^4^Bfev2S ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 Section.. Number 3S¥4-3 Form 113c, W. D„ S. G. O. 3—10543 (Revised June 13, 1936) I A MANUAL OF PRACTICAL OBSTETRICS: ARRANGED SO AS TO AFFORD A CONCISE AND ACGTJRATE DESCRIPTION OF THE J&anagement of llreternatural SLatoours; PRECEDED BY AN ACCOUNT OF THE MECHANISM OF NATURAL LABOUR. FROM THE FRENCH OB' JULIUS HATIX, Doctor of Medicine of the Faculty of Paris, Professor of Obstet- rics and of the Diseases of Women and CMldren~d&X}i8F& /» BY S. D. GROSS, M. Ji.C'o *£ WITH AN APPENDIX, CONTAINING „ ^ . , \)» A PHYSIOLOGICAL MEMOIR UPON THEBRAIN, FROM THE FRENCH OF M. MAGENDIE, BY JOSEPH GARDNER, M. D. PHILADELPHIA: J. GRIG^G, NO. 9, NORTH FOURTH STREET. 1828. «* Wq Eastern District of Pennsylvania, to wit: BE IT REMEMBERED, that on the fourth day of Novem- ber, in the fifty-third year of the Independence of the United States of America, A. D. 1828, John Grigg of the said district hath deposited in this office the title of a book, the right where- of he claims as proprietor in the words following, to wit: "A Manual of Practical Obstetrics: Arranged so as to Afford a Concise and Accurate Description of the Management of Preternatural Labours; Preceded by an Account of the Mechanism of Natural Labour. From the French of Julius Hatin, Doctor of Medicine of the Faculty of Paris, Profes- sor of Obstetrics and of the Diseases of Women and Chil- dren, &c. &c. By S. D. Gross, M. D. With an Appendix, Containing a Physiological Memoir upon the Brain. From the French of M. Magendie, by Joseph Gardner, M. D. In conformity to the act of the Congress of the United States, entitled " An act for the encouragement of learning, by secur- ing 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 se- curing the-copies of maps, charts, and books to the authors and proprietors of such copies during the times therein mentioned,' and extending th» benefits thereof to the arts of designing, en- graving, and etching historical and other prints." D. CALDWELL. Clerk of Vie Eastern District of Pennsylvania. TO THE MEDICAL. STUDENTS THROUGHOUT THE UNITED STATES, THE FOLLOWING PAGES, PREPARED CHIEFLY FOR THEIR USE, ARE RESPECTFULLY INSCRIBED. Philadelphia, September, 1828, ' I OF THE MANAGEMENT on PRETERNATURAL LABOUR. The management of preternatural labour has for its object the extraction of the foetus from the geni- tal parts of the mother. This extraction is sometimes performed exclu- sively by means of the hands; sometimes by the aid of blunt instruments, and sometimes again by means of operations performed upon the mother or the in- fant. From this simple exposition, it is obvious, that preternatural labours may be divided into three classes according to the manner in which they ter- minate. In the first two classes the parts are generally well formed, and the obstacle to the termination of the labour often depends on a defect of the relations which exist between the diameters of the pelvis of the mother and those of the foetus. From this it is evident, that it is of the utmost importance to dis- tinguish this kind of obstacle, and in order, there- fore, to afford the proper remedy for its removal, it is necessary that we should be possessed of a tho- 2 2 MANUAL OP OBSTETRICS. rough knowledge of all the details of the mechanism of natural labour. In order to be well acquainted with this mechan- ism, we should have an accurate knowledge of the interior parts of the osseous canal of the pelvis of the mother, and of the principal parts of the foetus at the full term of utero-gestation, such as the head, the shoulders, and the breech. It is, in fact, upon the relations which exist between these different parts that is based the mechanism of natural labour. PART 1. Of the Pelvis of the Mother. The pelvis is a kind of osseous canal, situated at the base of the trunk, between the vertebral column, which rests upon its middle and posterior part, and between the ossa femora, which are articulated with its antero-inferior parts. The pelvis is divided into an external surface, an internal surface, a base, and a summit. We shall treat here only of the internal surface, because it is the only one that is useful to be known in order to explain the mechanism of natural la- bour. The internal surface of the pelvis comprehends the great pelvis, the superior strait, the cavity of the pelvis, and the inferior strait. Great pelvis.—The great pelvis is divided into four regions, an anterior, a posterior, and two late- ral. •/Interior region.—The anterior region exists only MANUAL OP OBSTETRICS. 3 in the recent state, and is formed entirely by the parietes of the abdomen. Posterior region.—It presents in its middle the termination of the vertebral column, and laterally the marks of the sacro-iliac symphyses. Lateral regions.—They are formed by the inter- nal iliac fossa?, which are occupied in the recent state, by the psoae and iliac muscles. Dimensions of, the great pelvis. Width.—The width of the pelvis from one iliac crest to the other is about 10 inches; from one an- tero-superior spinous process to the other, about 9 inches, and from one antero-inferior spinous process to the other, about 8 inches. Depth.—From the middle of the iliac crest to the superior strait, about three inches and a half, and to the level of the antero-superior spinous process of the ilium, about three inches. Extent from behind forwards.—The extent of the great pelvis can not be determined in this di- rection, on account of the parietes of the abdomen, which are susceptible of more or less considerable extension. Superior strait.—This is the osseous border which separates the great from the small pelvis. Form.—It varies in its form, though most fre- quently it is elliptical. Dimensions.—The superior strait has four di- ameters, viz., an anteroposterior, which extends from the sacro-vertebral angle to the symphysis pubis; a transverse, which extends from one side of the pelvis to the other,and two oblique, which extend from the sacro-iliac symphysis of one side, to thelinea 4 MANUAL OF OBSTETRICS. ilio-pectinea of the opposite. The antero-posterior diameter measures four inches; the transverse, on the skeleton, five inches; but in the recent state it is about half an inch less on each side, in consequence of the presence of the psoas and iliac muscles; so that it really measures but four inches. The oblique diameters measure each four inches and a half. Inclination.—When the woman is in the erect posture, the superior strait is not situated horizon- tally, but its posterior part is much more elevated than its anterior; so that it is directed obliquely from above downwards, and from behind forwards, and presents an inclination from about 35 to 40 degrees. %flxis.—The axis of the superior strait may be re- presented by an imaginary line, which shall com- mence at the umbilicus, pass through the centre of the superior strait, and terminate at the inferior part of the sacrum. Cavity of the pelvis.—The cavity of the pelvis is divided into four regions, an anterior, a posterior and two lateral. interior region.—The anterior region is slight- ly concave from one side to the other, and presents the posterior part of the symphysis and body of the pubis; more externally and towards either side is the foramen thyroideum, which is filled up by the obturator internus muscle. Posterior region.—The posterior region is form- ed by the anterior face of the sacrum and os coccy- gis. It is concave and presents the transverse lines which indicate the place of union of the different pieces of which the sacrum and the os coccygis are composed. It presents also the anterior sacral for- amina which gives passage to the anterior sacral nerves. MANUAL OP OBSTETRICS. 5 Lateral regions.—The lateral regions are almost plane, being inclined from above inwards, and pre- senting the sciatic fissures, which, in the recent sub- ject, are converted into foramina by the sciatic liga- ments; a square surface corresponding to the aceta- bulum, and the spinous process of the ischium, which projects more within the pelvis than the parts which are situated before and behind it, and gives rise, on either side, to two inclined planes, an anterior and a posterior. During labour these inclined planes rotate the head of the child in such a manner as to carry its antero-posterior diameter ih the direction of the greatest diameter of the inferior strait. The anterior plane of one side enables the part of the head, which is directed in front, to glide under the arch of the pubes, while the posterior of the opposite side causes the part, which is directed backwards, to glide into the hollow of the sacrum. Dimensions of the Cavity of the Pelvis. Antero-posterior diameter.—This diameter ex- tends from the middle of the symphysis pubis to the middle of the sacrum, and measures about 5 inches, in consequence of the hollow of the sacrum which is about one inch deep. Transverse diameter.—Above the cavity of the pelvis, about 4h inches. This extent diminishes in proportion as we ap- ^ proach the inferior part of the pelvis. Depth.—The anterior paries measures about 18 lines; the posterior, without following the curve of the sacrum, Ah inches, and the lateral parietes 2h inches. Direction.—The cavity of the pelvis represents 2* 6 MANUAL OF OBSTETRICS. a canal which is considerably curved forwards, and cut perpendicularly to its axis at each extremity. Axis.— The axis of the cavity of the pelvis may be represented by a curved line which shall pass through the middle of the canal, so as to follow very nearly the curve of the sacrum. Inferior strait.—This is formed by the inferior opening of the pelvis. Its contour is osseous in front and upon the sides, while behind it is almost entirely ligamentous. Form.—Very irregularly rounded. Dimensions.—The inferior, like the superior strait, has four diameters; an antero-posterior, which extends from the point of the os coccygis to the in- ferior part of the symphysis pubis; a transverse diameter, whieh goes from one tuberosity of the is- chium to the other, and two oblique, which extend from the tuberosity of the ischium on one side, to the middle of the sacro-sciatic ligament of the op- posite. All these diameters are generally 4 inches in ex- tent; but the antero-posterior may be carried as far as 5 inches by the retrocession of the os coccygis. Direction of the inferior strait.—Its posterior part, as far as the tuberosities of the ischia, is in- clined downwards and backwards, while its anterior part is directed downwards and forwards. This last part constitutes what is called the arch of the pubes. Dimensions of the arch of the pubes. Width.—Superiorly, from 15 to 20 lines; in the middle 2\ inches, and inferiorly 4 inches. Height.—About 2 inches. Axis of the inferior strait.—The axis of the in- MANUAL OP OBSTETRICS. 7 ferior strait may be represented by an imaginary line which shall begin at the sacro-vertebral angle, and pass through the centre of this strait. OP THE PRINCIPAL PARTS OP THE F03TUS. The most important parts of the foetus that are concerned in labour, are the head, the shoulders, and the breech. But as an intimate knowledge ot these parts is not necessary to explain the mechan- ism of natural labour, we shall confine our attention merely to what relates to their form and volume. OF THE HEAD OF THE F03TUS. The head of the foetus, when separated from the trunk, is of an ovoid form, and slightly flattened in various directions. Division.—The head is generally divided into five regions and two extremities. The regions are the vertex or crown, the base, the face properly so called, and the temporal regions. The two extremities are represented, the one by the tubercle of the os occipitis, and the other by the chin. The vertex of the head presents some parts which are important to be known to the accoucheur. The principal are the anterior fontanelle, the sagittal su- ture, and the posterior fontanelle. The base of the cranium is never presented, un- less the head is separated from the trunk. The face, properly so called, is so well charac- terized that it is easily distinguishable. The temporal regions have sutures and fonta- 8 MANUAL OF OBSTETRICS. nelles, and when they present, they are particular- ly distinguishable by the presence of the ear. Dimensions of the head of the foetus. The head of the foetus presents five diameters and two circumferences. Of the five diameters. The first extends from the occiput to the chin, and is called the oblique or the occipito-mental diameter. Its extent is four inches and a half. The second extends from the occiput to the fore- head, and is called the occipito-frontal. Its extent is four inches and a quarter. The third extends from one parietal protuberance to the other, and measures three inches and a half. The fourth extends from the vertex of the head to the base of the cranium, and measures three inch- es and a half. The fifth extends from one mastoid process to the other, and measures from two and a half to three inches. Of the two circumferences. The first divides the head perpendicularly into two lateral hemispheres, and has an extent of from fourteen to fifteen inches. The second divides the head perpendicularly into two halves, an anterior and a posterior. The extent of this circumference is from ten to eleven inches. The head of the foetus is composed of two dis- tinct parts, one of which is superior and is called MANUAL OP OBSTETRICS. 9 the vault of the cranium, and the other, which is inferior, is termed its base. The vault of.the cranium is formed of osseous pieces, which are separated from each other by mem- branous intervals, some of which are denominated fontanelles, the others sutures. This disposition causes the vault of the cranium, when compressed, to diminish in volume by the approximation or over- lapping of the different bones of which it is com- posed. The base of the cranium is irreducible. Motions of the head upon the trunk. The head of the foetus may be flexed upon the superior part of the thorax, turned backwards, or inclined to either side. It may also perform a small degree of rotary motion. OF THE SHOULDERS OF THE FCETUS. The shoulders of the foetus, considered in an ob- stetric point of view, are only interesting as far as regards their volume. Measured transversely, they present a diameter of four inches and a half; but a considerable allow- ance should be made for their structure; for it may be remarked, that by simple pressure, the extent of this diameter may be diminished one inch. BREECH OP THE FCETUS. The breech of the foetus, like the shoulders, is only interesting in respect to its dimensions, though its volume, should it even be double, never presents 10 MANUAL OP OBSTETRICS. any real obstacle to the termination of the labour. It is composed of fourteen osseous pieces which are separated by cartilages, whose approximation may considerably facilitate the delivery. From the preceding observations, we may draw the following conclusions: 1. From the comparison of the diameters of the pelvis of the mother with those of the principal parts of the foetus; 2, from the different directions of the axes of the pelvis of the mother, and 3, from j the difference of the length between the anterior and posterior parietes. 1. The greatest diameters of the foetus exceed the smallest diameters of the pelvis of the mother; I but the greatest diameters of the latter exceed the 1 greatest diameters of the foetus; whence we ought to conclude, that, in order that the labour may terminate naturally, it is indispensable that the greatest diameters of the foetus should always cor- respond to the greatest diameters of the pelvis of the mother. 2. The longest diameters of the superior strait are the oblique, while in the inferior strait, the antero-posterior is the longest. From this it fol- lows, that the largest parts of the foetus, being situ- ated obliquely in the superior strait, must perform a rotary motion in order to be placed in a proper situation in the inferior strait. 3. The three axes of the pelvis represent a kind of curved line whose concavity corresponds to the pubis, and the convexity to the sacrum, and the foetus, in its progress, must necessarily follow this direction. 4. The posterior paries of the small pelvis, has j an extent of five inches, while the anterior paries 1 MANUAL OP OBSTETRICS. 11 is only eighteen lines long. This difference of length explains, why, in presentations of the vertex, where the occiput always'passes out first, the first two presentations are much more favourable than the last two; for, in the first case, the occiput, in order to pass out, has to traverse an extent of only eighteen lines, while, in the second, it is obliged to follow an extent of nearly five inches. OF THE MECHANISM OF NATURAL LABOUR. In natural labour, the foetus may present the head, the feet, the knees, or the breech. OF THE PRESENTATIONS OP THE HEAD. There are four presentations of the head, which correspond to the oblique diameters of the pelvis. FIRST REPRESENTATION. Principal relations.—The occiput corresponds to the left cotyloid cavity, and the forehead to the right sacro-iliac symphysis. The posterior region of the foetus presents forwards and to the left, and the anterior backwards and to the right. The feet are at the fundus uteri. Mechanism.—Pressed by the contractions of the uterus, the head of the foetus is flexed upon the thorax, and its occipito-mental diameter becomes parallel to the axis of the superior strait. In this manner, it traverses the whole cavity of the pelvis, until it has arrived at the inferior strait, where it encounters the inclined planes, which make it ro- tate in such a manner, that the occiput becomes placed under the arch of the pubes, and theiace in the hollow of the sacrum. As soon as this has taken 12 MANUAL OF OBSTETRICS. place, the greatest diameter of the head is in relation with the greatest diameter of the inferior strait, and nothing more is opposed to the delivery of the part of the foetus, unless it be the resistance of the external genital parts. Being continually pressed by the contractions of the uterus, the head gradually ad- vances, and in such a manner, as to dilate the vulva: after each pain, however, it re-ascends to a greater or less extent into the cavity of the pelvis. Finally, after the parturient efforts have overcome the re- sistance of the external genital parts, the head is delivered. At this moment, the occiput turns un- der the arch of the pubes, and the different parts of the face are brought in front of the posterior com- missure. As soon as the head is free, it assumes its natural relations with the trunk; the occiput is | directed towards the left groin, and the face to- | wards the postero-internal part of the right thigh. I In this movement of restitution, there is nothing I which should surprise us, since the trunk does not J participate in the rotary movement which the head is obliged to make, in order to pass the infe- rior strait.* The shoulders, being situated obliquely in the superior strait, traverse the cavity of the pelvis, and as soon as they have arrived at the inferior strait, they encounter the inclined planes, which impress upon them the same rotary movement as upon the head. The right shoulder is brought under the arch of the pubes, and theleft into the hollow of the sacrum. At this moment, the head changes its relations; the face looks directly towards the middle and in- * It has been observed, that at this instant the head, instead of , assuming the position which it had in the superior strait, some- times assumes the second position. MANUAL OF OBSTETRICS. 13 • ternal parj; of the right thigh, and the occiput to- wards the middle and internal part of the left thigh. The shoulder, which is posteriorly, receives all the contractions of the uterus, and soon passes through the vulva, while that which is under the pubes, serves it as a point of support. As soon as the shoulders are delivered, the rest of the body is expelled with a great degree of ra- pidity, which is easily explained by the fact, that the rest of the foetus is smaller, and that the passage or the mother has been previously dilated by the more voluminous parts. SECOND PRESENTATION. Principal relations.—The occiput corresponds to the right cotyloid cavity, and the face to the left sacro-iliac symphysis. The posterior region of the foetus presents forwards and to the right, and the anterior backwards and to the left. The feet are atv the fundus uteri. Mechanism.—The mechanism of the second pre- sentation is precisely the same as that of the first, with the exception, however, that the rotary mo- tions are performed in an inverse direction. THIRD PRESENTATION. Principal relations.—The occiput corresponds to the right sacro-iliac symphysis, and the fore- head to the left cotyloid cavity. The posterior re- gion of the foetus is directed backwards and to the ' right, and the anterior forwards and to the left. The feet are at the fundus uteri. Mechanism.—In its mechanism, the third pre- 3 14 MANUAL OF OBSTETRICS. , sentation of natural labour differs but little from that of the first, since the same diameters of the foetus correspond to the same diameters of the pelvis of the mother. As in the first presentation, therefore, the head, while in the superior strait, is flexed upon the tho- rax, and the occiput is the first part that gets into the cavity of the pelvis. As soon as the head has arrived at the inferior strait, it encounters the in- clined planes, which impress upon it a rotary mo- tion, in such a manner that the occiput glides upon the posterior and right lateral plane, in order to gain the hollow of the sacrum, while the face glides upon the anterior and left lateral inclined plane, in order to be placed under the arch of the pubes. In this situation, the occiput, receiving all the contractile impressions of the uterus, traverses the hollow of the sacrum, the os coccygis and the perineum, at the same time that the face ascends into the cavity of the pelvis, and is flexed to the utmost degree upon the thorax. The occiput soon after appears at the vulva, which it gradually dilates; and after each pain, it again mounts up into the cavity of the pelvis. Finally, the resistance of the-external genital parts being overcome, the occipital region of the head is delivered by following the axis of the inferior strait; but, as it soon after rests upon the posterior com- missure, it is turned backwards, and the different parts of the face are disengaged from below the sym- physis pubis. As soon as the head is free, it assumes its natural relations with the trunk; the occiput corresponds to the posterior and internal part of the right thigh, and the face to the left groin. The shoulders, being situated obliquely in the MANUAL OF OBSTETRICS. 15 superior strait, traverse the cavity of the pelvis, and after having arrived in the inferior strait, they en- counter the inclined planes, which impress upon them a rotary motion. The right shoulder is placed in the hollow of the sacrum, and the left under the arch of the pubes. The head at the same time changes its relations: the face presents directly to the middle part of the left thigh, and the occiput to that of the right thigh. The shoulder, which is posteriorly, receives the contractile impressions of the uterus, and is the first that is delivered, while that which is under the pu- bes serves as a fulcrum. When the shoulders are delivered, the rest of the foetus passes without difficulty. Remark.—This third presentation is sometimes naturally converted into the second, and takes place, when the rotary motion, which is impressed upon the foetus, is properly directed. FOURTH PRESENTATION. Principal relations.—The occiput corresponds to the left sacro-iliac symphysis, and the face to the right cotyloid cavity. The posterior region of the foetus is directed backwards and to the left, and the anterior forwards and to the right. The feet are at the fundus uteri. Mechanism.—The mechanism of the fourth pre- sentation is exactly the same as that of the third, with the exception, that the rotary motions are per- formed in an inverse direction. Remark.—This presentation may be converted naturally into the first. 16 MANUAL OF OBSTETRICS. PRESENTATIONS OF THE FEET. The feet may present in four principal positions, which correspond to the oblique diameters of the pelvis. In these presentations, the foetus is placed in such a manner that the thighs are flexed upon the pelvis, and the legs upon the thighs, while the heels are applied against the breech. FIRST PRESENTATION. Principal relations.—The heels correspond to the left cotyloid cavity, and the toes to the right sacro-iliac symphysis. The posterior region of the foetus is directed forwards and to the left, and the anterior backwards and to the right. The head is at the fundus uteri. Mechanism.—Pressed by the contractions of the uterus, the feet pass without difficulty the cavity of the pelvis and the inferior strait. The breech soon arrives at the inclined planes and experiences a ro- tary motion, by which the left hip is placed under the pubes, and the right in the hollow of the sacrum. (This rotary motion, however, can not take place when the pelvis of the mother has only a certain size, and in this case the breech passes obliquely.) The hip, which is posteriorly, receives all the con- tractile impressions of the uterus, and passes out first, while that which is superiorly serves as a ful- crum. As soon as the breech has passed, it insen- sibly assumes the position which it had before its arrival'at the inclined planes. The shoulders are situated obliquely in the su- perior strait, at the same time that the arms are ar- rested in such a manner as to mount upon the lateral MANUAL OF OBSTETRICS. 17 parts of the head, and as soon as they have arrived in the inferior strait, they are placed in a direct position, and the one which is posteriorly escapes first. The head, while in the superior strait, is placed in an oblique direction, and the chin is flexed upon the thorax. No sooner has it arrived in the inferior strait, than it experiences its rotary motion; the face is placed in the hollow of the sacrum, and the occi- put under the arch of the pubes. In this situation the chin traverses all the hollow of the sacrum, the os coccygis, and the perineum, and soon appears at the vulva. The different points of the face are disengaged anteriorly to the posterior commissure, and the oc- ciput is the only part that remains to escape. SECOND PRESENTATION OF THE FEET. Principal relations.—The heels correspond to the right cotyloid cavity, and the toes to the left sacro-iliac symphysis. The posterior region of the foetus is directed forwards and to the right, and the anterior backwards and to the left The head is at the fundus uteri. Mechanism.—The mechanism of the second pre- sentation of the feet is precisely the same as that of the first, except that the rotary motions are perform- ed in an inverse direction. THIRD PRESENTATION OF THE FEET. Principal relations.—The heels correspond to the right sacro-iliac symphysis, and the toes to the left cotyloid cavity. The posterior region of the 18 MANUAL OF OBSTETRICS. foetus is directed backwards and to the right, and the anterior forwards and to the left. The head is at the fundus uteri. Mechanism.—The mechanism of this third pre- sentation differs but little from that of the first, since the same diameters of the foetus correspond to the same diameters of the pelvis of the mother. The feet being pressed by the contractions of the uterus, pass without difficulty the cavity of the pel- vis and the inferior strait; and the breech, having reached the inclined planes, assumes a straight po- sition, or else, if the pelvis of the mother be very large, it passes obliquely. The shoulders pass ob- liquely through the superior strait, and upon their arrival in the inferior, they assume a straight posi- tion. The head is situated obliquely in the superior strait, and the chin is flexed upon the thorax; and no sooner has it arrived in the inferior strait than it receives a rotary motion, by which the occiput is placed in the hollow of the sacrum and the face un- der the arch of the pubes. In this situation the occiput traverses the hollow of the sacrum, the os coccygis, and the perineum, while the face mounts-up into the pelvis. In a short time, however, the neck, resting upon the posterior commissure, is turned backwards, and the face is de- livered. The occiput is the last to escape. Remark.—The spiral motion which is impressed upon the breech, upon its arrival in the inferior strait, may be sufficiently strong to convert this presentation into the second. This conversion is favourable to the termination of the labour. MANUAL OF OBSTETRICS. 19 FOURTH PRESENTATION OF THE FEET. Principal relations.—The heels correspond to the left sacro-iliac syntphysis, and the toes to the right cotyloid cavity. The posterior region of the foetus is directed backwards and to the left, and the anterior forwards and to the right. The head is at the fundus uteri. Mechanism.—The same as in the third presenta- tion, except that the rotary motions take place in an inverse direction. Remark.—This fourth presentation may be con- verted naturally into the first. PRESENTATIONS OF THE KNEES. The knees, like the feet, may present in four principal positions which correspond to the* oblique diameters of the pelvis. The foetus is disposed in such a manner, that the legs are flexed upon the thighs, while these are extended upon the pelvis. FIRST PRESENTATION. Principal relations.—The anterior part of the legs corresponds to the left cotyloid cavity, and the anterior part of the thighs to the right sacro-iliac symphysis. The posterior region of the1 foetus is directed forwards and to the left, and the anterior backwards and to the right. > SECOND PRESENTATION. Principal relations.—The anterior part of the legs corresponds to the right cotyloid cavity, and the anterior part of the thighs to the left sacro-iliac 80 MANUAL OF OBSTETRICS. symphysis. The posterior region of the foetus pre- sents forwards and to the right, and the anterior back- wards and to the left. THIRD PRESENTATION. Principal relations.—The anterior part of the legs corresponds to the right sacro-iliac symphysis, and the anterior part of the thighs to the left cotyloid cavity. The posterior region of the foetus looks backwards and to the right, and the anterior for- wards and to the left. FOURTH PRESENTATION. Principal relations.—The anterior part of the legs corresponds to the left sacro-iliac symphysis, and the anterior part of the thighs to the right coty- loid cavity. The posterior region of the foetus pre- sents backwards and to the left, and the anterior for- wards and to the right. MECHANISM OF THE FOUR PRESENTATIONS OP THE KNEES. The mechanism of the four natural presentations of the knees, is precisely the same as that of the corresponding presentations of the feet, except that the knees present first. PRESENTATIONS OP THE BREECH. The breech, like the feet and the knees, has four presentations. The foetus is disposed in such a man- ner that the thighs and the legs are raised and ap- plied against the anterior surface of the trunk. MANUAL OF OBSTETRICS. 21 FIRST PRESENTATION. Principal relations.—The posterior part of the sacrum corresponds to the left cotyloid cavity, and the posterior part of the thighs to the'right sacro- iliac symphysis. The posterior region of the foetus is directed forwards and to the left, and the anterior backwards and to the right. The head is at the fundus uteri. SECOND PRESENTATION. Principal relations.—The posterior part of the sacrum corresponds to the right cotyloid cavity, and the posterior part of the thighs to the left sacro- iliac symphysis. The posterior region of the foetus is directed forwards and to the right, and the ante- rior backwards and to the left. The head is at the fundus uteri. THIRD PRESENTATION. Principal relations.—The posterior part of the sacrum corresponds to the right sacro-iliac symphy- sis, and the posterior part of the thighs to the left cotyloid cavity. The posterior region of the foetus is directed backwards and to the right, and the an- terior forwards and to the left. The head is at the fundus uteri. FOURTH PRESENTATION. Principal relations.—The posterior part of the sacrum corresponds to the left sacro-iliac symphy- sis, and the posterior part of the thighs to the right cotyloid cavity. The posterior region of the foetus 22 MANUAL OP OBSTETRICS. is directed backwards and to the left, and the ante- rior forwards and to the right. The head is at the fundus uteri. MECHANISM OF THE FOUR PRESENTATIONS OF THE BREECH. The breech, being situated obliquely in the supe- rior strait of the pelvis, gradually passes into the in- ferior, where it receives a rotary motion, by means of which, one of the hips is placed in the hollow of the sacrum, and the other under the arch of the pubes. The hip, which is posteriorly, is the one that is first disengaged, while that, which is under the pubes, serves it as a point of support. The trunk passes without difficulty, though the inferior ex- tremities are flexed upon its anterior regions. The axillaj present obliquely in the superior strait; the arms are raised against the sides of the head, and the rest of the delivery terminates precisely in the same manner as" in the corresponding presentations of the feet. MANUAL OP OBSTETRICS. 23 PART II. OF THE MANAGEMENT OF PRETERNATURAL LABOURS. SECTION I. OF THE LABOURS WHICH TERMINATE BY MERE MANUAL ASSISTANCE. General causes which should induce us to act. On the part of the mother.—Inertia of the ute- rus, hemorrhage, convulsions,prostration of strength, syncope, great obliquity of the uterus, an aneurism, a strangulated hernia, &c. On the part of the infant.—The escape of the umbilical cord, its shortness or twisting around the foetus, and the presence of several infants in the uterus, &c. Position of the woman. —The woman should be placed on her back with the breech elevated and well covered; and the thighs and legs should be demi-flexed and properly separated. Assistants are directed to keep her in this position. Rules for introducing the hand.—The hand should be well lubricated with some oleaginous sub- stance, which renders the introduction less painful and protects the accoucheur against the virus with which the parts of the woman may be infected. The hand should present the least possible volume, and,in order to effectthisobject, the thumband fingers 24 MANUAL OF OBSTETRICS. should be united in such a manner as to form a kind of cone, the apex of which shall correspond to the extremities of the fingers. In introducing tlje hand, it should be strongly pronated; but in proportion as it enters the parts, it must be brought to a state of supination, so as to follow the direction of the two axes of the pelvis. The accoucheur should introduce the hand into the vagina during a labour pain, and when this has gone off, he should penetrate the os tinea?. In endeavouring to enter the os tinea?, the fundus uteri should be steadied by the other hand, which is to be placed upon the abdomen. In this manner the woman is spared from much unnecessary pain. PBESENTATIONS OF THE FEET. The feet present in four principal positions, which correspond to the oblique diameters of the pelvis. We have given a detailed account of them in the article on natural labour. The foetus may be delivered in any one of these four presentations; but as the termination in the first and second is more favourable, and as the foetus may al- ways be brought to these two presentations, we should never neglect doing so. Characteristic marks of the feet.