TURNING.

Turning is that operation in midwifery where the feet, which had not presented at the time of labour, are artificially brought down into the os uteri and vagina, and in this manner the child delivered. (NaegelÉ, MS. Lectures.)

Besides turning with the feet foremost as now described it has also been proposed, as being safer for the child, to bring down the nates or the head, but these operations, especially the former, have scarcely ever been practised, and in most cases are impracticable.

Turning, in the strict sense of the word, is that operation, by which, without danger to the mother or her child, the position of the latter is changed, either for the purpose of rendering the labour more favourable, or for adapting the position of the child for delivering it artificially.

The delivery of the child with the feet foremost, by means of the hand alone, may be looked upon as a second stage of the operation; where, however, the turning has been undertaken on account of malposition of the child, it has been very properly recommended by Deleurye, (TraitÉ des Accouchemens, 1770,) Boer, (Naturliche GeburtshÜlfe, 1810,) Wigand, (Geburt des Menschen, 1820,) and other high authorities in midwifery, that as the position is now converted into a natural one, (viz. of the feet,) it should be left as much as possible to the natural expelling powers; hence, therefore, under these circumstances, artificial extraction of the child with the feet foremost can scarcely be said to exist, the operation itself being confined to changing the position of the child.

Where, however, the circumstances of the case require that labour should be hastened in order to avert the impending danger, the extraction of the child with the feet foremost, by means of the hand alone, becomes a distinct operation.The artificially changing the child’s position into a presentation of the feet is indicated in cases where, on account of malposition of the child, the labour cannot be completed, or at least without great difficulty.

Indications. The artificially delivering the child with the hand alone, or the extraction of it with the feet foremost (which of course presumes that it has presented with the feet, either originally or has been brought into that position by interference of art,) is indicated in all cases where the labour requires to be artificially terminated either on account of insufficiency of the expelling powers, or from the occurrence of dangerous symptoms. Under this head, on the part of the mother, are violent floodings, especially under certain circumstances, convulsions with total loss of consciousness, great debility, faintings, danger of suffocation from difficulty of breathing, violent and irrepressible vomiting, rupture of the uterus, death of the patient, &c.;—on the part of the child, prolapsus of the cord under certain circumstances. (NaegelÉ, Lehrbuch der GeburtshÜlfe, §§ 394, 395. 3d edit.) Hence, therefore, the general indications of turning are the same as those of the forceps, it being indicated in all those cases where nature is unable to expel the foetus, or which demand a hasty delivery of the child, but which cannot be attained by the application of the forceps.

Turning is an operation which is far inferior to that of the forceps, both as regards the safety of the mother and her child, and also the ease with which it is performed. Whenever the circumstances under which it is undertaken are unfavourable, it not only becomes a very difficult operation, but also one of considerable danger: for the child especially is this the case, as the very circumstance of its being born with the feet foremost shows that it is necessarily exposed to the same dangers as those already mentioned in nates presentations, in addition to those of the first part of the operation, viz. the changing its position.

The most favourable moment for undertaking the operation of turning is when the os uteri is fully dilated and the membranes are still unruptured. In this state, the vagina and os uteri are most capable of admitting the hand, and the uterus, from being filled with liquor amnii, is prevented contracting upon the child, the position of which is changed with great ease and safety; but when the os uteri is only partially dilated, its edge thin and rigid, the membranes ruptured, and the liquor amnii drained off for some hours, it becomes a matter of great difficulty and danger either to introduce the hand into the uterus under such circumstances, or to attempt changing the child’s position: the os uteri tightly encircles the presenting part, and the uterus contracts upon the child itself so as to render it nearly, if not altogether immoveable.

The os uteri ought always if possible to be fully dilated: this however is not so essential as with the forceps, for when once it has reached the size of a crown piece, it mostly yields easily to the introduction of the hand. Where turning is indicated in malposition of the child we may safely await its full dilatation so long as the membranes remain unruptured. Where the membranes have been ruptured some hours and the os uteri hard, thin, and rigid, it will be impossible to turn until, either spontaneously or by proper treatment, it becomes soft, cushiony, and dilatable.

