If now we make vigorous traction from below upon the trunk, we en gage the posterior shoulder as soon as possible. Then forcibly raising the trunk toward the symphysis, we disengage the posterior arm with the right hand; then lowering the trunk, we free the anterior arm in the same way, and terminate the extraction by forcibly raising the trunk toward the symphysis. This presupposes rotation completed, and flexion main tained. If flexion has not persisted, two fingers of the left hand are in troduced into the mouth, the chin depressed, two fingers of the right hand applied to the occiput which is pushed up, and flexion thus effected, after which the head is rapidly disengaged.
If rotation has not taken place, the fingers introduced into the mouth effect at once both flexion and rotation, and this generally without diffi culty. It is self-evident that this manoeuvre must be quickly executed, and that traction must be exercised only during the pains, except in cases of absolute necessity.
If, on the other hand, the foetal heart-beats indicate that the child is suffering, extraction must be effected as early and rapidly as possible. The feet furnish a good hold, and, without awaiting the evolution of the trunk, the foetus must be extracted. The life of the foetus here depends to a great extent on the skill of the operator. But then the conditions are no longer normal, and the state of the cervix, the dimensions of the pelvis, the intensity of the contractions, the volume of the foetus, and particularly primiparity or multiparity, are so many circumstances which may have a more or less serious influence on the results of the operation.
II. Feet.—The conduct must be the same as in the preceding cases. De livery is generally morn prolonged, and hence the dangers run by the foetus are more numerous. Intervention is, therefore, more frequently in dicated.
III. Breech Presentation, Metnbers extended, Fa3tus bent double.—Here the difficulties are much greater. If we are obliged to interfere, we have not got the hold the feet afforded in the preceding case, and on the alter hand, in these cases in particular, labor is prolonged, and the engagement and disengagement of the buttocks do not occur or do so very slowly. The foetus suffers, the mother tires herself out, and we must interfere.
We cannot search for the feet of the foetus because they are too far away, and even if they were within reach, they could not be brought to the vulva without fracturing the leg or thigh. Hence we must work up on the hips of the foetus. It has been advised: first, to introduce into the inguinal fold a bent finger and bring down the breech, a measure which is good in. theory, but usually fails in practice; second, to pass into
the inguinal fold a blunt hook, the extremity of which is turned outward; but in the two cases in which we have seen it employed, by experienced men too, the thigh was fractured in one, and in the other the abdominal wall was lacerated above the inguinal fold.
[We disagree with the author in regard to the finger, whilst we would absolutely reject the blunt hook. The finger, if it can be passed into the groin—and if it cannot rarely can anything else—makes an efficient trac tor, and, by grasping the wrist with the other hand, the breech may usu ally be brought down. The finger further is preferable to the fillet. It takes too long to introduce this, and in the cases referred to, the fcetns's life depends on quickness. Should the finger fail, the forceps applied over the trochanters, and carefully used, will often succeed, and this too without damage to the fcetus.—Ed.] Playfair passes between the limbs of the foetus, above the inguinal fold, a brass wire to which is attached a fillet of wool or linen which is intended to embrace the upper part of the limb. We believe that this mast pro duee the same lesions as the hook. Hecker advocates the fillet; Gueniot advises to pull partly on the inguinal fold with fillet or hook, partly with the bent finger introduced into the anus, taking hold on the coccyx or the ischiurn, and thus to attempt to bring down the breech until able to act with the fingers of each hand on the inguinal folds.
Steidele and Gergues have invented double hooks forming pelvic tongs, which possess no superior advantage.
Now as to the forceps. Although rejected by Baudelocque, Flamant, Mme. Lachapelle, Schweighauser, Weidmann, and Stolz (who neverthe less has employed them), they have given unexpected results in the hands of Stolz himself, of Haake, Depanl, and Tarnier. We give them the preference. Although we must not forget that the forceps applied to the pelvic bones may expose the fcetus to some dangers, these are no greater than those inherent to the other procedures. If the fcetus be not extracted, it inevitably perishes, and therefore we are authorized to use an instrument which cannot of itself jeopardize the existence of the fcetus if prudently managed, and so applied that the blades grasp the breech in the bis-iliac diameter, while their extremities must not pass beyond the crests oP the ilia.