ARMY MEDICAL LIBRARY
FOUNDED 1836
WASHINGTON, D.C 
 
 
AN
          ABRIDGMENT



                   OF



HUB, IDRjMHBPS »AIi»4TO©ir


                   OF



          BAUDELOCQUE'S     >*"





     MIDWIFERY.







              j©itS j&otef,


    BY WILLIAM P.  DEWEES, M.D.

        LECTURER OX MIDWIFERY IN PHILADELPHIA;
Member of the Philadelphia Medical Society; Mem. of the Academy of Medicine;
             Mem. Amer. Phil. Soc. &c.
THIRD EDITION, WITH ADDITIONS.


      Illustrated by Engravings.
             PHILADELPHIA:


Published by Thomas Desilver, No. 253, Market Street.

         Clark <ir Rater, Printers, 33 Carter's Alley.

                  1823.     .   ,,,   .   ,1 
                 .  Wz.

333?a,
     ISS3
ft/fr|  no.//30£
Eastern District of Pennsylvania, to wit .•

   BE IT REMEMBERED, That on the first day of Oetober, in the forty-eighth year of the
independence of the United States of America, A. D. 1823, Thomas Desilver, 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. Lecturer on Midwifery in Philadelphia; Member of the Phil.
    Med. Soc-; Mem. of the Academy of Medicine; Mem. Amer. Phil. Soc. &c. Third edition,
    with additions.
   In conformity to the act of the Congress of the United States, intituled, " 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 Eastern 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 extend-
 ing the best system on this subject I  believe this or any other
 country is in possession of.   I  have used Mr. Heath's transla-
 tion of this work; and by comparing  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 pa-
 ragraphs, 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 author.  At other times, I have left out entire chapters,
 from an  opinion they were either useless  or unnecessary, to the
 intended form of the work; thus, I have  omitted his considera-
 tions 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
 acknowledged he  has done this in the most masterly manner,
 yet it does  not add a particle  to the student's, knowledge: I con-
 sider myself in this the more excusable, as he has given in ano-
 ther place the cases in which  he judged it proper to employ this
 instrument, and directions 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 in-
utility, and so completely triumphed over its advocates, that it
is now  no longer considered as a resource of the art.  It would 
IV
APOLOGY.
have, therefore, been more than idle, to have given a descrip
tion of an operation never to be performed;  or even to have de-
tailed the reasons by which he gained this Victory.  It may be
proper, however, in this place, to state, that Baudelocque,  had
to call in question the propriety of this cruel operation,  and next
to demonstrate, in the most satisfactory 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 con-
trary, I am of opinion it can well bear this pruning, and  all
that is useful be  retained.  Unnecessary repetition, useless de-
tail,  and tedious  minuteness, are the  frequent faults of our au-
thor; these I have endeavoured to obviate.
  With a view to an extensive circulation of this truly valuable
work, cheapness has  been regarded;  to insure 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  nothing  to the student's in-
formation, while they very considerably augment expense.
W, P. DEWEES. 
/ 
Plate An.
iii
 
TO  INSTRUMENT  MAKERS.
  The forceps dei  ;ated  in plntt  VII. are reduced to a third
of the size of the original.   They differ a little from those  ex-
pressly mentioned in nu  work :   1st. In not having the thread
running round the edg< >  1 the internal face of the forceps.   2d.
In having the internal edges of the <  <; »;ings in the blades made
nearly as thin as the external or superior and inferior edges; by
whi rh means more room i allowed for -Aw. head to Accommodate
itself when seized by the iri  Irument.  This is considered  as  a
great improvement; 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 re-
main, and consequently diminislirs 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.   Sdly.  The slide at the top of the
female branch, which was  intended to secure the pivot of the'
male branch, is omitted as useless. 
Directions for placing the Plates.
Plate  I. to face page 20
      II.             36
     III.             37
     IV.             51
      V.             52
     VI.             69
     VII. to face the Advertisement, p. v. 
CONTENTS.
                         PART  I.
                                                       PAGE
Of 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 Delivery      3
Of the Os Ilium      -             -       -      -         4
Of the Os Ischium              ....      7
Of the Os Pubis      -----         8
Of the Union of the Ilium, Ischium, and Pubis; of the com-
  mon Parts which result from that Union;  and of the natu-
  ral 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 Dimensions    32
Of the Deformities of the Pelvis, considered with respect
  to Delivery      -       -       -      -      -      -   38
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 De-
  livery        __-...      ^1
Of the Uterus      -       -       -      -      -      -   72
Of the Parts dependent on the Uterus                       76
Of the changes which Pregnancy produces in the Volume,
  Figure, and Structure of the Uterus     -      -      -   81
Of the Action of the Uterus    -      -       -       -      88
Of the Descent or Prolapsus of the Uterus, of its Retrover-
  sion, and Anteversion     -       -      -      -      -   93
Of the Obliquity of the Uterus         -                    107
Of the Menses     -       -       -      -      .      -  118
Of Generation   -       -      -      -       -       .     121
Of Conception     -       -       -      -      -      -  124 
Mil
CONTENTS.
Of Pregnancy    -----      125
Of Touching   -            -----   127
Of the Foetus    ------      137
Of the Attitude and Situation of the Foetus in Utero          140
Division of the Child       -      -      -       -       -   143
Of the Secundines, or After-birth, and particularly of the
  Placenta      ------      147
Of the Membranes   -       -       -      -       -       -   151
Of the Umbilical  Cord.....152
Of the Waters of the Amnion       -      -       -       -   154
Of the Manner in which the Child is nourished during Preg-
  nancy         ------      156
Of the Circulation of the Blood in the  Foetus       -       -   158
Division of Labour, of its Causes, its Signs, &c.         -      161
Of the common determining Causes of Labour      -       -   163
Of the natural efficient Causes of Labour       -       -      165
Of the Causes accessory to the Action of the Uterus    -     166
Of some of the principal Phenomena of Labour     -       -   167
Of Labour Pains        -       -      -      -       -'      ib.
Of the Dilatation of the Neck of the Uterus         -       -   168
Of the Mucus tinged with Blood, which drains from the Va-
  gina  -------      170
Of the Gathering of the Waters    -      -       -       -    ib.
Exposition of the preceding Phenomena, and  of some others,
  according to the order in which they generally happen      17-2
Of the Phenomena of the La3t Period of Labour        -      174

                         PART II.
Of Natural or Unassisted Labour, and the various Kinds of
  it.......177
Of the first general Species of  Natural Labour,  or that  in
  which the Child presents the Head   -                    178
Distinguishing Signs of the Vertex, and of its different Posi-
  tions      -       -       -       -      -       -       -    ib.
Of the Mechanism of Natural Labour, where the  Child pre-
  sents the Crown of the Head in the first Position     -      181
Of the Mechanism  of Natural Labour, where the  Child pre-
  sents the Crown  of the Head in the  Second Position        183
Of the Mechanism of Natural Labour, where the Crown of
  the Head presents in the Third Position         -       -   185 
CONTENTS.
IX
Of the Mechanism of Natural Labour, where the Crown of
  the Head presents in the Fourth Position     -      -      186
Of the Mechanism of Natural Labour, where the Child pre-
  sents the Crown of the Head in the Fifth Position        -  187
Of the Mechanism of Natural labour, where the Crown of
  the Head presents in the Sixth Position      -      -      189
Of the Second general Species of Natural Labour, or that in
  which the Child presents the Feet       -       -      -  190
Of the Signs which indicate that the Child presents the Feet   ib.
Of the Mechanism of Natural Labour, where the Child pre-
  sents the Feet in the First Position    -                    192
Of the Mechanism of Natural Labour, where the Child pre-
  sents the Feet in the Second Position.    -                 194
Of the Mechanism of Natural Labour, where the Child pre-
  sents the Feet in the Third Position         -      -       195
Of the Mechanism of Natural Labour, where the Child pre-
  sents the feet in the Fourth Position         -      -       196
Of the Third  general Species of Natural Labour, or that in
  which the Child presents the Knees        -       -       198
Of the Fourth general Species of Natural Labour, or that in
  which the Child presents the Breech        -      -       200
Of the Mechanism of Natural Labour, where the Child pre-
  sents the Breech in the First Position    -       -      -  201
Of the Mechanism of Natural Labour, where the Child pre-
  sents the Breech in the Second Position  -       -          ib.
Of the Mechanism of Natural Labour, where the Child pre-
  sents the Breech in the Third  and Fourth Positions      -  202
Of the Management of the Woman during Labour       * -  203
Of the Treatment which the State of the Woman generally re -
  quires in the First Period of Labour      ...  204
Of the Situation of the Woman during Labour     -      -  208
Of preparing the Parts of the Woman for Delivery  -      -  210
Of quickening lingering Pains       -       -       -      -  211
Of opening the Membranes         ...      -  212
Of what is necessary to be done after  the Membranes are
  open     -------  215
Particular Precautions relative to each Position of the Head,
  or to other Circumstances which sometimes render Natural
  Labour a little more difficult     -              -      -  218
                            b 
X
CONTENTS.
Of the Management of the new-born Child         -       -   221
Of the usual Method of treating a new-born healthy Child      ib.
Of the Treatment of a Child born in a Morbid State       -   222
Sequel of the Treatment of healthy Children       -       -   228
Of the Manner of dressing new-born Children      -       -   229
Of delivering the After-birth, and the Regimen to be observed
  in the Month     -       -              -       -       -   231
Of Deliverance      ------   232
Of the unassisted Delivery of the  Placenta         -       -    ib.
Of the Signs which indicate  the Time when we ought to co-
  operate in delivering the Placenta, and the Method of do-
  ing it in the most usual Cases    ...       -   234
Of accidental Circumstances which oblige  us  to deliver the
  Placenta sooner or later, and to vary the Mode of operating   236
Of the Method of delivering the Placenta in case of Flooding   237
Of Obstacles to  delivering the  Placenta,  arising from  an
  Atony of the  Uterus, and from a  natural  or  spasmodic
  Contraction of its Neck         -       -       -       -    ib.
Of Obstacles to  Deliverance, proceeding from preternatural
 • Adhesions of the Placenta; and  of what must be done in
  those Cases.    • -       -       -       -       -       -   238
Of the Retention of a Portion of the Placenta, and of Clots of
  Blood in the  Uterus;  and  the Precautions  necessary in
  those Cases      ------   243
Of Deliverance when the Placenta is encysted      -       -   245
Of Deliverance in those Cases where the Placenta is attached
  to the Neck of the Uterus        -                        246
Of Deliverance after an Abortion   -                        250
Of Deliverance after the Birth of Twins    -                 254
Of what is to be done immediately after Deliverance, during
,  the Time the Woman must remain on the Couch        -   255
Of putting the Woman to Bed      -                        257
Of the principal Phenomena which manifest themselves in the
  Month    -----..   259
Of the Regimen for Women in the Month  -       -       -   262

                         PART  III.
Labours of the second Order, commonly called Preternatural  268
Of the Causes which may render  Labour preternatural     -    ib. 
CONTENTS.
XI
Of Hemorrhage, considered with respect to the Necessity of
  immediate Delivery      -----  270
Of Convulsions, considered particularly with respect to La-
  bour and Delivery       -----  277
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   -      -      -       -  288
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     -  292
Of the proper Situation for  the Woman in  a preternatural
  Labour.......293
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 pre-
  sents the Feet    ------  308
Labours  in which the Child presents the Knees.  Of the
  Causes which render a Labour, in which the Child presents
  the Knees, difficult, or preternatural     -                317
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 -       -  318
Of Labours in which the Child presents the Breech -       -  320
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  distin-
  guishing  Signs    ------  321
Indications in those Labours where the Child presents the
  Breech.......322
Of the Signs which characterize the different Species  of La-
  bour, in which the Child presents the Breech, and the Me-
  thod of bringing down the Feet in those Cases   -       -  325
Labours  in which the Child presents the Crown of the Head
  at the  Orifice of the Uterus       -       -     -       -  328
Of the Causes which may render those Labours in which the
  Child  presents the Crown of  the Head, difficult or preter-
  natural, and  the Indications they prescribe      -       -    ib>
Of bad Situations of the Child's Head in general, and parti- 
xu
CONTENTS.
  cularly of that which it is sometimes forced to take as it ad-
  vances in the Pelvis      -----  329
Of the Indications in those Labours  in which the Child pre-
  sents the Crown of the Head, when complicated with Cir-
  cumstances that render them difficult    -                332
Of the Method of turning the Child to bring it by the Feet,
  when  it presents the Crown of the Head.  General Rules  335
Of the distinguishing Signs of the first, second, and third Spe-
  cies of preternatural Labour,  in which the Child  presents
  the Crown of the Head,  and the Manner of  turning the
  Child in those Cases      -----  339
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  -                342
Labours in which the Child  presents the Face      -      -  345
Of the Causes,  Signs, and Differences of Labours in which
  the Child presents the Face, and the Indications they pre-
  scribe    -------  346
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    -      -  352
Of the Causes, Signs, and  Differences of Labours in which
  the Child presents the Breast    -                       353
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  -       -    ib.
Labours in which the Child presents the occipital Region at
  the Orifice of the  Uterus.  Of the Causes and distinguish-
  ing Signs of those Labours,  and their  Indications       -  356
Labours in which the Child presents the Back of the Neck,
  commonly called  the Nape. Of their Causes, Signs, Differ-
  ences, and general Indications   ...       -  358
Labours in which the Child presents the  Back.  Of their
  Causes, Signs, Differences,  and Indications      -       -  359 
CONTENTS.
Xtll
Labours  in which the Child presents the  Loins.  Of their
  Causes, Signs, Differences and Indications       -       -  359
Labours in which the Child presents  the lateral Regions of
  its Surface       -       -       -       -       -       "  360
Labours in which the Child presents the right or left Side of
  the Head.   Of their Causes,  Signs, Differences and Indi-
  cations   -------  0^*
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......-  369
Of the Indications presented by these Labours, and the Mode
  of operating in them     -                              370
 Labours in which  the  Child presents one of the Shoulders.
   Of their Causes, Signs, Differences, and Indications      -  371
 Method of operating when the Child presents the Shoulder    372
 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, Differences,
   and Indications         -                              s89
 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 neces-
   sary in the Practice of Midwifery, particularly the Forceps
    and Lever       -       -       -      -     - "      "  ^12
 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 Passage
    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 
XIV
CONTENTS.
   Forehead to the Sacrum; and also in that in which the Oc-
   ciput is against the latter, and the  Forehead 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 Symphysis; and in
   that where the Forehead is behind the left Foramen Ovale,
   and the Occiput opposite the right Sacro-iliac Symphysis    441
Method of using the Forceps, 1. in that position in which the
   Occiput answers to the right Foramen Ovale, and the Fore-
   head 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 infe-
   rior 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 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 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 Fore-
   head answers to the left Side, and the Occiput to the right  456
Method of using the Forceps when the Head, presenting the
   Vertex, is wedged in the superior Strait        -      -  459
Method of using the Forceps, when the Head is locked length-
   wise between the Pubes and  the Sacrum, superiorly     -   ib.
Method of using the Forceps when the Head is wedged trans-
   versely 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 Position
   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       ------  4^4 
                         CONTENTS.                      XV

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 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 to-
  wards 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 Vertex
  in which the Occiput answers to the Pubes of the Mother,
  and the Face to  the  Sacrum; and  in that where the Oc-
  ciput 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 inferior Strait -  483
Labours which cannot be terminated without the Application
  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 Woman,
  which constitute what is commonly called the Passage, con-
  sidered as a Cause of laborious Labour         -      -  510
Indications presented by a deformity of the Pelvis, relative
  to Delivery       ---.._  515
A succinct Analysis of Delivery by the Feet; of the Use of
  the Forceps, Crotchets and Perce-cranes, in Cases of De-
  formity of the Pelvis     --..-  517
A succinct Analysis of the  Cesarean Operation    -      -  519 
XVI
CONTENTS.
Of premature Delivery, proposed on Account of a Deformity
   of the Pelvis, with a View of avoiding the Cesarean Opera-
   tion      -      -       -       -      -      -      -  523
Of Regimen, considered as a Means of preventing the diffi-
   culties of Labour, which  proceed from a Deformity of the
   Pelvis     -------  528
Of the Cesarean Operation  -----  529
Of the Causes which require the Cesarean Operation; the Pre-
   parations necessary for it; the proper Time to perform it;
   and the Instruments and other requisite Apparatus      -  531
Of the Part where the external Incision ought to be made   -  535
Method of performing the Cesarean Operation      -      -  542
Of the proper Treatment after the Cesarean Operation     -  547
Of the Causes of the Rupture of the Uterus, and the princi-
   pal Accidents attending it       -                       553
Signs of a Rupture of the Uterus   -                       559
Of the Indications presented by a Rupture of the Uterus   -  561
Of Compound Pregnancy, its  Signs, and the Indications  it
   presents relative to Delivery     -                        567
Of the Signs of Pregnancy composed of several Children   -  569
Of the Indications presented by Twins relative to Delivery   570
Of False Pregnancy, its Signs, and curative Indications    -  576
Of the Signs which characterize a False Pregnancy        -  580
Of the Mechanism by which the Substances which constitute
   the different Species of False Pregnancy are expelled; and
   the Assistance they require from  Surgery       -       -  582
Of the Causes of Abortion, and its Symptoms      -       -  584
Indications in Cases of Abortion                 -          587 
A  SYSTEM
11,
                    PART I.

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

    1. Midwifery 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 per-
formed by the natural force of the organs of the woman;
but no other function  of the animal economy requires
the concurrence of so  many powers, or is so laborious
and painful.  The facility of its execution 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 measure
reduced to that of a mere spectator, in those cases where
this function is performed according to the intentions  of
                         A 
2                 Of the Parts, fyc.

Nature, there are others in which his assistance  is ab-
solutely necessaiy.  Sometimes it is proper to  moderate
the action of the natural powers, which would  expel the
child  too  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  distin-
guish  between the boundaries of Art and Nature! to know
when  to let that provident  mother act, or  to assist her
seasonably! We ought to  be acquainted,  in every pos-
sible 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, Sfc.             3
   Of the Female Pelvis, considered  with respect to
                      Delivery.

   5. The 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  articu-
lated.  The  facility  of delivery always depends  on the
more or less  favourable 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  constitute the
sides and the fore part; the sacrum  and  coccyx, which
form the back part:  but we observe a greater number in
the foetus, and in infancy;  each os ilium being then  com-'
posed of three parts—the ilium (properly so  called) the
ischium, and the pubes; the sacrum of five,  called false
vertebras;  and the coccyx of three, as it likewise is in the
adult.
   7. Most of these bony pieces are soft  and flexible in
the foetus,  some of them being still in a manner  cartila-
ginous; and the edges of the others are found incrusted
with a similar substance.   It is some time before they
acquire that solidity which  constitutes  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 expression, is no more than sketched; for
Nature follows the same course in the development  of all
the parts  which are to form the frame  of the  edifice, 
1        Of the Bones of the Pelvis, separately.
Those who have thought they discovered dispositions fa-
vourable to delivery, in the multiplicity of bones which
form  the pelvis  of the foetus, in  the  manner of their
connexion,  and in the little  solidity which results from
the whole, and who have advanced that those bones un-
dergo the  same changes of figure in the course of la-
bour as those of the cranium, have deceived themselves;
and we  may be assured that their opinion is as little con-
sonant 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 commonly called  the hip
bone.   Its form is nearly triangular; 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
anterior, and the posterior; as well as three angles.
   9.  A kind of angle, or line, pretty sharp  in the poste-
rior two-thirds of its extent, and a little  rounded 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.

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

which is larger, and a little concave, forms the iliac fossa:
the other, which is inferior, presents behind a sort of tu-
berosity, to which is attached a great number of tendinous
and ligamentous fibres; and a little forwarder a cartilagi-
nous articular impression which has some resemblance to
a crescent.   The rest of the internal face of the ilium
makes part of the brim and cavity of the pelvis and de-
scribes  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 accou-
cheur, that I shall dispense with describing it.  It is co-
vered by the glutei muscles which are attached  to it.
   11.  The superior edge of the ilium, which  is called
the crista, is turned nearly like the italic S.  It  is car-
tilaginous  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 exactly the insertions  of
certain muscles,  which will be mentioned  in the sequel.
The internal lip forms a kind of angle more or less ob-
tuse, at about  the posterior  third of its length, where  is
 inserted  a ligament, attached to the  other  end to the
 transverse 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 infe-
 rior 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 superior edge forms almost a right angle, which
 is called the anterior superior spine of the ilium, to di? 
 6       Of the Bones of the Pelvis, separately.

 tinguish  it from  the  other  apophysis mentioned above.
 They serve for the insertion of several muscles.
   13.  We see nearly the same disposition  in the poste-
 rior edge of the ilium;  a  bony projection makes two
 notches in  it, of which the largest only forms the sum-
 mit of one  more considerable, placed at the side of the
pelvis, and a  little backward, called the sacro-ischiatic
 notch.  The union of this  edge with the superior forms
 another angle, called the posterior 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 on it, which have
 no resemblance to each other.   One, pretty large, a lit-
 tle concave, and whose superior edge describes a kind of
 crescent, forms nearly a  third of the acetabidum, which
 receives the head of the osfemoris; 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 acetabular portion is
 extremely  thin, very smooth, and continually moistened
 during life  by  a mucous  liquor, known  by  the name of
 synovia.   Those which cover the other two facettes  are
 of a different nature: 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.       t


                  Of the Os Ischium.

   15.  The os ischium  is  situated  almost  perpendicu-
larly 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 regards the
inside of the pelvis; the second, the outside; and it is on
th£ 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, inter-
nally 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 considered as the branch of
it.  One of the edges of this apophysis contributes to the
formation of the foramen ovale; and the other to that of
the arch of the pubes, or the great notch at the fore part
of the  pelvis.   Its point is  joined to a production of the
os pubis, 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 distinguish 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. 
8        Of the Bones of the Pelvis, separately.
and the two others  serve for the union of the ischium
with the pubes and ilium;  the fourth regards the inside
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 triangular 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 behind,
narrow before, and a little concave between its extremi-
ties, serves for  a channel to the crural vessels at their
exit from  the abdomen.   The internal and external faces
present some little difference; they are broad before, and
narrow towards the acetabular 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 length-
ened, by which it is united to the ilium and  ischium, by
means of a cartilage which ossifies insensibly, and in time
A line is the twelfth of an inch. 
         Of the Bones of the Pelvis, separately.       9

totally disappears.   We remark also at this extremity ano-
ther facette, much more  extensive, a little concave,  and
covered with a layer of cartilage extremely thin, by which
the os pubis concurs with the ilium and ischium to form
the acetabulum.
   22. The anterior extremity of the os pubis presents a
cartilaginous and ligamentous impression, fifteen or eigh-
teen lines long, and about six  in  breadth, which serves
for the  union of this  bone with its fellow.   The direc-
tion of  this articular impression is almost vertical when
the pelvis rests on the  tuberosities of the iscMa 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 extremities 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 salient, which serves for the inser-
tion 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 narrower at its point,
 descends from the anterior extremity of the body of the
 os pubis,  and passes  commonly for the branch of that
 bone.   It is, as it were,  twisted from  the  inside of the
pelvis outwards, in such a manner that one of its edges
 is almost anterior, and the other posterior:  the posterior
 makes  part of the foramen ovale;  the anterior, part of the
 arch of the pubes.
                           B 
10      Of the Bones of the Pelvis, separately.
  25. The branch of the pubes does not descend per
pendicularly to the horizon; it constantly inclines 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 disposition 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  Innominatum in
  Adults.

  20-. These three bony  pieces, destined to  form but
one after infancy, are united in that early age by a pretty
thick cartilage, but of a different nature from those which
form part of the sacm-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 exceedingly rare.   This junction of the ilium,
ischium and pubes, is made near the middle of the ace-
tabulum, 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 sali-
ent,  which anatomists call  linea ilin-pectinea, because it
is formed by the union of the ilium and pubes.
   27.  It often happens, in children affected by the rick-
ets before the age in which this consolidation  is perfect,
that the three pieces which form  the acetabulum are
pushed inwards by the head  of the femur, which nar-
rows the entrance of the pelvis, and renders it so irregu- 
        Of the Bones of the Pelvis, separately.      11

lar 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 cartilage which
ossifies  after some years.   By the  connexion  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 anterior edge of the acetabulum.
  29. The os innominatum, in a woman of the ordinary
size, is  about six inches broad, from the  anterior supe-
rior 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 su-
perior 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 before than
behind, pretty much resembles the section  of  a cone.
In the middle of it, we see a cartilaginous impression of
an  oblong figure, and  cut very obliquely from before
backwards, by which 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 
12      Of the Bones of the Pelvis, separately.
them form channels which lodge the fifth pair of lumbar
nerves, at their exit from the vertebral canal: these apo-
physes unite themselves  to similar ones of the aforesaid
vertebra, as we shall see hereafter.
  32. The  point of the sacmm presents also a cartila-
ginous facette, transversely oblong; but  much  smaller
than that of the base, and  inclined in a contrary direc-
tion; 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 observe  in it
four transverse  lines, resulting from the consolidation of
the five pieces which constituted this bone in  early in-
fancy. These lines terminate at each side  in as  many
holes, which pierce the thickness of the bone very ob-
liquely,  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 sacmm:
they are not all of the same size; and some  of them are
lengthened m 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 vertebras,  and others to the ob-
lique 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 tubercles  are two other apertures,
nearly of a triangular figure, of which one forms the be-
ginning, and the other the end of the sacral canal.  From
the extremity of this canal descend two little  productions,
in the shape of a bodkin, which unite by means of a liga-
ment with the superior and  posterior part of the coccyx.
  35. Each edge of the sacrum presents  superiorly a 
        Of the Bones of the Pelvis, separately.      13

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 oblique-
ly from above downwards, from without  inwards, and
from  before backwards; so that their anterior edge and
their  superior extremity 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 sacrum, unless it be a little
notch in  their inferior extremity.   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 middle of its base anteriorly, to the extremity of
the spiny  tubercle of its first false vertebra, is two inches
and a half.  This last dimension varies so little, that I
have  not  found a difference of a line in between  thirty
and forty pelves, the greater part of which  were deform-
ed; 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 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
necessary to show their connexions with each other, and 
 11               Of the Union of the
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-cartilaginous substance, by which it is united
to the extremity 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 pre-
served 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; consequently the same
kind of connexion.  This third piece is  longer  and nar-
rower than the preceding, and terminates in a sort of tu-
berosity, 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 anatomists, each os pubis
is covered by its own cartilage: 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 
                 Bones of the Pelvis.               15
that each os pubis is  really covered by a cartilage at its
anterior extremity; that  this cartilage is thicker before
than behind, and in its superior and inferior parts than
in the middle of its length; that these bones, thus cover-
ed, are bound together  by means of a substance which
seems ligamentous, and whose fibres, which are mostly
transverse, go from one to the other; that these fibres are
so disposed, that the  deepest are  the shortest,  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 articu-
lations, and which are commonly supposed to be synovial
glands.   We  observe, farther, that this fibrous and liga-
mentous 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 arthro-
dia.   If we open this symphysis towards 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 apparent  fibres are  transversal; afterwards
two  cartilaginous faceltes,  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 faceltes  comprehend nearly the
middle third of the length of the symphysis, and the poste-
rior third of its thickness.  This symphysis then presents
in one-third of its extent, or thereabouts, a true articula-
tion; and, in the rest,  a syneurosis  and synchondrosis at
the same time.
   39. This compound and articular substance, being de-
 tached from the bones, forms a kind of wedge, whose base 
16
Of the  Union of the
constitutes the anterior part of the symphysis, and its edge
the posterior; so that these bones seem to touch towards
the inside of the pelvis, and  appear separated to the dis-
tance 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 be-
low;  where  this substance, becomes 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 co-
vered and fortified in  all  parts,  but especially before, by
bundles of ligamentous and aponeurotic  fibres.  Inde-
pendently of the thick and very strong ligamentous struc-
ture  which forms the forepart of the  symphysis, we ob-
serve 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 re-
mark, 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 sacmm is engaged  like a wedge between
the posterior parts of the ossa innominata, to which  it is
united.  Although  some anatomists  pretend  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 inequalities which are mutually re- 
Bones of the Pelvis.              17
ceived;  but we sec nothing of that kind in the junction
of the pubes.   These articular cartilages have not the
same thickness 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 discover,  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 articula-
tions, which I  shall often mention by the name of sacro-
iliac symphyses, derive 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 faceltes: 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 trans-
versely from the anterior edge of the articular 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
symphyses; 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 vertebra to the
superior edges of the articular faceltes of the sacrum and
ilium, spreading itself over the top of the symphysis;
and the other goes from  the points of those same apophy-
ses to the  angle made inwards by the crista of the ilium,
                         C 
 18               Of the Union of the
 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 ine-
 qualities 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 middle of the ischiatic notch, these liga-
 ments 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
 offalx, which has caused it to be called the falciform
 ligament.  These two  ligamentous branches  leave be-
 tween them  a kind  of triangular  space, through which
 pass some nerves, and the tendon  of the internal obtu-
 rator.
  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 oblong, which we
 see in the middle of  its basis, to a similar impression  in
 the body of the last lumbar vertebra, by means of an elas-
 tic substance; 2,  and  3,  by  two little articular  masses
 which are fixed in the posterior edge  of that first impres-
sion, and which answer to similar substances in  the ver-
tebra before mentioned. 
                 Bones of Hie Pelvis.               19

   48. The elastic substance which unites the middle of
the base of .the sacrum to the spine, is entirely similar in
its  nature to that seen between the bodies of all the ver-
tebras.   It is very thick before, and thin behind; which
renders the  angle necessarily resulting from the disposi-
tion of the articular faceltes of these two parts  more ob-
tuse.  This sacro-vertebral junction is surrounded by an
infinity of ligaments, some without, and others concealed
within the spinal canal.
   49. All motion is not prohibited in this kind of junc-
tion ; but, as it only  depends on the compression 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 be-
tween each  of the  lumbar vertebra*, 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 alteration  in the de-
gree 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, according  as the trunk  is bent
backward or forward, or by raising  or  lowering the
breech when the  woman lies on her back; which merits
particular attention in the practice of midwifery.   We
may by this means make a favourable change in the di»

  * 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, may be augmented or diminished by that motion; and
that error might contribute to deprive women of a means which ge-
nerally relieves those troublesome pains in  the back which so fre-
quently torment them during labour. 
20          Explanation of the First Plate.
rection 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 circumstances, by
making the woman preserve  a proper attitude.
   51. The junction of the coccyx with the sacrum is en-
tirely similar to that  called sacro-vertebral, with respect
to the medium which constitutes it: it  permits that ap-
pendix to move, and yield to  the pressure it undergoes
in different circumstances.  This mobility, which  is ex-
treme in youth, diminishes insensibly, and in time is en-
tirely lost.   If it diminishes considerably, or is lost be-
fore the time in which  a woman becomes sterile, it pro-
duces, in some cases, but very rarely, an obstacle to de-
livery.
   52.  The  pelvis has connexions with the  inferior ex-
tremities, which are hot so important for the accoucheur
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 articula-
tions are enarthroses, which  permit motion in every di-
rection.



            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 fossce.
   b, b, b, b, The  angle which divides  transversely, and
 obliquely from behind forward, the internal face of the 
76 
 
           Explanation of the First Plate.         21

os ilium into two parts, and which makes part of the brim
of the pelvis.
  c, c, c, c, The cristas 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 anterior two
thirds, and  to which is attached a ligament 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.
   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. 
-2         Of tlie Separation of tiie Bones.
  t, t,  Another ligament which descends from those same
apophyses to the superior edge of the sacro4liac symphy-
ses.
  G, G, The femur, or thigh bone.
  V, V, The head of the femur received in the acetabu-
lum.
  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 sa-
 cmm are united together—however numerous 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 re-
 laxed and weakened to such a degree,  as to allow an ap-
 parent 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; which in either
 case might seem necessarily to procure a greater capacity
 in the pelvis,  and give an  easier passage to the child.
 Such in fact is  the opinion 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 
            Of the Separation of the Bones.         23

this separation, and in the solidity which it was likewise
necessary to give  to  the  symphyses of the pelvis; and
without this double advantage, according to those authors,
the woman could not have transported herself from place
to place  so conveniently and safely, nor bring forth chil-
dren so easily.
   51. All authors have not however had the same idea of
the separation of the bones of the pelvis.  If some, zea-
lous admirers of the resources of nature, entirely occu-
pied 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 opinions
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 experience demon-
strates that this separation, far from being common, is
very rarely met with,  and is not more usual after a  labo-
rious, than after an easy labour; nor in a distorted pelvis,
than in one well formed.   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 semm into the ligamentous tis-
sue of the symphyses, must be regarded as the most usual
predisposing cause of the separation of the bones of the
pelvis, and  whatever may occasion that infiltration will
become the remote cause.   The pressure which the ute-
rus, loaded with the  produce of the conception, exerts
during several months on  the trunks of the vessels which
are distributed to  these symphyses, and on those which
return the  blood  from the inferior extremities, cannot 
 24         Of the Separation of tlie Bones.
 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 pressure  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 considera-
 ble in women pregnant of several children, as well as in
 those who have a narrow pelvis; and  nevertheless the re-
 laxation is not more frequenUn those cases than in others.
 In examining the bodies of several women 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
 accident is not  less the most usual  predisposing cause of
 the separation of the bones of  the pelvis; and it was ac-
 knowledged to be such in the time of Severin Pineau.—
 See his Opusc.  d'Anat. et de Physiolog.
   57. Though the  relaxation of the symphyses, produced
 by the infiltration of  serum into their ligamentous tissue,
 is generally regarded as the predisposing  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 may  affect the ligaments, the cartilages which
 incrust the extremities of the  ossa pubis, as well as  the
 articular faceltes 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. 
            Of the Separation of the Boms.         25

in order to separate large masses  from them*  The
structure of the symphyses, better  known at present, no
longer admits  those ingenious comparisons; and the ex-
plication of the phenomena is not  less clear on that ac-
count.  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 uierus  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 capa-
city in the pelvis, and a greater breadth of hips, even in
women 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, which
sometimes  happens in labour, is not always the effect of
a  relaxation and  stretching of  the ligamentous 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

  * See Memoires de l'Academie Royale  de Chirurgie, torn, iv,
Dissertation  sur PEcartement des Os du Bassin, par M. Louis.
                          D 
26          Of the Separation oftlie Bones.
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 section  of the
symphysis of the pubes, I shall take notice of them when
I come to treat of that  new operation, and shall relate
some examples  of the rupture 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, properly 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 deliveries, to which those
efforts seemed  to contribute nothing; and it has some-
times been found in  consequence  of an external percus-
sion, or of a fall.
   60. Being deceived  in the principle of this  separation,
they necessarily erred in the consequences deduced from
it.   It has been so firmly believed to take place in all  la-
bours, that it was thought to be absolutely necessary, and
that without it  many women could not be delivered but
with extreme difficulty.  " It would be in vain/' says Se-
verin Pineau, * that the neck of the uterus and the other
soft 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 narrow a, way."
   61. Having thus mistaken the necessity and pretended
advantages of  this  separation, the natural resistance of
the  symphyses, and, above all, the dryness and  rigidity
necessarily induced  in them by age,  were consequently 
Of the Separation of the Bones.         27
reckoned among the causes of laborious and difficult la-
bours.  Obstacles have been attributed to  the  state of
these symphyses, which merely depended on the resist-
ance 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, fomentations,
&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 expected, 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 fallacy which  has prevailed on
this point, if it had not led some practitioners into a very
serious consequence;* but the interests of humanity, and
the honour of the art, oblige me to expose it, and if pos-
sible endeavour to dissipate it.  In order to appreciate
all these means, and fix the  degree of confidence to be
placed in them, supposing that they could effect the  re-
laxation of the symphyses of the pelvis, it is necessary to
determine what degree of amplitude can be given to that
cavity, by the separation of the bones which constitute it.
  ' 63. The ossa pubis cannot separate without augment-
ing 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 diameter be  in-
creased? If the  circumference were perfectly circular,
every possible diameter would partake a third of that aug-
mentation; but as the entrance of the pelvis is in general
the more elliptic as it deviates more from the natural state,
it follows that its different diameters cannot increase in  the
See the Chapter on the Section of the pubis. 
28          Of the Separatum of the Bones.

same proportion, and that there is, as I may say, none
but the transversal which can become larger.
  64.  The augmentation of the antero-posterior diameter
is reduced almost to zero, when  the separation is mode-
rate; 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 diame-
ter shall be increased six lines, and often more.
  65.  The pelvis being larger in most women than is ne-
cessary 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 addi-
tional source of inconveniences in those women who are
subject 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 inevitably accompany
the separation, and the mobility of the bones which form
that  cavity. Far from favouring delivery  in all these cases,
it could not but render it more tedious and painful to the
woman, as experience has convinced me.f  If we ought

  * See Nos. 86, 87.
  t A woman of a good habit, and of th,. 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 preg-
nancy, felt acute pains in the symphyses 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 the 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 preceding, although the
child was much smaller than the former. 
            Of the Separation of the Bones.         29

to expect 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 deformed; and where
the defect which rendered delivery impossible did  not
exceed  two lines at the most,  since the separation  of an
inch cannot procure 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 sepa-
ration of an inch, which has never taken place between
the ossa pubis without a rupture of their symphyses, we
are not to expect an augmentation 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 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 not exceed the little diame-
ter 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 be-
  * The, relaxation of the symphyses of the pubes was so great, that
we could separate them fourteen lines, and put  them again in con-
tact.  The pelvis was of the  largest size, and the body entirely
putrid. 
30          Of the Separation of the Bones.
tween 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 under-
gone the Cesarean operation.
   68.  The proscription of the section of the symphysis
of the pubes, though performed several times within these
ten years with all the success its author could desire, seems
an inevitable consequence of those same reflections;  that
operation  being  the  fruit of an  opinion too hastily em-
braced by persons of science, but too credulous concern-
ing the pretended advantages of the spontaneous separa-
tion of the ossa pubis.—See the sequel of this work.
   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 danger of it! Even
if it were  in the power of art to procure this separation
without cutting the symphysis of the pubes, if  that sepa-
ration could in some cases destroy the obstacle which ob-
structed 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 suddenly,
severe pains in the parts divided, an impossibility of walk-
ing, and sometimes even of moving the inferior extremi-
ties, inflammation, fever, abscesses, caries, and lastly death 
            Of the Separation of the Bones.         31

itself, have generally  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 attend-
ing 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 afterwards!
   72. We should be in the wrong if we were to suppose
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 conse-
quence of a very small separation,  and of the slightest
movement between the ossa  innominata.   A woman to
whom I was called had kept her bed ten months, a prey
to the most excruciating pains in the junction of the ossa
pubis, and of one of the ilia with the sacrum,  whenever
she attempted 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 accident had been first felt in the time of
labour, and the  midwife was accused of having luxated
the bones.  The lameness which results from the relaxa-
tion of the symphyses of the pelvis is not always so pain-
ful; if the woman suffers pain at first whenever she at-
tempts to walk,  it lessens gradually, because  the parts
which constitute the  symphyses accustom themselves to
the dragging occasioned  by the mobility of the bones.
   73. According to these observations, the separation of
the bones of the pelvis will appear to be an  unnecessary 
32          Of Die Separation of the Bones.

accident, and sometimes a very serious one;  since it may
influence the subsequent symptoms,  and even affect the
life of the  woman, or render her  existence a long time
burdensome.  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 pe-
riods, 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 re-
quire it.*  The indications are very  different, and much
more urgent, when the symphyses are ruptured:  we must
prevent inflammation 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 Di-
                      mensions.

   74. A ridge, rarely circular, often elliptic,  and some-
times of another figure, but always more or less inclined

  * A few turns of a bandage rolled tight on the pelvis were suffi-
cient, in a woman who had been delivered eighteen or twenty days,
to enable her to walk in her chamber, though before she could not
move in  her bed without great pain: No other means were used
but that bandage.  Another woman, who had been delivered nine
months, having used topical  astringents and aromatic fumigations
without success, could not recover the faculty of walking but by
the use of cold baths almost freezing.t
  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 even-
tually cured by a continuance of it.—W. P. D. 
           Of the Division of the Pelvis, tyc.         33

forward, divides the cavity of the pelvis 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 basin, is very wide at  the sides, and quite
open  before.  Its breadth, taken from the anterior supe-
rior 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  fossas.   The  know-
ledge of this part is not the least interesting with respect
to delivery.
   76.  The lower part, called  by the French the little
basin,  forms  a kind of canal, whose entrance and outlet
are somewhat  narrower  than the  middle;  which  has
caused it to be distinguished  into the superior 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 pro-
jection of the sacrum to the superior 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 ob-
                          E 
34           Of the Division of the Pelvis,
lique diameters: 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 lat-
ter divide those angles into acute ones.
   79.  The respective length of these diameters,  consi-
dered relatively to delivery, is not  what I have just indi-
cated; the soft parts within the pelvis causing 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
respect to the muscles.  The long or transverse diamer
ter is almost the only one which the psoas diminish in their
passage:  they diminish it more or  less  in different sub-
jects, 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
longest; and we ought to consider them as such in respect
to delivery, except in some deformed pelves.
   80.  The inferior strait, in general smaller, and of a
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  be-
hind and at the sides by the sacro-ischiatic ligaments, and
forming before a kind of  circular notch, called the arch
of the pubes.  (See the third plate.)  We are also to re-
mark  as many diameters 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 
            and of its natural Dimensions.          85

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, because the latter aug-
ments  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 observa-
tion, 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 ad-
vantage of it, in many cases, the finger alone, well directed,
will dispel obstacles which would have been  difficult  to
overcome with instruments, or which could not be over-
come by those means  without exposing the child to great
inconveniences, 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  disposition,
which  proceeds  from  the curve of the sacrum, is  as fa-
vourable 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 necessarily 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 inches deep behind,
three and a half or thereabouts at the sides, and at most
eighteen lines before.
  83.  The arch  of the pubes does not merit less  to be 
36         Explanation of tlie Second Plate.
be well understood than the parts I have just described,
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, aug-
ments insensibiy as it descends; so that its sides are more
than  three inches and an  half apart at the bottom, even
four inches, 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, be-
cause 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 atti-
tude of the body.
  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 extremities 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 traverses
the lower part of the first false vertebra of the sacrum, and
crosses that of the other strait at a very obtuse angle.
           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 fossas. 
 
 
           Explanation of the Third Plate.         37

  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 acetabida.
  g, The symphysis of the pubes.
  The lines indicate the different diameters of the supe-
rior 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.
  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 strait of a  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 ligaments,
  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, 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. 
38
Deformities of the Pelvis.
A, A, The antero-posterior or great diameter.
B, B, The transverse or little diameter.
C C, D D, Oblique diameters.
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 1 have just described,
as to disturb the natural order of labour, and  render it
more or less difficult,  ought  to be accounted so many de-
formities, if we  consider  them relative to that function:
they all consist in the excess 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 con-
sequence  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 essential 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 de-
livery, strictly speaking, 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 conformation so favoura- 
              Deformities of the Pelvis.            39

ble in appearance,  are  more exposed than others to the
effects of obliquity of the uterus, and to its descent; es-
pecially  in  time  of labour,  when  that viscus,  already
charged  with the weight of the child, is entirely subject-
ed  to  the  expulsive  force of the abdominal  muscles.
Feebly retained by  its ligaments, in women who have al-
ready 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 strong-
ly on the  extremity  of the  rectum,  and  as  well by its
weight as volume impedes the discharge of the fceces and
urine, as well as the free course of the blood in the veins
which pass through the pelvis;  which is often the cause
of very  important accidents.   If they  partly vanish to-
wards the middle of pregnancy, they sometimes  reappear
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 totality of the uterus did before.  If we add to
these accidents  those which may result from a too sud-
den and too easy delivery, it will not appear surprising
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  acci-
dents, 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 viscus
in its natural position, when it has taken an unfavourable
one.  We may prevent it from prolapsing in time of la-
bour, by keeping the woman in  a horizontal position; by
recommending to her not to  make the most of her pains, 
 40            Deformities of the Pelvis.
 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 the
 child's head, is so far prolapsed that the head appears en-
 tirely 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 ad-
 vanced,  we begin by pushing back what is prolapsed, and
 proceed as directed above;  that  is to say, we are to sup-
 port  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 ren-
 dering it extremely difficult.
   90. The narrowness of the pelvis, considered with re-
 spect 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 lat-
 ter  from the bad conformation of the pelvis itself.  To
 fix a just estimate of the various degrees of both these
 species, and determine the consequences they might pro-
 duce, 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 inches six lines in diame- 
Deformities of the Pelvis.
41
ter, from one parietal protuberance 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 but one of the straits,
and in that case the other is pretty commonly of the natu-
ral 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 trans-
versal; and sometimes it only affects one  side.  We re-
mark the contrary in the  inferior  strait;  for there it  is
generally 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 direc-
tion of the spinal column we shall  see that the weight of
the body must insensibly push the base of the sacrum to-
wards 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 pubis, particularly in  these latter cases
must be pushed towards the sacrum; but in  such a man-
ner,  however,  that their posterior extremities often ap-
proach a little nearer to the projection of the base of that
                          F 
42            Deformities of the Pelvis.
bone than  their anterior extremities, or the symphysis.
If the superior strait does not constantly present 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  other approaches less; if the
symphyses of the pubes is removed in many cases, from 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 junctiqns;
and because the attitude which the child takes in walking
or sitting may change a little the  direction of  the com-
pressing  powers  which I  have just mentioned.   The
weight of the body may also equally hurt the form of the
inferior strait, but variously, according 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 be-
fore backwards; in this attitude if it inclines habitually to
one side, one of the ischiatic tuberosities will be thrown
inwards,  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 de-
formities 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 con-
stantly in the arms, as is done almost every where.
   93. The deviations of nature do not present fewer va-
rieties in the dimensions of the pelvis, than in the contour
of its straits.  If the diameter of some, considered  from
the pubes to the middle of the projection of the sacrum,
is only defective a few lines; in others the defect is of se- 
               Deformities of the Pekis.             43

veral inches,  so as scarcely to leave one between those
two bones.   The intermediate  degrees are  more  fre-
quently found than these two extremes;  and the latter of
them is never so  great in the inferior strait as in the su-
perior.  I have seen 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 the right  acetabulum to the
projection of the  sacmm;  and in another, which is like-
wise  in my collection, that projection is  fourteen lines
distant from  the  symphysis of the pubes.*   There  are
no examples  of the inferior strait being ever so contract-
ed: that  related by M. Herbiniaux, a surgeon of Brus-

  * In a case which occurred in the Alms House of this city about
four years since, the measurements of  the pelvis were found  after
death as follows, viz.
  Distance from the anterior part of the body, the last
    lumbar vertebra to the right acetabulum .  .   .  f of an inch.
  To the left acetabulum.........1£  inch.
  To symphysis pubis...........2§
  Laterally opposite foramina thyroidea   .  .  .   .  f-
  From the tuber of one ischium to the other .  .   . 2$
  From coccyx to symphysis pubis......2f
  From coccyx to the tuber of the ischium on the
    right side.............f
  From  do.           do.         left side .   . 1
  Posterior depth of pelvis.........If
  From projection of the sacrum to the point of the
    coccyx..............2
  The measurements in this case were not taken from the projec
tion of the sacrum, but from the anterior surface of the body of the
last lumbar vertebra, as  the base of the spinal  column was so fat
sunk into the pelvis, as to place the superior surface of this verte .
bra on a line with the brim of the pelvis.—W, P. D. 
44            Deformities of tfie Pelvis.
sels, Observation VII. being contradicted by the fact it-
self; 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 circum-
ference,  and yet be large enough for an easy delivery: a
common-sized head, when it passes through  that canal,
presenting a circumference 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.  When this vicious con-
formation leaves an opening  of but three inches and a
quarter, delivery becomes so much the more tedious and
painful,  in proportion  as the frictions which  the  child's
head must undergo in passing through the pelvis are more
numerous and strong.  If the obstacles are more consi-
derable when the pelvis has but three inches in the little
diameter, yet they  are not even then always insurmount-
able by the natural agents of delivery; and the woman may 
              Deformities of the Pelvis.            45

still be delivered without help, notwithstanding the appa-
rent disproportion 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 diameter
is but two inches and three quarters, as I have seen seve-
ral times.  These natural labours ought only to be consi-
dered  as exceptions to the rule:  the uncommon supple-
ness 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 con-
sequences which might arise from a deformity of the pel-
vis: a suppleness of the cranium, 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 pelves 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  manner, that its longest diame-
ter was eight inches all but two lines; that which goes
from one parietal protuberance  to the other, being re-
duced to  two inches five or  six lines.   I have seen simi-
lar changes 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 very little  of  being of the dimensions usual at
that time.  The history of  the section of the  pubes fur-
nishes us with more convincing proofs of the possibility 
46            Deformities of the Pelvis.
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  successively, 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 opera-
tion, the section of the pubes, and  premature delivery,
have been recommended  in these cases; but the first is
the only one which surgery has authorized: 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 delivered
naturally,  when  the contracted pelvis has no more than
two inches and a half in the little diameter, 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
cranium riding  one over  the other, or  being fractured
and  depressed,  compress   or wound  the brain,  which
causes it to become plethoric, and produces internal ex-
travasations, which are generally mortal.—See the chapter
on the locked head, and the manner of using the forceps.
  99. The obstacles which are produced by a deformity
of the pelvis, and the accidents which result from it, show
themselves sooner or later, according as it is the supe-
rior or inferior strait  which is vitiated.  When they are
See the article on the section of the pubes. 
Deformities of the Pelvis.
47
both so,  those obstacles manifest  themselves as soon as
labour begins;  and very often  the expulsive powers are
so exhausted by exerting themselves against  the  obsta-
cles 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, re-
mains 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 thickness 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 compress-
ing  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 first period, and which  is still ne-
cessary  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,
during the stay of the head in the excavation; but reap-
pear, and  increase anew,  when  the  labour  comes on
again with force.
   100. When  the superior strait alone  is  contracted,
the  child's  head at first  advances with great difficulty;
but  as soon as the parietal protuberances have cleared 
48            Deformities of the Pelvis.
the strait, the other parts of the pelvis being relatively
or absolutely larger, the head passes 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 de-
scends easily into the  lower part of the pelvis, 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 para-
graphs 98 and 99, manifest themselves later in this than
in the preceding case.
  102.  The accoucheur who  has  not yet by long prac-
tice enabled himself to form a just estimate of the pow-
ers  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
observations 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  committed in such
cases.  More than  forty persons were witnesses to  the
disagreeable consequences of a mistake of this kind, in
a woman whose  pelvis I  have  long had by me.  The
operator having  pronounced that  the  woman would be
speedily delivered, on account of the facility with which
the child's head  had engaged with the first pains—and
attributing 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—waited
two days in perfect security; and  then, by a more blind 
               Deformities of the Pelvis.            49

temerity than the former, used a crotchet on a child whose
life might  by other  means have been preserved.  The
superior strait of the pelvis, divested of all its coverings,
presented a circumference of fourteen inches, in a cir-
cular 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 ischiatic
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 possible in its contour.
   103. The middle part, or excavation, of the pelvis, is
much seldomer defective than  the  straits; and, when it
exists, must arise from  some exostosis,  or from the sa-
crum's describing a straight line in its anterior part, in-
stead of being curved as usual.   This defect in the cavi-
ty can produce no other effects than those which have
just been described.
   A straight and flat form  of the sacrum, in general,
produces fewer obstacles to  delivery than  the too great
curve of that bone.   The former fault commonly only
affects the cavity of the  pelvis;  which cannot hinder the
passage of the child, if the canal be otherwise well dis-
posed:  whereas the latter, or too great  curve of the sa-
crum, generally injures  the two straits,  and  contracts
them from before backward, at the same time that it di-
minishes the  depth of the pelvis posteriorly, and the re-
spective 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 stop-
ped in its  course by the inferior part of the sacrum, be-
fore 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,
                           G 
 50            Deformities of the Pelvis.
 the  lengtn 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
 observe that they are scarcely ever met with  alone, and
 that they are  generally the  consequence  of a bad con-
 formation 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 between 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 extremity
 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 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.

  * This precept advises pushing back the coccyx, when the head,
though low down, cannot disengage itself easily. 
*
• 
399999 
t
                       (  51   )


            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 trfe 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.
   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 acetabu-
 lum, 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 a half from the middle of the projection
of the sacrum to  the symphysis of the pubes.
  The inferior strait in both  these pelves is very large. 
(  52  )
           Explanation of tJie 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 sacro-iliac symphyses.
  g, The symphysis of the pubes.
  h, h, The foramina ovalia, 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 su-
perior strait.
  A, A,  From the pubes to the projection of the sacrum,
in the natural state of this pelvis, two inches two lines.
  B, B, The transverse diameter, three inches eight
lines.
  C, C,  From the middle and left side of the projection
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  projec-
tion of the sacrum, to that part of the margin which an-
swers 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. 
re
 
 
                Of the Soft Parts, Sfc.              58


      Of the Soft Parts connected with the Pelvis.