In cases which require turning as a means of hastening labour, as for instance in flooding from placenta prÆvia and other causes, the hÆmorrhage is seldom so severe as to demand it without at the same time rendering the os uteri so relaxed as to present little or no obstruction to the hand. Where convulsions indicate turning, the bleeding and other depleting measures, which are necessary to control them, will have a similar effect in preparing the os uteri for this purpose.

In ordinary cases of turning there will be no need to change the patient’s position, as it will be just as easy to perform it as she lies upon her left side, merely bringing her pelvis nearer to the side of the bed in order to reach her with greater facility. Where, however, from the position of the child or from the state of the uterus, the introduction of the hand and searching for the feet will probably be attended with considerable difficulty, it may be advisable to place her across the bed, sitting upon its edge, her back supported by pillows, her feet resting on two chairs, in the same way as it is used by the Continental practitioners for applying the forceps; or if it be really a case of very unusual difficulty, it will be better to put her upon her knees and elbows, for in this position we gain the upper and anterior parts of the uterus with greater ease.

In choosing which is the best hand for performing the operation, the practitioner must not only be guided by the position of the child, but also by the hand with which he possesses most strength and dexterity: many always use the left hand for turning when the patient lies upon her left side; for our own part we have always used the right, and have never failed except in one or two cases of great difficulty, where we judged it more prudent to put the patient on her knees and elbows than risk any injury by using too much force. In introducing the hand into the vagina as the patient lies on her left side, the right is moreover preferable, as we can pass it more completely in the axis of the vagina, than we can the left.[88]

The directions which are usually given to introduce one hand or the other according to the child’s position, are not practical, because cases occur where it is impossible to ascertain this point without passing the hand into the uterus, as in placenta prÆvia, and occasionally in shoulder presentations; and it would be by no means justifiable to make the patient undergo the suffering from a repetition of this operation, merely because the position of the child is such as is stated in books to require the left hand instead of the right.

Having evacuated the bladder and rectum, and greased the fore-arm and back of the hand, we should gently insinuate the four fingers, one after the other, into the os externum: the whole hand must be contracted into the form of a cone; the thumb will pass up easily along the palm; the passage of the knuckles is the most difficult, for as the os externum is the narrowest part of the vagina, and the hand is widest across the knuckles, it follows that this is the point of the greatest resistance and suffering, and that, when once this is overcome, our hand will advance with greater ease both to ourselves and to our patient. This part of the operation can scarcely be conducted too gradually or gently, for if we give the soft parts sufficient time to yield, it is scarcely credible what an extent of dilatation may be effected by a comparatively moderate degree of pain; the os externum is also the most sensitive part of the vagina, and serious nervous affections may even be provoked by the intolerable agony arising from a rude and hasty attempt to force the hand through it. We must not advance the hand merely by pushing it onwards, but endeavour to insinuate it by a writhing movement, alternately straightening and gently bending the knuckles, so as to make the vagina gradually ride over this projecting part as the hand advances.

