feet.
   823. The umbilical cord is  not always so much
compressed as to destroy the circulation in it when
it is down; therefore, as long as the pulsation is free,
and the child's  head engages  easily,  we ought to
wait, as the delivery will either soon  terminate, or
the head will descend so low as easily to be extract-
ed with the forceps;  these are to be  preferred to
turning,  if they are at hand.
   824. The danger to the child when  the end is
prolapsed, is increased by a narrow pelvis, as  the

  * This opinion I do not think sufficiently well founded, as I
met with a case where the pulsation continued in  the cord six
hours and a half after the birth of the child. See Med. Muse-
um, vol. ii. part 2. page 140.                 W. P. D. 
          Signs of Preternatural Labour.      291

cord now must suffer more compression; and the
death of the child is almost certain let us employ
what means we may.
   825. The exit of the umbilical cord presents no
particular indication when it is cold, without pulsa-
tion, or putrid: the child being already dead, we
must leave its expulsion to Nature; the cord alone
cannot oppose it, though it form a loop without.
   826. It is generally supposed that the cord by its
shortness, or frequent windings on the child, opposes
considerable obstacles to delivering; such as keep-
ing the head back, or if it allows it to advance du-
ring pain, it makes it recede immediately after; thus
mistaking the reaction of the perinaum,  and bones
of the cranium, for the action of the cord. This will
point out the futility of the advice of some authors
who recommend  the cutting of the cord, &c. the
more especially, as we cannot determine the length
of the cord before the exit of the child, nor can we
determine that it is twisted round the child's neck,
until the head is delivered.
Of the Signs, in general, which show that a Labour
  will be preternatural; of the Indications presented
  by that  Kind of Labour; and some general pre-
  cepts relative to it. Signs and curative Indications.

  827. A  Preternatural labour  begins with
pains, whose cause,  progress, and effect, are no way
different from those of the most natural labour. The
signs which characterize it, are deduced  from acci-
dents which complicate the labour, from the situa-
tion of the child, and from the existence of some of
the causes already mentioned. 
292     Situation on Preternatural Labour.

  828.  We may easily  distinguish the cases in
which the woman suffers a flooding, convulsions or
any other accident, from those which are not com-
plicated with any of those circumstances:  but  it is
by touching qnly we can discover the  situation of
the child. Though we sometimes acquire this know-
ledge without  any trouble, even before the mem-
branes are open; at other times we cannot without
a great deal of difficulty, as  we shall see in the
sequel.
  829. These  labours present general and particu-
lar indications. The former consist in turning the
child to bring  it by the feet; in changing some posi-
tions of the head, in order to procure a better; in
correcting the bad course it sometimes takes, as it
engages in the pelvis, or merely in pushing back an
extremity, whose presence hinders it from advan-
cing: but the  particular indications are different,
according to the situation of the child, the part it
presents at the entrance of the pelvis, and the  cir-
cumstances which determine us to operate.
Of the proper Situation for the Woman in a preter-
                natural Labour.

  830. The situation of the woman, in this case,
as in all others, is not very important before the
time of delivering, unless particular circumstances
oblige us to prescribe one rather than another; but
it is  very different at the time when we must ope-
rate.
  831. The woman must then be laid on the back,
and  as horizontally as possible,  the breech being
placed at the edge of the bed, so that the coccyx 
       Situation on Preternatural Labour.    293

and perinaum may be free, the thighs and legs half
extended, and the feet resting on two chairs placed
properly, or supported by assistants*
  832. A common bedstead is  preferable in these
cases to the lit de sangles, which is generally used
in natural  labours. We ought  likewise  to prefer
one  of a moderate breadth,  and take care that it
be not mounted on castors; as well for the security
of the woman, as for the convenience of the accou-
cheur and  his assistants. This bedstead should be
furnished  with several mattresses,*  and a solid
cushion  put under their extremity, to prevent the
breech from sinking in, and make it more  steady;
the end of the bed may be covered with some fold-
ed sheets, and some pillows must be placed towards
the middle.
  833. The  woman  being laid according to the
directions in par. 831, must be covered with a sheet,
and even a blanket, if the season require it, to de-
fend her from the cold, and prevent her being ex-
posed naked to the eyes of the assistants; and also of
the accoucheur, to whom, in these cases,  the touch
is much more useful than the sight. Two assistants,
with one hand applied to the knees, and  the other
to the feet, must  fix  the  inferior extremities,  and
separate the thighs properly; a  third, if necessary,
may be placed  behind the shoulders, to keep her
firm, and prevent her from sliding down,  while a
fourth furnishes every thing occasion may require.
  * These are certainly unnecessary, one is often convenient
but not indispensable.                     W. P. D- 
294             Beneral Precepts.
 General Precepts relative to Preternatural Labour.

   834. When we have but imperfectly discovered
the situation of the child at the orifice of the uterus,
if the  absence of the signs  which denote the pre-
sence of the head gives suspicion that the situation
is not favourable, we must wait till the opening of
the membranes, to dissipate our doubts, and acquire
a certainty concerning it.
   835. Before that epoch, nothing invites us to ter-
minate a labour which the bad position of the child
renders preternatural, unless the woman be attack-
ed  by  some of those dangerous accidents already
mentioned: when that happens, all long delay is con-
trary to the principles of sound practice; but the
consequences which  may result  from  immediate
delivery, sometimes  oblige us to defer it awhile, in
order to attend to the particular and  pressing indi-
cations which they prescribe.
   836. If there is reason to fear plunging the uterus
into a state of atony, by delivering as soon as  we
have discovered the  bad situation of the child; if
the force  necessary to be exerted in opening the
neck of the uterus,  to  turn the  child before the
instant prescribed, is equally alarming; an engorge-
ment, and inflammation of  the uterus, which may
be the  consequence of the useless efforts to which
it is sometimes abandoned after the  evacuation of
the waters, will not seem less to be dreaded.
   837. Therefore the most favourable moment for
operating  is  that of the greatest  dilatation of the
neck of the uterus, and of the spontaneous opening
of the  membranes  when it takes place in proper 
General Precepts.            295
time. We ought to wait for that time when we are
called before it; but when we are called much later,
we must  operate  immediately,  unless the inflam-
matory state of the uterus  forbid it: for then it is
necessary, before  every thing, to take.off the ten-
sion of that viscus, and diminish  the engorgement of
its vessels.
   838. The  case  where the accoucheur is called
some time after  the  spontaneous opening  of the
membranes, is not the only one in which he cannot
take advantage of the most favourable moment for
turning the  child; for often at that moment the
labour  presents with the fairest appearances, and
the accidents which ought to determine us to ope-
rate, do not manifest themselves till later.  In this
case, indeed, the child's head almost always present-
ing, descends more or less into the lower part of the
pelvis, and may be easily extracted with the forceps,
so that the labour differs little from a natural one.
   839. We  are also  forced to let slip the moment
which would, in some respects,  have been the most
favourable for turning the child, when  the mem-
branes burst at the beginning of labour, and before
the  neck  of the uterus is sufficiently relaxed and
open for the admission of the hand.
   840. Bleeding, emollient and mucilaginous injec-
tions, baths, and moist fumigations, joined to dila-
tations methodically performed with the fingers, are
sometimes very useful in such  cases, for weaken-
ing  the rigidity of the neck of the uterus, and faci^-
litating its opening.*
   841. As soon as the favourable moment for ope-
rating shall be indicated, whether by the nature of

   * I believe we shall rarely find it necessary to employ any
of the other remedies prescribed in this paragraph, if  we in-
dulge sufficiently in the use of the lancet.       W. P. D. 
269            General Precepts.
 the circumstances, or the state of the labour, the
 accoucheur having prepared himself for  it, must
 place  the  woman in the  situation prescribed in
 par. 831.
   842. When it is necessary to introduce  the hand
 into the uterus, to perform the delivery, some prac-
 titioners are still in the habit of putting on an apron,
 baring their arms, and even putting on false sleeves,
 Sec; but these precautions, most of them useless,
 always strike the  woman with terror, and a less
 frighful apparatus has often thrown them into a
 state of anxiety and disorder, difficult to remove.
   843. If it is necessary to uncover the  arms to
 turn the child, it is proper to do it no farther than
 the arm penetrates into the uterus. Some cloths,
 laid on one of the chairs which support the woman's
 feet, will serve the accoucheur  to guard himself
 from the blood and  waters which drain from the
 uterus; and to wipe his hand every time he with-
 draws  it, that it may  not be exposed bloody to the
 eyes of the woman and assistants.
   844. The operator should always proceed cooly,
 and appear tranquil, even  in the  most desperate
 cases,  that he may not augment the fears of  the
 woman to whom  the smallest  embarrassment, the
 most trifling motion, or gesture,  are then as  so
many mouths which seem to her to announce her
destruction.
   845. Before we introduce the  hand, it ought to
be dipped in some mucilageyor anointed with butter,
 or any  other fat substance, that.it  may pass more
easily,  and with less pain. This precaution may like-
wise sometimes be very useful to the accoucheur.
   846. In all cases we ought to act slowly, move
the hand little, and choose the  favourable moment
for advancing it.  When the external parts of the 
General Precepts.            297
woman are tight, the fingers must be introduced
successively, so that the first, by dilating a little, may
prepare the way for the others.  We should choose
the time of a pain for advancing  the hand  in  the
vagina, it is of great importance to act only during
the latter, when  we insinuate it  into the uterus, and
afterwards not to move it at all during  the pain;
because the sides of that viscus, then embracing the
child more strongly, and being more stretched, give
a greater resistance, and  are more subject to be
torn.
  848. We cannot act with too  much  slowness,
and circumspection, in dilating the  neck of  the
uterus, when it continues thick, and  is not very
supple, least we tear it from its junction with the
vagina, in which part almost the whole action of any-
considerable efforts would centre.
  849. After the hand has cleared the entrance of
the  uterus, we  are  often obliged  to  withdraw it
many times, before we can reach the child's feet,
especially  if we  do  not  proceed methodically;
because it is so compressed by the action of  that
viscus, or the pain, that it is benumbed,  or  suffers
such painful cramps, that it loses all power of  act-
ing.
   850. During  the whole time that we are introdu-
cing the hand, and turning the child, the other hand
should be applied externally, above the  fundus of
the uterus, to fix it, or change its direction occasion-
ally, and to make certain  pressures, which circum-
stances, more difficult to determine here, than to
perceive while we  are acting, render sometimes
necessary.
   851. The two hands are not always equally con-
venient for finding the feet of the child, and turn-
ing it: if there are cases where we mav  use either
                       2P 
298             General Precepts.
indifferently, there are many more which require
one of them, and not the other. The choice depends
on the particular situation of the child; and on that
choice often depends the facility of the operation,
and even its success.
  852. The direction which the hand must follow,
the position it must preserve as it advances in the
uterus, and  the extent of surface it goes over, must
also be varied according to the situation of the child,
and the part which it  presents; so that we  can give
here none but very general rules on the subject.
  853. We ought always to insinuate the hand at
the part most easy and certain for finding the child's
feet. Sometimes it is  along one of the  sides of the
uterus, but  much oftener  along its back part; and
hardly ever  between its fore part and the child.
  854. When it is necessary to turn the child, the
feet must always  be brought down on its anterior
surface; in order to bend the trunk more and more
in the same direction, and make  it describe a
smaller arch in the uterus.  We ought never to pull
the extremities in such a manner as to bend the
child  backwards,  or subject the spine  to  any dan-
gerous flexions, or contortions.
  855. Although  we  might, in many cases, where
we turn the  child, extract it by one foot, it is always
better to take them both; because it will then come
along more easily. Besides, in some cases,  this pre-
caution is so necessary, that without it we should
sooner tear  off  the leg thaii  bring the child along.
It is indeed  often  difficult to bring down  both ex-
tremities at  the same  time, because, being slippery
with  glaire  and blood, as well as the hand which
operates, it is not easy to grasp them together, and
one of them is very apt to slip from the fingers. In
that case, after  having brought one of the feet to 
General Precepts.            299
the entrance of the vagina, we must keep it there
by means of a fillet, while we search for the other.
  856. We ought never toattempt turning the child
during a pain, because it is then more  confined in
the uterus; but when the feet are without, and the
head  is  sufficiently removed  from the superior
strait, when it presented there  at first, we ought, as
much as possible, to  wait for a pain to extract it.
The woman also ought to suspend her efforts while
the accoucheur is employed in turning the child, but
she cannot bear down too much while he extracts it.
  857. Some accoucheurs would have  us indiscri-
minately abandon the  expulsion of the  child to the
efforts of Nature, after having  brought the feet to
the orifice of the vagina; but  the child not being
then entirely turned,  those efforts would become
useless,  and  sometimes  dangerous.  If we would
follow this precept, we ought at least to bring the
child's breech to the  passage:  otherwise, far from
obviating the inconveniences which it is pretended
we  should by that  means avoid, we should often
only expose  the  child to greater.  The  cases, in
which we might follow this  precept  with the  least
danger, are precisely those in which we might finish
the extraction of the child  without any risk,  by
pulling at the parts already delivered.
  858. This operation ought never to be perform-
ed precipitately, nor  must the extremities of the
child be  pulled by jerks; but always in a slow and
continued manner, especially  when  the waters of
the amnion are but lately evacuated:  in order to
prevent the effects of a too sudden depletion of the
uterus, and to hurt the parts less on  which we act.
  859. The danger to which the mother and child
are exposed in preternatural labour, is always rela- 
300          Preternatural Labours.
tive to the kind, and  the violence of the accident
which renders it so; as well as  to other circum-
stances which must be deduced from the time when
the waters  were evacuated, that in which we ope-
rate, the more or less bad situation of the child, &c.
   860. When we have discovered that the  labour
will be difficult or preternatural, whether on account
of the bad situation of the child,  or any other acci-
dent, we ought to  advise the woman's relations of
it, and acquaint them of all the difficulties and the
danger,  if any exist, in order to avoid the blame
which they think they have a right to throw on us,
in case of a disagreeable event.  But we should be
more reserved with respect to the woman, lest we
frighten her, and increase her danger: except when
religion requires us to inform her of it.
Of the general Indications, in those Labours where
           the Child presents the Feet.

  861. When the labour is not complicated with any
troublesome accident, we ought to observe the same
conduct, with respect to the woman, till the mem-
branes open, as if the child presented the head: but
at that epoch we are to disengage the feet, if we
can,  by means of two  fingers introduced into the
vagina, that we may avoid the difficulties stated  in
par. 524 and 864; or at least direct them in such a
manner that they may not be stopped against any
part of the pelvis, during their descent.
  862. When the feet are without we must assist
by gently pulling at them, more especially if the
woman be weak: in the latter case we cannot wait
many times for the feet to come down spontane- 
Preternatural Labours.         301
ously, but are obliged to take hold of them at the
orifice of the uterus, and deliver the child immedi-
ately.  Besides the causes  we have enumerated
(from par. 785 to 826) may render these labours,
preternatural, we may add the  manner in which the
feet present and advance.  We have reduced these
in four prihcipal ones.
   863. One foot frequently presents, and advances
in the vagina, while the other is so situated as com-
pletely to oppose the exit of  the  child.  It is not
always necessary to bring down this second extre-
mity; it  however in general is best to do  it;  and
indispensable when it would require, much force on
the protruded extremity to make the body descend.
To prevent accidents to the joints and bones of the
leg, we should when we pull  at a single extremity
do it in  such a direction as will  carry the whole
limb towards its  companion, if it were also disen-
gaged.  And to divide the force as much as possi-
ble, we should hook the groin  as soon as the breech
is low  enough.  When  the breech is  without it
must be grasped with both hands, placed  as  high
as the hips, and the trunk  brought along till the
second foot comes  down.
   864.  When we  wish to search for the second
foot, we should retain the one already down, either
by the  hand or  fillet. When the breech descencte
with both feet, it is sometimes difficult to disengage
them, as the pelvis is not sufficiently large  to allow
all these parts to pass  together. This may  be pre-
vented by bringing down the  feet before the breech
is engaged in the pelvis, and overcome when it ex-
 ists, by  pushing up the breech above the superior
strait, before we attempt to pull down the feet.
   865.  It is often necessary to search for the second
 foot, when the child presents  but one; it is not less 
302          Preternatural Labours.
 proper, when we meet with three, or four, to dis-
 tinguish the two which belong to the same child,
 that we may not risk bringing down twins at  the
 same time. We ought to use the same precaution
 when we find but two feet at the orifice of the ute-
 rus, because it is possible that each twin may pre-
 sent one.*
   866.  When we are obliged to advance the hand
 to the orifice of  the uterus to take hold of the feet,
 we must do it as we can, passing the fore-finger be-
 tween them, and grasp them closely with the others.
 They are then to be wrapped in a soft dry cloth, as
 soon  as they  are without,  that  they  may be held
 more easily, and firmly; being very slippery with
 the greasy  mucus which always covers them. After
 that we bring the breech to the passage  by pulling
 obliquely downwards.
  867.  We then apply the hands above the knees,
 to ease the joints of the feet and  legs;  and, in order
 to spare those of the thighs, as soon as the hips are
 without, we take hold of them.
  868. But we  ought never  to apply the hands to
the  belly and breast of the child, with a view of act-
ing nearer  to the parts retained, for in doing that
we  might impede or stop the  motion of the heart;
we  might  likewise compress and bruise the liver,
which is very large and veryr  tender at that epoch:
and nothing could  be of more  dangerous conse-
quence. It  is the hips only that we ought to handle,
 till the shoulders are without.
  869. When we have brought down both feet, the
child  descends easily, till the axilla  arrive at the
superior strait; because the inferior extremities and
the  trunk,  so far, form a long and pretty regular
* See the article on twins. 
Preternatural Labours.          303
wedge. After that, its course becomes slower and
more difficult, from the projection of the shoulders,
and  the  obstacles the arms meet with,  in  rising
towards  the  sides of the head:  which obliges the
accoucheur to exert more force to bring it along.
   870. We  cannot, in general, extract  the  child
too  slowly, in order  that the woman's parts may
be dilated more gradually, and with less pain. We
ought  likewise to' take care that  the force exerted
act in the direction of the axis of the pelvis. A slow
continued traction, directed alternately upward and
downward, but so as to cut the inferior strait of the
pelvis obliquely, is preferable to  all the more  com-
plex motions.
   871. When we are  forced to deliver by the feet,
the umbilical cord does not always descend in the
same proportion as the child's trunk, on which we
immediately  act.  It can be  drawn down only by
that; but first, it is very much stretched, and the
umbilicus is in danger of being torn, if the cord be
retained  ever so little  above the pelvis. To prevent
that  rupture, the consequences of which might be
very troublesome, we must not forget, as soon as
the breech appears, to insinuate  two fingers along
the child's belly, and taking hold of the umbilical
cord, pull down a loop  of it, longer or shorter, ac-
cording to circumstances; we must repeat the same
thing from time to time, as the trunk descends. In
this kind of labour, the cord is also sometimes found
between  the  child's thighs, which may expose the
umbilicus to the same danger of tearing: it must then
be relaxed by pulling down that portion of it which
ascends along the child's back, and, if we can, enough
to slide it over one side of the breech;  we may then
pass one of the legs through it, and place it by the
side  of the child. 
304         Preternatural Labours.
  872. If the cord be so tight, that we cannot bring
down any part of it, whether because it is twisted
round the child's neck, or from any other cause, it
is better to cut it, and just squeeze the two ends a
little with the extremities of the fingers, without ty-
ing them, than to pull the child in that tense state
of the cord.
  873. As soon as  the axilla appear at the vulva,
we ought to bring down the child's arms. The cases
where we might dispense with bringing them down,
are  always those  in which it is most easy to do it;
the  mother's pelvis being then very large relatively
to the size of the head. But  when that favourable
proportion  does not exist, it is of the utmost con-
sequence to follow the method I propose, because
the  arms can  only  add to the relative size of the
head, and render its exit more laborious.
  874. In disengaging the child's arms, we must
always bring them  down on the  fore part of  the
breast, by making the elbow follow the same course
which  it seems to have  done in ascending to  the
side of the head. We ought to begin  with the arm
which  is underneath,  because it is commonly less
compressed than that which is behind the pubes.
  875. Before we bring down the first arm, we raise
the  child's trunk, wrapped in a napkin, and sup-
ported  by one hand, obliquely towards one of  the
woman's groins, while with the other hand we  act
in the following manner. We first bring down  the
shoulder as much  as we can, in a line with the body,
by taking hold of it  with the thumb, and fore  and
middle fingers. Afterwards we insinuate one or both
of those fingers into the vagina, along the arm, and
posterior part of the child's neck, as far as the bend
of the elbow, on which we rest the fingers, to bring
it down towards the breast, and disengage  it. 
Preternatural Labours.         305
  876. That extremity must be wrapped in the same
cloth which is round the child; the body  is then to
be carried downwards, towards the point diametri-
cally opposite to that where it had been raised be-
fore, and supported by the hand which disengaged
the first arm, while with the other we bring down
the second, observing the same rules as before.
  877. The obstacles which may, and often do op-
pose the bringing down the arms, sometimes arise
from forgetting  some of the principles I have just
stated; and sometimes, because the head being too
high, or too low, strongly presses the arms against
the internal edge of the superior or  inferior strait.
These difficulties may likewise depend on one of
the arms descending directly behind the symphysis
of the pubes, or because  it is crossed over the back
of the child's neck.
  878. The obstacles which proceed from no other
cause than the omission of some of the precautions
I have  recommended, may be easily surmounted
by recollecting them seasonably;  but it is not so in
the other cases. When the head is still so high, that
the shoulders scarcely appear at the  entrance of
the vagina, we must bring it down farther, if it can
be done without endangering the  child's life: other-
wise, the arms must be  brought  down first; which
we may always be able to do, however difficult it
may seem, by proceeding slowly  and methodically.
But when the head is too low, and presses the arms
against the edge of the  inferior strait, it must be
pushed up a little, that they may be  less confined.
   879. If one of the arms be found strongly pressed
between the child's head, and the symphysis of the
pubes, we must also push the head back  a little, in
order to free the arm, and enable us to make it pass
towards that side of the pelvis,  to which the face
                     2Q 
306          Preternatural Labburs.
answers. When one of the arms crosses the child's
neck, we must act in the same manner, but bring
the other arm down first.—See par. 913, and fol-
lowing.
   880.  After having disengaged the arms, we must
apply to the extraction of the head; and whether it
remain  awhile in the pelvis, when that is ever so
little contracted, or we endeavour to extract it im-
mediately, by pulling at the trunk and shoulders,
this seems to be the most  critical and dangerous
moment for the child:* on one side it is exposed to
the disagreeable consequences  of a compression of
the cord, and on the other to the melancholy effects
of an extension and stretching of the spinal marrow.
   881.  Some practitioners,  with a view of preserv-
ing the  child, have advised  leaving the expulsion of
the head to the efforts of Nature; while others have
thought, when once it is in the cavity of the pelvis,
we cannot extract it too quickly: both opinions may
be equally dangerous.
   882.  When the pelvis of the woman and the head
of the child are in their just proportions to each
other, the accoucheur must only act in concert with
the efforts of Nature; but before all things, he must
take care to give the head a favourable  situation, if
it has not taken it of itself:  he must place the face

  * It must be allowed, however, that its death would not be
so sudden in this case, as in that where the breast occupies
the whole length of the canal of the pelvis, supposing the um-
bilical cord to suffer the same degree of compression; because
it may respire when the head fills the cavity of the pelvis, if
we take care to direct the mouth towards the vulva, as I have
convinced myself a number of times: which may allow us to
wait for the expulsive pains with less inconvenience. But in
the other case, as it cannot respire, it must  die presently, if
the compression on the cord be strong enough to stop the
(irculation in it. 
Preternatural Labours.         307
 on one side, if the head be still above the superior
 strait;  and underneath when it occupies the cavity
 of the pelvis.
   883. He must afterwards introduce a finger into
 the  child's mouth, but  much less for the sake of
 pulling on the  lower jaw, than  to make the chin
 form a continued plane with the breast, and hinder
 it from hitching on any part of the pelvis. He must
 support the trunk with the same  hand, and the fore
 arm, while with the other, placed on the  child's
 back, he  grasps the hind part of the neck, by means
 of the fore and  middle fingers bent over the shoul-
 ders.
   884. While  the head is still above the superior
.strait, we ought to pull almost directly downwards
 to make it descend; but cautiously, and only during
 the  efforts of the woman, which we must then so-
 licit briskly,  by confirming her  hopes ofa speedy
 deliverance. When the head is descended into the
 cavity  of the pelvis, and the face  is towards the sa-
 crum,  if  we continue our efforts to extract it, it
 must only be by raising the child's body towards
 the pubes of the mother: for by pulling in any other
 direction, and especially downwards, we should di-
 rectly oppose the intentions of nature. The delivery
 of the  head becomes then almost entirely her work;
 and external efforts, though  well directed, are at
 that time of little  use.
   885. Things do  not  however always terminate
 so happily, in the last period  of  labour, when the
 child comes by the feet; because  the proportion be-
 tween  the dimensions of the head, and of the pelvis,
 is not  always so favourable. When there is a defect
 of proportion between those parts, the greater  that
 defect is, the less the security for the child's  life;
 and the more cautiously the accoucheur must pro- 
308          Preternatural Labours.

ceed, because his efforts, which are then unfortu-
nately necessary, increase the real and almost inevi-
table danger of the child.
  886.  Its death in this case is almost always less
the effect of the compression of the head, than of
the umbilical cord and the breast: but it depends
more especially  on the straining which the spinal
marrow suffers, in the violent extensions of the ver-
tebral column; as  well as on the Compression, and
even tearing, of that medullary substance; because
external efforts cannot act on the head, till they have
violently stretched, and dragged the neck.  A  me-
thod by which we might act immediately, and  as
it were exclusively on the head,  would be much
less  dangerous,  and  more  useful.   Smellie  seems
first  to have perceived this  important truth, and he
put it in practice several times with success; since
we read in his collection of cases, that he obtained
advantages from the  forceps,  in the unhappy cir-
cumstance in question, which he would have sought
in vain any other way.
Of the different Species of Labour, in which the
             Child presents the Feet.

  887. I shall not repeat here what has been said
in par. 520 concerning the distinguishing signs of
the first  species of labour, in which the child pre-
sents the feet. I shall only remark that no other pre-
sents fewer particular  indications; because the situ-
ation of the child is such, that the greatest diameter
of the breech, of the shoulders, and the head, suc-
cessively present themselves diagonally at the en-
/ 
Preternatural Labours.         309
trance of the pelvis, if the accoucheur takes care to
maintain those parts in their primitive direction.
  888.  In  this species of labour, as in the others,
we are to endeavour to disengage the feet, by intro-
ducing  one or two fingers into the vagina, as soon
as the membranes open; and if we cannot, we must
be contented to direct them properly, and wait till
they be sufficiently descended, to be grasped by
those fingers, and brought without. But when the
woman  is  attacked by any dangerous  accidents,
we  must introduce the whole hand, and take hold
of them at  the entrance of ^the uterus.
  889.  When the breech is without, we ought to
insinuate the fore and middle fingers of the left hand
along the child's belly, to examine the state of the
umbilicus, and if it be threatened with a rupture, re-
lax  it,  by  bringing down the cord, as directed in
par. 871, and following. We then wrap all the parts
without in  a dry cloth, and grasp  the  right hip of
the  child with the right hand, and the left hip with
the other, and pull obliquely downwards till we meet
with some difficulty;  our efforts  must then be di-
rected differently, and the hands only act alternately
in the following manner.
  890.  With the right hand we pull the right hip,
by raising all the parts already without towards the
right groin of the woman; and  then  do the same
with the left,  by carrying them  obliquely down-
wards, in a line which would pass under the woman's
left thigh. The same thing must  be repeated alter-
nately,  but very slowly; and care  must be taken to
give those  motions sufficient extent, to disengage
each time a portion of the trunk.
  891.  When it is time to bring down the child's
arms, we must  raise  the  trunk obliquely towards
the  woman's right groin, where it must be support- 
310          Preternatural Labours.
ed by the left hand, while with the other we bring
down the right arm, which is underneath, according
to the principles already established: then wrapping
it in the  same cloth with the trunk, we must carry
the whole downwards, and towards the woman's left
thigh;  where it must  be supported by  the  right
hand, while with  the  left we disengage the other
arm  from under the pubes.
  892. The second species of labour where the child
presents  the  feet.  The situation  of the child with
respect to  the pelvis will appear the same in both,
if we only consider their relative dimensions. The
only difference we observe in them  is, that in the
first  species,  the  child's back answers  to the left
side  of the mother, and in the second to the right.
  893. After the  arms are brought down, we ex-
amine the situation of the face at the superior strait;
if it  be not to one side of it we place it there, or if
it be descended in the pelvis we assist in turning it
downwards; we then proceed as already directed.
  894. We proceed in this species of labour as with
the one just described, except the change of hands,
and  the  direction  given to the child's body;  what
the left hand did in the other, the right does here,
and vice  versa; the same may be said of the direc-
tion  the  child's  body  is to  be moved in, the left
groin in  this answers to the right in the other, &c.
  895. The position of the feet which constitutes
the  third species of this kind of labour, is rather
rare; and it would be far from being so favourable
as the two former, if the child did not usually, as I
may say, turn of itself, in proportion as it descends,
and change insensibly to one of them.—See par. 562
and following.
  896. We cannot too early make the child's trunk
take that direction, when it presents with the heels 
Preternatural Labours.          311
to the pubes,  and the toes  towards the sacrum, if
Nature does not do it herself; in order to  turn the
face in time from over the sacro-vertebral projection,
and hinder the  head from  presenting its greatest
length, parallel to the smallest diameter of the su-
perior strait.
   897. We must not,  however, judge of the true
situation of the head, relatively to the superior strait,
by the position we have given to the trunk,  nor  of
the position of the trunk, by that of the feet:  for we
should very often be deceived, to the disadvantage
of the child, it being possible for the face to be on
one side, while the breast  is underneath, and the
feet in some other direction; and vice versa.
   898. As soon as the feet are without, the toes
are to be directed towards  the right or left side of
the pelvis, and a little downwards, to bring them to
the first, or second position. The breast  must be
turned the same way,  in proportion as  the trunk
descends; and when the  shoulders are sufficiently
low, we must assure ourselves of the position of the
head  by introducing the finger along the neck, and
examining whether the face has undergone the same
change of position, and whether it be turned towards
the side to which we have directed the breast.
   899. If the brim be a  little contracted from the
pubes to the sacrum, it would be better to keep the
child's trunk in its primitive position, that is to say,
to bring down the back directly behind the pubes;
we ought even to bring it to that position, if it were
in one of the two former,  because it would descend
more easily. But then, as soon as the shoulders have
cleared the superior strait,  we  must not forget to
turn the face to one side,  by advancing several fin-
gers on one of the child's cheeks, and not by turn-
ing the trunk  on  its axis. 
312          Preternatural Labours.
   900. If the head should be jambed with its great-
est length between the pubes and sacrum, either by
the efforts of nature, or the ill-directed manoeuvres of
a midwife, or unskilful accoucheur, the child rarely
lives, even when proper assistance is called, so much
injury has previously been done.
   901.  When  the head is thus  retained in the su-
perior  strait, it must be disengaged by pushing it
up a little; and  afterwards turning the  face  to  one
side. We ought never to expect this change of po-
sition from any efforts which can be exerted on the
trunk without,  by turning it one way or other on
its axis, or by pushing it back, or otherwise; for all
these movements are so much the more free,  and
succeed  so much the less, as the child's neck  has
been more stretched. Besides, the efforts which we
exert on the trunk, do not always act on the head,
unless we give  to those  movements a much greater
extent than their natural limits permit; which would
be extremely dangerous to  the child, if it were still
alive.
   902. To change the situation of the head certainly
and properly, we must begin by  bringing down the
child's arms with all possible caution.* We then
introduce the hand, or some of the fingers only, into
the vagina, to push up the occiput  ever so little above
the pubes; and to turn the forehead from before the
sacro-vertebral  angle, and  place it opposite one of
the sacro-iliac symphyses;  but preferably towards
the right. After that, we go on to extract the head
as in the most common cases.
   903. This situation of the child, in the fourth

  * This refers not only to being careful to do no injury to
the arms, but also, not to draw too powerfully at them, and
'hus jamb the head still more.               W\ P. D. 
Preternatural Labours.          313
 species of labour where it presents the feet, is such,
 that the face always comes upwards; and though it
 generally turns a little away from the symphysis of
 the pubes, as the head approaches the superior strait,
 it never fails to place itself under it, as soon as the
 head descends into the cavity of the pelvis: which
 renders the labour more difficult and laborious, than
 in the  three former species.
   904. It is generally recommended in this fourth
 presentation of the feet, to turn the face completely
 downward by rolling the trunk on its axis  as  soon
 as the  hips are without, with a view to prevent the
 child's hitching  on the pubes,  if this were  even
 obeyed before the head had  cleared the superior
 strait,  we should run an equal risk of making the
 chin hitch backwards, or at least we  should make
 the head engage with its  greatest length, parallel
 with the smallest diameter of the upper strait.
  905. It has been advised by others to merely turn
 the face to one side, or towards one of the sacro-iliac
 symphyses; but as the head does not obey the mo-
 tions executed on the trunk, the face would almost
 always be left over the pubes.
  906. In order to lay down more clearly the mode
 of proceeding in this case, I shall distinguish three
 times  in it. In the  first,  the  child's  feet are still
 within  the uterus; in the second, the child is de-
 livered as far as the loins,  and the waters have been
drained off a considerable  time; in the third, the
 shoulders are without, or appear at the vulva, and
the head is adapted to the superior strait.
  907. In the first time, as soon as the accoucheur
 can with one hand take hold of the child's  feet, he
 ought  to turn the toes underneath,  pulling almost
directly downward.  He must take care afterwards
to turn the  breast in proportion as it descends, at
                      2R 
314          Preternatural Labours'.
least, opposite one of the sacroiliac symphyses, but
preferably before the right; and do the same  with
respect to the face, as soon as the shoulders appear.
This change of position is easily performed in the
first time,  but  not  so in  the second; because the
shoulders and head being more closely embraced
by the uterus, follow  more difficultly, and imper-
fectly, the movements given to the parts without.
  908. In the conversion, which the child must be
made  to undergo in the second time, regard  must
be had to the relation which the breast has to the
sacro-iliac symphyses, in order to turn it towards
that which it is nearest to. To perform this change
of position, we must  take care to grasp the child's
trunk, as near as possible to the  entrance of the
uterus, and not to act but in the interval of the pains.
In order to do it in the most convenient  manner,
especially when we meet with any difficulty, we in-
troduce the four fingers of each hand at the entrance
of the vagina, or even a little farther; those of one
hand along the  loins, and the other to the belly;
consequently to the sacrum and pubes of the mother.
We first endeavour to push up the trunk a  little,
and immediately afterwards bring it down again as
far as before, or a little  farther  each time:  these
movements are to be repeated a good many  times
successively, and in the course of them the breast
must be inclined towards the sacro-iliac symphyses,
to which we intend to turn the face. We ought in-
deed to turn it a little beyond the symphysis, accord-
ing to the advice of Smellie, and then bring it back
again; in order to allow for the natural mobility of
the neck, and the twist it is susceptible of, without
losing sight of the observation made in par. 901.
   909. Notwithstanding  all these precautions, we
must  not flatter  ourselves that we shall always be 
Preternatural Labours.          315
able to make the head take the favourable position
which we  endeavour to give it:  for sometimes the
face still remains over the pubes. This case is ex-
ceedingly dangerous for the child, if we do not pay
the greatest attention to it before we pull the trunk,
on account of the violent twist in the neck. There-
fore, after  having  turned the breast downward, as
I have just directed, we must ascertain the true po-
sition of the head.
  910. It almost always happens, when we turn the
child's trunk thus round its axis, that one of the
arms places itself  obliquely behind the neck, and
below the occiput,  by which it afterwards becomes
more or less confined against one of the ossa pubis:
which increases the difficulty of bringing it down,
and often renders  the descent of the head  more
laborious.  When the accoucheur has not succeed-
ed in turning the face in proper time from over the
pubes, if he perceives it when the  head is but just
arrived at the brim, he may yet hope  to change its
position, by conducting.himself as I  have just re-
commended: but he must not promise himself any
thing from this mode of proceeding, when an igno-
rant person has  pulled inconsiderately at the trunk,
with a design to extract the head thus retained, or
when Nature has a long time endeavoured to expel
it.
   911.  It is exceedingly rare in these cases for the
chin to be  retained, and, as it were, hitched on the
edge of the ossa pubis; it is almost always the mid-
dle of the  face, near the root of the nose; and the
head being then engaged, makes it much more dif-
ficult to change its position. The same remark is
equally applicable  to the  third position, when the
face descends directly before  the projection of the
sacrum; for it is not usually the chin which stops
at that part. 
316         Preternatural Labours.
   912. The child is generally the victim of this bad
position of the head. If it is not always entirely
deprived of life, there is little room for hope, when
the midwife or accoucheur confess their inability,
and call in a second.
   913. To change the position of the head thus
retained at the entrance of the pelvis, we must act
immediately upon it, in order to avoid the rock on
which the mobility of the trunk, in these circum-
stances, has precipitated many an accoucheur, who
imagined they had turned the child's face to one side,
or underneath, because they  had easily turned  the
breast so.* It must be remembered, that this rota-
tory motion of the trunk is always more free and easy,
as the child's neck has been more stretched; and that
we only twist  it, and facilitate the separation of the
trunk  from the head, when we  exceed its  proper
limits.
   914. After having brought down the child's arms
cautiously, especially if it be still  living,  we must
support the trunk  with  the left hand, and slide the
right, except the thumb, along the back of the neck,
to push  up the occiput above the sacro-vertebral
angle, and turn it towards  one of the sacro-iliac sym-
physes, or even  to one  of the acetabula if we can.
While we turn away the occiput thus from the pro-
jection of the sacrum, we must take care to turn the
trunk, which  is without, in the  same  direction.
When the  head is completely in the cavity of  the
pelvis, we may place the face underneath, in order
to extract it conveniently.

 * See de la Mothe, among others, Observ. 275, nouv. edit. 
Preternatural Labours.          317
  Labours in which the Child presents the Knees.

  915. The union of all the circumstances, with-
out which delivery cannot be performed naturally,
that is, without assistance, is so rarely met with in
a woman whose child presents the knees, that  we
may be allowed  to class  this species of labour
among  the  preternatural, independently of those
circumstances  which may render it so  when it
begins with the most favourable appearances.
Of the Causes which render a Labour, in which the
   Child presents  the Knees,  difficult, or preterna-
   tural.

   916.  The  obstacles which  most  frequently
oppose the intentions of Nature in this species of
labour, arise from the presentation of only one knee
at the orifice of the uterus,  while the other extre-
mity, folded up, is retained above the margin of the
pelvis, so that the child cannot descend, notwith-
standing the violence of the efforts which tend to
expel it.
   917. Neither can the delivery be easily performed
without assistance, when the two knees present toge-
ther; because  those parts, as they come down, may
but against the curve of the sacrum, and stop there,
while the feet, pushed down  by the breech, which
is then forced to engage, tend  to come out first;
which cannot  take place unless the pelvis be very
large. When it is narrow, delivery becomes impos-
sible without  help. 
318         Preternatural Labours.
  918. To these causes, which frequently make i-
necessary to have recourse to art, in labours where
the child presents the knees, we may add all those
which  I  have mentioned before, such as convul-
sions, flooding, &c.—See par. 785, and following.
 Of the Characteristic Signs of the several Species of
   Labour in which the  Child presents the  Knees,
   and the Indications they present relatively to the
   Mode of operating.

   919. The essential differences of those labours
 where the child presents the knees, as well as their
 signs, having been stated in par. 548, and following,
 it remains now to treat of the indications presented
 by these labours. Among those indications, some
 are general,  and others  particular. The latter are
 deduced from the situation of the knees, as  well
 with  respect to each other, as to the pelvis of the
 mother, and  from the accidents which complicate
 the labour.  The  general  indications are the same
 as  in those labours where the child presents the
 feet.
   920. Some practitioners have thought it right to
 bring down the feet, whenever the knees present;
 but far from giving such a precept, I  shall lay it
 down as an invariable rule, never to search  for the
 feet, unless the labour be  complicated  with some
 accident, and the knees still at the entrance of the
pelvis, or capable of being easily pushed back to it:
 otherwise, we must let them descend, and content
 ourselves with favouring their progress, by turning
 them off from those parts of the pelvis where they 
Preternatural Labours.         319
might be stopped; till we can hook them  with the
fore finger of each hand, insinuated into the  bend
of the hams, and so bring them along.
   921. These aids, which  in  common  cases are
only, as I may say, of a relative utility, become ab-
solutely necessary when the woman is exhausted,
or when any alarming accident requires us to deliver
immediately. If the knees are still far off at the time
when we are obliged to operate, we must push them
up above the margin of the pelvis, then introduce
the hand, and search for the feet. We proceed in
the same manner when the knees, pushed down by
the efforts of labour, are stopped  in the curve of the
sacrum, and the feet are descended as low on another
side, so that the legs lie across the pelvis: we then
push up the  knees, and bring down the feet. But
we act  differently  when  the knees are low down,
and the feet still high up. We ought, in that case,
to endeavour to bring them down, by means of the
fingers insinuated into the hams, as  directed in the
preceding paragraph;  if we cannot succeed with the
fingers, we may have recourse to a fillet.
   922.  The best fillet is made of a piece of tape an
inch wide, and an ell  long.  We double it, and
adapt the loop to the end of the fore finger, keep-
ing it fixed there,  by pulling the two ends with the
other hand. We introduce the finger, covered with
the fillet, on the outside of the knee; then insinuate
it between the leg and  thigh, turning  it into the
bend of the  ham, so that  its extremity may pass
across it, to the inside of the knee:  there we must
fix it with the end of the thumb  while we bring the
finger round from the other side;  then with the
finger and thumb draw down one of the ends. It is
never  necessary to apply a fillet upon each knee,
one being fully sufficient. 
320         Preterm tural Labours.
   923. The fillet being thus fixed on the bend of the
 ham, we take hold of both ends with one hand, and
 winding them, if they are long enough, two or three
 times round the fingers, pull downwards according
 to the axis of the pelvis; while with the fore finger
 of the other hand  a  little bent, and applied to the
 outside of the second knee, we keep it  close to the
 first, that it may be obliged to descend at the same
 time, and follow the  same direction.
   924. For want of a fillet we may advantageously,
 and  with  much less trouble, use a  blunt hook, in
 the same manner as  I have frequently applied that
 which terminates the handles of Levrefs forceps to
 the groin, when the breech has been a long time
jambed in the pelvis, and could not advance: but
 for the knee a different hook will be necessary, such
 as I  have recommended in par. 935.
  925. Whether we have  recourse to  fillets or to
 the blunt hook, whether wre propose to push back
 the knees  and  bring  down  the feet, or  only direct
the former so that they may easily pass through the
canal of the pelvis,  it is of  no  great importance
whether we use the right or left hand.  But it is not
so when only one knee is advanced, and the second,
being retained above the  brim,  opposes delivery.
In that case, in which we must at least search for
the foot of the retained  extremity, if  we  cannot
bring down  both, by first pushing up a little the
knee which has descended; the facility of the opera-
tion depends on the choice of the hand  which we
insinuate into the uterus; and that choice must be
determined by the relative situation of the two infe-
rior extremities of the child, as well as by the par-
ticular situation of that which is retained at the brim
of the pelvis; so that  sometimes we must introduce
the right hand, and sometimes the left. 
Preternatural Labours.          321
 Of Labours in which the Child presents the Breech.

   926. By  recollecting here what  I have  said in
 another place concerning the causes  which may
 render a labour preternatural, though it had begun
 in the most advantageous manner, and the diffi-
 culty which most women experience in delivering
 themselves, without help, of a child presenting the
 breech, it will be allowed that those labours may
justly be classed as such; and that having in another
 place shown the mechanism by which they are some-
 times performed without help, it is  proper to state
 the causes which may render them difficult, and to
 describe the manner of  terminating them in those
 circumstances.
 Of the Causes  which may render those  Labours
   where the Child presents the Breech, difficult, or
   preternatural: the essential Differences of those
   Labours,  and their distinguishing signs.

   927. I shall confine myself to the exposition of
the causes which may render this species of labour
impossible,  or at least very difficult and dangerous
without assistance. Among those causes, some have
been the subject of several preceding sections (see
par. 785, and following); others are peculiar to this
species  of labour, and sometimes  depend on the
extraordinary size of the child's breech, relatively
to the pelvis of the mother, and sometimes onlyT on
their situation.
   928.  The essential differences of these labours
arise from the manner in which the breech presents
with respect to the  brim of the pelvis.
                      2S 
322          Preternatural Labours.
  929. It is not always more easy to  discover the
position of the breech, than  to determine whether
that is the part which  presents.  We  often find a
great  deal of difficulty in  it, especially before the
membranes are open, and when the breech has been
a long time engaged and jambed between the bones
of the pelvis.  In the first  case it is, as I may say,
not only beyond the reach of the finger, but recedes
still farther on the least pressuie; the  child enjoy-
ing a  great mobility while surrounded by the liquor
amnii. In the second case,  where the waters are
evacuated, the breech is always found  considerably
tumefied.   Some  accoucheurs  have  mistaken it,
but chiefly in the latter case, for the child's  head,
whose teguments they supposed were swelled and
puffed up.
Indications in those Labours where the  Child pre-
                sents the Breech.

   930.  The idea which  has  been formed  of the
relation which the dimensions  of the child's breech
bear to  those of the mother's pelvis, has given birth
to a variety  of opinions concerning the mode  of
operating in these labours. The indications in this
species  of labour are different, according to the cir-
cumstances which complicate it, its advancement,
the position of the breech, and its size.
   931.  When none of those accidents before men-
tioned exist, if the child's breech be small, or even
of a middling size, relatively to the diameters of the
pelvis, provided also  that it be well situated, we
ought to leave its expulsion to the efforts of Nature.
But if it  comes along with difficulty, when  it  is 
Preternatural Labours.          323
arrived at the lower part of the pelvis, we may assist
it by pulling towards  us, during every pain, with
the fore finger of each hand, curved like hooks, and
insinuated into the groins; or with one finger only,
applied preferably to that groin which  answers  to
the sacrum of the woman.  After thus disengaging
the trunk and the feet, we finish the delivery, as if
the latter had presented naturally.
   932. When the obliquity of  the uterus is consi-
derable, and when it contains a great deal of water,
the child's body may be so inclined, relatively to the
axis of the pelvis, as to present  but one buttock.  In
that case, delivery can seldom  be performed with-
out help,  whatever may be  the size of the breech;
at least, unless the second  buttock, which is retain-
ed  on some part of the margin of the pelvis, ap-
proach the superior strait,  so  that they may both
engage  at the same time:  or, in other  words, the
length of  the body must become nearly parallel to
the axis of the superior strait. This change is often
procured  by making the woman lie on  the side
opposite to the deviation of the uterus, at the begin-
ning of labour, and especially at the time the waters
are evacuated.  When  that  precaution is not suffi-
cient, we  must introduce  the hand  to the  entrance
of the uterus to bring the buttock which rests on the
edge of the pelvis to the superior strait; or, which
is infinitely better, to bring  down the feet.
   933. The feet must always be sought for,  when
the woman is attacked or threatened with any acci-
dent, and  when the volume of the breech so far sur-
passes the size of the pelvis that it cannot engage in
it, or not without a great deal of difficulty; because,
in all those cases, it is to be feared that the woman
may be exhausted, and sink, before  that  part  be
sufficiently advanced, to  be hooked,  and  brought 
324          Preternatural Labours.
along with the fingers, in the manner directed in
one of the preceding paragraphs.  We must not
however undertake to bring down the feet, every
time that any accident requires us to  deliver with-
out delay, when the child presents the breech. This
method cannot be safely  put in practice, but when
the breech is still at the entrance of the pelvis, or so
little  advanced, that it  is easy to push  it back.
When it occupies the bottom of that cavity, or  is
strongly wedged in it, and  especially when it has
cleared the orifice of the uterus, we  ought not  to
think of bringing down the feet; * because it would
expose both mother and  child to additional danger.
   934. In these latter cases  we must  endeavour to
bring along the breech with the fore finger of each
hand, curved like a hook in the bend of the groins.
If we do not  succeed  by that method,  recourse
must be had to fillets, or blunt hooks. Were we  to
consider only the materials of these different instru-
ments, and  their mode of acting, the fillet would,
no doubt, merit the preference: but its application
is so  difficult,  that it is  with a sort of repugnance
that I reckon  it here among  the resources of the
art.
   935. Blunt hooks merit the preference in all these
cases:  many   accoucheurs  have proposed  them
before me.  These  hooks should be about an inch
and a quarter  long, rather round than flat, and ter-
minated nearly in the figure of an olive: their stems
must be about a foot long, and a little curved, that
they may accommodate themselves to  the convexity
of the child's hips; and, besides, must  be so formed,
that one may easily be united to the other,  and  form
  * The student's attention is requested to these important
distinctions.                             W. P. D. 
Preternatural Labours.          325
if needful, a kind of forceps. For want  of these
hooks, I have often successfully used those which
terminate the handles of the forceps.
  936. One hook may suffice to extract the child's
breech when it is engaged diagonally, provided we
place it on that groin which is next the sacrum of
the mother;  but  when  it presents in the third  or
fourth position, and is strongly wedged in the pelvis,
as the obstacles to its exit are much greater, it may
perhaps  be  necessary  to apply two crotchets, in
order to use them like a pair of forceps.
Of* the Signs which characterize the different Species
  of Labour,  in  which the  Child presents  the
  Breech, and the method of bringing down the Feet
  in those Cases.

  937. In  the first of these species of labour, the
breech presents diagonally at the entrance of the
pelvis; so that the child's  left  hip answers to the
right acetabulum of the mother, and  the right hip to
the left sacro-iliac symphysis; the back being placed
under the anterior and left lateral part of the uterus,
and  the  breast turned towards the posterior  and
right lateral part of  it.  Of all the positions of the
breech, this is the  most  favourable for its exit,
whether it be performed without help or not.
   938. When the circumstances which complicate
the labour require us to bring down the  feet, the
accoucheur must search for them with the left hand,
which he will introduce  by sliding it up before the
right sacro-iliac symphysis.  He must first raise up
the breech, if it has  begun to engage, and direct it
over the fore part of the left iliac fossa.  Then insi 
326          Preternatural Labours.
nuating the hand  along the  posterior part of the
child's thighs and  legs, if they should be extended
towards the breast, he will find  the feet, which he
may hook with the ends of the fingers, a little bent,
and bring them to the entrance of the vagina. He
must then take hold of them differently, to bring
them entirely down,  and finish the delivery as if
the feet had presented naturally in the first position.
—See par. 829, and following.
  939. In this case, as in  many others, but parti-
cularly, when the breech  presents, provided the
child be not very large relatively to the capacity of
the mother's pelvis, we may content ourselves with
bringing down one foot, if we find any difficulty in
bringing down both.  We need not fear that the
other inferior extremity, if we bring down but one,
should be stopped at the edge of the strait, so as to
hinder the descent of the breech: but we must be
careful to observe the precautions given in par. 863,
till it is without.
  940. In the second position of the breech, as in
the first, it presents its greatest  breadth diagonally
at the entrance of the pelvis;  but so that the child's
right hip answers to the left acetabulum, and the
left hip to the right sacro-iliac symphysis; the  back
being then under the anterior and right lateral part of
the uterus, and the breast towards the posterior and
lateral part of it.  When bringing down the feet is
judged necessary we are to employ the right  hand
in searching for them, and then proceed as in a
second presentation of the  feet.—See par. 889.
   941. The position of the  breech which consti-
tutes the third species, is such that the child's back
answers  to  the anterior part of 'he uterus and the
pubes of the mother; the face and breast being towards
the posterior part, and consequently underneath. 
Preternatural Labours.          327
   942. When it is necessary to search for the feet,
we must introduce the hand  towards the posterior
part of the uterus, along the hind part of the child's
thighs and legs.  We first remove the breech from
the superior strait, carrying it forward and over the
pubes, and then take hold of the extremities. We
might immediately make the breech describe the
demi-tour mentioned in the preceding paragraph, if
it did not appear better to wait for that till the feet
are entirely disengaged.
   943. In the fourth position of the breech it is so
placed,  that the child's back is towards the lumbar
column of the mother, while the face and breast are
under the anterior part of the utetus. It is the least
frequent and least favourable of all the four posi-
tions.
   944.  In this case, Nature generally finds so many
obstacles to delivering herself without help, that it
is always better  to remove  the breech, and bring
down the feet, when we arrive in time, than to aban-
don the woman to efforts, which might be useless,
and besides augment  the  difficulties  inseparable
from this species of labour. We  ought never to
neglect this rule  but when we are called too late to
follow it. In that  case, when the breech is, as it were,
wedged at the  bottom of the pelvis, we must endea-
vour to  draw  it down with the  fingers applied to
the groins, or with blunt hooks if circumstances
require it:  but in  disengaging  it then, we must
observe to make it describe the  demi-tour men-
tioned above,  in order to begin to turn  the face
from over the pubes.
    945. In this species of labour it is very indiffe-
rent whether we introduce  the  right hand or  the
left into  the uterus, to search  for  the  child's feet.
 Either one or  the other should be introduced in a 
 328         Preternatural Labours.

 state of supination, when the breech is engaged in
 the superior strait, in order to push it up more
 easily: we then direct the fingers united  on one of
 the child's hips, and the thumb on the other, so as
 to enable us to grasp  the lower part of the trunk
 firmly, and make it describe a quarter turn, or more
 if we can, to bring the back towards one of  the
 iliac fossa of the mother; that is to say, towards the
 right when we use the right hand, and vice versa.
 After that, we search for the child's feet by advanc-
ing the hand along the  posterior part of the thighs,
and bring them down, as in all the preceding posi-
 tions.
Labours in which the Child presents the  Crown of
      the Head at the Orifice of the Uterus.

  946. Those labours, in which the child presents
the crown of the head at the orifice  of the uterus,
would always be the most advantageous, if the laws
of Nature in this function were immutable, if women
were exempt from every species  of accident,  and
if the proportion usually found between  the  dia-
meters of the head and those of the pelvis were con-
stantly the same:  for the obstacles which obstruct
these labours, or render  them difficult and dange-
rous,  proceed only  from these  three   sources,
united or separate. 
Preternatural Labours.      ,    329
Of the Causes which may render those Labours in
  which the Child presents the Crown of the Head
  difficult or preternatural, and the indications they
  prescribe.

  947.  These causes, the  greater part of which
have been already explained, in as many particular
sections, are very numerous. Those which proceed
from the mother, depend on the defects of the pelvis,
on the want of sufficient strength to expel the child,
and on accidents which supervene before, or during
the course of  labour.  Those which depend on the
child arise from the extraordinary size of the head,
relatively to the pelvis of the mother; from the man-
ner in which it presents at the entrance of that cavi-
ty; from the presence of a hand, or a foot, which
hinders it from engaging  in it; from  the direction
which the expulsive forces of the uterus impress on
it; from the descent of the umbilical cord, &c* In
order to determine more  clearly what I mean by
bad positions of the head, and demonstrate the me-
chanism by which several of those positions may
take place in  the  course of labour, I shall  make
them the subject of a particular section.

