THE 
Natural Midi of lalpiwolatis, 
AND ITS IMITATION BY ART. 
BY 
A. F. A. KING, M.D., 
Prof, of Obstet..etc , in the Med. Dept, of the Columbian University, Washington, D. C., 
and in the University of Vermont. Member of the Amer. Gynecol. Soc.; of the 
British Gynec. Soc.; of the Wash. Obstet. and Gynec. Soc.; and of the 
Medical, Philosophical, Anthropological, and Biological Societies 
of Washington, D C., etc. 
[Reprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Vol. XXII., No. 6, 1889.] 
NEW YORK: 
WILLIAM WOOD & COMPANY, PUBLISHERS, 
56 & 58 Lafayette Place. 
1889. THE 
laid Mificali of lalpiwnlatas, 
AND ITS IMITATION BY ART. 
BY 
A. F. A. KING, M.D., 
Prof, of Obstet.,etc., in the Med. Dept, of the Columbian University, Washington, D. C., 
and in the University of Vermont. Member of the Amer. Gynecol. Soc.; of the 
British Gynec. Soc.; of the Wash. Obstet. and Gynec. Soc.; and of the 
Medical, Philosophical, Anthropological, and Biological Societies 
of Washington, D. C., etc. 
[Reprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Yol. XXII., No. 6, 1889.] 
NEW YORK: 
WILLIAM WOOD & COMPANY, PUBLISHERS, 
56 & 58 Lafayette Place. 
1889. THE 
, NATURAL RECTIFICATION OF MALFRESENTATIONS, 
AND ITS IMITATION BY AKT. 
1. The title explained.—Tlie title of this paper is not suf- 
ficiently explicit, nor could I easily make it so without sacri- 
ficing brevity. My object is to study the influence of thigh- 
pressure—pressure of the flexed thighs upon the antero-lateral 
regions of the abdomen, produced by certain postures (notably by 
squatting)—as a factor in the natural rectification of transverse 
or oblique presentations, and other malpositions of the child. 
2. Novelty of the subject.—While the literature of obstetrics 
abounds with elaborate essays on “ posture during parturition,” 
and while the same subject has received attention in nearly all 
text-books, in no instance, so far as my researches extend, has 
any author directly, or even indirectly, referred to the factor of 
thighpressure in changing the position of the fetus as here 
proposed. 
3. This study necessarily theoretical.—Since transverse pres- 
entations, to which this paper will chiefly refer, only occur 
once in about two hundred and fifty labors, it is not likely that King : The Natural 
my opportunities for clinical observation will afford me the 
occasion for demonstrating the practice I propose within any 
reasonable time. I am, therefore, only able now to present 
theoretical views, which, however, I trust may be sufficiently 
well founded to enlist the co-operation of others who may 
possess better facilities for demonstration. Speculation is the 
pioneer of discovery. If there be any virtue in the methods 
proposed, it may as well be demonstrated by one as by another, 
so far as concerns the progress of our science and art, which is 
the main object in view. 
4. Necessity for caution in studying nature.—If, in our 
study of any natural process, one important factor, among 
others, by which Nature accomplishes the desired consumma- 
tion, be omitted, then our understanding of that process neces- 
sarily becomes incomplete and our conclusions liable to error. 
And thus, I think, have our studies of natural labor—especially 
the study of its mechanism—been rendered imperfect by our 
leaving out, or not sufficiently taking in, the element of posture 
as a modifying factor. Our present understanding of the mechan- 
ism of labor is based, for the most part, upon the observations 
of Naegele and his successors, but these observations have been 
uniformly made upon women in the recumbent posture. No 
one, so far as I know, has watched and demonstrated this 
mechanism throughout its several stages while the woman was 
sitting, kneeling, or squatting. Hence the conclusion that in 
these latter instances the mechanism is exactly the same as 
when the woman is recumbent is only assumed, not proven. 
So, too, if the views propounded in this paper be correct, it 
will be evident that our ideas concerning malpresentations aud 
their natural termination have also suffered from our leaving 
out one of the mechanical influences of posture that normally 
belonged to primitive woman, and which is usually deficient 
in the civilized' one. The study of natural labor in women who 
follow the customs, fashions, and instructions of modern ob- 
stetrics cannot be a study of Nature, pure and simple, but of 
Nature modified and incumbered by artificial interferences. 
The highest aim of our art is to imitate and assist Nature, but 
we must be sure that our notions of Nature’s methods are not 
imperfect or erroneous. As Denman wrote, more than half a 
century ago (“ Pract. of Mid.,” Am. edition, 1825, p. 453): 
“ In the most perfect state of society, all just and true knowl- Rectification of Midpresenlotions. 
