cervix of the pregnant uterus is to be removed as in the non-
pregnant. Abortion is not inevitable upon operation in such
cases, and the patient should not be allowed to suffer by delay.

Still more imperative is the obstetrician's duty in pregnancy
complicated by ovarian tumors. So soon as a diagnosis can be
made such a tumor should be removed. Under antiseptic pre-
cautions the prognosis for recovery and continuation of pregnancy
is excellent.



CHAPTER XXVIII.

THE SURGICAL TREATMENT OF COMPLICATED LABOR.

IT is sometimes necessary to terminate labor by a resort to surgi-
cal operations. Such operations have for their object the saving
of the life of the mother and child, or saving the life of the
mother at the sacrifice of that of the child.

Under the first heading may be included the Csesarean sec-
tion, and amputation of the pregnant uterus. By Csesarean sec-
tion is understood an incision into the abdomen, an incision into
the uterus, the extraction of the child with its placenta and mem-
branes, and the closure of the uterus by suture. This operation
is of great antiquity, taking its name from the Roman Caesar
who is said to have been born in this manner. Since antiseptic
surgery has attained its present perfection, this operation has
been revived with excellent results.

The indications for the Caesarean section deserve especial con-
sideration. The child must be living and viable; the mother
must not be infected by septic infection, nor can her uterus be
the seat of a pathological process which would prevent a uterine
incision from healing. There must be such disproportion
between her birth-canal and the size of her foetus that the
delivery of the latter alive is impossible. The consent of the
mother, or, in the event of her being unconscious, of her nearest
relative, must be secured. When these conditions are present
the success of the operation will depend upon three grounds :

i st. A knowledge and faithful application of antiseptic pre-
cautions.

2nd. The co-operation of at least one intelligent assistant.

3d. Adequate closure of the uterine incision.

In regard to the first, the operator should thoroughly antisepti-
188



THE SURGICAL TREATMENT OF COMPLICATED LABOR. 189

cize his hands, instruments and appliances. The abdomen of
the patient should be scrubbed with soap and water, washed with
ether and then with a solution of bi-chloride of mercury, one to
one thousand. No antiseptic fluid should be introduced within
the abdominal cavity. If it is necessary to wash out the abdo-
men, it should be done with boiled water at a temperature of
100. If the interior of the uterus is found in a condition re-
quiring disinfection, this can best be accomplished by tamponing
it with iodoform gauze, the ends of the tampon emerging
through the vagina. The assistant, whose co-operation is
essential, has for his function compression of the uterus to pre-
vent haemorrhage. He should also observe the strictest antisep-
tic precautions by especial attention to cleansing his hands.

The question of the method of closing the uterine incision has
occasioned much discussion, and seems finally to have reached a
satisfactory solution. When the Caesarean operation was revived
by Saenger, it was thought necessary to close the muscular tissues
of the uterus, and also the peritoneum covering that organ, by a
separate line of sutures. While this is undoubtedly a safe and cor-
rect method of operating, yet others have performed the opera-
tion successfully by including the peritoneum and muscular tissue
in one suture, approximating the edges of the incision with great
care. As first performed, the sutures during the operation were
not passed through the decidua lining the uterus, but in various
operations this has been included in the sutures without disastrous
results. It is of the greatest importance, however, that a suffi-
cient number of sutures be used to solidly approximate the edges
of the incision. It is of paramount importance that the edges
of the peritoneum covering the uterus be brought carefully into
apposition so that they may unite perfectly.

The material employed for sutures may be silver wire, catgut,
or silk. If catgut be employed, none but the best quality should
be used, as otherwise septic infection or loosening of the edges of
the incision may result disastrously to the patient. If possible,
the patient should be prepared for operation in the manner usual
before all abdominal sections. No solid food should be taken



1 90 MANUAL OF PRACTICAL OBSTETRICS.

for a day before the operation, the bowels should be thoroughly
emptied, several antiseptic vaginal douches should be given, and
if a suspicious discharge from the uterus persists, the vagina
should be tamponed at the time of operation with iodoform
gauze. Beside the chief assistant already mentioned, two others
will be found useful, with a trained nurse. One of the assistants
should give the anaesthetic, the other should be ready to devote
his entire attention to the resuscitation of the child.

