In the case of spontaneous version, as well as in that of spontaneous evolution, it is necessary to exhibit first a pelvis seen from the front, then a section as seen from the side; because in the earlier stages the movement is across the pelvis, and in the later stages the head comes forward above the symphysis, and the movement in a circle around this centre is from behind forwards.

Now, we may ask, What are the conditions required for the execution of spontaneous version, or natural turning? Some of them, probably, are not understood. Certain it is that we are hardly yet in a position to predicate in any given case of shoulder-presentation, seen at an early stage, that spontaneous version will take place, as we might be, if all those conditions were known and recognizable. They would be more familiar if the law to turn were not laid down in such imperative terms -if the dread of evil as the consequence of neglect of that

ILLUSTRATING END OF SPONTANEOUS EVOLUTION, ROTATION COMPLETED.

B, the head is fixed above symphysis; a escapes from pelvis after doubling of rod.

law were not so overwhelming. But if Nature be always superseded, if the physician always resort to artificial turning as soon as he detects a shoulder presenting, how can we obtain sufficient opportunities for discovering the resources of Nature, and how she acts in turning them to account? The principal conditions seem, however, to be these: 1. A live child, or one so recently dead that the tone or resiliency of its spine is still

perfect. 2. A certain degree of mobility of the child in utero. 3. Strong action of the uterus and auxiliary muscles. A roomy pelvis does not appear to be always necessary.

Spontaneous version is not likely to take place when the shoulder has been driven down in a point with a part of the chest-wall low in the pelvis, and the uterus is strongly grasping the foetus in every part, bending its long axis by approximating the head and breech. It is not likely to take place when the head has advanced towards a position above the symphysis pubis, that is, when the movement of rotation has commenced.

But the practical question will arise, Is spontaneous version ever so likely to occur, that we shall be justified in trusting to Nature? Ample experience justifies an answer in the affirmative. But it appears to me that the great lesson taught by the observation of the phenomena of spontaneous version is this: If Nature can by her unaided powers accomplish this most desirable end, we may by careful study and appropriate manipulation assist her in the task. We shall be the better ministers to Nature in her difficulties as we are the better and humbler interpreters of her ways. Natura enim non nisi parendo vincitur.

It has been already stated that spontaneous version may take place either by the head or by the pelvis. Examples of spontaneous version by the pelvis have been given in Lecture VIII. I will give two examples of spontaneous turning by the head.

Velpeau relates the following case of cephalic version. A woman was in labour at the École de Médecine (1825). The os was little dilated. The left shoulder was recognized. The waters escaped five hours after this examination. Four students recognized the shoulder. The pains were neither strong nor frequent and "being not without confidence in Denman," Velpeau did not search for the feet. In five hours later, the shoulder was sensibly thrown to the left iliac fossa. The pains increased, and the head occupied the pelvic brim. The vertex came down, and the labour ended naturally.

Dr. E. Copeman, of Norwich, records the following case: +

• "Traité complet de l'Art des Accouchements," 1835.

† J. G. Crosse's "Cases in Midwifery," 1851.

Some time after the waters had escaped in great quantity, the child was found lying across the pelvis, with the back presenting: neither shoulders nor hips could be felt. At a later period, preparing to turn, Dr. C. was surprised to find the pelvis filled. He endeavoured to pass his hand over the right side of the child towards the pubes, but in so doing he felt the child recede, and therefore confined himself to raising the child's pelvis with his flat hand and fingers; whilst the pains forced down the occiput, the head descended, and delivery was quickly completed. Dr. C. thinks, if he had waited a little longer, spontaneous evolution would have occurred, and the child would have been born even without manual interference. The child was a full-grown male, lively and vigorous.

APPLICATIONS OF

LECTURE X.

THE KNOWLEDGE OF THE MECHANISM OF SPONTANEOUS VERSION AND SPONTANEOUS EVOLUTION TO THE PRACTICE OF ARTIFICIAL VERSION AND ARTIFICIAL EVOLUTION-THE BI-POLAR METHOD OF TURNING, HISTORY OF ARTIFICIAL VERSION BY THE HEAD REASONS WHY VERSION BY THE BREECH IS COMMONLY PREFERREDILLUSTRATIONS OF HEAD-TURNING, OR CORRECTION OF THE PRESENTATION, BEFORE AND DURING LABOUR IN OBLIQUITY OF THE UTERUS AND FETUS-SHOULDER PRESENTATION— FOREHEAD AND FACE PRESENTATIONS-DESCENT OF HAND WITH HEAD-DESCENT OF UMBILICAL CORD.

FROM the observation of the spontaneous or accidental changes of position of the foetus in utero, the transition is natural to the account of those changes which can be effected by art. The observations already referred to prove that the foetus in utero may, under certain conditions, change its position with remarkable facility. It follows that the judicious application of very moderate forces may, under favourable circumstances, effect similar changes.

We have seen that spontaneous version may be effected by the substitution of the head for the shoulder, and of the pelvic extremity for the shoulder; also that spontaneous evolution may be effected by the descent of the head with the presenting shoulder and arm, or by the descent of the chest and trunk with the presenting shoulder and arm. Now, each of these natural or spontaneous operations for liberating the child may be successfully imitated by art. Let us study the conditions which guide us in the selection of the natural operation

we should imitate, and the methods of carrying out our imitations.

A successful imitation of natural version by the head or by the inferior extremity demands the concerted use of both hands. You must act simultaneously upon both poles of the fœtal ovoid. This combined action may be exerted altogether externally-i.e., through the walls of the abdomen-or one hand may work externally, whilst the other works internally through the os uteri. The first method-that practised by Wigand, D'Outrepont, Esterlé, and others--has been called the bi-manual proper. The second, which was first clearly taught by Dr. Braxton Hicks, has been called by him combined "internal and external version." But the same principle governs both. As I have already said, you must act at the same time upon both poles of the long axis of the fœtus. It would be more correct to describe them both as forms of the bi-polar method of turning; and by this designation, proposed by me in the first edition of these lectures, they are now generally known. It is an accident, not a fundamental difference, if, in one case, it is more convenient to employ the two hands outside; and in another, to employ one hand outside, and the other inside. Each form has its own field of application. We should be greatly crippled, deprived of most useful power, if we were restricted to either form. At the same time, I am of opinion that the combined internal and external bi-polar method has the more extensive applications to practice.

I have found the bi-polar method serviceable, adjuvant in every kind of labour in which it is necessary to change the position of the child. It is true that a rather free mobility of the fœtus in utero is most favourable to success; it is true that the external bi-polar method can hardly avail unless at least a moderate quantity of liquor amnii be still present; it is true that the internal and external bi-polar method requires, in its special uses, if not the presence of liquor amnii, at any rate a uterus not yet closely contracted upon the foetus. But I am in a position to state that amongst more than 200 cases of turning of which I have notes, there was scarcely one in which I did not turn the bi-polar principle to more or less advantage; and in not a few cases of extreme difficulty from spasmodic concentric contraction of the uterus upon the foetus, with jamming