542 OBSTETRIC OPERATIONS. 



it and the pelvic walls to search for a deviated limb, for example, or to 

 bring this limb into a proper position. 



The passage must, therefore, be freed from the obstacle, and this can 

 be accomplished in various ways, the most common of which is as fol- 

 lows : The fore-limbs, if present, are corded and pushed as far towards 

 the uterus as possible ; then the head is secured by cording the lower 

 jaw, a pointed hook fixed in each orbit, or a head-collar over the head if 

 it can be placed. Four or five assistants now pull at the head by these 

 appliances, so as to bring it as near the vulva as circumstances will per- 

 mit ; while another assistant keeps the labia apart, in order to expose as 

 much of the head as he can, and prevent injury to the organs of the 

 parent. The operator, with a convenient knife (the curved finger-scalpel 

 is very useful), incises the skin around the neck — first one side, then the 

 other — close to the occiput, passes his fingers between it and the muscles 

 beneath, and pushes it well back on the neck — the assistants pulling at the 

 head at the same time facilitate this separation. A few cuts now divide 

 the soft tissues down to the vertebrae, and nothing more remains to be 

 done than to produce disarticulation by vigorous traction, and a twisting 

 movement of the head at the same time ; the ligaments gradually yield 

 and tear, the head extends and at last comes away, and the body of the 

 foetus recedes more or less suddenly into the abdominal cavity. If the 

 limbs have been previously secured, they are brought into the passage by 

 the cords attached to them \ or if they are not so accessible, they must 

 be sought for in the way already indicated, and delivery completed : care 

 being taken to cover the exposed bones of the neck by the surplus skin, 

 while the foetus is being brought through the passage. 



Another method is to make an incision through the skin across the 

 forehead, in front of the ears, and to separate it by means of the fingers 

 or spatula as far as the occipital articulation. The knife divides this 

 joint, as well as the soft tissues around it, and particularly the ligaments ; 

 traction will bring away the head. The upper part of the neck is covered 

 by the loose skin — which may be fixed there by ligature — and directed 

 into the middle of the passage. Crotchets should now be placed on the 

 bodies of the vertebrae, or even on the ribs if they can be reached ; as the 

 limbs do not offer sufficient resistance if they alone are pulled at, neither 

 do they bring the body fairly into the passage. Traction should be made 

 on the sternum, not the withers, as the latter ought first to enter the inlet. 



A third method consists in removing the lower jaw, and excising the 

 head from below. Or this excision may be practise<^ from the mouth, 

 the chisel being used to divide the vertebrae, after the cheeks, masseter 

 muscles, and soft tissues behind the lower jaw have been cut through. 



Decapitation, under the most favorable circumstances, is often a long 

 and fatiguing operation, as the greatest care has to be observed in order 

 to avoid injuring the parent. But this fatigue and anxiety are vastly in- 

 creased, when the head is deeply buried in the passage or the uterus. 

 Then, as Saint-Cyr truthfully says, the hand, moist with the fluids of the 

 genital organs, embarrassed by shreds of the foetal envelopes, ham- 

 pered by the presence of the limbs, compressed and paralyzed by the 

 uterine contractions — the hand can then scarcely hold and guide the 

 cutting instrument, or distinguish what belongs to the foetus and what to 

 mother, and has no longer any strength to divide the tissues, which 

 are all the more difficult to cut by reason of their softness and flaccidity. 

 It will readily be understood how such an operation must be difficult for 