The instruments needed are a scalpel, several pairs of haemo-
static forceps, two sizes of curved needles, a needle-holder, and
a piece of stout rubber tubing as large as the little finger, two or
three feet in length. If the patient have no bronchitis or dis-
ease of the kidneys, ether may be employed as an anaesthetic,
but should either of these complications be present, chloroform
may be used. At the time of operation, the nurse should have
ready bottles filled with hot water; whisky or brandy, digitalis,
aromatic spirits of ammonia, fluid extract of ergot, or a solution
of ergotine especially prepared for hypodermic injection, and a
solution of morphia. The usual basins and pitchers for washing
sponges and for irrigating the abdominal cavity should be in
readiness. It is well to have also a fountain syringe with a suit-
able tube for giving a vaginal douche. In addition, there should
be in readiness a small tub filled with hot water for use in resusci-
tating the child. The patient having been anaesthetized, the
chief assistant stands beside the operator with the rubber tubing
already mentioned within convenient grasp. The operator will
desire to incise the uterus upon its anterior aspect about midway
between the fundus and the lower uterine segment. The period
of labor chosen for operation is preferably the end of the first
stage when dilatation is nearly complete. An abdominal incision
of from three to five inches should then be made over the portion
of the uterus which the operator wishes to enter. The peritoneum
having been incised, two courses are then open for the operator ;
one is to enlarge the incision sufficiently to turn the uterus for-
ward out of the abdominal cavity; the other is to incise it as it
lies in the abdomen. If the uterus is turned out, towels which



THE SURGICAL TREATMENT OF COMPLICATED LABOR. 191

have previously been boiled and wrung out of freshly boiled
warm water should be laid over the intestines behind the uterus
and upon the abdomen so that the uterus may rest upon them.

Two methods of checking haemorrhage are available at the time
of the uterine incision. One consists in drawing the elastic tube
tightly about the uterus at the junction of the cervix and the
body; the other is grasping the uterus with both hands at the
region indicated, while the incision is made. The former pro-
cedure was followed by Saenger with good results; the latter has
been successfully employed upon several occasions. When the
uterus has been exposed, and the site of the incision determined,
and when the chief assistant is ready to check the haemorrhage
either by the tubing or by his hands, the operator opens the
uterus by an incision from three to four inches in length, ruptures
the membranes, feels for one of the foetal limbs, and extracts the
child as soon as possible. The cord should be immediately tied
and cut, and the child given to a second assistant, who devotes
his energies to establishing respiration. The operator should then
peel off the placenta and membranes and deliver them. If the
placenta and lining membranes of the uterus are found to be
healthy, the uterus may be immediately closed by two rows of
sutures, one through the muscular substance at intervals of not
more than half an inch, the other row of sutures passing through
the peritoneum. In the first, the needle should not pass through
the lining membrane of the uterus if possible, but should enter
the muscular substance, emerging just above the decidua. For
the second, or peritoneal suture, a continuous suture of catgut
may be employed, if desired. When the uterus has been properly
sutured, pressure made by the hand of the chief assistant or by
the rubber ligature should be relaxed. If an atonic condition of
the uterine muscle is present, ergot or ergotine may be given by
hypodermic injection. Should this prove ineffectual, the uterus
may be tamponed through the vagina with iodoform gauze. If
amniotic fluid has escaped into the abdominal cavity, free irriga-
tion with boiled water, at a temperature of 100, should be em-
ployed. The abdomen is then closed in the usual manner, a



192 MANUAL OF PRACTICAL OBSTETRICS.

firm antiseptic dressing placed over the incision, and the patient
treated in the manner usual after an abdominal section.

The placenta will often be found directly in the line of the inci-
sion. When this occurs, the operator cannot avoid incising the
placenta and causing free haemorrhage. He should not, however,
hesitate to incise the placenta, rapidly extract the child and sep-
arate and deliver the placenta, when the uterus will contract and
haemorrhage cease. Should the case proceed favorably, the pa-
tient will have the usual phenomena of the lying-in period. The
secretion of milk will be normally established, the involution of
the uterus will proceed with very little deviation from its usual
course, and no difference should be observed in the general
phenomena of the patient's recovery. In two weeks the stitches
may be removed from the abdominal incision, and in a month the
patient may go about, wearing an abdominal bandage. The lochia
are usually red in these cases, and less abundant than after normal
labor. The child presents upon examination a notable absence of
the configuration of the head usually seen after labor It is differ-
ent, however, in no other way from the child born naturally.

