SPONTANEOUS EVOLUTION. 425 



We should wail for the dilatation of the os uteri; if the uterus is 

 obliquely situated, we must endeavor to restore it to its natural at- 

 titude; should the head project over the hypogastric notch of the 

 pelvis, it should be pushed backwards over the edge of the strait; 

 when the fcstus is so movable that the head, the shoulder, or some 

 other part come to present successively at the orifice, it is proper, as 

 has been said, to rupture the membranes without waiting too long, 

 and choosing the exact moment when the head happens to be over 

 the strait. 



But if the OS uteri is already sufficiently dilated, if the membranes 

 are already ruptured or on the point of giving way, it is important 

 to decide at once, whether or not the hand is to be carried into the 

 womb. Denman tells us that we may dispense with doing so in a 

 majority of cases, seeing that the womb, most generally, will bring 

 about the spontaneous evolution, and that if the child should really 

 come down doubled, its escape would not, on that account, be wholly 

 impossible. The French accoucheurs think, on the contrary, that 

 we ought to act immediately in all cases; for, say they, the longer 

 we wait the more will the womb contract, and the more difficult will 

 it become to enter it and eflect the turning. 



The conduct of Denman in this case does not appear to me to be 

 of the very wisest; by imitating him, it is true, some foetuses that we 

 deliver by the feet might come away spontaneously, but many more 

 of them would fall victims to such an expectant mode of practice, 

 and which might be saved by operating in good time. As to de- 

 livering the fojtus double, it is manifest that it must be very difficult, 

 that it will most generally not lake place at all, and that the woman 

 will be exhausted with useless efforts, and may lose her life; that 

 even under the most favorable conditions of this kind, the child gene- 

 rally dies long before it is born, at least if we may judge from 

 Denman's own cases, since out of thirty of them only one was bora 

 living. 



Thus, although spontaneous evolution may lake place, and rigo- 

 rously speaking, some women may be delivered without it, it is 

 nevertheless more conformable to the dictates of prudence and hu- 

 manity to turn the child, or apply the forceps. To this rule an ex- 

 ception should be made of those cases where the shoulder is not 

 fully engaged, those where the vertex or the pelvis is near enough 

 to the orifice to allow us to rely upon a fortunate transmutation, and 

 lastly, those where the introduction of the hand is so difficult that it 

 would not be more dangerous to wait than to proceed at once to the 

 operation. 



37* 



