HISTORICAL AND STATISTICAL.
LEISHMAN says that Caesarean section with its perfection in detail of operation and splendid results is of modern date. It is true that it has a history dating back no Numa Pompelius who “forbade the burial of pregnant women in whom the operation had not been performed.” We have no early authentic statement that Caesarian section was performed upon living women. Though no mention is made of it by the old writers, such as Hippocrates and others, yet its great antiquity is admitted.
The first mention of Caesarian section is in the Chirurgia Guidonis de Cauliaco, published in the middle of the fourteenth century, and here only after the death of the mother. It was performed the first time on a living woman in 1500 by Jacques Nufu on his own wife. At first no attempt was made to close the uterine wound, for all of the attention seems to have been given to the manner of closing that of the abdomen. In 1769, Libas was the first to close the uterus with sutures after the operation, but this proceeding was lost sight of until 1828, when it was carried out by Dr. Frank E. Pollen, who first used the silver wire suture for the uterine wound.
Sir F. Gould, in 1742, is the first British author who notice the operation and says it may be performed “either while the mother is living or after her death”.
The Caesarian operation meant one of three different proceedings, viz.:.
First.-Cutting the os when hard fibrinous deposits are found around it, or when other conditions exists which necessitate its opening and enlargement; this is vaginal Caesarian section.
Second.-Abdominal Caesarian section for the removal of the foetus from the abdominal cavity, or ectopic gestation.
Third.-Caesarian section where the incision is made through the abdominal and uterine walls for the extraction of the foetus.
In abdominal section there are three conditions which indicate the operation, viz.:.
First.-When the foetus is alive and the mother died in labor, or in the last two or three months or pregnancy.
Second.-Where the foetus is dead but cannot be delivered in the usual way on account of the deformity of the mother or the disproportionate size of the child.
Third.-When both the mother and child are living, but delivery cannot take place from the same cause as in the second example.
History records the bitter opposition to the operation as well as the strenuous efforts made to support it during the seventeenth and nineteenth centuries. To-day it is an accepted operation under existing conditions with results favorable.
The conditions which warrant the operation are largely disputed. In Germany it is asserted that where the conjugate diameter of the brim is only 21/2 inches. Americans say that craniotomy can be performed where the diameter is only 1 1/2 inches, but the conjugate is not the test.
Cazeau thinks the operation is indicated when the pelvic contraction measures five centimetres (two inches), and Tarnier is of the same opinion. DePaul prefers the Caesarian section when the pelvic contraction is only six centimetres and the child is alive.
Scanzoni would even prefer the operation for a living child if the contraction was only eight centimetres. This diameter may be from 1 1/2 to 2 1/2 inches and other conditions exist which demand the procedure. These conditions may be a shelving brim, an exostosis, a fibroma, pelvic bones, spondylolisthesis, placenta praevia, the kyphotic pelvis, the scolio-rachitic pelvis, the Roberts pelvis, the osteo-malacia pelvis, or the ruptured uterus. Moreover, the operation is indicated in cases in which the mother prefers the operation rather than to sacrifice the life of the child; also in cases of death of the mother while the child is viable.
The following statistics by Schroeder up to 1874 gives the percentage of deaths at 54 per cent. Dr. Robert P. Harris gives the following statistics of operation: In North America, 135 cases with 60 cures; in England, 141 cases, 25 cures.
He further states that in 120 operations in this country the percentage of cures in the country was 62 1/2 per cent.; in the small towns, 34 per cent., and in the cities 33 per cent. The same authority, in a report dated September, 1886, gives the results of Caesarean section performed when the condition was favorable, viz.: saves, 75 per cent. of the mothers in this country and 80 per cent. of the children. it further gives a statistical report as follows:.
Caesarean operations of the United States. 144.
Women saved, 37 1/2 per cent, 54.
Children living when delivered, 64.
First 50 operations saved, 54 per cent, 27.
Last 50 operations saved, 24 per cent, 12.
Operation for decade ending Dec. 31, 1885, 25.
Women saved, 48 per cent, 12.
Children living, 13.
Operations for decade ending Dec. 31, 1865, 24.
Women saved, 45 5/6 per cent, 11.
Children living, 10.
Operations for decade ending Dec. 31, 1875, 36.
