CÆSAREAN OPERATION.
Indications.—Different modes of performing the operation.—History of the Cæsarean operation.
Indications.—Different modes of performing the operation.—History of the Cæsarean operation.
The next operation in Midwifery for delivering the full-grown fœtus alive is that ofHysterotomy, commonly called the Cæsarean operation, viz. where the fœtus is extracted through an artificial opening made through the parietes of the abdomen and uterus.
Theindicationsfor performing the operation are so different in this country to what they are elsewhere that they require especial mention: in England the operation is never performed upon the living subject except where the child cannot be delivered by the natural passage; under these circumstances it is scarcely undertaken in this country for the purpose of saving the child’s life, but merely that of the mother, it being considered preferable to deliver the child by perforation or embryotomy, even when known to be alive, than to expose the mother to so much suffering and danger.
On the Continent and also in America, it has not been considered in so dangerous a light as in this country, still less as an operation almost certainly fatal to the mother: therefore, besides being indicated as a means for preserving the mother’s life, it is performed for the purpose of saving the child’s life in cases where, by using the perforator, the child might be brought through the natural passages. The results of the Cæsarean operation have been so unfavourable, and the character of the process so frightful, as to have rendered it a measure of peculiar dread to practitioners, and in different times and countries the strongest feelings have been excited against it. By many of the celebrated authors of former times, viz. Ambrose Paré, Guillemeau, Dionis, &c. it was looked upon as altogether unjustifiable, and a similar opinion was entertained by many of our own countrymen at a much more recent period, (Dr. W. Hunter, Dr. Osborn, &c.)
There is no doubt that in England it has been peculiarly unsuccessful. Dr. Merriman has collected the results of 26 cases of Cæsarean operation: of these only 2 mothers and 11 children survived; thus out of 52 lives only 13 were saved. On the Continent it has been far more successful. Klein has collected with the greatest care 116 well authenticated cases, of which 90terminated favourably; and Dr. Hull, in hisDefence of the Cæsarean Operation, has recorded 112 cases, of which 69 were successful. M. Simon has not only collected a number of cases which were favourable, to the number of 70 or 72, but which were performed on a few women, “some of them having submitted to it three or four times, others five or six, and even as far as seven times, which if they were all true, would superabundantly prove that it is not essentially mortal.” (Baudelocque, transl. by Heath, § 2095.)
During the last fifteen or twenty years the operation has become remarkably successful in the hands of the German practitioners, so that there has been scarcely a journal of late from that part of the Continent which has not contained favourable cases of it. One of the most interesting instances of later years is that recorded by Dr. Michaelis, of Kiel, where the patient, a diminutive and very deformed woman, was operated upon four times:[97]the second operation was performed by the celebrated Wiedemann, and is stated to have been completed in less than five minutes, and without any extraordinary suffering on the part of the patient, who complained most when sutures were made for bringing the lips of the wound together. The uterus became adherent to the anterior wall of the abdomen, so that in the fourth operation the abdominal cavity was not even opened, the incision being made through the common cicatrix into the uterus.
There is every reason to suppose that the chief cause of its want of success in this country has been the delay in performing it. “In France and some other nations upon the European Continent,” says Dr. Hull, “the Cæsarean Operation has been and continues to be performed where British practitioners do not think it indicated; it is also had recourse to early, before the strength of the mother has been exhausted by the long continuance and frequent repetition of tormenting, though unavailing pains, and before her life is endangered by the accession of inflammation of the abdominal cavity. From this view of the matter we may reasonably expect that recoveries will be more frequent in France than in England and Scotland, where the reverse practice obtains. And it is from such cases as these, in which it is employed in France, that the value of the operation ought to be appreciated. Who could be sanguine in his expectation of a recovery under such circumstances as it has generally been resorted to in this country, namely, where the female has laboured for years undermalacosteon(mollities ossium,) a disease hitherto in itself incurable; where she has been brought into imminent danger by previous inflammation of the intestines or other contents of the abdominalcavity, or been exhausted by labour of a week’s continuance or even longer.” (Hull’sDefence of the Cæsarean Operation.)[98]
The difficulty of deciding upon the operation according to the indications of the Continental practitioners, is much more perplexing than according to that which is followed in this country: the question here is, can the child under any circumstances be made to passper vias naturaleswith safety to the mother? The impossibility of effecting this object is the sole guide for our decision. In using the operation as a means for preserving also the life of the child, we must not only feel certain that the childisalive, but that it is also capable of supporting life, before we can conscientiously undertake the operation upon such indications. This uncertainty as to the life or death of the child greatly increases the difficulty of deciding. Under circumstances where there is reason to believe that, although the child may be alive, it is nevertheless unable to prolong its existence for any time, and the pelvis so narrow that it can only be brought through the natural passage piecemeal, we are certainly not authorized in putting an adult and otherwise healthy mother into such imminent danger of her life for the sake of a child which is too weak to support existence. Circumstances may nevertheless occur where the pelvis is so narrow that the child cannot be brought even piecemeal through the natural passage: in this case, even if the child be dead, the operation becomes unavoidable.
