ON PROLAPSE OF THE ARM IN TRANSVERSE PRESENTATIONS. 
BY 
FRANK P. FOSTER, M.D., 
New York. 
While it is my particular object in this paper to call atten- 
tion to a certain method of managing the prolapsed arm, which 
may, as it seems to me, sometimes facilitate combined external 
and internal version; I am inclined, in view of the conflicting 
opinions 'which have been held in regard to prolapse of the arm, 
and the brevity with which the subject is treated of in the 
more familiar text-books, to think that a general review of the 
doctrines held and taught in regard to this complication of 
transverse presentations may be of service. 
It has been suggested, that the term prolapse cannot properly 
be applied to the descent of the arm in shoulder presentations, 
since the member forms an integral portion of the presenting 
part, and that the word should be restricted to cases of such 
descent in conjunction with a cephalic or pelvic presentation.1 
But, as the expression is in common use and well understood, I 
can see no good reason for discarding it. 
Prolapse of the arm is of very frequent occurrence in shoulder 
presentations. According to Fritsch,' it always takes place in 
protracted cases. The hand alone may be found in the vagina, 
or the forearm or the whole limb, with the elbow either flexed 
or extended, may be driven down into the vagina, or even be- 
yond the vulva. As a matter of course, it is generally the lower 
arm which escapes from the uterus, but, in case the pains are 
powerful, the upper arm also may be pressed down to a certain 
extent, and, in presentations of the back or breast, or in cases of 
twins, we may find two arms lying wholly without the uterus. 
Indeed, Crede3 states that all four of the extremities may 
prolapse in a transverse presentation. Finally, according to 
' See Depaul's Lemons de Clinique Obstetricale. Paris, 1872-6, p. 625. 
2 Klinik der alltaglichen geburtshiilflichen Operationen. Halle, 1875, p. 162. 
3 Klinische Vortrage iiber Geburtshiilfe. Berlin, 1853, p. 577. 2 
Foster : On Prolapse of the Arm in 
Fritsch, in cases of pendulous abdomen, with a dorso-anterior 
position, the presenting shoulder may be arrested by the sym- 
physis pubis, the child's belly turn downwards, and the upper 
arm slip down posteriorly. 
The older authors looked upon prolapse of the arm as a com- 
plication which necessarily rendered parturition very difficult, 
but it is now generally considered as, of itself, exerting little or 
no influence upon the progress of labor, although in some cases 
it is recognized as materially complicating the situation. On 
the other hand, it is held to present certain advantages, and, on 
the whole, is viewed as a favorable circumstance. Hodge1 says : 
" In presentations of the shoulder, it is a matter of minor im- 
portance whether the arm be retained within the uterus, or 
whether it glides out of the os uteri, through the pelvis and os 
vaginae; yet, upon the whole, it is"more favorable, as will be 
seen, that it should be retained within the uterus." In this 
opinion Hodge stands almost alone among modern authors. 
Many writers, as, for instance, Pinard,2 state in general terms 
that they attach no importance whatever to the mere prolapse 
of an arm, but subsequently, when they come to speak of 
details, it is evident that they do regard it as of some conse- 
quence under certain circumstances. Denman® says that " there 
is always less difficulty if both arms present, than if there should 
be but one arm." I presume he founds this statement on the 
fact that both shoulders are not as likely to be impacted in the 
pelvis as one alone is, and that consequently the child will be 
more readily movable. 
As regards the advantages which have been supposed to 
attach to prolapse of the arm, none are more generally recog- 
nized than those which are turned to account in diagnosis. 
In the first place, as to the presentation. Having made sure 
that the prolapsed limb is really the arm and not the leg (for 
which purpose, if the prolapse be only partial, it is not only 
justifiable but advisable to make it complete by drawing down 
the hand gently-even beyond the vulva, so as to allow of in- 
1 The Principles and Practice of Obstetrics. Philadelphia, 1866, p. 357. 
2 Des Contre-Indications de la Version dans la Presentation de 1'fipaule 
(These d'Agregation). Paris, 1875, p. 26. 
3 An Introduction to the Practice of Midwifery. New York, 1802, vol. ii. 
p. 124. Transverse Presentations. 
3 
spection), the question arises, is the child presenting trans- 
versely ? According to Kiwisch1, any very decided prolapse of 
the arm establishes the diagnosis of shoulder presentation, but 
De Soyre2 records a case in which the whole arm, with the elbow 
bent, lay within the vagina, and yet the head presented. De- 
paul' observes, that we should not hastily conclude that the 
shoulder presents, even when the prolapsed arm hangs out from 
the vulva, but should make a careful examination, to discover if it 
be not a case of true prolapse by the side of the head or breech. 
There can be no doubt that such an examination should always 
be made, upon the general principle that no source of corrobo- 
rative or corrective information should be and the 
examination is doubtless facilitated, as remarked by Smellie,4 
Burns,* Hohl,6 von Siebold7, and others, by making gentle 
traction on the arm, which, being thus made tense, serves as a 
guide for the examining finger. 
Having ascertained that the presentation is really transverse, 
we have next to inquire as to the position of the child. Here, 
too, we derive valuable information from an examination of the 
prolapsed member, as is amply set forth in all the text-books ; 
by ascertaining which hand it is that is prolapsed, and in which 
direction the palm looks, the forearm being in a state of supi- 
nation. It is generally stated that, in this position of the fore- 
arm, the palm corresponds to the child's abdomen and the 
thumb points in the direction of the head. Blundell8 advises 
that for this purpose the hand should be placed " intermediately 
between supination and pronation." It seems to me that we 
should not place such absolute trust in this test as the text-books 
inculcate. It is doubtless true, that in the usual dorso-anterior 
and dorso-posterior positions the palm, in a state of supina- 
tion, looks in the same general direction with the abdomen; 
1 Die Geburtskunde. Erlangen, 1851, I. Abth., p. 403. 
2 Archives de Tocologie, vol. i. 1874, p. 571. 
3 Op. cit., p. 552. 
4 A Treatise on the Theory and Practice of Midwifery. London, 1779, vol. 
i. p. 304. 
6 The Principles of Midwifery. London, 1809, p. 228. 
6 Lehrbuch der Geburtshiilfe. Leipzig, 1855, p. 952. 
1 Lehrbuch der Geburtshiilfe. 2te Aufl., Braunschweig, 1854, p. 194. 
8 The Principles and Practice of Obstetricy. Castle's edition. London, 1834, 
p. 394. 4 
Foster : On Prolapse of the Arm in 
but, apart from the fact that there may be more or less rotation 
of the humerus, the prolapsed arm may belong to the upper 
shoulder, in which case the palm would look towards the child's 
back, or the presentation may be abdominal or dorsal, and then 
the palm would look towards the head or the breech. It is 
therefore manifestly necessary to make a careful digital exami- 
nation of the shoulder and as much of the adjacent parts as can 
be reached; supplementing this, too, with external palpation 
and auscultation. 