In passing the os uteri the same precautions must be observed, particularly when the os uteri is not fully dilated; at the same time we must fix the uterus itself with the other hand, and rather press the fundus downwards against the hand which is now advancing through the os uteri. In every case of turning we should bear in mind the necessity of duly supporting the uterus with the other hand; for we thus not only enable the hand to pass the os uteri with greater ease, but we prevent in great measure the liability there must be to laceration of the vagina from the uterus, in all cases where the turning is at all difficult. “In those cases (says Professor NaegelÉ) where artificial dilatation of the os uteri is required to let the hand pass, it should be done in the following manner:—during an interval of the pains, we introduce, according to the degree of dilatation, first two, then three, and lastly four fingers; and by gently turning them and gradually expanding them we endeavour to dilate it sufficiently to let the hand pass. This must only be done under circumstances of absolute necessity and always with the greatest caution—in fact, only in those cases where the danger consequent upon artificial dilatation of the os uteri is evidently less than that, to avert, which we are compelled to turn before it is sufficiently yielding or dilated.” (Lehrbuch der GeburtshÜlfe, p. 212. 3tte ausgabe.) This observation from so high an authority evidently applies to those cases where the os uteri is not only soft and yielding, but also nearly dilated; the forcible dilatation of the os uteri is justly deprecated by Madame la Chapelle: “I never attempt to produce this forced dilatation, not even in cases of hÆmorrhage. But we may frequently promote the dilatation of the passages in a remarkable manner by moistening and relaxing them and diminishing their state of excitement, viz. by the steams of hot water, tepid injections, and more particularly by warm baths and bleeding.” (p. 49.) Her diagnosis of the condition in which the os uteri will yield to the introduction of the hand is well worthy of attention. “If the inactive uterus be unable to expel the child, or to make the head clear its orifice although considerably dilated, if, in this state of affairs, the membranes give way, we can feel the os uteri retract, from being no longer pressed upon. How different is this state of passive contraction to the rigidity of an orifice which has not yet been dilated: in this case, although the os uteri is contracted and even thick, it is soft, supple, and easily dilatable; there is no feeling of tightness or resistance; it is little else than a membranous sac, and the head has not descended sufficiently to press upon it; or if the head does not present, it is some part of the child, as for instance the shoulder, which is unable to advance and act upon the os uteri: in this case operate without fear—in the other wait.” (Pratique des Accouchemens, p. 86.)

If the membranes be not yet ruptured we should use the greatest caution to preserve them uninjured: the hand must be gently insinuated between them and the uterus, and should be passed either until the feet are felt, or at least, until it has gained the upper half of the uterus. Now, and not till now, ought they to be ruptured. As this is done at the side of the uterus little or no liquor amnii escapes, for the torn membranes are pressed closely against the uterine parietes, and the vagina is completely closed by the presence of the arm in it acting as a plug; the uterus is unable to contract upon the child on account of the fluid which surrounds it, and the hand, therefore, passes up with great facility. The uterus is not diminished by the loss of its liquor amnii; its contractile power is, therefore, not increased. When the hand has broken the membranes it can move about in perfect freedom: if the feet have not as yet been reached they will now be easily found, and the position of the child will be changed without difficulty.

The importance of passing in the hand without rupturing the membranes was first shown by Peu in 1694.[89] But it excited little or no notice at the time, not even by La Motte, who paid so much attention to improving the operation of turning. Dr. Smellie appears to have been the first after Peu who recommended this mode of practice, although he makes no mention of his name. “Then introducing one hand into the vagina we insinuate it in a flattened form within the os internum, and push up between the membranes and the uterus as far as the middle of the womb: having thus obtained admission, we break the membranes by grasping and squeezing them with our fingers, slide our hand within them without moving the arm lower down, then turn and deliver as formerly directed.” (Treatise on the Theory and Practice of Midwifery, vol. i. p. 327. 4th edit.) In 1770, Deleurye again pointed out the value of this mode of introducing the hand, and expressly directs us “introduire la main dans la matrice sans percer la poche des eaux, dÉtacher les membranes des parois de ce viscÈre, et les percer À l’endroit oÙ l’on juge que les pieds peuvent le plus naturellement se trouver.”[90] Dr. Hamilton, of Edinburgh, five years afterwards recommended the same method, and in nearly the same terms. Little notice, however, has been taken of it since, either in this country or upon the Continent, and the old objectionable mode of rupturing the membranes at the os uteri is still taught even by the most modern authors. The celebrated Boer also added his testimony in favour of Deleurye’s mode of practice,[91] and it has still farther been confirmed by Professor NaegelÉ.

