uterus, convulsions, prolapsed funis, &c. the operation is available and has been used with great success.

It is right to mention that Denman and some other writers recommend turning when the pelvis is slightly too narrow for the child's head, but I must confess that this practice appears to me more than questionable.

The next point for our investigation is the period most suitable for making the attempt, so as not to interfere rashly on the one hand, nor to delay too long on the other, "neque temerè nec timidè." Of the two errors it is hardly too much to say, that excessive delay is the most serious.

1. If the case be one requiring cephalic version for the rectification of a malposition, it is clear that the operation can only be safely, if at all, performed before the uterine efforts have wedged the head into the upper strait; the attempt should be made so soon as it is evident that the natural powers will not rectify the malposition. It will be an additional motive for prompt assistance, if we find the pains violent, and that the patient have had many children, lest the head, not being able to enter the brim, should be turned aside, and forced through the uterine or vaginal parietes.

2. (a) If we are called to an arm presentation or any demanding podalic version, before the escape of the liquor amnii, and we find the os uteri hard and undilatable, it will be advisable to wait until some change takes place, before we introduce the hand: neither is there any risk worth mentioning, provided we remain with the patient to operate if the waters break.-(Baudelocque, Hunter, &c.)

(b) If we see the patient before the rupture of the membranes, and find the os uteri soft and dilated or dilatable, there is no reason for deferring the attempt, if the case require this kind of interference, and great advantage in operating whilst the uterus is distended. "If we take it when the os uteri will admit the finger and knuckles, it is the better time, because we then turn the child as if in a bucket of water; and this gives us

s tear an advance that it needs no explanation."-(Clarke," Foner. Goochat Asovai, Ramsbotham.")

. Feari be datable, the sooner the attempt is made her he escape of the waters the better. Gardien' says fat the most brourable moment is just when the waters break. Arte escape of the waters, we sometimes find the os meri nether rigid nor much dilated, and the pains moderate. In such cases, no time shoald be lost: the hand should be introduced in the vagina, and gentle yet firm and persevering efforts made, to pass the hand into the uterus. Dr. Blundell serget li crimary cases, if the mouth of the womb be as broad as a crown piece, and if the softer parts be relaxed horoughly, the introduction of the hand is not exposed to greater risk than usual; there seems to be no circumstances preclusive of the operation, and the sooner you commence the

So far, although the cases I have noticed have increased in dcity, yet in none of them has any very great difficulty, either of decision or of execution, been experienced. We are, bowever, often called to a class of cases where our utmost judgment, patience, and skil will be needed. I refer to those cases of arm presentation, where, in the language of Foster, “the membranes have been a long time ruptured, the waters totally evacuated, and the womb closely contracted around the fœtus, which is then thrust considerably into the pelvis, the parts of the woman being dry, hot, tender, and often in a state of inflammation and tumefaction, especially when unskilful endeavours have been used either to extract or turn the foetus, or to dilate the parts.">

* London Practice of Midwifery, p. 245.

* Principles and Practice of Midwifery, p. 196.

< Lectures, p. 233.

* Observations, vol ii. p. 48.

d On Parturition, p. 355.

Traité d'Accouchemens, vol. ii. p. 439.

* Principles and Practice of Obstetricy, p. 391. * Principles and Practice of Midwifery, p. 196.

In such a case, to force the hand through the os uteri would be to rupture that organ, and cause the death of the woman. It is admitted by all authors, I believe, that the operation must be postponed for a time, and means tried to soften the uterus and suspend its contractions. For this purpose, all are agreed in the propriety of taking away sixteen or eighteen ounces of blood from the arm, and following up this with a large dose (gtt. lxxx. to gtt. c.) of laudanum.-(Denman, Merriman,a Hamilton, jun., Ashwell, Burns, Blundell.) Dr. Collins has proposed another remedy of great value. He says "In such a situation, where the individual is strong and plethoric, twelve or fourteen ounces of blood should be taken from the arm, and a tablespoonful of the following mixture given every half hour, which I have found exceedingly useful both in quieting uterine action and inducing relaxation :

e

B. Aquæ Fontis, 3 vi.

Antim. Tartar. gr. iv.

