when or where the membranes are ruptured, for the sudden escape of the waters is prevented by the arm acting as a plug.

In head presentations the operation is performed in the same way. The foot in front is usually close to the head, and can easily be grasped. Sometimes turning fails, because the head is fixed too firmly in the brim, and by drawing upon the foot, it descends lower down together with the foot. The head may then be pushed back with the thumb, whilst the foot is held between the index and middle finger and drawn upon. If this also gives no satisfactory result, the double manipulation, first recommended by Justine Siegemund, may be adopted. It consists in putting a sling round the foot and drawing upon it, whilst the other hand pushes the head back. If the foot cannot be brought into the vagina, and we do not wish to let it escape, a sling is put round it by means of a sling carrier. Braun's instrument for replacing the funis is very useful for the purpose. It is brought to the foot, the sling put round it, and then held.

If the waters have only shortly before escaped, and the child is still freely movable in the uterus, turning, though not quite so easy as when the membranes are intact, is yet practicable without any great difficulty. Prolapse of an arm in transverse position by no means impedes turning. It is generally left there because it remains then extended along the abdomen of the child, and its artificial liberation is not required. If there is any fear that in turning it may recede into the uterus it may be put into a sling; at any rate there can be no question of replacing it.

When the waters, however, have escaped a long time previously, the operation may present considerable difficulties.

As the energy of the uterine action increases with the amount of the resistance, it follows that in neglected transverse positions the pains set in in rapid succession, and force the presenting shoulder continually deeper into the true pelvis. The intervals between the pains become shorter and shorter until, finally, the uterus has reached the climax of its activity, and persists in uninterrupted tetanic tension. Such forcible contraction, uninterrupted by even a short interval, is easily followed by inflammation of the parenchyma of the uterus, and of its serous covering.

Since this rigid contraction of the uterus drives the presenting shoulder with great force into the brim, and keeps it fixed there, the introduction of the hand will meet with considerable opposition.

Chloroform is the sovereign remedy in such cases, and should always be employed.

In deep narcosis the tension of the uterus subsides, and the operator is able, quietly and gradually, to insinuate his hand past the presenting part without using any great force.

When chloroform is not at hand large doses of opium may be given, or by a warm bath relaxation of the contracted uterus can be brought about. Venesection, also, in the erect posture of the woman, until she faints, has a decided influence upon the relaxation of the uterus. Such a treatment, however, must be restricted to very extreme cases, for women, under such conditions, cannot bear the loss of much blood.

In these difficult cases of turning the woman is always to lie on

her side; for it greatly facilitates the introduction of the hand and the seizure of the feet of the child, particularly when they lie more in front above the symphysis. Sometimes the knee-elbow posture would offer advantages, but then the use of anaesthetics must be given up. If the space of the brim is very limited, Levret, Stein senior, Deleurge, and Birnbaum propose to bring the other arm down, so as to enable the hand to pass.

When the hand has passed the presenting part there is often great difficulty in seizing the foot, while the knee is close at hand. The advice of Simpson, Simon Thomas, and R. Barnes, not to turn in such cases by the foot, but by the knee, deserves all consideration in such difficult cases. The knee is nearer than the foot, and to grasp the latter the whole hand is required, whilst the knee can be brought down by hooking the index finger over it.

Sometimes when the lower extremities are too far from the brim, they may be made to approach, the hand manipulating internally by rotation of the trunk round its longitudinal axis. Von Deutsch expects great advantage from this proceeding.

Or it may be comparatively easy to engage the breech in the brim if the shoulder does not lie too deep, when there are insurmountable difficulties in seizing one of the feet or a knee.

Even if one foot has been seized turning the child by it in such protracted cases may be almost impossible; double manipulation will then be advantageous, or the other foot must also be brought down, and the child turned by them.

B.-Embryotomy as a means of Extracting the Child

Embryotomy has already been mentioned as a means of delivering the woman in cases of malformation or diseases of the foetus; in the highest degrees of pelvic contraction, the breech presenting; or when, after craniotomy, the strongly developed foetal trunk cannot pass through the pelvis without reduction of its bulk. It is also indicated when a dead child, presenting by the shoulder, cannot be turned, or when this at least is more dangerous to the mother than embryotomy. If the pelvic deformity is not too great it may be advisable to defer embryotomy for some time, in the hope that delivery may be effected in the natural way, by what is termed spontaneous evolution.