  * I do not speak here of those  causes which absolutely
require the help of instruments; I shall speak of them in the
fourth part of the work.
                       2T 
330          Preternatural Labours.
Of bad Situations of the Child's Head in general,
  and particularly of that which  it is sometimes
  forced to take as it advances in the Pelvis.

  948. The position of the head is disadvantage-
ous,  though  it presents  the vertex, whenever its
greatest diameter is not placed parallel to the greater
diameter of the strait which  it must pass: it will
therefore be  so when the occiput  or the forehead
shall be turned towards the pubes at the beginning
of labour, or remain towards one of the ischia at the
latter end. In all these cases, the  position  of the
head will be so much more disadvantageous, as the
woman's pelvis shall depart farther from a good con-
formation;  and much more still, as the face  shall
have more propensity to turn towards the pubes in
the last period of labour.—See par. 479, and fol-
lowing.
  949.  Although the child's  head present favour-
ably at the entrance of the pelvis, the labour cannot
be easy, unless in its descent it take the course which
I have described in treating of the mechanism of the
different species of natural labour. When it engages
otherwise, its greatest diameters advance foremost,
and  present  themselves  in all their length to those
of the inferior strait; sometimes in one direction,
and sometimes in another: which generally renders
its delivery very difficult, and sometimes impossible
without help.
  950.  When the head  takes its natural course, it
preserves its anterior flexion, and the chin remains
against the upper part of the breast, till the base of
the occiput come against the  centre of the arch of
the pubes,  or on the anterior edge of the perin_eum,
if the face come upward. But we observe the con- 
Preternatural Labours.          331
trary in the case in question; the chin quits the
breast,  and the head turns backward as soon as it
begins to engage; so that it is the anterior fonta-
nelle, or the upper part of the forehead, which at
last places itself in the centre of the inferior strait.
   951.  This position is the effect of the direction
of the expulsive forces of the  uterus, and of the
manner in which they act on the head.  We hardly
ever observe the obliquity of the uterus,  which  is
the determining cause of it, not  to be on the same
side to which the occiput answers. The direction of
the expulsive forces in other cases is constantly such
that they act on the head so as to make the occi-
pital extremity descend; but in this, the direction
of those same forces  traverses  the head obliquely
from  the base to the vertex, and from the occiput
to the forehead, a little before the centre of motion,
and obliges it to turn backward in proportion as it
advances.
   952.  It is always pretty easy to prevent the head
from  taking this  bad position as it engages in the
pelvis, and make it follow its usual course: we need
only change the direction of the uterine  forces  in
proper time, and support the anterior part of the
head a little while, to make the occipital extremity
descend. We must then, in great obliquities of the
uterus,  begin by rectifying that viscus, and bringing
its axis nearly  parallel to that of the  pelvis; either
by causing the woman to lie on the side opposite to
the deviation, or by making a convenient pressure
on the belly. Then,  by means of several fingers in-
troduced into the vagina, we must support the child's
forehead, during each pain, in order that the natural
efforts,  whose direction is no longer the same, may
act on the occiput, and force it down. But in doing
this, we ought carefully to avoid pressing on the 
332          Preternatural Labours.
anterior fontanelle, or its environs, where the bones
are very  supple, lest the child be destroyed by their
depression, and the consequent injury to the brain,
which however cannot be very great if we act me-
thodically.
   953. We must act in the same manner to rectify
the position of the child's head, and reduce  it to its
natural course, when we have  not been able to pre-
vent the bad situation in question. The woman being
laid on the side opposite to the  deviation of the fun-
dus, we must push up the forehead as much  as pos-
sible during the pain,* and with the precautions
already recommended. If we  should  not succeed
completely in this manner, we must  introduce the
fore and  middle fingers of the  other hand above the
protuberance of the occiput, to assist its descent, by
pulling downwards, as if we were making  use of
a crotchet.
   954. It is so rare that  we cannot by this  double
action bring about the necessary change, or convert
the bad  position of the head  into a better, that it
might seem useless to prescribe any other methods:
but however, as the  head may be so wedged be-
tween the bones  of the pelvis,  that the fingers may
not be able to penetrate above the occiput, I shall
mention  this case again in the sequel,  when I treat

  * I would recommend pushing up the forehead during the
pain, and  not during the calm which follows it; because the
efforts of Nature, whose direction we have changed, by chang-
ing the position of the uterus, act on the  occiput, and force it
down as they do in a natural labour, which we greatly assist
by pushing up the forehead at the same time.f
  11 am  sorry to differ with  our author in this advice, my
experience being much in favour of acting on the  forehead
in the absence of pain; and maintaining the forehead with my
fingers until the contractions  of the uterus force down the
vertex.                                 W. P. D. 
Preternatural Labours.          333
of those labours, in which the lever, commonly cal-
led Roonhuisen's, may be of some use.
  955.  The  head almost always passes the pelvis,
and the labour terminates with the first pains which
come on  after we  have  corrected the position, at
least if no other causes obstruct it.  But if circum-
stances require it,  we may use the forceps, or act
differently according to the nature of the case.
Of the Indications in those  Labours in which the
   Child presents the Crown of the Head, when com-
  plicated with Circumstances that render them dif-
  ficult.

   956. The greater  part of the causes stated in
par. 947, present different indications in some re-
spects, not only according to their species, and their
violence, but also according as they manifest them-
selves sooner or later in the  course of labour.
   957. When the head presents its greatest length
to the small diameter of a pelvis rather narrow from
the pubes to sacrum, we have no other indication to
fulfil, than to remove it, and place it in a better po-
sition, as directed in par. 612, and following. When
this faulty position only takes place at  the  inferior
strait,  we proceed in the same manner, with this
difference, that we direct the length of the head ac-
cording to the diameter which goes from the pubes
to the sacrum. If the  presence of a hand, or a foot,
opposes the descent of the head, we must push them
up above it, and return them into the uterus, unless
some other circumstances require us to act differ- 
334          Preternatural Labours.
 ently.* Lastly, we must correct the defective course
 of the head, when it deviates from that which I have
 traced, in treating of each species of natural labour.
   958. Whenever a violent flooding, or any other
 serious accident,  happens in the course of labour,
 we ought  to  deliver immediately; but in different
 ways, according as the labour shall be more or less
 advanced at the instant when the operation becomes
 indispensable. If the child still  preserves all its mo-
 bility  above the  entrance  of the pelvis, or if it be
 but just beginning to engage in that strait, and the
 waters have not been long discharged, we ought to
 turn and extract it by the feet.  But if the head has
 descended  half its length, especially if the waters
 have  been  some time evacuated,  it is better to use
 the forceps. That instrument merits the preference
 much more still, when the head occupies the lower
 part of the pelvis, and must be employed exclusively,
 whenever it has cleared the  neck  of the uterus, and
 is entirely in the vagina; for then no other  method
 can save the child.
   959. The forceps merit  exclusively the prefer-
 ence when the head entirely occupies the cavity of
 the pelvis, and nothing but not having them at hand
 when the necessity is urgent, can justify turning;
 this is indeed only admissible, first, where the head
 has passed  the superior strait easily, and secondly^,
 when it has carried before it the circle which con-
 stitutes the neck of the womb. Some may condemn
 this last precept, by urging the danger it offers to
 mother and child; but experience  enables me to de-
 clare, that the child's head may be pushed back with
little inconvenience if it were even yet lower, pro-
 vided it be not enveloped in the neck of the uterus.
* See par. 1077, and following. 
Preternatural Labours.          335
   960.  I  have before remarked, in par. 455, that
the head might occupy the lower part of the pelvis,
without having cleared the orifice of the uterus, and
that it was important to distinguish this case accu-
rately from that in which it is entirely in the vagina.
Though in the former case there is no more incon-
venience in pushing up the head above the superior
strait, and in  turning the child, than in that where
it is but little advanced, every thing with respect to
the conformation  of the pelvis, the contraction of
the uterus, &c. being the same, there would be a
great deal when it has cleared the neck of that vis-
cus, and is entirely in the vagina. By pushing it up
then above the brim, we should  run the greatest
risk of tearing the vagina from its connexion with
the uterus, &c. The forceps  are exclusively indi-
cated in this circumstance, as I have already said,
unless the certainty of the child's death  permit us
to use crotchets:  and I  should prefer them in the
other, because their application is simple, and their
effects quicker and more certain, than those of turn-
ing the child.
   961.  The accidents stated in par. 1079, such as
flooding, convulsions, frequent syncopes, an exhaust-
ment of the  woman, and the  exit  of the umbilical
cord, &c. are not the only causes which reduce us
to the necessity of turning a child who presents the
crown of the head: a deformity of the pelvis some-
times prescribes 5the same indications. Almost all
those who have advised and practised it on account
of this last circumstance, have done it without any
regard to  the extent of the disproportion between
the dimensions of the child's head  and those of the
pelvis; so that for one child they have saved by this
method, a great number have  been victims  to it.
This  method  cannot be proper but in those cases 
336          Preternatural Labours.
Where the disproportion which obstructs delivery is
very small: when it is more considerable, it requires
the forceps, crotchets, the cassarian operation, &c.
according to the state of the child, as we shall see
ih the sequel.
General Rules for turning the Child to bring it by the
  Feet, when it presents the crown of the Head.

  962. When v/e are obliged to turn a child who
presents the crown of the head to the orifice of the
uterus, the membranes are entire, or not,  and  the
watdrs recently discharged, or a long time  ago. In
the  former case, the child is in some measure free
in the midst of the uterus: and in the latter, it is so
closely embraced by it, that the hand cannot pene-
trate it without difficulty, even when well directed.
It is in the latter state I shall suppose it to  be,  be-
cause it  requires more sagacity on the part of the
accoucheur than the other case, and because he can-
not then neglect the following rules, without expos-
ing both mother and child to great inconveniences.
  963. The woman being placed conveniently,  we
must introduce the right or left hand into the ute-
rus, according to the position of the head. We must
then disengage it from the superior strait, if it be
engaged  in it, by pushing it upward and forward,
to make it follow the direction of the strait. We
then apply the hand to the forehead, and carry  the
head towards one of the iliac fossa, where it must
be retained during the operation, by means of  the
wrist and fore-arm, to hinder it from being forced
downward again by the pains, while we search for
the feet, 
Preternatural Labours.          337
   964. In order to  find the feet, and bring them
 down more easily, having removed the head suffi-
 ciently  from the superior strait, we must insinuate
 the  hand along that side  of the trunk which is
 nearest the  posterior part of the uterus. We first
 pass the fingers close together over the ear, from
 thence over the side of the neck, but a little back-
 ward, in order to avoid the projection of the shoul-
 der; we then conduct them  gently along the side
 and hip, from whence we pass along the thigh and
 leg to the feet. We  hook the feet with the ends of
 the fingers a little bent, and bring them to the en-
 trance of the vagina,  making them pass over  the
 breast and  face of the child. When  we can take
 hold of but one foot at once, we must take that
 which belongs to the side that the hand has passed
 over; unless it  be engaged in the bend of the ham
 of the other leg, as we sometimes meet with it; for
 then we must begin by bringing down the  foot of
 that leg first.  As soon as we have brought one foot
 out of the uterus, we must introduce the hand again
 to search for the other, either by tracing the same
 course as before, or along the back of the extre-
 mity already brought down, according to the diffi-
 culty or facility we meet with: which  will be more
 precisely determined by laying down the rules which
relate to each particular case.
  965. By strictly observing the route  which I have
just  laid down, we  shall avoid taking the child's
 shoulder for the hip, the elbow for the knee, and
 the hand for the foot; which it is not always very
easy to  distinguish, when the hand that operates is
 strongly pressed in the uterus: for all these extre-
mities  will present themselves successively to the
fingers, and  not pell mell, as we generally meet with
them, when, according to the advice of most accou-
                      2U 
338          Preternatural Labours.
cheurs, we pass the hand along the child's breast.
Besides,  by  following  that  course, the feet  are
almost always found against the back of the hand,
and we can neither distinguish them, nor take hold
of them; so that sometimes we search for them far
off, when they are  very near: add to that, that we
remove the child's arms from the axis of the trunk,
and  render  turning more difficult. By the first
method, on the contrary, we  bring all those parts
to a common centre, we roll the child up, as I may
say, like a ball, and turn it with greater facility.—
See the paragraphs  853 and 856.
   966. Some practitioners, in whom strength seems
to supply  the place of knowledge,  most frequently
content themselves  with bringing down one foot,
whether the child present the crown of the head, or
any other part. But though  they  sometimes per-
form the delivery by pulling only at one extremity,
sometimes also,  after having luxated,  fractured,
and even torn it off, they are reduced to the shame-
ful necessity  of searching for the other. At most,
it is only when the  waters are but  just drained off,
and the pelvis is of the  natural size, that we may
dispense searching for the second foot, and under-
take to deliver  by one:  but that is precisely the
case in which there is the least trouble in bringing
down both at once.
   967. When we find much difficulty in bringing
down the feet, if we can bring one out, or  only to
the vulva, we must fix a fillet on it, to keep it down
while we  search for the  other.
   968. When we have brought both feet to the ori-
fice of the uterus, it is not always without a great
deal of trouble that we are able to bring them down;
either because it is difficult to grasp them both with
one hand, or  because the  head is  still  retained in 
             Preternatural Labours.          339

the neighbourhood of the superior strait, and cannot
of itself recede sufficiently to allow the  breech  to
engage in it.  Though it is  necessary in that case,
in order to obtain the proposed end, to remove the
head, yet we are not always able to do it conveni-
ently with the same hand which holds the feet; be-
cause we are sometimes obliged to pull them down,
at the same time that we push the head back: which
happens more  particularly when the waters have
been long evacuated, and much more still in some
other presentations.  But as it is impossible  at
once to pull down the feet, and push back the head
with the same  hand, and not  less so  to introduce
both hands together into the vagina,  in order  to
apply one to the head and the other to the feet, we
place a  fillet on one of the latter, to bring it down
by pulling at a distance, while with the other hand,
introduced at the entrance of the uterus,  we remove
the child's head from the superior strait. By acting
thus, a moderate force will suffice to overcome an
obstacle, which that of several persons united, ap-
plied to the feet only, would often scarcely be able
to surmount.
  969. It is  never necessary to  apply  a fillet on
each foot, nor to inclose both feet in one fillet: it is
sufficient to apply it to one, and we generally place
it on that which is next the pubes.*
  970. To apply the fillet, we double it in the mid-
dle, and  pass the two ends through the  loop, so  as
to form a kind of slip knot.  It is  easy to pass it
over the foot as far as the ankle, when it appears at
the vulva; but very difficult, when it is still high up

  * This must depend on which foot is brought down; we
cannot apply a fillet on the foot next the pubes when it is the
one next the sacrum which is down, and when both are down
the fillet is certainly unnecessary.            W, P. D. 
340         Preternatural Labours.
in the pelvis. In that case, some practitioners slide
the loop of the  fillet over the  hand, on the wrist,
and introducing the same hand into the vagina, take
hold of the foot, and slip the loop over it, by push-
ing it  forward with the  fingers of the other hand,
tightening it more or less by pulling the two ends
which hang without.
Of the distinguishing Signs of the first, second, and
   third Species of preternatural Labour, in which
   the Child presents the Crown of the Head, and the
   Manner of turning the Child in those Cases.

   971. I shall here only just repeat the character-
istics of that position of the head which constitutes
the first species of labour, having already treated of
them sufficiently at large  in  another  place.  That
position is such, that the sagittal suture crosses the
pelvis  obliquely, from  the  left acetabulum,  to the
right sacro-iliac junction; the forehead being before
the latter, and the occiput behind the former.
   972. Though it  may seem indifferent to some,
whether they introduce the right or left hand into
the  uterus,  to turn the  child,  immediately after
opening the  membranes, when the head  presents in
this  position, yet, when the waters have been long
evacuated, it is so important to use  the left, that to
the want of attention to this circumstance we may
attribute all the difficulty in  getting hold of the feet,
as well as that apparent  impossibility of doing it,
which has often  obliged  the operator to withdraw
his hand twenty times  before he could accomplish
it. If the  left hand  is so necessary in the  latter case,
it cannot  be denied that it is preferable to the right 
             Preternatural Labours.          341

in the former; for  in both, the left hand has much
less ground to go over than the right, to arrive at
the feet, and with that we may bring them down
in the most natural direction, and turn the child in
the most favourable manner: which it is almost im-
possible to execute with the right  hand, especially
when the waters have been long evacuated, as may
be clearly demonstrated on the machine.
   973.  The left hand is always to  be used in this
species of labour, it must be introduced in such a
manner as the  palm of the hand will apply to the
forehead of the child; the head is to be removed to
the left iliac fossa  where it must be retained by the
wrist and fore arm,  while we search for the feet,
and bring them down as already directed.
   974.  After the feet are brought to  the middle of
the vagina, the head must again be removed from
the superior strait, that the  body may fold more
easily.  If we cannot bring both feet  beyond the
middle  of the vagina, we must let go  one,  and
search for it again when the other is disengaged.
   975.  As soon as the feet appear without, "we must
pull almost entirely,  but for an instant only, on  that
which is under the pubes. By that means we favour
the descent of the breech, we often avoid some  dif-
ficulties, and  constantly turn  the child's breast
towards the left sacro-iliac junction; so that  the
trunk, as it descends places itself in the same man-
ner as in the second  species of the presentation of
the feet. The rest of the operation must be conduct-
ed  as in that species.—See par. 893, and follow-
ing.
   976. The position of the head, which constitutes
the second species, will appear the  same as the pre-
ceding,  if we only consider the proportion between
the dimensions of the head and those of the entrance 
342          Preternatural Labours.
 of the pelvis; since in both the sagittal suture crosses
 that strait obliquely. The difference between them
 is, that in this second position the  occiput answers
 to the right acetabulum, and the forehead to the left
 sacro-iliac junction.
   977. We employ the right hand in  this position
 and  proceed as directed in par. 964, and following;
 when the feet are without  we observe the rule stated
 in par. 1205.
   978. In the third species of labour, in which the
 child presents the crown  of the head, the sagittal
 suture crosses  the  entrance of the pelvis  directly
 from before backwards, so that the occiput answers
 to the pubes, and the face to the sacrum.
   979. This position, of  itself, may render labour
 difficult or preternatural, independently of any other
 cause, when the woman's pelvis is  not perfectly of
 the natural size; because the largest diameter of the
 head presents parallel to  the smallest diameter of
 the superior strait, and in the direction in which
 that  strait is the oftenest contracted: but when the
pelvis is well formed, this position may be as favour-
 able for delivery as the preceding ones.  The indi-
 cation which it presents in the former case, is easily
 deduced  from  what has  been said of the relative
 dimensions of the head to those of the strait.  We
 must remove the occiput  from over the pubes, and
 direct it towards one  of the acetabula: the finsrers
 introduced into the vagina are commonly sufficient
 to procure  this change,  provided  we attempt it
 early.
   980. When  any of those  circumstances occur,
 which require us to turn the  child and bring it by
 the feet,  either hand  may be introduced  into the
 uterus, with equal advantage, provided  the accou-
 cheur be accustomed  to use them equally.  We 
Preternatural Labours.          343
must slide it up, along the sacrum, till we can grasp
the forehead, and a part of the rest of the face. We
then give the head a quarter turn, so as to place the
face on one side; and we must remember afterwards
to do the same by the trunk; because the first move-
ment is confined to the head, and  is effected  only
by a twist of the neck. When we use the right
hand, we turn  the  face towards the woman's left
side, carrying the head towards the right iliac fossa,
and vice versa: and then finish the delivery, as  in
the first and second species, according to the hand
we have made choice of.
 Of the Signs of the fourth, fifth, and sixth Species
  of Labour, where the Child presents the  Crown
  of the Head, and the Method of operating in all
  those Cases.

  981. In the fourth and  fifth of these  species of
labour, the child's head presents diagonally  at the
entrance of the pelvis; but  so that in the  fourth the
occiput answers to the  right sacro-iliac symphysis,
and the forehead to the  left acetabulum; whereas in
the fifth  the  forehead is situated behind the right
acetabulum, and  the  occiput  opposite to the  left
sacro-iliac symphysis.
  982. I  have  obseived in paragraphs  479, 501,
and following, that labour is, in  general, more dif-
ficult when the child's  head presents  in either of
these positions,  than in the  former:  because  in
these the face almost always turns under  the pubes.
But it is  very rare, when the pelvis is well formed,
that this circumstance alone obliges  us to turn  the
child; either  because  the head can pass it, though 
344          Preternatural Labours.
with a little more difficulty, or because the obstacles,
which result from these positions, do  not manifest
themselves till the head is low in the pelvis, and
when  it is too late  to push it back and search
for the feet, the forceps being  then  much more
eligible.
   983.  If the head cannot disengage in this position,
in which the forehead answers  to the arch of the
pubes, we must make  use of the forceps: but if other
circumstances, independent of this position, invite
us to deliver sooner; especially if  they manifest
themselves while the  head is free above the pelvis,
we ought to deliver  by the  feet. The method of
turning the child,  when the crown of the head pre-
sents  in the fourth position, is exactly  the same as
for the second; and in the fifth position we proceed
as in  the firj,t. See the paragraphs 973 and 977,
where I treat of those two species of labour.—I shall
only observe here, that in these two species of labour
especially,  the accoucheur must pull almost entirely
at the foot  which is under the pubes, from the time
they both appear without; that is to say, at the left
foot in  the fourth  species, and at the right in the
fifth; in order to bring down the breech more easily,
and at the same time  to turn the breast towards one
of the sacro-iliac symphyses.
  984.  In  the sixth  species of the presentation of
the crown of the head, the forehead answers to the
pubes in every period of the labour, and the occiput
to the sacrum.   }>
  985. This species of labour, considered as a natu-
ral one, unites all  the difficulties essential to the
third, fourth, and fifth species; for the head presents
its largest diameter to  the smallest one  of the brim,
and the face constantly places itself under the pubes.
   986.  In order to shorten the labour, which in this 
Preternatural Labours.          345
 case is always very tedious, even when the pelvis is
 of the natural size, we ought to turn away tht occi-
put from over the projection of the sacrum, as soon
 as the membranes open, if we are called in time,
 and bring it insensibly towards the arch of the pubes,
 in proportion as the head advances in the pelvis: but
 we must never attempt this change of position when
 the head is entirely in that cavity; for it would not
 then be without very great force, that the face could
 be conducted from under the pubes to the sacrum;
 and  as that  deplacement  could  not be  executed
 without an extraordinary twist to the neck, it would
 be very dangerous to the child, if it did not kill it
 instantly.
   987. When the pelvis is a little narrow, especially
if any  accidents occur, if the head can still be easily
  ushed back, we  may turn the child, and bring it
  y the feet: otherwise we must use the forceps.*
In the former case, we may introduce either hand
into  the uterus; we first apply the fingers to one of
the sides of the head, and the thumb to the other,
in order to grasp it with sufficient strength to turn
the face on one side; that is to say, towards the left
side, if we use the right hand, and vice versa. After
having removed the head in this manner,  and re-
duced it to one of the two first  positions, we con-

  * I believe it would be sound practice in this position to turn
immediately if called in proper time; and if the labour be ad-
vanced to use the forceps. By this means we should save the
woman a great deal of unprofitable pain,  as the chances  are
more than even we should be obliged to have recourse to
them at last. It is to be remembered we except where there
is a great disparity between the size of the head and pelvis,
and where of course the child advances easily. I have seen
two instances of this  presentation, where this obtained, and
where the labour was rapidly finished. These were two twin
cases it may be proper to remark.            W. P. D.
                       2X
I 
346          Preternatural Labours.

tinue to  advance the hand in order to take hold of
the feet, in the manner prescribed in those positions.
Only we must observe, as we proceed, to  turn the
child's breast the same way as the face, and make
the trunk perform the same movement, as was given
to the head at first. Then finish the delivery as in
the preceding species.
   Labours in which the Child presents the Face.
i   ■                                          .
   988. Authors furnish us with a great many ex-
 amples of labours in which the child presented the
 face to the orifice of the uterus, and I could have
 added a pretty, large number to them; because those
tlabours are not extremely rare. Of women, whose
 children present  thus, some have  been  delivered
 without he/p, and the labours of others have been
 extremely laborious.
Of the Causes, Signs, and Differences of Labours in
  which the Child presents the Face, and the Indi-
  cations they prescribe.

  989. Almost all those  who have mentioned this
bad position of the child, have attributed it to an
obliquity of the uterus; and we cannot deny that that
obliquity may be, at least, a remote, or predisposing
cause of it. But whatever may be the kind  or de-
gree of that deviation, the face hardly ever presents
at the beginning of labour: at first, the top  of the
forehead presents, and the face only advances as the
contractions of the uterus  are repeated. 
Preternatural Labours.          347
   990. Those who have perfectly comprehended
 what I have said in par. 950, and following, con-
 cerning the mechanism of the bad situation the head
 sometimes takes as it advances in the pelvis, when
 it presents the vertex, will not be at a loss to explain
 why the face may present; and they will also clearly
 conceive whence the  difficulties  arise  which then
 obstruct delivery, or, at least, always render it ex-
 tremely  long and laborious.
   991. We easily discover the face, by touching
 the woman immediately after the opening of the
 membranes; because the signs which distinguish it
 are not  then obscured  by  the  tumefaction  which
 arises soon afterwards:  those distinguishing signs
 are, the nose,  the mouth,  the  chin, the edges of
 the orbits,  and the suture  which runs along the
 forehead.
   992. I shall distinguish four species of labour, in
 which the child presents the face,  relatively to four
 principal positions which that region may  take with
 respect to the pelvis.
   993. In the first, the length of the face presents
 along the smallest diameter of the superior  strait^
 the forehead is situated over the pubes, and the chin
 answers  to the sacro-vertebral angle.
   994. In the second position, the  length of the face
 presents also parallel to the smallest diameter of the
 entrance of the pelvis:  but the chin is behind the
pubeS, and the forehead before the sacrum.
   995. In the third, the face is situated transversely
 With  respect to the pelvis, so that  the forehead an-
 swers to the left side of it, and the  chin to the right.
   996. In the fourth species, the situation is ex-
 actly  contrary,  the forehead being placed towards
 the right side, and the chin to the left.
   997. These  four positions are  not equally  fre- 
348          Preternatural Labours.
quent; the two latter are the most common, though
even they are  very rare, if we consider them rela-
tively to some of the other positions which have
been already described.  These labours ought to be
accounted preternatural, independently of the acci-
dents which may render those so in which the child
presents in the most advantageous manner. For them
to be terminated without help,  it is requisite that
the head  should be very small, and the mother's
pelvis at the same time very large; otherwise they
become very long and difficult; the children are born
with the face tumefied and livid, and almost always
deprived  of life, or ready to lose it, on account of
the engorgement of the brain.
   998. The most general indication in these labours,
is, to rectify the child's head; that is to say, to make
the face ascend, and bring down the occiput, so as
to reduce the  vertex to its usual situation.  When
we cannot so  happily second the efforts of nature,
either because we are called too  late, or because ac-
cidental circumstances require instant delivery, we
are obliged to  turn the child, and bring it by the
feet,  or extract the head  with instruments, if it be
far advanced, and wedged in the pelvis.
   999.  According to some,  it  is losing precious
time  to endeavour to change this bad position of
the head to a  better, because, say they, we so rarely
succeed in it:  but if we succeeded still more rarely,
we ought never to neglect the attempt,  because of
the advantages the  child may  reap from it, if we
accomplish it, and the danger which often accom-
panies the other methods of delivering.
   1000.  When we propose to reduce the head to
 its natural  position,  it is not so much on the face
that  we ought to act,  by pushing it up, as most
 tccoucheurs have advised, as on the occiput, which 
Preternatural Labours.         349
we ought to endeavour to hook with the fingers, to
bring it downwards.  Experience authorizes me to
say that that may be  executed without much trou-
ble,  when the head  is moveable at the entrance of
the pelvis,  or capable of being easily  pushed back
to it: but it  is always difficult, and often impracti-
cable, when it is low down, and wedged tight; be-
cause the fingers can  no longer penetrate far enough
to grasp the occiput properly.
   1001. If  then  we find nature strong enough to
perform the delivery, we ought to endeavour to re-
duce the head to a good position: but in the con-
trary state,  we must turn, and deliver by the feet,
unless other circumstances forbid it, and require the
use  of  the  lever, or forceps,  as will be more par-
ticularly stated in the sequel of this work.
Methods of operating  in  the  different Species of
  Labour in which the Child presents the  Face,
  when it can  be  done with the  Hand alone.

  1002. The first of these species of labour is one
of the most seldom met with, and the position which
constitutes it is very far from being one of the best.
That position is such, that it can seldom be reduced
to one of those which would favour the exit of the
head; because  the hand cannot be conducted di-
rectly on the occiput to  bring it down, as in the fol-
lowing positions. In order to reduce the head to its
natural  situation in the present case, we must push
up the face by means of the  fingers placed on each
side of the  nose,  which,  however, is not without
inconvenience  to the  child, even supposing little
force to be necessary; or else we must begin by 
3 50          Preternatural Labours.
 changing the position of the face, and directing it
 transversely with respect to the pelvis, that we may
 afterwards apply the hand to the occipital region,
 as prescribed for  the  third and  fourth  positions.
 These manoeuvres not being easy to execute, even
 at the instant the membranes open, with much more
 reason ought we to have little  confidence  in them,
 when the head has already cleared the superior strait,
 and occupies the cavity of the pelvis. It  is almost
 always indispensable in the first position of the face,
 to turn the child and bring it by the feet.*
  1003. To do this we proceed as directed for the
 third  presentation of the head in par. 980, and at
 the same  time,  remembering to observe the same
 caution recommended, of turning the face next the
 hand that operates.—See par.  987.
  1004.  We  cannot expect to reduce the head to
 a natural  position, in  the second presentation;  it
 would be wrong and dangerous to attempt it, but
 when the  membranes have just opened. If we de-
 termine on it then, the hand must be advanced along
 the sacrum, until the fingers can sufficiently grasp
 the occiput to bring it down; it should be directed
 towards one of the acetabula, that it may insensibly
 be brought under the arch of the pubes.
  1005.  When  circumstances require the child to
 be turned, either hand may  be used.  We proceed
as directed in par. 987.
  1006. When we have no other indications to ful-
 fil in  the  third  species of the face  presentations,
 than that of reducing the head to its natural situa-
tion, we must introduce the right hand towards the
left side of the pelvis, till we can bend the fingers

  * I believe it always best both in the first and second posi-
 tions of the face.                         W. P. D, 
             Preternatural Labours.         351

over the occiput, to bring it down by pulling  it
towards us.  If the head is low down in the pelvis,
without however being wedged tight in it, so that
we cannot advance the fingers far enough on the
occiput, we must push up the head, or else endea-
vour very carefully to raise up the  face, by means
of the fingers of the left hand applied to the upper
jaw, and at  the sides of the nose. If we can thus
push up the lower part of the face,  we  give the
other hand more liberty to act on the occiput; but
as we cannot act too cautiously on the face, lest we
bruise and hurt it, if we find  any difficulty in it, it
is better to push up the whole head, and  then en-
deavour to bring down the occiput.
   1007. When we are obliged to  turn the child,
whether we have reduced the head to its natural
position or  not,  we must proceed as in  the first
species where the crown of the head presents. We
introduce the  left hand into the uterus, directing it
along the child's left side, till we can take hold of
the feet.—See par. 973.
   1008. The fourth species of labour in which the
face presents,  differs little from the  preceding with
respect to the mode  of operating; except that we
must execute  with the left  hand all that is  there
prescribed for the right, and  vice versa.
Labours in which the Child presents the fore part
     of the Neck, commonly called the Throat.

  1009. From  the  silence  which  most authors
have observed  concerning those labours in  which
the child presents the anterior part of the neck, we
may infer that they are extremely rare: De la Motte 
352          Preternatural Labours.
is almost the  only one who has mentioned them,
and he has cited but two cases.*
   1010. Cause. Obliquity of the uterus, or the great
quantity of water it may contain.
   Marks. The chin, the top  of the breast, top of
the sternum and  clavicles.
   Indication. Search for  the feet.
     Mode of Operating,
   Either   hand;  when  we
 seize the feet, proceed as di-
rected  for turning in  third
 species of head.
   Left hand invariably, and
^.proceed as  directed in  first
 species of head.
   Varieties.  1.  Where"
the length of the neck is
from pubes  to  the  sa-
crum, face to the pubes,
and  breast  to  the  sa-
crum.
   2.  Face to the sacrum, ?   RiSht or left hand as *e
and hreast to toube*      \ face may be turned from the
ana oreast to puoes.     > lxinihar coIumn.t
   3.  Neck placed trans-
versely, so that the face
is to the left iliac fossa,
and  the  breast  to  the
right.
   4.  Breast  at the  left"!   The right hand, and pro-
iliac fossa and face to the [>ceed.  as d«*cted  in  second
 . , J                    \ species of head.
right.                   j

   * Our author proceeds to enumerate a great variety of pre-
sentations of other parts of the body, with the mode of pro-
ceeding in each;  but as  in all  there  appears to be but  one
resource, that is  turning, I  have thought it best, to merely
enumerate the different presentations marked by him, and
give a succinct analysis of the mode of treatment, rather than
confound the student with such multiplied, and, I conceive,
rather unnecessary distinctions.               W. P. D.
   t It is an invariable rule to use that hand  whose palm can
be applied to the face of the child.             W. P. D. 
Preternatural Labours.          353
  Labours< in which the Child presents the Breast.

   1011. We  shall not be surprised  that there are
scarcely any examples well defined to be met with
in authors, of labours where the child  presented
the fore part of the breast, if we consider the atti-
tude it must take to place itself in that manner. It
may present the back, the loins, the shoulders, the
head, the knees, or the feet, with the hands and the
cord*,  without losing the oval figure in which it is
naturally folded in the womb; but the fore part of
the breast cannot  place itself at the entrance of the
pelvis, unless the  head, at  least, be turned on  the
back.  Some practitioners have even  represented it
so, having also the thighs extended, the legs bent,
and the feet placed on the loins.
Of the Causes, Signs, and Differences of Labours in
       which the Child presents the Breast.

   1012. Cause.  Extraordinary capacity of the ute-
rus, relatively to the foetus.
   Marks.  The ribs,  the clavicles, sternum  and
upper part of the abdotnen.
   Indication.  Turning.

  * Authors are full of cases in which the child present-
ed the hands, the knees, or  the feet, and the cord at the
same time, at the orifice of the uterus. I shall not, however,
treat of those labours as a particular species, because they
require no practical rules, but what are applicable to others,
                       2 Y 
354          Preternatural Labours.
   Varieties. 1. Fore part
of  the  neck  over the
pubes and belly over the
sacrum.
   2. Belly over thepubes,~)
and neck to the  base  of £>
the sacrum.         ,   J
   3. Neck  and head on"^
left iliac fossa, belly on J>
the right.              J
   4. Neck and head onl
right iliac fossa, and bel- ^>
ly on the left.          J
par
  Mode of Operating.
As directed for the neck in
  1010.
ditto.
ditto.
ditto.
  Labours in which the Child presents the Belly.

  1013. Those labours in which the child presents
the  belly, will not appear less  extraordinary than
those where it presents the breast, if we form a just
idea of the attitude it must then necessarily take in
the  uterus; an attitude  which does not seem to be
always precisely the same, if practitioners have dis-
tinguished it  perfectly; for I have found  it vary
from their descriptions. Though in these cases the
child may sometimes have the trunk bent backward,
the  head turned on the  back,  the thighs extended,
and close together, the legs  bent, and resting on
the  loins, as most authors  have  described it, so as
to form a kind of ellipsis,  whose greatest diameter
extends from  the crown of the  head to the knees;
sometimes also, as I  have seen, the inferior extre-
mities are folded in the usual  way, the knees being
only a  little farther asunder, and placed, as it were,
at the  sides of the belly. 
Preternatural Labours.          355
   1014. Cause. The  same as  those of neck and
 breast.                    r
   Signs. The soft abdomen,  terminated by the
 heart and pelvis.
   Indication. Turning.
   Varieties.   1.   Breastl     Mode of Operating.
 over pubes,  inferior ex- i> RiSht or left hand m*> be
     .[.                  j used.
 tremities over sacrum.  J
   2. Breast over sacrum,}          ^tt0
 thighs over pubes.      S
   3. Breast  on left iliac")
fossa:  thighs and  knees J>       Left hand.
 on right.               j
   4. Breast on right iliac]
fossa,  thighs and  knees > XT  t* ^!ghthand-     .
    \r                   j . N. B. The common rules
 on left.                 J for turning to be constantly
                          kept in mind.
   Contingency. The umbilical cord almost always
 down.
Labours in which the Child presents the fore part
  of the Thighs, and of the Pelvis; their Causes,
  Signs, Differences, and the mode of operating in
  them.
  1015. Cause.  The same as determines the pre-
sentation of the abdomen or breast.
  Signs. Abdominal  Tumor; parts  of  generation,
especially of the male, two parallel columns, formed
by the thighs.
  Indication. Searching for the feet.
  Varieties. 1. Knees to"
the sacrum,abdomen over
the pubes, breast and face,
under the anterior part of
the uterus.
  Mode of Operating.
As for belly and breast. 
356          Preternatural Labour's.
  2. Knees towards the"!
pubes,  abdomen, &c. to !>    Mode of Operating.
    „,                      As for belly and breast.
sacrum.
  3.   Child  is  placed"
transversely, knees to the
right  iliac fossa, breast f
and belly over the left.  J
  4. Breast and belly to"|           ditto
right  iliac fossa,  knees ^»  Following the numerical
over the left.           j order.
ditto.
Labours in  which the Child presents  the  different
  Regions of its posterior Surface to the Orifice of
  the Uterus.

  1016. These labours are met with a little oftener
than those in which the child presents one of the re-
gions of its  anterior surface. We have already seen
what a strange and uneasy attitude it must take, to
present the face, the neck, the breast or the helly,
to the orifice of the uterus, and what must be the
concatenation of causes necessary to  produce that
effect.  It  is not so in the labours I am now going
to treat of; very simple causes,  such as an obliquity
of the  uterus, and a greater quantity of water than
usual, may occasion them: because the child, with-
out  losing  that oval form, in  which it is naturally
folded, may present the occipital region, the Itind
part of the neck, the  back and the  loins.
   1017. Nor does the same danger attend these two
orders of labours. Those which 1 am  now going to
treat of are, cateris paribus, less  disagreeable both
for  the mother and child, and present much fewer
difficulties than the former. 
Preterm tural Labours.           357
Labours in which the Child presents the occipital
  Region at the orifice of the Uterus.  Of the Causes
  and distinguishing  Signs of those  Labours, and
  their Indications.

  1018. Cause. Obliquity of the uterus, or great
quantity of water.
  Signs. A solid tumour, on which may be distin-
guished the posterior fontanelle, and lambdoidal su-
ture.
  General Indications. To make the  woman lie on
the side opposite to the deviation of the uterus,  or
on that side on which the crown of the head is placed.
If this  does not  succeed,  the hand must be intro-
duced to bring the vertex to the centre of the pel-
vis.  If  complicated with accidents, we must turn
and  bring by the feet.
                          Particular  Indications  and
                              Mode of Operating.
                            Lay the woman on her back;
                          if this does not succeed, bring
                          the summit of the head down
                          to the entrance of the pelvis,
                         yhy turning it towards one of
                         ^*the acetabula. Then leave it to
                          the efforts of Nature.  When
                          accidents  complicate  it, we
                          must turn, in the same way
                          as directed in the third pre-
                          sentation of the vertex. See
                          par. 978.
   Varieties.  1. Crown of
the head against the pro-
jection of the sacrum,and
the back of  the neck on
the edge of  the os pubis;
back to the anterior part
of the uterus.
   2.  Vertex over the os
pubis, the hind part of the
neck on the base of the
sacrum; back to the pos-
terior part of the  uterus.^
   Turn invariably, observing
 the cautions, &c. for the sixth
^presentation of the  vertex.
 See par. 984, and following. 
358           Preternatural Labours.
   3.  Crown of the head
to the left iliac fossa, hind
part of the neck on the
inferior edge of the right
iliac fossa; back to the
right lateral part of the
uterus.
   4. Crown of the head
to the  right side  of the
pelvis,  hind part  of  the
neck to the left, back of
the child to  the left side.
 Particular  Indications  and
     Mode of Operating.
   The patient  to lie on the
 left side; if this does not suc-
 ceed, introduce the hand, and
p-bring the vertex to its natural
 situation. When circumstan-
 ces require turning, proceed
 as directed for a second pre-
 sentation of the vertex. See
 par. 976, and following.
   Lay the woman on the right
 side; if this be  not sufficient
 to enable  nature  to  deliver
 herself, reduce  the vertex to
>its natural  situation. If acci-
 dents complicate the  labour,
 proceed as in a first presenta-
 tion of the vertex. See 971,
 and following.
Labours in which the Child presents the Back of the
   Neck,  commonly called the Nape,  their  Causes,
   Signs,  Differences, and Indications.

   1019. Cause. Obliquity of the uterus, or an over
quantity' of water, or both.
   Signs.  The spiny tubercles of the cervical verte-
bra; the angles of the lower jaw, and superior edges
of the scapula.
   General Indications. As delivery cannot take place
in any of these cases without assistance, we must
first endeavour to restore the  head to  its  natural
situation, provided the woman is able to go through
the labour. But as this indication for the most part
is difficult to fulfil, it is better in general, to disre-
gard it, and search for the feet; if accidents compli-
cate the labour we must turn, without attempting
other methods. 
Preternatural Labours.          359
 Occipuf]
ie hubea.
  Varieties.  1.
on the edge of the pubes
back over the base of the
sacrum.
  2. Occiput on one side
of the projection of the
sacrum,   and  the  back
over the pubes.
 Particular  Indications  and
     Mode of Operating.
   Turn invariably as directed
 for a sixth presentation of the
 vertex. See par. 984, &c.
   We may attempt to reduce
 the head if called immediately
 after the discharge of the wa-
fers; it is in general however,
 best to search for the feet as in
 a third presentation of the ver-
 tex. See par. 978, &c.
   Try to reduce the head with
   3.  Occiput on the left  the right hand; if this does not
«•/-•   r     u  i      ^.l  >succeed, turn as in a second
iliac fossa, back over the fpreSentation of the vertex.
right.                   J See par. 976, &c.

                            The same indications as the
   4. Occiput on the right  *ast;but the left hand must be
iliac fossa, back over the LemPloyed: if7e turn w« Pro*
i  r,                      r ceed as in a first presentation
left.
of the vertex.
Sec.
See par. 971,
Labours in which the Child presents the Back. Of
 their Causes, Signs, Differences, and Indications.

   1020.  Cause. The same as the preceding.
   Signs.  A large unequal tumour, on which may
be distinguished the spiny tubercles of the vertebra,
the ribs, and inferior edges of the scapula.
   Indications. The  same  as  those  labours of par.
1019, that is turn, and  bring by the feet.
   Varieties.  1. Back of]     Mode of Operating.
the neck, on the edge of.  We employ the right hand
fhe'os pubis, and the loins  to turn, and proceed  a* has
over the sacrum.          been Erected. 
360          Preterftatut&l Labours.
   2. Loins over thepubes,~)     mde af operating.
 nape Of the neck over the I   Proceed asin second pre-
   r       j    r_u  _.  /  >-sentation of the nape oi the
 posterior edge of the pel- rneck  See par.  ml
 vis.
                         'S   We may operate to  turn
                           with either hand, but differ-
   ft  u -j • ■ «t  i  c •;■     ently. If the left, we insinuate
   3. Head in the left iliac  it at7the tight ^cy^a, if the
fossa, the loins  over the fright,  we raise the child and
 right.                     cany the back above the pubes",
                           andsearchforthefeet,and pull
                           almost entirely at the left.
   a  u^r.-i ;«  +u~ -ArAJt\   The same indications as the
   4. Head in  the right l^ ^ ^    ^ ^ ^
 iliac fossa, the loins in the >ther hand acCording/ to  cir-
 left.                     J cumstances.
Labours in which the Child presents the Loins, their
     Causes,  Signs, Differences and Indications.
   1021. Cause. Obliquity of the uterus, or an over
portion of water.
   Signs. The false ribs on one side, and the pos-
terior angles of the ossa ilia on the other.
   Indication. Turn and bring by the face.
                              Mode of Operating.
                            The same as in the presen-
                           tation of the back.  See  par.
                           1020.
X
   Varieties. 1. Back over
the  pubes, breech over
the sacrum.
   2. Breech and feet over
the pubes*  and back and
head to the posterior part
of the uterus.
   3. Back over left iliac-j
fossa, breech and feet over J-
the right.               J
   4. Back and head over-j
the right iliac fossa,breech L
and feet over the left.   J
    ditto.
See par. 1020.
    ditto.
See par. 1020.


    ditto.
See par. 1020. 
Preternatural Labours.          361
Labours in which the Child presents the lateral Re-
               gions of its surface.

   1022. Every one knows that the surface of the
body presents two sides perfectly similar; the right,
and the left; and  that we may distinguish several
regions in them. I shall fix the number necessary to
be distinguished for our purpose  to five: 1. the side
of the head; 2. that of the neck;  3. the shoulder;
4. the side properly so called, or the lateral part of
the breast; 5. the hip.
   1023. Either of these five regions may present at
the orifice of the uterus at the time of labour, though
some of them are met with more frequently than
others, and they present different indications relative
to the mode of operating: for these indications vary
not only for each region,  and their different posi-
tions, but also according as they belong to the right
or left side of the body. The better to demonstrate
all  the  difference between the same regions on the
opposite sides of the body, after having stated what
relates to  any position of a region of the right side,
I shall immediately treat of the same position of the
left  side.  I shall not hesitate even to repeat what  I
have said before,  if necessary to develop the me-
chanism of these labours more clearly. These bad
situations of the child depend on the concatenation
of several causes, which would be difficult always
to determine: an  obliquity  of the uterus, and the
great quantity of water which sometimes surrounds
the child, favour them all, and  seem  sufficient to
occasion some of them, independently of any other
cause.
                      2Z 
362          Preternatural Labours.
  1024. The diagnqstic of these labours is not more
difficult to distinguish,  than those described in the
preceding chapter; and the prognostic of them, ca-
teris paribus, must also  be the same.
 Labours in which the kjhildpresents the right or left
   Side of the Head.  Of their Causes, Signs, Differ-
   ences, and Indications.

   1025. These labours may be the  effect of the
 general causes stated  in par. 1024, or  of one of
 them only: for the great diameter of the child's body
 cannot be parallel to the axis of the pelvis, when the
 uterus is much inclined in any direction, or when it
 contains a large quantity of water.
   1026. We may easily distinguish the lateral parts
 of the head, especially after the evacuation of the
 waters.  We  then find a solid roundish tumour at
 the entrance of the  pelvis,  in which we can touch
 neither the anterior nor the  posterior fontanelle. If
 we meet with any thing like them, it is those mem-
 branous  spaces which are found  at the bottom of
the lambdoidal and  coronal  sutures.  But  the ear,
which is the  most salient part of it, clearly demon-
strates it to be  the side of  the head  that presents.
 We  have then nothing to do,  but  to examine
whether  it be  the right or left side:  to distinguish
which is very essential, in  order to determine  the
best  mode of operating.  To make this distinction,
we must carefully observe the relation which all the
abovementioned marks have to the pelvis; as  we
 shall see in the following position, which will serve
 for an example.
   1027.  In  the first position of the sides of  the 
Preternatural Labours.         363
 head, which is far from being the most common of
 the four I am going to describe, the vertex is over
 the edge of the os pubis, against the anterior part of
 the uterus, and the base of the cranium towards the
 sacrum; so that  the  face  is towards the left iliac
fossa when the right side of the head presents, and
 towards the right iliac fossa when it is the left side:
 which we may distinguish by the situation of the
 posterior edge of the ear, that of the angle of the low-
 er jaw, or of any other of the marks with respect to
 the pelvis. We may be certain that it is the right
 side of the head which presents in the first position,
 if we  find the posterior edge of the ear toward the
 right side of the pelvis.
   1028.  In the second position, which is the most
 frequent, the vertex is situated transversely over
 the union of the sacrum  with the vertebral  column,
 and the base of the lower jaw or the neck over the
 pubes: the face is towards the right iliac fossa when
 the right side of the head presents, and towards the
 left when it presents the left side.
   1029. In the.third position the vertex answers to
 the lower part of the left iliac fossa, and the base of
 the  lowrer jaw to the right; so  that the face lies
 transversely over the sacro-vertebral symphysis when
 the  right side of the head presents,  and under the
 anterior part of the uterus  when it is the left side.
   1030.  In  the fourth position the vertex answers
 to the right iliac fossa, and the base of the cranium
 to the left; so that the face is situated under the an-
 terior  part of the uterus, over the pubes, when it is
 the right side of the head, and over the sacro-verte-
 bral symphysis when it is the left.
   1031. It must be remembered that the head can-
 not present one of its sides at the orifice of the ute-
 rus, without being  bent on the opposite shoulder. 
364          Preternatural Labours.

It will then lie against the left shoulder whenever it
presents  the  right side,  and on the right shoulder
when it presents the  left.  This remark  itself indi-
cates what ought  to be done in all these cases, to
restore Nature to her rights, and enable her to per-
form the delivery^.
  1032.  Labours in  which the child presents one of
the sides of the head present different indications,
according to the circumstances which  complicate
this bad  position.  Sometimes they consist in redu-
cing the  head to its natural  situation, in order to
commit the expulsion of the child to the forces of
the motherland sometimes in turning it, to extract
it by the  feet.
Method of operating where the Child presents one of
              the Sides of the Head.

   1033. The first of these species of labour pre-
sents one of those cases in which it might be proper
to place, the woman on her elbows and knees, if any
advantage were ever to be expected from that situ-
ation; because it seems the most likely to  restore
the head to its natural position: but it is so incon-
venient, that the woman cannot continue  in it any
time, and therefore we ought never to prescribe  it.
It is better to keep the woman on  her back, and in-
troduce one hand to the entrance  of the uterus,  to
remove the base of  the child's cranium from the
projection of the sacrum;  while with the  other we
press  more or less  on the  hypogastric region, to
force down the vertex towards the centre of the su-
perior strait. If we  cannot compass this first inten-
tion, which is to reduce the head to its natural situ- 
Preternatural Labours.          365
ation, we must turn the  child and bring it  by the
feet, as we also must whenever the labour is com-
plicated with any of those accidental  circumstances
which I have repeatedly mentioned.
  1034.  To turn the child when the right side of
the head presents, we must introduce the right
hand into the uterus,  towards the left iliac fossa,
where the face is, in order to remove the head from
that side, and push it towards the right iliac fossa:
then we  search for the feet, and finish the delivery
in.the same manner as in the second  species, where
the vertex presents.
  1035.  When the left side of the head presents in
the first position, we must operate with the left hand.
It must be introduced  towards the right iliac fossa,
where the face is, to direct the head over  the left
iliac fossa, and search for the feet as in the first
position of the vertex.
  1036.  I  have  already observed that the position
of the head, which constitutes the second  species
of these  labours, is the most common of the four,
into which they are divided.  It  cannot occur but
when the uterus is very much inclined forward; and
experience has  frequently convinced me,  that in
most cases, diminishing the obliquity of the  uterus,
by laying the woman on her back, and  as horizon-
tally as possible, is sufficient to restore the head to
its natural situation. If this precaution fail, we must
endeavour to procure the change of position, by in-
troducing one of the hands into the uterus, above
the base  of the sacrum, to hook  the vertex which
lies there, and bring it to the centre of the entrance
of the pelvis.
  1037.  When particular  circumstances   do not
permit us to commit the delivery to Nature,  but re-
quire us to terminate it immediately, we must turn 
366          Preternatural Labours.
the child, and extract it by the feet.  In that case, if
the right side of the head presents, we use the left
hand, which must be introduced above the vertex,
to rectify the  position of the  head, as I have just
directed; while with the other hand we press more
or less on the woman's belly, to diminish the ante-
rior obliquity of the uterus. After that,  we search
for the feet in the same manner as if the vertex had
presented in the first position.
   1038. If we find the left side of the head at the
orifice of the uterus, we operate with the right hand.
We begin, as before, byr bringing  down the vertex
to the superior strait; and then push the head over
the right iliac fossa, in order to search for the feet,
as in the second position of the vertex.
   1039. We cannot call to mind the position of the
head  which constitutes the third  species of these
labours, without perceiving that it is more difficult
to reduce it to its natural situation, than in the pre-
ceding case.  To  procure that reduction, when the
right side of the head presents, we must remove the
child's face from the base of the sacrum, by advanc-
ing the right hand in the  neck of  the uterus, while
we make a pressure with the other on the hypogas-
tric region of the woman, to force  the occiput down
towards the  middle of  the pelvis;  and we must
direct the woman to lie a little on the left side, to
incline the fundus uteri that way.
   1040. We must in some respects proceed in the
same  manner in the third position  of the left side of
the head,  if we attempt to reduce it to its natural
situation.  But it  is much  more  easy to  perform
than in the preceding case, because the occiput rests
on the base  of the sacrum, and we can carry the
hand directly upon it,  to bring it down to a proper
situation at the entrance of the pelvis. 
Preternatural Labours.         367
  1041. When circumstances require us to turn the
child, and bring it by the feet, we use the right hand,
if the right side of the head presents. It must be in-
troduced along the sacrum and under  the  child's
face; we raise the head, carrying it forward, and at
the same time towards the right iliac fossa; then
search for the feet as  in the second position of the
vertex; and finish the delivery as directed in that
species of labour.
  1042. We may also operate  with the right hand
in the third position  of the left side of the head.
We slide it up under the occiput which rests against
the base of the sacrum, and proceed at first as if we
only intended to reduce the head to its natural situ-
ation: but at the same time carrying it on the fore-
part of the  right iliac fossa, in order to search for the
feet, in the same  manner as in the  preceding case.
After having brought them to  the entrance  of the
vagina, we must  observe to pull a little stronger on
the left foot for a few seconds, in order to favour
the movements of the trunk necessary for  the de-
scent of the breech.  The rest of the operation must
be conducted as usual.
   1043. We might also operate with the left hand
in this third position of the  left side of the head;
but we must slide it up towards the right iliac fossa
of the mother, and  push the head towards the other,
in order to search for the feet by passing the hand
along the left side of the child.  If this method,
which is more difficult than that described in the
preceding paragraph, should be preferred, we must
pull almost entirely on the right foot, after they are
both brought into  the vagina; to accomplish the
same views as were intended before, when I direc-
ted the greatest force to be exerted on the left foot.
   1044. When the right side of the head presents 
368          Preternatural Labours.
 in the fourth position, we may reduce it to its natu-
 ral situation without much trouble, by introducing
 one hand under the occiput which  rests against the
 base of the sacrum, and bringing it to the  centre of
 the superior strait, while  with the other we incline
 the fundus uteri a little towards the right side.
 When it is necessary to turn the child, and extract
 it by the feet, we  may use either  the  right or  the
 left hand.  If we prefer the former,  we  must direct
 it towards the left iliac fossa of the mother, to search
 for the feet along the right side of  the child: and
 when they are both brought to the entrance of  the
 vagina, we must pull chiefly on the left foot, to faci-
 litate the conversion of the trunk,  and the descent
 of the breech in a proper direction. The rest of the
 delivery to be conducted  as usual.
   1045. If we use the left hand, we must  insinuate
 it along  the sacrum under the occiput, to bring it to
 the  centre of the  superior strait, as if  we only
 wanted  to reduce the head to its natural situation;
 we then remove the head  from the entrance of  the
pelvis, pushing it over the forepart of the  left iliac
fossa, and then search for the feet along the child's
 left side. As soon as they are both disengaged from
 the uterus,  we pull only on the right foot, to bend
 the trunk more easily on its anterior part, and favour
 the descent of the breech; after that we pull equally
 on both  feet, and finish as in the  preceding case.
   1046. To reduce the head to its natural situa-
 tion, when the left side of it presents in the fourth
 position, we introduce one hand at the entrance of
 the uterus, and backward, to raise the face which
 lies  against the base of the sacrum; while with the
 other we exert a pressure on the hypogastric region
 of the woman, strong enough to force the occiput
 down towards the superior strait.  Having accom- 
Preternatural Labours.         369
plished this purpose, we may turn the woman  a
little on her right side, to rectify the  axis  of the
uterus, too much inclined to the left, and make  it
parallel to that of the pelvis; then leave the delivery
to the efforts of Nature.
   1047. When  we cannot  reduce the  head to its
natural  situation, or accidental circumstances re-
quire immediate delivery, we must turn the child,
and extract it by the feet. For that purpose we must
introduce the left hand in a  state of supination,
towards the posterior part of the uterus. We remove
the face as we go along from the base of the sacrum,
on which it rests transversely, carrying  the head at
the same time on the fore part of the left iliac fossa.
Then we trace the left side of the child, to take hold
of the feet, and finish the delivery according to the
rules prescribed for the other positions.
Labours in which the Child presents one of the sides
  of the neck. Of the Causes, Signs, and Differences
  of these Labours.

