cessive departure of the chin from the breast, or failure of flexion; that is the first principle: and that the chief indication founded upon it is to restore the flexion by pushing up the forehead, and bringing down the vertex; and where that cannot be done, the next indication is to rotate the chin to the front, so that flexion may take place as soon as possible after the chin has emerged.

I am not capable at present of stating the number of face cases I have had occasion to treat. The number has been considerable. The result, as to its influence on my opinion, is that they are rarely formidable when the great precept of bringing the chin to the pubis is understood and can be fulfilled. Certainly, I have not been, in a majority of my cases, called upon to use any extraordinary measures of relief.

I have a word of counsel for the Student as to the care of his own reputation in the conduct of such cases. There can rarely be met a more disagreeable spectacle than that of a new-born child's face, after a bad face-labor. It is frightfully suggillated, and often covered with blebs filled with yellow or bloody serum: the lips are completely in a state of ectropy, the eyes closed by infiltration of the palpebræ, and the nose enormously swollen. Bystanders cannot comprehend why these appearances should exist in a neonatus that has been tenderly treated-and are therefore too apt to assign as the probable cause the rudeness and brutality of the medical man. As soon as the young beginner has surely made his diagnosis, let him announce the probability of a swollen and blistered face, notwithstanding the gentleness of the treatment which he is about to administer. In this way he may save and augment not only his own credit, but that of his art, a pleasing duty for every true scholar.

As I shall have occasion to revert to the consideration of face-positions when I come to treat of the various uses of the forceps, I shall close the present chapter, in order to take up the consideration of those labors in which the child presents the breech, knees, or feet, when descending.

CHAPTER XII.

ON PRESENTATIONS OF THE PELVIC EXTREMITY OF THE FŒTUS.

As the length of the gravid uterus, at full term, does not exceed twelve inches, and as a well grown foetus is nineteen or twenty inches in length, it is evident, as I have already said, that it must, while in utero, be folded up in a very compact form, and that it will be an oval body, one of the extremities of which ought to be directed towards the orifice of the womb, and the other to the fundus. The most natural position of the foetus is certainly that in which the head points downwards; so that the vertex, or some other part of the head, may, in labor, advance first. But it happens that about one in every forty-five or fifty cases presents the other extremity of the ovoid to the os uteri; and in doing so, it is a matter of mere chance whether the breech, or the knees, or the feet, prove to be the presenting part. In strictness, the breech ought to descend first in these labors, but if the feet happen to be near when the membranes give way, they are quite likely to prolapse into the opening, and pass, soon afterwards, out at the vulva; so that, supposing the breech presentation to be, after that of the vertex, the most natural, we may properly include, in the account of the presentations of the pelvic extremity, those of the knees and feet, and regard them as mere accidents of the pelvic presentations, and all to be included under the head of natural labors, agreeably to the doctrine expressed in a former page of this work-a doctrine that announces two essential presentations of the foetus, one a cephalic, and the other a pelvic presentation; each of them is liable to the accidents appurte nant to their form.

It is not an easy matter to determine why the breech presentation occurs about once in forty-five or fifty labors, and it is far less easy to say what is the reason that certain women are prone to this sort of labor to such a degree as to bring all their children so. I knew a woman whose children, four in number, were all born with the breech presentation, and it is by no means very rare to meet with persons who have been similarly situated in more than one of their labors.

Dr. Collins, of Dublin, in his Practical Midwifery, informs us that one woman who was delivered at the Dublin Lying-in Hospital had preternatural presentations in every one of her labors, and she had given birth to nine children. While that gentleman was master of the Dublin Hospital, sixteen thousand four hundred and fourteen women were delivered, of whom three hundred and sixty-nine had presentations of the breech, feet, or knees; making rather more than one such labor in every forty-five cases. Out of 54,723 labors stated by Boer, Bland, Merriman, Boivin, Lachapelle, and Nægèle, there were 1694 cases of breech, feet, or knee presentations, which give us one pelvic presentation in thirty-two and one-fifth cases nearly. It is commonly assumed that about one in forty-eight, or more generally two in 100 cases will prove to be pelvic presentations.

Causes of Pelvic Presentations.-The causes which produce these presentations must be purely accidental. The most natural presentation is that of the head, which is turned towards the os uteri from the earliest period of pregnancy. The insertion of the navelstring is nearer to the pelvis than to the head of the child, the head therefore hangs downwards; but when the cord, by the growth of the ovum, has become of a very considerable length, the child ceases to be dependent from it, for the cord is not unfrequently from twenty to thirty inches long. It seems very probable that while the foetus is yet small, it may change its position in the uterus; but if it happen to turn as late as the fifth month, it will be apt to retain the attitude it may then acquire till the end of the pregnancy, as its length does not admit of its changing again very readily after that period. It is not to be doubted, however, that the attitude may, by certain extraordinary or violent movements of the mother, be reversed, at a later period, so that the head, which was originally at the os uteri, may be afterwards brought to the fundus, and vice versa. Prof. Paul Dubois, of Paris, has an article in the Mém. de l'Acad. Royale de Méd., in which he endeavors to show that the child does turn its head downwards in consequence of a certain instinct at about the seventh month, but I am far from being convinced by his arguments.