In a given case it is, of course, a matter of some difficulty to decide which method of delivery is the least hazardous to the mother. Embryotomy is not an operation entirely indifferent to the mother, although no immediate dangers can accrue to her if performed with some skill. All that can be said is that a gentle attempt at version can always previously be made. But by no means is force to be used in turning. If this is too difficult, and spontaneous evolution is out of the question, recourse must be had to that destructive instrument, and at the sight of the mutilated child the accoucheur must console himself with the consciousness of having preserved the life of the mother.

Embryotomy can be performed after two methods. Either the thoracic and abdominal cavities are eviscerated, in order to allow of version and extraction in the faulty position, or the head is

separated from the trunk, and they are each of them separately extracted.

The first method is, then, only to be recommended when the neck is so high up that it cannot be reached without great difficulty, and when, consequently, the breech and the feet are nearer to the brim.

The operation is performed in the following way:-Guided by the left hand, a scissor-shaped perforator is introduced, and pushed into the thorax, so as to open an intercostal space. If a prolapsed and greatly swollen arm materially impedes the operation, it is to be amputated at the shoulder-joint by strong scissors; but if this can possibly be avoided it is better for this reason alone that it forms an excellent handle for extraction. The finger will then be able to separate the two contiguous ribs so that several fingers can be passed into the thoracic cavity in order to remove its contents. From this perforation is continued through the diaphragm into the abdominal cavity, or a new incision is made into the abdominal walls in order to empty the abdominal cavity also. The proceedings following evisceration are different. Podalic version is, as a rule, very difficult, even at this time, and is, moreover, unnecessary. Where the shoulder is high up it is best to bring the pelvic extremity down, either by the finger, or, if necessary, by the crotchet or the craniotomy forceps, and thus to imitate the process of spontaneous version. If the shoulder is in the pelvis and the arm prolapsed, the process of spontaneous evolution may be imitated by dragging the shoulder low down, in a direction opposite to that where the breech lies, and the pelvic extremity is then drawn past the thorax. Occasionally it may be useful to adopt the process of Michaelis. He proposes to break the vertebral column and to extract the child doubled up, that is, thorax and abdomen and head and pelvis together. Simpson recommended spondylotomy, that is, complete division of the child at the most prominent point of the vertebral column.

If the neck is easily accessible decapitation is preferable, for even after evisceration delivery may still offer very great difficulties. If the arm has prolapsed this is strongly drawn upon in order to make the neck descend deeper; then the index finger, or, in difficult cases, a blunt-hook is put round the neck, and firm traction made upon it. Guided by one or two fingers placed around the neck the soft parts and the vertebral column are then divided by strong and bent scissors.

C. Braun has constructed an instrument (the decollator) to wrench off the head from the trunk. It consists of a steel rod fitted to a transverse handle, and terminates in a sharply-bent hook provided with a knob. When the neck has been made accessible in the way above described the hook is introduced under the guidance of the hand, put around the neck, and fixed by firm traction. By repeated rotatory movements in one direction, with simultaneous traction, the head is separated from the trunk. Experience, extending until now over thirty cases, seems to be in favour of this instrument.

A number of other instruments have been designed for decapitation. Of these the écraseur of Stiebel junior, deserves most to be recommended.

After the head has been separated from the trunk, the extraction of the latter can easily be effected either by the arm or by means of

a hook fixed in it. The extraction of the head also is not difficult when the pelvis is not too much contracted. Under normal conditions, if the head is not expelled by the pains, it may be removed from the uterus by external pressure as the placenta is, or one hand is introduced and the head is extracted, either by the lower jaw or by grasping it by the orbits and the base of the skull. In a greatly contracted pelvis the extraction of the head may meet with serious obstacles; but it is usually successful by drawing upon the lower jaw, assisted by powerful external pressure, the more so since the brain can escape through the foramen magnum. In other cases the head, fixed externally, is perforated and extraction again tried. If it then also fails the head is to be extracted by the craniotomy forceps, one blade being introduced into the cranial cavity through the opening made by the perforator, or the cephalotribe is applied, and after having grasped the head it is so turned that its blades come to lie in the smallest diameter of the pelvis. Thus extraction is accomplished.

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