Finally, there is another difficulty on which Depaul lays stress with good reason, that is, contraction of the cervix upon the neck of the fcetus. This is so grave a complication that the foetus almost inevitably succumbs. Hence we must try, by introducing the fingers between the cervix and the festal neck, to overcome the obstacle and extract the head; but if the cer vix be resistant, Depaul does not hesitate to incise it. It is hardly neces sary to dwell on the fact that the difficulty of this manipulation compli cates the prognosis for mother and fcetus.
When the head alone remains to be delivered, sometimes the hand, sometimes the forceps, must be resorted to.
Huter demonstrates that the extraction of the breech by means of the fingers introduced into the inguinal fold succeeds very rarely, and that the blunt hook is either useless or dangerous; that the fillet of Hecker and Playfair does not succeed any better, and that the pelvic tongs of Seidele and Gergues equally fail. He advises the forceps, which, how ever, should never be applied unless the breech is movable and still at the superior strait.
Kleinwiichter gives preference to the fillet to bring down the breech, and applies the forceps only to the after-coming head.
Braun rejects the fillet, the blunt hook, and the forceps. If the child be living, we should restrict ourselves to manual interference. Hegar combines the methods of extraction of Smellie and Braun.
Barnes rejects all instrumental intervention, and always searches for a foot, by means of which he extracts.
Kormann, after having fully shared Schroeder's opinion, and sided with him regarding the principle that, if manual extraction fails to deliver a living child, the forceps will not bring us any farther, has even gone so far as to say that the application of the forceps to the after-coming head is extremely dangerous to the mother, and has plainly advised perforation. Ile does so with certain reservations, for of thirty-one cases in which he was obliged to extract the after-coming head, he was constrained in four, after vain attempts at manual extraction, to resort to the forceps, and had living children in three, and only one dead child. He shows be sides that.the application of the forceps to the after-coming head has a frequency of eleven per cent. of all cases, and that the indications for the forceps may be summarized under the three following heads: 1. Rigidity of the cervix and its contraction upon the neck of the fcetua which exposes it to the danger of a laceration the extent of which cannot be determined.
2. Arrest of the chin above the symphysis, the occiput having descended into the posterior portion of the lesser pelvis.
3. Considerable disproportion between the head of the foetus and the walls of the pelvis which exposes these parts to excessive compression. He lays down the following precepts which comprise his practice: 1. When the breech remains high up and the child is living, we must always search for the anterior foot, and by the aid of the latter bring down the breech. But if the child is dead, we must have recourse to the blunt hook.
2. When the breech is deeply engaged, we should always try to bring it down by means of the anterior foot. If the foot is beyond our reach,
we must resort to the method of expression according to Kristeller, to the bent finger, or the fillet. The forceps should never be applied to the breech. If the child is dead, the blunt hook.
When the head alone remains and the child is living, the head should be extracted by the method of Veit, of Prague; if the cervix is rigid, the chin arrested in front, if the cranium is excessively compressed, the for ceps. If the child is dead, perforation of the cranium.
However, whatever procedure be employed, the extraction of the foetus in cases of pelvic presentations is far from being a simple matter. Be sides the dangers threatening the foetus from the presentation alone, the extraction is liable to cause lesions grave enough to jeopardize its life.
Lesions of the Iletus produced during Extraction in Petrie Presentations.
Following the lead of Pajot in 1853, the study of these lesions has been taken up anew of late years, particularly by Rage and Ducourneau, both in 1876. While Scanzoni, Kiwisch, Lange, Spaeth, and Braun consider the extraction of the fcetus as an inoffensive operation in itself, Wigand, Joerg, Hohl, Naege16, Martin, Ahlfeld, Schatz, Rokitansky, and Ruben sohn show by personal observations, not only that the extraction entails dangers upon the foetus, but that it is in itself liable to determine lesions grave enough to endanger its life.
Rage, who has collected the majority of German observations reported until 1876, has found in 44 cases lesions following extraction, due to podalic version, and in 29 cases lesions following extraction in primary pelvic presentations, that is to say, 73 cases. He shows that certain of these lesions are frequent, and others rare, and he instances hemorrhages into the cervical region, into the muscles, into the cellular tissue sur rounding the muscles, and, finally, true muscular lesions to the extent even of complete rapture of these muscles. The latter lesions may even tuate in suppuration or in cure, terminating finally in retraction of the sterno-cleido-mastoid—congenital torticollis. In sixty-four cases, he noted these lesions eighteen times. Finally, he mentions hemorrhages into the abdominal cavity—underneath the capsule of the liver and of the kidneys, —intra-cranial hemorrhages, tears of the sinuses, retro-pnlmonary conges tions, and fractures of the vertebral column.
After the above analysis, he compares the various methods of extraction, and pronounces himself in favor of that of Martin, and Kristeller, that is to say, he advises upward traction on the occiput, and depression of the face, assisted by careful compression. This is the method to which we usually resort. The forceps he rejects.
Transverse Presentations.—Here all authorities are in agreement. The diagnosis should be made during pregnancy, and the mal-presentation corrected by external version, transformed, in other words, into a presen tation of the vertex. During labor recourse must be had to internal version, and, in the event of this failing, to embryotomy.