5 
edge in this art ” (obstetrics) “ being founded upon observation 
of the proceedings of Nature, and all sound practice upon the 
imitation, the well-judging practitioner would recur to the con- 
sideration of the primitive state” Woman (like man) has 
inherited her skeleton, her pelvis, muscles, and nervous sys- 
tem from numberless generations of ancestry extending back 
through a long wilderness of ages preceding the recorded his- 
tory of man, compared with which the few thousand years of 
modern time are scarcely more than the swing of a pendulum. 
And whatever slight modifications of recent date may have oc- 
curred, there can be little question that these fundamental 
structural inheritances confer upon her (other things being 
equal) the disposition to perform the parturient act in the same 
manner now as was common with her progenitors thousands of 
years ago. To study, therefore, the yiatural process of labor, 
we must study primitive woman—woman and the earth that 
she inhabits, not woman bolstered up in bed with the hundred 
other appurtenances of civilized life. A pregnant woman is 
liable to fall in labor at any hour and in any place ; she knows 
not when nor where. The earth is always with her: not so 
the productions of a furniture shop. The parturient capacities 
she has inherited would be manifestly imperfect if they re- 
quired the coincident aid of any exterior artificial appendage. 
The silent, automatic, prehistoric evolution of a woman’s or- 
ganism could no more anticipate the construction of, and adapt 
itself to use, beds, chairs, etc., than a tree of the forest could 
anticipate, and provide itself with protection against, the wood- 
man’s axe. I repeat, therefore, if we would understand natural 
parturition, pure and simple, we must study primitive woman 
—woman of the forest and the field. 
5. The squatting posture more frequently assumed hy prim- 
itive than civilized woman.—According to Dr. George J. En- 
gelmann, whose elaborate paper on *{ Posture in Labor ” ap- 
peared in 1880 (Trans. Amer. Gynec. Soc., 1880, pp. 182-184, 
etc.), a squatting posture is still assumed during labor in some 
parts of Russia and Great Britain, also in Persia, Arabia, 
Egypt, Kaffraria, Wazegua, Guatemala, Polynesia, West Micro- 
nesia, as well as among various Indian tribes, Mexicans, half- 
breeds, negroes, and the lower class of whites in North Amer- 
ica. This posture is, however, repugnant to the refined 
civilized woman, and for the reason, most likely, that it sug- 6 
King : The Matured 
gests defecation. In fact, Dr. Engelmann very properly 
remarks (p. 196) that “ we may, in a general way, consider all 
postures as squatting which resemble that assumed in defeca- 
tion.” 
Now, with regard to the influence of this posture as a factor 
in the rectification of malpresentations, we must not lose sight 
of the fact that primitive woman also resorted to the squatting 
attitude during defecation, while the refined civilized woman 
does not, but performs the act upon a commode or the elevated 
seat of her closet. 
We observe, then, this difference between primitive and mod- 
ern woman : viz., that during pregnancy, before labor—when a 
transverse (really only oblique) position of the child is easily 
rectified by suitable external pressure—the squatting posture is 
frequently resorted to during defecation by primitive woman, 
and not by the civilized one; and the same difference, as we 
have seen, is observed during labor. If, therefore, it can be 
shown that the thigh-pressure produced by this posture exerts 
any material influence in changing the position of the child, we 
cannot afford to omit the recognition of the circumstance in our 
study of natural parturition. 
6. Mechanism of thigh-pressure, produced by squatting, in 
the rectification of oblique positions of the child during and 
before labor.—It is scarcely necessary to define the squatting 
posture. Any one of my readers may demonstrate it for him- 
self : let him rise from his chair and squat; and in doing so, if 
he will place his closed fist, or even his flat hand, in the vicinity 
of Poupart’s ligament, between the acetabulum and the abdo- 
minal wall, he will find his hand pinched and compressed be- 
tween the thigh and the abdomen, and with considerable force, 
varying, however, with the degree of his embonpoint. 
Now let us take a case of oblique position of the child dur- 
ing pregnancy, which, if not corrected, becomes a transverse 
or shoulder presentation during labor. The most common of 
these presentations is the dorso-anterior position of a right- 
slioulder presentation. The head is on the left iliac fossa, the 
occiput being usually both visible and tangible as a projecting 
tumor over the left antero-lateral margin of the pelvic brim, in 
the vicinity of the acetabulum or ilio-pectineal eminence; the 
other end of the fetal ovoid—the breech—is on the other side Rectification of Malpresentations. 
of the pelvis, high up towards the crest of the ilium or above 
it. (See Fig. 1, page 567.) 