Under the above-mentioned circumstances, it is the duty of the surgeon to perform the operation; and he can do it with the more confidence from the knowledge of many cases upon record where it has succeeded even under very unfavourable circumstances, and where it has been performed very awkwardly: moreover, it seems highly probable that the unfavourable results of this operation cannot often be attributed to the operation itself, but to other circumstances. Not unfrequently the uterus has been so bruised, irritated, and injured by the violent and repeated attempts to deliver by turning or the forceps, and the patient so exhausted, and brought into such a spasmodic and feverish state by the fruitless pains and vehement efforts, together with the anxiety and restlessness which must occur under such circumstances, that it is impossible for the operation to prove successful. Here it isan important rule that we should decide as soon as possible, whether she can be delivered by the natural passages or not: we should allow of no useless or forcible attempts to deliver her; and if these have been made, we should carefully examine whether the passages, &c. have been injured, and proceed to the operation without delay. Moreover, the patient can the more easily make up her mind to the operation, as she will suffer far less than from the fruitless efforts and attempts to deliver her by the natural passages. (Richter,Anfangsgründe der Wundarztneikunst, band vii. chap. 5.)
Although it is so important that we should lose no time, still nevertheless it does not appear desirable to operate before labour has commenced to any extent; for unless the os uteri has undergone a certain degree of dilatation, it will not afford a sufficiently free exit for liquor amnii, blood, lochia, which, by stagnating in the uterus after the operation, would soon become irritating and putrid, in which case they would be apt to drain through the wound into the abdominal cavity and create much mischief.[99]
Different modes of operating.The incision has been recommended to be made in different ways by different authors; but the highest authorities, as also later experience, combine in favour of that in the linea alba. Richter states, that one great advantage from making it in this direction is, that when the uterus contracts and sinks down into the pelvis, the incision in it still corresponds with that through the abdominal parietes, and therefore admits of a free discharge of pus, &c. through the external wound; whereas, if it have been made to one side, viz. at the outer edge of the rectus abdominis muscle, as recommended by Levret for the purpose of avoiding the placenta, the wound in the uterus when contracted ceases to correspond with it, and the discharge escapes into the abdominal cavity. Besides this the abdomen is usually more distended at the linea alba; the uterus here lies immediately beneath the integuments; the intestines are usually pressed towards each side; and therefore when the incision is made on one side they frequently protrude, a circumstance which rarely happens when it is made in the linea alba, except perhaps towards the end of the operation. In the linea alba we have only to cut through the external integuments in order to reach the uterus, while at the side, we have to cut through considerable layers of muscle.
Previous to operating, the rectum and the bladder should be emptied, particularly the latter, because it is desirable to carry the incision of the abdominal integuments, for reasons just given, as near as possible to the symphysis pubis (viz. an inch and a half,) which otherwise would endanger the safety of the bladder. The experience of later years proves decidedly that three intelligent assistants are necessary, “two to prevent the protrusion of the intestines, and a third to remove the placenta and fœtus.” (Neue Zeitschrift für Geburtskunde, band iii. heft 1. 1835.) We are convinced, that the success of the operation depends more upon carefully preventing the slightest protrusion of any portion of the intestines, and excluding all access of the external air than upon any other cause, for by this means alone can we save the patient from the dangerous peritonitis which is so apt to follow. The two assistants, whose duty it is to support the abdominal parietes and keep the edges of the wound closely pressed against the uterus, should be furnished with napkins or sponges soaked in oil in order instantly to cover any coil of intestine which may protrude, and press it back as quickly as possible; it is to this that the great success of the Cæsarean operation in later years is chiefly owing.
The incision in point of length varies from five to six, seven, or more inches, beginning at about two to four inches below the navel, and terminating at rather less than that distance above the symphysis pubis. The peritoneum is usually divided with a bistoury and director, and the wound through the uterus made an inch or two shorter than that of the abdominal integuments. If, on dividing the uterine parietes, the placenta presents, it must be separated, and removed as quickly as possible to one side, the membranes ruptured, and the child extracted; after which the uterus rapidly contracts, and thus prevents all fear of hæmorrhage: for this reason the sooner the child is removed the better, as otherwise the uterus is apt to contract upon a portion of it when passing through the wound, and thus retain it. It is desirable to remove the membranes as far as possible, especially from the os uteri, to allow of a free discharge from the uterus per vaginam. No sutures are needed for the uterine incision: the contractions of the organ not only diminish its length, but generally bring its edges into sufficiently close contact.
