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made an autopsy with care and assured himself that the forceps had produced no lesion, either of the pelvis or of the abdominal viscera. Hüter, in his excellent treatise on Obstetrical Operations (Leipsic, 1874), declares that no better instrument exists, for the extraction of the breech, than the forceps. Dr. Henry Fruitnight, of New York, published in the July number of the “ Virginia Medical Monthly," 1877, a successful case in which the forceps was used at the suggestion of Dr. E. C. Harwood. In the same year, Dr. Agnew reported two successful cases to the London Obstetrical Society. Dr. I. E. Taylor informs me that he has applied the forceps to the breech six times with success.
In 1877, Haake published five cases, in which, as he says, to the astonishment of the physicians present, the extraction with the forceps was easily and quickly ended without the slightest injury to the fætus. Last year I saw, in consultation with Dr. F. A. Castle, a case of breech-presentation in a primipara who had passed her thirtieth year. We both essayed extraction with the fingers, but in vain. The breech was in the pelvic cavity, but had not yet completed its descent through the cervix. The fætus occupied an oblique diameter, with the back directed forward and to the left. In accordance with Haake's suggestion, I applied one blade of Simpson's forceps over the posterior surface of the thigh, and the other over the sacrum, with the extremity of the latter blade just above the crest of the ilium. In spite of the rigidity of the soft parts, the child was extracted alive in about fifteen minutes. The pressure-marks of the forceps were inconsiderable. Dr. Harvey, Professor of Midwifery in the Medical College of Bengal, in an essay just received, reports six cases; in three out of six the success was complete, in one the forceps was without avail, while in the other two the instrument did not slip until it had brought down the breech so as to allow him in one case to get his fingers over the groin, and in the other to apply the fillet, which he had before attempted unsuccessfully. Dr. W. H. Van
Haake, “Ueber den Gebrauch der Kopfzange zur Extraction des Steisses,” “Arch. für Gynaek," Berlin, 1877, Bd. xi, S. 558.
Wyck, of New York, reports to me by letter two cases in which, in the years 1865 and 1867, he extracted the children by the breech with the forceps. Both children were born living.
Since the invention by Tarnier of axis-traction, however, a new impetus has been given to the method advocated. With axis-traction, not only is the resistance offered by the pelvic canal diminished, but, as Pinard states, the pressure is regulated and is not increased by traction. The fætal portion is therefore seized solidly and with the least risk of harm. Ollivier reports successes with Tarnier's latest model, in his own practice and in that of Budin, Thomas, Berthaut, Lobat, and Cayla. Thus it will be seen that the weight of experience is favorable to the use of the forceps as a breech-tractor, while the objections are for the most part theoretical. As regards the rules governing the application of the forceps to the breech, it should be stated that the instrument is inadmissible. so long as the breech does not engage in the pelvis. Haake limited its employment to cases in which the breech was already in the pelvic outlet, and after complete rotation had taken place. The history I have related shows that this rule is not inflexible even with the ordinary forceps. With the axis-traction forceps, the indication is certainly extended, as a rule, to all cases in wbich the breech has passed below the pelvic brim and the dilatation of the os is well advanced. If rotation have taken place, the blades should be applied over the sacrum and the posterior surface of the thigh, as recommended by Haake. If the hips occupy a transverse diameter, the blades should be applied to the lateral surfaces of the thighs, as suggested by Ollivier. The application of the blades over the trochanters, with the extremities overlapping the crests of the ilia, is to be deprecated, as the ilia are compressible and allow the forceps to slip (Ollivier). The extraction of the child should not be made an exhibition of strength; and the rigidity of the maternal structures is rarely to be overcome by any justifiable degree of force. The slow descent of the breech, effected by intermittent tractions, insures the physiological softening of the tissues in advance of the presenting part. In this respect, the rule is the same as in head-presen
tations. As the genital canal softens and relaxes, but little force is required to effect the birth of the breech. The tractions are most effective if made during the pains. If possible, they should be aided by simultaneous pressure, exerted by an assistant, upon the fundus of the uterus. If these rules be observed,
the efforts to extract the breech will, in a large number of cases, I am sure, be crowned with success. If they fail, at least no injury to either mother or child is likely to result from the trial.
If the forceps fail, or if, owing to the non-engagement of the breech, its use be contra-indicated, and if an extremity can not be brought down without the employment of force, a resort to the fillet is admissible. The theoretical objections to its use are the following: 1. The fillet is apt to become twisted, and, when moistened with the vaginal secretions, it forms an uneven band, which, even with care, is capable of cutting deeply into
the tissues. 2. In some cases it causes partial extension of the extremity, and, as a consequence, slips forward upon the thigh, when a fracture of the thigh-bone becomes inevitable. The reports from the Lying-in Institution of Munich, where, owing to the advocacy of Hecker, the fillet has been assiduously tested, do not confirm these gloomy prognostications. Thus, in the last report of von Weckberger-Sternefeld, the records of thirty-one cases are given (twenty-one of primiparæ, nine of pluriparæ, and
one not stated). The mothers all did well. One of the children was in a macerated condition when the fillet was employed. Of the remaining thirty, twenty-four were born living. Of these, eight were partially asphyxiated, but seven were revived. In no one of the children born dead was the result in any way attributable to the means of extraction employed. Twenty-three of the children left the Institution in a healthy condition. In four cases, deep pressure-marks, but without excoriation, resulted from the fillet. In the others, either no traces of pressure
were found or they were of an insignificant nature. In all, the marks disappeared in a few days. In one instance only, fracture of the thigh occurred; and, in this, the back of the child was turned to the right and to the rear. Ollivier has shown that in the dorso-posterior positions special caution is demanded when traction is made at the groin. A glance at the accompanying diagram will show that it is not easy, in these cases, to direct the
tractions in such a way as to avoid partial extension of the limb and a transfer of the pressure to the thigh-bone. In a series of experiments in which a dead fætus was dragged, by means of the fillet, through an artificial pelvis, Ollivier found that it was possible, in dorso-posterior positions, to prevent the extension of the thigh, by passing the hand behind the breech and pressing forward during the tractions. He suggests, therefore, that in actual labor this danger may be avoided by exerting a similar