   106.  The  accoucheur would  have but an imperfect
knowledge of the pelvis, if, after having studied it in  the
skeleton, he should not consider it in conjunction with
the soft parts which surround it on all sides; since some
of these latter  cause great  changes in its form and di-
mensions; 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 dur-
ing pregnancy,  that he can  explain the greater part of
the phenomena which occur in that period, and during
labour.
   107.  The pelvis, making part of the abdominal cavi-
ty, is bounded superiorly by the diaphragm, which sepa-
rates  that cavity from the breast; behind, by the spinal
column, the quadrati muscles,  and others; before,* and at
the sides, by  the abdominal muscles, &c.  These latter
have too much influence on the mechanism of labour,
for us not to  take notice, at least, of their principal at-
tachments, 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 cristas of  the  ossa innominata, form-
ing three distinct planes by  the direction of  their fibres:
those of the external plane  descending more or less  ob-
liquely from  behind forwards; those of the second  as-
cending from before backwards; and  the fibres of  the 
54                Of the Soft Paris
 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  Poupart's liga-
 ment, and the inguinal ring; that of the  internal oblique
 divides  into two  layers, one of which unites  itself inti-
 mately 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 de-
 scend 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 immediately
 to the peritoneum, and is covered externally by the pyra-
 midal 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 junc-
 tion  of  the  aponeuroses  of the oblique  and  transverse
 muscles  of each  side;, but whose fibres  are so crossed
 and interwoven, that those of the external 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 symphy-
 sis 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, es-
 pecially at the  height  of the umbilicus;  and sometimes
the  umbilical  ring is singularly open.  We observe also 
               connected with the Pelvis.            55

that the linea alba is then very thin; and that its sepa-
rated fibres leave in many places considerable meshes,
which have  sometimes given  birth to certain hernias.
The abdominal muscles, independently of their uses re-
lative to the motions 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 contributes.
   110.  In order to mark the place which nature has de-
signed to each of the viscera of the abdomen, of which I
shall here only enumerate the  names, it is proper to re-
collect the names of the different regions of that  cavity.
We reckon three principal ones: viz. one superior, call-
ed  the  epigastric; one middle, the  umbilical; and one
inferior, the hypogastric: we  may estimate the  extent of
them by drawing two transverse lines from  one side  of
the abdomen to the other, at two fingers' breadth  above
and below the umbilicus.   Each of these regions  is sub-
divided into three others; one middle, which  is  called
the principal  region;  and two lateral,  known by  the
names of hypochondres, lumbar and iliac regions.
   111.  The  stomach, the liver, the spleen, the  duode-
num, and the pancreas,  occupy the first of these prin-
cipal regions; the greater part of the small intestines, the
colon, almost the whole of the omentum, the kidneys, and
their dependencies,  are  situated in  the second.  The
other contains the caecum; a portion of the ilion and of the
colon; some of the parts of generation; and others  which,
having a more immediate 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 former, whose
fibres are as it were  radiated, covers the iliac fossa; and 
59
Of the Soft Parts
the other descends from the lateral part of the lumbar
column, over the side of the superior strait and above the
acetabulum, where they join and unite themselves strict-
ly, to be inserted  together into the little trochanter: the
psoas, in this course, narrows at the entrance of the pel-
vis 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  emi-
nence, called ilio-pectineus.
   113.  Behind, and in  the substance of the psoas  mus-
cles, are found the nerves which form the obturator and
the crural, as well as other branches furnished by the
three first  pair of lumbar nerves, especially by the  first;
which, following a different course,  are lost in the tegu-
ments 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  aug-
mentation  of the  volume of the belly, that we are to
attribute the 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 ob-
turator nerves  suffer before their exit from  the ab-
domen, that weakness of  the inferior extremities, which
makes most pregnant women  so apt  to fall  on  their
knees, or the breech, and  makes  their gait so  unstea-
dy; for  these accidents cannot depend entirely on the
alteration of the centre  of gravity during pregnancy. We
know that the obturator and the crural nerves are formed
by the union of several chords which are derived  from
the second, third,  and fourth pair of lumbar nerves; that 
                connected with the Pelvis.            51

 the obturator goes out of the pelvis at the posterior and
 superior part of the foramen ovale, to be distributed to
 the muscles of the inside of the thigh; that the cniral
 passes out  under the  ligamentum Fallopii, where it di-
 vides into a great number of branches, some of which go
 as  far as the foot.
    114. Before the last lumbar vertebra, and frequently
 before the fourth, we remark the bifurcation of the aorta,
 and of the  vena cava  inferior;  and  soon after the divi-
 sion 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 de-
 scends into  the pelvis, to rise  again  at  the side of the
 bladder and umbilicus, forming a curve from which arise
 the obturator 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-i/zac,  or hypogastric.
 The veins are distinguished by the same names.
   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 acquires 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  sacmm by a very loose
 cellular tissue, in which we mark the sacral and hemor-
rhoidal vessels, the  extremity of the great sympathetic
nerves, and  especially the sacral nerves.
  116. These latter, to the number of five pair, pass out
                         H 
58                Of the Soft Parts
of the canal of the os sacrum, through  the  holes which
have  already been remarked in its interior face.   The
three first pairs, with a cord from the two last lumbares,
are almost entirely employed in forming the sciatic nerves,
which are  distributed through  the whole extent of the
inferior  extremities, after passing out of the pelvis at the
ischiatic notch.  The fourth and fifth pairs go only to the
parts within the pelvis, to some of the muscles which sur-
round 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 convulsive 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 sacro-ischiatic
ligaments, and the ischio-coccygei muscles.   A littie for-
warder  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 ges-
tation it is almost always found entirely above those bones;
and  the ureth/a 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 peritonceum.
   121.  A great number of muscles, of  which some be-
long to  the thighs and legs, others to the back, loins, and 
connected with the Pelvis.
59
arms, are attached to the outside  of the pelvis.  These
muscles,  and much more those of the abdomen,  by act-
ing on the pelvis, and drawing it sometimes to one side
and sometimes to the other, according to circumstances,
may change the direction of its  axis a little,  relative to
that of the body; and may in another manner also affect
the mechanism  of delivery.
   122. The teguments and the cellular membrane, more
or less loaded with fat,  according to the lustiness of the
woman, form a common covering to the hard and soft
parts which we have comprised under the name of pel-
vis.  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 ex-
ample, that the  cellular membrane  is always  pretty thin
behind, in the places which answer to the spiny tubercles
of the false vertebral of the sacrum, whatever may be the
lustiness  of the  subject.  We know that the teguments
present several large openings on the outside 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 extremities 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 perinasum becomes
extremely tight; which renders the  development of that
^>art more difficult, as well as that of the vidva;  and re-
tards delivery, at the same time  exposing  the fourchette
and the  perinasum itself to be more torn.  We  see, ac-
cording  to  this observation,  that we ought at that mo-
ment to  keep the woman's  thighs,  at  most, moderately
bent and separated, &c 
60           Examination of the Pelvis.


Of the Examination  necessary to discover whether the
             Pelvis is well or informed.

   123. No one can be acquainted with certain funda-
mental truths of the art of Midwifery, without knowing
all the importance of this examination: but its difficulties
are only perceived  by those obliged to  make these re-
searches; and a frequent exercise 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 demonstrated
all the necessity of it,  with respect to deformed women;
and if those women had submitted  to it before  they en-
gaged in marriage, we should probably still have been ig-
norant of those sad  resources of our art, which have had
so  many victims for a few mothers and  children which
they  have saved from certain destruction.   What wo-
man 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 operation,
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 object,
it will appear equally important:  whether the question be
of a young woman, whose external deformity gives occa*'
sion  to fear concerning the state of the pelvis; or of a
married woman ready to lie in, or whose labour is begun
—the accoucheur becomes, in some sort, the arbiter of
her destiny;  and his decision may affect the life of one 
             Examination of the Pelvis.           61

or of several individuals.   The more distressing the con-
sequences 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 defect in  the  form
and dimensions of the pelvis.  It cannot be determined
by inspecting the spinal column; nor by the irregularity
of the inferior extremities, 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 de-
formities does not always affect the form of the pelvis so
as to render delivery impossible, or even  difficult; and,
on the other side, we have seen these deformities manifest
themselves in infancy, disappear in youth,  and the pelvis
alone retain  the impressions of the rickets which had
produced them: so that  many crooked women may be
delivered  naturally; while others,  who enjoy  the finest
external proportions, cannot have the same good fortune,
the narrowness of the  pelvis producing obstacles insur-
mountable by the common agents of delivery.  There is
no rock on which these external appearances, favourable
or unfavourable, have  not thrown the unskilful practi-
tioner.  His security, in  some cases where he had per-
suaded himself that the pelvis was well formed, has suf-
fered some women 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 required a little dex-
terity on his part.  It is not only the forceps which have
been abused in these latter cases, but the  Cesarean ope-
ration, and  much more still the section  of the pubes 
62
Examination of the Pelvis.
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 favourable
moment to  operate; the  apparatus  was  prepared; the
woman was ready to place herself on the  couch; twelve
or fifteen persons, as well  physicians as surgeons, were
going to be witnesses of this afflicting scene; when touch-
ing the woman for the first time, I declared strenuously
that she would be delivered naturally, and without diffi-
culty; as actually happened two  hours afterwards, and the
child was strong and healthy.
   126.  The consideration of the external form of the
pelvis may be very useful to us  in the examination which
I am going  to describe: for the negative signs of a good
conformation are so  many indications 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 posterior
part of the sacrum; an extent of four or five inches from
the centre of that depression to  the extremity of the coc-
cyx; a thickness of seven or eight inches in women mode-
rately 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 con-
formation.   An irregularity of the hips, whether in their
roundness or elevation; a distance much smaller than that
which  I have  assigned between the  superior anterior
spines of the oss,a ilia;  a too high or too flat form of the 
Examination of the Pelvis.
63
pubes; too deep a fall in the small of the back; a great
convexity of the sacrum behind;  an inflection of the lum-
bar 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 superior parts
of the sacrum  more sunk in.  The inferior 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 trans-
versely, the region of the pubes is salient, instead 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 appears 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 insufficient,
and cannot enable  us to determine the degree of opening
 which a  deformed pelvis presents interiorly.  However
 experienced we may be, the application of the hands ex-
ternally will  never  inform us sufficiently to  determine the
choice of the  means  proper to be used for terminating
the delivery 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 mistakes.  It is easy,
especially, to determine the length of that diameter of the
 superior  strait which goes from the pubes to the sacrum, 
64
Examination of the Pelvis.
 the only one which is generally defective  respecting de
 livery.   Many instruments  are used for measuring it,
 which are so many kinds of compasses, some of which
 are developed within the pelvis, and some without; I pre-
 fer one of these  latter, which  I call compas d'epaisseur
 (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 subjects;  and  because  the result of it
 has appeared to me more  certain.
   130. To determine how much the superior strait is de-
 fective in the aforesaid diameter, and measure it by means
 of these  compasses, we take  the thickness of the woman
from the middle of the mons veneris to the centre of the
 depression of the base of the sacrum posteriorly, by apply-
 ing one of the points of  the instrument before, against
the symphyses of the pubes;  and  the other behind, a lit-
 tle under the spine of the  last lumbar vertebra;* and de-
 duct 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 contracted in all manner of ways;
 and  in all possible degrees.  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 may  add one or two lines more when
 it is excessive, because the fat which forms the mons vene-
 ris easily shrinks  under the  lenticular extremity of  the
 leg of the  compasses.   The  result of this procedure is
                  * See the Sixth Plate. 
Examination of the Pelvis.            65
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 experi-
ments.  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 de-
pend on a line more or less in the diameter of the pelvis.
According to these data,  the knowledge of this diameter
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 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 developed
within the pelvis,  have often presented a result 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
parts 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, concerning whom their doubt-
ful parents may consult us  before marriage;  nor even in
married women, except in time of labour.
   132.  The fore finger likewise introduced into the va-
gina, and properly directed,  may equally serve to make
known  the  length of the little dianieter of the superior
strait; and the knowledge of it is the more easy to obtain,
as the pelvis is more  contracted.  We  advance the ex-
tremity of this finger to the middle of the most project-
ing part of the base of the sacrum, near its junction with
                          T 
66
Examination of the Pelvis.
the body of the last lumbar vertebras;  and, by raising the
wrist, we apply the radial edge of the same finger to the
inferior 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
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 versed  in these exami-
nations, 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 in-
ferior 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 delivery.  Though the external dimen-
sions of the pelvis cannot demonstrate the transverse  dia-
meter of the superior strait, and though the finger intro-
duced 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 obstacles 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 mea-
sure the transverse  diameter from one iliac notch to the 
              Examination of tlie Pelvis.           6 7

other,  that is to say,  between the most distant points of
the superior 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 transverse 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 deformed pelves, and that in many it pass-
es under the projection of the base of that bone.   If the
transverse  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 as-
signed, but nevertheless always  greater  than the antero-
posterior diameter.
   134. We discover  the extent of the diameters of the
inferior  strait,  within  a very trifle, by feeling externally
till we can clearly distinguish the ischiatic tuberosities, the
point of the coccyx, and the inferior edge of the symphy-
ses 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 ac-
count of the great number of muscles which are attached
to them, and the direction of those muscles: but  we dis-
cover 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 tube-
rosities 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 dis-
tance between the fingers which touch the ischiatic tube- 
68
Examination of the Pelvis.
rosities, 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 measurement;
and sometimes five or six lines, when the bones are very
thick.
   135. As often as the condition of the subject to be ex-
amined 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  circumstances were sufficiently
favourable to permit it; as, for example, in time of la-
bour.   This procedure conducts us more surely still to
the knowledge of the pelvis, since it enables us to disco-
ver things which cannot be perceived by simply examin-
ing the  outside of this part; such as exostoses, whfch
sometimes affect it, &c.  By thus examining the inside 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 superior strait, as I  have already
explained.  In the same manner we may measure the
distance of the coccyx from the symphysis  of the pubes,
by keeping the radial edge of the finger against the in-
ferior 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 measured
 by the length of the sacrum; at the sides, by taking half
 the height of the ossa ilia  from  the anterior 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 
 
''.M'j.
WO






  *,0 if
+s 
           Explanation of live Sixth Plate.          69

example, if the former is eighteen lines, and the lateral
depth of the pelvis is three inches 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-meler of M. Contouli, and my calipens.
   Fig. I. A, A, A, A, The four last lumbar vertebras.
   B, B, B, The os sacrum.
   C, C,  The coccyx.
   d, d, Surface resulting  from the section  of  the  sym-
physes 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, 
70         Explanation of the Sixth Plate.
   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.*
   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 com-
prised between the branches.
   Fig. III.  The pelvi-meter of M. Contouli developed in
the pelvis.
   A,  A,  The first branch, whose  square, B, is applied 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 scrupulously 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.

   * This  scale  is contained in a deep groove cut lengthwise in
the branch of the calipers, from  the letter e  to the hinge B; and
passes through a mortise made in the other branch, under the
letter/. 
Female Parts of Generation.
71
Of the Parts of the Woman concerned in Generation and
                      Delivery.

   138. These may be divided into external and inter-
nal: the external are the mons veneris, the labia pudendi,
the sinus called the vulva, the nymphas, the clitoris, the
urethra, the orifice of the vagina, the hymen  in virgins^
the carunculas myrtiformes, the fourdtette, and the fossa
navicularis.  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 be-
fore  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 con-
trary, pale  in  those who have had children.  Their ex-
ternal face  is  covered with hair at the age of puberty.
The  labia pudendi, in their natural state, have  only a
very narrow chink between them; but, when we  sepa-
rate 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  nymphas\
which are  two bodies narrow and close at their origin,
but separate as they recede backwards, so as nearly to
represent  a pair of compasses  moderately extended.
They serve to direct the urine downwards, and also serve
to augment the entrance of the vagina when the head of
the child is about to pass it. 
 72             Unimpregnated Uterus.
  ■ 142. Above the nymphas a semilunar fold is perceived
 which hoods the clitoris; this part is extremely sensible,
 and supposed to be the seat of venereal pleasure—the cli-
 toris 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 nymphas we discover the uri-
 nary passage; this is  the extremity of the urethra,  it is
 shorter in women than in men, although its structure dif-
 fers very little from it.  It passes under the symphysis of
 the pubes, and rises obliquely backward  to the bladder.
 Its direction  is altered by pregnancy, so that at the lat-
 ter periods, it rises almost perpendicular behind the sym-
physis, and sometimes even a little curved over it.
   144. Below the orifice of the urethra is found the en-
 trance of the  vagina.  This opening is bordered by the
 carunculas myrtiformes in women,  and in virgins by the
 hymen.  A little below the hymen we find a  semilunar
 fold called the Jourchette; this for the most part is destroy-
 ed by labour.   Between  these two we remark the fossa
 navicularis.
   145. The  perinasum is the space  between the vulva
 and anus.  It is about two fingers in  breadth, in the na-
 tural 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 important
work of generation, is almost always  performed.   This 
                 Unimpregnated Uterus.              73
fleshy, vascular, and  membranous viscus,  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, or thereabouts;  its breadth  is
from eighteen to twenty-four lines, and its thickness ten
or twelve only.
   148. It is distinguished into/imo'tts, body,  and neck.
The fundus comprehends all that part above the inser-
tion  of the fallopian  tubes; the body is immediately be-
low it, and extends to the narrowest part of this organ,
where the neck commences; this  latter terminates in the
vagina, forming a kind of large nipple, which has some
resemblance to the mouth of a tench.*   The uterus, con-
sidered externally, presents  two faces, both a little con-
vex: three edges, one of which forms the fundus, and
the other two the  sides: lastly, three angles;  that  is to
say,  two superior and  lateral, where the fallopian tubes
enter; and one inferior, which projects into the vagina,
and  is called the os tineas.   Excepting this last part, the
uterus is  covered by  the pentonosum  through its whole
extent; and this membrane adheres to it so closely, that

  * The division of the uterus here spoken of, has been made for
mere convenience; but we have for many years past looked upon
them as essential to the well understanding of the functions of this
organ; as  we regard them as possessing distinct  actions, and en-
joying separate  and independent powers.  Thus  the fundus may
be in a state of relaxation, while the other parts may be in a state
of contraction; it may be in a state of contraction, while the others
are in a state of atony; and so on with the other parts.  Without
making these distinctions, it would be impossible to explain a variety
of phenomena presented  by pregnancy and delivery. See this sub-
ject more fully treated in " Essay on the Means of Lessening Pain
in certain Cases of Parturition," by W. P. Dewees, M.D.—W. P. D.
                            K 
74             Unimpregnated Uterus.
it seems to enter its very structure; though it only enve-
lops it  in its duplicature, as we observe with respect to
the other viscera.
   149.  When the uterus is unimpregnated, we cannot
absolutely determine what is the order and arrangement
of its fibres,  they are  so  inextricably interwoven.   It
would be as difficult also to know their nature,  if their
common properties with muscles had not often manifest-
ed 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.
   150. On opening the uterus longitudinally,  we dis-
cover its cavity; and may estimate the  thickness of its
parietes, which in general is but three or four lines: its
substance appears spongy, and as it were diploical, in the
fundus, and through the whole  extent of its body; but
denser  and closer in the neck, 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 dis-
tinguish them from each other, and to describe them se-
parately.   That of the body is of a triangular 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  membrane,
which adheres as strongly to the substance  of the uterus,
as the peritonasum which covers it exteriorly.
   153. This  membrane is so porous, that it appears,  as
it were, reticular.  The most considerable of these open-
ings lead to winding cavities, called uterine sinuses; and 
                Unimpregnated Uterus.             75
others to folliculi or glands, which furnish 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 absorbing or exhaling vessels.   These
latter are equally distributed throughout; but the first are
more numerous 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  mid-
dle 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 into  the vagina by a little trans-
verse 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 tineas seems about  four or five lines long
before, and a little more, backward; its thickness 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 ap-
pear thicker than the other.
   156.  Pregnancy and delivery commonly so efface these
characters, that the os tineas  is entirely different  in wo-
men 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, festooned.
   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 the
branches go backward and forward, making an infinite
number of convolutions round themselves, forming a great 
76             Unimpregnated Uterus.
number of areoke and anastomosing with each other;
that is to say, the spermatics with those which come from
the hypogastric, 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 ves-
sels, known by the name of  sinuses.   The sinuses form,
as it were, so many reservoirs, where the blood deposited
by the arteries is reabsorbed by the veins, which  return
it into the circulating mass.
   158. We cannot doubt  of the existence of lymphatic
vessels in the uterus; but  their source and 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 inter-
costal, and the sacral nerves.   Considering these nume-
rous sources, and the communication of these nerves, we
ought not to be surprised at  the extraordinary 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 Paiis dependent on the Uterus.

  160. The parts dependent on the uterus, are its liga-
ments, the fallopian tubes, the ovaria, and the vagina 
           Parts dependent on the Uterus.         77

  161. There are four principal ligaments, two broad,
and two round; the two former are folds of the peritonosum,
which seem to 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 fallopian tubes are enveloped,  and at their infe-
rior the ovaria—their use is to fix the uterus in the cen-
tre of the pelvis.
  162. Through the cellular membrane which connects
these two folds of the peritonosum, the different 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 ligaments  bend towards
the pubes,  and pass out through the rings  in the oblique
muscles: they divide into many branches; and, forming
a kind of crow-foot, lose themselves in the cellular mem-
brane, 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 ligament—they are also
folds or  duplications of the peritonosum; their use the
same as the broad ligaments.
   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 nar-
row a  little, and then  dilate again:  they  terminate in a
kind of expansion, which is bordered by a fleshy fringe. 
78
Parts dependent on the  Uterus.
This extremity is loose and floating in  the cavity of the
pelvis.
   166. The structure of the tubes appears to be abso-
lutely the same as that of the uterus;*  like that they are
enveloped by the peritonasum;  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 order  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 wo-
man is fruitful; and,  according to some authors, are mark-
ed 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 necessary
for generation;  and that to deprive animals of them, is
sufficient to take away from them the faculty of propaga-
tion.
   169. The tubes, the ovaria, and the ligaments of the

  * The propriety of this remark may be very justly challenged,
since the functions of the two parts are so very different. We are
certain, (as far as similarity of function  at least can prove identity
of structure,)  that the lining membranes are not the same in both,
since that spread through the tubes have never been known to fur-
nish the menstrual discharge.—W. P. D. 
            Parts dependent on the Uterus.          79

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  different branches go to their
destination.
   170.  The vagina  is a membranous  canal, naturally
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 returns to  its natural state when the causes of
its alteration cease to act; which proves that its  texture
is very elastic.
   171.  The anterior part of the vagina is much shorter
than the posterior, because that canal is a little curved
towards the pubes, and its two extremities 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 tineas, 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  con-
strictor muscles.   The plethora and  swelling of the for-
mer, joined to the contraction 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 mem-
branes; of which the  internal, much more extensive and 
80         Parts dependent on the Uterus.
of a closer texture than the other, forms an infinite num-
ber of folds  or wrinkles, which singularly diminish the
capacity of that canal: while the external is merely cel-
lular.  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 considerable
blood-vessels; and there we find a great number of glands,
which secrete  the mucous liquor 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 cel-
lular membrane, with  the canal of the urethra, with the
lower part of the fundus of the  bladder,  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 sensi-
ble from one month to another at the beginning of preg-
nancy: but it becomes so large in the sequel, that it is dif-
ficult 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 
Gravid Uterus.
81
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 direction
during pregnancy,  in proportion to the augmentation of
the produce of conception; yet all its diameters do not
increase in the  same proportion in  every period, whether
in respect to themselves, or to the foetus.   The longitudi-
nal axis of this viscus increases  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 first two
months, and very small in the latter.
Of the  Changes which Pregnancy produces in the Vo-
      lume, 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 necessary 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 enlargement for the foetus, and  its ap-
purtenances. 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.
                          L 
 82                 Gravid Uterus.
   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
 tineas 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 utems, which
 obliges them to unfold so rapidly, that the neck is effaced
 completely in two months.  If the  uterus  enlarges  still
 more after this period, it is entirely at the expense of the
 fibres of the neck,  which so arrange themselves as not
 to be thicker sometimes at the orifice, than two or three
 folds of common paper.
   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  period 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 pro-
 per 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 support  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  unfold at the time intended by nature;
either because the fibres of the superior parts are  more
extensive and less irritable than usual, or because  the
neck is affected by a scirrhous hardness. 
Gravid  Uterus.
83
   183.  This double assertion is not, as some may ima-
gine, 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  entirely owing to the feeble organiza-
tion, either natural or accidental, of the neck of the ute-
rus.
   184.  When we  compare the utems at the approach of
labour with  what it was before pregnancy, 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.
According to M. Levret, the solid mass of the utems in
its natural state, or  in a state of  vacuity, is about 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 1H.*
   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 ca-
pacity, 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 thickness, others have maintained
that that thickness diminishes insensibly from the first pe-
riod of gestation to that of labour; and some, of an ab-
solutely contrary opinion, assure us that, far from dimi-
nishing, it  augments in the same  proportions as the ute-
rine cavity  becomes larger.
*  L'Art dee Accouchemens, troisieme edit. 390. 
84
fciravid Uterus.
   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 endea-
voured 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 individual, there are accidental ones, which depend on
the smaller or greater degree  of dilatation, in each preg-
nancy, 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 exa-
mine  that viscus in the state of its greatest dilatation,  that
is to say, before the waters of the amnion are evacuated;
for that thickness augments in proportion as it contracts,
and its cavity diminishes, 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 al-
ways thinner, than  its  natural state.  The place where
the placenta is attached, is always that where the thick-
ness of the parietes of the uterus is the most considerable;
and the  vicinity of the orifice  that where it is least.  If it

   * We believe this discrepancy of opinion has in a number of in-
stances arisen, from the nature of the disease of which the woman
has died who was examined, and especially the cases of  those who
have declared  that it becomes  thinner and thinner, from the mo-
ment of conception, to the full period of utero-gestation.  We think
it more than probable, that the  declaration of its becoming thinner
from pregnancy, has arisen from the examination of women who
had died of uterine hemorrhage, as in those cases, the uterus is uni-
formly found thin, because it is entirely deprived of blood.
                                                W. P. D. 
Gravid Uterus.
85
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 ori-
fice is often no thicker than two or three folds of writing
paper.
   188. If it is demonstrated that the parietes  of the ute-
rus 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 develops 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 pregnancy, and per-
mit 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 recognise in
them all the  appearances of muscular  fibres: like them
too, they are extremely irritable and capable of contrac-
tion.
   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 degree. 
S6                 Gravid Uterus.
    192.  If that dilatation is not observed  in all the re-
 gions of the uterus where there are sensible vessels, 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 reoeive the end of the little  finger, and the others  a
 moderate  sized quill.  It is not only the  sanguine ves-
 sels which are developed to that degree during pregnan-
 cy: the  lymphatic vessels are much more so, in propor-
 tion to their primitive diameters; since, according to Mr.
 Cruikshank, they become as large as a goose-quill; and
 besides appear so numerous, that the utenis 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 reser-
 voirs, which  communicate 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 natural ef-
 fects of the development of the uterus  during pregnancy,
 its contraction at the moment of delivery produces others
 not less interesting, since they furnish us with useful re-
 flections  in practice.
   195. In proportion as the  cavity of this viscus dimi-
 nishes, the vessels fold  and become convoluted as they
 were before impregnation; they suffer a compression not
 only so much the stronger, as the action of the uterus on
 the contained body is more powerful, and as that body
gives a greater resistance; but also as  it approaches nearer
to its natural state. 
Gravid Uterus.
87
   196.  During this  time the blood flows with more dif-
ficulty 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 transmit less into  the
parts indicated in par. 193.
   197.  The blood passes with so much difficulty in  the
arteries of the utems when the labour becomes strong
and lasting after the  evacuation of the waters of the am-
nion, that all communication seems to be intercepted be-
tween that kind of vessels and the sinuses in which they
partly terminate; and between the sinuses themselves and
those of the placenta: so that the child can be no longer
vivified  by the blood of the mother, nor is there any con-
siderable flooding to  be feared if the placenta should be
detached;  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 de-
livering 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 followed by most accou-
cheurs  before his   time, in cases of  violent flooding.*
They serve equally for the base of an enlightened theory
on the  origin and natural cessation of the sanguine and
serous lochia, and for the explication of several other ef-
fects which I  shall speak of in the sequel.

   * Voyez POuvrage de Puzos, Memoire sur les Pertes de Sang. 
88                Action of the Uterus.
               Of the Action of the Utems.

   199. The uterus, very sensible and very irritable, 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 mo-
mentary.*  By the former, when it is distended it  con-
stantly endeavours to restore itself to its original state;
but it is by the latter that it acquires the force necessary
to overcome the obstacles  to that restoration, and to de-
liver itself  of the  bodies which encumber  and incom-
mode it.
   200. The tonic action of the uterus, or  its elasticity,
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 ;f and it is likewise proved by the con-
traction of the uterus,  which takes place as quickly and
strongly as  after the most common labour, when we  ex-
tract its contents at the instant life ceases.J   If we have

  * We should constantly prefer the term alternate to that of spas-
modic, as the latter constantly presents the idea of pain being es-
sential to labour.  We have combatted this opinion elsewhere, to
which we beg to refer. Med. Museum, vol. i. p. 274.—W. P. D.
  t Many authors assure us, that some women have been sponta-
neously 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 my-
self 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.
  % M. Le Roux, surgeon of Dijon, perceived, in delivering a wo-
man who had been dead about a quarter of an hour, that the uterus 
Action of the Uterus.               89
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 des-
troyed.  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 ex-
haustment; or, in one word, of syncope, to make use of
the expression 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 stimu-
lating 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 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 of that viscus, or only one.   Some-
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 pro-
ceeded 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 delivered 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.
                           M 
90
Action of the Uterus.
times 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, afterwards; it may go off and reap-
pear 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 delivery,
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 consti-
tution in the woman; an haemorrhage from the utems
itself, which sometimes precedes or accompanies labour;
an extreme dilatation,  when the  uterus  contains  much
water, or several children.  It may be the effect of strong
and  long continued  labour  pains,-^because  the forces of
the uterus may be exhausted,  as  well as those of other
organs; and a sinking  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 torpor and relaxation, which for a time
suspend its contractile faculties*
   204.  This state  of uterine syncope is  more or less

   *  To these causes we may very properly add another, which per-
 haps is more common than either stated in the text, namely, the re-
 prehensible hurry in delivering the shoulders after the escape of
 the head through the external parts, and thus not permitting time
 for the uterus to contract and expel them.—W. P. D. 
Action of the Uterus.
91
troublesome and dangerous, as it continues a longer or
shorter time; as it affects all the parts of the uterus, or
only one; and as the placenta preserves more or less of
its connexions with that viscus.   The  atony whose re-
mote cause is an haemorrhage which has preceded labour,
is more dangerous than that which arises from the quick
and  too sudden evacuation of the contents of the uterus.
In this latter case there is nothing alarming while the
placenta is not detached in  any part;  but  it may have
consequences equally dangerous, if that body should sepa-
rate before the forces of the uterus he  sufficiently re-
stored.  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 lat-
ter, 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 can-
not  take  place unless the placenta be detached, 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 aug-
mented by the labour pains which have preceded it* The
haemorrhage is not always apparent:  the blood sometimes
is retained in the uterus; and may so far dilate  it, as to

   *  A woman lost  before my  eyes,  and  in presence of at least
thirty-five of my pupils, more  than four  pounds of bjood in the
 short space of three or four minutes, notwithstanding the prompti-
 tude with which she was assisted: the coagulum collected 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, without the toast inconvenience. 
*   92
Action of the Uterus.
give it nearly the capacity it had before  the exit of the
child*
   206. A concealed  haemorrhage is more usual when
only the body and fundus of the Merits 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  formed, 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, and
a little firm to the  touch; as also if the woman exerts
strong efforts to expel it, while that viscus is soft and in-
active.
   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;f 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 treat-

  * In the woman whom I mentioned in one of the former observa-
tions, though at the seventh day of her lying-in, the extravasation
of blood in the uterus was  so considerable, that its fundus rose
above the umbilicus.
  t This direction is of the greatest importance in cases where the
delivery has been  sudden,  or the woman  much exhausted; and
should be immediately employed before any attempt whatever is
made to deliver the placenta.  We shall have occasion to advert
to this practice as a remedy, when our author speaks  of uterine
hemorrhage.—W. P. D. 
Displacement of the Uterus.            93
ment; 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 pro-
duced by an irritating cause unknown to us; and, unlike
that of most of the muscles, is not subjected to the will:
no woman can augment its force, or diminish it;  accele-
rate 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 equally disposed; nor equally
numerous in those  two parts:  each fasciculus, taken se-
parately, seems to act with the same degree of force.
 Of the Descent or Prolapsus of the  Uterus, of its Retro
                version, 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 presents a greater sur-

  * We believe what our author calls the " spasmodic contraction"
of the uterus, to be a very different condition of the muscular fibres
of this organ from other muscles of the body affected with this affec-
 tion. We have already said we prefer the term alternate contrac-
tion, as we are of opinion that it is merely an exalted degree of the
 same power that produces the tonic contraction.—W. P. D. 
94
Displacement of the Uterus.
face to those same viscera, which renders their  impul-
sion stronger, as because its weight becomes specifically
greater.  It not only descends farther at every impulse
it receives, to rise again afterwards; but in  general we
find it habitually lower in these first periods of gestation
than it was before; and we observe that its fundus is al-
most always  inclined  backward, and its orifice  turned
forward.
  210. The accidents which arise from this first species
of deplacement,  are in proportion to its extent, and the
volume of the uterus relatively to the capacity of the pel-
vis.   A sensation of heaviness at 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, low-
ness, and faintness supervenes, if the uterus descends fat-
ther; 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 remaining 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 re-
tention of urine, a  constipation, and other accidents which
will arise from those, as well as from the pressure which
the uterus must exert on the other circumambient parts.
  212.  It is not only in those cases where the uterus is
thus developed in  the midst of the pelvis, that it occasions
a retention of urine; the same  accident may happen  if 
             Displacement of the Utems.           95

the uterus, less voluminous, descends so far as to engage
itself very forward in the external parts,  and show itself
without.   This case, more easy to  distinguish than the
former, and in appearance 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
slowly, and  it is very rare that it takes place before  the
fourth month of pregnancy.   At first the woman only
finds a little difficulty in making water; and greater  ob-
stacles succeed, by insensible degrees, till the retention
becomes complete.
   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 assis-
tance 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 deve-
loped that it cannot descend again into the pelvis; which
generally does not take  place till after the fifth  month of
pregnancy,  and sometimes 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 
96           Displacement of the Uterus.
midst of the pelvis, in the first periods of impregnation,
notwithstanding the augmentation of its volume, and the
inclination which it takes in sinking a little, expose it to
another species of deplacement, less known and more rare
than the prolapsus; but whose consequences have hi-
therto appeared more disagreeable.   In this new species
of deplacement, the utems seems to be laid  lengthwise,
between the pubes and  sacrum; but so that its fundus
sometimes remains  a little higher than its orifice, and
sometimes much lower, or appears on the same line; which
constitutes so many degrees necessary 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 anteversion,
that in which the/tmeftts 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 anteversion cannot become so con-
siderable as the retroversion: 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 deplace-
ment; 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 ne-
vertheless to prove, that  this inversion 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 preg-
nancy five months/
                 *  Smellie, trad. Franc- 
              Deplacement of the Uterus.           J?

  218.  This inversion may take place slowly or sudden
ly;  and the determining causes are then different.  In the
former case, we may observe its progress from day to day,
or from week to week,  and it  arrives  insensibly at its
highest degree; in the latter it becomes complete in less
than an hour, and often in an instant.
  219.  When it takes place slowly,  it seems to depend
on the slight but continued pressure of the floating abdo-
minal viscera on the fundus of the uterus; either on its
anterior or  posterior part, according to the species  of
obliquity it  has  taken; so that  this  pressure sometimes
occasions the anteversion, and  sometimes the retrover-
sion.   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 ab-
dominal muscles, or by external agents.  The iderus 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 compression of
the belly.   Some of the accidents produced by  this de-
placement soon  add to its  first causes, and render  it
more considerable, as I shall have occasion to remark in
 par. 225.
   220.  The accidents which proceed from the retrover-
 sion 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 natural size, whether itsfun-
 dis be  turned towards the sacmm 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
                           N 
98            Deplacement of the Utems.
about the neck of the bladder, and rectum, which excites
frequently an  inclination to  make water  and to go to
stool.  These symptoms augment in proportion to the
efforts the woman makes to  overcome  the obstacles
which oppose the evacuation  of the urine and fasces.  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 the
uterus is inverted, when it is  plethoric and tumefied, or
when its volume is augmented by pregnancy; because it
then acts with more force on  the neighbouring parts, and
is  itself  more incommoded.   If the  painful draggings
which we have just mentioned 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
uneasy sensations in the bladder mdrectum are stronger;
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 inverted in the third
or fourth month  of pregnancy: because 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 
              Deplacement of the Uterus.            99

inversion of the uterus  takes  place gradually, 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 deplacement,  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 so far effaced as no longer  to  permit
the discharge of urine, or of the most liquid fasces.  It may
happen, in these circumstances, that the catheter cannot
penetrate the bladder, and it may be equally impossible
to administer clysters.
  224.  The utems, already, as it were, wedged in  the
middle of the pelvis, when the accidents are increased to
this pitch, is wedged much more strongly in it in the se-
quel, if we do not speedily effect  the  reduction.   Conti-
nuing to be developed, because its contents continue to
increase, and  not being able  to  do  it according to  the
order in which that development  is made in the common
state of pregnancy, it moulds itself to  the form of the
cavity of the pelvis, extending itself  towards those parts
where it finds the least resistance.   The  augmentation
of its volume, in this latter period, does not only depend
on the  farther development of the produce of concep-
tion; it proceeds also from the  tumefaction of its sub-
stance, which becomes  full and inflamed.   As the space
which the utems then  occupies is greater than the su-
perior strait;  as it completely fills that space, and even
finds itself compressed there; the  reduction of it becomes
extremely  difficult, and may even be impossible; because 
100           Deplacement oftlve Uterus.
the length of its diameters exceed those  of the superior
strait*
   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
viscus, already depressed towards the sacrum, at least
with a force equal to the weight of the urine it contains;
and that weight may amount to more than ten or  twelve
pounds in some cases.  The fasces, retained and accu-
mulated in the upper part of the rectum, above that por-
tion 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 fasces
receive every moment 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

   * In one of the interesting observations of Dr. Hunter, inserted
in the fourth and fifth volumes of the Medical Observations of Lon-
don, we find that the uterus could not be reduced; 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 form-
ed the beautiful collection of Dr. Hunter. 
             Deplacement of the Uterus.           101

case of anteversion; for they seem  rather to concur  in
restoring the uterus to its natural  position than in re-
moving it farther from it;  which may be easily perceived
by the slightest attention to what is  stated in the pre-
ceding paragraph.
  227. Although the  abovementioned accidents are so
many symptoms of those deplacements of the uterus call-
ed  retroversion  and anteversion, they cannot 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 that we  can certainly
discover these deplacements, and judge of the  extent of
each species: at a little 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 sur-
face 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 fundus resting against the sa-
crum, the  orifice answers to  the pubes;  in the former,
the orifice is backward, and it is  the fundus which  de-
presses the neck of  the  bladder.  In either case, if we
pass the finger into the anus, to a  convenient height, we
find a tumour formed by the fundus or neck of the uterus,
 which depresses  the intestine;  and the catheter  intro-
 duced 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 some-
 times insurmountable, when  it has existed several dav^ 
102          Deplacement of the Utems.
 or weeks, and the voluminous uterus is wedged  tight in
 the cavity of the pelvis*   Though the  principal indica-
 tion consists in replacing the uterus, as I have just stated,
 the accidents which  arise from  its inversion sometimes
 present more pressing indications, and require a treatment
 which becomes preparatory to the reduction, and without
 which in many cases it could not be obtained.
  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 body of the uterus from the urethra and neck of the
 bladder,  or by introducing a  catheter.   We must  also
 evacuate the fasces, if clysters  can penetrate and soften
 what are accumulated and hardened in the upper part of
 the rectum, and of 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 reduc-
 tion 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 after-
wards, and even in a manner spontaneously.
  230. The position of  the woman which seems most
 advantageous, when we proceed  to the reduction of the
uterus, is that in  which the abdominal viscera make the
least pressure on  it.  Therefore it has been recommend-
 ed 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 ne-
 cessary that the  woman should not make any pressure

    See the case already quoted in  the London Medical Observa-
 tions. 
Deplacement of the Utems.           103
downwards  while we  are employed in  replacing the
uterus.*
   231. Reducing the uterus, is raising the fundus to  its
natural situation.  To effect this, it is  recommended  by
some  to introduce the fingers into the vagina,  and  by
others to introduce them into the rectum.   It is impossi-
ble  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 consequence, 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, instruct-
ed by experience that it could not be accomplished, in

   *  Whenever attempts are made to reduce the retroverted uterus,
it is next to impossible for the woman to  desist from forcing down-
wards; and by the pressure made  upon the uterus by the abdo-
minal viscera,  it is prevented from ascending, and  our efforts are
thus counteracted.  I have therefore made it a rule, in cases where
symptoms required  the reduction, to take off all  resistance by
bleeding my patient ad deliquium.  When a state of faint is in-
duced, 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 lubricated with hogslard,  that immediate advantage may
be taken of the relaxation; I then introduce my hand in a state of
 supination along the internal face  of the perinceum 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 introduce 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 fceces  are discharged
 previously, if possible, to any attempt at reduction. The success
 of this method has been invariable with me.—W. P. D. 
104           Deplacement of the Uterus.
some cases, without first diminishing its volume, has re-
commended 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 way dangerous in itself, has not yet been practised
with that view; because the case for which Hunter re-
commended 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 circumstance.! {

  * This practice, I trust, is very rarely necessary, even  in the
most desperate cases;  as I believe few cases of this kind can oc-
cur, where the practice  I have ventured to recommend will not
succeed.   At least,  Dr. Hunter's method should  not be had re-
course to, until the other has failed.—W. P. D.
  t See  the Observations of Dr. Hunter in the London Medical
Observations, vols. iv. and v.
  X The practice proposed by Dr. Hunter, and approbated  by our
author, has since  been actually performed in France by M. Jourel
with entire success, though not without much danger to the patient.
As  this case is highly interesting and but very little known, we
hope we shall be excused in introducing it in this place.  We shall
take the liberty of condensing it, that it may not too much exceed
the ordinary length of a note.
  " A woman aged 23 years, was at the period of six weeks of
pregnancy, rudely handled in a frolic; she was soon after seized
with an  hemorrhage from the uterus, accompanied with pains in
the back and groins, with a sensation of weight in the perinaeum, a
difficulty in walking and voiding her faeces.  M. Jourel was con-
sulted at the end of a fortnight; he recommended rest, and the use
of some astringent drinks. The woman went into the country, and
was not  seen by M.  Jourel for  a month.  At the end of this time
she told him the discharge from the vagina had ceased within two
days; but that all her other symptoms had increased, so that she
voided both urine and faeces with great difficulty.   Relief was ob-
tained by the catheter and injections.  Six days after her return,
an examination per vaginam, was made by M. Jourel and  one of
his  friends, and  the  uterus was found in a state of retroversion. 
Deplacement of the Uterus.            105
   233.  The uterus being reduced, must be maintained in
its natural situation.   A proper  position on  the part of

An attempt was made, without success, at reposition; this was re-
peated on the next day with a similar result: they now attempted
to produce abortion, by introducing a  catheter into the mouth of
the uterus, but the neck of  this viscus  was so bent, as to prevent '
the operation from succeeding.   It  was then agreed to  adopt Dr.
Hunter's method of puncturing the uterus, in  preference to Gar-
dien's operation of  pubic  synchondrotomy.  M. Jourel operated
with a common trocar, passed along the fore-finger of the left hand,
so as to pierce the posterior part of the vagina.  The canula trans-
mitted about a pound of bloody fluid; the uterus immediately be-
came softer, the pulse less frequent, and the general condition of
the woman was improved.   As the  woman was  much fatigued, im-
mediate reduction was not attempted.
  "From  this  time the urine was freely evacuated; the next day
things continued in the same state—much  serum oozed from the
vagina—the uterus  became a little  painful, and narcotic fomenta-
tions were prescribed for its relief.   After this the pulse  became
smaller and more frequent; the belly was  sore to the touch; the
uterus harder and more tender. The difficulty of discharging urine
returned in the forenoon; she vomited twice, and had discharges
of flatus per anum.  Her strength failed;  the discharge was inter-
rupted, but returned the next day; her stools thin.  Towards even-
ing the symptoms became  milder, and continued to subside, but
she remained very weak.   She voided her  urine partly involun-
tarily.
  " Typhoid symptoms began  to show themselves, and  there was
putrid discharge from the vagina—a copious and involuntary dis-
charge of urine when in a vertical situation.  Bark injections were
employed. By the use of tonics her strength was improved; the
putrid discharges only took place  at  intervals.  On the  27th of
September, thirteen days  after the  operation, the uterus restored
itself to its natural position.  On the 2d of October it was reduced
to its usual size.
  " There was a discharge of a puriform substance from the anus,
which gradually subsided, and ceased altogether on the 10th of the
same month.   The patient went into the country for three weeks;
                              O 
106           Deplacement of the Utems.
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 indirectly
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 re-
duction, it may be continued by the inflammation of that
part, or  by an atony of the bladder in consequence of its
extreme dilatation.   The surgeon  must endeavour to dis-
cover the cause, and treat it accordingly.

during this interval, and till the 15th December, when menstrua-
tion was  restored, she experienced a distressing tightness of the
abdomen, and some colicky pains; but after the  restoration of the
catamenial discharge, she enjoyed good health."   Dictionnaire des
Sciences  Medicales, art. Deviation, vol. ix. p. 81.
   It may be proper to add here, that this was not a case that im-
mediately called for the operation, though it was attended with suc-
cess; and that we continue to think, that had the means proposed
by us been employed, they would have succeeded, and have spared
the poor woman much suffering.  As a dernier resource, this plan
must be considered as highly important.  In addition to the above
mean we may add, that Dr. Cheston* has succeeded by tapping
the bladder above the pubes, where there was an  entire suppression
 of urine,  and the bladder very much distended.—W. P. D.
• Medical Comment, vol. ii. p. 6. 
(  107   )
             Of the  Obliquity of the Uterus.

   235. The  authors who have spoken of the  obliquity
 of the uterus,  have established four general kinds of it:—
 1. An  inclination forwards;  2. Backwards;  3. To  the
 right side; and, 4. To the left.  One of the most cele-
 brated  has divided them into others;* and indeed they
 might be multiplied ad infinitum.   After the right lateral
 obliquity, the  anterior is the  most common; that of  the
 left side is pretty rare;  and we may doubt the possibility
 of a posterior obliquity, which M. Levret and his follow-
 ers only admit when the lumbar vertebras are curved in a
 direction contrary to their natural state ;f that is to say,
 when their assemblage  describes  a concavity forwards,
 instead of that convexity, which has hitherto appeared to
 me so  much  the greater, as the woman was more  de-
 formed.
   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 always draws that viscus

  * M. Levret l'Art des Accouchemens, edit, troisieme, sect. 283,
et suiv. sect. 638.
  t L'Art des Accouchemens, edit, troisieme, sect. 635. 
108            Obliquity of the Uterus.
to the  side next which it  is attached.   The  most com-
mon cause after this,  continues  M. Levret, is the origi-
nal or accidental bad  conformation of the uterus, or of
some of its parts, or even  of those in its neighbourhood.*
   237. The  obliquity  of  the uterus seems to be a ne-
cessary consequence of the roundness it acquires in de-
veloping;  of the figure and situation of  some of  the sur-
rounding  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  implantation of the placenta in any
other part but the centre of thefundus uteri, it would con-
stantly 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 ute-
rus 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 oblique form, as  is asserted
by M. Levret, nor even any other form than it would have
acquired  in  developing, 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  utems, in  that
same part, is softer,  more spongy, and more humid.   M.
    '* L'Art des Accouchemens, edit, troisieme, sect. 633, 634. 
               Obliquity of the Uterus.           109

Levret has not a different opinion of it; for he expresses
himself thus, sect.  279: " When  the  placenta  attaches
itself to the fundus of the uterus, that part of it preserves
a great deal of thickness, notwithstanding its prodigious
extension at the latter end of pregnancy/'
   239. The anterior obliquity is caused by the direction
of the axis of the pelvis; the inclination of the superior
strait in a well-formed pelvis is generally 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 cannot  therefore rise  through  it but  by  in-
clining forward, and  resting against the abdominal mus-
cles;  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 spe-
cies of obliquity is, caeteris  paribus,  greater each preg-
nancy.
   240. It will perhaps appear more  difficult to assign
the true  cause  of lateral obliquities.   I am inclined to
think  they are  determined by the relation of the uterus
to the rectum, and  the Roman  S of the colon; by the  an-
terior convexity of the lumbar column, 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 utems, developed and round-
ed 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 pel- 
110            Obliquity of the Uterus.
 vis, we shall be forced to agree that the centre of its pos-
 terior convexity cannot remain  constantly against  the
 convexity of the anterior surface of the rectum, which on
 each side offers its planes so much the more inclined, as
 it is then, though momentarily, more dilated by the fasces.
 This salient point of the posterior part of the uterus will
 then turn away, and place itself on one of the sides of
 the intestine;  which cannot take place without removing
 the middle of the fundus from the axis of the pelvis, and
 inclining it  towards one of the lateral parts.   If the rec-
 tum descended in a right line from the middle of the pro-
jection 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 leav-
 ing its curve less free on that side than on the right,  the
posterior convexity of the iderus is almost always direct-
 ed 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 discovered by the touch, in most women,
after the second or third month of gestation; the orifice
of the iderus 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 fasces  in the rectum and
the extremity of the Roman S of the colon, and the di-
rection of the course  they must take  to pass out, are ad-
ditional 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 ex-
pels them is itself greater. 
Obliquity of the Uterus.            111
  243.  These  causes  acting almost always in the same
manner; and not being  able to act otherwise,  at least
without a vicious conformation, a transposition of the Ro-
man S of the colon, and of the superior extremity of the
rectum—we ought not to be surprised that the fundus of
the uterus inclines so 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 left
so rare, that perhaps we should be far from establishing
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 de-
pend on the same mechanism, nor on the attachment of
the placenta to the side of the uterus, what must then be
the determining cause of it? We can only attribute it to
the concurrence of some of the accessory causes here-
after mentioned.
   244.  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 direction: so
that the small intestines are obliged to give way to it, and
go towards the left side;  to which, according to the dis-
position of the mesentery, they seem to have  a more na-
tural inclination.
   245.  The convexity of the lumbar column very much
favours the lateral obliquity; and might determine it, ex-
clusively of any other  cause, if it did  not already exist,
in a slight degree, before the iderus 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 adapt-
ed to its figure.  Supposing then that it has risen above 
112
Obliquity of the Uterus.
 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 direction, and in-
 cline to one side;  because the  greatest convexity of its
 posterior part, which would then answer to that of the
 second and third lumbar vertebras, could not rest on that
 point: it is in this  manner that the left lateral obliquity
 must happen, when no other cause determines it  acci-
 dentally.
   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  extent, 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  as-
 sisted a great number of women who have been deliver-
 ed in a few pains, though the uterus was so inclined for-
 ward,  that  the belly,  like a wallet, fell down .to the
 knees when  they were  standing.
   248. When the obliquity is considerable, the  neck of
 the uterus, commonly applied against  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 
                Obliquity of the Utems.            IIS

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 labour 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, which it has  extend-
ed and forced to descend before it, while the orifice is
carried  farther  and  farther backward; which produces
much greater accidents, if the accoucheur does not pre-
vent them in time; by checking those efforts which de-
pend 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 towards
the centre of the pelvis, and maintaining it in that situa-
tion.  The two  following cases appear to me very fit to
demonstrate the  disagreeable consequences  of obliquity
of the uterus in such circumstances, and the  salutary ef-
fects of the conduct which I recommend.   One of these
cases is extracted from a memoir on the obliquity of the
utems, which was communicated to the Royal Academy
of Surgery  by M.  Bavaii,  surgeon-accoucheur in  the
states of Brabant;* the other happened under my 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 re-
course 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
  * 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.
                          P 
114            Obliquity of the Uterus.
at the vulva, enveloped in the anterior part of the uterus,
when the 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 discover without a great deal of trouble, answered to
the superior part of the sacrum, and was not open  far-
ther 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, be-
ing scarcely able to keep back the child's head, and pre-
vent it from clearing the vulva enveloped in the portion
of the uterus which covered it, thought of laying the wo-
man so that the breech might be higher than the  shoul-
ders; and notwithstanding 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 placen-
ta 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 utems
answered to the nape of the child's neck, the head hav-
ing 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 expres-
sions of the author, presents in a clear and alarming
manner, the  melancholy effects of an  obliquity  of the
uterus, when  the  woman is left to  herself, or committed
to the hands of blind and temerarious ignorance.   The
following, on the contrary, demonstrates what we may ex-
pect from the assistance of art, when well directed.  I
have chosen it from among many which have fallen with-
in my own observation, because it  is impossible  that any
one can be more  similar to that of M. Bavaii. 
                Obliquity of the Uterus.             115

  Case II. Towards the end of the  year 1773, a wo-
man, robust and well  made, and who had already had
several  children, presented herself to be delivered in
presence of my pupils; and by her obstinacy procured
them an opportunity of observing perfectly the effects of
obliquity of the  uterus, when it is not corrected  sea-
sonably, as well as what may be expected from the timely
application of the precepts 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
difficultly 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  standing,  giving herself
up inconsiderately to the most violent efforts, whenever
she felt a pain; so that, after twelve or fifteen hours' la-
bour, the child's head  appeared to occupy the lower part
of the pelvis, covered 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 neces-
sary to insinuate the finger  almost to the base of the sa-
crum,  to touch its anterior edge*—The portion of the

  *  A case happened in this city, some years ago, in which this
obliquity of the uterus was mistaken for an obliteration of it?
mouth.  The woman had been in labour many hours without any
opening being discovered in the uterus; the head  pushed very low
down, covered by the uterus: it was agreed upon, in consultation 
116             Obliquity of the Utems.
uterus pushed forward,  and forming under the child's
head a kind of cap which covered it entirely—more ap-
parent 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
became troublesome.   She was  in a high fever, and her
ideas began to be deranged, notwithstanding several bleed-
ings; when a fortunate incident  rendered 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.   In-
timidated by the unexpected appearance of two men of
the law, dressed in their robes, she laid herself on the bed:
I raised  up the belly with one hand,  to diminish the obli-
quity of the uterus; while with two  fingers of the other,
after having pushed back the child's  head a very little, 1
was able to hook the anterior edge of the orifice, to bring

that " as there was no outlet to the uterus," one should and must
be made.  Accordingly, the anterior portion of the uterus was di-
vided by a scalpel, and the pains permitted to dilate it sufficiently
to allow of the  passage of the child.   The woman recovered, and
was subsequently delivered naturally,—a clear proof how unneces-
sarily the operation was performed.
  This case teaches this important caution,—that  the hand should
be passed into the vagina, and the whole  posterior surface of the
depending portion  of  the uterus carefully examined  for the os
uteri. If such  examination be made, the mouth of the uterus will
be discovered at or near the projection of the sacrum, and of course
out of the reach of the finger when it is alone introduced.  When
found, the case  must be treated as directed in the text.—W. P. D. 
               Obliquity of the Uterus.            117

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 deliver-
ed 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 narrow, 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 perpen-
dicularly on the portion of the 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 ori-
fice  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 fuiuius,
in order that the utems, charged with the weight of the
child,  may  incline that way; and to this  precaution we
may 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 wo-
man not to bear down; because  those efforts would be-
come contrary to the end proposed, and would only aug-
ment 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, 
118                Of tlie Menses.
proceeds from the want of this favourable relation of the
orifice of the uterus to the pelvis;  and that the most cer-
tain  means of accelerating 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 inflamma-
tion of the neck of the uterus, nor flooding, &c.
                   Of the Menses.

  252. The iderus, before the age of puberty, receives
no more blood than is necessary for its  nutrition  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 abundant, known by the name
of menses.
  25%. Almost all women are subject to this evacuation;
the derangement or suppression of which,  except during
the time of gestation, or giving suck, seldom fails to in-
jure their health.
  254. The first and last appearance of the menses are
sooner or later, according to the  constitution of the wo-
man, 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 
Of the Menses.                119
from infancy, and in others they have continued to an ex-
treme age.
  25Q.  In a well constituted woman, the duration of this
evacuation, and its  periods, are almost invariable; 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 men-
struate  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 quan-
tity 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 noxious quali-
ties which some have  attributed to it.   If it does not al-
ways 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 ;|
   * Deventer, sur l'Art des Accouchemens, chap, xv.t
   t A case of this kind came under my notice in the year 1791, at
 Abington.—W. P. D.
   X This fact has frequently been proved by ourselves; and one
 remarkable circumstance  attends it, namely, that conception can
 take place as certainly as if the discharge was more elaborated or
 sanguineous.  An inattention to this fact, has led to the supposi-
 tion, that a woman has been impregnated before puberty; an oc-
 currence certainly wanting proof.—W. P. D. 
120
Of the Menses.
sometimes they begin by a discharge of serum, and finish
in the same manner.   Often also, in girls, they are pre-
ceded 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 pre-
sent well known: we know that it distils from those open-
ings which we observe in the whole extent 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 vessels  furnish it; for some maintain that
it comes from  the arteries, and others assure us it is dis-
charged 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 ple-
thora 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 that plethora, nor why it re-
turns constantly  at the same period.
  262.  If  this evacuation is an astonishing phenomenon,
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, be-
fore that period, sometimes  occasions such an infinity of
accidents.