  1048. Labours in which the child presents one
of the sides of the neck, are less frequent than the*
preceding, though they proceed from the same ge-
neral causes: which we must doubtless attribute to
the particular form of those regions.
  1049. It is impossible to distinguish  the  lateral
parts of the neck, and judge of their situation rela-
tively to the pelvis of the mother,  before the open-
ing of the membranes;  nor then, without introdu-
cing the whole hand into the vagina: but we ought
not to make such  an examination  till it is time to
deliver;  that is to say, till the parts of the woman are,
well prepared, and the pains very strong.
                        A 
 370          Preternatural Labours.

   1050. This region itself offers no sensible mark
 to the touch, whereby we can distinguish it from
 others. It is only by the  top  of the  shoulder, the
 clavicle, the angle of the lower jaw, and the lower
 part of the ear, which circumscribe it, that we can
 discover it; it can never present at the orifice of the
 uterus, without the greater part of these marks being
 near the circle of it.
   1051. In  the  first position  of either side of the
 neck, the ear and the angle of the lower jaw are
 placed on  the edge of the os pubis, and the shoul-
 der is over  the  base of the sacrum.   The face is
 towards the  left  side of  the mother when the right
 side of the neck presents, and vice versa.
   1052. In  the  second  position, the angle of the
 lower jaw and the ear are  situated against the base
 of the sacrum, and the shoulder is over the pubes;
 so that the face answers  to the  right iliac fossa when
 the right side of the neck presents, and the left iliac
fossa when it is the left side.
   1053. The child is placed transversely over the
pelvis in the two other positions.  In the third, the
 side of the head  is found  resting  on the left iliac
fossa, and the shoulder on the  other. The face an-
 swers  to  the sacro-vertebral symphysis when the
 right side of the  neck presents, and to the  anterior
 part of the uterus, over the os pubis, when it is the
 left side.
   1054. In the fourth position, the side of the head
 rests on the  right iliac fossa, and  the shoulder on
 the left; the face is placed transversely  over the
pubes if the right  side of the neck presents, and over
 the sacro-vertebral symphysis when it is the left side. 
Preternatural Labours*          371
Of the Indications, presented by these labours, and
         the Mode of operating in them.

   1055.  Wf  have  nothing to  expect from the
forces of the mother, when one of the sides of the
Child's neck  presents at the orifice  of  the uterus,
except after we have brought the head or the feet to
the passage. But it is always so difficult to accomplish
the first of these indications, that I would advise it
never to be attempted, but to search for the feet in
all these cases.
   1056. The manner of operating is absolutely the
same as in the different species of labours where one
of the sides of the head presents. We must proceed
in each position of the right side of the  neck, as in
that of the  right side of the head  described  by the
same numerical name; and in  the different situa-
tions of the left side, we must follow the directions
given for those of the left side of the head.
Labours  in  which  the  Child presents one  of the
  Shoulders. Of their Causes,  Signs, Differences,
  and Indications.

  1057. Though these labours seem to depend on
the same causes as the  preceding, they are  never-
theless much more frequent; which no doubt arises
from the shoulder's b;eng more salient and rounded,
whereby it accommodates itself better to the form
of the entrance of the pelvis, than the side of the
neck can.
  1058. It is easy enough to discover the shoulder
by the touch;  by the clavicle, the angle of the sea- 
372          Preternatural Labours.
 pula, the arm, and the ribs. When the hand comes
 down, it  sufficiently denotes the presence  of the
 shoulder at the orifice of the uterus, and may also
 demonstrate, in what manner it is situated, and whe-
 ther it be the right or left shoulder.
    1059. The shoulders may present  in  different
 positions at the orifice of the uterus. In the first, the
 side of the neck  rests on the edge of the os pubis,
 and the side  of the breast over the sacrum; so that
0 the fore part of the  breast is  towards the left iliac
 fossa when the right shoulder presents, and towards
 the right iliac fossa when it is the  left shoulder.
    1060. In the second position, the side of the neck
 is over the superior edge of the sacrum, and the side
 properly so called is over the pubes; the breast aiv
 swers to the right iliac fossa when the right shoulder
 presents, and vice versa.
    1061. In the third, the neck and the head rest on
 the left iliac fossa, while the side and the hip are over
 the  right;  so that the back is  placed transversely
 under the anterior part of  the uterus when it is the
 right shoulder,  and on the posterior part of that
 viscus when it is  the left.
    1062. The child is also placed transversely in the
 fourth position of the shoulder; but the head lies in
 the right iliac fossa, and the lower part of the trunk
 over the left; the breast is under the anterior part of
 the  uterus when it is the  right shoulder, and over
 the sacrum when is is the left.
    1063. The indication in these  labours is easy to
 perceive: it consists in extxi jjpg the child  by the
 feet. In all these cases we shuuld be little founded
 in advising the reduction of the head to its  natural
 situation. 
             Preternatural Labours.         373


  Method of operating when the Child presents the
                    Shoulder.

   1064.  When the child presents the shoulder in
 the  first of the four positions stated above, it is by
 no means indifferent whether we introduce the right
 hand or the left into the  uterus to search for the
 feet; especially when the  waters have been some
 time evacuated.  The  right  hand  is  exclusively
 proper when it is the right shoulder; and vice versa.
 In the first case we slide the hand along the  poste-
 rior and left lateral part of the uterus, removing the
 shoulder from the entrance of the pelvis, pushing it
 as much as we can over the right iliac fossa; in or-
 der  to get hold of the feet, and bring them succes-
 sively into  the vagina. If we meet with any diffi-
 culty in  bringing them entirely down,  after having
 brought them so far,  we must remember to remove
 the  shoulder again from the superior strait, in the
 same manner  as I have frequently recommended
 the head to be  removed from it.
   1065.  When the left shoulder presents, we intro-
 duce the left hand along the posterior and right late-
 ral part of the uterus, in order to turn the child. We
 first remove the shoulder from the entrance of the
pelvis, pushing it towards  the left  iliac fossa, and
 proceed  in the  rest of the operation with the same
 precautions as  in the preceding case.
   1066. In the second species, if the right shoulder
 presents, we introduce the  left hand along the right
 lateral part  of  the uterus,  in order to find the feet,
 and  turn the child in  the easiest manner. We re-
 move the shoulder from the entrance of the pelvis,
 as we go along; then the head, which is a  little far-
 ther off;  and direct them towards the left iliac fossa, 
374          Preternatural Labours.
 while we incline the fundus uteri a little to the right
 side, by pressing externally on the woman's belly.
 When  we have reached the feet, we bring  them
 down successively; and if we meet with any diffi-
 culty in bringing them entirely down, we must re-
 move the shoulder anew  from the superior strait.
 The rest of the operation to be conducted as usual.
   1067.  We operate on the same principles in the
 second position of the left shoulder: but we  must
 search for the feet with the right hand.  We intro-
 duce it towards the left side of the uterus, and re-
 move the head and shoulders from the superior strait
 as we go along, directing them over the  right iliac
fossa; while wre incline the fundus uteri to the  other
 side, by making a convenient pressure on the wo-
 man's belly.  After that we bring down the feet with
 the usual precautions, and finish the operation as in
 the preceding cases.
   1068. When the right  shoulder presents in the
 third position, we  must introduce the right  hand
 along the posterior part of the uterus, passing it un-
 der the child's breast, which we must remove from
 the lumbar column of the  mother, carrying it over
 the os pubis,  till the shoulder be entirely disengaged
 from the superior strait; we then search for the feet,
 directing the  fingers along the right side of the child.
 When they are brought down to the entrance of the
 vagina, we must pull a little while almost entirely
 on the  left foot, taking  hold of it with the fingers
 only, while with those of the other hand we  push
 the shoulder  farther and farther above the os pubis,
 in order to favour the flexion and rotation which the
 trunk should execute, that the breech may  engage
 more freely.   Afterwards we  pull equally on  both
 feet, and continue  to extract  the  child,  as if those
 extremities had presented naturally. 
             Preternatural Labours.         SI5

   1069. When the left shoulder presents, in order
to find the feet easily, and bring them down in the
most favourable manner, we must introduce the
left hand, nearly in a middle state between that of
pronation and supination,  along the left  side of the
child, and the anterior and right lateral  part of the
uterus,  till the fingers meet with them. We then
bring them down successively, beginning with that
belonging to  the side which the hand has passed
over, but taking care to make them both pass over
the child's breast. We then pull almost entirely on
the right foot,  while with  the fingers of the other
hand we push the shoulder  up above the projection
of the sacrum.  Afterwards  we act equally on both
feet with the usual  precautions.
   1070. The method of operating is not more in-
different in the fourth position  of each shoulder,
than in that which I have just described. When the
right shoulder presents, we must introduce the right
hand along the anterior and left lateral part of the
uterus,  bending it  a little over  the pubes, till the
fingers can hook the feet, to bring them down suc-
cessively, beginning with the right foot, and making
them pass over the child's breast, behind the pubes
of the mother. As soon as they are both in the va-
gina, we pull only on the  left foot,  while we push
the shoulder upward and backward, with the ends
of the fingers, as recommended in par. 1069; espe-
cially if we find any difficulty in bringing down that
foot. We then act equally on both extremities, till
the breech is engaged, and finish the operation as
in the other cases.
  1071. When the left shoulder presents  in the
fourth position, we  must slide the left hand into the
uterus, carrying.it in a state  of supination under the
child's breast.  We disengage the shoulder by lifting 
376          Preternatural Labours.
it up above the edge of the os pubis; we aftenVards
direct the fingers towards the right side of the wo-
man, tracing along the left side of the child, passing
successively over the hip and  thigh  to the  foot:
having brought the  latter into the vagina, we pass
the hand again into  the  uterus to bring down the
other; when it is brought as low as the first, we con-
tinue to pull on it till the breech is engaged. After
that  we pull on both  equally,  and extract the  child
according to the precepts already given.
 Labours in which the Child's Hand presents first.

  1072.  I thought it better to class those labours
in which the child presents one of its hands, under
this article,  than any other,  though the hand may
present when the shoulder is not placed over the
entrance  of the pelvis: because in those cases the
hand rarely escapes alone from  the  uterus; which,
on the contrary, very often happens  in the different
species of labour which make the subject of the two
preceding sections.
  1073.  Among  the precepts which have  been
transmitted  to us concerning these labours, there
are many which are contrary to  the principles of
the art, and to those sentiments of humanity with
which all men ought to  be endued. Nothing can
excuse the cruel practices which have been so often
exercised on those unfortunate children who present
the arm  first,  especially  that which is but too fre-
quently done at the present day.
  1074.  To throw more light upon what concerns
these  labours, I shall distinguish  the different cir-
cumstances in which the hand may present; because
we must  not act in the same manner in all of them. 
Preternatural Labours.          311
  1075.  The hand often presents at the orifice of
the uterus before the membranes are open; at other
times it  does not  appear and engage in it till long
after the  waters  are discharged. The hand almost
always accompanies the head in these circumstan-
ces, and cannot advance without the head's engaging
in the pelvis at the same time: sometimes it appears
along with the breech, or any other region  of the
child's surface. If it oftener denotes the presence of
the shoulder at the orifice of the uterus, when it is
descended very low, it is because the shoulder pre-
sents oftener than most of the other regions, the
head, the breech, and the feet excepted.
  1076.  It is very rare that the presence of the
child's hand obstructs delivery, when it accompa-
nies the head, the breech, or  the feet, at the  orifice
of the uterus, if the woman's pelvis be well formed;
because  in that  case  it is larger than is necessary
for the passage of a head of the  usual size. In most
women, when the hand engages with the head, and
continues to advance before  it,  it produces but fee-
ble obstacles to the progress of labour, and even
those obstacles do not exist  every time it presents
before the membranes  open, or  at the instant of
their opening; because it generally recedes of itself,
and the  head engages alone: it is easier to explain
this effect, than to comprehend why it does not al-
ways happen in similar cases.
  1077.  But though the presence of the child's
hand can generally oppose but  feeble obstacles to
the descent and exit of the head, it is however right
to prevent them; and it is better to push it back than
let  it come down, when we discover it  betimes.  1
have often demonstrated, in presence of my pupils,
that supporting the child's hand with the extremity
of a finger, pressing it against the head,  and direct^ 
378           Preternatural Labours.
ing it towards the face, while the head itself engaged
in the superior strait, was sufficient to make it dis-
appear.  We  do not push it up, but hinder it from
coming down, till the head has got under it; after
which it will go up of itself. We must never attempt
to push it back when the head is low down in the
pelvis; but, if it visibly obstructs delivery, remove
the arm from the side of the cavity, towards one of
the ischiatic notches.
   1078. It is only when the pelvis  is defective, and
a little narrow, that the exit of the  child's hand can
produce great obstacles  to that of the  head at the
same  time.  But  then there is the utmost necessity
of pushing the hand above the head, if the time be
not  past;  that  is to say, if the head be not too far
advanced, and wedged among the bones of the pel-
vis:  for in that case it is sometimes better to deliver
with the forceps.*

  * I find several examples of the application of the crotchet
in similar cases; but only one of the application of the forceps,
and that was after the cranium was perforated, and the brain
evacuated. The two following cases  tend to demonstrate that
the presence of the arm does not prevent the use of the latter
instrument, and that its utility is not less evident in this than
in many other circumstances.
  The 29th of January, 1776, I was  called to a woman of low
stature, the small diameter of whose pelvis, was at most but
three inches and a quarter at the brim. She was at her full
time of her first child, and had been in labour twenty hours;
eighteen hours had elapsed since the waters were evacuated,
and the pains were very strong. The child's head presented
well,  the occiput being turned towards the left acetabulum;
but it was scarcely at all engaged, though the great tumefac-
tion of the scalp made it appear far advanced. The fore-arm
placed on the  right  side, and strongly pressed behind the
pubes, made a deep depression in the scalp, like a gutter, and
was itself so strangulated, that the hand was swelled in an
extraordinary manner, and very livid. The labour having been
very severe, her pulse was quick and hard, her face inflamed, 
Preternatural Labours.           3l'9
   1079. It very rarely happens that both hands pre-
sent with the head,  and more rarely still that we are
©bliged to push it back, and turn the child, on ac-
count of this  slight complication,  so  easy  it is to

respiration difficult, and the abdomen hard and painful. Af-
ter having bled  her  a  second  time, for she  had been  bled
three hours before, I endeavoured to push back the child's
hand; but not being able to do it, and presuming  that, if I
could, she would not be delivered without a great deal of diffi-
culty, on account of the narrowness of the superior strait, and
the exhausted state of her strength; and foreseeing  also too
much danger in  turning the child, and bringing it by the feet,
I applied the forceps.  I conducted  them as I have directed
for that position of the head, sliding the branches to the height
of seven inches  at least, in order to take hold of it properly,
having first pushed it up above the strait, to give more liberty
for their application;  and I brought the child alive: though it
appeared a little fatigued, it so well recovered by the methods
I  used, that  an  hour after its birth  it was as strong as any
other. M. Legrand, D.  M. Professor of Midwifery at Amiens,
was present at this labour.
   My brother applied the forceps in a similar case, June 25th
1785, in presence of two foreign physicians and surgeons, cor-
respondents of the Royal Academy of Surgery at Paris, Messrs.
Audiberty and Assaliny, who then attended my lectures. The
child's hand had been without more than five hours; the arm
appeared as far as the elbow, was swelled, livid, and cold; it
came down on the right side of the pelvis, and a little behind
the pubes. The head, large and solid, occupied the lower part
of the pelvis; it had cleared the neck of the uterus, and had a
a  tumor on the vertex, which  entirely concealed the sutures
and fontanelles, and prevented a discovery of its true situation.
The woman was weak, and had a very small pulse: the labia
pudendi  were swelled, inflamed, and covered with vesicles.
On one side, the woman was in danger of sinking before she
was delivered, if it were not performed  quickly; on the other,
there was as great a  risk of the child's life from any hasty
measures, and the head could not be pushed back to bring it
by the  feet.  My brother determined to use the forceps, and
by their help preserved the lives of both. In  four days, the
tumefaction of the hand, the fore-arm, and head of the child
was dissipated, and on the fifth the woman could  sit up. 
380         Preternatural Labours.
remedy it. We ought not to recur to that often dan-
gerous expedient, but when we cannot re-establish
the head in its natural situation, after having  re-
turned the hand into the uterus.
   1080. The presence of the hand or the arm at the
orifice of the uterus, in whatever direction it may
be, presents no particular indication before the open-
ing of the membranes; and afterwards we have only
to consider the principal region of the child which
presents, and its position, to  determine the mode
of operating.
   1081. Some have imagined that they could  ex-
tract the child by pulling at  the arm; others that
we ought to return the  arm into the uterus, in or-
der to turn the child, and extract  it by the feet.
Some have torn off the arm, and even both of them,
by twisting them round till they pulled them away
from the body; and some, from a principle of  hu-
manity, have amputated the arm as high as possible,
with sharp nippers,  or otherwise,  thinking amputa-
tion less cruel than tearing it off; or have contented
themselves with making deep incisions into it, with
a view of lessening its size, when it has been tume-
fied, and appeared  gangrened. An accoucheur of
the last age* advised passing a fillet round the body,
by means of  a blunt  hook pierced, to bring down
the breech, while the  breast is pushed up;  and in
our days, another has proposed to  search  for  the
child's other  hand,  when  we  cannot penetrate  the
uterus to find the feet.f
   1082. Those who  know the relation which the
dimensions of a  child  at full time,  whose  arm  is

   *' Peu, Pratique des Accouchemens, p. 412.
   t M. de Leurie, Traite des Accouchemens, edit. 2, p. 311,
Sc smivans. 
Preternatural Labours.          381
out of the uterus, bear to those of a pelvis of the
natural size, will see clearly what is to be expected
from efforts exerted on that extremity, with a design
to extract the body.  If delivery has sometimes been
terminated in that manner, it was because the  child
was very small, and the mother's pelvis large enough
to let it pass double: these examples are extremely
rare, and cannot serve for general rules.
   1083. Returning the arm into the uterus, would
be much more laudable, if it could be done in all
cases: but except when the waters are recently
drained off, we cannot accomplishit; and all attempts
for that purpose would  be dangerous in proportion
to the force employed.
   1084. The reduction of the arm, always difficult,
and generally impossible, is not essentially neces-
sary in any of these cases.  It is not the presence of
that extremity engaged in the passage,  which op-
poses the introduction  of the accoucheur's  hand;
that could not of itself hinder it from penetrating to
search for the feet, and turn the child. It is the con-
traction of the uterus itself, the hardness of its  neck,
and the little dilatation of its orifice, which  are the
obstacles, if any are met with.  It is easyT to  con-
vince ourselves of this truth, if we consider the na-
tural size of the woman's pelvis, the extreme dilata-
tion of which the  orifice of the uterus is susceptible,
and that which it undergoes  in all labours; and  es-
pecially  by comparing its dimensions when  fully
dilated, with the  hand of the accoucheur added to
the child's arm.
   1085. The bigness of the arm,  even when  swel-
led to the greatest degree, can never entirely fill the
passage, and that extremity, joined to the operator's
hand, never surpasses the size of the breast or head
of the child.  Now if the orifice of the uterus is sus- 
382          Preternatural Labours.
ceptible of so  great a dilatation, and the pelvis is
naturally large  enough to give a passage to those
parts; if we have seen them clear this double pas-
sage, though preceded or accompanied by an arm,
or one of the inferior extremities, as in those labours
where the  child comes with the breech foremost;
how is it possible to believe that the arm, either in
its natural state, or swelled, can oppose the entrance
of the accoucheur's hand into the uterus? How has
it been possible to persuade  sensible persons, that
the arm could entirely block up the passage, that it
was right to amputate it, or tear it off, and that that
operation was necessary?
   1086. When we proceed to deliver at the moment
of the evacuation of the  waters, if the neck of the
titerus is supple, and its orifice well dilated, we in-
troduce the hand into it, and turn the child with as
much ease as if the  arm had not come  down. In
some cases,  where  the  presence  of the arm has
seemed to oppose the greatest obstacles to the intro-
duction of the hand, a sudden flooding has removed
those obstacles, and given an opportunity of termi-
nating, without farther trouble, a labour whose dif-
ficulties began to  be looked  upon as beyond the
salutary resources  of the art,  from the repeated
efforts that had been  made  in vain to  surmount
them.  But what more could that  haemorrhage do,
than relax the neck of the  uterus, weaken its resis-
tance, and  dissipate the natural or spasmodic con-
traction of the whole body of that viscus?  And what
is there in  that which art cannot operate with less
danger than Nature has sometimes done it with ac-
cidentally?
   1087. The true indication in all these cases con-
sists in procuring this suppleness in the fibres of the
uterus, whenever they do not enjoy that favourable 
Preternatural Labours.          383
and even necessary disposition for delivery, before
we attempt to turn the child, whether the arm pre-
sent  or not.  By accomplishing this first intention,
the accoucheur will prepare himself an easy access
to the child's feet, and will no longer think himself
in the melancholy necessity of tearing off or ampu-
tating the arm of the unfortunate infant. He will also
be convinced that it is not  necessary to return it
into the uterus, in order to finish the delivery.
   1088. Even the putrefaction of the  arm, which
might seem to leave  no  hope for  the child but in
amputation, cannot authorize us to practise it before
delivery; because if it be indispensable, it can  be
done much  better afterwards, than while the child
is inclosed in the womb.  Those practitioners who
have taken off this limb, only because they thought
from its putrefaction  that the child was dead, will
not appear less  culpable in the eyes of the skilful,
who know that this putrefaction is often only local,
that it is no certain sign of death, and that many who
thought they were only mutilating a dead  carcase,
have mutilated,  and afterwards extracted,  a  living
child.  Those examples show us with what caution
we ought to proceed  in all these cases.
   1089. Whatever may be the state of the arm come
down,  it always requires less attention than the state
of the body  and neck of the uterus. If that has not
been fatigued by ineffectual efforts, or by imprudent
hands, if its  neck is supple and wrell dilated, we must
introduce the hand into it, according to the  rules
laid down for each position of the shoulders, in order
to search for the feet,  and turn the child, in the same
manner as if the arm  were not come down.
   1090. When the uterus is in a state of spasm,
which  is not very common,  or is already  strongly
cqntracted on the body of the child, it must be soft- 
384          Preternatural Labours.
 ened and relaxed by proper methods, such as bleed-
 ing at the arm, baths,  &c. And we ought never to
 attempt to deliver, till  we have satisfied this first in-
 dication, which is always the most urgent in these
 cases. I  must observe  here that we ought not to be
 afraid of letting blood  copiously, when the case re-
 quires it, by repeating the bleeding at the arm; but
 that it would be dangerous to take for a rule on this
 subject the advice given by a young physician in
 1774, at  that time scarcely initiated in the elements
 of midwifery.* Experience had not yet taught him
 how much was to be hoped or feared from those re-
 peated bleedings,  which he looked upon as the sheet
 anchor of the woman.f

  * M. Alphonse le Roy, Journal de Medicine  du mois de
 Mais 1774. This was the first year that he began to practise
 and teach the art of Midwifery.
  t I cannot pretend to determine  how frequently Le  Roy
 has advised bleeding to fulfil the intended indication laid down,
 never having seen the work alluded to; but must differ from
 our author, when  he  supposes the necessary relaxation  may
 be procured by other means than blood-letting; I believe it to
 be the  only remedy  that can with  certainty  be employed,
 where local  inflammation, fever, and  rigidity  accompany
 the labour. But 1 agree, it should not  be done  by repeated
bleedings;  as I rather believe them ineffectual, if not some-
 time mischievous.  If any benefit is to be derived  from bleed-
 ing, it must be performed quickly and extensively; by quick-
 ly, I mean, a large quantity drawn in a short space of time;
for this purpose, a large vein and a large orifice are necessary;
by extensive bleeding, I wish to be understood, until the  pa-
tient become sick or  faint, or at least until the uterus is suf-
ficiently relaxed. This happy disposition of the uterus is some-
times obtained in a few minutes by a large bleeding, as I have
demonstrated to my pupils in several instances. 1 have obliged
one of them to introduce a finger into a rigid os uteri, while I
drewblood from the arm, and my rule  for stopping was syncope,
an approach to it, or until I  was informed by the person touch-
ing, that the wmis was sufficiently dilated.     W. P. D. 
              Preternatural Labours.         385

   1091. A state of spasm, or a strong contraction
ef the uterus, are not the only causes which may
hinder us from passing the hand into it, in order to
turn a child whose arm is without. Frequently we
cannot do it, merely because the orifice of the ute-
rus is but very little dilated, at the time that extre-
mity comes down, and its edge is still too thick and
rigid to permit it to open farther, without great incon-
veniences; because the membranes have  burst pre-
maturely, and the pains  have not  yet had time to
procure  the requisite dilatation.  All attempts  to
deliver immediately would not be less  dangerous
in this case, than- when the uterus, fatigued  by the
length of the labour, or affected by a spasm, strongly
opposes the entrance of the hand. They would only-
augment the difficulties naturally attendant  on this
epoch of labour, either by exciting the contraction
of the neck  of the uterus, or by depriving the parts
of the woman of the mucus designed  by  Nature to
soften  and relax them, rendering them painful, and
disposing them to inflammation, or by accelerating
the tumefaction of the child's arm:  which would
render the ease, already sufficiently disagreeable in
itself, much more so.  We must then wait  till the
fibres which constitute the edge of the orifice of the
uterus are moistened, weakened and relaxed; in one
word, till they acquire the necessary degree  of sup-
pleness for the requisite dilatation, or till that dila-
tation take place  spontaneously, before we attempt
to operate. During this  delay, we ought to avoid
touching the woman too frequently, as some do with
a view of assisting the dilatation, lest we should pro-
duce the contrary effect. If the resistance of the neck
of the  uterus does not yield to the natural efforts of
labour, bleeding at the arm,  baths, and  emollient
injections may be of great use. We may give it the
                       3 C 
 386          Preternatural Labours.

 necessary time, because the presence of the arm
 never of itself offers any very urgent indication.*
   1092. From I have said concerning labours in
 which the child's hand is without, and the arm en-
 gaged in the orifice of the uterus, we may establish
 the following principles:  1. That in all these cases
 we ought to attend more to the state of the uterus,
 than to that of the extremity of the child, which of
 itself presents no essential indication, except some-
 times after delivery, when it happens to be tumefied,
 livid, or gangrened: 2. That we ought never to at-
 tempt to return it into the uterus when the  waters
 have been sometin_e evacuated:  3.  That  its reduc-
 tion, though possible at the time  the membranes
 open, that is, at the instant of its escape  from  the
 uterus, is not essentially^ necessary: 4. That it is con-
 trary to  the  principles of the art to tear off or ampu-
 tate  the  limb: 5. That it would be absurd when the
 child is living to think of extracting it by  pulling at
 its arm,  as well as to attempt to search for the other
 hand, when the strong contraction of the uterus, and
 the little dilatation of its orifice prevent our entering
 it to search for the feet:  6. That it would not be

  * I would observe here, I believe it to be the best practice
 not to wait too long for the powers of nature to relax the ute-
 rus, after the arm has come down; as they are very often tardy,
 and in some instances never accomplish the object. I conceive
 it a duty to relieve the woman as quickly as possible.  Inflam-
 mation very soon comes on in these cases, more especially
 where the woman has been  officiously touched; to  act as
 quickly after the escape of the waters as the uterus will allow,
is not  only desirable, but sometimes essential to the  welfare
of the child; therefore as we have a remedy at hand, namely,
copious bleeding, I think it best to employ it.  Should it not
be immediately successful, which, by the by, will very rarely
happen, it will at least, very much hasten the  desired object,
                                        W. P. D. 
Preternatural Labours.          387
rational in these cases, to hook the other hand and
pull at it, in order to change the position of the child's
trunk, even if it should be near enough to the orifice
to be brought out by insinuating some of the fingers
only into it: 7.  That we must always search for the
feet and turn the child, but that it would be danger-
ous to attempt  it before the parts of the woman are
well prepared for it, either by nature or art.
  1093. It often happens  in these capes,  that the
child's  hand disappears, and seems to return into
the uterus, in proportion as the  feet descend, this
effect, the  cause of which is easily discovered, is
not always fortunate for the child. If the arm some-
times places itself so in the pelvis, as afterwards to
rise  to the  side of the head, in the same manner as
when the  child presents the  feet naturally; at other
times also, the  arm folds in the pelvis, and the elbow
buts against  some point of the sides of that cavity,
and  obstructs the descent of the trunk, or else ex-
poses the humerus to be fractured.
   1094. To avoid these inconveniences, we must
take care  to make this  extremity descend in the
same proportion as the trunk. Therefore if it disap-
pear entirely, as soon as the  thighs are  disengaged,
we ought to search for the hand again, and keep  it
extended along the side of the body. It would how-
ever be more certain and expedient to apply a fillet
on the child's wrist, before  we search for the feet,
as I have recommended long since, in a little work
published  for midwives. We may reap a double ad-
vantage from this fillet; 1. That of fixing the child's
arm lengthwise against one of the sides of the pel-
vis, in order to prevent its folding in that canal,
while we  introduce  the hand into the uterus,  to
 search for the feet; 2. That of preventing the incon-
 veniences stated in the preceding paragraph. If we 
388         Preternatural Labours.
employ the fillet, we must take care not to pull it
while we endeavour to bring down the feet, lest we
fix the shoulder at the entrance of the pelvis,  at a
time when it must necessarily recede from it; but
remember to do it as soon as the breech is engaged
in the passage.
Labours in which the Child presents one of its Sides.
   Of their Causes, Signs, Differences, and Indica-
   tions.

   1095. Cause. The same as for the back and loins.
   Signs. The ribs, the axilla, the arm, the hips; the
right or left side may be distinguished by attending
to the situation  of these  parts with  respect to the
pelvis.
   Indication. Turning and bringing by the feet.
   Varieties. 1. The ax-
illa of  either  side  may
rest on the pubes, and the
    Mode of Operating.
  If the right side presents we
use the right hand; if the left
hip over the sacrum; the uide the left hand;  we seize
breast towards the left Hi- *the feet and finish the delive
ac fossa, when the right
side  presents, and vice
versa when the left.
  2. The axilla over the
base of the sacrum and
hip over  the pubes;  the
breast answers  to right
iliac fossa when it is the
right side, and vice versa.
 ry as directed in par. 1064 for
 the first presentation of shoul-
 der.

   When the right side pre-
 sents we use the left hand, and
 vice versa; we grasp the feet
r»and finish the labour as direct-
 ed for the second presentation
 of shoulder. See par. 1066. 
Preternatural Labours.          389
   3.  The axilla on left"
iliac fossa, the hip on the
other, breast to posterior
part of the uterus, when
the right  side presents,
and vice versa.
   4.  The axilla to right*
iliac fossa, the hip on the
left; back to the posterior
part of the uterus, when
right side presents, and
vice versa.
     Mode of Operating.
   If the right side,right hand,
v.if the left, the other; finish as
in a  third presentation
shoulder. See par. 1068.
of
   When the right side pre-
 sents, the left hand must be
>used, and vice versa; finish as
 in a fourth presentation of the
 shoulder. See par. 1070.
Labours in which the Child presents one of the Hips
   at the Orifice of the Uterus. Of their Causes, Signs,
   Differences, and Indications.

   1096. Cause.  Obliquity of the uterus, or a super-
abundance of the liquor amnii, or both.
   Signs, Crista of the ilium, the  last of the false
ribs, the anus, &c.
   Indication. Bring down the feet.
   Varieties.  1. Breech"
over the base of the sa-
crum; the  crista of  the      Modc °f Operating.
ilium against the pubes; )>  Right hand when right hip
breast to the left Udf> nf f Presents>and viceversa;finish
oreast to the lelt side ot  as directed for breech or feet
the uterus, when right hip
presents, and vice versa.
  2. Breech againstpubes,'
crista of the ilium to the
sacrum; breast  towards
the right side, when right
hip presents, andvicever-
sa.
   When right hip,  we use
>the left hand, and vice versa;
 finish as above directed. 
390        Labours of the third Order.
  3. Breech on the bot-
tom of right iliac fossa,
crista of the ilium towards
    Mode of Operating.
  When right or left presents,
we first endeavour to change
the position of the child by
the left; the breast to the i>obliging the woman to lie on
posterior part of the ute-
rus, when the right hip
presents, and vice versa, j or breech
   4.  Breech on left iliac'
fossa, crista of the ilium
towards the right; breast
under the anterior part of
the uterus, when right hip
^presents, and vice versa._
her right side. If this does
not succeed we introduce the
left hand and finish as for feet
   We oblige the woman to lie
 on her left side; if this fails,
>we use the right hand tobring
 down the feet and finish as for
 feet or breech presentations.
    Labours of the third Order, or Laborious.

   1097.  Although the term laborious mayr seem
to be applicable only to those labours which are ex-
ceedingly difficult, and which cannot be terminated
without the help of instruments, I shall however make
use of it to signify all those which compose this third
order, and which could not be performed in a more
advantageous manner, than with some of those same
instruments. I confess that among those labours,
there are many which are less difficult, less painful,
and less dangerous than the greater part of those
which I have described under the name of preter-
natural, and even than  many  of those which are
usually considered as natural.
   1098.  Though the impossibility, or the danger
of operating with the hand alone, constitutes the dis-
tinguishing character of laborious labours; though
Lhe absolute or relative necessity of employing some 
Of the Forceps.             391
instruments to terminate them, establishes a kind of
relation among them, yet they present us with very
great differences, and their species are not less va-
rious than those of the two preceding orders: those
differences arise, as we shall see hereafter, from the
nature of the circumstances,  or accidents, which
render those labours impossible or dangerous with-
out the help  of instruments;  from the diversity of
those instruments; from the parts of the mother, or
of the child, on which they must be applied; from
their mode of acting, and from the consequences of
their application, &c.
   1099. In order to lay down what relates to this
latter order of labours with more clearness and me-
thod, I think it right to treat first of the instruments
necessary to be employed in them. Some I shall only
mention; but I shall dwell on the description, and on
the mode of acting of the forceps, and the lever, a^
being of more general and familiar use.
 Of the Forceps, and their general Mode of acting.

   1100. The name alone of this instrument might
give to those who know its true signification, a ge-
neral idea of its form and mode of acting; it is be-
sides in such common  use, that I might dispense
with any description of it. It is a species of pincers
or lever, composed of two branches perfectly simi-
lar; except at the place of their junction, where we
remark, in one  of them, a moveable pivot, and in
the other, an opening fit to receive  it.*

  * It will be understood that I speak here only of the French
forceps, and particularly of those of M. Levret. 
392             Of the Forceps.
  1101. From this difference arise the names which
serve to  distinguish  the two parts of the forceps;
that which has the pivot is called the male branch,
and the other the female.
  1102.  Each of them represents, in one third of
its length, or thereabouts, a  kind of spoon, open
nearly through its whole extent;  round the inner
edge*of it runs a flattish ridge, which might  be ef-
faced with advantage;  for though it may give the
instrument a little firmer hold on  the head,  some-
times it hurts the teguments, bruises and tears them,
so as to denude the bones. The rest of the branch
forms the handle of  the instrument, the  extremity
of which  is terminated by a blunt hook, an inch
long, and a little curved. We  have already seen the
benefit which may be derived from these hooks in
some particular cases (see par. 935); and they would
be much fitter for the use I have made of them in
those cases, if they only described a gentle  curve,
or even almost a right angle with the body of the
instrument, if they were a little  narrower,  more
rounded, and terminated somewhat in the shape of
an olive.—See par. 935.
   1103.  The  invention of the  forceps is not very
ancient. Without assigning the exact epoch  of it, I
shall remark that they were scarcely known before
every accoucheur eagerly applied himself to making
alterations in them: but not all  with the  same suc-
cess. Though some have brought them nearer per-
fection, others have  made  them  more  imperfect.
None have laboured more successfully in this way
than Smellie and Levret: so much did they change
the form, and extend the advantages of this  instru-
ment,  that we  might even look upon them a.e the
authors of it. Among the corrections they made in
it, none is of more importance than the double curve 
                Of the Forceps.              393

which they added to it: but it would be difficult to
decide, to which of those two equally celebrated men
the art is most indebted in this respect.
   1104.  The English forceps nevertheless differ a
good deal from those of M. Levret. Those of the
latter appear to me more  perfect, and  have advan-
tages which would be vainly sought in the former.
Some changes might however still be made in them:
but perhaps, and I perceive it would be so, in per-
fecting them in one respect, we should render them
more imperfect in another. As it is not the instru-
ment which operates,  but the hand which directs it,
the understanding easily supplies those little defects;
and unless they appeared greater, I should leave it
to those who are proud of inventing new instruments
to correct them.
   1105. Some have lengthened M. Levret's forceps
several inches, and othershaveeffaced the ridge which
runs along the interior edge of their blades; others
have increased the new curve; while some, by alter-
ing the form of its branches, by dividing them, and
substituting a number of pieces to the simple pivot
which fixed them in their junction, have made it a
most complicated instrument, without rendering it
more recommendable. If the former have increased
the advantages of the forceps, by making really use-
ful corrections in them; the latter have rendered their
use more difficult and less certain on some occasions.
   1106. The forceps which I prefer are two inches
longer than those of M. Levret: which renders their
new curve much easier.* We shall see in the sequel

   * By the new curve of the forceps, we are to understand
that which is placed on their  edges: so M. Levret explains it.
The addition in length is  not  my invention; we are indebted
to M. Pean for it.
                      3D 
394             Of the Forceps.
the reasons which lead me to choose them so. Ex-
perience has convinced me, notwithstanding the vain
clamours of ignorance, that they have no more in-
conveniences, in skilful hands, than the shorter for-
ceps, and that there are resources in them, in many
cases, which cannot be obtained from the latter.
   1107. The forceps may be considered as the most
useful  of all surgical instruments, for no other has,
like  that, the advantage  of preserving the lives of
several individuals at once, without hurting either
of them;  but on that very account, perhaps, no other
instrument will appear more fruitful in inconveni-
ences.  If it should be proved, and I am not very-
far from believing it, that the forceps have been more
fatal than useful to society, that they have destroyed
more than they have saved from inevitable death, I
should nevertheless look upon them as the most im-
portant discovery that has ever been made in the art
of midwifery. Those who regard them as an instru-
ment  absolutely  dangerous, and entirely useless,
neither know their mode  of acting, nor the difficul-
ties  of the art, and have doubtless judged them ac-
cording to the abuse which they themselves have
made  of them; and have forgot that the most salu-
tary instrument often becomes  murderous  in the
hands  of ignorance and prejudice.
   1108.  The use of the forceps has bounds, beyond
which they become useless, and even dangerous;
and  the manner of using them is not arbitrary. Their
application is subject to  certain rules, and it is on
the strict observation of those rules, that the advan-
tages to be expected from them depend. When ap-
plied  without method, or principles, far from ob-
taining the  good expected  from them, they some-
times  only  serve to  perpetuate  the obstacles, and
even to  augment them in proportion to the efforts 
Of the Forceps.             395
made to conquer them; and, in many cases, we can-
not terminate a labour  by their assistance, which
Nature would easily have done, if she had not been .
counteracted.
   1109.  The forceps were at first proposed only to
extract the head  stopped in  the passage, in those
cases where  it was suspected to be locked; if we
consider  their form, dimensions, and relation to all
the other parts of the body, we shall see, in fact,
that they are  proper only in that sort of cases; but
their  use, then too limited, is since become a little
more general. Besides that practitioners have recom-
mended  them for taking hold of the child's head
above the pelvis, when it cannot engage in the pas-
sage; others have prescribed them for extracting it
after the  exit of the trunk,  and for disengaging  the
breech, when it is too far advanced and too  closely
wedged,  to be expelled by the natural powers, or
to be pushed back to search for the feet.
   1110.  If the forceps may be reckoned among the
resources of the  art in this latter case, it can only
be as a means of extracting the breech, but not of
saving the child's life.  If they should be applied in
that case,  what disorders would they not produce
within the breast and abdomen? The extremities of
the forceps acting on the sides of those cavities, re-
duces them tranversely to  the  breadth of  an inch
and a half, or two inches, if  we grasp  them suffi-
ciently tight, to get  a proper hold for extracting the
child; as I have proved on a great number  of dead
children. We often fracture some of the ribs, strong-
ly compress the viscera, and contuse the liver, which
is very voluminous at that epoch, if we advance the
blades to that height, on the child's sides; and if we
do not, it would be vain to expect a firm hold with
the instrument. 
396              Of the Forceps.
   1111. Even the death of the child, if we could be
certain of it when the breech is strongly wedged in
the passage, though it would destroy the apprehen-
sions of danger from the pressure, ought not how-
ever to determine us in favour of the  forceps; be-
cause there are other methods more simple, and a
great deal  more certain.  The  forceps themselves
present them to  us  in  the extremities  of their
branches:  the blunt  hooks,  which terminate them,
are exceedingly convenient in these cases, and might
be made much more so by means of the little altera-
tions suggested in par. 1101.
   1H2. The forceps then  ought never to be ap-
plied but with a view to extract the head; and their
advantages and inconveniences are proportionate to
the relation which exists between the dimensions of
that part, and those of the pelvis.  When  that rela-
tion is in the natural  order, the forceps, well direct-
ed, do no injury to the mother or child; but  when
that natural relation  does not exist, and the head
cannot pass through the pelvis without a considera-
ble reduction of its size, both of them are more or
less affected.
   1113. It is commonly thought that the forceps
cannot compress the head in one direction  without
forcing  it  to lengthen  in another; and that these
changes take place in a reciprocal proportion; that
the capacity of the cranium  suffers  no diminution,
and that the  brain is but slightly affected by them.
Such advantages  would render the forceps much
more recommendable still than they are; but these
are very far from  being their real effects.  We can-
not, by compressing the head in one direction, oblige
it to lengthen in another; or if we do,  it is so little,
that it cannot balance what it loses in the first di-
rection. If the  forceps compress it four lines only, 
Of the Forceps.             397
the cavity of the cranium almost always diminishes
in the same proportion, and the brain is exceedingly
affected by it. To put these truths out of doubt, let
us suppose  the  head locked and fixed lengthwise
between the pubes and sacrum of the mother; a spe-
cies  of locking for which this instrument has been
particularly  recommended.  From the manner in
which most practitioners still apply the forceps, it
should  seem that they imagine the head is always
in this position.
   1114. If  we then apply the forceps on the sides
of the head, compressing it from one parietal pro-
tuberance to the other, we certainly shall not force
it to lengthen from the occiput to the forehead, since
those two parts are in very close  contact with  the
pelvis. If the forceps, in this case, tend to force the
occiput forward, and the forehead backward,  it can
only increase the force with which they are pressed
against the pubes and sacrum; for the interior circle
of that cavity remains always the same. Neither can
the head, thus fixed, lengthen from the  summit to
the base, except a very little;  the  sinus of the in-
strument being much too narrow downward for that
effect to be very remarkable, even if the disposition
and solidity of the bones were more yielding: what
it gains that way can by no means compensate what it
loses in the direction in which it is compressed. If
then the forceps, applied in this manner,  diminish
the transverse thickness of the cranium^ it is only
 by depressing the parietal bones, by flattening them,
and much more by making them ride one over the
 other at their superior edges: which cannot happen
 without contracting the cavity which contains the
brain,  compressing  it, and more or less deranging
 its organization.
   1115. We must not argue concerning the effects 
398              Of the Forceps.
of the forceps from  those  which we see the head
sometimes suffer in passing naturally through a nar-
row pelvis; because  there  is scarcely any parallel
between the two cases; the form of the mould, which
such a pelvis presents to the head, being very differ-
ent from that of the forceps, and the powers of art
being  never so gradual, nor so well combined as
those of Nature.
   1116. The head pushed  forward for  hours to-
gether by the natural agents of delivery,  becomes
insensibly softer and more pliable, and at  length ac-
quires the necessary disposition for  moulding itself
to the form of the pelvis.  If it then flattens in one
direction, it really lengthens in another; the form of
the cranium only changes,  and its cavity contracts
so little, that the  brain is scarcely affected by  it.  I
have taken children  whose  heads seemed to have
lost  nine or ten  lines of their natural thickness, in
passing the superior strait, and seemed to have
lengthened  in the  same proportion, without com-
prehending the tumor formed in the  scalp, before
the posterior fontanelle. The  heads of several of
these children  were  above  six inches and an half,
and  even seven  inches long, from  the chin to the
top of the aforesaid tumor; while the thickness from
one parietal protuberance to the  other was but two
inches and  an  half, or two and three quarters  in
some, and three inches in others.*  In a few hours
afterbirth, the heads of these children spontaneously
recovered the thickness which they had lost in de-

  * M. Solayres informed us one day in his lectures, that he
had taken a child the evening before, whose head, at the mo-
ment of birth, was eight inches long all but two lines, mea-
sured between the  two points indicated above; while it had
preserved but two inches five or  six lines  in  thickness. The
clay after, this head had recovered the usual dimensions. 
Of the Forceps.             399
livery, and lost the length they had acquired by it.
The head not only loses its form thus,  in some
cases,  but sometimes even bends in the manner of
a crescent,  so that one of its sides shall be a little
concave,  and the  other rounded, without at all af-
fecting the child's life.
   1117. But this good fortune is so far from attend-
ing all children who are obliged to traverse a pelvis
of less than  three inches in the small diameter, that
the greater part of them perish before they are born.
Among those which I have dissected, some had the
bones of the cranium fractured, with depression; in
others, those same bones were profoundly depressed
without  fractures; and in all, the pericranium and
dura mater were detached from  the parietal bones
in the environs of the sutures; the substance which
unites  these bones was torn; which proves that they
had rode considerably over each other; there were
deep engorgements and extravasations in the cranium,
as well as on several parts of its external  surface.
The fate of these children therefore will be different,
according to the degree of solidity in the bones of
the cranium, and of firmness  in the sutures.
   1118. The effects of the  forceps always to be
dreaded on the child's account, when there exists a
disproportion between its  head and  the  mother's
pelvis,  must be more or less so in proportion to
these different states of the bones of the  cranium.
Those accoucheurs who imagine that we may with
that instrument diminish the size of the head six
lines and more, without danger, in all probability
form their judgment from some observations simi-
lar to those  I have just stated in par. 1115, and not
from the effects of the forceps themselves. They es-
timate the degree of compression which the head
suffers between the blades of the instrument, by the 
400             Of the Forceps.
  degree of force  which they apply to extract it; by
  the separation of the external extremities  of the
  branches,  and the degree of approximation which
  they undergo in the operation,  or  the space they
  pass through to come into contact.  For one fortu-
  nate case, which they produce in support of their
  assertions, they perhaps pass over ten in silence,
  which, though unfortunate,  might have instructed
  us equally. The following experiments may serve
  to throw some light on the degree of reduction which
  the  head may undergo between the blades  of the
  forceps.
    1119. These experiments were repeated on nine
  children, who died immediately, or a few hours af-
  ter their birth; and were of different sizes, though
  all  at full  time. To render them more conclusive,
  we took care to restore to the heads of these children
  the same suppleness which they had when alive, by
'  plunging them into warm water, and moulding them
  with the hands; and we made use of the.lengthehed
  forceps mentioned in par. 1105. We provided three
  pair, all alike,  of the best construction and temper.
  We applied them on the transverse thickness of the
  head, as I recommend them to be alwayrs applied;
  and  afterwards according to its length, that is, one
  branch on the  middle of the  forehead, descending
  from the fontanelle to the root of the nose, and the
  other on the occiput; in order to know the reduction
  we could procure in those two directions, and how
  much the head would gain in one,  while it lost in
  the other. Whatever distance there was between the
  extremities of the handles of the forceps, when the
  blades were applied to the sides of the head, we
  brought them  close together, and fixed them in that
  state by means of a ribband, that the  reduction of
  the head might not vary, while we measured its di- 
Of the Forceps.             401
mensions anew, in order to compare them with what
they were before the experiment. It cannot be ob-
jected to us, that the heads of all these  children
might have been reduced still farther between the
blades of the forceps, than we reduced them; since
in each experiment we brought the handles  of the
instrument together till they touched at the extremi-
ties opposite to those same blades; and because the
force which we used, sometimes with the  hands
alone, and sometimes with the ribband which  served
to fix and tie them together, was  such, that those
three select pair of forceps which we had provided,
were all so bent and deformed, that they could not be
used again, without being retouched by the maker,
I shall now give the result of our experiments.
   1120.  The head of the  first child,  which was
three inches and a quarter thick, from  one parietal
protuberance to the other, could not be compressed
more than  three lines in that direction; and  was so
far from lengthening from the forehead to the occi-
put,  that it lost more than  a line in that,  though it
was at liberty on a table; and three lines more, from
the chin to  the top of the posterior fontanelle. The
parietal bones crossed each other superiorly a line
and a half, and seemed to advance as much over the
edges of the frontis and occiput. This  same head,
taken from the forehead to the occiput, was com-
pressed to eight lines; and  the  handles of the for-
ceps, then  separated an  inch  and three  quarters,
could not be brought nearer than the distance of six
lines notwithstanding all the force Ave could use.  At
that degree of compression  the sagittal suture open-
 ed, the teguments burst in the middle of that suture,
 and a portion of the brain escaped.
   1121. Another head, of the same thickness, could
 not be reduced more than two lines; and its length,
                       3E 
402             Of the Forceps.
which was four inches, did not vary. Taken in the
latter direction, we could not compress it more than
three lines; and to accomplish that, we employed so
much force, that the instrument lost four lines of its
curves,  that is to say, that the extremities of the
blades were four lines farther distant, than they were
before the experiment.
   1122. A third head, of three inches two lines thick,
could be reduced but two lines in that direction, and
afterwards five in its length. These three heads ac-
quired no increase in length, while they were com-
pressed transversely;  nor any additional  breadth,
whatever  reduction was made  from the forehead to
the occiput.
   1123. A  fourth, of three inches four lines  from
one parietal protuberance to the other, but softer
than the preceding, and having the sutures and fon-
tanelles more  lax, was compressed four lines, with
more facility than the  second  and third had  been
compressed only two;  and its  length was increased
half a line.  Taken between the blades in the latter
direction, it was reduced eight lines, but its thick-
ness did not augment.
   1124.  The fifth  head,  as soft as the fourth, and
having  two lines less thickness, being compressed
with the  same degree of force, also lost four lines,
and gained nothing in its length. Taken from  the
forehead to the occiput, it lost half an inch, without
increasing its  thickness.
   1125.  The sixth, which was  only  three inches
thick, was  reduced four lines and an half, and did
not lengthen in any direction. Pressed from the fore-
head to the occiput, it lost eight lines, and its thick-
ness was  increased one line.  In this degree of re-
duction, the region of the anterior fontanelle became
very salient, and  an opening of six lines made with 
                 Of the Forceps.             403

a history instantly discharged a portion of the brain
as large as a hen's egg.
   1126. A seventh head, three inches and a quar-
ter thick, could not be compressed more than three
lines: and an eighth, of three inches eight lines, could
be reduced only three lines and an half.*
   1127. We may conclude from these experiments,
1. That the reduction which the child's head suffers
between the*, blades of the forceps, is different in some
respects, according as the bones of the cranium have
more or less solidity at the time of birth, and as the
sutures, as well as the fontanelles, are more or less
firm; 2. that  that reduction can,  in  no case, be  so
great as accoucheurs have pretended, and that it will
very rarely, and not without great difficulty, go be-
yond four or  five lines when the instrument acts  on
the  sides of the head;  3. that we ought never to es-
timate  its extent by the separation of the handles of
the  instrument at their extremities, and the degree
 of approximation they are made to undergo before
 we  extract the head, nor by the  force we apply to
 bring them thus together:  4.  and lastly,  that the.
 diameter, which crosses the direction in which  we
 compress the head, far from augmenting in the same
 proportion as the other diminishes, does not usually
 increase a quarter of a line, and sometimes decreases.
   1128.  It will be objected, that a head more  vo-
 luminous than those of the children I have just men-
 tioned, which we took at random  from among many
  others, would suffer a greater reduction than we pro-

