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the stump. The operation is said to be very simple, and seven out of the eight cases he has thus operated on recovered.1

[The Cæsarean Section of 1893.-It may be of interest to go back fifty or sixty years and quote the opinions then held, and estimates of mortality then made; but it will be much more profitable to consider what has been done in the last decade, and what is being done now.

One of the great obstacles to success in the operation has been a fear to perform it, because of its fatality; and this dread of the issue has been a chief factor in determining the measure of its danger. British opinion has, until quite recently, had much to do with moulding that of our own obstetric surgeons; but thanks to recent successes in America and Continental Europe, we are beginning to think more independently, and to look upon this form of delivery with far less anxiety and fear than formerly.

Even Great Britain, through her younger accoucheurs, has recently shown signs of a change of base, under the influence of the already quoted successes of Murdock Cameron, which will be much more potent than the still better results in Leipzig, Dresden, and Vienna, because accomplished at home.

In our own country we are slowly doing better, and the work of the last three years (August, 1890, to August, 1893) shows a record of 28 cases, with four women and four children lost. These women died after labors respectively of twelve days, seven days, three days; and one fœtus was stillborn; one was delivered in a dying state; a third was of six months' gestation, but alive; and the fourth lived two days. Three of these infants were the offspring of mothers who were also lost.

One thing we can be certain of, i. e., that but few women will die in this country as a result of the Caesarean operation under good hands, where there is good ground upon which to base a favorable prognosis. In the cases of eight women where I made this estimate, there was not one that terminated fatally. In one, labor had just begun; in another it had lasted a few hours, with slight pains; in two, it was induced; and in four, it had not commenced. We have operators in New York, Philadelphia, and Baltimore who are convinced that the operation, performed a few days prior to the time for labor to set in, has decided advantages over that where the hour is determined by the commencement of parturition. The fear that the cervix may not be sufficiently patulous for drainage, or that the uterus will not properly contract, appears to be groundless. It must be a very ex

1 It may interest the reader to learn the views of my American editor, Dr. Harris, of Philadelphia, on this subject. It is well known that Dr. Harris has devoted an immense amount of time and labor to the study of these operations, on which he may be taken to be one of our most reliable authorities. He says: "We believe that the Porro operation will, in all probability, meet with better success than the conservative,' in Great Britain, from the fact that the last five cases in order have recovered. Holding the views there generally advocated, the section will only be made in badly deformed rhachitic dwarfs and in the subjects of malacosteon, which are much more frequently thus delivered than the former. These will probably do better under the exsective method, which besides has the advantage that it sometimes cures malacosteon, as shown by the results in Continental Europe."-Harris, note to seventh American edition.

[The remarkable successes (1888-1893) of Dr. Murdock Cameron, of Glasgow, have set this opinion aside. The Porro operation should be elected in cases of osteomalacia, as the disease has been arrested by it in a number of instances.--ED.]

ceptional case where this organ is not excited to action by incising its wall. We have only to look at the effect of Cæsarean horn-rips, to determine the action of the uterus when it is opened before labor.

What is wanted in England, and especially in London, is more hopefulness in the operation, and this can only be begotten by a careful examination of the record of the past decade. Let someone collect the cases, and present the causes of success and failure; and it will soon be learned how death is to be avoided. The death-rate in London is placed conjecturally at 50 per cent.; but it should be known what it is positively. If it is as much as one-half, it can certainly be reduced. Recently a rhachitic primipara from Yorkshire, of four feet six inches, was operated upon in Philadelphia, and is now rapidly recovering. We expected to save her and her child, and are not surprised at the result. If this can be attained here, upon an English woman, why not in London? It should be borne in mind that a very short labor is often the key-note to a recovery and a saved fœtus.