—The articu- lation of the foot with the leg at a right angle, the heels, the small length of the toes, the convexity of the dorsal region, the inverse disposition of the plantar, and the projection of the maleoli, are the marks by which we may always readily distinguish the feet. General rules for introducing the hand.—The MANUAL OF OBSTETRICS. 2.5 hand should always be preferred that corresponds naturally to the heels. Or rather, when the heels present to the left of the pelvis, the right hand should be introduced, and when to the right, the left hand. When they present to the pubis or sacrum, either hand may be introduced; and when the proper choice has been made, the hand that is introduced must decide the position in which the labour is to be accomplished. FIRST PRESENTATION OF THE FEET. Principal relations.—The heels correspond to the left cotyloid cavity, and the toes to the right sacro-iliac symphysis. Characteristic signs of the presentation.—The simple direction of the feet is sufficient to indicate the position in which they are presented. Thus, in the first presentation, the plantar face is extended obliquely in the direction of a line, which,.com- mencing at the left cotyloid cavity, terminates at the right sacro-iliac symphysis. The heels are an- teriorly and the toes posteriorly. Management.—It is the same in the two straits of the pelvis. The accoucheur grasps the feet behind, and places his index finger between them. If one foot only presents, he should search for the other, so that he may extract both at the same time. When the feet are delivered, he should be con- vinced that they belong to the same infant; and having satisfied himself of this, he wraps them in a piece of cloth in order to prevent his fingers from slipping. He now grasps the left limb with the 16 MANUAL OF OBSTETRICS. left hand, and the right with the right hand, tak- ing care to place the thumbs upon the posterior part of the legs and the fingers upon the anterior part: in this manner the limbs are kept in contact, and afford a mutual support. The legs and the thighs must be delivered in succession by pulling them in the direction of the axis of the superior strait, and the cloth and the hands must be moved in proportion. When the breech has arrived in the inferior strait, the accoucheur must raise it, in order to disengage the hip which is posteriorly; and this being done, he passes the right hand beneath the thighs of the foetus, to raise it a little towards the left groin. He now passes the index and middle fingers of his left hand along the belly of the infant, to assure himself of the safety of the cord. If this has been stretch- ed, it should be relaxed by pulling at the portion which is attached to the placenta, and if it is placed between the two thighs, the upper one ought £o be flexed, so that it may be relaxed, and, if possible, brought back to its proper place. If the cord can not be relaxed, the accoucheur should divide it and terminate the labour. After the cord has been secured, the accoucheur applies his left hand upon the left hip, and his right upon the right hip, and alternately elevates and de- presses the foetus in the direction of a line, which, commencing at the right groin, terminates at the posterior and internal part of the left thigh. In this manner he removes the trunk as far as the ax- illa?; and when these appear at the vulva, the ac- coucheur elevates the foetus towards the right groin, and holds it firmly with his left hand, in order to extract the right arm, which he accomplishes in the MANUAL OF OBSTETRICS. ^7 following manner:—He begins by introducing the thumb of the right hand into the anterior commis- sure of the vulva, and carries it to the posterior part of the shoulder; then, introducing the index and middle fingers of the same hand into the posterior commissure and carrying them in front of the ar- ticulation, he pulls it in a direction parallel to the axis of the trunk. By passing the index and mid- dle fingers afterwards to the back part of the arm, and the thumb into the axilla, he causes the limb to traverse the hollow of the sacrum, and disengages it from the opposite side, by flexing the forearm up- on the arm and by traversing successively every part as far as the extremities of the fingers. At this moment, it is proper to incline the foetus to the left of the woman, in order that the delivery of the arm may be more easily effected. The right extremity being delivered, it is to be placed against the corresponding side of the trunk, while the foetus, being supported on the right hand, is depressed towards the posterior and internal part of the left thigh of the mother, by pressing upon the left hip. This being done, the accoucheur de- presses the limb that remains to be disengaged, by- grasping it between the index finger which is car- ried behind, and the thumb which is placed in the axilla; then, without leaving his hold, he depresses the index finger as far as possible, and makes the limb, which is disengaged in the same manner as the preceding, traverse the hollow of the sacrum. The two superior extremities being delivered, the accoucheur introduces his right hand as far as the face of the foetus, and places two fingers on each side of its nose, at the same time that he carries the index and middle fingers of the left hand along the back 2S MANUAL OF OBSTETRICS. of the infant as far as the occiput; then, drawing it with the hand placed upon the face, at the same time that he pushes it, with the two fingers placed on the occiput, he thus flexes the head upon the chest. Then, without deranging his hands, he pulls the head of the foetus into the inferior strait, follow- ing the direction of the superior strait. He now places the index and middle fingers of the left hand transversely upon the mastoid process of the right side, and the same fingers of the right hand trans- versely upon the left side of the chin, and rotates the head; then, elevating and moving it from side to side, in order to direct it in the direction of the axis oftheinferiorstrait,hedisengagesit. Just as the foetus is upon the point of issuing, the accoucheur carries his left hand in front of the perineum and below the head, and supports these two parts. He glides at the same time his right hand upon the breech of the foetus, and, when the delivery is completed, he places it across the genital parts. SECOND PRESENTATION OF THE FEET. Principal relations.—The heels correspond to the right cotyloid cavity, and the toes to the left sacro-iliac symphysis. Characteristic signs of the presentation.—The soles of the feet present obliquely in the direction of a line, which, commencing at the right cotyloid cavity, terminates at the left sacro-iliac symphysis. The heels are anteriorly, and the toes posteriorly. Extraction of the foetus.—In the second presen- tation, we must proceed precisely in the same man- ner as in the first, with this exception, that every thing is done in an inverse order. Thus, the accoucheur seizes the two feet with the MANUAL OP OBSTETRICS. -_]i) left hand, and draws them out of the vulva, and this being done, he wraps them in a piece of cloth, and grasps the left limb with the left hand, and the right with the right hand. When the breech is about to pass, the foetus should be raised, in order to disengage the posterior hip. The left hand is now to be passed in front of the thighs, so that the foetus may be raised towards the right groin; then, with the index and middle fingers of the right hand, he should ascertain the situation of the umbilical cord. This done, the accoucheur carries his right hand upon the right hip, and the left upon the left hip, and alternately elevates and depresses the trunk, in the direction of a line, which, commenc- ing at the left groin, terminates at the postero-inter- nal part of the right thigh: these motions should be continued until the axilla? have arrived at the vulva. Then, securing the foetus upon the right hand, and keeping it elevated towards the left groin, he should proceed to deliver the other limb. Supporting the foetus upon his left hand, and depressing it towards the postero-internal part of the right thigh, he dis- engages the superior limb; then, gliding the left hand upon the face, and the first two fingers of the right hand upon the occiput, he flexes the head, and brings it into the inferior strait. This being done, he places the first two fingers of the right hand across the left mastoid process, and the same fingers of the left hand upon the right side of the chin, and rotates the head; and then by elevating and moving it late- rally, he disengages it. When the head is about to escape, he should carry the right hand in front of the perineum, and the left upon the breech; and when the delivery is accomplished, he should lay the infant across the parts of generation. 30 MANUAL OF OBSTETRICS. THIRD PRESENTATION OF THE FEET. Principal relations.—The heels correspond to the right sacro-iliac symphysis, and the toes to the left cotyloid cavity. Characteristic signs of the presentation.—The soles of the feet present in the direction of a line, which, commencing at the right sacro-iliac sym- physis, terminates at the left cotyloid cavity. The heels are posteriorly, and the toes anteriorly. Management.—The management of this presen- tation, is precisely the same as that of the preceding, with the exception, however, that, in proportion as the foetus advances, it ought to be brought to the second presentation. Remark.—If the accoucheur arrives, after a part of the trunk has already been delivered, he should apply his right hand upon the belly of the fcetus, and the left upon the back, and should proceed in such a manner as to bring the infant to the second presentation. FOURTH PRESENTATION OF THE FEET. Principal relations.—The heels correspond to the left sacro-iliac symphysis, and the toes to the right cotyloid cavity. Characteristic signs of the presentation.—-The direction of the soles of the feet is obliquely from behind forwards, and from left to right. Management.—The accoucheur grasps the feet with his right hand, and draws them out; and this being accomplished, he grasps the right foot with the right hand, and the left with the left hand, and MANUAL OF OBSTETRICS. 31 in proportion as the parts advance, he reduces them to the first presentation. Remark,—If the trunk has already been, in part, delivered, the accoucheur should place his left hand upon the abdomen of the child, and the right upon the back; the presentation should be remedied, and in proportion as the child advances, it should be reduced to the first. 1. The heels may correspond directly to either side of the pelvis, as has been admitted by Baude- locque. In these presentations, we should conform to the general rules for introducing the hand. If the heels be to the right of the pelvis, it is necessary to introduce the left hand and to bring them to the se- cond presentation; but if they present to the left, we should introduce the right hand and reduce them to the first presentation. II. In the presentations where the heels corres- pond to the pubis or the sacrum, either hand may be introduced; but then the one that is used is to decide the position in which the labour is to be completed. By introducing the right hand, the heels may be brought to the left of the pelvis, so as to be converted into the first presentation; but if the left hand be introduced, the heels must be brought to the right of the pelvis, and be converted into the second presentation. Remark.—In these preternatural presentations, where the trunk is already, in part, delivered, we must endeavour to push it up by placing ojje hand under the belly and the other upon the back, so as to bring the foetus to a diagonal position in propor- tion as it advances. In case the whole trunk has passed the neck of the uterus, and the head alone remains in the supe- 32 MANUAL OF OBSTETRICS. rior strait, it will be impracticable to push it up. The arms, therefore, should be extracted as in ordi- nary cases, provided the anterior region of the foetus presents towards the sacrum; but, should this not be the case, they must be brought under the arch of the pubes. This being done, the head should be turned in a diagonal position, by placing two fingers upon the mastoid process of one side, and two others upon the opposite side of the chin. The head should now be brought down into the inferior strait, and the rest of the labour must be conducted in the same manner as in the corresponding presentations of the feet. RECAPITULATION OF THE DIFFERENT MANAGE- MENTS APPLICABLE TO THE PRESENTATION'S OF THE FEET. I. In the first and fourth presentations, and in that where the heels correspond directly to the left side of the pelvis, the management is precisely the same. In fact, the heels being always to the left, the accoucheur should invariably use the right hand, and terminate the labour by the first presen- tation. II. In the second and third presentations, and in that where the heels correspond directly to the right side of the pelvis, the management is precise- ly the same: indeed, we should always use the left hand and deliver by the second presentation. III. When the heels correspond to the sacrum or the pubis, either hand may be introduced. The feet should always be grasped from behind, and the index finger placed between them. In every MANUAL OF OBSTETRICS. 33 presentation we should grasp the feet as soon as they are delivered, the right with the right hand, and the left with the left hand; and the posterior limb should always be delivered first. PRESENTATIONS OP THE KNEES. The knees, like the feet, present in the superior and inferior straits, in four principal positions which correspond to the oblique diameters of the pelvis. These positions have already been pointed out in speaking of the mechanism of natural labour. Characteristic marks of the knees.—The knees present under the form of two rounded tumours, which are hard and much larger than the elbows, the only parts with which they can be confounded. These two tumours are usually placed beside each other. If there be any doubt, however, the fingers should be introduced farther up, and the examina- tion of the neighbouring parts will soon convince us of the diagnosis. As the management is not the same in both straits, we shall speak first with regard to that of the infe- rior strait, PRESENTATIONS OF THE KNEES AT THE INFERIOR STRAIT. The knees, when in the inferior strait, may be extracted, 1st, with the aid of the fingers placed in the popliteal fold; 2d, with the aid of a blunt hook, and 3d, by means of a fillet. The application of the fingers alone is seldom suf- ficient. 34 MANUAL OF OBSTETRICS. The blunt hook is more convenient, but it terri- fies the woman, and should, therefore, be avoided. The fillet answers the purpose of the blunt hook, and is not attended with the same inconveniences. General rules in relation to the fillet.—In the first and fourth presentations, the fillet should be placed in the" right hand, and in the second and third, in the left hand. The fillet should be applied to the popliteal fold of the anterior leg; or, if the hams be directed the one to the right and the other to the left, either hand may be introduced, and one only is necessary for its application. When the fillet is fixed, it represents the extremi- ty which it embraces, and should always be grasped with the hand that corresponds to that extremity by name. FIRST PRESENTATION OF THE KNEES AT THE INFE- RIOR STRAIT. Principal relations.—The anterior part of the legs corresponds to the left cotyloid cavity, and that of the thighs to the sacro-iliac symphysis. Management.—The accoucheur fixes the fillet upon the apex of the right index finger, and carries it from above .downwards-in the fold of the ham which is superiorly, draws it, with the thumb and in- dex finger of the same hand, between the two knees, and forms its extremities into two, nearly equal, heads. These heads should be firmly secured in the palm of the left hand by the last three fingers, while the index finger is extended upon the external part of the thigh which is above. The index finger of MANUAL OF OBSTETRICS. 35 the opposite hand should be carried upon the exter-, nal side of the limb which is below. The knees are to be brought down, in the direc- tion of the axis of the superior strait, as soon as they are sufficiently disengaged to be grasped by the hand. The fillet is now to be removed, and the thumbs are placed upon the anterior part of the legs, and the fingers upon the anterior part of the thighs. As soon as the breech appears at the vulva, the foetus is to be elevated, in order to disengage the posterior hip; and the feet, being afterwards brought under the arch of the pubes, are delivered by flexing the thighs upon the pelvis. When the feet are delivered, the labour is to be finished as in the first presentation of the feet. SECOND PRESENTATION OF THE KNEES AT THE IN- FERIOR STRAIT. Principal relations.—The anterior part of the legs corresponds to the right cotyloid cavity, and the anterior part of the thighs to the left sacro-iliac symphysis. Management.—The fillet is to be introduced with the left and grasped by the right hand, and the index finger of the other hand should be placed along the inferior limb. The delivery of the knees is afterwards effected in the manner already point- ed out. When the feet are disengaged, the pre- sentation is to be converted into the second presen- tation of the feet. 36 MANUAL OF OBSTETRICS. THIRD PRESENTATION OF THE KNEES AT THE INFE- RIOR STRAIT. Principal relations.—-The anterior part of the legs corresponds to the right sacro- iliac symphysis, and the anterior part of the thighs to the left coty- loid cavity. Management.—The fillet is to be introduced with the left hand, and, as it embraces the right ham, it must be grasped with the right hand. The left in- dex finger is placed behind, and the delivery of the knees is to be conducted in such a manner that they may be brought to the second presentation. When the feet are disengaged, the labour is to be accom- plished in the same manner as in the second pre- sentation of the feet. FOURTH PRESENTATION OF THE KNEES AT THE IN- FERIOR STRAIT. Principal relations.—The anterior part of the legs corresponds to the left sacro-iliac symphysis, and the anterior part of the thighs to the right co- tyloid cavity. Management.—The fillet is introduced with the right hand, and as it embraces the left ham, it must be grasped with the left hand. The index finger of the right hand is extended upon the pos- terior limb, and the knees are drawn down and brought to the second presentation. When the feet are delivered, the labour is to be conducted as in the first presentation of the feet. 1. When the anterior part of the legs corresponds directly to the left side of the pelvis, the accou- cheur must introduce the fillet with the right hand, MANUAL OF OBSTETRICS. 37 grasp it with the left, and convert the presentation into the first. 2. When the anterior part of the legs corresponds directly to the right side of the pelvis, the ac- coucheur is obliged to introduce the fillet with the left hand, grasp it with the right, and convert the presentation into the second. 3. When the anterior part of the legs corresponds directly to the pubis or the sacrum, the accoucheur may introduce the fillet with either hand, and con- vert the presentation into the first or second. RECAPITULATION OF THE DIFFERENT MANAGE- MENTS APPLICABLE TO THE PRESENTATIONS OF THE KNEES AT THE INFERIOR STRAIT. 1. In the first and fourth presentations, and in that where the anterior part of the legs corresponds to the left side of the pelvis, the management is the same; for in all these presentations, the accoucheur introduces the fillet with the right hand, grasps it with the left, and finishes the labour by the first presentation. 2. In the second and third presentations, and in that where the anterior part of the legs corresponds directly to the right side of the pelvis, the manage- ment is precisely similar; for in all these presenta- tions, the accoucheur introduces the fillet with the left hand, grasps it with the right, and converts the presentations into the second. 3. In the presentations where the anterior part of the legs corresponds to the pubis or the sacrum, the fillet is introduced with either hand, and the foetus is brought to the first or second presentation. 5 38 MANUAL OF OBSTETRICS. PRESENTATIONS OF THE KNEES AT THE SUPERIOR STRAIT. In these presentations, it is preferable to bring down each foot separately, and to accomplish the delivery as in the presentations of the feet. Choice of the hand.—When the feet are to the left of the pelvis, the accoucheur introduces the right hand. When they present to the right, he introduces the left hand. When they present to the pubis or the sacrum, he may use either hand. Rules for delivering the Feet. The accoucheur should always first examine the member which is behind, but he should extract that first which is superiorly. When the posterior limb is delivered first, it is to be used as a guide in searching for the other; but when this has been extracted first, we must again traverse the limb which is situated behind in order to disengage it. This general rule being applicable to all cases of delivery of the feet, we shall not again revert to it. FIRST PRESENTATION OF THE KNEES AT THE SU- PERIOR STRAIT. Principal relations.—The same as at the inferior strait, only that the parts are less engaged. Management.—The accoucheur introduces the < right hand as far as the posterior limb, carries it along the thigh to the knee, and from thence along * MANUAL OF OBSTETRICS. 39 the leg until he meets the foot, which he grasps be- tween the thumb and the fingers and draws it out. The first limb being delivered, it should be used as a guide in searching for the other. Passing his hand along its postero-external side, the accoucheur takes care to apply his thumb to the internal part, and carrying it up as far as the breech, where he meets the other extremity, he draws it down by passing his four fingers to its upper part, and by pressing upon the extremity that has been already delivered. The two extremities being delivered, the labour is finished by bringing the foetus to the first presen- tation of the feet. SECOND PRESENTATION OP THE KNEES AT THE SUPE- RIOR STRAIT. Principal relations.—The same as at the inferi- or strait. Management.—The accoucheur introduces the left hand and brings down the feet precisely in the same manner as in the first presentation; and, as soon as the feet are delivered, he finishes the labour by bringing the child to the second presentation of the feet. THIRD PRESENTATION OP THE KNEES AT THE SUPE- RIOR STRAIT. I Principal relations.—The same as at the inferior strait. Management.—The accoucheur, introducing his left hand, delivers the feet in the same manner as in the second presentation; and as soon as this is ac- complished, he will find the presentation converted 40 MANUAL OF OBSTETRIC S. into the third presentation of the feet, which must be reduced to the second. FOURTH PRESENTATION OF THE KNEES AT THE SU- PERIOR STRAIT. Principal relations.—The same as at the inferior strait. Management.—The accoucheur, introducing the right hand, delivers the extremities, precisely in the same manner as in the first presentation, and this being done, he converts it into the fourth pre- sentation of the feet, and this into the first. I. When the anterior part of the legs corres- ponds directly to the left side of the pelvis, the ac- coucheur introduces the right hand, and delivers the feet in the same manner as in the first and fourth presentations.—The labour is completed by bringing the foetus to the first presentation of the feet. II. When it corresponds directly to the right side, the accoucheur introduces the left hand, and pro- ceeds as in the second and third presentations.—The labour is finished by bringing the foetus to the se- cond presentation of the feet. III. When the anterior part of the legs corres- ponds to the sacrum or pubis, the accoucheur may introduce either hand, with this provision, that the 'one which he uses must determine the position in which the labour is to be completed. Thus, when the right hand is introduced, the accoucher should turn the feet of the foetus to the left side of the pel- vis, and vice* versd. MANUAL OF OBSTETRICS, 41 RECAPITULATION OF THE DIFFERENT MANAGE- MENTS APPLICABLE TO THE PRESENTATIONS OF THE KNEES AT THE SUPERIOR STRAIT. 1. In the first and fourth presentations, and in that where the anterior part of the legs corresponds directly to the left side of the pelvis, the manage- ment is precisely the same; for in all these presen- tations, the feet being to the left, the accoucheur must always introduce the right hand, and bring the foetus to the first presentation of the feet. 2. In the second and third presentations, and in that where the anterior part of the legs corresponds directly to the right side of the pelvis, the manage- ment is precisely the same. For in all these pre- sentations, the feet being to the right, the accou- cheur introduces the left hand, and brings the foetus to the second presentation of the feet. 3. In the presentations where the anterior part of the legs corresponds to the pubis or the sacrum, the accoucheur may introduce either hand, and bring the foetus to a diagonal position, in order to proceed in the same manner as in that presentation. PRESENTATIONS OF THE BREECH. The breech, like the feet and the knees, presents at the superior and inferior straits in four principal positions, which correspond to the oblique diame- ters of the pelvis. These presentations, having been already pointed out in speaking of the mechanism of natural labour, need not, therefore, be treated of on the present occasion. 5* 42 MANUAL OF OBSTETRICS. Characteristic marks ofthebreech.—The breech may be known by a large rounded tumour, which is softer than the head, and harder than the abdo- men, and presents three osseous projections, which are formed by the os coccygis behind, and by the tuberosities of the ischia on either side, and in the middle a deep groove, in which are the anus and the genital organs. The accoucheur may be still farther aided in his diagnosis, by the two columns which are formed by the thighs, and by a discharge of meconium. The management not being the same in both straits, we shall treat first of the presentations of the inferior strait. PRESENTATIONS OP THE BREECH AT THE INFERIOR STRAIT. When the breech presents at the inferior strait, it is almost always impossible to push it up into the uterus, and the accoucheur is obliged to extract it in the position in which it presents. To effect this, the accoucheur may employ his hands, a fillet, or the blunt nooks, whTfch are to be placed in the folds of the groins. As the blunt hooks generally deserve the prefer- ence, we shall point out those presentations which demand the employment of instruments; though, strictly speaking, the breech may be extracted either by means of the fingers alone, or with the aid of a fillet. MANUAL OP OBSTETRICS. 43 Rules for the application of the fingers, the fillet, and the blunt hooks. Fingers.—If the accoucheur determines on using his fingers, he should invariably place the right in- dex finger in the fold of the right groin, and the left in the fold of the left groin. But as the fingers generally glide upon the parts which they embrace, a sufficiently firm hold can not be obtained for the extraction of the breech. Fillet.—If the accoucheur employs the fillet, he should place it in the fold of the anterior groin. In the first and fourth presentations, it is to be car- ried there with the index finger of the right hand, and in the second and third, with that of the left hand. When the fillet is applied, it represents the ex- tremity which it embraces, and should be invaria- bly grasped with the hand that corresponds to that extremity by name. The introduction of the fillet is attended with much difficulty, and is, therefore, seldom employed in extracting the breech. Blunt hooks.—When two blunt hooks are to be used, they are applied the one in the fold of the an- terior groin, and the other in the fold of the poste- rior; but as a general rule, one is sufficient, and is invariably applied in the fold of the anterior groin. The blunt hook to be used should form a right an- gle with its handle; so that there may be no danger of its penetrating the thigh, a circumstance which might happen, if the curve of the instrument be too narrow to surround the whole limb. It is of little importance with which hand the 44 MANUAL OP OBSTETRICS. blunt hook be introduced; though in the first and fourth presentations, it is preferable to use the right, and the left in the second and third. The index finger of one hand should always be used as a guide to the hook, in order that its intro- duction may be the more safe and easy. When the hook is secured, it represents the ex- tremity which it embraces, and should always be grasped with the hand that corresponds to that ex- tremity by name. FIRST PRESENTATION OF THE BREECH AT THE IN- FERIOR STRAIT. Principal relations.—The posterior face of the sacrum corresponds to the left cotyloid cavity, and that of the thighs to the right sacro-iliac symphysis. Characteristic signs of the presentation.—The point of the os coccygis is behind the left cotyloid cavity, and the genital parts before the right sacro- iliac symphysis. Between these two points are the anus and the perineal raphe, which present in the direction of a line that passes from the left cotyloid cavity to the right sacro-iliac symphysis. Management.—The accoucheur applies the blunt hook in the fold of the left groin, and grasps it with his left hand; and then gliding the index finger of the right hand in the fold oTthe posterior groin, he pulls the breech in the direction of the axis of the inferior strait; and as soon as the parts have ad- vanced so far as to enable him to use his hands, he removes the instrument. The accoucheur then ap- plies the left hand to the left hip, and the right upon the right hip, and alternately elevates and depresses the trunk in the direction of a line, extending from MANUAL OF OBSTETRICS. 45 the right groin to the postero-internal part of the left thigh. By this management, the feet are soon disengaged, and the rest of the body may be de- livered as in the first presentation of the feet. SECOND PRESENTATION OF THE BREECH AT THE IN- FERIOR STRAIT. Principal relations.—The posterior face of the sacrum corresponds to the right cotyloid cavity, and that of the thighs to the left sacro-iliac symphysis. Characteristic signs of the presentation.—The point of the os coccygis is behind the right cotyloid cavity, and the genital parts before the left sacro- iliac symphysis. Between these two parts are the anus and the perineal raphe, which present in the direction of a line, that extends from the right coty- loid cavity to the left sacro-iliac symphysis. Management.—The aecoucheur places the blunt hook in the fold of the right groin and holds it with the right hand; then gliding the left index finger in the fold of the left groin, he pulls the breech in the direction of the axis of the inferior strait, and when the parts have advanced sufficiently to enable him to use his hands, he removes the instrument. He now applies his right hand upon the right hip, and the left upon the left hip, and alternately elevates and depresses the trunk in the direction of a line, extending from the left groin to the postero-internal part of the right thigh. The inferior extremities are soon delivered, and the rest of the labour is to be conducted on the same principles as in the second presentation of the feet. 46 MANUAL OF OBSTETRICS. THIRD PRESENTATION OP THE BREECH AT THE IN- FERIOR BREECH. Principal relations. —The posterior face of the sacrum corresponds to the right sacro-iliac sym- physis, and that of the thighs to the left cotyloid cavity. Characteristic signs of the presentation.—The point of the os coccygis is before the right sacro- iliac symphysis, and the genital parts behind the left cotyloid cavity. Between these two points are the anus and the perineal raphe, which present in the direction of a line, extending from the right ' sacro-iliac symphysis to the left cotyloid cavity. Management.—The accoucheur introduces the hook in the fold of the right groin, and holds it with the right hand; then passing the index finger of the left hand, in the fold of the left groin, he draws the breech in such a manner as to bring it to the second presentation. In other respects, he proceeds pre- cisely on the same principles as in the second pre- sentation of the breech. FOURTH PRESENTATION OF THE BREECH AT THE SU- PERIOR STRAIT. Principal relations.—The posterior face of the sacrum corresponds to the left sacro-iliac symphy- sis, and that of the thighs to the right cotyloid cavity. Characteristic signs of the presentation.—-The point of the os coccygis is before the left sacro-iliac symphysis, and the genital parts behind the right cotyloid cavity. Between these two points are the MANUAL OF OBSTETRICS. 47 anus and the perineal raphe, which present in the direction of a line, extending from the, left sacro- iliac symphysis to the right cotyloid cavity. Management.—The accoucheur introduces the hook in the fold of the left groin and holds it with the left hand; then gliding the index finger of his right hand in the fold of the right groin, he draws the breech in such a manner as to bring it to the first presentation. The labour is to be completed in the same manner as in the first presentation of the breech. I. When the posterior face of the sacrum corres- ponds directly to the left side of the pelvis, and that of the thighs to the right, the presentation will be cha- racterized by the os coccygis being to the left, and the genital parts to the right. The perineal raphe is directed transversely. Management. —Precisely the same as in the first and fourth presentations. II. When the posterior face of the sacrum cor- responds directly to the right side of the pelvis, and that of the thighs to the left, the os coccygis will be to the right, the genital parts to the left, and the peri- neal raphe transversely. Management.—Precisely the same as in the se- cond and third presentations. III. When the posterior face of the sacrum cor- responds directly to the pubis, and that of the thighs to the sacrum, the presentation will be characterized by the os coccygis being behind the pubis, the geni- tal parts before the sacrum, and the direction of the perineal raphe from before backwards. Management.