Charles Delucena Meigs Alfred Velpeau.

A complete treatise on midwifery: or, the theory and practice of tokology ... online

. (page 88 of 102)
Online LibraryCharles Delucena Meigs Alfred VelpeauA complete treatise on midwifery: or, the theory and practice of tokology ... → online text (page 88 of 102)
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says that, while A. Leroy discussed the necessity of the Caesarian operation, the
woman delivered herself without any assistance! It would be ridiculous to pro-
pose, at the present day, after the fears of Monro on the subject, as Aitken and
oarrois did, to place the woman under water during the operation, so as to pre-
vent the entrance of air into the peritoneum. Bleeding, baths, purgatives, or
any other proper means may be sometimes made use of. And lastly, the con-
duct here, in relation to the preparations, is the same as in all the great opera-

If the bag of water* is not ruptured, ought it to be torn, as Planohon advises,
previously to making the incision into the womb, or must it be let alone, as most
authors advise? By emptying the membranes, the escape of the liquor amnii
into the peritoneum is prevented, and there is less reason for fear as regards
hemorrhage and inertia of the womb. But these are not the most to be dreaded
of ail the occurrences that may take place during the operation; we are much
more frequently embarrassed by the contraction of the womb than by its inertia.
When the ovum is whole, the child can be much more easily extracted; the
wound in the uterus, at first more extensive, is, however, reduced^ last to much
smaller dimensions; lastly, there is less irritation excited in the womb, and upon
a careful consideration of all the circumstances, I believe, in common with M.
Desormeaux, that it is better to preserve the membranes whole.

We should never omit to empty the rectum and bladder, especially if it be
intended to follow the method of Mauriceau. The apparatus oonsists of a con-
vex bistoury, a straight probe-pointed bistoury, pincers, scissors, suture-needles,
thread, quill-barrels, adhesive strips, lint in rolls and in pledgets, or pieces of

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linen spread with cerate, of compresses both oblong and square, a bandage for
the body, small and large sponges, a syringe, canulas of gum-elastic, to be used
in case it should be necessary to make any injections, water, both cold and warm,
and vinegar; wine and Cologne water are also necessary.

If possible, the patient should be laid on the bed that she is to occupy during
the first few days after the operation; her position ought to be an easy one. She
should be placed on her back, with the legs and thighs very slightly bent, and
assistants are charged to watch against any sudden movements which the pain
might compel her to execute; two intelligent assistants must apply their hands
upon the sides and fundus of the womb, so as to circumscribe it very exactly, in
order that no organ may happen to slip betwixt its surface and the abdominal
parietes, and so that it may compose with the latter parts but one single mass.
For this purpose, the naked hands seem to me less suitable than they would be
if applied upon pieces of broad flat sponge, as advised by.Dr. HSdenus, as MM.
Walther and Kluge were in the habit of doing, and as I have done myself.

b. Incision. — With the convex bistoury the surgeon makes an incision through
the integument*, from near the umbilicus towards the pubis, in length from five
to six inches, without its being necessary, or always even possible, to pinch up a
large fold of them, as advised by Levret. The subcutaneous layer, the aponeu-
rosis and the muscular fibres, as well as the cellular tissue, provided we do not
operate upon the median line, are successively divided in the same manner and
to the same extent. This incision ought not to be carried too near to the pubis,
on account of the bladder, and because the abdominal parietes are generally very
thick in that situation. It would be better to extend it above the umbilicus,
taking care to pass to the left of it, so as to avoid the umbilical vein, and more
particularly the anastomosis which may exist between it and the epigastric vein,
an anastomosis which has latterly been noticed by M. Mesniere, Clement, and

After having opened the peritoneum, so as to admit of the introduction of the
left forefinger, to serve as a conductor for the instrument, the wound in that
membrane is to be enforced by means of the probe-pointed bistoury, to the same
extent as the wound in the skin.