   * It may not perhaps be unimportant to observe that we
  took the dimensions of all these heads with a pair of cahpeis,
  before  the experiment;  and that we marked the points  with
  ink, on which the branches of them were placed, that we migh.
  measure them again between those same points, when m the
  greatest degree of reduction. 
404             Of the Forceps.
 cured in our experiments, if we employ force enough
 to bring the handles of the forceps, which are then
 farther separated, close together. The reduction cer-
 tainly would be greater, if  the head, at the same
 time  that it were larger, were also softer; but by be-
 ing greater, it would only become so much the more
 dangerous for the child; since it cannot take place
 in any circumstance, without diminishing the capa-
 city of the cranium nearly in the same degree. If the
 head  be larger than those which served for our  ex-
 periments, it will  generally, at the  same time, be
 more solid, and much less susceptible of compres-
 sion,  unless the child be hydrocephalic. A head of
 four inches two lines from one parietal protuberance
 to the other (there are very few of that size at the
 time of birth), could not be reduced more than two
 lines; and the force requisite for that was so great,
 that the instrument was bent with it, and the blades
 were  opened an inch at their extremities.
   1129. The partisans of the forceps, and perhaps
 I am  the most strenuous one living, may also plead
 that the bony circle formed by the distorted pelvis,
 through which we endeavour to bring the head en-
 gaged between the blades of the instrument, must
 act on those same blades, like the ring which is  put
 on  the  handles of some pincers, and which, being
 advanced on them, closes their jaws, and more firmly
 fixes what they takefhold of; since the forceps, thus
 disposed,  form an ellipsis whose belly" is  above  the
 said bony circle. The force of this argument cannot
 be denied; it is very certain that the resistance of
 the bony circle in question, would produce the same
 effect on the forceps, as the ring on the handles of
the pincers, and would approximate  the  blades, if
the diameter of the bead, already compressed, should
 still surpass that of the pelvis, and if a sufficient force 
Of the Forceps.             405
be used to bring it through that canal.  But as the
pressure which the instrument then makes on the
parts of the woman, interposed between the back of
the blades and the bones of the pelvis,  is  equal to
that which the child's head itself suffers, what dis-
agreeable consequences may we not expect from it?
Whenever the hand cannot conveniently reduce the
diameter  of the head by means of the forceps, in
cases of disproportion, that instrument  ceases to be
recom mendable.
   1130. Ii it seems impossible to determine the de-
gree of absolute compression which the head suffers
between the blades of the instrument, from the space
left between the extremities of the handles, and the
approximation they are made to undergo, because
the reduction is subordinate, as I have already stated,
to the solidity of the bones of the cranium, to the
state of the sutures and fontanelles, to the manner in
which the instrument takes hold of the head, to the
length of its branches, to their temper, &c. it is not
less so to fix the degree beyond which the reduction
cannot be carried, without affecting the child's life,
which would be much more important to discover:
for its effects, relatively to the latter, are also differ-
ent, according to those same circumstances, and to
many others which may arise from the duration of
the efforts to which it has been exposed before the
application of the instrument. This however appears
certain, that a reduction of a given extent, when
made naturally, is attended  with much fewer bad
 consequences, than a similar reduction made with
 the forceps; because  it is brought about by  infi-
 nite gradations, and the latter must be made much
 quicker, notwithstanding the utmost possible slow-
 ness with which the accoucheur can act.
    1131. Some practitioners are of opinion that the 
406             Of the Forceps.
reduction may be carried much farther than was
done in our experiments; and affirm that it may go,
not only six lines, but also to an inch, or an inch
and a quarter, and that even at that degree it is not
very dangerous to the child.  Those  practitioners
are equally in an error on both these points: if there
existed an instrument with which we could possibly
reduce the diameter of the head an inch, it ought to
be rejected as a murderous instrument. If the  re-
duction of the head must be carried to that degree,
to kill the child, we should never have a right to at-
tribute  its  death to the forceps; for there  are none
which can reduce it so much.  And  supposing that
there were, they could not be prescribed while the
child is living; the intention of the art being as much
to preserve the child, as to extract it from its mother's
womb.
   1132. In order to ascertain that the child's head
has been reduced to such or such a degree, without
killing  it, the diameter on which the forceps have
been applied should have been measured  before it
was compressed; and should be measured  again af-
ter the exit of the head, in the state of reduction in
which  it was between the blades of the instrument:
which  no one has done, or ever will do. The gradu-
ated scale  which some have recommended to be
adapted to the handles of the forceps with that view,
could only serve to demonstrate the degree of sepa-
ration  and approximation of them, and not the re-
duction of the head.  Therefore we ought to place
no confidence in all that has been published on this
point;  because we have only general data, and those
very uncertain.
   1133. By  comparing the degree of separation at
the extremities of the handles of the forceps, in all
our experiments, with  what I have observed in  the 
                Of the Forceps.             407

course of my practice, whenever I have placed the
instrument on the sides of the head; and the degree
of force used in both cases, to approximate the han-
dles and bring them into contact, I can affirm, that
the reduction may go from two to four lines without
affecting the  child's life: but it is  not easy to deter-
mine  how much farther it can be carried, without
causing its death.
   1134. These reflections will appear of the utmost
importance to those who have declared openly against
the use of the forceps, and think it their duty to pro-
scribe them, under the vain pretence of defending
the cause of humanity: for, according to their prin-
ciples, the forceps necessarily adding the thickness
of their two blades, which is three lines, to the thick-
ness of the head, we must have a reduction of three
lines to compensate that addition. Therefore that re-
duction, which we cannot look upon as exempt from
every kind of inconvenience, seems to  them of no
use in delivery, since the thickness of the head
 with that of the instrument, remains the same rela-
 tively  to the diameter of the  pelvis. This reason-
 ing would be unanswerable, if we could compress
 the head but three lines, if the greatest thickness of
 the blades answered exactly to the parietal protube-
 rances, if those protuberances did not let themselves
 into the open part of the blades, so far as to be often
 level  with their external surface, and if the belly of
 the ellipsis formed by the instrument thus charged
 with  the head, exactly corresponded with the small
 diameter  of the pelvis. But things go on in a very
 different manner from what the detractors of the for-
 ceps have stated, especially with respect to some of
 these points, when they are  directed by a skilful
 hand.                            .            .
    1135.  If the forceps, conducted in the best and 
408             Of the Forceps.
 most methodical manner, are not without inconve-
 nience  to  the child,  when there is a disproportion
 between its head and the mother's pelvis, with much
 more reason is it so, when that instrument is in the
 hands of those  who, forgetting the axiom, sat citb
 si sat bene, imagine that their honour and their suc-
 cess depend on the celerity with  which they  ope-
 rate:  for instead of one victim, they often destroy
 two; the forceps, directed upon such principles, be-
 ing not less dangerous to the mother than the child.
   1136. The advantages of the forceps are never
 more evident than in those cases where it is only re-
 quired to assist or supply the strength of the mother;
 as well  as when we are led to use them only on ac-
 count of certain accidents, which sometimes com-
 plicate the labour, such as  an haemorrhage,  &c. But
 we are not always so fortunate as to have to use them
 only in such circumstances; and notwithstanding the
 danger  which seems attached to their use  in other
 cases, we are often obliged to have recourse to them
 to avoid operations  whose  success would be still
 more doubtful.
   1137. When  the small diameter of the mother's
pelvis is some lines less than three inches, we must
 not expect to bring the child alive, by means of the
 forceps; and their use is even dangerous when it is
 but three inches. Considering that instrument  only
 as a resource for terminating the delivery,  and  ab-
 stracting the fatal effects it may have on the child's
 life, and the parts of the mother; yet its use ought
 to be limited: for its application  is by no means
 safe, when the pelvis is so defective as not  to leave
 an opening of two inches six or eight lines. For in
 whatever manner we then apply  it, we ought to
 reckon  much less on the reduction it will procure,
 than on the advantage to be derived from it, as a 
                 Of the Forceps.             40

means of pulling at the child's head, and  by that
means seconding the expulsive efforts of the  mother.
   1138. Most authors have net used the forceps till
the child's head was descended into the cavity of the
pelvis, or at least engaged a third, or half its length.
Smellie seems to have  been the first who departed
from that rule, and  who employed them while the
head was still above the superior strait.  It was par-
ticularly with that view that he constructed his second
forceps longer than those he used at first, and added
a new curve to them, similar to that of Levrefs for-
ceps. Smellienoi only knew the possibility of carry ing
them so far, but also that it was easier to apply them
there, than when the head is engaged transversely in
the  superior strait,  and its sides strongly  wedged
between the pubes and sacrum; since in that case  he
recommends to  push it up entirely above the  brim
of the pelvis, in order to conduct  the blades of the
instrument on the child's  ears more easily.
   1139. Smellie knew how at the same time to esti-
mate the advantages and inconveniences of taking
hoicl of the head above the pelvis, with his  new for-
ceps. Having observed that the  latter were  often
greater than the former, he resolved not to  advise it
publicly, and not to demonstrate, even to his disci-
ples, all the benefit that might be derived from it,  for
fear, said he, of rendering them too enterprising.
   1140. He  among us  who honours Roederer with
being the author  of the  idea of taking hold of a
head free above the brim of the pelvis, with the  curv-
ed forceps, doubtless had not read the works of Smel-
lie, which are anterior to what that author has trans-
mitted us on the art of Midwifery: he  might there
have seen, not only what I have  just  related, but
moreover, that a Mr.  Puddicombe, as lar back as
the vear 1743, had successfully  delivered a child
                       3  F 
410              Of the Forceps.
with the forceps, whose head was still above the
superior strait. Besides, the fact related by Roederer
cannot be attributed  to him:* we see dearly in
the observation  itself, that  he is only  the  editor
of it.
   1141. If Mr. deLeurie is the first French accou-
cheur who has carried the forceps so far, as he de-
clares,!  he is not the  first who recommended  it
among us; for he says nothing about it in the edition
of his work  of  1770; and the late M. Solayres.%
who recommended it in his private lectures  from
the year 1769, put it in practice himself, in presence
of several of his pupils, in 1770. I have used the
forceps myself at least twenty times since, in simi-
lar circumstances;  but not always with the  same
success for the child, nor could it be,  because, in
some cases, I had not recourse to them till after its
death. It seems also that M. Coutouly, who likewise
attended the lectures of Solayres, practised it on the
same authority.
   1142. The utility of the forceps is not limited to
those cases only, in  which the crown of the head
presents at the  orifice  of  the uterus:  we employ
them also in other circumstances; as when the
child's face engages first, when the head is retain-
ed after the exit of the body, as we sometimes see
it in labours  where the child is extracted by the
feet. It  is also in the works of Smellie that we find
the first traces of the use of the forceps in the lat-
ter case; and that  author is so much esteemed
among  us, that 1 am inclined to  think it was from

  * Opuscula Medica Gottingae, 1763, pag. 206, obs. 1.
  t I know not in what year he applied the forceps  on the
head at the superior strait for the first time.
  I M. Solayres professed midwifery at Paris from 1769 to
1771 inclusively. 
                 Of the Forceps.             411

forgetfulness, and not with a design to detract from
his merit, that one of our countrymen has publish-
ed that Smellie only hinted the use of the forceps
in that case, and had not described the manner of
applying them.* I shall,  in the sequel, detail the
cases in  which we ought to employ  the  forceps,
and the method of using them in each.
* M. de Leurie. 
PART  IV.
 Of the Causes which make the Use of Instruments
   necessary in the Practice of Midwifery, particu-
   larly the Forceps and Lever.

   1143. A VIONG  the causes which ought to de-
 termine us to deliver with instruments, some leave
 us no resource but in their assistance; and others
 only indicate their use in preference to other means,
 the effect of  which would not be so prompt nor so
 salutary.
   1144. Of this last class, are, an uterine haemorr-
 hage, convulsions of the mother, frequent syncopes,
 exhaustment, the cessation of the pains; diseases
 which permit not the woman to yield to the efforts
 necessary for the expulsion of  the child, such as
 certain hernias, an habitual spitting of blood,  the
 descent of the uterus and an  inversion of the va-
gina:  lastly, the premature issue of the umbilical
 cord,  and  often  the  presence of a second child,
 which by its position considerably retards, or hin-
 ders the delivery  of the first.
   1145.   According  as  these  causes  manifest
themselves sooner or  later in the course of labour,
they indicate the  use of this or that  means  prefer-
ably to  others. When they attack with violence at
the beginning of labour, and continue with  the
same force, leaving no resource but in the extrac- 
                Of the Causes, Ssfc.           413

tion of the child, the head being still  above the
pelvis, we ought to turn it and bring it by the feet.
We should  however  be free  to  choose between
that method  and the  application of the forceps,
though more difficult, if we thought the success
more certain than that of  turning, which  in this
case generally requires more knowledge and dexte-
rity. This option between the two methods would be
still more allowable, if the head were engaged half
its length, or more, if they both promised the  same
advantages; but in my opinion the  forceps merit the
preference. That instrument  is indicated  exclu-
sively when one or more of the above mentioned
causes do not occur till the head arrives  at the bot-
tom of the pelvis. And no other  can enter into a
competition  with  it, when  the head has not only
cleared the superior  strait, but also the neck of the
uterus,  so  as entirely to  fill  the vagina* except it
be the crotchet when we are certain of the child's
deathjf because we cannot  then turn it and bring
it by the feet.
   1146. Certain disadvantageous positions of the
head, which we cannot rectify with the hand alone,
its being locked, an  extreme defect of size in the
pelvis of the  woman, and sometimes the monstrous
conformation of the child;  certain morbific  affec-
tions, whether of the child, or of the soft parts of
the  mother  concerned in delivery; extra-uterine
conceptions, and the rupture of the uterus,  are  in
general causes which  indispensably prescribe the
use of instruments.
   1147. The greater part of these causes having

  * See par. 958, and following.
  t See the  article which treats of the signs of the child's
death. 
           m
414          Of the Locked Head.

been already treated of in so many particular sec-
tions,* and as  the others cannot be explained more
seasonably, than when I lay down the method of
operatiiig in each of them, I shall confine myself
here to the locked head, and the distinction to be
made between that state, and that where the head is
only stopped in the passage.
              Of the Locked Head.

  1148. Locking is that state in which the child's
head, more  or  less advanced in the pelvis,  is so
wedged between the bones, that it cannot be pushed
farther, or even moved in any other direction, by
the  efforts of Nature alone.
  1149. The greater part of those who have spoken
of the locked head have had this idea of it; but some
have added  that it was equally impossible to  push
back the head with the hand alone above the point
to which it was advanced : which however I cannot
admit. " For the head to be really locked," says M.
Levret, " it is  absolutely necessary that it should
" be more or less advanced, without a possibility of
" being forced farther down by the efforts of Nature
c< alone, or of being pushed back  with the hand; for
" if one or  the other be possible, it is not perma-
" nently stopped, it is not really locked." After such
a definition,* one would not expect to find some of
those who admit it,  so often contradicting them-
selves, by employing the words locked head indis-
criminately to signify the state in question and that

  *  See from par. 786, to par. 826 inclusively.
  t  Suite des Observations sur la Cause de plusieurs Ac-
q?uchemens Laborieux, part. ii. p. 266. 
Of the Locked Head.           415
in which the head is merely stopped in the passage,
though they differ from each other in many respects.
See the following article, par.  1184.
  1150.  Some authors have distinguished two ge-
neral species of locking, relative to the manner in
which  they imagined the head might be fixed. In
one, say they, the head touches forcibly at two parts
of its surface diametrically opposite, whether against
tht pubes and sacrum, or against the lateral parts of
the pelvis;  and in the other it is equally jambed on
every side. We may reasonably deny this last spe-
cies; for, by the confession even of those who ad-
mit it, it cannot exist. " There  is no example," says
M. Levret, " of a locked head on which we cannot
" apply the forceps with more or less difficulty, either
" at one part, or another, because it is not  equally in
" contact with  the pelvis  every  where."*  The
opinion of Roederer on this subject is however very
different. " In the completeparagomphosis," says he,
"the child's head is so jambed on ail sides in the
"pelvis,  that we  should  not  be able  to pass the
" smallest  needle between them, in whatever part
" we might attempt it."f
   1151. I admit but one general species of locking;
that in which the head  is fixed only by two points
of its surface diametrically opposite. But this spe-
cies contains particular ones; for  the head is not
always situated in  the same manner, nor fixed by
the same points:  sometimes it is jambed with its
greatest  length between the pubes and sacrum, and
sometimes with its  thickness only. In the first case
it is the forehead and the occiput which are in con-
tact with the interior circle of the pelvis; in the se-

  * Elemenssur l'Art des Accouchemens, edit. iii. Aph. 617.
  f Roederer, § 431. 
416           Of the Locked Head.
cond, the parietal protuberances. This latter species
is much more rare than the former, and cannot hap-
pen but in a pelvis so narrow as to have but three
inches and a few lines in its smallest diameter, un-
less the head be excessively large.
  1152.  The  differences in  the  locked  head,
according to many authors, depend not only on the
extent of the points of contact  which fix it, but
also on the region which the  head presents to the
touch, and on the manner in which that region is
placed with respect to the pelvis.  Sometimes, say
they,  the crown of the head advances first, and at
other times  the occiput,  or one of  the  temporal
regions, or even the  face. It  is  not  very  easy to
conceive how  the head can be locked in these
latter cases, especially according to the definition
which those same accoucheurs  have given of
locking.  The  head  may advance more or  less
when it presents the face,  the occiput or one of its
sides, and then it  generally stops in the  passage;
but it is  never really  locked  unless the vertex,
or crown of the head,  advance first.  The  proof of
this truth is evidently discovered in the observations
of those who  have  treated of  the  locked head.
We there discover that for one head  really locked,
which they have met with, they  have charged ten
with being '_o,  although  they  were very  movable
in the pelvis, even when the vertex presented.
  1153. The sentiment of M. Levret  on  the me-
chanism of locking, and the circumstance  in which
that  accident most frequently happens,  does not
appear to me to be conformaole  to those extensive
views which he displays elsewhere on this subject.
" If," says  he, " the  waters drain off suddenly,
" either totally, or in part, in the first period of
" labour, and the bregma of the child should be op- 
Of the Locked Head.          417
" posite the middle of the projection which results
" from the union  of the body of the last  lumbar
"vertebra  and  the  sacrum,  that projection  may
" lodge in  the  bregma, by depressing it at  each
" contraction of the  uterus; which will hinder the
" head from turning in the  second period,  for the
" forehead to place itself on one side; it will fix it-
" self in  that  part, and then  the  occiput will first
" tend downwards as far as the neck: it  will lodge
" behind the arch of the pubes, and the shoulders
u will  rest on the superior branches  of the ossa
"pubis, hanging over them more or less; and if the
" head remain long in that state, it will be locked."*
How is it possible the  head should be locked in
this case? It cannot follow a more favourable course
in its descent; it is its posterior extremity which
first advances in the cavity of the pelvis; where it is
scarcely  arrived  before  the  back of  the neck is
found  against the  symphysis of the pubes,  and
the occipital region answers  to the arch of those
same bones, under which it  must engage, to rise
up before  the  mons veneris turning round on the
inferior edge  of  the  symphysis,  as  on its  axis;
it is this position which the  head generally  takes
with respect to the inferior strait, whether it has
traversed  the  superior  in a  diagonal  position,
or  any other: this  is the  best possible position,
considered in the latter period of labour, and that
which we ought to place the head in, when the ef-
forts of Nature do not direct  it  so. See what I have
already said on the mechanism of the different spe-
cies of natural labour.
   1154. If the  head in  the case  described above,

  * Observation sur les  Accouchemens Laborieux, part. ii.
edit. 4me. page 277.
                       3 G 
418           Of the Locked Head.
sometimes stops and remains in the lower part  ol
the pelvis, after having followed the course indi-
cated by M. Levret, whether it be retained there by
the situation of the  shoulders  over the ossa pubis,
or by any other cause, it  cannot be locked there.
To be  really locked, the  head must follow a very
different course at the beginning of labour; for it
cannot  be  fixed with its  greatest  length between
the sacrum and pubes, unless the occiput rest behind
the latter superiorly, and remain  there  in some
measure immovable,  while the forehead is forced
to descend posteriorly opposite the sacro-vertebral
an^le.  By  following this  course, it is the largest
diameter of the head which tends to advance fore-
most; it is  the anterior fontanelle  which presents
more and more, in proportion as i he  head advances;
it is on  this fontanelle that the teguments swell and
puff up; and it is this same point which consitutes
the summit of  the conical figure acquired by the
head when  locked in the  pelvis, instead of being
sunk and depressed by the projection of the sacrum,
as asserted by M. Levret.
   1155. The head may also be locked or jambed
lengthwise  between  the pubes  and  sacrum, if the
occiput  resting against the latter ceases to  advance,
while  the  forehead  shall   be  obliged to descend
behind the former. In either case,  it is  the large
diameter of the head which tends to pass  horizon-
tally between those two bones: which cannot happen
wiihout causing considerable frictions, even when
the pelvis wants but a few lines of its natural size
in that  direction. I delivered a woman  in  whom
the child's head had been locked in  that  manner
for  two  days, although the pelvis was of  the usual
size. Five children, each  more voluminous than
that, had already passed it without difficulty; because 
              Of the Locked Head.          419

their heads had presented differently, and the ute-
rine  forces were then differently directed.  I have
since that time met with the same case in two other
women; I was obliged to deliver them also, after a
very long labour. Whenever  the child's head fol-
lows the course stated by M. Levret, for from offer-
ing its greatest diameter foremost between tht pubes
and sacrum, it only places  its height there, consi-
dered from the base of the cranium to its summit, or
its perpendicular diameter, which is generally fifteen
or eighteen lines less than the former.
   1156. The child's head when locked, always ac-
quires the form ofa wedge more or  less lengthened,
whose base remains above the part where it stops; as
de la Matte has very clearly expressed it, by com-
paring it then, with respect to the pelvis, to  the key-
stone of an arch: whence we see that it cannot be
locked  but by passing from  a larger space into a
narrower, and that it is not impossible  to  push it
back above the point where it is stopped and fixed.
  Of the Causes, Signs, and Accidents of the
                 Locked Head.

  1157.THEhead cannot be locked without the con-
currence of several causes, of which some are predis-
posing, and others determining or efficient. The lat-
ter depend on the action of the uterus, and the eher
powers  which contribute to  the  expulsion of the
foetus: but that action must be vehement, and con-
tinue a longtime: we need never fear  it in a delicate
and exhausted woman, whatever causes exist which
might otherwise occasion it.
  1158.  The causes which we call predisposing 
420
Causes, &c.
 arise from  both  mother and child, and generally
 consist in a defect of proportion between the dimen-
 sions of the pelvis and of the head which must pass
 it.  This delect of  proportion  sometimes  depends
 only on the bad position of the head; at other times
 on  its extraordinary  size and  solidity^, or on the
 deformity of the pelvis.  It is so difficult to  discover
 and estimate by the touch, not only the degree of
 disproportion which may cause  the  head  to  be
 locked, but also the necessary degree of solidity in
 the head, and the quantity of force which the woman
 must exert for it, that we cannot absolutely judge
 at the beginning of labour,  without  fear of mis-
 taking, whether the  head will be locked, or whether
 it will only meet with more or less difficulty in tra-
 versing the pelvis. One  thing we  are very sure of,
 that the head can  never  be locked in a pelvis very
 small or very large, relative to its own volume; and
 that that accident is no  more to be dreaded when
 it is very supple, and the woman very weak. It may
 stop in the latter case, but never be really  locked.
  1159. The immobility of the head is the  essential
 mark and pathognomonic sign of  its being locked.
 The tumefaction of  the hairy scalp, that of the neck
 of the uterus, which then forms a kind of pad more
 or less thick under the head, the engorgement of the
parietes of the vagina and the external parts of the
 woman, are but accessory effects, though  insepa-
 rable from it.
  1160. These effects always precede the head's be-
 ing locked, and augment during its continuance. It
 is only to be dreaded when those symptoms manifest
 themselves;  but it does not always happen when they
 are present. We frequently observe those symptoms,
 but the head is very seldom really locked.
  1161. It is not necessary that the head should ad- 
Of the Locked Head.           421
vance between the bones of the pelvis, and be strongly
jambed there for the teguments of the cranium, the
neck of the uterus, the vagina, and the external parts
of the woman to be engorgedand inflamed; it is suffi-
cient that it be strongly pressed on the entrance of
that cavity, to occasion all those effects; since we see
them appear, in the same order, when there exists,
as I may say, no proportion between the diameters
of the superior strait, deformed in the highest de-
gree,  and those of the head;  so that  it cannot any
way engage in  it. De la Motte and Roederer inform
us, that in this last case, the hairy scalp sometimes
swells  and projects  so far  into the vagina, that it
might lead us  into  an error, by making us believe
that the cranium  itself was advancing, while it re-
mains entirely above the pelvis; which I  have ob-
served as well as  they. I have  moreover seen gan-
grenous eschars in the neck  of the bladder after
these  same  cases: when the woman has not been
assisted in time with respect to the delivery.
   1162. Of all the signs which indicate the head's
being locked,  there is none less certain than the
swelling of the teguments  of the cranium  and the
tumefaction of the parts of the woman. If it some-
times depends on the pressure  which it  suffers
between the bones  of the pelvis, it much oftener
is  caused only by the rigidity or hardness which
continues after the opening of the membranes, in the
pad which constitutes  the neck of the uterus. It is
indeed easy to judge from which of these two causes
it  proceeds. In the first case, the swelling extends
higher than the edge of the orifice of the uterus, as
far as the part where the bony case is pressed against
the surface of the pelvis; and the orifice itself is also
tumefied, and  more or less painful: in the  second,
the pad formed by  the neck of the uterus  is hard, 
422               Causes, &c.
 not  very thick, and the swelling of the teguments
 of the cranium is limited to the same height. Mu< h
 oftener still, the tumefaction in question depends only
 on the resistance which the external parts oppose to
 the  passage of the head, as we almost always remark
 in a  first labour. As to the tumefaction of those parts
 themselves, of the vagina and neck of the uterus,
 how many times has it not been occasioned by fre-
 quent and inconsiderate touching,  either of an ac-
 coucheur or midwife? Lastly, this tumefaction may
 be anterior to labour, and depend only on pregnancy,
 or even on other causes which are foreign to it.
   1163. Not only, these symptoms  do not certainly
 characterize the locked head, since  some of them
 may be foreign  to labour and pregnancy; but we
 should not  always be founded in supposing a head
 to be locked which has ceased to advance after de-
 scending to the bottom of the pelvis, though pushed
 forward by violent efforts; and even when it  seems
 impossible  to push it back: for though it cannot then
 descend farther, nor recede in a sensible manner, it is
 often movable on its pivot, and may  turn round as
 on its axis; which proves that it is  not locked but
 only stopped in the passage. See par. 1185, and fol-
 lowing. I could quotea great number of facts in sup-
 port  of all these assertions; and in many of them the
 finger methodically placed, and a different position
 or. ihe part of the woman, have happily terminated
 labours, that could not have been finished with the
forceps.
  1164. The head is not really locked but when  it
 cannot make any of these movements:  when no
 instiument whatever can pass over more than about
a quarter of its circumference, any more than that
 oi the ir.si-le of the pelvis, nor penetrate the  places
 where those parts are in contact. 
Of the Locked Head.           423
  1165. It would be very advantageous if we could
distinguish the cases in which the child's head must
be locked, from those in which it is only threatened,
that is to say, in which the head cannot,  without a
great  deal of difficulty, traverse the canal presented
it by the pelvis; that we  might  in the  latter  case
abandon the delivery to Nature, and in  the other,
deliver before the accident takes place. But it  is al-
most always impossible to make that distinction, be-
cause the  same symptoms which precede the lock-
ing, equally manifest themselves when the head only
threatens to become so.
   1166. In either case, the head not being able to en-
gage but by the crossing of the bones, or riding over
each  other's edges, the  teguments of the  cranium
form  into folds in the direction of the sutures; those
same  teguments swell, and produce a tumour larger
or smaller, indued  with a sort of elasticity which
never  deceives the finger  of  an accoucheur.  The
head having engaged with extreme difficulty, sooner
or later stops; or else it advances at last so rapidly,
that it makes more progress in fifteen minutes, and
often  in one, than it had done before in fifteen hours
or longer.
   1167. This difference arises from the form of the
pelvis. When the head stops in the middle of its
course, and becomes locked, the pelvis is not only
narrow at its entrance, but also in  the middle.  This
last, which is called the excavation,  is on the  con-
trary  larger than common, or at least as large, as well
as the inferior strait, when the head descends rapidly
at the latter end of labour. In the former case,  the
head  suffers a more considerable friction as it ad-
vances farther, till  it be entirely fixed:  which  in-
creases the force  and intensity of  the  symptoms
stated above. In the latter  case, it undergoes  those
• 
424               Causes, &c.
 frictions only in its passage through the superior
 strait, and its greatest breadth has no sooner cleared
 that, than all the above mentioned effects disappear;
 as it then finds itself in a larger space, and  is no
 longer compressed, because the Hbones of the cra-
 nium recover their former state, and the circulation
 intercepted in some of the veins of the teguments and
 of the aponeurotic covering of the head is restored.
   1168. We should then be obliged to leave almost
 entirely to time to distinguish the head which will
 be locked, from that which, after threatening it, shall
 be delivered without help, if we could not,  in all
 these cases, judge of the form of the pelvis, of the
 solidity of the bones of the cranium, and the firmness
 of their sutures; as well as the strength of the woman.
 If there are eases where we can have no other rule
 but time, we ought to  know  how to estimate that
 time, that we may be able to decide seasonably what
 measures are to be pursued;  the salvation of both
 mother and child often depends on an instant, and
 the accoucheur  is in some  measure the arbiter  of
 their fate: too much confidence in the unknown re-
 sources of Nature, or in the effect of certain reme-
 dies, may be as pernicious to both, as too precipitate
 and  ill directed manoeuvres.
   1169. The locking of the head is always very per-
 nicious to both mother and child:  it cannot  exist
 long without destroying the latter, and exposing the
 former to a thousand accidents,  which often  leave
 a dreadful train of evils behind, render her  life  a
 burden, and make her every moment wish for death.
  1170. Depression, and of en fractures of the bones
 of the cranium, deep engorgements, extravasations in
 the ventricles of the braii\ under tht dura mater, be-
tween that and the bones, under the pericranium itself
 detached from the parictalia, &c. aswell as profound 
Of the Locked Head.          425
 ecchymoses between the sub-occipital muscles, are ef-
 fects which I have observed in many children after
 their heads had been locked.
   1171. The head cannot be locked without strong-
 ly compressing, and in  some measure destroying
 the soft parts of the woman in the places where it
 is in contact with the interior circle of the pelvis; and
 causing a swellingand inflammation of the parts situ-
 ated underneath, such  as the  neck  of the bladder,
 the  urethra, the edge  of the orifice of the uterus,
 the membranes of the vagina,  the rectum, and even
 the external parts. The urine ceases to flow, and we
 cannot draw it off with the catheter, because the  ca-
 nal of the urethra is totally obliterated. The woman
 tormented at the same time by the necessity of dis-
 charging it,  and by the pains  of labour which per-
 haps  she is solicited to  make the most of,  gives
 herself up to inconsiderate efforts, till she is ex-
 hausted, or her pains go off. A fever comes on,  the
 blood is heated, and carried impetuously towards the
 superior parts,  where  it often produces new dis-
 orders, the effects of which are more dreadful than
 those of the first.
  1172. If the inflammation of the parts which cover
 the inside  of the pelvis,  sometimes subsides after
 delivery, when the head has been locked, sometimes
 also,  and doubtless too often, a gangrene  is  the
 consequence. The falling off of the eschars leaves
 broad and rebellious ulcers, as well as openings into
 the neck of the bladder and the  rectum; and to com-
plete  the misfortune, when the woman survives,
the urine and faces fall continually into the vagina,
cover the surface of those ulcers, increase their pu-
trefaction, and would render them incurable, if they
 were not so in their own  nature.
                      3ji 
426
Indications, &c.
Indications in  the Locked Head, considered exclu-
  sively of the Accidents which are the consequence
  of it.

  1173. According to the sketch I have just given
of the consequences of the head being locked, we
see how salutary it would be to prevent it, by ter-
minating the  delivery  seasonably.  If we cannot
always procure this good fortune to the mother and
child, at least  we ought to operate  without delay,
when we  discover that it has taken  place; unless
particular circumstances which are already conse-
quences of it present more pressing indications, and
require us  to use  means which  then  become
preparatory to delivery;  such as  bleeding,  baths,
emollient topics, &c. though it is to be feared  they
would be employed without effect, since they cannot
reach the first cause of all those accidents, which is
the locking itself.
   1174. The extraction of the child is the  principal
indication; but the method of performing it must be
varied according to  the state of the child, as well as
of the parts of the mother.
   1175.  The  ancients used  crotchets to open the
head and extract it; and some as late as the middle
of the present century, only used them after they had
opened the  head more methodically with other in-
struments,  and  emptied it.  Several, among   the
moderns,  have proposed fillets variously arranged,
which have been very happily forgotten since the
invention and improvement of the forceps. If  the
former thought themselves reduced to the deplorable
necessity of mutilating the child, the latter directed
all their endeavours to preserve it.
   1176. Mauriceau, whose  work is  still much es- 
Of the Locked Head.           427
teemed, thought it was a necessary cruelty to kill the
child when the head was locked, in order to save the
mother, whose  death appeared to him not less ine-
vitable if that method were nottaken;andcfe/rt Mothe,
more timid, waited till it was deprived of iife to open
the head and extract it with the crotchets. The con-
duct of the latter would  not at present inspire less
horror than that of the former:  such  practices  could
not  be tolerated, but in the times in which their
authors lived; the art had not then counted Smellie
and Levret among  its masters,  and many others,
who have since enriched it with their discoveries.
   1177. If the forceps in this disagreeable circum-
stance do  not always secure the life of the  child,
already languishing more or less, at  the time we use
them, it must at least be  confessed that a great num-
ber have been indebted to them for their existence,
who would otherwise have been  sacrificed for the
safety of their mothers.  Though  this  instrument
adds little  to the accidents the woman then suffers,
if we use  it with method and judgment,  it adds
enough nevertheless to justify us upon some occa-
sions, in preferring the crotchets and other instru-
ments  destined to open  the head, if we could have
certain signs of the child's death.
   1178. Roonhuisen's lever, published and so much
boasted of towards the middle of this century,  has
all  the inconveniences of the forceps, without  any
of their advantages,  though some accoucheurs still
give it the preference. It would be the most proper
instrument, if it could be insinuated into the very
parts where the points of contact are, which essen-
tially constitute the locked  head,  if the greatest
thickness of the  head were engaged as far as  those
points, and if that head had only to pass out ofa nar-
rower place into a larger. The lever would be the 
428
Indications, k?c.
most proper instrument to make it execute that first-
step; but we  ought to expect nothing more from it.
Its utility would be limited to that; and all that has
been attributed to it beyond is illusive.
   1179. The Cesarean operation, recommended by
Roederer, in what he calls aparagomphosis, in which,
says he, the head is wedged on all sides against the
internal edge of the pelvis, and makes but one body
with it, though it would endanger the mother's life,
would  not certainly save that of the child;  the locked
head however never is such as that author has des-
cribed  it. The advantages of the Cesarean operation,
if any could be then allowed it, would be much in-
ferior to the section of the pubes. The circumstance
in question is precisely that in which that new ope-
ration would  have  the most success, if the ossa pubis
could be separated with as little inconvenience as its
partisans have asserted; for the separation of those
bones,  by destroying one of the  points of contact
which keep the head fixed, would certainly favour its
exit.
   1180. Whenever there are any hopes of extract-
ing the locked  head with the forceps, we ought to
have recourse  to  them: the cases, if any exist, in
which they are insufficient, must be excessively rare.
No other method can enter into  competition with
that while the child is living; but when we are certain
of the child's death, if the parts of the mother are
in a state of inflammation and pain, it is better to
open the cranium  and empty  it,  in order to bring
away the head with the crotchets, than to  use  the
forceps: this method has the advantage of destroy-
ing the force of the points of contact which constitute
the locking;  whereas the forceps, in many cases,
augment it: which may give birth to new accidents,
or aggravate those  which exist already.
   1181. Before we enter into the detail of all these 
Of the Head, &fc.            429
operations, and of the instruments to be made use of,
it is necessary  to show wherein the locked head
differs from the head merely stopped in the passage.
Circumstances in which the  Head may stop in the
  Passage without being locked, and the difference
  between those two States.

  1182. Authors have used the word passage so
vaguely, and in such different cicumstances, that it
is not very easy  to decide what they meant to ex-
press by that term. Have theyr given that name to
the whole extent of the canal which the head must
pass; or only to the inferior strait and the opening of
the soft external parts, as seems to  appear  through
the obscurity of the writings of most of them? To
determine the ideas of the reader on this subject, I
advertise him here,  that by  the word passage con-
sidered with respect to the pelvis alone, I only mean
the inferior strait; and I acknowledge no head stop-
ped in the passage, but that which cannot pass it,
notwithstanding the most powerful efforts of Nature.
  1183. Divers causes may stop the head at  that
place, and every  one of them presents different in-
dications.  The head may stop in  the  passage, 1.
whenever it preserves the transverse or diagonal posi-
tion, in which it cleared the superior strait; 2. when
the chin recedes from the top of the breast, and the
occiput turns backward from the time it begins to
advance; because it then comes with the upper part
of the forehead to the centre of the inferior strait, and
presents the whole length of its longest diameter to
it, as observed in par. 949, and following; 3. it may
find the same obstacle to its  exit, whatever may be 
430
Of the Head
 its position, when the inferior strait is contracted; 4.
 when  the external parts make much resistance; 5.
 lastly, if the shoulders themselves stop at the superior
 strait. According to the opinion of  many accou-
 cheurs, the shortness of the umbilical cord, and its
 being  twisted round the neck of the child when it is
 very long, may also retain the head in the  passage,
 and hinder it from passing: I think I have sufficiently
 exposed that error in another place,  and therefore
 shall not discuss it again. See par. 459, 819, and fol-
 lowing.
   1184. The head which is merely stopped in the
 passage differs from that which is really  locked, in
 not being absolutely immovable as that is. In ge-
 neral, we might push it back with a view of search-
 ing for the child's feet, if we had no other resources
 for terminating the  delivery:  excepting, however,
 when it has cleared the neck of the uterus,  or when
 it has  not passed the superior strait, more or less
 contracted, without extreme difficulty. Though the
 head in this last case cannot go back, yet it enjoys
 a rotatory motion, however limited it may be, which
 it cannot execute when locked.
   1185.  If the head is not immovable in this case,
 as in that where it is really locked; if it advances a
 little during the pain, and afterwards goes  back; if
 we can easily push it back even above the  margin
 of the  pelvis,  or make it turn on its axis,  there is
 nevertheless a circumstance in which its movements
 are so  limited, as to  give reason to suppose it really
 locked. To explain this circumstance,  we must suo-
pose the straits of the pelvis of a certain given size,
Under the natural dimensions of the head, while the
excavation is respectively larger: which often  hap-
pens when the sacrum is deformed by too  great a
curve.  I shall fix the distance at three inches and a 
stopped in the Passage.          431
few lines from the pubes to the sacrum superiorly,
and to the bottom of the first piece of the coccyx
inieriorly.
  1186. Proceeding on this  supposition, which is
not begged, since we find many pelves similar to that
supposed, the head,the transverse thicknessof which
is commonly three inches and a half, taken between
the parietal protuberances, cannot clear the superior
strait, but by diminishing several lines in that di-
rection; nor the inferior strait, but by suffering an
equal reduction from its summit to the base of the
cranium, since it is that dimension which must then
pass in the direction of the small diameter of that
strait.
   1187.  The progress of the  head in this case is at
first very slow, folds are  formed in the teguments
which cover it, and we presently perceive a tume-
faction more or less extended,  which continues to
augment till it has cleared the superior strait; as we
observe  when it is  going to be  locked.  But no
sooner has it passed that strait, than all the above
mentioned effects vanish, if the pains go off, or abate;
and the head recovers its original thickness, as hap-
pens before our eyes when the child comes into the
world with the cranium lengthened, and as it were de-
formed:  because  it is then at liberty in the excava-
tion of the pelvis,  and is no longer compressed at
the sides, as at first. This restitution  of the trans-
verse thickness of the head takes place so much
the more speedily, in this case, because the pressure
which the vertex suffers on the point of the sacrum,
the  coccyx and perinaum, tends to diminish its
height,  to curve the parietal bones, throw their
protuberances outwards,   and lastly,  augment the
breadth of the cranium in that direction.
   1188. Unless the efforts of the woman continue 
432              Of the Head
yet a  long time, and with vehemence,  the  head
thus retained cannot  be expelled from the pelvis;
so difficult it is for it to lessen sufficiently from the
summit to its base. If those efforts  continue, the
tumefaction of the hairy scalp, far from diminishing,
as I have  said above, augments more and more, as
we see when the head is really locked;  and if it
then differs in any thing  from the  locked head,
it is that it can still descend a little during  each
pain and go back again immediately,  that it can be
moved a little on its  axis, and touches no where
with so much  force, but  that we may introduce a
proper instrument between it and the parietes of
the pelvis.
   1189. The cranium is  then as  it were, shut up
in the middle of that cavity, without  being able to
advance or recede  sensibly; for  whether we at-
tempt  to  extract the  head or push it  back, we
must diminish its size in the diameter which is to
pass between the pubes and sacrum.  It  must be
flattened from the vertex to the base, to come out;
and from one parietal protuberance to the  other, to
go back again above the pelvis, as it was when it
came down; which cannot be brought about  with
the hand  alone, and  besides would be  attended
with much danger.
   1190. I have already stated that every cause ca-
pable of stopping the head in the  passage presents
a different  indication; this is the time to demon-
strate that truth. When the obstacle which prevents
the head from  engaging in the inferior strait  only
arises from its transverse  position with respect to
that strait, it must be changed, and the occiput
brought under the pubes;  unless reasons already
known direct us to turn  it towards  the  sacrum.
When  the head engages in such a manner that the 
              Stopped in the Passage.         433

superior part of the forehead presents at the centre
of the i;-f rior strait, we must push back this' pan to
h''v j; -e  wn that where the sagittal suture joins the
lambdoidal, as we see in par. 958, and following. We
must extract the head with the forceps whenever it is
stopped in the passage by a defect in the dimensions
of the inferior strait, except that defect he excessive;
for then it will require other methods.* While on the
contrary, it will suffice, to reiax and mollify the ex-
ternal soft parts, when they oppose a resistance su-
perior to the action of the organs which endeavour
to expel the  child, and when the head is stopped by
no other cause. We cannot so easily change the
direction of  the shoulders, at  the superior strait,
when it  is they which oppose the effect of that same
expulsive  action,  though  M.  Levret  has recom-
mended  it;f and I foresee the astonishment which
the proposition  of the forceps in this case would
cause in  the minds of those who have not sufficiently
considered it.
   1191. It is only by inference that  we  can  ever
judge that it is the shoulders resting on the superior
strait which  obstruct the expulsion of the head. For
that  inference to be well founded, it is necessary, 1.
that the pelvis be of the usual depth, moderately con-
tracted at its entrance, but its other parts well form-

  * Crotchets  if the child be dead; and the Cesarean opera-
tion it living. We  must not here confound the case where the
extreme narrowness of the inferior strait obstructs the exit
of the head and the application of the forceps, with those men-
tioned in par. 1185 and following, and which have given occa-
sion to the note on par. 1 179, because it is very different from
them. When the inferior strait is so much contracted, the su-
perior is very wide, and the head may easily be pushed back.
  f M. Levret, Suite des Observations sur la Cause  & des
Accidens  de plusieurs Accouchemens  Laborieux, 4me. e(rjt
page 4, Observ. ii.
                        3 I 
434               Of the Head
ed, that  is to say,  of a good breadth at the inferior
strait; 2. that the head when in the excavation should
be free and not wedged; 3. That the external parts
should not appear to hinder its exit, and, that the ex-
pulsive forces of the woman continue in action long
enough to expel it in any other case. If we are well
founded then in attributing the obstacle to the situ-
ation of  the shoulders, and their relation to the su-
perior strait, yet it is not till after the exit of the head
that we can be certain it depended on no other cause.
   1192.  This case differs in  many  respects from
that for  which  M. Levret recommended changing
the  direction  of   the  shoulders at the superior
strait, either by advancing a hand into the vagina,
or by using one of the blades of the  forceps.*  I
think I have demonstrated that the obstacle which
then opposed the expulsion of the head, arose from
its position only and from the manner in which it had
engaged; and that it no way depended on that of the
shoulders.f In the  case in question, on the contrary,
it depends on that entirely: resting on the margin of
the pelvis and hanging over it, they spread still far-
ther during the effort which tends to push the trunk
downward, the shoulders  hinder that  same effort
from acting on the head and expelling it. It would be
equally in vain, says the celebrated author I have just
quoted, to endeavour to extract it, since the shoul-
ders could notfollow.t  If we attend to  the mobility
of the child's neck, and at the same time compare
its length with the  depth of the pelvis,  we shall see

  * The head has not turned on the back of the neck as it
advanced,  as  remarked in par..958 and following; It is the
posterior/ottta/z'V/r which presents here at the bottom of the
ptlvU, and not the  top of the forehead.
  t See par. 950 _.:.d following.
  % Levret, in the  part already  quoted in par.  1190. 
              Stopped in the Passage.         435

that the opinion of M. Levret is not so well found-
ed as it appears at first  sight,  and that  we may ex-
tract the head though the shoulders should not en-
gage a single line. To place this truth in a clear li.^ht,
le;.  us suppose the child's head at the bottom of the
pelvis, the occiput behind the left foramen ovale, and
the posterior fontanelle near the edge of the arch of
the pubes on the same side. The mobility of the neck
allows us to bring the occiput perfectly and without
inconvenience under the pubes, that is a fact which
no  one can doubt of; and its length, which exceeds
that of the symphysis of the latter, permits us to dis-
engage it entuely by raising it up before the mons
veneris, as it disengages in a common labour. As the
length of the neck posteriorly is then  nearly < qui-
valent to that of the symphysis oi the pubes, so the ex-
tent of its anterior part,  taken from the chin to the top
of the breast when the chin  is turned backward, at
least, equals the length of the sac-rum; whence we see,
that the chin may arrive at the bottom of the vulva,
before the shoulders and breast quit the margin  of
the pelvis, and without  stretching the neck painfully.
The extraction of the  head is therefore possible  in
cases where the shoulders, fixed over the superior
strait, render its expulsion impossible; and I prefer
it to that which M. Levret recommends. If the
shoulders do not descend after the exit of the head,
we may remove them more easily7 and advantage-
ously than could have been  done  before; because
there will then be more room in  the  pelvis. That
is the method which I have  several times followed
in cists of this kind; and which f shall repeat, if 1
meet with any more of them. 
436
General Rules
 General Rules concerning the Use of the Forceps.

   1193. Among the rules to be observed in the use
uf this instrument, some regard the  situation of the
woman, and others the mode of operating.
   1194. There is but  one single  position proper in
all cases. The woman  ought to be laid on her back
at the foot  of the bed, so that her breech may pro-
ject a little beyond it;  as  I  have  recommended for
preternatural labour: and the same precautions must
be taken to fix her in that attitude.  All other positions
seem to me inconvenient, either  for the woman  or
for the operator.
   1195. Th - rules which concern decency must not
be neglected: it would  be superfluous to point them
out to  a well bred man.
   1196. But those which relate to the application  of
the forceps, are only known to the enlightened prac-
titioner. We must take care; 1. to warm the instru-
ment a little, to  separate its  branches, and anoint
them with butter or pomatum; 2. to  insinuate them
separately, and in a different  manner, according to
the position of the child's head, and the part of the
pelvis which it occupies.*
   1197. The blades of the  forceps ought always to
be applied  on the  sides of the head;  if there are ex-
ceptions to this rule, they are very few in number,
and I shall  point them  out in the sequel. Someiimes

  * It is pretty much the custom to conceal the forceps from
the woman, for fear of alarming her; but I am of opinion that
nothing can encourage her more, than to make her understand
them, and allow her to exa nine  them, since we cannot use
them without her perceiving it. I have  never used them
without in a manner receiving them from the hands of the
woman  herself. 
            for applying the Forceps.        437

it is best to introduce the male branch first, that is to
say, that which has the pivot; and at other times the
female branch. I have observed above, that the blades
of the forceps ought always to be placed on the sides
of the head, except perhaps in one single case which
I shall mention in the sequel;  but at whatever part
of the pelvis they are introduced, each of them ought
to be preceded by the extremity of one or several
fingers, to direct them more certainly to the proper
place, and under the edge of the orifice of the uterus.
There are very few  cases where it is necessary  to
introduce the whole  hand into the vagina to guide
them thus, even if there were space  enough  to
admit  it.
  1198. We ought never to apply the forceps till
the edge of orifice be soft and well dilated, or easily
susceptible of farther dilatation. The external parts
require the same attention and  care, i cannot  con-
ceive any case where we ought to" have  recourse to
them before all those parts are in a proper  disposi-
tion for their application.
  1199. We ought never to push the blades of the
instrument forcibly in order to carry them to the re-
quiite height. As the obstacles which oppose  their
progression generally depend only on some folds of
the teguments of the cranium, or of the parts of the
mother,  we almost always surmount them easily, by-
vary iug the direction of the instrument a  little. If we
sometimes meet with more considerable ones,  they
proceed from the end of the blade's going with too
moe.ii force against the head, or against  the side of
th* pelvis, so that the curves of the instrument are
no exactly adapted to those of the pelvis and head,
We  surmount also  these difficulties, by changing
the direction  which we had hitherto given the in-
strument; either by raising or lowering the extre- 
438
General Rules
mity which is without, or by inclining it towards one
thigh, or the other, according to the circumstances of
the case, which can only be determined by the ope-
rator.
   1200. When the child's head has already cleared
the orifice ;>f the uterus,  and fills the cavity of the
pelvis, the fingers of the accoucheur being no longer
able to reach the edge of the orifice, to direct the
instrument under  it,  he  must carefully observe in
the introduction of the blades, to keep  their extre-
mities  applied as  close as possible to the head; in
order i hat they may of themselves pass within the
uterine circle and avoid pinching the edge of it in the
sequel, and that they may not go against  the union
of the uterus with the vagina, which would expose
that part to be torn, if we were to attempt pushing
the instrument farther up by applying more force.
   1201. In all cases, we ought to contrive th a  he
head should be grasped,  as  much as possible, ac-
cording to its greatest length; that is to say, so that
a line which would divide the sinus of the forceps
into two equal parts, from the junction of the two
branches, to the  centre  of the  space  between  the
extremities of their  blades, should cross the head
obliquely from the posterior extremity of the sagittal
suture, to the chin, or from the chin to the extremity
of the said suture-, as may be seen in the XVIIIth
and XXXVth plates of Smellie.
   1202. The pressure which the forceps  exert on
the child's head while we extract it must always be
relative to the proportion which the dimensions of
 that part bear to those of the pelvis. When the latter
 is well formed, we must not grasp the head  very
 tight  between the blades, but only so  much as to
 prevent their slipping. When the pelvis is deformed
 we must grasp the head more strictly;  because  it 
            for applying the Forceps.        439

cannot then clear that cavity without diminishing in
siz- , at least in one direction, and without om t m-
ploying a great deal of force to  extract it. It is off en
necessary in this last case, to bring the handles of
the forceps close together, and fix them in that s'ate
with a bandage, or a napkin rolled up, which we may
wrap round the whole, as far  as the  parts of the
woman;  in order to hold the instrument more firmly
than we  could if it were  naked.
   1203.  When we have  applied the  forceps on  a
head stopped  or wedged  in  the superior strait, we
ought to extract it without expectingany thing Item
the forces of the mother, and not, after bringing  it
into the cavity of the pelvis, commit the expulsion of
it to Nature.
   1204. Whenever we use the  forceps, we ought to
make the head takea course relative to itsposnu ri.as
I have laid it down from actual observation, in treat-
ing of the mechanism of the different species of na-
tural labour; that is to say, that we must make  it pre-
sent only its smallest diameters to the small ones of
the pelvis. See par. 483,  and following, to par.  545
inclusively.
   Iz05. We ought never to pull the forceps in a
right line, because that would  make  the  head de-
scend with more difliculiy;  as the  celebrated au-
thor of that instrument has  already observed.  But
we ought also to set bounds to the rotatory motions
whi h that accoucheur recommends with a view of
umvrinkling the vagina,  h is sufficient to carry the
external extremity  oi the forceps a  littie towaids
eaeh of the woman's  thighs alternately, at the same
time that we pull towaids us. We must be equally
atu-ntive to raise this s. me extremity in.ensibiy to-
wards the belly of the woman,  in propter ion  as the
head en_ra_;es in the interior strait and the vulva. At 
440         Application of the Forceps.
this last period, we ought to hold the instrument with
one hand, and apply the other against the perinaum
to support it, and prevent its rupture; as we do in a
natural labour. We ought not to take off the forceps
till the parietal protuberances of ihe child have clear-
ed the opening of the vulva.
  12; 6. The application of the  forceps requiring
in general fewer precepts, and presenting less  diffi-
culty, as the head is nearer to the external parts of
the woman, and vice versa, I  shall first show how
we ought to act when  the  head  is entirely  in the
cavi-y of the pelvis; in order to proceed from the
simple to the more complex; and describe the dif-
ferent modes of operating more clearly.
Of the  Application of the Forceps in that Position
  in which the Occiput answers  to the Arch of the
  Pubes. and the Forehead to the Sacrum; and also
  in 'hat in which the Occiput is against the latter,
  and the Forehead opposite the Arch of the Pubes.