  * The sentiments of later physiologists on this subject are very
different from that of our author: most are now of opinion, it is a
secretion from the membrane immediately lining the uterus.
                                              W. P. D. 
Of the Menses.
121
  263.  The  cessation of the menses unfortunately does
not always happen thus.   They most frequently become
very irregular before they arrive at that period: some-
times they are excessive, and sometimes flow in so small
a quantity as scarcely to  mark the linen:  they often ap-
pear 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 at-
tack them, ever after drag on a miserable and languish-
ing life.   That epoch is also in some women that of the
return of their health, which the continual vicissitudes of
this evacuation had constantly deranged.
  265.  The sterility of women who are entirely deprived
of their menses, the suppression of that evacuation during
pregnancy and giving suck,  sufficiently declare that it is
not a depuration, but merely a depletion, and that  that
blood had a much more precious destination.  It is indeed
so necessary for the development of the foetus during preg-
nancy,  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.
                          Q 
122                Of Generation.
  267. But this reproduction, is it only the development
of a pre-existing 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 con-
tent  myself with mentioning them very briefly.   They
may be reduced to two principal  ones;  that of the mix-
ture of the two seeds, and that of eggs.
  269. The first was that of the ancients,  who imagined
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 her-
self  up to the pleasures of hymen, it seems probable that
some fluid flows from the ovaria towards the uterus;  for
that sensation cannot be excited by the liquor which the
woman emits without, since it is felt by the greater num-
ber  independently of that apparent emission.
  270. M. de Buffon has only embellished this first sys-
tem.  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 or-
ganical 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,  be- 
Of Generation.
123
cause of their continual motion, are so shaped and form-
ed, that they cannot unite and assimilate but with the par-
ticles sent from the same parts of the other sex; that is
to say,  that the particles furnished by the eyes of the
man, cannot 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 dif-
ferent in the two sexes, not being explicable by this inge-
nious 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 particles 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
vesiculas with which the ovaria of women are replenished
at the age of puberty: that discovery immediately excited
the attention of physiologists.  It now began  to  be be-
lieved that  man and  all other animals come from eggs;
and that all the difference between viviparous and the ovi-
parous 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 greater
part of the moderns, the fecundated egg descends into
the uterus by means of the fallopian tubes; but has any
one seen it? We maybe 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 won-
der of his age.*
The Baron De Haller. 
124
Of Conception.
  274.  The partisans of this system, though agreed on
the admission of eggs, are nevertheless divided concern-
ing the mode of their vivification.   Some have thought
that the foetus was  ready formed in the e£g, 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  receive one of the little animakula
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 phenome-
na of generation, shows 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 researches.
                   Of Conception.

  276. The  union of the principles furnished by both
sexes for the purpose of generation, in the human spe-
cies, is called  conception.   If this union is not always
performed in one of the ovaria, it will be agreed, at least.
that it  is performed there  sometimes:  since the remains
of foetuses, and even foetuses 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 rup-
ture of the tube, or of the membrane of the ovarium, fur- 
Of Pregnancy.
125
nish 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 habitation of
man, and that the tube is only destined to transport the
fecundated egg into  the uterus—ought we not to be sur-
prised that so many eggs get into that viscus; and that the
tube, whose extremity is so large, and whose internal ori-
fice 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 internal  movements
which they feel, the  greater part never suspect that  they
have conceived till after the suppression of the menses.
It would be a desirable thing, however, in many cases, to
have  a certain 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 sometimes perni-
cious.
                   Of Pregnancy.

  280. The state of a woman who has conceived is ex-
pressed 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 preg-
nancy, relatively to the nature of the  produce of concep- 
126                Of Pregnancy.
tion; 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 preg-
nancy to those collections 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 accom-
panied by  some of the  rational symptoms of  common
pregnancy; because, like that, they occasion a  develop-
ment of the belly, and may keep the most skilful accou-
cheur a long time in  the greatest uncertainty concerning
the true state of the woman.
  282. A true pregnancy has received different denomi-
nations, according to  the place occupied by the  child.  It
is called an uterine pregnancy whenever the child is con-
tained 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 compound.   We may
also call it a compound pregnancy, when the child is ac-
companied by a mole, and when  there is already an  extra-
uterine pregnancy existing; which is not without exam-
ple, though we rarely meet with it.
   284.  These different  species  of pregnancy have some
signs common to them  all, and others which are pecu-
liar 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. 
                    Of Touching.                127

  285. These symptoms, which are called rational signs
of pregnancy, characterize it however in  a very uncer-
tain  manner; and will appear very equivocal, if we re-
collect that they have been often observed 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 have ceased to be  so a long time be-
fore conception, and some few being so only during preg-
nancy.
   286. Though  the  greater part  of these  symptoms
united, or separate, offer us at most but probabilities
concerning the state of  the woman  who experiences
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 different periods, &c.  It
is by touching that we discover all these things.
                     Of Touching.

   287. Touching,  considered  relatively to  the art  of
 midwifery, is not confined to the introduction of the fin-
 ger 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, &c.
   288. Touching is one of the  most difficult and most
 essential parts of the art of midwifery.   If Deventer and 
 128                Of Touching.
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 frequently,
especially in great cities, where women are more nume-
rous, and where persons of both sexes dedicate themselves
solely to the profession of midwifery.  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.   Some-
times 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 reputation,  who
implores information from our knowledge, as soon as her
suspicions commence; sometimes a woman whose preg-
nancy, still  doubtful, is complicated with accidents, or ac-
companied  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
guilty of crimes which merit the extremest rigour, de-
clares 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 affec-
tions of the hidden parts of generation, that we  judge of
the size of the pefeis, and of its deformities;  it is by that
we  discover pregnancy, its different periods,  and the ap-
proaches of labour; that we distinguish  the true pains
from  false, the part of the child which presents, its vo-
lume, the turns it makes in descending, &c.
  291.  To touch with advantage in most cases, and espe- 
                    Of Touching.                 129

dally in  discovering a doubtful pregnancy, in the first
periods, we must begin by habituating ourselves to judge
skilfully by this means of the natural 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 touching
dead  bodies, where we may rectify our knowledge, and
correct our errors;  and then touch  women not pregnant,
in great number, and in  different attitudes, to enable us
to judge more exactly of the volume of the uterus, of the
figure and situation 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 fasces;  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 vagina.  We must employ the fore finger;
but we ought to learn to  touch with both right and left.
   294. We separate the labia with the extremity of the
finger, pass it into the vagina, until we meet with the os
tineas.  We examine this part  and  ascertain 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 tineas, and raise up the
uterus a little,  while we search  for its fundus just 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
                          R 
130                 Of Touching.
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 ena-
bled to form a judgment, 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 development of these  parts,
we determine a pregnancy, and its period.  But as these
changes may take place from a cause foreign to pregnan-
cy, we cannot, strictly speaking, say that there is any cer-
tain sign of it, except the motions of the child.
  297. These motions are of two kinds: one depends 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.
  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  dis-
tinguish  these motions sooner, as  those of a contrary con-
stitution 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 
                     Of Touching.                 131

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 be-
come sensible to the mother, nor to the accoucheur 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.
  300.  The rolling of the foetus in the uterus is indepen-
dent of its muscular  action; it  exists after death, as be-
fore;  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 utems, and  of the woman,
and may be excited by the accoucheur.
  301.  This rolling commences, as I may say, with preg-
nancy;  but it is so weak in the first periods, on account

  * The birth of this child will not appear premature, when we ob-
serve  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 moment, 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 months  and a 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 preg-
nancies.t
  t I knew a case where the motions of the child were never per-
ceived ; yet this child was born alive and healthy.—W. P. D. 
132                 Of Touching.

of the extreme lightness of the foetus, that the accoucheur
cannot discover it; and, notwithstanding the strictest in-
quisition, it cannot be perceived 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
accustomed to seek it in women farther advanced in preg-
nancy.
  302.  To  excite and distinguish  this rolling, we  ad-
vance 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 downward with the finger and with
the hand, till we distinguish the  movement in question;
observing, however, not to  mistake  the  motion  of  the
uterus, for that of the  child contained  in it.
  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 discover 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 preg-
nancy  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  the  uterus, 
                    Of Touching.                 133

and be moved in it  in  this manner:  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 conjec-
tures 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 utems.  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 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 augmenta-
 tion of the utems, but to an  inflation  of the  intestines.
 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;  because it is then
 manifestly above the edge of the  os pubis.   It is then
 the hand begins to discover it easily, by pressing on the
 aforesaid region.

   * 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. 
134                Of Touching.

   308.  When this development is caused by pregnancy,
it  is observed only in the body of the uterus, and  the
neck has no share in it: the kind of globe felt  by the
finger introduced into the vagina, and which may  be  dis-
tinguished by the other hand applied externally above
the pubes, is regular in its surface, and has a sort  of sup-
pleness.   This body, developed by a plethora of its sub-
stance, and affected 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 distinguish all these
shades,  in doubt concerning the state of a  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 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 hypogastric region is then salient, rounded, and tight.
   310.  In the sixth month the uterus rises above the um-
bilicus, which seems less sunk in; the neck begins to en-
large 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 mdva in proportion as it is developed: the  um-
bilicus 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  ap-
proaches so near the pit of the stomach, in most women, 
                    Of Touching.                135

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 sym-
physes, right or left.
   313. In order to reach so far, we must proceed  in the
following  manner:—The woman being standing, leaning
a little backward, and resting her back against something
solid, we place the hand open between the thighs, and in-
troduce the fore  finger into the vagina; so that the ra-
dial edge of the middle finger may lie along the perinosum
and coccyx,  and the thumb against the pubis; so  that
these two  fingers and the thumb are  at length very dis-
tant from each other.  By proceeding thus we have advan-
tages which  cannot be obtained  any other way; because
the middle finger pressing upon the external parts of the
perinaium and coccyx,  forces them upward, and dimi-
nishes so  much of the  depth of the pelvis;  which per-
mits  the extremity of the fore finger  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
 uferus 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 extent of the pudendum,  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 distant when
 the edge of the orifice is very thin and soft; whereas it
 is often a month or six weeks off when this circle  is hard
 and  thick, whatever may be the diameter or degree of 
136                 Of Touching.
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 concerning the
period of labour.   We ought always to look upon it as
very near, when the membranes  tighten and relax alter-
nately.   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
relaxation are remarked in the edge of its orifice.
  317.  Though all the symptoms  constantly announce
the approach of labour, they do not so certainly indicate
the period of the ninth month; and, 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  uterus; to the size  and hardness of
the head, which we distinguish by the touch, &e.
  318   The elevation of  the fmulus 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  difference,  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, 
Of the Foetus.               137
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
tineas remains thicker in the latter months; so that expe-
rience is necessary, not to be deceived in these signs.
                    Of tlie Fostus.

  319. The rudiments of the foetus appear at first only
as a mucilaginous  cloud, 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 sketched as that.
  320. The illustrious Halter assures us that he has ob-
served nothing of the  kind in sheep before the seven-
teenth day;  and that it was not till the nineteenth that he
distinguished a mucous foetus, of the size of a small 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 big-
ger than an ant: they were bent forward, as M. De Hal-
ter  says, and  enveloped in a mucous cloud.   They ap-
peared to the  naked eye to have more  resemblance to
that little bone of the ear  called malleolus, than to any
thing else;  having, like that, one end very thick, and the
other  extremely slender.   Among the women who pro-

  * It is more than probable that this crescent form of embryos was
produced from the action of the alcohol in which they were gene-
rally examined.—W. P. D.
 
138                OftheFostus.
duced these embryos, some thought themselves a month
gone only, and others five weeks; some of them were of
the number of those who are generally able to tell  the
moment 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 immediately to the trunk,  the
arms, thighs, and legs being scarcely visible.  Some were
of six weeks and  others of seven, according to the  ac-
count 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 capsida,
as it were, spongy, or covered with a very thick down ex-
ternally.   Those of the former were nearly of the size of
a middling hen's egg, and those of the others bigger.
   324. These species of eggs are composed  of two mem-
branes: one external and thicker, on the surface of which
rises  the down already  mentioned; that is  the chorion:
the other internal, thin, and transparent, through which
we may see the body of the foetus in the midst of the lim-
pid 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 membranes 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  containing the waters  and
foetus immediately escapes, while the  former  is not ex-
pelled till some time afterwards.
   326.  In this case the woman discharges only a kind of
membranous egg, without the least down  upon it;  and 
OftheFostus.                139
when the downy membrane comes away, if it be not ex-
amined 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 be-
comes 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 linea-
ments.  As soon as it is  sketched, its increase is so sen-
sible, from one month to another, and even from fort-
night to fortnight, that it is difficult to conceive how such
great and wonderful differences could be the work of so
short a time.
   329. These differences are not however absolutely the
same in every individual.  We observe, for example, as
much variety in the length, bigness, and weight of a cer-
tain number of foetuses of five months, all proportions be-
ing observed, as  in a like number at full time: some are
longer, bigger, and  heavier; others shorter, thinner, and
lighter; so that  we  cannot exactly determine  how far
pregnancy was  advanced  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 extremes
from sixteen to twenty-two or twenty-three.   Their me-
dium weight, according to the tables of Roederer, 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 ad-
vanced, and others ready to cut; its bulk was so great, 
140             Attitude of the Foetus.
that I can scarcely believe there ever were any born of
twenty-five pounds,  or even fifteen, as we hear related
by the good women*  I have seen some also at full time
who weighed 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 con-
clude that there are children of eight months larger and
heavier than others of nine, and vice versa: notwithstand-
ing that, an experienced accoucheur will not judge them
to be of the same term.  There are always marks of im-
maturity in the exterior of a foetus of eight months, though
bigger than another 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 Foetus 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 there-

  * Instances have frequently occurred in this country, of chil-
dren weighing more than fifteen pounds;  I have seen I think seve-
ral ; two I  am certain of, as I  carefully weighed them.  The cir-
cumference of the head of one, was eighteen inches  and a 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. 
                Attitude of the Foetus.             14\

abouts; and its smallest, which extends from one shoul-
der 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 dimensions of its prin-
cipal 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 advanced, 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 utems.   Such  was the  idea  of the
 ancients on the position of the child, and such is  at pre-
 sent the  opinion of  most moderns.   If there is  no in-
 convenience, as some have said, in admitting the move-
 ment 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 inconve-
 nient 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.
* M. Levret, sect. 426, et suiv. 
142             Attitude of the Fostus.
   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 period 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, consequently can-
not 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 demonstrated that the
child's head almost always occupies 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  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 sup-
posed; 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. 
(  143   )
                Division of the Child.

  340.  The surface of the child, considered relatively
to our object, might be divided into  thirty-four  regions,
which however I shall reduce to twenty-three.
  341.  Of all the principal parts of the child, considered
with respect to labour, the head must be allowed 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 accommo-
dates 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 direc-
tion, 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 however distin-
guish in it five  regions,  two extremities,  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 posterior;
we call that the occipital, or vertex: the other its 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  ob-
liquely from the symphysis of the chin to the posterior
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 
144
Division of the Child.
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
diameter;* although many persons, without giving them-
selves 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  fifteen in-
ches; the other is only ten or eleven.  The latter passes
transversely over the middle of the summit of the base of
the cranium, as well as over the parietal protuberances:
the first, over the two fontaneUes, the face, the chin, the
occipital foramen, and the tubercle of the same bone; in
a word, over the extremities of the oblique and longitu-
dinal diameters, and over those of one of the two small
diameters.
   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 poste-
rior angle of the parietal bones: but it  cannot undergo
this lengthening without diminishing in thickness from
one side  to the other, and often from the  summit to the
base.

    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 ob-
served, I give notice that that is the diameter I shall  mean when-
ever in future I shall  make use of the terms great or large diame-
ter: and when I  say little diameter, I shall always mean the trans-
verse. 
Division of the Child.
145
   348. These changes have limits, however, which can-
not without manifest  injury be  exceeded, they differ in
different individuals, according as the head may be more
or less ossified; the breadth of  the sutures, or width of
the fontaneUes; they cannot therefore be precisely esti-
mated.   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 fostus 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 is 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 a fontanelle;  though there is
scarcely ever  any membranous space in  it, as in the for-
mer.  This fontanelle, which  in the course of this work
will always be called the posterior fontanelle, differs also
from the preceding, in being formed  of  only three bony
angles,  and in being only as it were the point of union of
three branches of sutures: while the anterior is composed
of four  angles, and as many sutures terminate in it; which
makes them easily distinguishable by the touch.*
      >
  * 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. Notwithstanding that, it differs
-o much  from the former, that it is  almost impossible to be de-
                           T 
146             Division of the Child.
  352.  The articulation of the head with the trunk, its
natural  situation, and  motions, are not less necessary to
be known.  The first is a species of ginglymus, which
permits but very small motions, either forward, backward,
or on the sides: if the  head executes greater, they de-
pend on the combined motion of all the cervical vertebras.
  353.  These motions are freer in the foetus than in the
adult; but they have their  limits, which cannot be  ex-
ceeded  without  danger to  the child; the pivot-like mo-
tion especially,  which depends  almost entirely on  the
twisting of the neck, cannot with safety be made to ex-
ceed 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 the  axis of the trunk pass a lit-
tle before the  posterior 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 with-
out injury,  when the head is supposed to be the fixed
part.
   355. The fundamental principles of midwifery may be
perceived, by comparing the principles thus far establish-
ed  between the pelvis of the  mother, and the child to be
born.   We learn from them that  delivery can only be

 ceived in  it, even when we cannot touch them both, to compare
 them.t
  t I 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. 
Of the Placenta.
147
effected, by having the occiput behind one of the aceta~
hula, and  the forehead before one of the sacro-iliac sym-
physes of  the other side.  It must descend so, that the
occiput may turn  under the arch of the pubes, and the
forehead into the hollow of the sacrum; while the shoul-
ders 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
diameters  to the largest diameters of the pelvis, &c.
Of the Secundines, or Afterbirth, and particularly of the
                      Placenta.

  356. These substances, although called secundines, 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 & foetus, but never a foetus with-
out 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 preg-
nancy.  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 secmutines, in the first months  of gestation,
are not such as we find  them at the end: after several
weeks, they are nothing but a kind of membranous blad-
der, 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 without separating the tufts
of that down.—See par.  323. 
148
Of the Plaeenia.
   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,
thicken the middle, and thin  at  its edge:  it is seven or
eight inches in diameter, and twelve or fifteen lines thick
in the centre, at full time.  These  dimensions however
vary a little, according  to  the constitution 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 ap-
pear very unequal, and deeply furrowed; whereas in its
natural state we  only  discover very superficial convo-
luted furrows, covered  by a thin layer of cellular mem-
brane, and which have  a kind of resemblance to  the an-
fractuosities of the brain.

  * Our author appears to be in an 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 sup-
poses, but  only becomes more developed  and  extended by an in-
crease 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 consequently opposite  the belly of the
child; which in the very early  periods of gestation is found almost
in contact with the internal face of the amnion, owing to the ex-
treme shortness of the cord: in the more advanced  periods of preg-
nancy, 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 afterbirth occupied
the whole surface of the uterus, few women would escape a  fatal
bcBmorrhagy, when it became separated.—W. P. D. 
Of the Placenta.
149
   861. 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 uterine 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 by
 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  arteries  and
 veins; which serves as  a base to the umbilical cord, of
 whose vessels it is only a ramification.  The veins unite
 eventually in one trunlc and form the umbilical vein.  The
 arteries are a continuation of the primitive  iliacs of the
foetus.  When they arrive  at  the  placenta they  divide
 into very minute branches, and anastomose with  the veins.
 If one of the umbilical arteries be injected, the whole plex-
 us becomes filled.  The veins have no valves, but they
 are found most generally in the arteries.
   364. When there are twins or triplets, we sometimes
 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, notwithstanding this connexion, there
 is scarcely  any  communication between  their vessels
 which may have great advantages.
   365. Twins have  however  almost  always something
 common  to both, in those cases where there is a placenta
 for each; for they are enveloped  in the same chorion. 
150
Of the Placenta.
which unites the  two masses of placenta 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 gene-
rally 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 inferior 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
iderus, and observing whether it descends from the poste-
rior or anterior part, or from one of the sides.  It is not
till the  placenta  is delivered that we can estimate how
far it  was removed  from the orifice, by attending to the
distance from the opening of the  membranes to the cen-
tre of the internal surface of that  mass.  As that opening
constantly 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 placenta, the farther that was removed
from the fundus, &c.
   368.  Whatever may be  the  strength of the adhesion
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 recep-
tion which some  talk of; and the firmer or weaker  ad-
hesion  does not depend on the eminences of the one
being more  strongly or  feebly engaged  in the sinuses of
the other.
       * See the article on twins, at the end of this work. 
(  151   )
                 Of the Membranes.

  369. The bag in which the child is contained is com-
posed of two membranes.  The outer one or chorion is
cellular externally, and especially near the placenta, by
which it is attached to the iderus.  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 ex-
tremely fine membranous layer covering the anfractuosi-
ties mentioned in par.  360.  The inner membrane or
amnion is a very thin transparent 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 continued 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 mem-
brane, which might be regarded as the produce of con-
ception, if it existed really, and separately from the two
former, in every period of pregnancy: 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 membrane, decidua, does  not seem to exist  mani-
festly 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. 
(  152   )
                Of the Umbilical Cord.

   371. The umbilical cord is known to all, but its struc-
 ture is not equally so.   It is formed of two  arteries, and
 one vein, whose diameter is larger than those of the arte-
 ries.  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,  like ivy round a tree;  and
 sometimes the vein does the  same round  the arteries.
 This vein often folds itself into a  kind of loops of differ-
 ent lengths, or forms  itself into a species of knots, sub-
 ject to become 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 peritonasum, towards the scissure of the liver,
 to enter the sinus of the vena porta; and the arteries de-
 scend towards the lateral parts of the fundus of the blad-
 der, from whence they make a turn towards the iliac ar-
 teries,  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 in-
 serted  into the vena cava inferior.  When this bifurcation
 does not  take place,  the venous canal rises from  the
 sinus of the vena porta;  and that is what we find most
 frequently. 
Of the  Umbilical Cord.
153
   375. Another kind of cord rises from the top of the
bladder towards the umbilicus of the foetus, where it ter-
minates; that is the urachus; it is almost  always  liga-
mentous throughout, and has no cavity, at whatever pe-
riod 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 always  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 prevent the
ordinary development of -the foetus nor occasion its death,
as has been  imagined by some.
   380. There may, when the head is delivered, an incon-
venience arise from the cord being too short, either natu-
rally, or from its being several times twisted  round the
neck of the child, such as a swelling and lividity of the
child's face, from the compression the jugular vessels suf-
 fer, from the cord being  tightly drawn; and also a  drag-
 ging, or separation of the placenta, and even a  rupture
 of the cord itself.
   * M. VHeritier, master in surgery, was a witness of the fact at
 the Hotel-Dieu of Paris.
                          U 
(   154  )
             Of the  Waters of the Amnion.

   381. The waters  contained in the cavity of the amnion
are usually  clear, and without any disagreeable odour;
sometimes they are whitish, milky, and full of flakes of a
matter which appears like cheese.  In some women they
are muddy, thick like broth; sometimes they are greenish,
brownish,  or greyish, and of an odour singularly fetid.*
   882. In  the natural state, these waters have  all the
characters of  the liquors of the pericardium, the pleura,
and the peritonasum;  being,  like this latter, lymphatic,
and a little greasy to the touch.   They exude from the
membranes  by a mechanism exactly similar to  that by
which the liquor of  the pericardium is supplied.!

  * 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 could remain near
the bed.
  t From the experiments of Vauquelin  and Buniva,  these sub-
stances would appear very different; their analysis furnishes the
following component parts of the liquor amnii,  viz.
              98.8 Water,
                   {Albumen,
                   Muriat of Soda,
                   Phosphat of Lime, Lime.

             100.0
While  the liquors of the pericardium,  pleura, peritonaeum, &c.
would seem to be nothing but serum; which, from the experiments
of the gentlemen just mentioned, was found to consist almost en-
tirely of albumen, a little soda, and a small proportion of water or
serosity.  It has been  asserted that, the liquor amnii, when ex-
posed to heat, would, like serum, coagulate: this, from the experi-
ments 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 coagulating, since serum loses this quality
when diluted with six quantities of water.—W. P. D. 
              Of the  Waters of the Amnion.         155

   383.  The saffron colour which, agreeably to Holler,
has been discovered in the waters of pregnant women
who  have taken much of this drug;  and their property,
according to Levret, of whitening copper in women who
have used mercury during 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 lat-
ter months   than  at the beginning:  but their  absolute
quantity is greater at the approach of labour than at any
other time.
  * 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, which very much call in question the received opinions
of that time;—this has especially been the case with mercury.
The experiments of Dr. Physick on this subject are conclusive, as
far as respects the observation of M. Levret; he found, that, neither
by gold, nor copper, nor any other test, could the presence of mer-
cury be detected  in the serum of the blood, or saliva of people who
were profusely 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 circulatorv
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 immediate product of
the mother?  By no means.—The foetus,  without doubt, from its
earliest formation derives its nourishment or fluids from the mo-
ther;  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 fcetal blood must also contain it;  consequently, when the thin-
ner 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 amnios.—-W. P. D. 
156         Of the Waters of the Amnion,
   385.  Nothing is more various than the absolute quan-
tity of this fluid:  some women  scarcely discharge a pint
or even half a pint, in  time of labour,  while others dis-
charge many quarts.
   386.  They are one of the instruments which nature
uses to  effect the dilitation of  the uterus in pregnancy,
and the opening of its orifice in labour.   These waters,
on account of their lymphatic quality, 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 inspi-
ration, and thinks  they serve to cool the blood of the
foetus, which is difficult enough to comprehend.*
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 nou-
rishment by the umbilical cord; and the proof of it is so
clear, that no one would dare contest it: but the same va-
riety of opinions exists concerning the nature of the fluids
transmitted to it by that canal.

            ':  M. David, Traite sur la Nutrition. 
Nutrition of the Fostus.             157
  389.  The difficulty of passing the thinnest  injections
from the vessels of the uterus into those of the placenta,
and vice versa;  the milky humour 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 vessels 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 vessels of the placenta, in the first periods
of pregnancy, when  the fostus 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 san-
guification for  the foetus;  and others, that the mother
transmits the blood to it ready  prepared.
   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 em-
 bryo exists, as  well as the floodings which succeed a  se-
 paration of that mass from the uterus in every period of
gestation, demonstrate it clearly.  But we may be allow-
 ed to doubt its arrival at the foetus in the first periods of
its formation; 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 
 158           Circulation of the Fostus.

placenta itself that these veiny roots take up 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, mix-
ed with those same nutritious fluids; in  the same man-
ner as the pudica and splenica take  up the blood extra-
vasated  in  the cavernous 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 accompany those veins, does
not go directly into the veins  of the utems.  There is no
anastomosis between those  two kinds of vessels;  but
there  are  cavities into which the  blood is poured from
both.
  393.  These  reservoirs  are the uterine sinuses, conti-
guous 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 re-
turn it into the general mass of humours of the  woman.
the other to conduct it to the foetus.
     Of the Circulation of the Blood in the Foetus.

  394.  The blood taken  up from the cells of the pla-
centa 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 
               Circulation of the Fostus.           159

it passes into the vena cava inferior, as well by the venous
canal, as by the hepatic veins, to  be transmitted into the
left auricle of the heart, along with the blood which re-
turns from the inferior extremities, and from some parts
of the breast and abdomen: while the  right auricle re-
ceives from  the  vena cava  superior what returns from
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 with-
out 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 veidricle  in the adult
distributes it only to the lungs.
   397.  In the foetus the blood propelled by the contrac-
tion   of the  right ventricle, is  immediately divided into
three columns; of those columns the  two smallest go  to
the lungs, while the  principal one is transmitted into the
aorta inferior by the arterial canal, and communicates  to
the blood which has  been propelled thither by the action
of the left ventricle all the force which  it has itself re-
ceived from  the  contraction of the right ventricle:  so
that  the fluid circulates through the aorta, and all its di-
visions, by the united force of the two ventricles.
   39S.  The course of the blood carried by the aorta in-
ferior of the foetus, extends at  least as far as the  caver-
nous tissue of the placenta; since a part of that fluid  is
brought thither by the  umbilical arteries.  These, after 
160
Circulation of the Fostus.
transmitting a part of it into the veins of the same name,
by means of the  immediate communications which exist
between them, 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 uterus to
the placenta, from that to  the fostus, and vice versa, is
performed thus till the time of labour; but it then under-
goes surprising changes, some  of which depend on the
contraction and closing of the uterus, and the others on
the respiration which is established 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 di-
minishes their diameter, but retards the circulation with-
in them; so that the sinuses of the uterus, and cells of the
placenta, receive and transmit  less blood in a given time.
  401.  The retardment of the motion  of the blood  in
the uterine arteries is in proportion to the contraction,
and diminution of the uterus itself; so that in the begin-
ning of labour it is  much less, than when the labour is
fully confirmed, and after the  expulsion of the placenta.
This is proved by the diminution 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 extends to the
placenta and  child.   The placenta, pressed between the
child's  body and uterus so  as to obliterate many of  its
cells after the evacuation of the waters, does  not receive
as  much blood as before, either from mother or child. 
                 Division of Labour.              161

That of the mother passes with difficulty into the sinuses
of the uterus, and is  again taken up by the  correspond-
ing veins; while that  of the child, instead  of being pur-
sued  into the cells of the placenta, is returned to it by
means of the umbilical  veins  without receiving a new
mixture of the mother's blood.
   403. This action becomes sometimes so violent, as en-
tirely  to destroy the circulation  between mother  and
child;  to this must be attributed the extravasations and
congestions which  are sometimes  observed in a child,
when a long series of efforts has been necessary 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 es-
cape from  the uterus, and the  uterus almost as suddenly
contracts.   The almost immediate cessation of circula-
tion in the umbilical arteries as soon as the child is born,
is one of those  surprising phenomena which has never
been satisfactorily  accounted  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, fyc.

  405.  The general division of pregnancy into true and
false, as well as custom, requires that we should  distin-
guish labour, properly so called, from the expulsion of a
                          x 
162
Division of Labour.
mole, or any other body which might be the produce of
conception.
  406.  When we consider the great disproportion 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 constitution of each; but
in general that  probability is greater, as their birth ap-
proaches nearer  to the time of their perfect maturity;
and we do not look upon them as  viable till the period
of seven months complete.
  407.  The causes which determine  the birth of a  child
before the time fixed  by nature, may also influence the
probability of its living.   One of seven months,  for ex-
ample, which comes naturally, is more likely to live than
one of eight, whose birth is owing to a violent or  acci-
dental cause.
  408.  The most usual epoch of labour is the end of the
ninth month of  gestation, but it is not invariable.  The
child may be born sooner, or a little later.   Some wo-
men  are delivered naturally at seven or eight months;
and others have  carried their children beyond the ninth,
without any reason to suspect  an error in their calcula-
tion, or that they had violated their conjugal faith.
  409.  The exit of the child has  received  different de-
nominations, according to the period of pregnancy in
which it happens, or the mode of its operation.  It is call-
ed a miscarriage, before the seventh month; delivery be-
fore 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 laborious, &c.  These 
            Determining Causes of Labour.         163

scholastic distinctions being arbitrary, I shall divide them
into  three  principal orders:  1. Those which are per-
formed naturally, or without 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 employ them.
   411. If in these latter cases the action of the organs
of the woman is not sufficient to perform the expulsion
of the fast us, at  least it begins the labour: on which ac-
count all labours have some causes common, and some
particular;  which may be again distinguished into  de-
termining, and efficient.
   412.  The common causes, of which we shall presently
treat, are sufficient to effect deliveries of the first order.
As to the particular causes, being different  not only in
each order,  but in each species of labour, I shall not men-
tion 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, because they almost always
act at the same period, and rarely before the end of the
ninth month.
  414. Naturalists have formed  different opinions con-
cerning these latter:  some attributing them to the foetus 
164        Determining Causes of Labour.
and others to the uterus itself.  The former have thought
that the child, excited  by the want of nourishment,  the
necessity of respiration,  the troublesome weight of the
meconium in  the intestinal canal, &c. endeavours to  get
out, and overcome the obstacles which  oppose its pas-
sage.   Others have imagined that the uterus was excited
to contraction only by the acrimony of the waters of the
amnion, or by the violent distension 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 acri-
monious as some have asserted), nor the violent disten-
sion of the fibres of that organ, that provoke the efforts
of labour, when it comes on prematurely; since the wa-
ters are not in immediate 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 uterine fibres  conti-
nually 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 solicit-
ed to it; and because, not being all  developed at  the
same time, the action of some is counterbalanced by the
natural resistance of others. 
(  165   )
       Of the natural efficient Causes of Labour.

  417. The vulgar suppose that the child is the  princi-
pal agent of its birth; that it opens the parts of the woman
by  repeated  efforts,  and  thus  surmounts the  obstacles
which oppose its exit.
  418. The expulsion of the child is a function entirely
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 some-
times longer, no two individuals presenting the same phe-
nomena, 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, press-
ed on all sides, is forced out of it, it is because the resist-
ance 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 diametrically opposite to
the centre, which serves as a fulcrum to all  its  fibres; 
166          Efficient Causes of Labour.
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, be-
cause 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 rupture of the uterus.
   Of the Causes accessory to the Action of the Utems.

   424.  The diaphragm and abdominal muscles have an
important share in  the  expulsion  of the foetus.   The
efforts which the woman makes  to relieve herself in the
moment of pain  call  these parts into action, and are near-
ly the same as those made to expel the urine and faices.
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
fostus, but becoming in  some  measure contiguous to the
uterus,  which they press, either mediately 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 when
the bones to which they are attached are fixed and im- 
Of Labour Pains.               167
moveable: therefore the contraction of a great number.of
other muscles becomes equally necessary in labour; but
these latter only co-operate with the former in a very in-
direct manner.
   427.  While the sterno-mastoidei muscles, the scaleni,
the pectorales major, and minor, the serrati, and others,
fix the thorax, and prevent its obedience to the abdomi-
nal 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 prin-
cipal phenomena of labour; such as the pains, the dilata-
tion of the orifice of the uterus, the discharge of mucus
tinged  with blood, and the formation of what is vulgarly
called the gathering of the waters; before I indicate the
order in which they manifest themselves, as well as seve-
ral others which will be mentioned in the sequel.
                  Of Labour Pains.

   129.  The pains are  the  first sensible phenomena of
labour;  it is they which announce it, and no woman 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 pass-
ed through  many degrees to become sensible.  In the
beginning,  that  contraction  is so slight,  that  it merely
produces an internal sensation like that of a tenesmus. 
168
Of Labour Pains.
  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 pricking.   If they are
sharper towards the end, it is because the contraction of
the uterus is stronger, its fibres are more stretched, and
become more sensible, 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 them-
selves 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 abdomen, from whence they
pass  to the small of the back, where they torment ex-
ceedingly.  The best are those which are directed to-
wards the orifice of the uterus, or the fundament.
  433. These  pains  of the  back  sometimes manifest
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 some-
times 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.
     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 
               Plumomena of Labour.            169

it by following, step by step, the order of the development
of that  viscus, and by attending 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 contrac-
tions of the uterus present to its orifice.
  437.  Although in many cases, where the waters drain
off  prematurely,  no part of the child can engage in the
orifice of the uterus,  yet  it  does not fail to open, in the
same manner as if the bag  formed by the protrusion of
the membranes were entire; 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 concurrence
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 pres-
sure which they continually make on all the neighbouring
parts, determines a repletion in them, which favours  their
development, and renders it less painful.
   439.  In general, it requires more  time and labour to
open the orifice of the utems the breadth of a half crown,
than  to obtain all the rest of the dilatation 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
                          Y 
170
Phenomena of Labour.
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 be-
ginning of labour, than at others after twelve or fifteen
hours of strong pains; which depends on certain circum-
stances, 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 pregnancy, 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
delivery;  but this  is not always the case.
           Of the  Gathering of the Waters.

  442. In  proportion as the orifice of the uterus is di-
lated, 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 agreeably
to the situation of the mouth of the uteims; its degree of 
                Phenomena of Labour.            171

dilatation; or laxity of the membranes themselves; some-
times, circular, oblong, or extended like a pudding.  The
portion of the membranes which forms this tumour bursts
from the impulse of the waters pushed forward by the
contractions of the uterus.   The time of this rupturing is
however various, sometimes happening at the very com-
mencement 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 renders it more
tedious; not because it produces a dry labour, but because
one of the causes which ought to co-operate in the dila-
tation  of the orifice fails before it is effected.*   If the
membranes do not 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  sponta-
neously; 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.

   : 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 dis-
pose them to yield, and not to the loss of the waters as  a mechani-
cal agent.  For we see many instances of the most perfect dilata-
tion  happen, when  the membranes  are not protruded beyond the
orifice of the uterus; and, on the other hand, we see speedy de-
livery 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 torpor
bv the sudden  depletion of the liquor amnii.^—W. P. D. 
172
Phenomena of Labour.
Exposition of the preceding Phenomena,  mid of some
  others, according to tlie Order in which they generally
  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, accompa-
nied 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 aug-
ment in the course of  labour, except the first; for the
orifice afterwards,  far from contracting, is obliged to en-
large at every pain.
  448. In the second period of labour the pains become
stronger and more frequent; the orifice of the uterus en-
larges, 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 that it  is never farther from the
finger than at this  moment.  The woman feels a weight
below, which invites 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 by the action of the ab-
dominal 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 
Phenomena of Labour.
173
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 longer; 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 per-
fect; and is not commonly troubled by any of those unea-
sinesses 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 begins 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 wo-
men 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 fre-
quent, but  it iS almost always irregular; the face grows
red, the eyes inflame, and the heat 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 seasona-
bly to calm this universal agitation, by the relaxation
which the  evacuation of  the waters produces; 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.      ♦ 
174            Phenomena 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 engages in  the orifice,
and approaches the vulva  at  every pain; so that, when
all things are well disposed, the delivery is terminated in
a very little time.
   455.  As soon as the head is completely in the cavity
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  themselves 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 them-
selves on a close stool, we should have the mortification
to see some of them delivered in  that attitude; which
might have disagreeable consequences, either to them-
selves or their children.
   457.  When this sensation is felt, if the perinasum yields
easily, we see it stretch at every pain, on tne 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 hap-
pens  in  a first labour, delivery is often several hours dis-
tant still.
   458.  In  this latter case, though the perinaeum  distends,
and is forced outward  during  every pain, it shrinks im-
mediately afterwards; and the head, which was visible at
the vidva,  recedes, and returns  again into  the pelvis. 
                Phenomena of Labour.            175

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 perinosum
remains distended; and the head, which appears almost
entirely enveloped 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 proposed divers
means for facilitating  delivery in that  case.  It will per-
haps appear surprising that I should rise  up against so
many  authorities, and assign no other cause for this ef-
fect but the elasticity of the perinosum, 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 re-
 turn again after the pain, the perinosum,  then much dis-
 tended 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 tearing.   To prevent this acci-
 dent,  we ought to direct the woman to suspend or mode-
 rate those efforts which depend  on her will; while  the
 accoucheur supports  the perinosum with the  palm of one
 hand, in order to counterbalance the rest, till the exter-
 nal 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 camnculas myrtiformes
 disappear, the nymphas diminish, and the fourchette com-
  monly tears.  To this, the  most painful  moment  of la-
 bour, succeeds a calm,  till then unknown to the woman;
  and  that  calm, joined to the joy of being a  mother, ren-
  ders  this instant inexpressibly agreeable. 
176            Phenomena of Labour.
  462. But new pains would soon come, and disturb this
delicious moment, if the accoucheur should abandon the
expulsion of the child's trunk, and of the placenta, to na-
ture 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 excited by the
presence of clots which are formed in the uterus, or by
the fulness of the vessels of that organ; they are called
afterpains. • If the first labour is in general the longest
and most painful, women are in some  measure recom-
pensed 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 whicli the women might be delivered without
help, we may divide them into four general species, each
of which may be subdivided into particular ones. 1. Those
where the child presents 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 con-
currence of several causes,  some of which depend 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 sufficient
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 delivery.
   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.
                          z 
178
Unassisted Labour.
Of the first general  Species of Natural Labour, or that
         in which the  Child presents the Head.

  468.  By this generical term, of a 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 essential  differ-
ences, relatively  in which the head  may present  to the
superior strait.   Among the various  positions which the
region of the vertex is susceptible of, I shall distinguish
but six, which  will constitute so many particular species
of labour.
Distinguishing Signs of the  Vertex, and of its  Different
                      Positions.

   470. A round tumour, of a certain extent, and pretty
solid, on  which we  may distinguish  several sutures and
fontaneUes, characterizes the vertex, or  the superior part
of the head.
   471. It is the direction of the sutures, and the situation
of the fontaneUes, with respect to the pelvis, which ena-
ble  us  to judge of  the  position in which the vertex or
crown of the head presents.  It is often  sufficient for that
purpose to touch either of the fontaneUes.
   472. In the first  position, the sagittal  suture cuts the
pelvis obliquely from left to right, and from before back-
ward.  The  posterior fontanelle is  situated behind the 
Unassisted Labour.
179
 left acetabulum, and the anterior before the right sacro-
 iliac symphysis.
   473.  In the second  position, the sagittal suture also
 traverses the pelvis diagonally, but passes from the right
 acetabulum to the left sacro-iliac symphysis; so that the
 anterior fontanelle is before the latter, and  the  posterior
 behind the former.
   474 In the third position,  the posterior fontanelle an-
 swers 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 directed as
 in the first; with  this difference, that the  anterior fonta-
 nelle answers to the left acetabulum, and the posterior to
 the right sacro-iliac symphysis.
   476. In the fifth, the sagittal suture is likewise direct-
 ed obliquely with  respect to the pelvis; the  anterior fon-
 tanelle being situated behind  the right acetabulum,  and
 the posterior behind the left sacro-iliac symphysis.
  477. Lastly, in the  sixth position, the  anterior fonta-
 nelle  is behind the symphysis of the pubes,  and the pos-
 terior before the sacrum; the  sagittal suture  being direct-
 ed as in  the third  position.
  478. Some of these positions are not met with so fre-
 quently as others.  It has appeared to  me that  the pro-
 portion 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, they
 are  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 distinguished into good 
180
Umssisled Labour.
and bad.  For the head to be well  situated, it must pre-
sent diagonally to the superior strait, and in such a man-
ner that the occiput may turn under the arch of the pubes,
as soon as it is descended 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 thereto of the woman: for notwithstanding this fa-
vourable 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 obstacles to its progress,
though  it had  at first presented in the most advantageous
position  at  the superior  strait; which depends on  the
concurrence of several causes, whose presence adds so
considerably 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 performance of
this function, that the head, besides the conditions already
stated, should follow a determined course:  but  different,
in some respects, in each of the six positions which I have
established. 
Unassisted Labour.
181
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 po/sterior 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  tmnk,
till the  chin rests  against the upper part of the breast.
During  this time the posterior fontanelle  approaches
more or less to the centre of the pelvis;  and the head in
that state of flexion continues to descend in the direction
of the axis of the superior strait, till  stopped by the in-
ferior part of the sacmm, coccyx, and perinosum:  one of
the parietal protuberances  passing  before the left sacro-
iliac symphysis,  the other behind the right acetabulum.
    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 answers to the left
 limb of that arch; and that the other branch of that su-
 ture is towards the left ischiatic notch.
    485.  The head cannot remain long in that state;  press-
 ed by new efforts, and not being able to follow its form-
 er direction, it passes forward along the inclined plane
 offered it  by the sacrum, the coccyx, the perinosum, and
 sides of the pelvis; but in such a manner that, in de- 
 182               Unassisted Labour.

 scending 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  occiput
 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 necessary 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 posterior fontanelle towards the mid-
 dle of the arch  of the pubes; from whence the sagittal
 suture goes backward, rising obliquely towards the pro-
 jection 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, dilating the vulva, and
 rising up before the mons veneris; 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 mother; while the chin
describes a very extensive curve behind, passing succes-
sively over every point of a  line which would divide the
sacrum, coccyx,  and perinosum, longitudinally  into two
equal parts. 
Unassisted Labour.               183
  489.  In this species of labour, the shoulders, which
had  engaged  obliquely in the  superior strait, present
themselves differently at the inferior.   The right shoul-
der turns towards the pubes, and the left towards the sa-
crum; so that their greatest breadth becomes parallel to
that of this strait.   After this change, the left shoulder
continues to advance towards 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 circumference.  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.
Of the Mechanism of Natural Labour, where the Child
  presents the Crown of the Head in the Second Position.

  493. This position of the head, whose characters are
described in par. 472, will appear as favourable to the

  ■  The student's attention is begged to these truths.—W.  P. D. 
 181.              Unassisted Labour.
 exit of the child as  the first, if we only attend to the re-
 lation of the dimensions of the head to those of the pelvis.
   494. Nature however  often finds obstacles in this se-
 cond 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
fasces which it often contains—appear to he the princi-
 pal sources of them.  The first  of these causes obliges
 the head, as it engages in the  pelvis,  to follow that dis-
 advantageous course indicated in  par. 950; and the se-
 cond 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
 sacmm.
  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 afterwards turns under the arch of the
pubes, and  disengages itself by turning on the  inferior
 part of the symphysis, while  the chin describes back-
 ward a very long curved line,  as stated in par. 488.
  496. As  soon  as  the head  is delivered, the left shoul-
 der presently places  itself under the pubes; and the right
 goes  towards the sacrum,  to advance in the order indi-
 cated in par. 489. 
Unassisted Labour.              185
Of the Mechanism of Natural Labour, where the Crown
      of the Head presents in the Third Position.

   t97.  Most accoucheurs, even  at  this day,  imagine
that the head generally presents in this position,  see par.
473.
  498.  This third position will perhaps appear less ad-
vantageous than  the two preceding, because  the longi-
tudinal  diameter  of the  head is parallel to the  smallest
diameter of the superior strait; but if we recollect that
this latter is generally four inches in extent, and  that the
diameter of the head in question 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 dia-
meter, to the small diameter of the superior strait.
  500. As soon as  the vertex  is arrived  at the inferior
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 inferior strait, as stated in par.
489;  but sometimes it is the right shoulder which goes
backward, and sometimes the left: whereas in the other
positions their course is almost constant.
2A 
186              Unassisted Labour.
Of the Mechanism of Natural Labour, where the Crown
      of the Head presents in the Fourth Position.

  501.  In this species  of labour, the position of the head
(see  par, 474) is such,  that its delivery becomes exceed-
ingly difficult when the pelvis is not extremely large, re-
latively 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 occiput  descends into the pelvis, passing before  the
right sacro-iliac symphysis, till the posterior and supe-
rior 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 forehead sliding along the inclined
plane of the left side of the pelvis, goes under the pubes.
  502.  It sometimes however happens, but unfortunate-
ly 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 sa-
crum.
  503.  These examples  of the fourth position reduced,
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 accoucheur may always determine the head to
take that favourable direction.
  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 sacmm.   While this latter continues to  advance  for- 
Unassisted Labour.
187
ward along the coccyx and perinosum, the forehead, placed
opposite the arch of the pubes, and not being able to en-
gage in it  as the occiput does in the former positions, is
obliged to remount behind the symphysis, against the in-
ferior  edge of  which  the  anterior fontanelle  is  then
strongly pressed, till the posterior appear at the bottom
of the vulva.
   505. At that instant the anterior edge of the perinamm,
much more distended than in  the former positions, not
being able  to remain on  the summit of the inclined  and
slippery plane of the occipital  region, 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 perinosum,
or towards the anus of  the woman, while the face disen-
gages from under the pid>es, and the chin describes  a
curved line, of the same extent  as that it describes back-
ward, in the three former positions, before it  appears at
the bottom of the  vulva;  but in a contrary direction.
The chin scarely appears 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 shoul-
der places itself under  the pubes, and the right goes to-
wards the  sacrum, to disengage first.
Of the Mechanism of Natural Labour, wJiere tlie 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 po* 
188
Unassisted Labour.
sition 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 per-
formed must, casteris paribus,  be also perfectly the same.
   508. The occiput descends first into the cavity of the
pelvis, passing before the left sacro-iliac symphysis, as it
does before the right in the  fourth  position.   It after-
wards 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 sacmm, in order to follow the
course which has been already assigned them.
   509. Sometimes the occiput, instead of turning to-
wards  the sacrum, gradually approaches the left acetabu-
lum, 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 position,  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 ad-
vantage.
   510. Sometimes also this species of labour, often dif-
ficult in itself, on account of the tendency of the face to
place itself under the pubes, in proportion as the head
descends in the pelvis, becomes much more so, from ac-
cidental circumstances, and especially from a  left lateral
obliquity of the fundus uteri. 
Unassisted Labour.              189
 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 presents;
 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 eva-
 cuation 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 pre-
sentation of the length of the head parallel to  the entrance
 of the pelvis, as some perhaps  may think, than on the in-
 evitable presence of the face under the pubes in the last
period.
  513.  In  the sixth position of the head, when  the pel-
vis is well formed, the occiput descends before the  sacrum,
 as it does before the sacro-iliac  symphyses 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 middle of. the crescent formed  by the lower
part of the vulva, when the perinaeum is much distended.
At this instant the anterior edge of the perinosum retires
towards the anits of the woman and the neck  of the child.
as observed in par. 505;  the occipti^immediately begin?
to turn back the same way; and the face disengages from
under the  pubes,  according to  the course  indicated iu
par. 506. 
190
Unassisted Labour.
  514.  As soon as the chin is delivered, the face turns
towards one of the woman's groins,  but indifferently to-
wards the right or the left, without our being able to as-
sign a particular reason for it
  515. The shoulders soon afterwards present their great-
est breadth to the length of the vulva; one of them turn-
ing towards the pubes, the other  towards the sacrum; in
order to disengage as in the five former species 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 proved
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 preternatural, 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
indications, according to circumstances in another place.
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 preceding, and are
accompanied by the same phenomena, till the opening of
the membranes.
  518. It is generally so easy to distinguish the feet, that
I think we may dispense with a description of their cha- 
Unassisted Labour.              191
racters;  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 utems; because of the ex-
treme  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  with-
out; 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 present at
the superior strait.
   519. Relatively to these latter parts we shall distinguish
four principal positions, to which all others may be refer-
red.   These four positions will constitute so many spe-
cies 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 ante-
rior 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 lit-
tle backward.   The  trunk and head are so situated, that
the breast .and face  answer  to that  part of the utems
which is over the left sacro-iliac symphysis, and the back
to the anterior and right lateral part of that viscus.
   522. In  the third  position, the heels are turned  to-
wards 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 poste-
rior part of the uterus; while the toes, the face, and breast.
are under its anterior part 
132               Unassisted Labour
 Of itus 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 which they are placed.  They sometimes
advance  with difficulty, because the legs, crossing one
another casually in the pelvis, produce considerable obsta-
cles to their descent.  When they are without, the breech
soon appears at the vulva,  where it almost  always pre-
sents diagonally; the left hip, in this first position, answer-
ing to the right limb of the arch of the pubes, and the
right hip  to the left sacro-ischiatic ligament.   The breech
continues to advance in that direction,  rising a little to-
wards  the mons veneris, in proportion as the trunk disen-
gages; 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 position 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 descend, be-
cause  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 dispositions, they accommodate them-
selves to the  figure of the pelvis,  and engage in it, by the
efforts of the uterus, and of the auxiliary powers. 
Unassisted Labour.              193
  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 sacro-iliac sym-
physis.
  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, favours the descent of
the former.
  529.  If the head engages  diagonally  in the  superior
strait, it does  not fail soon to change its direction.  It
has scarcely cleared that strait, before it describes a ro-
tatory 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 to  its  round
figure,  and  offers it a larger space.   After this motion,
the face lies along the coccyx  and peritonaeum; the nape
of the neck being placed against the inferior edge of the
symphysis of the pubes, behind which the occiput is in
some measure concealed.
   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 fontanelle, and the vertex;
all which pass successively before the fourchette, or ante-
rior edge of the perinaium; 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
 utems  assisting very little at that  time.  This remark
                          2B
                                   r 
194              Unassisted Labour.
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 de-
scend, become almost parallel to the neck—those parts
are scarcely delivered, and  the head advanced into  the
cavity of the pelvis, before  the arms disengage of  them-
selves.
   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 shoulders,  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  cir-
cumferences.
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, with-
out remarking the same relation of dimensions between
the foetus and  the pelvis of the mother, as in the  pre-
ceding position, and  without  being convinced that the
mechanism of the expulsion of the child must be the same
in both cases. 
                  Unassisted Labour.              195

  535.  In fact, the feet descend in this position as in the
first; the breech traverses the pelvis in a diagonal direc--
tion; the shoulders engage in it in the same manner, and
their breadth becomes  afterwards parallel to the length
of the vulva; the head presents its greatest extent ac-
cording to one of the oblique diameters of the superior
strait, but so that the occiput answers to the right aceta-
bulum, 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 sacmm, and continues to ad'
vance  along the curve of that bone, the coccyx and peri-
naeum; 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. 350, 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 characterizes this
species  of labour, has always passed for the most favour-
able  of the  four which I have assigned them:  and will
still appear so to those who only pay attention to the re-
lation 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 sacrum: 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 deliver-
ed, in this species of labour, preserving their primitive
position with respect to the woman:  that  is  to say, with 
196
Unassisted Labour.
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 descend
in that manner, and pass over the angle formed by the
union of the base of the sacrum with the last lumbar ver-
tebra, as it descends into the pelvis.
   538.  Although the child's back sometimes disengages
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.
Of the Mechanism of Natural Labour, where the Child
       jpresents the Feet in the Fourth  Position.

   539. The  fourth position of the feet is  generally re-
garded 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 ob-
struct 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-found-
ed, and that the precautions recommended  to prevent it
had only served to favour it. 
Unassisted Labour.
197
  540. It is however certain, that delivery is performed
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 lat-
ter period of labour, as it finds towards the sacrum in the
other cases.
   541.  When we let nature act without constraint, and
not,  under pretence  of assisting her,  perform any ma-
noeuvre 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, can-
not descend exactly along the middle of the convexity of
the lumbar column, to stop 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 diago-
 nally at the entrance of  the pelvis,  but  so that the face
 answers 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  descending backward  towards
 one of the sacro-iliac symphysis, and  turning afterwards
 towards the middle of the sacmm,  it passes down behind 
198              Unassisted Labour.
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 peri-
nosum, 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 quarter 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 ver-
tex, disengage  successively from under the pubes.  But
the expulsion of the head  is  performed with  more diffi-
culty than in those cases where the face is  turned to-
wards the sacmm; because the arch of the pubes  is nar-
rower, in its superior part, than the forehead and vertex
of the child.
Of the Third general Species of Natural Labour, or that
         in which the Child presents tlie Knees.

  546. If we call to mind  the  respective dimensions of
the foetus and the pelvis of  the  mother, and tfce mecha-
nism of those labours which make the subject of the pre-
ceding article, it will not appear surprising that I reckon
here,  among natural labours, those where the child pre-
sents  the knees; because it will be seen  that it may be
performed by the powers of the mother alone.  If in the 
Unassisted Labour.              199
sequel I consider them otherwise, it is because there fre-
quently occur circumstances which render them preter-
natural; that is to say, impossible without assistance.
  547. The child almost always offers but one knee to
the orifice of the utems;  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 paral-
lelism 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  mecha-
nism  of the different species of natural labour, where the
child comes presenting the knees, to distinguish four prin-
pal positions, as we  have done with respect to the feet;
because all others we  can meet with have a  perfect re-
semblance  to those.
   550.  In the first species, the  child's legs, always bent
when the  knees  engage in the  pelvis,  are towards  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 sacmm of the mother, and the legs
are under the pubes.
  553. We  observe the  contrary in the fourth species; 
200
Unassisted Labour.
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
with 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 article may be  consulted.
Of the Fourth general Species  of Natural Labour, m
      that in which the Child presents the Breech.

  555. A pretty large tumour,  in which we discover
neither the hardness of the head, nor the softness 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 distinguish
this part perfectly before the opening of the membranes,
it is almost impossible  to mistake it afterwards; and not
to discover also its situation 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 utems, beyond  what
we have done for the  feet and knees; but I shall distin-
guish only foxir principal ones, as I have done for them. 
Unassisted Labour.
201
Of the Mechanism of Natural Labour, where the Child
       presents the Breech in the First Position.

   558.  In this species of labour, the breech presents 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-posterior 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 advance along the  slope of the sacrum, coccyx, and
perinaeum; while the left only turns on the inferior edge
of the symphysis of the pubes, as I have observed 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 to-
wards the mons veneris: and the child's trunk, as it is de-
livered, bends a little in the same  direction.  When the
breech is sufficiently descended, the feet, which were ex-
tended 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

  *  That is, the diameter running from the  inferior edge of the
symphysis pubes to the point of the coccyx.—W. P. D.
                         2C 
20%              Unassisted Labour.
the entrance of the pelvis; but so that the child's back
is towards the right side of the  uterus,  and a little for-
ward.  The breech engages by 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 perinaeum,  while the right hip  only
turns a little under  the symphysis of the pubes.   The
child's trunk  disengages,  bending lightly towards 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 placed so that the back is up-
ward and the belly downward.  It is seldom that it de-
scends in that position; and more  seldom still that the
forehead does not afterwards turn away from the pro-
jection 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 posterior part of the
uterus.   If its breadth, from  one hip  to the other,  is at
first placed transversely, with respect to the superior strait,
it becomes insensibly parallel to one of its oblique diame-
ters,  and afterwards to the  largest  diameter of the infe-
« 
            Management dining Labour.         ~03
nor 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 Qf
the acetabula.
  Of the Management of the Woman during Labour.