The vjomh is now exposed; it is to be incised layer by layer, and slowly, until
we reach the surface of the ovum; then, in order to retain for the cervix as
much of its length as possible, the assistants are told gently to press the fundus
of the uterus downwards and make it turn somewhat in front ; we might, indeed,
like Dr. Kluge, hook the lower angle of the wound of that organ with the finger,
so as to favor such a movement, which, by affording a facility for extending the
section very far upwards, permits us to guard the cervix. With reason, Deleurye
and Levret advise the incision of the womb to be made from below upwards so
as to prevent the intestines from escaping, as they well supposed that the uterus
should serve as a point dappui for the incision of the abdominal parietes. In
order to avoid the risk of wounding the vessels of the placenta, it is better to
use the probe-pointed bistoury to finish the incision, than to have recourse to the
grooved director to guard the bistoury with. Further, I can conceive no objec-
tion to letting the point of the finger detach the placenta and membranes to a
certain extent

This is the moment, and not before the commencement of the operation, that
it would be perhaps well to follow the advice of Planchon, and rupture the mem-
branes by the vagina, either with the fingers alone, or with the instrument of
Siebold, as is generally done in Germany. Supposing, which appears to me pre-
ferable, that the membranes should be pierced from the incision, it will be neces-
sary for the assistants to redouble their care to prevent the parietes of the abdomen
from abandoning the womb. In this way the effusion of the waters into the cavity

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of the peritoneum will be obviated, and the tendency of the viscera to escape oat-
wards will remain ineffectual.

c. The extraction of the child ought to take place without delay; when it pre-
sents by the head or by the breech, it is drawn away in that position, and, to favor
its escape, the assistants are told to press gently upon the sides of the womb through
the parietes of the abdomen; if it be situated otherwise, the feet must be got hold
of, and the extraction performed with the same precautions as in delivery by the
natural passages, special care being taken not to bruise or stretch the lips of the
wound in the uterus.

As soon as the foetus is withdrawn, the practice recommended by Planohon
might be adopted, viz., by means of a sound the cord might be repassed through
the wound, for the purpose of removing the after-birth through the vagina, but
no beneficial effects would be ultimately obtained by it, and the oelerity of the
operation would be sensibly lessened. After all, the retraction of the womb, which
would most generally render this operation impossible, soon forces the placenta to
engage in the wound, and thus points out the route we should select in extracting
it. In order that it may present less volume and less resistance, one of its edges
even may be taken hold of, if possible, rather than pull it away by the cord only.
As to the membranes, they must be carefully twisted into a rope as in a natural
delivery, to prevent any of them from remaining in the uterus. Should any
blood have been lost and formed into clots, these ought to be removed with the
hand. It would be well, moreover, to cleanse all the parts by means of an injec-
tion of warm water: but I do not think, with Wigand, that it is neoesBary to
carry the hand into the uterus to excite its contraction, and to repel the placenta by
the natural way : nor, with Stein, that we should place in its cavity a piece of
sponge three inches long, to be left there as & point tfavpui for the uterus, or to
absorb the injections; nor that, for the purpose of keeping the os uteri open, it is
of any advantage to place in it the tent recommended by Baudelocque, or the
cierge pertuui of Buleau, or the tent of Kousset, or the sound of M. Tarb&s, or
any species of canula whatever; these means would not prevent the os uteri from
closing, and would augment the irritation to no purpose. The finger introduced
from time to time suffices to keep it free enough, should it cease to give issue to
the matters, which, after all, nothing can prevent from passing wholly or partly
out of the wound.

d. Brewing. — The operation being terminated, we must next think of putting
a stop to the flow of blood. In the lateral operation, and especially in that of
Lauverjat, several arteries may have been divided; they should now be tied, pro-
vided they should not have been secured during the progress of the operation.
During the operation, the principal orifices of the uterine arteries have been closed
by the fingers of the assistants; there never can arise any question about obliterat-
ing them with the ligature; although Sieboldand M. Bitgen have thought proper
to recommend it But it has been recommended to cauterize them with vitriol ;
to touch them with alcohol; to apply, as Heister does, the balsam of copaiba to
the wound ; and, generally, to trust diem to the contraction of the womb, which
is to be solicited, provided it be slow in taking place, by irritating the cavity of
the organ or tho lips of the wound with the fingers, or linen moistened with vine-
gar and water. After a few minutes, the length of the incision in the womb is re-
duced to from one to two inches, and thenceforth hemorrhage of any kind becomes
impossible. I shall pay no attention to the advice of M. Michaelis, who, in order
to prevent future impregnation, and especially, says he, to avoid too great reaction,
proposes the extirpation of the uterus; nor to that of Blundell, who recommends
cutting the Fallopian tubes, or, better still, the excision of a part of them with the
same view !

