PAPERS READ AT THE SEMI-ANNUAL MEETING HELD IN ST. JOSEPH, MARCH 22 AND 23, 1906.

IS VAGINAL CESAREAN SECTION JUSTIFIABLE?

Palmer Findley, M. D., Omaha.

Professor of Gynecology, College of Medicine of the University of Nebraska, Omaha.

T

HE question, Is vaginal Cesarean section justifiable, is introduced in the spirit of investigation rather than criticism. The time is not yet when we can pass final judgment upon the merits of this operation, but we can learn something from the limited experience of those who have tried the procedure. Any method that promises to facilitate and perfect the delivery of a viable fetus in complicated cases should engage our serious attention, and is worthy of our criticism.

If we accept, without question, the endorsement of the advocates of this procedure, we find in vaginal Cesarean section an operation simple in technic, rapidly executed and attended by little risk. Are these the facts?

With more than one hundred cases now on record, and the number rapidly increasing, would it not be well to critically review the indications and results of these cases to the end that we may judge of the true merits of the operation. The history of surgery and obstetrics warrants such an undertaking, for innumerable operations have been proposed and enthusiastically endorsed by a goodly number of the profession, but have failed to stand the test of time and application. Will vaginal Cesarean section

share their fate, and follow in the wake of vaginal fixation, likewise proposed by Dührrsen?

I am convinced from personal observations and the study of the reported cases that the operation, so far as concerns its indications, is in the experimental stage. Cases have been operated which would have delivered themselves if time had been allowed, and in not a small number of cases nothing more would have been demanded than the usual manual dilatation of the cervix, to be followed by the application of forceps or by version and extraction. In every reported case, and in all cases which I have observed, it has occurred to me that some other method of delivery would have been preferred, and I have come to the conviction that the indications for the procedure must be restricted before it will find its legitimate place in the obstetrics of the future.

Less extensive incisions of the cervix have been practiced for more than a century, and their value has been fully appreciated. As far back as 1808 Coutouly recommended the operation, as did also Morgagni. In 1847 Simpson incised a carcinomatous cervix, and about this time Bedford operated two cases of atresia of the cervix in pregnancy by making transverse incisions in the cervix. Later we find the procedure generally adopted. Carl Baun, in advocating incisions of the cervix, laid down the dictum that the supra-vaginal portion of the cervix must be dilated before the incision is made for fear of tearing beyond the incision; thus he foreshadowed one of the dangers involved in vaginal Cesarean section.

Credit should be given Acconci for the introduction of vaginal Cesarean section in 1896, though it was Dührrsen who, in the same year, broadened the indications for the operation and placed it prominently before the profession. The operation was first suggested by him as a rapid means of delivering eclamptic cases, while his first operated case was a complication due to ventrofixation of the uterus. The following were his indications for vaginal Cesarean section:

"1. Abnormal conditions of the cervix and lower segment of the uterus (carcinoma, myoma, rigidity, stenosis, partial pouch-like distension of the lower uterine portion).

"2. Dangerous conditions of the mother, which may be removed or relieved by prompt emptying of the uterus (affections of the heart, lungs, kidneys, eclampsia).

"3. Conditions of the mother when death is imminent and can be foreseen.

The technic of the Dührrsen operation consists briefly in grasping the anterior lip of the cervix on either side of the median line with bullet forceps. A transverse incision, one and one-half inches in length, is made through the vaginal mucosa at the point of reflection of the anterior vaginal wall upon the cervix. The vaginal wall and bladder are stripped off the cervix and lower uterine segment as far as the utero-vesical fold of peritoneum. By elevating the bladder and vaginal wall with a retractor, the anterior surface of the cervix and lower uterine segment are exposed. A still greater exposure may be made by incising the vaginal mucous membrane from a point just below the meatus to the mid point of the transverse incision. Firm traction is made upon the cervix by the bullet forceps as the incison is carried in the middle line of the anterior lip

FIG. I.-Showing initial incisions. Transverse incision one inch in length across the anterior lip of the cervix. Vertical incision in anterior vaginal wall extending from a point immediately below the urethra to a mid-point in the transverse cervical incision.

of the cervix from the external os to the internal os; very little bleeding results. If a still greater opening is required for the ready delivery of the fetus, a median incision is made through the posterior lip of the cervix to the point of deflection of the posterior vaginal wall upon the cervix. Forceps are then applied or version is performed, and the incisions are closed by catgut.

This operation would appear to be ideal in selected cases, but may we not with profit note the possible dangers attending it, and then raise the question as to whether other methods of delivery should not have been chosen for the indications laid down by Dührrsen and his followers.

In the first place, it must be admitted that there are no absolute indications for vaginal Cesarean section, such as we admit for abdominal Cesarean section-at most the indications are relative, and hence subject to oriticism. More than 90% of all abdominal Cesarean operations are indicated by pelvic deformities; these must, of course, be excluded in the consideration of the indications for vaginal Cesarean section.

A brief consideration of the indications for vaginal Cesarean section, as laid down by Dührrsen and his followers, will be of interest. Dührrsen's first operation was performed in a case complicated by a previous ventrofixation. In this case, as in all such cases, would not abdominal Cesarean section have been preferred, if for no other reason than that the cause of the complication could have been removed by severing the offending attachment of the fundus to the abdominal wall, thereby preventing a repetition of the accident in subsequent pregnancies?

In cancer of the cervix, complicated by pregnancy, I question the safety of extending the incision through carcinomatous tissue for fear of infection which is so commonly associated with malignant growths, and for fear of extending the incision through the friable tissue by the extraction of the child. I can find no justification for the attempt to do a vaginal hysterectomy for cancer of the cervix of a full term pregnant uterus. The technical difficulties of the operation and the necessarily high mortality attending it, do not warrant such a procedure, with all due deference to the skill of Dührrsen, who advocates and practices the procedure.

Where death is imminent and can be foreseen, and it is desired that the life of the fetus should he saved, if possible, it would be quicker and safer for the fetus if the abdominal route be chosen. Such babies are rarely vigorous because of the condition of the mother, and can ill withstand the necessary manipulations required in the delivery through the incised cervix.

Affections of the heart, lungs and kidneys complicating pregnancy, so grave as to require surgical interference in the delivery of the fetus, are in themselves contraindications for an operation of any magnitude; would seem more conservative to resort to the bag in dilating the cervix. The indication for delivery would rarely be so urgent as to not permit of the necessary time to effect dilatation by the bag or hands. In the very exceptional cases, where the cervix has not dilated and the emptying of the uterus is urgently and immediately demanded to save the life of the mother, it may be found expedient to incise the cervix., even to the extent advocated by Dührrsen, but such a condition can scarcely arise