Some discrepancy of opinion has existed respecting the treatment of the external wound: sutures are of course the most secure means of retaining the edges in apposition, but they produce great suffering, and, from taking up a good deal of time, delay the closing of the abdominal wound more or less; whereas, straps of sticking plaster are applied much quicker and without any suffering to the patient. To do this most effectually it will be advisable to arrange them under the loins previous to the operation: they should be from five to six feet long, and the endsmay be rolled up until wanted; the wound can thus be instantly closed and in the most secure manner. Where the operator finds it necessary to use sutures, he must avoid puncturing the peritoneum as far as possible: the lower inch of the wound should be left open to allow any matter to drain out, and the whole dressed according to the common rules of surgery. The patient should be placed upon her side with the knees bent to relax the abdominal parietes. A grain of the hydrochlorate of morphia has been given in these cases with the best effects, having procured sleep and allayed the disposition to spasmodic coughing and vomiting, which so frequently exists after the operation.
One of the greatest triumphs of modern surgery is the performance of this dangerous operation four times successively on the same patient. The first operation was performed in June 1826, the woman being then in her twenty-ninth year, the second in January 1830, the third in March 1832, and the fourth on the 27th June, 1836. The second operation was performed by Wiedemann, of Kiel, and scarcely lasted five minutes; nor does it appear that the patient’s sufferings were very great, for the application of sutures on this occasion elicited more complaint than all the operations put together.[100]
History.Although the early records of the Cæsarean operation are not very distinct, still we possess sufficient data to pronounce it of very considerable antiquity. The earliest mention of it shows that it was at first used merely for the purpose of saving the child by extracting it from the womb of its dead mother, a law having been made by Numa Pompilius, the second king of Rome, forbidding the body of any female far advanced in pregnancy to be buried until the operation had been performed.
The mythology of the ancients refers to two cases of an exceedingly remote period where a living child was taken from the dead body of its mother: these were the birth of Bacchus and Æsculapius; but as these traditions are so enveloped in allegory and mystery, it is difficult to come to any other conclusion than a mere inference of the fact: one circumstance, however, connected with the birth of Bacchus is curious, viz. that his mother Semele died in the seventh month of her pregnancy.
The oldest authentic record is the case of Georgius, a celebrated orator born at Leontium in Sicily,B. C.508. Scipio Africanus, who lived about 200 years later, is said to have been born in a similar manner. There is no reason to suppose that Julius Cæsar was born by this operation, or still less that itderived its name from him, for at the age of thirty, he speaks of his mother Aurelia as being still alive, which is very improbable if she had undergone such a mode of delivery. We would rather prefer the explanation of Professor Naegelé, viz. that one of the Julian family at Rome had been deliveredex cæso matris utero, and had been named Cæsar from this circumstance, so that the name was derived from the operation, not the operation from the name.
“The earliest account of it in any medical work is that in theChirurgia Guidonis de Cauliaco, published about the middle of the fourteenth century. Here, however, the practise is only spoken of as proper after the death of the mother.” (Cooper’sSurg. Dict.) Among the Jews, however, it appears to have been performed on thelivingmother at a very early period; a description of it is given in theMischnejoth, “which is the oldest book of this people, and supposed to have been published 140 years before the birth of our Saviour, or, according to some, even antecedently to this period. In theTalmudof the Jews, also, their next book in point of antiquity, the Cæsarean operation is mentioned in such terms as to render it extremely probable that it was resorted to before the commencement of the Christian era. In theMischnejoththere is the following passage, ‘In the case of twins, neither the first child which shall be brought into the world by the cut in the abdomen, nor the second, can receive the rights of primogeniture, either as regards the office of priest or succession to property.’ In a publication called theNidda, an appendix to theTalmud, there is the following remarkable direction: ‘It is not necessary for women to observe the days of purification after the removal of the child through the parietes of the abdomen.’” (Introduction to the Study and Practice of Midwifery, by W. Campbell, M. D. p. 260.)
The first authentic operation upon a living woman in later times was the celebrated one by Jacob Nufer, upon his own wife, in 1500, after which, owing to its fatal character and the strong feeling against it, it was performed but rarely: still, however, sufficient evidence existed to mark its occasional success and urge its repetition in similar cases; and from what we have already stated, the history of the last twenty years shows that its results have rapidly become more and more favourable, so that in the present day it can be no longer looked upon as an operation of such extreme danger and almost certain fatality, as it was in former times.[101]
ARTIFICIAL PREMATURE LABOUR.
History of the operation.—Period of pregnancy most favourable for performing it.—Description of the operation.
History of the operation.—Period of pregnancy most favourable for performing it.—Description of the operation.
Perhaps the greatest improvement in operative midwifery since the invention and gradual improvement of the forceps is the induction of artificial premature labour for the purpose of delivering a woman of a living child, under circumstances of pelvic contraction, where either the one must have been exposed to the dangers and sufferings of the Cæsarean operation, or the other to the certainty of death by perforation, or at least where the labour must have been so severe and protracted as to have more or less endangered the lives of both. It consists in inducing labour artificially, at such a period of pregnancy that the child has attained a sufficient degree of development to support its existence after birth, and yet is still so small, and the bones of its head so soft, as to be capable of passing through the contracted pelvis of its mother.