In England, in Germany, and also in France, the wound in the abdomen is
generally closed by the interrupted or twisted suture, because, it is said, that is

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560 of OBffrraic operations.

the only means of keeping the lips in contact, and of preventing hernia of the
viscera. Zang and Autenrieth even insist on the satores being applied before the
incision is made into the womb, so that it may be closed up as soon as possible.
Sabatier and Deleurye, however, think it ought to be dispensed with, and say
that, unless the whole thickness of the abdominal parietes be included in each
stitch, which would be dangerous, the adhesive stripe will do as much as the
sutures, without compromitting, in the same manner, the safety of the patient
But, notwithstanding the reasons urged by that learned author, it seems to me to
be preferable to have recourse to the suture, even where Lauverjat's operation has
been adopted. In all cases, the lower corner of the wound should be left free to
allow the matter to escape. Besides, the sutures do not prevent the application
of adhesive strips over their intervals, nor the favorable action of a uniting band-
age and a proper position.

The wound is then covered with a piece of linen, perforated, or with strips
spread with cerate; two long and broad compresses are placed on the sides; some
pledgets of soft lint, common compresses, and a body-bandage well applied, will
complete the dressing.

Previously to leaving the woman, the linens soiled during the operation should
be removed ; she is to be placed in the middle of her bed, taking care to move
her as little as possible, and we should endeavor to place her so that her muscles
may be all in a state of relaxation.

Some antispasmodic potions, slightly opiated, to calm the nervous agitation ;
some precautions to ensure the discharge of the lochia by the vagina instead of
their escaping into the peritoneum ; diluting drinks, bleeding and leeching, as
soon as any symptoms of inflammatory action become manifest; and the greatest
repose, both of mind and body, are all that the surgeon can recommend to the
patient to obviate the dangers which threaten her.

B. Vaginal Caesarian Operation. 1. Indications. — According to the reports
of authors, there are a great number of causes which may necessitate the per-
formance of the vaginal Caesarian operation. An obliteration, with fibro-cartila-
ginous induration of the os uteri, as in the case related by Simson, and also in
that other case spoken of by Van Swieten, is one of the most common causes.
Mad. Laohapelle and Duges have published three cases, and in that of Gauvy a
stylet could scarcely be introduced into the cavity of the uterus. Besides these
contractions, the possibility of the existence of which some persons have accused
me of denying, although I have never thought of so doing, and all doubt of
which has been removed by many examples which have been published, there
may exist also an actual occlusion of the os uteri which would demand still more
imperatively the vaginal incision. To what I have stated while speaking of the
deviations and occlusion of the uterine orifice in the article Dystocia, Lobetein's
case and that of Berger may be added as the most authentic ; and it is equally
necessary to append the examples of Rummel, Grimm, Rainer, and Meisner.
The operation on the patient of Lobstein was very successful, although the womb
closed again. Morlanne's case would have been still more positive if the body of
the woman, who died without being delivered, had been opened, and if her
parents had permitted an examination of the womb in situ.

Violent convulsions which endanger the life of the woman while the orifice is
too tense, and still insufficiently dilated to admit of the introduction of the hand,
as is observed in the cases by Dubosq and Lambron, are of the same kind.

An extreme obliquity of the orifice backwards, while the head of the child at
the same time forces down into the excavation, and even as low as the vulva, the
anterior portion of the womb, which it extends, renders thin, and would at
last rupture, provided an incision were not soon made, as was done by Lauverjat,
is the occurrence which has most frequently rendered it necessary.

Callosities and obliterations of the os uteri had already originated the idea from
the time of Maurioeau ; for Fournier, who advised it, said that he performed the

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incision by catting behind and in front with the fbrcep* deceptorius, or, even
better, with a sheathed bistoury of his own invention. Mesnard speaks in the
same way, and Barbaut maintains that in a similar case an incision of the os
uteri with or without the speculum suffices, and that it should supersede the
operation of gattro-hysterotomy.

