born, the face looks backwards and to the right, viz. to the back part of the mother's right thigh, for the shoulders are by this time passing through the pelvis in its left oblique diameter, the right shoulder being forwards and to the right, and lowest in the pelvis: it is also that which is first expelled.

Such is the manner in which the head presents in the first or most common position: a slight modification of it is occasionally observed during the early stages of labour, without influencing the favourable character of its progress: the head at first is in the left oblique diameter of the pelvis, the occiput towards the left sacro-iliac synchondrosis, the anterior fontanelle towards the right acetabulum; but as the labour advances, the head turns, so that the occiput corresponds to the left acetabulum, the anterior fontanelle being turned towards the right sacro-iliac synchondrosis, the sagittal suture running parallel with the right oblique diameter of the pelvis. This peculiar commencement of the labour is probably not detected so frequently as it really occurs, owing to its changing into the common position at so early a period.

Second position of the cranium. The other or second position of the cranium is, where the left side of the head presents. It is, in fact, merely the reverse of the one just described: the sagittal suture crosses the os uteri at the beginning of labour, as in the former case, only now the posterior fontanelle is turned to the right instead of to the left; it is the left parietal protuberance which is deepest in the pelvis, and which the finger first touches upon. As the labour advances, and the head approaches the pelvic outlet, it is the posterior and superior quarter of the left parietal bone which first enters the vagina and protrudes through the os externum, and upon which the swelling of the scalp or caput succedaneum is situated.

The chief peculiarity is, that the change, which we noticed in the first position as an occasional occurrence at the beginning of labour, is in this case the regular commencement of it. In the second cranial position, the head at the beginning of labour, with very few exceptions, is always with its long diameter parallel with the right oblique diameter of the pelvis, the posterior fontanelle turned towards the right sacro-iliac synchondrosis, the anterior one towards the left foramen ovale. During the early periods of labour, when the head is passing through the brim, both fontanelles may be reached; and, generally speaking, the posterior one with greater ease, from its being usually somewhat the lower; but as labour advances, and the head has fairly engaged in the pelvic cavity, they may both be reached with equal ease, the anterior fontanelle still corresponding to the left foramen ovale, or rather to the descending ramus of the left pubic bone. "As soon as the head experiences the resistance which the inferior part of the pelvic cavity opposes to it, or, in other words, the oblique surface which is formed by the lower end of the sacrum, the os coccygis, the ischiadic ligaments &c. by which it is compelled to move from its position backwards in a direction forward, it turns by degrees with its great diameter into the left oblique diameter of the pelvic cavity, viz. the posterior fontanelle is directed to the right foramen ovale, and as the head approaches nearer and nearer to the inferior aperture, it is the posterior and superior quarter of the left parietal bone which is felt in the cavity of the pelvis opposite to the pubic arch, so that when the point of the finger is introduced under and almost perpendicular to the symphysis pubis, it touches nearly the middle of the posterior and superior quarter of the left parietal bone; and this is precisely the part as the head advances further, which first distends the labia, with which the head first enters the external passages, and the spot upon which the swelling of the integuments forms itself." (Naegelé, Mechanism of Parturition, transl.)

The manner in which this change in the position of the head takes place, varies a good deal in different labours: in primiparæ it usually takes place slowly, and requires several pains before it is completed; as the pain comes on, the posterior fontanelle, which was backwards and to the right, now advances more forward and comes more within reach; the anterior fontanelle, which was towards the left foramen ovale, retreats, so that when the pain has

reached its maximum the head will for a moment be felt in the transverse diameter of the pelvis, and again resumes its former position as the pain goes off; with the recurrence of each pain there is a repetition of this screw-like motion, but by degrees the head not only passes from the right oblique into the transverse diameter, but from the transverse into the left oblique, so that at length the anterior fontanelle corresponds to the left sacro-iliac synchondrosis, and the posterior one to the right foramen ovale.

In women who have already had children, the whole change is frequently effected during one pain, so that the head, which but a few minutes previously was presenting in what is called the third position of the German schools, will now be found to be in the second.