  1207. Of all the positions in which the crown of
the  head can present at the inferior strait, no one is
more favourable for its exit and for the application of
the  forceps, than that in which the occiput answers
to the arch of the pubes, and the  forehead to the
middle  of the sacrum. Whether the head be locked,
in that  direction, or the defect of the expulsive
pains, the weakness of the woman, an haemorrhage,
or any other cause, oblige us to have recourse to
that  instrument, it must be used in  the following
manner.
  1208. The woman being placed as directed in par.
1194, and the  following, and evcryr thing properly 
Application of the Forceps.        441
prepared we insinuate the male branch of theforceps,
towards the left side of the pelvis, and the other at the
right side. We first introduce two fingers of the right
hand, or one only under the edge of the orifice of the
uterus, at the left side, if they7 can reach it, or if not,
as high as possible on the  child's head. With  the
other hand, holding the male branch of the instru-
ment by its middle, nearly as we hold a pen, we pre-
sent the end of the blade to the vulva, its new curve,
or concave edge, being turned towards the pubes and
its other extremity inclined over the woman's right
groin. We slide this blade into the vagina along the
inside of the fingers which prepare the way for it;
and when its extremity has passed them, we begin to
change the direction of the external  end, and with-
draw it a little from the bend of the groin towards
which we had kept it inclined. We then lower it in-
sensibly, carrying it towards the woman's left thigh,
but only in proportion as the blade advances farther;
and we continue this procedure till the blade  has
penetrated to the height of four or  five inches, and
the portion of the instrument which is without  be
nearly parallel  to the axis of the woman's trunk.
   1209. We must slide this branch to the height of
four or five inches, that its extremity may be applied
somewhere about the angle of the lower jaw, or near
the cheek. We may be certain that  it is thereabouts
and that the blade is well placed, if it will not shake
easily, and if the pivot answers to the symphysis of
the pubes, though distant from it  several inches,  if
the forceps I have adopted are used; lastly, if in pul-
ling the instrument in a right line, we perceive a kind
of resistance at its hidden extremity.
   1210. The height at which we ought to keep the
end of the instrument which is without, must be
varied a little according to the particular  direction
                      l3K 
442        Application of the Forceps.
of the pelvis oi the woman, and the inclination of its
axis relatively to the horizon. Although I cannot give
positive rules on this subject, I may say, however,
that in the case in question the external extremity
ought to be elevated so that the portion of the in-
strument which is in sight, may form, with a line
drawn horizontally from the  bottom  of the vulva,
between the woman's knees, an angle of from thirty
to forty degrees. We suppose here the woman laid
on her back, with the breech  a little  elevated.  An
intelligent  assistant ought to keep this first branch
of the forceps in the situation indicated, while we
apply the second.
   1211. We slide up this last with the same precau-
tions, but holding it with the right hand, and so that
the extremity of its handle  be at first  inclined over
the left groin. Two fingers of the other hand, or one
only, introduced into the vagina, between the head
and the right side of the pelvis, must guide the blade
in its progression. Inproportionasitpenetrat.es, we
gradually lower the external end, and bring it from
the woman's left thigh; so that the opening  in this
branch destined to receive the pivot of the first, may
do it easily, by coming opposite to it. We then unite
the two branches, and fix them in that state by giving
the pivot a half turn.
   12i 2.  We then take  hold of the  forceps  with
both hands; that is to sayr, with the left placed be-
yond the junction of its branches, near the pubes of
the woman, and the right at its extremity, as is
seen in the eighth plate.  We then pull towards us,
carrying the extremity of the instrument alternately
towards each thigh  of the  subject; but so that the
line it describes in these  alternate motions may not
exceed seven or eight inches. We likewise raise the
end of  the instrument insensibly toward the wo- 
           Application of the Forceps.        443

man's belly, in proportion as the head engages in the
inferior strait, as I have already observed. When it
is advanced so far as to distend  the perinaum,  we
must support that with one hand, and  pull the  in-
strument only with the other; but acting very slow-
ly,  to give the external parts  time to  unfold, and
dilate more gradually. By proceeding thus we make
the head  describe the same course which it takes
when expelled by the efforts  of  Nature alone, and
art  should always imitate her.
  1213. After the position  of the head of which I -
have just spoken, there is none that  requires a more
simple  procedure than that in  which the child's
forehead is concealed behind the inferior edge of the
symphysis of the pubes, and  the occiput lodged in the
sinus of the curve of the sacrum.  I have observed in
par.  501, and following,  that  this position was,
cateris paribus, much  less favourable for  the exit
of  the head than  the preceding,  and that some wo-
men  experience  so  much difficulty in delivering
themselves without help in this  case, that it would
often be better to use the forceps, than to expose
them, as well as their child, to the danger of so long
and severe a labour. If this position of itself,  and
exclusively of all other causes, ought not to deter-
mine us to recur to that method in most women,
at least it becomes necessary  when any accidents
supervene.
   1214. The  manner of applying  the forceps is abso-
lutely the same as that which has been described for
the preceding position. 
444        Application of the Forceps.
 Method of using the Forceps in that Position of the
   Head, in which  the  Occiput answers to the  left
   Foramen Ovale, and the Forehead to  the right
   Sacro iliac Symphysis; and in that where the Fore-
   head is  behind  the left  Foramen Ovale, and the
   Occiput opposite the right Sacro-iliac Symphysis.

   1215. I  have  observed in treating of  natural
 labour, that the head usually descended in the first
 of  these  positions, and that the  occiput  turned
 towards the arch of the pubes, only in proportion as
 it began to engage  in the inferior strait. When the
 head does not execute this turn, but preserves its
 first direction, notwithstanding the violent efforts
 which tend to expel it, if we cannot make it describe
 that movement with the finger, we must have re-
 course to the forceps. We must also use them when
 any  accidents supervene which permit  us not to
 leave the delivery any  longer to the  efforts of
 Nature. But the mode of using them must be a little
 different from that which I have just described.
   1216. If the  general  rules  which I have esta-
 blished concerning the use of the forceps be recol-
 lected,  it will be seen  that in this position  of the
 head, the male branch ought to be placed towards
 the left ischiatic notch, and the female  branch under
 the rightforamen ovale, that they may closely embrace
 the sides of the head. We  conduct the first  branch
 with the left hand, holding its external  extremity-
 at first very high, and a little less  inclined towards
 the right groin than in the preceding positions. We
 direct the end of the blade by the  help  of  one or
 more fingers of the right hand introduced into the
vagina, beyond the left sacro-ischiatic ligament,  and 
Application of the Forceps.        445
we insinuate it in  that direction  to the height of
four inches or thereabouts, making it cross the fore
part of the sacrum a little, to reach the cheek of the
child, whose face is then  towards the right  sacro-
iliac symphysis. Whence we  see how  attentive we
ought to be to lower the external extremity, and in-
cline it in the same proportion towards the left thigh;
but  in such  a  manner that the point  of the pivot
destined to join the two branches  of the instrument
may remain upward, and a little turned towards the
woman's left  groin: for otherwise,  the  greatest
breadth of the  blade could not closely embrace the
convexity of the parietal region.
   1217. We insinuate the female branch with the
same care towards  the right side of the pelvis, but a
little forwarder, so that it may pass obliquely behind
the foramen ovale and under the acetabulum. It must
be moreover directed in such a manner as to join
easily with the first.
   1218. The extremity of the instrument is to be
kept at a moderate height above the horizontal plane,
and inclined at  the same time  towards the left thigh,
the point of the pivot inclining obliquely toward the
groin of that side.* We then take  hold of the instru-
ment with  both hands,  the left placed  over   it
close to the pubes of the woman, and the other at its
extremity. We compress the head according to the
necessity of  the case, and turn it in the pelvis so as
to bring the  occiput under the  arch of  the  pubes;
but to do that we must raise the handles  of the for-

   * The woman  is always supposed to be laid on her back,
with the breech raised by means ofa cushion.  But if the breast
should be higher than the breech, we should  be obliged  to
keep the handles of the forceps  much lower than the point
assigned. The direction of the canal of the pelvis must be the
operator's guide. 
446        Application of the Forceps.

ceps, making their extremity  describe  an  arch
whose convexity *ould be towards the left thigh, till
it comes to  the point indicated in par. 1210, and
the point of the pivot be exactly upward. In general
this  rotation is easily made. We meet with no ob-
stacles to it, but when  the sacrum of the woman is
flattened, or when the child's head has turned a little
backward as it advanced, and the forehead is too low
with respect to the occiput. In this last case, before
we endeavour to turn the head round, we must push
up the forehead as much as is necessary, as I  have
directed in par. 953.*  After  this  rotatory  motion,
the head being reduced to its first position, it is to
be extracted as recommended in that position.
   1219. There are cases in which we absolutelv
cannot turn the  head in this  manner, and in which
it  would be dangerous not to attempt it cautiously:
those cases are excessively rare, and  I have met
with them, at most, but five or six times. In seve-
ral of those women, I have seen the head come
forth, after a very long labour, in  a diagonal  situa-
tion with respect to the inferior strait; and in the
others,  I have, extracted it by means of the forceps,
in a similar position, after having endeavoured to
turn it round and bring the occiput under the pubes.
These  cases  happen when the sacrum is straight,
fiat, and destitute of that curve which gives the mid-
dle of the pelvis more space than the  straits have in
the direction from before backward.
   1220. Though I place next in order, the position
in which the occiput answers to the right sacro-iliac
junction, and the forehead to the left acetabulum, it

   * We ought  to attend to this  circumstance in all other
diagonal positions of the head, when we find any difficulty ift
making it turn on its axis. 
          j Application of the Forceps.        441

is not because it is the most frequent of all the di-
agonal positions which the head is capable of taking
with respect to the inferior strait, after that which I
have just described; but because these two positions
are exactly the same, if we only  consider the rela-
tion between the dimensions of the head and those
of tht pelvis; and because the forceps must be placed
in the same manner. For in both, the greatest length
of the head  is parallel to the same oblique diameter
of the pelvis; one  ear answers to the right foramen
ovale, and the other to the left ischiatic  notch: it is
before the latter and behind the former that we must
insinuate the blades to grasp the head properly.
   1221. We ought never in this  position to endea-
vour to turn the child's face towards the sacrum;
because it could  not arrive  at it without  passing
over a good third of the internal circumference of
the pelvis; and that movement could not  be execu-
ted without giving the child's neck a dangerous, and
perhaps a mortal twist.
Method of using  the  Forceps, 1. in that position in
  which the Occiput answers to the right Foramen
  Ovale, and the Forehead to the left Sacro-ischiatic
  Notch;  2. in that in which the Occiput is placed
  opposite the said Notch, and the Forehead behind
  the right Foramen Ovale; 3. when  the Crown of
  the Head is situated exactly across at the  inferior
  Strait.

  1222. When circumstances require  us to recur
to the forceps in that  position of the head in which
the occiput answers to the right foramen ovale, we
must insinuate the male branch obliquely behind the 
448        Application of the Forceps.
left foramen ovale, holding it with the left hand, and
directing it with some of the fingers of the right in-
troduced  towards  that  part.  In proportion  as
it  penetrates,  we  lower  its  external extremity,
which we held very high at first, and  inclined to-
wards the thigh, but so that the point of the pivot
which serves for its junction with the other branch,
may always be towards the groin of that side.  We
afterwards slide up the other branch, which we hold
with the right hand, between the child's head,  and
the right sacro-ischiatic ligament of the mother, di-
recting it  with one or more fingers of the left hand.
We pass it  on in the direction  of the sacro-iliac
symphysis of that side, crossing the fore part of the
sacrum a little,  and observing to lower the external
end in proportion as it penetrates, till  the opening
destined to receive  the pivot  of the  first  branch,
meets it; we then join them together, and fix them;
and afterwards take hold of the  extremity  of the
instrument with the left hand, and place the right
towards its middle, near the parts of  the woman;
then we turn the head in the pelvis, in order to bring
the occiput under the arch of the pubes, to extract  it
afterwards as if it had presented originally in the first
position. See par. 1_;12.
   1223. The relation of the dimensions of the head
to those of the pelvis, being absolutely  the same in
the position in which the forehead answers to the
right foramen ovale, and the occiput to  the  left is-
chiatic notch,  as in the preceding, the forceps must
be applied according to the same principles, when
circumstances require their use.
   1224. It is excessively rare for the child's  head to
present its greatest length exactly across at the infe-
rior strait, so as for one ear to answer exactly to the
symphysis of the pubes, and the other to the middle 
            Application of the Forceps.        4ic>

of the sacrum. And the best method of applying the
forceps in that case differs so little from what I have
recommended  for  the diagonal positions,  that  I
might have confined myself to them, without leaving
a great deal to be added after me. These transverse
positions  can only be two in number: in one the
occiput answers  exactly to  the left side of  the
pelvis, and in the other to the right.
   1225. To  apply the forceps conformably to the
principles I have established, we are to  introduce
the female branch of the  instrument directly under
the pubes, and  the other  before the sacrum, in the
first of these two  cases;  always keeping their  ex-
ternal extremities inclined towards the left thigh of
the  woman.  When they are well placed, united,
and fixed, we take hold of the end of the instrument
with the right hand, and  the  middle part with the
left; then  turn the head so  as to bring the occiput
under the pubes,  and afterwards  extract it in the
manner directed for the most favourable  position.
   1226. In that transverse position,  in which the
occiput answers to  the right  side of the pelvis, we
must introduce  the male branch of the forceps di-
rectly under the pubes, and  the female before the
sacrum; with the precaution of inclining the  ex-
tremities  of both towards the right thigh of the
woman. Having then  taken hold  of the middle of
the instrument with the  right hand, and of the ex-
tremity with the other, we turn the occiput under the
arch of the pubes, as in the preceding position; and
terminate the delivery in the same manner.*

  * These  cases offer much more difficulty to the application
of the forceps than the preceding; and two cases have occur-
>;d, where  I found it impossible to apply them in this direc-
tion; I therefore changed the situation of the head to the dia-
gonal, by using one of the blades of the forceps as a lever; I
                       3 L 
450        Application of the Forceps.
 Causes which ought to determine us to use the For-
   ceps, while the Head is still above  the superior
   Strait; and general Rules to be observed in it.

   1227. It is  often so difficult  for those who are
not well versed in the use of the forceps, to take a
good hold of the head with that instrument, when it
is still above the pelvis, and so many inconveniences
may result from it, that we ought never to attempt
it but when the circumstances, which complicate the
labour, leave us no hopes of employing any method
more gentle or more certain. Although the difficul-
ties are less for those who  have a rational habit of
using the  instrument, who perfectly know its rela-
tions to the child's head and the plevis of the mother,
they are nevertheless great enough topreventourpre-
ferring it to other methods  sometimes equally prac-
ticable. The accidents which require us to deliver,
while the head is still far off, are not sufficient to de-
termine us to give that preference to the forceps. A
defect of size in  the superior strait, relatively to the
volume of the head, ought alone to induce us to do
it; and even then there ought to be space enough to
give hopes of bringing the child  with  less danger,
than by turning it, and extracting it by the feet.
   1228.  Although there are  fewer accidents to be
feared in carrying the forceps so far, when  the pelvis

then very  easily applied the instruments  and extracted the
head. I would therefore recommend this mode in preference
to the other; to effect this change we apply a blade of the
forceps, on the vertex and depress it, and at the  same  time
incline it towards the foramen ovale, or the arch of the pubes.
If the vertex is to the left side of the pelvis we use the  male
blade and vice versa.
                                       \V. P.  D. 
            Application of the Forceps.        451

is  well  formed, than in the contrary state, since
there is more space for applying them, and the parts
of the woman, as well as the child's head, will not
suffer so strong a pressure from them, yet we ought
not in that case to  use them;  because the more
moveable the head is over the brim  of the pelvis,
the more difficult it  is to take hold of it  prOperly.
The extraction of the child by the feet then merits
the preference, after the usual preparations, if the
state of the uterus requires them:  that method is
more easy for the greater part of practitioners, and
safer for the woman, in their hands, than the use of
the forceps.
   1229. If we  are  not founded in preferring the
forceps, but when the superior strait is contracted,
neither are they always proper when it is so much
so that the head  cannot engage  in it;  an extreme
deformity  much less  admitting the  use  of  that
instrument than a good conformation. In the latter
case, we only reject it  because it seems preferable
to turn the child, and because its application re-
quires an extent of  knowledge which  the greater
part of those who devote themselves to the practice
of midwifery do not possess, and which they cannot
acquire by reading: in  the other  case it is totally
inadmissible.
   1230. We ought to take great care in all cases,
but particularly in that where the narrowness of the
superior strait obliges us to recur to the forceps, to
fix its branches in such a  manner,  that we may by
their help place the  diameters of the head  in a
proper relation to those of the pelvis, and dimmish,
according to the necessity of the  case, that which
is to pass in the direction of the smallest diameters
 of the  straits: which I shall more particularly ex-
 emplify in the following sections.  1 shall suppose 
4e>2        Application of the Forceps.

in all these cases  that the  length  of the  smallest
diameter  of the superior strait, is less than three
inches and an half, and more than two inches three
quarters.
Method of using the Forceps in that Position of the
   Head in which the Occiput rests on the  Top of the
   Symphysis of the Pubes, and the Forehead against
   the Sacro-vertebral Angle; and in that where the
   Occiput answers to the said Angle, and the Fore-
   head to the Pubes.

   1231.  In  the first of these positions, which is ex-
cessively  rare  at  the  beginning  of  labour,  the
impossibility of the  woman's  delivering  herself
without  help, often arises much less from the  bad
conformation of the pelvis,  than from the manner
in which the child's head presents  itself to  it. It is
then its greatest diameter which tends  to pass  in
the direction of the  smallest diameter  of the su-
perior  strait, which cannot take place,  unless this
last be nearly of its natural  length. To change the
direction of the head, would be sufficient to  put the
woman into a condition to deliver  herself without
farther help, if  the bad conformation of the strait in
question  were but moderate, and left it three inc-hes
and a quarter, or three inches and an half in its little
diameter.
   1232.  When we judge the use of the forceps
preferable to any other method,  we must apply the
blades to the  sides of the head, sliding them up
along the lateral parts of the pelvis, to an equal
height; which must be seven or eight inches at the
least, if we would have them grasp  the head closely 
           Application of the Forceps.        453

and properly. My rule on this subject,  when  the
forceps I have  adopted are used (see par.  1106),
is  to  slide up the branches, till  the  part destined
for their junction touches the edges of the vulva.
   1233. As it is difficult to reach high enough on
the sides of the head, to direct the blades of the  for-
ceps with  certainty, by passing only two fingers into
the vagina, as directed in all the cases stated in the
preceding article, we may introduce the whole hand
except the thumb. As we ought to  introduce the
male branch of the forceps first, and hold it with the
left hand,  we introduce the fingers of the right hand
under the edge of the orifice of the uterus,  before
the left sacro-iliac symphysis, to  guide the  end of
the instrument  thither. When  we have carried the
instrument a little beyond the  ends of the fingers,
we are to bring it exactly  on the side of the head,
and of the pelvis; but by slow degrees, and  in pro-
portion as it penetrates farther. We are to observe
at the same time to lower the extremity which is
without, and much more than if the head occupied
the cavity of the pelvis; setting  however different
bounds to it, according to the particular inclination
of the pelvis of the woman relatively to the horizon,
and according as the curve of the  sacrum shall be
more or less considerable, &c: which can only be
determined by  the operator himself.
   12J4. The  female branch is to be placed  with
the same  care on the other side, conducting it with
the right  hand, while with some of  the fingers of,
the left, introduced at the entrance of the uterus, we
direct its  extremity within the neck  of that viscus,
opposite the right sacro-iliac symphysis, from  whence
it is to be brought  insensibly opposite to the other
branch; so that  at first  it  covers  the side of the
forehead,  and afterwards the parietal  convexity. 
454        Application of the Forceps.
   1235. The two branches being united, we are to
compress the  head as much  as  is necessary, by
bringing their extremities more  or less together,
and fixing them  so  by means of a garter or the
corner of a napkin. We are then to turn the length
of the cranium from the  direction of the little di-
ameter  of  the superior strait, inclining the occiput
towards one of the sides of the pelvis, or if the strait
be moderately narrow, only as far as the acetabulum:
but preferably to the left. In order to that, we are
to hold  the instrument with  both hands, the right
placed at its extremity, and the left near the parts of
the woman, in such a manner that the  fore-finger of
the latter introduced into the vagina, may constantly
touch the top of the head, between the two blades.
The greatest care  must be taken, in  proportion as
we turn the head over the superior strait, to lower
the handles of the forceps, as much as the external
parts of the woman will permit, canying them, at
the same time, insensibly  towards the left thigh.
   1236. It is in this direction, downward and to-
wards the  woman's  left thigh, that we must pull
the instrument to bring  the  head into  the lower
part of the pelvis.  Without that precaution we
should not succeed, either in changing its position,
or  bringing it down; and we should exceedingly
bruise the  internal soft parts of the pelvis; as we
may be  convinced by only reflecting on the natural
direction of that bony canal. It is the ignorance of
most accoucheurs, in this respect, which has ren-
dered  their efforts  fruitless; which has induced
them to think and publish that the forceps cannot
be usefully applied while the head is still  above the
pelvis,  and to  accuse  those of  insincerity  who
affirm that  they  have reaped  the  same advantage
from them then, as when it  occupies the  bottom 
Application of the Forceps.        455
of the pelvis. The precautions i have recommended
are so  necessary, that the omission  of only  one
may render all the rest useless.
   1237. When the head is come into the cavity of
the pelvis, we raise the extremity of  che forceps a
little, but keeping it nevertheless inclined  towards
the woman's left  thigh. Afterwards we change the
direction of 'hie head again, and Oriiie,  die  occiput
under the arch of the  pubes,  over  which it was at
first: proceeding for that purpose, and in the sequel,
as directed in par. 1218, and following.
   1238. If, contrary to all expectation, the superior
strait should  not be found narrower  from side to
side, than from before backward,  as  it has  been
seen, though very rarely, we ought to  bring down
the  head  in  its primitive  direction:  but  then
it would be proper to raise the forehead as  much
as possible above the sacro-vertebral angle, that the
top of the occiput may present more perpendicularly
at the superior strait. By that means, it will be the
height of the head taken from the summit to the
base, which  will correspond  with  the diameter
which goes from the pubes to the sacrum, and not
the length of  the cranium as before; which will
render its descent much easier.
   1239. The position  in which the  forehead  rests
against  the top of the  symphysis of the pubes,  and
the occiput on the sacro-vertebral  angle,  is  stitl
more rare than the last. It is also less  favourable
for delivery",  because the face is upward, and  alter
having turned it on one side, to favour the passage
of the head through the superior strait, we  cannot
dispense with  bringing it back  again  under the
pubes.
   1240.  We  must operate in the same manner as
in the preceding case,  -with  respect to the appli-
cation of the forceps. 
456        Application of the Forceps.
Method of using the Forceps when the Head, retained
  above the superior Strait, presents the Occiput at
  the left side, and the Forehead at the right: and
  also when the Forehead answers to the left side,
  and the Occiput to the right.

  1241. The greatest length of the head seldom
presents so diagonally  at  the  entrance  of a  pelvis
contracted in its little diameter, as we  find it in  a
natural labour; nor is  it more common  to find  it
exactly  transverse. But suppose  that its great di-
ameter should cut the  superior strait obliquely in
this case, as in that where the pelvis is well formed,
it could not remain in that diagonal situation during
the application of the forceps; because, being move-
able on the superior strait, it yields to the pressure
exerted on one of its sides, by the introduction of
the first blade of the instrument, and places  itself
so nearly across, that we may, with  respect to the
application of the forceps, consider it in that  situa-
tion.
  1242. If the child's  head, resting on  the margin
ofa contracted pelvis, could be fixed in one of the
diagonal  positions which we  generally  observe
when the pelvis is  well formed, we might apply the
blades of the forceps much more easily on the pa -
rietal regions, by following the rules which I have
laid down respecting each of those positions, when
the head occupies  the lower part of the pelvis: ob-
serving only  to slide   the  instrument  higher, and
lower its  external  extremity  more. The forceps
might be  applied with  still much less trouble;  if
we could  previously,  with the hand,  reduce the
head to one of the  positions which I have described 
            Application of the Forceps.        457

in the preceding section; that is to  say, bring the
occiput or the forehead over the pubes; as is clearly
seen by considering the relation of its  dimensions
to those of the superior  strait: but, unfortunately,
the time when we might hope to do  that, is often
long elapsed, when we are called to operate. 1 shall
then consider all these positions as transversal, or
nearly so, since it is in that  direction,  as we  have
already seen, that the length of the head must  be
placed to bring it  down, when the superior strait
is contracted to the degree stated in  par. 1230.
   1243.  To operate conformably to the principles
dictated  by the very nature of the obstacle which
opposes  delivery,  in the  transverse positions of the
head in question, we  must place the blades o_' the
forceps on the ears; consequently, one before the
sacrum, and the other under the pubes. The introduc-
tion of the first is easy enough, but that of the se-
cond requires care, knowledge and dexterity.
   1244. We must place the female branch under
the pubes, and the male branch before  the  sacrum,
whenever the occiput answers to the left side of the
pelvis. It is also  necessary  to introduce that first
which is to be under the pubes, because the  diffi-
culties  which oppose its progression  towards that
part, would  be augmented  by the presence of the
other branch if that were already introduced behiud,
that is to say, before the sacrum. To place the first
properly, we must begin by  directing it with some of
the lingers of the  left hand  introduced into the  va-
gina, under the edge of the orifice of the uterus U iore
the right sacro-iliac symphysis; and advance i   h it
direction tin the blade closely embraces the sKie of
the forehead It is not till then that we oughtto berin
to bring it towards the pubes, to place it under the
symphysis, by passing it over the face and temple 
458        Application of the Forceps.
of the child. But to make it execute that movement
more easily and certainly, we  ought to apply the
fingers, introduced into the vagina, under the con-
vex edge of the  blade,  and push  it from  behind
forward with respect to the pelvis;  while, with the
other hand, we  lower the  external  extremity  as
much as we can, turning the point of the hook which
terminates it insensibly downwards, till it be directly
towards the floor.
  1245. Before we withdraw the fingers  from the
vagina, which have served for a guide to the first
blade, we insinuate the  second along the sacrum,
and within the posterior  edge of the  orifice  of the
uterus; placing it in such a manner relatively to the
body of the other, that when it is  introduced to a
proper height, they  may naturally join. It is also to
be held with the right hand, the handle very high
and inclined towards the left os pubis, the end of the
blade low, and its concave edge obliquely regarding
the woman's left thigh. It is to be  introduced flat,
under the  head  and passed up along the sacrum;
which is to be effected by insensibly lowering the
handle which at first was held  very high.
  1246. As to the extraction of the head, it must
be performed as I have  prescribed in par.  1235,
and following.
  1247. The position in which the occiput answers
to the right side of the  superior strait  being the
same as the preceding,  as to the relation  of the
dimensions of the head  to those of that strait,  we
must use the forceps agreeably to  the  principles
established for that. But the male branch must  be
placed under  the pubes,  and  the female  branch
before the sacrum;  in order that their new curve
may answer to the occiput,  which must be brought
under the anterior arch of the pelvis,  as soon as the
head shall be descended into that cavity. 
Application of the Forceps.        4$P
Method of using the Forceps, when the Head pre-
  senting the Vertex, is wedged in the superior
  Strait.

  1248. Hitherto we  have spoken of the use of
the forceps, only in cases where  the  head  of  the
child was free in the cavity of the pelvis, or above
the superior strait: it is  now time to treat of those
in which it  is locked in  that strait.  Although  this
state differs little from that in which the  head is  still
above the pelvis, as to the application of the instru-
ment, yet in order to explain them with  more clear-
ness and  precision, I thought it best  to treat of
them in two separate articles.
  1249. I shall  repeat here,  that the child's head
may be locked  either with its length, or its thick-
ness, between the pubes and sacrum,  and that  it
must then be in one of the four  positions stated in
the preceding article.
Method of using the Forceps,  when  the Head is
  locked lengthwise, between  the Pubes and  Sa-
  crum, superiorly.

  1250. The head locked lengthwise, may present
the occiput or the forehead against the pubes, which
constitutes two  positions essentially different,  but
which are the same were we to consider them only
with respect to the relation  which the  dimensions
of the head bear  to those  of  the pelvis, and the
mode of operating necessary to terminate  the de-
livery. In  both, the longitudinal diameter of the
head is parallel to the little diameter of the entrance 
460        Application of the Forceps.
 of  he pelvis; in bin it is the occiput and forehead
 which are in contact with the anterior and posterior
 parts of that cavity, while the sides are free.
   1251. For the head to be locked in that direction,
 the little diameter of the superior strait must be of
 such an extent, that the head might pass it without
 much difficulty,  in a  transverse position:  which
 indicates the course we oughtto make it take with
 the instrument, in order to extract it.
   1252. We must place the branches of the forceps
 on  the sides of the head and  of the pelvis, with the
 same precautions laid down in the  second section of
 the preceding article, par. 1232, and following; ex-
 cept that they are not to be passed so high by about
 an inch and an half; and when fixed, we are to keep
 the handles a little less downward  and backward
 than directed in par. 1233,1236, &c. We ought never
 to attempt to bring down the head in either of these
 two positions; because by pressing it on the sides
 with the forceps, far from diminishing its length
 from the forehead to the occiput,  it must augment
 the force of the contact of  those  parts with  the
 sacrum and the pubes; increase  the frictions of
 the head, and render its descent more difficult  and
 laborious, both for the mother and child. We must
 then begin by giving it a transverse situation, in
 order to place its smallest diameter in the direction
 of the smallest diameter of the superior strait.  To
 procure this change with less difficulty,  we are to
 unwedge the head, by making it rise above the part
 where it is locked, which  is easily done;  not  by
 pushing it directly upwards with  the forceps,  but
 by shaking it a little, and carrying the extremity of
 the  instrument alternately and repeatedly towards
each of the woman's thighs; in the same manner as
we would shake a nail  to draw it  with a  pair of 
Application of the Forceps.        461
pincers.* We miy  be convinced of the possibility
of unv.\dging the  head, and  pushing it up, by
shaking it in this manner, if we recollect  the form
which it takes in  locking, and that  its base  or
greatest  breadth  is then above the  two points  of
contact which fix it. and hinder it from descending;
and  moreover,  that  we  push  it back from  a
narrower space into a wider. See par. 1156.
   1253.  When  we have unwedged the  head, by
shaking  it thus, and pushing it up,  we are to turn
the occiput or the forehead from over the symphysis
of the pubes, according as it is  the one or  the oiher
which is found there,  and  we  direct it preferably
towards  the left  side  We bring dcnvn the head  in
this new position to the  bottom of  the pelvis, and
as soon as it is arrived there,   we are  to  turn the
part which was over the symphysis at the beginning,
under the arch of the pubes: and afterwards  finish
the delivery as usual. In  these different periods of
the operation, we are  to  observe all  that is prescri-
bed in the paragraphs 1233, and following, to 1240
inclusively.
Method of using the Forceps when the Head is wedged
        transversely in-the Superior Strait.

  1254. This species of locking cannot take place
but when the small diameter of the superior strait
is less than three inches and an half,  or when the
head is much more voluminous than usual; because
its thickness does not commonly exceed that, and
it does not stop and become locked, till after it has

  * Experience has often confirmed the truth of all the propo-
sitions contained in this paragraph. 
462        Application of the Forceps.
 suffered some reduction in that  direction in which
 it undergoes the greatest friction. When the  head
 is fixed thus, we ought to endeavour to push it up
 with the hand,  as Smellie advised; and afterwards
 eonduct the branches of the  forceps in the same
 order, and according to  the same directions which
 I have prescribed in the  third section of the  pre-
 ceding article. If we cannot accomplish the putting
 it back in this manner, we  must apply the forceps
 at the sides of the pelvis, placing one branch on the
 face and the  other on the occiput, 'taking  care
 to slide them both up to the same height; for other-
 wise they could not be joined. But it seems to me
 out of all probability that a case should ever happen
 in which we could not push back a head wedged
 only in the superior strait, since  the part where it
 preserves the  greatest thickness is then  alwayrs
 above that strait. See par. 1253 and 1156. We must
not confound this case with that which is the subject
 of the following paragraph.
   1255. If we  admit it to  be impossible to push
back a head strongly wedged with its sides against
the pubes and sacrum, we must  apply the  forceps
to the sides of  the pelvis, consequently on the face
and occiput of the child. Though in that case  it is
not exempt from  inconveniences, it has  not all
which I have attributed to it in the  transverse po-
sitions of the head above the pelvis; Nature having,
before the application of the, forceps, effected almost
all the  reduction of its thickness, necessary for its
passage through the superior strait; since it is al-
ready wedged in  it, which could not be without
its advancing at least a third, or even the half of its
length.
   1256.  When we are reduced  to the necessity of
following this method,  we are to change the situa- 
and of the Lever.            463
tion of the blades of the instrument as soon as the
head has cleared the superior strait, and place them
on  the ears, in such a manner that their  concave
edge.inay be towards  that side of the pelvis which
answers to the occiput;  in order  to bring  it under
the arch of the pubes,  and finish  the delivery as
usual.*
Method of using the Forceps and the Lever, when
         the Child presents the Face.

   1257. I have already demonstrated what a num-
ber of obstacles Nature has to encounter in deliver-
ing herself without help of a child presenting the
face, and how  much difficulty we find in assisting
her, when we are not called early enough to operate
at the  moment of the evacuation of  the waters  of
the amnion. In establishing the essential indication
presented by this kind of labour, in which the child's
head  is  constantly turned backward, I have  also
observed that we could not always fulfil it, that is
to  say,  correct  this bad  situation  with the  hand
alone,  and that it is sometimes necessary to use the
lever for that purpose.  In many of these cases, the
forceps cannot be applied with advantage but after

  * A case occurred to me some years since, where  I was
obliged to apply the forceps on the face and occiput, in conse-
quence  of the  fore arm being between the head and tccrum;
small force was sufficient to bring the head in the vagina; the
forceps were then removed and placed at the sides of the head;
the child  was  delivered living and healthy—this  case was
witnessed by Mr. now Dr. Brown.
  From this it  would appear that, cases may occur, where we
are obliged to depart from the ordinary mode of practice.
                                       W. P.  D. 
464        Application of the Forceps,

the lever; and though we are sometimes obliged to
use them first, it does not always dispense  us from
recurring to the lever in the sequel, as we shall see
in the following sections: but in all those  cases,  a
branch of the forceps  may  be substituted for the
lever, and procure the same advantage.
Method of using the Forceps and the Lever in that
  Position of the Face, in which the Forehead an-
  swers to the Pub's, and the Chin to the Sacrun;
  as well as in  that in which the Forehead is against
  the latter, and the Chin towards the former.

  1258. We very seldom meet with the position of
the face in which the forehead answers to the pubes
and the chin to the sacrum; and  when it  happens,
we still seldomer see the head descend, and advance
as far as the bottom of the pelvis, at  least unless
the latter be extremely  large: the head  generally
stops in the superior strait.
   1259. When we find the head entirely  engaged
at the time we are obliged to operate, we endeavour
to correct its bad position with  the hand alone, as
prescribed in par. 1002. If we cannot accomplish it,
we insinuate the lever behind the symphysis of the
pubes, carrying it along the crown of the head till
it is above the posterior fontanelle, in order, as  it
were, to hook  the  occiput with the end of the in-
strument.* The  accoucheur then pulling the lever
almost directly  downwards,  must endeavour to
make the back of the head descend, while with the

  * It is on that account that I prefer  a iever a little more
curved and broader than the common one. 
and of the Lever.            465
extremities of the fingers of the other hand properly
applied on the sides of the face, he tries to push up
the chin towards the base of the sacrum. Notwith-
standing the objections which may be made on this
procedure, the difficulties and uncertainty of which
I know as well as any one, I nevertheless propose it,
because it is more conformable to the principles of
the art than those we find described in authors, and
because, if it should not succeed, the attempt would
be attended with fewer inconveniences.*
  1260. When  the  head remains  very  high, and
fixed between the pubes and sacrum, if we cannot
rectify it with the hand, in order to commit its expul-
sion to the efforts of Nature; nor remove it to search
for the  feet, either because that removal is impos-
sible, or because there would be too much danger
in turning the child; we  must introduce the blades
of  the  forceps  on the sides, as if it presented the
vertex  in the first position, that is  to say, with the
occiput behind the pubes. We are then to give it a
transverse position, and pull it down into the cavity
of the pelvis; where being more at liberty, we may
more easily accomplish the pushing up the face, and
bringing down the occiput. For that purpose, while
we make  the head advance by pulling the forceps
with one hand, taking care not to grasp it very tight,
with the ends of the fingers  of the other hand pro-
perly disposed on the sides  of the upper jaw, we
must support the lower part of the face, to hinder  it
from advancing so much as the occiput, and make
the head  turn in some measure, even  in its pro-
gression,  between the  blades of the instrument.
   1261. When we do not succeed at first, in bend-

   * I am convinced from many trials made  on the machine
 that the vertex can never be reduced by this method.

                       3 N 
 466        Application of the Forceps,

 ing the head forward  on the breast,  as much as is
 necessary to enable it to clear the inferior strait easi-
 ly, we must again push up the face as soon as it is
 entirely in the lower part of the pelvis; taking care
 then to grasp it less tight between the blades of the
forceps, that it may move more freely between them.
 If we cannot in that manner accomplish the proposed
 design, we must withdraw one of the branches of the
 forceps, and use the other as a lever to bring down
 the occiput:* but in doing that, we must  have a re-
 gard  to the side  of the pelvis  to which we  have
 turned  the child's forehead; for both places cannot
 be used indiscriminately in all  cases. When we
 have turned the forehead towards the left side of
 the pelvis,  we withdraw the female branch, and di-
 rect the other on the vertex and top of the occiput,
 to bring down the latter; as directed for the trans-
 verse  position  mentioned in par.  1268  and fol-
 lowing. If we have turned the forehead to the right
 side of the  pelvis, we must withdraw  the male
 branch  of the forceps, and use  the female  branch
 as a  lever,  according  to  the  principles  already
 stated.
   1262. After  having  sufficiently  brought  down
 the back of  the head,  and reduced it to one of its
 natural  positions,  if we think proper to extract it,
 we replace the branches of the forceps on the ears;
 consequently, one before the sacrum, and the other
 behind  the pubes;  but  so  that their  concave edge
 may be towards the occiput.  We  turn that under
 the anterior arch of the pelvis, to finish the delivery

  * This 1 conceive to be the true method  of acting in this
 case; it should therefore be immediately adopted, as soon as
 tht heaa'  na.- hcen n.aue to descend; as it must be fruitless
to atten.pt acting with the  hand as recommended, while the
forceps occupy the vagina.                 \V. P. D. 
and of the Lever.            467
as in those cases where the vertex presents  in one
of the tranverse positions which have been already
described.  If we suppose  the  woman able to de-
liver herself and without inconvenience,  instead  of
replacing the branches of the forceps in the manner
indicated,  we withdraw that with which we had
lowered  the  occiput,  and wait  for the expulsion of
the head, which soon takes  place when things are
well disposed for it.
   1263.  It is not only to change  the position  of
the  face  with  respect to the superior  strait and
bring down the head to the bottom  of the pelvis,
where we may, in some cases, rectify it with less
inconvenience, that  I have recommended the for-
ceps, but also to extract it in that very position in
which it has advanced; either when we  absolutely
cannot rectify it, that  is to say, raise up the face
and lower the occiput, or  when we cannot  do it
without  great danger to the mother: as  when the
head is  strongly wedged, or  the  uterus  strictly
contracted and closed on the child. We then prefer
the forceps to bring the head along in the attitude
we find it in, because fewer inconveniences result
from it to  the child,  than would in any  other me-
thod, to both child and mother. We place them on
the sides of the head, and disengage it in the posi-
tion stated in par. 1258, and in that  which will be
 stated in par.  1264,  when ever we find them in
those  positions. But if the face be situated trans-
versely with respect to the inferior strait,  we first
 reduce it to the latter,* as directed by Smellie. My
 brother  obtained all possible success from this me-
 thod,  in a case of this last species, though the head
* That is, to the situation mentioned in par, 
468        Application of the Forceps,
 had been far advanced for more than forty-eight
 hours: the midwife not having discovered that the
 face presented.
   1264. The position of the face in which the fore-
 head rests against the sacrum and the chin against
 the pubes,  is still  more rare  than the preceding;
 and it is equally  difficult for the head then to ad-
 vance to the bottom of the pelvis, even when it is
 well formed. If however it is so far advanced at the
 time we ire called to the assistance of the  vtoman,
 we miis, endeavour to push up the face behind the
 symphysis of the pubes, till the posterior fontanelle
 answers to the point of the  sacrum: and when the
 hand alone cannot make it execute that movement,
 we"must use the  lever.  But though  its application
 appears easier and more certain in this than is. the
 former case, we must not however flatter om selves
 that we shall always be able to obtain the  desired
 success from it, so many  obstacles we sometimes
 meet with. To apply that instrument advantage-
 ously in this case, we must slide it along the  sac-
 rum and the crown of the head above the posterior
fontanelle, which is easier to execute than in the
 preceding position; and endeavour to bring down
 the occiput,  while we push up the face with the
 extremities of the fingers in the  prescribed direc-
 tion. When the face presents in this position at the
 inferior strait, it may  happen, if the head be  very-
 small relatively to the pelvis, that the chin may ap-
 pear at the top of the vulva and engage under the
 the arch of the pubes. In that  case,  we  must not
 endeavour to push up the face behind the sym-
physis, as in the preceding circumstance, but  only
 to bring down the occiput with  the lever till it has
 cleared the bottom of the vulva. What i have said
 in  par. 1293,  may be consulted, as well  for  the 
and of the Lever.            469
manner of applying the levei, as of performing the
extraction of the head.
   12)5. The difficulty of carrying the lever  far
enony h for its extremity to embrace the top of the
occiput, when the head is only engaged  in  the >u-
pen t  strait, in this position; and the impossibility
of doing it  when  it is strongly  wedged between
the pubes and sacrum, sometimes oblige us to em-
ploy rhe forceps first, to  remove it, and  bringing it
into the cavity  of the pelvis, where we find less
difficulty in  rectifyine it.
   1266. In  this case we are  to place the instru-
ment at the  sides,  as in the preceding position, and
turn away the chin from the symphysis of the pubes,
carrying it towards the left side of the  pelvis,  till
the face be  placed across.  The head  is to  be
brought down in that state, proceeding as  for the
second position of the vertex above the  superior
strait.  See par. 1239. When it is brought into the
cavity  of the pelvis, we may try to rectify it in the
sinus of the  forceps, holding it loosely for that pur-
pose. But if we cannot do it so, we must withdraw
the male branch of the instrument,  and place the
other on  the vertex  which answers to the right
side of the pelvis,  to endeavour to bring down the
occiput; while we  push up the-face and assist the
action of the lever by means of the fingers of the
right  hand properly disposed on  the sides of the
nose under the cheeks, as I have recommended to
be done in the transverse positions of the face. See
par. 1268, and foliowing.
   1267. After having sufficently lowered the occiput,
and rectified the h< .d, if circumstances require us
to extract it, we  must  replace the blades on its
sides, so that the male branch  may be  under the
pubes and the other before  the sacrum; to  bring 
470        Application of the Forceps,
the forehead  upward  or  tou^-ds the  arch of the
pubes, and finish the delivery7 in the manner recom-
mended for the second position of the vertex  or
crown of the head.
Method  of using the Forceps  and Lever in the
   transverse Position  of the  Face, in  which  the
   Forehead answers to the left Side of the Pelvis,
   and the  Chin to the right  Side; and in that in
   which  the Forehead is  towards  the  right Side,
   and the Chin to the left.

   1268.  When the face presents across, as it may
advance  much farther than in the  preceding  po-
sitions, we  commonly find it in the lower part of
the pelvis when  we are called  in second to deliver
the woman, and sometimes we can  no longer rec-
tify it with the hand alone, nor remove it to search
for the feet. Smellie recommended in that case to
apply one branch of the forceps under the pubes,
and the other before the sacrum, to bring the head
entirely down, and, afterwards turn the chin under
the anterior arch of the pelvis, in order to extract
it in that position. But the forceps cannot be  very
salutary in  this case, at least, till the head has been
rectified, that is, till we have  pushed up the  chin
on the top of the child's breast, and brought down
the  occiput.  That is  what M. Levret  intended
when he  advised to  carry one of the branches of
of the forceps on the occipital region of the child, and
to use it like a lever.* The views of that celebrated

  * This method is what M. Levret dictated in his private
lectures. 
and of the Lever.            47.1
accoucheur would have been  excellent, if he had
not recommended to bring the face afterwards un-
der the pubes; that is the only defect in his method.
It is much better to turn the face downward,  than
to bring it upward,  when we have it equally  in
our power to turn it one way or the other.
  1269. Though we may  use  one of the  branches
of  the forceps instead of the common  lever,  to
rectify the position of the head, it is not indifferent
which we make choice of; the male branch is  the
only one proper  to be used in that  transverse po-
sition of  the face  in which  the vertex answers
to the left side of the pelvis and the chin  to  the
right,  as  the female branch  is  to be  employed
exclusively in the position which I shall describe
next.
  1270. We introduce the former at the left side
of  the pelvis, and along the  crown of  the  head,
till  its extremity reaches beyond the posterior fon-
tanelle,  and  i's  curve exactly embraces the  con-
vexity of the occiput. We then  take  hold  of the
instrument with  both hands, viz. the right  placed
at its extremity, and the other close to the parts of
the woman. We then pull towards us, in a line pa-
rallel with the woman's left thigh, which I suppose
extended, till the  occiput be  brought sufficiently
down; observing to  replace the  instrument  pro-
perly as often as it slips from  over the  head; for
we  very seldom succeed at the first trial.  To fa-
vour this movement of the head, we are sometimes
obliged to push up the face with the ends of some
of the fingers of the left hand,  while with the other
we  pull down the occipital region by means of the
lever: which  cannot be done   unless we  place the
thumb of the first hand so as to serve  for a ful-
crum to the instrument. 
472       Application of the Forceps.

 *  1271. After  having sufficiently  brought down
the occiput, and pushed the chin up to the breast,
we may commit the delivery to Nature;  or if cir-
cumstances require us to deliver the woman with-
out delay, we may  apply  the two  branches of the
forceps on the sides of the head: proceeding  con-
formably to the principles established for that posi-
tion of the vertex,  in which the occiput answers  to
the left side of  the pelvis.  See par. 1225.
   1272. The transverse  position  of  the  face  in
which  the forehead answers to the right  side  of
the pelvis, and the chin  to  the left, presents the
same indications as the preceding, being perfectly
similar to it, with respect  to the relation  of the di-
mensions of the head to those of the pelvis If we
cannot with the hand alone rectify  the head which
is  turned on the child's back, we  must make use
of the  lever, or the female branch  of the forceps.
   1273. When we  have properly rectified  the po-
sition of the head, we are  to use the forceps to ex-
tract it, if circumstances do not permit us to leave
the expulsion of the child to the efforts of the wo-
man.  But then the  male branch of the instrument
must be placed under the pubes, and the female
branch before the sacrum; to enable us to bring the
occiput under the anterior arch of the pelvis, as in that
transverse position of the head in which the occiput
answers to the right side.  See par.  1226.
   1274. There  are  circumstances, though indeed
extremely rare, in which we are obliged  to deviate
from the rules I have just laid down with  respect to
the transverse positions of the  face,  and in which
we cannot rectify the head  and reduce it to its naural
situation, nor turn the child  and extract it by die
feet: because,  on one side, the head is too far ad- 
            Application of the Forceps.        473

vanced and wedged in the pelvis; and on the other,
the uterus is too much contracted, too ,tight, and
painful, and the child's life also  too uncertain. In
these extraordinary cases, in which the established
principles are not applicable, and in which the woman
alone seems to merit all our attention, we must ex-
tract the head with the forceps, as Smellie did, and
in the manner already  described in par. 1263.
Method of applying the Forceps, when the Head is
  retained by its Base in that Position in which the
  Occiput answers to the  Pubes, and the Face to
  the Sacrum; and in that where the  Occiput is
  against the  latter, and the  Face towards  the
  Pubes.

  1275. In  the first case, after  having disengaged
the  child's arms, and wrapped them up in the same
napkin which is round the trunk, we raise the whole
properly towards the woman's belly, in which situa-
tion it must be supported by an  assistant. Then we
insinuate the branches of the instrument at the sides
of the pelvis, with the same cautions, and in the same
manner, as in the  first position of the crown of the
head; attending only to the height of the base of the
cranium, that their blades may be advanced more or
less, and their external extremities properly lowered.
W^hen the two branches are united  and fixed, we
draw  down  the head,  making it describe  a different
course, according  to the part of the pelvis which it
occupies, and the straits which it has to clear.
  1276.  When it is only stopped at  the inferior
strait, we pull with the right hand at the extremity of
the  forceps,  raising it insensibly as the face advances
                      3 O 
474        Application of the Forceps.

towards the lower part of the vulva, and continue to
do so till the forehead is without; while we support
the perinaum with  the other hand, to prevent its
rupture.
  1277.  When the head is still above the pelvis, we
carry the blades of  the forceps farther than in the
preceding case, and keep their extremities much
lower. We afterwards take  hold of the extremity
with the right hand; and the middle of the instrument
with the left;  we remove the  head, and give it a
transverse situation with  respect to  the superior
strait; but turning  the occiput preferably towards
the left side of the pelvis. If the head should be en-
gaged and wedged  in the superior strait, before we
turn it transversely  we should shake it a little and
push it up a few lines, carrying the extremity of the
forceps  alternately  towards  each of  the  woman's
thighs, as directed in par. 1818. In turning the head
afterwards  to  give  it the transverse position indi-
cated, we must lower the end of the instrument
more and more, and carry  it  a little  towards the
woman's left thigh.  It is also  in that direction that
we must pull to bring the head into the cavity of
the pelvis; but as soon as it is there, we are  to turn
the head again, to bring the occiput behind the sym-
physis of the pubes, and continue to extract it, as
directed in the preceding paragraph; that is  to say,
by insensibly raising the extremity7  of the forceps,
and pulling them towards us.
   1278.  The person who  supports the body of the
■child, must make  it follow the same movements
which are given to the head. While the accoucheur
turns the occiput towards the left side of the pelvis,
the child's  back must  be  inclined  towards  the
woman's left groin, and be turned upward again as
it was before,  when we  bring the  occipital  region 
            Application of the Forceps.         475

behind the symphysis of the pubes.  The same pre-
cautions are to be observed in the positions I am
going to describe.
   1279. When the head stopped by its base, pre-
sents the occiput to the sacrum and the  face to the
pubes, instead of raising the child's trunk towards
the  belly of the mother, as directed in par. 1275,
we must carry it a little backward, where it is to be
supported in  that  position  by  an assistant,  and
wrapped up in a linen cloth, in which the arms are
to be included also.  The blades of the forceps are
to be introduced as in the preceding position; but
above the body of the child, conducting them with
the ends of some of the fingers, till they are beyond
the  sides of the  lower jaw. The extremity of the
instrument is to be kept a little  higher than in the
first case, if the head occupies the lower part of the
pelvis; and as low as possible, without hurting the
child, when it is stopped at the superior strait.*
After having  placed the instrument properly, we
proceed to  the extraction of the  head in the follow-
ing  manner.
   1280. When it is still in the superior strait, we
shake it a little, to enable us, first to  push it up,
and afterwards to turn the  face from  behind  the
pubes, more easily; which is not difficult to do, if

   * When the child's head is still so high, if we find too much
difficulty in introducing the branches of the forceps above the
body of the child, on account of the impossibility of lowering
the extremity of the instrument so much as we do in the pre-
ceding position, we must, as in that, raise the trunk of the
child towards the belly of the mother, and try to carry the in-
strument underneath. But some inconveniences would result
from it afterwards  in making the head take' the course pre-
scribed in par. 1281; inconveniences which can only be avoided
by withdrawing the instrument, when the head shall be de-
scended into  the cavity of the pelvis, and by replacing it as
in the transverse position which I shall describe next. 
476        Application of the Forceps.

we take care, while we turn it, to lower the extremity
of the instrument, and incline it towards the thigh of
that side to which we direct the face; but I would
recommend the left preferably.  Having placed the
greatest diameter of the base of the cranium accord-
ing to the greatest diameter of the superior strait,
we are to pull the instrument in a direction  which
would tend to pass under the woman's left thigh, to
bring the head into the cavity of the pelvis;  where
we make it execute another rotation, by  which we
bring the face under the pubes.  As  we  lower  the
extremity of the instrument, and incline it towards
one of the  woman's thighs, at the  same  time  that
we change  the position  of  the  head with  respect
to the superior strait, so we must raise  it up  and
bring it  opposite the pubes,  in the latter  period,
when we bring the  face  back  again under  that
bone.
  1281. To finish the extraction of the head, as soon
as we have reduced it to the  position in question
with respect to the inferior strait, we hold the for-
ceps with the right hand only, placed at the extre-
mity, and apply  the left against  the  perinaum of
the woman and under the child's  neck,  which wc
support with the radial edge of the index, so as to
make that the centre of motion  for the head as it
disengages, and not the commissure of the vulva or
the fourchette. We pull towards us with  the right
hand, raising the  handles of the instrument gradu-
ally  and carrying  them alternately towards each
of the woman's thighs, till  the  whole  of the  face
and the vertex are  disengaged successively from
under the pubes: for so the  head must be delivered
in this position, that it may present its smallest di-
ameters to  those of the pelvis; as I have  observed
in treating  of the  mechanism of that natural labour,
in which the  feet  present with the toes upward. 
Application of the Forceps.        All
   1282. If the head be retained only by the inferior
strait, at the time  when we think it necessary to
recur to the forceps, it will be  so much the  more
advantageous, as well with respect to the intro-
duction of the blades of the instrument, as for the
extraction of the head itself; and we must conduct
ourselves on both points as directed in par.  1279
and 1281. We must  not attempt to turn the face
towards the sacrum in the  case which is  the sub-
ject of those same paragraphs, but with the greatest
care and caution.
Method of using the Forceps, when the Head is re-
  tained in a transverse Position, after the Exit of
  the Trunk.

  1283. It is generally in this direction that the
base  of the  cranium stops at  the superior strait,
when the child comes by the feet, and this accident
is to be feared whenever the distance from the pubes
to the sacro-vertebral angle is less than three inches
and  an  half. The position  of the head,  though
transverse, is however not always exactly the same;
for  the occiput sometimes answers to the left  side
of the pelvis, and at  other times to the  right:  this
remark  is not unimportant with respect to the ap-
plication of the curved forceps; for their branches
ought not to be placed in the same manner in  both
cases. It is not enough that they be directed on the
sides of the head and to a proper height; they must
also  be so disposed,  that their  concave edge  may
be towards the occiput, that we may bring it under
the pubes in the last period.
  1284. As  it is proper to place the blades of the 
478       Application of the Forceps.

forceps on the sides  of the head, and as we can
never do that more easily than when they can at
the same time be introduced towards the  sides of
the pelvis, the accoucheur would spare himself
some difficulties,  if he could with the hand  alone,
after having brought down the child's arms, change
the position of the head, and reduce it to the first of
those which I have described;  that is to say7,  if he
could turn the face towards the sacrum: but gene-
rally, and indeed almost always, he would attempt
that removal in vain. We therefore proceed in the
following manner.
   1285.  When the occiput answers to the left side
of the pelvis, we begin by inclining the trunk and
arms of the child, wrapped up in the same  cloth,
towards the thigh of that side,  where an assistant
must support them while  we apply the forceps. We
first introduce the female branch towards the right
side of the pelvis, directing the extremity  of the
blade with the fingers of the left hand, till it passes
beyond the child's chin;  but a little on  the right
cheek, that it may not stop under the jaw, nor  go
into the mouth, or against the nose, in its passage.
We continue to slide it up in  the  same direction,
nearly to the height of the  child's  forehead; after-
wards by pushing it with the  ends of the fingers
which have served to guide it, placed on the pos-
terior or convex edge, it  is to  be passed over the
face and the left temple, to conduct it under the
pubes; while with the other hand we lower its ex-
ternal extremity,  but by  insensible degrees, and
turn  the end of the hook which  terminates the
handle, directly towards  the floor:  as I  have  re-
marked on account of one  of the transverse posi-
tions of the crown of the head. See par.  1244.
   1286. We then insinuate the other branch  di 
            Application of the Lever.        479

rectly before the projection of the sacrum, and to
the same height as the first, as directed in par. 1245.
After that, we unite and fix them, in order to ex-
tract the head in the following manner.  We first
pull downwards as much as possible, till the  head
has cleared the superior strait, observing, as it de-
scends, to incline the extremity of the forceps a
little towards the woman's left thigh. But as soon
as it is in the cavity  of the  pelvis,  we  bring the
occiput under the pubes, by  raising the end of the
instrument,  and bringing it  opposite to the sym-
physis, to extract the head as in the first position.
   1287. We place the forceps in the same manner,
in that transverse situation of the base of the cra-
nium, in which the hind part of the head answers to
the right side of the pelvis; but with this difference,
that the male branch must be under  the symphysis
of the pubes, and  the female  branch before  the
sacrum.
            Of the Use of the Lever.

