V. EMBRYOTOMY.
Embryotomy, properly so-called, is an operation which consists in cut ting off the neck or the body of the fmtus, when delivery is not possible, either by the forceps, version, or cephalotribe. It is, hence, an operation which is only exceptionally called for. The indications may be summed up under the following heads: 1. In presentation of the shoulder, where version is not practicable, ow ing to contraction of the uterus, or deep engagement and immobilization of the presenting part.
2. In pelvic contraction here the foetus cannot be extracted without risk to the mother.
3. In case of monstrosities, where there is excess in size of the fcetus. Of these indications it is unquestionably the first which is the most frequent.
The study of embryotomy has been pursued most completely by Pinard, in 1875, and by Thomas, in 1879. Pinard resumes the contra-indications of version as follows: A. Non-dilation of the Cervix.—The contra-indication is temporary, or else, in certain instances of cancer and fibrous tumors, it is absolute.
B. Deep Engagement of the Thtus.—The contra-indication is absolute.
C. Tetanic Retraction of the Uterus.—The contra-indication is similarly absolute.
D. Extreme pelvic Contraction.—Version contra-indicated in all pelves measuring less than 2.73 inches, if the infant is living; version is allowa ble whenever the hand can be introduced, if the infant is dead; below 2 inches version is not possible. The same rule applies in casq of any osse ous tumor obstructing the parturient canal.
We cannot accept in its entirety this classification, and although we share Pinard's opinion in regard to the three first indications for embry otomy, where version is impossible, we are absolutely at variance with him in case the infant is dead. In presence of the difficulty of version in contracted pelves, in presence of the death of the fcetus, it is not to version we would resort, but to embryotomy, in particular to decapitation. When carefully performed, decapitation is without risk to the mother; in 7 cases where we have resorted to it, in slight degrees of pelvic defor mity, it is true, we have had 7 recoveries. Evisceration, eventration, on the
contrary, is much more grave, and in the three cases where we have per formed it, we have had but a single recovery. To attempt version, how ever, where the infant is dead, and where there is marked pelvic contrac tion, seems to us just as grave a procedure as eventration.
The operations which may be performed on the foetus in presentation of the shoulder are : 1. Decapitation, detruncation.
2. Section through the entire body.
3. Evisceration.
4. Section of the vertebral column, or spondylotomy.
b. Section of the upper extremities, or brachiotomy.
Detruncation is certainly the simplest of all these operations, but un fortunately it is not always possible to reach the neck.
Although embryotomy has been practised from the earliest times, since it may be found mentioned by Hippocrates, it is only since the beginning of the present century that precise rules for its performance have been formulated, so that we are in a position to state definitively the aim of each one of the possible procedures. Pinard ranges these aims in the following categories: 1. Evisceration or exenteration, preceded or not by brachiotomy, aim ing at forced version.
2. Evisceration or exenteration, without brachiotomy, but occasionally with spondylotomy, aiming at forced evolution.
3. Spondylotomy at the neck or the centre of the body, aiming at the successive extraction of the fa3tus in portions.
1. Method which aims at forced Version. A. Robert Lee's Procedure. —Thiiconsists in performing brachiotomy, then perforating the thorax, and by means of a hook inserted into the pelvis or the lower part of the vertebral column, to make traction on the foetus, and deliver without damage to the maternal parts.
Rejected by Chailly and Cazeaux, brachiotomy has been practised by Dubois as a means to assist in decapitation. Stoltz, Pajot, Deland, Blot, admit that it is useful, and iu certain instances indispensable. By bra chiotomy we mean, of course, disarticulation of the shoulder.