It may also become useful where the uterus, having escaped from the pelvis
during pregnancy, has never been reduced, and where its orifice cannot be di-
lated l)y means of the fingers, although there may be danger in delaying the
delivery, as in the examples cited by M. Thenance, Jacomet, and a surgeon at
Vaux mentioned by M. Bodin and several others, of whom I have spoken in
the article Displacements of the Uterus, have cited oases of it ; but it has been
proposed more particularly in cases of scirrhus, and where the orifice presents
such a resistance to the contractions of the womb that the woman is exhausted
in vain efforts without affecting its dilatation.

The simple relation of the accidents which require it shows that the vaginal
Caesarian operation may be performed in two very different conditions. Some-
times, indeed, it is only necessary to unbridle the natural os uteri, which may be
more or less contracted or diseased ; at other times, on the contrary, we may be
forced to make an entirely artificial opening to reach the child. Its necessity in
the first case has been experienced by many practitioners. Lemoine said, long
since, that, if the callous os uteri resists bleeding and relaxing means, it is better
to cut it than to wait for it to tear. Smellie had his scissors for its performance,
and we see how Coutouly and Lauverjat gave it their confidence. The second
case also occurs frequently. The same plan of procedure should be followed,
whether in complete obliteration, as in the case met with by Solera, or for a
simple deviation, as in the examples of Lauverjat and Martin.

Lastly, it would be equally well indicated, as M. Bodin has attempted to
demonstrate in cases of arm presentation, should it ever in any case be found
really impossible to proceed in search of the feet, and if no' other means of
avoiding the amputation of the arm could be made available.

Although generally attended with but little danger, the accoucheur would be
blamable who should perform it without a well-ascertained necessity. I cannot,
therefore, but condemn in decided terms the temerity of those practitioners who
do not hesitate to employ it, simply because the os uteri happens to be somewhat
tense, and does not dilate according to their impatient desires ; and according to
what I said, when speaking of Deviations of the Os Uteri, I have no doubt that
it has often been performed when it might have been easily dispensed with.

2. Method of operating, a. Incision of theos uteri. — In all cases, if there
is an orifice, nothing is easier than to perform this operation; the speculum em-
ployed by some persons is of no use.

The woman should be placed as in touching, or the operation of version, accord-
ing as one or the other of these positions is most convenient to the accoucheur,
and best enables him to reach the point to be incised. Smellie's scissors, ana
the utero-stomatome of Coutouly, and all other instruments specially adapted
to the purpose, are of no advantage here.

A probe-pointed bistoury, wrapped round with a narrow strip of linen to with-
in eight or twelve lines of its point, is passed up upon the index finger; in this
way, we carry it without difficulty within the os uteri, provided it be not too far
distant from the centre of the pelvis ; in the contrary case, Pott's curved bistoury
should be substituted for the straight one. Strictly speaking, one incision might
be deemed sufficient, as Dubosq and Lambron advise. But, as it is important
that it should not be too deep, it would be preferable to make several of them
at a small distance from each other. This is the process on which Coutouly and
Lauverjat have already insisted, which Parea de Maggenti practiced with success
in 1791, and which Hoscati especially tried to bring into favor. The multiple

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incision gave to this practitioner complete success in the cue of a woman whose
08 uteri would scarcely admit a stylet. Paletta succeeded in the same way on
the same woman fifteen months afterwards. On the contrary, a patient who
was operated on by Moscati, the elder, by a single incision, died from a laceration
of the parte. Other persons have since related eases in favor of the multiple
incision. It was resorted to with success at the MatemiU at Paris, in a case of
contraction of the os uteri with adhesion of the posterior lip. Grimm was also
successful after three incisions in a case of contraction with great deviation.
Bonaiovani did the same in a case of hardening of the os uteri, in which he
failed with the forceps. The woman recovered. Soek acted in the same way,
and I have besides found examples where pregnancy with descent of the uterus
has called for the same operation. At a first view, it would seem that the pas-
sage of the head could not take place without enlarging such wounds so as to
extend them to the body of the womb, and lacerate the peritoneum ; but in fact
this does not happen, and they commonly remain limited to the substance of
the os uteri. In operating for a scirrhous or fibrous induration, but a very few
ounces of blood are found to flow from the wound. M. Mignot practiced vagi-
nal hysterotomy on a cow for an induration of the os uteri, saving both the
mother and her young, and succeeded as well on a woman.