Of what value is the condition of the arm in assisting to es- 
tablish a knowledge of the death of the child? "In brachial 
presentations," says Blundell, " the putrescency is known by the 
state of the arm." Rosshirt1 states, that, on the death of the 
child, the swollen arm becomes smaller and softer. Chiari, 
Braun, and Spath2 looked upon maceration of the prolapsed 
arm as justifying a resort to embryotomy in difficult cases. 
On the other hand, de La Motte3 gives a case in which a physi- 
cian had pulled on the arm for more than six hours, until it 
was so swollen, black, hard, cold and insensible, that an ill- 
informed person would have thought it right to remove it; and 
yet de La Motte turned and extracted a living child, and the 
arm regained its natural condition in the course of two or three 
days. Osiander,4 too, observes, that " we often find the pro- 
lapsed arm swollen, hard, livjd, and even blackish-blue, with 
the epidermis easily stripped off, without our being able to re- 
gard it as a sure sign that the child is dead." He refers these 
conditions to injury inflicted by the mother or the midwife, the 
swelling and dusky color being caused by compression of the 
veins by the os uteri tightly embracing the shoulder. In view 
of such statements as these, and of the many instances in which 
the arm has been amputated in the belief that the child was 
dead, but in which nevertheless it has been born living, we are 
not justified in concluding from the condition of the arm, in the 
absence of corroborative evidence, that the child is dead. But, if 
we can detect muscular movements of the hand or arm, we have 
sufficient proof that the child is still living, and, if there be no 
1 Lehrbuch der Geburtshiilfe. Erlangen, 1851, p. 555. 
2 Quoted in Scanzoni's Beitrage, I., 1854, p.319. 
3 Traite Complet des Accouchemens. Paris, 1765, vol. ii. p. 675. 
4 Handbuch der Entbindungskunst. 2te Aufl. Tubingen, 1833, Bd. iii., p. 330. Transverse Presentations. ' 
5 
spontaneous movements, there can be no objection to endeavor- 
ing to provoke them by simple measures calculated to stimulate 
reflex action, such as the application of ice and the like. 
Among the advantages not connected with diagnosis, it is 
generally agreed that, in case version is to be followed by ex- 
traction, the prolapsed arm can be prevented from rising by 
the side of the head, whereby we avoid, at least as regards that 
one arm, the delay and difficulty which often occur at a critical 
juncture from the necessity of liberating the arms. This point 
will be more fully referred to in a subsequent portion of this 
paper, together with the advantages to be obtained by making 
use of the prolapsed arm in various operative proceedings. 
The disadvantages which have been attributed to prolapse 
of the arm are, that it impedes version, and that it interferes 
■with the introduction of the hand for other operations. 
Cephalic Version.-It may naturally be supposed that the 
expulsion of an arm from the uterus diminishes the probability 
of spontaneous version by the head; and it may very likely be 
the case, that, in those instances of obliquity of the head at the 
commencement of labor in which an accident may either cause 
the head to engage or establish a frank transverse presentation, 
the prolapse of the arm may be the determining factor in pro- 
ducing the latter condition. Thus, Fritsch alludes to a case in 
which, " on account of obliquity of the head, an arm prolapsed, 
and a shoulder presentation resulted from the action of a few 
strong pains following each other in quick succession." But, 
on the other hand, Barnes,1 in mentioning the rarity of spon- 
taneous cephalic version, says: " But some cases of head-first 
deliveries have been observed. Pezerat relates a case that seems 
free from ambiguity. The child was large, the shoulder pre- 
senting. Pezerat tried to push it up, but could not. A violent 
pain drove the head down. Fichet de Flechy gives two cases. 
In both the midwife had pulled upon the arm. Balocchi re- 
lates a case. It was an eight-months' child. He says the case 
is unique rather than rare, but still regards it as a natural 
mode of delivery in shoulder-presentation. Lazzati thinks the 
descent of the head in these cases is always the result of trac- 
tion upon the presenting arm. As the expelling power is 
1 Obstetric Operations, 2d Am. ed. New York, 1874, p. 151. 6 
Foster : On Prolapse of the Arm in 
exerted mainly upon the breech, tending to drive the head away 
from the brim, it is indeed not easy to understand how sponta- 
neous action can restore the head, if the shoulder is forced low 
down in the pelvis. Monteggia held the same opinion. He 
relates two cases, in both of which tractions had been made. I 
myself have seen an instance of the kind." In a case recorded by 
the late Dr. Elliot,1 a second twin presented the arm, with 
the head in the left iliac fossa, spontaneous cephalic version 
occurred. " The head of the child was driven into the pelvis, 
and the elbow turned down so as to pass with it into the world." 
There is no mention of traction having been made. Dr. Ed- 
mund Arnold,2 of Yonkers, gives a case of transverse presen- 
tation, with prolapse of arm and funis (the latter being trace- 
able to the umbilicus), in which spontaneous cephalic version 
occurred, after several fruitless attempts to turn by the feet, 
apparently without any traction having been made on the arm. 
As regards artificial cephalic version, Bosshirt includes pro- 
lapse of the arm among the conditions unfavorable to -its per- 
formance, and Pinard quotes from Dubois3 to the effect that 
the operation is impracticable under such circumstances. Brax- 
ton Hicks4 says, however: " If, in these malpresentations, the 
fcetal hand protrude, it is eventhen quite possible to induce ceph- 
alic presentation, provided the thorax has not yet descended." 
Podalic Version.-Hodge states that spontaneous version by . 
the feet is more apt to occur when the arm is retained within 
the uterus. On the contrary, Osiander saw five cases of spon- 
taneous breech version-three of the children being mature, 
and twro immature. In all of them the arm was markedly pro- 
lapsed [ragte der Arm weit hervor]. In one case the midwife 
was so astonished to see the breech born, after she had pulled 
long and hard on the prolapsed arm, as to exclaim, "Man 
konne an der Geburt die Allmacht Gottes erkennen." 
According to Crede, artificial version by the feet may be hin- 
dered in various ways by the prolapsed arm; by the space 
which it takes up in the os uteri and vagina, and by its inter- 
fering with the recession of the presenting part. Pinard says 
r 1 Obstetric Clinic, New York, 1873, p. 346. 