—The accoucheur may introduce the hook in either groin and convert the presentation into the first or second diagonal, in such a manner as 48 MANUAL OF OBSTETRICS. to leave the limb, which is embraced by the hook. in front. The other steps of the labour are to be conducted as in the first or second diagonal presen- tation. IV. When the posterior face of the breech cor- responds directly to the sacrum, and that of the thighs to the pubis, the os coccygis will be found before the sacrum, the genital parts behind the pubis, and the perineal raphe directly from before back- wards. Management.—The accoucheur places the hook in one of the groins and reduces the presentation to the third or fourth diagonal, in such a manner as always to have the instrument in front. RECAPITULATION OP THE DIFFERENT MANAGE- MENTS APPLICABLE TO THE PRESENTATIONS OP THE BREECH AT THE INFERIOR STRAIT. 1. In the first and fourth presentations, and in that where the sacrum corresponds to the left side of the pelvis, the management is precisely the same. In fact, in all these presentations, the accoucheur introduces the hook or fillet in the fold of the left groin, passes the right index finger in the fold of the right groin, and delivers by the first presenta- tion. v 2. In the second and third presentations, and in that where the sacrum corresponds to the right side of the pelvis, the management is precisely similar. For in all these presentations, we should place the hook or fillet in the fold of the right groin, pass the index finger of the left hand in the fold of the left groin, and deliver by the second presentation. MANUAL OP OBSTETRICS. 49 When the posterior face of the breech corres- ponds to the pubes or the sacrum, the accoucheur in- troduces the hook or fillet in either groin, and brings the foetus to a diagonal position in order to terminate the labour by the first or second presentation. PRESENTATIONS OF THE BREECH AT THE SUPERIOR STRAIT. As long as the breech is in the superior strait, it is always easy to push it up, so as to get at the feet. By this management the presentations of the breech will be converted into those of the feet. Indications to be fulfilled before searching for the feet. As the breech obstructs the superior strait, and as the feet have not yet descended, it would be im- possible, under these circumstances, to introduce the hand, so that we must endeavour by a well directed management, to free the superior strait, and bring down the feet. This double indication is fulfilled by pushing the breech to one of the internal iliac fossa?, and by inclining the uterus to the opposite side. General Rules for displacing Presentations oftht Breech at the Superior Strait. Whenever the accoucheur introduces the right hand, he should push the foetus to the right, and when he introduces the left, he should push it to the left. The uterus should always be inclined to the side opposite to that towards which he pushes. 50 MANUAL OF OBSTETRICS. Choice of the hand.—When the feet areyto the left of the pelvis, the accoucheur introduces the right hand, and when they are to the right, he uses the left hand. Whenever they present to the sacrum or the pubis, he may employ either hand. FIRST PRESENTATION OF THE BREECH AT THE SUPE- RIOR STRAIT. Principal relations.—These are the same as at the inferior strait, with the exception, that the parts are less engaged. Characteristic signs of the presentation.—The same as at the inferior strait. Management.—The accoucheur, introducing the left hand, places the thumb in front and the fingers behind the breech, and pushes it towards the left iliac fossa, while, with the right hand applied upon the fundus uteri, he inclines this organ to the left; then, passing his hand along the posterior leg until he meets the foot, he grasps it between his thumb and fingers, and brings it down. When this limb is disengaged, it should be used as a guide in searching for the other, which is ge- nerally placed across the anterior part of the abdo- men and thorax. The accoucheur passes his hand along the postero-external part, leaves the thumb on Hhe inside, and, upon reaching the anterior region of the trunk, he soon finds the second extremity, which he brings down by passing up his four fingers. When both feet are delivered, the labour is finished as in the first presentation of the feet. MANUAL OF OBSTETRICS. 51 SECOND PRESENTATION OP THE BREECH AT THE SU- PERIOR STRAIT. Principal relations.—These are the same as at the inferior strait. Characteristic signs of the presentation.—The same as at the inferior strait. Management.—-The accoucheur introduces the right hand and pushes the foetus towards the right iliac fossa, at the same time that he inclines the uterus towards the left, with the other hand placed upon the abdomen. The delivery of the feet is then accomplished upon the same principles as in the first presentation; and, as soon as they are without, the labour is conducted as in the second presenta- tion of the feet. THIRD PRESENTATION OF THE BREECH AT THE SU- PERIOR STRAIT. Principal relations.—These are the same as at the inferior strait. Characteristic signs of the presentation.—The same as at the inferior strait. Management.-^-The accoucheur introduces the right hand, and, pushing as much as possible to- wards the right iliac fossa, he endeavours to bring the breech to the second presentation. This being done, he inclines the uterus towards the left, and proceeds to deliver the feet in the same manner as in the second presentation. When the feet are dis- engaged, the labour is to be accomplished as in the second presentation of the feet. 52 MANUAL OF OBSTETRICS. FOURTH PRESENTATION OP THE BREECH AT THE SU- PERIOR STRAIT. Principal relations.—These arc the same as at the inferior strait. Characteristic signs of the presentation.—The same as at the inferior strait. Management.—The accoucheur introduces the left hand, and, in pushing the breech to the left iliac fossa, he endeavours to convert it, if possible, into the first presentation. At the same time that this is doing, he should incline the uterus towards the right and deliver the feet upon the same principles as in the preceding presentations. This being done, he proceeds as in the first presentation of the feet. I. When the posterior face of the sacrum cor- responds directly to the left side of the pelvis, and the posterior face of the thighs to the right, the presentation will be characterized by the same signs as at the inferior strait; and the labour is to be con- ducted as in the first and fourth presentations. II. When it presents directly to the right, the accoucheur proceeds in the same manner as in the second and third presentations. III. When the posterior face of the sacrum pre- sents directly to the pubes, the accoucheur intro- duces either hand, and brings the foetus to the first or second diagonal presentation, in such a manner that the inferior extremities shall correspond to the hand introduced. Thus, if the right hand be intro- duced, he must push to the right, and to the left, if he introduce the left hand; The labour is then to be conducted upon the same principles as in the di- agonal presentation into which it is converted. MANUAL OP OBSTETRICS. 53 IV. When it presents directly to the sacro-ver- tebral angle, the accoucheur may introduce either hand, and convert the presentation into the third or fourth diagonal; and proceed afterwards in the same manner as we have just pointed out. RECAPITULATION OF THE DIFFERENT MANAGE- MENTS APPLICABLE TO THE PKESENTATIONS OF THE BREECH AT THE SUPERIOR STRAIT. 1. In the first and fourth presentations, and in that where the sacrum corresponds directly to the left side of the pelvis, the management is precisely similar. In fact, in all these presentations, the feet being directed to the right of the mother, the ac- coucheur introduces the left hand, pushes the breech towards the left iliac fossa, and inclines the uterus to the right. When the feet are delivered, the la- bour is conducted as in the first presentation of the feet. 2. In the second and third presentations, and in that where the sacrum corresponds directly to the right of the pelvis, the management is precisely the same. For in all these presentations, the feet be- ing to the left of the mother, the accoucheur must introduce the right hand, push towards the right, incline the uterus to the left, and finish as in the se- cond presentation of the feet. 3 When the breech presents directly to the sa- crum or the pubes, the accoucheur may introduce either hand, and convert the presentation into one of the diagonal presentations of the feet. >t MANUAL-OP OBSTETHIC5, PRESENTATIONS OF THE VERTEX OF THE HEAD. The head, like the feet, the knees and the breech, may present at the superior and inferior straits in four principal positions, which correspond to the oblique diameters of the pelvis. These presenta* tions, having already been pointed out in speaking of the mechanism of natural labour, need not be re- peated here. Characteristic marks of the head.—The head presents under the form of a hard, large and rounded tumour, having certain membranous intervals, called fontanelles and sutures. The peculiar characters of the hairy scalp may also serve in pointing out the diagnosis. The management applicable to the presentations of the head, is not the same in both straits. When the head is at the inferior strait, whether it has passed the cervix uteri, or not, we should ap- ply the forceps. We shall revert to this series of presentations when speaking of those labours which demand the employment of instruments. When the head is at the superior strait, it would often be more proper to use the forceps, yet the child may be turned, and the labour terminated by the aid of the hand alone. EXTRACTION OF THE FCETUS WHEN THE VERTEX 01 THE HEAD PRESENTS AT THE SUPERIOR STRAIT. In these cases the aid of the hand can be employ- ed only in turning the foetus. Indications to be fulfitl^,—Previously to his searching for the feet, the accoucheur should free MANUAL OF OBSTETRICS. 59* the superior strait, by pushing the head towards one of the iliac fossa?, and bring down the feet, by in- clining the uterus firmly to the.opposite side. Rules for displacing the Presentations of the Vertex of the Head at the Superior Strait. These have been pointed out in speaking of the presentations of the breech at the superior strait. Choice of the hanafc-Whenever the accoucheur wishes to get at the feet of the foetus, he should pass one of-his hands along the side of the trunk. The hand, which is introduced, should invariably cor- respond by name to the side along which it is di- rected. In the diagonal presentations, this side is always directed backwards. In the direct presentations, the lateral regions of the foetus correspond directly, the one to the right, and the other to the left; so that either hand may be introduced. FIKST PRESENTATION OF THE VERTEX OF THE HEAD AT THE SUPERIOR STRAIT. Principal relations.—The occiput corresponds to the left cotyloid cavity, and the forehead to the right sacro-iliac symphysis. The left side is be- hind, and the right anteriorly. The feet are at the fundus uteri. ** Characteristic signs of the presentation.—The posterior fontanelle is behind the left cotyloid cavi- ty, and the anterior bqfore the right sacro-iliac sym- physis. Between these two fontanelles, is the sa- gittal suture, which presents in the direction of a 56 MANUAL OF OBSTETRICS. line, extending from the left cotyloid cavity to the right sacro-iliac symphysis. Management.—The left side of the foetus being behind, the accoucheur introduces the left hand, and applying his thumb upon the forehead, and his fin- gers upon the posterior part of the head, he pushes it towards the left iliac fossa, at the same time that he inclines the uterus firmly towards the right, by placing his right hand upon the abdomen of the mother. Then passing down his hand as far as possible, he directs it successively along the side of the head, the neck, the shoulder, the side properly so called, and the hip, until he arrives at the breech, where he will generally find the feet, which may be brought down together, though it will be fetter to deliver them separately. In order to effect this, the accoucheur glides his hand down the thigh as far as the knee, and then up along the leg until he finds the foot, which he grasps between his thumb and fingers and brings it down. When one of the feet is delivered, it should be secured by means of a noose, which is to be applied above the maleoli and given to an assistant. The accoucheur now passes his hand along the external and posterior part of the extremity that has been delivered, until he reaches the breech, where he finds the second foot, which he brings down by passing up his four fingers. After the two extremities have been delivered, the labour is to be conducted as in the second pre- sentation of the feet. It sometimes happens, that the head is arched against the superior strait, so as to impede the ex- traction of the foetus. Under these circumstances, MANUAL OP OBSTETRICS. 57 we should push it up with the right hand, at the same time that we pull at the feet. * SECOND PRESENTATION OF THE VERTEX OF THE HEAD AT THE SUPERIOR STRAIT. Principal relations.—The occiput corresponds to the right cotyloid cavity, and the forehead to the left sacro-iliac symphysis. The right side of the foetus is behind, the left in front, and fhe feet at the fundus uteri. Characteristic signs of the presentation.—The posterior fontanelle is behind the right cotyloid cavity, and the anterior before the left sacro-iliac symphysis. The sagittal suture presents obliquely in the direction of a line, extending from the right cotyloid cavity to the left sacro-iliac symphysis. Management.—Precisely the same as in the first presentation, with the exception, that instead of the left, we should employ the right hand. Thus, the accoucheur pushes the head towards the right iliac fossa, inclines the uterus to the left, passes his hand along the posterior side of the foetus, and brings down the feet separately. When the extremities are delivered, the labour is to be finish- ed as in the first presentation of the feet. Should the head impede the extraction of the fujtus, the accoucheur must push it up with the left hand, at the same time that he draws down the feet with the right. 58 MANUAL OF OBSTETRICS. THIRD PRESENTATION OF THE VERTEX OF THE HEAD AT THE SUPERIOR.STRAIT. Principal relations.—The occiput corresponds to the right sacro-iliac symphysis, and the forehead to the left cotyloid cavity. The right side of the foetus is behind, the left in front, and the feet at the fundus uteri. Characteristic signs of the presentation.—The posterior fontanelle is before the right sacro-iliac symphysis, and the anterior behind the left cotyloid cavity. The sagittal suture presents obliquely in the direction of a line, extending from the right sacro-iliac symphysis to the left cotyloid cavity. Management.—Precisely the same as in the se- cond presentation. FOURTH PRESENTATION OF THE VERTEX OF THE HEAD AT THE SUPERIOR STRAIT. Principal relations.—The occiput corresponds to the left sacro-iliac symphysis, and the forehead to the right cotyloid cavity. The left side of the foetus is behind, the right in front, and the feet at the fundus uteri. Characteristic signs of the presentation.—The posterior fontanelle is before the left sacro-iliac sym- physis, and the anterior behind the right cotyloid cavity. The sagittal suture presents in the direc- tion of a line, extending from the left sacro-iliac symphysis to the right cotyloid cavity. Management.— Precisely the same as in the first presentation. I. When the occiput presents directly to the left MANUAL OP OBSTETRICS. 59 side of the pelvis, and the forehead to the right, the presentation will be characterized by the posterior fontanelle being to the left, the anterior to the right, and the sagittal suture transversely. Management.—Precisely the same as in the first and fourth presentations. II. When the occiput corresponds directly to the right side of the pelvis, and the forehead to the left, the presentation will be characterized by the pos- terior fontanelle being to the right, and the anterior to the left. The sagittal suture will be situated transversely. Management.—The accoucheur proceeds pre- cisely in the same manner as in the second and third presentations. III. When the occiput presents directly to the symphysis pubis, and the forehead to the sacrum, the presentation will be characterized by the poste- rior fontanelle being behind the symphysis pubis, and the anterior before the sacro-vertebral angle. The sagittal suture will present directly from be- fore backwards. Management.—The accoucheur introduces either hand, and converts the presentation into the first or second diagonal, in such a manner as to direct the side of the foetus, which corresponds by name to the hand which is introduced, backwards. The rest of the labour is conducted upon the same principles as in the first or second diagonal presentation. IV. When the occiput corresponds directly to the sacrum, and the forehead to the symphysis pubis, the posterior fontanelle will be before the sacro- vertebral angle, and the anterior behind the sym- physis pubis. The sagittal suture will be directed as in the preceding presentation. 60 fc MANUAL OF OBSTETRICS. Management.—Theaccouclieurintroduceseither hand, and converts the presentation into the third or fourth diagonal, and alwa^fc in such a manner as to direct the side of the foetus, which corresponds by name to the hand that is introduced, backwards. The rest of the labour is conducted as in the pre- sentation into which it is converted. RECAPITULATION OP THE DIFFERENT MANAGE- MENTS APPLICABLE TO THE PRESENTATIONS OF THE VERTEX OP THE HEAD AT THE SUPERIOR STRAIT OP THE PELVIS. 1. In the first and fourth presentations, and in that where the occiput corresponds directly to the left side of the pelvis, the management is precisely the same. In fact, in all these presentations, the left side of the foetus being behind, the accoucheur must introduce the left hand, push the head towards the left iliac fossa, incline the uterus towards the right, and deliver by the second foot presentation. 2. In the second and third presentations, and in that where the occiput corresponds directly to the right of the pelvis, the management is precisely similar. For in all these presentations, the right side of the foetus being behind, the accoucheur must introduce the right hand, push the head towards the right, incline the uterus to the left, and deliver by the first foot presentation. 3. In those presentations where the occiput pre- sents to the pubes or the sacrum, the accoucheur in- troduces either hand, and converts the presentation into one of the diagonal presentations, in order to proceed afterwards as in these presentations. MANUAL OF OBSTETRICS. 61 PRESENTATIONS OF THE TRUNK. Before speaking of the presentations of the trunk, it would be natural to study those of the face and of the occipital and temporal regions, but as these different presentations of the head present nothing peculiar, and as they may be confounded with those of the trunk, it appears to be more simple and pro- per to arrange them all under one head. Thus, we shall include in the regions of the trunk, the face properly so called, and the occipital and temporal regions. The trunk of the foetus comprehends four grand regions, an anterior, a posterior and two Jateral. If we were to study the management that is ap- plicable only to each of these regions of the foetus, we might dispense with subdividing them into se- veral other secondary regions; but in order to point out with more precision the distinguishing charac- ters of the different parts of the same region, we shall retain the subdivisions that have been admitted by most authors. But, when treating of the manage- ment, we shall consider the grand regions of the foetus as one and the same part, which in present- ing at the superior strait of the pelvis, obliges the accoucheur to fulfil the following indications. First indication.—If the bad presentation of the foetus be the only obstacle to the natural termina- tion of the labour, we must confine our whole man- agement to replacing it in a proper position,that is, to bringing its nearest extremity to the centre of the superior strait of the pelvis. Management.— When this extremity is to the left of the pelvis, the accoucheur introduces the 62 MANUAL OF OBSTETRICS. right hand, pushes to the right of the mother and inclines the uterus to the left. If, on the contrary, it be to the right, he introduces the left hand, pushes to the left, and inclines the uterus to the right. As soon as the child is properly replaced, nature will accomplish the rest of the labour. Second indication.—It sometimes happens that preternatural presentations are complicated with inertia of the uterus, hemorrhage, convulsions, &c. Under these circumstances it is not merely necessa- ry to place the foetus in a proper position, but the labour should be terminated as soon as possible by bringing down the feet.* Management.—The accoucheur introduces (he hand, which corresponds to the side of the foetus, along which he is desirous to pass it. In the pre- sentations of the anterior and posterior regions, this side is behind; and below, in the presentations of the lateral regions. The accoucheur pushes to the side of the mother, which corresponds, by name, to the hand that is introduced; brings the parts of the foetus close together, and carries his hand along the side which we have just indicated, until he meets the feet, which he brings down in the manner al- ready pointed out. (v. page 38.) POSTERIOR REGION OF THE TRUNK. The posterior region of the trunk comprehends the occipital region of the head, the neck, the back and the loins. * If the head be found very near the superior 6trait, it would, perhaps, be more easy to bring it to the centre of the pelvii, and to apply the forceps. MANUAL OF OBSTETRICS. 63 CHARACTERISTIC MARKS OF EACH OP THESE PARTS. Occipital region.-^-Thh region may be known by the posterior fontanelle, the lambdoidal suture, the tubercle of the os occipitis, and by the neighbour- hood of the posterior part of the neck. Phe neck.—This region may be recognised by the projection of the spinous processes of the cervi- cal vertebra?, the small size of the neck, compared with that of the head, and by the shoulders. The back.—The back is characterized by the pre- sence of the scapuloe, by the spinous processes of the dorsal vertebra?, by the ribs and intercostal spaces. The loins.—The loins are characterized by the spinous processes of the lumbar vertebra?, by the want of resistance on each side of the vertebral co- lumn, by the presence of the last rib superiorly, and by that of the bones of the pelvis inferiorly. Presentations.—The posterior region of the trunk may present in four principal directions which correspond to the oblique diameters of the pelvis. FIRST PRESENTATION OP THE POSTERIOR REGION OF THE TRUNK. Principal relations.—The head corresponds to the left cotyloid cavity, and the breech to the right sacro-iliac symphysis. The back is directed downwards, the belly upwards, the right side back- wards and to the left, and the left side forwards and to the right. Characteristic signs of the presentation.—The direction of the spinous processes of the vertebra?, 64 MANUAL OF OBSTETRICS. will, in itself, be sufficient to enable us to distinguish this presentation; especially, if we remember the different characters which belong to each region in particular. Thus, in the first presentation, we shall find, in front and to the left, the peculiar characters of the superior parts of the foetus, and behind and to the right, those which belong to its inferior parts. The spinous processes present obliquely in the direction of a line extending from the left coty- loid cavity to the right sacro-iliac symphysis. Management.—When the head is to the left of the pelvis, near the superior strait, the accoucheur introduces the right hand, and by placing the thumb in front and the fingers behind, he pushes the ver- tex to the right of the mother and brings it in the pelvis, at the same time that he inclines the uterus to the left, by placing the left hand upon the abdo- men. The presentation is converted into the third vertex presentation, and the rest of the labour is ac- complished by the efforts of nature. When the breech is to the right of the pelvis, near the superior strait, the accoucheur introduces the left hand, and by placing the thumb in front and the fingers behind, he pushes it to the left and brings it to the centre of the pelvis, at the same time that he inclines the fundus uteri to the right by applying his right hand upon the belly. By this manage- ment, the presentation will be reduced to the first foot presentation, and the rest of the labour will be accomplished by the efforts of nature. Second indication.—When the right side of the foetus is behind, the accoucheur introduces the right hand, and pushing it first above the pubis, and then to the right of the mother, he brings down the dif- ferent parts of the foetus close together upon its an- MANUAL OF OBSTETRICS. 65 terior region, and in such a manner as to turn the feet to the left side of the pelvis. This being done, he passes his hand along the right side of the foetus until he reaches the feet, which he brings down in the manner already pointed out at page 38. The rest of the labour is finished as in the first presenta- tion of the feet. SECOND PRESENTATION OP THE POSTERIOR REGION OF THE TRUNK. Principal relations.—The head is at the right cotyloid cavity, and the breech at the left sacro-iliac symphysis. The back presents downwards, the belly upwards, the right side forwards and to the left, and the left side backwards and to the right. Characteristic signs of the presentation.—The spinous processes present obliquely in the direction of a line extending from the right cotyloid cavity to the left sacro-iliac symphysis. To this direction of the vertebral column, we may add the signs that may be drawn from the characters which we have assigned to the posterior region of the trunk. Management. First indication.—When the head is to the right of the pelvis, near the superior strait, the ac- coucheur introduces the left hand, and by pushing to the left, he brings the vertex of the head to the centre of the pelvis, at the same time that he in- clines the fundus uteri to the right, by applying his right hand to the abdomen of the mother. By this management the presentation is converted into the 66 MANUAL OP OBSTETRICS. fourth vertex presentation, which is terminated by the efforts of nature. When the breech presents to the left of the pel- vis near the superior strait, the accoucheur intro- duces the right hand, pushes the breech to the right and brings it to the centre of the pelvis, at the same time that he pushes the fundus uteri to the left, by applying the left hand upon the abdomen. By this means the presentation is converted into one of the second foot presentations, which terminates by the natural efforts of nature. Second indication.—The left side of the foetus being behind, the accoucheur introduces the left hand, and by pushing the foetus first above the pu- bis, and then to the left of the mother, he disposes it in such a manner as to bring the feet to therightside of the pelvis. Then passing his hand along the left side of the foetus until he reaches the feet, he brings them down in the same manner as was pointed out at page 38, and finishes the labour in the second presentation of the feet. THIRD PRESENTATION OF THE POSTERIOR REGION OP THE TRUNK. Principal relations.—The head corresponds to the right sacro-iliac symphysis, and the breech to the left cotyloid cavity. The back presents down- wards, the belly upwards, the right side forwards and to the right, and the left backwards and to the left. Characteristic signs of the presentation.—The spinous processes of the vertebra? present in the di- rection of a line, extending from the right sacro-iliac symphysis to the left cotyloid cavity. Posteriorly MANUAL OP OBSTETRICS. 67 and to the right are the characters peculiar to the superior parts of the foetus, and anteriorly and to the left those belonging to its inferior parts. Management. First indication.—If the. head be found near the superior strait, when it presents to the right of the pelvis, the accoucheur introduces the left hand, push- es the head towards the left side of the mother, and inclines the uterus to the right. This being done, the labour terminates in the first vertex presenta- tion by the natural effort. If the breech be found near the superior strait, when it presents to the left of the pelvis, the ac- coucheur introduces the right hand, pushes to the right and inclines the uterus to the left. The rest of the labour terminates naturally by the third pre- sentation of the feet. Second indication.—The left side of the foetus being posteriorly, the accoucheur introduces the left hand, and proceeds precisely in the same man- ner as in the second presentation. FOURTH PRESENTATION OF THE POSTERIOR REGION OF THE TRUNK. Principal relations.—The head is at the left sacro-iliac symphysis, and the breech at the right cotyloid cavity. The back presents downwards, the belly upwards, the right side backwards and to the right, and the left side forwards and to the left. Characteristic signs of the presentation. —The spinous processes present obliquely in the direction of a line, extending from the left sacro-iliac sym- 68 MANUAL OF OBSTETRICS. physis to the right cotyloid cavity. The characters peculiar to the superior parts of the foetus are found posteriorly and to the left, and those belonging to its inferior parts are anteriorly and to the right. Management. First indication.—If the head be near the supe- rior strait, the accoucheur must bring it to the cen- tre of the pelvis with the right hand, while with the other applied to the abdomen, he inclines the uterus to the left. This being done, the labour terminates naturally in the second vertex presen- tation. If the breech be near the superior strait, the ac- coucheur brings it to the centre of the pelvis with his left hand, and inclines the uterus to the right. This being done, the labour naturally terminates in the fourth presentation of the feet. Second indication.—The right side of the foetus being behind, the accoucheur introduces the right hand, and proceeds precisely in the same manner as in the first presentation. 1. When the head corresponds directly to the left side of the pelvis, and the breech to the right, the presentation will be characterized by the trans- verse direction of the spinous processes of the ver- tebra?. The superior parts^f the foetus will be found to the left, and the inferior to the right of the pelvis. Management.—The accoucheur should proceed to fulfil the two indications precisely in the same manner as in the first and fourth presentations, with this exception, that in fulfilling the first indication, he should endeavour to bring the extremity that is MANUAL OF OBSTETRICS. 69 in the centre of the pelvis to one of the first diago- nal presentations of the vertex or of the feet. II. When 'the head corresponds directly to the right side of the pelvis, and the breech to the left, the presentation will be characterized by the trans- verse direction of the spinous processes, and by the superior parts of the foetus being to the right and the inferior to the left. Management.—In order to fulfil the two indica- tions, the accoucheur proceeds precisely in the same manner as in the second and third presentations; only, that in fulfilling the first indication, he should endeavour to place the extremity in one of the first diagonal presentations of the vertex or of the feet. III. When the head corresponds directly to the pubis and the breech to the sacrum, the trunk will present directly from before backwards, the supe- rior parts will be anteriorly and the inferior poste- riorly. Management. First indication.—Head.—The accoucheur may introduce either hand and push backwards, so as to convert the presentation into the third vertex pre- sentation, when he uses the right hand, and into the fourth, when he employs the left. Breech.—The accoucheur should push forwards, and when he employs the right hand he should con- vert the presentation into the second presentation of the feet, and into the first, if he use the left. Second indication.—The accoucheur may intro- duce either hand, and convert the presentation into the first or second diagonal, always taking care to 70 MANUAL OF OBSTETRICS. direct the side of the foetus, which corresponds by name to the hand that is introduced, backwards. IV. When the head corresponds directly to the sacrum, and the breech to the pubis, the trunk will have the same direction as in the preceding presen- tation; but we shall find that the superior parts of the foetus will present posteriorly, and the inferior anteriorly. Management.—If the head be near the superior strait, the accoucheur may introduce either hand, push towards the anterior part of the mother, and bring the extremity to the centre of the pelvis, so as to reduce it to the second vertex presentation when he uses the right hand, and to the first when he uses the left. If the breech be near the superior strait, the ac- coucheur may introduce either hand—when he uses the right hand he should push backwards and con- vert the presentation into the third presentation of the feet, and into the fourth, when he uses the left. Second indication.—The accoucheur may intro- duce either hand, and reduce the presentation to the third or fourth diagonal, by directing the side of the foetus, which corresponds by name to the hand that is introduced, backwards. ANTERIOR REGION OF THE TRUNK. The anterior part of the trunk comprehends the face, properly so called, the anterior part of the neck, the thorax, and the abdomen. MANUAL OF OBSTETRICS. 71 DISTINGUISHING CHARACTERS OF EACH OF THESE PARTS. The face.—Upon the mesian line are the small coronal suture, the nose, the mouth, and the chin; and laterally, the orbits and the cheeks. All these characters are so prominent and well marked, that there can be no difficulty in distinguishing the face, unless the soft parts should be much tumefied. Anterior part of the neck.—The vicinity of the chin and of the superior part of the thorax, and the relative narrowness of the neck, are generally suffi- cient to enable us to distinguish this region of the foetus. The thorax.—The characters which distinguish the thorax are drawn from the presence of the ster- num, the clavicles, the ribs, and the intercostal spaces. The abdomen.—The belly may be known by a soft tumour, bounded on one side by the last ribs, on the other by the bones of the pelvis, and pre- senting in its middle the insertion of the umbilical cord. PRESENTATIONS OF THE ANTERIOR REGION OF TH* TRUNK. The anterior region of the trunk may present in four principal directions, which correspond to the oblique diameters of the pelvis. Principal relations.—The head corresponds to the left cotyloid cavity, and the breech to the right sacro-iliac symphysis. The belly is directed down- wards, the back upwards, the left side backwards. 