  563. The  greater part of women, if left entirely to
themselves during labour, would nevertheless be delivered
without help: this truth, founded in nature, has no need
of new proofs.   But those same women, if assisted sea-
sonably, 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 with-
out help, some take place so precipitately,  that the great
and  sudden depletion of the uterus sometimes becomes
the source of several mortal accidents, or at least ex-
tremely dangerous; and others are so tedious and labo-
rious,  that  their  consequences 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.
   565. Though nature would, sooner or later, surmount
some of the obstacles to delivery, there are many others
under which the woman would infallibly 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 spectator.
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 
204         Management during Labour.
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 generally re-
         quires in the First Period of Labour.

  567.  Women, almost always uncertain concerning the
period of their pregnancy, often mistake for the begin-
ning 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  ef-
fect of these pains a little while, ought  to endeavour to
distinguish their true character, and discover 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 hap-
pens.
  569.  Touching alone can enable us to distinguish these
two species of pains with certainty; for  they are some-
times 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 cha-
racterize 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 contrary
very various, both on account of  the diversity of their 
            Management during Labour.          205

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 indi-
gested or putrid matter in the  first passages, by a stone
in the kidneys, ureters, or in the bladder; and sometimes
from several of these  causes  together.   We  never ob-
serve any of the effects mentioned in the preceding para-
graph, during the action of these false pains, at least un-
less they have excited contractions of the uterus, and true
labour pains.
   572.  After having perfectly recognised the character
of  the true pains, whose frequent return, and augmenta-
tion, constitute what is usually  called labour; the accou-
cheur must endeavour to discover whether the woman be
at her full time or not; that he may not forward an acci-
dental labour, which  he might have put off, if he had
sought its true cause.   In order to which, he must recal
to mind  the characteristic signs of the different periods of
pregnancy.—See the article on touching.
   573.  When these pains are not felt till the time of the
perfect maturity of thefostus, we must attend to their fre-
quency and intensity; to the  size of the orifice of the
uterus, and to the hardness of  its edge; in  order to esti-
mate nearly what will be the duration of the labour, and
the time when it will terminate.  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 
206
Management during Labour.
of the child presents, and its position;  in order to pre-
scribe early that situation which is best adapted  to the
state of the woman.
  575. AH women should not  be treated  in  the same
manner during the course of labour, because the circum-
stances 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 terminate,  if they stand in need of any ali-
ment;  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 concerning the
drink we allow to a woman in labour, than about the na-
ture 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 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*

  *  Too strict attention cannot be paid  to the diet and drinks of a
parturient woman, and especially if it be with her first child. All
stimulating substances should be withheld, and particularly those
of the  diffusible kind: they dispose  to  feverish excitement when
not  present, and sure to increase it when it has taken place.  We
are  persuaded, from frequent observation, that the giving of wine
or other liquors during the progress  of a slow labour  especially,
renders it more tedious and painful always, and not unfrequently
converts it into a preternatural one—that is, into one that would re-
quire the  interference of the accoucheur,  ^ee Essay on the Mean*
of Lessening Pain, &c—W. P. D. 
            Management during Labour.         207

  577. Glysters should not be neglected: one is sufficient
to evacuate the gross excrement which might  add some-
thing 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  sensa-
tion 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, hemorrhage, in-
flammation of the uterus, &c.
   579. Baths, demi-baths, emollient fomentations,  and
moist fumigations,  may be employed with success.  These
means are never more useful than when time has taken
from the parts concerned in delivery, the natural supple-
ness of youth, so necessary for a facility in this operation.
But we must by no means have recourse  to them, and
 especially 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  beneficial in
 some circumstances, so much they become pernicious in
 this latter, whether to the mother, or to the child. 
208           Sduation during Labour,


     Of the Situation of the Woman during Labour.

   580. The situation of the woman is not always arbi-
trary: it must be varied according to circumstances, and
the period of labour.  When it is but just begun, and is
not complicated with any accident, and every thing rela-
tive 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 late-
ral obliquities, on one side, but on that which is opposite
fo the deviation, 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 convenience  to the
women, are almost always less consulted than custom.
In some countries, as  in  Flanders, Holland, Spain, &c.
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 sepa-
rated by a pillow.
   583. In some of our provinces the women are deliver-
ed kneeling on a cushion, 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 
               Situation during Labour.           209

adopted among us.   Roederer  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 a half to  three feet at  most, and  co-
vered 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 sinking, 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 wo-
man 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 perinosum and
vulva are hid.  In the latter, the lower part of the tmnk
being placed on the end  of the folded mattress, all those
parts are  entirely free, and are  much  more  easily deve-
loped; 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 expelled.

   r Roederer practised midwifery in a nation where the chair  was
very much in fashion.
   t Lit de Sangles  is a little bedstead without any transverse
pieces at the ends; the feet of which cross each other at their cen-
tres, 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.
                           2D 
210
Of preparing the Parts.
   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 wo-
man 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 intel-
ligibly, the dilatation of the parts.  This they often do
without knowing whether  the woman be  in  labour or
not, and  sometimes even without being sure that she is
with child; which indeed I should scarcely believe,  if I
had not been several times a witness of it.
   587. These manoeuvres, which they  entitle prepara-
tory dilatations, often produce  an effect quite contrary to

  * The mode usually pursued here, is  to have the patient's bed
made in the conunon way, with the addition of a folded blanket in
the middle of it, and under the lower sheet; then we separate the
vheets 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 ad-
vanced 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 fa-
tigue or even disturbance.—W. P. D. 
               Of quickening the Pains.           211

what they expect from them: for by depriving 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 ex-
tremely painful.
   588.  It is sometimes necessary to prepare these parts
for delivery, and even to begin those preparations during
the latter periods of pregnancy; but then we must pro-
ceed in a very different manner.   Warm  baths, or demi-
baths,  emollient vapours, and the repeated application
of fat or mucilaginous substances, may be advantageously
employed.  Emollient  injections, such as the mucilage
of marsh mallows, or of linseed, would not be less useful;
but there is something so  disgusting in them, that few wo-
men will submit to their  use, except in accidental cir-
cumstances which  are more severe than those that ac-
company a labour which  is merely long and laborious.
           Of quickening Lingering Pains.

  589. Nothing is less regular than the progress of la-
bour  pains: sometimes  they  augment  suddenly;  some-
times they diminish, slacken,  and even go  entirely off
for  a time; which may depend on  a variety of causes,
each of which presents a particular indication.
  590. Many persons, without regard to those  different
indications, always prescribe irritating remedies, 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 pre- 
212
Of quickening Hie Pains.
scribe ipecacuanha, to excite vomiting;  and some to keep
the woman standing or walking about, which is  quite as
imprudent: 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 medi-
cines.   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  fomentations, 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 by tear-
ing 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  in-
convenience, 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 mem-
branes often renders labour more tedious, and in some
respects more laborious; the same inconveniences some-
times also arise from  their not opening in proper time:
whence we see  that it would not be less useful to open 
             Of opening the Membrarws.          213

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 extended farther.  The la-
bour ought moreover to be in its full force; which sup-
poses the pains to be strong and frequent.
   594. The manner of opening the membranes is in gene-
ral 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 be-
cause 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 sufficiently.
    596. When the membranes present their thickest part
 at the orifice of the uterus, or are so strong that we can-
 not tear them  by the method recommended above, we
 must  begin by weakening them in one point, by scratch-
 ing 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 scissors,
 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
* See par. 794 and 813. 
211
Of opening the Membranes.
 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 sufficiently to fill and
 distend it, it  must be torn by pincing  the membranes be-
 tween 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 scissors, or any  other in-
strument; 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 apply-
ing an instrument, or the nail, to the uterus, which  some-
times still covers  the  head,  though it is very low in the
pelvis.  It is so much  the more easy  for persons not ex-
ceedingly skilful to  be deceived in this latter  case, be-
cause  the orifice  of the  Uterus is  concealed backward;
and that portion of it which covers the child's  head, be-
comes at length, and especially during the pain, as smooth
and as tense  as the membranes*—See par. 249, and the
observations  relating to it.
   * We were once called  to the assistance  of a midwife, who was
in attendance on  a young woman with her first child. The  woman
 had suffered much from spurious pains, which her ignorant atten-
 dant mistook for genuine labour pains.  The poor woman had been
 much fatigued  by the rude and ill-judged handling of the midwife,
 and our advice was requested.  On visiting the sick woman, the
 midwife informed us, that the labour was alone delayed  by the
 thickness of the  membranes, which she had in vain attempted to
 tear or scratch  through. We examined the poor woman, and found 
General Precautions.
215
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 dis-
cover it before;  or to observe whether the head engages
in a favourable manner, or not: in order to let nature act,
or prevent 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 engage those who are sub-
ject to a descent of the uterus, 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 en-
gage the woman not to bear down:  the accoucheur must
likewise support the edge of the orifice of the uterus du-
ring 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.

that the os uteri was completely closed ; and what had been sup-
posed by the midwife to be the protruding membranes, was the ute-
rus itself, stretched very thin ;—but fortunately through which, this
old woman could not make her way by all the power of  nails she
could employ.  The patient  was obliged  to be bled several times,
fully purged, and kept upon a strict antiphlogistic regimen for se-
veral days; at the end of which time genuine labour  took place,
and was safely delivered, and  without any subsequent inconve-
nience ensuing.—W. P. D. 
216             General Precautions.
   602. When  there is an hernial tumour, we must en-
deavour to reduce it;  and prevent its return by a conve-
nient 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 intestine from insinuating
itself into the tumour, and endangering a strangulation:
as I saw in a woman who had had a large epiplomphalocele
nine years, and who for two days had in vain exerted the
most violent efforts for delivery.
   603. When  the woman  is much troubled with pains
in the small of the back,  a folded napkin may be pass-
ed 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 intensity 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 supporting themselves on the heels and shoulders.
   604.  When the woman  is attacked by the  cramp in
the legs and thighs, which is often less supportable than
the most violent labour pains, we must endeavour to re-
lieve her, either by dry frictions  on the  part affected, or
otherwise, according to circumstances: 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 moments.   Be-
sides fat substances, such  as lard, &c. which we are te 
General Precautions.
217
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 perinosum.   But
this is  only to be done in  the interval of the pains;  con-
tenting ourselves,  during their action, with supporting the
perirweum with the palm of the hand, in order to prevent
its tearing, and hinder the head from being delivered too
suddenly.
   606. These preparations  are never more  necessary
than in a first labour.  If they are omitted then, we are
commonly freed from the necessity  of using them after-
wards; because the perinosum being  torn, never unites
perfectly, nor do the other parts ever  recover their natu-
ral tone.
   607. When the posterior extremity of the head is en-
gaged  in the vidva, as in  a  kind of crown, if the four-
chette is not too much distended, we may permit the wo-
man to indulge her inclination to bear down; and during
that time, without however discontinuing to support the
perinosum, we may favour the exit of  the head, by press-
ing against it  underneath, and near the anus of the wo-
man, as it were to oblige  it to ascend towards the mons
veneris.
   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.   After-
wards  we examine the situation  of the shoulders with re-
spect to the inferior strait: and push one of them towards
the sacrum, and bring the other under the pubes, if they
                         2E 
2J8
Particular Precautions.
are not  placed so naturally.  We then deliver them, as
well as the rest of the body, by pulling gently and cau-
tiously 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 consi-
derable force at the head and neck of the  child, with a
view to extract the trunk, when the breadth of the shoul-
ders obstructs its progress; for nothing can be more dan-
gerous  than  such efforts.  In that case, we must intro-
duce the fore finger of each hand into the  axillae,  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
abovementioned; for even the smallest cannot be deliver-
ed transversely without extreme difficulty; as is very easy
to comprehend.
Particular Precautions relative to each Position of the
  Head, or to other Circumstances which sometimes ren-
  der Natural Labour a little more diffkult.

  611.  Circumstances, which would be too long to de-
tail here, may add to the natural difficulties of labour, by
obstructing more or less the pivot-like motion, by which
the occiput or forehead place themselves opposite to the 
Particular Precautions.
219
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 na-
ture considerably, supposing her able to accomplish it.
   612. When the head  presents in the  third position,
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 occiput from over the sym-
physis of the pubes, and direct it towards one of the ace-
tabula: which is generally pretty easily executed  at the
time of the opening 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 posi-
tion; 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 laws to her: and the facility of the deli-
 very 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  ac-
 complish that, even if we pass the hand into the utems 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 
220
Particular Precautions.
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 pelvis;  and that mo-
tion, which would be entirely at the expense of the neck,
the trunk being fixed, and closely embraced by the ute-
rus, would be of the most dangerous consequence to  the
child.
   615. In the best positions,  as well as in the others,  the
head sometimes  engages in such a manner,  that the fore-
head descends more than  the occiput, so that the head
presents the whole length of its greatest diameter to  the
inferior strait; which generally produces insurmountable
obstacles to its exit  It is easy to prevent these obstacles,
by changing  the situation of the uterus betimes, and \fy
supporting the fore part of the head a little, to oblige the
occiput to descend.   I shall treat more amply in the se-
quel 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 disposi-
tion, though  it does not  produce those obstacles to  the
exit of the head, which have been commonly attributed
to it, yet requires  some precautions on the part of the
accoucheur:  but they do not become necessary till the
head is without; that, in disengaging the trunk, the  um-
bilicus, already stretched, may not be  torn, nor the  pla-
centa 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 
              Management of the Child.           221

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 indica-
tions presented by the other species of natural labour; as
well as the various circumstances which, by complicating
them, often render them preternatural.
      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 transverse-
ly, 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, with-
out 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. 
222           Management of the Child.
   622.  In fact, we ought to leave it  as short a time as
possible under the clothes; because there it can only re-
spire 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 in-
voluntarily in  the last  moments of labour; very different
from that pure  and temperate air,  which  its  delicate or-
gans require.
   623.  A ligature made  about two inches from  the um-
bilicus, is all that is necessary; two have been employed,
but the second is useless, nay even hurtful 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 pass-
ing it once round the cord and tying,  is sufficient.
  Of the Treatment of a Child born in a Morbid State.

  624.  Some children are born  in a state of apoplexy:
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 deple-
  * This important direction should never be neglected, as very
consequential results  depend upon the compliance with it.  The
highly necessary changes  in the foetal  circulation are never com-
plete, until  the route of the blood  through the cord is interrupted
by a change of its direction through the lungs.  It would therefore
be very wrong to stop this by artificial means, as the necessary al-
terations for a new circulation have not yet been effected.
                                               W. P.  D. 
                  Management of the Child.           223
\
    tion it procures, is the most efficacious assistance 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 weakened in
    these cases, that it is with difficulty we obtain a few drops
    of blood, by the section of the  umbilical cord; which can-
    not be sufficient to save the life of the child.  We must
    then endeavour to procure a greater discharge by  press-
    ing 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 disappear, without plunging the child up to the arm-
    pits into a bath more  than warm, arid 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 contractions,
    and quicken them so far,  that we soon see 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 at-
    tempts.   One of these children gave but very uncertain
    signs of life half an hour after its birth, and did not show
    any positive ones till more than half an hour; for we can-
    not regard  as  such,  the oscillations excited by the heat
    arid activity of the bath.
       628.  Having brought these children  into a free  and
    temperate air, whether we keep them in the bath I have 
224          Management of the  Child.
just prescribed, or not, as may be thought proper,  then
mouths must be cleansed from the slime which often fills
them;* and then we procure them a kind of artificial res-
piration, 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 libe-
rally 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 perhaps the  most efficacious
means of awakening the principle  of life in this sort of

  * Many children may be saved, I am convinced from experience,
by a proper attention to this circumstance. The best mode of free-
ing them from the mucus, &c, which obstructs the passage of air to
the lungs, is to suspend them  by the heels with the mouth down-
wards ; 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 fin-
gers, and introduce it to the back part of the mouth; the mucus ad-
heres to the rag, and is withdrawn with it. To this must be added,
artificial inflation of the lungs, and the air expelled from them by a
gentle pressure upon  the thorax.  This should be frequently re-
peated; but, after nearly every inflation,  the attempt to dislodge
the mucus should  be renewed.—W. P. D. 
Management of the Child.          225
children.  We may advantageousl} 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 administered too sparingly,
or who  perhaps had been deprived 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 probable 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 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  useless,
because there is no blood flows.*  After taking the child

  * Our author does not mean that the ligature should nojt be em-
ployed, though he says it is useless after the pulsation in the cord
has ceased;  for it is a fact well known to almost every practitioner
in midwifery, that a bleeding sometimes takes place many hours
after birth, and even when the precaution of the ligature  has been
                          2 F 
226
Management of the Child.
from under the clothes, it must be kept warm, and treat-
ed as directed in par. 626, and following.   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  threatened
with convulsions, and others  have  been  taken out with
the face tumefied and  livid,  and as in  a state of apo-
plexy.*
   633. After natural labours which have been difficult
and very long, whether on account of the narrowness of
the straits of the pelvis, or the resistance of the soft parts,
children are  born with a tumour  more  or less volumi-
nous, 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 de-
formed; sometimes also the bones are depressed in cer-
tain 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 suf-
ficient  to  foment it with  wine,  with salt and water,  or
any vulnerary infusion.   This tumour is  more difficultly

used.  This especially happens, where the cord is very large, and
very difficult to compress in consequence of this thickness; and
 also from the improper nature of the ligature itself, such as tape of
 too great width, cotton thread, &c.—W. P. D.
   * We can add our own testimony to that of our author upon this
 subject.  We are persuaded we have seen evils many times arise,
 from incautiously washing the child with brandy or  other liquor:
 we are therefore in the constant habit of bearing testimony against
 this practice.—W. P. D. 
Management of the Child.
227
resolved when it  is sanguine; and especially when the
blood  is extravasated under the pericranium,  or under
the teguments, and is  there coagulated, as I have often
seen:* we are sometimes obliged to open this species of
tumour.f  If the consequences of it are simple  when the
blood is  only 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 end  mould the child's head, to  restore it its na-
tural 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 entire-
ly; for the head soon recovers  it 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 ac-
cidents which depend on the fracture and depression of
the bones.  This case requires the  aid of a skilful sur-
geon, and  not of a midwife.
  636. After a preternatural and  laborious labour, the

  * We have never seen this assertion of our author confirmed: in
every instance we have witnessed of these tumours, the blood re-
mained not only fluid within them, but did not coagulate when ex-
posed by our once having punctured one of them.  See note to this
par. below.—W. P. D.
  t This, I conceive, can never be necessary, unless suppuration
has been added to extravasation; as in 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. 
228           Management of the Child.
accoucheur has sometimes  a fracture or luxation to re-
duce;  because  he cannot  always,  notwithstanding  the
most exact precautions, free the child from those acci-
dents:  he ought therefore to examine it well before he
leaves  it to the nurse.
     Sequel of the Treatment of Healthy Children.

  637.  After having  attended to  the  pressing indica-
tions respecting the  mother, having delivered  the  after-
birth, and put her into a condition to pass a few seconds
on the  couch, the accoucheur  must again attend to the
child.   He ought to preside at the  dressing, in order to
forbid  every thing that may be hurtful; and should pre-
scribe the method of managing the  child in the first pe-
riods.
  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 it
from this glutinous slime, we must begin by moistening
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
  * This substance has been analysed by Vauquelin and Buniva,
and found most to resemble fat.  They have not discovered any
thing which readily unites with  it.—W. P. D. 
              Management of the Child.           22%

obliged  to rub harder, we irritate and inflame the skin,
so that it  becomes, as it were,  erysipelatous  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 disagreeable.
     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 un-
happily 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 prevent an umbilical hernia,
till  the ring be sufficiently contracted to oppose it by it-
self.
  642. At first this bandage must be made of three corn-
presses;  that  is to say, two of,a  few inches square, and
another long enough to go  round  the body   In the mid-
dle 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 both sides,  with  a little butter, tha< it
may not slick to the umbilicus, nor to the cord- and 'uat
we  may  change it, when needful, without i-*m\'-.% and
tearing the vessels, before the time of their periiect obli- 
230          Management of the Child.
teration.  This compress being placed on the belly, we
pass the cord  into the notch, turning it upward and to-
wards the left side, and then cross the two  ends under-
neath; so that  the skin of the belly, which  advances on
the cord, may not appear, nor the umbilicus be stretch-
ed.  We place the second compress  over the first; and
secure all with the third, with which  we make a circu-
lar round the body, moderately tight.
   643.  Although the cord falls off 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
proposed views  be  accomplished:  but it must no longer
he opened in the middle as at first.
   644. The child ought to be dressed as simply as pos-
sible,  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, and 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 pre-
serve 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. 
              Delivery of the Afterbirth.           231

  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 till the second
or third day after delivery, we ought not thence  to con-
clude that the milk does not begin to secrete in them
before that epoch, or that the child has no need of nou-
rishment till then; as many have unfortunately imagined.
The mother ought to give it the  nipple as  soon as pos-
sible; 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 sensa-
tion, from those caused by pain or other uneasiness.
Of delivering the Afterbirth, and  the Regimen to be ob-
                 served in the Month,

  649.  Delivering the  afterbirth, and the regimen 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. 
232
Delivery of the Afterbirth.
                     Of Deliverance.

    650. Bv the word deliverance has  long  been under-
' stood the exit of the placenta,  and the membranes.  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 contribute very  little  to it, though
 the people  imagine the  contrary, and  regard our minis-
 try 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  pretended that we
 ought always to commit the expulsion 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, with-
 out doubt, and I shall distinguish them carefully, where
 the accoucheur is obliged to deliver the placenta instantly;
 and others  where  circumstances require that he should
 abandon it almost entirely to nature: but, in all, he may co-
 operate usefully, by seizing the favourable moment for it.


       Of the unassisted delivery of the Placenta.
    654. The deliverance which is performed without help
 comprehends two periods, that of the detachment of the 
               Delivery of the Afterbirth.          233

placenta, and  that of its expulsion.   The utems is the
principal agent of this double operation; its action alone
forces the placenta to detach itself; but standing in  need
of help to disencumber itself entirely of it, the contrac-
tion 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 placenta, 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 placenta is shut up
for a few minutes: but  that viscus, still very much irri-
tated, not being able to bear this now foreign body, pre-
sently contracts to expel it, and forces its  orifice to re-
open to give it a passage;  the woman also, stimulated by
the uneasiness  caused by the placenta engaged in the va-
gina,  soon makes some efforts  to  accelerate her delive-
rance.
   657. The placenta always brings the membranes away
with  it, unless their union with the utems 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  delivering
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.
                          2G 
234
Delivery of the Afterbirth.
  Of the Signs which indicate the Time when we ought to
    co-operate in delivering the Placenta, and the Metlwd
    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 pre-
  sence  of a body which begins to engage in the vagina.
  confirm it.
   660. We favour the deliverance, by  suffering  the pla-
  centa to empty itself by the umbilical vein; by  frictions
  on the hypogastric region, to  excite or maintain the ac-
  tion of the utems; 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 precau-
  tion 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 utems, to  push the  base of the cord
 strongly backward, making it describe  an elbow in that 
               Delivery of live Afterbirth.           235

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 be-
tween the anus and the point of the coccyx, and conse-
quently 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 extract-
ing the placenta; which might induce  us to suppose it
very 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 acci-
dents which have often been  the consequence of the re-
tention  of some of their fragments in the uterus.
   667.  Whenever we find  any difficulty in extracting
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 action of the uterus more power-
fully; and if  the accoucheur  cannot  perform  them him-
self,  he must examine that region,  from  time to time, to
inform himself of the degree of contraction and hardness 
236           Delivery of the Afterbirth.
of the globe of the uterus, that he may avoid dragging
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 de-
liver the placenta before the union of all the signs  indi-
cated above,  none  is more urgent than a flooding; be-
cause the uterus, then weakened by the loss of blood,
wants force  to expel it, and its presence increases the
haemorrhage.
  669. The haemorrhage may be either apparent, or con-
cealed.  In die 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 distended and its cavity filled.
  670.  This concealed haemorrhage is never more to be
dreaded, than after  a labour preceded by a copious flood-
ing, 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 hap-
pen  after the placenta is delivered, if we  should stop up
the vagina, without any other precaution, in order to op-
pose the flow of blood, continued  by  an atony of the Ma-
ries.—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. 
Delivery of the Afterbirth.
237
 Of the MetJiod 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 as-
sistant solicits the expulsive action of the uterus,  by pro-
per frictions on the belly.  If the placenta resists  these
united efforts, we must introduce 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.
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 de-
liver the woman instantly, when it is accompanied by a
violent  flooding,  it prescribes a very different conduct
when there is no haemorrhage; for then we ought to do
nothing which may occasion a separation of the placenta,
till the uterus recover from its insensibility, and  be  in a
state to contract itself. 
238
Delivery of the Afterbirth.
  675. The  spasmodic contraction of the neck of the
uterus generally produces no more than a momentary ob-
stacle to deliverance.  It rarely gives any trouble, unless
it become universal, or is  accompanied by any other ac-
cident.  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.
Of Obstacles to Deliverance, proceeding from preternatu-
  ral Adhesions of the  Placenta;  and of what must be
  done in those Cases.

  677. The union of the placenta with the utems 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 action of the hand; at least,
unless we risk exposing the woman to accidents a thou-
sand times more dangerous than those we would free her
from by delivering 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 cristas which some  accoucheurs 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. 
              Delivery of tlie Afterbirth.           2 39

  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 utems;
but these  may be found at any part of the placenta.
  680.  When the placenta  is partly detached the opera-
tion of separation is easier; but it presents more pressing
indications,  as an haemorrhagy necessarily 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 placing
the fingers before the cord; and when it  is fixed to the
posterior  part, we place the  fingers  behind  the cord;
when it may be at the sides, we place our  fingers agree-
ably 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 ne-
cessary 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 re-
commend the reader  to consult him  on  the  subject*
" It very  often happens," says he, " in this case, that the
" placenta appears to  adhere very strictly, when we pull
" 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 battle-
" dore, and applied wet on a plane parallel to its surfaces;
" for we should sooner tear off the handle  of the paper,

   * M. Levret, Suite des Observations sur la Cause et les Acci-
dens des plusieurs Accouchemens Laborieux, page 139, 4me edi-
tion. 
 240          Delivery of the Afterbirth.
 "than separate it whole: whereas, if we lift up the handle
 " to detach it, it easily quits the plane on  which it is ap-
 « plied."
   682. When the  adhesions of the placenta resist the
 well-directed efforts which can be exerted on the umbili-
 cal cord, or when  the cord is so weak that we cannot
 make use of it,  many accoucheurs, even among the mo-
 derns, 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 very prudent if we
 had nothing  to fear from the retention of the placenta:
 but how 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 ute-
rus!
  683.  We must then introduce the hand, to try at least
 to deliver the woman, and shield her from those accidents.
This precept, authorized by the greater part of practi-
tioners, becomes of the  greatest 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 immediately,
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 time, and even extract it, when the
natural efforts shall  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. 
Delivery of the Afterbirth.
241
  686.  We easily find the placenta while the cord  ad-
heres 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  dis-
tinguish 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.
   687.  As it is very rare  that the placenta is not already
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 the 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 convenient and easy.
   688.  When it is found  already separated from the ute-
rus  in  some part of its circumference  the ends of the
fingers  must be  insinuated under it,  and the hand ad-
vanced 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 umbilical cord, to enable us
 to  grasp  the  detached  part  with the ends  of all the
 fingers; which is not difficult 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
                          2 11 
242           Delivery of the Afterbirth.
means in a case of that sort, after I had tried other ways
in vain.
   690.  Before we endeavour to extract the placenta, we
must carefully observe whether it be  entirely detached;
for,  being  of  a fungous nature, and easily torn, the ad-
hering portion might remain in the uterus, 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, 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 ute-
rus, 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 pla-
centa may relax,  or dissolve;  and  it  will then present it-
self readily to the hand of the accoucheur.
   693. We must not however conceal how dangerous
the consequences of this circumstance, happily very rare,
may, be; especially if we do not pay  it the strictest atten-
tion.  The putrefaction of the placenta, almost always
inseparable from  its retention  in the uterus, may become
the source of a multitude of  accidents; among which a 
               Delivery of the Afterbirth.           243

foetor of the lochia, suffocation of the uterus, syncopes,
 a slow fever, and insomnia, are the slightest
   694. Accoucheurs  have hitherto  applied themselves
 more to provoke the expulsion of the placenta,  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 be more inconvenience in ex-
 tracting it, or provoking its expulsion, than in leaving it.
 Of all the remedies to  which empiricism, rather than ra-
 tional 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 irregu-
 lar motion by which it is then too  often agitated, &c.
   695. Antiphlogistics and antiseptics ought  rather to
 be employed, according to circumstances.  Great advan-
 tages may likewise be  derived from emollient, detersive,
 and  antiseptic  injections, repeated several times a  day.
 They  relax the adhesions of the placenta,  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 may no longer
 corrupt the lochia,  or  retain them in  the uterus, by stop-
 ping its.orifice;  and that health may be more quickly re-
 stored.

 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.
   697. The extraction of a portion of the placenta, or
 of a clot formed in the iderus, must be considered as a 
244           Delivery of tlie Afterbirth,
part of the deliverance; since the presence of such fo-
reign bodies may cause the same accidents as the reten-
tion of the whole of the placenta.
   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 wbfefher any part of  the pla-
centa is left in the uterus, by collecting and putting toge-
ther all which is extracted; but we  cannot discover the
existence of cotyledons, or those little masses  I have just
mentioned, but by introducing 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 im-
mediately: whereas the traces which the others leaye on
the  membranes, are  exceedingly  equivocal: so that we
can have no  certain  signs of their existence, either im-
mediately after  deliverance, or in the sequel; because the
accidents they produce may proceed from another cause.
   700.  The retention of these portions of the  placenta
is no otherwise alarming, than as it becomes the cause of
 other accidents, of which the most to be feared is an hae-
 morrhage.   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 re-
 tained portion of the placenta, we must have  recourse to 
              Delivery of the Afterbirth.           245

the injections indicated in par. 695, and vary them ac-
cording to circumstances.
   702.  If we were certain of the existence of these por-
tions of the placenta  at the time of the deliverance, it
would be better to extract  them  immediately, than  to
wait till succeeding accidents oblige us to it: but if we are
not called till some time afterwards, there must be very
great accidents, to determine  us  to take the same me-
thod: because nature alone  almost always delivers her-
self of these foreign  bodies;  and  we have only to  guard
against the effects  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 ute-
ms; but which nevertheless sometimes  appears as dis-
tinct, 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 utems  is thus divided,
the placenta is sometimes  found in  one cell, and some-
times in the other; or each of them  contains 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 maybe encyst-
 ed, the deliverance is generally performed in  the  usual
 way;  it is only a little more difficult, because nature has
 to overcome  not  only the resistance of the  neck of the
 iderus, but that of the entrance of the cyst also.
    706. If we cannot perform it in the usual way, that is 
246           Delivery of the Afterbirth.

to say,  by pulling methodically at the umbilical cord,
while an assistant endeavours to solicit the  expulsive ac-
tion of the uterus, we must advance the hand to the en-
trance of the cyst, dilate it properly, 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 at-
           tached to the Neck of the Uterus.

   707.  We no longer fear now, as in the time  of De-
venter, being charged with advancing a paradox, in de-
claring that the placenta  is sometimes  attached  to the
neck  of the uterus, and covers its orifice.  Real  practi-
tioners are agreed on the  certainty of this fact; because
there are none who have not several times met with it.
   708.  When the placenta presents first, a flooding be-
fore delivery seems to be essential  to it: but it may ma-
nifest itself sooner or later, according to circumstances.
Sometimes it appears as early  as the sixth month, some-
times not till the ninth, or even till  the approach of la-
bour; but generally from the seventh to the eighth month.
It is  always slight, and may be stopped by the usual re-
medies 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 la-
bour.
   709.  We cannot discover whether the orifice  of the
uterus be the seat of the placenta or not, without passing
the finger into it Instead of the very smooth membranes
which are  usually felt, we then find a  soft and fungous 
              Delivery of the Afterbirth.           247

substance; all other signs 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  separation, we  need not trouble our-
selves at  the beginning with endeavours  to discover its
seat
   711. When the haemorrhage is slight, or even  mode-
 rate, we prescribe the most exact repose;  and keep  the
 woman as much as possible in an horizontal 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 incrassating 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
 vaghut, or even into the neck of the uterus, if it be suffi-
 ciently open.   If  the flooding resists all these methods,
 and endangers the woman's life, we must excite  the la-
 bour pains, and deliver her.
    712. If this last resource is salutary to the mother, and
 preserves her  life, we ought  not to dissemble how dan-
 gerous 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 utems 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 loss is inevitable if we neglect it, and that of the mo- 
248           Delivery of the Afterbirth.
ther is not less 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 celerity, and less timidity.
   713.  Since we  must then have recourse to delivery,
we ought to perform it in the surest and gentlest 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 hae-
morrhage  is suspended for a moment when the waters
are  evacuated, it  soon appears  again;  and becomes so
much the more abundant, as the orifice of the uterus di-
lates farther, and as the violence of the labour increases.
I have met with but one case, where the flooding has en-
tirely ceased after the  evacuation of the waters, out of at
least five-and-twenty where the placenta was attached to
the neck of the utems; but  this single case cannot esta-
blish a rule.f

  * Puzos advised, in case of violent flooding, to excite the labour
pains by dilating the  neck of the uterus, and opening the mem-
branes.—See his excellent observations on uterine haemorrhages at
the end of his work.
  t A midwife had extracted the placenta some hours before I was
called, and had not been able to turn the child, whose arm was en-
gaged below the head.  The uterus, irritated by the manoeuvres of 
               Delivery of the Afterbirth.           249

   714. If in this case we should determine to evacuate
the waters of the amnion before the state of the neck of
the utems 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 advantageous 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 me-
thod, as well because its application  might produce  in-
conveniences, as because the evacuation  of the waters
then cannot  be of any utility.
   715. When the orifice of the uterus is properly dis-
posed 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 tn the orifice.   We
tear the membranes at the edge of the mass, then search
for the child's feet, and extract it as in common cases.
   716. Some practitioners prefer piercing the placenta
in the middle, and passing the hand through it to turn
the child; but this method is more difficult, and less cer-
tain,  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 umbili-
cal cord.  Besides, the child  being obliged to descend
through the  placenta, seldom fails to  bring it along with
its shoulders: which  augments the difficulties, by adding
the volume of that mass to that of the shoulders; and oc-
casions some other inconveniences.
   717. When the placenta still preserves a part of its

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 off near the umbilicus, and more sur-
prised still not to  find the afterbirth in the uterus, I discovered
that it had been extracted a long time before my arrival, and care*
fully concealed.
                          21 
250           Delivery of the Afterbirth.
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 re-
newal 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 membranes seldom come  away, without
the greatest attention; because  they detach themselves
circularly from the placenta, if their adhesions resist ever
so little.  We 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  accidents; and the accou-
cheur should be taxed  with inattention 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 cau-
tiously; 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 maybe  obliged to commit
the deliverance to nature, and confess the impotence of
art to effect it, are never more frequent than after abor-
tions; since we then have scarcely any of those resources,
which we meet with after a birth at full time.
   719.  The difficulties of delivering the placenta, in these
cases, generally increase in an inverse proportion to the
term of gestation:  they are  so  much the  greater as that
is less advanced, and diminish 4n proportion as the abor-
tion or delivery approaches  nearer to the  period of nine
months. 
Delivery of the Afterbirth.           251
   720.  Before the third month, nature finds fewer diffi-
culties in freeing herself from the whole produce of con-
ception at once, than in expelling the afterbirth sepa-
rately; but after that  period we  observe  the contrary.
Experience teaches us,  moreover, that it  is very rare
that those deliveries are  not performed according to the
intentions of nature, when  the accoucheur does not dis-
turb 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  tedious 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 ute-
rus 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 contents 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 retard-
ed  several days; because by that evacuation the utems,
loses  a part of the sensibility and irritability it had ac-
quired, and which were  necessary for the farther pro-
gress of its contractions; and because its  orifice closes
during that state of rest
   723.  If we were near the woman at the time the mem-
branes open, we ought to  introduce  one or two fingers

  * We cannot agree with  our author in this dirction, as we are
persuaded this is  never safe until near the fifth month, unless every
means to stop haemorrhage have  proved ineffectual.—W. P. D. 
152           Delivery of the Afterbirth.

into the orifice of the utems, to hinder  it from closing,
and favour its farther  dilatation,  till it  be sufficient for
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 dilatxl, will admit  at most  but a single
finger, which, far from serving  to extract any portion of
the placenta 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 favoura-
ble to deliverance, if the flooding is not violent, the ac-
coucheur must content himself with soliciting the action
of the uterus briskly, and  endeavouring to make it con-
tract 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 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 de-
liverance.
   121. Though we may temporize thus, or confine our-
selves to these feeble succours, when the flooding is mo-
derate, we must act very differently when it is so consider- 
              Delivery oftlie Afterbirth.           253

able 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 of
a  coagidum, which, by exactly filling the cavity of the
uterus, may stop the mouths  of the gaping vessels, and
check  the violence of the  haemorrhage.  For  this pur-
pose 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 sup-
port this plug properly, till the uterus, irritated by its pre-
sence,  by  that of the coagulum, and  the afterbirth, con-
tract with sufficient force to deliver 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 disa-
greeable consequences if we were  to employ it without
any other precaution, after  a delivery at full  time: be-
cause there might then be an internal  extravasation ca-
pable of destroying  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  several
times with success, we must, while  we support the plug
with one hand, oppose the  development 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
'■■  Observation 386, nouv. edit. 
254          Delivery of the Afterbirth.
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 incommoded 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 practice.
   731.  Each twin  having sometimes its involucra very
distinct, and perfectly separate, and the placenta of one
being only placed close to that of the  other, we  might
without the least inconvenience, immediately after the
exit of the first child, extract  its  afterbirth, and do the
same with  regard to the second: but how can we  disco-
ver 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 placenta  for the twins—or  that the two
masses  are so  bound together by means of the chorion
which envelops the two children,  that we could not ex-
tract 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 af-
terbirth of the first child presents itself, as it  were,  to the
hand of the accoucheur.
   732.  Since then  we ought  not to extract the placenta 
             Management after Delivery.         255

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 useless 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.
   733.  We begin by pulling both cords, and proceed as
if there had been  but  one child.  If the placenta, 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.
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 invert-
ed part immediately.
  735.  When, in this respect, every thing is in the na-
tural order, it will  suffice to rub the abdomen with  the
hand, and repeat it now and then, to excite and maintain 
 256          Management after Delivery.

 the spring or tonic action of the utems, to favour its de-
 pletion, and prevent  the  formation of clots, which often
 become the source of many accidents.
   736.  As the woman ought to remain some time on the
 couch where she has been delivered, either to rest  her-
 self a little, or because it would be imprudent, 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 hap-
 pen), she must be kept clean by substituting dry  clothes
 for those which are wetted.*
   737.  She must be kept at first as much as possible in
 a horizontal  position; she may draw her legs 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  disagreeable  consequences.
 How  many  women have  been victims of  an impulse of
joy, of immoderate anger, or other similar passions,  im-
 mediately 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 in-
discreetly 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  inconveniences  here spoken of, are obviated by having
the patient placed as recommended in note to par. 585.—W. P. D. 
Putting the Woman to Bed.
251
the uterus.  This is what the nurses call putting the wo-
man to bed.  Though the accoucheur is rarely admitted
to this toilette,  and still more rarely obliged  to put his
hand to it; it is however 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 endeavour to procure for
the time  to  come; or at least  of their ignorance, or of
that of their nurses.  Those  women will perhaps be
obliged to me for attending to their first adjustment; then
it will be of little  importance that some accoucheurs re-
proach me for having entered into these details.
  742. Every  nation has, as  I  may say,  its  particular
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 established 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 ab-
domen,  the utility of which has been demonstrated by
Smellie.
                        2K 
25$
Putting the Womun to Bed.
  744. Experience, which had confirmed its advantages
to me before I knew  the precepts of Smellie, has since
taught me that  it may be made useful  in some cases of
flooding after delivery, by making a pressure on the ab-
dominal vessels, and moderating the course of the blood
towards the uterus.   At other times it opposes the dilata-
tion  and puffing up of  the intestinal canal: it prevents
hernias, by resisting the impulsion of the floating  parts.
Lastly, I have remarked 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 observations,
that  this  bandage ought not to be omitted; and that in
some cases, it  should be applied immediately after de-
liverance.
  146. The bandage for the belly is made in the follow-
ing manner:—We  first  apply a very soft napkin, folded
in a square or triangular form,  to the hypogastric region;
then apply another over it, folded lengthwise, which  must
go round the belly.  It should not be very strict at  first;
but we may afterwards 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 pre-
scribe 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 pre-
cepts on the subject, without first  making  known the
principal phenomena which manifest themselves after de-
livery, and  their differences relatively to the various cir-
cumstances which may happen.  I shall state them very
briefly. 
Subsequent Symptoms.
259
Of the principal Phenomena which manifest themselves
                    in the Month.

   749. The symptoms subsequent to delivery have been
distinguished  into natural  and accidental.   The former
present us with an infinite variety, dependent on the con-
stitution 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 ac-
coucheur, the neglect of a proper regimen, or  on some
unforeseen events.  I shall only speak of the usual subse-
quent symptoms.
   750. A kind of faintness, or lassitude, like that which
is felt  after violent exercise, soon succeeds to the agita-
tion excited  by labour: but the pulse quickly revives, a
warmth is diffused through  the body, the  skin  becomes
moist, a salutary perspiration breaks forth,  the  limbs re-
cover their former liberty, the order of the functions is
re-established;  and a perfect calm succeeding to this vio-
lent effort of nature, permits the woman to enjoy peace-
ably the  happiness of being a mother.
   751. During the first days there is a copious discharge
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 com-
monly 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 spe-
cies of lochia likewise depend on a great  number of dif- 
260            Subsequent Symptoms.
ferent circumstances, which I shall not mention  in  this
place.  The sanguine lochia sometimes flow during the
first two days, with or without 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 mechanism
by which these first lochia stop, it would be matter of
astonishment  that  all women do  not  perish by an  hae-
morrhage 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 the blood  to reappear  from  time to time during the
first  weeks, and even the whole month; which proceeds
from the weakness of the uterine vessels, and the preter-
natural size which  some of them still retain.
   754. The source of these different kinds of discharge
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 trans-
lated 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
  * I am convinced that this milk fever is in great measure, if not
altogether, of artificial origin.  It never occurs  to patients who
strictly follow my directions after delivery.   It is the product of
improper regimen.  When  women, who are not predisposed to
fever, are kept quiet, from all stimulating drinks, from animal food
and broths,  who have cool  and diluting drinks, as water,  toast
water, balm tea, &c, who have fresh air freely admitted into  their
chambers, who have frequent  changes of cloths, who have  their
bowels  freely opened  on the second or third day, never have this
milk fever as it is termed.—W. P. D. 
                Subsequent Symptoms.            261

women, that the skin seems to be in danger of bursting.
The engorgement often extends to the axillas, and some-
times renders respiration  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 al-
ways restores a calm.  It often continues twenty-four
hours, or even longer, with  very short intervals.  We
ought to do nothing that may disturb 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 myself.  All we ought to  do is, to favour this
evacuation 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 abundant; and the lochia
then resemble a milky or purulent matter, which after-
wards acquires more or less consistence.
  758.  At the end of the fourth day the swelling of the
breasts usually begins to lessen; as they now empty them-
selves 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 abun-
dantly 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. 
262            Treatment in the Month.
       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 more sensibly
 felt than at this time.
   760. Nothing is of greater importance than the quali-
 ty 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 new-
 ly delivered, than that which is loaded  with the  hetero-
 geneous particles I have just  mentioned.  It is very es-
 sential that the chamber they are in should be well situ-
 ated, and capable of being well opened, in order to renew
 the air from time to time, and warm or cool it, as occa-
 sion may require.
   761.  The woman ought to  receive no more visits on
 the first days than are absolutely indispensable.  She
 ought to be lightly covered in bed, except  it be in win-
 ter;  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 win-
 dows 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 moreover to have but little light by
day,  and only one candle at night, which should he kept
from the eyes of the woman. 
               Treatment in the Month.           263

  763. We ought not to oblige the'woman newly deli-
vered to continue constantly in the same position, and re-
main 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 at-
titude, they ought  not to be hindered from  doing it, ex-
cept after a flooding, or when  there is some reason to
fear that accident. If nothing of that kind is to be dread-
ed, 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 see-
ing the child carried  away by  the nurse they had pro-
vided for  it
   765. Nothing  is more  conformable  to the intentions
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 cho-
lic.   We  ought not to dispense  with them, except at the
time  of the crisis and  copious  sweats  which I have al-
ready 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, or of mel mer-
curialis, or something more active, if the case require it 
264
Treatment in the Month.
   166. 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, ma-
 tricaria, 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 however
 useful in some cases where there is more weakness than
 astriction in the vessels of the uterus:  but as it often hap-
 pens, when we prescribe a light infusion, that the women
substitute a strong decoction of the plants ordered them,
 of which I  have several times been a witness, the accou-
 cheur ought to explain 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,  must be deter-
mined 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 
Treatment in the Month.
265
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, and 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 de-
livery,  we  may without fear  allow the woman  two little
basins  of broth a day,  or even three;  with rice, or other-
wise: or a little soup with a crust of bread.  Though it
is necessary to deprive her of the broth during the con-
tinuance 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 pa-
tient to thin gruel, and make her drink abundantly; in
order to furnish a proper vehicle for  the milky humour,
and restore the serum to the blood, which it has been de-
prived  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 descent of the uterus, or in whom the symphy-
ses 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.
2L 
266           Treatment in the Month.
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 substitute a decoc-
tion 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 depletion of the ute-
rus, which some degree of erithismos renders more diffi-
cult in many women.
   777.  The sal de duobus is too frequently given to wo-
men 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 indifferent  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 in-
dicated, 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 with sweat,
or otherwise; provided that what is substituted be very
dry, and  properly warmed.   They  may also from  the
first days be carefully moved into their little bed, while 
Treatment in the Month.
267
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 Preter-
  j                     natural.

  780.  It is  pretty generally  agreed to call those la-
bours preternatural, in which  the child presents any
other part but the crown of the head to the orifice of the
uterus;  because it was falsely imagined that in that case
it could not be born without assistance.   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 preterna-
tural, 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.  A labour may be essentially preternatural, or
become so  accidentally.  In the first case, it is always
the bad situation of the child which1 is the cause of it; in
the second, a variety of circumstances may complicate it,
which I consider as so many accidents.
   782.  In order to have a just idea of what is to be here
understood by a bad position of the child, we must recol-
lect what has been already said of its dimensions, and of
those of the woman's pelvis; and remember that it can- 
           Causes of Preternatural Labour.        269
not be born without presenting to the  orifice of the ute-
rus one of the extremities of its largest diameter, or of
the oval figure in which it is naturally folded.   Its situa-
tion 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 rela-
tively to the pelvis of the  mother.
   783. When several parts present successively to the
orifice of the uterus, if at any time we find the head there,
we  ought instantly to pierce the  membranes, and dis-
charge the waters.
   784. Among the  causes of preternatural  labours  in
general, none is more justly so called, than a deformity
of the pelvis.   It seems  indeed rather to belong 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.  There-
fore I shall not enter fully into the discussion of it, till I
 come to the fourth  part of the work.
    785.  The  accidents which do not permit us to aban-
 don the labour to nature, either because it would endan-
 ger the  life  of the mother, or of the child, and often
 both; or because it absolutely cannot be performed with-
 out help, or  an haemorrhage, convulsions,  and frequent
 faiutings  or  syncopes; an exhaustment of the woman's
 strength, a lingering or cessation of the pains, the exist-
 ence of an irreducible hernia, with a disposition to stran-
 gulation; sometimes  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  reciprocal
 prevent each other's exit; the issue of the umbilical cord 
270                  Of Flooding.
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 Haemorrhage, considered with respect to the Necessity
                of immediate Delivery.

   786. The haemorrhage known by the name of flood-
 ing,  may endanger the lives of both mother and child
 during pregnancy and labour;  it is always the conse-
 quence 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 appa-
 rent; for the blood, instead of being shed without, is
 sometimes  extravasated behind the placenta, and retain-
 ed there by the strong adhesions of its edge to the uterus,
 sometimes by those of the membranes, 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 hae-
 morrhage,  one  apparent, the other concealed.
   788. Though the structure of the uterus, and the re-
 sistance which  its parietes oppose to  the agents of its de-
 velopment, seem to favour the opinion  that much blood
 cannot be  extravasated behind the placenta, experience
 does not coincide with that opinion, but has several times
 proved to me that  this sort of  extravasation  might be-
 come so considerable, as manifestly to affect  the  strength
 of the woman  and  the life of the child*   Besides, the
  * There was an extravasation of this kind in Madame de * * * \
 •ifter  being bled in the arm, which had occasioned frequent syn- 
Of Flooding.
271
dyke, which retains the blood thus, must be broke through
sooner or later; the haemorrhage then becomes apparent,

copes; and the symptoms, stated in par. 790 and 791, appeared al-
most immediately.  The pains continued during three weeks, be-
coming stronger every day;  and  this lady was delivered of a dead
child, at the period of eight months.  There were behind the pla-
centa two clots of blackish blood, solid, and in a manner dried, of
the size of a 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 de-
livered of a dead child, after having suffered most of the symptoms
described in the paragraphs indicated.  The extravasation became
more considerable, and the consequences 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 con-
tinued 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 morn-
ing.  Her weakness and exhaustment, the syncopes which  were.
continually repeated,  and the paleness and alteration of her  coun-
tenance, not being  accountable  from the small quantity of  blood
she had evacuated, for there appeared scarcely a porringer full, be-
sides a few cloths  slightly tinged with it, made  me suspect an in-
ternal extravasation :  the rapid augmentation 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 con-
firmed it.  About  seven months advanced in her pregnancy, and
scarcely showing it before  this  accident, the uterus was so de-
veloped, as to make any one, at first sight, suppose her at full time,
and pregnant of two children rather than one.   The expulsive ac-
tion 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 con-
tinuing to flow  afterwards, the  danger augmenting, and the  little 
212                  Of Flooding.

and a fresh loss of blood which the vessels pour out plen-
tifully, 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 extravasations of blood
may be  formed  during pregnancy; they may also  take
place in the cavity of the membranes 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 ignorance, 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  become  vari-
cous. J  From the testimony of my own senses, I can as-
sert 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.

hope of preserving the  woman by deferring the delivery, deter
mined 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 moderated
   t I can add my testimony in favour  of what our author has just
advanced x>n 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 sus-
pected an internal haemorrhagy.   Leave was obtained to inspect
the body, and  my suspicions were verified.—W. P. D.
   '* Levret, Suite des Observ. sur la Cause de plusieurs Accouche-
mens Laborieux, obs. 35me, page 139, edit. 4me.
  t Observ. 249, nouv. edit, tome ii. page 79.5. 
Of Flooding.                 273
  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 long time doubt-
ful, unless it increase very suddenly.  A dull deep-seated
pain, accompanied by a sensation of weight in the place
where the extravasation is  made, manifests itself almost
at the instant of its commencement, and augments insen-
sibly with it.  The region of the uterus under which this
collection is formed, rises in proportion to its quantity.
  791.  The extravasation cannot  become considerable
enough to produce  such changes  in  the volume of the
uterus, without strongly exciting its expulsive action: nor
is it long before pains are felt similar to those of labour,
and labour  is  soon  the consequence  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 sufficiently open, if the extravasation has
been made  behind the placenta; but not till 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*
  792.  The necessity of delivery, without any regard to
the period of gestation, when the flux of blood is so co-
pious as to  endanger the lives of the  mother and child,
has been acknowledged for two centuries 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

  * The concealed hemorrhage 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 suspended most pro-
bably after this discharge happened, as  the patient said she was
now free from pain, and  wished to be allowed to sleep.—W. P. D.
                         2M 
274                 Of Flooding.
great number of observations.   A long and too fatal ex-
perience has equally proved, that an  hours, 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 gentlest 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 ad-
 mit the finger; at other  times, it  does not happen  till
later, nvhen the parts are  already  prepared for delivery,
or when  the  labour is begun, and  even considerably ad-
 vanced.
    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 applica-
 tion of cold and stimulating 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

   * We are sorry our author  does not lay more stress upon  this
 last direction than he does, as we are convinced it is of the greatest
 importance, and  should always be had  recourse to whenever the
 flooding is threatening.  We  do not consider it either necessary or
 proper to stop up the mouth of the uterus, as every advantage can be
 procured by plugging up the vagina, and  this without the risk of
 irritating  the uterus  too much. The best tampon we know, is a
 piece of fine sponge, of such  size as will fill up the vagina after it
 is introduced.  It should be well washed, and all the  earthy parti-
 cles which frequently adhere  to the sponge be separated: it may be 
                     Of Flooding.                 275

advantage by these means,  he must excite the labour
pains,  by gently stretching the edge of the orifice of the
utems, 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 utems, 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; sup-
posing the accoucheur has them  at hand;  for  the  acci-
dent is too serious to allow him time to send for them.
Otherwise he may still push back the head, though pret-
ty far advanced, 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 proceed in this manner; be-
cause the open or ruptured vessels cannot cease to pour

 washed in vinegar before it is employed: it may be secured, if ne-
cessary, by a T bandage. It should be changed every ten or twelve
hours.—W. P. D.
   * Should the child  be so situated as to render turning either
very difficult or improper, we may gain important time by the use
 «f the tampon, as just directed: it would in such case require the
 T bandage to secure it in its situation.—W. P. D. 
 216                   Of Flooding.

