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and experience, we are indebted for this operation being greatly improved, by means of his valuable work, in 1668; but it is Philip Peu, in 1694, and William Mauquest de la Motte, in 1721, to whom the merit is due of having pointed out the value of two great laws in turning-the one of not rupturing the membranes, as already mentioned, the other of not attempting to push back the arm which presents.*

⚫ See DYSTOCIA FROM MALPOSITION OF THE CHILD. [The student who desires to investigate this subject farther, may consult Dr. Churchill's Researches on Operative Midwifery. Essay ii, on Version.-AM. ED.]

CHAPTER III.

CESAREAN OPERATION.

INDICATIONS.-DIFFERENT MODES OF PERFORMING THE OPERATION.-HISTORY OF THE CESAREAN OPERATION.

THE next operation in Midwifery for delivering the full-grown fœtus alive is that of Hysterotomy, commonly called the Cæsarean operation, viz. where the foetus is extracted through an artificial opening made through the parietes of the abdomen and uterus.

The indications for performing the operation are so different in this country to what they are elsewhere, that they require especial mention: in England the operation is never performed upon the living subject except where the child cannot be delivered by the natural passage; under these circumstances it is scarcely undertaken in this country for the purpose of saving the child's life, but merely that of the mother, it being considered preferable to deliver the child by perforation or embryotomy, even when known to be alive, than to expose the mother to so much suffering and danger.

On the continent and also in America, it has not been considered in so dangerous a light as in this country, still less as an operation almost certainly fatal to the mother: therefore, besides being indicated as a means for preserving the mother's life, it is performed for the purpose of saving the child's life in cases where, by using the perforator, the child might be brought through the natural passages. The results of the Cæsarean operation have been so unfavourable, and the character of the process so frightful, as to have rendered it a measure of peculiar dread to practitioners, and in different times and countries the strongest feelings have been excited against it. By many of the celebrated authors of former times, viz. Ambrose Paré, Guillemeau, Dionis, &c. it was looked upon as altogether unjustifiable, and a similar opinion was entertained by many of our own countrymen at a much more recent period, (Dr. W. Hunter, Dr. Osborn, &c.)

There is no doubt that in England it has been peculiarly unsuccessful. Dr. Merriman has collected the results of 26 cases of Cæsarean operation: of these only 2 mothers and 11 children survived; thus out of 52 lives only 13 were saved. On the Continent it has been far more successful. Klein has collected with the greatest care 116 well authenticated cases, of which 90 terminated favourably; and Dr. Hull, in his Defence of the Cæsarean Operation, has recorded 112 cases, of which 69 were successful. M. Simon has not only collected a number of cases which were favourable, to the number of 70 or 72, but which were performed on a few

women, "some of them having submitted to it three or four times, others five or six, and even as far as seven times, which, if they were all true, would superabundantly prove that it is not essentially mortal." (Baudelocque, transl. by Heath, § 2095.)

During the last fifteen or twenty years the operation has become remarkably successful in the hands of the German practitioners, so that there has been scarcely a journal of late from that part of the Continent which has not contained favourable cases of it. One of the most interesting instances of later years is that recorded by Dr. Michaelis, of Kiel, where the patient, a diminutive and very deformed woman, was operated upon four times: the second operation was performed by the celebrated Wiedemann, and is stated to have been completed in less than five minutes, and without any extraordinary suffering on the part of the patient, who complained most when sutures were made for bringing the lips of the wound together. The uterus became adherent to the anterior wall of the abdomen, so that in the fourth operation the abdominal cavity was not even opened, the incision being made through the common cicatrix into the uterus.

There is every reason to suppose that the chief cause of its want of success in this country has been the delay in performing it. "In France and some other nations upon the European Continent," says Dr. Hull, "the Cæsarean operation has been and continues to be performed where British practitioners do not think it indicated; it is also had recourse to early, before the strength of the mother has been exhausted by the long continuance and frequent repetition of tormenting, though unavailing pains, and before her life is endangered by the accession of inflammation of the abdominal cavity. From this view of the matter we may reasonably expect that recoveries will be more frequent in France than in England and Scotland, where the reverse practice obtains. And it is from such cases as these, in which it is employed in France, that the value of the operation ought to be appreciated. Who could be sanguine in his expectation of a recovery under such circumstances as it has generally been resorted to in this country, namely, where the female has laboured for years under malacosteon (mollities ossium,) a disease hitherto in itself incurable; where she has been brought into imminent danger by previous inflammation of the intestines or other contents of the abdominal cavity, or been exhausted by labour of a week's continuance or even longer." (Hull's Defence of the Cæsarean Operation.†)

The difficulty of deciding upon the operation according to the indications of the Continental practitioners, is much more perplexing than ac

[Prof. Gibson has operated twice on the same patient, and both times successfully, for mother and children. See American Journal, for May, 1838.-ED.]

[† Dr. Churchill has collected the statistics of 409 cases of Cæsarean section, of which number, 228 mothers were saved; and 181 lost, or about 1 in 24; and out of 224 children, 160 were saved, and 64 lost-or about 1 in 3.

Of the above cases, 40 occurred in the practice of British practitioners, of which, 11 mothers recovered, and 29 died; or nearly three fourths-and 37 cases, in which the result to the child is mentioned, 22 were saved, and 15 lost-or 1 in 24.

