Let not the Student then expect to find the face looking full down into the excavation, at the beginning of these cases; but rather, let him expect to find it coming more and more completely down as the labor draws to its close; hence, all face cases are at first cases of forehead presentation, and, whenever the chin departs from the breast in a labor, let him take heed lest it lead to a face presentation.

I propose to the American Student to adopt Dewees's recommendation, to have only two face presentations, and to let the first be that in which the forehead is to the left, and the chin to the right side of the pelvis-while the second position is that in which the forehead is to the right, and the chin to the left side of the pelvis. Let this be the decision; and let the Student, though he finds the chin disposed to address itself to a point in rear of the transverse diameter, still consider it as a first position, or a second position, as the case may be.

Suppose a case of face presentation to be caused by a right lateral obliquity of the womb, the point of the head being repelled above the edge of the strait: the womb, in its oblique state, leans to the right and forwards, and not directly towards the right; whence, if the accident occur in the manner supposed, the chin could not fail to be placed to the right, and a little forwards; the same thing is true of cases caused by left lateral obliquity—mutatis mutandis-as before stated. This furnishes a striking manifestation of the wisdom which, in giving form to the pelvis, even provided us herein a remedy for the accidents that might occur to thwart or prevent the parturient act. Should the chin be towards the posterior part of the pelvis, and not susceptible of being directed towards the front of the pubis, the most serious mischiefs might be expected to occur; whereas, when the chin advances toward the pubis, little embarrassment is, in general, to be apprehended.

If we could know, antecedently to the descent of the presenting parts, what they are, it might be supposed that we could easily restore them when wrongly placed, to their proper situation; but, while the presenting part of the child is above the brim, it is very rare, if not indeed impossible, to have such a good degree of dilatation as to admit of the hand being introduced, in order to effect the needful changes. The womb opens as the part comes down, and only as it does come down. Hence, when a face case is ascertained to exist, it is mostly (I say not universally) too late to return it into the abdomen or superior basin; and as to attempting to bring down the vertex, after the head has once sunk well into the excavation, I regard it as a rash, if not an impossible operation; rash, since it could not be done without very great violence; and generally impossible, since we cannot turn or

see-saw a diameter of full five inches in a pelvis furnishing less than that space. Where it is possible to push the whole mass back, and bring down the vertex, let it be done, if deemed really necessary; but the opportunity to do this good action will rarely occur in practice. Viardel tells us that, in Sept. 1669, he was called to Madame Nissole, who had been already two days in labor with a face presentation. He made use of a compress, with which, thrusting upwards with the fingers, he pushed the face, i. e. the head, back again; and so enabled him, after he had raised it up, to slide his hand along the face until he got hold of the vertex, which he pulled downwards, and thus restored the chin to the breast, placing the head in extension. Viardel boasts of this case-but it is doubtful whether he could have pushed the head back if it were already out of the womb at the time of his arrival. And if it were not yet in the vagina, he did an imprudent act of meddlesome midwifery in his operation. He relates the case at p. 110 of his Obs. sur la Prat. des Acc.

Dead, and half putrid children, in whose tissues there is scarcely any resiliency or resisting power left, are not so unapt to come face foremost as living children, in whom departure of the chin from the breast occasions such a great extension of the head as to be painful, whence the living child instinctively opposes the wrong tendency, by acting with all its strength, to get the chin back, or the head flexed again.

Let me repeat that it is not to be expected that, at the very beginning of a labor, the face of the child shall be found looking directly downwards. When the examination is made early in a labor, the os uteri being dilated very little, the accoucheur ordinarily rests content with ascertaining that the head presents, and does not endeavor to complete the diagnosis as to position. Hence, there is almost always an early mistake in the diagnosis and prognosis, for it is the forehead that is first felt; and the face itself does not appear in the excavation for some time after the commencement of the parturient throes. The head turns over only by degrees, and allows first one eye to be felt, and then the other, the nose, the mouth, and the chin. In order to exemplify these processes, I shall cite some cases from my record. book.

On the 5th day of February, 1830, I was called to attend Mrs. in labor with her second child. When I reached her house, it was half past six o'clock in the morning. She told me that she had had pain for a day or two, but was seized with regular labor-pains at four o'clock this morning. Upon making examination per vaginam, I found the os uteri from one inch and a half to two inches in diameter, with

the edges thin and ductile, and the very tense membranes protruding through them during the pains. I could, at first, just feel the even smooth surface of the foetal cranium, which seemed to be resting or lodged upon the top of the symphysis pubis, and not in the least degree engaged, or entered into the superior strait; this was all that I learned from this first examination, and was all that I wished to learn.

As the pains were regular and good, I expected soon to find the head engaged within the passage; but I observed that the uterus was very large, as if distended with an undue amount or excess of liquor amnii.

At nine o'clock A. M., the pains, although regular and of increasing severity, had not caused the head to engage in the slightest degree; it remained exactly as at the first Touching. These circumstances led me to suspect that the womb was unprovided with a proper degree of energy, on account of its being distended beyond its just dimensions. I deemed it, on this hypothesis, advisable to rupture the ovum, in the expectation that, as soon as the womb should condense itself a little by the flowing off of the waters, it would acquire such vigor as to compel the head to engage in the strait, and thence pass speedily into the excavation, as I had repeatedly observed to be the case in other persons.