 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 generally admitted at all periods
 of gestation, as in  those of  flooding; even if it should be
 certain  that the strong pressure of the utems on the ab-
 dominal vessels was the determining  cause of that hae-
 morrhage, but I do not hesitate to recommend  it, when
 that accident happens during the efforts of labour; for it
 would be as unskilful to expose the woman to a long con-
 tinuance of those efforts, or not to deliver her, as to suf-
 fer her  to sink under a common flooding.*

   * There are few cases of disease occurring during pregnancy or
 labour that are so alarming in their appearance, and serious in their
 consequences, as Haemorrhagy.   Our author lays 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 dis-
 covered for the suppression of haemorrhagy—I mean the acetate of
 lead.   Its general certainty in this accident is now so well esta-
 blished, that it would be loss of time to dwell on it; wc shall there
 fore, without hesitation, recommend this remedy wherever the ne-
 cessity 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 recommend the blood to be
 taken pretty suddenly away, by which means we induce a disposi-
tion to syncope 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 ob-
tained.  It will perhaps surprise, when this remedy is recommend-
ed in such quantity and in such quick  succession; but I have no
hesitation in declaring I have not only found  it safe in such quanti-
ties, but necessary; and with respect to the frequency of its exhi-
bition, I believe if it does not produce the desired effect in half an 
Of Convulsions.
€77
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 constitutional,
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

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 ol
a grain will in general be sufficient.   I have in some cases found,
where opium has disagreed, joining a grain of the powdered capsi-
cum has been useful: this, however,  is only to be used where the
system is prostrated, from the long continuance or excess of the
discharge.  By employing this remedy we sometimes obtain, if no-
thin* more,  an important truce, more especially at the latter pe-
riods of pregnancy, 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 sue-
 ceeded frequently, in considerable discbarges 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 had
 no effect when given by the mouth,  but where it has produced an
 almost instantaneous one, when Bj. to a gill of cold water, with ft.
 of Tinct. Thebiac, has  been given as an enema.—W. P. D. 
278                Of Convulsions.
leaves no other consequences than what they did before
the woman was pregnant.   In other  cases, the convul-
sions are only symptomatic or accidental, and the remote
causes of them  are  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 sanguine plethora,
or on an  excessive flooding, on a  fulness of the prima
viae, on  an extreme sensibility of the uterine fibres, a vio-
vent distention of the edge of the orifice of the uterus,
and  of  the parts which form the entrance of the puden-
dum, on a rupture  of the  body of the  uterus,  and, ac-
cording to some authors, 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 at that  period of preg-
nancy when these causes are united in the greatest num-
ber,  it is also that when women are oftenest seized  with
convulsions.  The uterine fibre is not, in fact, so sensi-
ble, nor so irritable,  in any period of pregnancy, as  in
that  of labour: those two properties, inherent in the mus-
cular 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  muscles,
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 fre-
quency  of the pains,  &c.   From the state of perturba-
tion which we observe in most women when the  force of
labour is  at its  greatest  height, especially  in a  first la- 
Of Convulsions.
279
hour, to a state  of convulsions, the passage is short and
rapid.
  802. The concurrence of all these causes  is not ne-
cessary 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 perio-
dical, and in which the paroxysm is very long.   M. Lev-
ret  mentions a woman  in whom this paroxysm was  re-
peated every day at the same hour, and towards the lat-
ter end of pregnancy lasted eighteen hours out of four-
and-twenty.*  I have delivered one, who suffered con-
vulsions  periodically every month, during three succes-
sive  pregnancies: they seized  her at the time when  the
menses used to appear,  and attacked  her twelve succes-
sive days in each month of the first pregnancy, augment-
ing  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  periodi-
cally 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 prevent them.f  Convulsions
of a different kind were  so  exactly periodical for four
 days, in another woman, that there was not a minute's

   *  Levret, Essai sur l'Abus des Regies generates, &c. p. 15.
  t  See the note on par. 809. 
280
Of Convulsions
 difference in the  commencement  and duration of each
 paroxysm.
   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 countenance  is tranquil during the
 paroxysm, and the convulsion affects only the large mus-
 cles, 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 agi-
 tation of the muscles of the face, the neck, the tmnk and
 extremities;  the jaws are locked, and she  grinds her
 teeth; the mouth  is covered with froth, and the nostrils
 throw it out  likewise; respiration is quick, irregular and
 loud; sometimes also there is an ejection of the urine and
faeces.  A stiffness of the body and limbs succeed this
 convulsive agitation,  and the woman remains  immovable
 during 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.   Some-
 times  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 pregnancy more than a week after the convul-
 sions, having 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 convulsions affect  only the  muscles
which serve for the animal functions,  and especially the 
                    Of Convulsions.               281

large muscles, it scarcely causes  the 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 understanding, 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 convulsion had in-
terrupted.
  807.  These different  species of convulsions are  not
equally  troublesome, nor do they equally disturb the pro-
gress 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 labour, at whatever pe-
riod  of pregnancy  they  happen,  when they  are of  the
species  described in par. 805; but they bring them on
the more certainly, as pregnancy 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
progress of gestation, or happen in the  course of  labour,
however frequent they  may have been before.  Delivery
took place but fifteen days before the usual time, in the
woman  who is the subject of M. Levrefs 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 deli-
vered of her first child.  Yet the convulsions in the lat-
ter 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 re-
                         2N 
282                Of Convulsions.
peated more than ten times during the paroxysm, and
with a rapidity which the eye could not follow.
   808. Though  convulsions sometimes attack without
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 sudden blindness  and deaf-
ness; the mind  seems disturbed, and the  eye becomes
wild, &c.  Though these symptoms in some women only
denote a nervous 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 antihysterics, 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  convul-
sions 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 practi-
tioners on this  point   I  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.'

   *  The woman who is the subject of this observation,  had convul-
 sions of this species at the instant of a bleeding in the foot, which
 a suppression of the menses, some years before marriage, had seem-
 ed to require.  Being attacked with convulsions in the first month
 of pregnancy, eight or ten drops of  the mineral anodyne liquor of
 Hoffman, taken in  a spoonful of  orange flower water, rendered the
 fit longer by half than it had been the evening before; and a similar 
Of Convulsions.                  283
There are circumstances in which evacuants are exclu-
sively indicated: but I cannot state them here.*

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 a 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 ap-
peared 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 became very strong; done at
the instant of its commencement, the  paroxysm went off; at the
time when the precursive symptoms announced it, it was prevented:
so that it had constantly the same success, whether it was employed
with a curative or preventive intention.
  Bleeding at the arm was  not less salutary in the  same woman,
since the third pregnancy,  on  account of convulsions proceeding
from a suppression of the menses.   Recourse was not had to it till
after the trial of many other methods which had augmented them,
and they ceased  immediately after that bleeding: it had the same
success two following months.  The convulsions 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 per-
suaded in nine cases out  of ten in this country, it is the only re-
medy to be depended upon.  I cannot agree with him as to the im-
portance 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 con-
tract on their  contents, and thus  fail in diminishing their vigour:
it should therefore be an invariable rule, to draw the blood from a
large orifice, and  a  large vein;  on this account, I have sometimes 
284                 Of Convulsions.

   810. Although the danger which arises from convul-
sions is as great  in  many cases, as that which  proceeds
from an excessive flooding, yet we ought not to endeavour
to bring on labour, as in the latter circumstance; because
it would not be attended with the same success.  Besides
that convulsions do not always essentially depend on preg-
nancy, 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
still more grievous.  I except however those cases where
they happen during the course of labour, and at a time

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 suggested, and the relief obtained by bleed-
ing 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 powerful, and the
determination to the head evident, by the swelling and lividity of
the face, projection  of the eyes, and almost complete 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 promptly, if
good  be expected  from it; it is too  late, when  effusion has taken
place in the brain.   I  had not long since an opportunity of seeing
the head of an unfortunate woman who died  from this kind of con-
vulsion.  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 rest  appeared
healthy, as did the other parts of the brain.—W. P. D. 
                   Of Convulsions.                285

when the parts of the woman are already well disposed
for the passage of the child.  When  these natural dispo-
sitions do not exist, the violence which must be exerted
to solicit the expulsive action 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 iderus, in order to penetrate it  more easily,
as several accoucheurs have practised?  This proposi-
tion, 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 pe-
 riods 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 restore and  properly relax those
 same fibres.  Without  admitting  their opinion on the
 cause of convulsions, I allow that this practice has some-
 times had the desired 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 utems: but those  cases 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 preceded them. All authors
  relate examples of women who have been delivered with-
  out help after several fits of strong convulsions, and others
  while they were actually convulsed, whether  there were
  lucid intervals between, or that the loss of understanding 
286                 Of Convulsions.
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, notwithstanding the disorder  in  her functions,
can perform in a short time, what we could not obtain
but with abundance  of efforts  and dangerj besides that
a calm may be  restored, notwithstanding the number of
convulsions 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 practitioners  of too much pre-
cipitation, 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 la-
bour, having often no other cause than  the excess of
pain, the extreme sensibility which the fibres of the ute-
rus 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, augment-
ed by the heat excited by continued efforts; the engorge-
ment of the vessels of the brain, &c. seem to require dif-
ferent  aids, and call for less delay in  the delivery.   If
they continue, with  loss of understanding, after a copi-
ous bleeding, we may open the membranes, in order to
diminish the volume  of the iderus, relax its fibres, calm 
Of Convulsions.               287
the excess 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 in*
ferior aorta, and  thus  recall the blood in greater quan-
tity into  the vessels of  the abdomen, and the lower ex-
tremities.   If the convulsions subsist with the same force
after the administration of these succours, we may per-
form the delivery, unless it appears disposed to take place
speedily.
   814. There are  cases in which  we  cannot dispense
with turning the child and  extracting it by the feet; be-
cause  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 immediately after the evacua-
tion of  the waters, whether  the convulsions  subsist  or
not.   There are other cases, where it would be better to
extract it with the forceps,  if we could procure them  in
time, and the distance of the head ought not to be a mo-
tive 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 dan-
 ger 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 can-
 not extend beyond what they have done before, nor tear;
 whether because  they are too dry and too rigid, as we
 observe particularly in women advanced in age when they
 are in labour of their first child,*  or because that part
   * M. Dubosc, professor in the College of Surgery of Teulouse,
 communicated to the Royal Academy of Surgery, in  1781, one of 
288         Causes of Preternatural Labour.
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 operation.
 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, or faintings, if frequently  repeated in
 the course of labour, although we may not be able pre-
 cisely to determine the cause of them,* as well as a ge-

 the most interesting observations on  this subject.  We there re-
 mark, that the preservation of the woman was the fruit of the sec-
 tion 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 convulsions 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 symptoms
 were mild.
  *  One of those women who were delivered in my theatre, for the
 instruction of my pupils, in 1774, after violent convulsive agita-
 tions on the part of her child, at the beginning of labour, suffered
 frequent faintings, followed by an abundant 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 open-
ing 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 adhering to  the inferior and right lateral part of the uterus, 
Causes of Preternatural Labour.       289
neral weakness or exhaustment, which deprives the wo-
man of the power of exerting sufficient  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  preferable
to the useless attempts which are made to  quicken linger-
ing 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 strangulated.*
   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 attention should how-
ever be directed to this condition of the uterus: we there-
fore 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 delivery impos-
sible without help.   The circle which constitutes the in-
ternal orifice more frequently  contracts than the external

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 accident,
towards the middle of November, 1774.  A loop of intestine, in the
efforts of labour, had insinuated itself through a mass of the omen-
tum, about the size of a hen's egg,  which for nine years had formed
an umbilical hernia, and was there strangulated.  The woman al-
ready 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 al-
ways  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.
                           20 
290
Causes of Preternatural Labour.
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 difficulty.  When it is the internal orifice that con-
tracts, the inconveniences are  not so great, as the head
has  not  descended  so low,  and may always be  pushed
back, and which allows the  hand  to pass under the ute-
rine 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 cord, and diminishes the  mo-
tion of the blood in it; as of the compression which after-
wards intercepts the course  of that fluid through itf
   821. This accident is, without  doubt dangerous;  but
the precept of delivering instantly, by turning the child,

   * 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 witness, the child's head had occu-
pied 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 body of the child, and brought down the feet.
   t 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. Museum, vol. ii.
part ii. page 140.—W. P. D. 
           Causes of Preternatural Labour.        291
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 expul-
sion 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  sometimes inseparable from turning the child, and
bringing it by the  feet.
   823.  The umbilical cord is not always  so  much com-
pressed 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 extracted 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 pro-
lapsed, is increased by  a narrow pelvis, as the 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 par-
 ticular indication when it is cold, without pulsation, 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 short-
 ness, or frequent windings on the child, opposes conside-
 rable obstacles to delivering; such as keeping  the  head
 back, or if it allows it  to advance during pain, it makes 
292         Signs of Preternatural Labour.
it recede immediately after; thus mistaking the reaction
of the perinosum, and bones  of the cranium, for the ac-
tion  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 deter-
mine 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 tJie Indications presented by that
  Kind of Labour; and some general precepts 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 accidents which com-
plicate the labour, from  the situation of the  child, and
from  the  existence of some of  the causes already men-
tioned.
  828.  We may easily distinguish the cases in which the
woman  suffers a flooding, convulsions or any other acci-
dent,  from those which are  not complicated with  any of
those circumstances: but it is by touching only we can
discover the  situation of the child.   Though  we some-
times acquire  this knowledge without  any trouble, even
before the membranes 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 particular in-
dications.   The former  consist in turning the child to 
Situation in Preternatural Labour.      293
bring it by the  feet; in changing some  positions 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 advancing: 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 Preternatu-
                     ral Labour.

  830.  The situation of the woman,  in  this case, as in
all others, is not very important  before the time of de-
livering, unless particular circumstances oblige us to pre-
scribe one rather than another;  but it  is very different at
the time when we must operate.
  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 and  perinosum 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 cas-
tors;  as well  for the security of the woman, as for the
convenience of the accoucheur and his assistants.   This
bedstead  should be furnished with several mattresses,*

  * These  are certainly unnecessary; one is often convenient,
but not indispensable.—W. P. D. 
 294               General Precepts.
 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 folded
 sheets,  and some pillows  must be  placed towards  the
 middle.
   833.  The woman being laid according to  the direc-
 tions in par. 831, must be covered with a sheet, and even
 with  a  blanket, if the season require it, to defend her
 from the cold, and prevent her being exposed 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 in-
ferior 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  re-
quire.
   General Precepts relative to Preternatural Labour.

   834.  When we have but  imperfectly discovered  the
situation of the child at the  orifice of the utems, if the
absence of the signs which denote  the  presence of the
head gives suspicion that the  situation is not  favourable,
we must wait  till the opening of the membranes, to dis-
sipate our doubts, and acquire a certainty concerning it.
   835.  Before that epoch, nothing invites  us to termi-
nate a labour which the bad position of the child renders
preternatural,  unless  the woman be attacked by some of
those dangerous accidents already mentioned: when that
happens, all long delay is contrary to the  principles of
sound practice; but the consequences which may result 
                  General Precepts.               295

from immediate delivery, sometimes oblige us to defer it
awhile, in order to attend to the particular and pressing
indications 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 disco-
vered the bad situation of the child;  if the  force neces-
sary to be exerted in  opening the neck of the uterus, to
turn the child  before the instant prescribed, is equally
alarming; an engorgement, and  inflammation of the ute-
rus, which  may be the consequence  of the useless  ef-
forts to which it is sometimes abandoned after the eva-
cuation of the waters, will not seem less to be dreaded.
   837. Therefore  the most favourable moment for ope-
rating 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 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, un-
 less the  inflammatory state of the utems forbid  it:  for
 then it is necessary, before every thing, to take off  the
 tension of  that  viscus, and  diminish  the engorgement of
                                                    i
 its vessels.
    838.  The  case  where the accoucheur is called some
 tin* after the spontaneous  opening of the membranes, is
 not the only one in which he  cannot fake  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 operate, 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 pel-
 vis, 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 
296                General Precepts.
would, in some respects, have been the most favourable
for turning the child, when the  membranes burst at the
beginning of labour, and  before the neck of the uterus
is  sufficiently relaxed and open for the admission of the
hand.
   810.  Bleeding, emollient and mucilaginous injections,
baths, and moist fumigations, joined to dilatations metho-
dically performed  with the fingers,  are sometimes very
useful  in such cases, for weakening  the rigidity of the
neck of the uterus, and facilitating its  opening.*
   841.  As soon as the favourable moment for operating
shall be indicated, whether by the nature of the  circum-
stances, or the state of the labour, the accoucheur having
prepared himself for it, must place the woman in the si-
tuation prescribed in par. 831.
   842.  When it is necessary to introduce the hand into
the  uterus,  to  perform the delivery, some practitioners
are still in  the habit of putting  on an apron, baring their
arms, and  even putting  on false sleeves, &c.; but these
precautious, most of them useless, always strike  the wo-
man with terror, and a less frightful apparatus has often
thrown them into a state  of anxiety and disorder, diffi-
cult 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 pene-
trates  into the uterus.  Some cloths, laid on one of the
chairs which support the woman's feet, will serve the ac-
coucheur to guard  himself from the blood and waters
which drain from the uterus; and to wipe his hand every
time he withdraws it, that it may not be exposed bloody
to the eyes of the woman  and assistants.
   *  I believe we 9hall rarely find it necessary to employ any of the
other remedies prescribed in  this paragraph, if we indulge suffi-
ciently in the use of the lancet.—W. P. D. 
                  General Precepts.               297

  844. The operator should always proceed coolly, 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 ges-
ture, are then as so  many mouths whicli seem to her to
announce her destruction.
  845. Before we introduce  the hand, it ought to be
dipped in some mucilage, or anointed with butter, or any
other fat substance,  that it may  pass  more  easily, and
with less  pain.   This  precaution  may  likewise some-
times 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 ad-
vancing it.  When the  external parts of the  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 ad-
vancing 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 embrac-
ing 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 cir-
cumspection, in dilating the neck of the uterus, when it
continues thick, and is not very supple, lest 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
lay the action of that viscus,  or  the pain, that it  is be-
                          2P 
298               General Precepts.

numbed, or suffers such painful cramps, that it loses all
power of acting.
   850. During the whole time that we are introducing
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 occasionally, and  to make
certain pressures, which circumstances, more difficult to
determine  here, than to perceive while we are  acting,
render sometimes necessary.
   851. The two hands  are not always equally convenient
for finding the feet of the  child, and  turning it:  if there
are cases where we may use either 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 faci-
lity of the operation, and even its success.
   852. Tbe direction which  the  hand  must follow, the
position it must preserve as it advances in thewimes, 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 be-
tween  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 di-
rection, and make it describe a smaller arch in the uterus.
We ought never to  pull  the extremities  in such a man-
ner as to bend the child backwards, or subject the spine
to any dangerous flexions or contortions. 
                  General Precepts.               299

  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 precaution is so ne-
cessary, that without it we  should sooner  tear off the leg
than  bring the child along.   It is  indeed often  difficult
to bring down both  extremities at the  same time, be-
cause, being slippery with glaire and blood, as well as the
hand which operates,  it is  not easy to  grasp them toge-
ther, and one of them is \ery apt to slip from the fingers.
In that  case, after having brought one of the feet to 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 to attempt turning the child dur-
ing a pain, because it is then  more confined in the uterus;
but  when the feet are without, and the head is sufficient-
ly 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 indiscrimi-
 nately 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 dan-
 gerous.  If we  would  follow this precept,  we ought at
 least to bring the child's breech to the  passage:  other-
 wise, 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 dan-
 ger, are precisely those in which we might  finish the ex- 
300            Preternatural Labours.
traction of the child without any risk, by pulling at the
parts already delivered.
  858.  This operation ought never to be performed pre-
cipitately, nor must the extremities of the  child be pull-
ed 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 sud-
den 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 relative to the
kind, and the violence of  the accident which renders it
so;  as well as to other circumstances which must be de-
duced from the time when  the waters were evacuated,
that in which we  operate, 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  accident, 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 wo-
man, lest we frighten  her, and increase her danger: ex-
cept 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 
Preternatural Labours.            301
conduct, with respect to the woman, till the membranes
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 manner  that they may not be
stopped against  any part of the pelvis, during their de-
scent.
  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 spontaneously, but are obliged to
take hold of them at the orifice of the uterus, and deliver
the child immediately.  Besides the causes we have enu-
merated (from par. 785 to 826) may rendef these labours
preternatural, we may add the manner  in which the  feet
present and advance.  We have reduced these in four
principal ones.
  863.  One foot frequently presents,  and advances in
the vagina, while the other is so situated as completely to
oppose the exit of the child.  It is not  always necessary
to bring down this second extremity; it however in gene-
ral is best to do  it; and indispensable when it would re-
quire 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 ex-
tremity do it in  such a direction as will carry the whole
limb towards its companion,  if it were also disengaged.
And to divide  the force as much as possible, 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 
302
Preternatural Labours.
should retain the one already down, either by the hand
or fillet.   When  the breech descends with both feet, it
is sometimes difficult to disengage them, as the pelvis is
not sufficiently  large to allow all these parts to pass toge-
ther.   This may be prevented by bringing down the feet
before the breech is engaged in the pelvis, and overcome
when it exists,  by pushing up the breech above the supe-
rior 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 pro-
per, when we meet  with three, or four, to distinguish 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 uterus, because it is possible that each twin
may present one.*
  866. When we are obliged to advance the hand to the
orifice of the utems to take hold of the feet, we must do
it as we can, passing the fore-finger between  them, and
grasp them  closely with the  others.  They are then to
be wrapped  in a soft dry cloth, as soon  as they are with-
out, 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 acting nearer
to the parts  retained, for in doing that  we might impede
* See the article on twins. 
Preternatural Labours.             303
or stop the motion of the heart; we might likewise com-
press and bruise the liver, which is very large  and very
tender at that epoch: and nothing could be of more dan-
gerous consequence.   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 axillae arrive at the superior strait;
because  the  inferior extremities and the trunk, so far,
form a long  and pretty regular wedge.  After  that, its
course becomes slower and more difficult, from the pro-
jection 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, direct-
ed alternately upward and downward, but so as to cut the
inferior strait of the pelvis obliquely, is preferable to all
the more complex motions.
   871. When we are forced  to deliver by the  feet, the
umbilical cord does not always descend in the same pro-
portion  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,  accord-
ing  to  circumstances; we must repeat the  same thing 
304
Preternatural Labours.
 from time to time, as the  tmnk 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 pull-
 ing 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.
   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 extre-
 mities  of the fingers, without  tying them, than to pull the
 child in that  tense state of the cord.
   873.  As soon as the axillae 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 consequence to follow the me-
 thod I  propose, because the arms can only add to the re-
 lative 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 supported by
 one hand, obliquely towards one of the woman's  groins,
 while with the other hand we act in the following man- 
Preternatural Labours.            305
ner.   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 in-
sinuate 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.
  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 diametrically op-
posite to that where it had been raised before, and sup-
ported 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 oppose
the bringing  down the arms,  sometimes arise from for-
getting  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 like-
wise  depend on one of the arms descending directly be-
hind 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 re-
commended,  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: otherwise, the arms must be  brought down
first; which we may always be able to do, however diffi-
cult it may seem, by proceeding slowly and methodically.
But when the head is too  low, and presses the arms against
                         2Q 
306            Preternatural Labours.

the edge of the inferior strait, it must be pushed up a lit-
tle, that they may be less confined.
   879. If one of the arms be found strongly pressed be-
tween 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 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 following.
   880. After having disengaged the arms, we must apph
 to the  extraction  of the head; and whether  it  remaiu
 awhile in the pelvis, when that is ever so little contracted,
 or we endeavour to extract it  immediately, by pulling at
 the trunk and shoulders, this seems to be the most criti-
 cal and dangerous moment for the child:* on one side it
 is exposed to the disagreeable consequences  of a com-
 pression 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 preserving the
 c}iild, 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.

    * 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 umbilical 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 di-
 rect 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 circulation in it. 
                Preternatural Labours.            307

   882. When  the pelvis of the woman and the head of
the child are in their just proportions to each other, the
accoucheur must not 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 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 vyith 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
shoulders.
  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 solicit briskly, by confirming
her hopes of a speedy deliverance.   When the head is
descended  into the cavity of the pelvis,  and the face is
towards the sacrum, 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 di-
rection, and especially downwrards,  we  should directly
oppose the  intentions of Nature.  The delivery of the
head becomes then almost entirely her work; and exter-
nal efforts, though well directed, are at that time of little
use.
  885. Things do not however always terminate so hap-
pily, in the last period of labour, when  the child comes
by the feet:  because the proportion between the dimen- 
308            Preternatural Labours.
sions of the head, and of the pelvis, is not always so fa-
vourable.   When there is a defect of proportion between
those parts, the greater that defect  is, the less the secu-
rity for the child's life; and the  more cautiously the ac-
coucheur must proceed,  because his efforts, which are
then unfortunately necessary, increase the real and almost
inevitable 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 um-
bilical cord and the breast: but it  depends  more espe-
cially on the straining which the spinal marrow suffers,
in the violent extensions of the vertebral 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  method 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 circumstance 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 presents the feet.  I
shall only remark that no other presents fewer particular
indications; because the situation of the child  is such. 
Preternatural Labours.
309
that the greatest diameter of the breech, of the shoulders,
and the head, successively present themselves diagonally
at the entrance 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 introducing  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 descend-
ed, to be grasped by those fingers, and brought without.
But when the woman is  attacked by any dangerous ac-
cidents,  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 insinu-
 ate 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,  relax 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 directed differently, and the hands only act alternate-
 ly 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 downwards, in  a line which
 would  pass under the woman's left thigh.   The same
 thing must be repeated alternately,  but very slowly;  and
 care must be taken to give those motions sufficient ex-
 tent, 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 
310            Preternatural Labours.

right groin, where it must be supported by the left hand,
while with the other we bring down the right arm, which
is underneath, according to the principles already estab-
lished: then wrapping it in the same cloth with the tmnk,
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  re-
spect to the pelvis will appear the same in  both, if we
only consider their relative dimensions.   The only  dif-
ference 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 examine
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 de-
scended 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 direction 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  for-
mer, 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 tmnk take 
                Preternatural Labours.            311

that direction, when  it  presents with the heels 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 small-
est diameter of the superior strait.
   897. We must not, however, judge of the true situa-
tion 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 direc-
tion ;  and vice versa.
   S98. 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 se
cond  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 un-
dergone 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 ad-
vancing several fingers  on one of the child's cheeks, and
not by turning the trunk on its axis. 
Preternatural Labours.
   900.  If the head should be jambed with its greatest
 length between the pubes and sacmm, either by the ef-
 forts of Nature, or the ill-directed manoeuvres of a mid-
 wife, 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 superior
 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 position  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, un-
 less  we give to those movements a  much greater extent
 than their natural limits permit; which would be extreme-
 ly 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 intro-
 duce the hand, or some of the fingers only, into the va-
 gina, 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.  Af-
 ter that, we  go on to extract  the head as in the most
 common cases.
   903.  This situation of the child, in the fourth species
 of labour where it presents the  feet, is such, that the  face
  * This refers not only to being careful  to do no injury to the
 arms, but also, not to draw too powerfully at them, and thus jamb
the head still more.—W. P. D. 
               Preternatural Labours.            313

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 pre-
sentation of the feet, to turn the face completely down-
ward 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  then  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 symphy-
ses; but as the head does not obey the motions executed
on the  tmnk, 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 delivered 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 down-
ward.   He must take care afterwards to turn the breast
in proportion as it descends, at least, opposite one of the
sacro-iliac  symphyses, but preferably before the right;
                         2R 
314            Preternatural Labours.
and do the same with respect to the face, as soon as the
shoulders appear.  This change of position  is easily per-
formed 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 imperfectly, 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 wdien we meet with any difficulty,  we introduce
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 indeed
to turn it a little beyond the symphysis, according 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 obser-
vation made in par.  901.
   909.  Notwithstanding all these precautions, we must
not flatter ourselves  that  we shall always be able to make
the head take the favourable position which we endea-
vour to give it: for sometimes the face still remains over 
Preternatural Labours.
the pubes.   This case is exceedingly dangerous for the
child, if we do not pay the  greatest attention to it before
we pull the tmnk, on account of the violent twist in the
neck.  Therefore, after having turned the breast down-
ward, as I have just directed, we must ascertain the true
position 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 diffi-
culty of  bringing it down, and often renders the descent
of the head more laborious.  When  the accoucheur has
not succeeded 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 recommend-
ed: but he must not promise himself any thing from this
mode of proceeding, when an ignorant person has pulled
inconsiderately at the trunk, with a design to extract the
head thus retained, or when Nature has a long time en-
deavoured 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 middle of the face,
 near the root of the nose; and the  head being then en-
 gaged, makes it much more difficult to change its position.
 The same remark is equally applicable to the third posi-
 tion, when the  face descends directly before the projec-
 tion of  the sacmm; for it is not usually  the chin which
 stops at that part.
    912.  The child is generally the victim of this bad posi-
 tion of the head.  If it is  not always entirely deprived of 
316
Preternatural Labours.
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 circumstances,  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 rotatory 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 cau-
tiously, 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 occi-
put above the sacro-vertebral angle,  and turn it towards
one of the sacro-iliac  symphyses, or even to one of the
acetabula if we can.   While  we turn away  the occiput
thus from the projection of  the sacrum, we must take
care to turn the trunk, which is without, in the same di-
rection.   When the head  is  completely in the cavity of
the pelvis, we may place the face underneath, in order to
extract it conveniently.
     Labours in which the Child presents the Knees.

  915. The union  of all  the  circumstances,  without
which  delivery cannot be performed naturally, that is,
* See de la Mothe, among others, Observ. 275, nouv. edit. 
Preternatural Labours.
317
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 appear-
ances.         •
Of the Causes which render a Labour, in which the Child
     presents the Knees, difficidt, or preternatural.

  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
utems, while the other extremity, folded up, is retained
above the margin of the pelvis, so that the child cannot
descend, notwithstanding 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 together;
because those parts, as they  come down, may butt against
the curve of the sacmm, 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, de-
livery becomes impossible without help.
   918. To these  causes, which frequently make  it  ne-
cessary  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 convulsions, flooding.
&c.—See par. 785, and following. 
318
Preternatural Labours.
 Oftlte Characteristic Signs of the several Species of La-
   bour in which the Child presents the Knees, ami the
   Indications they present relatively to the Mode of ope-
   rating.
                                     «
   919. The essential differences of tlfose labours where
 the child presents the knees, as well as their signs, hav-
 ing 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  com-
 plicate 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 invaria-
 ble 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
 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 absolutely neces-
 sary when the woman is exhausted, or when any alarm-
 ing 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 
Preternatural Labours.
319
pelvis, then introduce the hand, and search for the feet.
We proceed in the same manner when the knees, push-
ed down by the efforts of labour, are stopped in the curve
of the sacrum, and the feet are descended as low on ano-
ther 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 re-
course 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, keeping 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 ringer
and thumb draw down one of tl^ends.  It is never ne-
cessary to apply  a fillet upon each knee, one being fully
sufficient.
   923.  The fillet being thus  fixed on the bend of the
ham, we take hold of both ends with one hand, and wind-
ing 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 direc-
tion. 
320
Preternatural Labours.
   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 termi-
nates the  handles of Levret's 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 we 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 operation depends on
the choice of the hand which we  insinuate  into the ute-
rus;  and that choice must be determined by the relative
situation of the two inferior extremities of  the child, as
well  as by the particular situation of that which is re-
tained at  the  brim of the pelvis; so that sometimes we
must introduce the right hand, and sometimes the left
   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 advan-
tageous manner, and the difficulty which most women 
Preternatural Labours.
321
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
sometimes performed without  help, it is  proper to state
the causes which may render  them difficult, and to  de-
scribe the manner of  terminating them in those circum-
stances.
Of the Causes which may render thd%e 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 impossU
ble, or at least very difficult and dangerous without as*
sistance.  Among those causes, some have been tty^sub-
ject of several preceding secticg^^e par.  785,^jnOol-
lowing); others are  peculiar^J Bpecies of labour, and
sometimes deffend on the ex«|  jP^ry size of the child's
breech, relatively to the pelvis of the mother, and some-
times only on their  situUfion.
   928. The essential  differences of these labours arise
from the manner in which the breech presents with re-
spect to the brim of the pelvis.
   929. It is not always  more easy to discover the posi-
tion of the breech,  than to  determine whether that is the
part which presents.   We  often find a great deal of dif-
ficulty 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
                          2S 
322            Preternatural Labours.
it is, as I may say, not only beyond the reach of the fin-
ger, but recedes  still  farther on the least pressure; the
child enjoying a great mobility while  surrounded by the
liquor amnii.  In the second case, where the waters are
evacuated, the breech is always found considerably tume-
fied.  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 presents 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
fopinions concerning the mode of operating in these la-
 bors.  The indications in  this species of labour are dif-
 feiSu^ccording tojfcunrcumstances which complicate
 il!TusaavancemenT,^fc^sition of the  breech, and its
 size.              4|  pp
   931. When none ofthose accidents before mentioned
 exist,  if the child's breech be srfflfll, 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 expul-
 sion to the efforts of Nature.  But if it comes along with
 difficulty, when it is 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, ap-
 plied preferably to that groin which answers to the sacrum
 of the woman.   After thus  disengaging the trunk and the 
Preternatural Labours.
323
feet, we finish the delivery, as if the latter had presented
naturally.
   932.  When the obliquity of the uterus is considerable,
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 without help, whatever  may be the
size of the  breech;  at least, unless the  second buttock,
which is retained on some part of the margin of the pelvis,
approach the superior strait, so  that they may both en-
gage 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 beginning of labour,  and especially at the
time the waters are evacuated. %When  that precaution
is not sufficient, we  must introduce  the  hand to the en-
trance 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 accident, and
when the volume of the breech so far surpasses 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 along with the fingers, in the manner direct-
 ed 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 without delay,
 when the child presents the breech.   This method can-
 not be safely put in practice, but when the breech is still
 at the entrance of the pelvis, or so little advanced, that it 
324            Preternatural Labours.
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.
   931. 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 suc-
ceed by that method, recourse  must be had to fillets, or
blunt hooks.  Were we to consider only the materials of
these different instruments, and their mode of acting, the
fillet would, no doubt, merit the  preference:  but its ap-
plication 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 terminated 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 if needful,  a kind  of forceps.   For want of these
hooks, I have often successfully used those which termi-
nate the handfes  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 po-
sition, and is  strongly wedged in  the pelvis, as the obsta-
cles to its exit  are much greater, it may perhaps be ne-
cessary to apply  two crotchets, in order to use them like
a pair of forceps.
   * The student's attention is requested to  these important dis-
tinctions.—W. P. D, 
Preternatural Labours.
325
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 symphy-
sis; 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 po-
sitions 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 insinuating  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 particularly
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 
3.26            Preternatural Labours.
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 en-
trance 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 fo* them,  and then
proceed as in a  second  presentation of the feet.—See
par. 889.
   941.  The position of the breech which constitutes the
third species, is such that the child's back answers to the
anterior part of the uterus  and the pubes of the mother;
the face and breast being towards the  posterior part, and
consequently underneath.
   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, car-
rying 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 
Preternatural Labours.            327
part of the uterus.  It is the least frequent and least fa-
vourable of all the four positions.
   944.  In this case, Nature generally finds so many ob-
stacles 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 abandon 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
endeavour 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 mentioned above, in order to begin
to turn the face from over the pubes.
   945.  In this  species of labour it is very indifferent
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 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 fossae
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 advancing the hand along the pos-
terior part of the thighs, and bring them  down, as in all
the preceding positions. 
328            Preternatural Labours.
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 diameters of  the head  and
those of the pelvis were constantly the same:  for the ob-
stacles which obstruct these labours, or render them dif-
ficult and dangerous,  proceed  only from these three
sources, united or separate.
Of the Causes which may render those Labours in which
  the Child presents the Crown of tfie 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 extra-
ordinary size of the head, relatively to the pelvis of the
mother;  from the manner  in which it presents at the en-
trance of that cavity; from the presence  of a hand, or a
foot, which hinders it from engaging in it; from  the di-
rection which the expulsive  forces of  the uterus impress 
Preternatural Labours.
329
on it; from  the descent of the umbilical cord, &c*  In
order to determine more clearly what I mean  by bad po-
sitions of the head, and  demonstrate the mechanism by
which several of those positions may take  place in the
course of labour, I shall make them the subject of a par-
ticular section.
Of bad Situations of tlie Child's  Head in general, and
  particularly, of that which it is sometimes forced to lake
  as it advances in the Pelvis.

  948.  The position of the head is  disadvantageous,
though it presents the vertex, whenever its greatest diame-
ter 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 disadvantage-
ous,  as  the woman's pelvis shall  depart  farther from a
good conformation; and much more stillj as the face shall
have  more  propensity to turn  towards the  pubes in the
last period of labour.—See par. 479, and following.
   949.  Although the child's head present favourably at
the entrance of the pelvis, the labour cannot be easy, un-
less in its descent it  take the course which  I  have de-
scribed in  treating  of the mechanism of  the  different
species of natural labour.  When it engages otherwise,

  * I do not speak here of those causes which absolutely require
the help of instruments : I shall speak of them in  the fourth parjt
>>f the work.
                          2 T 
330             Preternatural Labours.
its greatest diameters advance foremost, and present them-
selves 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  pre-
serves 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 perinaeum, if  the face come up-
ward.   But we observe the contrary in the case in ques-
tion;  the chin quits the breast, and the head turns back-
ward  as soon as it begins  to engage; so that  it is  the an-
terior fontanelle, 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 oc-
ciput  answers.  The direction of the expulsive forces in
other cases is constantly such that they act on the head
so as to make the occipital 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 mo-
tion, 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 
Preternatural Labours.
331
 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  fin-
 gers introduced into the vagina, we must support the
 child's forehead, during each pain, in order that the na-
 tural 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 anterior
fontanelle, or its environs, where the bones are very sup-
 ple, lest the  child be destroyed by their depression, and
 the  consequent injury to the brain, which however can-
 not  be very great if we act methodically.
   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 prevent the bad
 situation in question.  The woman being laid on the side
 opposite to the deviation of the fundus, we must push up
 the forehead as much as possible during the pain,* and with
 the  precautions already recommended.   If we should not
 succeed completely in  this manner, we must introduce

   *  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 changing 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.t

  t I am sorry to differ with our author in this advice, my expe
 rience  being much in favour of acting on the forehead in  the ab-
 sence of pain, and maintaining the forehead with my fingers until
 the contractions of the uterus force down the vertex.—W. P. D 
332            Preternatural Labours.
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 ac-
tion 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 between  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 of those  labours, in which the lever, com-
monly called 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 circumstances 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  complicated
  with Circumstances that render them difficult.

  956.  The greater part of the  causes  stated in par.
947, present different indications  in some respects, not
only according to their species, and  their violence, but
also  according as they manifest  themselves  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. 
                Preternatural Labours.            338

than to remove  it, and place it in a better position, as
directed in  par. 612, and following.  When this faulty
position  only takes place at the  inferior strait, we pro-
ceed in  the same manner,  with  this difference, that we
direct the length of the head according to the diameter
which  goes from the pubes  to the sacmm.   If the pre-
sence of a  hand,  or  a foot, oppose  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 differently.*   Lastly,  we must correct the de-
fective  course of the  head, when it  deviates from that
which I have  traced, in treating of each species of natu-
ral labour.
   958  Whenever  a  violent flooding, or any other se-
rious accident,  happens in the course of  labour, we
ought to deliver immediately; but in different ways, ac-
cording as the labour shall  be  more or less advanced at
the instant when the  operation  becomes indispensable.
If the child still  preserves all its  mobility above the en-
trance of the pelvis, or if it be but just beginning to en-
gage 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 prefer-
ence 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  preference
■■ See par. 1077, and following. 
334
Preternatural Labours.
when the head entirely occupies the cavity of the pelvis,
and  nothing but not having them at hand when the ne-
cessity 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 constitutes  the neck of  the  womb.
Some may  condemn this last precept, by urging the dan-
ger it offers to mother and child;  but experience enables
me to declare, 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.
   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  accurately from that in
which it is  entirely in the vagina.  Though in  the for-
mer  case there is no more inconvenience 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  viscus, 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 indicated in this cir-
cumstance, 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 turning the child.
   961.  The accidents stated in par.  1079, such as flood-
ing,  convulsions, frequent syncopes, an  exhaustment of 
Pretenwtural Labours.
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 sometimes prescribes the same
indications.  Almost all those who have advised and prac-
tised it on account of this last circumstance, have done it
without any regard to the extent of the disproportion be-
tween  the dimensions of the child's head and those of the
pelvis; so that for one child they have saved by this me-
thod, a great number have  been victims to it.  This me-
thod cannot be proper but in those cases where the dis-
proportion which  obstructs delivery is very small: when
it is more considerable, it requires the forceps, crotchets,
the ca3sarian operation, &c. according to the state of the
child,  as we shall see in the sequel.
General Rules for  turning  the Child to bring it by the
     Feet, when it presents the Crown of the Head.

  962. When we are obliged to turn a child who  pre-
sents the crown of the head to the orifice of the utems,
the membranes are entire," or not, and the waters recently
discharged, or a long time ago.  In the former case, the
child is in some measure free in the midst of the utems:
and in the latter,  it  is so closely embraced by it, that the
hand  cannot penetrate it without difficulty,  even when
well directed.  It is in the latter state I shall  suppose it
to be, because 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 exposing
both mother and  child to great inconveniences. 
336
Preternatural Labours.
  963. The woman being placed conveniently, we must
introduce the right or left hand into the uterus, 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 fossae, where it
must be  retained during the operation, by means of the
wrist and fore-arm, to hinder it from being forced down-
ward again by the pains, while we search for the feet.
  964. In  order to find the feet, and bring them down
more  easily, having removed the head sufficiently from
the superior strait, we must insinuate the hand along that
side of the trunk which is  nearest the posterior part of
the utems.   We first pass  the fingers close together over
the ear, from thence over the side of the neck, but a little
backward, in order to avoid the projection of the shoulder;
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 entrance  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 extremity already brought down, according
to the difficulty or facility we meet with: which will  be 
Preternatural Labours.            337
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 extremities will present themselves  succes-
sively to the fingers, and  not pell melt, as we generally
meet with them, when, according to the advice of most
accoucheurs, 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 perform the delivery by pull-
ing only at one extremity, sometimes also, after  having
luxated, fractured, and even torn it off, they are reduced
to the shameful 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 undertake to deliver
                         all 
338            Preternatural Labours.

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 orifice
of the uterus, it is not always without  a great deal of
trouble that we are able to bring them down; either be-
cause it is difficult to grasp them both with one hand, or
because the head is still  retained in the neighbourhood
of the superior strait,  and cannot  of itself recede suffi-
ciently 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 conveniently with the same hand which holds the feet;
because  we are  sometimes obliged  to  pull them  down,
at the same time that we push the head back: which hap-
pens more  particularly when the waters have been long
evacuated,  and much  more still in some other presenta-
tions.  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 va-
gina, 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,  applied 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 enclose both  feet in one fillet: it is sufficient 
Preternatural Labours.            339
to apply it to one, and w7e generally place it on that which
is next  the pubes*
   970.  To apply the  filter, we double it in the middle,
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 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 pushing 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 characteristics
of that position of the head  which constitutes the first
species of labour, having already treated of  them suffi-
ciently 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.

  * 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 cer-
tainly unnecessary.—W. P. D. 
340
Preternatural Labours.
  972. Though it may seem indifferent to some, whether
they introduce  the right or left hand  into the iderus, to
turn the child, immediately aftea 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 circum-
stance 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 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 al-
most impossible 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 fossae, where it
must be retained by the  wrist and fore  arm,  while we
search for the  feet, and bring them down as already di-
rected.
   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 
Preternatural Labours.
341
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 difficulties, and con-
stantly turn the child's  breast towards the left sacro-iliac
junction; so that the trunk, as it descends, places  itself in
the same manner as in the second species  of the presenta-
tion of the feet.   The rest of the operation must be con-
ducted as in that species.—See par. 893, and  following.
   976. The position of the head,  which constitutes  the
second species, will appear the same as the preceding, if
we only consider the proportion between  the dimensions
of the head and those of the entrance of the pelvis; since
in both  the  sagittal suture crosses that strait  obliquely.
The difference between them is,  that in this second posi-
tion 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 diffi-
cult 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 con-
tracted:  but when the pelvis is well formed, this position
may be as favourable for delivery as the preceding ones.
The indication which it presents in the former case, is 
342            Preternatural Labours.
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 to-
wards one of the acetabula:  the fingers 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 utems, with equal ad-
vantage, provided the  accoucheur be accustomed to use
them equally.   We must  slide it up, along the sacmm,
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  tmnk; because the
first movement 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 fossae, 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 
Preternatural Labours.            343
left acetabulum; whereas in the fifth the forehead is situ-
ated behind the right acetabulum, and the occiput oppo-
site to the left sacro-iliac symphysis.
   982. I have observed  in paragraphs 479, 501, and fol-
lowing, that labour is, in general, more difficult 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
with  a little more difficulty,  or because the obstacles,
which result from these positions, do not  manifest them-
selves 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  presents  in the fourth position, is exactly the same
as for the  second; and  in the fifth position we proceed
as in  the first.  See the paragraphs 973 and 977, where
I treat of those two  species of labour.—I shall only ob- •
serve 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 ap-
pear 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 
 344            Preternatural Labours.
 turn the breast  towards one  of the sacro-iliac symphy-
 ses.
    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 natural
 one, unites all the difficulties essential to the third, fourth,
 and fifth species; for the head presents its largest diame-
 ter to the smallest one of the  brim, and the face  con-
 stantly places itself under the pubes.
    986. In order to shorten the  labour, which in this
 case is always  very tedious,  even when the pelvis  is of
 the natural size, we ought to  turn away the occiput  from
 over the projection of the sacrum, as soon as the mem-
 branes open, if we are called  in time, and bring  it insen-
 sibly 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 push-
 ed back, we  may turn the child, and bring it by  the feet:
 otherwise we must use the forceps.*  In the former case,

   * 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 wo
 man a great deal of unprofitable^ pain, as the chances are more than 
Preternatural Labours.
345
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, to-
wards the left side, if we  use the  right hand, and vice
versa.  After having removed the head in this manner,
and reduced it to one of the  two first positions, we con-
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.

   988.  Authors furnish us with a great many examples
of labours in which the child presented the face to  the
orifice of the utems, and I could have added a pretty large
number to them; because those labours are not extremely
rare.  Of women, whose children present thus,  some
have been delivered  without  help, and the labours of
others have been extremely laborious.

even should we be obliged to have recourse to them at last.  It is
to be remembered, we except where there is a great disparity be-
tween the size of the head and pelvis, and where of course the
child advances easily.  I have seen two instances of this presen-
tation,  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 
346
Preternatural Labours.
Of the  Causes, Signs,  and  Differences of Labours in
  which the Child presents the Face, and the Indications
  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  degree of that devia-
tion, 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.
  990.  Those who have perfectly comprehended what I
have said in par. 950, and following, concerning the me-
chanism 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  pre-
sent; and they will also clearly conceive  whence the dif-
ficulties arise which then obstruct delivery, or, at least,
always render it extremely 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 ob-
scured 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. 
                Preternatural Labours.            347

  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 pre-
sents 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 answers to the
left side of it, and the chin to the right
   996.  In  the  fourth species,  the situation is  exactly
contrary, the forehead  being placed towards  the right
side, and the chin to the left.
   997.  These four positions are not equally frequent;
the two latter are  the most common,  though even they
are very rare, if we consider them relatively to some of
the other positions which  have been  already described.
These labours ought to be accounted preternatural, inde-
pendently of the accidents which may  render those so in
which the child presents in the most advantageous man-
ner.  For  them to be  terminated without help,  it is re-
quisite that the  head should be very small, and the mo-
ther'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 de-
prived of life, or ready to lose it, on account of the en-
gorgement 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 ocfiput, so as to reduce
the  vertex to its usual situation.   When  we cannot so
happily second  the efforts of nature, either  because we 
348            Preternatural Labours.
are called too late, or because accidental circumstances
require instant delivery, we are obliged to turn the child,
and bring it by the feet, or extract the head with instru-
ments, 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 ne-
glect the attempt, because of the advantages the child
may reap from it, if we  accomplish it,  and the  danger
which often accompanies 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 accoucheurs have
advised, as on the occiput, which we ought to endeavour
to hook with the fingers, to bring it downwards.   Expe-
rience authorizes me to say that that may be executed
without much trouble, 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;  because
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  reduce the  head
to a  good position: but  in  the  contrary 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 particularly stated in the sequel of this work. 
Preternatural Labours.             349
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 con-
stitutes 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; be-
cause  the  hand cannot  be  conducted directly  on the
occiput  to bring it down, as  in the following positions.
In  order to reduce the head  to this 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, howe-
ver, is not  without inconvenience to the child,  even sup-
posing little force  to be necessary; or else we must begin
by changing the position of the face, and directing it trans-
versely 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 recom-
mended, of turning the face next the hand that operates.
—See par. 987. .
  * I believe it always best, both in the first and second position^
of the face.—W. P. D. 
 350            Preternatural Labours.

    1004. We cannot expect to reduce the head to a natu-
 ral position, in the second presentation; it would be wrong
 and  dangerous to attempt it, but when the  membranes
 have just opened.   If we determine 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 in-
 sensibly 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 di-
 rected in par. 987.
    1006. When we have no other indications to fulfil in
 the third species of the face  presentations,  than that of
 reducing the head to its natural situation, we  must intro-
 duce the right hand towards the left side of the pelvis, till
 we can bend the fingers 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 endeavour very care-
 fully 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 endeavour to bring
 down the occiput*

  * The direction in this paragraph will be very ambiguous to the
young practitioner, as it would lead him to suppose our author pro-
posed to use both hands at the same time  to rectify this bad posi-
tion of the head.  But this is not his meaning: he is to be under-
stood, that the left hand should  be employed to push up the face, 
Pretermlural Labours.             351
   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 uteius, 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 ob-
served concerning those labours  in which the child  pre-
sents the anterior part of the neck,  we may infer  that
they are extremely rare: De La Motte is almost the  only
one who has mentioned them, and he has cited but two
cases.*

as it would be very awkward and inconvenient to use the right;
and that where this has been effected, the right hand will then have
more room to act upon the occiput.—W. P. D.
  * Our author proceeds to enumerate a great variety of presenta-
tions of other  parts of the body, with  the mode of proceeding 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. 
352             Preternatural Labours.
   1010.  Cause. Obliquity of the  utems,  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
   Varieties. 1. Where the"
length of the neck is  from
pubes to  the sacrum,  face
to the pubes, and breast to
the sacrum.
   Mode of Operating.
Either hand; when we seize
the feet, proceed as directed for
turning in third species of head.
1
  Right or left hand as the face
may be turned from the lumbar
column.*
   2. Face to  the sacri
 and breast to pubes.
   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 iliac}   ™e W* hand' a,nd pr?ceedf
 r       , r       ,,    • i .  >as directed in second species ot
fossa and lace to the right f head.
   Left hand invariably, and pro-
ceed as directed in first species
 of head.
     Labours in which the Child presents the Breast.

   1011. We shall not be surprised that there are scarce-
ly 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 attitude 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,f without  losing the  oval figure in

  * It is an invariable rule to use  that hand whose palm  can be
applied to the face of the child.—W. P. D.
  t Authors are full of cases in which the child presented the
hands, the knees, or the feet, and the cord at the same time, at the 
                Preternatural Labours.            353

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 uterus,
relatively to the foetus.
   Marks  The ribs, the  clavicles, sternum and upper
part of the abdomen.
   Indication. Turning.
   Varieties.  1. Fore  parti     Mode of Operating.
of the  neck over the pubes J> As directed for the neck in
and belly over the sacrum.} par. 1010.
   2.  Belly over  the pubes,"}
and neck to the base of the J>           ditt(r-
sacrum.                   J
   3. Neck and head on lefO
iliac fossa,  belly  on  the ')>           ditto.
right.                     j
   4. Neck  and  head onl
right iliac fossa, and  belly ^           ditto.
on the left.                j

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.
     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 at-
 titude it must then necessarily take in the uterus; an at-
 titude which does not seem  to be  always precisely the
 same, if practitioners have distinguished it perfectly; for
 I have found it vary from their descriptions.   Though in
 these cases the child may sometimes have the hunk bent
 backward,  the head turned  on the back, the thighs ex-
 tended, 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 extremities 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.
   1014.  Cause. The same as those of neck and breast.
   Signs. The soft abdomen, terminated by the heart and
 pelvis.
   Indication.  Turning,
   Varieties. 1.  Breast overl      Mode of Operating.
 pubes,  inferior extremities ')>  Rjsht  or left hand m*y be
                           i used.
 over sacrum.             j
   2.  Breast over sacmm,?
 thighs over pubes.        £            dltto"
   3.  Breast  on  left iliac]
fossa, thighs and knees on )>         Left hand.
 right                     J
   4.  Breast on right iliac}         Right hand.
fossa, thighs and knees on ^ N.B. The common rules for
•j &      °                 {turning to be constantly kept in
 e                        J  mind.
   Contingency.  The umbilical cord almost always down. 
Preternatural Labours.            355
Labours in which the Child presents the fore part of the
   Thighs, and of the Pelvis;  their Causes, Signs, Dif-
  ferences, and the Mode of operating in them.

   1015. Cause. The same as determines  the presenta-
tion of the abdomen or breast.
   Signs.  Abdominal Tumour; parts  of generation, es-
pecially of the male, two parallel columns, formed by the
thighs.
   Indication. Searching for the feet.

   Vaiietes. 1. Knees to the"
sacrum, abdomen  over the
pubes,  breast and face un-
der the anterior part of the
uterus.
   2.  Knees  towards  the"]
pubes, abdomen, &c. to sa- ^>
crum.                    j
   3. Child is placed trans-"
versely, knees to  the right
iliac fossa, breast and belly
over the left
    4. Breast  and  belly  to"l
 right iliac fossa, knees over )>  Following the numerical or-
 the left.                   j der-
 Mode of Operating.
As for belly and breast.
ditto.
ditto.
ditto.
Labours in which  the  Child presents the different Re-
  gions of its posterior Surface to the Orifice of the Ute-
  rus.

   1016. These  labours  are met  with  a little  oftener
than those in which the child presents one of the regions 
356            Preternatural Labours.
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 belly, 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 la-
bours  I am now going to treat of; very simple causes,
such as an obliquity of the iderus,  and a greater quantity
of water  than usual,  may occasion  them:  because the
child, without losing that oval form, in which it is natu-
rally folded, may present the occipital  region, the hind
part of the neck, the back and the loins.
   1017. Nor does the same danger attend these two or-
ders of labours.   Those which  I  am now going to treat
of are, coeteris paribus, less disagreeable both for the mo-
ther and child, and present much  fewer  difficulties than
the former.
Labours in which the Child presents the occipital Region
  at the Orifice of the Uterus.   Of the Causes and dis-
  tinguishing Signs of those Labours, and their Indica-
  tions.

  1018. Cause. Obliquity of the uterus, or great quan-
tity of water.
  Signs. A solid tumour, on which may be distinguished
the posterior fontanelle, and lambdoidal suture.
  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 introduced to bring 
Preternatural Labours.             357
the vertex to the centre of  the pelvis.   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, by
   Varieties.  1.  Crown  of
the head  against the  pro-
iection of the  sacmm,  and l™e prance or  tne pelvis  by
•'    .    ,    «  .,       i      ^turning it  towards one  of  the
the  back Ol  the  neck on  acetabula.  Then leave it to the
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 sa-
crum; back to the posterior
part of the uterus.
   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.
 efforts of Nature.  When acci-
 dents  complicate it,  we must
 turn, in the same way as direct-
 ed in  the third presentation of
 the vertex.  See par. 978.

   Turn invariably, observing the
 cautions, &c. for the sixth pre-
 sentation of the vertex. See par.
 984, and following.


   The patient to lie on the  left
 side; if this  does not succeed,
 introduce the hand, and bring the
 vertex to its natural  situation.
>When  circumstances  require
 turning, proceed as  directed for
 a second presentation of the ver-
 tex.  See par. 976,  and follow-
 ing.

   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 accidents compli-
 cate the labour, proceed as  in a
 first presentation of the vertex
 See 971, and following. 
358            Preternatural Labours.
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 utems, or  an  over
quantity of water, or both.
  Signs.  The spiny  tubercles of the cervical vertebras;
the angles of  the lower  jaw, and  superior edges of the
scapulae.
   General Indications. As delivery cannot take place in
any of  these cases without assistance, we  must first en-
deavour to restore the head  to its natural situation, pro-
vided 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 disregard it,  and  search for the
feet;  if accidents complicate the labour,  we must  turn,
without attempting other methods.
                            Particular Indications andMode
                                    of Operating.
                              Turn  invariably as directed
                            for  a sixth presentation of the
                            vertex.  See par. 984, &c.
                          "J  We may attempt to  reduce
  9   nrrivmt on  one  side  the head if cal,ed  immediately
  d.  Uccipui on  one  sme  afterthedigchargeofthewaters.
of the projection Ot the sa- Ut K in general, however, best to
   Vatieties.  1.  Occiput on
the  edge of  the pubes,
back over the  base of the
sacrum.
cmm,  and  the back over
the pubes.

   3.  Occiput  on  the  left
iliac fossa,  back over  the
right.
                            search for the feet as in a third
                            presentation of the vertex.  See
                            par. 978, &c.
                              Try to reduce the head with
                            the right hand; if this does not
                            >succeed, turn as in a second pre-
                            sentation of the vertex.  See par.
                            976, &c.
                           "|   The same indications as the
  4.  Occiput on the right LLast;i bu*.th^left +hand must ^»e
•»•    *   ^ \   i        ru   >employed:  if we turn  we pro-
iliac fossa, back over  the | cee£ as in a first presentation of
left.                        J the vertex.  See par. 971, &c. 
Preternatural Labours.
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 dis-

tinguished  the spiny tubercles of the  vertebras, the  ribs,

and inferior edges of the scapulas.
   Indications.  The same as those labours of par. 1019,

that is turn, and bring by the feet.