   1288. From what I have  said, the use of the
lever will not appear so general as that of the forceps,
and every practitioner may easily convince himself
of it, if he will pay the  slightest  attention  to the
mode of acting of those two instruments. The lever
ought only to be employed for correcting certain
bad positions of the head, and  secondarily favour-
ing its exit; but the forceps can extract it whenever
the disproportion  between the head and the mother's
pelvis is not too considerable.
   1289.  The head as it engages in the pelvis, some-
times deviates from the course which it ought  to 
480        Application of the Lever.

follow to enable it to disengage again from it freely'.
The posterior part of the vertex, or  the  region of
the posterior fontanelle, instead of advancing more
and more, may recede in proportion as the head
descends; so that the upper part of the forehead
comes to the centre of the inferior strait,  as is ex-
plained  in par. 946,  and following. The  occiput
being more  or less turned on the child's back,  and
the chin removed from the breast, so that the head
presents its  greatest diameter foremost, delivery
becomes impossible in many women, without as-
sistance, or  at least so difficult, that we cannot be
too much on our guard  against this bad position,
whether to prevent it, or  to correct it when  we are
called later.  See par. 952, and  following.
   1290. The indication, in the first case, consists in
supporting the top of the forehead to hinder it from
descending;  and in the second, in bending the head
on  the child's breast, either by pushing  up  the
forehead in a proper direction,  or  by pulling the
occiput downward.  The hand  is  almost  always
sufficient to  procure this advantageous change; and
it is only when that fails that we ought to have re-
course to the lever. I must state here that the cases
in which  the latter becomes necessary, are so rare,
that I and my brother have never met with any one
where it was indispensable.
   1291. It is always on the occiput,  that we ought
to apply this instrument,  the curve of which should
be proportioned to  the  convexity  of that  region;
that it may embrace it exactly, and that  its extre-
mity may find a rest sufficient to bring  it down.
We.ought to use it as a kind  of blunt hook,  and
not as a common  lever.  The manner of using it,
though always according to the same principles,
must nevertheless be a little  different in each posi- 
Application of the Lever.         481
tion of the head; because we must have a regard
to the natural course  which  it ought  to describe
in the various situations, in which  it may present,
in order to clear the pelvis with the fewest obstacles.
Method of using the Lever in that Position  of the
  Vertex  in  which  the  Occiput answers to  the
  Pubes of the Mother, and the Face to the Sacrum;
  and in that where the Occiput is against the latter,
  and the Face behind the Pubes.

   1292. Supposing that it  has at first presented
the occiput behind the pubes, and that,  as the head
engaged,  it has turned on the back, if we cannot
push up the forehead, or bring  down the occipital
region with the fingers alone,  we  must insinuate
the lever  behind the symphysis of the pubes till its
curve exactly  embraces the convexity of the occi-
put. That we may introduce it  more certainly  and
methodically, we must hold it with one hand, so that
the extremity which serves for a handle be very low,
and we must direct the other end to the place indi-
cated, by means of the fore  and middle fingers of
the other hand, or one of them only, introduced at
the entrance of the vagina.* To make the instru-

  * In cases similar to the one stated in the  text, Ihave al-
ways applied the lever differently from our author. I intro-
duce it, at the  inferior  part of the vagina by holding the
handle immediately over the pubes;  then  by  gradually de-
pressing it, make  the blade sweep over the sides of the head
and pass the ear, and thus laterally place  its broad extremi-
ties on the vertex; when placed in this manner the breadth of
the instrument will be againsi one of the  legs of the pubes,
and consequently, as we depress, may with ease be brought
under the arch of these bones.               W. P. D.
                        3P 
 482        Application of the Lever.

 ment penetrate  more easily, we must take care to
 raise a little, but very gradually, the extremity which
 is without, carrying it a little alternately towards
 each of the woman's thighs, till the length of that
 portion which is in sight be nearly parallel to  the
 horizon.
   1293. Having slid it up to a convenient height on
 the head,  we take hold of it with one  hand, placed
 over it, nearthe pubes, and the other at its extremity.
 With the latter, we pull towards  us, and a little
 downwards, while with the former we act as if we
 wished  to  depress the head towards the coccix of
 the mother, and carry it backwards; by  this means
 we shall give it a kind of vertical turn, in which the
 occiput will descend, while the chin will rise towards
 the breast. If we do not succeed by this method in
 bringing down the  occiput as much as the circum-
 stance requires,  we must, at the same time that we
 act with the lever on the back of the head, push up
 the forehead a little, by means  of  the extremities
 of some of the fingers of the hand which grasps the
 middle of  the instrument;  but  so  disposed that it
 may keep the lever firm, and act with some of the
 fingers on the forehead at the same time. When we
 have made the head execute this  vertical turn, it
 seldom fails to come along, unless other causes ob-
 struct it: but then  we have recourse to the forceps,
 if circumstances do not permit  the woman to de-
 live< herself without help.
   1-zvA. The utility of the lever is  not less evident
 in the position in which the forehead answers to the
pubes and  the occiput to  the sacrum, than in  the
 preceding, when the child's chin  has quitted  the
 upper part of its breast too soon, and the head has
 advanced turning a little on the back: but we ought
 not to use it, except when the fingers alone cannot 
            Application of the Lever.         483

rectify the head, that is  to say bring down the
occiput.
   1295. We then slide up the  instrument between
the occiput of the  child and  the  sacrum  of the
mother, holding it pretty nearly as we hold the staff
for sounding in the common method,  or  over the
belly, with this difference however, that its extre-
mity must be less inclined on the belly, than the end
of the staff. To make the instrument penetrate far
enough,  and go above the occipital protuberance,
we must gradually bring down the extremity, as far
as the external parts of the woman permit it, carry-
ing it alternately from side to side as before directed.
Being assured  that the lever is well placed on the
head, we take hold of the middle part,  of it  under-
neath, with one hand near the perinaum, in order
to keep it fixed on the occiput; and with the other
hand we pull at its extremity. We take care to act
at first almost in an horizontal  direction, and after-
wards rising a little,  till the nape,  or  back of the
child's neck begins to appear at the lower part of
the vulva. We then  withdraw  the  lever,  and dis-
engage the face from under the pubes, as in a natural
labour where it presents in that manner.
Method of using the Lever in all Cases where  the
  Child's Head is placed diagonally or transversely
  at the inferior strait.

  1296. The diagonal positions, with respect to
the inferior strait,  are the consequence of those
which we almost always  observe at  the superior
strait, and which are th.e most  favourable for  the
descent of the head.  It is not to  change those posi- 
484         Application of the Lever.

tions that I propose  the lever: the finger  is suffi-
cient to make the head take another direction, and
bring one of its extremities under the pubes, when
it does not turn so of itself, which it very rarely  fails
to do. If the efforts of Nature, and the finger of the
accoucheur be insufficient, it  would be the forceps
we ought to have recourse to, and not the lever. I
have already fixed the number of these  positions to
four, which I shall here briefly recapitulate. In the
two first, the occiput answers to one of the foramina
ovalia; these are the most common:  in  the  >wo
others,  it is  situated opposite one  of the sacro-
ischiatic notches.
  12y7. When the  head has advanced in one or
other of these positions turning on the child's back,
as I  have stated  in par. 1277 and following, we
must endeavour to push up the forehead and bring
down the occiput, in the manner  indicated in the
same paragraphs. If the  fingers alone are not suffi-
cient to procure this change, we must have recourse
to the lever.
  1298. When the occiput is  placed behind one or
other of the foramina ovalia,  the instrument must
be conducted on it nearly as for the position men-
tioned  in par. 1292; except that we direct it a little
on one side, instead of insinuating it directly under
the symphysis of the pubes; in order that it may al-
ways be applied  on the back of the head, which
we  must bring  down  properly,  and then leave
the  rest of the delivery to  the care  of  Nature;
unless  circumstances oblige us to operate  immedi-
ately; which must then be done with the  forceps.
But the success of the forceps would be extremely
uncertain if we were to use them before we  have
brought down the occiput; as any one may convince
himself by recollecting the  manner  in which  that
instrument acts, and the relation of the dimensions 
            Of Cutting Instruments.         485

of the head thus turned on the  back, to those of
the inferior strait.
   1299.  When  the occiput answers to one  of the
ischiatic  sinuses, we must insinuate the lever in that
direction; keeping the end which is without, very
high at first, and more or less inclined towards the
groin of  the opposite side. The rest of the operation
to be conducted as when the occiput answers  di-
rectlv to the sacrum, till we have brought it down,
and reduced it to a proper position.
   1300.  The lever may be useful,  not only in all
the cases stated in this chapter, but also in those in
which the face presents, as 1 have already observed.
In all of them, in case of  necessity, one of  the
branches of the forceps may  be substituted for  it,
though perhaps with somewhat less advantage, and
its application requires more care and attention.
Labours which cannot be  terminated  without the
  Application  of some cutting  Instrument to the
  Body of the Child.

  1301. The mother and child do not always de-
rive equal advantages from the science  of mid-
wifery; because there are  circumstances in  which
we  cannot secure the life of the  one, but by  more
or less exposing that of the other.  Although  these
circumstances are much more rare at  present, than
in the last age, or even at the commencement of
the present, when crotchets  and other instruments
for  opening the cranium were frequently employed;
we  still however meet with some in which we are
obliged to apply these instruments to  the child; as
likewise  with others that oblige us to  perform 
 486         Of Cutting Instruments.

 painful and even dangerous operations on the parts
 of the mother, to rescue her, as well as her child,
 from certain death.
   1302.  Crotchets and perce-cranes are  not the
 only  cutting instruments which we are obliged to
 apply to the child in its mother's womb; the history,
 the trocar, or the scissars, are sometimes indicated
 preferably.  The child is almost always living when
 these latter merit the preference;  and if it perishes
 after  their application,  it is not so much an effect
 of the division  which  they  have made, as of the
 disease which required them. It is  not the same
 with crotchets, and other instruments of that kind;
 nothing but the death  of the child  can authorize
 the use of them, whatever obstacles may obstruct
 delivery;  because they  almost always kill. Though
 we have  sometimes extracted children alive by
 their  means, we have  generally had the mortifi-
 cation to see them expire, a few minutes afterwards,
 in consequence of their wounds.
   1303. The causes which ought to determine us
 to use these instruments, are  generally, a deformity
 of the pelvis of the mother, or of the child, whether
 of the head  or trunk; a dropsy  of the cranium,
 breast or  abdomen, &c. All  these causes shali be
 stated in  the sequel, as I treat  of the operations
 they require; but  before all, it seems to me pro-
 per to explain the signs which may  enable us to
judge, whether  the child contained  in  the  womb
 be living  or dead; because  it would not be less
 contrary to the rules of the art and to every prin-
 ciple of humanity, to mutilate a living child in the
 womb of its mother,  with a view of sparing her
the pain and danger of the  Cesarean  operation,
than to perform it, to give ,an exit to a child al-
ready deprived of life, which might have been ex- 
Signs of the Child's death.        487
tracted at the usual passage, after being dismem-
bered. I shall neglect nothing which may enable
young accoucheurs  to  steer clear  of those  disa-
greeable rocks:  if I cannot place them in perfect
security, because of the, uncertainty which some-
times attends the signs I, am going to lay down,
I shall, at least,  render them exceedingly circum-
spv-.-i in the  use, already  become too familiar,  of
this  kind of instruments.
Signs by which we usually judge whether the Child
                be living or dead.

  1304. The regular increase of the woman's belly,
her enjoying a good state of health, the movements
which she feels within her  after the fourth  month
of pregnancy, or which the accoucheur distinguishes
fey applying his hand to the part where they are felt,
are before the  time of labour, the signs by which
we commonly judge  that the child is living. But
how often have we been  deceived  on this subject!
   1305. These signs in fact will  not appear deci-
sive,  if we consider that the volume of the woman's
belly sometimes increases after the death  of the
child; that many  women feel internal movements
like those of a child, although they  are not pregnant;
that others, who are really  so, scarcely distinguish
any7, notwithstanding the child be in perfect  health;
lastly, that some have been delivered  of a child,
dead and putrefied, a day,  nay  even  the  instant
after they thought they felt it move.*
   1306. When the child  is  living, other signs make

  * I advance nothing on this subject which is not the resifk
*\ observation. 
488        Signs of the Child's death.
 it known in the course of labour. Many accoucheurs
 think the pains are brisker and more constant, and
 that the waters of the amnion are clear and limpid, but
 we cannot establish a judgment on such symptoms;
 and the following appear much  more  certain. The
 skin of the cranium is tight, it enjoys the elasticity
 proper to the teguments, and there forms a tumour
 or swelling in it more or, less considerable, when-
 ever the head advances with difficulty. We distin-
 guish the pulsation of the heart, and of the arteries
 of the cord, when the fingers  can reach them, as
 well as the motions of the tongue and  of the lower
jaw, when we introduce it into the mouth: but un-
 fortunately we cannot always carry the finger so far
 in that disagreeable circumstance, in which the art
 leaves us no other resources but the Cesarean op-
 eration, or the section  of the child in utero.  We
 must then refer  to the commemorative  signs, and
 to  those  which  may be  deduced  from the  part
 which the child presents at the orifice of the uterus.
 The least equivocal of all, is the  tumefaction which
 arises on the head, during the efforts of labour, or
that which arises on the part  that presents, or is
pressed against the entrance of the pelvis.
  1307. I have observed in par.  350, that the ante-
rior fontanelle has no pulsation before birth; and I
shall remark here, 1. that the pulsation of the arteries
of the finger which we use in these researches, is
 often mistaken for that of the arteries of the part of
the  child subjected to the touch: 2. that the irregu-
larity and slowness of  the labour pains are most
commonly independent  of the  life or death of the
child; as well as the colour and odour of the waters
of the amnion. I have frequently found  the latter
very clear, and without any extraordinary odour,
though  the child was  dead; and  at  other times 
Signs of the Child's death.        489
 turbid, greenish or grayish, and of an insupportable
fetor,  when the child has been living and  healthy.
   1308.  The absence of the apparent signs of life
 in the child in utero, does not always characterize
 its death in a manner sufficiently evident, to secure
 us from falling into error on this subject;  and no-
 thing can more clearly convince  us  of  this truth,
 than the difficulty,  and  even impossibility which
 we sometimes find, to determine whether  a child,
 which is entirely submitted  to our  senses, which
 we can see and touch, be living or  dead. I  have
 known some living, who at first had  been  thought
 dead, and had even been abandoned as such, after a
 long continuance of apparently fruitless endeavours
 to revive them. If it is so difficult then to pronounce
 on the state of the child, with what prudence ought
 we to do it, when we can only touch, as I may say7,
 a single point of its  surface,  as almost always  hap-
 pens when the pelvis is so much deformed as, to
 require the Cesarean operation, or the  section of
 the child in the womb!                       ?
   1309.  The child's death is not always the effect
 of one and the same  cause; sometimes that accident
 is the consequence of the disorders of the  mother,
 and at other times of those of the child, or of an
 external cause, as ofa blow, a fall, &c. Among the
 former, I know none more dangerous for the child,
 than convulsions and a plethora.
  1310 The commemorative signs,  at  most, can
 only be of use in the case where the child perishes
 some time before the usual epoch of its birth; we
 can derive no advantage from them when its death
 happens during the course of labour.
  1311. When the child dies during pregnancy, if
 the mother retains  it some  time, instead  of the
 movements she had been used to feel, she  soon  finds
                     3Q 
490        Signs of the Child's death.

a troublesome rolling in the uterus, and a sensation
of heaviness in the side she lies on. From the third
to the fourth day, the belly commonly swells, and
becomes painful, and then grows less; the face soon
after becomes pale, the eyes sink in, and the eyelids
are surrounded by a blackish, livid or lead coloured
circle; she has  a bad taste  in her mouth,  yawns
frequently, has pains in her head, singing in the ears,
nausea and vomiting,  syncopes  and spontaneous
lassitudes; her belly shrinks, and she is often con-
sumed by a slow continual fever.*
   1312. These effects seldom fail to manifest them-
selves when the woman retains the dead body of the
child  some time; but I have seen them occur in the
same  order, after a fall which a woman had in the
sixth month of pregnancy, though the child was not
dead.  The woman remained a fortnight in the same
state,  without distinguishing  the least  motion that
could be attributed to the organs of the child; but
she afterwards felt some slight ones, which grew
stronger by degrees, and  she  was not delivered till
after two months; the child was alive, but very weak
and languishing; it however recovered, and became
as strong as usual.
  1313. Another woman almost at full time, in her
second pregnancy,  being  awaked by  a  frightful
dream, and thinking she still saw  the subject of it,
leaped out of bed to defend herself, and call  for
help.  Being come to herself, she only complained

  * When the child dies any time before its delivery, that is,
five or six  days at least previously, we almost always find
an attempt, (and frequently a successful one) in the breasts to
form milk; the uterus after the death of the child appears to
be, with respect to the breasts, as if the child had been ex-
pelled. I therefore consider this almost a decisive sign, and
one of great importance sometimes, more especially in threat-
fflling abortion.                          W. P. D 
            Signs of the Child's death.        491

of the extraordinary motions of the child, which from
the next day gave no other indications of its  pre-
sence, than the troublesome rolling mentioned  in
par. 1311.  The symptoms stated in the same para-
graph afterwards appeared, and the woman, over-
come by those accidents, as well as by the alarming
prospect of seeing her child born dead, was delivered
the tenth day;  not as she feared, but of a strong
healthy child weighing nine pounds at least.
   1314. When the child dies some days before  its
expulsion, the waters of the amnion are most com-
monly thick and turbid, as if mixed with meconium;
and have a fetid and cadaverous smell. The bones
of  the  cranium are loose,  the skin  which covers
them is very slack, and  it is sometimes formed into
a bag under the crown of the head, which is found
full of a glairy  reddish water.
   1315. The concurrence of all these signs leaves
no doubt of the child's death; but as they can only
be the effect of its putrefaction, they do not always
exist at the time of labour; either because it is but
lately dead, or because it may remain in the waters
of the amnion without putrefying.*  We should
therefore sometimes endanger the life of the mother,
 if we were to wait for the  union of all these  signs
 before we determined the mode  of proceeding.
 The child's death never causing such a sensible
 alteration in the  natural order of the circumstances
 which have preceded it, as to make  it known  im-
 mediately, prudence must guide  us in the  choice
 of operations which may effect its life, or that of
 the mother.

   * I have received children who had remained sound seve-
  ral months after  their death. Their skins were white and
  shrivelled, as if withered. They had died long before the na-
  tural period of labour. 
4£2        Signs of the Child's death.

  1316. T have already remarked that  there is a
tumor formed in the  teguments  of the cranium,
when the head ofa living child is strongly pressed
against the margin of the pelvis, or wedged in the
superior strait,-\  and that  that effect cannot  take
place,  when  the  child's  death has preceded the
opening of the membranes, even  a single instant.
We also know that it softens  and  becomes flaccid,
if the child, though alive at the beginning of labour,
should die in the course of it. But the  absence of
that tumor does not always indicate its death with
certainty,  as  some have  believed and  published,
any more  than the flaccidity which succeeds to the
elasticity which the tumor first had, when it takes
place, though the head remained locked, as some have
pretended. " When the head threatens  to be lock-
ed," says the celebrated Levret,  " a tumor is for-
" med on  the part which presents, which continu-
" ally augments in volume  and solidity, till  it is
" unwedged,  or the child  dies: in the  latter  case,
" the tumor  not only augments no farther, but it
" grows softer." He adds farther on: " If the tumor
" ceases to augment before the head is unwedged,
" it is a certain sign of the child's death."
  1317. If from that circumstance alone, we were
to determine  to dismember the child, or open the
cranium,  we  should  sometimes have to reproach
ourselves  with having sacrificed. the living.  The
tumor  in  question may soften from a  cause very
foreign to the death of  the  child,  and  without  its
ceasing to live. The flaccidity which succeeds to
the elasticity  it possessed at first,  is sometimes the
effect of an extravasation  of fluids,  which before
were merely engorged. Another species  of sanguine
t See par. 1161. 
             Signs of the Child's death.         4.93

tumor  by  extravasation,  in consequence of the
rupture of some of the veins,* frequently succeeds
those elastic tumors. In labours which the  defor-
mity of the pelvis renders very difficult and tedious,
touching inconsiderately practised, may favour the
formation of both these tumors; and especially soften
the former, without  forming any considerable col-
lection, but only an  extravasation in the subcuta-
neous cellular membrane.
   1318. The discharge of the meconium, the irregu-
larity of the pains, and their  cessation, are not more
certain signs of the child's death,  than  the fetor of
the humors which  drain from the vagina;  or the
separation of  the epidermis  from the  part  which
presents to the touch.} A  coldness in  the umbili-

 ' * I have three times  met with this  sort of tumors, and
each time was in a first labour. At first, the teguments of the
crainum were swelled, and the tumor was evidently elastic.
It softened all at once> and augmented so far, in one of the chil-
dren, that it equalled the half of a duck's egg cut across. The
three children in question  were born living; and had  it not
been for those  extravasations  of blood  on the  outside  of
the  cranium, they  would probably have been victims, like
many others, to an engorgement, or rupture of the vessels of
the  brain. I  shall  publish my  thoughts on this  subject  at
some future  time.f
  11 can add my testimony to what our author here advances;
and think it proper also to put the young practitioner on  his
guard against mistaking this tumor for the unruptured  mem-
branes:  a mistake I have twice seen committed, to the serious
injury of the child; the teguments being scratched through
with a view to force the waters.              W. P. D.
  \ Notwithstanding repeated  observations which  demon-
strate the uncertainty of these signs, by presenting examples,
as I  may say, of so many victims to the use of crotchets, they
are still frequently made use of. The following fact will perhaps
inspire  more diffidence in those symptoms, because there ia
no case, where they can  be united in  greater  number,  or
where we should appear better founded  in recurring  to the 
494         Signs of the  Child's death.
cal cord, its putrefaction, and the want of pulsation
in its arteries are more  certain signs of it;  but we
cannot judge of  them,  except when that  part is
without, or when it forms a loop across  the orifice
of the uterus.
   1319. As these symptoms considered  separately,
present us but equivocal signs of the child's death,
the concurrence of all, or the greater part of them at

crotchets. Being furnished with the forceps, which I had just
successfully used  in delivering Madame D***, the 15th of
August, 1782,  about the middle of the night, a poor woman
in the neighbourhood desired my assistance; but from the bad
state in which I found her, and the certainty I thought there
was of the child's death, I determined to prefer the crotchets,
but I deferred their  application a few hours; as well because
I had them not with  me, as because the case presented more
pressing indications than that of terminating the  delivery. The
poor woman had  been two whole days in labour, the pains
were now scarcely perceptible, the belly  was  exceedingly
swelled, tense and painful; the air of an insupportable fetor
was every instant discharged with noise from the' uterus; and
the fluids which drained  from it were  not less fetid. The
child's head resting  on the superior strait, appeared  to be not
at all advanced, and  the small  diameter of the strait was but
three inches or thereabouts.  The scalp was loose, pendant,
and in a manner rotten; the cuticle* and the hair came away
easily and stuck to the finger. No motion of the child had been
felt for more than twenty-four hours. The woman's pulse  was
weak, but very quick; her tongue, lips, and gums were black
and parched: and every thing exhaled a cadaverous stench.
Judging that the  child  was  dead, I determined to extract it
with the crotchet, and the instrument was already in my hand,
when a fortunate presentiment led me to substitute the for-
ceps, which I applied in the manner directed  in par. 1244.
and following; I extracted a child living and healthy, except
a gangrenous slough which it had on the crown of  the head,
but which went no deeper than the skin, and cast off imme-
diately.  The mother, already  very ill, remained so a long
time, and had scarcely begun to mend a month after. M. de
Beauchesne, M. D. was a  witness of this  labour, and gene-
rously attended the woman, in the Sequel. 
Of the Crotchets, Este.           495
least, ought alone to authorize us to make use of
cutting instruments, of the nature of crotchets and
perce-cranes: and even then we ought to prefer the
forceps, when we can use them.
Of the Application of Crotchets,  and other Instru-
         ments of that Kind, to the Head.

  1321. The  use of crotchets  ought then to  be
very limited: though these instruments are equally
capable of penetrating  all  parts of  the child,  we
ought only to apply them on the  head, or at most
on the upper part of the trunk, when  the head has
been torn off in the passage.
  1322. The causes  which ought to engage us to
employ the crotchets exclusively, are all  those
which  require  us to terminate the delivery without
delay,  at a time when the head of a dead child oc-
cupies the lower part of the pelvis;  or when  we
cannot, without danger to the mother, push it up
again,  and search for the feet  though much less ad-
vanced; as when the waters have been long drained
off, or when the uterus is strongly contracted, tense,
and painful; lastly, when it is  so  softened by  putre-
faction, that the forceps cannot get a sufficient hold
to bring it along.
   1323. It is  on the occiput  that we ought to  fix
the crotchet when the head comes first; and  on the
upper jaw, or  the forehead, when we are obliged to
use it in preternatural labours,  after  the trunk is
delivered. By acting in this  manner,  we make  the
head descend with one of its extremities foremost,
and it  presents only its smallest diameters in every
part of its passage. We should  likewise consider 
496          Of the Crotchets, &c.

the particular direction  which it ought to take in
each position in which it may present, that it may-
traverse the pelvis with the least possible difficulty.
   1324. We should take great care in every part of
the operation to do  no injury to the woman by the
point of the crotchets,  by guarding it  with the
thumb placed  under  where it is fixed.  The ac-
coucheur must also be  on his guard not to injure
himself.
   1325.  When this  instrument is employed  to
evacuate the contents of the head, its size must
exceed that of  the pelvis, or the straits it has  to
pass through. This may arise  from defect of size
in the pelvis, or excess in the head.
   1326. It is very rare that the diameters of the
head surpass the natural dimensions of the pelvis,
except in the case of an hydrocephalus; but it often
happens that the dimensions ofa deformed pelvis are
inferior to the usual dimensions of the head; which
constitutes two very  different  states, though  pre-
senting nearly the same indications with respect to
delivery7.
   1327. All people  of the profession know that hy-
drocephalus is  the name given to  a collection  of
water formed within  the cranium; and sometimes
also to a species of anasarca which is confined to the
surface of the head, though it be not a true dropsy7.
I shall speak only  of the first species,  and that
without any regard to the  distinctions  which au-
thors have  made in  it, that is to say, without deter-
mining the true  seat of the extravasation; only con-
sidering this disease relatively to the obstruction it
may give to delivery7.
   1328.  All  children affected  with hydrocephalus
are not incapable of being born naturally; the labour
is a little  more contracted and severe. It is but 
Of the Crotchets, fcfc.          497
when the head is much augmented, that it requires
assistance.  This  disease is easily known, by the
thinness and softness  of the bones of the  cranium,
and by the separation of their edges at the sutures.
The head hardens during pain by the protrusion  of
its contents against the external teguments. As this
disease is extremly dangerous to the child, no one
will be rash enough  to propose the Cesarean ope-
ration for its  delivery. It  is  much better to dis-
charge the  water by puncture. This may be done
alone on the suture by7 a pair of scissars, trocar, &c.
   1329.  An hydrocephalic child does not always
present the head, and unless it  be found  in the
neighbourhood  of the orifice, sometimes we are
obliged to  turn it, and bring it by the feet. In that
case, we do not discover the disease till  after the
exit of the trunk, or,  at  least, till the  volume  of
the head, augmented  by the water, obstructs the
delivery: for things  go on as usual, till it arrive at
the superior strait. When it cannot clear that, it is
proper to open it, as in the former case: but we then
do it by plunging the instrument towards the fon-
tanelles which are at  the bottom of the lambdoidal
suture, or even  in the occipatal  hole, behind  the
first cervical vertebra.
   1330. A  simple  puncture of the cranium,  in the
case of an hydrocephalus, is sufficient to evacuate
the waters, and  reduce the head to the  size proper
for its exit: but it is not  so when  the disproportion,
which obstructs it, depends on a deformity  of the
pelvis. Besides that a similiar puncture could  not
prepare an exit for the brain, a solid and well con-
stituted head  cannot  shrink and  contract like one
that is hydrocephalic. Though the indication, aris-
ing from a defect in the capacity of the pelvis, is
the same as in that where the accidental size of the
                      3R 
498           Of the Crotchets, fcte.
child's head renders delivery impossible, though in
both cases that  indication  consists in diminishing
the bigness of the head, yet we must set about it
very differently.  Every kind  of instrument, provi-
ded it be pointed and sharp, may serve for opening
the cranium in case of an hydrocephalus, and a little
dexterity is necessary for its application: but in the
other case, a  great  number have  been invented,
either  for dividing  the head, or for extracting it:
and their  application requires a great deal of care.
The best is the one  proposed by  Smellie, namely
his scissars, for opening the head, and the crotchet
the best for extracting it.
   1331. We ought always, if possible, to open the
cranium in the sutures, and especially in the  sagit-
tal. A crucial, or angular incision, would more cer-
tainly favour the  contraction of the bony  pieces
which form that cavity, than a simple incision, and
would consequently be  preferable. The head  is
never more favourably disposed for this operation,
than when it presents the vertex, and the operation
is so much the easier; as it is farther advanced, and
more wedged  between the  bones of the pelvis.
   1332.  The  instrument is to be  directed by the
help of some of the fingers, which  have been pre-
viously passed into the vagina; and must be plunged
into the cranium; we must enlarge  the opening by
extending the handles without, and giving the whole
instrument a rotatory motion. The cranium being
sufficiently open,  we withdraw the instrument and
introduce the fingers to evacuate the brain.* We
afterwards bring the head along,  either with  the
fingers bent within, or a crotchet applied  on the
occiput.

  * Or what is much better the crotchet itself.
                                       \V. P. D. 
Of the Crotchets, &c.          49,9
  1333.  If we have attempted to extract a child by
the feet, in a case where the pelvis is not large enough
for the passage of the head, we must open the crani-
um with the same care. But as we  cannot then carry
the instrument into the sagittal suture,  we must cut
into the middle of the forehead, and on one of the
branches of the coronal suture, or in the direction of
the lambdoidal, to make an angular section. By means
of that section we may easily bring down the  occiput,
or one side of the os frontis, or force them inwards,
and give an easy exit to  the  brain. By proceeding
thus,  we avoid much difficulty, and often  prevent
the detachment of the child's head.
  1334. Whenever we have emptied the cranium, it
is proper to inject warm water into the  uterus, after
the delivery is completed; to wash  away the  remains
of the brain which might  be retained in that viscus,
or in the vagina: but it is not necessary to repeat it.
Of the Retention of the Child's Head after the Trunk
  is torn from it, and the Method of extracting it.

   1335.  It sometimes  happens in preternatural la-
bours, when the child is brought by the feet, that the
trunk is torn  away from the head, and the latter left
behind. Though a skilful man may always avoid this
disagreeable accident, yet he cannot flatter himself
that he shall never be called when others have exert-
ed such manoeuvres as to cause that separation.
   1336. We may avoid tearing  away the child's
trunk, either  by directing the head properly, or by
applying the  forceps, or by opening the cranium to
lessen its bulk;  for that  accident is always a  conse-
quence of the omission  of one or more of those three
things. 
500           Of the Crotchets, &?c.
  1337.  A deformity of the pelvis is not so often
the remote cause of this accident as is  supposed.
The child's head may stop at  either of the straits,
though large enough to give it a passage, if well di-
rected. Experience has supported this truth a thou-
sand times; since in many cases, changing the posi-
tion of the head has been sufficient to enable the wo-
man to expel it, or to be delivered of it without any
other assistance than  that of the  hand.  The head,
though properly directed, is not always secure from
being torn off, if the accoucheur knows no  other rules
to bring it along, than those of  pulling  at the trunk.
Sometimes the dimensions of  the head so surpass
those of the pelvis, that it cannot  be brought along
in any way, especially if the bones are already so so-
lid, and the sutures  so close, that it cannot  lessen,
and mould itself in some degree to the form of the
canal.
  1338.  An  excessive putrefaction of  the child, is
also one of the predisposing causes of the separation
of the head; but  in all cases it is the efforts which the
accoucheur exerts inconsiderately on the trunk with-
out, which are the immediate or efficient cause of it.
  1339.  Authors are not all agreed on  the mode of
proceeding in these cases. Some are for abandoning
it entirely to the efforts of Nature;  while others insist
we  cannot deliver it too soon—both  perhaps are
wrong, in the extreme.  Nature ought  not  to  be
trusted where the head is jambed or badly situated
with respect to the pelvis, as her efforts would be un-
availing;  and the advantage which some  have sup-
posed might be derived from putrefaction  coming on
and  separating the bones  of the cranium, must  be
visionary, since the woman must inevitably suffer,
whenever this should take place.
  1340. Nature should be only trusted then where the 
Of the Crotchets, &Pc           50-1
head would pass readily through the pelvis; the cer-
tainty of this can only be determined by passing the
hand  into the  uterus, unless it be a labour of seven
or eight months; and if we must  pass our hand into
the uterus, why not free it from  this foreign body?
This might more especially be done, as Nature finds
more difficulty cateris paribus in delivering a detach-
ed, than a connected head, owing to the  uncertain
situation it takes at the entrance of  the pelvis; there-
fore, as we cannot dispense but very rarely with in-
troducing  the hand into the uterus, either to ascer-
tain the size,  or give a proper direction to the head,
it seems a  duty to  spare the woman all fruitless ef-
forts by delivering  it.
   1341. When its volume does  not exceed  the ex-
tent of the openings of the pelvis, its separation from
the trunk having proceeded from no other cause than
the ill-directed efforts exerted on  the latter, the hand
will suffice to extract it.  We first  examine if the
greatest length of the cranium be placed according to
the greatest diameter  of the superior strait,  and di-
rect it so, if  it be not.  Wc afterwards hook it by
means of two fingers insinuated into the mouth, and
the thumb placed under the chin, or on the posterior
part of the neck, of which there is almost always a
portion left.   We  pull towards us  and according to
the axis of the pelvis, till the head has cleared the su-
perior strait, while  the woman pushes strongly down-
wards.  When  it is descended into the cavity of the
pelvis, we turn the face underneath, and  continue to
pull at the lower jaw, raising the hand a little, in or-
der to bring the chin to  the vulva, and disengage it
entirely.  If the lower jaw has been torn off, we must
use a crotchet, and fix it in the top of the forehead.
See par. 1323.
   1342.  If Nature still finds resources in herself; if 
 502           Of the Crotchets, &fc.

 she  can,  strictly speaking, deliver herself without
 help in the case we have just stated, it is not so when
 a considerable disproportion exists between the di-
 mensions of the head  and those of the pelvis.  The
 woman has then, in fact, no certam resources but in
 the assistance of art, and the  application of instru-
 ments. We should expose her to an almost inevitable
 death, if we were to commit the expulsion of the
 head to Nature; for she could not deliver herself of
 it, but by the effect of putrefaction, and that is a fruit-
ful source of accidents.  This case is therefore evi-
dently within the province of art; it presents the same
indications as if the head were still attached to the
 trunk; but it is a little  more difficult to  accomplish
them.
   1343.   The  accoucheur may accomplish  these
views perfectly, with the hand which he introduces
into the uterus to direct the instruments destined to
open the cranium.* He must begin by bringing the
crown of the head to the  superior strait, in a trans-
verse situation, and fix it so, by bending the fingers
over the base of the cranium. He must then conduct
the instrument, which  he holds with the other hand,
along the thumb, and direct its point into the course
of the suture it  is designed to penetrate,  to open the
cranium, as directed in par. 1332. After having with-
drawn the instrument, we  may pass several fingers
into the cranium to force out  the  brain,  and lessen
the bulk  of the bony case, in order to bring it along
with die  same hand;  or, if that fail, by  means of a
crotchet placed on the  face or on the occiput.
   1344.  Though this operation is absolutely neces-
sary  when the volume of the head is  such that its
dimensions far surpass those of the pelvis, and though

  * I conceive no instrument so well  calculated to fulfil this
intfintion as Smellie's scissars.              W. P. D. 
            Separation of the Head.-          503

ni all cases it is better to extract the head, than com-
mit its expulsion to Nature, we are often obliged to
temporize, and first attend to the more pressing in-
dications presented by the inflammatory state of the
uterus, of its neck, &c. &c.
Of the Beheading the Child, or  the  Separation  of
  the Head from the Trunk;  and of several other
  Cases  which require the Application  of cutting
  Instruments to the Trunk itself.

  1345.  As  the trunk may be separated from the
head  in  preternatural labours  where  the child  is
brought by the feet,  so also where the head presents
first, it may be separated from the trunk, and the lat-
ter be left in the womb of the woman.  A neglect of
some of  the fundamental principles of the art, a pu-
trefaction of the child; and a preternatural bigness of
the  trunk, whether it arises from a monstrous confor-
mation, or from an extravasation of fluid in one of its
cavities, are so many predisposing causes of this ac-
cident.
  1346. It is always much easier to extract the trunk,
after the  head has been torn from it, than  to deliver
the  woman of the head.  To change the direction of
the  shoulders, is sometimes sufficient to enable us to
bring it along easily, either with fillets or blunt hooks
placed in the armpits, or with common crotchets fix-
ed in the top  of the breast or back. M. Levret seems
to have proposed his crotchet with a  sheath  at first
for this case only. When the shoulders are still above
the  superior strait, we may bring down  the child's
arms, and apply fillets on the wrists, with a view of
pulling with one hand to extract the trunk, while wi-Ii 
504          Separation of the Head.
the other introduced into the vagina we keep the
portion of the  neck, if any remain, in the direction
of those same  extremities.  Sometimes, instead of
bringing down the arms, it is better to turn the trunk
and extract  it by the feet.
   1347. When  the breast or the abdomen contains
water  enough  to render  these efforts fruitless, we
•must evacuate the fluid, by opening the cavity7 which
contains it,  either with a crotchet or any other pro,
per instrument.  But when the monstrous conforma-
tion of the trunk prevents its exit, it must be divided
as will be stated in the following paragraphs.
   1348. A  dropsy of the breast  is excessively rare
in the  foetus, as well as that of the abdomen in the
degree that  would render delivery impossible with-
out help; and it scarcely ever disturbs  the  natural
order of that function.
   1349. It is extremely difficult to be assured of the
existence of this disease when the child presents the
head.  If we have a right to presume that it is dropsi-
cal, when that part, though of a moderate size, ceases
to advance, notwithstanding violent efforts  on the
part of the woman, yet we cannot discover it certain-
ly but  by introducing the hand as far as die seat of the
extravasation; which is not easy, because the  head
which then  fills the passage, strongly opposes those
researches.  But it is not so when the child presents
the feet; as they are  scarcely without before those
difficulties manifest themselves, we  may easily insi-
nuate the hand along the thighs to judge of  the na-
ture of the obstacle.  A dropsy may be known by the
size, by the tension of the belly, and especially by
the fluctuation.
   1350. Being perfectly discovered, the indication
relative to delivery is not difficult to determine: the
water  must be evacuated, by opening the  belly or 
Of Monsters.              505
the breast. Very long scissars, the point ofa crotch-
et, a common knife, and especially that which some
have proposed for opening the cranium are equally
proper to accomplish the vieWs of the accoucheur.
   1351. A very small incision will suffice; and we
ought not to make a large one but when we are cer-
tain of the child's death. The part in which it is made
is of  no importance in the  latter case,  and it is only
when the child is alive that we ought to  prefer one
place to another. After opening  the belly we place
two fingers separated at the sides of the incision, to
press it a little and favour  the discharge of the wa-
ter, which without that  precaution might still find
some obstruction to its exit;  because the neigbour-
ing parts of the woman, against which  the surface of
the child immediately applies, may stop the opening.
   1352.  The misconformations  which a child may
present at birth are very numerous: but they do not
all equally merit the name of monstruosities, nor give
the same obstruction to delivery.  Those which con-
sist in the want of certain essential parts, as the head
or the  extremities, seem  more likely to favour it,
than  render it more difficult: but it is not so in those
extraordinary conformations where several heads are
placed on one trunk, two trunks attached to the same
head; or in which twins are united, either by the te-
guments only, or  by other parts, so as to form but
 one whole; as is frequently observed.
   1353. The examples of some deliveries which
 have been performed by the efforts of Nature alone,
 notwithstanding so strange and monstrous a confor-
 mation,* far from throwing any  light  on the rules to

   * In 1763, a woman of the  town of Amiens was delivered
 very naturally, and without any other assistance than that of
 a neighbouring midwife, of a living child who had two heads,
 two trunk!*, and six or seven extremities as  well superior a*
                       3S 
506               Of Monsters.
be observed in such cases, only make us more  un-
certain what method to determine on: these are cases
where the ignorant seem to triumph, while the man
of skill dares  propose nothing.  Though experience
teaches us  that there have  been women so happily-
constituted as to deliver themselves without help, of
a child having two heads or two trunks, it also teaches
us that the assistance of art sometimes becomes ne-
cessary.*
   1354.  We cannot discover  these  sorts of mon-
struosities but by carrying the hand into the  uterus;
and even then it must be difficult to distinguish ex-
actly what they are, on account of the manner in
which the  child is folded up, and the confusion in
which all its limbs present to the touch.
   1355.  It is impossible for the two heads of a child
thus formed to engage at the  same time, when they
present first; whether the delivery be performed with-
out assistance or not; one of them  always turns back
on  the trunk, while the other descends.  The same

inferior.  Each  head was nearly of the natural size, and the
body of the second child appeared seated on the left arm of
the first.  I shall observe in favour of the  opinion of those who
attribute these  effects to the force of the mother's imagina-
tion, that this woman had passed almost the whole time of her
pregnancy at the feet of an image of the virgin, situated in
one of the churchyards of the town; sacrificing all her do-
mestic affairs to the love she had conceived for this statue,
when  she became pregnant. Three other children of a simi-
lar conformation, were born with as little difficulty at the time
I was employed about the first edition  of this work; one at
Paris; another in a neighbouring village; and the third in
Bretagne.
  * At the time when the disputes concerning the section of
the pubes were at the greatest height, some public papers
mentioned that  the Cesarean operation had been recently per-
formed, and with success, by M. Zimmerman, surgeon major
of the regiment of Sterburi,to deliver the countess of Chercy
of a child which had three heads. But I cannot certify the
truth of the fact. 
Of Monsters.              501
thing happens with  respect to the inferior extremi-
ties when the child is extracted by the feet, unless
we take care to bring them all down: but in this lat-
ter circumstance, we cannot hinder the two  heads
from presenting and engaging together; which ren-
ders their exit extremely difficult.  In all cases, the
mother's pelvis must be excessively large, for her to
be delivered by the natural passage without mutilat-
ing the child.
   1356. It would be very useful if we could early
distinguish the cases of this kind where Nature could
dispense with the assistance of art, from those where
that  assistance is indispensable;  that we  might not
expose her to fruitless efforts in the  latter, and leave
her at liberty in the former. But it  is not less diffi-
cult then to explore the bounds of her power, than to
fix on the best  method to be employed when she is
unequal to the task.     '
   1357. When we  reflect on the difficulty of dis-
membering in  the womb a child so misformed and
so monstrous as those in question, independently of
the danger which may result from it to the  woman
herself, we find it hard to decide whether such a pro-
cedure be preferable to the Cesarean operation. Or
is it allowable to take that method, when the child is
living?  Though monstrously formed, has it no right
to life, and do  the laws  authorize us to destroy it, to
save the mother from an operation which does not
appear to us, either more painful, or more dangerous
for  her, than that  by which it is pretended  her life
might be secured? If we knew the history of all the
women who have undergone the Cesarean operation,
and  of those whose children have been dismembered
with crotchets or other instruments of that kind, per-
haps we should find, that  in an  equal number, death
had spared fewer of the latter than of the former. But 
508
Of Monsters.
every one has related his successes, and seems to
have thrown a veil over the rest.
   1358. Yet if  we could have any certainty of the
death of a child thus formed, and if we could clearly
perceive the possibility of separating the superfluous
parts without injuring the mother, we ought to prefer
that resource to the Cesarean operation. Weought also
to have recourse to it, if twins, though living, were
only joined by a portion of their teguments; except
it were by the tops of their heads only, as we see in
the tables of Ambrose Pare; because they might then
be extracted without separating them,  and the  ope-
ration be performed with  more certainty after their
birth.
   1359. We must reckon among the monstruosities
of the child, relative to delivery, large tumors which
it is sometimes  born with.  I  have seen one whose
dimensions far surpassed those  of the head of a foetus
at full time; being five inches long, and four thick in
every direction.   It was placed at the bottom of the
trunk, and hung between  the thighs. Its nature was
fungous and steatomatose: its  surface was furnished
with a great number of veins, and presented the same
appearance as  the surface of the brain  covered with
the pia mater, so thin and transparent  was the  skin
become. The head passed through the pelvis with-
out much difficulty,  but I foetid a great deal in ex-
tracting the trunk, and, notwithstanding my utmost
care, the child died in the  passage. Having no longer
any concern for  the child, i  proportioned my efforts
to the resistance 1 met with, the teguments of the tu-
mor burst, and it lengthened and accommodated it-
self to the form  of the pelvis.*

   * We meet with a pretty similar example in the work of
Peu. Since the time when I observed that tumor, I have met 
Deformities of the Soft Parts.       509
Of the vitious Conformation of the Soft Parts of the
   Woman, which constitute what is commonly called
   the Passage, considered as a cause of laborious La-
   bour.

   1360. Avitious conformation of the soft parts
of the woman may be from birth, or accidental.  In
the first case, the defect may consist in an agglutina-
tion of the labia, in a narrowness of the entrance of
the vagina, on account of the form and hardness of
the hymen in the small size  of that canal, or the mem-
branous  intersections which are sometimes found in
it; in a partial closure of the neck of the uterus; lastly,
in the  privation of all the external parts which form
the vulva.   The accidental misconformation of all
these parts may be an effect of the presence of a tu-
mor, or  the  consequence of ulcerations which  may
have caused preternatural adhesions.
   1361. Among the tumors which may arise in the
parts of  the woman, some are inflammatory and are
formed suddenly; others are of an indolent nature and
increase slowly:  but all, according to their volume

with two  others nearly  of the same size, and also situated at
the bottom of the trunk, but they contained only water. M.
Piet presented the Academy of Surgery, in 1787, with an ex-
ample of one much larger still, which he was obliged to open,
to finish the extraction of the child: he estimated the diame-
ter at a foot. It was formed in two lobes at the lower part, one
of which was smaller than the  other. The cyst, covered with
the teguments, distended and dried at the time I had a sketch
taken of it, presented the following dimensions.  Its breadth,
from one  thigh to the other, and above its division into two
lobes, was nine inches and a half, and its height seven inches
and a half; the breadth of the  great lobe, and its thickness
from before  backward, five inches eight lines;  the breadth
and thickness of the small lobe four inches and a half. 
510      Deformities of the Soft Parts.

and situation, may give more or less obstruction to
the exit of the child.
   1362. It  is easy to discover the nature of the
greater  part of these  tumors; but  there are some
which may  be confounded with others to which it
would oe dangerous to apply a cutting instrument; as
in those entero-vaginal hernias described by Garange-
ot,* and the hernias of the bladder mentioned b)7 se-
veral authors.  We may easily distinguish an abscess
which is the consequence of an inflammatory tumor,
from an indolent deposition;  because the previous
symptoms are not the same: but we often cannot dis-
cover the nature of the latter  till we have opened it.
It is this species which we  sometimes find  difficult
to distinguish from the hernias I have mentioned,
and more difficult still from certain sanguine tumors
seated  in  the  cellular  tissue of the vagina: which
ought to render us extremely circumspect in open-
ing them, when they obstruct delivery. Though cer-
tain that they are humoral, if their  nature  remains
doubtful, we ought to make but a very small  inci-
sion; but we may  act with less reserve in  opening
tumors that have been inflammatory.
   1363. An oedema is the most usual of all the tu-
mors which may arise in the parts of the  woman;
and the cellular substance within the pelvis is not al-
ways exempt from that infiltration which sometimes
extends even into the substance of the symphysis. A
moderate infiltration, far from opposing delivery, ra-
ther favours it, by weakening the tone of the parts which
form the passage, and moistening them; but a more
considerable infiltration may obstruct it, or render it
very difficult: as we see when the labia are very thick
and tense; when the anterior part of the vagina forms

  * See the memoirs of the Royal Academy of Surgery, t. i. 
Deformities of the Soft Parts.      511
a large tumor without, which contracts the entrance
of that canal; lastly, when the infiltrated fluid spreads
far and wide into the whole of the cellular substance
within the pelvis. In all these cases, we are obliged
to make  scarifications in the  inside of the bottom of
the  labia, to disgorge the parts and render the passage
accessible to the child.*
  1364.  Varicous tumors are the most  frequently
met with after the oedema; but they are almost always
very small and  very numerous. They are found par-
ticularly  in the  labia, and in the internal parts of the
vagina, and I have met with them even in the neck
of the uterus. The veins which wind through the cel-
lular substance of the vagina and of the neighbour-
ing parts, may  also dilate  and become  varicous.
Though  these tumors seldom acquire a sufficient vo-
lume to oppose the exit of the child, their bursting
may at least give some obstruction to it, by causing
an extravasation of blood in the cellular tissue of the
surrounding parts, as appears by the following case.
A woman whose external parts  of generation were
affected with varicous  tumors at  the time of labour,
was scarcely delivered before she was again attacked
with pains, which made her imagine she had another
child, and obliged her to send  for M. Solayres, from
whose theatre she had just retired. That accoucheur,
suspecting that the retention of a clot of blood might
be the cause of those pains, and endeavouring to cer-
tify himself of  it by the touch, found the  passage so
stopped  that he could not introduce his finger into it.

  * I have seen two cases when the swellings from this cause
were so extensive as to entirely close the vagina, and prevent
the  exit of the child. The fluid was evacuated by numerous
punctures in the labia, and most depending parts, and  the
child then readily passed:—no ill symptoms succeeded  the
delivery.                                 W- P- D- 
512       Deformities of the Soft Parts.
It not being easy to discover the nature of the tumor
which occupied all these parts, by the touch, he un-
covered  the woman, and  saw that the labia were
turned from within outwards, the nympha in a man-
ner effaced, and the lower part of the vagina inverted;
that those parts were considerably swelled, tense, and
ofa colour which denoted a sanguine infiltration. Sur-
prised at such a phenomenon, of which he had never
seen an  example, M. Solayres sent for M. Levret,
who could not come, but sent his senior pupil. They
prescribed emollient and discutient lotions and cata-
plasms, waiting till other indications should present.
Several days  afterwards the lochia  began to appear,
the vagina became accessible to the finger, the pains
abated a  little, and the tumor softened and shrunk.
The woman discharged a great deal of putrid bloody
humor, which was looked  upon  to be produced, as
much from the disgorgement  of the cellular sub-
stance of the tumor and of the neighbouring parts, as
from the lochia retained in the uterus.  Solayres attri-
buted the tumor to the  bursting of one of the vari-
cous veins already mentioned; and the disgorgement
of it, to an opening which Nature had made towards
the farther end of  the vagina, though he  could not
discover  it by the touch.*
   1365.  Admitting these conjectures, the first of

  * A case similar to this occurred  to a midwife in this city,
to whom it gave great alarm. I was sent for, and before my ar-
rival, the internal face of the right labium had given way, and
discharged a considerable quantity of blood; the labium before
its bursting was said to be nearly as large as a child's head; it
became frequently distended afterwards, and would yield six
or eight ounces of blood whenever the coagulum would give
way. This woman's pelvis was very small: she was delivered
of twins. The parts healed with considerable difficulty, as the
rent of the labium extended to the verge of the anus.
                                        W. P. D. 
          Deformities of the Soft Parts.      515
                                            •
which seems exceedingly well founded, the bursting
of the varicous tumor must have happened during
the efforts of labour, though the sanguine inundation
did not  take  place till  afterwards:  which may be
easily understood by  considering the compression
which the cellular substance within  the pelvis must
have suffered during the passage of the child.  If that
inundation had manifested  itself sooner in so great
a degree, it is certain that it would  have obstructed
delivery, and  that it would have been necessary to
scarify the inside of the labia, to promote their deple-
tion, as well as that of the more distant parts, in order
to favour the exit of the  child.  It is  therefore some-
times convenient to open varicous tumors which ap-
pear without, to prevent the rupture of those which
are concealed, and that species of sanguine infiltrations
of which we have just treated; although those tumors
could not of themselves  give any great obstruction to
delivery.
   1366. Scirrhous tumors with small or large ba-
ses may  affect the internal  and external part of the
pelvis. These  cannot always be removed; when they
have a small neck, they  may be for the most part ex-
tirpated, more especially in the time  of labour, as the
head  of  the child then presses  the tumor forwards,
and makes them  approach the external parts.  But
the contrary obtains with tumors whose bases involve
much of the neighbouring parts and cellular  mem-
brane: in these cases the mode of proceeding must
be left to the judgment,of the surgeon.
   1367. Sometimes the pad which constitutes the
neck  of the uterus in the latter periods of pregnancy
and in time of labour is  hard, schirrous,  incapable of
any extension  or dilatation, so as entirely to hinder the
exit of the child. After a convenient delay to ascer-
tain that the efforts of Nature cannot overcome the
                            3T 
514           Various Indications in
resistance, and the administration of proper methods
to relax it, it must be cut in several places, as some
practitioners have done.  Those incisions are prefer-
able' to rents which might take place in  it, and have
never been attended  with the same consequences.
They must be made more or less extensive, accord-
ing to the thickness of the pad which is callous, but
always so much so, that  the orifice may afterwards
open sufficiently.*
Indications presented by a Deformity of the Pelvis,
               relative to Delivery.

   1368. A  deformity of the pelvis, considered
with respect to delivery, may depend on an irregula-
rity of the bones which  constitute  that canal, as  I
have already said; on a fault in their junction; or on
certain exostoses rising upon their internal surface.
It does not always affect the pelvis in the same direc-
tion, part, or degree: wherefore it is not always equal-
ly contrary to the exit of the child.  Most frequently
the superior strait alone is vitiated, and it is pretty
constantly from before backward: sometimes also that
strait is found large enough, and the inferior is con-
tracted.  Between the two extremes of this deformi-

   * Induration of the mouth of the uterus is not unfrequently
met with, more especially with women advanced in life and
in labour with their first child; but scirrhi I believe are rarely
met with. Instead therefore of applying cutting instruments,
we should employ extensive blood-letting first; should this not
succeed,  we always have the other in reserve. I believe this
would rarely fail if the bleeding be carried to sufficient extent;
and I trust I am warranted in this assertion  from the success
I have met with where I had feared no other resource but di-
viding the rigid parts was left me.  See Medical Repository
and Medical Museum.                       W. P. D. 
Deformities of the Pelvis.         515
ty, we observe infinite degrees which I have else-
where fixed to three or four principal ones; in order
to shew their effects more clearly, and cause their in-
dications to be perceived with more justness and pre-
cision: I shall recapitulate them here in a few words.
  1369. The small diameter of the pelvis, consider-
ed in the superior or inferior strait, may be half an
inch less than in the  natural state,  without  causing
any great obstacles to  delivery, if  the child's head
does not exceed  the most usual size.  From three
inches and a half in the small diameter, which is the
lowest degree ofa well formed pelvis  with respect to
delivery, to two inches and a quarter or two inches
and a half, which seems to be that where the exit of
a child entire, that way, ceases to be possible, we find
pelves of all the intermediate dimensions. The gra-
dations  of deformity which we  meet with under the
extent of two inches and a half, are not less various;
since there are women in whom the pelvis  has  an
opening of no more than ten or twelve lines, and in
others still less.   Though the latter degrees all pre-
scribe the same indications with respect  to delivery,
the former  leave us in some measure at liberty to
choose  among different modes of operating.
  1370. We may refer all the resources of the  art,
in cases of the deformity of the pelvis, to the seven
following.
  1.  The extraction of the child by the feet.
  2.  By means of the forceps.
  3.  By the assistance of crotchets and other instru-
        ments of that kind.
  4.  The Cesarean operation.
  5.  Premature delivery.
  6.  Regimen during pregnancy.*

  * To this list our author added the section of the pubes, but
this operation is now so entirely laid aside, that it is not any 
516            Various Indications in
All these resources having been employed with vari-
ous success, I shall examine them as far as the  limits
of the work will  permit;  but,  however,  sufficiently
to demonstrate their advantages and inconveniences,
and determine the cases where they seem admissible.
A succinct Analysis of Delivery by the Feet; of the
   Use of the Forceps, Crotchets  and Perce-cranes,
   in cases  of Deformity of the Pelvis.