History.Few improvements have met with more violent opposition, or have been more unjustly stigmatized or misrepresented, than artificial premature labour, and it redounds, not a little, to the credit of the English practitioners that they have not only had the merit of its first invention, but with very trifling exceptions, have been the great means of bringing it into general practice and repute.
To the late Dr. Denman we are under especial obligations in this respect; for, although himself not the inventor of this operation, he, nevertheless, was one of the first who widely recommended it to the profession, and actively promoted it by the powerful support of his name and writings. “A great number of instances,” says he, “have occurred to my own observation of women so formed that it was not possible for them to bring forth a living child at the termination of nine months, who have been blessed with living children, by the accidental coming on of labour when they were only seven months advanced in their pregnancy. But the first account of any artificial method of bringing on premature labour was given me by Dr. C. Kelly.He informed me that about the year 1756 there was a consultation of the most eminent men in London, at that time, to consider of the moral rectitude and advantages which might be expected from this practice, which met with their general approbation. The first case in which it was deemed necessary and proper, fell under the care of the late Dr. Macauley, and it terminated successfully.[102]Dr. Kelly informed me he himself had practised it, and among other instances mentioned that the operation had been performed three times on the same woman, and twice the children had been born living.” (Denman’sIntroduction to the Practice of Midwifery, 2d ed. vol. ii. p. 174.) Since this the observations of Mr. Barlow, Dr. Merriman, Mr. Marshall, Drs. J. Clarke, Ramsbotham, &c. &c., have afforded an ample body of evidence in its favour, and have, we trust, tended not a little to diminish the frequency of perforation. On the Continent it experienced a very different reception, being regarded as immoral, barbarous, and unjustifiably endangering the life of the mother and her child. In France, although at first successfully adopted by a few practitioners, (Sue,) its farther progress was completely stopped by the powerful opposition of Baudelocque, and by the plausible though erroneous objections which he made against it. A similar course was pursued by Gardien and Capuron, and even by the celebrated Madame la Chapelle, all of whom have taken a singularly incorrect view of it and assign it a totally different object to that which is intended: the very name which they have given to it ofAvortement artificiel, plainly shows how little they have understood of its real character.
Among his objections, Baudelocque states, that “the neck of the uterus at seven months has seldom begun to open; it is still very thick and firm. The pains, or the contractions of that viscus, cannot then be procured but by a mechanical irritation pretty strong and long continued; but those pains, being contrary to the intentions of nature, often cease the instant we leave off exciting them in that manner. If we break the membranes before the orifice of the uterus be sufficiently open for the passage of the child, and the action of that viscus strong enough to expel it, the pains will go off in the same manner for a time, and the labour afterwards will be very long and fatiguing; the child deprived of the waters which protected it from the action of the uterus, being then immediately pressed upon by that organ, will be a victim to its action before things be favourably disposed for its exit, and the fruit of so much labour and anxiety will be lost. Premature delivery obtained in this manner is always so unfavourable to the child, that I think it ought never to be permitted except in those cases of violent hæmorrhage which leave nochance for the woman’s life without delivery; the nature of the accident also disposes the parts properly for it.” (Baudelocque, transl. by Heath, § 1986, 1987.) All this plainly shows that Baudelocque did not rightly understand the real objects and nature of artificial premature labour, to which, in fact, his objections do not apply, but to theaccouchement forcéof the French practitioners, where, on account of the sudden accession of dangerous symptoms, such as hæmorrhage, convulsions, &c. &c., the os uteri was rapidly and violently dilated by the hand, which was then passed into the uterus, the feet seized, and the child forcibly delivered, an operation which is now rarely performed in Germany and never in this country.
The celebrated Carl Wenzel, of Frankfort, was the first in Germany who declared himself in favour of the operation. Kraus and Weidemann followed, the former two having performed it with complete success. The favourable results also in the hands of English practitioners and its increasing reputation quickly silenced the virulent abuse which was levelled at it by Stein, jun., and some other German authorities; the celebrated Elias von Siebold, of Berlin, who had first opposed it, candidly confessed his error and became one of its earliest supporters. Increasing experience showed that it could scarcely be looked upon as a dangerous operation for the mother, and that in by far the majority of instances it was also successful as regarded the child. Professor Kilian, in his work on operative midwifery, has collected the results of no less than 161 cases of artificial premature labour. (Operative Geburtshülfe, erster band, p. 298.) Of these, 72 occurred in England, 79 in Germany, 7 in Italy, and 3 in Holland: of these cases, 115 children were born alive and 46 dead; of the 115 living children, 73 continued alive and healthy; 8 of the mothers died after the operation, but of these, 5 were evidently from diseases which had nothing to do with the operation.
The most unfavourable circumstances under which the operation can be undertaken are, where the child presents with the arm or shoulder: here it will require turning, which, in many cases, owing to the faulty form and inclination of the pelvis, cannot be effected without considerable difficulty, and greatly diminishing the chances of the child being born alive. With this exception we cannot see why it should not be as favourable as labour at the full term of pregnancy; it is far less dangerous than other species of premature labour, for the hæmorrhages, which are so apt to attend them, are never known to occur here.