It is to the celebrated Naegelé of Heidelberg that we are indebted for having first pointed out the uniform occurrence of this change in the second position. From his extensive and accurate observations, confirmed since by ourselves, as well as by many others, the head presents with the occiput originally forwards and to the right very rarely, but passes into this position during the course of labour. No one has ever described the mechanism of parturition so minutely and correctly; and the value of his investigations is the more enhanced, when we recollect what erroneous notions have prevailed upon this important subject up to the present time. "In the former part of my practice,” says this distinguished obstetrician," not knowing that the head made this turn, I always concluded that my examinations in the early part of labour were incorrect, and was very uneasy that I did not find it all exactly as the books described, and attributed my want of success in ascertaining the position to my own awkwardness. At length in a private case, in which I was much interested, I again felt what I thought was the anterior fontanelle towards the left foramen ovale; and circumstances occurring which rendered it necessary to apply the forceps and terminate the labour, I found that the head had been actually in the position which I imagined I had felt. Since this time I have, in many cases, sat by the bed-side during the whole labour, with my finger upon the head, and thus come at the truth." (MS. Lectures.)

The very circumstance of this change in the position of the occiput from the sacro-iliac synchondrosis to the foramen ovale of the same side, is of itself quite sufficient to mislead; nor is it to be wondered at that it should have been so long unnoticed, when we recollect how difficult the examination is at this early stage of labour, and how few give themselves the trouble to attain that degree of dexterity and tact, which, even under the most favourable circumstances, is required for this species of investigation.

The diagnosis of the sutures and fontanelles may be rendered more difficult by other circumstances: when there is a large quantity of liquor amnii between the head and membranes, it renders the diagnosis exceedingly obscure in the early part of labour. In some cases the cranial bones are remarkably thin and yielding, and communicate a sensation to the finger as if it were touching a fontanelle; in others, the sutures run an irregular course, and form ossa triquetra, &c. which may easily mislead. We may also notice the changes, already mentioned, which are produced by the death of the child, and the various congenital anormalities of hydrocephalus, acephalus, &c. &c. In some cases the sagittal suture is continued backwards through the occipital bone, dividing it into two equal portions, and thus making the posterior fontanelle four cornered, and not to be distinguished from the anterior. Nor is it always easy to distinguish the posterior from the anterior fontanelle under more normal and favourable circumstances; for it would be hazardous to conclude that it is the posterior fontanelle merely because we feel three sutures meeting together, as it may possibly be the anterior one, and we are not able to reach the sagittal suture beyond. In this case we may ascertain which it is by the following rule: if it be the posterior fontanelle in the first position, we shall feel a suture running more or less forwards (the right lambdoidal), but none backwards; but

he the anterior fontanelle forwards and to the left, we shall also feel a

suture (the right coronal) running backwards. Lastly, in the second cranial position, the face when born turns to the posterior surface of the mother's left thigh.

Such are the two positions in which the head presents during labour, and such is the manner in which it passes through the pelvis and external passages. Slight deviations do occasionally take place, the chief of which is, that the head in the second position does not always make the quarter of a turn as above described, but comes out with the anterior fontanelle forwards and to the left: this is by no means of common occurrence, and, as far as we have observed, increases the difficulty of labour very little.

Face presentations. The face, like the cranium, may present in two ways, either with its right or left side forwards. The former is the most frequent occurrence, and bears a striking analogy to the first cranial position; indeed, we cannot too strongly impress upon the minds of our readers the advantages of accurately knowing the different features of the two cranial positions just described, for by this means the positions of the face will be rendered much more simple and easy of comprehension. Whether the right or the left side of the face presents (first or second facial position), the root of the nose crosses the os uteri exactly in the same manner as the sagittal suture does in the two cranial positions; the chin is turned to the right acetabalum, and as the face descends through the pelvis during the progress of the labour, the chin moves somewhat more forwards, as the occiput does in the cranial positions.