Turning under these circumstances is an easy operation, and a very different affair compared with its performance in cases in which the membranes have been some time previously ruptured, and the uterus drained of liquor amnii: the hand is passed up with difficulty, the feet are quickly found, and the child moved round with a degree of facility which is scarcely credible. Where, however, the uterus is irritable and closely contracted upon the child, the liquor amnii having long since escaped, where the os uteri is not more than two-thirds dilated, its edge thin, hard, and tight, as is especially seen in a neglected case of arm or shoulder presentation, every step of the operation is attended with the greatest difficulty, and in fact is neither possible nor justifiable, until by bleeding to fainting, by the warm bath and opiates, we have succeeded in producing such a degree of relaxation as to enable us to introduce the hand. “Blood-letting is the only remedy with which we are acquainted that has any decided control over the contracted uterus. It is one almost certain of rendering turning practicable under such circumstances, if carried to the extent it should be. A small bleeding in such cases is of no possible advantage, for unless the practitioner means to carry the bleeding to its proper limits, which is a disposition to, or the actual state of syncope, he had better not employ it.” (Dewees’ Compendious System of Midwifery, § 629.) “The vagina is never so soft, so dilatable, and capable of admitting the hand as during the presence of an active hÆmorrhage, and this is equally the case in primiparÆ as in those who have had several children: and it is a mistaken kindness in the medical attendant, who in order to spare his patient’s sufferings, under these circumstances delays to introduce his hand until the hÆmorrhage shall have ceased. The moment this is the case, the vagina regains more vitality, sensibility and power of contraction, the hand now experiences much more opposition, and excites far greater pain than during the state of syncope.” (Wigand, Geburt des Menschen, vol. ii. p. 428.)

When once a powerful impression has been made upon the system by an active bleeding, opiates, which before it, would have only tended to render the patient feverish, are now of great value: they relax the spasmodic action of the uterus, allay the general excitement and irritability, and induce sleep and perspiration. As with bleeding in these cases, they must be given in decided doses: a grain of hydrochlorate of morphia given at once, or in two doses quickly repeated, and at the same time from half a drachm to a drachm of Liquor Opii Sedativus thrown into the rectum with a little thin starch or gruel, will rarely or never fail to produce the desired effect. The opiate by the mouth may be advantageously combined with James’s powder, and thus assist its diaphoretic action. The warm bath will also prove a valuable remedy.

“If the arm or funis of the child presents and is prolapsed into the vagina, we must not try to push back these parts into the uterus again, but we must endeavour to pass our hand along the inner surface of the presenting arm; or if it be the cord, we must guide it so as to press the cord as little as possible: if however a coil of it has passed out of the vagina and is still beating, we had better carry it upon the hand with which we are about to turn the child.” (Boer, op. cit. vol. iii. p. 5. 1817.) For farther information on this head we must refer to the observations on Malposition of the Child.

If the head or nates be occupying the brim of the pelvis it will be necessary to raise them gently and press them to one side: this however is usually effected by the very act of passing up the hand, and seldom produces any difficulty, unless these parts have already advanced deeper into the pelvis; in which case, as turning under these circumstances can only be undertaken with a view to hasten labour, it will become a matter of consideration whether we shall not be able to attain this object better by the aid of the forceps.

Although it ought ever to be considered as a rule that turning must not be attempted whilst the pains are violent, the introduction of the hand into the uterus always excites it more or less to contraction: the degree of pressure and impediment which it will produce to the progress of the hand will in a great measure depend upon the quantity of liquor amnii which it contains. Where the uterus has been drained of the fluid, every contraction will be felt in its full force by the operator: his hand is firmly jammed against the child, and if it happens to be caught in a constrained posture at the moment, is liable to be attacked with a severe fit of cramp, which benumbs and renders it powerless. Wherever we find that the hand is tightly squeezed during a pain, we should lay it flat with the palm upon the child, and hold it perfectly still: in this posture it will bear a powerful contraction without inconveniencing ourselves or injuring the uterus; and by letting it be quite flaccid and motionless we shall not provoke the uterus to farther exertions. Attempting to turn during the pain would not only be useless, but we should exhaust the strength of our hand which cannot be spared too much; we should torture the patient unnecessarily, and run no small risk of rupturing the uterus.

