is nearest to, and on the same side as, the presenting arm, and this, moreover, is generally more readily done.

As soon as the head has reached the fundus, and the lower extremity is brought through the os, the case is converted into a foot or knee presentation, and it comes to be a question whether delivery should now be left to Nature or terminated by art. This must depend to a certain extent on the case itself, and on the cause which necessitated version, but, generally, it will be advisable to finish delivery without unnecessary delay. To accomplish this, downward traction is made during the pains, and desisted from in the intervals (Fig. 166). As

FIG. 166.

Showing the completion of version. (After BARNES.)

the umbilical cord appears, a loop should be drawn down; and if the hands be above the head, they must be disengaged and brought over the face, in the same manner as in an ordinary footling presentation. The management of the head, after it descends into the cavity of the pelvis, must also be conducted as in labors of that description.

Turning in Placenta Prævia.-In cases of placenta prævia the os will, as a rule, be more easily dilatable than in transverse presentations. Hicks's method offers the great advantage of enabling us to perform version much sooner than was formerly possible, since it only requires the introduction of one or two fingers into the os uteri. Should we not succeed by it, and the state of the patient indicates that delivery is necessary, we have at our command, in the fluid dilators, a

means of artificially dilating the os uteri which can be employed with ease and safety. If we have to do with a case of entire placental presentation, the hand should be passed at that point where the placenta seems to be least attached. This will always be better than attempting to perforate its substance, a measure sometimes recommended, but more easily performed in theory than in practice. If the placenta only partially presents, the hand should, of course, be inserted at its free border. It will frequently be advisable not to hasten delivery after the feet have been brought through the os, for they form of themselves a very efficient plug, and effectually prevent further loss of blood; while, if the patient be much exhausted, she may have her strength recruited by stimulants, etc., before the completion of delivery.

Turning in Abdomino-anterior Positions.-In abdomino-anterior positions, in which the waters have escaped, and in which, therefore, some difficulty may be reasonably anticipated, the operation is generally more easily performed with the patient on her back; the right hand is then introduced into the uterus, and the left employed externally (Fig. 167). In this way the internal hand has to be passed a shorter distance and in a less constrained position. The operator then sits in front of the patient, who is supported at the edge of the bed in the lithotomy position with the thighs separated, and the right hand is passed up behind the pubes and over the abdomen of the

child.

Difficult Cases of Arm Presentation.-The difficulties of turning culminate in those unfavorable cases of arm presentation in which the membranes have been long ruptured, the shoulder and arm pressed

down into the pelvis, and the uterus contracted around the body of the child. The uterus being firmly and spasmodically contracted, the attempt to introduce the hand often only makes matters worse, by inducing more frequent and stronger pains. Even if the hand and arm be successfully passed, much difficulty is often experienced in causing the body of the child to rotate; for we have no longer the fluid medium present in which it floated and moved with ease, and the arm of the operator may be so cramped and pained by the pressure of the uterine walls as to be rendered almost powerless. The risk of laceration is also greatly increased, and the care necessary to avoid so serious an accident adds much to the difficulty of the operation.

Value of Anesthesia in Relaxing the Uterus.--In these perplexing cases various expedients have been tried to cause relaxation of the spasmodically contracted uterine fibres, such as copious venesection in the erect attitude until fainting is induced, warm baths, tartar emetic, and similar depressing agents. None of these, however, is so useful as the free administration of chloroform, which has practically superseded them all, and often answers most effectually when given to its full surgical extent.

The hand must be introduced with the precautions already described. If the arm be completely protruded into the vagina, we should pass the hand along it as a guide, and its palmar surface will at once indicate the position of the child's abdomen. No advantage is gained by amputation, as is sometimes recommended. When the os is reached, the real difficulties of the operation commence, and, if the shoulder be firmly pressed down into the brim of the pelvis, it may not be easy to insinuate the hand past it. It is allowable to repress the presenting part a little, but with extreme caution, for fear of injuring the contracted uterine parietes. Herman' has pointed out that in some cases the difficulty is increased by the shoulder of the prolapsed arm being caught beneath the contraction ring (Bandl's), and he advises that it should be released by pressing it toward the centre of the cervical canal. It is better to insinuate the hand past the obstruction, which can generally be done by patient and cautious endeavors. Having succeeded in passing the shoulder, the hand is to be pressed forward in the intervals, being kept perfectly flat and still on the body of the foetus when the pains come on. It is much safer to press on it than on the uterine walls, which might readily be lacerated by the projecting knuckles. When the hand has advanced sufficiently far, it will be better, for the reasons already mentioned, to seize and bring down one knee only.