   1371. Although I have already treated of these
different methods in  a very circumstantial manner,
perhaps it will not be displeasing if I recapitulate here
their  respective  advantages and  inconveniences in
order to bring into one view, every thing relating to
deformities of the pelvis.
   1372. Though the extraction of the child by the
feet  is not the most  ancient of  these methods, as
might be supposed, at least it seems the most  natu-
ral. If it pass also for the gentlest in the eyes of the
vulgar,  who  dread every kind of instrument,  an
accoucheur ought to think less  advantageously of
it. He ought not to be ignorant how difficult it is to
turn a child and bring it by the feet, when the waters
have been long evacuated. Its death, too often to be
feared in such cases,  even when the pelvis is nearly
of the natural size, is so  much the more certain as

longer by judicious practitioners considered as a resource of
the art. It is but justice to add, that our author has, by demon-
strating most satisfactorily its insufficiency  for the end pro-
posed, contributed much to the cause of humanity, by bring-
ing this horrible operation into complete  disgrace.  I shall
therefore be excused, I hope, for having entirely omitted it
in this abridgment                         W. P. D. 
Deformities of the Pelvis.         517
its canal recedes farther from that state, and as its
straits are more contracted.  The extraction of the
chiid by the feet is therefore but a dangerous method
when the pelvis is vitiated, and only a kind of re-
source  for the mother; often also it is not without
great inconveniences to her.  Besides, this method
is not admissible in all cases of distorted pelvis, ab-
stracting the accidents which are  inevitably attached
to it; since it is impossible to extract the child entire,
when the small diameter of that cavity has not about
two  inches and a half of extent.
  1373. The use of the forceps appears a little more
gentle in some of these cases; because on  one  side,
it spares the child the fatal effects of the extension
and  stretching of the spinal marrow,  as well as of the
luxation of the neck and the head; and on the other,
the parts of the woman are less fatigued by it, than by
the introduction of the hand to the fundus of the ute-
rus:  but it has also its inconveniences and its limits.
This instrument is sometimes dangerous to  the child,
when the pelvis has only three inches in  the small
diameter, and much more dangerous, if  not mortal,
when that diameter is still farther contracted: at the
same time that it destroys the child, it also exposes
the  mother to accidents  more or less severe.  The
forceps are no way proper, when the  pelvis is vitiated
in the last degree, that is  to say, when its  small di-
ameter has not two inches and a half of extent.
  1374. The application of crotchets and other in-
struments destined to open the cranium, to discharge
the brain and dispose the  head to shrink, is  still more
fatal to the child, than that of the forceps; since death
more or less sudden, and  always  cruel, is the certain.
consequence of it.  Nothing can excuse the practi-
tioner who should  use them without being certain
that  the child is already dead; for that alone can.give 
518          Various Indications in

us a right to prefer these instruments to other me-
thods. If we recollect how difficult it is to obtain that
certitude, we shall see with what caution they ought
to be employed. The limits also, within which their
use should be circumscribed, are not less contracted
than those of the two preceding methods. We ought
not to employ those instruments, though well assured
of the child's death, but when the forceps cannot be
applied.  They are never exclusively indicated but in
those cases where the child cannot pass whole through
the pelvis; and even then they cease to be applicable,
when that cavity has but an inch and a half, or even
two inches in its little diameter: for the section of the
child in the womb might then become as dangerous
to the mother, and even more so than the Cesarean
operation, to rescue her from which would be the
view in performing it.
  A succinct Analysis of the Cesarean Operation.

  1375.  The Cesarean operation consists in open-
ing a passage for the child, through  the parietes of
the abdomen and the substance of the  uterus: with re-
spect to the child, it is the gentlest and most certain
of all the methods we can employ for  terminating the
labour.  We may always secure it from accident by
the Cesarean operation; because  we can render its
exit as quick as easy, by giving a little greater ex-
tent to the  way the instrument prepares for it.
   1376. If we had no other view but the preserva-
tion of the  child, we should therefore prefer this me-
thod to the others, whenever there is reason to fear
any  obstacles to delivery by the usual passage:  but
the  mother having the same right to life, and this 
Deformities of the Pelvis.        519
operation being generally fatal to her, whatever care
we take to assure its success, it ought not to be prac-
tised but when evidently necessary, and when deliv-
ery cannot be  performed otherwise.  If nothing  but
the death of the child can authorize us to dismember
it in the womb of its mother, when it cannot be ex-
tracted entire;  so also, its life alone can justify the Ce-
sarean operation, in the same case. I however except
that where the pelvis is contracted in the highest de-
gree,  that is to say, where its small diameter is under
two inches: for then there is no other resource to de-
liver the woman, but the Cesarean  operation. It is
unfortunate  when her child is dead,  to have nothing
to present her but a corps, for the reward of her re-
signation, and the  sacrifice which she  in some mea-
sure makes of her own life. Though she runs an ex-
ceeding great  risk of losing it in consequence of the
Cesarean operation, she would be much less sure of
preserving it,  if she were not delivered in that man-
ner; as we shall see in the article which treats of the
rupture of the uterus, and of extra-uterine pregnan-
cies.
   1377. The consequences of the Cesarean opera-
tion have almost  always  been so formidable,  that
many accoucheurs of the last age, and even  of  the
present, haye not dared to perform it. Mauriceau, who
in his time was the oracle of the science, as M. Lev-
ret was in ours, recommended waiting for the wo-
man's death to open the body, and treated as fabu-
lous the account of the Cesarean operations which
were then said to have been performed with success.
But by thus exposing the mother, we should often
have to reproach ourselves with having suffered both
to perish; for in those cases her death hardly ever hap-
pens before  that of the  child.
   1378. The authority of Mauriceau cannot be re- 
520           Various Indications in
ceived as a law among us, as in his own time. That
operation has not only been performed with success,
and several times on the same  woman, if all the ob-
servations which have been transmitted to us are
true, but we  also remark that some  of those who
have undergone  it, have suffered no other accidents
in consequence,  than what are usual in large simple
wounds penetrating the abdomen; and which are even
looked upon as necessary for their reunion. Such ob-
servations as these have made some practitioners be-
lieve that the danger of the  Cesarean  operation  did
not essentially depend on the injury done to the parts
concerned in it,  but on the morbific state  in which
those parts, and the  woman also, were  at the time of
the operation.
   1379. It is very certain that the low and exhausted
state which succeeds a long and severe labour, as
well as the erithismos  and inflammatory  state of the
uterus, may increase the accidents annexed to the Ce-
sarean operation, as much and perhaps more than the
manner in which it  is performed.  But the unfortu-
nate consequences which it has almost always had,
did not proceed  from those sources only7, since the
fate of those women who have had it  performed by
the most skilful  surgeons, after convenient prepara-
tions and at the most favourable time,  has not been
very different from that of others who  have suffered
it  from people without experience, and  even abso-
lutely strangers to the art. We shall therefore never
be able to prevent or avoid every thing  which may
render the success of such an operation uncertain.
   1380. Two sorts of hemorrhages are to be feared
in the Cesarean operation, if we consider them rela-
tively to their source: one comes from the sinous ves-
and sels of the uterus which terminate in the placenta,
the other from the section of the principal branches 
Deformities of the Pelvis.         521
of the uterine arteries and veins which are found
near the lateral parts of that viscus. We may prevent
the latter by operating at the middle of the belly, and
opening the uterus at its anterior part;  but it is not
so with the former; that may happen during the ope-
ration, if we should cut the uterus at the part where
the placenta  is ingrafted, which  we cannot always
avoid; or  it may supervene some time afterwards,
though the incision  have been made far  from that
part.  In the latter case it is the effect of an atony  of
the uterus, like the hemorrhage which  sometimes
succeeds a natural labour.  In the other, it manifests
itself immediately, because it proceeds from the sec-
tion of the sinuses and other uterine vessels, and the
woman may lose a great deal of blood before the ope-
ration be finished; as I  observed in one of the two
cases that I shall relate.
   1381.  An hemorrhage is not the accident most
frequently observed after the Cesarean operation: an
inflammation of the uterus and of the other viscera of
the abdomen, fever, suppuration, a discharge of the
lochia, either  sanguine, purulent or lacteal, into the
abdominal cavity, accompany it much more frequent-
ly; and when the woman has  the good fortune  to
escape from so many perils, she almost always finds
herself exposed to considerable hernias, very difficult
to manage, but which might easily  be prevented by
means of a proper bandage.
   1382.  Since the Cesarean operation is so dange-
rous to the woman, that scarcely one in ten survives
it, it ought not to be undertaken but in cases where
it is evidently indispensable: but that is what accou-
cheurs have determined in a very vague and uncer-
tain manner, with respect to a deformity of the pelvis.
We otiffht not to perform it but  when that miscon- 
522          Various Indications in

formation is such as to leave no hope of bringing the
child alive by the natural passage.
   1383.  Without endeavouring  to carry the hand
into the uterus (which ought to be carefully avoided
in  cases which require the Cesarean operation),  in
order to ascertain whether it will pass through the
pelvis freely or not, with one of the child's feet,  as
the passage  from M.  Levret seems to insinuate, we
may determine the cases where the operation be-
comes actually7 necessary; because we may with the
finger alone, or with any kind of pelvi-meter,* mea-
sure the extent of the small diameter of the strait,
within a line,or two.  See par. 123 and following, to
par. 137 inclusively7.  I am of opinion  that it is per-
fectly indicated, whenever the extent of the diame-
ter is not more than two inches and a half.
Of premature Delivery, proposed on account of a
  Deformity of the Pelvis, with a view of avoiding
  the Cesarean Operation.

  1384.  Some examples of children born at the
eighth or at the seventh month of pregnancy, and
even sooner, with a constitution strong  enough to
complete their development  like those born at the
natural period, and to live as  long, have suggested
the idea of premature delivery as a salutary resource
for those whose birth would be  impossible at the pe-
riod of nine months, on account of a deformity of
the pelvis, without having recourse to the Cesarean
operation. Although it might suffice to object to its
partisans the little success they have experienced from
* See Fig. III. page 80. 
            Deformities of the Pelvis.         523

it in such cases, I shall nevertheless examine whe-
ther there be any parity between a premature deli-
very which takes place naturally in all respects, and
one brought on by art at the same period of preg-
nancy.
   1385. Without entering into  the  interest which
many persons have had to make children born at full
time pass for those of seven months,  I shall remark
that most women are never  sufficiently sure of the
time when they became pregnant, for us to lay down
any thing very  certain concerning the epoch of deli-
very from their account. In the same manner as some
women have thought they went ten and even elevea
months, because a suppression of the  menses and
slight  indispositions had in them preceded Concep-
tion; other women have imagined they were deliver-
ed at seven months, because  they had  been  regular
in the two first, and because the circumstances which
they look upon as so many proofs of the existence of
pregnancy,  had not manifested themselves  till the
suppression of the menstrual  evacuation.
   1386.  The  neck of the uterus,  in women whose
labour comes on naturally at  seven or eight months,
develops much earlier than in those who go the usual
time.  The pains begin without being brought on by
any apparent cause; they are  not the effect of a want
of expansion in the uterine fibres, nor  of the acci-
dental irritation which results  from it;  but of the want
of an  equilibrium  between the fibres which consti-
tute «the neck of the uterus, or the resistance which
they oppose, and the action of the other parts of that
 viscus, which press the produce of conception down-
ward; as is generally observed at the period  of nine
 months.  Those pains continue and succeed each
 other, as in a labour of full time; their gradation is
 the same, and  their effects manifest themselves in the 
524
Various Indications in
same order. From the premature development of the
neck of the uterus, I have several times predicted to
my pupils, as early as the fourth month of pregnancy,
that labour would come on naturally in the fifth; at
other times, at that epoch, that it would terminate at
six months, &c. and the event has always confirmed
my judgment.
   1387. We hardly ever meet with those favourable
dispositions at the period of seven or eight months,
in women who have the pelvis so deformed as to ren-
der delivery impossible at the period of nine, and con-
sequently in whom it seems that it might be advan-
tageous to force it to come on prematurely. The neck
of the uterus at seven months has seldom  begun to
open; it is still very thick and very firm.  The pains,
or the contractions of that viscus, cannot then be pro-
cured but  by a mechanical irritation pretty strong
and long continued; but those pains being contrary
to the intentions of Nature, often cease  the instant
we leave off exciting them in that manner. If we
break the membranes before the orifice of the uterus
be sufficiently open for the passage of the child, and
the action of that viscus strong enough to expel it, the
pains will go off in the  same manner for a time, and
the labour  afterwards will  be very long and very fa-
tiguing; the child, deprived of the waters which pro-
tected it  from the action of the uterus,  being then
immediately pressed by that organ, will be a victim
to its action before things be favourably disposed for
its exit, and the fruit of so  much labour and anxiety
will be lost.
   1388.  Premature delivery,  obtained in this  man-
ner, is always so unfavourable to the child, that I
think it ought never to be  permitted except in those
cases of  violent hemorrhage which leave no chance
for the woman's life, without deliverance: the nature 
Deformities of the Pelvis.        525
of the accident also  disposes the parts properly for
it.  Supposing  it be admitted in cases of deformity
of the pelvis, in order to dispense with the Cesarean
operation at the time of the child's maturity, as some
have recommended, should it be at seven or at eight
months that we ought to solicit it?
  1389. To consider this resource, if premature de-
livery can be regarded as such, only  with respect to
the advantages it may procure to the child, we ought
to recur to it as late as possible; for it is, in general,
so much the stronger, and so much the more viable
as its birth approaches nearer to the period assigned
it by Nature:  it  should  therefore  rather be  at the
eighth month than at seven.  But if we examine it in
another point of  view equally essential,  it ought to
be brought on sooner or later,  according to the de-
gree of narrowness or deformity in the woman's pel-
vis; for that deformity may  be such, as to give as
much  obstruction to the exit of a  child of seven
months, in some women, as to one of eight in others.
Premature  delivery, if we were always to solicit it
at the same period,  might be as long, as laborious,
as fruitless, and even as impossible, in some cases, as
if we had not undertaken to deliver  the woman  till
the ninth month, The following cases will prove the
truth of this observation.
   1390. A woman whose  two first children had
been victims of the efforts of labour, on account of
the deformity of the pelvis, had a fall in the eighth
month of her third pregnancy, which at first I looked
upon as a fortunate accident; because it immediately
occasioned a discharge of the waters,  and a few hours
afterwards pains strong and  frequent enough to give
hopes ofa speedy delive  aiice: but I  was disappoint-
ed.  Having waited  twelve  hours, and  then  seeing; 
526
Various Indications in
that the child's head, though well situated, and  be-
sides much smaller than those of the two former, was
not at all  advanced, notwithstanding the strength of
the pains, and the violence of the woman's efforts, I
determined to extract it with the forceps. I found as
much difficulty in it as in the preceding labours, and
the fate of the child was the same as that of the others.
But how much more difficulty should I have found,
if the pelvis of this woman, which had,  according to
the estimation I made of it, two inches three quarters
in the small  diameter,  had had no more than two
inches, or even less, like several which I  have by me?
   1391.  Another  woman,  on whom the Cesarean
operation had been successfully performed in her first
pregnancy, was delivered four times  since, but at
most, not later than at  seven  months;  and though
the children were small for the time, the labours were
always very long and severe.   In the third of them
she was delivered in my theatre, in presence of forty-
five pupils at least, after a brisk labour  of more than
fifteen hours: the woman thought herself at full time,
because her menses had been suppressed more than
nine months.  I predicted her labour some days be-
fore, and I added that she was at most in the seventh
month of her pregnancy7, and the event soon  proved
it to be true.  The child, when born, weighed  no
more  than two pounds eight ounces and a half; the
diameter of  its head was but two inches eight lines
from one parietal protuberance to the other, that is
to say, in  its greatest thickness; but restored to its
natural state, for at the  moment of its exit it was de-
pressed on one side, at the part which had lain against
the projection of the sacrum, two lines at least. The
child lived but two days and a half;  I keep the skele-
 on of it in my cabinet,  The fourth labour was still 
Deformities of the Pelvis.         527
longer, though the child was as small:  this last died
almost as soon as born.*
   1392.  Such are the  fruits to be expected from
premature  delivery,  when Nature has  set  some
bounds to the deformity of the pelvis:  what can be
hoped from it,  when the diameter  of the entrance of
that cavity is no more than twelve or fourteen lines,
as in a pelvis in my collection, or when it is still nar-
rower, f
Of Regimen; considered as a Means of preventing
  the Difficulties of Labour, which proceed from a
  Deformity of the Pelvis.

  1393. If the bigness of the child were in propor-
tion to the quantity and quality of the aliment taken
by  the woman during her pregnancy, as the vulgar
think, the regimen  which some  have recommended
to make her  observe, with a  view of moderating or
limiting the growth of her child, would be very laud-
able in some cases; but we see the contrary too of-
ten. Women nourished in the bosom of plenty, and
who, in the  variety of aliments which the easiness of
their fortune procures them, can scarcely find enough
to satisfy  themselves, have children veiy small and
extremely delicate; while others exhausted by dis-
ease, or by being compelled to live on the most rig-

  * These observations ought to justify M. Millot in the eyes
of those who have accused him of having performed the Ce-
sarean operation on this woman without necessity.
  f  Notwithstanding what our author urges against this prac-
tice, there are  instances of success from it on record. It re-
mains therefore for: the decision of future experiment.
                                        \V. P. D. 
528       Of the Cesarean Operation.

orous diet, often have children very large and strong.
I have succoured some consumed by a marasmus,
and scarcely  able to breathe,  who  have produced
children of nine or ten pounds;  others have grown
strong and lusty, and increased their weight thirty or
five and thirty pounds, though their children weighed
no more than five or six pounds and a half.
  1394.  Besides, the little difference presented by
the  bony frame in a great number of children at full
time,  evidently shows that any regimen observed by
the  mother, even if  it could moderate their growth,
would be of no use, except to those who have to pass
through a pelvis but little deformed and whose di-
mensions are nearly in the natural state.  Whatever
influence the regimen of the pregnant woman  may
have on the development of her child, it  cannot be
reckoned among the resources of our art, in cases of
extreme deformity of the pelvis.
           Of the Cesarean Operation.

   1395.  That  operation is called Cesarean, by
which any other way is opened for the  child,  than
that destined for it by Nature. Though for that pur-
pose we sometimes only cut  through the common
and proper coverings of the abdomen, we are gene-
rally obliged to open the uterus also,  and it is parti-
cularly in this latter case that the  operation has re-
ceived the name of Cesarean; for in the former it may
be expressed simply by that of Gastrotomy. It seems
to me useless to distinguish it into  abdominal and va-
ginal, as has been  done lately;  comprehending under
that  new denomination all operations performed on
the neck of the uterus, without affecting the neigh- 
Of the Cesarean Operation.       529
bouring parts:  for we  might with  as much  reason
give the same name to  incisions in the perinaum, to
the section of bridles or cicatrices which narrow the
vagina: to that of the hymen, tumors, &c. if the child
could not  be  born without those aids.
   1396. The origin of the Cesarean operation is too
obscure, for us  to be able to assign  its epoch; that is
to say, the time when  it was  first  put  in practice.
Some have fixed it at the birth of Julius Cesar, and
others  have  carried it farther  back.  I have  already
stated, that before the present age,  the  greater part
of surgeons dared not perform it before the death of
the woman;  because they thought it essentially mor-
tal. But care has been taken since to collect the most
known and proper cases tb cause  it to be adopted,
not as a certain resource for the woman in all cases
where the deformity of the pelvis may  obstruct de-
livery in an insurmountable manner, but as the only
one which can be salutary.  The collection of M. Si-
mon, inserted among the memoirs of the Royal Acad-
emy of Surgery, contains  seventy or seventy-two of
these cases, in  which we observe that the operation
has been performed with success; and we might at
present add an  equal number to them.
   1397. Among the former we find someon whom
it was performed without necessity, since the women
had been  delivered naturally before, or were safely
delivered  afterwards.  This collection of M. Simon
also teaches us that the greater  part of these opera-
tions to the number of seventy and upwards were
performed on a few women: some  of them having
submitted to it three or four times;  others five, six,
and even as  far as seven times: which, if they were
all true, would superabundantly prove that it is not
essentially mortal, since there  is no need of more than
a single example to establish  the proof  of it.
                       3  X 
530        Of the Cesarean Operation.
Of the causes which require the Cesarean Operation;
   the Preparation necessary for it; the proper time
   to perform it; and the Instruments and other re-
   quisite Apparatus.

   1398. A deformity of the pelvis is not the only
cause which may render delivery impossible by  the
natural passage,  and which ought to determine us to
recur to the Cesarean operation;  certain affections of
the soft parts which I have already mentioned, such
as scirrhous  tumors with a very large  base, which
cannot be  extirpated without exposing the woman
to a more imminent danger than that of the Cesareaa
operation, as well as extra-uterine pregnancies, may
require  the same assistance:  but  it would be abusing
it to employ it in all the cases for which it has been
lately recommended.
   1399. This operation may be practised both on
the living, and on the dead woman.  If it requires a
great deal of attention with respect to the former, so
also we cannot entirely dispense  with it in regard to
the latter; because it is sometimes very difficult to be
immediately certain whether she be really dead or not.
If we waited to perform this operation till the most
certain signs of death manifested themselves, it would
be useless to the child, who cannot long survive its
mother, if it remain in the womb. On the other side,
we ought not  to consign her to an  inevitable fate,
when perhaps she is only dead in appearance.
   1400. We cannot too often recal  the observation
of M. Rigaudeaux* to the minds of those who may

  * M. Rigaudeaux, principal assistant surgeon of the hospi-
tals at Douay, and accoucheur. 
Of the Cesarean Operation.        531
have occasion to perform these sorts of operations: it
is inserted in the Journal des Savans for the month of
January 1749. At the same time that it demonstrates
how difficult it is, in some  cases, to distinguish a
state of asphyxy from real  death, it teaches us that it
is not always necessary to open the body of a woman
who appears to  have been some time deprived of
life, in order to save that of the child.  That surgeon
not having been able to go to a woman in the coun-
try as soon as he was called to deliver her, learned on
his arrival, that she had been dead two  hours, and
that they7 had not been able to find any person to per-
form the Cesarean operation on her.  Having wiped
off the sweat which covered  her, perceiving that she
still retained a little warmth  and suppleness  in  the
limbs, that the orifice of the uterus was much dilated
and the waters well gathered, he determined to de-
liver her by the usual passage, and performed it ea-
sily, bringing the child by the feet, after turning it.
Though  the child  appeared dead, he  did not fail to
pay some attention to it, as soon as he had  delivered
the mother,  and recommended both of them to the
women who  were present. Their  pains which  ap-
peared fruitless at first, were not so in the  sequel.
They revived the child so  perfectly, that a few hours
afterwards it cried with as much strength as if it had
been born in the most  natural manner. M.  Rigau-
deaux going to see the woman again  before he re-
turned home, caused the sheet in which she was
wrapped, to be removed, and finding her limbs as sup-
ple as at first, though she appeared to have been dead
more than seven hours, he tried some  methods pro-
per to ascertain whether she were really so  or not,
and did not  go away till he  had  made the  assistants
promise  that they would not put her again into her
winding sheet till her limbs should be stiff.  If he was 
532        Of the Cesarean Operation.

agreeably surprised when he found the child was re-
stored to life, he was much more so when they came
in the evening to inform him that the mother was re-
vived two hours after he had left her. It was on the
eighth of September 1745, and both mother  and
child were still alive in  August 1748; but  the  for-
mer had continued deaf, paralytic and almost dumb.
   1401. If immediately after the woman's death, we
were to find dispositions as favourable to delivery, as
those stated in the observation ofM. Rigaudeaux,
we ought to prefer the extraction of the child by the
usual passage to the Cesarean operation.  We ought
never to perform the latter but when the parts are not
so favourably disposed, and then proceed with as
much care as if we expected the greatest success
with regard to the mother.  A simple incision in the
rection  of the linea alba, and about  seven or eight
inches long, ought to be substituted for  the crucial
section  which has almost always been made in simi-
lar cases.
   1402. Before we subject the living woman to such
an operation, it might be useful to prepare  her by
general remedies, such as bleeding, purging, warm
baths, &.c. as is done with respect to the other great-
er operations;  these precautions would  sometimes
perhaps insure success.  But unfortunately we  can-
not always employ them, except  bleeding;  because
we may be  called too late,  and often even when the
parts of the woman have been fatigued, irritated,  con-
tused or lacerated by the manoeuvres of a bold and
ignorant hand.
   1403. The Cesarean operation, like many others,
has a time of election and one of necessity: the latter
always  takes place when  the waters are evacuated,
except  circumstances foreign to those which oblige
us to operate, present more urgent indications.  The 
Of the Cesarean Operation.        533
instant of the woman's death, no matter at what pe-
riod of gestation, and that of the child's passing into
the cavity of the abdomen, from a rupture of the ute-
rus, also constitute that time of necessity.  As to the
time of election, some think we ought not to operate
till after the evacuation of the waters, and others that
we ought to do it before, and as soon as the labour
shall be certainly begun; provided  that the neck of
the uterus be effaced, and the orifice open enough for
the discharge of the lochia: this time appears to me
preferable to the former.
   1404. If we  should operate at the beginning  of
labour, and before the waters are  evacuated,  " we
"  should,"  says a modern author, " risk leaving the
"  uterus in  a state  of atony, by disincumbering it
"  too suddenly:  which would infallibly cause a flood-
"  ing, that would carry the woman off." But the rea-
sons that author gives  are not so conclusive, nor so
conformable to  the present notions of physiology.
The motive which  determined M. Levret to recom-
mend operating before the opening of the membranes
is much better founded:  by operating before that in-
stant,  says  he, the  extent given to the  incisions, as
well in the containing parts of the belly as in the bo-
dy of the uterus, would  be much  smaller after the
exit of the  child, than if the operation had not been
performed till after the discharge of the waters. It is
very  certain that an incision of six inches affects a
smaller number of fibres and vessels, when the uterus
is still distended by the waters, than when it is strong-
ly contracted on the child's body, and reduced a fif-
teenth or a  twelfth part in its size.  In the latter case,
an opening of six inches is much larger relatively to
the volume of that viscus, than when it is in its great-
est degree of dilatation.
    1405.  It seems to me to be advantageous to have 
534        Of the Cesarean Operation.
two histories in order to perform this operation well,
viz. one straight and one curved; the latter must cut
with its convex edge, and the former  must have a
very narrow blade and be probe pointed. We ought
to have crooked needles and waxed thread to stitch
the external wound  where it may be thought neces-
sary; fine linen, compresses, a bandage to go round
the body, and some  spirituous liquors, such as aqua
vulneraria, brandy, or  spirit of wine, which  may
be lowered  according to circumstances with com-
mon water.
   1406.  The  woman should be  placed on a  bed
pretty narrow and sufficiently high, that the operator
and his assistants may act freely,  and with  as little
incumbrance as possible. It should also be on that on
which she is to remain, that we may not be  obliged
to remove and disturb her immediately after the
operation. It must be covered so that the bed be not
wetted with the blood and water, and that when the
cloths are withdrawn the woman may be left dry. She
ought to be laid on the back, with the legs and thighs
extended while the  incision Is made; and half bent,
during the extraction of the  child.  We may also
place a bolster under her loins to support them, and
make the belly more protuberant.  We ought also,
before we operate, to put on her lying-in shift, that
is to says one very short, and open before.
 Of the Part where the external Incision ought to
                    be made.

  1407.  There is scarcely any part of the abdomen
where the external incision has not been made in the
Cesarean operation. Some have made it on the sides; 
Of the Cesarean Operation.       535
others transversely., either above or below the umbi<-
licus; and several in the linca alba.  Among the for-
mer,  some  have advised making it obliquely, de-
scending from the extremity of the cartilage of the
third fafse rib towards the pubes; others have given it
the form of a crescent, and M. Levret directed it to
be made parallel to the external edge of the rectus
muscle, but so that it should be equidistant from that
muscle, and from another line drawn from the extre-
mity of the third false rib to the superior spine of the
os ilium. They have all recommended making it  on
the right, or left side, according to the state of the
interior viscera; in order to avoid, for example, car-
rying the instrument on a scirrhous tumor, or a her-
nia,  &c. Besides these reasons for a preference, M.
Levret advised having a regard to the  accidental  at-
tachment of the placenta,  in order to determine  on
which side to operate, and not to open the uterus in
the part where that body is, as it were, ingrafted. I
have already  demonstrated  the  uncertainty of the
signs by which that celebrated accoucheur  affirmed
the  part where the placenta is attached might  be
known, and consequently the little attention due to
the latter precept. If we must operate  at the side of
the belly, it ought to be on that where the fundus of
the uterus is inclined;  in order that that viscus may
present better to the opening, and that the intestines
and omentum  may not immediately escape  through
the wound.
   1408.  The  incision seems  more fruitful in acci-
dents and more  difficult to execute at the side  of the
belly than in the line a alba.  There are at the side, as
in all other parts, the teguments and the cellular mem-
brane,  and we  meet moreover with three  muscular
planes whose fibres intersect each other in such a
manner that we cannot avoid cutting the greater part 
536        Of the Cesarean Operation.
of them across or obliquely: which causes them to
retract, and afterwards hinders that coaptation of the
whole thickness of the edges of the wound, necessary
for their exact reunion. By making the incision ex-
actly in this part, we sometimes cut branches of the
epigastric veins, which run beyond the edge of the
rectus muscle on which the incision often extends;
because it acquires a great breadth in the latter peri-
ods of pregnancy: which causes an hemorrhage some-
times considerable  enough to give some alarm, and
to oblige us to tie the vessels, or touch their extremi-
ties with  styptics,  as  was done  by M. Piestch.*
When we  make the incision at the side, the perito-
naum is scarcely open,  before the intestines, confined
in the abdomen, escape, dilating at the same time, and
increase the natural difficulties of the operation.  If
we are not always secured from  this inconvenience
by making the incision in the linea alba, at  least it
will happen more rarely, and much fewer intestines
will always escape. The longitudinal axis of the ute-
rus being never exactly parallel to the oblique incision
of the abdomen, we cannot open that viscus without
cutting the greater part  of its  fibres transversely;
which causes them to retract, renders the wound
more gaping, afterwards favours the exit of the lo-
chia that way, and exposes the woman to other acci-
dents.! When the section is made in the linea alba,
we only separate, as it were, the  longitudinal fibres
of the uterus; so that the wound contracts much more

  * M. Piestch was obliged to apply this styptic to a branch of
the epigastric artery which he had cut in the Cesarean ope-
ration. See Journal de Medicine, Suppl. 1770, page  173.
  t On opening the body  of a woman, who a few days before
had undergone the Cesarean operation, a portion of intestine
was found engaged and strangulated  in the opening of the
uterus. 
            Of the Cesarean Operation.        537

after the operation.  Lastly, in the lateral  section of
the belly, we cannot open the uterus in its middle,
but the incision must be made near one of its sides,
and therefore runs more risk of affecting the vessels
which may be considered as the source of all those
that are distributed to that organ, the injury of which
is more to be dreaded than that of the sinuses or re-
servoirs that lead to the placenta.
   1409. M. Solayres, in his Lectures on Midwifery,
used to tell us, that the inconveniencies attached to
the lateral and oblique incision of the abdomen, would
one day engage practitioners to make it in the linea
alba.  In the mean time,  added he, / advise you to
perform it in that part, the incision is easier and less
painful, because there are fewer parts to cut; the ute-
rus presents itself to the hands, it is divided into its
middle part, and in a direction parallel to its principal
fibres.
   1410.  In whatever part we may open the abdomen,
and in whatever method we may perform  it, we shall
never much diminish the danger  of the Cesarean op-
eration; because we cannot remove every thing which
may oppose its success,  nor procure every thing
which might insure it.  It ought  to be  performed
methodically, that is an incontestable truth, and the
method which would be quickest,  easiest, and least
painful to  the woman, would be preferable to any
 other, provided the consequences of it were not more
 disagreeable.  In performing the section in  the linea
 alba,  surgery has made one step towards improve-
 ment,  but not the most difficult one.  It is necessary
 to guard against the purulent and milky discharges
 which are made into the abdomen; to defend the vis-
 cera from the contact of those humors, and preserve
 them from the dangerous effects of them:  the section
 in the linea alba has not those advantages. It had suc-
                       3 Y 
538         Of the Cesarean Operation.
ceeded twice* at the time I published the  first edi-
tion of this work, but four women afterwards died in
consequence of it, and extravasations of putrid mat-
ter were found in them. If it has had other successes
since, it has also had other victims. I have performed
it twice;  but though I saved the children, one of the
women died on the fourth day, and the other on the
fifth: the latter was of a very bad constitution, and so
scorbutic as to leave no hope of rescuing  her from
death;  but the former was robust, and in a proper
state to bear the operation. I was obliged to proceed
to it without delay; she having been in strong labour
twenty-four hours, and the waters discharged twen-
ty-one or thereabouts.  It was M. Sigault  who sent
for me to this woman; the case not seeming to him
favourable to the section of the pubes.
   1411.  It  is easy to perceive, says  M. Deleurie, all
the advantages of having the wound in the uterus as
I may say before the eyes, during the progress of the
cure, and having it answer directly to the external in-
cision; by that means the humors discharged from
the uterus have a free exit. These advantages would
doubtless be very  valuable, and would  often insure
the success of the Cesarean  operation: but hitherto
they have been rarely obtained, and then merely by
chance.   To insure them a little  farther, the uterus
should be opened at the top of its anterior part, al-
most to the  centre of its fundus, and not at its infe-
rior part, as has been most frequently done: for that
is the region which has been always found opposite
the external wound, on examining the bodies of those
women who have died in consequence of the Cesa-
rean operation; while the  wound in the uterus was

  * Messrs. Deleurieand Waroquier seem to be the only sur-
geons who have performed the Cesarean operation in the li-
nea alba with success. 
Of the Cesarean Operation.        539
concealed behind the teguments  that had been pre-
served above the pubes, and which it is almost impos-
sible  not  to preserve, on account of  the bladder;
which would equally favour  the extravasation of the
lochia into the abdominal cavity, by masking a part of
the wound in the uterus, even if that of the teguments
could be extended to the pubes.
   1412. If the wound in the uterus corresponds with
that in the abdomen, at the time of the operation, it
will not be found opposite to it an  instant after, and
still less during the cure; unless the edges of the one
contract adhesions  with those of the other;  which
has sometimes happened.  To procure this desirable
relation, we ought to prolong the external incision to
the height of the umbilicus;  begin  that of the uterus
about the middle of that incision, and extend it above
the superior angle, cutting  under the coverings of
the abdomen, as I did in the  two women on whom I
performed it: the two wounds would become parallel
through their whole length,  in proportion as the ute-
rus should contract its dimensions after the delivery,
and nothing more would be  necessary to preserve
their  parallelism,  than to fix that viscus by a bandage
properly disposed round the belly.
   1413.  It seems to me to be  much more impor-
tant to  prolong the external wound to the umbilicus,
or even above it according to circumstances, than to
carry it downwards to the pubes; because by that we
discover  the body of the  uterus, which should be
opened as high as possible.   By prolonging the ex-
ternal incision downward, we only expose the infe-
rior part  of that organ, which  in the natural state
constitutes its neck, and which ought to be preserved
in the  Cesarean operation.* Besides, an  opening

   * The neck of the uterus is not only that little pad called
the os tinea, in the natural state, and which projects more or 
540         Of the Cesarean Operation.

made in this part of the uterus would always be out
of the surgeon's sight, in the sequel, even if he should
divide  the  coverings of the abdomen as far  as  the
pubes; since the bladder always covers the major part
of it, even when it contains no urine. See the end of
par. 1411.
   1414. By opening the uterus in its inferior part,
an  easy passage is prepared  for  the lochia into  the
abdomen; because the cavity of the body of that vis-
cus, which  serves as a reservoir for those fluids, re-
mains almost entire, and is above the incision, which
seems to have been made in the most depending part
merely to favour their discharge.  Besides, the inci-
sion preserving after the operation a greater extent
than  the orifice of the uterus, and presenting fewer
obstacles to the passage of the lochia, also favours
their extravasation.  By opening  the uterus near  its
fundus, the inferior part of its cavity remaining entire,
may serve for a first receptacle for those fluids, as they
distil from  the inferior vessels; so that they may es-
cape more easily by the neck. Moreover, as the open-
ing will in this case be opposite the wound in the ex-
ternal teguments, the extravasation will not be so easily7
made into the cavity of the abdomen. If we recollect
the fortunate successes which bold but unskilful men
have obtained from the Cesarean operation, by open-
ing the  belly transversely at the height of the umbi-
licus, and the uterus doubtless in the fundus; and the
example of M. Guenin,  who  extended  the incision

less into the vagina; it often forms more than a third of the
whole length of the uterus.  Though it is entirely developed
in the two latter months of pregnancy, it recovers its form af-
ter delivery,  and returns insensibly to its natural state.  It is
the fibres of that part which  I advise not to be cut in the Ce-
sarean operation; but to guard against that, the incision must
be begun at least two inches above the circle which constitute*
■he edge of the orifice. 
           Of the Cesarean Operation.        541

of that organ to within an inch of that part, we shall
perceive all the value of this remark; it is that which
has engaged M. Lavverjat to reduce this procedure to
a regular method.* Two or three successes not ap-
pearing to me sufficient to entitle it to a preeminence
over the other methods, I neither adopt nor reject it;
because all of them have obtained some.  In the mean
time I shall prefer the section in the linea alba.
  Method of performing the Cesarean Operation.

  1415.  After having determined the part of the
abdomen and of the uterus proper to be opened in the
Cesarean  operation, it is necessary to  indicate the
manner of doing it.  But before all, it seems impor-
tant to observe  that  we must begin by emptying the
bladder with the catheter, especially when the woman
has not made water  for some time.  Notwithstanding
this precaution, the bladder still sometimes rises up
in such a manner before the uterus, that it conceals
the major part of it; as I observed  after the external
incision,  in a woman on whom I saw the operation
performed. The fundus of the bladder, in that case,
was almost as high  as the umbilicus, and the bladder
itself, though care had  been  taken to evacuate the
urine from it, presented through the whole extent of
the incision in  the teguments of the abdomen.
   1416.  The woman being placed as directed in par.
1406, we must cut  deeply through the teguments and
fat, if the subject be lusty, till we perceive the apo-
neuroses  which form the linea alba. That  must be

  * See his work entitled, Nouvelle Methode de pratiquef
1'Operation Cesarienne, 1788. 
542        Of the Cesarean Operation.
 cautiously divided  to discover the peritonaum in
 which a small opening is to be made; proceeding in
 that respect nearly as in the operation for a hernia.*
 We introduce the fore-finger of the left hand into the
 abdomen, to lift up the teguments a little, and remove
 the parts which might be hurt, out of the way of the
 instrument, to which the finger serves as a conduc-
 tor.! We then extend the incision towards the umbi-
 licus, or the pubes, according as it was begun higher
 or lower, cutting from within outward.  Though the
 history with a convex edge is proper for the first in-
 cision, I think the straight history with a probe point
 and narrow blade is preferable for the latter: it renders
 the grooved director needless, which would be neces-
 sary to conduct the common history.
   1417. This first incision must extend from the
 umbilicus to within an inch and a half at most of the
 symphysis of the pubes. It will be a little longer than
 it is  usually made, it is true; but then we  discover
 the upper part of the uterus better, and we may open
 it nearer to the fundus. It seems to me better also to
 open the peritonaum from above  downwards, than
 from below upwards; taking care to go along one of
the sides of the bladder, when it rises up in the man-
 ner mentionedin the latter end  of par.  1415.
   1418. While  we cut the  teguments of the abdo-
men, an assistant should fix the uterus in the middle,
by pressing a little with both hands on the sides, and
another make a similar pressure above the umbilicus,
 in order to circumscribe in some measure the uterine

  * The peritoneum is twice opened in this operation, once
in penetrating into the abdomen, and  again in cutting the ute-
rus. The Cesarean operation cannot be performed without it.
  t A better method is to introduce  the fore and middle fin-
 gers, and cut as it were between them.        W. P. D. 
           Of the Cesarean Operation.        543

tumor ^ and hinder the intestines from presenting at
the wound.
   1419.  The abdomen being  open to a convenient
extent, we are to cause a little stronger pressure to
be made above the umbilicus, to bring the fundus of
the uterus nearer to the level of the superior angle of
the wound, and then open it in the middle of its ante-
rior part, with a convex history, till we perceive the
membranes.  We then make a  small opening in them
just large enough to receive the finger, taking care
not to wound the child;  and pass the fore-finger of
the left hand into their cavity, to serve as a conductor
for the straight history, with which we  continue to
open the uterus cutting from within outwards, in the
same manner as we did in dividing the external parts;
extending the incision at least to the height of the
superior angle of the wound  in the teguments, and
terminating it at an  inch and a half or thereabouts
above  the inferior angle; because by continuing it
farther towards the pubes, the  lower part of it would
be concealed behind the  bladder, in a few hours after
the operation.  The extent of this incision must be
determined by the volume of the child, which we
suppose to  be such  that  its  head is generally ten
inches or ten and a half in the small circumference.
An opening of five or six inches is commonly suffi-
cient;  but  in general it is better to make it a little
larger than  smaller, to avoid tearing its angles when
the child passes it. That augmentation, says M. Lev-
 ret, is of little consequence, on account of the dimi-
 nution the wound undergoes after deliverance, espe-
 cially if it be made before  the bursting of the mem-
 branes, as I recommend.
   1420. We must cut the placenta, if it should pre-
 sent its centre under the  edge of the  history:  but
 when we meet with its edge in the neighbourhood of 
<544       Of the Cesarean Operation.
the wound, it is better to detach it in order to open
the membranes; as I did in the first of the two ope-
rations I have mentioned, and as is done when it is
attached to the neck of the uterus.
   1421. Having opened the uterus' properly,  we in-
sinuate the hand into it to  find the child's  feet and
bring them without;  proceeding in that respect,  in
the same  manner as if we wanted to turn the child,
and  extract it the natural way.  We  disengage the
arms in the same manner, when the  shoulders  are
sufficiently advanced, and afterwards introduce a fin-
ger into the mouth to  bring  along the head.  We
ought not to swerve from this rule, except when the
head presents  naturally to the wound  in the uterus;
if it be not expelled speedily by the contractile efforts
of that viscus, we may favour its exit by  pressing
lightly at the sides of the woman's belly, and at some
distance from the incision; or else by insinuating the
fore-finger of each hand, under the angles of the lower
jaw.
   1422. The uterus continuing to close after the exit
of the child, soon forces the placenta towards the
wound and expels it; which we  may also favour by
pulling the umbilical cord, and much more  certainly
by taking hold of the edge of the placenta with the
fingers as soon as it presents,  in order to disengage it
more easily, and make it present a smaller volume
than if we brought it along by continuing to pull the
cord.  We must also take care to extract any clots
which may have formed in the uterus, and  to pass a
finger through the neck of that viscus, to force any
that  may have lodged there into the vagina.  If the
uterus remain  soft and inactive after the exit of the
placenta, we must touch it a little externally and sti-
mulate it, to rouse it from that state of languor and
oblige it to close itself. 
Of the Cesarean Operation.        54s5
   1423. There is little blood  discharged  from the
wound in the uterus, when it has been made in the
middle of its anterior part; except the placenta be at-
tached there,  and even then the hemorrhage  does
not last long, if the uterus contract forcibly. It is not
so when the incision has been made elsewhere and
towards its sides;  when the instrument has divided
some of the large arterial and venous branches, the
blood may flow more abundantly, because the he-
morrhage lasts a longer time, however strongly the
uterus may contract.  If it should continue so copi-
ously as to occasion any alarm, we ought to touch the
lips of the wound with cold water,  or even  with  a
little rectified  spirit of wine, as some  have already
recommended:* for want of that, which is not always
at hand, we may use vinegar and water.|
   1424.  The  hemorrhage  may supervene some
hours, and even  several days after the operation; but,
cateris  paribus, it is then  less dangerous  than that
which proceeds  from the division of the large vessels
which correspond with the placenta, or  of those
arterial  and venous branches I have  just mentioned.
It will suffice, in order to stop the flow of blood,
to excite the tonic action of the uterus, which is al-
ways languid  in those cases; either  by rousing and
stimulating  that viscus  externally,  or by injecting
into it, through  the wound, cold water, pure,  or with
a little vinegar,  according to the degree of atony; as
is done  by the  orifice,  after  a common  labour, in
flooding cases.

  * See the Institutes of Surgery by Heister.
  f Or what has been found still better for the  suppression
of hemorrhagy, is  a strong solution of the acetate of lead, or
the spirit of turpentine.                     W. P. D.
                       3Z 
546        Of the Cesarean Operation.
    Of the proper Treatment after the Cesarean
                   Operation.

   1425. If any blood and water have been extra-
vasated in the cavity of the abdomen during the ope-
ration, we ought to procure its discharge before we
dress the wound; either by placing the woman in a
convenient position, or only by pressing on the two
sides above the hips.  Sometimes injections of warm
water have  been employed, to wash the surface of
the viscera  which had been bathed with those fluids.
Such extravasations will seldom happen at the time
of the operation, when it is performed in the linea
alba.
   1426. The wound in the uterus requires little at-
tention: it contracts and diminishes more than half in
a very few  minutes, except when that viscus remains
in a state of atony, and cannot close itself.  This
wound would easily heal, if it did not generally serve
for an outlet to those abundant fluids which the ute-
rus discharges in the first days of lying-in.  The re-
union  is the work of Nature,  and the hemorrhage
alone requires a particular attention.  In all ages, the
suture has been used  to procure the reunion pf the
external parts, and it has been performed in all pos-
sible ways.  It is, without dispute, the most certain
method of obtaining a firm and solid cicatrix: the
necessity of keeping a passage open for the discharge
of the fluids which escape through the wound in the
uterus,  is the only thing which  can counterbalance
its  utility, and it is with  that view that  those who
have employed  it have preserved a kind of opening 
            Of the Cesarean Operation.        547

at the bottom of the wound, by passing a little unra-
velled bandage round it.*
  1427. The suture  is not however indispensably
necessary after the Cesarean operation, that is a fact
which experience has already7 several  times proved;
because there is no wound whose edges may be more
easily brought together;  pregnancy having disposed
all the surrounding parts favourably for it, and the
coverings of the  belly being  then a third, at least,
larger than necessary to embrace the viscera closely.
But it must  be confessed that there is no circum-
stance in which it  is more difficult to keep those
edges in perfect contact, on account of their thinness
and the little support they have underneath,  especi-
ally when the  incision has  been made in the linea
alba; the smallest movements of the woman, and the
least pressure on the environs, destroying that con-
tact so  necessary to a perfect reunion: so that very
often, at the time of dressing, a  bunch of intestines
has been found without, quite shrunk up under the
bandage.  The utility of the suture therefore seems to
arise here, from the very dispositions which  lead us
to dispense with it.
  1428. The suture has inconveniences;  every  one
knows that it has often been found necessary to loos-
en it, and even cut it; either on account  of the ten-
sion of the belly, or to give an exit to clots of blood
formed in  its  cavity: but  notwithstanding  that,  I
think it ought not to be entirely rejected.  The quill-
ed suture, which is neither  more  difficult to make
nor moVe painful to the woman, than the interrupted
suture which has been substituted for it without any
reason,  is the most proper for obtaining the aggluti-

  * A bandage with  the cross threads drawn out at the part
opposite the wound. 
548        Of the Cesarean Operation.
nation of the whole thickness of the divided parts:
otherwise the teguments reunite.
   1429. The wound in question is not to be consi-
dered as a simple wound, which would only require
a reunion; and indeed no one has  considered it as
such; for all have reserved a passage in it for the lo-
chia, which rarely fail, during the first days, to be
discharged that way. But can it be necessary to keep
an opening of six or seven inches  for the discharge
of those fluids, when one much smaller may suffice?
The air is inimical to the viscera of the abdomen, and
we cannot preserve them from it too carefully.  Be-
sides, the intestines require to be kept soft and light,
and it often happens that they are bruised by the band-
age, when we endeavour to spare the woman the pain
of the suture.
   1430. It would be an abuse to multiply the stitches
as some ignorant persons have done; but we ought to
make two or three to unite  about the superior two
thirds of the length of the wound.  It is sufficient, to
preserve an opening of about two inches at the infe-
rior part of it;  the uterus being not much larger the
day after the operation when that viscus is contracted,
as it usually is after delivery.  I shall not describe the
manner of making  this suture, because all surgical
authors have mentioned it: I shall only observe that
the knots should be tied with bows, that they may be
loosened and tightened occasionally.
   1431. We place oblong compresses on the sides
of the wound, and a square one over it; all moistened
with the white of egg beat up with water quickened
with a little spirit, such as brandy, spirit of wine, or
arquebusade. I think we ought to put two little cush-
ions very soft  at the sides, above the hips, to make
the bandage steady, and force forward any fluids that 
Of the Cesarean Operation.        549
may be extravasated in the abdomen. The whole to be
retained by a folded napkin passed round the body.
   1432.  This wound requires dressing oftener than
any other wound penetrating the abdomen,  in order
to prevent extravasations and the formation of clots
of blood  which the bandage retains between the lips
of the wound in the uterus and of the teguments: we
mii.r;' then take off the dressings every day, or even
several times in the twenty-four hours, if we have oc-
casion to suspect those extravasations, or the protru-
sion of the intestines or the omentum.  But we may
dress more seldom when the lochia have taken their
natural course, and when the lower part of the exter-
nal wound presents no  other indication but that of
reunion.  The dressings ought always to be very sim-
ple, and  without ointment.
   1433.  It would sometimes be very useful to in-
ject warm water, or weak barley water, to cleanse the
surface of the viscera from the lochia, in the neigh-
bourhood of the wound. It would not be less advan-
tageous to throw it into the uterus itself by the wound,
to keep its orifice free, and dispose the lochia to pass
that way. Rousset, Verduc, Ruleau and others, with
the latter view, have recommended  the introduction
of a canula or species of hollow pessary, into the neck
of the uterus; but besides that  it would be difficult
to keep the  instrument  there, it could not give a pas-
sage to clots, among which some are very large.  The
conduct  of M. Guenin appears to  me preferable,
though it is not conformable to the general opinion.
A woman on whom he had performed the operation
nine hours  before, being  in a state of considerable
suffocation, suffering  frequent faintings, and vomit-
ing almost every minute,  he uncovered the wound
and loosened the suture, to extract from the belly and
uterus, the clots formed in them. He afterwards pour- 
550        Of the Cesarean Operation,  s
ed in warm wine, and forced it to pass into the va-
gina, by insinuating his finger through the wound
into the neck of the uterus, to unstop it: this, says
he, restored the course of the lochia, which had been
suspended by a clot of blood.  I think that sufficient
attention is not paid to this article, and that by clear-
ing the neck of the uterus, from  time  to time, the
success of the  Cesarean  operation would  be more
certain. With that  intent, I have used an unravelled
bandage.   I have been reproached  for it in a work
very lately published; but it has been condemned in
opposition to all reason.
   1434. We cannot lay down fixed rules for the rest
of the treatment; because it must depend on accessory
circumstances.  If the woman  is strong and robust,
she may be bled some hours after the operation, and
that evacuation  may be repeated according to the na-
ture and violence of the accidents which shall occur.
The belly must be kept open, by clysters;  and the
patient must be kept to a strict diet and  antiphlo-
gistic  drinks, such as veal or chicken  broth, very
weak,  sharpened with a little nitre, &c* As we can

  * We should consider in  this country a strict antiphlogis-
tic regimen a very different one, from what our author points
out; we should certainly and very scrupulously forbid animal
broths of any kind; the stimulating quality of which is not suf-
ficiently attended  to; for  I have no hesitation  in believing,
that were two patients every way  similarly situated, to be
subjected to the trial of one being indulged in broth, however
weak, and the other to abstain from it, that the one using the
broth where symptoms  ran high might perish, while  the
other, with equally unfavourable previous symptoms might
escape  It is however to be understood, that in other respects
the treatment is to be alike. I have  chosen to bear this testi-
mony against broth or animal juices here,  as  the operation
considered in the text is confessedly one of the most serious
kind, and should have every advantage from regimen, 8cc. that
the operator can give;  and the more especially is this caution 
             Of the Cesarean Operation.       551

here give only general rules on the subject, it must
be  left to the  sagacity of the surgeon to  prescribe
particular ones according to the exigency of the case.
   1435. We ought to persuade the woman to suckle
her child; unless the first accidents of the operation,
or those which have preceded  it, deprive her of the
power of doing it.  Many practitioners have already
given this precept, and have supplied the  suction of
the child, by glasses or young  puppies.  That is the
way to attract the milky  humor towards the breasts,
to withdraw it from the uterus, and more speedily dry
up the  source of the discharges  which  are made
through the wound of that viscus.*
   1436. After the perfect consolidation of the wound,
the woman ought never to go without a proper band-
age, to prevent a subsequent hernia, which happens
to the greater part of those  who have undergone the
Cesarean operation, and  which sometimes becomes
of an enormous size.

necessary with respect to this article of diet, as  it is but  too
frequently supposed to have but little effect on  the system,
and may be indulged in under almost any circumstance, than
which, nothine; can be more  erroneous or injurious.
                                          W. P. D.
   * Nothing can be more  visionary than the opinions  the
French writers have on this subject; they imagine that milk
may be deposited or translated to any part of the  body of a ly-
ing-in woman, hence the above caution; it must  nevertheless
be agreed, that the practice above recommended is good, how-
ever improbable the theory may be. May not the  discharge of
 milk be useful as an evacuation? and also by inviting a power-
 ful sanguine determination to a remote part, and to one  that
 very powerfully sympathizes with the uterus?    W. P. D 
552          Rupture of the Uterus..
 Of the Causes of the Rupture of the Uterus, and the
         principal Accidents attending it.