b. Incision of the cervix uteri. — When the anterior wall of the uterus is divided
without extending the cut down to the os uteri, as Lauverjat, Martin, Lobstein,
Gaffe, Ac., have done, we are obliged to make use of a straight, or convex, and
not a probe-pointed bistoury, to begin the operation with, which is always a
more delicate one than the preceding. Too much care cannot be taken to avoid
wounding the presenting part of the foetus while making the incision. But,
when the womb has been once penetrated, the forefinger becomes a sure director,
and the instrument may enlarge the wound as much as necessary, without any
danger ; let us, however, observe that there is less hazard in extending the inci-
sion backwards than forwards, on account of the bladder, and also that it is
useless to make it very large. Posteriorly, the incision may reach the recto-
vaginal cul-de-sac of the peritoneum, or even the intestine. It is better, there-
fore, to resort to the multiple incision than a single cut If the woman remains
on her back, the head of the foetus runs less risk during the first incision, but
the tissues are also less easy to divide. When she is standing, the uteris is
lower down, and is put more fully on the stretch.

After the delivery, the wound contracts very rapidly, and it often happens
that not a half day elapses before the os uteri recovers its natural situation. If
blood should flow in too large a quantity, it would be easily arrested by injec-
tions of oxycrate, and by the tampon ; and the cautery, which is easy to apply,
will rarely be necessary in such cases. As to the lochias, they escape either from
the wound or from the orifice of the uterus, and in these respects the woman
requires only such cares as are common after an ordinary parturition. Prudence,
however, would dictate that a large gum-elastic catheter, or at least a tneche of
fine lint, should be maintained for some weeks in the new opening, if there has
been a real occlusion, or if the os uteri manifests any disposition to dose again
after the operation. M. Lobstein, who was obliged to withdraw this dilator
sooner than he wished, saw the cut close up speedily. The menses did not
subsequently appear with any regularity. Caffe was more fortunate, for the
menses took place through the cut from the woman upon whom he operated;
but it remains to be seen whether this will continue for a length of time.


England, the perforation of the cranium or reduction of the foetus, by

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removing successive portions of it, even where it is still known to be living, since
Osborne s time, is generally preferred to the Caesarian operation. Wigand, com-
bated by Bosch, maintains the same sentiment in Germany, while Osiander does
not seem to admit it in any case. The younger Stein gave the greatest possi-
ble extension to the employment of cephalotomy. He recommended it when
the labor was interfered with by any causes purely dynamic ; as, for example, in
oases of convulsions caused by the pressure of the head on the nerves of the pel-
vis. We agree still less with M. Kitgen who, in doubtful cases, prescribes com-
pression of the head, and such traction as to cause the death of the child before
perforating the cranium.

A. In France, the operation of cephalotomy is not performed, except where
the death of the child has been certainly ascertained, or at least become very pro-
bable, and where the delivery by the natural passages is altogether impossible.
When the pelvis has a diameter less than fifteen lines, or the whole hand cannot
penetrate into the womb, the Caesarian operation is preferred, even though the
child be dead. Upon this subject I will remark that our neighbors too rarely
have recourse to hysterotomy, and that they are too ready to sacrifice the child,
for fear of compromising the life of the mother ; that here we fall into an excess
of quite an opposite kind, and which is, perhaps, scarcely less blamable. In a
case where every circumstance announces that the foetus is still in full vigor, and
that it is robust, there is no doubt that, instead of sacrificing it, as is done in
Great Britain and at the north, it ought to be extracted without endangering its
life, by means of operations which indeed are severe, but not always fatal to the

Online LibraryCharles Delucena Meigs Alfred VelpeauA complete treatise on midwifery: or, the theory and practice of tokology ... → online text (page 88 of 102)