In letting the pressure of our hand be upon the child during a pain, instead of against the uterus, we must select any part rather than its abdomen, for pressure here seems to act as injuriously as pressure upon the umbilical cord.

Rules for finding the feet. In searching for the feet we must endeavour to gain the anterior surface of the child, for (unless its position be greatly distorted) they are usually turned upon the abdomen: in arm presentations the position of the hand will also guide us, the palm of it being mostly turned in the same direction as the abdomen, and therefore points to the situation of the feet; the rule also, as above given by Boer, of passing the hand along the inside of the presenting arm, is well worthy of recollection, for this can scarcely fail to guide us to the anterior part of the child. Where, either from the pressure of the uterus or other circumstances, it is difficult to distinguish the precise position of the child, it will be better to follow Dr. Denman’s simple rule, that the hand “must be conducted into the uterus, on that side of the pelvis where it can be done with most convenience, because that will lead most easily to the feet of the child.” The soft abdomen, the curved position of the child, and its extremities crossed in front are so many reasons why there should be more room in this direction.

During all this time the other hand placed externally will be of great service, not only in supporting the uterus, but in fixing the child and rendering the different parts of it more attainable. Where the feet are at some distance, we frequently come first to an arm or thigh, which soon leads us to the elbow or knee; if the introduction of the hand has been attended with some difficulty, it will not be very easy to distinguish these joints from each other, without bearing in mind the following diagnostic points:—the knee present two rounded prominences (condyles of the femur) with a depression between them, whereas, the elbow presents also two rounded prominences, but with a sharp projection (olecranon) between.

If the foot is not easily reached, there will be no need of forcing up the hand farther to gain it: it will be much better and safer to hook the finger into the bend of the knee and hold by it for a pain or two: this will generally be sufficient to bring it within reach; or during an interval of the pains, the leg may be gently disengaged and brought down. Not unfrequently we can only feel the toes with the extremities of our fingers, and therefore cannot maintain a sufficient hold upon the foot so as to bring it down: here again the same rule will be applicable, for by keeping but a slight hold upon it during a pain, it will be found to have approached nearer when the pain has gone off; in fact our first attempt to move the child must be done in this cautious manner, and we shall effect our object with greater certainty by merely holding the feet still during the pain, not allowing them to recede from that position in which we had placed them during the intervals, than by using considerable efforts to bring them to the os uteri. By the time we have got one foot fairly within grasp, the other is seldom very distant and should always be brought down if possible: by bringing down both feet we cause the hips of the child to enter the brim of the pelvis more equally; whereas, if one leg only is brought down, the pelvis of the child comes more or less awry, and the ischium of the other side is apt to lodge against the brim of its mother’s pelvis.[92] This practice has been recommended on the grounds that, by bring down only one leg, we make the presentation rather resemble a breech case, which is known to be more favourable for reasons already mentioned, and that by having the other leg turned upon the abdomen it will protect the cord from undue pressure. As far as the abdomen is concerned this may possibly be the case, but the pressure of the head upon the cord, which is the real source of danger to the child in turning, can in no wise be influenced by this position.In bringing down the feet it must be done with the articulation, that is, the child must be turned forwards; at the same time the hand upon the abdomen, externally, will be of great service in assisting us to move the child, and in preventing the change of its position from taking place in too sudden and violent a manner, a circumstance which is apt to paralyze the uterus considerably, and even produce alarming symptoms from the shock it occasions.

Extraction. When once we have brought the feet into the vagina, the first part of the operation, viz. the changing the position of the child, is completed: it has now become a presentation of the feet, and as such ought to be treated, unless some source of danger be present which requires that the delivery should be hastened. The value of this practice in footling cases was first pointed out by Deleurye,[93] and particularly applied to the second act of turning by Wigand. “I have made it,” says he, “a strict rule in turning, from the moment that I have brought a foot of the child as far into the vagina as I can without force, to do nothing beyond patiently waiting for the return of the pains, even if this did not take place for many hours, and leaving the rest of the labour entirely to nature. I have found by doing so that when the pains at length began to expel the child, they did it with so much force and activity as was not even seen in the most natural case of head presentation.” (Geburt des Menschen, vol. ii. p. 130.)