   Varieties.  1. Back of the"!            fOeratin
neck, on the edge of the os I  We enyo%f Hgffiand to
pubis,  and the loins over [turn,* and  proceed as has been
the sacrum.               J directed.

   2. Loins over the pubes, |  Proceed as in second presen-
 nape of the neck over the Ration of  the nape of the neck.
 posterior edge of the pelvis.] See Par*1019*
                           "J  We may operate to turn with
                              either hand, but differently.  If
                              the left, we insinuate it at the
                              right iliac fossa; if the right, we
                             ^raise the child and carry the
                              back above the pubes, and search
                              for the feet, and pull almost en-
                              tirely at the left.

    4.  Head  in  the right")   _       .  ,.  ..       ,,
  ...    *     .,   i •   •  fu  L  The same indications  as the
  lluHC fossa, the loins in me fthird; we may operate with either
  left.                       J hand according to circumstances.
Labours in  which  the Child presents the frrins,  their
      Causes, Signs, Differences, and Indications.

   1021. Cause. Obliquity of the utems, or an over por-
tion of water.
   3. Head in the left iliac
fossa, the  loins  over the
 right. 
360             Preternatural Labours.
   Signs.  The false ribs on one  side, and the posterior
angles of the ossa ilia on the other.
   Indication.  Turn and bring by the face.
   Varieties.  1.  Back over")      Mode of Operating.
the pubes, breech over the L  The sarae as  in the  presen-
sacmm.                   J™£ of the back«  See Par-
   2. Breech and feet over"!
the pubes,  and  back  and I
head  to  the  posterior part f        See par.°;020<
of the  uterus.              J
   3. Back  over  left iliac]
fossa, breech and feet over ±        _   dltto;___
the right.                 J        Seepar.1020.
   4. Back and head over!
the right iliac fossa, breech \>        „   dltto-
and feet over the left.      J        See •""• 10»
Labours in which the Child presents the Lateral Regions
                    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 
Preternatural Labours.
361
region,  and their different positions, 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 mechanism 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 utems, and the great quantity of water which some-
times surrounds the child, favour them all, and seem suffi-
cient to occasion some of them, independently of any
other cause.
   1024. The diagnostic of these labours is not more diffi-
cult to distinguish, than those described in the preceding
chapter; and the prognostic of them, costeris paribus,
must also  be the same.
Labours in which the Child presents the right or left Side
  of the Head.  Of their Causes, Signs, Differences, 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
                         2Z 
362            Preternatural Labours.
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 membranous 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
demonstrates 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 es-
sential, 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 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 lower
jaw, or of any other of the marks with respect to the pel-
vis.   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  fre-
quent, the vertex is situated  transversely over the union
of the sacrum with  the vertebral column, and the base of
the lower jaw of the neck over the pubes: the face is to- 
Preternatural Labours.            363
 wards 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 lower
 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 anterior part of the
 uterus,  over the pubes, when it is  the right side of the
 head, and over the sacro-vertebral symphysis when  it is
 the left.
   1031. It must be remembered that the head cannot
 present one of  its sides at the orifice of the uterus, with-
 out being bent on the opposite shoulder.   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 indicates what ought to be done in all
 these cases, to restore nature to her rights, and enable her
 to perform 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 reducing the head to its natu-
ral situation, in order to commit the expulsion of the child
to the forces of the  mother; and sometimes in turning it,
to extract it by the  feet. 
364
Preternatural Labours.
Method of operating where the Child presents one of the
                  Sides of tlus Head.

   1033. The first of these species of labour presents
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 situation;  because it
seems the most  likely to restore the head to  its natural
position: but it is so inconvenient, 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 introduce one hand to the entrance of the uterus, to
remove the base of the child's cranium from the projec-
tion of  the  sacrum; while with the other we press more
or less on the hypogastric region, to force down the ver-
tex towards the centre of the superior strait.   If we can-
not compass the first intention, which is to reduce the
head to its natural situation, we must turn the child and
bring it by the feet, as we also must whenever the labour
is complicated 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 info the
uterus, towards  the  left iliac fossa, where the face is, in
order  to remove the  head from that side, and push it to-
wards the right iliac fossa: then we search for the feet,
and finish the delivery  in the same manner as in the se-
 cond 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, 
Preternatural Labours.             365
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  la-
bours, 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 obli-
quity of the  uterus,  by laying the woman on her back,
and  as horizontally 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 introducing  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 entrance of the centre of  the
pelvis.
   1037. When particular circumstances do  not permit
us to commit the  delivery to  Nature, but require us to
terminate it immediately,  we must turn  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 anterior obliquity of the uterus.  After that, we search
for the feet in  the same  manner as if the vertex had pre-
sented in the first position.
   1038. If we find the left side of the head at the  ori-
fice of the  uterus, we operate with the right hand.  We
begin, as before,  by bringing down the vertex to the su-
perior 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 
 366            Preternatural Labours.

 which constitutes the third species of these labours, with-
 out perceiving that it is more difficult to reduce it to its
 natural situation, than in the  preceding  case.  To pro-
 cure that reduction, when the right side of the head pre-
 sents, we must remove the child's face from the base of
 the sacrum,  by advancing the right hand in the neck of
 the uterus, while we make a pressure with the other on
 the hypogastric region of the woman, to force the occi-
 put 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.
   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 intro-
 duced 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 tiie vertex;  and finish the de-
 livery 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 re-
duce  the head to  its natural situation: 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 
Preternatural Labours.             367
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 prefer-
red, 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  directed
the greatest force  to  be  exerted on  the left foot.
   1044. When the right side of the head presents  in the
fourth position, we may reduce it to its natural 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 uteii 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 di-
rect 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  facilitate the con-
version  of  the trunk, and the descent of the breech in a
proper  direction.  The rest of the delivery to be con-
ducted as usual 
368
Preternatural Labours.
   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 re-
duce the head  to its  natural situation;  we then remove
the head from the entrance of the pelvis, pushing it over
the fore part 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 situation,
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 accomplished 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  natu-
ral situation,  or accidental circumstances require imme-
diate 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 
Preternatural Labours.
369
child, to take hold of the feet, and finish the delivery ac-
cording 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 preced-
ing, though they proceed from the same general 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 relatively to the
pelvis of the  mother, before the opening of the mem-
branes; nor then,  without introducing the  whole hand
into the vagina: but we ought not to make such  an ex-
amination till  it is time  to deliver; that is to  say, till the
parts of the woman are well prepared, and the pains very
strong.
   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
ed^e of the os pubis, and the shoulder is over the base
of the sacrum.  The face is towards the left side of the
                         3 A 
370             Preternatural Labours.
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 sa-
crum, 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 pel-
vis 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 answers to the sacro-
vertebral symphysis when the right side of the neck pre-
sents, 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 sym-
physis when it is the left side.
Of the Indications  presented  by these Labours, and  the
             Mode of operating in tliem.

   1055.  We 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 al-
ways so difficult to accomplish the first of these indica-
tions, that I would  advise it never to be atttempted, but
to search  for the feet in all these cases. 
               Preternatural Labours.            371

  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 po-
sition 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 situations 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 nevertheless much
more frequent;  which no doubt arises from the shoulder's
being more salient and rounded, whereby  it accommo-
dates itself better to the form of the entrance of the pel-
vis, 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 scapula, the
arm. and the ribs. When the hand comes down, it suffi-
ciently denotes the presence of the shoulder  at the orifice
of the uterus, and may also demonstrate, in  what manner
it is situated, and whether 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 sacmm; so that the fore part of the
breast is towards the left iliac fossa when the right shoul-
der presents, and towards the right iliac fossa when it is
the left  shoulder. 
372             Preternatural Labours.
  1060.  In the second position,  the  side of the neck is
over the  superior edge of the sacrum, and the side pro-
perly so called is over the pubes; the breast  answers 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  iderus
when it is the right shoulder, and over the sacrum when
it is the left.
   1063.  The indication in these  labours is easy to per-
ceive: it consists in extracting the child by the feet.   In
all these cases we should be little founded in advising  the
reduction of the head to its natural situation.
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 utems 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 posterior and left lateral part of  the utems, removing 
Preternatural Labours.            373
 the  shoulder from the entrance of the pelvis, pushing it
 as much as we can over the right iliac fossa; in order to
 get  hold of the feet, and bring  them successively into the
 vagina.   If we meet with any difficulty in bringing them
 entirely down, after having brought them so far, we must
 remember to remove the shoulder again from the supe-
 rior strait, in the same manner as I have  frequently re?
 commended the head to be removed from it
   1065. When the left shoulder presents, we introduce
 the left hand along the posterior and right lateral 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 pre-
 sents,  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 remove the shoulder
 from the entrance of the pelvis, as we go along; then the
 head, which is a little farther off; and direct them towards
 the left iliac fossa, while we incline the fundus uteri a lit-
 tle  to the right side, by pressing externally on  the wo-
 man'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 remove 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 se-
 cond position of the left shoulder: but  we must search
 for  the feet with the right hand.  We  introduce  it  to-
 wards the left side  of the uterus, and remove the head
and shoulders from the superior strait as we go along, di- 
374
Preternatural Labours.
recting them over the right iliac fossa; while we incline
the fundus uteri to the other side, by making a convenient
pressure on  the  woman'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 pos-
terior part of  the uterus, passing  it under  the child's
breast, which we must remove from the lumbar column
of the mother, carrying it over the os pubis, till the shoul-
der 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.
   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 an-
terior 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 
               Preternatural Labours.            375

we push the shoulder up above the projection of the sa-
crum.   Afterwards we act equally on both feet with the
usual precautions.
   1070. The method of  operating is not more indiffer-
ent 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 an-
terior and left lateral part of the uterus, bending it a lit-
tle over the pubes, till the fingers can hook the feet, to
bring them down successively, beginning with the  right
foot, and making them pass over  the child's breast, be-
hind  the pubes of the mother.  As soon as they are both
in  the  vagina, 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; especially
if we find any difficulty in bringing down that  foot.   We
then  act equally on both extremities, till the breech is en-
gaged,  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, car-
rying it in a state of supination under the child's breast.
We disengage the shoulder by lifting it up above the edge
 of the os pubis;  we afterwards direct the fingers towards
 the right side of the woman, 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 utems  to bring down the
 other;  when it is brought as low as the first, we continue
 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. 
376
Preternatural Labours.
   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 arti-
cle, than any other, though the hand may present when
the shoulder is not placed over the entrance of the pel-
vis: because in those cases the hand rarely escapes alone
from the uterus; which, on the contrary, very often hap-
pens in the different species  of labour which  make the
subject of the two preceding  sections.
   1073. Among the precepts which have been transmit-
ted 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
frequently done at the present day.
   1074. To throw more light upon what concerns these
labours, I shall distinguish the different circumstances in
which the hand may present;  because we must not act
in the same manner in  all of them.
   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 circumstances, 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 iderus,
when it is descended very low, it is because the shoulder 
Preternatural Labours.            377
presents  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 accompanies the head,
the breech, or the feet, at the orifice of the iderus, 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  feeble 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 en-
gages alone: it  is easier  to  explain this  effect,  than to
comprehend  why it does not always 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.  I 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  directing  it towards the face,  while the
head itself engaged in the superior strait, was sufficient
to  make it disappear.  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  iwtches.
    1078. It is only when the pelvis is defective, and a
 little narrow, that the exit of the child's hand can pro-
                           3B 
378
Prtternalural Labours.
duce 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 pelvis:  for in that case it is some-
times 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 circum-
stances.
   The 29th of January, 1776,1 was  called  to a woman of low sta-
ture, the small diameter of whose pelvis wa's 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 en-
gaged, though the great tumefaction 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,
respiration difficult, and  the abdomen hard and painful.  After hav-
ing bled her a second time, for she had been bled three hours be-
fore,  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 de-
livered  without a great deal of difficulty, on account of the narrow-
ness 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 li- 
Preternatural Labours.
379
   1079.  It very rarely happens that both hands  present
with  the head, and more rarely still that we are obliged
to push  it back, and turn the  child, on account of this
slight complication, so easy it is to remedy it.   We ought
not to recur to that often dangerous expedient, but when
we cannot re-establish  the head in its natural situation,
after having returned the hand into the uterus.
   1080.  The presence of the hand or the arm at the ori-
fice of the uterus, in whatever direction it may be,  pre-
sents no  particular indication  before the opening of the
membranes; and afterwards we have only to consider the

berty 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, corres-
pondents of the Royal Academy of  Surgery  at Paris, Messrs. Au-
diberty 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 clear-
ed the neck of the uterus, and had a tumour on the vertex, which
entirely concealed the sutures and fontaneUes, and prevented a dis-
covery 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 3. 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.
principal region of the child which presents, and its posi-
tion, to determine the mode of operating.
   1081. Some have imagined that they could extract the
child by pulling at the arm;  others that we ought to re-
turn the arm into the  uterus, in order 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 princi-
ple of humanity,  have amputated  the arm as high as pos-
sible, with sharp  nippers, or  otherwise, thinking amputa-
tion less cruel than tearing  it off; or have contented them-
selves with making deep incisions into it, with a view of
lessening its size, when it has been tumefied, and appear-
ed 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 pene-
trate the uterus to find the  feetf
   1082. Those who know  the relation which the dimen-
sions of a child at full time, whose arm is out of  the ute-
rus, 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 de-
livery 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

  * Peu, Pratique des Accouchemens, p. 412.
  t M. de Leurie, Traite des  Accouchemens, edit. 2, p. 311, &
suivans. 
Preternatural Labours.            381
except when the waters are recently drained off, we can-
not accomplish  it;  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 necessary in any
of these cases.  It is  not the presence of that extremity
engaged  in the passage, which opposes 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 contraction of the uterus itself, the hard-
ness of its neck, and the little dilatation of its orifice, which
are the obstacles, if any are met with.   It is easy to con-
vince ourselves of this  truth,  if we consider the natural
size of the woman's pelvis,  the  extreme dilatation of
which the orifice  of the uterus is  susceptible, and  that
which it  undergoes in all labours; and especially by com-
paring 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 swelled 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 susceptible 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 passage, though preceded or accompanied by
an arm, or one of the inferior extremities, as in those la-
bours 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 pos-
sible to persuade sensible persons, that the arm could en- 
382            Preternatural Labours.
tirely 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 utems is
supple,  and its orifice well dilated, we introduce 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 pre-
sence of the arm has seemed to oppose the greatest ob-
stacles to the introduction of the hand, a sudden flooding
has  removed those obstacles, and  given an opportunity
of terminating, without  farther  trouble, a labour whose
difficulties began to be looked upon as beyond the salu-
tary 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 resistance, and dissipate the natu-
ral or spasmodic contraction of the whole body of that
viscus? And what is there in that which art cannot ope-
rate with less danger than Nature has sometimes done it
with accidentally?
   1087. The true indication in all these  cases consists
in procuring this suppleness in the fibres  of the uterus,
whenever they do not enjoy that favourable and even ne-
cessary disposition for delivery, before we attempt to turn
the child, whether the arm present or not  By accom-
plishing 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 tear-
ing off or amputating the arm of the unfortunate infant
 He will also be convinced that it  is not necessary to re-
 turn it into the utems, 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. 
Preternatural Labours.            383
cannot authorize us to practise it before delivery; because
if it be indispensable, it can be done much better after-
wards, than while  the child is enclosed  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 well dilated, we must introduce the
hand into it, according to  the rules laid down for each po-
sition 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 contracted on
the  body of the  child, it  must be  softened and  relaxed
by proper methods, such as bleeding at the  arm, baths,
&c.  And we ought never to  attempt to deliver, till we
 have satisfied  this first indication,  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 requires 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 mid- 
384
Preternatural Labours.
wifery*   Experience had not yet taught him how much
was to be hoped or feared from those repeated bleedings,
which he looked upon as the sheet anchor of the woman.f
   1091.  A state of spasm, or a strong contraction of the
uterus, are not the only causes which may hinder us from
passing the hand  into it, in order to turn a child whose1
arm is without.  Frequently we cannot do it, merely be'-
cause the orifice of the  uterus  is  but very little dilated,
at  the time that extremity comes  down, and  its  edge is
still too thick and rigid to permit it to open farther, with-
out great inconveniences; because the membranes have
burst prematurely, and  the pains have not yet had time

  * M. Alphonse le Roy, Journal de Medicine du  mois de Mars,
1774.  This was the first yea* that he began to practise and teach
the art of Midwifery.
  t I cannot pretend to determine how frequently Le Roy has ad-
vised 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 inef-
fectual, if not sometimes mischievous.  If any benefit is to be de-
rived from bleeding, it must be performed quickly and extensively;
by quickly, I mean, a large quantity drawn in a  short  space of
time; for  this purpose, a large vein and a large orifice are neces-
sary; by extensive bleeding, I wish to be understood, until the pa-
tient become sick or faint, or at least until the uterus is sufficiently
relaxed.   This happy disposition  of the uterus is  sometimes  ob-
tained in a few minutes by a large bleeding, as I have demonstrated
to my pupils in several instances. I  have obliged  one of them to
introduce a finger into a rigid os uteri, while 1 drew blood from
the arm, and my rule for stopping was syncope, an approach to it,
or  until I was  informed by the person touching, that the uterus
was sufficiently dilated.—W. P. D. 
Preternatural Labours.
385
to procure the requisite dilatation.  All attempts to deli-
ver immediately would not be less dangerous in this case,
than when the uterus, fatigued by the length  of the la-
bour, or affected  by a spasm,  strongly opposes  the en-
trance of the hand.   They would only augment the diffi-
culties 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 de-
signed 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 case, 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 suppleness for  the requi-
site  dilatation, or till that dilatation  take place sponta-
neously, 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 produce the contrary effect.   If the resistance  of
the neck of the uterus does not yield to the natural ef-
forts of labour, bleeding at the  arm, baths, and emollient
injections may be of great use. . We  may give it the ne-
cessary time,  because the presence of the arm never  of
itself offers any very urgent indication.*

  * 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 uterus, after the
arm has come down; as they are very often tardy, and in sonic in-
stances never accomplish the object. I conceive it a duty to re-
lieve the woman as quickly as possible.  Inflammation very soon
conies on in these cases, more especially where the woman has
been  officiously touched: to act as quickly after the escape of the
                          3C 
386
Preternatural Labours.
   1092. From what I have said concerning labours in
which the child's hand is without, and the arm  engaged
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 ex-
tremity of the child, which of itself presents no essential
indication, except sometimes after delivery, when it hap-
pens  to be  tumefied, livid, or gangrened: 2. That  we
ought never to attempt to return it into the uterus when
the waters have been some time evacuated: 3. That its
reduction, 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 contrary to the
principles of the art to tear off or amputate 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 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  dangerous to attempt it
before the parts of the woman  are well prepared for it,
either by nature or art.

 waters, as the uterus will  allow, is not only desirable, but some-
times essential to the welfare of the child: therefore, as we have a
remedy at hand, namely, copious bleeding, I think it best to  em-
ploy it.  Should it not be immediately successful, which, by the by
will very rarely happen, it will, at least, very much hasten the de-
sired object.—W. P. D. 
Preternatural Labours.
387
   1093. It often happens in these cases, 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  sometimes places itself so in the pel-
vis, 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 butts against  some point  of the sides of that cavity,
and obstructs the descent of the trunk, or  else exposes
the humerus to be fractured.
   1094. To avoid  these inconveniences,  we must take
care to make this extremity descend in the same propor-
tion as the trunk.   Therefore,  if it disappear 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 however be more  certain and expe-
dient to apply a fillet on the child's wrist, before we search
for the feet,  as I have recommended long since, in a lit-
tle work published for midwives.  We may reap  a double
advantage  from this fillet;  1. That of fixing  the child's
arm lengthwise against one  of  the sides of the pelvis, in
order to prevent its folding in that canal, while we intro-
duce the hand into the uterus,  to search for the feet; 2.
That of preventing the inconveniences stated in the pre-
ceding paragraph.  If we 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 re-
member to do it as soon as the breech is engaged in the
passage. 
388
Preternatural Labours.
Labours in which the Child presents one of its Sides.  Of
    their Causes, Signs, Differences, and Indications.

   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 axilla"
of either side may rest on
the pubes, and the hip over
the sacrum; the  breast  to-
wards the  left iliac fossa,
when  the  right  side  pre-
sents,  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.
   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 presents, we
use the right hand;  if the left
"side, the left hand ; we seize the
feet  and finish the delivery  as
directed  in  par. 1064, for  the
first  presentation of shoulder.
  ^V hen the right side presents
we  use the left hand, and vice
versa;  we  grasp the  feet and
finish the labour as directed for
the second presentation of shoul-
der. See par. 1066.
  If the right side, right hand;
if the  left, the other; finish as
in a third presentation of shoul-
der.  See par. 1068.
   When the right side presents,
 the left hand must be used, and
^vice versa; finish as in a fourth
 presentation  of the shoulder.—
 See par. 1070. 
Preternatural Labours.             389
Labours in  which the Child presents one  of the Hips at
   the  Orifice  of the  Utems.   Of their  Causes, Signs,
   Differences, and Indications.

   1096. Cause. Obliquity of the uterus, or a superabun-
dance 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 sacrum; the
crista of the ilium  against
the pubes;  breast to the left
side  of the uterus,  when
right hip presents,  and vice
versa.
   2. Breech against pubes,"
crista of the  ilium to the
sacrum; breast towards the
right  side,  when  right hip
presents, and vice versa.
   3. Breech on the bottonfj   when right or left pregents>
 of right iliac fossa,  crista  we nrst endeavour to change the
 of  the  ilium  towards  the  position of the child by obliging
 left; the breast to the pos- J.the  woimm to^lie on the right
 terior  part of  the  uterus,
 when the right hip presents,
 and vice versa.             j
      Mode of Operating.
   Right hand when right hip pre-
sents,  and vice versa;  finish as
 directed for breech or feet.
   When right hip, we use the
>left hand, and vice versa; finish
 as above directed.
side.  If this does not succeed,
we introduce the left hand, and
finish as for feet or breech.
   4. Breech  on  left iliac"
fossa, crista of the ilium to-
 wards the right; breast un-
 der the anterior part of the
 uterus, when right hip pre-
 sents, and vice versa.
   We oblige the woman to lie
 on her left side; if this fails, we
'"use the right hand to bringdown
 the feet, and finish as for feet or
 breech presentations. 
390
Preternatural Labours.
      Labours of the Third Order, or Laborious.

   1097. Although the term laborious may seem to be
applicable  only to those labours which  are  exceedingly
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 diffi-
cult, less painful, and less dangerous than the greater part
of those which I have described under the name of pre-
ternatural,  and even than many of those which are usually
considered as  natural.
  1098. Though the impossibility, or the danger of ope-
rating with the hand alone, constitutes the distinguishing
character  of laborious labours; though  the  absolute or
relative necessity of employing some instruments to termi-
nate them, establishes a kind of relation among them,
yet they present us with very great differences, and their
species  are not less various than those of the two prece-
ding orders: those differences arise, as we shall see here-
after, 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 in-
struments;  from the parts of the mother, or of the child,
on which they must be applied; from  their mode of act-
ing, 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 method,  I think
it right  to treat first of the instruments necessary to be
employed  in them.  Some I  shall only mention; but I 
Preternatural Labours.
391
shall dwell on the description, and on the mode of acting
of the forceps, and the lever, as 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  general idea
of its form and mode of acting; it is besides in such com-
mon use, that I might dispense with any description of it.
It is  a species of pincers  or lever, composed of two
branches  perfectly similar;  except at the place of their
junction, where we remark, in one of tbem, a moveable
pivot, and in the other, an opening fit to receive it*
   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 fe-
male. •
   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 flat-
tish ridge,  which  might be effaced with advantage; for
though  it may give the instrument a little firmer hold on
the head, sometimes 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
  • It will be understood that I speak here only of the French for-
ceps, and particularly of those of M. Levret. 
392            Preternatural Labours.

(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  success.   Though some  have
brought them nearer perfection, 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 in-
strument,  that we might even look upon them as the au-
thors  of it Among the corrections they made in it,  none
is of more importance than the double curve which they
added to it: but  it would be difficult to  decide,  to which
of those two  equally celebrated men the art is most in-
debted in this respect.
   1104. The English forceps nevertheless differ a  good
deal from those of M. Levret.   Those of the latter ap-
pear  to me  more perfect, and have advantages 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 perfecting them in one re-
spect, we should render them more imperfect in another.
As it is  not the instrument 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 instru-
ments to correct them. 
                   Of the Forceps.                393

   1105.  Some have lengthened M. LevreVs forceps se-
veral  inches, and  others have effaced the ridge which
runs along the interior edge of their blades; others have
increased the new curve;  while some,  by altering  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 instru-
ment, without rendering it more recommendable.  If the
former have increased the advantages of the forceps,  by
making really useful 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 the rea-
sons which lead me to choose them so.   Experience has
convinced me,  notwithstanding the vain clamours of igno-
rance, that they have no more inconveniences,  in skilful
hands, than  the shorter forceps, and  that there are re-
sources in them, in many cases, which cannot be obtain-
ed from  the latter.
   1107.  The forceps may be considered as the most use-
ful of all surgical instruments, for no other has,  like that,
the advantage of preserving the lives of several  indivi-
 duals at once,  without hurting either of them; but on
 that very account, perhaps, no other  instrument will  ap-
 pear more fruitful in  inconveniences.  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

   * By the new curve of the forceps, we are  to understand that
 which is placed on their edges: so M. Levret explains it.  The ad -
 dition in length is not my invention; we are indebted to M. Pean 
394                Of the Forceps.
they have destroyed more than they have saved from ine-
vitable death,  I  should nevertheless look upon them as
the most important discovery that has ever been made in
the art of midwifery.   Those who regard them as an in-
strument absolutely dangerous, and entirely useless, nei-
ther know  their mode of acting, nor the difficulties of the
art,  and have doubtless judged them  according to the
abuse which they themselves have made  of them; and
have forgot that the most  salutary instrument often be-
comes murderous  in the hands of ignorance and preju-
dice.
   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 applica-
tion is subject to certain rules, and it is on  the strict ob-
servation of those rules, that the advantages to be expect-
ed  from them depend.  When applied without method,
or principles, far from  obtaining the  good expected  from
them, they sometimes only  serve to perpetuate the obsta-
cles, and even to augment them in proportion to the ef-
forts 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 ex-
tract 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 be-
come a  little  more general.  Besides  that practitioners
have recommended 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 
                   Of the Forceps.               395

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 re-
sources 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, reduces them transversely to the
breadth of an inch and a half, or two inches, if we grasp
them sufficiently 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, strongly
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.
   1111. Even the death of the child, if we could be cer-
tain of it when the breech is strongly wedged in the pas-
sage,  though it would destroy the apprehensions of dan-
ger from the pressure, ought not however to determine
us in favour of the forceps;  because there are other me-
thods 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 alterations sug-
gested in par. 1101.
   1112. The forceps then ought never to be applied but
with a view to extract  the  head; and their advantages
and inconveniences are proportionate to the relation which 
396                Of the Forceps.

exists between the dimensions of that part,  and those of
the pelvis.  When that relation is in the natural order,
the forceps, well directed,  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 consi-
derable 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 cra-
nium  suffers  no diminution,  and  that the brain is but
slightly affected by them.   Such advantages would ren-
der the forceps much more recommendable still than they
are; but these are very far from being their real effects.
We cannot, by compressing  the head in one  direction,
oblige it to lengthen  in another; or if we do, it is so lit-
tle, that it cannot balance what it loses in the  first di-
rection.  If the forceps compress it  four lines only, 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 species of  locking  for
which this instrument has been particularly recommend-
ed.   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 protuberance 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 
Of the Forceps.
397
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 instrument
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 cra-
nium, it is only by depressing  the parietal bones, by flat-
tening them, and  much more by making them ride one
over the other at their superior edges: which cannot hap-
pen without contracting the cavity which contains the
brain, compressing it, and more or less  deranging its or-
ganization.
   1115. We must not argue concerning the effects of the
forceps from those which we see the head sometimes suf-
fer in passing naturally through a narrow 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 different from  that of the forceps, and
the powers of art being never so gradual, nor so well com-
bined as those of Nature.
   1116. The head pushed forward for hours  together by
the natural agents of delivery,  becomes insensibly  softer
and more pliable, and at length acquires 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 
 398                Of lite Forceps.

 by it  1 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  comprehending  the  tumour
 formed in the scalp, before the posterior fontanelle.  The
 heads of several of these children were above six inches
 and a half,  and even seven inches long, from the chin to
 the top of the aforesaid tumour; while the thickness from
 one parietal protuberance to the other was but two inches
 and a half, or two and three quarters in some, and three
 inches in others.*  In a few hours after birth, the heads
 of these children spontaneously recovered the thickness
 which they  had lost in delivery, 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 attending
 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 cra-
 nium 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 stdures;

   * M. Solayres informed us one day in his lectures, that he had
 taken a child  the evening before, whose head, at the moment of
 birth, was eight inches long all but two lines, measured between
 the two points indicated  above; while it had preserved but two
 inches five or six lines in thickness.  The day after, this head had
recovered the usual dimensions. 
                    Of the Forceps.               399

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 sur-
face.  The fate of these children therefore will be differ-
ent, 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 similar to those
I  have just stated in par.  1115,  and not from the effects
of the forceps themselves.  They estimate the degree  of
compression which the head suffers between the blades  of
the instrument, by the degree of force which they apply
to extract  it;  by the separation of the external extremi-
ties  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 fortunate
case, which they produce in  support of their assertions,
they perhaps pass over ten in silence,  which, though un-
fortunate, might have instructed us equally.  The follow-
ing  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 chil-
dren, who died immediately,  or a few hours after their
birth; and were of different sizes, though all at full time.
To render them  more conclusive,  we took care to re- 
400                Of the Forceps.

store 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 lengthened forceps mentioned in par.  1105.
We provided three  pair,  all alike, of the best  construc-
tion and temper.   We applied them on  the transverse
thickness of the head, as  I recommend them to be always
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 riband, that the  reduction
of the head might not vary, while we measured its dimen-
sions anew, in order to compare them with what they were
before the experiment  It cannot be objected 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 extremities opposite to those same blades; and because
the force which we  used,  sometimes with the hands alone,
and sometimes with the riband 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 re-
sult of our experiments.
  1120.  The head of the first  child,  which  was three 
                    Of the Forceps.                401

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  occiput,  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 supe-
riorly 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  forceps,
then separated an  inch and three  quarters, could not be
brought nearer than the distance of six lines notwith-
standing all the force we  could use.  At that degree of
compression the sagittal  suture opened, 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,  which
was four inches, did not vary.  Taken in  the latter di-
rection,  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 after-
wards five in its length.  These three heads acquired no
increase in length,  while  they were compressed  trans-
versely;  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
                          3E 
402                 Of the Forceps.

preceding, and  having the sutures and fontaneUes 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 thickness 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 a half, and did not lengthen
in any direction.  Pressed from the forehead to the occi-
put,  it lost eight lines, and its thickness was increased
one line.   In this degree  of reduction, the region of the
anterior fontanelle became very salient, and an opening
of six lines made with a history instantly discharged a por-
tion of the brain as large as a hen's egg.
   1126. A seventh head, three inches and a quarter thick,
could not be compressed more than three lines:  and an
eighth, of three inches eight lines, could be reduced only
three lines and a 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

   * It may not perhaps be unimportant  to observe that we took
the dimensions of all these heads with a pair of  callipers, before
the experiment; and that we marked the points with ink, on which
the branches of them were placed, that we might measure them
again  between those same points, when in the greatest degree of
reduction. 
                   Of the Forceps.              403

less solidity at the time of birth,  and as the sutures, as
well as the fontaneUes, 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 with-
out great difficulty, go beyond four or five lines when the
instrument acts  on the sides of the head; 3. That we
ought  never  to estimate  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 diame-
ter, 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 volumi-
nous than those of  the children I have just mentioned,
which we  took  at random  from among  many others,
would suffer a greater reduction than we procured in our
experiments, if we employ  force  enough  to bring the
handles of the forceps,  which are then farther separated,
close together. The reduction certainly would  be greater,
if the head, at  the  same time that  it were larger, were
also softer; but by being greater, it would only become
so much the more dangerous for a child; since it cannot
take place in any circumstance,  without diminishing the
capacity 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 compression,  unless
the child be hydrocephalic.   A head of four  inches two
lines from  one  parietal protuberance to the other, (there
rue very few of that size at the time of birth,) could not 
404                Of the Forceps.

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 extremi-
ties.
   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 engaged 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 take  hold 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 ef-
fect on the forceps, as the ring on the handles of the pin-
cers, and  would approximate the blades, if the diameter
of the  head, already compressed, should still surpass that
of the pelvis, and if a sufficient force be used to bring it
through that canal.   But as the pressure which the in-
strument then makes  on the parts of the woman, inter-
posed  between the  back of  the  blades and the bones of
the pelvis, is equal to that which the  child's head itself
suffers, what disagreeable consequences may we not ex-
pect 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
recommendable.
   1130. If  it seems impossible to determine the degree
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 
                   Of the Forceps.               405

they are made to undergo,  because the reduction is su-
bordinate, as I have already stated, to the solidity of the
bones of the cranium, to the state of the sutures and fon-
taneUes,  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
different, according to those  same circumstances, and to
many others which may arise from the duration of the ef-
forts to which it has been exposed before the application
of the instrument. This however appears certain, that a re-
duction of a given extent, when made naturally, is attend-
ed with much fewer bad consequences, than a similar re-
duction  made with the  forceps;  because  it  is brought
about by infinite 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 reduc-
tion 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
 reduction of the head must be carried to that degree,  to
 kill the child, we should never have  a right to attribute
 its death to the forceps; for there  are none which can re-
 duce it so much.   And supposing that there were,  they
 could not be prescribed while the child is living; the in- 
406                Of the Forceps.

tention 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 after 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 graduated 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 separation
and approximation of them, and not the reduction 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 ex-
periments, with what I have observed  in the 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 handles 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 determine how much farther it can be car-
ried, without causing its death.
   1134.  These reflections will appear of the utmost im-
portance to those who have declared openly against the use
of the forceps, and think it their  duty to proscribe them,
under the vain pretence of defending the cause of hu-
manity:  for, according to their principles, the forceps ne-
cessarily adding the thickness of  their two blades, which
is three lines,  to the thickness of the head, we must  have 
                   Of the Forceps.                407

a reduction of three lines  to  compensate that addition.
Therefore that reduction, 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 relatively to the
diameter of the  pelvis.  This reasoning would be unan-
swerable, if we could compress the head but three lines,
if the greatest thickness of the blades answered exactly to
the parietal protuberances,  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 dia-
meter of the pelvis.  But  things go on in a very differ-
ent  manner from what the  detractors of the forceps 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 most
methodical manner, are not without inconvenience 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, for-
getting the axiom, sat citd si sat bene, imagine that their
honour and their success depend on the celerity with which
they operate: for instead of one victim, they often  destroy
two; the forceps, directed upon such principles, being 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 required to
assist or supply the strength of the mother; as well as when
we  are led to use them only on account of  certain acci-
dents, which sometimes complicate the labour, such  as an
haemorrhage, &c.   But we are not always so fortunatr 
408                Of the Forceps.
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.  Con-
sidering  that instrument only as a resource  for termina-
ting the delivery, and abstracting 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 means of pulling at
the child's head, and by that means seconding the expul-
sive efforts of the mother.
   1138.  Most authors have not 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  particularly 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 forceps.  Smellie not only knew the
possibility of carrying them so far,  but  also that it was
easier  to apply them there,  than when  the head is en-
gaged  transversely in  the superior  strait, and  its sides
strongly wedged between the pubes and sacrum; since in 
                    Of the Forceps.                409

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 estimate
the advantages and inconveniences of taking hold of the
head above the pelvis, with his new forceps.  Having ob-
served that the latter were often greater than the former,
he resolved not to advise it publicly,  and not to demon-
strate, even to his disciples, 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 curved forceps, doubtless
had not read the works of Smellie, which  are anterior
to what that author has transmitted us on the art of Mid-
wifery: he might there have seen, not  only what I  have
just related, but moreover, that a Mr. Puddicombe, as far
back as the year 1743, had successfully delivered a child
with the forceps, whose  head was still above the superior
strait.   Besides, the fact related by Roederer  cannot be
attributed to him:* we see clearly in the observation itself,
that he is only the editor of it.
   1141. If Mr. de Leurie is the first French accoucheur
who has carried the forceps  so far, as he declares,! 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

   * Opuscula Medica Gottingse,  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.
   \ M. Solayres  professed midwifery at Paris from 1769 to  1771
inclusively.
                          3F 
410                Of the Forceps.

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 similar
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. Coutoidy,  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 retained after the exit of  the body, as
we sometimes see it in labours where the child is extract-
ed 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  latter
case;  and that author is so much esteemed among us, that
I am  inclined to think it was from forgetfulness, and not
with a design to detract from his merit,  that one of our
countrymen  has published 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.f

  ' M. de Leurie.
  t We would earnestly recommend this chapter  to the serious
study  of the student or young practitioner, as it is in itself  almost
a complete treatise upon these valuable, but too often abused in-
struments.
  Caprice, or the  desire of notoriety, has altered the forceps into
a great variety of strange, and even untoward forms—we  cannot
approve fully of any of these innovations; for if any thing is  gained
on the one hand by the change, it is sure to be lost upon the other. 
                      Of the Forceps.                  411

We  therefore from long experience unhesitatingly declare in fa-
vour of the long French forceps, and for these plain reasons; first,
because they can be advantageously used where the short, or Eng-
lish forceps cannot; and  secondly,  because, there is no situation
of the head in which the English forceps  can be employed, that
cannot with as much certainty be relieved by the French.
                                                     W. P. D. 
PART  IV.
Of the Causes which make the use of Instruments neces-
  sary in the Practice of Midwifery,  particularly the
  Forceps and Lever.

  1143.  Among the causes which ought to determine 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 haemorrhage,
convulsions of the mother, frequent  syncopes,  exhaust-
ment, 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 habi-
tual spitting of blood, the descent of the uterus and an in-
version of the vagina: lastly, the premature issue of the
umbilical cord, and often the presence of a second child,
which by its position considerably retards, or hinders 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 preferably to others.  When
they attack with violence at the beginning of labour, and
continue with the same force, leaving no resource but in
the extraction 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 
Of the Causes, 6fC.             413
and the application of the forceps, though more difficult,
if we thought the success more certain than that of turn-
ing, which in this case generally requires more knowledge
and  dexterity.   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 pre-
ference.  That instrument is indicated exclusively when
one or more of the above mentioned causes do not occur
till the head arrives at the bottom 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 death ;f
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 affections, 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 been
already treated of  in so  many particular sections,| and  as
the  others cannot be explained more seasonably, than
when I lay down the method of operating in each of them,
I shall confine myself here to the locked head, and the dis-

  * See par. 958, and following.
  t See the article which treats of the signs of the child's death.
  % See from par. 786, to par. 826 inclusively. 
414             Of the Lacked Head.
tinction 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, with-
" out  a possibility of being forced farther down by the ef-
" forts of Nature alone, or of being  pushed back with
"the  hand; for if one or the other be possible, it is  not
"permanently 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 themselves, by
employing the words locked head indiscriminately to  sig-
nify the  state in question  and that 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.

  : Suite des Observations sur la Cause de plusieurs Accouchemens
Kaborieux, part. ii. p. 266. 
                Of the Locked Head.             415

   1150.  Some authors have distinguished two general
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 diame-
trically opposite, whether  against the pubes and sacmm,
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 species; for, by the confession even of those
who admit 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 con-
tact with the pelvis every  where."*  The  opinion of
Roederer on this subject is however very different   " In
the complete paragomphosis," says he, " the child's head
" is so jambed on all sides in the  pelvis, that we should
" not be able to pass the smallest  needle between themA
" 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 sur-
face diametrically opposite.  But this  species 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 contact with the  interior  circle of the pelvis; in the
second, the parietal protuberances.   This latter species
is much more  rare than the former,  and  cannot happen
but in a pelvis so narrow  as to  have but three  inches and

   * Elemens sur I'Art des Accouchemens, edit. iii. Aph. 617.
   f Roederer, §431. 
116             Of the Locked Head.
 a few lines  in its smallest  diameter, unless 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 re-
 gions,  or even the face.  It is not very easy to conceive
 how the head can be locked in  these latter cases, espe-
 cially according to the definition which those same accou-
 cheurs 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 so, although they were
 very moveable in the pelvis, even when the  vertex  pre-
 sented.
   1153. The sentiment of M. Levret on the mechanism
 of locking,  and the circumstance in which that accident
 most frequently happens, does not appear to me to be
 conformable to  those  extensive  views which he  dis-
plays  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 opposite the middle of  the projection
" which results from  the union  of the body of the last
 c lumbar vertebra and the sacrum, that projection  may 
                 Of the Locked Head.            417

vk lodge  in the bregma,  by depressing it at each contrac-
" tion of the uterus; which will hinder the head from turn-
'• ing in the second period, for the forehead to place it-
" self on one side; it will fix itself 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 shoul-
" ders will rest on the superior branches of the ossa pubis,
"hanging over them more  or less; and if the head re-
" main long in that state, it will be locked."*   How is it
possible the head should be locked in  this case? It can-
not 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 posi-
tion, or any other:  this is the best possible position, con-
sidered  in the latter period of labour, and that which we
ought to place the head in, when the efforts of Nature do
not direct it so.   See what  I have already said on  the
mechanism of the different species of natural labour.
   1154. If the head  in the  case described above, some-
times stops  and remains in the lower part of the pelvis,
after having followed the  course indicated by  M. Levret,
whether it be retained there by the situation of the shoul-
ders over  the ossa pubis, or by any other cause, it cannot
be locked there.   To be really locked, the head must fol-

  * Observation sur les Accouchemens Laborieux, part ii. edit.
4m". page 277.
                         3 G 
418
Of the Locked Head.
low a very different course at the beginning of labour:
for it cannot be fixed with  its greatest length between
the sacmm and pubes, unless the occiput rest behind the
latter superiorly, and remain there in some measure im-
movable, while the forehead is forced to descend poste-
riorly opposite the sacro-vertebral angle.   By following
this course,  it is the largest diameter of the head which
tends to advance foremost;  it is the  anterior fontanelle
which presents more and more, in proportion as the head
advances; it is on this fontanelle that the teguments swell
and puff up; and it is  this same  point which constitutes
the summit  of the conical figure acquired by the head
when locked in the pelvis, instead of being sunk and de-
pressed by the projection of the sacmm, as  asserted by
M. Levret.
   1155. The head may also be locked or jambed length-
wise 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 horizontally between those two bones: which cannot
happen without 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, al-
though  the pelvis was  of the usual size.   Five children,
each more voluminous than that, had already passed it with-
out difficulty;  because their heads had presented differ-
ently, and the uterine forces were then differently direct-
ed.   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
follows the course stated by M. Levret, far from offering 
                 Of the Locked Head.            419

its greatest diameter foremost between the pubes and sa-
cmm, it only places its height there, considered 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-acquires
the form of a wedge more or less lengthened, whose base
remains above  the part where it stops; as de la Motte
has very clearly expressed it, by comparing 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.  The head cannot be locked without the concur-
rence of several causes, of which some are predisposing,
and others determining or efficient  The latter depend
on the action of the uterus,  and the other powers which
contribute to the expulsion of the fostus:  but that action
must  be vehement and continue  a long time: we need
never fear it in a delicate and exhausted womau, whatever
causes exist which might otherwise occasion it.
   1158. The causes  which  we call predisposing  arise
from both mother and child, and generally consist in a
defect of proportion between the dimensions of the pelvis
and of the head which must pass it.   This defect of pro-
portion sometimes depends  only on the  bad  position of 
420
Causes, fyc.
the head; at other times on its extraordinary size and so-
lidity, or on the deformity of the pelvis.   It is so difficult
to discover and estimate  by  the touch, not only the de-
gree 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 begin-
ning of labour, without fear of mistaking, whether the
head  will be locked, or  whether it will only meet with
more or less difficulty in traversing 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 tume-
faction 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 inseparable from it.
   1160.  These effects always precede the head's being
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
WTe  frequently observe those symptoms, but the head is
very seldom really  locked.
   1161.  It  is  not  necessary that the head should ad-
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 engorged and inflamed; it is sufficient that 
Of the Locked Head.             421
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 pro-
portion  between the diameters of the superior strait, de-
formed  in the highest degree, 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 remains en-
tirely above the pelvis; which  I have observed as well
as they.  I have moreover seen gangrenous 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 sometimes 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, not very thick, and the swelling of the
teguments  of the cranium is limited to the same height.
Much  oftener still,  the tumefaction  in question  depends
only on the resistance which the  external parts opposo 
422                  Causes, eye.

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 frequent and
inconsiderate touching, either of an accoucheur or mid-
wife? 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 cha-
racterize the locked head, since some of them may be fo-
reign to labour  and pregnancy; but we should not al-
ways be founded in supposing a head to be locked w&ch
has ceased to advance after descending  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 following.   I could quote a great number  of facts
in support  of all these assertions; and in many of them
trfe finger methodically placed, and a different  position
on the part of the woman, have  happily terminated la-
bours, that could not have been finished with the forceps.
  1164.  The  head is not  really locked but when it can-
not make any of these movements: when  no instrument
whatever can pass over more than about a quarter of its
circumference, any more  than  that of the inside of the
pelvis,  nor penetrate  the  places where  those parts are
in contact.
  1165.  It would be very advantageous  if we could dis-
tinguish the cases in which the child's head must  be lock-
ed, from those in which it is only threatened, that is to 
                 Of the Locked Head,             423

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 Na-
ture, and in the other, deliver before  the accident takes
place.   But it is almost always impossible  to make that
distinction, because the  same symptoms which precede
the locking, 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  tegu-
ments  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 ad-
vances 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 pel-
vis.  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 contrary larger than com-
mon, or at least  as large,  as well as  the inferior  strait,
when the head descends  rapidly at the latter end  of la-
bour.   In  the former case, the head suffers a more con-
siderable friction as it advances  farther, till  it be entirely
fixed:  which  increases the  force and  intensity  of the
symptoms  stated  above.   In  the latter case, it undergoes
those 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 
\24
Causes, 6cc.
it then finds itself in a larger space, and is no longer com-
pressed, because the bones of the cranium recover their
former state, and the circulation  intercepted in some of
the veins of the teguments and of the apoiwurotic cover-
ing of the head is restored.
   1168.  We should then be obliged to leave almost en-
tirely to time to distinguish the head which will be lock-
ed, from that which,  after threatening it, shall be deliver-
ed 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 cases 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 salva-
tion of both mother and child often depends on an in-
stant, 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 remedies,
may be as pernicious to  both, as  too  precipitate and ill
directed manoeuvres.
   1169.  The locking of the head is  always very perni-
cious to both mother and child: it cannot exist long with-
out 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 often fractures of the bones of
the cranium,  deep engorgements, extravasations  in the
ventricles of the brain, under the dura mater, between
that and the bones, under the pericranium itself detach-
ed from the parietalia, &c. as well as profound ecchymo-
ses between the sub-occipital muscles,  are effects which 
                 Of the Locked Head.             425

I have observed in many children after  their heads had
been locked.
   1171. The head cannot be locked without strongly
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
swelling and inflammation of the parts situated  under-
neath,  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 canal of the urethra is totally oblite-
rated.  The woman tormented  at the same time by the ne-
cessity of discharging it, and by the pains of labour which
perhaps she is solicited to make the most of, gives herself
up to inconsiderate efforts, till she is exhausted, or her pains
go off.   A fever comes on, the blood is heated,  and car-
ried impetuously towards the superior parts, where it
often produces new disorders, 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 ul-
cers, as well as  openings into the neck of the bladder
and the rectum;  and to  complete the misfortune, when
the woman survives, the urine and faeces fall continually
into  the vagina,  cover  the surface of those  ulcers, in-
crease  their putrefaction, and render them incurable, if
they were not so  in their own nature.
3 11 
426
Indications, fyc.
Indications in the Locked Head,  considered exclusively
    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 terminating the de-
livery  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 consequences of it present more pressing indi-
cations, 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 em-
ployed 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 in-
dication; but the method  of performing it must be vari-
ed 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 pre-
sent century, only used  them after  they had opened the
head more  methodically with  other  instruments,  and
emptied it.   Several, among the moderns, have proposed
fillets variously arranged, whicli have been very happily
forgotten since the invention and improvement of the for-
ceps.   If the former thought themselves reduced to the
deplorable necessity of  mutilating the child, the latter di-
rected all their endeavours to preserve it.
   1176. Mauriceau, whose work is still much esteemed,
thought it was  a necessary cruelty to kill the child when 
                 Of the Locked Head.             427

the head was locked, in order to save the mother, whose
death appeared to him not less inevitable if that method
were not taken;  and de la Mothe, more timid, waited till it
was deprived of life to open the head and extract it with
the crotchets.   The conduct  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 circumstance
do not always secure  the life  of the child, already lan-
guishing more or less, at  the time we use them, it must
at least be confessed that a great number have  been  in-
debted  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 judg-
ment, it adds enough nevertheless  to justify us upon some
occasions, in preferring  the  crotchets  and other instru-
ments destined  to open the head,  if we could have cer-
tain 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  ad-
 vantages, though some accoucheurs still give it the pre-
 ference.   It would be the  most proper instrument, if it
 could be insinuated into  the very parts where the points
 of contact are,  which essentially 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 of a narrower place into a larger.  The lever would
 be the most proper instrument to make it execute that 
428
Indications, §c.
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 Roe-
derer, in what  he  calls a paragomplwsis,  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 described  it.   The advantages
of the Cesarean operation, if any could be then allowed
it, would be much inferior to the section of  the pubes.
The circumstance in question is precisely that in which
that new operation 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  extracting
the locked  head with  the forceps, we ought to have re-
course 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 des-
troying  the  force of the points of contact which consti-
tute 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 ope- 
Of the Head, fyc.
429
rations, and of the instruments  to be made use of,  it is
necessary to show wherejn the locked head differs from
the head merely stopped in the passage.
Circumstances  in which the Head may stop in the Pas-
  sage without being locked, and the difference between
  those two States.

  1182.  Authors have used the word passage so vaguely,
and in such different circumstances, that it is not very
easy to decide  what they meant to express by  that term.
Have they 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
considered with respect to the pelvis alone, I only mean
the  inferior strait; and I acknowledge no head stopped
in the passage, but that which cannot pass it, notwithstand-
ing the most powerful efforts of Nature.
  1183.  Divers causes may stop  the head at that place,
and every one of them presents different indications. The
head  may stop in the passage, 1.  Whenever it  preserves
the transverse  or  diagonal position, 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. 
430
Of the Head
it may find the same obstacle to its exit, whatever may be
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 accoucheurs, the short-
ness of the umbilical cord, and its being twisted  round
the neck of the child when it is very long,  may also re-
tain 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 following.
   1184.  The head which is merely stopped in the pas-
sage differs from that which is really locked, in not being
absolutely immoveable as  that is.   In general, we  might
push  it  back with  a  view of searching 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 supe-
rior strait, more or less contracted, without extreme diffi-
culty.  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 immoveable in this case, as in
that where it is really locked; if it advances a little du-
ring 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 circum-
stance, we must suppose  the straits of the pelvis of a cer-
tain given size, under the natural dimensions of the
head,  while the excavation is respectively larger: which
often  happens when the sacrum is deformed by too great 
               Stopped in tlus Passage.            431

a curve.   I shall fix the distance at three inches and a
few lines from the pubes  to the sacmm  superiorly, and
to the bottom of the first piece of the coccyx inferiorly.
   1186.  Proceeding on this  supposition, which is not
begged, since we find many pelves similar to that supposed,
the head, the transverse thickness of which is commonly
three inches and a half, taken between the parietal pro-
tuberances, cannot clear the superior strait,  but by dimi-
nishing several lines in that direction; 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 diame-
ter 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 tumefaction 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
 happens 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 excavation of
 the pelvis, and is no longer compressed at the sides, as at
 first.  This restitution of the transverse 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 sacmm,  the coccyx and perinaeum, tends to dimi-
 nish its height,  to curve the  parietal  bones, throw their
 protubeiances outwards,  and lastly, augment the breadth
 of the cranium in that direction.
    1188.  Unless the efforts of  the woman continue yet a 
432
Of the Head
 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 attempt 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 capable
 of stopping the head in the passage  presents a different
 indication; this is  the time  to demonstrate that  truth.
 When the obstacle which prevents  the  head  from en-
 gaging 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 sacmm.
 When the head engages in  such a  manner that  the supe-
rior part of the forehead  presents at the centre of the in-
ferior strait, we must push back this part to bring  down 
                Stopped in the Passage.            433

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 pas-
sage by a  defect in the dimensions of the inferior strait,
except that defect  be excessive; for then it will require
other methods*  While on the contrary, it will suffice,
to relax and mollify the external soft parts, when they op-
pose a resistance superior 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 recommended 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 contracted at its  entrance,
 but its other parts well formed,  that is to say,  of a good
 breadth  at the inferior strait;  2.  That the head  when  in

    * Crotchets, if the child be dead; and the Cesarean operation, if
 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 mentioned in par. 1185
 and following, and which have given occasion  to the note on par.
  1179, because it is very different from them.  When the inferior
 strait is so much contracted, the superior is very wide, and the head
  may easily be pushed back.
    t M. Levret, Suite des Observations sur la Cause & des Acci-
  dens de plusieurs Accouchemens Laborieux, 4°»e. edit, page 4, Ob-
  serv. ii.
                            31 
434
Of the Head
the excavation should be free  and not wedged; 3. That
the external  parts should not  appear to hinder its  exit,
and, that the expulsive 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
situation of the shoulders, and their relation to the supe-
rior 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 ob-
stacle which then exposed  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 farther 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 ex-
tract it, since the shoulders could not follow. J  If we at-
tend 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  that the opinion of M. Levret  is not so well

   * 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 fontanelle
 which presents here at the bottom  of the pelvis, and not the top of
 the forehead.
   t See par. 950 and following.
   i Levret, in the part already quoted in par. 1190. 
                Stopped in the Passage.           435

founded as it appears at first sight, and thatwe may ex-
tract the head  though the shoulders  should  not engage
a single line.   To place this truth in  a  clear  light, let 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;  this is a fact which no  one can  doubt of;  and its
length, which exceeds that of the symphysis of the latter,
permits us to disengage it entirely  by  raising it up before
the  mons veiwris, as  it disengages in a common  labour.
As the length of the neck posteriorly  is  then nearly equi-
valent to  that of the  symphysis of 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 sacrum; 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  extrac-
tion of the head is therefore possible in cases where the
shoulders, fixed over the superior strait, render its expul-
sion 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 easily and
 advantageously than could have been  done  before; be-
 cause there will then be more room in  the pelvis.   That
 is the method which I have several times followed in cases
 of this kind;  and which I shall repeat, if I meet with any
 more of them. 
436
General Rules
    General Rides concerning the Use of the Forceps.

