of the older plan that it was widely adopted, and in the hands of such men as Carl Braun, Breisky, Leopold, Krassowsky, Frank, Fehling, Tait, and Porro himself, the mortality of Cesarean section was reduced to less than half of what it had been. Scarcely, however, were these results beginning to be appreciated by the medical world at large when Sänger proposed the close and accurate suturing of the uterine wound, including the peritoneal covering. Coincident almost with the adoption of this great improvement in the operation there began the aseptic era in abdominal surgery and the appreciation of the common-sense rule that Cesarean section, when required at all, should not be postponed until the patient is at the last gasp, after every other means of delivery had been tried in vain.

By a combination of three factors-close suturing of the uterine wound, aseptic technic, and early operations-results were secured of such brilliancy as to throw the achievements of Porro and his followers completely in the shade. Meanwhile, however, Cesarean section by celiohysterectomy had undergone an evolution from which attention was distracted by the glamour of the results following the Sänger operation. All gynecologists are familiar with the improvement in the technic of hysterectomy which has made the intraperitoneal treatment of the stump a much safer as well as a much more satisfactory method of operating than the extraperitoneal fixation of the cervix. In the past eight years a number of Cesarean sections followed by hysterectomy have been performed by the best and most modern technic-ligating the arteries of the broad ligament, dropping the cervix and sewing over it a peritoneal flap. It is too soon, however, to collect statistics of this operation and to compare its results with those of celiohysterotomy. There are disadvantages, moreover, in the mere statistical study of any subject which the practical worker has often reason to appreciate. Without an array of figures, therefore, to support his statement, the author can say, from his own experience, that not only does it add nothing to the danger of a Cesarean section to remove the womb, but, on the contrary, it diminishes the risk of the operation, for it eliminates the possibility of postpartum hemorrhage and lessens enormously the chance of puerperal infection. Certain complications in the puerperium also, as well as others at later periods in the individual's life, are surely avoided by a hysterectomy. These are retention and decomposition of the lochial discharge, to which the undilated cervical canal does not give free vent if the operation is performed before labor; adhesions between the anterior uterine and abdominal walls; persistent fistulæ communicating with the uterine cavity; rupture of the uterus in

subsequent pregnancies and labors, and the necessity for repeated Cesarean sections if the woman is allowed to become pregnant again.

In consideration of these incontrovertible facts it is clear that the statistics of the future, studied with discrimination, and taking into account the woman's life-history, will demonstrate the superiority in results of the modern Porro operation over the conservative classical Cesarean section.

Whatever one's predilection may be in favor of hysterotomy or hysterectomy, there are certain conditions in parturient women which forbid a freedom of choice and compel the selection of the latter operation. It is important, therefore, to learn the proportion of cases in which the Porro operation must be performed and a mere hysterotomy should not be relied upon.

The author's experience in Cesarean section amounts to 26 operations, performed for the following indications: fibroid tumors, 2; dermoid cysts impacted in pelvis, 2; cancer of the cervix, I; partial atresia of vagina, 2; cornual pregnancy, I; contracted pelves, 18, of which there were I kyphotic pelvis, I obliquely contracted and flat, I transversely contracted, 15 flat rachitic. Among this number it would have been absolutely necessary to perform a Porro operation in 14 cases. In 7 of the operations for contracted pelvis the patient had been in labor many hours. Futile attempts at delivery had been made with forceps, and in two instances by craniotomy. The uterus was already infected, and the birth-canal injured by slipping instruments or by the exercise of unjustifiable force in efforts at extraction. In one of the cases of impacted dermoids the woman had been in labor four days. The pelvic connective tissue and lower uterine segment were extraordinarily edematous, and the endometrium was almost black in color. In the two cases of fibroids attached to the lower uterine segment a hysterectomy was necessary to remove the tumors. In the cases of atresia of the vagina and of cancer of the cervix it was obviously improper to leave the womb behind.

If the author may judge by his experience alone, it appears that a Porro operation is required in practice a little more frequently than the so-called "conservative Cesarean section."1

It is fair to assume, therefore, that any physician who may be called upon to perform a Cesarean section should always be prepared for a hysterectomy as a part of a Cesarean section.

Whether the uterus should be removed in the majority of cases depends upon one's viewpoint in regard to the justifiability

1 Leopold in 100 Cesarean sections performed the Porro operation twenty-nine times (loc. cit.).

of repeated pregnancies in women who can only be delivered by a Cesarean section. It is perfectly plain to the author's mind that a woman should not be condemned to the probability of a repeated Cesarean section unless she herself and her husband. demand it. This, however, is a remote contingency. In almost every case in which the subject is submitted to the patient or to her husband, the surgeon is urgently requested to prevent the possibility of another conception.