A number of cases are on record where the Caesarean operation
has been performed twice, occasionally three times, upon the same
patient. When the uterus is examined in such instances, no traces
can be found of the former incision. If catgut be used it will have
been absorbed. Silk is sometimes absorbed and sometimes encysted ;
silver wire of course remains, but so far as any difference in the
uterine tissue is concerned, the union is commonly perfect.

The prognosis for the mother and child in Caesarean section,
when performed as we have indicated, gives nine chances out of
ten for recovery to both.

AMPUTATION OF THE PREGNANT UTERUS. When the body of
the uterus is the site of a pathological process so that its tissues
when incised will not heal kindly, it is best to amputate the
uterus at the cervix. Thus, in cases of fibroids, where the inci-
sion would pass through a fibroid in performing Caesarean sec-
tion, necrosis and septic absorption would result if the usual
Caesarean operation were employed. In cases where the pelvis is



THE SURGICAL TREATMENT OF COMPLICATED LABOR. 193

so small that Etnbryotomy cannot be performed without great
danger to the mother, if the foetus be dead, and especially if sep-
tic infection has already begun, the uterus should be amputated.
The operation is made with the precautions which have already
been described as regards antisepsis. An incision is made over
the uterus, and the latter is tipped forward and out of the abdom-
inal cavity. It may then be encircled by the elastic ligature,
and steel needles resembling knitting-needles be thrust through
the ligature and cervix to keep the former from slipping when the
uterus is amputated. The uterus should then be incised, and the
child and its appendages removed. Instead of closing the womb
by suture, as in the Caesarean operation, the operator then ampu-
tates the uterus just above the elastic ligature. The peritoneal
covering of the uterus is then stitched over the stump, the stump is
brought up to the lower end of the abdominal incision, the perito-
neum is closed down to and around the stump, leaving the cut
surface above the line of peritoneal suture. The abdominal inci-
sion is then closed from above downward, the stump of the uterus
remaining at the lower end of the abdominal incision. If oozing
from the stump persists it may be powdered with iodoform and
plaster of Paris. If oozing be not present, iodoform should be
thoroughly sprinkled upon it, and an antiseptic dressing be placed
over it. The theory of the operation is that the stump of the uterus
will atrophy, contract and heal by granulation at the lower edge of
the abdominal incision. This process is slower than union in the
Caesarean section, and destroys any future possibility for repro-
duction on the part of the patient. Various other methods for
controlling the haemorrhage and ligating the stump have been em-
ployed. The stump has also been ligated, its peritoneal covering
drawn over it, and it has been dropped into the abdominal cav-
ity, but the method described has furnished the best results, and
is most practicable in the greatest number of cases. The chief
dangers following amputation of the uterus are haemorrhage and
septic absorption. Of these, the latter can almost invariably
be avoided by proper antisepsis ; the former is occasionally be-
yond control.
9



CHAPTER XXIX.

THE SURGICAL TREATMENT OF COMPLICATED LABOR.

EMBRYOTOMY. When the foetus is so much larger than the
birth-canal of the mother that it cannot be delivered without
sacrificing its own life and endangering that of the mother, one
of two procedures is inevitable, either to remove the fcetus by
the Caesarean section, or amputation of the pregnant uterus, or
to deliver the fcetus by lessening its size. The latter sacrifices
the life of the fcetus, if it be not already dead through pressure
of the uterus in efforts made to deliver the child. When the
fcetus has already perished, the duty of the obstetrician is to
deliver it through the natural channels, having previously lessened
its diameters. As any procedure which makes the fcetus smaller
accomplishes this by cutting the child, such a procedure is
termed Embryotomy. Thus, Embryotomy embraces piercing
the head, spinal column, thorax or abdomen, allowing the body
of the child to partially collapse, thus reducing its size. Em-
bryotomy would also include amputation of fcetal members in
cases where a fcetus becomes impacted in a transverse position.
The portion of the fcetus which is most frequently pierced to
lessen its size is the fcetal head, and a separate name has been
given to the operation of piercing the head and evacuating a
portion of its contents, namely, Craniotomy.