   1437.  Most authors, in treating of the rupture of
the uterus, have attributed it only to  the extraordi-
nary motions of the child,* without considering that
many women had  felt none at the time when it took
place, and that in others, it had not  happened till
after the  death of the child. Whatever force we may
suppose in those motions, they will never be able to
effect that rupture,  unless other causes act at the same
time, or have already disposed the uterus to it; but,
on the  contrary, those  causes may produce it with-
out the assistance of the child's motions.  The child
is almost alu ays passive at the time the uterus tears; if
it becomes the instrument of the rent, it acts no other-
wise than any other solid body of the same volume,
inanimate, and of an  angular  surface  would, on
which the uterus should be strongly contracted. The
extraordinary movements which have been regarded
as the cause of these accidents, have generally  been
only the consequence of them.  It is not in the uterus
that the child had  moved in that manner, but in the
abdominal cavity,  whither it had been forced by the
rupture in question: it was easy  to be deceived in it;
because the instant of the child's passage into the ab-
domen, and  that of the rupture  by which it passes,
are,  as I may say7, indivisible, the same  effort pro-
ducing both.

  * De la Motte, torn. ii. page 1189, edit, de 1775.
  Levret,  Art des Accouchemens, edit. 3, § 559 and follow-
ing.
  Crantz, Commentarius de Rupto in Partus Doloribus Foetu
Utero 1756, and many other authors. 
             Rupture of the Uterus.          £53

   1438. The violent and sometimes convulsive ac-
tion of the uterus  on the  child's body,  is almost
always the only cause of its rupture; and it will take
place much more certainly, if that action is assisted
by that of the muscles which surround the abdominal
cavity, which press the uterus unequally, as they can-
not act  in all parts immediately on its surface, and
serve for a support to every point of it. Those mus-
cles act nearly  as any other power would do which
should  press the belly strongly, if the  back were
placed  against a wall.  It is always at the height ofa
pain, or of a contraction of the uterus, and at the time
when the woman bears down the strongest to second
that effort, that the rupture  takes place. It is not how-
ever necessary, in order to effect it, that those united
powers should act with all the  force  of which they
are susceptible, since that accident has happened in
some cases, at a time when the labour was scarcely
begun: it is sufficient that that force be superior to
the  resistance opposed to it by the part which tears.
   1439. An uterus perfectly sound may tear, as well
as one  affected by any disease  which has previously
weakened its tissue.  If every point of its surface is
so disposed as to  support equally the effort which
tends to expel the  child, at the beginning of labour,
 it is not always the same at the latter end of a very
 long labour, when great obstacles oppose the deli-
 very; because the substance of the uterus necessarily
 weakens in some part,  and especially at those points
 which  answer  to the regular parts of the child, or
 which  are pressed  by its head against the margin of
 the pelvis and sooner or later, those parts give way.
    1440. The rupture in  question cannot happen in
 any case, unless the uterus has been predisposed to it
 by  those means, or by other causes which are all ac-
 cidental. Sometimes a tumor weakens the substance
                             4A 
554          Rupture of the Uterus.
of the uterus, and disposes it to tear; sometimes an
ulceration more or less superficial, or the preternatu-
ral tenuity of  one of  its regions;  at other times, it
may  proceed from indurations and callosities of its
neck, or of the vagina, a deformity of the pelvis, and
even from the obstacles arising from the external
parts, the  bad situation of the child, or of the head
alone, &x.
   1441.  External causes may tear the uterus, with-
out the assistance of all those I have just mentioned,
at whatever period of pregnancy they may act, pro-
vided however that it be  towards the period of its
maturity.  We find examples of it from a fall, from
a strong pressure on the belly; and much oftener from
the unskilful application of the hand, or of instru-
ments destined to perform the delivery.
   1442.  There is not a single point where the ute-
rus may, not tear; but we observe, nevertheless, that
it is  generally  towards its sides, the fundus or the
neck: which is not difficult to account for. The part
where the placenta is implanted is not  more secure
than  the rest; and the rupture has taken place in some
cases at the very part which seemed to be fortified by
a scirrhous  tumor with a large base.  The rupture
does not always follow the same direction, nor always
present the same aspect.  Sometimes it happens lon-
gitudinally,  at  other times transversely, obliquely, or
in a semilunar form. Sometimes the edges are even,
and it only presents the appearance of a simple burst-
ing,  or of a wound made with a cutting instrument;
at other times  they are unequal, as it were ragged,
and it resembles a  contused wound.
   1443.  We must distinguish these two species of
rupture, from  ulcerations of the uterus which arise
from some  of the causes already mentioned;  as in
consequence of a long and severe labour, in  which 
             Rupture of the Uterus.          555

Nature  had not been able to deliver herself of the
child by the usual passage: whether the obstacle arose
from a deformity of the pelvis, or from some tumor
of the neck of the uterus and of the vagina; or only
depended on the bad situation of the child, which had
not been rectified in time: or whether those ulcera-
tions were  only the consequence of an external per-
cussion, &c.  In the former case, the place which an-
swers to the hardest and most projecting parts of the
child, those which  have been long  bruised by the
head pressing against the margin  of the pelvis, in-
flame and ulcerate,  in the same manner as that which
has been struck, and  an opening is produced smaller
or larger, very different from a simple rupture which
takes place suddenly. Most frequently,  before these
ulcerations are formed, the uterus contracts adhesions
with the neighbouring parts, which also ulcerate at
length, and the event is different, according  to the
parts where those adhesions take place.   When they
take place before, the  foetus  may be discharged
whole,  or  piecemeal  through the  ulcer: when they
are formed elsewhere, the woman's life is in more
danger; because we cannot give her the same assist-
ance.
   1444. Although the rupture of the superior part
of the vagina in the part where  it is united with the
os tinea, has more  relation to the  simple rupture of
the uterus, than to  these ulcerations, it must also be
distinguished from it, because it is not so dangerous
as that, and because  it presents different indications,
 considering them at  the same time only relatively to
 delivery.  These rents of the vagina have been fre-
 quently confounded  with those which happen in the
 neck of the uterus  near its insertion in that canal; be-
 cause the  latter have often, like  them, a  semilunar
 form, and because the os tinea is entirely  effaced  at 
556          Rupture of the Uterus.
the time when we discover them, and when we ex-
tract the child.
   1445. The danger which threatens the  woman
whose uterus is torn, arises much less from the rup-
ture simply considered, than from the passage of the
child and the placenta into the abdominal cavity, and
the extravasations of blood which are formed there at
the same time.  It is true that the child does not al-
ways go thither, nor does the placenta always follow
it, when it  passes entirely out of the  uterus; Nature
in some cases throwing it off by the usual passage.
Sometimes only a single limb of the child  escapes
from the uterus through the rupture; sometimes an
arm or a leg; or the two inferior extremities and the
half of the trunk; at other times,  the head alone. Al-
though  the rupture be large enough for the exit of
those parts, it sometimes happens that no one passes
through it; because it answers to a part of the child's
surface, which is much larger still;  so that  it remains
entirely in the uterus, if it cannot be expelled the na-
tural way.
   1446. The passage of the child into the abdomen
and the extravasation of blood into that cavity, are not
the only complications of the rupture of the uterus;
the  intestines floating above, sometimes insinuate
themselves through the opening, into its cavity; even
before the child is out of it. If they be not reduced,
while the opening preserves nearly its original size,
they are strangulated in it, in proportion as the uterus
closes; because the rupture contracts and diminishes
in the same proportions as the volume of that viscus,
and the woman is destroyed by die accidents  of a
strangulated  hernia; as we particularly observe in a
case communicated to  the Academy by M. Percy,
the son, from his father.*
   * The hernia was not discovered till the opening of the bo-
dy; the wound  in which it was strangulated was scarcely sen- 
             Rupture of the Uterus.         557

  1447.  The fear of being charged with unskilful-
ness in announcing the rupture  of the uterus, at the
instant it happened, has hindered accoucheurs who
have been witnesses of it, from employing the only
possible means of preserving the mother and child,
much more than the opinion they held that it was es-
sentially mortal.  M. Levret, who, as well as many-
others, thought that gastrotomy was the only resource
in such cases, seemed to doubt whether it would ever
be put in practice.  The mother and the child are in-
evitably lost, says he, when the uterus tears before
delivery; there is no means of saving them  but the
section of the abdomen performed instantly: but, con-
tinues he, what accoucheur would be bold enough to
perform it in time, and what parents would have cou-
rage enough to permit it to be executed without de-
lay? A great number of cases attest the truth of M.
Levrefs prognostic, and there are some which no
less demonstrate the necessity of recurring to the
operation which  he dared  not  recommend  openly;
and show that  there have been surgeons so regard-
less of their own interest as to propose performing it
instantly, and that there have been women courage-
ous enough to submit to it.
        Signs ofa Rupture of the Uterus.

  1448. The greater part of the predisposing causes
of the rupture of  the uterus being most frequently
unknown to us during the course of labour, and that
rupture not  always taking place in  cases where the

sible, though it had been prodigiously large, says M. Percy
the father, who was a witness of the fact, before the contrac-
tion of the uterus. 
558          Rupture of the Uterus.
most apparent of those causes render delivery impos-
sible, it seems difficult to  indicate the  signs which
show that accident  is likely to  happen, and conse-
quently to lay down the prophylactic treatment.
  1449. When the woman is threatened with a rup-
ture of the uterus in a laborious  labour,  according to
Doctor  Crantz,* the belly  is very prominent  and
tight, the vagina lengthened, and the orifice of the
uterus very high;  the pains  are strong, leave  little
interval, and do not advance the delivery.  M. Lev-
ret adds, that the pain the  woman suffers, is always
seated towards  the middle of the epigastric region;
that a last effort or violent  leap  succeeds to the re-
peated  strugglings of the child, which announces its
death and the rupture of the uterus. But these symp-
toms are too uncertain for  us to  take them for a rule.
The rupture of the uterus has often taken place with-
out being preceded by any of them, and has not hap-
pened  in other cases where their union seemed to
declare  it inevitable.  If we were to take them for our
guide,  we should sometimes trench upon the rights
of Nature, by performing a delivery which she would
have been able to terminate  without inconvenience;
we  ought not to flatter ourselves, in any case, that we
have prevented a rupture of the uterus.
  1450. What those authors advance concerning die
symptoms which succeed the rupture of the  uterus
and which denote it, are much  more conformable to
experience.  At the time when  it  happens, say7 they,
the woman feels an acute  pain in  the part itself, and
shrieks suddenly;  her  face grows pale; she has fre-
quent  syncopes, and  her  pulse  becomes  small; the
form of the belly changes  more or less according to

  * M.  Crantz, Dissert, sur la Rupture de la Matrice, trad.
Fran9. 
Rupture of the Uterus.          559
the part of the child which has escaped from the ute-
rus: cold sweats succeed, with convulsions, vomit-
ing, and other accidents, according as the child acts
on this or that viscus of the abdomen; and death soon
closes  the  scene, if  we abandon  the woman to her
melancholy fate.
   1451. But those symptoms do  not  characterize
the rupture of the uteres so clearly, that we may not
be  deceived by them in  some cases:  touching de-
monstrates it in a much more certain manner.* When
that accident precedes the opening of the membranes,
the pouch  shrinks immediately,  and becomes very
flaccid, though no fluid  is discharged without, be-
cause it is discharged into the belly; the orifice of the
uterus contracts, at least, unless a part  of the child
be engaged in it before the rupture;  if the child passes
entirely into  the abdomen, the uterus closes and re-
duces itself to the size which we  commonly observe
after a natural labour; the motions of the child, if it
be still living, are felt in a different part from that they
were felt in before; lastly, we  may  easily distinguish
its limbs by  laying the hand on the woman's belly,
if we search  for them immediately; but the swelling
and painful tension of the parts prevent it afterwards.
   1452. The labour pains properly so called cease
as soon as the child is entirely in  the abdominal cav-
ity, and especially if it is followed by the  after-birth;
but the woman feels pains of another kind, which
were unknown to her before. When the effort which
has torn the uterus has not been able to expel the
child from it, the pains continue, because the uterus,
notwithstanding  its  rupture,  continues to contract
and endeavour to get rid of it: sometimes it expels

   * See the dissertation already quoted, and the works of M
Levret. 
560          Rupture of the Uterus.

the child the natural way, and  sometimes  forces it
into the cavity of the belly, according as it finds one
to be easier than the other.  In the former case, the
part which it presented advances more and more, and
in the other  it recedes insensibly and disappears.
Sometimes also  it remains in the  uterus  whose
strength is exhausted, and the labour ceases.  In
other cases where the  head has descended into the
pelvis, or strongly engaged in the strait, it keeps its
position there, while the rest of the body, especially
the extremities, and the  inferior part of the trunk,
penetrate into the abdomen. The same thing has been
observed after the rupture of the vagina.
 Of the Indications presented by a Rupture of the
                     Uterus.

   1453.  It would incontestably be more advantage-
ous to prevent a rupture of the uterus by performing
the delivery, than to wait till it happen, to terminate
it afterwards; but on what grounds shall we decide
to pursue a method which may also be attended with
accidents, either with respect to the mother or the
child, since, strictly speaking, no certain  sign  can
indicate that  the rupture in  question is inevitable?
The means of preventing it would consist in extract-
ing the child  by the usual passage, or by the Cesa-
rean operation, and the  latter is recommended by
Doctor Crantz in a number of cases:  he  observes
however that  it would be entirely out of season, if
the child's head were locked in the pelvis. I will ven-
venture to add that it would then be contrary to every
principle of humanity; as well as in those  circum-
stances where the pelvis of the woman is well enough 
              Rupture of the Uterus.          561

formed to give the child a passage; since the art pre-
sents more gentle and certain resources for the mo-
ther.  The Cesarean operation is not exclusively in-
dicated but when the pelvis is absolutely too narrow;
and then it is much less the fear of a rupture of the
uterus which leads us to perform it, than the impos-
sibility of terminating the delivery any other way.
   1454. Bleeding,  warm baths, fomentations, muci-
laginous injections into  the vagina, the incision of
the neck of the uterus when it  is hard and callous,
the section of bridles in the vagina, &c. the applica-
tion of the forceps, the extraction of the child by the
feet, and by means of crotchets; and lastly, the Cesa-
rean  operation, are so many prophylactic methods
which must be employed according to the exigency
of the case.
   1455.  The curative method in the rupture of the
uterus considered relatively to delivery, must not be
less varied than the prophylactic. Though the section
of the coverings of the abdomen is often the only re-
source in  surgery to save the mother and child, or to
rescue the former from terrible accidents, by extract-
ing the latter, and its after-birth, as well as the blood
 which is extravasated; sometimes also that operation
 would not be less contrary to the principles of the art,
 than if we were to perform it on account of most of
 the predisposing causes of that rupture: for notwith-
 standing that accident, it is not always impossible to
 extract the child by the usual passage. De la Motte
 and others furnish examples of it, which however I
 do not quote to serve for models.  The former turned
 a child searching for the feet through the rent in the
 uterus, as far as the middle of the belly whither they
 had penetrated; and others assure us they had brought
 back a child that way, which had escaped completely
 out of the uterus:  which will not appear probable to
                       4B 
562          Rupture of the Uterus.
those who know how much the uterus closes from
the moment it is emptied, and how much the rupture
then loses of its extent.
   1456.  When the head presents after the rupture
of the uterus, even if it should not be engaged in the
pelvis, provided the deformity of  the latter  does
not offer  any great obstacles to it, we  ought to ter-
minate the delivery with the forceps; whatever part
may have penetrated into the abdomen.  It may easily
be conceived to what danger we should expose the
woman by attempting to turn a child the major part
of whose trunk should be in  the abdominal cavity,
and the rest in the ruptured uterus.  If we cannot ex-
tract it by means, of the forceps, or with the crotchet
when dead, gastrotomy,  that is to say, the incision
of the coverings of the belly, is  as  manifestly indi-
cated as when it has been entirely forced  into that
cavity.
   1457.  The section of the coverings of  the abdo-
men will not appear so indispensable after  a rupture
of the vagina as after that of the uterus, to extract a
child which has passed entirely into the abdominal
cavity,* if we attend to  the difference of these two
cases, with respect to the rupture itself.  After the
exit of  the  child, the rent of the uterus contracts in
proportion to the reduction in the volume of that vis-
cus, to that degree that the finger has hardly been able
to penetrate it two days after it has happened, though
large enough at first, to let half of the  child into the
abdomen,  and the hand of the operator  also: but that
of the superior part of the vagina does not diminish
in the same manner,  whatever may be the contrac-

  * Saviard, Observ. M. Thibaut, Journal de Medecine, tome
I. 1754;  M. Chevreul and M. Chaussier, Observ. communi-
cjuees a l'Acad. de Chirurgie. 
Rupture of the Utefus.           563
tion of the uterus.  Those who have sought for the
child when it was entirely in the abdomen, and have
extracted it by the natural passage  some hours after
the rupture had  taken place, have  doubtless taken
the rupture of the vagina for that of the neck of the
uterus: for it is not practicable except in the latter
case.  The operation which I recommend, not only
for extracting the child  and its after-birth from the
cavity of the belly, but  also to give an exit to the
blood and waters which may have been extravasated
there, and which cannot be discharged otherwise, is
more easy to execute than the  Cesarean operation
properly  speaking, and does not seem to be more
dangerous; for on  one side, we  have not the uterus
to open, and on  the other, the  rupture of that viscus
is not essentially mortal.  It has been  done several
times with success to the woman, and probably it
would have had as much with  respect to the child,
if it had  been performed immediately after the rup-
ture of the uterus instead of deferring it several hours,
as has been done in all those cases. M. Thibaut des
Bois, a surgeon of the town of Mans, published the
first example  of it in 1768,* and  the Academy of
Surgery has since received two others much more
interesting.
   1458.  In M.  Thibaut's case, every thing was ex-
ceedingly well disposed, and seemed to announce a
speedy deliverance, when the woman felt a sharp and
very short pain towards the superior and left lateral
part of the uterus, after which, the  head which had
presented favourably, disappeared.  Not finding then
either the child or the placenta in that viscus, M. Thi-
baut was not afraid to propose gastrotomy, and to de-
monstrate the danger of deferring it. He performed
* See the Journal de Medecine for 1768. 
564          Rupture of the Uterus*
it, but not till after some  hours; which rendered  it
useless to the child.  The woman suffered, in a man-
ner, nothing but the usual consequences of a common
labour. Gastrotomy, performed twice on the same
woman, by M. Lambron, a surgeon of Orleans,*
was not more salutary to the child; the first time be-
cause it was not performed till eighteen hours after
the rupture of the uterus.  But the woman at the end
of three weeks seemed to be nearly recovered, when
a tumor of the size of a fist appeared in the hypogas-
tric region, and seemed disposed to open, as in fact
it did, four days afterwards.  Notwithstanding this
gangrenous abscess,  out  of which came eighteen
worms from four to six inches long, and of the same
species as were discharged at the same time, from the
anus and vagina, the woman resumed her labours in
the fields  in six weeks from the time of the opera-
tion.  Being again pregnant the following year, she
suffered the same accident, the child again passed
entirely into the abdomen, and M. Lambron,  who
was present, again performed the operation of gastro-
tomy; without any farther delay than what the woman
demanded to receive the sacraments. The child gave
signs of life during half an hour after the operation,
and the subsequent symptoms were very mild. This
woman became pregnant again,  and was delivered
naturally of a healthy child.
   1459. The operation in question is not  the only
possible resource for a woman whose uterus is torn
by the efforts of labour; Nature, always attentive to
our preservation, sometimes saves her life, after hav-
ing led her from one danger to another. But the suc-
cesses which I have just quoted, no less on that ac-

   t The 9th of August  1775, on the wife of Charles Dumon:.
 gardener at St. Jean de la Ruelle near Orleans. 
Rupture of the Uterus.         565
count, demonstrate the pre-eminence of the operation
over those singularly rare efforts, and which would
have been still most  commonly fruitless, if surgery
had not aided them seasonably; either by  opening
the abscesses which  formed, or by dilating the en-
trance of the sinuses containing  the child or its re-
mains, or by extracting them.
   1460.  The rupture of the uterus does not always
present one and the same indication; because the dan-
ger attending  it does not always arise from one and
the same cause. After having extracted the child, its
after-birth, the blood and waters if any have  been
extravasated into the abdomen, it seems to require no
other treatment than the wound made methodically
in the Cesarean operation; because it contracts  like
that, and consolidates in the same manner. If a loop
of intestine gels into it, it must be  disengaged from
it; if it is so strangulated that we cannot withdraw it,
the wound must be dilated, in the  same  manner as
the inguinal ring in a common hernia. This compli-
cation becomes much more troublesome when the
child  has been extracted the natural way.   Though
we may then push back the intestine into the abdo-
men immediately after delivering the woman, as sev-
eral authors have done, and particularly Rungius,*
how can that reduction be obtained,  when the acci-
dent has been mistaken at first, and when the intes-
tine is strictly confined in the wound of the uterus,
as we remark in the case quoted in par. 1446. from
M. Percy? The woman must quickly sink if we do
not effect the reduction; whatever difficulties it may
present, they  are not above the resources of the art.
I would not recommend carrying  the hand armed
with a history into the uterus, to  enlarge  the ring

  * Quoted by Heister, Instit. de Chir. tome ii. page 137 
566
Of Twins.
formed by the contracted wound, as a surgeon  as-
serts he did with success the third day after delivery,
to reduce a loop of intestine which had fallen into
that viscus some hours before, having reduced a still
larger portion at the time of delivery;* but might it
not be allowed in such a desperate case to open  the
abdomen to withdraw the intestine, as  was  proposed
by Pigrai for a strangulated inguinal hernia, and as
has been practised by some surgeons to remove inte-
rior strangulations?
Of Compound Pregnancy; its Signs, and the Indica-
       tions it presents relative to Delivery.

   1461.  Compound pregnancy is  that which con-
sists of several children, and the name of twins is
usually given to them, without any regard to their
number;  though that name, strictly  speaking, signi-
fies only  two; the others being triplets, quadri-gemi-
ni, &c. A pregnancy of two children  is rather rare;
one of three is still more so, and we hardly ever meet
with quadri-gemini.
   1462.  These children are not always enveloped in
the same membranes, nor situated in the same man-
ner, either with respect to  each other, or to the ori-
fice  of the uterus; which often  presents  particular
indications relatively to delivery.  Though they are
sometimes  contained in the same  membranes,  at
other times only one is common to both of them,
that is the chorion, and each twin  has its separate

 * A case  communicated to the Academy of Surgery in 1775,
by a country surgeon, and which would be extremely inte-.
testing if its circumstances were well described. 
Of Twins.
567
amnion; lastly, there are some who have both mem-
branes very distinct and perfectly separate; so that
each of them  has its own chorion, its own amnion,
placenta and wraters.
   1463. In the former case, the chorion and amnion
form  but one bag, in which  the twins float in the
same waters, and there is but one placenta, or else
the two masses appear to form but one. This mode
of being is not the most usual with twins, and we
may add that it is not the most advantageous. When
they are thus disposed, their cords may be entangled,
and form knots upon each other during pregnancy;
both  children may present some of  their parts toge-
ther at the orifice  of the uterus in labour, and advance
at the same time, or reciprocally oppose each other's
exit:  which happens much seldomer than in the other
cases, &c.
   1464. In the second case, each twin is contained
in a particular bag, formed by the amnion only; and
those bags are covered by a common membrane.
 They often have but  one placenta; and when each
 has its own, those masses are as it were grafted on the
 same base, so that we cannot extract one without the
 other.  The twins are not bathed in the same waters;
 their cords cannot be entangled as in the preceding
 case; one of them may die, and putrefy without in-
 juring  the health of the other, as I have several times
 observed;  they seldom present any of their parts to-
 gether uncovered at the orifice of the uterus in la-
 bour, &.C.
    In the third case, each twin  being contained in a
 particular bag, formed by the chorion and amnion,
 they have their  placenta distinct; so that we might
 extract one of the children, and its after-birth imme-
 diately afterwards, without much inconvenience.  It
 is in such circumstances, that accoucheurs, not sus- 
568
Of Twins.
pecting the existence of a second child, have invo-
luntarily abandoned it to the care of Nature, which
has often not expelled it till the next day or several
days afterwards. As no sign can demonstrate before
deliverance, whether the children have their involu-
cra common or particular, we ought never to attempt
the extraction of the after-birth till after the exit of
the last child.
   1465. The situation of twins, with respect to each
other, or to the orifice of the uterus, is exceedingly
various.  Sometimes they are placed parallel to each
other, and sometimes they cross forming angles more
or less acute; one of them presenting the head, the
feet, the  knees,  or the  breech at the orifice of the
uterus, and the other a different part; as we shall see
hereafter.
 Of the Signs ofa Pregnancy composed of Several
                    Children.

   1466. The extraordinary size of the belly at any
given period of pregnancy, its division into two tu-
mors more or less apparent in the latter months, an
oedema of the inferior extremities from the third or
fourth month, and the motions the woman may feel
in several parts at the  same  time, are exceedingly
uncertain signs of the presence of several children.
There is not one of them which we have not observed
in women who were big of only one, while we have
often remarked nothing of the kind in those who were
really so of two.  I  do  not  however  deny that the
union of all these  signs sometimes gives strong pre-
sumptions of the  existence of twins;  but touching 
Of Twins.
569
alone can dissipate  our doubts, and that only in the
last months of pregnancy.
   1467. When the belly is so large as to give a sus-
picion of two children, if there is but one, it is always
very movable;  because it is then in a large quantity
of water: we easily move it by means of the finger
introduced into the vagina, and its rolling is never
more manifest  than when we do that.  When there
are two, that movement is scarcely sensible; we ea-
sily distinguish that the child we endeavour to move
by touching, is surrounded by only a little fluid, and
that it is incumbered by another solid body; if we
apply a hand on the woman's belly in  one of these
moments when the parietes of the uterus are  supple,
and as  it were slackened, we may discover those
children as  clearly as in other cases we distinguish
the feet, the knees, or the arms of that which is sin-
gle.
 Of the Indications presented by Twins relative to
                    Delivery.

  1468.  Though  the pregnancy consist of several
children, delivery may take place  as  naturally as if
there  existed but one; provided that they present
successively and in a proper situation at the orifice
of the uterus. We observe only that  the expulsion
of the first is generally performed with a little more
difficulty than in a common labour: which doubtless
is because the uterus does not embrace it equally in
all parts, and cannot act immediately on it except on
one side: for each twin is in general smaller than the
child which constitutes a common pregnancy.*

  * I have however seen twins, the least of which surpassed
the middle size of children at full time; its head having three
inches eight lines in the transverse diameter. 
570
Of Twins.
   1469. When the first child presents well, if the
head advances in the usual direction according to the
position it is in, we ought to leave its expulsion to
the efforts of Nature. We proceed in the same man-
ner with respect to the second, if it  should  place
itself as advantageously at  the orifice of  the uterus,
and if the mother retain strength enough to deliver
herself without help, or with only the assistance usu-
ally given in a natural labour; but when  it presents
badly, we ought to search for the feet and bring them
down.  Though it is proper  to begin the operation
before the uterus closes strongly7, it is not less advan-
tageous to wait  till  that viscus endeavours to  expel
it, to go on with the extraction: for it might be dan-
gerous to empty the uterus suddenly, and before its
own action contributed to it; as I have shown in ano-
ther place. Twins do not always present  so favoura-
bly for their exit, and sometimes that of the first can-
not take place without assistance, though it be placed
properly and its volume be moderate relatively to the
pelvis of the mother. This is in my opinion, because
the uterus cannot press the child equally on all  sides,
and  because its expulsive forces are  divided upon
both children, so that the first is subjected to only
the smallest part of them: as when the second child
is placed across.  See par 1475.
   1470. Among the positions which twins may take,
as well with respect to each other, as to the orifice of
the uterus, I shall only distinguish the principal  and
those which are the most common; because they will
suffice to demonstrate what the others require: be-
sides,  if I were to  undertake to state  them all, the
greater part would escape  my notice, so much may
they be varied.
   1471. Each twin may present the head at the en*
trance of the pelvis, but in a different manner; the 
Of Twins.
571
face of one being upward, downward, or on one side,
at the same time that that of the other is turned in a
contrary direction.   Though  they are sometimes
placed parallel  by the  side of  each other; at other
times they cross one another obliquely; so that the
head  of that whose  trunk occupies the right side of
the uterus, rests in the  left iliac fossa, while the right
iliac fossa supports the  head of the other, whose body
occupies the left side of the uterus. In this case, de-
livery cannot take place without assistance; because
the direction in which the head of each twin is press-
ed down, is such that neither of  them can advance,
and because the two heads recede from each other,
turning back on the shoulders, or  pressing harder
against the sides of the pelvis.  When they are paral-
lel, that of the two heads which is nearest the middle
 of the entrance of the pelvis,  may engage in it and
 force the other from it;  but when it is  got into the
 excavation it may also stop and  remain there a long
 time, and even sometimes cannot be expelled from
 it, though small  relatively to  that cavity; as I have
 observed, and as M.  Solayres  remarked before me,
 as well as many others.*

   * The head of one of the children forced down by the first
 pains to the bottom of the pelvis, in a woman exceedingly well
 formed, remained there from Wednesday morning till about
 five o'clock on Friday afternoon, notwithstanding the natural
 efforts were  very strong: which induced me at that time,
 which was when I was first called, to extract the child with
 the forceps. After its exit, I found a second which presented
 the feet.  I pass over the detail of the state into which the
 fruitless efforts of Nature, continued  so long a time, had
 thrown the woman: I shall only remark that she speedily re-
 covered, and that the children  were extracted living.  M. So-
 layres was a witness to a similar case: but both children were
 dead when  he delivered the woman, and one of them was
 placed transversely under the other, so that they formed a
  cross. 
572
Of Twins.
    1472. When both children present the head cross-
 ing each other in the manner just stated,  they must
 be  turned with  the necessary precautions, and ex-
 tracted by the feet. We must in that case begin with
 the child which  is underneath;  because in bringing
 that down, the other will remove itself from the en-
 trance of the pelvis, and go towards the fundus of the
 uterus into the void which the  first leaves as it ad-
 vances.   In  fact, it would  be very difficult in  this
 case, to pursue any other conduct.
   1473. If  circumstances foreign to those I have
 already mentioned, require us to deliver without de-
 lay  when the two children are parallel to each other,
 and present the head at the orifice of the uterus, it is
 of no consequence whether we begin with that which
 is placed at the right side of the uterus, or that at the
 left: the  preference must then depend  on the hand
 which the operator introduces  into the womb.  In
 this case, as  in all those relative to twins, we must
 be careful to take hold of the feet which  belong to
 the  same child, that we may not bring them both
 down  at once; and as soon as  they are without, to
 remove from the superior strait, not only the head of
 the first  child, but also that of the second, that they
 may not be entangled  in the neighbourhood of that
 strait, and one be brought along by the other, which
 might happen, just as a knotted cord  put into a bot-
 tle in order to extract a  cork, hooks it and draws it
 out.
   1474. We have seen one of the twins present the
 head in a favourable situation, and the other the feet.
 Though  such a situation seems to indicate pushing
 back the  latter, and removing them from the entrance
 of the pelvis,  that the former may engage in it, expe-
rience has proved that that method would not always
answer our expectations.  It would often be better to 
Of Twins.
573
 begin by extracting the child that presents the feet,
 taking care to prevent  its breast or its  head from
 bringing down the head of the other; as we observe
 in a case published in the Journal de Medecine.*
   1475.  The two children may present the feet at
 the  same time, and that case is the most favourable
 after that where they come without help. Sometimes
 also we  meet with but  one foot of one child at the
 orifice of the uterus and both feet of the other.  In
 both cases it is equally necessary7 to be careful not to
 take one foot of each child, supposing them to belong
 to the same.  We must  begin  then by ascertaining
 that the two feet belong  to the child we wish to ex-
 tract, and bring them  down with one hand,  while
 with the other we remove the extremities of the se-
 cond, pushing them as high as possible towards one
 of the iliac fossa.  Twins may present the feet suc-
 cessively, that is to say, the second child after  the
 exit of the first, as 1 have seen. I have also met with
 some who presented the breech in the same order.
 In another case, one of the twins presented the head,
 and the other the feet.  (See the note on par. 1471.)

  * M. Enaux, of the city of Dijon, having been called to a
 woman whose labour was far advanced, pulled at the child's
 feet, which he found in the vagina, and the trunk came along
 easily till  he had brought down the arms; but the obstacles
 then obliging him to slide up his hand under the child's body,
 he was surprised to find that the head of a second had been
 drawn down below the projection of the sacrum.  Not being
 able to push it back, and having again in vain attempted to ex-
 tract the first child, he determined to apply the forceps to the
 head of the second, while an assistant raised up the body which
 was without towards the pubes of the mother. By this proce-
 dure M. Enaux delivered the woman of that twin first, which
 it seemed should have come last.  He observes that the chil-
dren were very  small, and that the woman was only at the be-
 ginning of the ninth month of her pregnancy. See the Journal
 de Medecine for the month of November  1771. 
574
Of Twins.
In a fourth woman, the relation of the twins was such
that they crossed each other; the first presenting the
breech in the usual situation, and the second being
placed across on the posterior  part of the uterus.
They as well as their mother were victims of the ig-
norance of a midwife who for six days had not found
out that the woman was in labour; and who neither
knew how to discover the situation of the first child,
nor to estimate the obstacles which opposed its exit,
and consequently  what the natural powers  which
tended to expel it, could do. She had been in horri-
ble convulsions from the evening before, when a phy-
sician took me to  her  house,  but I only arrived in
time to see her expire in that state: so that I did not
deliver her till after her death of two children which
were also dead.  The cord, or  the hand of one twin
may be without, while the other presents the head or
a different part, Sec.
   1476. When the cord of one  child is without,  if
the head of the second is low in the pelvis, we ought
to extract it with the forceps,  especially if we sup-
pose it likely to stay there some time; in order to turn
and deliver the other as quickly as possible.  But  if
the head were still above the pelvis, or if this child
should present any other part, we ought first to search
for the feet of that whose cord  is come down; that it
may suffer less from its compression. When the hand
of one precedes or accompanies the head of the other
and impedes its exit, we must endeavour to push  it
back.  If the head is too far advanced for that, or if
the woman finds herself unable to expel it, we must
extract it with  the forceps,  notwithstanding the pre-
sence of the hand or the  arm of the  other child; but
paying the necessary attention to that extremity that
it may not be hurt by the instrument. We ought to
begin by turning  that whose hand is without, if no 
False Conception.           575
part of the other be  far advanced; proceeding as if
there were but one child, till the feet be without: for
then we must attend to the second child, and see that
it be not drawn down by the first.  I shall say nothing
farther on the delivery of twins: the examples I have
stated  leaving little to be wished for concerning the
rules to be followed in other cases, every accoucheur
may supply them himself.
Of false Pregnancy, its Signs, and curative Indica-
                      tions.

   1477.  It is more difficult to give a good defini-
tion of false pregnancy, than to determine its species.
It is a state whose symptoms have affinity enough
with those  of common pregnancy, to make the exis-
tence of the latter be believed, and even lead those
of the profession whom the woman may consult, into
error.  I shall state two general species of false preg-
nancies, viz.  one which is a consequence of concep-
tion,  but  whose product  has  degenerated, and
changed its nature from the first periods;  and ano-
ther which seems absolutely foreign to it.  The latter
may be formed of water, air, blood, glairy and mu-
cous  matter, or by polypous excrescences.  It re-
ceives different denominations, according to the na-
ture of the fluid which constitutes it, as a dropsy of
the uterus, a  tympanites, &c: while the substances
which constitute the  former species are known by
the name of mole, or of false conception.
   1478. A mole and  a false conception seem to be
the same thing in  their principle, and I cannot see
why accoucheurs have made any distinction between
them. The remains of a foetus, when they have been 
576            False Conception.
 found in these spongy masses which characterize a
 false conception, at most, only indicate that the child
 died a little later then than in other cases, and that
 some of its parts had been preserved from putrefac-
 tion and dissolution: for the germ of an embryo has
 not less existed in the others, though no traces of  it
 may appear. All these abortive pregnancies were ori-
 ginally the same as those which go happily through
 their different periods.
   1479. The mole does not always seem to be of the
 same nature, being sometimes  entirely spongy, like
 the placenta, and at other times formed of a collection
 of  little  bladders filled with water and attached to a
 substance much like the former, which serves them
 for a base, and by which they adhere to the uterus.
 Each hydatid or bladder has its pedicle  longer or
 shorter, and a great number of them hanging to  the
 same stalk, form a kind of cluster, which  has made
 some ignorant and inexperienced people believe that
 this woman had been delivered ofa branch ofa goose-
 berry tree, another of a bunch of grapes, &c. and that
 these productions were the effects of certain longings
 in the early periods of pregnancy, which they were
 not able to satisfy. These masses sometimes acquire
 so great a volume  that  they  would fill a very large
 pan.  I have assisted some women who had carried
 them till the seventh month,  and others only till the
 third.
  1480.  The first species of mole does not  essen-
 tially differ from what constitutes the placenta in a
 common pregnancy.  The form of it is only a little
 different, and it seems less organized, because we do
 not find in it the plexus of arteries and veins,  which
 lines the  internal surface of the  latter.   Those who
recollect *the origin of those vessels and their uses,
 will not be surprised to find nothing of the kind in a 
False Conception.             511
mole.  This mass increases faster than the placenta;
but it only enjoys a kind of vegetative life.  There is
no regular circulation in it; the blood  it receives
passes  from the sinuses of the uterus into the venous
sinuses which we find on its surface, because they are
contiguous, and they pour it into the spongy sub-
stance  of which it is formed. Receiving much more
of that fluid than it returns to the uterus, it is always
so gorged with  it, that it detaches itself  with  the
smallest effort;  on which  account, the woman often
suffers irregular floodings while she carries this fo-
reign body.
  1481. These sorts of moles almost always have a
cavity  lined with membranes, which contains more
or less water.  Though  at the time of their exit, we
most frequently do not  find that fluid,  it is because
it has been discharged before, either by transudation,
or otherwise.  In  the former case, it is coloured by
the  blood which the action of the uterus expresses
from the little cells of the mole which are torn. When
that fluid is discharged  several weeks or  months be-
fore the  expulsion of the mole, the mass rolls itself
up in  some measure, without detaching itself from
the uterus, and  nevertheless continues to  increase.
Its cavity, not very spacious at  the time the waters
are evacuated, vanishes or contracts so  far that we
no longer find it after the expulsion of the mole which
then appears solid.  The cavity, on the  contrary, is
very apparent when the waters are not discharged be-
fore the expulsion of the mole, or but a short time
before it.
   1482.  Moles present also under two different as-
pects at the time Nature rids herself of them; being
sometimes humid and very full of blood, at other
times  withered and their spongy substance appearing
drier and closer. In the former case, they are much
                         4D 
578            False Conception.
larger, and their expulsion soon follows the show of
blood which always precedes them.  In the latter the
hemorrhage manifests itself a long time before; it is
moderate, and seems rather a depletion of the spongy
mass, than a flooding from the sinuses of the uterus.
I have attended several women who have discharged
these moles a  fortnight, a month, and even six weeks
after the cessation of the red discharge. These masses
were then, as it were, rolled up, and so dry, that it
would have been difficult to have expressed a few
drops of blood from them.
   1483.  The duration of these false pregnancies is
uncertain; Nature rids herself sooner or later of the
substances that constitute them, according to a vari-
ety of circumstances, the greater part of which may
be looked upon as accidental. Though it is generally
from the third to the fourth month, sometimes it is
not till the sixth,  the seventh, and even the ninth: it
is said that some women have carried such masses
for years.*
Of the Signs which characterize a false Pregnancy.

   1484.  There is no sign which can demonstrate
with certainty before the fourth or fifth month, whe-
ther a pregnancy be true or false; because it is not
till that time that the child  manifests itself easily to
the touch: nor can we  distinguish it even then in
many women. True and false pregnancy have com-
mon symptoms, which do not permit us to discrimi-
nate them in the first periods. The menses are gene-

  * It will be understood that I speak here only of those false
pregnancies which I consider as the produce of conception. 
False Conception.            519
 rally equally suppressed in both cases; if they some-
 times appear, it is but in very small quantity, just a
 show, and no more. Nauseas, disgusts, &c. accom-
 pany a false pregnancy, as well as the true; the belly
 augments insensibly; but, according to some authors,
 that augmentation i.-, more apparent in the first months,
 than in a good pregnancy; which however is  not  so
 constant as to allow us to draw the smallest conclu-
 sion from it. The breasts sometimes  secrete a sort
 of milky humor, which adds its  support to the other
 symptoms; and internal movements which women of
 the greatest experience take for the motions  of the
 child, confirm them in the idea that they are really7
 pregnant.   All  these symptoms may also manifest
 themselves, though no species of pregnancy7  should
 exist; as I have observed in several women.
   1485. Touching is the only method  which can
 lead us to the knowledge of the state of the woman;
 but it must not be limited to the mere application of
 the hands on the woman's belly, which might also,
 in these doubtful cases,  lead us  into error.  I have
 known women who have been pronounced pregnant
 from touching  the belly7,  and who were treated  as
 such, and yet were not pregnant at all, in any way:
 and others who had been assured of the contrary, and
 nevertheless were delivered some time afterwards.
 One of the former was attended by one of  the most
 eminent accoucheurs, who believed  to the last mo-
 ment that  she was really with child,  though she had
 only a sort of intestinal tympanites, which  vanished
 four and twenty or thirty hours after I had declared
 she was not  pregnant.   The belly had augmented
 gradually  for about nine months;  the menses only
just made  a show at each period,  &c. and from the
fourth month, this woman had  felt internal  move-
 ments which had been taken for those of the child, 
580             False Conception.
and which were sufficiently apparent externally, to
countenance that opinion.
   1486.  We ought to touch the woman according
to the rules already laid down, to ascertain the volume
of the uterus; for it is the state of that viscus which
must guide our judgment. When it is large enough
to make  us  presume a pregnancy  of  four  or  five
months, we must agitate it a little to excite that mo-
tion of the child, known by the name of rolling. The
absence of that motion, especially7 at  the period when
no one can mistake it, joined to the volume of the
uterus, characterizes a false pregnancy, when we are
certain at the same time that that viscus is not affected
by any disease.  But of what nature is that false preg-
nancy? That is the  most  difficult  point  to deter-
mine.
   1487. When a false pregnancy is formed of water,
the uterus is heavy, and we distinguish through its
substance, a fluctuation more or less deep. When it
is only a tympanites, it is light, though equally volu-
minous. It is not so easy to discover a mole, and to
distinguish whether it is in a mass or vesicular: the
absence of the signs already7 stated, and of those ofa
true  pregnancy at a time when  the  motions of the
child should  no longer be equivocal,  can  only lead
us to suppose it to be a mole.  We cannot infer any
thing from the state of the neck of  the uterus in fa-
vour of one of  these species of false pregnancy, ra-
ther  than another; for  the development of that viscus
is always performed  according to  the same laws,
when it contains substances susceptible of growth or
augmentation.  A dropsy of the ovaria, and  that of
the abdomen itself have often deceived practitioners
into an opinion of the existence of false pregnancies.
Although those diseases  have  their characteristic
signs, as well as all others, it must  be  allowed that
it is not easy to distinguish them at the beginning. 
False Conception.             581
 Of the Mechanism by which  the Substances which
   constitute the different Species of false Pregnancy
   are expelled; and the Assistance they require from
   Surgery.

  1488. The denomination of false pregnancy (fausse
grossesse,)  so often  used  by  authors, to signify
that which is formed by substances which cannot be
looked  upon as the produce of conception, or by that
produce when there exists no child, ought to have
led them also  to signify the exit or expulsion of those
substances, by the name of fausse-couche; to distin-
guish it from an abortion, which is a delivery more
or less premature.
   1489. The mechanism of the expulsion of all these
substances, is  nearly the same in all cases, and often
differs from that of common labour, only by the vio-
lence and duration of the efforts necessary to effect it.
When the uterus  contains nothing but air, water or
blood, if those fluids are retained  only by the contrac-
tion and closing of the orifice, they escape as soon as
that contraction ceases, or when  the fibres that con-
stitute the edge of the orifice can no longer counter-
balance the continual action of the distended and irri-
tated fibres, which form the rest of that viscus. It is
by the same cause that labour begins, and delivery is
performed.
   1490. Warm baths, emollient fumigations and in-
jections, might therefore, by weakening the spring of
the fibres of the neck of the  uterus, provoke the dis-
charge of those fluids,  before the time fixed by Na-
ture; as might also the dilatation of the orifice procured
by the introduction of the finger.  But  the latter of
these methods must not be  employed except when 
582            False Conception.                (

we are very certain of the existence of the species of  (^
false pregnancy in question. When these collections  t
are the consequence of an obturation, either natural
or accidental, of the neck of the uterus or of the va-
gina, we must render them pervious by means of a
cutting instrument: as has been often done on  ac-
count of a retention of the menstrual blood in young
women, and even  in those who had had children.
   1491. The expulsion ofa mole, and of mucous and
glairy humors, which are contained in a species of
cellular tissue more or less loose, or in separate cysts,
does not always take place  by a mechanism so sim-
ple and so easy to the woman, as the expulsion of wa-
ter, of blood or air. When it is a mole, labour begins
like that in a true pregnancy, and the violence of the
pain the woman suffers, is in proportion  to the ob-
stacles which oppose the  intentions of Nature.  This
labour is preceded by7 a  sensation of heaviness and
lassitude in the limbs, &c. and the greater part of its  .
symptoms resemble those of the true labour of child-
birth: the  body of the uterus hardens at each pain, as
in that, and afterwards relaxes; the neck is, at length,
effaced, the  orifice dilates insensibly, and the sub-
stances in question engage in it and clear it, in the
same manner as the child does.
   1492.  The expulsion of a mole must be entirely
confided to Nature, when the woman loses but little
blood; but the accoucheur must extract it when the
flooding is abundant; proceeding for that  purpose as
in delivering the after-birth after an abortion. See the
article on delivering the after-birth. 
Abortion.
583
   Of the Causes of Abortion, and its Symptoms.

   1493.  Abortion is the expulsion ofa child be-
fore  the usual period of pregnancy, and especially
before that in which it is strong  enough and suffi-
ciently developed to live after its birth.
   1494.  A  great  number of  causes may produce
abortion.  Sometimes it is the consequence of acute
or chronical diseases, which affect the woman during
pregnancy; of a sanguine plethora, or a want of food;
of a cough, or straining to vomit;  of a stiffness in the
fibres of the uterus, which cannot yield  and develop
themselves sufficiently; of some tumor which  af-
fects that viscus, of its extreme sensibility, or of its
weakness; of a violent passion, of a sudden fright, or
an external percussion,  by a blow, a fall, &c.   At
other times  it depends on the  state of the child, on
its diseases, or its death; on affections of the placenta,
its insertion over the neck of the uterus,  &c. I shall
not enter here into the mode in which all these occa-
sional causes of abortion act, because the explication
of them  should seem more properly to  belong  to a
treatise on the diseases of women and children, than
to this.
   1495. The greater part of these causes may pro-
duce an abortion  at any period of pregnancy indif-
ferently;  and the others do it pretty constantly at the
same period in the same woman, but in some sooner,
in others later.  I know women who have never car-
ried a child beyond the third month; others the fourth,
fifth, or sixth, without being influenced by any appa-
rent cause.  So many abortions seem to have been
only a consequence of the extreme sensibility of the
uterus, and of the rigidity of its  fibres which could 
584
Abortion.
not extend beyond a given point, without being vio«
lently irritated, and without contracting.  I have also
observed that other women, after having miscarried
several times at one of the stated periods, have carried
their children a little longer in the subsequent preg-
nancies, and have at last gone nearly the usual time,
by employing the precautions necessary to diminish
the sensibility of the uterus, relax its fibres, and dis-'
pose them to a more considerable extension.
  1496.  Though abortion sometimes happens with-
out any apparent cause producing it, and without be-
ing announced by any precursive symptom, at other
times the woman suffers troublesome pains towards
the loins and in the uterus, accompanied by a sensa-
tion of heaviness at  the  bottom of the belly, a long
time before; and it is often preceded by a flooding,
sometimes moderate, sometimes abundant, accord-
ing to the cause which has determined it.
  1497.  The consequences of abortion are more or
less disagreeable to the mother and child, according
to the nature of the cause which provokes it, the force
with which it acts, and the derangement it produces
in the functions. Abortion is not dangerous in itself;
it takes place by a mechanism similar to that of com-
mon labour, and its  subsequent symptoms differ lit-
tle from those of the latter. Among the children who
are born before the period of  the seventh month,
some are dead before their exit, and the greater part
of the others die soon afterwards.  It has however
been  asserted that some have  been preserved who
came at six months, five, and even four and a half,
and  that, notwithstanding the weakness and imper-
fection naturally attached to those periods, they have
lived to an extreme age. Such examples, supposing
the women were not deceived in their reckoning, are
*oo rare and too extraordinary,  for us to flatter our- 
Abortion.
585
selves we should be able to preserve children born at
these latter periods, whatever care we might take of
them: we must not however abandon them, nor ne-
glect that care.
         Indications in Cases of Abortion.

   1498. We might  often prevent abortion, if we
were perfectly acquainted with its cause, even when
the labour of it is  already begun.  A very plethoric
woman felt the pains of child-birth  towards the
seventh month of her pregnancy, and the labour was
very far advanced when I was called to her assistance;
since the orifice of the uterus was  then larger than a
half-crown.  Two little bleedings at the arm restored
a calm, so much that the next day, the orifice in
question was closed again, and the woman went the
usual time. Food of easy digestion prudently admin-
istered, quieted a labour not less advanced in another
woman,  where it  was suspected  to be the conse-
quence of a total privation of every species of nour-
ishment for several successive days: delivery did not
take place till two months and a half afterwards, and
at full time. Emollient  clysters, and a very gentle
cathartic, procured the same advantage to a third wo-
man, in whom the labour pains came on between the
sixth and seventh month of pregnancy, after a colic
of several days' continuance, accompanied with a di-
arrhoea and tenesmus,  &c. &c. &c.
   1499. If such means have been employed with so
much success in cases where abortion seemed on the
point of taking place,  with more reason ought we to
expect good effects from them, when the cause that
tends to provoke it has not yet exerted  its action on 
536
Abortion.
  the uterus to that extreme degree.  I  know women
  who have not carried their children the full time, till
  after they  had  miscarried three or four times, at six
  weeks, two, three, and four months, and who have
  been indebted for that advantage entirely to bleeding
.  at the arm, performed a few days  after the first i ime
  the menses had failed to appear,  and repeated during
  the course of pregnancy as soon as  the smallest symp-
  tom of plethora was perceived.  Bleeding is not less
  advantageous to those women in whom the sensibility
  of the uterus, its spasmodic contractions, the stiffness
  of its fibres, &c. have frequently occasioned abortion,
  than to  those of a sanguine constitution.   Diluting
  drinks, such as veal or chicken water;* and espe-
  cially the warm bath must not be  neglected in those
  cases.  In women attacked with  convulsions which
  depend only on those same causes, antispasmodics
  succeed the best; it is often important to begin  the
  use of them betimes, and continue them to the end of
  gestation.   We must proceed  differently when  the
  Weakness  of the woman is the cause of abortion; in
  that case, we must be sparing of her blood, prescribe
  rest, and endeavour to strengthen  her.
    1500.  When  the labour of an abortion is so far
  advanced that the pains are strong, the orifice of the
  uterus dilated, and there is no longer any hope of calm-
  ing it, we  must conduct ourselves according  to cir-
  cumstances. The expulsion of the child, as well as
  of the placenta must be left to Nature,  when no other
  accident attends it;  because she  delivers herself of
  both  in the same manner as at the usual  epoch of
  labour.  In the first  two or three months of pregnan-
  cy, Nature expels the whole produce of conception at

    '.This is surely inadmissible where plethora or fever exists.
                                         YV. P. D. 
Abortion.
587
©nee, unless under the vain pretence of assisting her,
we open the membranes.  The labour is easier to her
in that way, than if the waters of the foetus were  to
be discharged first. But we observe the contrary after
that  period; then the waters drain off sooner or later,
the foetus is delivered next, and the placenta is not
expelled till the last.*
   1501.  We ought  therefore to  avoid  tormenting
and  fatiguing the woman by touching her too fre-
quently in the course of an abortive labour, when it
takes place  in the first two or three months of preg-
nancy; and more particularly opening the membranes
with a view of accelerating the exit of  all the con-
tents of the uterus: for that is the way to retard their
expulsion and prolong the labour. The uterus being
lightened by the discharge  of the waters of part of
the load which  incommoded it, contracts for a time
with much less vigoui;  its action weakens, and often
does not become brisk  again for a long time.
   1502.  When abortion takes place at a more ad-
vanced period,  besides  the accidental circumstances
which may complicate the labour of it, and prescribe
particular indications, we must attend also to the sit-
uation of the child,  or  the manner in which it pre-
sents; for it cannot always come without help, espe-
cially after the  sixth month. We therefore proceed

   * I have seen several cases where an intense flooding has
been kept up by the  placenta being partially engaged in  the
mouth of the uterus, and which would, I In ve no doubt, have
proved fatal, had not this mass been removed. For this purpose
I employ a firm piece of iron wire bent at one extremity like
a crotchet, its end made very smooth and blunt; the other
end may be turned in such a manner as to serve for a  handle.
The small end is then carefully introduced into the mouth of
the uterus and made to reach to the fundus: it is then gently
drawn downwards, by which means we hook the placenta and
draw it out.  The flooding immediately ceases, am! the  wo-
man is rescued from threatening danger.        'Y\ p. B. 
588                Abortion.                    q
                                                 ♦
in that respect, and in all cases where any accidents i .,
occur, as if the woman were at full time; or else in jfi
the manner laid down in the article which treats of
the delivery of the after-birth, after an abortion. The
subsequent symptoms in all these species of abortion
being nearly the  same as after the  delivery at full
time, the  regimen the woman ought  to observe
should be the same in both cases.

13HE ENB. 
Mea .Hist).
   WZ
  k.10
 533?aX
  1111 
^/ o\ZaV4a\T 

_>°S
eo?Tr'
^' >-~
)  ^ ^.   .. w^ 
   *. V^UV»^tf»»:»*_**__r^^T_,fty'v. *







   w^-» .T^jyryi^itjii^fftrjyi V- ___S_.ieiiitivaFi











_•—         .    . •...» *•<*•*.'• *"V.»vT .»»»<''<^' ■••': *>i_!_
■*■-' '            •"  — ■■ *-^__:s*j3»«-.«*«r«3«*«M,.M _!*__
■_;"              • • • • •._•;*£;Si . eK.v"■*.(«-*'t-_™i
>-  "•         v';,':'.'.!;.   -■■■f'-.tX^'l^.l mj"*h
         ,    '  . .  ■■<*•  ^-__ ■■^iTMSiSSW!*-• *<«_•*

-ere
ee \ •*£<}•'». *;ejs