In such a case, wliat takes place when the squatting posture 
is assumed ? The thigh gradually approaches the abdomen, 
and compresses any intervening body or projection that may 
interfere with close approximation of the flexed thigh and an- 
terodateral margin of the pelvis, no matter whether the inter- 
vening body be outside the abdomen (as the closed fist previ- 
ously referred to), or inside of it, like any projecting part of 
the fetus. The thigh acts as a lever—a lever of the second 
kind, the resistance (or “ weight ”) being between the fulcrum 
and the power. The thigh-bone is the lever itself. The ful- 
crum is the acetabulum. The power is the pressure of the 
head of the tibia upon the femoral condyles at the very end of 
the lever; and the resistance is (when it exists) the projecting 
body coming in contact with the lever, between the fulcrum 
(acetabulum) and the power applied at the femoral condyles. 
In the transverse presentation just cited for illustration, the in- 
tervening body on the left side of the pelvis would be the occi- 
put of the child's head projecting over the antero-lateral margin 
of the pelvic brim, near the acetabulum. This projection, be- 
ing very close to the fulcrum, would, if it did not slip aside out 
of the way—in one or other direction—receive the brunt of 
the compression. Or, again, if we choose to consider tile body 
of the woman, when leaning forward in the squatting position, 
as another lever of the second kind, the two levers being united 
at the acetabular hinge like a pair of nut-crackers, then, as the 
arms of the two levers approached each other in the act of 
squatting, any intervening body, especially near the hinge, 
would be forcibly compressed if it did not glide out of the 
way as above stated. It is scarcely possible that a rounded, 
slippery (and, during pregnancy, almost floating) body like the 
fetal head, when gradually compressed by another somewhat 
rounded column—viz., the thigh—would not slip on one side, 
particularly so when we consider that between the head itself and 
the thigh-bone are placed a number of apposed, smooth, gliding 
surfaces, viz., the apposed s&fn-surfaces (of the thigh and 
abdomen); peritoneal surfaces (between uterine and abdominal 
walls); decidual surfaces (between the vera and reflexa); and 
the surface of the child’s scalp in contact with the amnion, etc. 
Moreover, while the thigh-lever comes in contact with and 8 
King : The Natural 
compresses that portion of the child’s head which is projecting 
over the left antero-lateral margin of the pelvic brim, there is, 
on the directly opposite side of the pelvis—viz., in the locality 
of the right sacro-iliac synchondrosis—no bony resistance to the 
receding head, but, on the contrary, an ample vacuous space, 
viz., that situated between the sacral promontory and the right 
postero-lateral margin of the pelvic brim. 
Still continuing our study of the illustrative case before cited, 
we find that the thigh-lever on the right side approaching or 
first making contact with the abdomen from below in the vicin- 
ity of the acetabulum, and the surface of contact being ex- 
tended from below upwards as the act of squatting becomes 
complete, the breech end of the fetal ovoid will be pressed up- 
wards and inwards towards the median line—in fact, changed 
from its oblique position to its normal place in the fundus 
uteri. As the child lies usually obliquely transverse, as we have 
said, with the curved surface of its convex back in front, the 
part that will first come in contact with the thigh-lever on this 
right side of the woman’s pelvis will be the lumbar or sacral 
regions of the child’s back—that is to say, very near the pelvic 
end of the fetal ovoid. 
Thus, then, we have, in this illustrative case, when the squat- 
ting posture is assumed, thigh-pressure on the tivo ends of the 
fetal ovoid: on the left side the projecting occiput is powerfully 
compressed (being near the hinge) by a force approaching from 
the antero-lateral direction, tending to push, or rather displace, 
it diagonally backwards and laterally, in fact towards the inlet 
of the pelvis ; while on the other end of the fetal ovoid, as just 
stated, the thigli-pressure tends to lift the breech upwards and 
inwards towards the fundus uteri. Thus the transverse, or 
oblique, presentation becomes a normal head presentation. 
The more readily to appreciate that the contact of thigh- 
pressure is really near the two ends of the fetal ovoid, we must 
remember that the shaft of the thigh-bone is even more external 
than the acetabulum, owing to the length and direction of the 
neck of the os femoris, “ -which, in the adult female, approaches 
more nearly a right angle with the shaft than it does in the male 
and ante-puberic girl ” (“ Gray’s Anat.,” p. 158, 2d Am. ed., 
1862). 
This is very well shown in Fig. 1. By reference to page 
145 of Lusk’s work, Fig. 86, showing front view of pelvis Rectification of Malpresentations. 