Of 369 cases in the practice of Continental practitioners, 217 mothers recovered, and 152 died, or 1 in 2}-and out of 187 cases, where the result to the child is given, 138 were saved, and 49 lost; or nearly 1 in 4. Researches on Operative Midwifery. By F. Churchill, M.D., Dublin, 1841. Editor.]

cording to that which is followed in this country: the question here is, can the child under any circumstances be made to pass per vias naturales with safety to the mother? The impossibility of effecting this object is the sole guide for our decision. In using the operation as a means for preserving also the life of the child, we must not only feel certain that the child is alive, but that it is also capable of supporting life, before we can conscientiously undertake the operation upon such indications. This uncertainty as to the life or death of the child greatly increases the difficulty of deciding. Under circumstances where there is reason to believe that, although the child may be alive, it is nevertheless unable to prolong its existence for any time, and the pelvis so narrow that it can only be brought through the natural passage piecemeal, we are certainly not authorized in putting an adult and otherwise healthy mother into such imminent danger of her life for the sake of a child which is too weak to support existence. Circumstances may nevertheless occur where the pelvis is so narrow that the child cannot be brought even piecemeal through the natural passage: in this case, even if the child be dead, the operation becomes unavoidable.

Under the above-mentioned circumstances, it is the duty of the surgeon to perform the operation; and he can do it with the more confidence from the knowledge of many cases upon record where it has succeeded, even under very unfavourable circumstances, and where it has been performed very awkwardly: moreover, it seems highly probable that the unfavourable results of this operation cannot often be attributed to the operation itself, but to other circumstances. Not unfrequently the uterus has been so bruised, irritated, and injured by the violent and repeated attempts to deliver by turning or the forceps, and the patient so exhausted, and brought into such a spasmodic and feverish state by the fruitless pains and vehement efforts, together with the anxiety and restlessness which must occur under such circumstances, that it is impossible for the operation to prove successful. Here it is an important rule that we should decide, as soon as possible, whether she can be delivered by the natural passages or not: we should allow of no useless or forcible attempts to deliver her; and if these have been made, we should carefully examine whether the passages, &c., have been injured, and proceed to the operation without delay. Moreover, the patient can the more easily make up her mind to the operation, as she will suffer far less than from the fruitless efforts and attempts to deliver her by the natural passages. (Richter, Anfangsgründe der Wundarztneikunst, band vii. chap. 5.)

Although it is so important that we should lose no time, still nevertheless it does not appear desirable to operate before labour has commenced to any extent; for unless the os uteri has undergone a certain degree of dilatation, it will not afford a sufficiently free exit for liquor amnii, blood, lochia, which, by stagnating in the uterus after the operation, would soon become irritating and putrid, in which case they would be apt to drain through the wound into the abdominal cavity and create much mischief.*

[* The propriety of an early resort to the Cæsarean section, in cases where it is necessary, has been very properly insisted upon; but the circumstances which render it necessary, are not always readily determined. M. Castel states, that in a case at the hospice de perfectionnement, in which the operation was determined on, some delay became

Different modes of operating. The incision has been recommended to be made in different ways by different authors; but the highest authorities, as also later experience, combine in favour of that in the linea alba. Richter states, that one great advantage from making it in this direction is, that when the uterus contracts and sinks down into the pelvis, the incision in it still corresponds with that through the abdominal parietes, and therefore admits of a free discharge of pus, &c., through the external wound; whereas, if it had been made to one side, viz., at the outer edge of the rectus abdominis muscle, as recommended by Levret, for the purpose of avoiding the placenta, the wound in the uterus when contracted ceases to correspond with it, and the discharge escapes into the abdominal cavity. Besides this the abdomen is usually more distended at the linea alba; the uterus here lies immediately beneath the integuments; the intestines are usually pressed towards each side; and therefore when the incision is made on one side they frequently protrude, a circumstance which rarely happens when it is made in the linea alba, except perhaps towards the end of the operation. In the linea alba we have only to cut through the external integuments in order to reach the uterus, while at the side, we have to cut through considerable layers of muscle.

Previous to operating, the rectum and the bladder should be emptied, particularly the latter, because it is desirable to carry the incision of the abdominal integuments, for reasons just given, as near as possible to the symphysis pubis (viz. an inch and a half,) which otherwise would endanger the safety of the bladder. The experience of later years proves decidedly that three intelligent assistants are necessary, "two to prevent the protrusion of the intestines, and a third to remove the placenta and foetus." (Neue Zeitschrift für Geburtskunde, band iii. heft 1, 1835.) We are convinced, that the success of the operation depends more upon carefully preventing the slightest protrusion of any portion of the intestines, and excluding all access of the external air, than upon any other cause, for by this means alone can we save the patient from the dangerous peritonitis which is so apt to follow. The two assistants, whose duty it is to support the abdominal parietes and keep the edges of the wound closely pressed against the uterus, should be furnished with napkins or sponges soaked in oil in order instantly to cover any coil of intestine which may protrude, and press it back as quickly as possible; it is to this that the great success of the Cæsarean operation in later years is chiefly owing.

The incision in point of length varies from five to six, seven, or more inches, beginning at about two to four inches below the navel, and terminating at rather less than that distance above the symphysis pubis. The peritoneum is usually divided with a bistoury and director, and the wound through the uterus made an inch or two shorter than that of the abdominal integuments. If, on dividing the uterine parietes, the placenta presents, it must be separated, and removed as quickly as possible to one side, the membranes ruptured, and the child extracted; after which the

necessary in order to find accommodation for the crowd of students who collected to witness it, and before this could be effected the woman was delivered naturally. M. Gimelle says, that at the hospital of M. Dubois, a small woman, who had five times submitted to the Cæsarean section, was delivered naturally the sixth time. Am. Journ. Med. Sc. Aug. 1838. ED.]

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