This mode of delivery has not only been proposed in cases of contracted pelvis: “There is another situation,” says Dr. Denman, “in which I have proposed and tried with success the method of bringing on premature labour. Some women who readily conceive, proceed regularly in their pregnancy till they approach the full period, when, without any apparently adequate cause, theyhave been repeatedly seized with rigour and the child has instantly died, though it may not have been expelled for some weeks afterwards. In two cases of this kind, I have proposed to bring on premature labour, when I was certain the child was living, and have succeeded in preserving the children without hazard to the mothers.” (Introduction to the Practice of Midwifery, 2d ed. vol. ii. p. 180.)
Period for performing the operation.Although under the head ofPremature Expulsionwe have stated that a fœtus is capable of maintaining its existence if born after the twenty-eighth week of pregnancy, we must not be supposed to recommend the artificial induction of premature labour at so early a period as this. “Experience has shown that it was not necessary to induce labour at so early a period as was first imagined, on account of the very great difference which even one or two weeks are found to make in the hardness of the fœtal skull. Thus, for instance, in cases where the antero-posterior diameter was only three inches, six weeks before the full term of utero-gestation were found sufficient, and where it was three inches and a half, fourteen days made sufficient difference.” (Naegelé,MS. Lectures.) Still, however, as it is so difficult to be quite sure of the data upon which we have made our reckoning, it will be safer to fix the operation a week or two earlier; and if we lose a little time by failing in our first endeavours to induce uterine action, it will be of so much the less consequence: hence, therefore, as a general rule, the most eligible time will be between the thirty-fourth and thirty-sixth week; and if the deformity be very considerable, we may commence operations as early as the thirty-second week or two months before the full term, short of which it will seldom either be justifiable or necessary. On the other hand, where the state of the cervix and the history of her pregnancy combine to make our reckoning nearly a matter of certainty, the later we can safely delay the operation the better, for by so doing the process resembles more a natural labour, and the chances in favour of the child are much increased.
Operation.The original mode of artificially inducing premature labour was merely by puncturing the membranes and allowing the liquor amnii to escape; the more gradually this is done the better, for by this means the uterus is not entirely drained of its fluid contents, and is, therefore, prevented contracting immediately upon the child; the value of this precaution was pointed out by the late Dr. Hugh Ley, and also by Wenzel. A considerable interval may elapse between puncturing the membranes and the first contractions of the uterus, generally varying from forty to eighty hours: it should be performed while the patient is in the horizontal posture, in order to prevent the escape of too much liquor amnii. A moderately curved male catheter, open at its point and carrying a strong stilet sharpened at the end, is the bestand simplest instrument for the purpose: on passing it up to the membranes, the stilet should be protruded, but to a short extent, to avoid injuring the child; and as soon as the liquor amnii runs from the other end, the instrument should be withdrawn, and the patient desired to remain quiet. A dose of opium has been usually given after the operation by the English practitioners, but its utility appears rather questionable: a brisk purge of calomel and jalap, some hours previously, is much more important; uterine action comes on much more regularly and effectively, and there will be much less chance of those rigours occurring which some practitioners, although erroneously, have supposed, were connected with the death of the child.
The practice of dilating the os uteri first, as recommended by Brüninghausen, Kluge, and others, has, as far as we know, never been attempted in this country, and resembles much too closely theaccouchement forcéof the French authors ever to be permitted.
The simplicity of the operation of tapping the membranes has rather led practitioners to overlook a still greater improvement, viz. the inducing uterine action first: this was proposed by Dr. Hamilton to be effected by passing up a catheter, and separating the membranes from the uterus to a considerable distance above the os uteri. The operation certainly succeeds in some cases; but our own experience goes to prove, that in the majority it is not sufficient by itself to provoke uterine contraction, and in order to ensure success we must combine with it other means.
The plan of treatment which we have found most certain is first to clear out the bowels by a full dose of calomel and colocynth, then to give the patient a warm bath, in which she may remain twenty or more minutes, after which the abdomen should be well rubbed with stimulating liniment as she lies in bed, and the secale cornutum given in doses of a scruple of the powder in cold water, repeated every half hour for five or six times. Contractions of the uterus rarely fail to follow, and although they generally require the secale to be renewed after a few hours, they will be found to have effected several very important changes preparatory to actual labour;—the abdomen has sunk, the fundus is lower, the cervix is shorter or has disappeared, and not unfrequently we feel the head has already passed the brim and is now in the cavity of the pelvis; the vagina and os uteri are lubricated with a copious secretion of remarkably pure and albuminous mucus; and in these cases especially, we frequently meet with those little lumps of inspissated mucus which were formerly called theovula Nabothi. All these precursory changes are so many preparations of nature for a natural labour, and contribute not a little to the successful termination of the case, advantages which cannot be enjoyed where the membranes have been previously ruptured. If, however, we do not succeed in producing more than a slight dilatation of the os uteri, if the repeatedexhibition of the ergot only produce vomiting, or constant pains which have no other effect beyond preventing rest and inducing exhaustion, the separation of the membranes from the uterus, as proposed by Dr. Hamilton, will now have the best effects: even if this fail and we are compelled to puncture the membranes, it will now be performed under so much more favourable circumstances, from labour having already commenced to a certain extent.
