Chapter 24

The object must be to turn the fetus so that one extremity or the other can enter the passage, and the choice of which end to bring forward will depend on various considerations. If one end is much nearer the outlet than the other, that would naturally be selected for extraction, but if they are equidistant the choice would fall on the hind end, as having only the two limbs to deal with without any risk of complication from the head. When the head is turned upward and forward it will usually be preferable to bring up the hind limb, as, owing to the drooping of the womb into the abdomen, rotation of the fetus will usually be easier in that direction, and if successful the resulting position will be a natural posterior presentation, with the back of the calf turned toward the rump of the cow. Similarly with the croup turned upward and forward, that should be pushed on forward, and if the forefeet and head can be secured it will be a natural anterior presentation, with the back of the calf turned upward toward the rump of the cow.

The womb should be injected with warm water or oil, and the turning of the calf will demand the combined action of the repeller and the hand, but in all such cases the operator has an advantage that the body of the fetus is wholly within the body of the womb, and therefore movable with comparative ease. No part is wedged into the pelvic passages as a complication. The general principles are the same as in faulty presentation fore and hind, and no time should be lost in making the manipulations necessary to bring the feet into the pelvis, lest they get inbent or otherwise displaced and add unnecessary complications.

With a transverse direction of the calf, the head being turned to one side, the pressure must be directed laterally, so that the body will glide around on one side of the womb, and the extremities when reached must be promptly seized and brought into the passages. Sometimes a fortunate struggle of a live fetus will greatly aid in rectifying the position.

_Breast and abdomen presented._--All four feet in the passages._--In this form the calf lies across the womb with its roached back turned forward and its belly toward the pelvis. All four feet may be extended and engaged in the passages, or one or more may be bent on themselves so as to lie in front of the pelvis. The head, too, may usually be felt on the right side or the left, and if detected it serves to identify the exact position of the fetus. The position may further be decided upon by examination of the feet and limbs. With the limbs extended the front of the hoofs and the convex aspect of the bent pasterns and fetlocks will look toward that flank in which lie the head and shoulders. On examination still higher the smooth, even outline of the knee and its bend, looking toward the hind parts, characterize the fore limb, while the sharp prominence of the point of the hock and the bend on the opposite side of the joint, looking toward the head, indicate the hind limb. (Pl. XVII, fig. 5.)

The remedy of this condition is to be sought in repelling into the womb those limbs that are least eligible for extraction, and bringing into the passages the most eligible extremities. The most eligible will usually be those which project farthest into the passages, indicating the nearer proximity of that end of the calf. An exception may, however, be made in favor of that extremity which will give the most natural presentation. Thus if, owing to obliquity in the position of the fetus, the hind extremities promised a presentation with the back of the fetus turned down toward the udder, and the anterior extremities one with the back turned up toward the spine, the latter should be selected. Again, if the choice for the two extremities is evenly balanced, the hind may be chosen as offering less risk of complication, there being no head to get displaced.

The first step in the treatment is to place a running noose on each of the four feet, marking those of the fore limbs to distinguish them from those of the hind ones. In case it is proposed to bring the anterior extremities into the passage, a noose should also be placed on the lower jaw. Then run the ropes attached to the two feet that are to be pushed back through the ring of a cord carrier (Pl. XXI, fig. 5), passing the rings down to the feet, and by the aid of the carrier push them well back into the womb and hold them there. Meanwhile drag upon the ropes attached to the two other feet so as to bring them into the passage (or, in case of the anterior extremity, on the two foot ropes and the head one). The other feet must be pushed back into the womb until the body of the calf is fully engaged in the passages. After this they can no longer find an entrance, but must follow as the body escapes.

NEGLECTED AND AGGRAVATED CASES.