2 Am. Med. Times, June 8, 1861, p. 367. 
3 Mem. de I'Acad. de Med., 1833, t. iii. p. 476. 
4 Trans. of Obstet. Society of London, vol. v. 1863, p. 219. Transverse Presentations. 
7 
that total emergence of the limb from the vulva " can exist 
only in case of a profound engagement of nearly the whole 
trunk in the pelvic cavity. Its occurrence prohibits any at- 
tempt at version. Not only would it be very difficult to intro- 
duce the hand as far even as the os uteri, but the rotation of the 
child would probably not take place without rupture of either 
the vaginal or the uterine portion of the genital canal." It will 
be seen that these remarks apply rather to impaction of the 
trunk than to the mere descent of the arm. 
Denman, Hohl, Schroder,1 and others, consider that the 
prolapsed arm can never materially obstruct version, and Tar- 
nier2 and Saboia3 declare that it facilitates the operation. It 
is probable that the latter authors refer, not so much to version 
itself, as to its issue in the birth of a living child being aided 
by our being able to prevent the arm from rising by the side 
of the head during extraction. 
There is great difference of opinion as to whether the arm 
may prevent the Introduction of the hand for the purpose of 
version and other operations. Smellie, while making no posi- 
tive statement upon this point, says, "if the arm that is come 
down be so much swelled that it is impracticable to introduce 
the hand," etc. Hohl declares that " experience has shown 
beyond a doubt that a prolapsed arm may be so greatly swollen 
as to preclude the introduction of the obstetrician's hand, as 
far as the elbow, through the vulva, or through the vagina and 
os uteri, with safety, whether for the purpose of turning, or 
for that of opening the child's thorax." Further on, he 
speaks of the impediment to the introduction of the hand 
through the vulva as causing pain to the woman and endanger- 
ing the perineum, cramping the operations of the hand in the 
vagina, and interfering with the introduction of instruments." 
As impeding the introduction of the hand into the uterus, he 
attaches importance to the arm being very much swollen, and 
occupying that side of the pelvis in which the hand is to be 
introduced. 
1 Manuel d'Accouchements, trad, par Charpentier. Paris, 1875, p. 313. 
'J Des Gas dans lesquels 1'Extraction du Foetus est necessaire. Paris, 1860, 
p. 139. 
3 Traite Theorique et Pratique de la Science et de 1'Art des Accouchements. 
Paris, 1873, p. 691. 8 
Foster : On Prolapse of the Arm in 
De La Motte met with a case in which the arm was so 
swollen, and the vagina so dry and narrow, that, although 
strongly opposed to the practice, he was obliged to remove 
the arm. 
Baudelocque1 maintains that the introduction of the hand is 
not prevented by the swollen arm, but by rigidity or spasm of 
the cervix uteri. Scauzoni2 denies that the swollen arm can 
prevent the introduction of the hand, and refers the trouble 
to impaction of the shoulder. He inculcates the practice of 
holding the arm close against the pubic arch, in which situa- 
tion, according to him, it no longer encroaches upon the pos- 
terior portion of the pelvic cavity. Rosshirt and Fritsch also re- 
commend this manoeuvre. Hohl says, however, " We have slung 
the arm and held it against the symphysis pubis, as taught by 
Scanzoni, without being able to overcome the obstacle which, 
in its swollen condition, it opposed to the introduction of the 
hand." 
The truth of the matter seems to be, that, in a pelvis of nor- 
mal dimensions, the prolapsed arm, if properly managed, can- 
not, by virtue of its encroachment upon the capacity of the 
pelvis, obstruct the introduction of the hand into the uterus; 
but that imp action of the shoulder or rigidity of the cervix 
uteri is the cause of the difficulty. But, on the other hand, 
there can be no doubt, I think, that an arm, whether swollen 
or not, protruding from the vulva, may seriously embarrass the 
introduction of the hand into the vagina. By holding the 
arm snug up under the pubic symphysis, we undoubtedly se- 
cure room enough, as regards the bony canal, but we do not, 
thereby, enlarge in any degree the vaginal canal. Remem- 
bering, then, that, in many cases of turning, more difficulty is 
met with in introducing the hand into the vagina than in all 
the rest of the operation, it seems to me that we must admit, 
that this difficulty may be materially increased by an arm 
hanging out from the vulva. 
As regards the whole matter of the part played by the pro- 
lapsed arm in favoring or impeding the satisfactory progress 
of cases in which version is indicated, I should say: (1) pro- 
1 A System of Midwifery, Heath's Translation. London, 1790, vol. ii. p. 
325. 
2 Lehrbuch der Geburtshiilfe. 4te Aufl., Bd. iii., Wien, 1867, p. 61. Transverse Presentations. 
9 
lapse does not, of itself, contra-indicate, or seriously embarrass 
any form of version, except in so far as it may interfere with the 
introduction of the hand ; (2) neither does it facilitate version 
as usually performed; but (3) it does facilitate extraction, 
thereby increasing the chances of the child being born alive, 
as will be more fully alluded to hereafter. 
What remains to be said can, I think, be best arranged in 
connection with the various methods which have been proposed 
for managing the arm, or for assisting labor by manipulations 
of the member. Without discussing the different expedients 
which were formerly resorted to, with a view to provoke the 
automatic retraction of the prolapsed arm, and which have now 
fallen wholly into desuetude, I will pass at once to the con- 
sideration of the measures which are mentioned by contem- 
porary writers. 
Replacement.-The old obstetricians considered it highly 
necessary that the prolapsed arm should be replaced within 
the uterus, and carried over the child's breast, in the direction 
of its belly. So thoroughly were they imbued with the notion 
that the prolapse was in itself a source of grave difficulty, that 
Mauriceau,1 following Pare, recommends amputation in case 
replacement should prove very difficult. According to Schro- 
der, Portal never replaced the arm, and Deventer, in 1701, 
first showed that it was not always necessary to do so. Hoorn 
also considered that replacement was not always necessary, and 
de La Motte, Puzos, Levret, and others stoutly opposed it. 
.Osiander speaks of it as now seen only in the rude practice of 
country midwives, and says that the arm when forced back into 
the uterus, at the risk of lacerating the vagina and os uteri, 
far from facilitating version, renders it much more difficult by 
getting in the way of the operator's hand. Siebold says, that 
unskilful replacement is apt to make the presentation more 
unfavorable. Burns, Rosshirt, Clay,2 and Schroder teach, 
that it should never be attempted. Scanzoni includes forcible 
replacement among the " crude and horrible proceedings " 
1 Traite des Maladies des Femmes Grosses, et de celles qui sont Accouchees. 
6me ed. Paris, 1721, tome I., p, 310. 