A warm bath and the other usual means for recovering the child should be in readiness. In most cases the secretion of milk follows as after labour at the full term, which is a great advantage; for the thin watery secretion of this early period is much better adapted to the weak digestive organs of the premature child. It is frequently a matter of some difficulty under these circumstances to make a child take the breast at first, and this is the chief reason why their digestive organs so soon become deranged. “In case no milk be present, a good substitute may be made by beating up fresh eggs and milk, boiling them over a gentle fire and straining off the thin fluid.” (Reisinger,die künstliche Frühgeburt.)
One great encouragement in cases requiring this operation is the fact that in every successive pregnancy the uterus is more easily excited to premature action; and in some cases where it has been induced several times, it has at length, as it were, got so completely into the habit of retaining its contents only up to a certain period, that labour has come on spontaneously exactly at the time at which in the former pregnancies it had been artificially induced.[103]We have already alluded to this circumstance in the chapter onPremature Expulsion of the Fœtus.[104]
PERFORATION.
Variety of perforators.—Indications.—Mode of operating.—Extraction.—Crotchet.—Embryulcia.
The perforation is that operation “where we make an opening into the cranial cavity, and, by allowing the brain to escape, thus diminish the bulk of the head.” (Obstetric Memoranda.)
Perforation is one of the most ancient operations in midwifery, for in former times it was the only means of artificially delivering the child when the head presented: hence we find that from the age of Hippocrates down to the last century, midwifery instruments almost entirely consisted of knives or lancets for piercing the fœtal head, and blunt or sharp hooks for extracting or dismembering the child.
Thus Hippocrates, Celsus, and Albucasis, and others, have described a variety of such instruments and given full directions for their use.
Variety of perforators.No instrument has been so greatly modified or has appeared under such different forms as the perforator; but it is not our object to enter into any detailed account of its history, for it would not, like that of the forceps, lead to any useful information; we shall, therefore, content ourselves with mentioning those few which have been in general use during the last century. They are chiefly of the scissor kind; the two most commonly known are the perforators of Dr. Smellie and M. Levret: the former are merely strong long-handled scissors, the backs of the blade being neither exactly sharp nor blunt,[105]and furnished each with a projecting shoulder or rest to prevent them from entering too far. Levret’s perforator, which is extensively used in this country under the name of Dr. Denman’s perforator, and which was originally invented by Bing, of Copenhagen, is also formed like scissors,but has its cutting edges outside; the blades are also furnished with rests or shoulders like the Smellie perforator.
Naegelé’s perforator.
A useful modification has been invented by Professor Naegelé, which supplies a considerable defect in the two above-mentioned instruments, viz. the necessity of using both hands to open the blades, thereby requiring that the hand which guides the instrument in the vagina should be removed at this moment: for this purpose the blades do not cross at the lock as the others do, by which means the grasp of one hand is sufficient to squeeze the handles together, and thus make the blades diverge in order to dilate the opening. A similar one has been invented by the surgical instrument maker, Mr. Weiss, but it does not appear to be quite so safe.
The object of these instruments is not merely to bore through the skull, but to break down the parietal bone to a certain extent, in order to enlarge the opening: a slight curve of the blades is advantageous, because their points thus impinge more directly upon the skull, and enter it at once without running the risk of slipping along the surface.
Indications.“The perforation is indicated, first, in all cases where the labour is dangerous for the mother, and where the antero-posterior diameter, although more than two inches and a half, is so small that the head which presents, cannot be delivered by the forceps. Secondly, it is indicated where the head is much larger than natural, as in hydrocephalus.” (Naegelé,MS. Lectures.) For a more detailed and special account of the precise circumstances under which it will be required, we must refer to those different forms ofDystocia, where it is occasionally required, particularly our fourth species, viz.Dystocia Pelvica.
Much discrepancy of opinion has existed as to how far the operation itself was justifiable, and has, therefore, given rise to very different results in the practice of different schools. The most obstinately prejudiced against perforation was the late celebrated Benjamin Osiander, of Göttingen, who asserted, that it was never necessary, for, where others were obliged to open the head, he would deliver the patient by means of his forceps, an instrument which, from its great length and the various hooks &c. for applying additional hands, was capable of exerting a degree of force which nothing could justify. In France, the predilection for using exceedingly powerful forceps to a degree, which in this country and the greater part of Germany wouldbe looked upon as very injurious, if not dangerous, has tended to render the perforation a comparatively rare operation: thus out of somewhat more than twenty thousand labours at the Maternité, of Paris, only sixteen were delivered by this means. Of the ninety-six cases in whom the forceps was applied, no mention is made as to the result with respect to the mothers; but, from the description of a forceps case at the Hôtel Dieu which we have received from an eye-witness, the force used must have been carried to a most unwarrantable extent.
