least compressible part of the foetus, increased by the thickness of the arms, forms a wedge which is very apt to stick in the brim. This is one great reason for not putting on extraction-force if it can be avoided. If, however, we find the arms in this unfortunate position, we must be prepared to liberate them promptly, and, at the same time, without injury. It is very easy to dislocate or fracture the arms or clavicles if the proper rules are not observed. are these rules?

What

The cases vary in difficulty, and therefore in the means to be adopted. In some cases the arms do not run up in full stretch along the sides of the head. The humeri are directed a little downwards, so that the elbows are within reach. In such cases it is an easy matter to slip a forefinger on the inner side of the humerus, to run it down to the bend of the elbow, and to draw the forearm downwards across the chest and abdomen, and then to bring the arm down by the side of the trunk. But many cases require far more skill.

The cardinal rule to follow is to observe the natural flexions of the limbs, always to bend them in the direction of their natural movements. The arms, therefore, must always be brought forwards across the breast. The way to do it is as follows:-Slip one or two fingers up along the back of the child's thorax, and bend the first joints over the shoulder between the acromion and the neck; then slide the fingers forwards, catching the humerus in their course, and carrying this with them across the breast or face. This movement will restore the humerus to its natural flexion in front of the body. Of course,

as the humerus comes forwards the forearm follows. Your fingers continuing to glide down will reach the bend of the elbow, and, still continuing the same downward and forward movement across the child's breast and abdomen, the arm is extended and laid by the side of the trunk.

That is what has to be done. which arm you shall bring down first?

But is it indifferent

The most simple rule is to take that first which is the easiest, for when

FIG. 68.

REPRESENTS THE MODE OF LIBERATING THE POSTERIOR OR SACRAL ARM.

one is released the room gained renders the liberation of the second arm easy enough. Generally there is most room in the sacrum; therefore it is best to take the posterior arm first.

Now I have to describe manoeuvres for overcoming the difficulties which not seldom oppose your efforts to

release the arms. There are two principal ones. The first is this: You want to bring the posterior or sacral arm within reach of your finger. Carry the child's body well forwards, bending it over the symphysis pubis. The effect of this is a twofold advantage. Space is gained between the child's body and the sacrum for manipulation; and as the child's body

FIG. 69.

REPRESENTS THE MODE OF LIBERATING THE ANTERIOR OR PUBIC ARM.

revolves round the pubic centre, the further or sacral arm is necessarily drawn lower down, commonly within reach. When the sacral arm is freed, you reverse the manoeuvre, and carry the child's trunk backwards over the coccyx as a centre. This brings down the pubic arm.

The second manoeuvre may be held in reserve

should the first fail. To execute it you must bear in mind the natural flexions of the arms. You grasp the child's trunk in the two hands above the hips, and give the body a movement of rotation on its long axis, so as to bring its back a little to the left. The effect of this is to throw the pubic arm, which is prevented

FIG. 70.

REPRESENTS A MODE OF LIBERATING THE ARMS.

The trunk is rotated an eighth of a circle from right to left, so as to throw the left arm across the face.

Then, your object

by friction against the canal from following the trunk in its rotation, across the breast. being accomplished so far, you

call to your aid

the first manœuvre, and bring this arm completely down. This done, you reverse the action and rotate

the trunk in the opposite direction. The sacral arm is thus brought to the front of the chest, and, by carrying the trunk back, your fingers will easily complete the process.

It is desirable, for reasons we shall presently explain, to avoid this rotation if possible; but under

FIG. 71.

REPRESENTS THE RESULT OF THE MANEUVRE BEGUN IN FIG. 70.

By rotating the trunk from right to left, the left arm is thrown across the face.

certain circumstances of difficulty it is exceedingly valuable. The rotation need not be considerable; an eighth of a circle is commonly enough, and as it is neutralized by reversal, an objection that might otherwise be urged against the manœuvre is removed.