in great mobility and crackling of the cranial bones; the caput succedaneum falling into loose skin-folds; the coming away of epidermis and hairs.

So long as there is tonicity, rigidity, or firmness of the limbs, life is present; but flaccidity is not a certain sign of death. A sign of threatening imminent death is a twitching or convulsive movement of the leg held in your hand. This indicates an attempt at inspiration, made to supplant the suspended placental circulation. When this is felt, it

is a warning to accelerate aërial respiration.

delivery, and to excite

The value of turning in moderate degrees of pelvic contraction rests greatly upon the truth of the following proposition:-The head will come through the pelvis more easily if drawn through base first than if by the crown first. Baudelocque affirmed this proposition.* He said: "The structure of the head is such that it collapses more easily in its width, and enters more easily when the child comes by the feet, if it be well directed, than when it presents head first." Osiander had maintained the same opinion. Hohl (1845) also pointed out that the bones overlapped more readily at the sutures when the base entered first. Simpson (1847) insisted strongly upon the truth of this proposition, and illustrated the mechanism of head-last labours with much ingenuity. The proposition has, however, been disputed, and that by Dr. M'Clintockt. He says:-"I do not believe that the diameters of the head are more advantageously placed with regard to those of the pelvis,

"L'Art des Accouchements."

"Obstetrical Transactions," vol. iv., 1863.

nor can I believe that the head is more compressible when entering the strait with its base than when it does so with its vertex, till this be demonstrated by direct experiment."

It is also contested by Professor E. Martin, of Berlin. He especially insists that when the vertex presents, moulding may go on safely for hours; but that if the base come first the moulding must be effected within five minutes to save the child.

I venture to submit that I have made such clinical observations as are equivalent to direct experiments. In the first place, let me state a fact which I have often seen. A woman with a slightly contracted pelvis, in labour with a normal child presenting by the head, is delivered, after a tedious time, spontaneously or by the help of forceps; the head has undergone an extreme amount of moulding, so as to be even seriously distorted. The same woman in labour again is delivered breech first; the head exhibits the model globular shape, having slipped through the brim without appreciable obstruction. For examples see my outlines of heads.†

In the second place, I have on several occasions been called to an obstructed labour, in which the head was resting on a brim contracted in the conjugate diameter. Of course, Nature had failed; the vis à tergo was insufficient. I have tried the long double-curved forceps, trying what a moderate compressive power, aided by considerable and sustained traction, would do to bring the head through, and have failed. I have then turned, and the head coming

base first has been delivered easily. Upon this point I cannot be mistaken; and I think this greater facility can be explained. Dr. Simpson has illustrated by diagrams how the head, caught in the conjugate at a point below its bi-parietal diameter, is compressed transversely as traction-force is applied below, causing the mobile parietals to collapse and overlap at the sagittal suture. And surely no one can doubt that the traction-power, and, therefore, the compressing power, acquired by pulling on the legs and trunk, is infinitely greater than can be exerted by the strongest forceps. But there is another circumstance in the clinical history of head-last labours in narrow conjugate which affords a remarkable illustration of this proposition. The head is rarely, or never, seized in its widest transverse diameter; it is seized by the conjugate at a point anterior to its greatest width-that is, in the bi-temporal diameter; the bi-parietal and occiput commonly finding ample opportunity for moulding in the freer space left in the side of the pelvis behind the promontory. The head, in fact, fits or moulds into the kidney-shaped brim wherever there is most room. I have given illustrations of this point also in the memoir referred to.* I think, therefore, it may be taken as demonstrated, that the head coming base first passes the contracted brim more easily than coming crown first; and if the head comes through more easily, it may be expected that the child will have a better prospect of being born alive.

Can we define with any precision the conditions as to degree of pelvic contraction that are compatible "Obstetrical Transactions," 1866.

with the birth of a living child? The question is not easy to answer; nor is it important to be able to answer it very precisely. The great fact upon which the justification of the operation rests is this: many children have been delivered by it alive, with safety to the mother. We know accurately only one element of the problem-namely, the degree of con

FIG. 85.

REPRESENTS THE HEAD ENTERING A CONTRACTED BRIM, BASE FIRST.

It is nipped in the small transverse diameter, the greater or bi-parietal diameter and the occiput finding room in the side of the pelvis. The cord lies in the side of the pelvis to which the face is directed, and is protected by the promontory.

mate.

traction of the pelvis. The other element, the relative size and hardness of the foetal skull, we can but estiWe must assume, in many cases, a standard head. With this assumption the practical question is reduced to this: What is the extreme limit of pelvic contraction justifying the attempt to deliver by turning? In other words, this means: What is the narrowest pelvis that

admits of the passage of a normal head? This is answered chiefly by experience. It is not to be answered by à priori reasoning like that urged by Dr. Fleetwood Churchill, who says, even in his last edition: "The bi-mastoid diameter in the six cases measured (by Dr. Simpson) varied from 28 to 3 inches, and a living child can pass through a pelvis of 3 inches antero-posterior diameter, with or without the forceps. With a pelvis of this size, then, the operation is unnecessary; and if the antero-posterior diameter be less than 29 inches, the operation would be impracticable. These, then, are the limits of the operation; for us to attempt to drag a child through a smaller space would be unjustifiable."

I

To this statement of the case serious objections may be taken. The proposition that a living child can pass through a pelvis with an antero-posterior diameter measuring 3.25", with or without the forceps, can only be accepted with considerable qualifications. I claim to speak with the confidence drawn from large experience, when I say that a head of standard proportions and firmness will hardly ever pass a conjugate reduced to 3.25" without the forceps, and very rarely indeed with the forceps-that is, alive. might even extend the conjugate to 3.50", and affirm the same thing. The compressive power of the forceps, unless very long sustained, is not great, rarely great enough to reduce a bi-parietal diameter of 4.00" to 3.50" without killing the child. My opinion, then, is, that a standard head, especially if it happen to be a female head, which is more compressible than a male one, may be drawn through a conjugate of 3′′, Theory and Practice of Midwifery," 1866.