They must, of course, never be drawn directly downward, or the almost certain result would be fracture of the fragile bones. We should endeavor to make the arm sweep over the face and chest of the child, so that the natural movements of its joints should not be opposed. If the shoulders be within easy reach, the finger of the accoucheur should be slipped over that which is posterior-because there is likely to be more space for this manoeuvre toward the sacrum -and gently carried downward toward the elbow, which is drawn over the face, and then onward, so as to liberate the forearm. The same manœuvre should then be applied to the opposite arm. It may be that the shoulders are not easily reached, and then they may be depressed by altering the position of the child's body. If this be carried well up to the mother's abdomen, the posterior shoulder will be brought lower down; and, by reversing this procedure and carrying the body back over the perineum, the anterior shoulder may be similarly depressed. It is only very exceptionally, however, that these expedients are required.

Birth of the Head.-The arms being extracted, some degree of artificial assistance is, at this time, almost always required. If there be much delay, the child will almost certainly perish. Attempts have been made, in cases in which delivery of the head could not be rapidly effected, to establish pulmonary respiration by passing one or two fingers into the vagina, so as to press it back and admit air to the child's mouth, or by passing a catheter or tube into the mouth. Neither of these expedients is reliable, and we should rather seek to aid Nature in completing the birth of the head as rapidly as possible. The first thing to do, supposing the face to have rotated into the cavity of the sacrum, is to carry the body of the child well up toward the pubes and abdomen of the mother without applying any traction for fear of interfering with the all-important flexion of the chin on the sternum.

If now the patient bear down strongly, the natural powers may be sufficient to complete delivery. If there be any delay, traction must be resorted to, and we must endeavor to apply it in such a way as to insure flexion. For this purpose, while the body of the child is grasped by the left hand, and drawn upward toward the mother's abdomen, the index and middle fingers of the right hand are placed on the back of the child's neck, so that their tips press on either side of the base of the occiput, and push the head into a state of flexion. In most works we are advised to pass the index and middle fingers of the left hand at the same time over the child's face, so as to depress the superior maxilla. Dr. Barnes insists that this is quite unnecessary, and that extraction in the manner indicated, by pressure on the occiput, is quite sufficient. Should it not prove so, flexion of the chin may be very effectually assisted by downward pressure on the forehead through the rectum. One or two fingers of the left hand can readily be inserted into the bowel, and the expulsion of the head is thus materially facilitated.

By far the most powerful aid, however, in hastening delivery of the head, should delay occur, is pressure from above. This has been, strangely enough, almost altogether omitted by writers on the subject.

It has been strongly recommended by Professor Penrose, and there can be no question of its utility. Indeed, as the uterus contracts tightly around the head, uterine expression can be applied almost directly to the head itself, and without any fear of deranging its proper relation to the maternal passages. It is very seldom indeed that a judicious combination of traction on the part of the accoucheur, with firm pressure through the abdomen applied by an assistant, will fail in effecting delivery of the head before the delay has had time to prove injurious to the child.

Application of the Forceps to the After-coming Head.-Many accoucheurs-among others, Meigs and Rigby-advocate the application of the forceps when there is delay in the birth of the after-coming head. If the delay be due to want of expulsive force in a pelvis of normal size, manual extraction, in the manner just described, will be found to be sufficient in almost every case, and preferable, as being more rapid, easier of execution, and safer to the child. The forceps may be quite properly tried, if other means have failed; especially if there be some disproportion between the size of the head and the pelvis.

Difficulties in delivery may also occur in sacro-posterior positions. Up to the time of the birth of the head the labor usually progresses as readily as in the sacro-anterior positions. If the forward rotation of the hips do not take place, much subsequent difficulty may be prevented by gently favoring it by traction applied to the breech during the pains, the finger being passed for this purpose into the fold of the groin.

It is after the birth of the shoulders that the absence of rotation is most likely to prove troublesome. It has been recommended that the body should then be grasped, in the interval between the pains, and twisted around so as to bring the occiput forward. It is by no means certain, however, that the head would follow the movement imparted to the body, and there must be a serious danger of giving a fatal twist of the neck by such a manoeuvre. The better plan is to direct the face backward, toward the cavity of the sacrum, by pressing on the anterior temple during the continuance of a pain. In this way the proper rotation will generally be effected without much difficulty, and the case will terminate in the usual way.