2 Handbook of Obstetric Surgery. Philadelphia, 1874, p. 241. 10 
Foster : On Prolapse of the Arm in 
which are now rejected as wholly superfluous. Leishman1 
states, that replacement should not be attempted in cases of 
impaction of the shoulder. Hodge, quoting from a paper on 
a method of rectifying shoulder presentations by correcting 
the obliquity of the uterus, published in 1850, by Dr. M. B. 
Wright, of Cincinnati, says: " Should the arm be prolapsed, it 
is advised to re-introduce it, and carry it, as far as practica- 
ble, toward the breast of the child." Crede observes, that 
by replacement the various difficulties in version, which are 
due to the prolapse, are overcome, but that it is possible only 
when the presenting part is still, to a certain extent, movable. 
De La Motte attempted, in a case occurring early in his prac- 
tice, to carry out the teaching which he had received, but 
found it impossible to replace'the arm. 
Hicks, in describing his method of combined external and 
internal version, says: " Where the arm has not descended so 
low as I have supposed above, but yet has fairly come into the 
vagina, it will be advisable always to endeavor to return it on 
to the chest of the child." In one of Elliot's cases (No. 100) 
the House Physician (Dr. Mead) replaced the prolapsed arm, 
and then performed bi-manual cephalic version. In another 
case (No. 88) Dr. Elliot performed external cephalic version, 
after " having carried the arm within the uterus above the 
chin of the child." Mr. J. Henderson,'1 in a case of double arm 
presentation, returned both arms and brought down the feet. 
As regards the manner in which replacement should be 
effected, Crede says: "We accomplish it by means of either 
an immediate or a mediate manoeuvre. In the immediate 
method we bend the elbow, grasp the limb with the fingers, 
and, pressing on the hand or the elbow, endeavor to carry it 
over the child's breast, holding it there a short time, and then 
carrying the hand further into the uterus, for the purpose of 
performing version. In the mediate method we introduce the 
hand past the arm, grasp the presenting part with the whole 
hand, lifting it gently aside in the direction of its dorsal aspect, 
and then return to the arm, which we treat as in the immedi- 
ate method. The mediate method should be tried, even if the 
presenting part has descended low, and it has the advantage 
1 A System of Midwifery. Glasgow, 1873, p. 380. 
■ British Medical Journal. Vol. i., 1875, p. 141. Transverse Presentations. 
11 
that at the same time it prepares the way for version, by 
raising the presenting part." 
I can imagine that some advantage might be gained by 
gently replacing the arm in cases which are seen early, and in 
which there seems to be a prospect of inducing a head pre- 
sentation. As regards the " mediate method " of Crede, the 
preliminary step-the elevation of the shoulder-is of such 
overshadowing importance, that the operation can scarcely be 
considered as forming a part of the treatment applicable to 
prolapse of the arm. 
lletropulsion.-Depaul employs this term to express the re- 
placement of an arm prolapsed by the side of the head. I 
have ventured to apply it, as regards transverse presentations, 
to a sort of manoeuvre which I made use of in the following 
case: 
Mrs. F., about 29 years old, was taken in labor with her 
third child, at term, towards midnight, April 12th, 1875. She 
had had vague pains for two days, but on the evening in ques- 
tion she had gone to bed and fallen asleep as usual. About 
midnight she was suddenly awakened by a copious gush of 
amniotic fluid, and by severe pain in the back. I arrived at 
about 1 a.m. of the 13th. On making an examination, I at 
once encountered the child's hand, lying low in the vagina. It 
was the left hand, the forearm in a state of pronation, the 
palm looking towards the mother's right hip, with the thumb 
directed forwards. External examination showed the abdomen 
to be somewhat smaller than usual, the long axis of the swelling 
being nearly transverse. The child's head was resting upon 
the right ilium, and the breech was situated somewhat higher 
up on the left side, the back being directed forwards. Muscu- 
lar movements of the arm in the vagina bore witness that the 
child was living. 
The uterus was acting but moderately, and the presenting 
part was freely movable. I decided to attempt combined ex- 
ternal and internal version. Having introduced my right hand 
into the vagina (the patient lying on her back), I seized the 
arm, with the intention of effecting replacement by Crede's 
immediate method, having placed my left hand on the abdo- 
men, above and to the right of the child's head, for the pur- 
pose of cephalic version. Somewhat to my surprise, this left 12 
Foster : On Prolapse of the Arm in 
hand informed me that every little movement which I im- 
pressed upon the child's arm caused a corresponding movement 
of its head. I soon found that, by gently pushing the arm 
upwards, and somewhat towards the mothers right side, taking 
care that the direction of the force should coincide with the 
axis of the arm, I could raise the head sufficiently to enable 
me to get my left hand fairly under it. I now abandoned all 
intention of attempting cephalic version, but continued to urge 
the head upward with my left hand, until the shoulder rose 
beyond the reach of my right hand, when, upon introducing 
my right forefinger into the os uteri, I found the child's left 
tuber ischii within reach. With the point of my finger I 
gently urged this along towards the mother's right side, and 
soon encountered the left foot, which, without any difficulty, I 
hooked down into the vagina. I immediately brought the 
foot down through the vulva, rotating it slightly, so that the 
toes looked backwards. 
The whole operation was so quickly and easily performed, 
that the mother (who was not anaesthetized) supposed that I 
had simply made an examination. The uterus remained almost 
quiescent for about six hours, at the end of which time efficient 
pains came on, and the child was soon born. The arms did 
not require liberation. The child (a good-sized girl) was 
moderately asphyxiated, but was readily revived. Both mother 
and child did well. 
Now, I have no doubt that in this case it would have been 
perfectly easy to turn the child without the manipulation of 
the arm which I have described, and I do not draw any infer- 
ence from the facility with which the operation as a whole was 
accomplished; but, when I say that the elevation of the 
cephalic pole, including the presenting shoulder, was by far 
the easiest and shortest part of the proceeding, it will be con- 
ceded, I think, that the retropulsion of the arm was the chief 
factor in effecting the child's revolution. I believe that it 
would prove of service in more difficult cases. Doubtless, like 
any other manipulation, it should be performed gently and 
carefully; but, when we consider that the force exerted acts in 
a line with the humerus, pressing the head of that bone directly 
against the glenoid cavity, it would seem that, with ordinary 
caution, there should be no danger of injuring the shoulder. Transverse Presentations. 
13 
It seems to me that it would be perfectly safe to use as much 
force in this way as would be justifiable iu any other way, in 
an attempt to raise an impacted shoulder; at all events, it is 
well known that the greatest difficulty in version is, often, to get 
the shoulder to rise, and it can scarcely be doubted that cases 
will occur in which, by making use of some such manipulation 
as that which I have described, a resort to the old operation of 
podalic version, by groping with the hand within the uterus? 
may be avoided. If we can once raise the shoulder, a point 
will be gained, even if we subsequently have to introduce the 
hand into the uterus to search for a foot, for, the shoulder 
being free, it will be a matter of indifference which foot we 
bring down. 