72 MANUAL OF OBSTETRICS. and to the left, and the right side forwards and to the right. Characteristic signs of the presentation.—The trunk presents in the direction of a line, extending from the left cotyloid cavity to the right sacro-iliac symphysis. The superior parts of the foetus are situated anteriorly, and the inferior posteriorly. Management. First indication.—If the head be to the left of the pelvis near the superior strait, the accoucheur introduces the right hand so as to push to the right, and inclines the uterus to the left. By this manage- ment the presentation is reduced to the first vertex presentation, and terminates by the natural efforts. If the breech be to the right of the pelvis, near the superior strait, we should push it up with the left hand, and incline the fundus uteri to the right, so as to reduce the presentation to the third foot presentation, which terminates by the natural efforts of the mother. Second indication.—The left side of the foetus being behind, the accoucheur should introduce the j left hand, in order to push towards the left side of the mother; and then, by passing the hand along the posterior side until he reaches the feet, he should bring them down according to the rules laid down at page 38. The labour is to be finished in the second presentation of the feet. SECOND PRESENTATION OP THE ANTERIOR REGION OP THE TRUNK. Principal relations.—The head corresponds to the right cotyloid cavity, and the breech to the left . MANUAL OF OBSTETRICS. 73 sacro-iliac symphysis. The belly presents down- wards, the back upwards, the left side forwards and to the left, and the right backwards and to the right. Characteristic signs of the presentation.—The trunk presents in the direction of a line, extending from^he right cotyloid cavity to the left sacro-iliac symphysis. The superior parts of the foetus are situated anteriorly, and the inferior posteriorly. Management. First indication.—If the head be near the supe- rior strait, the accoucheur introduces his left hand, and brings it to the centre of the pelvis, at the same time that he inclines the fundus uteri to the right. By this means the presentation is converted into the second vertex presentation, and terminates by the efforts of the woman. If the breech be near the superior strait, the ac- coucheur brings it to the centre of the pelvis with his right hand, and inclines the uterus to the left. The presentation will be converted into the fourth natural presentation of the feet. Second indication.—The right side of the foetus being behind, the accoucheur pushes it with the right hand towards the right side of the mother, and passing his hand along the right side of the foetus until he reaches the feet, he brings them down in the manner already pointed out at page 38. The rest of the labour is to be accomplished in the first foot presentation. 8 74 MANUAL OF OBSTETRICS. THIRD PRESENTATION OF THE ANTERIOR REGION OP THE TRUNK. Principal relations.—The head corresponds to the right sacro-iliac symphysis, and the bfeech to the left cotyloid cavity. The belly looks down- wards, the back upwards, the left side forwards and to the right, and the right side backwards and to the left. Characteristic signs of the presentation.—The trunk presents in the direction of a line, extending from the right sacro-iliac symphysis to the left coty- loid cavity. The superior parts of the foetus are posteriorly, and the inferior anteriorly. Management. First indication.—If the head be near the supe- rior strait, we ought to bring it to the centre of the pelvis with the left hand, and incline the uterus to the right. By this management the presentation will be converted into the third natural vertex pre- i sentation. If the breech present near the superior strait, it should be brought to the centre of the pelvis with the right hand, so as to convert the presentation into one of the first natural presentations of the feet Second indication.—The right side of the foetus being behind, the accoucheur introduces the right hand, and proceeds precisely in the same manner as. in the second presentation. MANUAL OF OBSTETRICS. 75 FOURTH PRESENTATION OF THE ANTERIOR REGION OF THE TRUNK. Principal relations.—The head corresponds to the left sacro-iliac symphysis, and the breech to the right cotyloid cavity. The belly presents down- wards, the back upwards, the left side backwards and to the right, and the right side forwards and to the left. Characteristic signs of the presentation.—The trunk presents in the direction of a line, extending from the left sacro-iliac symphysis to the right coty- loid cavity. The superior parts of the foetus are be- hind, and the inferior before. Management. First indication.—The head being to the left of the pelvis, the accoucheur brings it to the centre with the right hand, and inclines the uterus to the left. By this management the presentation is con- verted into the fourth natural presentation of the vertex. If the breech be near the superior strait, the ac- coucheur brings it to the centre of the pelvis with the left hand, and inclines the uterus to the right; so as to convert the presentation into one of the se- cond natural presentations of the feet. Second indication.—The left side of the fcetus being behind, the accoucheur introduces the left hand, and proceeds altogether upon the same prin- ciples as in the first presentation. I. When the head corresponds directly to the left side of the pelvis, and the breech to the right, the presentation will be characterized by the transverse 76 MANUAL OF OBSTETHICS. direction of the trunk, and by the superior parts of the foetus being to the left, and the inferior to the right. Management.—The management of the two in- dications of the first and fourth presentations is pre- cisely the same; only, that in fulfilling the first, the accoucheur should endeavour to place the extremity, which he brings to the centre of the pelvis, in one of the first diagonal presentations of the vertex or of the feet. II. When the head corresponds directly to the right side of the pelvis, and the breech to the left, the presentation may be distinguished by the trans- verse direction of the trunk, and by the superior parts of the foetus being to the right. Management.—The management of the two in- dications of the second and third presentations is precisely the same; only, that in fulfilling the first, we should bring the extremity to one of the first diagonal presentations of the vertex or of the feet. III. When the head corresponds directly to the pubis, and the breech to the sacrum, the trunk ex- tends directly from before backwards, and in front of the superior parts of the foetus. < Management. First indication.—If the head be near the supe- rior strait, the accoucheur may introduce either hand, and convert it into the first diagonal presenta- tion of the vertex, when he uses the left hand, and into the second when he uses the right. If the breech be near the superior strait, it should be brought to the centre of the pelvis, so as to be converted into the third diagonal presentation of MANUAL OF OBSTETRICS. 77 the feet, when we use the right hand, and into the fourth, when we use the left. Second indication.—The accoucheur may intro- duce either hand, and convert the presentation into the first or second diagonal, but always in such a manner as to direct the side of the foetus, which cor- responds by name to the hand that is introduced, backwards. IV. When the head corresponds directly to the sacrum and the breech to the pubis, the direction of the trunk will be the same as in the preceding pre- sentation; but the superior parts of the foetus will be behind. Management. First indication.—If the head be near the supe- rior strait, and the accoucheur wishes to convert the presentation into the third diagonal presentation of the vertex, he must introduce the right hand and push it forwards, and if he wishes to change it into the fourth, he must use the left. If it be necessary to bring the breech to the cen- tre of the pelvis, the accoucheur may introduce either hand; he should push backwards, and convert the presentation into the second diagonal of the feet; with the right hand, and into the first with the left hand. Second indication.—The accoucheur may intro- duce either hand, and convert the presentation into the third or fourth diagonal, taking care to direct the side of the foetus, which corresponds by name to the hand that is introduced, backwards. 8« 73 MANUAL OF OBSTETRICS. LATERAL REGIONS OF THE TRUNK. The lateral regions of the trunk comprehend the sides of the head, and of the neck, the shoulders, the sides of the thorax, and the loins. DISTINGUISHING CHARACTERS OF EACH OF THESE PARTS. >Side of the head.—This is chiefly characterized by the ear, whose different relations with the pelvis are so well marked, that there is no difficulty in dis- tinguishing either the side or the direction in which it presents. Thus, we know that the lobe corres- ponds to the feet, and the great convexity of the helix to the back. Side of the neck.—This is less distinguishable by itself, than by the neighbouring parts; thus, the pre- sence of the ear on one side, and that of the slioulder on the other, can scarcely deceive us in recognizee the lateral region of the neck. Shoulder.—The shoulder may be known by its presenting under the form of a rounded tumour, by the clavicle in front, and the scapula behind; our diagnosis may also be farther aided by the presence of the arm and the hollow of the axilla. Side of the thorax.—This region is characterized by the ribs and the intercostal spaces. Superiorly it has the hollow of the axilla, inferiorly the side of the parietes of the abdomen, anteriorly the sternum, and posteriorly the spinous processes of the vertebrae. Loin.—This region is distinguishable by its soft- ness, by the presence of the last rib above, and by that of the bones of the ilium below. MANUAL OP OBSTETRICS. 79 PRESENTATIONS OF THE RIGHT LATERAL REGIONS. The right lateral region of the foetus may present in four principal directions, which correspond to the oblique diameters of the pelvis. FIRST PRESENTATION OF THE RIGHT SIDE. Principal relations.—The head corresponds to the left cotyloid cavity, and the breech to the right sacro-iliac symphysis. The right side presents downwards, the left upwards, the back forwards and to the right, and the belly backwards and to the left. Characteristic signs of the presentation.—The trunk presents in the direction of a line, extending from the left cotyloid cavity to the right sacro-iliac symphysis. The superior parts of the foetus are an- teriorly and the inferior posteriorly. Management. First indication.—It requires precisely the same management as in the presentations of the back and the belly. Second indication.—The right side of the foetus being below, the accoucheur introduces his right hand, pushes it to the right of the mother and bends the foetus upon its anterior face, so as to bring the inferior extremities to the left side of the pelvis. This being done, he carries his hand along the right side of the foetus until he reaches the feet, which he brings down according to the rules laid down at page 38. The labour is finished in the first presen- tation of the feet. 80 MANUAL OF OBSTETRICS. SECOND PRESENTATION OF THE RIGHT SIDE. The head corresponds to the right cotyloid cavity, and the breech to the left sacro-iliac symphysis. The right side presents downwards, the left upwards, the back backwards and to the right, and the belly forwards and to the left. Characteristic signs of the presentation.—The trunk presents in the direction of a line, extending from the right cotyloid cavity to the left sacro-iliac symphysis. The superior parts of the trunk are anteriorly, and the inferior posteriorly. Management. First indication.—This should be fulfilled pre- cisely in the same manner as in the presentations of the back and the belly. Second indication.—The right side being be- low, the accoucheur introduces the right hand, and pushing to the right side of the pelvis, he passes his hand along the right side of the foetus until he reaches the feet, which he brings down in the man- ner pointed out at page 38. The labour is finished in the first presentation of the feet. THIRD PRESENTATION OF THE RIGHT SIDE. Principal relations.—The head is to the right sacro-iliac symphysis, and the breech to the left cotyloid cavity. The right side is below, the feet above, the back behind and to the left, and the bel- ly before and to the right. Characteristic signs of the presentation.—The trunk presents in the direction of a line, extending MANUAL OF OBSTETRICS. 81 from the right sacro-iliac symphysis to the left co- tyloid cavity. The superior parts of the trunk are posteriorly, and the inferior anteriorly. Management. First indications.—It requires the same manage- ment as in the presentations of the back and the bel- iy. Second indication.—It demands precisely the same management as in the second presentation. FOURTH PRESENTATION OP THE RIGHT SIDE. Principal relations.—The head corresponds to the left sacro-iliac symphysis, and the breech to the right cotyloid cavity. The right side is below, the left above, the back anteriorly and to the left, and the belly posteriorly and to the right. Characteristic signs of the presentation.—The trunk presents in the direction of a line, extending from the left sacro-iliac symphysis to the right co- tyloid cavity. The superior parts of the trunk are posteriorly, and the inferior anteriorly. Management. First indication.—It requires the same manage- ment as in the presentations of the back and the belly. Second indication.—It demands the same man- agement as in thefirst presentation. 1. When the head corresponds directly to the left side of the pelvis, and the breech to the right, the trunk will present in a transverse direction; and the 82 MANUAL OF OBSTETRICS. superior parts of the foetus will be to the left, and the inferior to the right. Management.—The management of the two in- dications is precisely the same as in the first and fourth presentations', only, that in fulfilling the first indication, we should bring the extremity to one of the first diagonal presentations of the vertex of the head, or of the feet. II. When the head corresponds directly to the right side of the pelvis, and the breech to the left, the trunk will have a transverse direction, as in the preceding presentation, but the superior parts of the foetus will be to the right, and the inferior to the left Management.—The management in the two in- dications is precisely the same as in the second and third presentations. But, in fulfilling the first in- dication, we should proceed as in the preceding presentation. 111. When the head corresponds directly to the pubis, and the breech to the sacrum, the trunk will extend directly from before backwards, and the superior parts of the foetus will be anteriorly, and the inferior posteriorly. Management. First indication.—If it be necessary to bring the head to the centre of the pelvis, the accoucheur may introduce either hand, (the right hand should be preferred,) and turn it backwards, so as to con- vert the presentation into the second diagonal pre- sentation of the vertex of the head. If it be necessary to bring the breech to the cen- tre of the superior strait, the accoucheur should in- MANUAL OF OBSTETRICS. 83 troduce the right hand, though he may use either, and push the breech forwards, so as to convert the presentation into the second presentation of the feet. Second indication.—The right side of the foetus being below, the accoucheur introduces the right hand, and converts the presentation into the second diagonal, and proceeds upon the same principles as he would in the latter presentation. IV. When the head corresponds directly to the sacrum, and the breech to the pubis, the trunk will be in the same direction as in the preceding pre- sentation; but the superior parts of the foetus will be posteriorly, and the inferior anteriorly. Management. First indication.—If the head be near the supe- rior strait, the accoucheur should introduce the left hand, though he may use either, and push it for- wards so as to bring it to the first vertex presenta- tion. If the breech be near the superior strait, the ac- coucheur should introduce the left hand, though he may use either, and push the breech backwards, so that by bringing it to the centre of the pelvis, he may convert it into the firstfoot presentation. PRESENTATIONS OF THE LEFT LATERAL REGION OF THE TRUNK. The left lateral region of the trunk, like the right, presents in four principal directions, which corres- pond to the oblique diameters of the pelvis. 84 MANUAL OF OBSTETRICS. FIRST PRESENTATION. Principal relations.—The head corresponds to the left cotyloid cavity, and the breech to the right sacro-iliac symphysis. The left side is below, the right above, the back posteriorly and to the left, and the belly anteriorly and to the right. Characteristic signs of the presentation.—These are precisely the same as in the first presentation of the right side. Management. First indication.—It requires the same manage- ment as in the first presentation of the right side. Second indication.—The left side of the foetus being below, the accoucheur introduces the left hand, and having pushed the foetus towards the left side of the mother, he passes his hand along its left side, until he reaches the feet, which" he brings down in the manner pointed out at page 38. The labour is to be finished in the second presentation of the feet. SECOND PRESENTATION. Principal relations.—The head corresponds to the right cotyloid cavity, and the feet to the left sacro-iliac symphysis. The left side of the foetui is below, the right above,—the back anteriorly and to the left, and the belly posteriorly and to the right. Characteristic signsof the presentation.—These are the same as in the second presentation of the right side. MANUAL OF OBSTETRICS. 85 Management. First indication.—The same rules are to be ob- served as in the second presentation of the right side. Second indication.—The left side being below, the accoucheur introduces the left hand, and by pushing the foetus to the left of the mother, he bends it forwards in such a manner as to bring the inferior extremities to the right side of the pelvis. This being done, he passes his hand along the left side of the foetus, until he reaches the feet, which he de- livers according to the rules laid down at page 38. The rest of the labour is to be accomplished in the second presentation of the feet. THIRD PRESENTATION. Principal relations.—The head corresponds to the right sacro-iliac symphysis, and the breech to the left cotyloid cavity. The left side of the foetus is below, the right above, the back anteriorly and to the right, and the belly posteriorly and to the left. Characteristic signs of the presentation.—These are the same as in the third presentation of the right side. Management. First indication.—In the first indication, the same rules are to be observed as in that of the third presentation of the right side. Second indication.—This requires the same man- 9 S6 MANUAL OF OBSTETRICS. agement as that of the second presentation of the left lateral region. FOURTH PRESENTATION. Principal relations.—The head corresponds to the left sacro-iliac symphysis, and the breech to the right cotyloid cavity. The left side is below, the right above, the back posteriorly and to the right, aiu! the belly anteriorly and to the left. Characteristic signsof' the presentation.—These are the same as in the fourth presentation of the right side. Management. First indication.—The same rules are to be observed as in the fourth presentation of the right side. Second indication.—This requires the same man- agement as that of the first presentation of the left lateral region. I. When the head corresponds directly to the left side of the pelvis,»and the breech to the right, the presentation will be characterized by the same signs as in the presentation of the right lateral re- gion. Management. First indication.—In this indication the same rules are to be observed as in that of the presenta- tion of the right side. Second indication.—This indication requires the same management as that of the first and fourth diagonal presentations of the left lateral region. MANUAL OF OBSTETRICS. 37 II. When the head corresponds directly to the right side of the pelvis, and the breech to the left, the presentation will be characterized by the same signs as that of the right lateral region. Management. First indication.—In this indication, the same rules are to be observed as in that of the corres- ponding presentation of the right side. Second indication.—It requires the same man- agement as that of the second and third diagonal presentations of the left lateral region. III. When the head corresponds directly to the symphysis pubis, and the breech to the saerum, we may distinguish the presentation by the same cha- racters as in that of the right lateral region. Management. First indication.—If the head be near the supe- rior strait, the accoucheur should introduce the left hand, though he may employ either, and by push- ing the head backwards, he should bring it to the first vertex presentation. If the breech be near the superior strait, the ac- coucheur may introduce either hand, though he should always prefer the left, and by pushing the breech forwards, he should bring it to the first na- tural presentation of the feet. Second indication.—The left side of the foetus being below, the accoucheur introduces the left hand, and by pushing to the left, he converts the presentation into the first diagonal, and proceeds SS MANUAL OP OI.^TETRICS. afterwards upon the same principles as he would in that presentation. IV. When the head presents towards the sacrum and the breech towards the symphysis pubis, the pre- sentation will be characterized by the same signs as in the corresponding presentation of the right side. Management. First indication.—If the head be near the superior strait, the accoucheur may introduce either hand, though he should prefer the right, and by pushing the head forwards, he should bring it to the second diagonal presentation of the vertex. If the breech be near the superior strait, he may introduce either hand, though he should give the preference to the right, and by pushing the breech backwards, he should bring it to the second natur- al presentation. Second indication.—The left side being below, the accoucheur introduces the lefthand,and by push- ing to the left, he endeavours to convert the pre- sentation into the fourth diagonal, and proceeds af- terwards in the same manner as in that presenta- tion. PRESENTATIONS OF THE HAND. When the parts of the mother are well formed, the presentation of the hand can afford no obstacle to the termination of the labour, whether it takes place by the breech or by the head. This being the case, it is obvious that it is neither proper to remove the arm by amputation or other- MANUAL OP OBSTETRICS. 89 wise, in order to diminish the volume of the foetus, or to return it into the uterus, as we have been ad- vised to do by a number of writers on midwifery. It is only, in fact, in those cases where the arm is at the superior strait of the pelvis, that we should push it up, or sustain it, until the head or the breech has descended into the opening of the strait. In case, therefore, one of the arms of the foetus is in the vagina, or in case it has passed the parts of generation, the labour should be conducted precise- ly in the same manner as if it were still in the ute*^ rus; with the exception, that the arm should be se- cured by means of a noose, to prevent its return and to maintain it on the trunk during the delivery. To verify the facts which we have just asserted, let us give an example of a presentation of the late- ral regions of the foetus, where one of the arms has already descended. We shall suppose it to be the first presentation of the left side, accompanied by the left arm. Management. The limb being fixed by means of a noose placed around the wrist, the accoucheur introduces his left hand and carries it along the other arm, until he reaches the trunk, which he pushes towards the left side of the mother, and proceeds to deliver the feet precisely in the same manner as if the arm were within the uterus. When the feet are brought out, he finishes the labour precisely in the same manner as in the second foot presentation, taking care, at the same time, to keep the arm against the trunk, so as to bring it down with it. Remark.—The arm which presents within the 9* 90 MANUAL OF OBSTETRICS. genital parts of the mother, may not always belong to the side of the foetus which is below; so that it is absolutely necessary, before we proceed to the delivery, to carry the hand as far up as where it is articulated with the trunk, in order to ascertain pre- cisely to which side it belongs. In every case, where we terminate the labour, we should use the hand which corresponds by name to the side of the foetus that presents. The direction of the hand that is delivered, may indicate the presentation of the trunk at the supe- rior strait of the pelvis; but we can only be certain after we have made an examination with the hand. If simple inspection does not enable the accouch- eur to distinguish the hand that has passed the vul- va, he may remove every doubt by comparing it with his own, which will correspond to it in all its parts. RECAPITULATION OF THE DIFFERENT MANAGE- MENTS APPLICABLE TO THE PRESENTATIONS OP THE TRUNK. All the presentations of the trunk, whatever re- gion the foetus may present, require the fulfilment of two indications. The first, which consists in bringing the nearest extremity of the foetus to the centre of the pelvis, requires precisely the same management in all the diagonal presentations, and in all those where the extremity of the foetus corresponds directly to either side of the pelvis, whether it be the anterior, the posterior, or lateral regions that present. When the extremity, whatever it be, presents MANUAL OF OBSTETRICS. 91 to the left of the mother, the accoucheur must in- troduce his right hand so as to push it to the right, while, with the other applied to the abdomen, he inclines the uterus towards the left. When it presents to the right, he must push it to the left, and incline the uterus to the right. In the direct presentations, the accoucheur may introduce either hand, and by pushing to the side oppositely to that towards which the extremity of the foetus presents, he should bring it to the centre of the pelvis, and convert it always into a diagonal presentation. As soon as the first indication is fulfilled, the la- bour will terminate by the efforts of nature. The second indication consists in passing the hand along one of the sides of the foetus, in order to bring down its feet. This side is directed backwards in all the diagonal presentations of the anterior and posterior regions, and in all those where the extlremities of the foetus correspond directly to the lateral regions of the pelvis: in the corresponding presentations of the lateral regions of the trunk, it is below. In order to fulfil this second indication, the ac- coucheur should always introduce the hand which corresponds, by name, to the side of the foetus along which he is obliged to pass it. The direct presentation should always be convert- ed into the diagonal, and should be managed upon similar principles. When one arm only is delivered, it should have no influence upon the management of the presenta- tions of the trunk. 92 MANUAL OP OBSTETRICS. OF COMPOUND LABOUR. When there are two or more children in the ute- rus, they should be delivered according to the rules which have been pointed out in the preceding parts of this work. I. If they both present the feet, we should first remove the one whose heels correspond to the hand that is introduced, and in order to be convinc- ed that we have both feet of the same child, we should carry the fingers as high up as the hips. II. If they both present the head, the accouch- eur should, in preference, turn that whose side, cor- responding in name with the hand introduced, pre- sents backwards; and the head of the second infant should be pushed up to a considerable extent if it be likely to enter the superior strait. III. If one of the infants present the head and the other the feet, the accoucheur should commence with the latter, unless, as Dr. Capuron has remark- ed, the head of the first has already descended so far down as to demand the application of the for- ceps. IV. If they both be placed aeross the superior strait, and in the same direction, the accoucheur should first bring down the one whose feet are the most easy of access. If one head be to the right and the other to the left, the accoucheur should first bring down the in- fant whose feet are to the left of the pelvis, pro- vided he has introduced the right hand, and vice versa. MANUAL OF OBSTETRICS. 93 SECTION II. OF INSTRUMENTAL LABOURS. The peculiar causes of these kinds of labour are the same as in those which terminate by mere ma- nual assistance, with the exception, that they may sometimes be attended with certain mal-conforma- tions, which may be so great as to preclude the pos- sibility of terminating the labour by the natural passages, without a previous operation. Instruments.—The instruments are three in number, the forceps, the lever, and the blunt hooks. APPLICATION OF THE FORCEPS. Description of the forceps. —The forceps used at the present day, represent a kind of lever, com- posed of two blades which are united by a joint. Each of these blades has three distinct parts, a middle and two extremities. The extremity, which is destined to embrace the head, is a large blade having a fenestra, and curves, one upon its borders, and the other on its faces. These two curves are arranged in such a manner that they may always be adapted to the form of the pelvis of the mother and to that of the child's head. The second extremity forms the handle of the in- strument. Each branch terminates in a hook, one of which serves as a perforator, and the other as a crotchet. The middle part serves to unite the blades, one of which contains a screw, moveable in every direc- 94 MANUAL OF OBSTETRICS. tion, and the other, an elongated mortise hole. This hole receives the screw, which serves, by its transverse direction, to unite the two blades. When speaking of the blades, we shall call that which contains the screw the left blade, and that which contains the mortise the^fight. The head of the foetus is the only part upon which we can apply the forceps. This instrument is not only proper in cases where the head presents first, but also in those where it is retained after the trunk has been already delivered. The forceps, when properly applied, embrace the lateral regions of the head, in the direction of the occipito-mental diameter. In this manner, the longest diameter of the head will always be repre- sented by one of its extremities. The forceps are applicable to both straits of the pelvis. General Rules for the Application of the For- ceps. 1. When the head of the foetus is placed in a di- rect position,* the accoucheur should first introduce the left blade with his left hand, and then the right with his right hand. 2. Whenever the head is placed diagonally, the accoucheur should ascertain which of the extremi- ties of the antero-posterior diameter is in front When the occiput or the forehead corresponds to * We shall always call those presentations direct, in which the occipito-frontal diameter of the head is placed in the direc- tion of the antero-posterior diameter of the pelvis. MANUAL OF OBSTETRICS. 95 the left cotyloid cavity, the accoucheur should first introduce the right blade, and then the left, and in both he should use the right hand; for in all the diagonal presentations, both blades should be intro- duced with the same hand. 3. When the occiput or the forehead corres- ponds to the right cotyloid cavity, the left blade must be introduced first and with the left hand. 4. The blades should always be placed in such a manner, that the convexity of their curves shall cor- respond to the concavity of the pelvis, and their con- cavity to the convexity of the head. 5. The hand, which remains free, should always be used as a guide to the blades, and be directed be- hind the sacro-iliac symphysis. It should be placed between the head and the uterus, when the head is still within the uterus, and between the vagina and the head, when it has passed the os tinea?. In this manner we may always avoid wounding the uterus or the vagina. 6. Each blade of the forceps should be held firm- ly in the hand, with the thumb placed along the ex- ternal side of the joint. 7. The forceps should be warmed and oiled, so as to facilitate the introduction. 8. The patient should be placed in the same po- sition as in manual labour. 9. In order to introduce the forceps, the accou- cheur should place himself between the thighs of the mother, and then, passing each blade in succes- sion behind the head, he applies them upon its lateral regions by means of the hand that is intro- duced into the parts. In order to bring the blade to its proper place, he should glide the index finger 96 MANUAL OF OBSTETRICS. behind the upper edge of the blade, and the middle finger behind, and the thumb below the lower edge. 10. When the instrument is applied, the accou- cheur may place himself to either side of the handle in the direct presentations, but in the diagonal, he should always place himself behind it. 11. The accoucheur, in order to grasp the forceps after they have been applied, must place his hands differently in the presentations of the inferior, and in those of the superior strait. In the presentations of the superior strait, the hand, which holds the handle of the forceps, should be placed below the instrument, while that which is near the vulva should be placed above. In the presentations of the inferior strait, the method of proceeding is directly opposite, with this exception, that the index finger of the hand, which is near the vulva, should be carried as high up as the head, in order to ascertain whether it follows the motions which the forceps are intended to im- press upon it. PRESENTATIONS OP THE VERTEX OP THE HEAB AT THE INFERIOR STRAIT OF THE PELVIS. With respect to the application of the forceps, accoucheurs generally admit six principal presenta- tions of the head at the inferior strait of the pelvis, viz. two direct, and four diagonal. We shall speak first of what relates to the direct presentations. MANUAL OF OBSTETRICS. 97 FIRST DIRECT PRESENTATION OP THE VERTEX OP THE HEAD AT THE INFERIOR STRAIT. Principal relations.—The occiput corresponds to the symphysis pubis, and the forehead to the hol- low of the sacrum. We shall not recapitulate the signs by which we may distinguish each presentation of the head, these having already been detailed in the article on man- ual labour. Application of'the forceps.