9 
with ligaments (from Quain), it will be seen that the upper part 
of the thigh-bone projects laterally about as far as the iliac 
crest, and yet not so far but that the ample cushion of fat and 
muscles covering the bone, especially along its inner surface, 
shall inevitably bring the femoral column in contact with the 
antero-lateral region of the abdomen in the act of squatting. 
The mechanism of rectification, by thigh-pressure, in the 
dorso-anterior position of a left shoulder presentation—the head 
being on the left iliac fossa—will be the same, except that the 
Fig. 1. 
events occurring on the right and left sides of the pelvis will 
be, respectively, changed to left and right, 
The mechanism of dorso-posterior positions of the fetus, it 
may be presumed, involves the same principles, though the 
rectification would not, we should think, be so easily accom- 
plished as in the more common dorso-anterior positions. 
7. Variation in the amount and direction of thigh-pressure 
produced by modifications of posture. In the foregoing theo- 
retical study we have, thus far, only considered the squatting 
posture (the posture in which tliigh-pressure would a priori ls ing : The Natural 
10 
appear to he most pronounced). We have also considered the 
act of squatting as if it were always the same, and as if it were 
symmetrical, so that the thigh-pressure were alike on both 
sides. It must now be observed that kneeling, and even sitting, 
provided the body of the woman lean forward sufficiently, will 
also bring the thigh-columns in contact with the antero-lateral 
regions of the abdomen. Moreover, the act of squatting itself 
may be varied (the thigh-pressure varying accordingly) in many 
ways, depending (1) upon the degree to which the thighs are 
adducted or abducted during the act; (2) upon the degree of 
forward inclination of the woman’s body ; (3) upon the greater 
or less distance between the feet, and upon one foot being, or 
not, in advance of the other. Again, (4) instead of being 
always symmetrical, the sole of one foot may be flat upon the 
ground, the other foot having only the toes or anterior end 
upon the ground. The corresponding thigh, in the former in- 
stance, will approach the abdomen much more decidedly than in 
the latter one. A woman may kneel with one lower extremity 
and squat with the other. Such variations might be further 
multiplied. Whether, in malpositions of the child, the instinc- 
tive sensations and inclinations of primitive woman prompted 
her to modify the squatting posture, and thus thigh-pressure, 
in a manner suited to rectify the various modifications of bad 
presentations, we cannot say ; but, if postures of this kind come 
to be employed as a method of rectification, it will be neces- 
sary, in the absence of such instinctive inclinations, to study 
the influence of each posture (and its varieties) upon each mal- 
presentation (and its varieties). That is to say, the degree, 
direction, and location of thigh-pressure, in the several instances, 
will require to be known, and selection made accordingly. 
To illustrate the variation in thigh-pressure from variation 
of posture, I here insert seven figures photographed from life, 
the model being a white, multiparous woman, of middle age, 
endowed with considerable embonpoint, but presumably not 
pregnant. Figs. 2 and 3 present, respectively, a side and 
front view of the kneeling posture, the thighs being nearly in 
apposition, and the body slightly inclined forwards. In both 
instances the antero-lateral support of the abdomen, in a mode- 
rate degree, is very well shown. 
Should the thighs, while still kneeling, be more widely 
separated 'from each other and the woman lean forward, the AMER. JOURN. OF OBSTETRICS 
AND 
DISEASES OF WOMEN AND CHILDREN, 
June, 1889. 
2 
3 
4 
5 Hectificcition of Malpresentations. 
11 
pendulous abdomen (and its pregnant uterus, if it had one) 
would fall forward between the thighs, the thigh-pressure, an- 
teriorly, being diminished, as shown in Fig. I; but the lateral 
pressure would still be present and tend to shorten the trans- 
verse space of the abdominal cavity. If now the woman 
kneel with one limb and sqxiat with the other, it is evident 
the antero-lateral pressure of the thigh upon the abdomen will 
be much greater on the side of the squatting limb than on that 
of the kneeling one, as shown in Fig. 5. 
Again, in squatting on both limbs, one foot being flat upon 
the ground, the other resting upon the toes (as in Fig. 6), it will 
be seen that upon the side where the sole of the foot rests flat, 
the surface of contact of the thigh with the abdomen is greater, 
and the amount of antero-lateral pressure also greater, than 
upon the side where the toes only touch the ground, the corre- 
sponding thigh being more nearly horizontal. 