In laying down the foregoing rules for giving assistance in critical cases of calving it is not intimated that all cases and stages can be successfully dealt with. Too often assistance is not sought for many hours or even days after labor pains, and the escape of the waters intimate the danger of delay. Not seldom the long delay has been filled up with unintelligent and injurious attempts at rendering assistance, violent pulling when resistance is insurmountable without change of position, injuries to the vagina and womb by ill-considered but too forcibly executed attempts to change the position, the repeated and long-continued contact with rough hands and rougher ropes and hooks, the gashes with knives and lacerations with instruments in ignorant hands, the infecting material introduced on filthy hands and instruments, and the septic inflammations started in the now dry and tender passages and womb. Not infrequently the death, putrefaction, and bloating of the calf in the womb render the case extremely unpromising and make it impossible to apply successfully many of the measures above recommended. The labor pains of the cow may have practically ceased from exhaustion; the passages of the vagina may be so dry, tender, friable, red, and swollen that it requires considerable effort even to pass the oiled hand through them, and the extraction of the calf or any portion of it through such a channel seems a hopeless task; the womb may be equally dry, inflamed and swollen, so that its lining membrane or even its entire thickness is easily torn; the fetal membranes have lost their natural, unctuous and slippery character, and cling firmly to the dry walls of the womb, to the dry skin of the calf, or to the hands of the operator; the dead and putrefying calf may be so bloated with gases that the womb has been overdistended by its presence, and the two adhere so closely that the motion of the one on the other is practically impossible. In other cases reckless attempts to cut the calf in pieces have left raw surfaces with projecting bones which dangerously scratch and tear the womb and passages.

In many cases the extreme resort must be had of cutting the fetus to pieces (embryotomy), or the still more redoubtable one of CÊsarean section (extraction through the flank).

DISSECTION OF THE UNBORN CALF (EMBRYOTOMY).

In some cases the dissection of the calf is the only feasible means of delivering it through the natural passages; and while it is especially applicable to the dead calf, it is also on occasion called for in the case of the living. As a rule, the living calf should be preserved, if possible, but if this threatens to entail the death of the cow it is only in the case of offspring of rare value that its preservation is to be preferred. To those acquainted with the toil, fatigue, and discomfort of embryotomy, no discussion is necessary so long as there is a prospect of success from the simple and generally easier method of rectifying the faulty position of the calf. When the correction of the position is manifestly impossible, however, when distortions and monstrosities of the fetus successfully obstruct delivery, when the pelvic passages are seriously contracted by fractures and bony growths, when the passages are virtually almost closed by swelling, or when the calf is dead and excessively swollen, no other resort may be available. In many cases of distortion and displacement the dismemberment of the entire calf is unnecessary, the removal of the offending member being all that is required. It will be convenient, therefore, to describe the various suboperations one by one and in the order in which they are usually demanded.

_Amputation of the fore limb._--In cutting off a fore limb it is the one presenting that should be selected, since it is much more easily operated on, and its complete removal from the side of the chest affords so much more space for manipulation that it often makes it easy to bring the other missing limb or the head into position. The first consideration is to skin the limb from the fetlock up and leave the skin attached to the body. The reasons for this are: (_a_) That the skin is the most resistant structure of the limb, and when it has been removed the entire limb can be easily detached; (_b_) the tough skin left from the amputated limb may be used as a cord in subsequent traction on the body of the calf; (_c_) the dissection and separation of the limb are far more safely accomplished under the protection of the enveloping skin than if the operator's hands and instruments were in direct contact with the walls of the passages or womb; (_d_) the dissection can be much more easily effected while the skin is stretched by the left hand, so as to form a comparatively firmer resistant point for the knife, than when it is attempted to cut the soft, yielding, and elastic tissues which naturally offer little solid resistance, but constantly recede before the cutting edge of the instrument. The preservation of the skin is therefore a cardinal principle in the amputation of all parts in which it is at all feasible.

The presenting foot is inclosed in a noose and drawn well out of the passages. Then a circular incision through the skin is made around the limb just above the fetlock. From this the skin is slit up on the inner side of the limb to the breast. Then the projecting part of the limb is skinned up to the vulva, traction being made on the foot by an assistant so as to expose as much as possible. The embryotomy knife may now be taken (Pl. XXI, fig. 2), and a small hole having been cut in the free end of the detached portion of skin, that is seized by the left hand and extended while its firm connections with the deeper structures are cut through. The looser connections can be more quickly torn through with the closed fist or the tips of the four fingers held firmly together in a line or with the spud, of which there are several kinds. Much of the upper part of the limb can be skinned more speedily without the knife, but that must be resorted to to cut across tough bands whenever these interrupt the progress. The skinning should be carried upward on the outer side of the shoulder blade to the spine or nearly so. Then with the knife the muscles attaching the elbow and shoulder to the breastbone are cut across, together with those on the inner side of the shoulder joint and in front and behind it as far as these can be reached. Steady traction is now made upon the foot, the remaining muscles attaching the shoulder blade to the trunk are torn through with a cracking noise, and the whole limb, including the shoulder blade and its investing muscles, comes away. If the shoulder blade is left the bulk of the chest is not diminished, and nothing has been gained. Before going further it is well to see whether the great additional space thus secured in the passages will allow of the missing limb or head to be brought into position. If not, the other presenting part, limb or head, is to be amputated and extracted. For the limb the procedure is a repetition of that just described.