Sänger, of Leipzig, and his followers in Germany, Austria, and America, have shown the capabilities of Cæsarean surgery where the cases are treated antiseptically and the uterine wound closed by multiple suturing of silk. Ovarian exsection has largely removed the old fear of cœliotomy; and we know now that if the mother and child are in a hopeful condition, skill and care will usually avail to save both. There need be no fear that the uterine wound will not readily heal, for it has been found well closed, in a case that died in twentysix hours, in Philadelphia, from conditions existing prior to the operation. There is nothing in the idea that the process of involution in the uterus is antagonistic to that of union by the first intention. When the uterine wound was not closed, or when it was sutured with catgut, gaping often took place, but it does not do this now, where the individual tension is made light by being divided among many sutures of carbolized silk. It is not required to use fifty stitches, as has been done in a few instances, but a dozen each of deep and superficial will make a good average. A dozen or even less of deep stitches alone have answered in the Cameron cases; but we prefer the example of Leipzig and Dresden, where the maternal loss has been 74 per cent. It should be remembered that a uterus heals the most readily whose muscular fibres have not been overtaxed and injured by long-continued and fruitless action, and it should be borne in mind that anæmia from hemorrhage, a dead foetus in utero, and the exhaustion of long labor, favor the production of sepsis, septic peritonitis, and fatal shock. Where the uterus contains a decomposing foetus, the Porro exsection should be performed as the only hope of avoiding death by septic absorption; cures have been secured in this way under very desperate conditions.-ED.]

CHAPTER VII.

CŒLIO-ELYTROTOMY ['] AND SYMPHYSEOTOMY.

BEARING in mind the great mortality attending the Cæsarean section, it is not surprising that obstetricians should have anxiously considered the possibility of devising substitutes which should afford the mother a better chance of recovery. Two proposals of this kind have been suggested, and from both great results were anticipated.

Cœlio-elytrotomy.-One of these is the operation of cœlio-elytrotomy as perfected by Thomas, of New York, in 1870. For some years subsequent to that date it attracted considerable attention and was frequently performed. The results were on the whole promising: out of fourteen cases, seven mothers recovered and nine children were born alive; and there was good reason to expect a still higher success as the technique of the operation was perfected and greater experience was acquired in its performance. The improved Cæsarean section and Porro's operation have, however, of late years shown such good results that cœlio-elytrotomy has fallen into disfavor. It does not appear to have been performed since 1887, and as it is a complex and difficult procedure it is not likely again to be adopted; nor, with the lessened mortality of the Cæsarean section, is there any reason why it should be. I, however, retain the account of it as a matter of obstetric interest.

History. The earliest suggestion of a procedure of this character seems to have been made by Joerg in the year 1806, who proposed a modified Cæsarean section without incision of the uterus, by the division of the linea alba and of the upper part of the vagina, the fœtus being extracted through the cervix. This suggestion was never carried into practice, and it is obvious that it misses the one chief advantage of celio-elytrotomy, the leaving of the peritoneum intact. In 1820 Ritgen proposed and actually attempted an operation much resembling Thomas's, in which section of the peritoneum was avoided. He failed, however, to complete it, and was eventually compelled to deliver his patient by the Cæsarean section. In 1823, Baudelocque the younger, independently conceived the same idea, and actually carried it into practice, although without success. Lastly, in 1837, Sir Charles Bell suggested a similar operation, clearly perceiving its advantages. Hence it appears that previous to Thomas's recent work in the matter, the operation was independently invented no less than three times. It fell, however, entirely into oblivion, and was only occasionally mentioned in systematic works as a matter of curious obstetric history, no one apparently appreciating the promising character of the procedure.

[From koilia, the abdomen; elytron, the vagina, and toma, to cut.-ED.]

In the year 1870, Dr. T. Gaillard Thomas, of New York, read a paper before the Medical Association of Yonkers, entitled "Gastroelytrotomy, a Substitute for the Cæsarean Section," in which he described the operation as he had performed it three times on the dead subject, and once on a married woman in 1870, with a successful issue as regards the child. It seems beyond doubt that Thomas invented the operation for himself, being ignorant of Ritgen's and Baudelocque's previous attempts, and it is certain, to quote Garrigues,' that to him. "belongs the glory of having been the first who performed cœlioelytrotomy so as to extract a living child from a living mother in his first operation, and of having brought both mother and child to complete recovery in his second operation."

Since Thomas's first case, the operation has been performed several times in America, and has found its way across the Atlantic, having been twice performed in England, by Himes in Sheffield, by Edis in London; and by Poullet in Lyons, France.

Nature of the Operation.-The object of cœlio-elytrotomy is to reach the cervix by incision through the lower part of the abdominal wall and upper part of the vagina, and through it to extract the fœtus as may most easily be done.