Braxton Hicks,1 in his first article on combined external 
and internal version, says: " The motor force is employed 
almost entirely from the outside, and .... the fingers within 
are used more as an indicator than as a propeller." Mani- 
festly, then, the motor force is to a certain extent wasted-the 
child's pelvic pole is first made to descend, not as a part of any 
motion of the child as a whole, but at the expense of more or 
less bending of its spinal column ; if now, the force continuing 
to act, the head rises, well and good; but if it do not rise, it is 
only driven against the ilium and rendered still less obedient 
to any effort on the part of the internal hand. In this state of 
things we may, as Hicks suggests in his longer article, supple- 
ment the force at work by pushing on the elbow, and in ordi- 
nary cases doubtless we shall usually succeed ; but it seems to 
me that, by so directing the force as to raise the cephalic pole 
at the outset, we shall be able to turn without introducing the 
hand into the uterus in some cases in which we should other- 
wise fail, thus widening the scope of the exceedingly valuable 
operation for which we are indebted to Hicks. 
Schroder,' in a case of combined external and internal 
version, did indeed act primarily upon the cephalic pole, 
making the external part of the operation consist in pushing 
up the head ; but, as the membranes were entire, it is not 
likely that any use was made of the arm. In one of Elliot's 
cases (No. 93) a second twin presented a foot, a hand, and the 
1 The Lancet, Feb. 9, 1861. 
4 Schwangerschaft, Geburt, und Wochenbett. Bonn, 1867, p. 148. 14 
Foster : On Prolapse of the Arm in 
funis. He " readily delivered a good-sized, still-born male 
child by pushing up the arm and drawing on the foot." It is 
not stated that the cephalic pole was pushed up by means of 
the arm. " When the shoulder presents," says Smellie, " and 
the arm lies double in the vagina, let him push them both up." 
It is evident from the context that Smellie intends this to be 
done, not to initiate a movement of revolution in the child, for 
indeed a head-first rotation would be contrary to the genius of 
the old operation, but simply to enable the hand to be intro- 
duced within the uterus. 
Although, then, I have been unable to find in literature any 
account of version having been effected by moving the child 
through the medium of the arm, I am inclined to think it must 
occasionally have been done by accident during attempts at 
replacement. 
Possibly, in cases of arrest of the shoulder over the symphysis 
pubis, with prolapse of the upper arm, such as I have already 
referred to as having been mentioned by Fritsch and supposed 
by him to be connected with a pendulous condition of the 
abdomen, it might be found serviceable to bring retropulsion 
to bear upon the prolapsed arm, thus maintaining.the dorso- 
anterior position until the dislodgment of the shoulder could 
be effected and perhaps the other arm brought down, thus con- 
verting the case into a frank shoulder presentation of the most 
favorable kind. 
Traction.-From time immemorial midwives seem to have 
been possessed with a blind impulse to pull upon any part of 
the child's body upon which they could lay their hands; hence 
a case of protracted transverse presentation, in which traction 
was not applied to the prolapsed arm, is something of a rarity 
in literature. Much damage has doubtless been done in that 
way, both to the mother and to the child, but, as we have seen, 
nature is often able to effect a favorable change in the child's 
position in spite of such rude interference. Nevertheless, trac- 
tion upon the arm is a recognized expedient, and, under certain 
circumstances and when properly managed, very serviceable. 
As a matter of course, traction properly so called, i.e. of 
such a sort as to produce any effect upon the child's body, 
should not be thought of until the diagnosis has been made 
perfectly clear. The mere drawing down of the arm for the Transverse Presentations. 
15 
purpose of examination, or simply holding it somewhat tense, 
to serve as a guide to the examining finger, is an entirely 
different matter. 
Barnes' observations, already quoted, would seem to show, 
that traction has sometimes aided in bringing about cephalic 
version, but they are not, in my opinion, sufficient to justify an 
attempt to turn by the head by means of traction in the ordinary 
sense of the term; nor do I suppose that Barnes meant to give 
that impression. It might serve the purpose better, if we were 
to first replace the arm within the uterus, and then make trac- 
tion upon it in a lateral direction-away from the head, at the 
same time pressing upon the latter with the other hand applied 
externally. 
We have seen also, that traction does not necessarily prevent 
spontaneous version by the pelvic pole, but it must have a 
tendency to do so under ordinary circumstances, although per- 
haps in the case of am immature child it might favor it. 
Baudelocque's brother easily completed the spontaneous 
expulsion of a small child (a second twin) by traction on the 
arm. Schroder teaches, that in case the shoulder is so wedged 
in the pelvis that version is become impossible, we may, pro- 
vided the pelvis is capacious, at least in its transverse diameter, 
the child small, and the mother's condition not such as to call 
for the speedy termination of labor, await spontaneous evolu- 
tion, or endeavor to make the child engage by traction on the 
arm or the pelvic extremity. Under such circumstances, "we 
may," says Pinard, "as recommended by Velpeau, draw upon 
the arm after the manner of Fab ricins Ilildanus or of Fichet 
de Flechy, a method which has been several times employed 
by P. Dubois." On the other hand, Hohl considers the 
practice in the highest degree objectionable. 
Scanzoni, in advocating the application of a fillet to the 
prolapsed arm, to prevent its rising by the side of the head 
during extraction, says, " at the same time we have in the arm 
thus secured with a noose a hold by means of which we may 
assist those rotations of the trunk upon its long axis which 
are often necessary." It is to be supposed that traction 
cannot produce any such result unless the shoulder from which 
the arm springs is more or less above the superior strait. 
Mention has already been made of such a proceeding in cases 16 
Foster : On Prolapse of the Arm in 
of prolapse of the upper arm. It is not easy to understand 
how traction upon an arm attached to a shoulder already 
deeply engaged in the pelvis can cause the child to turn on its 
long axis, and yet, in a case recorded by Depaul,1 in which 
disarticulation at the shoulder-joint was performed, it is stated 
that the tractions made upon the arm caused the child to 
revolve in such a manner that the other arm could be seized. 
In cases of moderate impaction a manipulation of this sort 
may render the child movable, and thus allow of version. 
Traction upon the arm for the purpose of rendering the 
neck more accessible, and thus facilitating decapitation, is so 
universally approved, that it need not be discussed. The same 
may be said in regard to traction upon the arm after decapi- 
tation, for the purpose of extracting the trunk. 