As Craniotomy is the most frequent operation for lessening the
size of the fcetus, it may be considered first. There are prac-
tically two methods for lessening the size of the fcetal head ; one
consists in piercing the skull with a sharp-edged instrument,
allowing the brain and its fluids to escape by the pressure of the
uterus upon the head; the other embraces the removal of a
portion of the cranial bones, leaving a permanent opening into
194



THE SURGICAL TREATMENT OF COMPLICATED LABOR. 195

the skull through which the brain is evacuated by the injection
of fluid. The second operation is done by means of a trephine
resembling that used in general surgery, but with a longer handle.
The instruments employed for simply piercing the head are based
upon the principle of a pair of sharp-pointed scissors having the
outer edge of the blades near the tips ground to a cutting edge (Fig.
94). The scissors are introduced and the handles separated, thus
causing the outer edges of the blades to enlarge the opening made



FIG. 94.




SMELLIE'S SCISSORS.

by the points. The scissors may then be turned at right angles
to the direction of insertion, and the blades opened a second
time, when a cross-shaped incision will result. Other more
elaborate perforators are based upon the same principle as the
perforating scissors (Fig. 95).

An indication for Craniotomy exists in a case where the foetus



FIG. 95.




BLOT'S PERFORATOR.



is too large for the mother's birth-canal, is presenting by the
head, and has already died. In a similar case where the foetus
is living, the patient and her friends must choose between a
Caesarean operation and the destruction of a living child by



196 MANUAL OF PRACTICAL OBSTETRICS.

Craniotomy. The opinion is gaining ground among the medical
profession that Craniotomy upon the living child is unjustifiable,
and this opinion is likely to obtain a still firmer footing as physi-
cians become more familiar with obstetric surgery. It is always
well to respect the beliefs of the parents of the child regarding
religious observances, as many persons discourage Craniotomy
upon theological grounds.

It should be borne in mind that Embryotomy requires antisep-
tic precautions as complete and as carefully carried out as an
abdominal incision. A vaginal douche of bi-chloride, one to
five thousand, should be given, the hands and arms of the opera-
tor should be disinfected, his instruments cleansed with boiling
water and immersed in a five per cent, solution of carbolic acid,
or a two per cent, solution of creolin. The patient should then
be anaesthetized, placed across a bed or upon a table, and the
operator should ascertain the exact position of the head by a
thorough examination.

If it is decided to pierce the skull without making a perma-
nent opening, the fingers of one hand should be introduced as a
guide, and with the other the point of the perforator should be
firmly but gently forced through the foetal skull. It is well not
to enter the head in a line of a suture, but to make an incision
through bony tissue. The blades of the perforator should then be
separated, the instrument turned at a right angle, and the blades
again opened as has been described. The case then should be left
to the expulsive efforts of the mother, the expectation being that
pressure of the uterus will force out the brain and its contents, and
then collapse the head. Should the mother's expulsive forces fail,
the forceps may sometimes be used to advantage in completing
delivery. If the head be well ossified, especially at the base of
the skull, the simple perforation may be followed by the use of an
instrument, designed to crush in the head by strong pressure,
known as a cephalotribe (Fig. 96). This is nothing more than a
strong pair of forceps with suitable apparatus for forcibly bringing
the blades in apposition. A better procedure, however, than in-
. cising the skull is removing a portion of bone by the trephine.



THE SURGICAL TREATMENT OF COMPLICATED LABOR. 197

Two sorts of obstetric trephines are in use, the straight and the
curved. Of these the straight trephine is the better because of
its simple construction and the ease with which it can be taken

FIG. 96.




LUSK'S CEPHALOTRIBE.

apart and disinfected. By removing the screw button at the end
of the trephine, the instrument can be separated into its three por-
tions, each of which is readily cleansed (Fig. 97). In addition

FIG. 97.