If rotation of the occiput forward do not occur, it is necessary for the practitioner to bear in mind the natural mechanism of delivery under such circumstances. In the majority of cases the proper plan is to favor flexion of the chin by upward pressure on the occiput, and to exert traction directly backward, remembering that the nape of the neck should be fixed against the anterior margin of the perineum. If this be not remembered, and traction be made in the axis of the pelvic outlet, the delivery of the head will be seriously impeded. In the rare cases in which the head becomes extended, and the chin hitches on the upper margin of the pubes, traction directly forward and upward may be required to deliver the head; but before resorting to it care should be taken to ascertain that backward extension of the head has really taken place.

It remains for us to consider the measures which may be adopted in those troublesome cases in which the breech refuses to descend, and becomes impacted in the pelvic cavity, either from uterine inertia, or from disproportion between the breech and the pelvis. The peculiar shape of the presenting part unfortunately renders such cases very difficult to manage.

Three measures have been chiefly employed: 1st, the forceps; 2d, bringing down one or both feet, so as to break up the presenting part, and convert it into a footling case; 3d, traction on the breech, either by the fingers, a blunt hook, or fillet passed over the groin.

Forceps.-The forceps has generally been considered unsuited for breech cases in consequence of its construction to fit the foetal head, which renders it liable to slip when applied to the breech. The objection, probably to a great extent true with reference to most forceps, seems not to hold good when the axis-traction forceps of Tarnier or Simpson is used. Lusk strongly recommends it, and Harvey, of Calcutta, has published six consecutive cases in which he employed this method of delivery, in three with complete success. Truzzi, who has written strongly in favor of the forceps in difficult breech cases, prefers it greatly to traction either by the fingers or the fillet when the breech is high in the pelvis, and recommends that, in order to secure a strong hold, the blades should be passed so that their extremities extend above the crests of the foetal ilia. I have only used it myself in one or two cases, but in these the results were extremely good, and delivery was effected with a facility which surprised me, and I can see no objection to a cautious trial of the instrument. [A better-fitting instrument is the special breech-forceps, with oval fenestræ, flat-edged blades, and long superimposed shanks, modelled to fit the sides of the breech over the trochanters and ilia.—ED.]

Bringing Down a Foot.-Barnes insists on the superiority of the second plan, and there can be no question that, if a foot can be got down, the accoucheur has a complete control over the progress of the labor which he can gain in no other way. If the breech be arrestd at or near the brim, there will generally be no great difficulty in effecting the desired object. It will be necessary to give chloroform to the extent of complete anæsthesia, and to pass the hand over the child's abdomen in the same manner, and with the same precautions, as in performing podalic version, until a foot is reached, which is seized and pulled down. If the feet be placed in the usual way close to the buttocks, no great difficulty is likely to be experienced. If, however, the legs be extended on the abdomen, it will be necessary to introduce the hand and arm very deeply, even u, to the fundus of the uterus, a procedure which is always difficult, and which may be very hazardous. Nor do I think that the attempt to bring down the feet can be safe when the breech is low down and fixed in the pelvic cavity. A certain amount of repression of the breech is possible, but it is evident that this cannot be safely attempted when the breech is at all low down. Traction on the Groin.-Under such circumstances traction is our

1 Gaz. Med. Ital. Lomb., August, 1883.

only resource, and this is always difficult and often unsatisfactory. Of all contrivances for this purpose none is better than the hand of the accoucheur. The index finger can generally be slipped over the groin without difficulty, and traction can be applied during the pains. Failing this, or when it proves insufficient, an attempt should be made to pass a fillet over the groins. A soft silk handkerchief, or a skein of worsted, answers best, but it is by no means easy to apply. The simplest plan, and one which is far better than the expensive instruments contrived for the purpose, is to take a stout piece of copper wire and bend it double into the form of a hook. The extremity of this can generally be guided over the hips, and through its looped end the fillet is passed. The wire is now withdrawn, and carries the fillet over the groins. I have found this simple contrivance, which can be manufactured in a few moments, very useful, and by means of such a fillet very considerable tractive force can be employed. The use of a soft fillet is in every way preferable to the blunt hook which is contained in most obstetric bags. A hard instrument of this kind is quite as difficult to apply, and any strong traction employed by it is almost certain to seriously injure the delicate foetal structures over which it is placed. As an auxiliary the employment of uterine expression should not be forgotten, since it may give material aid when the difficulty is only due to uterine inertia.