—The accoucheur, taking the left blade in his left hand, inclines its handle towards the right groin, and carries it along the right hand which directs it to the side of the head which corresponds to the left of the pelvis. As soon as the blade begins to enter, it should be supported by the thumb placed behind its posterior edge. When this blade has been properly applied, it should be parallel with the axis of the inferior strait, and its screw should be opposite the centre of the vulva.—It should be held firmly by an assistant. The accoucheur then takes the other blade in his right hand, and, by inclining the handle towards the left groin of the mother, he should carry it to the side of the head which corresponds to the right of the pelvis. This being done, he locks the instrument, and placing himself to one side, he should grasp the for- ceps in the manner pointed out at page 38, and should move the head laterally, first depressing it in order to bring the occiput below the pubes, and then elevating it so as to follow the axis of the in- ferior strait. The accoucheur should take care, 10 l-*S MANUAL OF OBSTETRICS. from time to time, to push the head back into the pelvis, in order that the parts may not be dilated too suddenly. When the perineum is much distended, it should be supported with the hand near the vulva, while with the other, the forceps should be turned towards the abdomen of the mother. When the head is delivered, the accoucheur should support the handle of the instrument upon his breast, and after having unlocked'the blades, he should cau- tiously withdraw them one after the other. When the head has been delivered, and the trunk can not be disengaged by the natural efforts, the ac- coucheur should grasp the foetus by its two shoul- ders, and extract it in the direction of the axis of the inferior strait. If the fingers alone be not sufficient to enable the accoucheur to accomplish the delivery, he should apply a blunt hook in the posterior axilla, and pro- ceed in the manner that we shall point out when speaking of the application of the hooks. SECOND DIRECT PRESENTATION OF THE VERTEX OF THE HEAD AT THE INFERIOR STRAIT. Principal relations.—The occiput corresponds to the hollow of the sacrum, and the forehead to the symphysis pubis. Application of the forceps.—The application of the forceps is precisely the same as in the preceding presentation, with this exception, that the handle of the instrument should be less elevated, that it may the better embrace the head in the direction of its length. The extraction of the head is also effected in the same manner as in the preceding presentation, with MANUAL OF OBSTETRICS. 99 the exception, that as the face is above, after the occiput has passed, the accoucheur should move the head from side to side, and should endeavour to pass up the hand which holds the handle of the forceps, ?o that by firmly depressing the instrument, he may bring the face below the pubes. In this case it is not necessary to unlock the for- ceps, it being easy to remove them, without fear of wounding the parts of the mother, merely by re- laxing the blades. DIAGONAL PRESENTATIONS OF THE VERTEX OF THE HEAD AT THE INFERIOR STRAIT. FIRST DIAGONAL PRESENTATION OP THE VERTEX OF THE HEAD AT THE INFERIOR STRAIT. Principal relations,—The occiput corresponds to the left cotyloid cavity, and the forehead to the right sacro-iliac symphysis. Application of the forceps.—The occiput cor- responding to the left cotyloid cavity, the accouch- eur takes the right blade in his right hand, and after having inclined it towards the left groin, he carries it along the left hand to the anterior side of the child's head. The thumb ought to be placed under the poste- rior edge of the blade as soon as it begins to enter, and when it is properly applied, it should be given to an assistant. The accoucheur then taking the other blade in the same hand, carries it below the first, and using his left hand as a guide, he glides it upon the posterior side of the head. Both blades being properly fixed, the accoucheur 100 MANUAL OF OBSTETRICS. should withdraw the left hand, and lock the instru- ment. Then placing himself behind the forceps, he grasps them in the manner already pointed out, rotates the head, and after the qcciput is brought below the pubes and the face in the hollow of the sacrum, he should proceed precisely in the same manner as in the first direct presentation. SECOND DIAGONAL PRESENTATION OF THE VERTEX OF THE HEAD AT THE INFERIOR STRAIT. Principal relations.—The occiput corresponds to the right cotyloid cavity, and the forehead to the left sacro-iliac symphysis. Application of the forceps.—The occiput corres- ponding to the right cotyloid cavity, the accoucheur should take the left blade in the left hand, and after having inclined it towards the right groin, he should carry it upon his right hand, which is to be used as a conductor, upon the anterior side of the head,tak- ing care to place the thumb underthe posterior edgeof the blade, as soon as it begins to enter. The blade being now held by an assistant, the accoucheur should carry it back without removing his hand from the vagina, and then taking the other blade in the same hand with which he introduced the first, he should glide it in front of it, and by using the hand, which was left in the parts, as a conductor, he should carry it upon the posterior side of the head. Both blades being introduced, the accoucheur withdraws his right hand, and locks the instru- ment. Then, placing himself behind, he applies his hands in the manner already pointed out, rotates the head, and proceeds afterwards precisely in the same manner as in the first direct presentation. MANUAL OP OBSTETRICS. 101 THIRD DIAGONAL PRESENTATION OF THE VERTEX OF THE HEAD AT THE INFERIOR STRAIT. Principal relations.—The occiput corresponds to the right sacro-iliac symphysis, and the forehead to the left cotyloid cavity. Application of the forceps.—The forehead cor- responding to the left cotyloid cavity, the forceps should be applied in the same manner as in the first diagonal presentation; but as the face presents up- wards, the handle of the instrument should be less elevated than in the preceding presentations, in or- der that the head may be more easily grasped in the direction of its length. The instrument being applied, the accoucheur places himself behind it, rotates the head, and after having thus brought the occiput in the hollow of the sacrum, and the face below the pubes, he should proceed in the same manner as in the second direct presentation. « FOURTH DIAGONAL PRESENTATION OP THE VERTEX OF THE HEAD AT THE INFERIOR STRAIT. Principal relations.—The occiput corresponds to the left sacro-iliac symphysis, and the forehead to the right cotyloid cavity. Application of the forceps.—The forehead cor- responding to the right cotyloid cavity, the forceps should be applied in the same manner as in the se- cond diagonal presentation, with the exception, that the handle of the instrument should be more de- pressed. The accoucheur then placing himself be- hind the forceps, rotates the head, and proceeds in 102 MANUAL OF OBSTETRICS. the same manner as in the second direct presenta- tion. I. When the occiput corresponds directly to the left side of the pelvis, and the forehead to the right, the accoucheur should proceed precisely in the same manner as in the first and third diagonal presenta- tions, with this exception, that one of the blades should be placed under the pubes, and the other in front of the sacrum. II. When the occiput corresponds directly to the right side of the pelvis, and the forehead to the left, the accoucheur should proceed in the same manner as in the second and fourth diagonal presentations. PRESENTATIONS OF THE VERTEX OP THE HEAD AT THE SUPERIOR STRAIT OP THE PELVIS. The head may present at the superior strait in the same manner as at the inferior. FIRST DIRECT PRESENTATION OF THE VERTEX OF THE HEAD AT THE SUPERIOR STRAIT. Principal relations.—The occiput is above the symphysis pubis, and the forehead in front of the sacro-vertebral angle. Application of the forceps.—The blades of the forceps should be applied precisely in the same man- ner as in the first direct presentation of the inferior strait, with the exception, that they must be carried farther up, and that the hand which serves as a con- ductor, should be placed between the uterus and the head of the foetus. When the forceps are applied, the accoucheur grasps them in the same manner as was pointed out MANUAL OP OBSTETRICS. 103 when speaking of the presentations of the superior strait, and accordingly as the head is placed to the left or to the i right, he brings it to the first or se- cond diagonal presentation of the superior strait. In order to produce this conversion, it is often neces- sary to push the head a little above the superior strait, and when it is placed in a diagonal position, to bring it into the cavity of the pelvis by following the axis of the superior strait, and by inclining the handle of the instrument to the corresponding side ' of the thigh. By this management, the presenta- tion will be converted into the first diagonal presen- tation of the inferior strait; and then, by placing his hands as was directed when speaking of the presen- tations of the inferior strait, he rotates the head, and proceeds in the same manner as in the first presen- tation of the inferior strait. SECOND DIRECT PRESENTATION OP THE VERTEX OP THE HEAD AT THE SUPERIOR STRAIT. Principal relations.—The occiput corresponds to the sacro-vertebral angle, and the forehead to the symphysis pubis. Application of the forceps. —The forceps are applied precisely in the same manner as in the pre- ceding presentation, with the exception, that the handle of the instrument should be more depressed, in order that the head may be more readily grasped in the direction of its length. When the instrument is applied, the accoucheur places himself either to the right or left side, and then, by pushing the head a little above the superi- or strait, he brings it to the third or fourth diagonal presentation. This being done, be draws the head 104 MANUAL OF OBSTETRICS. into the cavity of the pelvis by following the axis of the superior strait, and by inclining the handle of the forceps to the side of the corresponding thigh. The rest of the labour is to be conducted upon the same principles as in the diagonal presentations of the inferior strait. FIRST DIAGONAL PRESENTATION OP THE VERTEX OF THE HEAD AT THE SUPERIOR STRAIT. Principal relations.—These are the same as at the corresponding presentation at the inferior strait, with the exception, that the head is less engaged. Application of the forceps.—The application of the forceps is precisely the same as at the inferior strait, with the exception, that the blades and the hand which directs them must be carried into the in- terior of the uterus. The instrument being applied, the accoucheur should place himself behind it, and bring the head into the cavity of the pelvis; taking care always to follow the direction of the axis of the superior strait, by inclining the handle of the for- ceps towards the side of the left thigh. By this management, the presentation is converted into the first diagonal presentation of the inferior strait, and the accoucheur should proceed exactly accord- ing to the rules laid down for the management of that presentation. SECOND DIAGONAL PRESENTATION OF THE VERTEX OF THE HEAD AT THE SUPERIOR STRAIT. Principal relations.—These are the same as in the corresponding presentation of the inferior strait, except that the head is less engaged. MANUAL OP OBSTETRICS. 105 Application of the forceps.—The application of the forceps is exactly the same as in the correspond- ing presentation of the inferior strait, excepting that the blades and the hand which guides them, should be carried farther up. The head is to be brought to the second diagonal presentation of the inferior strait, taking care to follow the direction of the axis of the superior strait, by inclining the handle of the instrument towards the right thigh; then, changing the position of his hands, the accoucheur converts the presentation into the first direct, and terminates the labour according to the rules laid down for the management of that presentation. THIRD DIAGONAL PRESENTATION OP THE VERTEX OF THE HEAD AT THE SUPERIOR STRAIT. Principal relations. —They are the same as in the corresponding presentation of the inferior stra'it. Application of the forceps.—The forceps are to be applied in the same manner as at the inferior strait, except that they should be carried into the interior of the uterus. When the instrument is ap- plied, the accoucheur should place himself behind it, and bring the head to the third diagonal presenta- tion of the inferior strait; and then, by rotating it, he should terminate the labour in the same manner as in the second direct presentation of the inferior strait. FOURTH DIAGONAL PRESENTATION OP THE VERTEX OF THE HEAD AT THE SUPERIOR STRAIT. Principal relations.—They are the same as in the corresponding presentation of the inferior strait. 106 MANUAL OF OBSTETRICS. Application of the forceps.—The forceps are ap- plied in the same manner as in the corresponding presentation of the inferior strait. When the in- strument is properly fixed, the accoucheur places himself behind it, and brings the head to the fourth diagonal presentation of the inferior strait, and pro- ceeds according to the rules laid down for the man- agement of that presentation. I. When the occiput corresponds directly to the left side of the pelvis, and the forehead to the right, the accoucheur should proceed in the same manner as in the first and third diagonal presentations, ex- cept, that the first blade should be placed under the pubes, and the second in the hollow of the sa- crum. The rotary motion, which is impressed upon the head, should always be made with the view of bringing the occiput below the pubes, and the face in the hollow of the sacrum. II. When the occiput corresponds directly to the right side of the pelvis, and the forehead to the left, the accoucheur should proceed upon the same principles as in the second and fourth diagonal pre- sentations, with the exception, that the blades should be placed in the same manner as in the preceding presentation, one in front and the other behind. This being done, the occiput ts to be brought below the pubes, and the face to the hollow of the sacrum. OF IMPACTION OP THE HEAD AT THE SUPERIOR STRAIT. Authors, generally, admit two kinds of impac- tion of the head at the superior strait of the pelvis. In the first kind, the antero-posterior diameter of MANUAL OF OBSTETRICS. 107 the superior strait is less than four inches, and the head of the foetus is impacted in its occipito-fron- tal diameter. In the second kind, the antero-posterior diameter of the superior strait, i* less than three inches and a half, and the head of the foetus is impacted in its bi-parietal diameter.* FIRST KIND OF IMPACTION. IMPACTION OF THE HEAD IN ITS OCCIPITO-FROXTAL DIA3IETER. The head of the foetus may be impacted in its long diameter in two different presentations. FIRST PRESENTATION. Relations.—The occiput corresponds to the sym- physis pubis, and the forehead to the sacrum. SECOND PRESENTATION. Relations.—The occiput corresponds to the sa- crum, and the forehead to the symphysis pubis. Indications to be fulfilled.—The head should be pushed up, so as to bring it to one of the-diagonal pre- sentations—a circumstance which may always be accomplished in these presentations. Application of the forceps.—In both these pre- sentations, the forceps should be applied precisely • The bi-parietal diameter is the tranverse diameter which extends from one parietal protuberance of the head to the other.—S. U. G. 108 MANUAL OP OBSTETRICS. in the same manner as in the first and second direct presentations of the vertex of the head at the supe- rior strait, with the exception, that the blades are not to be carried quite so high up. The accoucheur, placing himself either to the right or the left of the instrument, should push the head, by moving it a little laterally, so as to bring it to one of the diagonal pre- sentations of the superior strait. This being done, he is to proceed exactly upon the same principles as in that presentation. SECOND KIND OF IMPACTION. IMPACTION OF THE HEAD IN ITS BI-PARIETAL DIA- METER. The head of the foetus may be impacted in its bi- parietal diameter in two different presentations. FIRST PRESENTATION. Relations.—The occiput presents directly to the left side of the pelvis, and the forehead to the right. SECOND PRESENTATION. Relations.—The occiput corresponds to the right side of the pelvis, and the forehead to the left. Indications to be fulfilled.—1. If the foetus be dead, it is advisable to open the cranium, in order to diminish its volume, and to remove it by means of the crotchets. 2. If the foetus be alive, we ought, above all things, to extract it by means of the forceps. But MANUAL OF OBSTETRICS. 109 upon what part of the head ought we to apply the blades? M. Gapuron, well aware that the head may always be pushed up, rejects the application of the forceps upon the face and the occiput, and advises us to push up the head in all cases, and to apply the forceps upon its lateral regions. He is of opinion, that the instrument adds but little to the thickness of the head, and that by pushing it up it may be sufficient- ly reduced to enable us to bring it into the cavity of the pelvis. If then we prefer pushing up the head above the superior strait, we should remember, with M. Ca- puron, to apply the blades of the forceps upon the lateral regions of the head, and in introducing them to observe the relations between the occiput and the pelvis. If the occiput present directly to the left, we should introduce the blades in the same manner as in the first and third diagonal presentations; but if it present to the right, we should proceed upon the same principles as in the second and fourth di- agonal presentations. But should it prove impossible to push the head above the superior strait, we should remember with Professor Baudelocque, to place one of the blades of the forceps upon the face, and the other upon the occiput. In applying the instrument, we should observe the rules that were laid down when speaking of the direct presentations. The head should be brought into the cavity of the pelvis, in the direction of the axis of the superior strait, and the blades of the for- ceps should be re-applied upon its lateral regions. In order to simplify this secondary application of the forceps as much as possible, we ought not to 11 110 MANUAL OP OBSTETRICS. withdraw the blade, which, according to the rela- tions of the occiput, should be placed behind, though in re-applying the blades, we should conform, in every respect, to the rules laid down when speaking of the transverse presentations. PRESENTATIONS OF THE FACE. The face of the foetus presents in six principal directions at the inferior and superior straits. Of these six presentations, two are direct and four diagonal. Indications to be fulfilled.—In the presentations of the face the accoucheur is obliged to fulfil two indications; one consists in turning the foetus in or- der to deliver it by the feet, and the other in cor- recting the position of the head. If the foetus can be turned, the accoucheur should proceed in the same manner as in the presentations of the^vertex of the head; if not, he should endea- vour to place the occiput in such a manner that the head may present by one of the extremities of its longest diameter. The position of the occiput may be corrected by means of the hand alone, but, as we have already had occasion to speak of it when treating of the an- terior region of the trunk, we shall not again re- vert to it. The position of the occiput may also be remedied by means of the lever, as we shall show when treat- ing of the application of that instrument. When the accoucheur has corrected the position of the head by either of these means, he should abandon the labour to the efforts of nature, unless MANUAL OP OBSTETRICS. Ill there be some accident which should oblige him to have recourse to the forceps, which should then be applied, as in the presentations of the vertex. In case the position be such, however, that the occiput can not be brought down, either with the hand, or the lever, we should, above all things, have recourse to the forceps. PRESENTATIONS OF THE FACE AT THE INFERIOR STRAIT. FIRST DIRECT PRESENTATION OP THE FACE AT THE INFERIOR STRAIT. Principal relations.—The forehead corresponds to the symphysis pubis, and the chin to the hollow of the sacrum. Characteristic signs of the presentation.—As we have already had occasion to point out the cha- racteristic signs of these presentations, in speaking of the anterior region of the trunk, we shall not revert to them on the present occasion. Application of the forceps.—The forceps should be introduced in the same manner as in the direct presentations, with the exception, that the head should be grasped only in the direction of the occi- pito-frontal diameter. When the instrument is properly fixed, the accoucheur holds the handle in one hand and depresses the occiput, while with the other, placed under the edge of the blades, he pushes the face into the interior of the pelvis. When the 112 MANUAL OF OBSTETRICS. position of the head is corrected, he should sepa- rate the blades without unlocking them, and pass them in the direction of the occipito-mental diame* .ter, by elevating the handle of the instrument. This being done, he should terminate the labour as in the first vertex presentation. SECOND DIRECT PRESENTATipN OF THE FACE AT THE INFERIOR STRAIT. Principal relations.—The forehead corresponds to the hollow of the sacrum, and the chin to the symphysis pubis. Application of the forceps.—In this presentation the forceps are applied in the same manner as in the preceding, but as it is possible to grasp the head in the direction of its occipito-mental diameter, by considerably elevating the handle of the instrument, it would be perfectly useless to correct the position of the occiput, because the chin will be delivered first. The forceps being applied, the accoucheur should place himself to one side and dispose his hands as is customary in the presentations of the inferior strait. Then, moving the head laterally, he should first depress the handle of the instrument in order to disengage the chin from below the pubes; and this being done, he should turn it towards the abdomen of the mother, so as to disengage the occiput which is behind. MANUAL OF OBSTETRICS. 113 FIRST DIAGONAL PRESENTATION OF THE FACE AT THE INFERIOR STRAIT. Principal relations.—The forehead presents to the left cotyloid cavity, and the chin to the right sacro-iliac symphysis. Application of the forceps.—The face being placed diagonally, the blades of the forceps should be introduced according to the rules applicable to these presentations. But here, as in the first direct presentation, the head should be grasped in the di- rection of the occipito-frontal diameter. The ac- coucheur, therefore, after having brought the face to the first direct presentation, should proceed pre- cisely according to the rules laid down for the man- agement of that presentation. SECOND DIAGONAL PRESENTATION OP THE FACE AT THE INFERIOR STRAIT. Principal relations.—The forehead presents to the right cotyloid cavity, and the chin to the left sacroiliac symphysis. Application of the forceps.—The application of the forceps is precisely the same, as in the second diagonal presentation of the vertex; but, as in the preceding presentation, the head should be grasped in the direction of its occipito-frontal diameter. The accoucheur, placing himself behind the in- strument, brings the face to the first diagonal pre- sentation, and proceeds according to the rules laid down for the management of that presentation. 11* 114 MANUAL OF OBSTETRICS. THIRD DIAGONAL PRESENTATION OF THE FACE AT THE INFERIOR STRAIT. Principal relations.—The forehead presents to the right sacro-iliac symphysis, and the chin to the left cotyloid cavity. Application of the forceps.—The blades of the instrument should be applied according to the rules for the first diagonal presentation: but the head should be grasped in the direction of the occipito- mental diameter, and in order to accomplish this, it will be sufficient to elevate the handle of the forceps. When the instrument is properly applied, the ac- coucheur should place himself behind it, and by bringing the face to the second direct presentation, he should proceed according to the rules for the management of that presentation. FOURTH DIAGONAL PRESENTATION OF THE FACE AT THE INFERIOR STRAIT. Principal relations.—The forehead is directed towards the left sacro-iliac symphysis, and the chin towards the right cotyloid cavity. Application of the forceps.—The forceps are applied in the same manner as in the second diago- nal presentation, with the exception, that the head should be grasped in the direction of its occipito- mental diameter. This being done, the accoucheur should place himself behind the instrument, bring the face to the second direct presentation, and finish the labour in the same manner as in that presenta- tion. MANUAL OF OBSTETRICS. 115 I. When the forehead presents directly to the left side of the jlelvis, and the chin to the right, the ac- coucheur should conduct the labour as in the first and third diagonal presentations. II. When the forehead corresponds directly to the right side of the pelvis and the chin to the left, the accoucheur should proceed in the same manner as in the second and fourth diagonal presentations. PRESENTATIONS OF THE FACE AT THE SUPERIOR STRAIT. The face may present at the superior strait in the same directions as at the inferior. The relations between the head and the pelvis being precisely the same as at the inferior strait, with the exception, that the parts are less engaged, we deem it altogeter unnecessary to repeat them. FIRST DIRECT PRESENTATION OF THE FACE AT THE SUPERIOR STRAIT. Application of the forceps.—The forceps are ap- plied precisely in the same manner as in the corres- ponding presentation of the vertex; and here, as at the inferior strait, the head should only be grasped in the direction of its occipito-frontal diameter. The forceps being properly applied, the accou- cheur places himself to one side, and by pushing the head a little above the superior strait, he should convert the presentation into the first or second di- agonal presentation of the superior strait. This being done, he should proceed according to the 116 MANUAL OF OBSTETRICS. rules which we shall point out presently in speaking of the diagonal presentations. SECOND DIRECT PRESENTATION OP THE FACE AT THE SUPERIOR STRAIT. Application of the forceps.—The forceps are ap- plied in the same manner as in the corresponding presentation of the vertex. The head should be grasped in the direction of the occipito-mental diameter, and then, by pushing it a little above the superior strait, it should be brought to the third or fourth diagonal presentation. This being done, the labour is to be conducted upon the same princi- ples as in those presentations. FIRST AND SECOND DIAGONAL PRESENTATIONS OF THE FACE AT THE SUPPERIOR STRAIT. Application of the forceps.—The forceps are ap- plied in the same manner as in the corresponding presentations of the inferior strait; but the blades, and the hand which serves to guide them, must be carried farther up. When the instrument is properly applied, the ac- coucheur should bring the face to the first or second diagonal presentation of the inferior strait, by in- clining the forceps towards the corresponding thigh; which being done, he should proceed precisely in the same manner as in the presentation into which he has changed ft. THIRD AND FOURTH DIAGONAL PRESENTATIONS OF THE FACE AT THE SUPERIOR STRAIT. Application of the forceps—The forceps are ap- MANUAL OP OBSTETRICS. 117 plied in the same manner as in the corresponding presentations of the inferior strait; only that the blades should be carried higher up. When the for- ceps are applied, the accoucheur brings the face to the inferior strait, and conducts the rest of the la- bour precisely in the same manner as in the presen- tations of the inferior strait. I. When the forehead corresponds directly to the right or left side of the pelvis, the accoucheur should apply the forceps, and finish the labour ex- actly in the same manner as in the corresponding presentations of the inferior strait, taking always care, however, to bring the head first into the cavi- ty of the pelvis. APPLICATION OP THE FORCEPS WHEN THE TRUNK HAS BEEN DELIVERED. After the trunk has been delivered, the head may be arrested, either at the superior or at the inferior strait of the pelvis. It may present at either strait in six principal po- sitions, viz, in two direct and four diagonal. In all these presentations, the principal relations between the head of the foetus and the pelvis of the mother are the same as in the presentations of the vertex, only that, instead of the occiput, the chin presents first. The presentations being alike, the forceps are to be applied in each case upon similar principles. 118 MANUAL OF OBSTETRICS. PRESENTATIONS OF THE HEAD AT THE INFERIOR STRAIT, WHEN THE TRUNK HAS BEEN DELIVERED. FIRST DIRECT PRESENTATION OF THE HEAD AT THE INFERIOR STRAIT, WHEN THE TRUNK OF THE F03- TUS HAS BEEN DELIVERED. Principal relations.—The occiput corresponds to the arch of the pubes, and the face to the hollow of the sacrum. Application of the forceps.—An assistant being desired to elevate the trunk and arms of the foetus, the accoucheur introduces the blades of the forceps below, so as to grasp the head in the direction of its occipito-frontal diameter. Then locking the instru- ment, he moves it from side to side, and delivers the head by turning the handle of the forceps upon the abdomen of the mother, at the same time that he firmly supports the perineum with the right hand. SECOND DIRECT PRESENTATION OF THE HEAD AT THE INFERIOR STRAIT, WHEN THE TRUNK HAS BEEN DELIVERED. Principal relations. —The occiput is in the hol- low of the sacrum, and the forehead under the arch of the pubes. Application of the forceps.—In this presentation the forceps should be applied above, so as to grasp the head in the direction of its occipito-mental di- ameter. An assistant is requested to support the trunk of the foetus; and when the instrument is properly ap- MANUAL OP OBSTETRICS. 119 plied, the accoucheur firmly supports the perineum with one hand, while with the other he depresses the handle of the forceps, so as to disengage the face from below the pubes. FIRST DIAGONAL PRESENTATION OP THE HEAD AT THE INFERIOR STRAIT, WHEN THE TRUNK HAS BEEN DELIVERED. Principal relations.—The occiput corresponds to the left cotyloid cavity, and the forehead to the right sacro-iliac symphysis. Application of the forceps.—The foetus being elevated by an assistant, the blades of the forceps are introduced below, and then, bringing the head to the first direct presentation, the accoucheur proceeds in the same manner as in that presentation. SECOND DIAGONAL PRESENTATION OF THE HEAD AT THE INFERIOR STRAIT, WHEN THE TRUNK HAS BEEN DELIVERED. Principal relations.—The occiput presents to the right cotyloid cavity, and the forehead to the left sacro-iliac symphysis. Application of the forceps.—The forceps are introduced in the same manner as in the preceding presentation, and the management of the rest of the labour is exactly similar. 120 MANUAL OF OBSTETRICS. THIRD DIAGONAL PRESENTATION OP THE HEAD AT THE INFERIOR STRAIT, WHEN THE TRUNK HAS BEEN DELIVERED. Principal relations.—The occiput presents to the right sacro-iliac symphysis, and the forehead to the left cotyloid cavity. Application of the forceps.—In this presentation the blades of the forceps should be introduced above the foetus, in order to grasp the head in the direction of its occipito-frontal diameter. The instrument being properly applied, the accoucheur should ro- tate the head so as to bring the face under the pubes, and the occiput in the hollow of the sacrum, and accomplish the delivery in the same manner as in the second direct presentation. If the accoucheur experiences a great deal of dif- ficulty in introducing the forceps above the foetus, he should introduce them below, and proceed upon the principles that we shall point out presently in speaking of the diagonal presentations of the superi- or strait. FOURTH DIAGONAL PRESENTATION OF THE HEAD AT THE INFERIOR STRAIT, WHEN THE TRUNK HAS BEEN DELIVERED. Principal relations.—The occiput presents to the left sacro-iliac symphysis, and the forehead to the right cotyloid cavity. Application of the forceps—In this, as in the preceding presentation, the forceps should be appli- ' ed above the foetus, in order to grasp the head in the direction of its occipito-mental diameter. This MANUAL OP OBSTETRICS. 121 being done, the accoucheur should rotate the head, and finish the labour in the same manner as in the second direct presentation. Should there be much difficulty in introducing the forceps above the foetus, it ought then, as in the preceding presentation, to be intro. ced below. I. When the occiput corresponds directly to the left side of the pelvis, and the forehead to the right, the forceps are to be applied in the same manner as in the first and third diagonal presentations. II. When the head presents in an inverse direc- tion, the accoucheur should proceed in the same manner as in the second and fourth diagonal presen- tations. PRESENTATIONS OP THE HEAD AT THE SUPERIOR STRAIT, WHEN THE TRUNK HAS BEEN DELIVERED. The head of the foetus may present in the same manner at the superior as at the inferior strait; and as its relations with the pelvis of the mother are the same, with the exception that the parts are less en- gaged, we shall not repeat them on the present oc- casion. FIRST DIRECT PRESENTATION OF THE HEAD AT THE SUPERIOR STRAIT, WHEN THE TRUNK HAS BEEN DELIVERED. Application of the forceps.—An assistant being requested to elevate the foetus, the accoucheur in- troduces the blades below, and when they are pro- perly applied, he pushes the head above the supe- rior strait, and converts the presentation into the first or second diagonal presentation, accordingly as 12 122 MANUAL OF OBSTETRICS. he is placed to the right or left of the instrument. This being done, he draws the head into the inferior strait, and accomplishes the delivery in the same manner as in the presentations of the inferior strait. SECOND DIRECT PRESENTATION OF THE HEAD AT THE SUPERIOR STRAIT, WHEN THE TRUNK HAS BEEN DELIVERED. Application of the forceps.