Aceti opii, gtt. xxx. M.”

By these means, after the lapse of a short time, we shall find the uterus relaxed, and the os uteri soften, so that with a little patience, and gentleness, and time, we may attain our object.

3. When the case is one of placenta prævia, or even of accidental hæmorrhage, (if it demand delivery,) it is a general rule to operate as soon as possible. The os uteri seldom offers any resistance, owing to the loss of blood, and as this loss is necessarily increased by the natural efforts in unavoidable flooding, it is evident that the earlier we deliver the better for the patient.

If we decide upon trying this operation in convulsions, prolapsed funis, or ruptured uterus, it will be wise to attempt it as soon as the state of the os uteri will permit.

a Synopsis, p. 89.

C Midwifery, p. 420.

e Practical Treatise, p. 67.

b On Parturition, p. 356.

d Obstetricy, p. 397.

Hawn of wer-Tis geration is usually divided ma are sags: be aroduction, the ting, and the extraci sal surly describe these in each kind of version. 2 Coomale veran-The rectum and bladder having been prenoist ended, the patent is to be paced in the posture most contement as the operate: some recommend that she sol. of a ler back. Chapman Dawkes, Smellie, Dewees,) chers that she shout knee F. O or lie on her left side, ai rimry abour. The later position is generally adopted nas councy. Wichever hand we choose to operate with, #1: te vei tied or scaped, and then insinuated through the as extern edgeways Great gentleness will be necessary, and contrary to the advice of some, it would seem better to do this during sa interval of pain. When the hand is nearly all in the mima i vill be necessary to change its direction, from that of the mis of the lower octet to that of the upper outlet. This moddiy to the vagina, and will bring the points of the fingers to about the situation of the os uteri. Through the os uteri ini membres if entire, the hand is to be insinuated very gradaily, in a conical form and during the interval of the pains, bolding still but not losing ground when the pain comes

When the band is in the womb, if our object be to rectify the position of the bead, it should be seized, and placed in one of the oblique diameters of the brim, with the posterior fontanelle corresponding to one of the acetabula, i. e. in the first or second position. If our object be to change the presentation, for example, to substitute the head for a shoulder, we must gently push up the shoulder, and then seizing the head bring it down to the brim and place it in the most favourable relation to the pelvis.

Having now done all that we can by the hand alone, it may be withdrawn, and the further progress of the labour left to the efforts of nature; should these be found inadequate, recourse must be had to the forceps.

This is the ordinary method of placing the head in position

for descending, but Wigand has stated that it is possible, before the waters have escaped, to change the position of the head, or even the presentation, by external abdominal manipulations. Velpeau confirms this from his own experience, and something similar is stated by Sennerta and Martins." Riecke has also related several such cases. Dr. Burns, in a note to his ninth edition, states, that "Mr. Buchanan, of Hull, informs me that he succeeded, in one instance lately,' where the left side of the breast of the fœtus lay diagonally over the pelvis with the head forward,' in bringing the head right, by making the patient kneel and raise the breech, whilst the shoulders were brought as low as possible. The water had not been discharged. The situation of the head, when it came down, was made more favourable by the finger. The child was alive."

2. Podalic version.-I shall not repeat what I have said as to the mode of introducing the hand through the os externum and os uteri. The hand and arm will be our guide, for it is better not to attempt to put it back, much less to separate it "after the manner of the ancients." "In no case is it necessary or in any wise serviceable to separate the arm of the child previous to the introduction of the hand of the operator. In some cases to which I have been called, in which the arm had been separated at the shoulder, I have found greater inconvenience, there being much difficulty in distinguishing between the lacerated skin of the child and the parts appertaining to the mother. The presenting arm is never an impediment of any consequence in the operation, and therefore, in my opinion, ought not to be regarded, or on any account removed." Arrived at this point, an examination should be made as to the position of the child's body; having ascertained all about this, the hand is to be passed over the front (chest and belly) of the child, as it is generally in front that we meet with the

a Deventer, p. 272. Midwifery, p. 417.

b Arch. Gen. de Med. vol. xxii. p. 385.

d Denman's Introduction to Midwifery, p. 352.