ON THE MANAGEMENT OF BREECH-CASES IN WHICH BOTH EXTREMITIES ARE REFLECTED UPWARD PARALLEL TO THE BODY OF THE CHILD.

By WILLIAM T. LUSK, M. D., of New York County.

Read November 19, 1884.

In the presentation of the following paper, I am well aware that I have no novel suggestions to make, and yet I feel sure that, to many practitioners, a more precise formulating of the indications for the employment of the resources of the obstetric art, in the difficulties which arise in that form of breech-presentation in which both extremities are reflected upward parallel to the body of the child, will be welcome and perhaps will contribute something to the diminution of infant-mortality.

In all forms of breech-presentations, it is the rule that the natural forces are capable of effecting the delivery of the child without assistance. When, however, in the interests of the mother or of the child, interference becomes necessary, all are familiar with the fact that, when the legs are flexed and both feet and breech present together, the bringing down of an extremity and the extraction of the child are accomplished by well-established procedures; while, in cases in which the extremities are parallel to the anterior surface of the fœtus, with the toes pointing over the shoulder, the operator is embarrassed by the absence of a natural handle by means of which extraction can be effected. It is precisely in the latter class of cases that nature oftenest fails to finish her work, and that obstet

ric aid is called for. Tarnier gives, as a reason for this, the fact that the extended extremities act as splints, which interfere with the lateral flexion of the trunk, and, consequently, with its accommodation to the curve of the utero-vaginal passage.

Theoretically, cephalic version by gentle manipulations through the abdominal walls, performed during the latter part of pregnancy or in the early stages of labor, most completely fulfills the required indication; viz., the saving of the child with the least risk to the mother. That external version may be successfully accomplished, in cases in which the breech is not engaged in the pelvic cavity and the membranes are intact, has been shown by Mattei, Hegar, and Pinard, all warm partisans of the measure. Tarnier at first opposed the proposition of Mattei, on the ground of its impracticability and the risk of rupturing the membranes after the conversion of the breechpresentation into a shoulder-presentation; but more recently he has practiced the procedure in many cases successfully and without inconvenience to the mother or child.'

In obstetric practice outside of lying-in-hospitals, this method is not likely to come into common use. It presupposes great familiarity with the process of mapping out of the fœtus by abdominal palpation, a relatively considerable quantity of amniotic fluid, and the absence of excessive irritability of the uterine walls. Certainly, in the experience of most medical men, the diagnosis of the presentation is first made after the breech has descended below the pelvic brim; i. e., at a time when cephalic version has ceased to be an elective operation.

Ahlfeld' has suggested that in primiparæ the hand be introduced immediately after the rupture of the membranes, or at least while its introduction is still practicable, and that the anterior extremity be brought down, as a prophylactic measure, leaving the child to be subsequently expelled by the natural forces. Zweifel, in his "Lehrbuch der operativen Geburtshülfe," makes the same recommendation; but Küstner, in com

1 Ollivier, "De la conduite à tenir dans la présentation de l'extrémité pelvienne, mode des fesses," Paris, 1883, p. 103.

Ahlfeld," Arch. für Gynaek.," Berlin, 1873, Bd. v, S. 174.

mon with most authorities, objects on the ground that the manoeuvres requisite to bring down a foot are liable to weaken the uterine contractions and to determine prolapse of the cord. In other words, in order to avert a remote danger, a near one, quite as serious in its nature, is invited.

When it becomes necessary to expedite delivery, in all cases in which it is possible to introduce the hand as far as the fundus of the uterus without imperiling the uterine structures, and when an extremity can be drawn into the vagina without resort to violence, such a method should, as a matter of course, be employed in preference to others; but in reality such cases are exceptional. Emergencies rarely arise before the breech has descended into the pelvic cavity. Most frequently, rupture of the membranes is followed by complete escape of the amniotic liquid and speedy retraction of the uterus upon the foetus. The introduction of the hand and forearm over the anterior surface of the child up to the fundus then becomes a serious undertaking and may lead to uterine rupture. Traction upon the extremity seized is not always followed by its descent, or, when force is used, the descent may be accomplished at the expense of a fracture. To be sure, the manœuvre is supported by the very high authority of Dr. Robert Barnes. "The wedge formed by the extended legs and the upper part of the trunk must," he says, "in some instances at least, be decomposed before delivery can be effected." He recommends complete anæsthesia, support of the fundus, and gentleness in passing the breech at the brim, the finger being applied to the instep. "I have brought a live child into the world," he says again, "by this proceeding when forceps, hooks, and various other means had been tried for many hours." But Barnes does not conceal either the difficulties of the operation or the address requisite for its successful employment; and many other accoucheurs, less fortunate than he, have placed on record their failures to decompose the wedge in the manner advised. I should urge, therefore, the utmost caution in seeking the feet, and suggest that the operator abandon the attempt in all cases in which address fails and force is found necessary.