At an early stage of labour the right eye and zygoma is that part of the face which is lowest in the pelvis, and which the finger first touches upon during examination, precisely as it was the right parietal protuberance in the first cranial position; and as in this case the caput succedaneum was situated upon the posterior and superior quarter of the right parietal bone, so here the livid bruise-like swelling, which the face brings with it into the world, is situated upon the right cheek, this part being the first which presses through the os externum ; the chin passes under the right branch of the pubic arch, as the occiput in the first cranial position does under the left, the face during the whole process preserving a strictly oblique position, both as to the transverse diameter and axis of the pelvis.*

Second position of the face. The second position of the face is merely the reverse of the first it is now the left side which is turned forwards, the left eye and zygomatic process being those parts which are lowest in the pelvis ; the chin is turned to the left side and somewhat forward, and advances towards the left foramen ovale during the further progress of the labour. As the face approaches the inferior aperture of the pelvis, it is the left cheek which first enters the os externum, and upon which the swelling is situated: likewise the chin passes beneath the left branch of the pubic arch.

It has been supposed by some authors, and we think correctly, that the majority (if not all) of face presentations are originally cranial presentations: if this be the case, we can easily understand why the right side of the face presents more frequently than the left, for if the head in the first cranial position moves round upon its transverse diameter, and thus allows the face to turn downwards, we shall immediately have a first position of the face. We are the more inclined to adopt this opinion, not only from the greater number of cases where the right side of the face presents, but also from our having more than once met with cases where, so long as the head of the child was movable above the brim, the presentation was midway between one of the cranium and of the face. On one side of the pelvis we could feel the anterior fontanelle; on the other we could, with some difficulty, reach the orbital process of the frontal bone: as the pains increased, and the head advanced lower, the side of the face

We have no words in the English language like the schrag and schief of the German to express these different species of obliquity.

K

came more within reach; so that by the time it had fairly entered the cavity of the pelvis, it had become a complete presentation of the face.*

We distinguish the face by the bridge of the nose, which from its crossing the os uteri may be detected at a very early period of labour: it is far better than the eye, for not only is this liable to mislead us in our examination, but it may also receive injury from the finger. Nor is the malar bone a guide, for this might easily be mistaken for the tuberosity of the ischium, or even for the shoulder. The nose not only tells us that the face is presenting, but also in which position, for at one end we shall feel, the soft cushiony extremity of it, at the other we shall reach the broad hard expanse of the forehead.

It was not until.nearly the end of the last century that presentations of the face ceased to be accounted unnatural, and impossible to be terminated by natural means. Although the fact had been pointed out by Portal so early as 1685, that these presentations were very little removed from the usual one, it seems to have excited but little attention until the time of Deleurye in 1770. "I have," says Portal," delivered several women whose children came with the face foremost, and always without any great difficulty, it being only observed, that in such cases no violence must be used, but nature be left to its own course; which done, there is no danger either of mother or child." (Portal's Midwifery, transl. obs. 66:) La Motte in 1721, although so accurate an observer, could not divest himself of the general opinion that these were unfavourable positions, even although the face was usually expelled by the natural efforts, after he had fruitlessly endeavoured to rectify it, and although he himself confesses never to have seen any that had not done well."

66

Giffard has recorded two cases of face presentation (Cases in Midwifery, 1734, p. 59. 443.), both of which he delivered by his extractor, which was one of the early forms of midwifery forceps; and in both, although the labour had lasted some time, the child was alive. He describes the position of the face in the second case, the chin being turned towards the right side. The only practical observation which he makes is, that turning is very difficult where the "waters are gone off, and the uterus closely envelopes the child." This is probably given as an explanation for his deviating from the usual practice of turning in these cases. Deleurye in supporting Portal's views observes," one daily sees similar labours terminate naturally: it is true they are somewhat longer, but they terminate without the aid of art." (Traité des Accouchemens, 1770, § 736.)

Lastly, the celebrated Boer of Vienna (1793) placed the matter in a still more decided point of view when he asserted, that "face presentations being merely a rarer form of natural labour, should be left to be completed by the natural efforts, since neither the mothers nor their children were exposed to any more danger in this form of labour than they were in the most usual forms of all." Having charge of the great lying-in hospital of Vienna, Boer had ample means of ascertaining the most accurate results on all points of practical midwifery and his observations on labours where the face presented are therefore peculiarly interesting, and tend strongly to contradict the prevailing opinion respecting the difficulty and danger of these presentations.