—In this presenta- tion, although the face is in front, we ought, above all things, to apply the blades of the forceps below the foetus, in order that they may embrace the head in the direction of its occipito-frontal diameter. The head is to be pushed above the superior strait, and the presentation should be converted into the third or fourth diagonal; and then, by drawing it into the in- ferior strait, it should be rotated so as to bring it to the second direct presentation. This being done, the accoucheur should unlock the forceps, unless the pelvis be very large, or the head small, with- out, however, withdrawing them from the parts, and then, by elevating the right blade, and depress- ing the left, he should pass them over the trunk of the foetus. The forceps are again locked, and by this simple manoeuvre, the head will be grasped in the direction of its occipito-mental diameter, and the rest of the delivery is to be accomplished in the same manner as in the second direct presentation. MANUAL OP OBSTETRICS. 123 FIRST AND SECOND DIAGONAL PRESENTATIONS OF THE HEAD AT THE SUPERIOR STRAIT, WHEN THE TRUNK HAS BEEN DELIVERED. Application of the forceps.—The forceps should be applied in the same manner as in the corres- ponding presentations of the inferior strait; only that the blades, and the hand which guides them, are to be carried higher up. The forceps being properly applied, the accouch- eur places himself behind the instrument, and brings the head into the inferior strait, by inclining the handle towards the corresponding thigh. This be- ing done, he rotates the head, and accomplishes the delivery precisely in the same manner as in the first direct presentation of the inferior strait. THIRD AND FOURTH DIAGONAL PRESENTATIONS OF THE HEAD AT THE SUPERIOR STRAIT, WHEN THE TRUNK HAS BEEN DELIVERED. Application of the forceps.—In these presenta- tions it is absolutely necessary to introduce the blades of the forceps below the foetus. When the instrument is properly applied, the head must be brought into the inferior strait, by inclining the handle towards the corresponding thigh, and then, by rotating it, the face will be brought under the pubes and the occiput in the hollow of the sacrum. This being done, the instrument is to be unlocked without removing it from the parts; and then, glid- ing the blades along the foetus until they reach the head, they are to be locked above. By this manoeu- vre, the head will be embraced in the direction of 124 MANUAL OF OBSTETRICS. its longest diameter, and the rest of the labour is to be conducted upon the same principles as in the second direct presentation of the inferior strait. I. When the occiput corresponds directly to either bide of the pelvis, the accoucheur should introduce the forceps and conduct the labour preciseJy in the same manner as in the corresponding presentations of the inferior strait, taking eare always to bring the head first into the cavity of the pelvis. RECAPITULATION OF THE DIFFERENT APPLICA- TIONS OF THE FORCEPS. In whatever manner the head may present, whe- ther by the vertex, by the face, or its base; and whether it be arrested at the inferior or at the su- perior strait, the rules to be observed in the appli- cation of the forceps are always the same. When the instrument is properly applied, it ought to embrace the lateral parts of the head, in the di- rection of their length, in order that the occiput or the chin may always be delivered before any other part. PRESENTATIONS OF THE INFERIOR STRAIT. Direct presentations.—In all the direct presen- tations of the inferior strait, whatever may be the part of the head that presents, the left blade of the forceps should always be introduced first, with the left hand, and then the other with the right hand. The instrument should be locked in such a manner that its pivot shall correspond to the centre of the vulva; and then, placing himself to one side, the ao- MANUAL OF OBSTETRICS. 125 coucheur seizes the forceps with both hands, one of which is to be placed at the lower part of the handle, and the other upon the upper edge of the blade, near the external parts. In this manner, he moves the head from side to side, and delivers it by turn- ing the instrument towards the abdomen of the mother, if the face present downwards, and by firm- ly depressing it if it present upwards. When the head is about to pass, the hand, which is near the external parts, should be applied against the peri- neum, which is to be firmly supported. Diagonal presentations.—In all the diagonal presentations of the inferior strait, whatever may be the part of the head that presents, the accoucheur is guided, in the application of the forceps, by the relation of the occiput or the forehead with the coty- loid cavities of the pelvis. Whenever the occiput or forehead corresponds to the left cotyloid cavity, the blades of the forceps are to be introduced with the right hand, taking care always to commence the introduction with the right blade. Whenever, on the contrary, the occiput or fore- head corresponds to the right cotyloid cavity, the blades are to be introduced with the left hand, tak- ing care always to begin with the left blade of the instrument. When the instrument is locked, the accoucheur places himself behind it, and then, taking the han- dle in one hand, and applying the other upon the upper part of the blades near the genital parts, he rotates the head, and terminates the labour either in the first or second direct presentation, accordingly as the occiput or the forehead is under the arch of the pubes. r 12* 126 MANUAL OF OBSTETRICS. I. When the occiput corresponds directly to the left side of the pelvis, the labour is to be conducted in the same manner as in the first diagonal presen- tation. II. When it corresponds directly to the right side of the pelvis, the labour should be conducted upon the same principles as in the second diagonal pre- sentation. PRESENTATIONS OF THE SUPERIOR STRAIT. Direct presentations.—In all the direct presen- tations of the superior strait, whatever may be the part of the head that presents, the forceps should be applied in the same manner as in the inferior strait, only that the blades, and the hand which directs them, are to be carried farther up. When the in- strument is properly applied, the accoucheur ap- plies one hand upon the upper part of the handle, and the other on the lower part of the blades, and carrying his index finger as far as the head of the foetus, he moves it from side to side, and places it in one of the diagonal presentations of the superior strait. This being done, he draws it into the infe- rior strait, and brings it to one of the diagonal pre- sentations, by inclining the handle of the forceps towards the corresponding thigh, and then finishes the labour in the same manner as in the presenta- tions of the inferior strait. Diagonal presentations.—In all the diagonal presentations of the superior strait, whatever may be the part of the head that presents, the forceps are to be introduced in the same manner as in the pre- sentations of the inferior strait, only that the blades, and the hand which guides them, must be carried MANUAL OF OBSTETRICS. 127 farther in. When the instrument is locked, the ac- coucheur should always place himself behind it, and apply one hand upon the upper part of the han- dle, and the other on the lower part of the blades, in such a manner as to carry the index finger within the parts. This being done, he should bring the head to one of the diagonal presentations of the in- ferior strait, and conduct the labour in the same manner as in the presentations of that strait. I. When the occiput corresponds directly to the left side of the pelvis, the labour is to be conducted in the same manner as in the first diagonal presen- tation. II. When it corresponds directly to the right side of the pelvis, it is to be conducted upon the same principles as in the second diagonal presentation. OF THE LEVER. By this name, says professor Desormeaux, ac- coucheurs designate an instrument which is intend- ed by its inventors to act as a lever upon the head of the foetus, and to force it through the canal of the pelvis and the organs of generation. The origin of this instrument is still involved in obscurity, though it has most generally been con- sidered as the invention of Roger Roonhuison. The lever that is used at the present day, resem- bles one of the blades of the forceps. The blade of the lever is formed in the same manner as those of the forceps. It has a fenestra, and is curved in such a manner as to have a con- cavity on one side which corresponds to the con- vexity of the head of the foetus, and a convexity on 128 MANUAL OF OBSTETRICS. the other which corresponds to the concavity of the pelvis. The handle of the instrument is made of wood. Remark.—Instead of the lever, accoucheurs often make use of one of the blades of the forceps; though, as has been justly observed by Professor Desormeaux, the lever, properly so called, is preferable when it can be made to act directly upon the occiput. If we use a blade of the forceps, we should always take care, in the diagonal presentations, to take the right when the occiput is to the right of the pelvis, and the left when it is to the left of the pelvis. In the direct presentations, we may use either blade; but we should, in every instance, introduce the one which we employ with the hand that corresponds to it by name. Use of the lever.—The use of the lever is gene- rally limited to correcting the position of the occi- ' put, and to draw it in such a manner as to bring it to the centre of the pelvis, when it is turned upon the back of the infant, as happens in the presenta- tions of the face. The lever may be used in the presentations of the inferior and in those of the superior strait of the pelvis. We shall point out the method of operat- ing in each particular case. PRESENTATIONS OF THE FACE AT THE INFERIOR STRAIT. FIRST DIRECT PRESENTATION. The occiput is turned backwards and corresponds to the symphysis pubis. Application of the lever.—One of the hands be- MANUAL OP OBSTETRICS. 129 ing introduced into the vagina, the lever is to be car- ried upon the side of the head, and by depressing its handle, it is applied upon the occiput by means of the fingers. When the instrument is properly secured, its handle is to be elevated and grasped with one hand, while the other is applied upon its upper part, near the symphysis pubis. This being done,the accoucheur depresses the handle of the in- strument by drawing it towards himself, while with the other hand he presses the head firmly from be- fore backwards. If the accoucheur does not succeed in this manner in correctingthe position of the occiput, he should, at the same time that he acts upon the lever, push the face backwards with some of the fingers placed near the symphysis pubis. When the head has assumed its natural position, the delivery is generally accom- plished by the efforts of nature, or if circumstances demand it, he must have recourse to the forceps. SECOND DIRECT PRESENTATION. The occiput corresponds to the sacrum. Application of the lever.—In this presentation we ought to glide the lever in front of the sacrum as far as the occiput, and, after it is properly applied, it should be seized with one hand near the perineum, while with the other we pull at the handle of the instrument and gradually elevate it. If there be muoh difficulty in rectifying the posi- tion of the occiput, we should push at the face with some of the fingers of the hand placed near the parts. Remark.—In this presentation, it would be pre- ferable to use the forceps, since the head may be 130 MANUAL OF OBSTETRICS. embraced in the direction of its length, and the chin made to pass first. j« FIRST AND SECOND DIAGONAL PRESENTATIONS. In the first, the occiput is turned backwards and corresponds to the left cotyloid cavity, and in the second, it is turned backwards and corresponds to the right cotyloid cavity. Application of the lever.—One of the hands be- ing introduced into the parts, the lever is to be car- ried upon the side of the head, and then upon the occiput, by depressing the handle of the instrument in the same manner as in the first direct presenta- tion. When the position of the head is rectified, the delivery is to be left to the efforts of nature, or if the case require it, we «nust apply the forceps. 1 THIRD AND FOURTH DIAGONAL PRESENTATIONS. In the first presentation, the occiput is turned backwards and corresponds to the right sacro-iliac symphysis, and in the second, to the left sacro-iliac symphysis. Application of the lever. —In these presentations the accoucheur introduces the lever, and proceeds precisely in the same manner as in the second di- rect presentation. Remark.—In these last two presentations the forceps are preferable to the lever, since it is prac- ticable to grasp the head in the direction of its oc- cipito-mental diameter, and to disengage the chin first. I. When the occiput is turned backwards and MANUAL OP OBSTETRICS. 13l» corresponds directly to the right o» left side of the pelvis, we must proceed upon the same principles as in the third and fourth diagonal presentations. PRESENTATIONS OF THE FACE AT THE SUPERIOR STRAIT. FIRST AND SECOND DIRECT PRESENTATIONS. in these presentations the relations of the child with the pelvis of the mother, are the same as in those of the inferior strait, only that the head is less engaged. Application of the lever.—The application of the lever is effected precisely in the same manner *s in the presentations of the inferior strait, but in proportion as we depress the occiput, we should f endeavour to bring the head to a diagonal presen- tation. DIAGONAL PRESENTATIONS. In all these presentations the relations of the foe- tus with the pelvis of the mother are the same as in the corresponding presentations of the inferior strait, only that th'e head is less engaged. Application of tlie lever.—In all the diagonal presentations of the face at the superior strait, we should introduce the lever and proceed in the same manner as in the corresponding presentations of the inferior strait. I. When the occiput corresponds directly to the right or left side of the pelvis, we should conduct the delivery in the same manner as in the third and fourth diagonal presentations. 132 MANUAL OF OBSTETRICS. Remark.—As the lever can be used with less advantage in the presentation^of the superior than in those of the inferior strait, many accoucheurs pre- fer the forceps; though Professor Desormeaux has employed it successfully in two cases, where the head was situated transversely, and could not be properly embraced by the forceps. OF THE BLUNT HOOKS. The blunt hooks which are employed for the ex- traction of the foetus have various forms, some being curved, while others form almost a right angle with the principal blade of the instrument. The handles of all these hooks are generally of wood. Remark.—The two blunt hooks which terminate the handle of the forceps, may, in all cases, be used instead of these single hooks, since they have pre- cisely the same form. Use of the blunt hooks.—The curved hook, with an acute angle, is intended to be applied in the hol- low of the axilla, in cases where the shoulders are retained within the pelvis, and can not be extracted by the fingers. This may also be used in extracting the knees when they present at the inferior strait. It may also be applied in the mouth in order to extract the head after the turning of a dead foetus. The hook, which forms a right angle with the principal blade of the instrument, is intended to be applied exclusively in the fold of the groin, in the presentations of the breech of the inferior strait. Professor Desormeaux is of opinion, that in the greatest number of cases where the use of the blunt MANUAL OF OBSTETRICS. 133 hook is indicated, the fingers mty be employed with much more advantage. Introduction of the blunt hook.—There are no very precise rules for the introduction of this instru- ment, and the only precaution that is necessary to be observed, is, to guide it with a finger, in order that we may be aware of the disposition of the part, where we wish to apply it. When the hook is in- troduced so as to embrace an extremity, it should always be seized with the hand that corresponds by name to that extremity; and in extracting the foetus, we should always take care to draw it in the differ- ent directions of the axes of the pelvis SECTION III. OF LABOURS WHICH MAT BE TERMINATED BY THE USE OP CUTTING INSTRUMENTS. Particular causes of these kinds of Labour. Amongst the labours which demand the employ- ment of cutting instruments, some are owing to dis- eases, or mal-conformations of the foetus, which may render its volume so considerable that delive- ry can not be accomplished without a previous ope- ration; while others, on the contrary, are owing to a narrowness of the pelvis of the mother, and to certain mal-conformations of her genital parts. Before entering upon an examination of what re- lates to these different kinds of labour, we shall say something of the instruments which are employed for their accomplishment. 13 134 MANUAL OF OBSTETRICS. OF THE PERFORATOR. The perforator is an instrument, by the aid of which we may divide the parietes of the cranium. Mauriceau, Smellie, Deventer and others, have in- vented different kinds of perforators; but all these instruments may be supsereded by a common knife, a bistoury, a trephine perforator, or by a kind of blade contained in the blade of the forceps, whose handle is curved to a right angle. Choice of the perforator.—The knife or the bis- toury is preferable when we wish to make a large angular opening into the cranium, for the purpose of extracting the brain. The trephine perforator may be used with much advantage where we wish merely to operate at a single point, in order to give passage to extravasat- ed fluids, as in cases of hydrocephalus. Place of incision.—When the head presents first, we should perforate the cranium at the supe- rior fontanelle, or at the sagittal suture. In case the head does not present until after the delivery of the trunk, we should perforate it in the occipital region, at the lambdoidal suture, or at the coronal, if it be within reach. Introduction of the perforator.—The instru- ment, whatever it be, should always be guided by several fingers introduced into the parts of the wo- man. OF THE CROTCHET. The ancients invented several kinds of crotchets, but all may be advantageously superseded.by theone MANUAL OF OBSTETRICS. 136 that is attached to the handle of the forceps. In- deed, this crotchet has all the desired advantages, and is not attended with the inconveniences of those that were formerly in use. Use of the crotchet.—As the crotchet does not diminish the volume of the parts upon which it is applied, it is evident that it should be employed only in those cases where these parts do not exceed the size of the pelvis of the mother. Place of application.—The crotchet may be applied upon every part that presents resistance, as the head, the chest, the pelvis,&c; but of all these parts the head is the one that demands its most fre- quent use. When we use the crotchet for the purpose of ex- tracting the head, we ought always to apply it in such a manner that it may pass by one of the extre- mities of its longest diameter. Thus, when the head presents first, the crotchet should be applied upon the occiput, and when it does not present un- til after the trunk has passed, it should be applied either upon the upper jaw or the forehead, as may be most convenient. Application of the crotchet.— Whenever the ac- coucheur introduces a crotchet into the uterus, says Professor Desormeaux, he ought to direct it with his fingers, so as to prevent it from injuring the parts of the mother. This being done, he should proceed precisely in the same manner as in the in- troduction of a blade of the forceps. Thus, one of the hands being in the vagina, or as high up as the uterus, the crotchet is to be glided upon it until it has arrived upon the head, when it is to be inclin- ed so as to penetrate its thickness. 136 MANUAL OP OBSTETRICS. OF EMBRYOTOMY. Embryotomy is the operation of dividing the foetus in utero, in order to extract it piece-meal. As the instruments which are employed in performing this operation do not deserve a particular descrip- tion, we shall confine our attention to pointing out their use. OF LABOURS WHICH REQUIRE THE USE OF CUTTING INSTRUMENTS UPON THE F03TUS. Causes.—The foetus may be affected by diseases or mal-conformations, which may render it so large that the delivery can not be accomplished without the aid of cutting instruments. The most frequent of these diseases are hydrocephalus, hydrothorax and ascites. The most ordinary mal-conformations are preternatural adhesions between the legs, and the presence of certain fungous or steatomatus tu- mours, on certain parts of the foetus. OF HYDROCEPHALUS. Principal signs.—When the disease has been carried to such an extent as to oblige us to employ cutting instruments, we may distinguish it by the great size of the fontanelles and sutures, by the ge- neral softness of the head, by evident symptoms of fluctuation, &c. Indications to be fulfilled.—Whether the foetus be dead or living, we ought to open the cranium, in order to discharge the fluid which it contains, and to reduce it in such a manner that we may be enabled to accomplish the delivery by the natural MANUAL OF OBSTETRICS. 137 passages. It is true, there have been some accou- cheurs, who have had the boldness to say that we ought to operate on the mother in case the foetus be alive; but is it not sheer ignorance and presumption thus to hazard the life of a mother in order to save that of an infant, which is doomed to certain destruc- tion? When the cranium is opened, the serosity escapes, the head assumes its original shape, and the delive- ry may be effected by the efforts of nature, or if it be necessary, we may have recourse to the crotchet, or the forceps. OF HYDROTHORAX AND ASCITES. Principal signs.—The size and fluctuation are the only signs by whick we can distinguish hydro- thorax and ascites. Indications to be fulfilled.—The fluid should be discharged by a puncture made with a trephine perforator; and then, if the natural efforts are not sufficient to accomplish the delivery, we ought to have recourse to the forceps or the crotchets. OF DETRUNCATION. When the head is the only part that remains in the uterus, we should endeavour, by means of the hand, to bring it to a proper position, and then to extract it with the fingers applied upon the inferior jaw. If this method of proceeding be unsuccessful, and if the size of the head exceed that of the pelvis of the mother, we should fix it at the entrance of the su- perior strait, by means of one of the hands introduced into the uterus, and perforate the cranium so as to let 13* 138 MANUAL OF OBSTETRICS. out its contents, and to terminate the labour by means of the crotchet. Professor Desormeaux re- marks that in this case, it is to be feared that on ac- count of the rolling motion of the head, in conse- quence of the tractions which are exerted upon it, the crotchet might slip, and in order, therefore, to avoid this accident, he advises us to give a preference to the forceps. OF THE EXTRACTION OF THE TRUNK. When the trunk alone is retained in the uterus, it may be extracted in various ways; first, by ap- plying the blunt hooks in the hollow of the axilla;; secondly, by first disengaging the arms in order to push them up; thirdly, by applying the crotchet upon the upper part of the vertebral column, or be- tween two ribs: the first of these methods is pre- ferred by Professor Desormeaux, because he fears that the crotchet may slip," in consequence of the brittleness of the ribs; fourthly, by turning it so as to deliver by the feet. In whatever manner weoperate, weshould always take care to place the longest diameters of the foe- tus in relation with those of the mother, and to with- draw it in the directions of the axes of the pelvis. OF THE EXTRACTION OF MONSTERS. 1. There may be cases in which two living twins may be united together at certain points of their surface merely by means of the integuments. In MANUAL OF OBSTETRICS. 139 these cases they ought to be separated by means of a cutting instrument, and should then be delivered according to the general rules of the obstetric art. 2. There may be instances in which the two twins may be united together at the vertex of the head; examples of which have been related by Bau- delocque and M. Caperon, on the authority of Am- brose Pare. In these cases, the one should be de- livered by the feet, and the other, which will ne- cessarily present by the head, if it should remain too long in the pelvis, ought to be extracted by means of the forceps. 3. When two heads belong to the same trunk and present at the same time at the superior strait of the pelvis, we ought, according to Doctor Gardien, to diminish their volume by opening them, in order to extract them by means of the crotchets. , 4. In case there be two trunks with but one head, and both presenting at the superior strait, it is evi- dent, that they ought to be separated, in order that they may be extracted one after the other. 5. In case there be large tumours upon certain parts of the surface of the foetus, which present an obstacle to the termination of the labour, we ought, according to the advice of the greatest number of accoucheurs, either to reduce their size, or to re- move them, and not to perform any operation on the mother. OF LABOURS WHICH DEMAND THE EMPLOYMENT OF CUTTING INSTRUMENTS UPON THE MOTHER. General causes.—These are, according to Pro- fessor Baudelocque; 1st, mal-conformations of the 140 MANUAL OP OBSTETRICS. genital parts of the mother; 2d, mal-conformation of the pelvis; 3d; rupture of the uterus and the vagina; and 4th, extra-uterine pregnancies. OP MAL-CONFORMATIONS OF THE SOFT PARTS. The mal-conformations of the soft parts may be either natural or accidental. " In the first case," says Professor Baudelocque, " the defects consist in the agglutination of the labia externa; in the nar- rowness of the entrance of the vagina, in conse- quence of the form and rigidity of the hymen; in the smallness of this canal, or the membranous in- tersections which occur there; in the imperfect ob- literation of the cervix uteri; and in short, in a com- plete want of all the parts which constitute the vulva. " The accidental mal-conformations of all these parts may be owing to the presence of tumours, or to some ulcerations which may give rise to preter- natural adhesions." Indications to be fulfilled in these different mal- conformations. 1. We may, observes the same author, without much danger to the mother, and without experienc- ing great difficulties, separate the labia externa, when they are united, as well as the hymen, when it obstructs the delivery, and the septa which are sometimes found in the interior of the vagina, or the cervix uteri, and the bands which prevent the dilatation of that canal. 2. When the orifice of the uterus is too narrow or completely obliterated; when it is schirrous, or as it were cartilaginous, we ought to make incisions MANUAL OF OBSTETRICS. 141 into it indifferent directions with a bistoury,guard- ed with a piece of linen to within half an inch of its point, and guided upon the finger. 3. When the os externum is imperforate, or the vulva be entirely wanting, we ought to make an in- cision in the direction of the raphe, extending from the symphysis pubis to within an inch and a half of the fore part of the anus. 4. (Edema of the genital parts may be treated by scarifications, which should be made at the infe- rior and internal part of the labia pudendi. By this means, the parts will be disgorged and the pas- sage become free. 5. The varicose tumours, which are sometimes developed in the thickness of the parts of generation, often acquire a very considerable size, and, though they do not impede the delivery of the child, they may break and give rise to considerable sanguine- ous infiltrations. To avoid this accident, accouch- eurs generally advise us to open some of the exte- rior ones, and to discharge their contents. 6. When the external genital parts are the seat of a large abscess, the pus should be discharged by means of an incision. 7. The vagina is sometimes filled with polypi, or schirrous tumours: when these are pedunculous, it is generally easy to free the woman, but when they have a large base it will sometimes be prefera- ble to perform the Caesarian operation. 8. The bladder may contain a large calculus. If we are called in time, we should push it up and keep it above the superior strait, until the head be delivered; but if the stone forms a tumour at the vulva and the head of the foetus remains a longtime in the cavity of the pelvis, we ought, above all things, 142 MANUAL OF OBSTETRICS. to make an incision into the vagina and the bladder in order to extract the calculus and to accomplish the delivery. OF THE MAL-CONFORMATIONS OF THE PELVIS OF THE MOTHER, AND OF THEIR EFFECTS UPON DE- LIVERY. Every part of the pelvis of the mother may be in a state of mal-conformation; but as the obstacles to the termination of the labour most frequently occur at the superior strait, in the direction of its antero- posterior diameter, it is upon the different degrees of extent of this diameter that we must base the mode of termination applicable to each kind of la- bour. In this article, however, we shall treat only of those cases which require the employment of cutting instruments upon the mother, having al- ready treated of those which demand their applica- tion upon the foetus. PRINCIPAL DEGREES OP DEFORMITY OF THE ANTE- RO-POSTERIOR DIAMETER.--INDICATIONS WHICH THEY PRESENT. Natural extent of the antero-posterior diameter four inches. First degree of deformity. — The antero-poste- rior diameter being from four inches to three and a half. In the first degree of deformity it may be possible to accomplish the delivery by the natural process, MANUAL OF OBSTETRICS. 143 since the head of the foetus has only an extent from one parietal protuberance to the other, of from three inches and a quarter to three inches and a half. Second degree op deformity:—The antero-pos- terior diameter being from three inches and a half to three inches. In the second degree of deformity, it will be im- possible to accomplish the delivery by the natural efforts; but it may be effected successfully by means of the forceps. The turning of the foetus, which has been proposed by some accoucheurs, can not be at- tended with the same advantages, and it may give rise to serious accidents, such as the distention of the vertebral column, the luxation of the head, de- truncation, &c. Third degree of deformity.— The antero-poste- rior diameter being from three inches to two inches and a half. In this degree of deformity it would be inconve- nient to apply the forceps. If the infant be living, we may perform the operation of symphysiotomy, and if it be dead, we must open the cranium. Fourth degree of deformity.— The antero-pos- terior diameter being from two inches and a half to two inches. In deformities of this kind, it is absolutely neces- sary, if the child be alive, to extract it by the Caesa- rian operation. If the infant be dead, however, we 144 manual op obstetrics. should have recourse to the operation of embryoto- my. fifth degree of deformity.—The antero-poste- rior diameter being less than tivo inches. Whether the foetus be alive or dead, we ought, above all things, to perform the Caesarian operation; for, in this degree of deformity, the dismember- ment of the infant in utero would be attended with more danger to the mother, than even the Caesarian operation itself. OF SYMPHYSIOTOMY. Definition.—Symphysiotomy is the name of the operation for dividing the fibro-cartilage which con- nects the bones of the pubes. Necessary instruments.—A sound and a bistoury are the only instruments that are required for the performance of this operation. The bistoury should have a convex cutting edge and a blunt point. Time when the operation should be performed.— The operation of symphysiotomy should be per- formed as soon as the neck of the uterus is suffi- ciently dilated, to enable us to introduce the hand, and while the pains are sufficiently strong to expel the foetus. Position of the woman.—The woman is to be placed upon the edge of the bed, or upon a table of convenient height, her breech must be raised by means of a firm pillow, and her thighs are to be flex- ed upon the pelvis and somewhat separated from MANUAL OF OBSTETRICS, 145 each other^ The legs should be supported upon two chairs. Position and duty of the assistants.—Two as- sistants should be placed on the outside of the in- ferior extremities, which they are requested to maintain in the position which we have just indi- cated. When the operation is nearly completed, they ought to be particularly careful, to support the thighs, in order that the separation of the pubes may not take place too suddenly. A third assist- ant is desired to hand the instruments to the ope- rator, and to afford him such aid as he may require. Operation.—Before we commence the operation, we should shave the pubes, and introduce the sound into the bladder, in order to evacuate the urine, and to depress the urethra downwards and to the right of the woman, for the purpose of protecting it from the instrument. An assistant should be requested to hold the sound. This being done, the operator draws the integu- ments towards the umbilicus, and commences his in- cision at the superior margin of the symphysis pubis, and carries it as far as the clitoris, without interfer- ing with the anterior commissure of the vulva. Then,carryinghisbistoury slowly from abovedown- wards, or according to Plenck, from before back- wards, he divides the fibro-cartilage. If the divi- sion of the cartilage be effected by carrying the instrument from above downwards, the operator should take care to protect its point with the nail of the left index finger, in order to avoid interfering with the bladder or the urethra. When the section of the fibro-cartilage is completed, he must divide the superior and inferior ligaments, and gradually separate the pubes, in order to avoid injuring the 146 MANUAL OF OBSTETRICS. sacro-iliac symphyses. When the operation is com- pleted, the labour is to be left to the efforts of na- ture, or if the circumstances of the case demand it, we may terminate it by the aid of the hand or the forceps. As soon as the delivery is accomplished, the bones should be approximated, and maintained in imme- diate contact by means of a bandage applied around the pelvis. Experience has proved, that a double roller of cloth or flannel, from six to seven inches wide, and furnished at one of its extremities with a buckle, and at the other with a strap, is the most convenient means that can be employed. The woman should observe the most perfect rest, until the parts are completely consolidated, and, al- though the bones are generally re-united at the end of a month or six weeks, she ought not to be per- mitted to walk about, before the lapse of two months. As to the exterior wound, it will readily heal by union of the first intention, and by means of simple dressings. Alphonso Leroy advises us, however, to dress the wound with a piece of lint, dipped in a mixture of brandy and the white of an egg. OF THE EXTENT TO WHICH THE PUBES MAY BE SE- PARATED WITHOUT LESION OP THE SACRO-ILIAC SYMPHYSES. In general the separation of the pubes may be carried to an extent of two inches without rupture of the sacro-iliac symphyses; but when carried beyond this, it will, according to the experiments of Baudelocque, produce the most serious accidents. The most frequent of these are inflammation, ab- MANUAL OF OBSTETRICS. 