   1193. Among the rules to be observed in  the use of
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 project a little be-
yond 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. The 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 practitioner.
We must take care; 1. To warm the instrument a  little,
to separate  its branches, and anoint them with butter or
pomatum;  2. To insinuate them separately,  and in a dif-
ferent 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 exceptions
to this rule, they are very few in number, and I shall point
them out in the sequel.  Sometimes it is best to introduce

  * 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 examine them, since we cannot use them without her
perceiving it.  I have never used them without in a manner re
ceiving them from the hands of the woman herself. 
              for applying the Forceps.           437

the male branch first, that is to say, that which has the
pivot; and at other times the female branch.  I have ob-
served 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  pore certainly
to the  proper place, and under the edge of the orifice
of the  uterus.  There are very few cases where it is ne-
cessary to introduce  the  whole  hand into the vagina to
guide them thus, even if there were space enough to ad-
mit it.
   1198. We ought  never to apply the forceps till the
edge of the orifice be soft and well dilated, or easily sus-
ceptible of farther dilatation.  The external parts require
the same attention  and  care.  I  cannot conceive  any
case where we ought to have recourse to them before
all those parts are in a proper disposition for their ap-
plication.
   1199. We ought  never to push the blades  of the in-
strument forcibly in  order  to carry them to the  requi-
site height  As the obstacles which oppose their pro-
gression generally depend only on some  folds of the tegu-
ments of the cranium, or of the parts of the mother, we
almost always surmount them  easily, by varying the di-
rection 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 much force against the head,
or against the side of the pelvis, so that  the curves  of the
instrument are not exactly adapted to those of the pelvis
and head.    We surmount also these difficulties, by chang-
ing the direction which we had hitherto  given the instru-
ment: either by raising or lowering the  extremity which 
438    , •          General Rules

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 operator.
   1200.  When the  child's head has already cleared the
orifice of 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 extremities  applied as close as  possible to
the head; in order that they may of themselves pass with-
in 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 instru-
ment farther up by applying more force.
   1201. In all cases, we  ought  to contrive  that the head
should be  grasped, as much as possible,  according 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 cannot then clear that cavity without
 diminishing in size, at least in one direction,  and with- 
for applying the Forceps.           439
out our employing a great deal of force to extract it.  It
is often necessary in this last case, to bring the handles
of the forceps close together, and fix them in that state
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 ex-
tract  it without  expecting any thing from 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 take a course relative to its position, as
I have laid it down from  actual observation, in treating
of the mechanism of the different species of natural la-
bour; that is to  say, that we must make it' present  only
its  smallest diameters to  the  small  ones of the pelvis.
See par. 483, and following, to par. 545 inclusively.
   1205. We ought never to pull the forceps in a right
line,  because that  would  make the head  descend  with
more difficulty;  as  the celebrated author of that instru-
ment has  already observed.  But we ought  also to set
bounds to the  rototary motions which  that accoucheur
recommends with a view of unwrinkling the vagina.  It
is sufficient to  carry the external extremity of the for-
ceps  a  little towards each of the woman's thighs alter-
nately, at the same time  that we  pull towards  us.  We
must be equally attentive  to raise this  same extremity
insensibly towards the belly of the woman, in proportion
as the head engages in the inferior strait and the vulva.
At this last period, we ought to hold the instrument with
one hand, and apply the  other against the perinosum to 
440          Application of the Forceps.

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 the child  have  cleared  the
opening of the vulva.
   1206.  The application of  the  forceps  requiring  in
general fewer precepts, and presenting less difficulty, 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 cavity of the pelvis;  in
order to proceed from the simple to the more complex;
and describe the  different 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 that in
  which  the  Occiput is against the latter, and the Fore-
  head 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 for-
ceps,  than that in which  the occiput answers to the arch
of the pubes, and the forehead to the middle of the sa-
crum.  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 every thing properly prepared,
we insinuate the male branch of the forceps, towards the 
              Application of the Forceps.          441

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 they can reach it, or if not, as high as pos-
sible on the child's head.  With the other hand, holding
the male branch of the  instrument by its middle, nearly
as we hold  a pen, we present  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
withdraw 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 some-
where 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 pulling 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
                          3K 
442           Application of the Forceps.

a little, according to the particular direction of the pelvis
of 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 ques-
tion the external extremity ought to be elevated so that
the portion of the instrument 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 se-
cond.
   1211. We slide  up this last with the same precautions,
but holding  it with the right hand, and so that the ex-
tremity of its handle be at first inclined over  the left
groin.  Two fingers of the other hand, or one  only, in-
troduced into the vagina, between the head and the right
side  of the pelvis,  must guide the blade in  its  progres-
sion.   In  proportion as it penetrates, 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.
    1212.  We then take  hold  of the forceps with both
 hands; that is to  say, with the left placed  beyond the
junction  of  its  branches,  near the pubes of  the wo-
 man, and the right at its  extremity,  as  is seen in the
 eighth plate.  We then pull towards us, carrying the ex-
 tremity 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. 
              Application of the Forceps.           443

We likewise raise the end of the instrument insensibly
toward the woman's belly, in proportion as the head en-
gages in the inferior strait, as I have  already observed.
When it is advanced so far as to distend the perinosum,
we must support that with one hand, and  pull the • in-
strument only with the other; but acting very slowly,  to
give the external parts time to unfold, and dilate more
gradually.  By proceeding thus, we make the head de-
scribe 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 con-
cealed 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 follow-
ing, that this position was, coeteris paribus, much less fa-
vourable for the exit of the head than the preceding, and
that some women  experience so much difficulty in de-
livering  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 ex-
clusively of all other  causes, ought  not to determine us
to recur to that method in  most women,  at least it be-
comes 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 Sym-
  physis; and  in  that where the Forehead 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 po-
sitions, 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, notwithstand-
ing the  violent  efforts which  tend to expel it, if we can-
not make it describe that movement with  the finger, we
must  have  recourse 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  established
concerning the use of the forceps be recollected,  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 right foramen 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 in-
clined towards  the right groin than in  the preceding po-
sitions.   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 incline  it in the same pro-
portion 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 other-
wise, 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 for-
warder, 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 in-
clined 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 instrument 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 forceps, making their extremity describe an arch

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

whose convexity would 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  obstacles 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 mo-
tion,  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 absolutely 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 several of those women, I have seen
the head come forth, after a very  long labour, in a diago-
nal situation 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, flat, and destitute of
that curve which gives  the middle 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  junc-
tion, and the forehead to the left acetabulum, it is not be-
cause it is the most frequent of all the diagonal positions

  ' We ought to attend to this circumstance in all other diagonal
positions of the head, when we find any difficulty in making it turn
on its axis. 
              Application of the Forceps.          447

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 relation between the dimensions of
the head and those of the 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 ob-
lique 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 endeavour
to turn the child's face towards the  sacmm; because it
could not arrive at it without passing over a good third of
the internal circumference of the pelvis;  and that move-
 ment could  not  be  executed 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 ex-
  actly 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/oraraen ovale, we must insinuate the
male branch obliquely behind the left foramen ovale, hold-
ing  it with the left hand, and directing it with  some of 
 448          Application of the Forceps.

 the fingers of the right introduced towards that part.  In
 proportion as it  penetrates, we lower its external extre-
 mity, 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-ischia-
 tic ligament of the  mother, directing 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 sacmm  a little, and observing to lower the ex-
 ternal 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 ori-
 ginally in the first position.  See par. 1212.
   1223.  The relation  of the  dimensions of the head to
 those of the pelvis,  being absolutely the same in the posi-
 tion in which the forehead answers  to the right foramen
 ovale, and the occiput to the left ischiatic 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 inferior
strait, so as for one ear to answer exactly to the symphy-
sis of the pubes, and the other to the middle of the sa-
crum. And the  best method of applying the  forceps in
that case differs so  little from what I have recommended 
Application of the Forceps.          449
for the diagonal positions, that I might have confined my-
self 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 princi-
ples I have established,  we are to introduce the female
branch of the instrument directly under the puces, and the
other before the sacrum, in the first of these two cases; al-
ways  keeping their external 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 instru-
ment 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 di-
rected 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 directly  under the  pubes,
and the  female before the  sacrum;  with the precaution
of inclining the extremities 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 extre-
mity 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 occurred, where
I found it impossible  to apply them in this direction;  I therefore
changed the situation  of the head to  the diagonal, by using one of
the blades of the forceps as a lever; I then very easily applied the
instruments and extracted the head.  I would therefore  recom-
mend  this mode in preference to the other; to effect this  change
                          3L 
450           Application of the Forceps.


 Causes which ought  to determine us to use the Forceps,
   whihs 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 circum-
 stances, which complicate the labour, leave us no hopes
 of employing any method more gentle or more certain.
 Although the difficulties are less for those who have a
 rational  habit of using  the  instrument,  who  perfectly
 know its relations to the child's head and the pelvis of the
 mother, they are  nevertheless great enough to prevent
 our  preferring it to  other methods  sometimes equally
 practicable.   The accidents which require us to deliver,
 while the head is still far off,  are not sufficient to deter-
 mine 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 extract-
 ing it by the feet.
   1228. Although there are fewer accidents to  be feared
 in carrying  the  forceps  so far,  when  the pelvis is well
 formed,  than in  the  contrary state, since there is more
 space for applying them, and  the parts of  the woman, as

 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.—W. P. D. 
              Application of the Forceps.          451

well as the child's head, will not suffer so strong a pres-
sure 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 pro-
perly.   The extraction of the child by the feet then me-
rits 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 ad-
mitting the  use of that instrument than a good conforma-
tion.  In the latter case, we only reject it because it seems
preferable to turn the child,  and because its  application
requires an extent of knowledge which  the greater  part
of those who devote  themselves to the  practice of mid-
wifery 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 par-
ticularly 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 dia-
meters of the head in a proper relation to those of the
pelvis, and diminish, according to the necessity of the case,
that which is to pass in the direction of the smallest dia-
meters of the straits:  which I shall more particularly ex-
emplify in the following sections.  I shall suppose, in all
these cases, that the length of the smallest  diameter of
the superior strait is  less than three inches and a hal£
 and more than two inches three quarters. 
452
Application of the Forceps.
 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-ver-
   tebral Angle;  and in that where the Occiput answers to
   the said Angle, and the Forehead to the Pubes.

   1231. In the  first of these positions,  which is exces-
 sively 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
 superior 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 mode-
 rate, and left it three inches and a quarter, or three inches
 and  a half in its little diameter.
   1232. When  we judge the use of the forceps prefera-
 ble 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 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 forceps  with
 certainty, by passing only two fingers into the vagina, as 
Application of the Forceps.          453
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 fin-
gers 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 proportion as it pene-
trates 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  particu-
lar 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.
   1234. 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, intro-
duced at the entrance of  the  utems,  we direct its ex-
tremity 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.
   1235. The two branches being united, we are to Gom-
press 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 diameter of the superior strait, inclining the 
454          Application of the Forceps.

occiput towards one of the sides of the pelvis, or if the
strait be moderately narrow, only as far as the acetabu-
lum: 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 wo-
man, 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 great-
est 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 wo-
man will permit, carrying them, at the same time, insen-
sibly towards the left thigh.
   1236. It is in this direction,  downward and towards
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 rendered
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 of the  pelvis.  The  precautions I have  recom-
mended 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 the forceps a little, but
keeping it nevertheless  inclined  towards  the woman's 
             Application of the Forceps.           455

left thigh.   Afterwards we  change the direction of the
head again, and bring the occiput under the arch of the
pubes, over which it was at first: proceeding for that pur-
pose, 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-verte-
bral 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 occipifr
on the sacro-vertebral angle, is still more  rare than the
last.  It is also less favourable for delivery, because the
face is upward, and after 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 application of the
 forceps. 
45b
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 light: and also when
   the Forelvead answers to the left side, and the  Occiput
   to the right,

   1241. The  greatest length of the head seldom pre-
sents 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  diameter 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  situa-
tion during the application of the forceps; because, be-
ing moveable on the superior strait, it yields to the pres-
sure 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 applica-
tion of the forceps, consider it in that situation.
   1242. If the child's  head,  resting on the margin of a
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  parietal 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:  observing 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 pre-
viously, with the  hand, reduce the head to one of the
positions which I  have described  in the preceding sec-
tion;  that  is to say, bring the occiput or the forehead 
               Application of the Forceps.          457

 over the pubes; as is clearly seen by considering the re-
 lation 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.
 I shall then consider all. these positions as transversal,
 or nearly so, since it is in that  direction, as we have al-
 ready 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 dic-
 tated by the very nature  of the obstacle which opposes
 delivery, in the transverse positions of the head in ques-
 tion, we must place the blades of the forceps on the ears;
 consequently, one before the sacrum, and the other under
 the pubes.   The introduction of the first is easy enough,
 but that of the second requires care, knowledge and dex-
 terity.
   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 difficulties which oppose its  pro-
 gression towards that  part,  would  be augmented by the
 presence of the other branch if that were already intro-
 duced behind, that is to say,  before the sacrum.  To
 place the first properly,  we must  begin by directing it
 with  some of the fingers of the left hand introduced into
 the vagina,  under the  edge of the orifice of  the uterus
 before the right sacroiliac symphysis; and advance in
that direction till the blade closely  embraces the side of
the forehead.  It  is not till then  that we ought to begin
to bring it towards the pubes, to place it  under the  sym-
physis, by passing it over the face and temple of the child.
                         3M 
458          Application of the Forceps.

But to make it  execute that movement  more easily and
certainly, we ought to apply the fingers, introduced into
the vagina,  under the convex 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 ter-
minates 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 in-
sinuate the  second along the sacrum, and  within the pos-
terior 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, regard-
ing the woman's left  thigh.  It is to  be introduced flat,
under the head and passed up along the sacmm; 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. 1335, and follow-
ing-
   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 fe-
male branch before the sacrum; m 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.          459
Method of using the Forceps, when the Head presenting
      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  lock-
ed 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 instrument, yet in order to explain them
with more clearness 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 thickness, 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 Sacmm, superiorly.

  1250.  The head locked  lengthwise, may present the
occiput or the forehead against the pubes,  which  consti-.
tutes 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 ter-
minate the delivery.  In both,  the  longitudinal diameter
of the head is parallel to the little  diameter of the en-
trance of the pelvis; in both it is the occiput and forehead 
 460          Application of the Forceps.

 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
 ought  to 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 pre-
 ceding article, par.  1232, and following; except that they
 are  not  to be  passed  so high  by about an  inch and  a
 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 situa-
 tion, in order to place  its smallest diameter in the direc-
 tion  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 
             Application of the Forceps.          461

pair of pincers*  We may be convinced of the possibility
of unwedging 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, ac-
cording as it is the one or the other which is found there,
and we direct  it preferably towards  the left side.   We
bring down 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 begin-
ning, 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 prescribed in the
paragraphs 1233, and  following, to 1240 inclusively.
Method of using the Forceps wlten  tlw Head is ivedged
          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 a 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 be-

  * Experience has often confirmed the truth of all the proposi
tions contained in this paragraph. 
 462          Application of the Forceps.

 come locked, till after it has 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 after-
 wards conduct 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 preceding article.
 If we cannot accomplish the putting it back in this man-
 ner, we must apply the forceps at the sides of the pelvis,
 placing one branch on the face and the other on the oc-
 ciput, taking care to slide them both up to the same height;
 for otherwise 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 always above that strait
 See par. 1253 and  1156.   We must not  confound this
 case with that which is the subject  of the  following pa-
 ragraph.
   1255.  If we admit it to be impossible to  push back  a
 head strongly wedged with its  sides  against the pubes
 and sacmm, 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 in-
 conveniences, it has not all  which I have attributed to  it
 in the transverse  positions of the head above the pelvis;
 Nature having, before the application of the forceps, ef-
 fected almost all the reduction  of its thickness, necessary
 for  its passage through the superior strait; since  it  is
 already wedged in it, which could  not be without its ad-
 vancing at least a third, or even the half of its length.
   1256.  When we are reduced to the necessity of fol-
 lowing this method, we are to change the situation of the 
              Application of the Forceps.           463
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  may 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 de-
livery as usual*
Method of using  the Forceps ami tlte Lever, when  the
                Child presents the Face.

   1257. I have already demonstrated what a number of
obstacles Nature has to encounter in delivering 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 the lever;

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

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 ad-
vantage.
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,  ami 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 sel-
domer 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 fonta-
nelle, in order,  as it were, to hook the occiput with the
end of the instrument*  The  accoucheur then pulling
the lever almost directly downwards, must endeavour to
make the back of the  head descend, while with the ex-

  * It is on that account that I prefer a lever a little more curved
and broader than the common one. 
and of the Lever.
465
Iremities of the fingers of the other hand properly applied
on the sides of the face, he tries to push up the chin to-
wards the base of the sacrum.  Notwithstanding the ob-
jections which may be made on this procedure, the dif-
ficulties and uncertainty of which I know as well as any
one,  I nevertheless propose it, because it is more  con-
formable to the principles of the art than those we find
described in authors, and because, if  it should not suc-
ceed, the attempt would be attended with fewer incon-
veniences*
   1260. When the head remains very high, and fixed be-
tween the pubes and sacrum,  if we cannot rectify it with
the hand, in order to commit its expulsion to the efforts of
Nature; nor remove it to search for the feet, either because
that removal  is impossible, or because  there would be
too much  danger in  turning  the child;  we must intro-
duce the blades of the forceps on the sides, as if it pre-
sented the  vertex in the first position, that is to say, with
the occipid 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 fin-
gers of the other hand properly 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.

   *  I am convinced from  many trials made on the machine that
the vertex can never be reduced by this method.—W. P. D.
                          3N 
466           Application of the Forceps,

   1261.  When we do  not succeed at  first, in bending
the head forward on the breast, as much as is  necessary
to enable it to clear  the inferior strait easily, 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 man-
ner 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 regard 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 direct the other on
the vertex and top of the occiput, to bring down the lat-
ter; as directed for the transverse position mentioned in
par. 1268 and following.  If we  have turned the fore-
head 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

   * This I conceive to be the true method of acting in this case; it
should therefore be immediately adopted, as soon  as the head has
been made to descend;  as it must be fruitless to attempt acting
with the hand as recommended, while the forceps occupy the va-
gina.—W. P. D. 
                   and of the Lever.               467

delivery as in those cases where  the vertex presents in
one of the transverse positions which have  been already
described.   If we  suppose the woman  able to deliver
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 re-
commended the forceps,  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 with-
out  great  danger to the mother: as when the head is
strongly wedged, or the iderus  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 method, to both child and mother.  We  place
them  on the sides  of the head,  and disengage it in the
 position stated in  par. 1258,  and in  that which will be
 stated in par.  1264, whenever we find  them in those po-
 sitions.   But if the face be situated transversely with re-
 spect to the  inferior strait, we first reduce it to the lat-
 ter,* as directed by  Smellie.   My brother  obtained all
 possible success from  this method, in a case of this last
 species, though the head had been far advanced for more

   * That is, to the situation mentioned in par. 1264.—W. P. D. 
468           Application of the Forceps,
than forty-eight hours: the midwife not having discover-
ed that the face presented.
   1264.  The position of the face  in which the forehead
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 advance to the  bottom of
the  pelvis,  even when it is well formed.  If however it
is so far  advanced at the  time  we are called  to the as-
sistance of  the woman, we  must endeavour to push up
the face behind the symphysis  of  the pubes, till the pos-
terior fontanelle answers to the point of the sacrum: and
when the hand alone cannot make it execute  that move-
ment, we must use the lever.  But though its application
appears easier and more certain  in this than  in the for-
mer case, we must not  however flatter ourselves that we
shall always be able to obtain the desired success from it,
so many obstacles we sometimes  meet with.  To apply
that instrument advantageously  in this case, we must slide
it along the sacrum 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  direction.   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 appear at the top of the vulva  and en-
 gage under the arch of the pubes.   In that case, we must
 not endeavour to push up the face behind the symphysis,
 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 con-
 sulted, as well for the manner  of applying the  lever, as of
 performing the extraction of the head. 
and of the Lever.
469
  1265.  The difficulty of carrying the lever far enough
for its extremity to embrace the top of the occiput, when
the head is  only engaged in the  superior strait, in this
position; and the impossibility of  doing it when  it is
strongly  wedged between the pubes and sacrum, some-
times oblige us to employ the forceps first, to remove it,
and  bringing it  into the  cavity of the pelvis, where we
find  less difficulty in rectifying it.
   1266. In this case we are to  place the instrument 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 supe-
rior  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  purpose.  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
following.
   1267. After  having sufficiently  lowered the occiput,
and rectified the head, if circumstances require us to ex-
tract it,  we must replace the blades on its sides, so that
the  male branch may be under the  pubes and the other
before the sacmm; to bring the  forehead upward or to-
wards the arch of the pubes,  and finish the delivery in
the  manner recommended for the second position of the
vertex or crown of the head. 
470          Application of the Forceps,


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 ad-
vance much  farther than in .the preceding positions, 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 rectify it with the hand alone, nor re-
move 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 en-
tirely down, and, afterwards turn the chin under the an-
terior arch of the pelvis, in order to extract it in that po-
sition.   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  the forceps on  the occipital region of the
child, and to use it like a lever.*  The views of that  cele-
brated accoucheur would have been  excellent, if  he had
not recommended to bring the face afterwards under 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

    This method is what M. Levret dictated in his private lec-
tures. 
and of the Lever.
471
forceps instead of the common lever, to rectify the posi-
tion  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 position 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 ex-
clusively 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 fontanelle, and its curve ex-
actly embraces the convexity 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
parallel with the woman's left thigh, which I suppose ex-
tended, till the occiput be brought sufficiently down; ob-
serving to replace the instrument properly as often as it
slips from over the head; for we very seldom succeed at
the first trial.  To favour 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 fulcrum to the in-
strument.
   1271. After having sufficiently brought down the occi-
put, and pushed the chin up to the breast we may com-
mit the delivery to Nature; or if circumstances require
us to deliver the woman without delay,  we may apply the
two branches of the forceps on the sides of the head: pro-
ceeding conformably to the principles established for that
position of the vertex, in which the occiput answers to
the left side of the pelvis.  See par. 1225. 
472           Application of the Forceps,

   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 pre-
ceding, being perfectly similar  to  it, with respect  to the
relation of the dimensions 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  position of
the head, we are to use the forceps to extract it, if  cir-
cumstances do not permit us to leave the expulsion of
the child to the efforts of the woman.  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  ex-
tremely 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 natural situation, nor turn the
child  and extract it by the feet: because, on one side, the
head  is too far advanced 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 prin-
ciples are not applicable, and in which the woman alone
seems to merit all our attention, we must extract the head
with the forceps, as Smellie did, and in the  manner al-
ready described in par.  1263. 
Application of the Forceps.          473
Method of applying the Forceps, when the Head is re-
   tained by its Base in that Position in which the Occi-
   put answers to the Pubes, aiui 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 to-
wards the woman's belly, in which situation it must be
supported by an assistant  Then we insinuate the branch-
es 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.  When 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  towards  the
lower part of the vulva, and continue to do so till the fore-
head is without; while we support the perinosum 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 after-
wards take hold of the extremity with the right hand,
and the middle of the instrument with the left; we re-
move the head,  and give it a transverse situation with
                         30 
474          Application of the Forceps.
respect to the superior strait; but turning the occiput pre-
ferably towards  the left side of the pelvis.  If the head
should be engaged and wedged in the superior strait, be-
fore 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 direct-
ed  in par. 1118.  In turning the head afterwards to give it
the transverse position indicated,  we must lower the end
of the instrument more and more, and carry it a little to-
wards 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 symphysis of the
pubes, and continue to extract it, as directed in the pre-
ceding paragraph; that is  to say, by  insensibly raising
the extremity 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 occi-
pital region behind the symphysis of the pubes.   The
same precautions are to be observed in the positions I am
going to describe.
   1279. When  the head, stopped by  its base,  presents
the occiput  to the sacrum and the face to the pubes, in-
stead 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 for-
ceps are to  be introduced as in the preceding position, 
Application of the Forceps.
475
but above the body of the child,  conducting them with
the ends of some of the fingers, till they are beyond the
*ides  of the lower jaw.   The  extremity of the  instru-
ment 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 stop-
ped at the superior strait*   After having placed the in-
strument  properly, we proceed to the extraction of the
head  in the following 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 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.   Hav-
ing placed  the greatest diameter of the base of the cra-
nium according 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

  r When the child's head is still so high, if we find too much dif-
ficulty in introducing the  branches  of the forceps above the body
of the child, on  account of the impossibility of lowering the  ex-
tremity of  the instrument so  much as we  do in the preceding po-
sition, we must, as  in that, raise the trunk of the child towards the
belly of the mother, and try to carry the instrument  underneath.
But some inconveniences would result from it afterwards in making
the head take the course prescribed in par. 1281: inconveniences
which can only be avoided by withdrawing the instrument, when
the head shall be descended  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.

under the pubes.  As we lower the extremity of the in*
strument, 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 <nder that bone.
   1281. To finish the extraction  of the head, as soon as
we have reduced it to the position in question with re-
spect to the inferior strait, we hold the forceps  with  the
right hand only, placed at the  extremity,  and apply  the
left against  the perinaeum of the  woman and under the
child's  neck, which we 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 gradually and
carrying them  alternately towards each of the  woman's
thighs, till the whole of the face and the vertex are disen-
gaged successively from under the pubes: for so  the head
must be delivered in this position, that  it may present its
smallest diameters to those of the pelvis;  as I have  ob-
served in treating of the  mechanism of that natural la-
bour, in which the feet present with the toes upward.
   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 introduction of the  blades of
the instrument,  as for the extraction of the  head itself;
and we must conduct ourselves on  both points as direct-
ed in  par. 1279 and 1281.   We must not  attempt to
turn the face towards the  sacrum in the case which is 
             Application of the Forceps.           477
                             »
the subject of those same paragraphs, but with the great-
est care and caution.
MetJiod of using the Forceps, when the Head is retained
  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 when-
ever the distance  from the pubes to the sacro-vertebral
angle is less than three inches and a half.  The position
of the head, though transverse, is however not always ex-
actly 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 application
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 for-
ceps  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 accou-
cheur 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
say, if he could turn  the face towards the sacmm: but 
478           Application of the Forceps.
                       *
generally, and  indeed almost  always, he would attempt
that  removal iu vain.  We  therefore proceed in the fol-
lowing 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; afterwards by push-
ing it with the ends of the fingers which have served to
guide it, placed on the posterior 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 external extremity, but by  insensible  degrees, and
turn the end of the hook which terminates the handle,
directly towards the floor:  as I have  remarked  on ac-
count of one of the  transverse positions of the crown of
the head.   See par.  1244.
   1286. We then insinuate  the other branch directly be-
fore  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  extract the head in the
following manner.   We first pull downwards as much as
possible, till the head has cleared the superior strait, ob-
serving, as it descends, to incline the extremity of the for-
ceps a little  towards  the woman's left thigh.  But  as soon 
               Application of the Lever.           479

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 symphysis, 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  cranium, 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 em-
ployed for correcting  certain bad positions of the head,
and secondarily favouring 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, sometimes
deviates  from the course which it ought to follow to ena-
ble 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 pro-
portion as the head descends;  so that  the  upper part of
the forehead comes to the centre of the inferior strait,
as is explained in par. 946,  and following.   The occiput 
480
Application of the Lever.
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 impos-
sible  in many women, without assistance, or at  least so
difficult, that we cannot beNtoo 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 sup-
porting the top of the forehead,  to hinder it from de-
scending, 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 ad-
vantageous Change; and it is only when that fails that we
ought to have recourse 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 ap-
ply this instrument,  the curve of  which  should  be pro-
portioned to the convexity of that region; that  it may
embrace it exactly, and that its extremity 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 princi-
ples,  must nevertheless be a little  different in each posi-
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. 
Application of the Lever.            481
Method of using the Lever in that Position of the Vertex
   in which the  Occiput answers to the Pubes of the Mo-
   ther, 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 oc-
ciput behind the pubes, and  that,  as the head  engaged,
it has turned on the back,  if we cannot push up the fore-
head, 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 occiput.  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 indicated, 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 instrument penetrate more easily,
we must take care  to  raise a little, but very gradually,
the extremity which is without, carrying it a little alter-
nately towards each  of the woman's thighs, till the length

   * In cases similar  to the one stated in the text, I have always
applied the lever differently from our author.  I introduced it at
the inferior part of the vagina, by holding the handle immediately
over the pubes;  then  by gradually depressing it, make the  blade
sweep  over the sides of the head and pass the ear, and thus late-
rally place its broad extremities on the vertex; when placed in this
manner the breadth of the instrument will  be against one of the
le"-s 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.

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,
near the 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 coccyx of the mother, and carry it back-
 wards;  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
 circumstance 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 exe-
 cute this vertical turn, it seldom fails to come along,  un-
 less other causes obstruct it: but then we have recourse
 to the forceps, if circumstances do not permit the woman
 to deliver herself without help.
   1294. 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 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, hold- 
               Application of the Lever.           483

ing it  pretty nearly as we  hold the staff for sounding in
the common method,  or over the  belly, with this differ-
ence however, that  its extremity  must be less inclined
on the belly, than the end of the staff.  To make the in-
strument  penetrate far enough, and  go  above the occi-
pital protuberance, we must  gradually bring down the
extremity, as far as the external parts of the woman per-
mit it,  carrying 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 perinaeum, 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 a horizontal direction,  and afterwards 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  with-
draw the  lever, and disengage 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 infe-
   rior Strait.

   1296. The diagonal positions, with respect  to the in-
ferior strait, are the consequence  of those which we al-
most always observe at the superior strait, and which are
the most favourable for the  descent of  the  head.   It is
not to change those  positions  that I propose the lever:
the finger is sufficient to make the head take another
direction, and bring one of its extremities under the pubes, 
484
Application of the Lever.
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 al-
ready 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 two  others, it is situated op-
posite one of the sacro-ischiatic notches.
   1297. 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 sufficient to procure this change, we must
have recourse to the lever.
   1298. When the occiput is  placed behind one or other
of theforamina ovalia, the instrument must be conducted
on  it nearly as for the position mentioned in par. 1292;
except that we direct  it a little on one side, instead of in-
sinuating it directly under  the symphysis  of the pubes;
in order that it may always 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; un-
less circumstances oblige us to  operate  immediately;
which must then be done with the forceps.   But the suc-
cess 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 man-
ner in which that instrument acts, and  the relation of the
dimensions of the head thus turned on the back, to those
of the inferior strait.
   1299. When the occiput answers to one of the ischia- 
               Of Cutting Instruments.            485

tic 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 directly 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 I 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 tlw Appli-
   cation  of sonve cutting Instrument to the Body of the
   Child.

   1301.  The  mother and child  do not  always derive
equal advantages from the science of midwifery; 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 com-
 mencement of the present, when crotchets and other in-
 struments for opening the cranium were frequently em-
 ployed; we still however meet with some in which we are
 obliged to apply these  instruments  to the  child;  as like-
 wise with others that oblige us to  perform 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 cut- 
486
Of Cutting Instruments.
ting instruments which we are obliged to apply  to the
child in its mother's womb; the bistory, the trocar, or the
scissors,  are sometimes indicated preferably.  The child
is almost always living when these latter merit the prefer-
ence; 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; be-
cause they almost always kill.  Though we have some-
times extracted children alive by their means, we have
generally had the mortification 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 shall be stated in the sequel, as I treat
of the operations they require; but before all, it seems  to
me _proper 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 principle 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
already deprived of life, which might have been extracted
at the usual passage,  after being dismembered.   I  shall
neglect nothing which  may enable young accoucheurs to
steer clear of those disagreeable rocks: if I cannot place
them in perfect security, because of the uncertainty which
sometimes attends the signs  I am going to lay down, I 
Signs of ilus Child's Death.          487
shall, at least, render them exceedingly circumspect in the
use, already become too familiar, of this kind of instru-
ments.
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 by applying his hand
to the part where they are felt, are before the time of la-
bour, 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 decisive,
if we consider that the volume of the woman's belly some-
times increases after the death of the  child; that many
women feel internal movements like those of a child, al-
though they are not pregnant; that others, who are really
so, scarcely distinguish any, 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 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 can-
not establish  a judgment on such symptoms; and the fol-
lowing appear much more certain.  The skin of the cra-

   ■■ I advance nothing on this subject which is not the result of
observation. 
488
Signs of tlte Child's Death.
nium is tight, it enjoys the elasticity proper to the tegu-
ments, and there forms a tumour or swelling  in it more
or  less considerable, whenever the head advances with
difficulty.   We distinguish 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 operation, 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 utems.   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 anterior
fontanelle has no pulsation  before birth;  and  I  shall re-
mark  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 irregularity  and
slowness of the labour pains are most  commonly inde-
pendent 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 ex-
traordinary odour, though  the child was dead; and at
other times turbid, greenish or greyish, and of an insup-
portable 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 
              Signs of the Child's Death.          489

into error on this subject;  and nothing 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 have been thought dead,
and had even been abandoned as such, after a long con-
tinuance 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 say, a single point of its surface, as
almost  always happens when  the pelvis is so much de-
formed as to require the Cesarean operation,  or the  sec-
tion 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  con-
sequence  of the disorders of the mother, and  at other
times of those of the child, or of an external cause, as of
a 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 ad-
 vantage 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 a troublesome
 rolling in the utems,  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 eye? 
490          Signs of the Child's Death.
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 sponta-
neous  lassitudes; her belly shrinks, and she is often con-
sumed by a slow continual fever.*
   1312. These effects seldom fail to manifest themselves
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 se-
cond 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 her-
self, she only complained of the extraordinary motions of
the child, which from the next day gave no other indica-
tions of its presence, than the troublesome rolling  men-
tioned in par. 1311.  The symptoms stated in the  same

  * 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 expelled.  I therefore consider
this almost a decisive sign, and one of great importance sometimes,
more especially in threatening abortion.—W. P. D. 
Signs of the Child's Death.          491
paragraph  afterwards appeared, and the woman, over-
come by those accidents, as well as by the alarming pros-
pect 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 ex-
pulsion,  the waters  of  the amnion  are  most commonly
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 with-
out putrefying.*  We should therefore sometimes endan-
ger 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 circum-
stances  which have preceded it, as to make it known
 immediately,  prudence  must guide us in the choice of
 operations which may affect  its life, or that of the mother.
    1316. I have  already remarked that there is a tumour
 formed in the teguments of  the cranium, when the head
 of a living child  is strongly pressed  against the margin of
 the pelvis, or wedged in the superior strait,] and that that

   * I have received children who had remained  sound several
 months after their death.  Their skins were white and shrivelled,
 as if withered.   They had died  long before the natural period of
 labour.
   t See par. 1161. 
492          Signs of the Child's Death.
effect cannot take place, when the child's death has pre-
ceded the opening of the membranes,  even a single in-
stant.  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
tumour does not always indicate its death with certainty,
as some have believed and published, any more than the
flaecidity which succeeds to the elasticity  which the tu-
mour first had, when it takes place,  though the head re-
mained locked,  as  some have  pretended.   " When the
head threatens to be locked,"  says the celebrated Lev-
ret,  " a tumour is  formed on  the part which presents,
" which continually augments in volume and solidity, till
" it is unwedged, or the child dies: in the latter case, the
" tumour  not only augments no  farther,  but it  grows
"softer."   He adds  farther on: "If the tumour 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 de-
termine to dismember the  child, or open  the cranium,
we  should  sometimes have  to  reproach  ourselves with
having sacrificed  the living.   The  tumour  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 san-
guine tumour by extravasation, in  consequence  of the
rupture of  some of the veins,* frequently succeeds those

   *  I have three  times met with this  sort of tumoura, and each
 time was in a first labour.  At first, the teguments of the cranium
 were swelled, and the tumour was evidently elastic. It softened 
.Signs of tlte  Child's Death.           493
elastic tumours.   In labours which the deformity of the
pelvis renders very difficult and tedious, touching incon-
siderately practised, may favour the formation of  both
these tumours;  and especially soften the former, without
forming any considerable collection, but only an extrava-
sation in the subcutaneous cellular membrane.
   1318.  The discharge of the meconium, the irregularity
of the pains, and their cessation,  are  not  more certain
signs of the child's  death, than  the fetor of the humours
which drain from the vagina; or the separation of the
epidermis from  the part which presents to  the touch.j

all at once, and augmented so far, in one of  the children, 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 extrava
sations of blood on the outside of  the cranium, they would proba-
bly have been victims, like many others, to an  engorgement, or rup-
ture  of the vessels of the brain.  I shall publish my thoughts on this
subject at some future  time.t
  t I 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 tumour for the unruptured membranes: 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.
  X Notwithstanding repeated observations which demonstrate 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 diffi
dence in those symptoms, because there is no  case, where they can
be united in greater number, or  where we should appear better
founded  in recurring  to the 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 crotchet*, but 
494           Signs of tlie Child's Death.
A coldness  in the umbilical 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, pre-
sent us but  equivocal signs of the child's death, the con-
currence of all, or the greater part of them at 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.

I deferred their application a few hours;  as well because 1  had
them not with me, as because the case presented more pressing in-
dications 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, ap-
peared 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 pre-
sentiment led me to substitute the forceps, 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 immediately.  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 generously at-
tended the woman in the sequel. 
Of the Crotchets, ^r.
495
Of the Application of Crotchets, and other Instruments
              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 ap-
ply 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 em-
ploy 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 occupies  the lower part of the
pelvis; or when we  cannot, without danger to the mo-
ther, push it up again, and search  for the feet though
much less advanced;  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 small-
 est  diameters in every part  of  its passage.   We  should
 likewise consider 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 
496              Of the Crotchets, Sfc.

where it is fixed.  The  accoucheur 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 the  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  a hydrocephalus; but it often happens that
the  dimensions of a deformed pelvis are inferior to the
usual dimensions of the head; which constitutes  two very
different states, though presenting  nearly the same indi-
cations with respect to delivery.
   1327. All people of  the profession know that hydro-
cephalus is the name given to a collection of water form-
ed 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 dropsy.  I shall speak only of
the  first species, and that without any regard to the dis-
tinctions which authors  have made in  it, that is to say,
without determining the true seat  of the extravasation;
only considering this disease relatively to the obstruction
it may give to delivery.
   1328. All children affected  with hydrocephalus are
not  incapable of being born naturally; the labour is a lit-
tle more contracted and severe.   It is but 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 extremely dangerous  to 
Of the Crotchets, fyc.
497
the child,  no one will be rash enough to propose the
Cesarean operation for its delivery.  It is  much better
to discharge the water by puncture.  This may be done
alone on the suture by a pair of scissors, trocar, &c.
   1329. A 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, ob-
structs the deliverfl for things go on as usual,  till it ar-
rives 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 fonta-
neUes which are at the bottom of  the lambdoidal suture,
or even in the occipital hole, behind  the  first  cervical
vertebra.
   1330. A simple puncture of the cranium, in the case
of a 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
similar puncture could not prepare an exit for the brain,
a solid and well constituted head cannot shrink and con-
tract like one that is hydrocephalic.  Though the indi-
cation, arising from a defect in the capacity of the pelvis,
is the same as  in that where  the  accidental size of the
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, provided  it be  pointed and
sharp, may serve for opening  the  cranium in  case of a
hydrocephalus,  and a little dexterity is  necessary for its
                         3R 
498             Of the Crotchets, $c.
application: but in the other case, a great number have
been invented, either for dividing the head, or for ex-
tracting it: and their application requires a great deal of
care.  The best is the one proposed  by Smellie, namely
his scissors, for opening the  head, and  the  crotchet the
best for extracting it
   1331.  We  ought always,  if possible, to open the cra-
nium in the sutures, and  especially in tl\e  sagittal.  A
crucial, or angular incision, would more certainly favour
the contraction of the bony pieces which form that cavity,
than a simple incision,  and would whsequently be pre-
ferable.  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 ad-
vanced, 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 previously 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 mo-
tion.   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 oc-
ciput.
   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 cranium with
the same care.  But as wo cannot then carry the instru-
ment into  the sagittal suture, we must cut into the mid-

     *  Or what is much better  the crotchet  itself.—W. P. D. 
                 Of the  Crotchets, See.             499

die 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 de-
livery 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 tlw Trunk is
     torn from it, and the Method of extracting it.

   1335.  It sometimes happens in preternatural labours,
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 disagree-
able accident, yet he  cannot flatter himself that he shall
never be called when others have exerted such manoeuvres
as to cause that separation.
   1336. We may avoid tearing away the child's  tmnk,
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 consequence of the omission
of one or more of those three things.
   1337. A deformity of the pelvis is not so often the re-
mote cause of this accident as is supposed.  The child's
head may stop at either of the straits,  though large enough 
500             Of the Crotclusts, <SfC.

to give it a passage,  if well directed.  Experience  has
supported  this truth a  thousand times; since in many
cases, changing the position of the bead has been suffi-
cient to enable the woman 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 se-
cure 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 sur-
pass those of  the pelvis, that it cannot be brought along
in any way, especially if the bones are already so solid,
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 accou-
cheur exerts inconsiderately on the trunk without, which
are the  immediate or  efficient cause of it
   1339. Authors are not all agreed on the mode of pro-
ceeding in these cases.   Some  are for abandoning it en-
tirely to the efforts of Nature; while others insist we can-
not  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 unavailing; and the advantage which
some have supposed 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
head would pass readily through the pelvis;  the certainty
of this can only be determined  by passing the hand into
the uterus, unless it be a labour of seven or eight months; 
                  Of the Crotchets, eye.             501

 and if we must pass our hand  into the uterus, why not
 free  it from  this foreign body? This might more espe-
 cially be done, as  Nature finds more difficulty costeris
 paribus in delivering a detached, than  a connected head,
 owing to the  uncertain situation it takes at the entrance
 of the pelvis; therefore,  as we cannot dispense but very
 rarely with introducing the hand into  the uterus, either
 to ascertain the  size, or give a proper direction  to the
 head, it seems a duty to spare the woman all fruitless
 efforts by delivering it.
   1341. When its volume does not exceed the extent 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 ex-
 tract it.  We first examine if the greatest length of the
 cranium be placed according to  the greatest diameter of
 the superior strait, and direct it so, if it be not  We af-
 terwards 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 downwards.
 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 order  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.*

  * We once  succeeded in delivering the head when separated
at the first vertebra of the neck, when the child had become putrid,'
by forcing the finger through the occipital foramen.  We obtained
a good hold by this  means, and quickly relieved the patient.— 
502
Of the Crotcliets, eye.
   1342. If Nature still finds resources in herself; if 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  dimensions of the head
 and those of the pelvis.   The woman has then, in fact,
 no certain resources but in the assistance of art, and the
 application of instruments.   We should expose her to  an
 almost inevitable death, if we were to commit the expul-
 sion of the head to Nature; for she could not deliver her-
 self of  it, but by the effect of putrefaction,  and that is a
 fruitful source of accidents.   This case is  therefore evi-
 dently within the province of art; it presents the same  in-
 dications  as if the head were still attached to  the tmnk;
 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 cra-

 The head is more likely to be separated  in  premature labours
 than at full time: as for the most part upon these occasions, where
 this accident is habitual, the child has been dead for some time, and
 the connexion of the head with the neck is impaired by putrefaction.
 It must, however, be understood, that this occurs only when impro-
 per  force has  been applied to the body, with a view to deliver  the
 head; and especially where  this has been conducted  by one igno-
 rant of the proper relations of head and pelvis, and  has suffered
 the  head to become  jambed with its greatest breadth parallel
 with the small diameter of the inferior strait.  When  separated.
 however, at this part of the pelvis, very little difficulty offers itself
 to the delivery, provided the head has escaped entirely from the
 uterus, and lies loose in the vagina.  But when it is still retained
 within the uterus, much  difficulty is sometimes experienced in  the
 delivery, especially in premature  labours or late  abortions. The
'ergot, agreeably to the suggestion of Dr. Beesiy, should be tried, as
 we think it bids fair to expel  the head, by the force with which it
 sometimes urges the uterus to contract.—W. P. D. 
               Separation of the Head.           503

nium*   He must begin  by bringing the crown of the
head to the superior strait, in a transverse situation, and
fix it so, by bending the fingers  over the base of the cra-
nium.   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 withdrawn the instrument, we may pass seve-
ral fingers into the cranium to force out the brain, and
lessen  the bulk of the bony case,  in order to  bring it
along with the 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 necessary
when the volume of  the head is  such that its dimensions
far surpass those of the pelvis, and though in all cases it is
better to extract  the head, than commit  its  expulsion to
Nature, we are often obliged to temporize, and first attend
to the more pressing indications  presented by the inflam-
matory state of the uterus, of its neck, &c. &c.
Of the  Beheading the  Child, or the Separation of the
  Head from  the Tmnk; 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 tiunk, and the  latter be  left in the

  '  1 conceive no instrument so well calculated to fulfil this inten-
tion  as Smellie's scissors.—W. P. D. 
504
Separation of the Head.
 womb of the woman.   A neglect of some of the funda-
 mental principles of the art, a putrefaction of the child,
 and  a preternatural bigness  of the trunk,  whether  it
 arises from a monstrous conformation, or from an extra-
 vasation of fluid in one of its cavities, are so many predis-
 posing causes of this accident.
   1346.  It is always much easier to extract  the tmnk,
 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 fixed 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 with 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 cavity which contains it, either
 with  a crotchet or any other proper instrument  But
 when the monstrous conformation of the trunk prevents
 its exit, it must  be divided as will be stated in  the follow-
 ing 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 without help;  and  it
 scarcely ever disturbs the natural order of that function 
               Separation of the Head.            505

  1349.  It is extremely difficult to be assured of the ex-
istence of this disease when the child presents the head.
If we have  a right to presume that it is dropsical, 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 certainly but by introducing the
hand as far as the 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
insinuate the hand alo»g the thighs to judge of the nature
of the obstacle.  A dropsy may be known by the size,
by the tension of the belly, and especially by the fluctua-
tion.
   1350. Being perfectly discovered, the indication rela-
tive to  delivery is  not  difficult  to determine: the water
must  be evacuated, by opening, the belly or  the breast.
Very long scissors, the point of a crotchet,  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 certain of the
child's death.   The part in whicli it is made  is of no im-
portance 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 water, which without that precaution
might still find some obstruction to its exit;  because the
neighbouring parts of the  woman, against which the sur- 
506                  Qf Monsters.
face  of the  child immediately applies,  may stop  the
opening.
   1352. The misconformations which  a child may pre-
sent  at  birth  are very numerous: but they do not all
equally merit the name of monstrosities,  nor give the
same obstruction to delivery.  Those which consist in the
want of certain essential parts,  as  the head or the extre-
mities, seem more likely to  favour  it, than render it more
difficult: but it is not so in those extraordinary conforma-
tions where several heads are placed on one trunk, two
trunlts attached to the same head;  or in which twins are
united, either by the teguments 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, notwith-
standing so strange and monstrous a  conformation* far
from throwing  any light on the rules to be observed in
such cases, only make us more uncertain what  method
to determine on: these are cases where the ignorant seem
to triumph, while the man of skill dares propose nothing.

  * In 1763, a woman of  the town of Amiens was  delivered very
naturally, and without any other assistance than that of a neigh-
bouring midwife, of a living child who had two heads, two trunks,
and six or seven extremities, as well superior as 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 imagination, that this woman had passed al-
most the whole time of her pregnancy at the feet of an  image of
the virgin, situated in one of the churchyards of the town;  sacri-
ficing all her domestic affairs to the love  she had conceived for this
    c?
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 ; ano-
ther in a neighbouring village j and the third in Bretagne. 
Of Monsters.
507
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 necessary.*
   1354. We cannot discover these sorts  of monstrosi-
ties but by carrying the hand  into the uterus; and even
then it must  be difficult to distinguish  exactly 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 without  assist-
ance or not; one of them always turns back on the  trunk,
while the other descends.  The same thing happens with
respect to  the  inferior extremities when  the child is ex-
tracted by the feet unless we  take  care to bring them all
down: but in this latter circumstance,  we cannot hinder
the two heads from presenting and engaging  together;
which renders 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  mutilating
the child.
   1356. It would be very useful if we  could early  distin-
guish the cases of this kind where Nature could  dispense
with the assistance of art, from  those  where that  assist-

  * At the time when the disputes concerning the section of the
pubes were at the greatest height,  some  public papers mentioned
that the Cesarian operation had been recently performed, and with
success, by M.  Zimmerman, surgeon major of  the regiment of Ster-
buri, to deliver the countess of Chercy of a child which had three
heads.  But I cannot certify the truth of the  fact. 
508
Of Monsters.
ance 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 difficult 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 dismember-
ing 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 procedure be preferable to the
Cesarean operation.  Or is it allowable to take that me-
thod, 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, perhaps
we should find, that in an equal number, death had spared
fewer of the latter than of the former.   But 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.  We ought 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 Pari; be-
cause they might then be  extracted without separating 
Of Monsters.
509
them, and  the operation be  performed with  more  cer-
tainty after their birth.
   1359.  We  must reckon among  the monstrosities  of
the child, relative to delivery, large tumours  which it is
sometimes  born with.   I  have seen  one whose dimen-
sions far surpassed those of the head of the foetus at full
time;  being five inches long,  and four thick in every di-
rection.  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 num-
ber 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 without much difficulty, but I found a
great deal in extracting 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 I met with, the teguments of the
tumour burst, and it lengthened and accommodated itself
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 tumour, I have met with two
others nearly of the same size, and alsj) situated at the bottom of
the trunk, but they contained only water.  M. Piet presented the
Academy of Surgery, in 1787, with an example of one much larger
still, which he was obliged  to open, to finish the extraction of the
child: he estimated the diameter 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'slcetch taken  of it, presented the following dimen-
sions.  Its breadth, from one thigh  to the other, and above its divi-
sion 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. 
Deformities of the Soft Parts.
Ofthevitwus Conformation of the Soft Parts of the Wo-
  man, which  constitute what is commonly  called the
  Passage, considered as a Cause of laborious Labour.

  1360.  A vinous conformation of the soft parts of the
woman  may be from birth, or accidental.  In the first
case, the defect may consist in  an agglutination 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 membranous intersections
which are sometimes found in it; in a partial  closure of
the neck of the utems; lastly, in the privation of all the ex-
ternal parts which form the vidva.  The accidental mis-
conformation of all  these parts may be an effect of the
presence of a tumour, or the consequence of ulcerations
which may have caused preternatural adhesions.
  1361.  Among the tumours 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 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 tumours; but there are some which may be
confounded with others, to which it would be dangerous
to apply a cutting instrument;  as in those entero-vaginal
hernias described by Garangeot* and the hernias of the
bladder mentioned  by several  authors.  We may easily
distinguish an abscess which is  the consequence of an
inflammatory tumour, from an indolent  deposition; be-
cause the previous symptoms are not  the same:  but we
often cannot discover the nature of the latter till we have
See the Memoirs of the Royal Academy of Surgery, t. i. 
            Deformities of the Soft Parts.         511

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  tumours
seated in the cellular  tissue  of the vagina: which ought
to render us  extremely circumspect  in  opening them,
when they obstruct  delivery.  Though certain that they
are humoral, if their nature  remains  doubtful, we ought
to make but a very small incision; but wa may act with
less reserve in opening tumours  that  have been inflam-
matory.
   1363. An oedema is the most usual of  all the tumours
which may  arise in  the parts of the woman; and the cel-
lular substance within the pelvis is not  always exempt
from  that  infiltration which  sometimes  extends even
into the substance of  the symphysis.   A  moderate infil-
tration, far from opposing delivery, rather 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 a large  tumour without, which
contracts the entrance of that canal; lastly, when the in-
filtrated 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 tumours  are the most frequently met
 with after the oedema; but they are  almost always very
   * I have seen two cases where  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.
small and very numerous.   They are found particularly
in the labia, and in the internal parts of the vagina, and
I have met with them even in the neck of the utems.
The veins which wind through the cellular substance of
the vagina and of the neighbouring parts, may also dilate
and become varicous.  Though  these  tumours seldom
acquire a sufficient volume 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 tis-
sue of the  surrounding parts, as appears by the follow-
ing case.  A woman whose external parts of generation
were affected with varicous  tumours 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 pajns, and endeavouring to certify him-
self of it by the touch, found the passage so stopped  that
he could not introduce his finger into it.  It not being
easy to  discover the nature of the tumour which occu-
pied all these parts, by the touch, he uncovered the wo-
man, and saw that the labia  were turned from within
outwards, the nymphas in a manner effaced, and the lower
part of  the vagina inverted; that  those  parts were  con-
siderably swelled, tense, and of a colour which denoted
a  sanguine  infiltration.   Surprised  at such a phenome-
non, of which  he  had never  seen  an  example, M. So-
layres sent for M  Levret, who could not come, but sent
his senior pupil.  They prescribed  emollient and dis'cu-
tient lotions and cataplasms, waiting till other indications
should present   Several days afterwards the lochia be-
gan to appear, the  vagina became  accessible to the fin-
ger, the pains  abated a little,  and the tumour  softened 
             Deformities of the Soft Parts.         513

and  shrunk.   The woman  discharged a  great deal of
putrid bloody humour, which was looked upon to be pro-
duced,  as  much from  the disgorgement of the cellular
substance of the tumour and of the  neighbouring parts,
as from the lochia retained  in the uterus.   Solayres at-
tributed the  tumour 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 which
seems exceedingly well founded, the  bursting of the va-
ricous tumour must have happened during the efforts  of
labour, though the sanguine inundation did not take place
till after a trds:  which  may be easily  understood by con-
sidering 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 depletion, as well  as that of the more distant parts,
in order to favour the exit of the  child.   It  is therefore
sometimes  convenient to open  varicous  tumours which

   * 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 arrival, the in-
ternal 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.
                           ST 
514.         Deformities of the Soft Parts.

appear without, to prevent the  rupture of those which
are concealed, and that species of sanguine infiltrations
of which we have just treated;  although those  tumours
could  not of themselves  give any great obstruction to
delivery.
   1366. Scirrhous tumours, with small or large bases,
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 extirpated, more es-
pecially in the time of labour, as  the  head of the child
then presses the tumours  forward,  and  makes them ap-
proach the external  parts.   But  the  contrary obtains
with tumours whose  bases  involve much  of  the neigh-
bouring parts and cellular membrane:  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, scirrhous, incapable of  any exten-
sion, or dilatation, so as entirely to hinder the exit of the
child.   After a convenient delay  to ascertain that  the
efforts of Nature cannot  overcome the 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 preferable to rents which might take
place in it, and have never been attended with the same
consequences.  They must be made more or  less exten-
sive, according to the thickness  of the pad which is cal-
lous, but always so much  so, that  the  orifice  may after-
wards open sufficiently.*

  * 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. In- 
Deformities of the Pelvis.
515
Indications presented by a Deformity of the Pelvis, rela-
                    tive to Delivery.

   1368. A deformity of the pelvis, considered with re-
spect to delivery,  may depend on  an irregularity 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 direction, part, or degree:  where-
fore it is  not always equally contrary to the exit of the
child.  Most frequently the superior strait alone is viti-
ated, and it is pretty constantly from before backward:
sometimes also that strait is found large enough, and the
inferior is contracted.  Between the two extremes of this
deformity, we observe infinite degrees, which I have else-
where fixed to three or four principal  ones;  in  order to
show their effects more clearly, and cause their indica-
tions to be perceived with more justness and precision, I
shall recapitulate them here  in a few words.
   1369.  The small diameter of the pelvis, considered in
the superior or inferior strait, may be half an  inch less
than in the natural state, without causing any great obsta-
cles  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 of a well form-
ed pelvis with respect to delivery, to  two inches and a

 Stead therefore of applying cutting instruments,  we should employ
 extensive  blood-letting first; should this uot succeed, we always
 have the others 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 fear-
 ed no other resource but dividing the rigid parts was left me.  See
 Medical Repository and Medical Museum.—-W. P. D. 
516
Farious Indications in
 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 gradations 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 prescribe the same indica-
 tions 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 instruments
        of that kind.
   4. The Cesarian operation.
   5. Premature delivery.
   6. Regimen during pregnancy.*
   All these resources having been employed with various
 success, I shall examine them as far as the limits of the
 work will permit; but, however, sufficiently to  demon-
 strate their  advantages and  inconveniences, and deter-
 mine the cases  where they seem admissible.

  * 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 longer by
judicious practitioners considered as a resource of the art.  It is but
justice to add, that our author has, by demonstrating most satisfac-
 torily its insufficiency for the end proposed,  contributed  much to
the  cause of humanity, by bringing this horrible operation into com-
plete disgrace.  I  shall therefore be excused, I hope, for having en-
tirely omitted it in this abridgment.—W. P. D. 
Deformities of the Pelvis.
517
A succinct  Analysis of Delivery by the Feet; of the Use
   of tlie Forceps, Crotchets and Perce-cranes, in Cases of
   Deformity of the Pelvis.