When the Foot is Brought Down but the Foetus will not Revolve. Even when the foot has been seized and brought through the os, it is by no means always easy to make the child revolve on its axis, as the shoulder is often so firmly fixed in the pelvic brim as not to rise toward the fundus. Some assistance may be derived from pushing the head upward from without, which, of course, would raise the shoulder along with it. If this should fail, we may effect our

1 "Note on One of the Causes of Difficulty in Turning," Obst. Trans. for 1886, vol. xxvii. p. 150.

object by passing a noose of tape or wire ribbon around the limb, by which traction is made downward and backward; at the same time the other hand is passed into the vagina to displace the shoulder and push it out of the brim. It is evident that this cannot be done as long as the limb is held by the left hand, as there is no room for both hands to pass into the vagina at the same time. By this manœuvre version may be often completed when the foetus cannot be turned in the ordinary way. Various instruments have been invented both for passing a fillet around the child's limb and for repressing the shoulder, but none of them can compete, either in facility of use or safety, with the hand of the accoucheur.

Mutilation of the Foetus.-Should all attempts at version fail, no resource is left but the mutilation of the child, either by evisceration or decapitation. This extreme measure is, fortunately, seldom necessary, as with due care version may generally be effected, even under the most unfavorable circumstances.1

CHAPTER III.

THE FORCEPS.

Use of the Forceps in Modern Practice. Of all obstetric operations the most important, because the most truly conservative both to the mother and child, is the application of the forceps. In modern midwifery the use of the instrument is much extended, and it is now applied by some of our most experienced accoucheurs with a frequency which older practitioners would have strongly reprobated. That the injudicious and unskilful use of the forceps is capable of doing much harm, no one will for a moment deny. This, however, is not a reason for rejecting the recommendation of those who advise a more frequent resort to the operation, but rather for urging on the practitioner the necessity of carefully studying the manner of performing it, and of making himself familiar with the cases in which it is easy or the reverse. Nothing but practice-at first on the dummy, and afterward in actual cases-can impart the operative dexterity which it should be the aim of every obstetrician to acquire, and without which there can be no assurance of his doing his duty to his patient efficiently.

Description. The forceps may best be described as a pair of artificial hands by which the foetal head may be grasped and drawn through the maternal passages by vis à fronte, when the vis à tergo is deficient. This description will impress on the mind the important action of the instrument as a tractor. to which all its other powers are subservient.

1 See note, p. 536.

The forceps consists of two separate blades of a curved form, adapted to fit the child's head; a lock by which the blades are united after introduction; and handles which are grasped by the operator, and by means of which traction is made. It would be a wearisome and unsatisfactory task to dwell on all the modifications of the instrument which have been made, which are so numerous as to make it almost appear as if no one could practise midwifery with the least pretension to eminence, unless he has attached his name to a new variety of forceps.

The Short Forceps.-The original instrument, invented by the Chamberlens, may be looked upon as the type of the short straight forceps, which has been more employed than any others and which, perhaps, finds its best representative in the short forceps of Denman (Fig. 168). Indeed, the only essential difference between the two is

FIG. 168.

Denman's short forceps.

the lock of the latter, originally invented by Smellie, which is so excellent that it has been adopted in all British forceps; and which, for facility of juncture, is much superior to either the French pivot or the German lock, while for firmness it is, for all practical purposes, as good as either. In this instrument the blades are seven and the handle four and three-eighths inches in length; the extremities of the blades are exactly one inch apart, and the space between them at their widest part is two and seven-eighths inches. The blades measure one and three-fourths inches at their greatest breadth and spring with a regular