As the feet descend towards the os uteri, the presenting part, particularly if the arm has been prolapsed into the vagina, begins to recede, the hand externally will assist in moving the child round, and we should perform this step of the operation so gradually as to be assured that the presenting part has quitted the pelvis before the feet have entered. Without attention to this point, the child may easily be fixed across the upper part of the pelvis, or even the body brought down, while the head is wedged into the cavitas iliaca of the ilium, and produce a serious obstacle to its farther advance. This is a sort of mishap which can rarely happen except to young practitioners. If the process be slowly and carefully conducted, we doubt much if it be ever necessary to disengage the presenting part as has been so frequently recommended: the uterus in fact will move the child round with very little assistance on our part, and we shall find that after every pain the advance of the feet and recession of the part has increased considerably. From our own observations we would say that in all difficult cases, of turning especially, it is desirable for the patient to have several pains between the moment of gaining the feet and bringing them fairly into the vagina: very little force is required to bring them down, and the uterus does not appear to suffer; but where the position of the child has been rapidly changed, its contractile power seems to be injured, and it is ill able to make those exertions during the last stage, which will be required of it in order to save the child’s life.

Not less necessary is it that we should proceed with the second stage as cautiously as possible: the grand principle is the same, viz. to conduct the expulsion as gradually as possible: there is no use whatever in hurrying this part of the operation, for if the child be alive, we place it in imminent danger of its life; and if it be dead, as will easily be known by the cord not pulsating, we are putting the mother to a great deal of suffering for no reason. Now that it has become a footling case, it must be managed according to rules already given for this species of presentation: the uterus must be emptied as slowly as possible, the anterior part of the child must be directed more or less backward, and the funis guided into the vicinity of one or other sacro-iliac synchondroses. By retarding the advance of the child, we resist the action of the uterus somewhat, and thus excite it to contract more actively, the head enters the pelvis in the most favourable position, and as the pains are still brisk, it passes through so quickly as to subject the child to little or no danger by pressing upon the cord. Where however the passage of the head through the pelvis threatens to be delayed, we would strongly recommend the application of the forceps in order to terminate the delivery before the child has begun to suffer: it is to this mode of practice that Professor Busch, of Berlin, attributes the extraordinary success of turning in his hands; of forty-four cases where turning was deemed necessary only three children are stated to have lost their lives from the effects of the operation, a result which is by far the most favourable known.

Turning with the nates foremost. It has been proposed by several authors of the last century to turn the child with the breech foremost, as being a less dangerous operation for it than the common one of bringing down the feet. Levret has distinctly proposed this mode (L’Art des Accouchemens, § 767,) and Smellie on more than one occasion has alluded to bringing down the nates. Dr. W. Hunter has also recommended turning with the breech foremost: still more recently has this mode of practice been confirmed by W. J. Schmitt, of Vienna,[94] also by some other continental authors; but the difficulty in bringing down a part of the child’s body, upon which we can exert so little hold, will always be very considerable, wherever the circumstances under which the operation is undertaken is at all unfavourable. Schmitt recommends that as soon as we reach the nates we should apply the hand flat upon them; while in order to turn the child, active pressure is kept up from without by the other hand: when once we have succeeded in moving the breech somewhat downwards, its farther descent is very easy.

A still more recent modification of turning the child in arm and shoulder presentations has been proposed by Dr. v. Deutsch, of Dorpat: it consists in raising the presenting part, and at the same time turning the child upon its long axis, as the hand placed in the axilla carries the shoulder to the upper parts of the uterus, after which, as the hand descends, it brings the feet along with it into the vagina.

