Essays In Pastoral Medicine

by Austin O'Malley; James J. Walsh

If the conjugata vera is from 10 to 9 centimetres, or from [{57}] 9.5 to 8.5 centimetres, labour without operation is the rule, and the child can usually be delivered by forceps. Should the child die during labour in these cases, it is best delivered by craniotomy, unless the longer diameter of its head has already passed the narrowest part of the pelvis.

When the conjugata vera is from 8.9 to 7.5 centimetres, about 50 per centum of the women will be delivered with forceps, but the other half will not. After about two hours of the second stage of labour delivery by forceps is tried, but prolonged traction is not applied. Occasionally delivery will come when least expected, but often it will not. If the head sticks, caesarean section is done in favourable circumstances, and craniotomy in unfavourable circumstances. If there is ground for supposing that septic infection of the mother has begun, the conditions are explained, and if she wishes to have the caesarean section done the risk is left to her. When the breech or face of the child presents in contracted pelves, the condition is especially unfavourable for the child.

There are very many varieties of deformed pelves, but the same rules apply to them as to those already mentioned, except that the caesarean section is oftener indicated. Difficulty also not seldom occurs in women with normal pelves from an excessive size in the child through prolonged pregnancy, bigness of one or both parents, or the advanced age or multiparity of the mother. The child's head alone may be of excessive size. Some monsters offer difficulty in delivery from size or shape, but, of course, they are human beings, and are to be considered as such in delivery. The technique of the caesarean section has only a medical signification, and it need not be described here.

Symphyseotomy is an operation in which the joint of the pelvis at the symphysis pubis is cut, and the pelvis is allowed to gape so as to let out the child. The operation has fallen into disrepute. The mortality as regards the mother is about the same as in the caesarean section, but the mortality of the children is higher. In symphyseotomy the infantile mortality is about 9 per centum, while in the caesarean section it is practically nothing. If in symphyseotomy an error is made in estimating the size of the pelvis or the child's head—and [{58}] such an error is often possible—the child will be killed, but in the caesarean section these errors make no difference. After the caesarean section the woman recovers promptly; after the symphyseotomy she recovers very slowly, and she may receive permanent injury.

Craniotomy is an operation wherein the head of the child is reduced in size to render delivery possible. The skull is perforated and the brain is broken up and removed or crushed out. Embryotomy is a similar operation wherein the viscera of the child are removed through an incision made in its thorax or belly (evisceration), or the head of the child is cut off (decapitation). There are numerous instruments and methods for performing craniotomy and embryotomy, but they all open the skull or belly, remove the brain or viscera, and then extract the child's body.

If the infant is hydrocephalic and is alive, the advocates of the operation warn us to be careful after opening the head to push the perforator into the base of the skull and stir it around well, so as to be sure the child will not be born alive. Pernice has recently reported a case of hydrocephalus which was delivered by craniotomy, but the operator did not work his perforator efficiently, and the child recovered, and grew up an idiot. A similar case occurred in Baltimore.

The indications for craniotomy among those that advocate its occasional use (and they are many) is in those cases in which the woman is so infected that caesarean section is dangerous, or where a child is hydrocephalic, or where an after-coming head is jammed (in this case even a caesarean section will not effect delivery), or in the case of a narrow pelvis and a moribund child, or finally in the practice of a country physician, who can not in an emergency get an assistant to do a caesarean section. One man can do craniotomy, but it requires three to perform the caesarean section. If the woman's narrow pelvis has a conjugata vera of five or more centimetres, craniotomy, if properly done, is not dangerous to the mother. With a conjugata vera less than 5 centimetres it is more fatal than the caesarean section. If the women are septic, the mortality in [{59}] craniotomy is from 10 to 15 per centum; in caesarean section about 25 per centum.

As to the morality of craniotomy on the living or moribund child, it is not permissible under any possible circumstances: a consideration of the ethical principles set forth in the article on Ectopic Gestation will make this assertion clear.

The Congregation of the Holy Office on August 19, 1888, decreed that "In scholis catholicis tuto doceri non posse licitam esse operationem chirurgicam quam Craniotomiam appellunt." They gave a similar decision May 28, 1884, and they repeated the prohibition, with the papal approbation, on July 24, 1895. The text of these decrees may be found in the article on abortion, miscarriage, and premature labour.

The Porro operation consists essentially in a removal of the uterus after caesarean section to prevent further conceptions. As a means to prevent conception it is altogether unjustifiable, because repeated caesarean sections in the same woman, if the surgeon is at all competent, are practically no more dangerous than normal labour.