Posta2 gives the following directions for managing the arm 
in such a manner as to facilitate evisceration of the chest: a 
noose is to be attached to the prolapsed hand, and confided to 
an assistant. If it be the right hand, the assistant should raise 
the child's arm almost perpendicularly against the mother's 
pubes, inclining it a little towards her right groin, so as to 
draw the axilla as far down as possible. Schroder advises, 
that if, after evisceration, the shoulder is fixed in the pelvis, 
spontaneous evolution should be imitated, by drawing the 
shoulder well down and towards the side opposite to that in 
which the breech is found, extracting by the pelvic extremity, 
which we cause to pass in advance of the chest. Veit3 lays 
stress upon the value of traction upon the arm after eviscera- 
tion, in his method of delivery conduplicato corpore. 
In a case of spondylotomy, reported by Aftieck and Macdon- 
ald,4 the operation seems to have been facilitated by traction 
on the arm. 
Application of a Fillet.-As a matter of course, the arm 
may be noosed to facilitate traction for any of the purposes 
1 Archives de Tocologie, III., Fev., 1876, p. 111. 
2 II Filatre Sebazio, March and April, 1857, quoted by Pinard, op. cit., p. 
84. 
3 Monatsschrift fur Geburtskunde, 1861, p. 457, quoted by Pinard, op. cit., 
p. 85. 
4 Edinburgh Medical Journal, July, 1872, p. 39. Transverse Presentations. 
17 
which have already been considered, but the fillet is thought 
essential by so many authors, for the special purpose of ena- 
bling us to make traction after podalic version has been per- 
formed and the arm has retreated within the uterus, with a 
view to prevent the arm from rising by the side of the head 
during the process of extraction, thus imperilling the child's 
life at the critical moment when the placenta has nearly or 
quite ceased its function as a respiratory organ, and yet there 
is no opportunity for air to enter the child's lungs-that it de- 
mands separate consideration. 
Those authors who mention the matter at all (including Osi- 
ander, Rosshirt, Hohl, Scanzoni, Hatin, Hodge,1 Schroder, 
Tarnier, Fritsch, Pinard and Saboia), almost without exception, 
urge its importance with more or less enthusiasm. Crede ad- 
vises that the application of the fillet should be followed by 
replacement. Scanzoni advocates its use if only the elbow be 
prolapsed. Depaul would have it applied to a hand brought 
down by mistake for a fopt. Levret2 says that the arm should 
be gently drawn out from the vulva, in order that the noose 
may be applied easily and without pain to the mother. 
Osiander and Saboia even recommend that the arm should 
be noosed within the uterus, the latter employing a porte-lacs 
for the purpose. Fritsch, however, while bewailing the fre- 
quent neglect of the fillet, advises against its application with- 
in the uterus, particularly by inexperienced practitioners, and 
Chiari, Braun, and Spath,3 who (in a series of 21 cases of arm 
presentation and another of 45 cases of " secondary " transverse 
presentation [the membranes having ruptured and the liquor 
amnii escaped]) did not noose the arm in a single instance, con- 
sider Trefurt's porte-lacs as dangerous and difficult to use, and 
all such instruments as superfluous. 
Crede advises that both arms should be noosed, in case they 
can both be readily reached before turning; while, curiously 
enough, Osiander, who is said to have noosed every arm he 
could feel, expressly declares that both arms should never be 
slung. 
The fillet is easily applied, and, if the hand can readily be 
1 Cours complet d'Accouchement. Paris, 1833, p. 180. 
a Quoted by Scanzoni. op. cit. 
3 Quoted in Scanzoni's Beitrdge, i. 1854, pp, 309 and 319. 
2 18 
Foster : On Prolapse of the Arm in 
brought outside the vulva, can do no harm, except, perhaps, by 
introducing some deleterious substance within the uterus. It 
should be applied to the wrist. Its use would oftenest be of 
service in the hands of those who are in the habit of perform- 
ing the old operation of podalic version, following it with ex- 
traction. As extraction may become necessary in any case of 
that sort, doubtless the more frequent use of the fillet would be 
of advantage. It can rarely if ever be required in a case of 
combined external and internal version. 
Scarification.-Hohl scarified the swollen arm in one in- 
stance, on the recommendation of Plenk and Scanzoni, for the 
purpose of so reducing its bulk as to allow of the introduction 
of the hand, but found it useless. 
Brachiotomy.-This term is applied to the removal of a por- 
tion or the whole of the arm, with or without the clavicle and 
scapula. Nearly all systematic writers, even those who admit 
the occasional necessity of the operation, speak of it with a 
feeling of horror-and yet it is frequently done. 
Denman, the younger Ramsbotham,1 Tarnier, Clay, Fritsch, 
and, according to Hohl, von Siebold, condemn the operation 
in unqualified terms. Scanzoni opposes it in his Leh/rbuch, but 
seems afterwards to have met with a case which Hohl consid- 
ers as supporting the views of those who advise removal of the 
arm under some circumstances.2 Among those who speak less 
positively, but who still oppose the operation, except in the very 
rarest cases, are Rosshirt, Crede, Pinard, Schroder, and many 
others. 
All admit, that it is unjustifiable if the child be living, and 
that it should be done only in case of necessity. In several in- 
stances it has been done in the belief that the child was dead, 
and yet it has been born living. De La Motte gives a case in 
which, after both this operation and craniotomy, the child was 
born alive. 
Among the specific objections to amputation of the arm, in 
addition to the repugnance which it excites, are the facts that it 
1 The Principles and Practice of Obstetric Medicine and Surgery, Keating's 
Am. ed., Philadelphia, 1861, p. 363. 
2 Geburtshiilflichen Operationen, quoted by Hohl, op. cit Transverse Presentations. 
19 
deprives us of a valuable means of traction, and that it tends 
to produce a confusion of the foetal and the maternal parts. 
According to Hohl, the younger Nagele regarded the removal 
of the arm as sometimes necessary, and Oehler and Michaelis 
were decidedly in favor of the proceeding. Hohl himself, in 
speaking of the obstacle which the swollen arm may offer to 
the introduction of the hand, uses the following forcible lan- 
guage : "We have no dynamic measure against this state of 
things; expectant treatment adds more and more to the diffi- 
culties of subsequent operative procedures, and is trifling with 
the mother's life, while the material advantage and necessitv 
of brachiotomy are before us. Empty phrases, to the effect that 
such a state of things cannot occur, lose their force in the pres- 
ence of a case." 