Women saved, 27 7/9 per cent, 10.
Children living, 11.
Operations for 10 1/2 years, ending Aug. 1, 1886, 37.
Women saved, 21 2/3 3/7 per cent, 8.
Children living, 16.
Late operations, nearly 84 per cent. of this.
division 31.
The late Dr. S.S. Lungren, of Toledo, O., collected reports of all cases on the same woman. On 48 women the operation was performed 119 times; 8 mothers only have died and 40 have been saved.
“The time most favorable for the operation is that which just precedes or immediately follows the rupture of the membranes; for at this time the os is well dilated and the uterine contractions, which have already exists for some time, acquire a more regular and intense character. If one operates much earlier than this, the uterine contractions after the operation are apt to be insufficient, and if much later, the danger to the child is considerably increased.”.
Statistics very: one report gives the advantages of an operation during or before the close of the first day of labor to be 73 per cent. of women and 86 per cent, of children, while Lusk says only 81 per cent. of women are saved.
Dr. Harris gives statistics as follows:.
Operations Cures.
24 hours before labor had commenced, 7 7.
34 hours before labor had commenced, 7 4.
34 hours before labor bad commenced, 10 1
Radfoot gives statistics of 100 cases as follows:.
Operations. Cures. .
24 hours before labor, 24 7.
24 hours after labor, 76 9.
Kayser’s statistics in relation to the rupture of the membranes is as follows:.
Mothers. Children.
Cases. cures. Cases. Cures.
Before or 6 hours after, 39 20 39 34.
7 to 24 hours after, 35 24 32 25.
More than 24 hours after, 38 13 37 19.
Of Porro’s operation the results for the first few years were very unfavorable. it is reported that the mortality of mothers was 58 per cent. For the period of five years to the close of 1889, from all countries-the general result is of 158 operations-there were 47 deaths-a mortality of 29 per cent. Italy, who gave us the Porro operation, and has thus far led all countries in the number of her Porro-Caesarean sections, has made the least satisfactory progress in reducing the percentage of deaths.
Caesarean operations in the United States where the obstruction was due to pelvic fibroids, 13.
Caesarean operations in the United States where the obstruction was due to pelvic fibrous tumors, 1.
Caesarean operations in the United States where the obstruction was due to pelvic exostosis, 8.
Women recovered in uterine fibroid cases, 4.
Women recovered in pelvic fibroid cases, 0.
Women recovered in pelvic exostosis, 4.
Children living in uterine fibroid cases, 5.
Children living pelvic fibroid cases, 1.
Children living pelvic exostosis, 5.
Time in labor in uterine fibroid cases, 42 hours to.
15 days, 9.
Time in saved cases: 9 1/2 hours, 14 hours, 3 days, 4 days,
respectively, 4.
Time not stated, but labor prolonged, 2.
Time in labor in pelvic exostosis cases, 24 hours.
to 3 days, 6.
Time in saved cases: “a few hours;” 12 hours, 24 hours and.
38 hours, respectively, 4.
Uterine fibroids, cases saved, 30 1/1 0/3 per cent.
Pelvic exostosis, cases saved, 30 per cent.
MODIFICATIONS OF THE OPERATION.
1. Porro’s Caesarean section; ovaro-hysterectomy; amputation of the uterus and ovaries immediately after the performance of Caesarean section, the stump being fastened at the lower angle of the abdominal wound.
2. Thomas’s operation; laparo-elytrotomy.
3. Porro-Muller operation. In this the uterus is brought out of the abdominal incision, an elastic ligature is applied around the cervix at the level of the internal os, and the uterus is then incised and the foetus extracted.
4. Porro-Veit operation. Modification of Porro’s operation by dropping the stump into the pelvis.
5. Sanger’s operation, sero-serous.
6. Pubeotomy.
NECESSARY STEPS IN THE OPERATION.
First.-Care for the patient in every particular, as in coeliotomy.
Second.-The abdominal incision should be sufficiently long to permit the lifting of the womb out of the abdominal cavity.
Third.-Protect the exposed uterus with hot clots.
Fourth.-Have a heavy rubber tubing passed around the cervix uteri, and tie in a single knot loosely; it may be useful in case of haemorrhage.