Turning with the head foremost. In former times, as the head was considered the only natural presentation of the child, every deviation of its position from this was looked upon as unnatural, and, therefore, the operation of turning only applied to bringing down the head, which had not presented: as, however, the difficulties already mentioned, in turning with the nates, would apply still more forcibly to bringing down the head, it is plain that this mode of turning would rarely be practicable. “Were it practicable at all times,” says Dr. Smellie, vol. i. book iii. chap. iv. sect. iv. number v., “to bring the head into the right position, a great deal of fatigue would be saved to the operator, much pain to the woman, and imminent danger to the child: he, therefore, ought to attempt this method, and may succeed when he is called before the membranes are broke, and feels by the touch that the face, ear, or any of the upper parts present.” Still, however, he confesses that the usual method of turning by the feet is the safest. In his first volume of cases, (collection 16, number 6, case 5,) he has given a description of this mode of turning. Dr. Spence also turned with the head foremost, as is shown by his thirty-second case, where the hand and cord were prolapsed into the vagina. “I introduced my hand into the vagina, and in the intervals between the pains reduced both the arm and the cord: but as I found they were like to return again upon my withdrawing my hand, I therefore continued to support them till such time as, by the strength of the pains, the child’s head was so far forced down as to prevent any danger of their returning, the happy consequence of which, was, that she was delivered of a live child in about half an hour after: both mother and child did well.” (Spence’s System of Midwifery, p. 465.) Dr. Merriman has recorded a similar case in his own practice: “The arm was returned at two o’clock; there was afterwards no occurrence of pain till six, after which, they became very strong, and between eight and nine the child was born. This was the only infant that Mrs. R. has seen alive out of six.” (Synopsis of Difficult Parturition, 1838, p. 250.) Still more recently turning with the head foremost has been tried by Dr. Michaelis, of Kiel, (Neue Zeitschrift fÜr Geburtskunde, vol. iv. 1836.) When once the faulty position has been altered, the liquor amnii is allowed to drain off, the uterus contracts and presses the head down into the pelvis, and the child is born without farther difficulty.

History of turning. Turning, as it is generally practised at the present day, viz. changing the position of a living child so that the feet are brought down foremost into the vagina, was unknown to the ancients. There is little doubt, however, that if they could have been induced to have looked upon presentations of the nates and feet as natural labours, they would have been in possession of this valuable means of effecting artificial delivery; as it is, we meet with detached allusions to it in their writings, although applying only to cases where the child is dead. In the writings of Aspasia and Philumenus, which, but for the quotations of Œtius, would have been entirely lost to us, we find directions for turning the child. Thus, Philumenus states, “Si caput foetÛs locum obstruxerit ita ut prodire nequeat infans in pedes vertatur atque educatur.” At a still later period, Celsus gave similar directions, but to all appearance they also merely apply to a dead child. “Medici vero propositum est, ut infantem manu dirigat, vel in caput vel etiam in pedes si forte aliter compositus est;” and again he says, “Sed in pedes quoque conversus infans, non difficulter extrahitur. Quibus apprehensis per ipsas manus commode educitur.” (Celsus, de MedicinÂ, lib. vii. cap. 29.)

From this time the whole subject seemed to sink into oblivion, until Pierre Franco, in his work on surgery[95] proposed the extraction of the child with the feet foremost: this was put into practice by the celebrated French surgeon, Ambrose ParÉ, (Ambr. ParÆus, Opera Chirurgia, 1594,) who, nevertheless, recommended turning with the head foremost, where it was possible. His work was afterwards translated into Latin by Guillemeau, who, although he still adhered to the old plan of bringing down the head, showed the value of ParÉ’s mode of turning in hÆmorrhages and convulsions. To Francis Mauriceau, a man of great learning and experience, we are indebted for this operation being greatly improved, by means of his valuable work, in 1668; but it is Philip Peu, in 1694, and William Manquest de la Motte, in 1721, to whom the merit is due of having pointed out the value of two great laws in turning—the one of not rupturing the membranes as already mentioned, the other of not attempting to push back the arm which presents.[96]