ARTIFICIAL DELIVERY THROUGH THE NATURAL PAS SAGES AS A SUBSTITUTE FOR THE POST-MORTEM ClESAREAN SECTION.
The choice of operative method will de pend upon which of these conditions is present.
1. Labor has begun; the Cervix is dilated or Although delivery by the natural passages, as a substitute for the Caesarean section, was advocated for the first time by Schenck, in 1665, it was Rigaudeaux who first resorted to it, in 1745, in a woman who was believed to be dead, but was only in a state of apparent death. Delivery by version was successful, and thereafter, Baudelocque, 1796, Capuron 1811, Gardien, 1824, Velpeau, 1835, pronounced themselves in favor of it. In 1832 Heymann, and in 1833 Rizzoli, even went so far as to advise the accouchement force in case the cervix was not dilated or dilatable, but in France and in Germany, Siebold, Naege1(, Velpeau, Chailly, Cazeaux, opposed this and pronounced in favor of the Caesarean section. Du parcque, Devilliers and Otterburg, nevertheless, agreed with Rizzoli, and in 1861, Depaul counselled delivery by the natural passages, no matter what the condition of the cervix. One thing, however, is indispensable, and this is a normal pelvis, since success will depend on the ease and rapidity of the operation. For lack of attention to this prerequisite, Beluzzi, in 1863, after vainly attempting delivery by the natural passages, resorted to the Caesarean section too late to save the child.
The pelvis being normal, either, 1, the head presents and is deeply en gaged, or, 2, it presents but is movable above the superior strait, or, 3, another portion of the fmtus presents.
In the first instance we should, of course, deliver at once by the forceps. Reinhard reports five cases, one successful (Jackson), and Devilliers one case, child dead—that is 6 cases, with 5 dead infants. Under the second condition there are no cases on record; under the third, version is indi cated, and ThIvenot cites 5 observations: Verhtift, 1819, child saved; Tali nucci, 1854, child dead; Bataille, 1861, child lived seven hours; Franchini, 1861, child saved; Ganiot, 1863, child dead. In all these instances delivery was easy, except in Ganiot's, where the extraction of the after coming head required incision of the cervix and the forceps. Success, it is apparent, will depend on the little time which elapses between the death of the mother and resort to operation; for although Villeneuve cites cases where living children were obtained by the Caesarean section from two and a half to four hours after maternal death, these cases are not authentic, and fifteen minutes must be stated as the extreme limit at which it is possible to obtain a living child.
2 Labor has not begun, or has just begun.—In this case, Duparcque, Heymann and Rizzoli, also counsel delivery per vias naturales, and state that the procedure is not of much greater risk to the infant than under the previous condition. Thevenot reports a number of instances, cases
of Rizzoli, Golinelli, Capari, Beluzzi, Hyernaux, Rivani, Talinucci, etc., and in five of the cases the mothers were only in a state of apparent death, the children being delivered alive. It is on account of the fact that we cannot always be sure of the mother's death that Thtvenot, and we agree with him, counsels delivery per vias naturales in preference to the Caesa rean section. Ordinarily the hand suffices for dilatation, although, where necessary, the cervix may be incised, and delivery accomplished by the forceps or by version.
In 1827, Costat claimed that it was incumbent on the accoucheur to terminate labor in every instance where pregnancy was complicated by a disease threatening the mother's life, whenever the fcetus was viable. Of the instances where this advice was followed we cite: Duparcque, 1840, consumptive woman in extremis; Guiseppe, 1844, in a case of apoplectic coma; Esterle, 18€1, reports 4 cases, infants all living; Beluzzi, 1877, 3 cases. Thtvenot collects, altogether, 15 instances of accouchement force, in extremis, with 13 living children, 6 surviving, and 5 mothers saved, 3 relieved. These cases are certainly encouraging, although we cannot quite share ThC.venot's opinion: " Delivery should be resorted to in the interest of the mother as well as of the child, and furthermore the ac couchement force, in extremis, is without danger." It is the opinion of all obstetricians that accouchement force in the living woman is a disas trous operation, and should only be resorted to as an ultimum refugium, and yet it is advocated on a dying woman, where the least shock may be the last drop which causes the goblet to overflow! The logic is false, and, as one of the observations proves, it is rather for the spiritual than for the temporal interest of the child that the practice has been advo cated, to baptize, in other words, the infant. The fact is that no one is in a position to say positively that the woman is dying, and therefore we would reject absolutely accouchement force under these conditions, and we would formulate our practice as follows: 1. Labor has commenced, cervix is dilated or dilatable; rapid extraction by forceps, or by version.
2. Labor has not begun.
a. The woman is dead, or in a state of apparent death; delivery per vial naturales, by incision of cervix, if necessary, and forceps or version.
b. The woman is in extremis: Respect her condition, and do not hasten her end by manoeuvres which may posssibly not save the child. Once the mother dead, however, act quickly in the interests of the child.