Advantages over the Cæsarean Section.-The advantages it offers over the Cæsarean section are that in dividing the abdomen the abdominal wall only is incised, and the peritoneum is left intact. The vagina is divided, but incision of the uterine parietes, which forms one of the chief risks of the Cæsarean section, is entirely avoided.

Cases Suitable for the Operation.-It may be broadly stated that cœlio-elytrotomy is applicable in all cases calling for the Cæsarean section when the mother is alive. In post-mortem extractions of the foetus, the Caesarean section, being the most rapid procedure, would certainly be preferable. Exceptions must be made for certain cases of morbid conditions of the soft parts which render delivery per vias naturales impossible, and in which cœlio-elytrotomy could not be performed, as in cases of tumor obstructing the pelvic cavity, also in carcinoma and fibroid of the uterus. When the head is firmly impacted in the pelvic brim, and cannot be dislodged, the operation would be impossible, as the vagina could not be incised. Unlike the Cæsarean section, the operation cannot be performed twice on the same patient, at least on the same side, since adhesions left by the former incisions would prevent the separation of the peritoneum and division of the vagina. It remains to be seen whether in certain cases of extreme deformity, with pendulous abdomen and distorted thighs, the site of incision might not be so difficult to reach as to render the necessary manœuvres impossible.

Anatomy of the Parts concerned in the Operation. It will facilitate the proper comprehension of the operation, and render an avoidance of its possible dangers more easy, if the anatomical relations of the parts concerned arebriefly described.

The abdominal incision extends from a point an inch above the anterior superior iliac spine, and is carried, with a slight downward

1 New York Med. Journ., 1878, vol. xxviii. pp. 837, 449.

curve, parallel to Poupart's ligament until it reaches a point one inch and three-quarters above, and to the outside of, the spine of the pubes. Beyond the latter point it must not extend, so as to avoid the risk of wounding the round ligament and the epigastric artery. In this incision the skin, the aponeurosis of the external oblique, and the fibres of the internal oblique and transversalis muscles are divided. The rectus is not implicated. After the muscles are divided the transversalis fascia is reached. It is fortunately rather dense in this situation, and is separated from the peritoneum by a layer of connective tissue containing fat.

The superficial epigastric artery is necessarily divided, but is too small to give any trouble. The internal epigastric is fortunately not divided, but is so near the inner end of the incision that it may accidentally be so. In one of Dr. Skene's operations it was laid bare. Starting from the external iliac, about a quarter of an inch above Poupart's ligament, it runs downward, forward, and inward to the ligament, thence it turns upward and inward, in front of the round ligament and to the inner side of the internal abdominal ring, behind the posterior layer of the sheath of the rectus muscle, which it finally enters. The circumflex iliac artery also rises from the external iliac a little below the epigastric. It runs between the peritoneum and Poupart's ligament until it reaches the crest of the ilium, to the inner side of which it runs. It thus lies altogether below the line of the incision, and is not likely to be injured.

After the transversalis fascia is divided the peritoneum is reached, and is readily lifted up intact, so as to expose the upper part of the vagina, through which the foetus is extracted. It is fortunate, as facilitating this manœuvre, that the peritoneum is much more lax than in the non-pregnant state, and it has been found very easy to lift it out of the way in all the operations hitherto performed.

The division of the vagina is the part of the operation likely to give rise to most trouble and risk. It is to be noted that, in cases of pelvic contraction calling for this operation, the uterus, with its contents, will be abnormally high and altogether above the pelvic brim; the vagina is, therefore, necessarily elongated and brought more readily within reach. It is enlarged in its upper part during pregnancy, and thrown into folds ready for dilatation during the passage of the child. It is loosely surrounded by the other tissues, and is composed of muscular fibres, easily separable, and an internal mucous layer. Its vascular arrangements are very complex, and the risk of hemorrhage is one of the prominent difficulties of the operation.

In Baudelocque's attempt, in which the vagina was cut instead of torn, the loss of blood was so great as to lead to a discontinuance of the operation. The arteries are numerous, consisting of branches from the hypogastric, inferior vesical, internal pudic, and hemorrhoidal. The veins form a network surrounding the whole canal, but are largest at its extremities, so that it is desirable to open the vagina as low down as possible.

Behind the vagina lies the pouch of peritoneum known as Douglas's space, and below that the rectum. In front of it lies the bladder, and

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