MARTIN'S STRAIGHT TREPHINE.

to the trephine, there is needed to evacuate the brain a tube of
metal or hard rubber sufficiently strong to be passed freely
around the interior of the skull, thus breaking up the brain and
its membranes. To this tube should be attached a piece of rub-
ber tubing through which an antiseptic solution may be injected
with considerable force by a strong piston-syringe. After the
head has been opened and the brain evacuated, there is required
for the extraction of the head some instrument one of whose
blades shall pass within the opening made by the trephine while
the other, applied upon the external surface of the skull, fits into
the first by a firm screw upon the handles, thus securing a sure
grasp upon the head. This instrument has a pelvic curve like



198



MANUAL OF PRACTICAL OBSTETRICS.



that of the forceps, and traction is made by it in the axis of the
pelvis as in axis-traction-forceps. As the head descends, pressure
of the walls of the pelvis collapses the head, and it emerges drawn
out in a shape somewhat resembling a sugar-loaf (Fig. 98). The



FIG.




FCETAL HEAD TREPHINED AND DELIVERED BY CRANIOCLAST.

procedure of extracting the head and collapsing it in this manner
is known as Cranio-Clasis, and an instrument designed for this
purpose is called a Cranioclast (Fig. 99). The instrument will
be better understood by reference to (Fig. 100) which represents
the Cranioclast devised by Carl Braun of Vienna.

To contrast the two methods of lessening the size of the head



THE SURGICAL TREATMENT OF COMPLICATED LABOR. 199

we may repeat that the skull may be entered by an incision through
the bone with a perforator. A pair of strong compressing forceps,
with a compressing screw at the extremity of the handles, may
then be employed to crush the head and extract it. This is known

FIG. 99.




GRASPING THE HEAD WITH THE CRANIOCLAST.



as Cephalo-Tripsy, and the compressing forceps is named a
Cephalotribe.

FIG. 100.




* BRAUN'S CRANIOCLAST.

On the other hand, the skull may be trephined and the brain
evacuated, and an instrument employed to make traction, one
blade of which is inserted through the trephine opening, the



200



MANUAL OF PRACTICAL OBSTETRICS.



other grasping the head externally, while compression is made
by a strong compressing screw. Traction in the axis of the



FIG. 101.




CRANIOTOMY WITH THE SIMPLE PERFORATOR.
FIG. 102.




CRANIOTOMY WITH THE TREPHINE.



THE SURGICAL TREATMENT OF COMPLICATED LABOR. 2OI

pelvis results in the collapse of the head through pressure of the
pelvic walls. This is Cranio-Clasis, and the instrument is a
Cranioclast.

In cases where twins have become impacted in the uterus, and
one or both have perished before assistance arrives, it may be
necessary to decapitate the child already partially born, to relieve
the mother. In cases of transverse presentation, where the uterus
is in a condition of rigid contraction known as uterine tetanus,
it may not be safe to attempt to make version because of the
danger of uterine rupture. There remains then nothing to do
but to decapitate the foetus and remove the body and head
separately.

In transverse positions, amputation of the head may be per-
formed by passing a heavy cord about the neck and, by a sawing
motion, cutting slowly through the tissues (Fig. 103). When the
child's spinal column is reached, if the cord be guided to the in-
tervertebral cartilage, decapitation may be accomplished without
especial difficulty. Should the cartilage not be readily found, a
cutting instrument may then be employed to finish the decapita-
tion. A very convenient and safe instrument for this procedure is
the hook devised by Carl Braun (Fig. 104). This hook is passed
over the child's neck, drawn strongly downward, and a rotary
movement from side to side kept up until finally the tissues are
completely severed. It is best to employ, if possible, some instru-
ment or device having no sharp cutting edge, as the danger of
wounding the soft tissues of the mother is great. Braun's hook is
carefully polished, and presents no edge which should injure the
maternal tissues (Fig. 105). In cases of impacted foetus where the
body of the child is already born, decapitation may be accomplished
by the use of a pair of ordinary strong scissors and a piece of
rubber tubing. The tubing should be passed about the neck and
tied, forming a circle around the child's neck. Its purpose is to
serve as a guard against cutting too high and injuring the tissues
of the mother. Guiding the scissors with the left hand, with the
right hand the tissues are severed just beneath the constricting tube,
and thus decapitation is accomplished.



202



MANUAL OF PRACTICAL OBSTETRICS.



Ingenious instruments have been devised by which a cutting
edge, in the form of an ecraseur or cutting wire, may be passed
about the head, but such instruments are more complicated and