147 scesses, &c. If we may credit, however, M. Gar- dien, who has founded his assertion upon the expe- riments of JVIM. Giraud and Ansiaux, the separation of the pubes may be carried to an extent of four inches, without any lesion on the part of the poste- rior articulations of the pelvis. OF THE BENEFITS OF THE OPERATION. Lines. If the pubes be separated to the extent of one inch, it will give an increase to the antero- posterior diameter of ----- 2 Two inches will give 4 Two and a half, according to Baudelocque, 6 Three inches, according to Giraud, - - 8 Four inches, according to the same author, 12 RESULTS OF THE OPERATION, CONSIDERED WITH RE- SPECT TO THE MOTHER AND THE INFANT. Upon 41 women, says Professor Baudelocque, upon whom the operation has been performed, 14 died, and 27 only survived. Of the 41 infants, 13 were alive, and 28 dead. Amongst the women that died after the operation, some appeared to have fallen victims in consequence of the operation having been performed at too late a period; and many, amongst those that survived, had had one or more children—a fact which proves, at least, that there was no great deformity of their pelves. In summing up the results of the above observa- tions, it will appear that symphysiotomy is a seri- ous operation, and that it should be performed only 148 MANUAL OF OBSTETRICS. in those instances where the necessity of the case absolutely demands it. OF GASTRO-HYSTEROTOMY, OR THE CAESARIAN OPE- RATION. Definition.—Professor Desormeaux defines the Caesarian operation to be an incision made in the parietes of the abdomen and in those of the uterus for the purpose of extracting the fo?tus. The origin of the Caesarian operation is lost in the obscurities of time, though it may be referred to a Very early period. It was for a longtime performed only upon the dead subject, and was for the first time practised upon a living female in 1500. Instruments.—The instruments which are ne- cessary in this operation are, two bistouries, one of the ordinary kind, and the other straight and probe- pointed, a pair of pincers, with needles and ligatures. There should also be at hand, a fine sponge, com- pressors, lint, bandages, &c. Time of election for performing the operation. —The most ancient method consists in making an incision upon one side of the abdomen, though the preference is given to the one to which the fundus uteri is inclined. Accoucheurs are not agreed with regard to the direction of the incision; some advise to make it obliquely in the direction of a line, extend- ing from the cartilaginous extremity of the third sternal rib to the symphysis pubis; others to make it semi-lunar; while Levret advises us to make it parallel to the external margin of the rectus muscle, and Lauverjat to give it a transverse direction. MANUAL OF OBSTETRICS. 149 Inconveniences of the Lateral'Method. « The lateral method is inconvenient: 1st, because we are obliged to divide three planes of muscles, which, in consequence of their different directions, present greatdifficulties to the process of cicatrization; 2d, in making the incision we are obliged to divide some of the branches of the epigastric artery, and some of the principal arteries of the uterus; and 3d, the fibres of the uterus being divided obliquely or transversely, can not contract without opening the wound and without giving rise, consequently, to an effusion of the lochia into the cavity of the ab- domen. Aware of the inconveniences of the lateral me- thod, the moderns, such as Mauriceau, Platner, . Solayrfes, and others, have preferred to make the incision upon the linea alba. This method also has its inconveniences; but as it is generally preferred, we shall describe the differ- ent steps of the operation, Proper time for performing the operation.— The Caesarian operation, says Professor Desor- meaux, has a time of necessity and a time of elec- tion; of necessity, when we are called in after a more or less protracted labour'and when the.life of the mother or of the infant would be endangered by longer delay; and of election, when we have time, during the course of pregnancy, to convince ourselves of the obstacles which may impede the delivery, and to fix upon the mode of conduct that ou^ht to be pursued. In these cases, accoucheurs are generally agreed, that, in order that the labour may be well conducted, we should take care that 14" 150 MANUAL OF OBSTETRICS. the cervix uteri be sufficiently dilated to give pas- sage to the blood which is effused upon the surface of the uterus, to the coagula which may form in its cavity and to the lochia. Notwithstanding this, the operation should always be performed before the evacuation of the waters has taken place, in order that the uterus may contract and reduce the incisions to a very small extent, and in order also that we may be less liable to wound the foetus. Preliminary measures.—If the woman be robust and plethoric, sljifi ought to be cautiously bled: but if she be excessively nervous and irritable, she should be placed in the bath, and take some anti-spasmodic potions. Previously to commencing the operation, we ought to shave the pubes, and to empty the bladder and the rectum. Position of the woman.—The woman is to be placed on the side of the bed, upon her back, her head and chest should be somewhat elevated, and her legs should be stretched during the incision, and demi^lexed during the extraction of the infant. Her loins should be raised by a pillow in order to render the abdomen more prominent. Position of the assistants.—Two assistants are requested to steady the uterus, in order to keep away Jhe intoetinesflrom the place where the inci- sion is" to be made. Other assistants are requested to hand the instruments to the operator and to af- ford him such aid as he may require; while others again, are charged with keeping the patient in her proper position. Operation.—The accoucheur being armed with a convex bistoury, makes an incision in the direc- tion of the linea alba, which, according to Professor MANUAL OF OBSTETRICS. 151 Baudelocque, ought to extend from the umbilicus, or above it, to within about an inch and a half of the symphysis pubis. Professor Desormeaux observes that when the incision is commenced above the um- bilicus, the bistoury should be carried to the left of that cicatrix. In carrying the incision above the umbilicus, it will be practicable to open the uterus at its most elevated part, and thereby to prevent the effusion of the lochia into the cavity of the abdomen. This first incision should extend merely through the skin and the subcutaneous cellular tissue. The linea alba is then to be cautiously divided towards its inferior part; and, by means of the probe-pointed bistoury carried upon the left index finger, the incision is to be continued from below upwards as far as the su- perior angle of the wound in the integuments. The peritoneum now alone remains to be divided, which should be done with the same caution and precisely in the same manner. The parietes of the abdomen being divided, one of the assistants, who steady the uterus, should de- press that organ as low down as possible, in order to bring its fundus to the superior angle of the wound in the parietes of the abdomen. This being done, the operator makes an incision into the ante- rior paries of the uterus to within about? one ijpch of the inferior angle of the wound in the abdomen. This incision should be about six inches in length. and ought to embrace exclusively the parietes of the organ. It is to be commenced with the convex, and finished with the probe-pointed bistoury, which is to be carried from within outwards, and from above downwards. The membranes should now be cau- # 152 MANUAL OF OBSTETRICS. tiously divided, and precisely in the same manner as the parietes of the uterus. If the placenta correspond to the opening in the uterus, the operator ought, according to the advice of Professor Baudelocque, to detach it, and pierce the membranes near its circumference. But, as pro- fessor Desormeaux observes, it is impossible to know beforehand the place where this body is in- serted, unless the new method of auscultation by M. deKergaradec may prove to be of some utility: when this place is known, it should be avoided. When the operation is completed, the operator should seize the feet, and extract the foetus ex- actly in the same manner as in a case of natural la- bour. If the head presents naturally at the wound of the uterus, and if it can not be expelled by the contrac- tions of that organ, its escape should be favoured by pressing slightly upon the sides of the abdomen, at some distance from the incision, or by insinuating the fingers under the angle of the lower jaw. We should proceed in the same manner, in case the breech presents at the incision. The afterbirths may be delivered through the wound by the natural efforts, or they may be ex- tracted by pulling at the umbilical cord, or what is still better, by grasping them with the fingers, in order that they may present less volume. After the delivery of the afterbirths, the uterus ■hould be freed of the coagula of blood which it contains, by passing a finger through the os tinea?, or by throwing up some tepid injections. If the uterus be effected with inertia, or any manifest hemorrhage, we should induce it to con- tract by external pressure, by stimulating the edges MANUAL OP OBSTETRICS. 163 of the wound with the fingers, and by washing them with a mixture of vinegar and water. Injections 0 of cold water, of vinegar and water, or even of pure 'vinegar, should also be thrown into the interior of the organ. Treatment after the Operation. The treatment of the woman, after the Caesarian operation, may be divided into local and general. Local treatment.—The local treatment consists in covering the wound with proper dressings; but we should take care, above all things, to free the cavity of the abdomen from the blood and the waters that may have been effused into it. To effect this, it will be sufficient to put the woman in a proper po- sition, and to make gentle pressure upon the sides of the abdomen, or to throw up tepid injections. The wound in the uterus will be reduced to a very small extent by the contraction of that organ, and will require no attention. As to the exterior wound, we are advised by Pro- fessor Desormeaux to unite it by means of two or three sutures, taking care to leave a small opening towards its inferior extremity for the passage of the fluids which may have been extravasated into the abdomen. Some even put a piece of linen into this opening in order to absorb these fluids. Baudelocque embraces the advice of Desormeaux, and advises us to place a piece of linen in the cervix uteri, in order' to favour the escape of the lochia by the natural passages. The use of the suture has not received general ap- probation. M. Capuron regards it as injurious, and as another cause of peritoneal inflammation; and as 154 MANUAL OP OBSTETRICS. perfectly useless, because the distention of the pe- ritoneum, which is wont to occur, has always a tendency to relax the points of the sutures, even so much so as sometimes to oblige us to cut them. Accoucheurs, therefore, have proposed the use of strips of adhesive plaster, or the employment of the uniting bandage; but as M. Desormeaux observes, these means are insufficient to keep the lips of so large a wound in contact, on account of the softness and flaccidity of the parietes of the abdomen. Dressing.—The whole dressing consists in plac- ing a long compress along each side of the wound, and in covering it with a piece of linen, a dossil of lint and square compresses. These must be sup- ported by means of a bandage carried around the abdomen. The dressing ought to be removed several times during the course of the first twenty-four hours, and afterwards once or twice a day, according to the circumstances of the case, and accordingly as there may be suspicion of extravasation. If the uterus contract any adhesions to the edges of the wound, we ought, according to the advice of Bacqua, MM. Capuron, Gardien, and others, to care- fully separate them; for if this be neglected, the fluids which have been extravasated into the abdomen will be retained, and the woman will be exposed to severe twitching pains in the uterus, to hemorrha- ges, &c. &c. General treatment.—The general treatment af- ter the Caesarian operation should be the same as in every other grand operation in surgery. Thus, the patient should be confined to the most perfect rest, her diet should consist of veal and chicken broths, barley water, herb teas, &c; her bowels should be MANUAL OP OBSTETRICS. 155 freely opened by mild clysters, and if the symptoms of the disease require it, she should be repeatedly bled. The woman ought to nurse her child as soon as possible, or at least to suckle it, during the first weeks, in order, as Professor Baudelocque observes, to invite the milk to the breasts, to divert it from the uterus, and to dry up more readily its secretions. As soon as the wound is completely healed, the woman should wear a bandage around her abdomen, in order to prevent consecutive herniae, which some- times acquire a very considerable size. RESULTS OF THE C2ESARIAN OPERATION, CONSIDER- ED WITH RESPECT TO THE MOTHER AND THE IN- FANT. With respect to the mother.—The most frequent causes which render the Caesarian operation fatal to the mother, are, inflammation of the uterus, of the peritoneum and intestines, suppuration, gangrene, and extravasations into the abdomen. Notwith- standing these causes, authors have related a great number of successful cases, and Baudelocque ob- serves, that out of one hundred and eleven women, upon whom the operation was performed, forty- eight survived. With respect to the infant.—The Caesarian ope- ration is the mildest and safest means that can be employed for the extraction of the infant; provided, however, that it sustains no injury during the per- formance of the operation. 156 MANUAL OP OBSTETRICS. OF THE RUPTURE OF THE UTERUS AND THE VAGINA, CONSIDERED WITH RESPECT .70 DELIVERY. When the uterus is ruptured during labour, the foetus most frequently passes, either in part or in whole, into the cavity of the abdomen. We shall only treat, on the present occasion, of those cases in which the foetus, not being able to be delivered by the natural passages, the accoucheur is obliged to employ cutting instruments upon the mother. These cases may be reduced to the following: 1st. Where nothing but the head of the foetus has passed through the opening, and the uterus is firm- ly contracted upon the neck of the infant. 2d. Where the head and the superior part of the trunk have penetrated into the cavity of the ab- domen, and where the uterus is affected with iner- tia, so as to permit the delivery of the foetus by the natural passages. 3d. Where the foetus is entirely in the abdo- men. Remark.—When the lower extremities and the inferior part of the trunk are the only parts that have penetrated into the cavity of the abdomen, the delivery should be accomplished by means of the forceps; or if the infant be dead, it will be proper to use the crotchets, provided, however, that the conformation of the pelvis be such as to permit the extraction of the foetus by the natural passages. MANUAL OF OBSTETRICS. 157 Of the signs which indicate the rupture of the Uterus and the passage of the Infant and its dependencies into the cavity of the abdomen. Rational signs.—Professor Desormeaux ob- serves: " The noise of the rupture is sometimes heard by the attendants, and there is a sharp and fixed pain where the rupture takes place, which has this peculiarity, that it is sometimes sharp and pierc- ing, and soon after numb. Those who experience this kind of pain are in the habit of designating it by the name of cramp." The woman feels a slight degree of heat throughout her abdomen, the pulse is feeble, the countenance pale, syncope super- venes, and a cold sweat extends over the whole bo- dy, &c. Sensible signs.—The sensible signs are obtained by the touch. If the infant and its dependencies have passed entirely into the cavity of the abdomen, it may be discovered by passing the finger into the vagina; the part of the foetus that presented will have disappeared, the os tincae will he closed, and the whole organ will be contracted as after a natural labour. The foetus may be easily distinguished by passing the hand over the parietes of+he abdomen, and, if it be still living, the mother will perceive its motions in a different place from that in which she had previously. Indications to be fulfilled.—As soon as it is known that the foetus and its dependencies have passed from the uterus into the cavity of the abdo- men, we should hasten to perform the operation of gastrotomy (v. page 160), in order to extract them. If the uterus, however, be affected with inertia, it 15 158 MANUAL OF OBSTETRICS. may be possible to search for the feet of the foetus and to bring them through the opening, as in the case reported by M. Gardien, and witnessed by Professors Deneux and Roux. This rule for per- forming the operation of gastrotomy as soon as the infant has passed into the abdomen, should not be weakened by the observations which prove, that in certain cases nature is able to make an artificial pas- sage for the foetus, and, that in others, the foetus has remained during more than twenty years in the in- terior of the abdomen. RUPTURE OF THE VAGINA. The rupture of the vagina, says Professor Dubois, is certainly an occurrence that takes place more fre- quently than that of the uterus, with which it is very often confounded, notwithstanding the ease with which it may be distinguished. In fact, the rupture of the uterus diminishes in proportion as the whole organ contracts, while that of the vagi- na always preserves the same form and extent. The vagina is generally ruptured at the place where it is united with the uterus, and most fre- quently in a transverse direction. If the foetus has passed through this opening into the cavity of the abdomen, we ought, since the opening always remains the same, to introduce the whole hand into the cavity of the peritoneum, in order to bring back the foetus so as to deliver it by the feet. MANUAL OF OBSTETRICS. 159 OF EXTRA-UTERINE PREGNANCIES. Definition.—The extra-uterine pregnancies are those which take place exteriorly to the cavity of the uterus. Different kinds of extra-uterine pregnancies.— Accoucheurs generally admit three kinds of extra- uterine pregnancies: that which takes place in the Fallopian tubes, in the ovaries, and in the cavity of the abdomen. Professor Desormeaux admitsafourth, that which takes place in a cavity formed in the thickness of the tissues of the uterus. Characteristic Signs of extra-uterine Pregnancy. The signs which distinguish extra-uterine preg- nancy are divided into rational and sensible. The first are perfectly similar to those which dis- tinguish uterine pregnancy. The second, which can not be perceived until the fourth or fifth month, are derived from an examina- tion, and are drawn principally, first, from the de- velopment of the abdomen, which is unequally dis- tended and is raised towards one of the iliac fossae, or the umbilicus; and secondly, from the motions of the foetus, which may be perceived by traversing the parietes of the abdomen, and especially from the small volume which the uterus presents at the sus- pected period of pregnancy! Can the different kinds of extra-uterine pregnan- cies be distinguished from each other? Professor Desormeaux is of opinion that it is impossible to distinguish whether the foetus be in the Fallopian tube, in the ovarium, or in the cavity of the perito- 160 MANUAL OF OBSTETRICS. neum. Fortunately this distinction is of little im- portance, since the management is the same in each case. Termination.—Nature is sometimes able to free the woman of an extra-uterine pregnancy; but these fortunate examples are few, while there are many which attest that these kinds of pregnancies most frequently terminate fatally both to the mother and the child! Indications to be fulfilled.—Some surgeons, amongst whom are Sabatier and Levret, afraid of the hemorrhage, which is the inevitable consequence of the separation of the placenta, have advised us to abandon the woman to he resources of nature. But would it not be more reasonable to have recourse to the operation of gastrotomy, since it has been proved by numerous observations, that, by this operation, we may save both the mother and the child? OF GASTROTOMY. Definition.—Gastrotomy is the name of an ope- ration which is performed upon the parietes of the abdomen. Instruments, fyc.—The same as in the Caesarian operation. Place of incision.—The place where the opera- tion of gastrotomy is to be performed, must be deter- mined by the kind of uterine pregnancy. If the foetus be developed in the cavity of the abdomen, we ought, according to M. Capuron, to make the incision in the place which corresponds to the linea alba; but if it be developed in the Fallopian tube or in the ovarium, the incision should be made at the side which answers to the extra-uterine tumour. MANUAL OF OBSTETRICS. 161 In case the head, after being engaged in the small pelvis, projects into the vagina, we should cut upon it through the corresponding paries of that canal, in order to extract the foetus and its dependencies by the natural passages. Time when the operation should be performed. Time of necessity.—We are obliged to perform this operation when the uterus has been ruptured, and the foetus has passed from it into the abdomen, and on account of the death of the foetus and the causes which produced it. Time of election.—If none of the preceding causes be present, at what time ought we to per- form the operation? Ought we to wait for a certain time for the efforts of nature; or should they be pre- vented? Authors are not agreed upon this subject, though it would appear more reasonable to act be- fore the supervention of the causes which often de- termine the efforts of nature to come on suddenly. Operation.—The operator must proceed precise- ly in the same manner as in the Caesarian operation; only, instead of opening the uterus, he must open the cyst which contains the product of conception. The foetus is to be extracted in the same manner as in the Caesarian operation. The delivery of the after-births is unquestionably the most difficult and dangerous part of the whole operation, for the separation of the placenta must necessarily give rise to hemorrhage which can not be arrested, like that of the uterus, by the contraction of the part into which this organ is inserted. If we con- sider, however, as Professor Desormeaux observes, that the placenta is sometimes so thin and delicate as 15' 162 MANUAL OF OBSTETRICS. to resemble a membrane, and that its vessels are so small that they can scarcely be traced with the scal- pel, we should suppose that its separation could not always be so dangerous as we might imagine. We should not, therefore, abandon it to the resources of nature, nor wait until it is detached and presents at the wound in the parietes of the abdomen. Treatment after the operation. When we perform this operation, says M. Gar- dien, it is exceedingly important that the woman should suckle her infant, in order to counterbalance the irritation which is generally created in the peri- toneum, and which constitutes one of the most se- rious affections that we have to combat. The ope- rator should take care to keep open the wound, in order that the extravasations which take place into the abdomen may escape, and to throw injections into that cavity from time to time, in order to re- move the fluids and produce their absorption. The general treatment is the same as in the Caesa- rian operation. SECTION IV. OF THE ARTIFICIAL DELIVERY OF THE SECUNDINES. Definition.—The artificial delivery of the secun- dines is that kind of delivery, which can not be confided to the efforts of nature, and therefore, de- mands the interference of the obstetric art. In order to facilitate our knowledge of every MANUAL OF OBSTETRICS. 163 thing that relates to this kind of delivery, we shall say a few words upon the mechanism of the natural delivery of the secundines. The mechanism of the delivery of the secundines, according to Professor Desormeaux, presents three distinct periods. In the first, the placenta is de- tached from the internal surface of the uterus; in the second, it is expelled from the cavity of that or- gan into the vagina, and in the third, it passes the vulva. MECHANISM OF THE NATURAL DELIVERY OF THE SECUNDINES. The most fortunate cases of this kind of labour are those in which the placenta is rolled upon itself in the form of a cupping-glass, in proportion as it is detached, and presents at the os tincae the apex of the cone which it represents. Pressed by the con- tractile efforts of the uterus, it soon passes the cer- vix uteri, in the direction of the axis of the superior strait of the pelvis, and having arrived in the vagina, it is in a short time expelled through the vulva, in the direction of the axis of the inferior strait. Here the placenta no longer receives the contractions of the uterus, and is, as Professor Desormeaux ob- serves, expelled by the falling down of that organ. The membranes are discharged after every other part of the after-births has been delivered. Sometimes the placenta, instead of offering its border, presents its foetal surface; in this case the delivery of the secundines is somewhat more diffi- cult. 164 MANUAL OF OBSTETRICS. OF THE ARTIFICIAL DELIVERY OF THE SECUNDINES. General causes. —Hemorrhage, convulsions, syn- cope, inertia of the uterus, spasmodic contractions of its neck, preternatural adhesions of the placenta, its retention, its insertion into the cervix uteri, abortion and compound pregnancy. Amongst all these causes, there are some, such as hemorrhage, convulsions, and syncopies, which de- mand a prompt delivery; while others, such as in- ertia of the uterus, the spasmodic contraction of its neck, the preternatural adhesions of the placenta, &c, permit or oblige us to retard the delivery. Of the manner of producing artificial delivery of the Secundines. This operation may become necessary, either when the placenta is detached, or when it still ad- heres to the uterus. In the first case, if the umbilical cord still re- mains and presents a certain degree of resistance, the delivery may, in general, be easily accomplish- ed. In fact, it will be sufficient, in order to effect its separation, to pull upon the cord in the direction of the axis of the pelvis; and to accomplish this, it will be necessary, at the same time that we pull with one hand at the foetal portion of the umbilical cord, to place the index and middle fingers of the other into the vagina, above the cord, in order to form a kind of pulley, which shall direct the first tractions in the direction of the axis of the superior strait. When the placenta has arrived in the vagina, the MANUAL OF OBSTETRICS. 165 accoucheur should remove it in the direction of the axis of the inferior strait, by elevating the hand, and by carrying it alternately from one thigh to the other. As soon as it presents at the vulva, he should carry one of his hands in front of the perineum in order to support it, and also to receive the placenta, which he rolls up, without removing it from the parts of generation. By this last manoeuvre, he obliges the membranes to roll themselves into a kind of cord, which renders their complete extrac- tion more sure. In the second case, that is, when the placenta is still adherent to the internal surface of the uterus, if the tractions upon the cord be not sufficient, we ought, above all things, to introduce one of the hands into the organ, in order to produce its sepa- ration. If the cord still remains, it should serve as a guide to the hand, which ought to be introduced according to the same rules and with the same pre- cautions as in cases of preternatural labours. When a part of the placenta is detached, the ac- coucheur carries his hand into the uterus, and glides it between that part and the internal surface of the uterus, until he has completely separated it. If the placenta be still adherent in every part of its surface, he should begin by detaching one of the points of its circumference, and proceed as in the pre- ceding case. When it has been detached in its middle, and is only adherent by its circumference, Professor Desormeaux advises us, after Baudelocque, to pierce its centre, and to carry the fingers through that opening, in order to effect the separation with more facility. In cases where a portion, or even the whole of the placenta adheres too firmly to be detached by the 166 MANUAL OF OBSTETRICS. method which we have just indicated, it would be better to leave behind such portions as can not be* extracted. When the placenta has been detached, the accou- cheur should draw it out with one hand, taking care at the same time, to bring away the portions which may be insulated, and the clots which are within the uterus. (M. Desormeaux.) Remark.—In the delivery of the secundines, in cases of abortion, as it is impossible to introduce the hand into the uterus, we ought, in cases of accident, to extract the placenta by means of two fingers, or with a pair of Levret's forceps. A PHYSIOLOGICAL MEMOIR UPON THE BRAIN, BY M. MAGENDIE: Read in a Public Sitting of thb Rotal Academt o? Sciences, os the 16th of June, 1828. FROM THE FRENCH, BY JOSEPH GARDENER, M. D. ^APPENDIX. A PHYSIOLOGICAL, MEMOIR UPON THE BRAIN. Since the blind and barren respect which the ancients professed for the dead, has"'given place to an ardent and enlightened desire to become acquaint- ed with the wonders of the organization of the hu- man body, anatomical science, by the constant la- bours of & host of distinguished men, has been gra- dually elevated to a high degree of perfection. There is not one of the numerous solid or liquid elements, whose admirable union constitutes our bodies, that has not been the object of an attentive study and exact description. We have engraving&v and lithographic prints, which represent in the mosiff exact manner all our organs; and more than this— within a few years there have been constructed of pasteboard, models of the human frame, which are such excellent imitations, as to be of essential ser- vice to students of medicine. In short, those anatomists, who, in the ardour of their zeal, still preserve the hope of finding some part hitherto unobserved, some peculiarity of struc- ture unknown to their predecessors, pursue their labours witrf.the aid of the magnifying power of 16 170 APPENDIX. lenses. This alone will suffice to demonstrate what is the actual state of the topography of the human body. The researches which I have for a long time pur- sued upon the functions of the nervous system, have, much to my gratification, enabled me to discover a new element of our organization; not one of those, which to be demonstrated requires minute research and delicate instruments; but, on the contrary, the element of which I speak, is so apparent, and occu- pies so much space, that it must have hitherto es- caped observation only in consequence of the belief, in other respects well founded, that no part of the body, however minute, could have escaped the ac- tive investigations of anatomists. I have discovered that there exists in the cavity of the cranium and spinal canal, a liquid which sur- rounds the brain, spinal marrow, and origin of all the nerves. This liquid,-which exists in a state of perfect health, its quantity amounting to several ounces, is too apparent to have passed unnoticed by several writers; but its presence has been attributed either to a state of disease, for which means of cure have lately been proposed, or to those physical changes which death produces in our organs. The gratifying satisfaction 1 experienced on as- certaining the reality of a fact so important, can on- ly be appreciated by you, gentlemen, who have experienced the lively pleasure arising from the free and independent cultivation of science. I was assailed by a crowd of conjectures concern- ing the functions of this fluid: was not the liquid which I had discovered, the animal spirits, of which ancient anatomists and modern metaphysi- cians have spoken so much without ever having seen APPENDIX. 171 it? was it not the ncrvoi^s fluid concerning which, certain physiologists still amuse us, without having critically examined it? was it rather the vital fluid.1 &c.—Had this discovery been made only fifty years since, it would doubtless have served as a founda- tion for a brilliant hypothesis, explaining every thing, whether capable of being resolved, or beyond the reach of human intellect. Such is not the march of science in our day. Thanks to the progress of good sense, experience is preferred to the most ingenious system, and the most simple truth is more fascinating than all the delusions of the imagination. The following pages contain the observations and experiments which 1 have made, both upon the hu- man subject and upon animals. 1 have already had the honour of communicating to you a part of my researches: I again ask permis- sion to present them to you, together with a great number of new results, which I have obtained from my experiments. It is necessary in the commencement, to give a name to my liquid—a name is an important appen- dage to an object in the science of anatomy. I have^ called it the cephalo-spinal liquid, (or cephalo-ra- chidian, for those whose ear might be wounded by an hybridous word,) because it exists at the same time in the cranium and cavity of the spine. It is necessary in the second place to state the exact quantity of the liquid. I have discovered that an adult of ordinary stature, and in the full enjoy- ment of his moral and physical faculties, has about three ounces; women, cseteris paribus, have a great- er quantity. In old men, the proportion of the cephalo-spinal liquid is still greater, and in some 172 APPENDIX. cases it mav amount to six or seven ounces, but un- der these circumstances, the mental and corporeal energies are generally greatly enfeebled. * The locality of the liquid is worthy of remark; it forms a layer around the brain and spinal marrow which varies in thickness according to its situation; in the neck it is four or five lines; in the lumbar re- gion it is more than an inch, around the brain it is generally one or two lines, and in certain cases and situations it approaches an inch in thickness. Do not the above facts form a powerful objection against a famous system, which pretends at nothing less than divining the most minute peculiarity of the volume and conformation of the brain, from an ex- amination of the dimensions and conformation of the cranium? If there exist, which no one can doubt, a layer of liquid between the cranium and the brain, and if this liquid is several lines in thickness, how is it pos- sible to judge of the dimensions of the brain from an examination of the cranium, and how can any one be confident that the protuberances and depressions upon the surface of the head do correspond with a similar configuration of the brain? The study of the liquid layer which clothes the brain has led me to a very singular fact, hitherto entirely unobserved, respecting the volume of this organ. The volume of the brain is represented as inva- riable, because it is supposed completely to fill the cavity of the cranium, and we never observe the head to become diminished or enlarged as other organs of the body; but nothing is less true: lam confident that the size of the brain always corres- ponds with the changes which take place in the vol- ume of the other organs of the human body. APPENDIX. 