The next figure (7) shows a nearly front view of a similar 
squatting posture, the left foot being flat upon the ground, the 
right one on its toes. It will be observed that on the right side 
the antero-lateral pressure is more decidedly upwards (i. e., more 
anterior than lateral) than on the left side, where the ante- 
rior (or upward) and lateral pressure appear about equal to 
each other. Note how in this instance the thigh columns 
forcibly compress and support the protruding abdomen, and 
that the surface of femoro-abdominal contact extends to within 
a few inches of the umbilicus. The body of the woman in this 
instance is comparatively erect, not leaning forward as far as 
she might dcr. 
In the next figure (8) is presented the most extreme antero- 
lateral pressure that can be obtained by posture, the woman 
squatting with both feet flat upon the ground, and the body 
leaning forward so that the nipples are almost on a level with 
the knees. Here the surface of femoro-abdominal contact is so 
increased that the thighs approach still closer to the umbilicus 
—closer, however, on one side (the left) than upon the other, 
owing to one foot being slightly in advance of the other, while 
the body leans a little towards the left side. 
The unilateral pressure of the thigh, even in the virgin, 
where one limb is kneeling and the other squatting, is well 
shown in Figs. 9 and 10, representing, respectively, “Venus 
at the Bath ” and “ The Crouching Venus,” which the au- 12 
King : The Natural 
thorities of the Corcoran Art Gallery have kindly permitted 
me to photograph from casts of the originals.1 
In the squatting posture, with both feet flat upon the 
ground, it is somewhat difficult, either in man or woman, to 
balance the body for any length of time without some support 
by the superior extremities, as is shown in Fig. 8 ; and the pos- 
ture is rendered still more insecure (provided there be no 
added manual support) when the toes of both feet are exactly 
on a line transversely—that is, when one foot is not in advance 
of the other in any degree. Any one can demonstrate this by 
Fig. 10.—“ The Crouching Venus.” 
experiment on liimself. It would therefore be next to impossi- 
ble in the squatting posture, especially in a pregnant woman, to 
assume this position in such a manner as to render the antero- 
lateral pressure of the thigh-pillars exactly alike, in direction 
and degree, on both sides. Even the muscular savage woman, 
1 The photographs from life, though presenting such varied appearances of 
the abdomen, were all taken within an hour. The woman was placed upon 
a table, only a little below the level of the camera. The photographing was 
done by Mr. Max Hausmann, of Washington, D. C., a medical student of 
the Columbian University. Rectification of Malpresentations. 
13 
the negress, when squatting with both feet flat, will have one 
foot in advance of the other, and still grasp a stake or tree with 
her hands to steady the body, as shown in Fig. 11. 
In this figure it will be observed that the inner and upper 
border of the tliigh-column almost touches the umbilicus; the 
uterus is poised between the two diverging thighs, the antero- 
lateral pressure upon the abdomen gradually diminishing in 
degree towards the woman’s knees, but maintaining its maximum 
degree deep down towards the line of Poupart’s ligament near 
Fig. 11.—Posture of the negresses in the Unyoro tribe of Central Africa. (From Wit- 
kowski’s “Histoire des Accouchements,” p. 409.) 
Fig. 12.—Posture of women among the Mexican half-breeds. (From Witkowski’s 
work above cited, p. 422.) 
Fig. 11. 
Fig. 12. 
the acetabulum. It scarcely seems probable that an oblique 
position of the child could maintain itself with the woman in 
such a posture. 
Another illustration of thigh-pressure may be seen in the 
posture of the Mexican half-breeds, who steady themselves 
during labor by grasping a suspended horizontal bar or stick of 
wood, as shown in Fig. 12. 14 
King : The Natural 
That in certain sitting postures thigh-pressure constitutes a 
factor in maintaining the normal position of the child may be 
Fig. 13.—Kaffir woman in labor. 
Fig. 14.—Sioux squaw in labor. 
inferred from Figs. 13 and 14, representing tlie Kaffir woman 
and Sioux squaw in labor (taken from Engelmann’s paper, 
Am. Gynec. Trans., 1880, pp. 196 and 226). AMER. JOURN. OF OBSTETRICS 
AND 
DISEASES OF WOMEN AND CHILDREN, 
June, 1889. 
7 
6 
8 Rectification of Malpresentations. 
15 
Reverting once more to the squatting posture, which was 
probably the most ancient and primitive of all positions during 
childbirth, and recalling the tendency to grasp some support 
with the hands in order to facilitate balancing the body, it is 
interesting to note that the civilized woman of the present age, 
even though recumbent during labor, still preserves the instinc- 
tive desire to grasp something with her hands during the pains, 
no matter whether she pull on it or not. Can this instinct be 
a rudimentary survival of the ancestral habit of grasping a 
stake, etc., while in a squatting posture ? And does it suggest 
that this posture was common with the ancestors of modern 
woman ? 