Embryotomy.-Failing all endeavors to deliver by these expedients, there is no resource left but to break up the presenting part by scissors, or by craniotomy instruments; but fortunately so extreme a measure is but rarely necessary.

Examination of the Child.-After a difficult breech labor is completed the child should be carefully examined to see that the bones of the thighs and arms have not been injured. Fractures of the thigh are far from uncommon in such cases, and the soft bones of the newly born child will readily and rapidly unite if placed at once in proper splints.

CHAPTER VI.

PRESENTATIONS OF THE FACE.

Presentations of the face are by no means rare; and, although in the great majority of cases they terminate satisfactorily by the unassisted powers of Nature, yet every now and again they give rise to much difficulty, and then they may be justly said to be amongst the most formidable of obstetric complications. It is, therefore, essential that the practitioner should thoroughly understand the natural history of this variety of presentation, with the view of enabling him to intervene with the best prospect of success.

The older accoucheurs had very erroneous views as to the mechanism and treatment of these cases, most of them believing that delivery was impossible by the natural efforts, and that it was necessary to intervene by version in order to effect delivery. Smellie recognized the fact that spontaneous delivery is possible, and that the chin turns forward and under the pubes; but it was not until long after his time, and chiefly after the appearance of Mme. La Chapelle's essay on the subject, that the fact that most cases could be naturally delivered was fully admitted and acted upon.

Frequency. The frequency of face presentations varies curiously in different countries. Thus, Collins found that in the Rotunda Hospital there was only 1 case in 497 labors, although Churchill gives 1 in 249 as the average frequency in British practice; while in Germany this presentation is met with once in 169 labors. The only reasonable explanation of this remarkable difference is, that the dorsal decubitus, generally followed on the Continent, favors the transformation of vertex presentations into those of the face.

The mode in which this change is effected-for it can hardly be doubted that, in the large majority of cases, face presentation is due to a backward displacement of the occiput after labor has actually commenced, but before the head has engaged in the brim-has been made the subject of various explanations.

It has generally been supposed that the change is induced by a hitching of the occiput on the brim of the pelvis, so as to produce extension of the head, and descent of the face; the occurrence being favored by the oblique position of the uterus so frequently met with in pregnancy. Hecker attaches considerable importance to a peculiarity in the shape of the fetal head generally observed in face presentations, the cranium having the dolicho-cephalous form, prominent posteriorly, with the occciput projecting, which has the effect of increasing the length of the posterior cranial lever arm, and facilitating extension when circumstances favoring it are in action. Dr. Duncan thinks that uterine obliquity has much influence in the production of face presentation, but in a different way to that above referred to. He points out that, when obliquity is very marked, a curve in the genital passages is produced, the convexity of which is directed to the side toward which the uterus is deflected. When uterine contraction commences, the foetus is propelled downward, and the part corresponding to the concavity of the curve is acted on to the greatest advantage by the propelling force, and tends to descend. Should the occiput happen to lie in the convexity of the curve so formed, the tendency will be for the forehead to descend. In the majority of cases its descent will be prevented by the increased resistance it meets with, in consequence of the greater length of the anterior cranial lever arm; but, if the uterine obliquity be extreme, this may be counterbalanced, and a face presentation ensues. The influence of this obliquity is corroborated by the observation of Baudelocque, that the occiput in face presentations almost invariably corresponds to the side of the uterine obliquity.

1 Ueber die Schädelform bei Gesichtslagen.

2 Edin. Med. Journ., vol. xv.