of the night, his wife was seized with the pains of labor, which immediately became violent and expulsive. He ran for an old woman in the neighborhood, who arrived just in time to receive the child, which she severed, and immediately proceeded to wash and dress it, leaving the woman lying upon the bed. "Ah-ha!" said the tailor, "this is a very good thing; we'll cheat the doctor out of his fee." And so he rejoiced and was very glad; but in a short time the poor woman fainted, and remained a long time insensible; whereupon, he came for me in furious haste, telling me that his wife was either dead or dying, and begging me, for God's sake, to give her speedy assistance. I soon reached the apartment, and found her speechless and pulseless, and pale, and lying in a puddle of coagula and fluid blood. Placing my hand upon her abdomen, I found there was another child there. I now took away all her pillows; opened the windows; dashed water freely upon her face and neck; and with difficulty succeeded in getting down a few swallows of strong brandy and water. The head presented; I ruptured the membranes, and passing my hand upwards to the feet, seized them, turned and delivered the child, and immedi ately afterwards removed the placentas. I was for some time doubtful whether she would live or die, but she finally rallied under stimulation, and got quite well.

I think that four minutes had not elapsed from the time that I reached her apartment until the child was delivered. Suppose that, like my friend mentioned in the former case, I had sent to my house for the forceps, would my patient have survived? Suppose he, instead of sending for his instruments had immediately delivered her by turning, would he have lost both the mother and her child? It is said, that it is the last straw that breaketh the mule's back. It might as truly be said, that it is the last ounce that kills in the uterine hemor rhage.

Having now described the operation for delivery in preternatural labors, the head presenting in the first vertex position, I have to indicate the method of proceeding in the other positions of the vertex. In all important particulars of the management, the former directions may be regarded as sufficiently full. But, as in the second position, the face of the child looks towards the left sacro-iliac symphysis, it is necessary, on that account, to employ in the turning the RIGHT HAND, and not the left hand, as before.

By introducing the right hand for the operation, the head will be pushed out of the plane of the strait to the right upwards, and made to lodge in part upon the brim, and in part upon the wrist and inner face

of the forearm, while the fingers, going up along the breast and belly of the child, seek for, and at length find, the feet.

When caught, one or both the feet are brought out of the os uteri into the vagina, and so through the ostium vagina. Due care should always be used not to force the version while the uterus is contracting. It may be expected to contract several times during the act of turning.

Inasmuch as the face looked to the left sacro-iliac junction at the beginning, it might be expected, when completely turned, to look towards the right acetabulum, and it would probably do so, if care were not taken to draw chiefly upon the left foot: by doing which, the left trochanter will be brought to the arch, and then it may, as soon as it has completely come forth, be forced over towards the right ischial ramus, which will serve to bring the left shoulder also to the right acetabulum when it begins to engage. The face of the child will of course, under these circumstances, be turned to the right sacro-iliac junction, and finally sink into the hollow of the sacrum. I need not here reiterate directions, already sufficiently explained and insisted on in the former article.

The operator may find the child that he is about to turn, presenting in the fourth position of the vertex, in which case the forehead will look to the left acetabulum, and the vertex to the right sacro-iliac junction. To turn in this position of the child, he should employ the right hand, which passing up on the left side of the pelvis, between the face and the brim, thrusts the head above the right anterior semicircumference of the strait, where it must be resisted by the wrist or arm, while the fingers explore the cavity in search of the feet. If the child were turned without being rotated upon its axis, its face, after the version, would be at the right sacro-iliac junction, and this would be well; but still, in order to insure an occipito-anterior position of the vertex after turning, it would be safest to act chiefly upon the left foot in making the tractions. I shall not repeat the directions for the other parts of the process.

In the fifth position, the fontanelle is found at the left sacro-iliac junction, and the top of the forehead at the right acetabulum. If the woman were lying on her left side and the accoucheur seated with his face turned in the opposite direction he might, conveniently, employ his right hand in the version, for the palm of the hand slightly pronated would glide along the right side of the breast and abdomen of the child in search of the feet. The child, having been completely turned, would have its face addressed toward the left posterior part of the womb; in making the last tractions, therefore, the Student ought

to be advised to draw chiefly upon the right foot in order to bring the right trochanter to the pubic arch, and, as soon as it shall have been fairly expelled, turn the trochanter towards the left ischial ramus, which will secure the descent of the shoulder in the neighborhood of the left acetabulum, and the subsequent engagement of the head in an occipito-anterior position. There is no necessity for repeating the minute directions as to the conduct of this version.