8., The influence of thigh-pressure in obviating the causes of 
malpresentation.—The most common and potent of these 
causes will here be considered separately. First: Obliquity of 
the uterus. This obliquity, whether lateral as in transverse 
and face presentations, or in the direction of anteversion as in 
cases of pendulous abdomen, can scarcely fail of correction 
when the womb is forcibly compressed, in a squatting posture, 
by the femoral columns on each antero-lateral region of the 
abdomen. In fact, the pregnant uterus, while the woman 
assumes this posture, will be contained in a sort of truncated 
cone formed by three pillars, viz. : the woman’s lumbar verte- 
brae behind and a thigli-pillar on each antero-lateral region of 
the abdomen. Considering the power of the thigh-pressure 
and the gliding surfaces of the apposed uterine and abdominal 
peritoneal layers, and remembering the facility with which the 
hands of the obstetrician can lift the oblique uterus into line by 
external manipulation, it seems almost incredible that thigh- 
pressure, in the manner stated, would not rectify the obliquity. 
Second : Laxity of the uterine and abdominal muscles. This 
is one of the conditions accounting for the greater frequency of 
malpresentations in multiparse. But when these muscular 
walls have not sufficient tonicity to maintain the fetus and 
womb in their normal position, how can we conceive of anything 
better adapted to reinforce the relaxed muscles, or to take their 
place, than the two cushioned pillars of the thighs forming the 
antero-lateral columns of the cone-shaped support already men- 
tioned? In fact, the uterine and abdominal walls being re- 
laxed, the influence of external thigh-pressure in rectifying 
abnormal position of the fetus would be all the more potent 16 
King : The Natural 
and effective. Third : Excess of liquor amnii. The influence 
of thigli-pressure in obviating this cause of malpresentation is 
not so evident. In a pronounced case, with great uterine dis- 
tention—the child, too, being usually small in size—the bulk of 
the fluid would, it may be supposed, intervene between fetus 
and uterine wall, so that the thigh-pressure could hardly reach 
the body of the child. Still there is this to be said : In a 
primitive woman with hydramnios, who resorted to a squatting 
posture in defecation during pregnancy, it is not improbable 
that compression of the womb by thigh-pressure would lead to 
rupture of the amnion and discharge of the fluid while in 
this posture / then, as the uterine distention lessened, the 
thigh-pillars would impress the child and divert it from a 
transverse presentation. But dropsy of the amnion is an 
uncommon and distinctly abnormal condition, so far removed 
from natural labor as to be rather out of place in this discussion. 
And the same may be said of a narrow pelvic brim and of 
placenta previa, which are additional causes of transverse pre- 
sentation. The occurrence of mal presentation in twin cases 
would probably meet with its correction or prevention by thigh- 
pressure as in single pregnancies. 
9. Relative frequency of malpresentations among women 
who do and those who do not assume the squatting posture 
during defecation and labor.—So far as I have been able to 
discover, there is not much evidence on this point; perhaps it 
has never been sought for. While transverse presentation does 
occur among primitive peoples, as observed on the borders of 
civilization at the present time, it has been found to be a rare 
occurrence. Dr. Engelmann tells us that a physician residing 
eight years among the Canadian Indians knew of no accident 
and heard of no deatli in childbed ; and another, living four 
years with the Oregon Indians, was not aware of any irregu- 
larity occurring during that time, nor was he ever called upon 
to perform a serious operation (Am. Journ. Obstet., July, 
1881, p. 608). He, however, speaks of cases of “ malpresen- 
tation” and “shoulder presentation” among the Nez-Perces 
Indians (ibid. p. 611) and the women of the Green Bay Indian 
Agency (p. 609), and states that in such cases “ the mother is 
generally doomed ” ; the child cannot be born, and death follows. 
“ Dr. Williams has observed that the Pawnees are more exempt 
from accidents than the Menomonees, and inquires whether it Rectification of Malpresentations. 
17 
is on account of the squatting posture assumed by the Pawnee 
women in labor” (ibid. p. 609). He does not mention the 
factor of thigh-pressure. 
I had hoped to find evidence on this matter in the published 
histories of recorded cases of “ spontaneous version or rectifica- 
tion ” among our own people. For this purpose I have exam- 
ined about one hundred journal articles under the captions 
of “Spontaneous Version ” and “Spontaneous Evolution” 
(from manuscript cards on those subjects prepared for the 
catalogue of the library of the surgeon-general’s office, kindly 
placed at my disposal by Drs. Billings and Fletcher). These 
references cover at least two hundred cases, but most of them 
(a good majority) are cases of spontaneous evolution instead of 
turning. And of the cases of spontaneous version, the posture 
and changes of posture of the woman are often not mentioned. 