173 In all diseases of a certain duration, in which the body becomes much emaciated, the brain undergoes an analagous diminution, and the convalescent who can stand with difficulty, and supposes his weak- ness to arise from the almost total disappearance of the muscles of his legs, can with much greater rea- son, attribute his mental enervation to the diminu- tion of the volume of his brain. I have discovered that in proportion as the ema- ciated organs regain their former dimensions, the brain also recovers that which it had lost. Thus one of the offices of the cephalo-spinal liquid, is to fill up the cavity produced by the diminished volume of the brain, as frequently as that occur- rence takes place. It answers the same purpose in cases of partial diminution, of which I have con- vinced myself, from an examination of those per- sons who, during many years of their lives, have had immovable contractions of their limbs. In these cases a fifth or a fourth of one of the cerebral lobes had disappeared, a large cavity was formed upon the sur- face of the organ, and completely filled by the ce- phalo-spinal liquid. What an admirable diversity of means are em- ployed by nature! The viscera of the thorax and abdomen frequently diminish in volume; but the parietes of those cavities, being flexible and press- ed upon by the atmosphere, follow the retreat of those organs, and a cavity is thus avoided. But on the contrary, the parietes of the cranium being in- flexible, can not follow the brain when its volume decreases; it is therefore necessary that the cephalo- spinal liquid should be present in order to occupy the space which the brain has abandoned. After having discovered what were the physical 16* 174 APPENDIX. uses of the cephalo-spinal liquid, I determined to pursue my researches for the purpose of discover- ing whether it exercised any influence upon life. In order to solve this curious and interesting ques- tion, it was necessary to have recourse to experi- ments upon animals, which also have a cephalo-spi- nal liquid, the quantity however being much less than occurs in the human body. I made my first experiment upon a fox that had been caught in a snare; he was old and fierce, and evinced no disposition to serve in the advancement of science. However, by means of a small punc- ture which I made in the nape of the neck, his ce- phalo-spinal liquid was in a few moments evacuated: the effect which followed was extremely striking: this animal, ferocious a moment before, became suddenly calm: he no longer made efforts to bite, and lay upon the ground without making the least movement. Seeing the animal in this disposition, I loosed it and set it at liberty in my garden, but it lay upon the ground and did not attempt moving its position until the next morning. It then began to show a disposition to rise, and during the course of tfae. day was enabled to walk several steps: in the space of thirty-six hours, it again endeavoured to bite and make its escape. I then made a new punc- ture in the neck, and convinced myself that the ce- phalo-spinal liquid was completely restored. So that by this experiment, which I repeated in many different ways, I discovered much more than I had sought—that it not only exercises a great influence upon the movements and instinct of animals, but that it is speedily reproduced. These experiments led" me to examine with much more attention than 1 had hitherto done, a disease APPENDIX. 175 of infants in which there occurs at the inferior extremity of the spine, a sac filled with water a situation where the natural liquid exists in the greatest quantity. • I discovered the liquid filling the sac, which has always been regarded as a conse- quence of disease, to be nothing but the natural fluid having distended its envelopes, and had produced a hernia in that situation. When this sac became ruptured the fluid escaped, and the death of the in- fants was the sudden consequence, probably be- cause the orifice remaining pervious, the cephalo- spinal liquid could not remain in the vertebral ca- nal, and protect, by its presence, the brain and spinal marrow. Thus, not only with men, but animals, the contact of the cephalo-spinal liquid with the brain is of the utmost consequence in preserving the integrity of the nervous functions, as well as being necessary for the continuance of life. But is it only as a liquid that this fluid is of so much importanc? Does not its chemical nature in- fluence it? To prove this I made an experiment in which, after having evacuated the cephalo-spi- nal liquid of an animal, I injected in its place dis- tilled water in equal quantity and at the same tem- perature, and was surprised to see the animal fall into extreme agitation—its movements were per- verted, and it seemed to have completely lost its instinct and habits. But on permitting the water which 1 had introduced to escape, the animal re- gained its natural condition. In order to judge whether the temperature of the liquid has also an effect upon the functions of the nervous system, I cooled the natural liquid which I had previously extracted from an animal and again introduced it into the cavity which it had occupied. 176 APPENDIX. The animal was seized with a general shivering, similar to that which precedes the hot stage of in- termittents. It may not be impossible that this ex- periment will throw some light-on the hitherto un- known cause of the cold and shivering stage of fevers. I therefore conclude from these facts and preced- ing experiments, as well as from many others which have been already published, that the cephalo-spinal liquid exercises an influence over the functions of the nervous system, 1st, by its contact with the brain and spinal marrow; 2d, by its chemical pro- perties; 3d, by its temperature, and that therefore this liquid, in consequence of its great utility in the animal economy, is worthy to be ranked with the blood, the tymph, &c. But I still have a subject of research much more important than any which has yet occupied us—it is concerning the influence which the cephalo-spinal liquid exercises over the intellectual faculties of man, a subject which requires the greatest circum- spection in my investigations, as well as the utmost severity in my deductions. To place every one in a condition to follow me and more fully understand the nature of my re- searches, I am under the necessity of saying a few words upon the conformation of the brain. 1 will be brief—nevertheless, it is of the utmost importance to have an intimate knowledge of that organ in which the inexplicable phenomenon of thought— that principal which is the most intimate and ele- vated of our nature, operates. The brain, that mass of nervous matter which fills the interior of the cranium, is divided into two portions. The larger, which occupies the whole supe- APPENDIX. 177 rior part of the cranium, is called the cerebrum, and the other, which is placed beneath, is called*he cere- bellum. The exterior surface of the brain presents a great number of convolutions, which vary in num- ber in different individuals, and are separated by deep sulci. This arrangement has induced some authors to believe that the brain is only a large membrane folded upon itself. There are several cavities in the centre of the brain, and it is in them most probably that some of the mysterious secrets of the intellectual functions take place. Can it be believed that these cavities, so important from the phenomena which they pro- duce, have been and still are called ventricles, that is to say, little bellies. Let it be added, however, to the honour of modern anatomists, that this epithet is derived from the ancients, with whom it was in such esteem that they applied it to every thing. That which we call the thorax, was termed by them a belly. The stomach was but lately termed a ven- | tricle. The heart has still its two ventricles. Each muscle has a belly, hence the degastric muscles. In a word the brain, because it is undoubtedly the I most noble of all our organs, has nothing less than f four little bellies—is it not time that this trivial no- menclature should be removed from anatomical lan- guage. Be this as it may, the nomenclature of the brain presents a very remarkable and striking circum- stance, to which I will now call your attention. Several of these parts have names which are used in hydraulics—here is an aqueduct—there a funnel —in another place a valve, and, in fine, there is even a bridge. The most of these terms may be traced to remote 17S APPENDIX. • ages__they are still in use, but they are considered only as the vestiges of an ancient system, which time and the progress of science are hastening on to ruin. What this ancient system was we are unable to say. Physicians, however, for a long time believed that the cavities of the brain were filled with water, which in certain cases escaped by the nose—a belief which passed among the vulgar and with whom it still exists. These ideas are regarded as erroneous by practical anatomists, according to whom the cavities of the brain do not contain any water in the healthy state, but a light, invisible vapour, which they do not hesitate to represent as the immaterial substance which presides over the operations of intelligence. Nevertheless, when we open a brain, we find its ventricles almost always filled by a limpid fluid, which anatomists are in the habit of regarding as the product of the disease which caused the death of the individual. After having acquired the knowledge of the li- quid which surrounds the brain and spinal marrow, I concluded, that the water which is so found in the cerebral cavities, must be the same humour which is found at the surface of the brain—from whence it results, that it naturally exists in the ventricles as was supposed by the ancient physicians, and is not, as is believed at the present day, the effect of disease. I conceived, however, that, in order to confirm this conjecture, it was absolutely necessary that there should exist a communication between the exterior of the organ and its internal cavities—a a communication, however, which had never been discovered. How has it escaped the numerous APPENDIX. 179 modern investigators of the brain?, but as the ce- phalo-spinal liquid has not been noticed1 by. them, I did not despair; and in fact, after examining the brains of several subjects, I at length found an open- ing of twoor three lines in diameter, completely con- cealed by a lobe of the cerebellum, and forming a true entrance into the cavities of the brain. I have represented this opening on a fine wax preparation which I presented to the Academy, and which is now exhibited at M. Dupont's museum. This fact once established, it became mechanically necessary that the cephalo-spinal liquid should en- ter into the cavities of the brain and fill them, in consequence of their communicating with each other. I had little difficulty in verifying this deduc- tion upon the bodies of individuals who had been killed by accident, and in whom I discovered a li- quid which filled the cavities of the brain, and which immediately communicated with that which sur- rounds the brain and spinal marrow. This discovery gave me the key of the hydraulic nomenclature, to which I have just alluded. I saw that these supposed ruins of ancient systems were simply the figurative but just designation of a col- lection of organs in full activity, and performing .their peculiar functions in the brains of those very persons who denied their existence or contested their mode of action. In fact, what is at present called the great valve of the brain, performs to a cer- tain extent the office of a valve. The aqueduct has really those functions which its name indicates, since it conducts the cephalo-spinal liquid from the fourth into the third ventricle. The infundibu- lum, or funnel, conveys the liquid to the pituitary gland—in a word, the bridge is truly an arch which 180 APPENDIX. traverses the current of the liquid. This bridge is established, notabove, but below the current which it passes, and in order to give you an idea of it, I can not do better than call your attention to the gigantic en- terprise which is now executing under the Thames. Behold then a complete restoration of the monu- ment, or, to be more modest and exact, of the hy- draulic apparatus which the brain presents—without being an exclusive flatterer of past times, I am oblig- ed to grant that in this circumstance we have ex- amined much less critically than our predecessors. Modern anatomists, however, in this case deserve praise in preserving those terms, although they re- gard them as false and illegitimate. In this they are wise, as men sometimes are in the affairs of this life, without being aware of it. The liquid which fills the cavities of the brain is never in repose—it experiences a continual agita- tion in consequence of a kind of flux and reflux, which takes place under the influence of respiration. Thus, at the moment when we draw the air into the thorax for the purpose of respiration, a proportion of the liquid flows from the cerebral cavities into the spinal canal—at the moment, on the contrary, when we drive the air from our lungs by expiration, the liquid re-enters these cavities by traversing the passages above mentioned, and particularly by run- ning through the aqueduct, which thus at different times conducts the liquid in opposite directions. The mechanical cause of the flux and reflux of the cephalo-spinal liquid is very simple—it is produced by the alternate swelling and depression of the veins, caused by the blood under the influence of respiration. This movement of the liquid may be arrested, or at least much retarded by compressing APPENDIX. 181 the abdomen—and this will explain the cause of belts proving injurious and even dangerous, when- ever the pressure which they exercise is too consi- derable. Whilst observing the movement of the liquid through the aqueduct, I believe I discovered the pro- bable use of the pineal gland, a small body placed in the centre of the brain, and which has preserved a certain degree of celebrity since the time of Des- cartes. This philosopher, who, notwithstanding the ex- tent and vigour of his mind, yielding frequently to the propensity which we ourselves experience, in filling with our illusions the immense space which is beyond the boundary of vision and intellect, has given an hypothesis, not upon the throne of the soul, as has been remarked, but upon the situation in which it exercises its functions, and upon the throne of the imagination and of common sense, all of which he places in the pineal gland. Voltaire, who delights in metaphysics, but loves still more to mock metaphysicians, has made a face- tious parody upon the supposition of Descartes, which has been more successful than the hypothe- sis itself—for anatomists to the present day apply the term reins of the soul to two nervous peduncles, which, accordingto Voltaire, are the guides by which the pineal gland, which he compares to a coachman, directs the movements of the two hemispheres of the brain. The functions of the pineal gland, which 1 propose to substitute for the hypothesis of Descartes, are very humble—but I believe them to be true, and that is a merit which, in science, ought to precede every thing. I regard the pineal gland as a tarn- 182 APPENDIX. pon, for the purpose of opening and closing the aqueduct of the brain. The gland is, in fact, plac- ed above the anterior opening of the aqueduct. Two voluminous veins are firmly placed upon the gland. These veins vary in size, being sometimes very much swelled, and at others nearly empty. It is inevitable, from the relative position of the parts that, at the moment when the veins are swelled, they must press down the pineal gland, and that this can not take place without closing more or less tightly the entrance of the aqueduct of the brain. But as one of the constant effects of violent exercise, crying, rage, and the exercise of any of the passions, is to swell considerably the veins of the head, and particularly those which press upon the pineal gland, it results, that in three different conditions, the entrance of the cephalo-spinal liquid into the ventricles must be intercepted, or at least rendered much more difficult. The office, or to speak more correctly, one of the offices of the pineal gland, must be, therefore, an in- dispensable mechanical agent, for the purpose of more or less completely closing the aqueduct of the brain, and to modify, according to circumstances,the motion of the cephalo-spinal liquid, as it enters or flows from the cerebral cavities. I come now to speak of the most important, and at the same time, the most interesting question which the study of the cephalo-spinal liquid can possibly present. What influence has this fluid upon the exercise of the intellectual faculties? In a research, so delicate as this, and one, which presents a prospect of arriving at the most import- ant and interesting results, the chances of com- mitting error must be exceedingly numerous. APPENDIX. 183 In order, therefore, to avoid error as much as possible, 1 have endeavoured to determine the ex- treme points, reserving to myself, if it should be desirable, the opportunity of noticing, at a subse- quent period, the intermediate facts. I will therefore state the quantity of the cephalo- spinal liquid, first, as it occurs in the sane; second, as it occurs in the imbecile; and, third, as it occurs in idiots. The details of the researches which I have made at the Salpetriere, where there are a great number of fools, idiots, and sane women, I am sorry to say, are too numerous to find a place in this paper:—I must be satisfied, therefore, by mentioning the prin- cipal results. , In speaking of idiots, I have reference to those who have become so accidentally, not of idiots from birth, in whom there exists some mal-conformation of the nervous system. The idiots of whom I speak, present a considera- ble quantity of the fluid. It occupies the surface of the brain, under the form of a thick layer, and dis- tends the cerebral cavities, displacing all the organs which they contain, and particularly the pineal gland, which neither retains its ordinary position, nor performs those functions which I have attributed to it. The aqueduct is also often considerably enlarg- ed. It is in these cases that the cephalo-spinal liquid may be found to amount to six or seven ounces; and the same circumstance obtains in cases of old per- sons who suffer from mental derangement. Fools likewise present a large quantity of the liquid; but it does not accumulate upon the surface of the brain. Whatever may be the variety of de- rangements, whether monomania, hallucination of 184 APPENDIX. the mind, furious mania, melancholia, &c, the ven- tricles are always much distended and enlarged by the cephalo-spinal liquid. In such cases, three ounces of the liquid have been found in the ventri- cles alone. The brains of those endowed with reason contain, in a majority of cases, less than an ounce of liquid in their ventricles at the moment of death. From this circumstance it is easy to distinguish the brain of an idiot from that of a sane person. I was once under the painful necessity of examin- ing the brain of a man of genius who died at an ad- vanced age, but who enjoyed the plenitude of his intellectual faculties. The entire quantity of the cephalo-spinal liquid contained in his brain and spinal canal was scarely two ounces, and the cere- bral cavities did not contain a drachm. These general results seem to establish the fact, that the development of the mind is in inverse ratio to the quantity of the cephalo-spinal liquid, a cir- cumstance which, to a certain extent, is easy of com- prehension, since the quantity of the liquid can not be increased, but at the expense of the mass of the brain, and that, in general, superior intelligence is observed in those who have voluminous and well formed brains. Thus, those persons who have a large head, a high and expanded forehead, and who attach a certain degree of vanity to this conformation, should not be without inquietude respecting the relative propor- tion of their cephalo-spinal liquid. I will add in this place, that this liquid should not be too abundant, and that its passage through the cavities of the brain and spine should be perfectly free and uninterrupted. I lately found in the brain of APPENDIX. 185 an aged singer, who, after having shone in our theatre, died an idiot in the Salpetriere, an oblite- ration of the opening by which the liquid entered into the ventricles; and as the brain of this female presented nothing else by which I could explain the disease of her mind, I was led to regard the oblite- ration of the opening into the ventricles as a cause, or one of the causes of her idiocy. You see, gentlemen, where my researches have led, but you also observe what remains to be per- formed in order to obtain a complete history of the cephalo-spinal liquid, whether considered in a state of health or disease. I have already collected a great number of facts; and I believe 1 have obtained several interesting re- sults, but I can not present them before you until I have sufficiently verified and perfected them. I must therefore terminate this memoir, hoping that the importance and novelty of a subject so ex- tremely interesting, will be an ample apology for the minute details into which I have been obliged to enter. 17* INDEX. Of the Management of Preternatural Labour, PART I. Of the pelvis of the mother, Great pelvis, Superior stmt, Cavity of the pelvis, Inferior strait. Of the Principal Parts of the Foetus, Of the head of the foetus, Of the shoulders of the foetus, Of the breech of the foetus, Of the Mechanism of Natural Labour, Of the presentations of the head, First presentation, Second do. Third do. Fourth do. Of the presentations of the feet, First presentation, Second do. Third do. Fourth do. Of the Presentations of the knees, First presentation, Second do. Third do. PAGE. 1 188 INDEX. Fourth presentation, Of the presentations of the breech, First presentation, Second do. Third do. Fourth do. page. 20 ib. 21 ib. ib. ib. PART II. Of the Management of Preternatural Labours. SECTION 1. Of the Labours which Terminate by mere manual assistance 23 General causes, - . . . . ib. Position of the woman, .... ib. Rules for introducing the hand, . . . ib. Of the Presentations of the Feet, . . .24 Characteristic marks of the feet, . . . ib. General rules for introducing the hand, . . ib. First Presentation of the Feet, . . . .25 Principal relations, . . . . ib. Characteristic signs of the presentation, . . ib. Management, . . . . . ib. Second Presentation of the Feet, . . .28 Principal relations, .... ib. Characteristic signs of the presentation, . . ib. Extraction of the foetus, .... ib. Third Presentation of the Feet, . . . .30 Principal relations, .... ib. Characteristic signs of the presentation, ib. Management, . . . . . ib. Fourth Presentation of the Feet, . . . . ib. Principal relations, .... ib. Characteristic signs of the presentation, ib. Management, . . . . . ib. Of the Intermediate Presentations of the Feet, . .31 Recapitulation of the different managements applicable to the Presentations of the Feet, . .32 Of the Presentations of the Knees, . . .33 INDEX. 189 \ Characteristic marks of the knees, Of the Presentations of the Knees at the inferior strait, First Presentation, Principal relations, Management, Second Presentation, Principal relations, Management, Third Presentation, Principal relations, Management, . Fourth Presentation, Principal relations, Management, . Of the intermediate Presentations of the Knees, Recapitulation, ..... Of the Presentations of the Knees at the superior strait, General rules for delivering the feet, First Presentation, .... Principal relations, Management, .... Second Presentation, .... Principal relations, . . Management, .... Third Presentation, .... Principal relations, Management, .... Fourth Presentation, .... Principal relations, . . , Management, .... Of the intermediate Presentations of the Knees, . Recapitulation, . Of the Presentations of the Breech, Characteristic marks of the Breech, Of the Presentations of the Breech at the inferior strait, Rules for the application of the fingers, the fillet and the blunt hooks, First Presentation of the Breech, Principal relations, 190 INDEX. Characteristic signs, .... Management, .... " Second Presentation of the Breech, Principal relations, .... Characteristic signs, .... Management. . Third Presentation of the Breech, Principal relations, .... Characteristic signs, . Management, . . - . Fourth Presentation of the Breech, Principal relations, .... Characteristic signs, . Management, . Of the intermediate Presentations of the Breech, Recapitulation, . . . . . Of the Presentations of the Breech at the superior strait, Indications to be fulfilled before searchingfor the feet, i General rules for displacing presentations of the breech at the superior strait, Choice of the hand, .... First Presentation of the Breech, Principal relations, . . . . Characteristic signs, . . . . Management, . Second Presentation of the Breech, Principal relations, . . . . Characteristic signs, . Management, . Third Presentation of the Breech, Principal relations, . Characteristic signs, . . . . Management, . Fourth Presentation of the Breech, Principal relations, . . . . Characteristic .signs, . Management, . . . . Of the intermediate Presentations of the Breech, IRDEX. 191 Recapitulation, Of the presentations of the Vertex of the Head, Characteristic marl* of the head, Of the extraction of the foetus, when the vertex of the head presents at the superior strait, Indications to be fulfilled, Rules for displacing these presentations, Choice of the hand, First Presentation of the Vertex of the head, Principal relations, Characteristic signs, Management, Second Presentation of the Vertex of the Head, Principal relations, Characteristic signs, . Management, Third Presentation of the Vertex of the Head, Principal relations, Characteristic signs, . Management, Fourth Presentation of the Vertex of the Head, Principal relations, Characteristic signs, • Management, Of the intermediate Presentations of the Vertex of the I Head, .... Recapitulation, Of the Presentations of the Trunk, First indication and management, Second do. do. Of the Posterior Region of the Trunk, . Characteristic marks, First Presentation of the Posterior Region of the Trunk, Principal relations, Characteristic signs, Management, Second Presentation of the Posterior Region of the Trunk, Principal relations, Characteristic signs, Management, 192 INDEX. Third Presentation of the Posterior Region of the Trunk, Principal relations, Characteristic signs, Management, .... Fourth Presentation of the Posterior Region of the Trunk Principal relations, Characteristic signs, Management, .... Of the Intermediate Presentations of the Posterior Region of the Trunk, .... Of the Anterior Region of the Trunk, Characteristic marks, Of the Presentations of the Anterior Region of the Trunk, First Presentation of the Anterior Region of the Trunk, Trunk, ..... Principal relations Characteristic signs, Management, . '"". Second Presentation of the Anterior Region of the Trunk Principal relations, Characteristic signs, Management, .... Third Presentation of the Anterior Region of the Trunk Principal relations, Characteristic signs, Management, .... Fourth Presentation of the Anterior Region of the Trunk Principal relations, Characteristic signs, Management, .... Of the Intermediate Presentations of the Anterior Region of the Trunk, .... Of the Lateral Regions of the Trunk, Characteristic marks, Of the Presentations of the Right Lateral Region, First Presentation of the Right Side, Principal relations, Characteristic signs, Management, .... INDEX. 193 Second Presentation of the Right side, Principal relations, Characteristic signs, Management, Third Presentation of the Right Side, Principal relations, Characteristic signs, Management, Fourth Presentation of the Right Side, Principal relations, Characteristic signs, Management, Of the Intermediate Presentations of the Right Side, Of the Presentations of the Left Lateral Region of the Trunk, First Presentation, Principal relations, Characteristic signs, Management, Second Presentation, Principal relations, Characteristic signs, Management, Third Presentation, Principal relations, Characteristic signs, Management, Fourth Presentation, Principal relations, Characteristic signs, Management, Of the Intermediate Presentations of the Left Lateral Re- gion, Of the Presentations of the Hand, Management, Recapitulation, . Of Compound Labour, 18 PAGE. 80 194 INDEX. SECTION II. Of Instrumental Labours, Instruments, Of the Application of the Forceps, Description of the Forceps, General Rules for the application of the Forceps, Of the Presentations of the Vertex of the Head at the In ferior Strait of the Pelvis . First Direct Presentation, Principal relations, Application of the forceps, Second Direct Presentation, Principal relations, Application of the forceps, First Diagonal Presentation, Principal relations, Application of the forceps, Second Diagonal Presentation, Principal relations, Application of the forceps, Third Diagonal Presentation, Principal relations, Application of the forceps, Fourth Diagonal Presentation, Principal relations, Application of the forceps, Of the Intermediate Lateral Presentations, Of the Presentations of the Vertex of the Head at the Su perior Strait of the Pelvis, First Direct Presentation, Principal relations, Application of the forcep Second Direct Presentation, Principal relations, Application of the forceps, First Diagonal Presentation, Principal relations, Application of the forceps, PAGE. 93 ib. ib. ib., 94 INDEX. 195 Second Diagonal Presentation, Principal relations, Application of the forceps, Third Diagonal Presentation, Principal relations, Application of the forceps, Fourth Diagonal Presentation, • Principal relations, Application of the forceps, Of the Intermediate Lateral Presentations, Of Impaction of the Head at the Superior Strait, First kind of impaction, Second do. do. Of the Presentations of the Face, Indications to be fulfilled, Of the Presentations of the Face at the Inferior First Direct Presentation, Principal relations, Characteristic signs, Application of the forceps, Second Direct Presentation, Principal relations, • Application of the forceps, First Diagonal Presentation, Principal relations, Application of the forceps, Second Diagonal Presentation, Principal relations, Application of the forceps, Third Diagonal Presentation, . Principal relations, Application of the forceps, Fourth Diagonal Presentation, Principal relations, Application of the forceps, Of the Intermediate Lateral Presentations, Of the Presentations of the Face at the Superior First Direct Presentation, Application of the forceps, Strait, Strait, 196 INDEX. Second Direct Presentation, Application of the forceps, First and Second Diagonal Presentations, Application of the forceps, Third and Fourth Diagonal Presentations, Application of the forceps, Of the Intermediate Lateral Presentations, Of the Application of the Forceps, when the Trunk has been delivered, Of the Presentations of the Head at the Inferior Strait when the Trunk has been delivered, First Direct Presentation, Second do. do. First Diagonal Presentation, Second do. do. Third do. do. Fourth do. do. Of the Intermediate Lateral Presentations, Of the Presentations of the Head at the Superior Strait, when the Trunk has been delivered, First Direct Presentation, Second do. do. First and Second Diagonal Presentations, Third and Fourth do. do. Of the Intermediate Lateral Presentations, Recapitulation, .... Presentations of the Inferior Strait, Direct presentations, Diagonal do. Intermediate lateral presentations, Presentations of the Superior Strait, Direct presentations, Diagonal do. . , Intermediate lateral presentations, Of the Lever, .... Use of the lever, Of the Presentations of the Face at the Inferior Strait, First Direct Presentation, Second do. do. PAGE. 116 ib ib ib ib ib 117 INDEX. 197 First and Second Diagonal Presentations, Third and Fourth do. do. Of thejntermediate Presentations, Of the Presentations of the Face at the Superior Strait, First and second direct presentations, Diagonal presentations, . Intermediate presentations, Of the Blunt Hooks, Use of the blunt hooks, . Introduction of the blunt hook, SECTION III. Of Labours which may be terminated by the use of Cut ting Instruments, Particular causes of these kinds of Labour, Of the perforator, Of the crotchet, Of embryotomy, Of Labours which require the use of Cutting Instruments upon the Foetus. Causes, Of hydrocephalus, Of hydro-thorax and ascites, Ofdetruncation, Of the extraction of the trunk, Of the extraction of monsters, .Of Labours which demand the employment of Cutting In struments upon the Mother, General causes, . Ofsnal-conformations of the soft parts, . •* Indications which they present, . Of the Mal-conformations of the Pelvis of the Mother, and of their effects upon delivery, Principal degrees of deformity of the antero-poste rior diameter, Of Symphysiotomy, Of the extent to which the Pubes may be separated with out lesion of the Sacro-iliac Symphyses, Of the benefits of the operation, 130 ib. ib. 131 ib. ib. ib. 132 ib. 133 ib. ib. 134 ib. 136 ib. ib. ib. 137 ib. 138 ib. 139 ib. 140 ib. 142 ib. 144 146 147 *v 198 INDEX. Of the results of the operation, considered with respect to the mother and the infant, Of the Caesarian operation, • **' Of the treatment after the operation, Of the results of the Caesarian operation, jjgnsidered with respect to the mother and the infant, Of the rupture of the uterus and the vagina, considered with respect to delivery, Of the signs which indicate the rupture of the uterus, and the passage of the infant and its dependencies into the cavity of the abdomen, Of the rupture of the Vagina, Of Extra-uterine Pregnancies, Of Gastrotomy, Operation of Gastrotomy, Treatment after the operation, . SECTION IV. Of the artificial delivery of the Secundines, Of the manner of producing artificial delivery of the Se- cundines, ..... APPENDIX, containing a Physiological Memoir upon , the Brain, ..... 147 148 153 1 155 ,*y 156 157 158 '., 159 160 161 162 ib. ( 164 167 MEDICAL, CHEMICAL, AND BOTANICAL BOOKS. THE FOLLOWING VALUABLE WORKS for sale by JOHX GRIGG, No. 9, North Fourth Street. 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