   1371. Although I have already treated of these  dif-
ferent methods in a very circumstantial manner,  perhaps
it will not be displeasing if I recapitulate here their re-
spective 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 sup-
posed, at least it seems the most natural.   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 its canal recedes farther from  that state, and as its
straits are more contracted.   The extraction of the child
by the feet is therefore but a dangerous method when the
pelvis is vitiated, and only a  kind of resource for the  mo-
ther; often also  it is not without great inconveniences to
her.  Besides, this method is not  admissible in all cases
of distorted pelvis, abstracting 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 
518
Various Indications in
spares the child  the  fatal effects of the extension and
stretching of the spinal marrow, as well as of the luxa-
tion 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 uterus: but
it has also its inconveniences  and its limits.   This instru-
ment 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
diameter has not two inches  and a half of extent.
   1374.  The application of  crotchets and other instru-
ments 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  practitioner who should
use them without being certain that the child is already
dead; for that alone  can give us a right to prefer these
instruments to other methods.   If we recollect how diffi-
cult 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 can-
not 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 
Deformities of the Pelvis.
519
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 perform-
ing it.
    A succinct Analysis of the Cesarean Operation.

  1375.  The Cesarean operation consists in opening a
passage for the child, through the parietes of the abdomen
and the substance of the uterus: with respect 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; be-
cause we can render its exit as quick as easy, by giving
a little greater extent to the way the instrument prepares
for it.
   1376.  If we had no other view but the preservation of
the child, we should therefore prefer this method 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 operation being generally fatal
to her, whatever care we  take to assure its  success,  it
ought not to  be practised but when  evidently necessary,
and when  delivery 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 can-
not be extracted entire; so  also, its life alone can justify
the Cesarean operation,  in the  same case.    I however
except that where the pelvis is contracted in the  highest
degree,  that is to say, where its  small diameter is under
two inches: for then there is no  other resource to deliver 
520             Various Indications in
the woman,  but the Cesarean operation.  It is unfortu-
nate when her  child is dead,  to have nothing to present
her but a corpse, for the reward of her resignation, and
the sacrifice which she in some measure makes of her
own life.  Though she runs an  exceeding  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 manner;  as we shall see in the article
which  treats of the rupture of the utems, and of extra-
uterine pregnancies.
   1377.  The  consequences of the Cesarean operation
have almost always been  so  formidable,  that many ac-
coucheurs of the last age, and even of the present, have
not dared to perform  it.  Mauriceau, who in his  time
was the oracle of the science, as M.  Levret was in ours,
recommended waiting for the  woman's death to open the
body, and treated as fabulous the account  of the Cesa-
rean operations which were then said to have been per-
formed 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 happens before that of the child.
   1378. The authority of Mauriceau cannot be received
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 observations 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  re-
union.  Such observations as these have made some prac-
titioners believe that the danger of the Cesarean opera- 
Deformities of the Pelvis.
521
tion 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 Cesarean operation,
as much and perhaps more than the manner in which it
is performed.   But^ the unfortunate consequences which
it has almost always had,  did  not  proceed from those
sources only,  since the fate of those  women who have
had it performed by the most skilful  surgeons, after con-
venient preparations  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 ab-
solutely strangers to the art.  We shall therefore  never
be  able to  prevent or avoid every thing which  may ren-
der the success of such an operation  uncertain.
   1380.  Two sorts of hemorrhages are to be  feared in
the Cesarean operation, if we consider them relatively to
their source: one comes from the sinous vessels of the ute-
rus which terminate in the placenta, and the other from
the section of the principal branches of the uterine arte-
ries 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 utems at its an-
terior part;  but  it is not so with the former; that may
happen during the operation, if we should cut the uterus
at the part where the placenta is engrafted, which we can-
not always avoid; or it may supervene  some time after^
wards, though the incision have  been made far from that
part  In the latter case it is the effect of an atony of the
                         su 
522             Various Indications in
uterus, like the hemorrhage which sometimes succeeds a
natural labour.  In the other, it manifests itself imme-
diately, because it proceeds from the section of the sinu-
ses and other  uterine vessels, and the woman may lose a
great deal of blood before the operation be finished; as I
observed in one of the two cases that I shall relate.
   1381.  An hemorrhage is  not  the  accident most fre-
quently observed after the Cesarean operation: an inflam-
mation of the uterus and of the other viscera of the abdo-
men, fever,  suppuration, a discharge of the lochia, either
sanguine, purulent or lacteal, into the abdominal cavity,
accompany it much more frequently; and when the woman
has the good fortune to escape from so many perils, she
almost always finds herself exposed to considerable her-
nias, very difficult to manage, but which might easily be
prevented by means of a proper bandage.
   1§82.  Since the Cesarean operation is so  dangerous
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 accoucheurs have deter-
mined in a very vague  and  uncertain manner, with re-
spect to a deformity of the pelvis.   We ought not to per-
form it but when  that misconformation is such as to leave
no hope of bringing the child alive by the  natural pas-
sage.
   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 ascer-
tain 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 becomes actually necessary; because
we may with  the finger alone, or with any kind of pelvi- 
Deformities of tlus Pelvis.
523
meter/  measure the extent of the small diameter of the
strait, within a line or two.   See par. 123, and following,
to par 137 inclusively.  I am of opinion that it is perfectly
indicated, whenever the extent of the diameter is not more
than two inches and a half.
Of premature Delivery, proposed on account of a De-
  formity of the Pelvis, with a View of avoiding the Ce-
   sarean 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 de-
velopment 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 im-
possible at the period of nine months, on account of a de-
formity of the pelvis, without having recourse to the Ce-
sarean operation.  Although it might suffice to object to
its partisans the little success they have experienced  from
it  in such cases, I shall nevertheless examine whether
there be any parity between a premature delivery which
takes place naturally in all respects, and one brought on
by art at the same period of pregnancy. -
   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 wo-
men are never sufficiently sure of the time when they be-
came pregnant, for us to lay down any thing very certain
concerning the  epoch of delivery from their account
* See Fig. III. page 70. 
524
Various Indications in
In the same manner as some women  have thought they
went ten and even eleven months, because a suppression
of the menses and slight  indispositions had in them pre-
ceded conception; other women have imagined they were
delivered at seven months, because they had been regu-
lar 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 sup-
pression 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 accidental  irritation which
results from it; but of the want of an equilibrium between
the  fibres which constitute 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 concep-
 tion downward; 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 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

   *  We must beg the student,  or young practitioner, (notwith-
 standing what our author says in this paragraph being strictly true,)
 to look upon it as constituting but exceptions to the general rule.
 The general data from which women infer their advancement in
 pregnancy, will, nineteen times out of  twenty, be  sufficiently cor-
 rect for all the purposes designed  for  this mode of obviating the
 inconveniences of a deformity of the pelvis.—W.  P. D. 
Deformities of the Pelvis.
525
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 dis-
positions at  the  period of seven or eight months, in wo-
men who have the pelvis so deformed as  to render de-
livery impossible at the period of nine, and consequently
in whom it seems that it might be advantageous 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 procured 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 man-
ner.  If we break the membranes before the orifice of
the utems  be sufficiently open for the  passage of the
child, and the action  of that viscus strong enough to ex-
pel 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 protect-
ed it from the action  of the uterus, being  then immedi-
ately 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 manner, is
always so unfavourable to the child, that I think it ought
never to be permitted  except in those cases of violent
haemorrhage which leave no chance for the woman's life,
without  deliverance:  the nature of the accident ajso dis-
poses 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? 
526
Various Indications in
   1389. To consider this resource, if premature delivery
can be regarded as such, only with respect to the advan-
tages 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 ap-
proaches 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 degree of narrowness or deformity
in the woman's pelvis; 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 vic-
tims 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 of a speedy deliver-
ance:  but  I was disappointed.   Having waited  twelve
hours, and then seeing that the child's head, though well
situated, and besides 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 ef-
forts, 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. 
              Deformities of tlie Pelvis.           527

But how much more difficulty should I have found, if the
pelvis of  this woman, who had, according  to  the  esti-
mation I  made of it, two  inches three quarters  in the
smalt 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  ope-
ration had been  successfully performed in her first preg-
nancy, 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 wo-
man thought herself at full  time, because her menses had
been  suppressed more than nine months.  I predicted
her labour some days before, and I added that she was
at most in the seventh month of her pregnancy, 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 natu-
ral state, for at  the  moment of  its exit  it was depressed
on one side, at the part whch had lain  against the pro-
jection  of the sacmm,  two  lines  at least.  The child
lived but  two days and a half; I keep the skeleton  of  it
in  rny  cabinet.   The fourth  labour was  still  longer,
though the child was as small:  this last died almost  as
soon as born*
   1392. Such are the fruits to be expected  from prema-
ture delivery, when Nature has set some bounds to the
   * These observations ought  to justify M. Millot in the eyes of
those who have accused him of having performed the Cesarean ope-
ration on this woman without necessity. 
528
Deformities of the Pelvis.
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 col-
lection, or when it is still narrower*
Of Regimen, considered as a Means of preventing the
  Difficulties of Labour, which proceed from a Defor-
  mity of the Pelvis.

  1393. If the bigness of theehild were in proportion 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 ob- >
serve, with a view of moderating or limiting the growth
of her child, would be very laudable in some cases; but
we  see the contrary too often.   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
very small and extremely delicate; while others exhausted
by  disease, or by being compelled to live on the most ri-
gorous 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

  '• Notwithstanding what our author urges against this practice,
there are instances of success from it on record.  It remains there-
fore, for the decision of future experiment.t—W. P. D.
  t The production of premature labour, (at, or about the  seventh
month,) has within a few years been frequently repeated, and with
the  most entire success in a number of instances; so that at pre-
sent we may look upon this operation as a valuable resource of our
art.  See Merriman, &c.—W. P. D. 
             Of the Cesarean Operation.          529

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 dimensions 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 purpose we some-
times only cut through the common and proper coverings
of the abdomen, we are generally obliged to open the ute-
rus also,  and it is particularly in this latter case that the
operation has received 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  vaginal, as has been done lately;  comprehending
under that new denomination  all operations performed
on the neck of the uterus, without  affecting the  neigh-
bouring parts:  for we might with as much reason  give
the same name to incisions in the perinaeum, to the seer
                          3X 
530          Of the Cesarean Operation.
tion  of bridles  or cicatrices which narrow the vagina.
to that of the hymen, tumours, &c. if the child could not
be born without those aids.
   1396. The origin of the Cesarean operation is too ob-
scure, 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 pre-
sent age,  the greater part of surgeons dared not perform
it before the death of the woman; because they thought it
essentially mortal.  But care has been taken since to col-
lect the most known and proper cases  to 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. Simon, in-
serted among the memoirs of the Royal Academy of Sur-
gery, 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 num-
ber to  them.
   1397.  Among the former we find some  on 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 operations, 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 
             Of the Cesarean Operation.          531


Of tlie  Causes which require tlie Cesarean  Operation;
  the Preparation iwcessary for  it; the proper Time to
  perform  it; and the  Instruments and other requisite
  Apparatus.

   1398. A deformity of the pelvis is not the only cause.
which may render delivery impossible by the natural pas-
sage,  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 tu-
mours with a very large  base, which cannot be extirpated
without exposing the woman to a more imminent  danger
than that of the Cesarean operation, as well as extra-ute-
rine 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 have
occasion to perform these sorts of operations: it is insert-
  * M. Rigaudeaux, principal assistant surgeon of the hospital at
 Douay, and  accoucheur. 
532          Of tlie Cesarean Operation.

ed in the Journal des Savans for the month of January,
1749.   At the same time that it demonstrates how diffi-
cult it is, in some cases, to distinguish a state of asphyxy
from real death, it teaches us that it is not always neces-
sary 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 country as  soon as he was called to de-
liver her, learned on his arrival, that she had been dead
two hours,  and that  they had not been able to find any
person to perform the Cesarean operation on her.   Hav-
ing 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  deliver
her by the usual passage, and performed it easily, bring-
ing 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 recom-
mended both of  them to the women who were present
Their pains, which appeared 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.
Rigaudeaux going to see the woman again before he re-
turned  home, caused the sheet in which she was wrap-
ped, to  be  removed, and finding her limbs as supple as
at first, though she appeared to have  been dead  more
than seven hours, he  tried  some methods proper to as-
certain  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   agreeably surprised
when he found the child was restored to life, he was 
             Of the Cesarean Operation.          533

much more so when they came in the evening to inform
him that the mother was revived 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 former 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 of M. Rigautkaux,  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 favour-
 ably 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 direction of the linea
 alba, and about seven or eight inches long, ought to be
 substituted for the crucial section, which has almost al-
 ways been made in similar 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  greater operations;
 these precautions would  sometimes perhaps insure  suc-
 cess.   But unfortunately we cannot always employ them,
 except bleeding;  because we may be called too late, and
 often even when the parts of  the woman have  been fa-
 tigued,  irritated,  contused or lacerated by the manoeu-
 vres 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 cir-
 cumstances foreign to those which oblige  us to operate,
 present  more  urgent  indications.  The instant  of the
 woman's death, no matter at what  period of  gestation, 
 534          Of the Cesarean Operation.
 and that of the child's passing into the cavity of the ab-
 domen, from a rupture of tlie utems, 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 flooding, that would carry the woman
 " off."  But the reasons that author gives are not so con-
 clusive,  nor so  conformable to the present notions  of
 physiology.   The motive which determined M. Levret to
 recommend operating before the opening of the mem-
 branes is much better founded:  by operating before that
 instant, says he, the extent given to the incisions, as well
 in the containing parts of the belly as in the body 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 wa-
 ters, than when it is strongly contracted on  the child's
 body, and reduced a fifteenth 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 greatest degree of dilatation.
  1405.  It seems to me to  be advantageous to have two
histories in order to perform this operation well, viz. one
straight  and one curved;  the latter must cut with its con- 
             Of tlie Cesarean Operation.          535

vex 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 necessary;  fine  linen  compresses, a
bandage to go round the body, and some spirituous li-
quors, such as aqua vulneraria, brandy, or spirit of wine,
which may be lowered according to circumstances with
common 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 dis-
turb  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 wo-
 man 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 say, one very short, and open before.
Of the Part wliere 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;
others transversely, either above or below the umbilicus;
and several in the lima alba.  Among the former, some
have  advised making it obliquely, descending from the 
536          Of the Cesarean  Operation.

extremity of the  cartilage of the third false rib towards
the pubes; others have given it the form of a crescent,
and M. Levret directed it to be made parallel to the ex-
ternal edge of the rectus muscle, but so that it should be
equidistant from that muscle, and from another line drawn
from the extremity 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,
carrying the instrument on a scirrhous tumour, or a her-
nia, &c.  Besides these reasons for a preference, M. Le-
vret advised having a regard to the accidental attachment
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 de-
monstrated the uncertainty  of  the signs by which  that
celebrated accoucheur affirmed the part where the pla-
centa  is attached might be known, and consequently the
little attention due to the latter precept  If we must  ope-
rate 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 accidents
and more difficult to execute at the side of the belly than in
the linea alba. There are at the side, as in all other parts,
the teguments and the cellular  membrane, and  we meet
moreover with three muscular planes whose fibres inter-
sect each other in such  a manner that we cannot avoid
cutting  the  greater  part 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 
              Of the Cesarean Operation.          537

the incision exactly in this part, we sometimes cut branch-
es 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 periods
of pregnancy:  which causes  an hemorrhage sometimes
considerable enough to give some alarm, and to oblige us
to tie the vessels, or touch their extremities with styptics,
as was done by M. Piestch*  When we make the incision
at the side, the pentonasum 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 in-
convenience by making the incision in the tinea alba, at
least it will happen more rarely, and much fewer intes-
tines will  always escape.   The longitudinal axis of  the
iderus being never exactly parallel to the oblique incision
of the abdomen, we cannot open that viscus without cut-
ting the greater part  of its fibres  transversely;  which
causes them to retract, renders the wound more gaping,
afterwards favours  the exit of the  lochia  that way, and
 exposes the woman to other accidents, f   When the sec-
 tion is made in the lima alba, we only separate, as it were,
 the longitudinal fibres  of the uterus; so that the wound
 contracts  much more  after the operation.  Lastly,  in the
 lateral section of the  belly,  we cannot open the utems
 in its middle,  but the incision must be made near one of
 its  sides,  and therefore runs  more risk of affecting the

   * M. Piestch  was obliged to apply this styptic to a branch of the
 epigastric artery which he had cut in the Cesarean operation.  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
 enlaced and strangulated in the opening of the uterus.
                          3 Y 
538           Of the Cesarean Operation.
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
reservoirs that lead to the placenta.
   1409. M] Solayres, in his Lectures on Midwifery, used
to tell us, that the inconveniences attached to the lateral
and oblique incision of the abdomen, would  one day en-
gage practitioners to make it in the tinea alba.  In tlie
mean time, added he,  J advise you to perform it in that
part, the incision is easier and less painful, because there
are fewer parts to cut;  the uterus presents  itself to the
hands, it is divided into its middle part, and in a direc-
tion 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 opera-
tion; 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 sec-
tion in the linea alba, surgery has made oife step towards
improvement, but not  the most difficult one.   It is neces-
sary to guard against  the purulent and milky discharges
which are made into the abdomen; to defend the viscera
from  the  contact of those humours, and preserve them
from  the dangerous effects of them: the section in the
lima alba has not those advantages.  It had succeeded
 twice* at the time I  published  the first edition of this
   * Messrs. Deleurie and Waroquier seem to be the only surgeons
who have performed the Cesarean operation in the  linea alba with
 success. 
              Of the Cesarean Operation.          539

work, but four women afterwards died in consequence of
it, and extravasations of putrid matter 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 res-
cuing 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
twenty-one or thereabouts.   It was M. Sigault who sent
 for me to this.woman; the case not seeming to him fa-
 vourable 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, ami
 having  it answer directly  to the external incision; by
 tltat means the humours discharged from the uterus have
 a free exit.   These  advantages would doubtless be very
 valuable, and would often insure  the  success of the Ce-
 sarean operation: but hitherto they  have been rarely ob-
 tained,  and then merely by chance.  To insure them a
 little farther, the utems should be opened at the top of its
  anterior part, almost to the centre of  its fundus, and not
  at its inferior 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  Cesarean
  operation; while the wound in the  iderus was  concealed
  behind the  teguments that had been preserved above the
  pubes,  and which it is almost impossible  not to preserve,
  on account of the bladder; which  would equally favour 
540           Of the Cesarean Operation

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 iderus 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 ad-
hesions 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 um-
bilicus; 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 uterus should contract its dimensions after the deli-
very, 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 important to
prolong the external wound  to  the umbilicus, or even
above it according to circumstances, than to carry it down-
wards to the pubes; because by that we discover the body
of the uterus, which should be opened as high as possi-
ble.   By prolonging the external incision downward, we
only expose the inferior part of that organ, which in the
natural state constitutes its neck, and which ought to be
preserved in the Cesarean operation*  Besides, an open-

  * The neck of the uterus is not only that little pad called the
os tincce, in the natural state, and which  projects more or  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 after delivery, and returns insen- 
              Of the Cesarean Operation.          541

ing made in this part of the uterus would always be out
of the surgeon's sight, in the sequel, even if he should di-
vide  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 tlie body of that viscus, which serves
as a reservoir for those fluids, remains 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 incision preserving after the operation  a
greater extent than the orifice of the uterus, and present-
ing fewer obstacles to the passage of the lochia, also fa-
vours 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 escape
more easily by the neck.   Moreover, as the opening will
in this case be  opposite the wound  in the external tegu-
ments, the extravasation will not be so easily 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 opening the belly trans-
versely  at the height of the umbilicus,  and the uterus
 doubtless in the fundus; and the example of M. Guenin,
 who extended the incision 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

 sibly to its natural state.  It is the fibres  of that part which I  ad-
 vise not to be cut in the Cesarean  operation; but to guard against
 that,  the incision must be begun at least two inches above the circle
 which constitutes the edge of the orifice. 
542          Of the Cesarean Operation.
procedure to a regular method*   Two or three success-
es not appearing to me sufficient to entitle it to a pre-
eminence 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 abdo-
men and of the uterus proper to be  opened in the Cesa-
rean operation, it is necessary to indicate the manner of
doing it.   But before all, it  seems important to observe
that we must begin by emptying the bladder with the ca-
theter, 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 ute-
rus, 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/wndus 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  apomuroses
which form the linea alba.   That must be cautiously di-
vided to discover the peritonaeum, in which a small open-

  * See his work entitled, Nouvelle Methode de pratiquer VOpe-
ration Cesarienne,  1788. 
              Of the Cesarean Operation.          543

ing 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 conductor.!   We then extend the incision towards the
umbilicus, or the pubes, according as it was begun higher
or lower, cutting from within outward.  Though the his-
tory with a convex edge is proper for the first incision,  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 necessary to conduct
the common history.
   1417. This first incision must extend from the umbili-
cus 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 jupper part of
the uterus better,  and we may open it nearer to the fun-
dus.   It seems to  me better also to open the peritonasum
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 manner mentioned  in the latter end of par.
 1415.
   1418. While we cut the teguments of the abdomen, 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 circum-

   * The peritonceum is twice opened in this operation, once in pe-
 netrating into the abdomen, and again in cutting the uterus. The
 Cesarean operation cannot be performed without it.
   t  A better method is to  introduce the fore and middle fingers,
 and cut as it were between them.—W.  P. D. 
544           Of the Cesarean Operation,

scribe in some measure the uterine tumour, and hinder
the intestines from presenting at the wound.
   1419. The  abdomen being open to a convenient ex-
tent, we are to cause a little  stronger  pressure to  be
made above the umbilicus, to  bring  the fundus of the
iderus  nearer to  the level of the superior angle of the
wound, and then  open it in the middle of its anterior
part, with a convex history, till we perceive the mem-
branes.  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
bistory, with which we continue to open the uterus, cut-
ting  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 tegumepts, and terminating it at an inch and a half
or thereabouts above the inferior angle; because by con-
tinuing 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 sup-
pose 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 sufficient; but in gene-
ral 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. Levret,  is of little  consequence,
on account of the diminution the wound  undergoes after
deliverance, especially if it be  made before the bursting
of the  membranes,  as I recommend.
   1420. We  must cut the placenta, if it should present
its centre under  the edge of the bistory:  but when we 
             Of the Cesarean Operation.         545

meet with its edge in the  neighbourhood of the wound,
it is better to detach it in order to open the membranes;
as I did in the first of the two operations I have mention-
ed, and as is done when it is attached to the neck of the
uterus.
   1421. Having opened the uterus properly, we insinuate
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 man-
ner, when the shoulders  are sufficiently advanced, and
afterwards  introduce a finger  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 con-
tractile 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 utems 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  utems remain soft and inactive after the exit of the
 placenta, we must touch it a little externally and stimu-
                       • 3Z 
546           Of tfie Cesarean Operation.

late it, to rouse it from  that state of languor and oblige
it to close itself.
   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 attached there, and
even then the haemorrhage 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 instru-
ment has divided some of the large arterial and venous
branches, the blood  may flow more abundantly, because
the haemorrhage 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 recommend-
ed* for want of that, which  is not always at hand, we
may use vinegar and  water.f
   1424. The haemorrhage may supervene some hours,
and  even several days  after the operation; but, casteris
paribus, it is then less dangerous than that which pro-
ceeds from the division  of the large vessels which corres-
pond 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 always 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 flood-
ing cases.
  * See the Institutes of Surgery by Bleister.
  t Or, what has been found still better for the suppression of he-
morrhagy, is a strong solution of the acetate of lead, or the spirit tf"
turpentine.—W. P. D,            * 
Of the Cesarean Operation.          547
Of the proper Treatment after the Cesarean  Operation.

   1425. If any blood and water have been extravasated
in the cavity of the abdomen during  the  operation, 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.  Some-
times 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 hap-
pen at the  time of the operation, when it is  performed
in the linea alba.
   1426. The wound  in  the utems requires  little atten-
tion: 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 uterus  discharges in the
first days of lying-in.   The reunion is the work of Na-
ture, and the haemorrhage alone requires a particular at-
tention.  In  all ages,  the suture has  been used to pro-
cure the reunion of the  external parts, and  it has been
performed  in all possible ways.   It is, without dispute,
the most certain method  of obtaining a firm and solid ci-
catrix:  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 at the bot-
tom of  tlie wound, by passing a little unravelled bandage
round it*
  f A bandage, with the cross threads drawn nut at the part nppo
site the wound. 
548           Of the Cesarean Operation.

   1427.  The suture is not however indispensably neces-
sary  after the Cesarean  operation; that is a fact which
experience has  already  several times proved;  because
there is  no  wound  whose edges may be  move  easily
brought together; pregnancy having disposed all the sur-
rounding 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 circumstance 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, espe-
cially when the incision has been made in  the linea alba;
the smallest movements of the woman, and the least pres-
sure  on the environs,  destroying that contact so neces-
sary  to a perfect reunion: so that very often, at the time
of dressing, a bunch of intestines has been found with-
out,  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  loosen it, and
even cut it; either on account of the tension 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 en-
tirely rejected.  The  quilled suture,  which  is neither
more difficult to make nor more painful to  the  woman,
than the interrupted suture which has been substituted for
it without any reason,  is the most proper for obtaining
the  agglutination of the whole thickness  of the divided
parts: otherwise the teguments reunite.
   1429.  The wound in question is not to be considered
as a  simple wound,  which would only require a reunion;
and  indeed no one has considered it as such; for all have 
               Of the Cesarean Operation.          549

 reserved a passage in it for the lochia, 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.  Besides, the intestines require to be kept soft
 and  light, and it often happens that they are bruised by
 the bandage, when we endeavour to spare the woman the
^ain 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 open-
 ing of  about two  inches at the inferior part of it; the
 uterus being not much larger the day after the  operation
 when that viscus is contracted, as it usually is after deli-
 very.   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 occa-
 sionally.
    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 cushions very soft at the
 sides, above the hips, to make the bandage steady, and
 force forward any fluids that 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
  ether wound penetrating the abdomen, in order  to pre 
550           Of the Cesarean Operation.
vent 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 must then take
off the dressings every day, or even several times in the
twenty-four hours, if we have occasion to suspect those
extravasations, or  the protrusion 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 external wound presents no other indi-
cation but that of reunion.  The dressings ought always
to be very simple,  and without ointment.
   1433.  It would sometimes be very useful to inject warm
water, or weak barley water,  to cleanse the  surface of
the viscera from the lochia, in the neighbourhood of the
wound.  It would not be less advantageous 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 re-
commended 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 passage 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 ope-
ration nine hours before, being in a state of considerable
suffocation, suffering frequent faintings, and vomiting al-
most every minute, he uncovered the wound and loosened
the suture,  to extract from tlie belly and uterus, the clots
formed in them.   He afterwards poured in warm wine,
and forced it to pass into the vagina, 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, 
Of the Cesarean  Operation.          551
which had been suspended by a clot of blood.  I  think
that sufficient attention is not paid  to this article, and that
by clearing  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 cir-
cumstances.  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 nature 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 antiphlogistic drinks, such as veal
or chicken broth, very weak, sharpened with a little nitre,
&c*  As we can  here give only general rules on the

  * We should consider in this country a strict antiphlogistic regi
men 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 sufficiently attended to; for
I have no hesitation in believing, that were two patients every way
similarly situated to be'subjeeted to the trial, of one being indulged!
in broth, however weak, and the other  to abstain from it, that the
one using the brotlh 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 liave chosen to bear this testimony
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, &c. that the operator can give;
and the more especially is this  caution  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 
552
Of the Cesarean Operation.
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 humour 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 bandage,
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.

any circumstance, than which, nothing 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 depo-
sited or translated  to any part of the  body of a  lying-in  woman,
hence the above caution; it must nevertheless be agreed, that the
practice above recommended is good, however improbable the theory
may be.  May not the discharge of milk be useful as an evacuation P
and also by inviting a powerful sanguine determination to a remote
part, and to one that very powerfully sympathizes with the uterus ?
                                               W. P. D. 
Rupture of the Uterus.
553
Of the Causes of the Rupture of the Uterus, and the prin-
              cipal Accidents attending it.

   1437. Most authors, in treating of the rupture of the
uterus,  have attributed it only to the extraordinary mo-
tions of the child,* without considering that many women
have 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 dis-
posed the utems to it; but, on the contrary, those causes
may produce it without the assistance of the child's mo-
tions.   The child is almost  always passive at the time
the uterus tears; if it becomes the instrument of the rent,
it acts no otherwise 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 abdomen, and that
of the rupture by which it passes, are, as I may say, indi-
visible, the same effort producing both.

  * De la Motte, torn. ii. page 1189, edit, de 1775.
  Levret, Art des Accouchemens, edit. 3, § 559 and following.
  Crantz, Commentarius de Rupto in Partus Doloribus Fcetu Utero,
1756, and many other authors.
                         4 A 
554            Rupture of the Uterus.
  1438.  The violent and sometimes convulsive action of
the utems 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 cannot act in all parts immedi-
ately on its surface, and serve for a support to every point
of it.  Those  muscles 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 of a 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
however 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 weak-
ened  its tissue.  If every  point of its surface is so dis-
posed  as to support equally the effort which tends to ex-
pel 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  delivery; because the  sub-
stance of the uterus necessarily weakens in some  part,
and especially at those points which answer to the regular
parts  of the child,  or whicli  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 
               Rupture of the Utems.            555

means,  or  by other causes  which  are  all accidental.
Sometimes a tumour weakens the substance of the uterus,
and disposes  it to tear; sometimes an  ulceration, more
or less superficial, or the preternatural  tenuity  of one of
its regions; at other times, it may proceed from indura-
tions  and callosities of its neck, or of  the vagina, a de-
formity of the pelvis, and even from the obstacles arising
from the external parts, the bad situation of the child, or
of the head alone, &c.
   1441. External causes may tear  the  uterus, without
the assistance of all those I have just  mentioned, at what-
ever period of pregnancy they may act, provided 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  instruments destined  to perform the
delivery.
   1442. There  is  not  a  single  point where the utems
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
tumour with  a large base.  The rupture  does not always
follow the same  direction, nor always present the same
aspect  Sometimes it happens  longitudinally, at other
times transversely,  obliquely, or in a semilunar form.
Sometimes the edges are even, and it  only presents the
appearance of a simple bursting, or of a wound made
with a cutting instrument; at other  times they are un-
equal, as it  were ragged, and it resembles a contused
wound. 
556            Rupture of tlie Utems.

   1443. We must  distinguish these  two species of rup-
ture,  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 Nature  had not
been  able to deliver herself of the child by the usual pas-
sage: whether the obstacle arose from a deformity of the
pelvis, or from some tumour of the neck of the utems and
of the vagina; or only depended on the bad situation of
the child,  which  had not  been rectified  in time:  or
whether those ulcerations were only the consequence of
an  external percussion, &c.   In  the former case,  the
place which answers 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 ulcera-
tions 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  assistance.
   1444. Although  the rupture of the superior part of
the vagina in the  part where it is  united  with the os
tincae, has  more relation  to the simple  rupture of the
uterus, than to these ulcerations, it must also be distin-
guished 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 
                Rupture of the Uterus.            557

rents of the vagina have been frequently confounded with
those which happen in the neck  of the uterus near its
insertion in that canal; because the latter have often,
like them, a semilunar form, and because the os tincae is
entirely effaced at the time when  we discover them, and
when we extract the child.
   1445. The danger which threatens the woman whose
uterus  is torn, arises much less from the  rupture  simply
considered,  than from  the passage of the child and the
placenta into  the abdominal cavity, and  the extravasa-
tions of blood which are formed there at  the same time.
It is true that the child does not  always  go thither,  nor
does the placenta  always follow it, when it passes  en-
tirely out of the utems; 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 tmnk;  at other times,
the head alone.   Although 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 re-
mains entirely in the uterus, if it cannot be expelled the
natural 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 uteiiis;  the in-
testines 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 rup-
ture contracts and diminishes in  the same proportions as 
558
Rupture of the Uterus.
the volume of that viscus, and the woman is destroyed by
the accidents of a strangulated hernia; as we particularly
observe in a case  communicated to the Academy by M.
Percy, the son, from his father.*
   1447. The fear of being charged with unskilfulness
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 essentially mortal.   M. Le-
vret, who, as well as many others, thought that gastro-
tomy was the only resource  in  such cases, seemed to
doubt whether it would ever be put in practice.  The
mother and the child are inevitably 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, continues he, what accoucheur would be
bold  enough to perform it in time,  and  what parents
would have courage  enough to permit it to be executed
without delay?  A great number of cases attest the truth
of M. Levret's prognostic, and there  are some  which no
less demonstrate the necessity of recurring to the opera-
tion which he dared  not recommend openly;  and show
that there have been surgeons so regardless of their  own
interest as to  propose performing it instantly,  and  that
there have been women courageous enough to submit
to it.

  * The hernia was  not discovered till the opening of the  body;
the wound in which it  was strangulated was scarcely sensible,
though it had been prodigiously large, says M. Percy the father,
who was a witness of the fact, before the contraction of the uterus. 
Rupture of the Uterus.
559
          Signs of a 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 most apparent
of those causes render delivery impossible, it seems diffi-
cult to indicate the signs which show that accident is
likely to  happen, and consequently to lay down the  pro-
phylactic treatment.
   1449.  When the woman  is threatened with a rupture
of the uterus in a laborious labour, according  to Doctor
Crantz* the belly is very prominent and tight, the va-
gina lengthened, and the orifice of the uterus very high;
the pains are strong, leave little interval, and do not ad-
vance the delivery.   M. Levret adds, that the pain the
woman suffers, is always seated towards the middle of the
epigastric region; that  a  last effort or  violent leap suc-
ceeds to  the  repeated strugglings of the child, which an-
nounces  its death and  the  rupture of  the uterus.  But
these symptoms are too uncertain for us to take them for
a rule.   The rupture of the uterus has often taken place
without  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 utems.

   • M. Crantz, Dissert, sur la Rupture de la Matrice, trad. Franc. 
560            Rupture of the Uterus.

   1450.  What those authors advance concerning the
symptoms which succeed  the rupture of the uterus and
which denote it, are much  more conformable to expe-
rience.   At the time when it happens, say they, the wo-
man feels an acute pain in the  part itself, and  shrieks
suddenly; her  face grows pale; she has  frequent syn-
copes, and her pulse becomes small; the form of the belly
changes more or less according to the part of the child
which has escaped from the uterus; cold sweats succeed,
with convulsions, vomiting, and other accidents, accord-
ing as the child acts on  this or that  viscus of the abdo-
men; 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  utems so clearly,  that we may not  be de-
ceived by them in  some cases: touching demonstrates 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, because it is discharged into the
belly; the orifice of the iderus 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 reduces 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 pain-
ful tension of the parts prevent it afterwards.
   1452.  The labour  pains properly so called cease  as

  * See the dissertation already quoted, and the works of M. Levret. 
Rupture of the Uterus.
561
soon as the child is entirely in the abdominal cavity, 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 conti-
nue, because the uterus, notwithstanding its rupture, con-
tinues to contract and endeavour to get rid  of it: some-
times it expels 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.  Some-
times  also it remains in the uterus whose strength is ex-
hausted, and  the labour ceases.   In other cases where
the head has descended into the pelvis, or strongly en-
gaged in the strait, it keeps its position there, while the
rest of the body, especially the extremities,  and the infe-
rior 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 advantageous
to prevent a rupture of the uterus by performing the deli-
very, 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
                          46 
562
Rupture of the Uterus.
in extracting  the  child by the usual  passage, or by the
Cesarean operation, and the latter is recommended by
Doctor Crantz in a number of cases: he observes how-
ever that it would be entirely out of season, if the child's
head were locked in the pelvis.   I  will venture to add
that it would then be contrary to every principle of hu-
manity;  as well as in those circumstances where the pel-
vis of  the woman  is well enough formed to give the child
a passage; since the art  presents more gentle and certain
resources for the mother.   The  Cesarean operation  is
not exclusively indicated 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 im-
possibility of terminating the delivery any other way.
   1454. Bleeding, warm baths, fomentations, mucilagi-
nous 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 application of the forceps,
the extraction  of the child by the feet, and by means  of
crotchets; and lastly, the Cesarean 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 ute-
rus considered relatively to delivery, must not be less va-
ried than the prophylactic.  Though the section of the
coverings of the abdomen is often the  only resource  in
surgery to save the  mother and child,  or  to  rescue the
former from  terrible accidents,  by extracting the latter,
and its after-birth, as well as the blood which is extrava-
sated; 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 notwithstanding that accident, it is 
Rupture of the Uterus.
563
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, whi-
ther they had penetrated; and others  assure us they had
brought back a child that way, which had escaped com-
pletely out of the iderus: which will not appear probable
to 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, pro-
vided the deformity of the latter does not offer any great
obstacles to it, we ought to terminate the delivery with the
forceps;  whatever part may have penetrated into  the ab-
domen.  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 utems.   If we can-
not  extract  it  by  means of the forceps, or  with the
crotchet when dead, gastrotomy, that is to say, the inci-
sion 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  abdomen
will not appear so indispensable after a rupture of the va-
gina as after that of the uterus, to extract a child which
has passed entirely into the abdominal  cavity* if we at-
tend to the difference of these two cases, with respect to
the rupture itself.  After the exit of the child, the rent of

   * Saviard, Obverv. M. Thibaut, Journal de Medecine, tome i.
1754;  M. Chevreul and M. Chaussier, Observ. communiquees a
1'Acad. de Chirurgie. 
 564            Rupture of the Uterus.

 the uterus contracts in proportion to the reduction in the
 volume of that viscus, to that degree that the finger has
 hardly been able to penetrate it two days after it has hap-
 pened, 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 contraction 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 va-
 gina for that of  the neck of the  utems:  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 ex-
 travasated there,  and which cannot be discharged other-
 wise, is more easy  to execute than the  Cesarean opera-
 tion 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 viscits 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 rupture of the uterus instead of de-
 ferring 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. Thibauts case, every thing was  exceed-
ingly well disposed,  and seemed to announce a speedy de-
          * See the Journal de Medecine for 1768. 
Rupture of the Uterus.
565
liverance, 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, disap-
peared. Not finding then either the child or the placenta in
that viscus, M. Thibaut was not afraid to propose gastroto-
my, and to demonstrate the danger of deferring it   He
performed it, but  not  till after some hours; which ren-
dered it useless to the child.  The woman suffered, in a
manner, nothing but the  usual consequences of a  com-
mon 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 because it was not
performed till eighteen hours after the rupture of the ute-
rus.  But the woman at the end of three weeks seemed
to  be  nearly recovered, when a  tumour of the size of a
fist appeared in  the hypogastric region, and seemed dis-
posed  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 la-
bours in the fields in six weeks from the time of the ope-
ration.  Being again pregnant the following year, she suf-
fered the same accident,  the child again  passed entirely
into the abdomen,  and M. Lambron, who was present,
again performed the operation of gastrotomy; without
any farther delay than what the woman demanded to re-
ceive the sacraments.  The  child  gave signs of life du-
ring half an hour after the operation, and the subsequent
symptoms were very mild.  This woman became  preg-
nant again, and was delivered naturally of a healthy child.
  * The 9th of August, 1775, on the wife of Charles Dumont,g&r
dener at St. Jean de la Ruelle near Orleans. 
566
Rupture of the Uterus.
   1459.  The operation in question is not the only possi-
ble resource for a woman whose uterus is torn by the ef-
forts of labour; Nature, always attentive to our preserva-
tion, sometimes saves her life, after having led her from
one danger to another.   But the successes which I have
just quoted, ho less on that account, demonstrate the pre-
eminence of the operation over those singularly  rare ef-
forts, and which would have been  still most commonly
fruitless, if surgery had not aided them seasonably; either
by opening the abscessess which formed, or by dilating
the entrance of the sinuses containing the child or its re-
mains, or by extracting  them.
   1460.  The rupture of the uterus does not always pre-
sent one and  the same indication; because the danger
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 gets into it, it must
be  disengaged from it;  if it is so  strangulated  that we
eannot withdraw it, the  wound must be dilated, in the
same manner  as the inguinal ring  in a common hernia.
This complication becomes much more troublesome when
the child has been extracted the natural way.  Though
we may then push back the intestine into the abdomen
immediately after delivering the woman, as several au-
thors have done, and particularly Rungius* how can
that reduction be obtained, when- the accident has been
mistaken at first,  and when the intestine is strictly con-

     : Quoted by Heister, Instit. de Chir. tome ii. page 137. 
                     Of Twins.                  567

fined  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; what-
ever difficulties it may present,  they are  not above the
resources of the art   I would not recommend carrying
the hand armed with a bistory into the uterus, to enlarge
the ring formed by the  contracted wound, as a surgeon
asserts 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  al-
lowed 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  practiseol
by some surgeons to remove  interior strangulations?
Of Compound Pregnancy; its Signs, ami the Indications
            it presents relative to Delivery.

   1461.  Compound pregnancy is that which consists of
several children, and  the  name of twins is usually given
to them,  without  any regard  to their  number; though
that name, strictly speaking, signifies only two;  the others
being triplets, quadri-gemini, &c.   A pregnancy of two
children  is rather rare;  one of three still  more so, and
we hardly ever meet with quadri-gemini.
   1462.  These children are not always enveloped  in the

  * A case communicated to the Academy of Surgery in 1775, by
a country surgeon, and which would be extremely interesting if i^
circumstances were well described. 
568                  Of Twins.
same membranes, nor situated in the same manner, either
with respect to each other, or to the orifice 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 amnion: lastly, there are some who have both
membranes  very distinct and perfectly separate; so that
each  of them has  its own chorion, its own amnion, pla-
centa and waters.
   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 dis-
posed, their cords may be  entangled,  and form knots
upon each other during pregnancy; both  children  may
present some of  their parts together at the  orifice of the
uterus in labour, and advance at the same  time,  or reci-
procally 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 injuring the health of the other,
as I have several times observed; they  seldom  present 
Of Twins.                  569
any of their parts together uncovered at the orifice of the
uterus in labour, &c.
  In  the third case, each twin being contained in a par-
ticular 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 immediately afterwards,
without much inconvenience.  It is in such circumstances,
that accoucheurs, not  suspecting the existence  of a se-
cond child, have involuntarily 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 demon-
strate before deliverance, whether the children have their
involucra  common or particular, we ought  never to at-
tempt 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 vari-
ous.   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 of a Pregnancy composed of Several
                      Children.

  1466.  The extraordinary size of the belly at any given
period of pregnancy, its division into two tumours 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
                          4C 
570
Of Twins.
same time, are exceedingly uncertain signs of the pre-
sence 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 how-
ever deny that the union  of all these  signs sometimes
gives strong presumptions of the existence  of twins;  but
touching 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 suspicion
of two children, if there is but one, it is always very movea-
ble; 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 easily 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 single.
Of tlie Indications presented by Twins  relative to Deli-
                        very.

   1468.  Though the  pregnancy consist of several chil-
dren, delivery may take place as naturally as if there ex-
isted but one; provided that they present successively and
in a proper situation at the orifice of the uterus.  We oh- 
Of Twins.
571
serve only, that the expulsion of the first is generally per-
formed with a little more difficulty than in a common la-
bour: which doubtless is because the uterus does not em-
brace 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 preg-
nancy.*
   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 manner 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 usually 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 strongly, it is not less
advantageous to wait till thatviscus endeavours to expel it,
to go on with the extraction: for it might be dangerous to
empty the uterus suddenly, and before its own action con-
tributed to it; as  I have shown in another place.  Twins
do not always present so favourably for their exit, and
sometimes that of the first cannot take place without as-
sistance, 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 sub-

   * I have, however, seen twins, the least of which surpassed the.
middle size of children at full time; its  head having three inchf*
bight lines in the transverse diameter. 
572
Of Twins.
jected to only the smallest part of them, as when the se-
cond 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: besides,  if I were
to undertake to state them all, the greater part would es-
cape my notice, so much may they be varied.
   1471. Each twin may present the head at the entrance
of the pelvis,  but in a  different manner; the face of one
being upward,  downward,  or on one side, at the same
time that that of the other is turned in  a contrary direc-
tion.  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,  delivery cannot  take  place without  assistance; be-
cause the direction in which  the  head of each twin  is
pressed down, is such that neither of them can advance,
and because the two heads recede from each other, turn-
ing  back on the shoulders, or pressing harder against the
sides of the pelvis.  When they are parallel, 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, 
                       Of Twins.                  513

   1472. When both children present the head crossing
each other in the manner just stated, they must be turned
with the necessary precautions, and extracted by the feet.
We must in that case  begin with the child which is un-
derneath;  because in bringing that down, the other will
remove itself from the  entrance of the pelvis, and go  to-
wards the fundus of the uterus  into the void which the
first leaves as it advances.  In fact, it would be very diffi-
cult, in this  case, to pursue any other conduct.
   1473.  If circumstances foreign to those I have already
mentioned, require us to deliver without delay 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

remained there from Wednesday morning till about five o'clock on
Friday  afternoon, notwithstanding the batural efforts were very
stror.?: 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
recovered, and that the children were extracted living. M. Solayres
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. 
574
Of Twins.
one be brought along by the other, which might happen,
just as a knotted cord put into a bottle, 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 lat-
ter, and  removing them from the entrance of the pelvis,
that the  former may engage in it, experience has proved
that that method would not always  answer our expecta-
tions.  It would  often  be better to 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


  * 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 extract 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 procedure, 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 begin-
ning of the ninth month of her  pregnancy.   See the Journal de
Medecine for the month of November, 1771. 
Of Twins.
515
equally necessary 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 extract,  and bring them down
with one hand, while with the other we remove the ex-
tremities of the second, pushing them as high as possible
towards one of the iliac fossae.   Twins may present the
feet successively, that is to say, the second child after the
exit of  the first, as I 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 otherjhe feet.  (See the note on par. 1471.)   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 ignorance of a midwife,
who for six days had not found out that the woman was
in  labour; and who neither knew bow 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 horrible  convulsions from the evening before,
when a physician took me to her house, but I only ar-
rived 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, &c.
   1476. When the  cord of one  child is  without,  if the
head of the second is low in the pelvis, we ought to ex-
tract it with the forceps, especially if we suppose it likely
to stay  there some time; in order to turn  and deliver the 
576
False Conception.
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 com-
pression.  When the hand of one precedes or accompa-
nies the head of the other and impedes  its exit, we must
endeavour  to push it back.  If the head is too far ad-
vanced for that, or if  the woman  finds  herself unable to
expel it, we must extract it with the  forceps, notwith-
standing the presence of the hand or the arm of the other
child; but  paying  the  necessary attention  to that ex-
tremity that it may not be hurt by the  instrument.   We
ought to begin  by turning that whose hand is without, if
no 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 follow-
ed 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 definition 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 existence of the latter
be believed, and even lead those of the profession whom
the woman may, consult,  into error.   I  shall state  two 
False Conception.              511
general species of false pregnancies, viz. one which is a
consequence of conception, but whose product has de-
generated, and changed its  nature from the first periods;
and another 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 receives
different  denominations,  according to the  nature 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 ac-
coucheurs have made any distinction between them.  The
remains of a foetus, when they have been 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 putrefaction 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 pregnan-
cies were originally 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 lit-
tle 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 inexpe-
                          4D 
578               False Conception.
rienced people believe that this woman had been deliver-
ed of a branch of a gooseberry 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 some-
times acquire so great a volume that they would fill a very
large pan.  I have assisted some women who had car-
ried them till the seventh month, and others only till the
third.
   1480. The first species  of mole does not essentially
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 sur-
face 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 mole.  This mass increases faster
than the placenta; but it only enjoys a kind of vegeta-
tive life.  There is no regular circulation in it;  the blood
it receives passes from the sinuses of the utefus into the
veiwus 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  ir-
regular floodings while she carries this foreign 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 for- 
                  False Conception.               579

mer 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 before the expulsion of the mole, the mass rolls
itself up in some measure,  without detaching itself from
the utems, and  nevertheless  continues to increase.  Its
cavity,  not very spacious at the time the waters are eva-
cuated, 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 before the expulsion of the
mole, or but a short  time before it.
   1482. Moles present also  under two different aspects
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 larger, and their expul-
sion 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 de-
pletion of the spongy mass, than a flooding from the sinu-
ses of the utems.   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 un-
 certain;  Nature rids herself sooner  or later of the sub-
 stances that constitute them, according to a variety of cir-
 cumstances, 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, 
580               False Conception.

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, whether a preg-
nancy 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 common symptoms, which do not
permit us  to discriminate them in the first periods.  The
menses are generally equally suppressed in  both cases;
if they sometimes 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 aug-
ments insensibly; but, according to some authors, that aug-
mentation is 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 conclusion from it.  The
breasts sometimes secrete a sort of milky humour, which
adds  its support to the other symptoms; and internal move-
ments which women of the greatest experience take for
the motions of the child, confirm them in the idea that
they  are really pregnant.  All these symptoms may also
manifest  themselves,  though no  species of  pregnancy
should exist; as I have observed  in several women.
   1485. Touching is the only method which can lead us

   * It will be understood that I speak here only of those false preg-
nancies which I consider as the produce of conception. 
False Conception.              581
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 belly,  and who
were treated as such,  and yet were not pregnant at all,
in any way:  and others who  have been assured of  the
contrary,  and nevertheless were delivered some time af-
terwards.   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  movements which had been taken for those
of  the child, and which were sufficiently apparent exter-
nally, 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 pre-
 sume a pregnancy of four or five months, we must agitate
 it a little to excite that motion of the child, known by the
 name of rolling.  The absence of that  motion, especially
 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 pregnancy?  That is the most difficult point to de-
  termine. 
582
False Conception.
   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 tym-
panites, it is light, though equally voluminous.   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 already
stated, and of those of a 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
favour of one of these species of false pregnancy, rather
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 exis-
tence  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.
Of the Mechanism by which the Substances which consti-
  tute tlw different  Species of False Pregnancy are ex-
  pelled; and the Assistame 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 sig- 
                  False Conception.              583

nify the  exit or  expulsion  of those substances by  the
name of fausse-couche; to distinguish 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  dif-
fers from that of common labour, only by the violence  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 contraction and closing of
the orifice, they escape as soon as that contraction ceases,
or when  the fibres that constitute the edge of the orifice
can no longer counterbalance the continual action of the
distended and  irritated  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 injec-
tions, might  therefore, by weakening the spring  of the
fibres of the neck of the uterus, provoke the  discharge of
those fluids, before the time fixed by Nature; as might
also the dilatation of the orifice procured by the introduc-
tion of the finger.   But the latter of these methods must
not be employed except when we are very certain of the
existence of the  species of false pregnancy in question.
When these collections are  the consequence of an obtu-
ration, either natural or  accidental,  of  the  neck  of the
iderus or of the  vagina, we must render them pervious
by means of a cutting instrument: as has been often done
on account of a retention of the menstrual blood in young
women, and even in those who had had children.
   1491.  The expulsion  of  a mole, and of  mucous  and
glairy humours, which are contained in a species  of  cel-
lular tissue more or less loose, or in  separate cysts, does 
584                   Abortion.
not always take place-by a mechanism so simple and so
easy to the woman, as the expulsion of water, 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 suf-
fers, is in proportion to the obstacles which oppose the
intentions of Nature.   This labour is preceded by a sen-
sation of heaviness and lassitude in the limbs, &e. 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
substances 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 con-
fided  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 de-
livering the after-birth.



     Of the Causes of  Abortion, and its Symptoms.

   1493.  Abortion is  the expulsion of a child  before
the usual period of pregnancy, and especially before that
in which it is  strong enough and sufficiently developed
to live after its birth.
   1494.  A great number of causes may produce abor-
tion.   Sometimes it is  the consequence of acute or chro-
nical diseases, which affect the woman during pregnancy;
of a sanguine plethora, or a want of food; of a cough, or 
Abortion.                   585
straining to vomit; of a stiffness in the fibres of the utems,
which cannot, yield and develop themselves sufficiently; of
some tumour which affects that viscus, of its extreme sen-
sibility, or of its weakness;  of a violent passion, of a sud-
den 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 occasional
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 produce
an abortion at any period of pregnancy indifferently;  and
the others do it pretty constantly at the same period in
the same women, but in some sooner, in others later.  I
know women who have never carried a child beyond the
third month;  others the fourth,  fifth, or sixth, without
being influenced  by any apparent cause.   So many abor-
tions seem to have  been only a consequence of the ex-
treme sensibility  of  the utems, and of the rigidity of its
fibres which  could not extend beyond  a  given  point,
without being violently irritated, and without contracting.
I have also observed that other women, after having mis-
carried  several times at one of the stated periods, have
carried  their children a little longer in  the subsequent
pregnancies, 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 dispose them
 to a more considerable extension.
   1496. Though abortion sometimes happens without
 any apparent cause producing  it,  and without being an- 
586
Abortion.
nounced by any precursive  symptom, at other times the
woman suffers troublesome pains towards the loins and in
the uterus, accompanied by a sensation of heaviness at
the bottom of the belly, a long time before;  and it is often
preceded by a flooding,  sometimes moderate,  sometimes
abundant, according 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 common labour,
and its  subsequent symptoms  differ  little  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 af-
terwards.  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 imperfection naturally attached to those periods, they
have lived  to an extreme age.   Such examples, sup-
posing the women were not deceived in their reckoning,
are too rare  and  too  extraordinary, for us to flatter  our-
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 neglect
that care. 
Abortion.
587
           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 lite-
ms was then larger than a half-crown.  Two little bleed-
ings 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 pru-
dently administered,  quieted a  labour not less advanced
in another woman, where it was suspected to be the con-
sequence of a total privation of every species of nourish-
ment 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 woman, 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 diarrhoea 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 the uterus to that ex-
treme degree.,  I know women  who have not carried
their children at 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 
688
Abortion.
entirely to bleeding at the arm, performed a few days
after the first time the menses had failed to appear, and
repeated during the course of pregnancy as soon  as the
smallest symptoms of plethora was perceived.*  Bleeding
is not less advantageous to those women in whom the sen-
sibility of the uterus, its spasmodic contractions, the stiff-
ness of its fibres,  &e. have  frequently occasioned  abor-
tion, than to those of a sanguine constitution.  Diluting
drinks, such as veal or  chicken water ;f  and especially
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 pro-
ceed 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 ad-
vanced that the pains are strong, the orifice of the utems
dilated, and there  is no longer any hope of calming it, we
must conduct ourselves according to circumstances.  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

  * We have succeeded in preventing abortion, by the  use of
leeches applied to the lower part of the back, so as to extract five
or six ounces of blood.  They should be applied as near as can be
well calculated, the  time at which the menses were wont to make
their appearance; and this repeated for two or three times beyond
the habitual period  of aborting—rest, low diet,  and free  bowels
should also be directed.—W. P. D.
  * This is surely inadmissible where plethora or fever exists.—
                                               W. P. D. 
Abortion.
589
usual epoch of labour.   In the first two or three months
of pregnancy, Nature expels the whole produce of con-
ception at once, 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 fostus were to be dis-
charged first.   But  we observe the contrary after that
period; then the waters drain off sooner or later, the fostus
is delivered next,  and the placenta is not expelled till the
last*
   1501. We ought therefore to avoid  tormenting and fa-
tiguing the woman by touching her too frequently in the
course of an  abortive labour,  when it takes place in the
first two or three months of pregnancy;  and more parti-
cularly opening the  membranes with a view of accelera-
 ting the exit of all the contents of the uterus:  for that is
 the way to retard their expulsion and prolong the labour.
 The  utems  being  lightened  by the  discharge  of  the
 waters of part of the load which incommoded it, contracts
 for a time with much less vigour; its action weakens,
 and often does not become brisk again for a long time.
    1502. When abortion takes place at a more advanced
 period, besides the  accidental  circumstances  which may

   •'* 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 have 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 and the woman is  rescued from  threatening danger.—
                                                 W. P. D. 
590
Abortion.
complicate the labour of it, and prescribe particular in-
dications, we must attend  also  to  the situation of  the
child, or the manner in which it presents; for it cannot
always come without help, especially after the sixth month.
We therefore proceed in that respect,  and in all cases
where any accidents occur, as if the woman were at full
time; or else in 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.
 
 
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