Moreover, some of them are cases in which original head and 
breech presentations were spontaneously turned or converted 
into shoulder cases. On the whole, I must confess this field of 
research afforded no conclusive evidence in support of the 
views I have here presented, although there are a few cases in 
which spontaneous version was found to have occurred while 
the patient wTas out of bed using the night stool; or immedi- 
ately after being placed in a bath; or after being placed in 
position for the operation of turning; or, again, after the 
woman had become ungovernable, tossing about, in every 
posture; or after she had “ sat up in bed because it was the 
easiest position ’’—cases which suggest, but do not prove, that 
the factor of thigh-pressure may have contributed to turn the 
child. 
10. Version by external manipulation, as now practised, an 
unconscious imitation of thigh-pressure y MaxorCs method 
considered.—Every one who lias practised external version in 
transverse presentations, or who will read the orthodox de- 
scription of that maneuvre, will see that the hands of the 
obstetrician—the one pressing the cephalic end of the fetal 
ovoid towards the pelvic brim, the other lifting the breech end 
upwards and inwards towards the fundus uteri—are doing 
exactly what I have shown the pressure of the two thighs may 
do in the squatting posture (see section 6 of this article). And 
besides, the direction of the thigh-pressure on each side, even 
the desired character of the pressure—viz., “ half-sliding and 18 
King : The Natural 
half-pushing ” (Lusk, p. 370, quoting Barnes), “the sliding, 
gliding movement ” (P. F. Munde in Am. Jour. Obstet., 
April, 1880, p. 344), “ series of gentle, gliding movements ” 
(Playfair, p. 460, 4th American edition)—are necessarily exe- 
cuted by the thighs gliding against the abdominal wall every 
time the slightest variation is made in their abduction and 
adduction, or in the degree of forward inclination of the 
woman’s body, etc., as before explained. 
It is quite probable that the effect of Maxon’s method in 
facilitating version is not due, as he • thought, altogether to 
gravitation of the child towards the fundus, but also, in part, to 
thigh-pressure; for, be it noted, he not only placed the woman 
in the knee-chest position, but also insisted that the knees, 
instead of being on the same level as the chest, should rest 
upon several pillows or a roll of folded guilts. Such a posture 
would bring the thigh-columns forcibly in contact with the 
antero-Vateral regions of the abdomen, and the woman, while 
thus wrong-side-up, would have her thighs and abdomen bear- 
ing somewhat the same relation to each other as would occur 
in a squatting posture. 
11. Thigh-pressure in the rectification of face presentation. 
—Since tlie most common cause of face presentation is obliquity 
of the uterus, the rectification of this obliquity by thigli-pressure 
in the manner previously stated will be obvious, particularly so 
in the more usual mento-posterior “ positions ” of the face. 
Schatz’s method of converting a face into a vertex presentation 
by external manipulation, early in labor, would appear to be 
quite possible of imitation by a suitable selection of posture to 
secure the kind and direction of thigh-pressure necessary to 
accomplish the desired conversion. By reference to the figures, 
it will be apparent that the thigh-pressure on either side of the 
abdomen may be varied in its location, direction, and degree, 
according to the posture selected by the obstetrician. 
12. Concluding remarks.—Few of us, perhaps, realize the 
frequency with which the fetus changes its attitude during 
the latter weeks of pregnancy, especially in multiparae who are 
not restricted as to changes of posture in themselves. Even 
the alleged constancy of position (of the fetus) in primiparm 
during the last three weeks, has been denied by Karl Schroeder 
(“Manual of Midwifery,” Carter’s translation, p. 29), who found 
changes of fetal position at this time in eighty-one out of two jRectification of Mcilpresentations. 
19 
hundred and fourteen primiparous cases. A transverse posi- 
tion was changed to a head in six instances, a transverse to a 
breech once, a head to a transverse once, and a breech to a head 
once. But this only states the observed changes : it does not 
and cannot state the ones, for to ascertain these 
latter the woman and her child would require to be watched 
during the entire twenty-four hours, from noon till midnight, 
and the examination repeated after every change of the woman’s 
posture likely to alter that of the child. And this leads us to 
the not improbable inference that the assumed constancy of 
fetal posture in any case is rather abnormal than otherwise, and 
would not occur if normal freedom of posture or of postural 
change were as unrestricted in civilized as*in primitive woman. 