Upon rupturing the ovum, there came off a very great quantity of water; I should think nearly two quarts in all; but the head did not advance until three or four pains had acted upon it; after which it came slowly down, and I felt a suture; but as yet no fontanel was distinguishable. The examination induced me to suppose it was a vertex presentation of the first position, in which opinion I was most egregiously deceived, in consequence of the very careless manner in which I made the investigation. At eleven o'clock, I made a more careful inquiry, and was distressed to find that the left side of the os frontis was in the middle of the excavation, and that, by passing the finger very strongly up towards the left sacro-iliac junction, I could feel the edge of the left orbit and root of the nose, beyond which it was impossible for me to reach, in the then state of the organs of generation.

It seemed, on account of the advanced state of the labor, too late to turn, even if that could have been considered the best resource; and I was the more averse to such a proceeding, considering that I had before delivered her of a large child, and also that the waters were now drained off, and the uterine contractions powerful.

As she had by this time become heated, and very much disquicted with her pains, from which the suffering was severe, I gave her thirty drops of laudanum, and soon afterwards took twelve ounces of blood from the arm. She also got an enema of flaxseed tea and olive oil.

The head was now fairly engaged, and the face was becoming more and more the presenting part, notwithstanding my repeated endeavors to push it up, by forcibly pressing against the ossa malarum during each pain; and I became thoroughly convinced that it was impossible to force up the face and bring down the vertex by the employment of any legitimate force, or by mere dexterity.

The pains had become so dreadfully severe, and the poor woman suffered such agonies, that I really entertained serious apprehensions that the womb might rupture itself or the vagina, in its vain efforts to carry on the parturient processes, lashed as it was into a rage of excitement by the obstacles to delivery.

At my request, Dr. James, at that time Professor of Midwifery in the University of Pennsylvania, was invited to see the patient, and arrived at two o'clock in the afternoon; and after having examined the case, left me with encouragement to hope that the vertex might come down after some further efforts of the womb. Dr. J. was to return to me at half past four o'clock.

In the mean time, I provided myself with the long right hand blade of Davis's oblique forceps; and when the professor returned, at four o'clock, it was found to be vain any longer to expect the descent of the vertex. I therefore introduced the blade above mentioned behind the right ramus of the pubis, got it upon the left parietal bone, and, using it as a vectis, drew down with it during the pains. The head advanced very much by this aid, and began to press upon the perineum; but there it stopped, and seemed no longer affected by the vectis.

I next attempted, with my Baudelocque forceps, to introduce the male blade behind the left obturator foramen. I was foiled, but Dr. James succeeded in adjusting it. Every attempt to adjust the female blade, whether made by Dr. James or by me, proved fruitless. They could not be made to lock; nevertheless, I rashly attempted to deliver with them by securing the joint with one hand, and by this means the head again advanced, but soon stopped. The forceps were now abandoned, after vainly attempting to make them lock. I next resorted to the oblique vectis again, and with it caused the head to advance so much, as to put the perineum in a state of tension. The chin turned to the pubic arch, and then emerged from the genital fissure: and as the successive portions of the face came forth, the chin rose up

to the mons veneris, and allowed the fourchette to slip backwards off the vertex, which immediately retired towards the coccyx.

The child was born, but the cord, which was tight around its neck did not pulsate; the infant, however, began at length to gasp, and after having been well dashed with brandy, cried lustily. It was born at half past six o'clock P. M., so that the labor was found to have continued about fourteen or fifteen hours.

At the time I last put on the vectis, the child's chin was in the left sacro-iliac corner of the pelvis. Both Dr. James and I expected that the rotation would inevitably carry the chin to the sacrum, to be consequently delivered at the perineum. I have every reason, therefore, to suppose that the vectis was the chief means of giving the head so favorable a rotation, a result attributable to the admirable curve of Dr. Davis's oblique blade.

The perineum was not hurt; the placenta came off in twenty minutes, and the mother found herself very comfortable, considering her great fatigue.

The face was one enormous suggillation, carried to the extent of producing numerous blebs or vesications on the eyelids and cheeks. The mouth was excessively swelled, and the left eye completely closed. The face was, on account of this state, directed to be frequently bathed with cream. This infant was carefully weighed on the evening of its birth, and was found to weigh nine pounds and three-quarters. On the sixteenth day after delivery, the woman was down stairs to dinner, and had no subsequent indisposition.

Fig. 84.

In giving the details of this case, I am liable, as I well know, to the charge of having, in an important matter, anticipated my subject: but although I have not yet come to the formal consideration of instrumental cases, I feel pretty well assured no evil will happen to any Student for having, by reading the foregoing relation, in some degree anticipated the regular and formal consideration of obstetric operations.

The cut Fig. 84, which represents the foetal head, in a face labor, thrown back to that degree as to press the occipital bone against the interscapular space, suffices to show how well founded were my fears lest the forehead, instead of the chin, should rotate to the front, to pre