Some persons will not agree with me in regarding the pelvic as a natural labor; yet notwithstanding the breech presentation is met with only once in forty-five or fifty labors, I am not inclined to regard it as a preternatural case, for I cannot discover any reason for classifying it along with that sort of births, in the mere fact that the head does not present. The breech composes one end of the foetal ovoid; and a breech labor requires, for its complete success, no greater dila

tation than that demanded for the passage of the head; it may be effected without any aid, and is, perhaps, not really fraught with greater danger for the mother than the other, the common vertex presentation. It is, however, far more dangerous for the child than the vertex case; and as the object of parturition is the safe birth of the infant, it might be absolutely proper to include, in the class of preternatural labors, all those in which the child is exposed to unusual hazard. Still, many breech presentations terminate favor ably with great celerity and without any artificial aid, whence I look upon them as not really preternatural.

In former times these presentations of the pelvic extremity of the foetus were regarded as much more serious events than they are at the present day.

The ancient Romans used to call all those persons that were born by the pelvic presentation Agrippas, as is seen in the following passage from Pliny, lib. vii. cap. viii.; and all such labors were regarded as not natural.

"In pedes procedere nascentem contra natura est, quo argumento eos appellavere Agrippas ut aegré partos; qualiter M. Agrippam ferunt genitum unico propé felicitatis exemplo in omnibus ad hunc modum genitis."

If the birth of Marcus Agrippa were really the only instance of a safe delivery of the child in a breech presentation, we should not have occasion for surprise at Pliny's opinion as to the preternatural character of such labors; but doubtless, thousands of Roman children must have been safely born so, and that without any assistance in the birth.

That sprightly and most delightful old book-the first Midwifery book ever printed in England-I mean the "Byrthe of Mankynde," by Thomas Rainald, Lond., 1565, at Fol. liii., has the following:

"Agayne, when it proceedeth not in due tyme, or after due fashion, as when it commeth forth with both feete, or both knees together, or els with one foote onlye, or with both feete downwards, and both handes upwardes, other els (the whiche is most perillous) sidelong, arselong, or backlong, other els (having two at a byrth) both proceade with theyr feete fyrst, or one with his feete, and the other with his head, by those and dyvers other wayes the woman sustayneth great dolour, payne and anguishe."

Thomas Rainald would be very much surprised and comforted could he see what facilities modern science has provided for the obvi ation of all these terrible occurrences.

The danger to the child, here depends on its liability to asphyxia,

from several causes: first, from the compression of the cord, which is pressed betwixt the child and the parts from which it is escaping; second, from the detachment of the placenta before the head is born, by which the uterine life of the child is destroyed before its birth; thirdly, the compression of the placenta itself betwixt the uterine parietes and the head of the infant; or fourthly, the constriction of the placental superficies of the womb, during the time that the child's head, still remaining in the vagina and lingering there, ceases to distend the uterus, which closely contracts on the after-birth, and even though still retaining its connection with it, yet suspends all the utero-placental operations, on which the foetus depends for existence antecedently to the establishment of its respiration.

The last named cause is, I presume, the one chiefly to be feared; and I have long deemed the pressure upon the umbilical cord, in breech cases, a matter of small moment as to the child's security, in comparison with the asphyxiating influence of the compression, detachment, or constriction of the placenta by the reduction of the superficial content of the placental seat. It is probable that that seat, which is eight inches in diameter before the commencement of the labor, is diminished to a diameter of four or even perhaps three inches by the time the head is driven out of the womb into the vagina in breech cases. Under such a reduction, no valid placento-uterine intercommunion can be supposed possible. Very often it must happen that the whole placenta is off long before the head gets even out of the womb and into the vagina.

The breech may descend into the excavation, and it may even pass through the vulva, without the least danger of compressing the cord; but when the body of the child has sunk so low as to bring its navel down into the bony pelvis, there is little danger that the arteries of the cord shall be completely obstructed for a period long enough to give the child a fatal asphyxia. Such an event is far more likely to occur where the feet present than where the breech advances; because, in the latter case, the thighs, and generally the legs, are extended along the front of the body in such a manner as to protect the cord from pressure, its vessels being fully guarded by its position betwixt the thighs, during all the time the body is escaping; thus enabling the infant better to bear the temporary pressure on the cord for the short time it must be compressed by the head only, while that part stops in the excavation; longer pressure by the head would easily extinguish the remains of a life that was already about to expire from preceding obstruction of the circulation. In general, the danger for the child is not great until the head has sunk down into the exca