Nor do most of us fully appreciate the real facility by which 
the child is moved, not only during pregnancy but during 
labor. “ Those of us who have given attention to this subject,” 
says Prof. Isaac E. Taylor (this journal for July, 1881, p. 
534), “ notice how easily it can be effected, when the breech or 
shoulder presents, by making it a head, or the head a breech; 
and sometimes it is done by only a few toadies of the finger on 
both sides of the abdomen, and even after the evacuation of the 
waters.” In the face of these facts, the verypoweyful pressure 
of the tliigli-lever upon the abdomen, as a factor in changing 
the attitude of the child, cannot be ignored. 
Velpeau tells us (Meig’s translation of V.’s “ Midwifery,” p. 
455) that tlie ancients were not wholly unaware of the passive 
movements undergone by tlie fetus in uiero, since they advised, 
for the purpose of bringing the head to the strait, that the 
woman should be shaken or assume certain positions ; and that 
the moderns have established a rule “ that the position of the 
child, while still inclosed in the membranes, is so variable that, 
in order to fix it, it becomes necessary to rupture the ovum, 
choosing a moment when tlie head corresponds to the centre of 
the pelvis.” Velpeau also refers to “ certain attitudes of the 
woman long persisted in ” as one of “ the principal causes of 
bad positions of the fetus ” (p. 455, ibid.) In this connection 
it is interesting to remark that primitive woman, when observ- 
ing a flow of fluid from her genitals due to rupture of the am- 
nion, would most probably at once assume a squatting posture 
as in urination (in fact, some of our modern women do so), and 
thus, if there be any truth in my thigh-pressure theory, the 20 
King : Tlie Natural 
pressure would be at once applied at the right moment to get 
and preserve tlie long axis of the fetus in line with that of the 
womb, in which correspondence it would now be maintained by 
the uterine walls after the evacuation of the waters. 
It is a not uncommon history of transverse presentations, 
among our own women, for the waters to break and be dis- 
charged at the beginning of labor, and after only slight pains, 
and then for the pains to cease entirely for hours or even days, 
as if the womb were waiting for something to occur and correct 
the malpresentation. In primitive woman, the thigh-pressure 
of a squatting posture probably constituted the missing “some- 
thing ” by which rectification and progress were secured. Why 
should not modern woman, in similar cases, be amenable to the 
same treatment? On the other hand, there are numerous cases 
on record among our own women where the rectification of a 
transverse presentation has occurred—though usually after long 
delay—while the woman remained recumbent, and numerous 
hypotheses, such as “ irregular uterine contraction,” or “ uterine 
retraction,” etc., have been suggested to account fur or explain 
them. They have been ably discussed by Dr. I. E. Taylor in 
the article previously referred to (this journal for July, 
1881, pp. 525-551). These cases only tend to show what Na- 
ture can accomplish in time, even under adverse circumstances. 
They by no means disprove that thigh-pressure produced by 
posture would not be a safer and speedier method of rectifica- 
tion. If the thigli-pressure method be the natural one, then it 
is the better and should be utilized by art. But this, as I have 
said, requires clinical demonstration. My only hope in this 
paper is to have presented the theory with sufficient clearness 
and plausibility to invoke clinical experiment. 
Tlie practical utility of tlie method proposed must not, how- 
ever, be confined to the mere rectification of malpresentations 
early in labor. I see no reason why it should not serve a good 
purpose in cases long delayed, even with protrusion of the 
arm and shoulder, and where version by ordinary methods is 
found to be difficult or impossible from partial impaction of the 
fetus and tight contraction of the womb. In some of these 
cases, even where the arm has repeatedly been pulled upon by 
a midwife or obstetrician, or in which an embryotomy opera- 
tion has been begun, or in which version has been attempted and 
failed—even in these cases, after very long delay, the arm has Rectification of Malpresentations. 
21 
been spontaneously withdrawn, and the head or breech has 
come down in its stead. Others have been turned by the Fos- 
ter method of using the humerus to make pressure upon the 
glenoid cavity and thus change the presentation; and others 
again by Maxon’s method, previously cited. The great desid- 
eratum in these cases is to lift ujp the presenting shoulder 
above the superior strait by main force, which is never done 
without danger of uterine or vaginal rupture. Is it not jwob- 
able that a suitable adjustment of the thigh-levers, secured by 
suitable posture, could accomplish this forcible elevation of the 
presenting shoulder more safely than by the orthodox nfetliods 
previously named ? If it did no good, the experiment would 
at least possess the virtue of being harmless.