_Amputation of the head._--The head is first seized and drawn well forward, or even outside the vulva, by a rope with a running noose placed around the lower jaw just behind the incisor teeth, by a sharp hook inserted in the arch of the lower jaw behind the union of its two branches and back of the incisor teeth, or by hooks inserted in the orbits, or, finally, in case the whole head protrudes, by a halter. (Pl. XXI, figs 4_a_ and 4_b._) In case the whole head protrudes, a circular incision through the skin is made just back of the ear, and the cut edge being held firmly by the left hand, the neck is skinned as far as it can be reached. Then the great ligamentous cord above the spine is cut across at the farthest available point, together with the muscles above and below the spine. Strong traction on the head will then detach it at this point and bring it away, but should there still be too much resistance the knife is inserted between the bodies of two vertebrÊ just behind one of the prominent points felt in the median line below, and their connecting fibrous cartilage is cut through, after which comparatively moderate pulling will bring it away. The detached neck and body at once slip back into the womb, and if the fore limbs are now brought up and pulled they are advanced so far upon the chest that the transverse diameter of that is greatly diminished and delivery correspondingly facilitated.

If the head is still inclosed in the vagina two methods are available: (1) The removal of the lower jaw and subsequent separation of the head from the neck; (2) the skinning of the whole head and its separation from the neck.

To remove the lower jaw the skin is dissected away from it until the throat is reached. Then the muscles of the cheeks and side of the jaw (masseters) are cut through and those connecting the jaw with the neck. When traction is made on the rope around the lower jaw it will usually come away with little trouble. Should it resist, its posterior extremity on each side (behind the grinding teeth) may be cut through with bone forceps or with a guarded bone chisel. (Pl. XX, fig. 8.) After the removal of the lower jaw the way will be open to separate the head from the neck, the knife being used to cut into the first or second joint from below, or the bone forceps or chisel being employed to cut through the bones of the neck. Then traction is made on the head by means of hooks in the orbits, and the hand, armed with an embryotomy knife, is introduced to cut through the tense resisting ligament, and muscles above the bones. The skin and the strong ligamentous cord attached to the poll are the essential things to cut, as the muscles can easily be torn across. Unless there are great difficulties in the way it is well to skin the head from the eyes back, and on reaching the poll to cut through the ligament and then bring the head away by pulling.

If it is decided to remove the entire head at once, it may be skinned from the front of the eyes back to behind the lower jaw below and the poll above, then cut through the muscles and ligaments around the first joint and pull the head away, assisting, if need be, in the separation of the head by using the knife on the ligament of the joint.

If the calf is a double-headed monster, the skinning of the head must be carried backward until the point has been reached where both heads branch from the single neck, and the separation must be made at that point. The muscles and ligaments are first to be cut through; and if the part can not then be detached by pulling, the bodies of the vertebrÊ may be separated by passing the knife through the joint. The second head may now be secured by a noose around the lower jaw or hooks in the orbits and brought up into place, the body being pushed back toward the other side by a repeller, so as to make room.

It should be added that, except in the case of a double-headed monster, or in case of the head protruding or nearly so, and one or both fore limbs presenting, it is rarely desirable to undertake amputation of the head. The space desirable in the passages can usually be obtained by the much simpler and easier procedure of removing one or both fore limbs.

_Amputation of the hind limbs._--This is sometimes demanded on the one extended limb when the other can not be brought up and delivery can not be effected; also in case of monsters having extra hind limbs; when the calf is dead, putrid, and bloated with gas; and in some cases of breech presentation, as described under that head.

When the limb is extended the guiding principles are as in the case of the fore limbs. The skin is cut through circularly above the fetlock and slit up to beneath the pelvic bones on the inner side of the thigh. It is then dissected from the other parts as high as it has been slit on the inner side and to above the prominence (_trochanter major_) on the upper end of the thigh bone on the outer side of the joint. In this procedure the hands and spud can do much, but owing to the firmer connections the knife will be more frequently required than in the case of the fore limb. The muscles are now cut through all around the hip joint, and strong traction is made by two or three men on the limb. If there is still too much resistance, a knife is inserted into the joint on the inner side and its round ligament cut through, after which extraction will be comparatively easy. This accomplished, it will often be possible to extract the fetus with the other leg turned forward into the womb. If the calf is bloated with gas, it may be necessary to remove the other leg in the same way, and even to cut open the chest and abdomen and remove their contents before extraction can be effected. In the case of extra limbs it may be possible to bring them up into the passages after the presenting hind limbs have been removed. If this is not practicable, they may be detached by cutting them through at the hip joint, as described under "Breech presentation," page 197.

