vation, because it commonly does not take a great deal of time for the whole of the body to pass through the dilated canal of the vagina; but the head, being subject to arrest while in the passage, may there fatally compress the cord betwixt itself and the bony sides of the pelvis.

We know that the prolapsion of the cord, in an ordinary vertex labor, is very apt to occasion the death of the foetus; and it is therefore easy to perceive that such compression of the cord, between the foetal head and the pelvis, is here the real cause of the loss of the infant. From this we might naturally suppose that those children that are lost in breech and footling cases are lost from the same cause, to wit, a compression of the cord. But I believe upon evidence, that the placenta is often detached as soon as the breech or even the head leaves the uterine cavity: and if so, then the child is rather lost from the suspension of the placento-foetal circulation by the afore-mentioned detachment, than from the compression of the cord only.

Fatalities in Breech Cases.-I think it probable that more than one child in every five that presents by the breech, or feet, or knees, perishes in the birth. Certainly, if we may judge from what Pliny says about the Agrippas, in the passage quoted but a little while ago, the highly civilized people of Rome, and probably the ancients in general, looked upon these labors as replete with danger, and hence, if four out of five children born in this manner escape with life, such a success is as much as we ought to expect-all the world over. In large lying-in hospitals, perhaps, the proportion of fatal cases is rather less unfavorable, in consequence of the prompt attention always paid in such establishments to the parturient female, and to the greater skill and dexterity acquired by abundant opportunities of practice. Of Dr. Collins's cases, 369 in number, of breech, feet, and knee presentations, 234 were born alive, and 135 were born dead-some of which were putrid, premature, &c.

In Dr. Cazeaux's Traité Théorique et Pratique de l'Art des Accouche mens, a work published in Paris in 1840, and which is said to enjoy the very highest favor in France, there are the following remarks upon the subject of the danger to the foetus in pelvic presentations. I translate it, as containing a late novelty upon the subject. "Delivery by the pelvic extremity is very dangerous for the child. The statistical results furnished by Madame Lachapelle prove that, out of eight hundred and four presentations of the pelvic extremity of the foetus, one hundred and two children were born feeble, and one hundred and fifteen were born dead. The proportion of dead children to the whole

number is one-seventh; whereas, in 20,698 vertex positions, there were only 668 dead born; which is one in thirty, or about onethirtieth. As to the prognostics of the several sorts of pelvic presentations, it has been remarked that, when the breech comes down first, the number of dead born is about one to eight and a half, which is about an eighth and a sixteenth. In footling cases, one out of six and a half die, a sixth and more; and lastly, for the knee cases, one out of four and a half"

M. Cazeaux goes on to say that the above is not a fair representation of the dangers to the child in these cases; for these results do not exclude those cases of dead born that are not properly assignable to the presentations as causes of the death; the statements ought to exclude putrid foetuses and deformed children; and he states, as the opinion of M. P. Dubois, that, setting aside all the cases in which the children appear to have been lost from causes not connected with the presentation, M. P. Dubois has arrived at this result, that in labors with footling presentations, there dies one child out of eleven, whilst in presentations of the head there dies one out of every fifty. It is plain that the difference is frightful.-P. 359.

Diagnosis. It is a question whether the nature of the presentation can be discovered by reference only to the movements of the fœtus in the latter stages of gestation. Some persons have foretold that the child was improperly placed, judging it so to be by feeling a greater degree of motion in the pelvic region than in the upper part of the uterus. It seems not difficult to believe that, if the motions of the child should be chiefly felt towards the cervix uteri, they ought to be accounted for by referring them to the presence of the feet in that quarter. However, I feel assured that those patients whom I have attended, and whose labors were accompanied with this presentation, were in general utterly unsuspicious of it in pregnancy; and they are, commonly, ignorant of it until the child is born. It is not rare, indeed, for women to fear that the child is to be born double, as it is called, when the vertex really does present; and some patients are quite convinced the child is wrongly placed, until labor comes on to prove their fears ill founded. There may be some certainty obtained by a diagnosis derived from the stethoscope applied to different parts of the uterine region; for, if the child's head be directed towards the fundus uteri, there will be heard, in consequence, a pulsation of its heart at a higher level than if the head occupy its more natural position-probably near the navel; but there will always remain some liability to wrong impressions, if they be derived from auscultation alone. The

surest way is that of the Touch, which is scarcely to be confided in except at the commencement of labor, or at a period when the presentation can be touched with the tip of the finger.

When the breech can be reached per vaginam, it ought to be recog. nized by its mass filling up the pelvis; by its softness, and its fleshy feel, so different from that of the foetal head; by the tubera ischii; by the point of the coccyx, the anus, and the organs of generation, male or female; by the spines of the sacrum, and by the sulcus found between the nates and the thighs, which tend upward from the presenting part; I may add, also, by the meconium, which is often discharged st a pretty early stage of labor, and comes away with the waters on the hand of the accoucheur; but let not the young accoucheur be deceived by this symptom, since it is possible for portions of the meconium to come away even in the best vertex position. It is also to be observed that the form of the bag of waters is commonly not so much like a segment of a sphere in the presentations of other parts than the head. In breech presentations, it is more like an intestine in shape, sometimes descending to the very orifice of the vagina, and yet not very considerably dilating that passage.