The English practitioners have frequently been accused by their Continental brethren with being too ready in the use of the perforator; but, with one or two exceptions, the charge is not just, for, as already stated, we are not justified in subjecting an adult and otherwise healthy woman to so much suffering and danger for the sake of a child which, after all, will be probably sacrificed by the severity of the labour.[106]
Operation.In performing the operation we introduce two or three fingers along the vagina to the presenting part of the fœtal head, and carefully guide up the perforator against it: these fingers will not only protect the soft parts from injury, but steady the point so firmly upon the skull, as to enable the other hand to bore through it without difficulty. Having passed the blades up to the shoulders or rests, we dilate the opening, first one way and then the other, to form a crucial incision: we now insert the instrument up to the basis cranii, breaking down the attachments and structure of the brain, and thus enabling it to come away with greater facility. To favour this object still farther, and make the cranial bones collapse more readily, we must pass a long elastic tube through the opening, and by means of a syringe, throw up a powerful stream of water into the cavity of the skull: if this be introduced to the base of it, the water will necessarily drive out the brain before it, so that with every stroke of the piston, a quantity of brain will be expelled nearly equal to that of the water injected.
When the perforation has been made, it will be desirable to wait a few hours before making any attempt to extract: we thus give the mother an opportunity of getting a little rest; the attachments of the cranial bones after a short time become more yielding, the head collapses more readily, and adapts itself better to the form of the passages. “In all circumstances,” says Dr.Osborn, “which admit and require precision, I would recommend the delaying all attempts to extract the child till the head has been opened at least thirty hours: a period sufficient to complete the putrefaction of the child’s body, and yet not sufficient to produce any danger to the mother. From such conduct, the beneficial effects of facilitating the extraction of the child, I am firmly convinced, by frequent experience, will much overbalance any possible injury which may reasonably be expected from the putrid state of the child and secundines in so short a time. The propriety, however, of this delay entirely depends upon the head being opened in the beginning of labour: for if we do not perform the first part of this operation till the labour has been protracted so long as that the woman’s strength begins to fail, we must expedite the delivery as speedily as possible, otherwise, the danger which we wish to avoid, will infallibly be incurred: no woman can suffer continued labour beyond a certain period without fever, inflammation, and the most imminent danger, if not death ensuing.” (Osborn’sEssays on the Practice of Midwifery.)
It has been recommended to perforate the head at the sutures, on account of the greater facility in passing the instrument through them: but that part of the head which is lowest in the pelvis, or which, in other words,presents, must necessarily be the most convenient, not only for the introduction of an instrument, but also for the evacuation of the brain. When the perforation is made at a suture, the edges of the bones gradually overlap as the head diminishes in size, and thus close the opening, a circumstance which cannot occur when it is made through a bone. Splintering the bone in making a crucial opening has been objected to on the ground that the sharp edges and spiculæ are apt to wound the soft parts of the mother: of this, however, there will be but little danger so long as they are covered by the scalp, which we should be somewhat cautious of, and not tear or otherwise destroy the cranial integuments unnecessarily, for it has long since been remarked by the celebrated Peter Frank, that inflammation of the uterus produced by wounds from spiculæ of bone or sharp instruments becoming blunt, &c., usually prove fatal: it is also desirable to disfigure the head as little as possible. Still, however, we are far from recommending the trepan-shaped perforators which have been used by Professors Assalini, Joerg, &c. as they cannot make a sufficiently free opening, nor break down the skull to the necessary extent.
Extraction.Where sufficient time has been allowed for the cranial bones to collapse, the finger inserted into the opening and acting as a blunt hook will, if assisted by the pains, be enabled to exert a sufficient degree of force to bring the head down to the pelvic outlet; by which time the action of the vagina and abdominal muscles in aid of the uterine efforts will soon succeedin pressing it through the os externum. By using the finger in this way we pull by that part of the head which is already lowest in the pelvis, and, therefore, run no risk of altering the position of the head and bringing it down in an unfavourable direction; this objection (among others) applies to the hook, whether it be fixed internally or externally, and thus frequently renders the passage of the head through the outlet and os externum more tedious, difficult, and painful, than it otherwise would have been. The craniotomy forceps are still more objectionable in all ordinary cases of perforation, for they not only alter the position of the head, but by tearing away portions of bone from time to time are very liable to wound the soft parts.
