In all cases in which the obstructions or deformities of the pelvis reduce the diameter of its excavation to two and three- fourths inches, the operation for inducing premature labor is proper after seven months of pregnancy. And the injury upon the vital organism is much less now than at an earlier period. And the prospect for saving both mother and child is much better by this operation, than by the Caesarean section.
But cases in which the least diameter of the pelvic excavation is but two and a half inches, had better be allowed to go to full term; and then submitted to Caesarean section. This course wards off the crime of murder, and affords a good opportunity for saving both mother and child; for this operation of the Caesarean section, performed by skilful hands, under Homoeopathic treatment, affords a very much better chance for saving the life of the mother, than under the Allopathic regime. Another consideration of great weight is the fact that nearly all the extreme pelvic deformities are only brought to light at the very time of parturition; and it stands us in hand to perfect ourselves in the surgical art, so as to be able, in such trying circumstances, to save both lives. (*For History of the operation of Caesarean section, see Meigs’ Velpeau, Philadelphia, 1852, p. 546.)
But if, after all, abortion must be produced by some timid persons, who dare not do right, or by those who feel incompetent to perform the operation of Caesarean section at full term; let it be performed in the best possible manner; and never unless the smallest diameter be under two and a half inches; and never at all until after the third month. The operation being determined upon, the same means should be employed as in the induction of premature labor. The most eligible time for the operation is between the fourth and fifth month.
But to return to the Caesarean section; this operation has been resorted to quite frequently in cases in which the passages have been found too restricted to give birth to the child. in the natural way. And this operation would always have been far more successful than former statistics show, had it been performed in a more timely season, and in a proper manner. In the great majority of cases it has been postponed till the subject as become nearly exhausted with fruitless efforts. This should not be. In the first place, the accoucheur should satisfy himself, or confirm his opinion by that of one or two other accoucheurs of nature judgment, that, from retraction or other deformity, the passage is certainly too small to admit passage of the child.
If the forceps can be applied, let every reasonable effort be make with them, to avert so formidable an operation an operation, as the Caesarean section. If the smallest diameter be less than two and a half inches, the Caesarean section will give a better prospect for the mother’s life, whether the child be living or dead. If the smallest diameter is greater than two and a half inches, and the child be dead, craniotomy may be preferable.
The time most favorable for saving the life of the child and of the mother, is to operate as soon as the os uteri has become dilated and the membranes ruptured, and before any attempt has been made to extract with the forceps or blunt-hook. Up to this time the patient has not become so much exhausted, while ample opportunity has been had for a correct prognosis of the case.
THE OPERATION OF THE CAESAREAN SECTION.
The operation of Caesarean section having been determined upon, the subject should be placed upon a bed of sufficient height for the convenience of the operator. An assistant should support the uterine tumor with considerable firmness upon each side; while a second assistant places one hand upon the fundus of the tumor, after stroking upwards any fold of intestines which may have slipped down between the uterus and the parietes of the abdomen. This hand must continue to press upon the fundus throughout the whole operation, with the view keeping the intestines from slipping down in from of the uterus.
The operator now makes a clean cut, from just below the umbilicus, down to or near the symphysis pubis, through the integument and subcutaneous fatty tissue, down to the peritoneum. This incision should be at least six inches long; and if necessary in order to secure this length, we must extend it to the left and along the umbilicus.
The next step is to cut a small opening into the peritoneum at the upper end of the womb into which a probe-pointed bistoury must be inserted, and this second, or internal incision, is extended to the lower extremity of the first or external one.
The uterus is now exposed; and through the tissues of this organ we must carefully cut, layer by layer, until the membranes are revealed.
The probe-pointed bistoury may be employed to divide these, in the same manner that it was used to divide the peritoneum.
An assistant should be employed to keep the lips of the womb apart; and in doing so he should keep the uterine and abdominal walls firmly together.
The extraction of the foetus is now to be accomplished by seizing the first extremity that presents. The uterus retracts at once by virtue of its elasticity; and by this means, also, the placenta is soon separated from the walls, and extracted at the same time, the membranes being twisted into a cord for their secure and complete removal.
After the uterus has been thoroughly emptied of all clots, &c., the wounded surfaces should be properly cleansed and allowed to come together. A simple dressing of the wound with adhesive plaster, a light compress thoroughly saturated with Calendula, and a body bandage to assist in keeping the abdominal walls in apposition, are all the external appliances that are needed. The patient must be allowed to drink as freely of pure cold water as she may desire; and for some days the abdominal compress must be kept well moistened with the preparation of Calendula. An occasional dose of Calendula, internally, will also be very serviceable. The patient must be kept quiet as possible; and very narrowly watched, so that the first symptoms of peritonitis may be combated, if any appear. See chapter on Puerperal Peritonitis. In this direction lies all the danger that need pertain to an operation conducted in the manner here described, and undertaken before the patient’s strength is too far gone to admit of hope of vital reaction from an operation whose very extent renders it grave. But as we so seldom lose a case of puerperal peritonitis arising in our practice, from all other causes, why should we not hope to be equally or even more successful here, where we have no miasm to contend with, noting but simple traumatic inflammation. But in all respects let the patient be treated din accordance with pure Homoeopathic principles.
This operation of Caesarean section should always be performed upon women who die with a viable foetus within their womb. It should be performed immediately after death; but with the same care at though the woman were alive, for sometimes death is only apparent. By this means many children have been preserved, and valuable lives saved to the community.
THE VAGINAL CAESAREAN SECTION.
This operation consists in making an incision into the lower segment of the uterus, in cases where there is no os to be found. The mode of operation is simply to make an incision into the segment, and them to introduce a probe-pointed bistoury, and make a crucial incision, taking care not to cut too far either way, for fear of wounding the bladder, the rectum, or the iliac vessels. After having thus made a crucial incision of an inch or an inch and a half each way, dilatation will be effected, the membranes will rupture and the child be expelled as in ordinary labors.
CRANIOTOMY.
This is an operation which should be performed only upon the dead child, and when the smallest diameter of the pelvis is above two and a half inches, and yet not large enough to admit the passage of the child by means of the forceps. If the smallest diameter is below two child by means of the forceps. If the smallest diameter is below tow
Fig. 123. Fig. 124.
Fig. 123. Smellie’s scissors closed.
Fig. 125. Smellie’s scissors opened.
and a half inches, the Caesarean section affords a better chance for the mother’s life.
The operation consists in puncturing the cranium; evacuating its contents; and, if necessary, in order to reduce the bulk of the head sufficiently to allow its passage, in removing the cranial bones till this object is secured.
In the first stage of the operation, Smellie’s scissors is perhaps the simplest means. The closed instrument is carried up the vagina, which it is prevented from wounding by the fingers being placed upon each side of the blade. See Fig. 125. In this manner it is directed against the most pendant portion of the cranium, when the sharp points may be made to pierce the skull by rotating the instrument back and forth in the hand which controls it. The fingers of the other hand should continue to guard the points till they have fairly entered the cranium, so that if they should slip, the soft parts of the mother will still be protected from harm.
