adjusted and locked; and traction made in the orbit of Carus' curve commonly brings the head away without further difficulty. During extraction, the fingers of the left hand should be kept upon the skull at the point of grasp by the instrument, guarding the soft parts from injury by spicula, and regulating the force and direction of traction. If there be any likelihood of difficulty in extraction, there is a last and an effectual resource in the cephalotribe. When the head is left behind after turning in contracted pelvis, the cephalotribe to crush down the head, having first performed craniotomy, is invaluable. BASE FIRST LECTURE XVII. TURNING IN CONTRACTED PELVIS AS A SUBSTITUTE FOR CRANIO- THE INDI THE OPE We now come to a long-contested and still undecided question in obstetric practice-Is turning ever justifiable as a means of delivery in labour obstructed by pelvic deformity? The next alternative in the descending scale of operations is a transition from conservative to what may be distinguished as sacrificial midwifery, involving the destruction of the child. It is obviously a matter of exceeding interest to cultivate any operation that shall hold out a reasonable hope of safety to the child, without adding unduly to the danger of the mother. So much may be conceded on both sides. The question, then, may be set forth as follows:-Do cases of dystocia from pelvic contraction occur in which the child can be delivered alive by turning, which must otherwise be condemned to the perforator, without injury or danger to the mother? And, not to blink in any way the serious character of the inquiry, it is necessary to append this secondary question to the first-namely: Assuming that such cases do occur, can they be diagnosed with sufficient accuracy to enable us to restrict the application of turning to them? And if we err by turning in unfitting cases, what is the penalty incurred ?-how can we retrieve our error? These questions I will endeavour to illustrate, if not to answer, by the light of the writings of others, and my own experience and reflections. The choice of an operation in obstetrics will, in many cases that fall within the debatable territory claimed by two or more rival operations, be determined by the relative perfection of these operations, and by the relative skill in them possessed by the individual operator. And in estimating the arguments of different authors, we must bear this law in mind. The operation of extracting a child through a contracted brim has no doubt often been performed as a matter of assumed necessity, as, for example, when the shoulder has presented; and contraction of the pelvis is certainly a cause of shoulder-presentation. The observation of such cases, a certain proportion of which terminated successfully for the child, could not fail to suggest the deliberate resort to the operation in cases of similar contraction where the head presented. Before the forceps was known, and before the instruments for lessening and extracting the head had been brought to any degree of perfection, turning was commonly resorted to in almost all cases of difficult labour. Thus Deventer, who wrote in 1715, as well as La Motte, declaimed against the use of instruments, and recommended turning by the feet in all cases of difficult cranial presentation. The consequence was that the art of turning was cultivated very successfully by some of the followers of Ambroise Paré. It appears to me evident that, in the early part of the last century, turning was better understood and more skilfully performed than it was at the beginning of the present century; and it is equally evident to me that, by turning, many children were saved under circumstances that are now held to justify their destruction. Of course this gain was not achieved without a drawback. If children were sometimes saved, many mothers were injured or lost by attempts to turn under circumstances which are now encountered successfully by the forceps or by craniotomy. As instruments were improved, the choice of means was extended. The forceps first contested the ground. The contest, indeed, was for exclusive dominion. The reputed inventor of the forceps, Hugh Chamberlen, did not hesitate to accept the challenge of Mauriceau to attempt to deliver a woman with extreme pelvic contraction by means of his instrument, feeble and imperfect as it was. He failed ignominiously. As science advanced, the contest was better defined. As the obstruction to delivery was due to contraction of the pelvic brim, and the problem was, how to extract a live child arrested above the brim, it is obvious that a short single-curved forceps must fail. It was only when the long double-curved forceps was designed, that the knowledge and the power arose which enabled the obstetric surgeon to bring another means into competition with turning, for the credit of saving children from mutilation. It is, then, from the time of Smellie and Levret, who perfected and used the long forceps, that the real interest of the inquiry dates. It is not a little remarkable that amongst those who have most distinctly recognized the value of the long forceps have been found the advocates for turning in contracted pelvis. The following words, written by Smellie in 1752, challenge attention now:-" Midwifery is now so much improved that the necessity of destroying the child does not occur so often as formerly; indeed, it never should be done, except when it is impossible to turn or to deliver with the forceps; and this is seldom the case but when the pelvis is too narrow, or the head too large to pass, and therefore rests above the brim." Pugh, of Chelmsford (1754), who advocated the long forceps, says "When the pelvis is too small or distorted, the head hydrocephalic or very much ossified, or its presentation wrong, provided the head lies at the upper part of the brim, or, though pressed into the pelvis, it can without violence be returned back into the uterus, the very best method is to turn the child and deliver by the feet." He then goes on to lay down the conditions which would induce him to prefer the curved forceps, and states that, as the result of these two modes, "I have never opened one head for upwards of fourteen years." Has not midwifery retrograded since his time? Perfect (1783), who used the long forceps, delivered a rickety woman whose conjugate diameter measured three inches, the head presenting, and brought forth the first living child out of four, the first three having been extracted after perforation. La Chapelle (1825) advised and practised the method. She relates that out of fifteen children extracted by forceps (long) on account of contracted pelvis, eight were stillborn, seven alive; and that out of twenty-five delivered footling, sixteen were born alive, and nine dead. It is not less remarkable that it is amongst those who reject the long forceps that the strongest opponents of turning in contracted pelvis are to be found. This is the more astonishing when we reflect that this school, rejecting the two saving operations, has nothing to propose but craniotomy for a vast number of children that claim to be brought within the merciful scope of conservative midwifery. Denman, who used the short forceps exclusively, was, upon the whole, adverse to the operation, although he relates a striking case in illustration of its advantages. He delivered a woman of her eighth child alive at the full period, all her other children having been stillborn. "The success of such attempts," he says, "to preserve the life of a child is very precarious, and the operation of turning a child under the circumstances before stated is rather to be considered among those things of which an experienced man may sometimes avail himself in critical situations, than as submitting to the ordinary rules of practice." Those who have studied the history of obstetric doctrine cannot fail to see that this dread of encouraging enterprise in practice lest disaster should result from unskilfulness, has cramped teaching, obstructed the progress of knowledge, and enforced a slavishly timid, yet barbarous practice, which still persists down to the present time. That the precepts and practice of Smellie and his immediate disciples were infinitely more scientific and successful than those which prevailed in the time of Denman, and in the first half of the present century, cannot be doubted. Thirty years ago or less craniotomy was still frightfully rife in this town and in many parts of the country. Possibly the cautious teaching of Denman and many of his successors was justified greatly by the general imperfection of medical education. They had, as we now have, to teach according to the average capacity and trustworthiness of their pupils. They taught men with the same feeling of reserve with which we should still teach midwives. But surely the |