Pinard considers that brachiotomy is admissible only when 
the arm is the sole accessible part of the child, and there is 
urgent need of delivery. Hodge advocates the removal of the 
arm, together with the clavicle and scapula, to favor version by 
the pelvic pole, by facilitating the ascent of the head and thorax, 
especially in cases of deformity of the pelvis or great rigidity 
of the os uteri; in cases of cephalic version, to prevent the 
simultaneous engagement of the head and arm; in cases of 
evolution; and, as recommended by Robert Lee,1 as a prelimi- 
nary to evisceration. 
The various views which have been held in regard to the pro- 
priety of brachiotomy for the purpose of facilitating the intro- 
duction of the hand rest upon the discrepant opinions which 
have prevailed as to whether or not the arm itself ever con- 
stitutes a serious impediment. This question has already been 
discussed, and no further reference will be made to it at 
present. 
Pinard, who adduces the experience of Oehler, Depaul, Blot, 
Pajot, and Stoltz, in rendering version possible in difficult cases 
by means of brachiotomy, is of the opinion, that both this pro- 
ceeding and evisceration, allowing of version force'e, should re- 
main rare operations-operations of necessity. " Why," he says, 
" does this simple operation suffice in these cases ? Is it because 
the vaginal canal is relieved of the prolapsed member? Assur- 
edly not. It is because, the shoulder being cut, we thus obtain 
1 Ed. Med. and Surg. Jour. Apr., 1828, p. 239. 20 
Foster : On Prolapse of the Arm in 
the result which Burton vainly sought to effect with his crutch. 
The shoulder, or rather the axillary region, rises, reascends 
to the superior strait, and the lower extremity of the child's 
trunk is then enabled to descend; whereas, if the scapular 
prominence be entire, the upper border of the shoulder be- 
comes fixed at the lower edge or posterior face of the sym- 
physis." 
Pajot1 concludes that amputation of the arm facilitates ver- 
sion, not only by favoring the introduction of the hand through 
a contracted pelvis, or into a constricted uterus, but also by 
enabling the head to rise and the pelvic pole to descend; but he 
expressly limits the application of this statement to cases in 
which the pelvis is so considerably contracted that the shoulder 
cannot engage. 
Osiander (who, it will be remembered, saw five cases of spon- 
taneous version after traction on the prolapsed arm) mentions 
amputation as among the resources left when all hope of spon- 
taneous version is at an end. Pinard quotes cases in which am- 
putation enabled Blot and Depaul to turn and extract by the 
feet in cases in which it was otherwise impracticable to do so. 
In Milroy's case of impaction with prolapse of both arms, in 
which two practitioners had failed in their attempts to turn, he 
gave chloroform, and then tried to turn, " but it was quite impos- 
sible to introduce the hand, and still impossible to put back the 
arms. There was no alternative now but to amputate one of the 
arms, which we did. After this was done, it was with the 
greatest difficulty I managed to turn." In De La Motte's case, 
in which he removed the arm, " en deux coups de main," to 
enable him to introduce his hand, he finally succeeded in turn- 
ing and extracting, but the amount of assistance which he de- 
rived from the removal of the arm may be inferred from the 
following words,with which he concludes his account of the case: 
" Je crus tres-certainement que je mourrois apres cet accouche- 
ment, ou j'epuisai et ma science et mes forces, et apres lequel 
je restai sans respiration; en sorte qu'il me fallut mettre surun 
matelas devant un grand feu, et me frotter avec des linges 
chauds pendant plus d'une heure, de meme que si je fusse sorti 
de jouer a la paume." 
1 Arch. Gen. de Hied., Sept. 1865, p. 257 Transverse Presentations. 
21 
Pajot, in speaking of impaction in a contracted pelvis, says: 
"The child being mature, and version recognized as impossible, 
amputation of the arm will certainly favor the evolution of the 
foetus." In a case of this sort Pajot and Banyan unsuccessfully 
attempted to turn by the feet, after which the arm was ampu- 
tated, and Danyau undertook to decapitate, but could not finish 
the operation. He then succeeded in bringing down the pelvic 
extremity. Delivery was completed by perforation through 
the vault of the palate. 
Boens1 removed the prolapsed arm, together with the scapula, 
in order to reach the neck, for the purpose of decapitation. In 
one case he removed both arms, but, failing in decapitation, 
eviscerated the thorax. Rosshirt states, that in cases of decapi- 
tation, "doubtless it often happens that the clavicle becomes 
separated from the sternum in the course of the operation, so 
that the arm, the shoulder-blade, and the clavicle, especially if 
the muscles chance to be ruptured, remain attached to the trunk 
by the skin only; but this is not intentional, and cannot be 
called a necessary removal of the arm." 
Hohl thinks, that in cases requiring embryotomy it is some- 
times necessary to violate the rule against disarticulating at the 
shoulder. Hodge, in speaking of cases in which evisceration 
becomes necessary, says: " The first step in the operation of 
embryotomy, in these cases, should be the complete removal of 
the arm and shoulder, including the whole scapula, and perhaps 
even the claviclethere will be then no obstacle to 
the ascent of the side of the thorax behind the pubes." Again, 
he quotes Robert Lee as "always recommending that the shoul- 
der be removed before evisceration and the crotchet be resorted 
to." Schroder says, that, in these cases, if the prolapsed arm 
were so swollen as to render the operation specially difficult, it 
would have to be removed, but that it should be preserved if 
possible, since its removal would deprive us of a valuable means 
of extraction. Oehlerf considers that the arm should not be 
removed for the purpose of facilitating evisceration, but only 
to make room for the introduction of the hand in turning. 
1 Jour, de Med. et de Chir. de Bruxelles, t. xxxi. 1860, p. 259, quoted by 
Pinard. 
2 Gemeinsame deutsche Zeitschr. f. Geburtsk., Bd. vii., 1832, p. 105; and 
Neue Zeitschr. f. Geburtsk., Bd. iii., 1835, p. 161. 22 
Foster : On Prolapse of the Arm in 
Pinard quotes a -case of Petrens', in which, after version had 
been attempted in vain, the arm and scapula were removed, and 
evisceration performed. Boens also teaches that this should be 
done. Pinard mentions a case in which Dubois found brachi- 
otomy necessary, as the first step in evisceration of the thorax. 
Doleris1 reports a case in which Depaul removed the limb, and 
then eviscerated the thorax. Depaula, in a case of labor occur- 
ring apparently after the completion of the tenth month of ges- 
tation, with cancer of the cervix and lower portion of the body 
of the uterus, and physometra, the right shoulder presenting, 
and the arm protruding beyond the vulva, first disarticulated 
the prolapsed arm with large scissors, and withdrew it by means 
of a fillet. The tractions made upon the arm caused the child 
to revolve in such a manner that the other arm could be seized. 