In cases of version in the third and sixth positions, cases never likely to occur, the accoucheur could use either the right or the left hand, as he might deem most convenient to himself; the choice being indifferent, the occipito-frontal diameter of the child coinciding with the antero-posterior diameter of the pelvis.

Turning in Shoulder Presentations.-The turning and delivery of the child in head presentations are less difficult than in the operation for version in shoulder cases.

Fig. 105.

In a former part of this volume, I have stated that there are two shoulder positions for each shoulder, making four in all. There are two positions for the right shoulder. In the first, the head of the child is on the left side of the pelvis, as in the annexed figure 105. This figure represents a shoulder presentation with the right hand prolapsed; the palm of the hand must look towards the mother's back, and its dorsum towards the pubis; the face looks backwards, and the feet of the child are in the back part of the womb, so that, in seeking for them, the accoucheur should pass his hand along the breast of the child, and expect to find its feet not far from its sternum. To pass the hand between the child and the pubes would be to make a distressing mistake,

for it would be impossible to turn the child in that way, and it would be wrong to expect to find its feet lying on its back. To perform version the woman should lie upon her back, the hips being near to the edge of the bed, the thighs abducted, and strongly flexed: the right hand should be chosen (to look at Fig. 105 is enough to show that the right hand is the preferable one), for the points of the fingers easily direct themselves towards the pelvic extremity of the foetus; and a moderate supination of the arm applies the hand to the breast and abdomen of the child; the fingers could scarcely close between

the abdomen of the child and the posterior aspect of the womb without grasping the feet or knees, whereas, to use the left hand would be to point the fingers towards the cephalic extremity of the foetus, and if the feet should be caught in that way, it would be necessary to let them go again. Therefore, in the first position of the right shoulder presentation, the Student will be careful to employ his right hand for the version.

Suppose the Student, in performing this version, should take hold of the left foot of the child, he would (let him look at Fig. 105) cause it to revolve upon its axis and bring its face towards the mother's abdomen. This is what he desires not to do, for the chief intention which he should set before him is that of bringing the vertex to the symphysis, and the face to the sacrum. He ought to get both feet, if possible: having both feet in his hand, it will be in his power to draw the child by the right foot, which will bring the right trochanter to the pubic arch, and the right shoulder to the left acetabulum, which will let the face come into the pelvis looking backwards towards the left..

The second position of the right shoulder presentation is neatly

Fig. 106.

figured in the accompanying drawing, Fig. 106. It represents the body of the child very much compressed by the contracted womb from which the waters have been expelled, and the hand of the accoucheur, which is here the right hand, partially engaged in the cervix uteri, seeking for the feet. It would be as well, in this particular labor, provided the patient were lying on the back, to use the left hand in version; but, if she were lying on her left side, the right hand would be far more convenient than the left, since, introduced between pronation and supination, it would apply itself to the breast and abdomen of the child.

Fig. 107 shows the process of operation, which is here being properly conducted, for the tractions are being made upon the left limb, which would serve to roll the child upon its axis so as to turn its face towards the posterior semi-circumference of the pelvis.

The left shoulder presentation has, likewise, two positions. In the first of them, the head is found on the left side of the pelvis, and the face of the child looks front. In the second, it is placed toward the

Fig. 107.

right side of the pelvis, the face looking backwards. In the first position, the left arm being down, the feet should be found between the belly of the child and the anterior wall of the womb; the rule obtains, therefore, in this as in all cases, of passing the exploring hand upwards along the front of the child's body. If the woman were lying upon her left side, with her knees drawn up with a pillow between them, the palm of the right hand would readily apply itself to the anterior aspect of the foetus: the left hand would be highly inconvenient for this operation; it might be used in the dorsal decubitus, but not so conveniently as the right.

The child's face is looking to the front;

it ought to be rolled upon its axis so that the face may look backwards, giving it at last an occipito-anterior position; therefore let the operator direct his chief efforts upon the right inferior extremity, which alone can roll it upon its axis and turn the face backwards.

In the second position of the left shoulder presentation, the head is on the right side of the pelvis, looking backwards, the left shoulder is down, and the hand or elbow prolapsed or not; it is indifferent whether they be or be not prolapsed.

Fig. 108.

Figure 108 explains the operation; the left hand is employed, for its fingers go out towards the pelvic extremity of the child, and its palm, in easy pronation, adapts itself to its anterior aspect. If the Student should draw the child down by the right inferior extremity, he would roll it on its axis. This would be wrong, since the child's face is already backwards; let him, therefore, make his chief tractions by the left limb, in order to bring the left hip to the symphysis, which, after it is born, should be rotated towards the right ischium, to bring the face into the hollow of the sacrum at last. I ought not to omit some advertence

to an accident that occasionally happens, whether in version or in