allow this base to descend. The uterus is apt to contract firmly upon the parts still retained in its cavity; and, the cervix encircling the wedge about its middle, a state of spastic rigidity ensues, which tends to lock up the head and chest and to impede descent and rotation. In Fig. 53 I have endeavoured to depict some of the conditions described.

THE POSITION OF THE FETUS WITH THE LEGS EXTENDED AS SEEN FROM A FRONT VIEW.

The breech has descended into the pelvis. The foetus forms a wedge, of which the apex A is turning forwards under the pubic arch. The base в c formed by the head and legs is wider than B'c', the transverse diameter of the pelvis.

Sometimes the cause of arrest is simple inertia : a little vis à fronte to compensate for defective vis à tergo may be all that is necessary. It is in the hope of extricating the child by this means that traction in various forms is resorted to. If this is unsuccessful, the case is rather worse than it would have been if left alone. The apex is dragged down a little more, the mother's pelvis is more tightly filled, and the uterus has become more irritable. I have on this account arrived at the conclusion that it is better not to resort

to direct traction upon the breech in any case where there is arrest. The proper course is, I believe, to bring down a foot in the first instance. Then traction, if still indicated, can be exerted by aid of the leg with safety and with increased power, and under the most favourable conditions for the descent and rotation of the child.

I have seen fruitless and injurious attempts made to extract by fingers, hooks, and forceps. I believe that all the best authors- that is, of those who have encountered and have had to overcome this difficulty, for it is little considered in our text-books-condemn the use of hooks and forceps. Chiari, Braun, and Spaeth,* Ramsbotham, H. F. Naegele, are decided in their reprobation; Hohl† says the forceps is neither necessary nor effectual. The breech is already in the pelvis. To apply the blades safely, the hand must be passed into the vagina, and, having done this, it may as well do the right thing at once-that is, bring down a foot. Special forceps made to seize the breech are also superfluous.

I have always succeeded in delivering these cases by the simple use of the unarmed hand; and since the cases in which I did so succeed were the most difficult that can be encountered, it follows that the unarmed hand is sufficient to overcome the cases of minor difficulty of the same kind. To determine us to reject hooks and forceps, it should be enough to remember that the child is probably alive, and that, under proper skill, it may be born alive. Now hooks and forceps will, in all likelihood, either destroy the child

or involve its death through the delay arising out of their inefficiency, or they may seriously injure the child. The blunt hook may fracture the femur, contuse the femoral vessels, or at least inflict severe bruises on the soft parts. The forceps may injuriously press upon the abdominal viscera.

The difficulty is seldom manifest until the breech has entered the pelvis, and this is the great cause of the obstacles opposing operative measures. To traverse the pelvis, the child's body must take a sinuous course, represented in Fig. 54.

FIG. 54.

REPRESENTS A SIDE VIEW OF A BREECH-PRESENTATION, IN WHICH THE BREECH HAS ENTERED THE PELVIS.

It shows the sigmoid form imparted to the trunk in its effort to traverse the pelvis.

The clear indication is to break up or decompose the obstructing wedge. This is done by bringing down one foot and leg. For this purpose, pass your hand through the os uteri in front of the breech where the feet lie; seize one by the ankle with two fingers; draw it down, and generally the breech will soon descend. It is better to leave the other leg on the abdomen as long as

possible, as it preserves greater rotundity of the breech, and helps to protect the cord from pressure. It will escape readily enough when the breech comes through the outlet.

The first thing to do is to determine the position of the breech in its relation to the pelvis, in order that you may know where to direct your hand to the feet. The breech simulates the face more than any other part, and so it is from the face that the breech has chiefly to be distinguished. There are four principal diagnostic points in the breech: the sacrum and anus behind, the genitals in front, an ischiatic protuberance on either side. The sacrum is distinguished by its uneven spinous processes from anything felt in a face presentation; and this is the most trustworthy characteristic, for the malar bones may pass for the ischia, and the mouth for the anus. In all cases of doubtful diagnosis it is well to pass the fingers, or hand, if necessary, well into the pelvis, so as to reach the higher presenting parts. In a breech case you will thus reach the trochanters, and above them the groins, where a finger will pass between the child's body and the thigh flexed upon it. Then in front will be the fissure between the thighs themselves; and here, if the legs are flexed upon the thighs, will be the feet to remove all doubt. These are what you are in search of. But you only want one. It is much more easy to bring down one foot than both; and it is, moreover, more scientific. The question now comes, Which foot to bring down? I believe the one nearest to the pubic arch is the proper one to take. To seize it, pass the index finger over the instep; then grasp the ankle with

the thumb, and draw down backwards to clear the symphysis pubis. When the leg is extended outside the vulva, it will be found that traction upon it will cause the half-breech to descend, and the child's sacrum to rotate forwards. The further progress of the case falls within the ordinary laws of breechlabour.

FIG. 55.

REPRESENTS A BREECH-PRESENTATION WITH THE LEGS FLEXED UPON THE THIGHS, AND THE MODE OF SEIZING A FOOT.

The second case-that in which the feet lie at the fundus of the uterus close to the face-is far more difficult. The wedge formed by the extended legs and the upper part of the trunk must, in some instances at least, be decomposed before delivery can be effected. The cause of the difficulty will be understood on looking at the diagram, Fig. 53; and on reflecting that the breech or wedge may in great part be driven low down into the pelvis, leaving but little space for the operator's hand to pass; and