This, in turn, was partly disarticulated, and then an attempt 
was made to sever the vertebral column. Failing to extract by 
these manipulations, the operator finally performed forced ver- 
sion by the feet. 
Pinard cites a case in which Depaul amputated, first the pro- 
lapsed arm, and then the other one, and afterwards performed 
craniotomy and cephalotripsy. Hohl says, that if it fehould 
be thought necessary to remove both arms, as Dubois3 was 
obliged to do, on account of an unskilful operator having 
brought them down with a foot, we should remove that one 
first Which offers the greatest impediment, and thus perhaps do 
away with the necessity of removing the other one. 
As to the way in which the arm is to be removed, Mauriceau 
recommends that it be done by torsion. Smellie says: " If the 
limb be much mortified, it may be twisted off; otherwise, it may 
be snipt and separated with the scissars." Hohl says: "If 
the head lie to the mother's left side, the right hand is to be 
introduced into the vagina, and if it lie to her right side, the 
left hand is to be introduced. If the forearm should impede 
the entrance of the hand through the vulva, we may dis- 
articulate at the elbow-joint. We seize the upper arm with 
1 Arch. de Tocologie, t. i. 1874, p. 632. 
2 Arch, de Tocologie, t. iii. 1876, p. 111. 
3 Quoted by Hohl, who refers to an article by Dubois in the Gaz. Med. de 
Paris, 1845, pp. 337, 346. That article, however, although by Dubois, is on 
the subject of hare-lip. I have not been able to find the original account of 
Dubois' case. Transverse Presentations. 
23 
the thumb and the ring and little fingers, and draw it down 
as far as we can, keeping the index and middle fingers free 
for the purpose of encircling the shoulder-joint and guarding 
the points of the scissors. We slip the latter between our 
hand and the child's arm up to the axilla, enter their points, 
and cut through the soft parts of the joint, keeping up the 
traction on the upper arm, and not allowing the points of the 
scissors to come out through the skin. Having cut through 
the joint, we draw the disarticulated arm downwards, grasp 
the joint with the hand, and cut the remaining attachments 
with the scissors in the hollow of the hand." 
I have thus taken pains to record, with some detail, the 
teachings and practice of various authors in regard to brach- 
iotomy, in order to show clearly the contrast between the 
doctrine which is held by most of them, that the operation 
should rarely if ever be resorted to; and, on the other hand, the 
frequency with which, in clinical reports, particularly, as it 
seems to me, those of the French, we find it stated that the arm 
was removed, and that too, without any special reason being 
given for its having been done. 
It is not certain that a prolapsed arm ever prevents cephalic 
version. If it did so in any case, I should think that replace- 
ment would be possible, unless there were other conditions 
present which would of themselves obstruct the version. I 
cannot see that the prolapse constitutes in itself any obstacle to 
podalic version, except by interfering with the introduction of 
the hand. Under such circumstances amputation may some- 
times be necessary, but I should consider that the cases 
requiring it must be very rare. I do not understand how the 
removal of the arm can facilitate decapitation, evisceration, or 
spondylotomy, except by getting rid of an impediment to the 
introduction of the hand. As a matter of course, it should 
never be done until it is certain, either that the child is dead, 
or that some mode of delivery necessarily involving its sacrifice 
is demanded. 
In conclusion, I should thus sum up the doctrines which I 
consider to be tenable in regard to prolapse of the arm in trans- 
verse presentations: 
1. Mere prolapse of an arm does not of itself indicate, with 
certainty, that the presentation is transverse. 24 
Foster : On Prolapse of the Arm in 
2. Inspection of the prolapsed hand will, in ordinary cases, 
roughly indicate the child's position, but should be supplement- 
ed by other means of diagnosis, and may, in presentations of 
the back or abdomen, or if the upper arm alone be prolapsed, 
give faulty indications, if conclusions be drawn in accordance 
with the rules commonly laid down. 
3. Death of the child cannot be positively known from the 
condition of the arm, but muscular movements in the limb show 
that the child is still living. 
4. Prolapse of the arm may cause the presentation to become 
transverse in cases which might otherwise end in a head pre- 
sentation. 
5. A prolapsed arm constitutes more or less of an impedi- 
ment to cephalic version, spontaneous or artificial; but yet 
6. Traction on the prolapsed arm may, in certain cases, favor 
cephalic version, but is not to be recommended for that purpose, 
unless preceded by replacement. 
7. The prolapsed arm does not always, even when pulled 
upon, materially hinder spontaneous version by the feet. 
8. Prolapse of an arm does not facilitate the old operation of 
podalic version; but 
9. It offers the means of avoiding the necessity of liberation 
of the arms, or at least of one arm, during extraction, and thus, 
by hastening delivery, increases the chances of the child being 
born alive. 
10. The arm may materially interfere with the introduction 
of the hand into the vagina and through the os uteri. 
11. On the whole, prolapse of the arm is of advantage in 
transverse presentations. 
12. The arm should be replaced within the uterus, by the 
" immediate " method of Crede, provided it can be done 
easily, in cases in which cephalic version is to be attempted, or 
in which there is reason to believe that a transverse position of 
the child is not yet thoroughly established. 
13. Replacement is not called for under other circumstances, 
and should never be done by force. 
14. Retropulsion, as described in this paper, may prove to 
be of service in combined external and internal podalic ver- 
sion. 
15. By retropulsion, in cases in which the upper arm alone rl ransverse 1 Cementations. 
25 
is prolapsed, we may be able to prevent the child from assum- 
ing a dorso-posterior position. 
16. Traction should not be made upon the arm until the 
diagnosis is established. 
17. Lateral traction in utero, after the arm has been re- 
placed, may assist in performing cephalic version. 
18. Traction may be used to complete spontaneous- evolu- 
tion. 
19. Traction, particularly if the shoulder be not deeply 
engaged, or if the force be applied to the upper arm, may 
cause the child to rotate to a certain extent on its long axis, 
and perhaps render it sufficiently movable to allow of ver- 
sion. 
20. Traction is of manifest advantage in rendering the neck 
or trunk accessible, and thus facilitating decapitation, eviscera- 
tion, or spondylotomy ; and, after either of these operations, it 
materially assists in delivery. 
21. A fillet should be applied to the wrist, provided it can 
be done easily, in case the old operation of podalic version 
is determined upon. This affords a means of preventing 
the arm from rising by the side of the head during extrac- 
tion, by making traction on the arm after its retreat within the 
uterus. 
22. The fillet should not be applied within the uterus. 
23. Amputation should never be performed, unless the child 
is clearly dead, or embryotomy be necessary ; and even then it 
should be avoided if possible, as it deprives us of a valuable 
means of traction, and may lead to confusion of the fojtal and 
the maternal parts.