Even if it were possible for the most skilful and experienced operator, dealing with patients in the most favorable condition and amid the best surroundings, to eliminate the dangers of Cesarean section, it would still be impossible to be certain that a woman would, on the next occasion, be so situated that she could command the best attention. Hence, Cesarean section is and will remain a dangerous procedure with a considerable mortality.

Taking into account the unavoidable, though small, mortality of Cesarean section under the most favorable circumstances; considering, moreover, the impossibility of always securing the best circumstances in many cases, it seems perfectly clear that it is unjustifiable to subject a woman with an insuperably cbstructed pelvis to the dangers of subsequent pregnancies and of repeated Cesarean sections. Once this point is conceded, it is unnecessary to argue further for a hysterectomy. No one can contrast in actual practice the greater facility and rapidity with which a Porro operation can be done, the entire freedom from many of the risks of the puerperium after the removal of the uterus, the impossibility of many complications that are likely in the Sänger operation, without preferring the former to the latter operation.

PART VII.

THE NEW-BORN INFANT.

CHAPTER I.

Physiology of the New-born Infant.

Respiration. There are two factors which explain the institution of respiration: (1) External irritation, the result of a change of environment. The child is almost instantaneously transformed from an aquatic to a terrestrial animal, passing from a liquid medium, with a temperature of 99° F., to the air, with a temperature of 70° F., the shock of this sudden transition causing a reflex action of all the muscles, including those of respiration. (2) The maternal supply of oxygen being cut off from the fetal blood as the placenta is separated or compressed, there is an accumulation of CO,, the primary action of which is that of a stimulant to the respiratory apparatus and to the brain-centers governing respiration. The power of the latter factor is often shown during or before labor. Should anything diminish the supply of oxygen to the fetal blood, such as pressure upon the cord, there is an immediate effort to respire. If the membranes are unruptured, liquor amnii is sucked into the lungs. If the head is in the vagina, or if air is admitted to the uterus after rupture of the membranes, respiration may be begun long before birth, and the child has actually been heard to cry aloud within the womb (vagitus uterinus).

The rate of respiration at birth is 44 to the minute, sinking shortly to 35.

The weight at birth is about 7 pounds. There is a steady increase of about 11⁄2 pounds each month before and I pound after the fourth month.

There is normally a loss of 51⁄2 ounces, on the average, during the first two to five days, which is usually made up by the end of the first week. Some children, however, gain steadily from birth.

It

Digestion is accomplished by the digestive juices, except the diastatic ferment of the pancreas and of the salivary glands. is partially dependent upon the bacteria normally present in the alimentary tract. A knowledge of the capacity of the stomach is important if one would avoid the common error of overfeeding a new-born infant.

The capacity of the infant's stomach is, on the average, during the first week, 46 c.c. (1.5 fl. oz.); second week, 78 c.c. (2.5 fl. oz.); third and fourth weeks, 85 c.c. (nearly 3 fl. oz.); third month, 140 c.c. (nearly 5 fl. oz.); fifth month, 260 c.c. (about 9 fl. oz.); ninth month, 375 c.c. (12.5 fl. oz.).

The greater the infant's weight, the greater the gastric capacity. One one-hundredth of the body-weight plus one gram each day is a fairly accurate formula for the expression of gastric capacity in the new-born. In a child of normal weight the capacity should be one ounce at birth and an increase of one ounce per month up to the sixth month, after which it is somewhat less (Holt).

The Position of Stomach.-Its axis is almost longitudinal, which in part explains the frequent regurgitation and vomiting of early infancy. It is placed high on the left side under the false ribs, so that it is influenced by the movement of the floating ribs in respiration.

Excretions. The urine is albuminous for the first few weeks. The quantity is difficult to estimate. It is always acid in reaction. The specific gravity is low, 1003-5. A trace of sugar is often found in breast-fed infants and in those fed upon an artificial food containing sugar of milk. The urine is voided six to twenty times in twenty-four hours. It does not, as a rule, stain the diapers, and the mistake may thus be made of supposing none to have been voided.

The movements from the bowels consists for the first fortyeight hours of meconium, a substance greenish-black in color, and consisting mainly of bile-salts and coloring matter. Later, the evacuations become light yellow, are not formed, are sour in smell, acid in reaction, and have a slightly fecal odor. The normal frequency of evacuation is from three to four times in the twenty-four hours.

The temperature is always slightly elevated directly after birth. It then sinks a little below normal. Its subsequent course is marked by considerable irregularity, with the variations usually above 98°. Comparatively slight causes produce high temperatures.