B. Guiseppe Portas's Procedure.—It consists of two stages: The first is to pass a filet over the arm, and make traction so as to engage the shoulder and the axilla deeply, when perforation is performed by means of a bistoury into the thorax, and thence the abdominal and thoracic vis cera aro removed; the second is to seek the feet and deliver by podalic version.
2. Method which aims at Evolution.—There are five procedures.
A. Veit's Procedure.—The foetus is eviscerated, without brachiotomy, traction is made on the arm and the breech simultaneously, and the infant extracted doubled on itself.
B. Michaelis's Procedure.—Evisceration, followed by spondylotomy and forced evolution of the foetus.
C. Macdonald's Procedure. —Spondylotomy without evisceration, ex traction of the foetus by the feet—in other words, delivery by forced ver sion.
D. Boens's of provident portions, that is to say, brachiotomy, thoracic and abdominal evisceration, crushing of the thorax by the fingers. Finally, section of the foetus in two, followed by separate extraction.
E. Championniere's Procedure. —Evisceration; spondylotomy by a screw rod; at times brachiotomy; removal of the foetus in two portions. Results; 3 operations with two deaths.. • 3. Method which aims at successive Extraction of Portions of the Fetus. —Section of the foetus may be practised on the neck or on the trunk. In the first instance we are dealing with decapitation, method of Celsus.
The instruments with which decollation may be performed are ranged as follows by Thomas: a. Knife embryotomes. b. Scissor embryotomes. c. Saw embryotomes. d. Embryotomes which act by pressure and lacer ation.
a. Knife this category belong the bistouries of Steinen and of Busch, the knives of Albucasis, Part, Rizzoli, Mauriceau, Rams botham, Jacquemier, the crochet of Simpson, the decapitator of Scan zoni, etc. In general, these instruments are defective, and by no means as'valuable as the scissors.
b. Scissor Embryotomes.—The best instrument is that of Dubois. It consists of long handles, very strong, short blades slightly curved on the flat, with blunt ends. (Fig. 171.) In using them, having carefully de termined the presentation, Dubois inserts the left hand into the vagina, and guides along the fingers a blunt hook which he endeavors to pass around the fatal neck. When successful, he withdraws the hand, and grasping the handle of the hook he makes strong traction to bring down the foetal neck. He then hands the hook to an assistant, inserts his hand again into the vagina, and places the end of his finger at the point where he intends to cut the neck. He passes the scissors along this finger up
to the fcetus, and cuts the integuments little by little, separating the blades only slightly, in order not to damage the maternal parts. During this procedure the finger which surrounds the neck must never leave it, but must take account of the progress of the section.
Mattei uses strong scissors which he calls endotomes; Lazarewitch uses an instrument which is at once a sector and a tractor. Tarnier contends that the scissors attack with difficulty the soft parts, and all the more the bone. Never, however, have Vie seen the operation last longer than ten minutes when performed by Depaul, and never, except in one has it required longer in our personal experience. The difficulty is not in the cutting, but in the passage of the hook around the neck. Where the neck is accessible, we believe the method to be the best. Where the neck is not accessible, we must eviscerate.
c. Saw Ernbryotomes.—Here belong Jacquemier's embryotome (Fig. 172,) Van der Ecken's crochet (Fig. 174), the crochets of Kilian, Mathieu, Heyerdahl, Kierulf, Hohl, Wasseige (Fig. 173), Stanesco (Fig. 175), Tarnier (Fig. 176), etc. All these crochets are intended to carry behind the neck or behind the trunk of the fcetus, a saw or 6craseur, in order thus to break up the infant.
Of all these instruments the simplest is that of Pajot. With a stout piece of silk or twine the foetus may be sectioned in a minute, the twine being worked backward and forward, and without risk to the mother. The twine may usually be passed around the fcetus by means of a blunt hook, and I have had a hole drilled in the blunt crochet of the forceps which receives the twine, and to the twine may be attached a small leaden weight, which assists the accoucheur in reaching the end which has been passed around. Tarnier has suggested Belloc's sound for the passage of the twine. [A gum-elastic catheter, the uterine sound, instruments which are apt to be in every accoucheur's bag, are as serviceable as any thing else.—Ed.] Wheh the twine has been passed, the hook is with drawn, the ends of the twine brought out through a cylindrical speculum, which is inserted to protect the vagina, and then by to-and-fro movements the operator may readily saw the neck, or the trunk. This method was first advocated by Boyer, and has been successfully used by Pajot, Tarnier, Rey, and others.