Another method of removing the hind limb is, after having skinned it over the quarter, to cut through the pelvic bones from before backward, in the median line below, by knife, saw, or long embryotome (Pl. XX, fig. 1), and then disjoint the bones of the spine (sacrum) and the hip bone (ilium) on that side with embryotome, knife, or saw, and then drag away the entire limb, along with all the hip bones on that side. This has the advantage of securing more room and thereby facilitating subsequent operations. Both limbs may be removed in this way, but on the removal of the second the operator is without any solid point to drag upon in bringing away the remainder of the fetus.

_Division across the middle of the body._--In cases of extra size, monstrosity, or distortion of one end of the body it may be requisite to cut the body in two and return the half from the passages into womb, even after one-half has been born. The presenting members are dragged upon forcibly by assistants to bring as much of the body as possible outside. Then cut through the skin around the body at some distance from the vulva, and with hand, knife, and spud detach it from the trunk as far back into the passages as can be reached. Next cut across the body at the point reached, beginning at the lower part (breast, belly) and proceeding up toward the spine. This greatly favors the separation of the backbone when reached, and further allows of its being extended so that it can be divided higher up. When the backbone is reached, the knife is passed between the two bones, the prominent ridges across their ends acting as guides, and by dragging and twisting the one is easily detached from the other. With an anterior presentation the separation should, if possible, be made behind the last rib, while with a posterior presentation as many of the ribs should be brought away as can be accomplished. Having removed one half of the body, the remaining half is to be pushed back into the womb, the feet sought and secured with nooses, and the second half removed in one piece if possible; and if not, then after the removal of the extra limb or other cause of obstruction.

_Removed of the contents of chest or abdomen._--If the body of the calf sticks fast in the passages by reason of the mere dryness of its skin and of the passages, the obstacle may be removed by injecting sweet oil past the fetus into the womb through a rubber or other tube, and smearing the passages freely with lard. When the obstruction depends on excess of size of the chest or abdomen or thickening of the body from distorted spine, much advantage may be derived from the removal of the contents of these great cavities of the trunk. We have already seen how the haunches may be narrowed by cutting the bones apart in the median line below and causing their free edges to overlap each other. The abdomen can be cut open by the embryotomy knife or the long embryotome in the median line, or at any point, and the contents pulled out with the hand, the knife being used in any case when especial resistance is encountered. If the abdomen is so firmly impacted that it can not be dealt within this way, one hind limb and the hip bone on the same side may be removed as described under "Amputation of the hind limbs," page 205. This will allow the introduction of the hand into the abdomen from behind, so as to pull out the contents. By introducing an embryotomy knife in the palm of the hand and cutting through the muscle of the diaphragm the interior of the chest can be reached in the same way and the heart and lungs removed.

When, in dealing with an anterior presentation, it becomes necessary to remove the contents of the chest, the usual course is to cut through the connections of the ribs with the breastbone (the costal cartilages) close to the breastbone on each side, and from the abdomen forward to the neck. Then cut through the muscles connecting the front of the breastbone with the neck and its hinder end with the belly, and pull out the entire breastbone. Having torn out the heart and lungs with the hand, make the rib cartilages on the one side overlap those on the other, so as to lessen the thickness of the chest, and proceed to extract the body. If it seems needful to empty the abdomen as well, it is easy to reach it by cutting through the diaphragm, which separates it from the chest.

_Delivery through the flank_ (_CÊsarean section, or laparotomy_).--This is sometimes demanded, when the distortion and narrowing of the hip bones are such as to forbid the passage of the calf, or when inflammation has practically closed the natural passages and the progeny is more valuable and worthy of being saved than the dam; also in cases in which the cow has been fatally injured, or is ill beyond possibility of recovery and yet carries a living calf. It is too often a last resort after long and fruitless efforts to deliver by the natural channels, and in such cases the saving of the calf is all that can be expected, the exhausted cow, already the subject of active inflammation and too often also of putrid poisoning, is virtually beyond hope. The hope of saving the dam is greatest if she is in good health and not fatigued, in cases, for example, in which the operation is resorted to on account of broken hip bones or abnormally narrow passages.