At the time when intervention becomes necessary, if the breech be well engaged in the pelvis, the fœtus being of ordinary size and the resistance offered by the pelvic floor being inconsiderable, unquestionably, extraction may be effected by hooking the index-fingers respectively into the anterior and posterior groins. In very easy cases, the breech, when high up in the pelvis, may be made to descend by traction on the anterior groin. The direction of the tractions, as Madame La Chapelle long ago insisted, should, at the brim, be downward and backward; in the cavity, directly downward; and, at the outlet, downward and forward. It is, however, hardly necessary, in the presence of a body of experienced practitioners such as I address to-day, to note how often, in primiparous women, this manœuvre utterly fails at the critical moment. In such an event, Braun von Fernwald' recommends the method of Boër, which consists in passing a single hand over the sacrum and seizing the pelvis with the thumb in one groin and the index-finger in the other.

Many, and perhaps most writers insist upon manual methods of extraction to the exclusion of all others. My own experience is favorable to the use of instrumental aids as additional resources, when the hand alone proves inadequate to accomplish the desired object. At the risk of exciting adverse criticism, I do not hesitate to advocate, in cases of need, the forceps, the fillet, the blunt hook, and, when the child is dead, the cephalotribe, and I recommend them in the order I have given.

I know that the right of the forceps to the place of honor in the foregoing list is not likely to pass unchallenged. Some months ago, a former pupil wrote me from the West, that a medical man in his vicinity had applied the forceps to the breech and had extracted the child alive. Both mother and child subsequently did perfectly well, but, during the exit of the breech, the perinæum was lacerated. A suit for malpractice was thereupon brought against the operator, and it was easy to array against him a formidable list of authorities who refer to the use of forceps in breech-cases in terms of the strongest reprobation.

1 Braun von Fernwald, "Lehrbuch der gesammten Gynaekologie," Wien, 1881, S. 747.

The case was referred to me for arbitrament, and I had no hesitation in recommending a dismissal of the proceedings.

The chief objection urged against the forceps is to the effect that, by its construction, it is designed to seize the foetal head only. As a consequence, therefore, when applied to the breech, to which its curves are not adapted, it does not grasp the presenting part securely and is liable to slip off when tractions are employed, thus endangering the maternal soft parts. If, in order to prevent slipping, the handles be firmly compressed, fracture of the thighs may result, the circulation in the cord may be accidentally arrested, or fatal injuries may be inflicted upon the foetus by pressure of the points of the forceps against the abdominal viscera. To obviate these difficulties, Miles1 has devised a pair of breech-forceps apparently well designed for seizing the pelvic extremity, and has given the histories of two cases in which they were successfully employed. As, however, a forceps of special construction is likely to be but rarely at the disposition of the physician when an emergency calls for action, it is not without interest to know how far the ordinary instrument is available in practice.

From the earliest period when the forceps was introduced to popular favor, there has been no lack of partisans for its employment as a tractor to the breech. Ollivier mentions among its earlier advocates, André Levret, in France, Roederer and Stein, in Germany, and Bertrandi, in Italy. More recently, Jacquemier declares it to be preferable to the blunt hook, and says: "It is inexact to state that it would crush the pelvic bones, and inevitably kill the foetus by bruising and lacerating the abdominal viscera. . . ." In his now famous article on the forceps, published in 1872, in the "Dictionnaire de médecine et de chirurgie," Tarnier stated that, under exceptional circumstances, neither Stoltz nor Dubois feared to apply that instrument to the breech, and added that he had several times. imitated their practice with success as regarded the mother and sometimes, also, the child. When the foetus was dead, he

1 Miles, "The Forceps in Difficult Breech Presentations," " American Journal of Obstetrics," New York, 1879, vol. xii, p. 135.