lowing: Cord around the child's body or neck; excessive liquor amnii; at the beginning of labor slight pains, later sudden and severe ones; goitre is often found in children with face presentation; deformity of the pelvis; obliquity of the uterus causing or favoring a hitching of occiput at the brim of the pelvis. Obliquity is often found on the right side, and the second face presentation, i. e., the chin pointing to the left side, is said to be the most frequent. Face presentations are supposed to be most frequently produced after labor has actually set in, and as a rule they do not exist before labor has set in. Diagnosis: In the beginning of labor before the os is dilated, and before the membranes are ruptured and the face engaged in the pelvic cavity the diagnosis is sometimes a difficult task. When the face has been long in the pelvic cavity there is so much swelling of the soft parts of the face that it will often take considerable care to distinguish it from a breech. Great care is necessary not to injure the eyes when the cavities are examined. I have found the tongue in several instances the most distinct structure; the guns, orbits and nostrils are among the distinguishing structures. The anus is smaller than the mouth and in a living child we can feel it contract, "it bites" as Winkel says. As a rule the diagnosis can be easily made, but in doubtful cases no positive diagnosis should be made before the tongue has been found. Much information may be gained by external examination; the occiput can often be felt through the abdominal walls. The shape of the uterus is somewhat like an hour-glass with the fundus to one side. chin or Prognosis: Although a great many cases terminate by the natural processes, yet it cannot be said that the prognosis is as good as in vertex presentation, as labor is much more tedious. In contracted pelvis and other abnormalities and where the chin is posterior, a living child by the natural processes is seldom born. The perineum is more apt to lacerate. The increased mortality for the child is very likely often due to pressure on the child's blood vessels of the neck while it is in the pelvic cavity; or when there is inuch delay when the child's chin is under the arch of the pubis. In this latter instance the child's heart should be watched. Schroeder gives the death-rate in the children at 13 per cent. In face presentation it is always well to inform the friends that the child is apt to be much deformed in the face, but that it passes away again in a few days, otherwise some unpleasant remarks may be made which may alarm the mother. Early rupture of the membrane is unfavorable in face presentation, so is cessation of labor pains, and when these conditions exist, active interference is as a rule indicated. Treatment: Under what conditions shall the case be left to nature? When the os is not dilated and the membranes not ruptured active interference is contraindicated. A temporary occurrence of face presentation in the early stages is not rare and spontaneous flexion may take place. Good care should be taken to preserve the membranes, and vaginal examinations should be carefully made. If we advise our patient to lie on the side towards which the chin points, the uterine contractions may have a chance to produce flexion, and so convert a face into a vertex presentation. When the os is fully dilated active interference, should it become necessary, is much more easily accomplished. We can also try Schatz's method in producing or favoring vertex presentation. Should it not succeed it will do no harın. Very little benefit can be expected from it unless the head is high, movable, the chin posterior, the pains weak, and when there is no indication of rapid delivery. It is performed about as follows: Without anasthesia, patient on the back, the operator standing on the side toward which the chin points; he grasps, between pains, the anterior shoulder and makes backward and upward pressure, while with the other hand he presses the breech upward and over to the anterior surface of the child. During a pain all manipulations should cease. If we look up the early history of obstetrics we find that active interference in face presentations was deemed imperative, no matter what the position of the face was, whether the case was progressing or not. During the last 100 years the cases have been left entirely to nature in the majority of instances with much better results. Zeller writes in 1789 that face presentations as a rule pursue a favorable course if left to nature, and that he had only two still-births out of 40 face presentations. In 1791 Bcer described the mechanism of face presentation accurately, and he gives 80 cases of face presentation; 79 of these were born without assistance; in one the forceps were used. From Beer on, the treatment of face presentations has changed very little, except, perhaps, it be manual flexion of the head which has of late been frequently practiced with good results. Version: About 100 years ago it was taught that version was indicated in every ease, no matter what the position of the child was, whether the membranes were ruptured or not, whether the pains were strong or feeble, or whether the case was progressing or not. But during the last century version was only advised when there was a special indication for it, and when other less dangerous procedures had failed. In all cases where there is long delay at the superior strait it is well, I think, to consider active interference while both mother and child are still in good condition. Before internal podalic version is decided on, an attempt should be made to flex the head. We convert it into a more simple case and version is thereby made easier and less dangerous, or the forceps can be applied. If, after flexion has been made, there is an immediate return of the face, we should proceed to turn the child. Version can be performed when the head is movable and has not become fixed in the pelvis. Schroeder says if the head remains high after membranes have ruptured, the os dilates, and the pains weak, the performance of version is rational. When the cord or a hand is prolapsed, version should be performed. If the face has become somewhat fixed in the pelvic cavity, and it seems impossible to pass the hand, we are advised by some (Fry and others, Am. Gyn. Soc.) to place our patient in the knee-chest or Trendelenburg's position. We can then often push the head above the superior strait and perform version which before seemed impossible. If we cannot pass the hand, and the face has become fixed in the pelvic cavity it seems that symphysiotomy would be the next proper thing, i. e., should we also fail with the forceps. I have never performed this operation myself, but as far as I have read and heard others about it, it seems to be a rational procedure. It should, however, not be considered a simple and extremely easy operation as some call it. Able and experienced men have often found it a serious one complicated by severe and even fatal hemorrhage from the pudic vessels. When both mother and child have become very weak, and flexion, version or the forceps are contraindicated, the horrible operation of craniotomy has to be considered in order to save the. life of the mother. Forceps: When the chin is anterior and the pains fail, the forceps should be applied, i. e., when the face is engaged in the pelvic cavity. As long as the head is movable, the forceps should |