From our own experience, we would recommend the application of the common curved forceps in all cases where the pelvic deformity is not of a very unusual degree, for by this means the hand is equally grasped and compressed, the soft parts to a considerable extent are protected by the blades, and the whole mass brought down exactly in the position in which it presented. On several occasions where the craniotomy forceps and crotchet have failed to move the head, the midwifery forceps has been applied, and the delivery easily and quickly accomplished. Dr. Smellie recommends the crotchet to be applied on the outside of the head, and was evidently aware that its position was liable to be altered by this means. He directs the practitioner to “introduce it along his right hand with the point towards the child’s head, and fix it above the chin, in the mouth, back part of the neck, or above the ears, or in any place where it will take firm hold. Having fixed the instrument, let him withdraw his right hand, and with it take hold on the end or handle of the crotchet, then introduce his left to seize the bones at the opening of the skull (as above directed)that the head may be kept steady, and pull along with both hands.” (vol. i. chap. 3. sect. 7. numb. 4.) Where there was considerable difficulty in bringing down the head, Dr. Smellie used to introduce a second crotchet opposite to the first, like the second blade of the forceps, and having locked them together was thus enabled to apply a greater degree of force.
Crotchet.The usual mode of applying the crotchet at the present day is to pass it into the cranial cavity, and endeavour to fix it upon some portion of the skull, which will afford a sufficiently firm hold for the purpose; the best spot is the petrous portion of one or other of the temporal bones. The plan of passing up the hook on the outside of the head is objectionable, for in most cases where there is much impaction of the head, it will be exceedingly difficult, if not impossible, to push the hook past it without much suffering and probable injury. Not wishing to differ from so great an authority as Dr. Smellie without reason, we have repeatedly tried this mode of using the crotchet, butinvariably found that its introduction on the outside of the head was attended with so much difficulty and pain as to make us relinquish the attempt. His objections to passing the hook into the cranial cavity are not valid, for we should never try to fix it upon the “thin bones,” nor should we hold it in such a manner that, if it did slip or tear through, it would wound either our hand or the soft parts of the mother.
The common form of the crotchet in general use is but ill adapted for taking hold of any part within the skull: it is, in fact, the very instrument left us by Dr. Smellie for applying on the outside of the skull: and, therefore, that which was intended to take hold of a convex surface cannot possibly be also suited for one of the contrary form, viz. a concavity; for this reason, the shank of the hook requires to be straight, so that the point may project at a considerable angle, by which means it will take hold with much greater ease.
The point of the hook guarded by the finger should be cautiously introduced up the vagina, and passed into the cranial cavity; having fixed it, as above directed, the finger should be applied externally, so as to correspond with the hook inside: by so doing, if the point slips or tears through the bone, the finger is ready to protect the soft parts from it; the operator is equally safe from injury, for, by grasping the shank of the hook with his thumb and other fingers, his whole hand moves with it and gives him instant warning of its going to slip. Where the deformity of the pelvis is very great, it may be necessary to break down the bones of the head still farther, in order to produce greater comminution; but even here, so long as the bones collapse well together, it will be better not to displace them from their attachments, the whole mass will come down better and with less chance of injuring the soft parts. Where, however, this is admissible, we must give the head sufficient time to undergo that process of softening which is one of the early stages of putrefaction; the cranial parietes may be gradually removed, one after the other, until we have nothing remaining but the base of the skull and the face. Dr. Burns recommends us now to convert it into a face presentation with the root of the nose directed to the pubes: “I have carefully measured, (says he,) these parts placed in different ways, and entirely agree with Dr. Hull, a practitioner of great judgment and ability, that the smallest diameter offered, is that which extends from the root of the nose to the chin.”
Embryulcia.This is merely a degree farther than the perforation: it consists in evacuating the chest and abdomen of their contents, and thus enabling their parietes to collapse. It is chiefly had recourse to in cases of deformed pelvis, where the arm or shoulder has presented, or where the distortion is so great as to prevent the trunk from passing without its bulk beinglessened. Dr. Smellie’s perforator with its scissor edges is best suited for this object. Having made an opening into the most presenting part of the thorax, we enlarge it by cutting away portions of the ribs and thoracic parietes, and removing the contents of the chest. The abdominal viscera are brought away in a similar way through a perforation in the diaphragm; and if this be not sufficient to let the trunk pass, the crotchet must be inserted into the brim of the child’s pelvis, which must be brought down doubled upon the spine, somewhat like the process of spontaneous expulsion.
The success of this operation, will, in a great measure, depend not only upon its being undertaken sufficiently early before the patient’s strength is exhausted, but upon a sufficient length of time intervening between the removal of the thoracic and abdominal viscera and the extraction of the child. The excellent rule of Dr. Osborn, above quoted, is peculiarly applicable here; for when softened by the effects of incipient decomposition, the body will sometimes even be expelled by the unassisted efforts of the uterus.
In a case of this sort, the perforation of the head is the last part of the process to be performed. It will be by all means, desirable not to separate it from the body, but to pass up the curved perforator along the neck, and make an opening behind the ears: this is effected without much difficulty, and the head can be brought away whole, or in portions, according to the nature of the case.
DYSTOCIA, OR ABNORMAL PARTURITION.