Notwithstanding we ought to be able clearly to distinguish betwixt the breech and the head presentations by the first touch, it is, I think, not very uncommon for us to make a great mistake, if I may judge from the instances of mistakes that have come under my knowledge; but I am sure that such errors are the results of mere carelessness, and they could therefore always be avoided. Let it not be here understood that, when the true nature of the presentation is known, it ought to be communicated to the patient; on the contrary, it should be carefully concealed from her, as not calculated to promote her easy deliverance, since she attaches to the circumstance the idea of greater suffering or danger, which, by depressing the powers of her mind, would be very apt to affect, in an injurious manner, the pains or the voluntary efforts that she ought to have in their greatest vigor. While the nature of the case, then, is carefully concealed from the patient, it should be formally announced to her husband, or to some responsible person, and all the hazards of such a situation for the infant should be explained, in order that, if any untoward incident should cause the infant to be still-born, no unjust imputations might lie against the candor, the skill, or dexterity of the accoucheur.

Not to bring down the Feet.-When the breech is found to be the presenting part, it is very natural to suppose that, could the feet be brought down, they would give us the command of the child, so

that we could very greatly assist in its delivery; and this is quite true; nevertheless it is bad practice to bring the feet into the vagina, except for some very well understood and sufficient cause. When the child descends double, as it is called, the parts yield very slowly for its advance, and this tediousness is a necessary consequence of its bulk, and the yielding nature of its substance. Unlike the head, which is hard and firm, this part, when urged downwards by the pains, gives way before them, and is compressed so much that each pain is half lost in compressing the yielding mass before the part becomes firm or condensed enough to make it act as a dilater. This slowness is greatly to be deprecated; and all proper means to obviate it may be safely resorted to, such as a venesection, or the administration of a clyster or a dose of castor oil, &c.; yet this very slowness, and the great size of the breech, serve as means for the child's security, at the last moments of labor. By their means the os uteri, vagina, and vulva are so completely opened, become so absolutely cylindrical, and are so entirely deprived of the power of resisting, that, when the head comes to take the place of the body in the excavation, a very little force of the woman's straining serves to extricate it; or at least the complete dilatation enables the accoucheur to employ his hand or his forceps to extract the head in time to save the child from an asphyxia, which is almost sure to affect children that are not born very soon after the escape of the shoulders, during the whole time the head is passing the vagina; for the placenta would be now so completely squeezed by, or even separated from, the womb, that the utero-placental functions must cease to be performed.

The impatience, which can scarcely be avoided when witnessing the throes of the mother or the struggles of the child, also exposes us to the danger of doing it a great harm by pulling strongly by the breech, shoulders, &c., in order to get both mother and infant the more speedily released; but if any one will take the time to reflect that the spinal marrow may be greatly injured by a violent extension of the neck, it will be evident to him that no very great amount of extracting force ought to be applied. It is best, therefore, as a general rule, to permit the breech to descend, and not in any manner to interfere with the feet until they are spontaneously born: an extracting force has also an invariable tendency to slip the arms upwards, so as greatly to embarrass the last and most important act of the breech labor. The child is wholly expelled by the uterine contraction, being pushed out of the womb in consequence of the approach of the fundus to the cervix of that organ: in that natural process, if the arms happen to be resting on the sides of the abdomen of the child, they ought to descend

pari passú with the parts on which they rest; but if the child be pulled out, then, as the fundus uteri does not press with a proper power upon the head, the arms will naturally slip up over or along. side of the head, where they sometimes are so firmly fixed as to make it a very difficult matter to bring them down again. Hence the soundest discretion teaches us to let the womb push forth the breech as we let it push forth the head, in vertex labors, without laying hold of it to drag it downwards as soon as the least purchase can be had on the presenting part.

The legs, in a breech presentation, may be turned upwards on the child's belly, or they may be flexed on the thighs, so as to bring the feet very near the nates. If the breech engages in the pelvis, or begins to pass the circle of the os uteri, the feet disappear, rising as the nates descend. There is no danger of injury to the hip or knee-joint, if the child be trusted to the natural powers employed for its birth or expulsion; but whenever much force is employed by putting the fingers in the groin, we do incur the hazard of breaking or dislocating the thighs.

Positions of the Breech.-The breech may have one of four positions: 1st, the child's back to the left acetabulum of the mother; 2d, to the right acetabulum; 3d, to the pubis; 4th, to the promontory. These several positions are easily discriminated in practice by the Touch, which ought not to mislead any attentive or considerate practitioner, since by the Touch it is easy to learn where are the coccyx, the tubera ischii, the genitalia, the sulcus betwixt the thighs, the sacrum, &c. &c.

Fig. 85.

As the escape of the breech occasions a great distension, the perineum requires very steady support by pressing a soft napkin against it, for the purpose, first, of resisting its too rapid advance, and second, in order to give to its movement that curvilinear direction which ushers it into the world in a course coinciding with the line of Carus's curve. Figure 85 exhibits to the Student the appearance of bending which is acquired by the pelvic extremity of the trunk while passing outwards in a breech labor. It is manifest that the perineum may be here subjected to a great degree of distension. As soon as the body is so far born as to permit the navel-string to be reached, it is to be drawn downwards a little, so as to free it from the danger of being broken