"Of eighty cases of face presentations which have occurred during a period of some years, and which I have myself observed and noted down, there were three, or at the most four, where the children were born dead. None of the patients suffered in the slightest degree from any of these labours; and, except one case, all were left entirely to nature: in one case only, on account of the weakness of the pains and doubtful character of the symptoms, I deemed it necessary to terminate the labour by the forceps." (Boer's Natürliche Geburtshülfe, erstes buch, p. 137.) In spite of this valuable practical fact, supported by experience on so great a scale, the opinion that face presentations were

* On the other hand, Dr. Merriman observes, that he has "twice known the presentation of the face converted by the pains alone into a natural presentation." (Synopsis, p. 48.)

preternatural, continued to prevail upon the Continent, being supported by the authority of Baudelocque and Osiander. A similarly unfavourable opinion was entertained by Dr. Smellie in this country, although Dr. W. Hunter, in his lectures delivered prior to the publication of his plates on the gravid uterus (and therefore at an early date), states, "in this case I do not turn the head round in order to deliver, but nineteen times in twenty leave it to itself to come as it will." (W. Hunter, MS. Lectures.)

Dr. R. W. Johnson, who dedicated his New System of Midwifery, &c. to Dr. W. Hunter and others in 1769, and probably attended his lectures, expresses a similar opinion, and says, that in these cases "nature herself will do the work." (p. 267.) Dr. Alexander Hamilton, in 1784, also speaks favourably of these presentations. "The head will however, in most cases, advance in that position by the force of the natural pains, though the delivery will be more slow or painful." (Outlines of the Theory and Practice of Midwifery.)

Further experience has shown that, so long as the pelvis is of the natural size, the head can be born in this position without peculiar difficulty, the soft parts usually require a little more dilatation than where the cranium presents, and therefore this stage of the labour is generally somewhat slower. Although presentations of the face are not so favourable for the child as those of the cranium, they stand next to them in point of safety. Where the cranium presents, a slight misproportion between the head and pelvis produces little or no increase of difficulty to the passage of the child; but under similar circumstances, where the face presents, the difficulty may become very serious, for if the labour is prolonged, "the brain and vessels of the neck," observes Smellie, "will be so much compressed and obstructed as to destroy the child." (Explanation to table 25.) A similar view has been given by Dr. Denman, and still more recently by Professor Chaussier of Paris and Professor Naegelé; the two latter authorities examined the brain in several stillborn children where the face had presented, and invariably found the cerebral vessels gorged with blood.

The presenting side of the face when born is frightfully distorted by the livid swelling above mentioned; the mouth is pulled to one side and upwards; the angle of the eye is drawn downwards, and the corresponding ala of the nose scarcely discernible amid the purple mass of tumefaction: the less this is meddled with the better, for in the course of a day or two the parts will have returned to their condition; whereas, if friction or hot poultices, &c. be used, ulceration may be the result, and produce considerable disfigurement.*

Nates presentations. "After the presentations of the cranium those of the nates are the most frequent in point of occurrence, and also the most natural," says the celebrated Boer in the work already quoted. Under the term nates presentations, we include those of the knees and feet, as these latter presentations can only be looked upon as modificatious of the former. Professor Naegelé jun. in his new edition of the admirable essay upon the mechanism of labour, published by his father in Meckel's Archiv. für die Physiologie, has very properly brought these different positions under one head, viz. "positions of the pelvic extremity of the child: " as however we possess no word in English to express this, we shall attain the same object by considering knee and footing births as mere modifications of breech presentations.

"As regards the relative situation of the limbs to the body of the child, the position is the same as in the two genera of head presentations above described, viz. the knees are usually drawn up to the abdomen, the feet close to the nates, so that not unfrequently they may both be felt together at the beginning of labour, and afterwards descend into the pelvis and are born

* According to the results of Dr. Collins's experience at the Dublin Lying-in Hospital, the face presented once in about every 504 cases; but as, in several labours, the presentation was not noted on account of their rapidity, the proportion is probably larger.