CÆSAREAN OPERATION.

The next operation in Midwifery for delivering the full-grown foetus 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:[97] 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.)[98]

The difficulty of deciding upon the operation according to the indications of the Continental practitioners, is much more perplexing than according 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.[99]

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 have 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 uterus rapidly contracts, and thus prevents all fear of hÆmorrhage: for this reason the sooner the child is removed the better, as otherwise the uterus is apt to contract upon a portion of it when passing through the wound, and thus retain it. It is desirable to remove the membranes as far as possible, especially from the os uteri, to allow of a free discharge from the uterus per vaginam. No sutures are needed for the uterine incision: the contractions of the organ not only diminish its length, but generally bring its edges into sufficiently close contact.

Some discrepancy of opinion has existed respecting the treatment of the external wound: sutures are of course the most secure means of retaining the edges in apposition, but they produce great suffering, and, from taking up a good deal of time, delay the closing of the abdominal wound more or less; whereas, straps of sticking plaster are applied much quicker and without any suffering to the patient. To do this most effectually it will be advisable to arrange them under the loins previous to the operation: they should be from five to six feet long, and the ends may be rolled up until wanted; the wound can thus be instantly closed and in the most secure manner. Where the operator finds it necessary to use sutures, he must avoid puncturing the peritoneum as far as possible: the lower inch of the wound should be left open to allow any matter to drain out, and the whole dressed according to the common rules of surgery. The patient should be placed upon her side with the knees bent to relax the abdominal parietes. A grain of the hydrochlorate of morphia has been given in these cases with the best effects, having procured sleep and allayed the disposition to spasmodic coughing and vomiting, which so frequently exists after the operation.

One of the greatest triumphs of modern surgery is the performance of this dangerous operation four times successively on the same patient. The first operation was performed in June 1826, the woman being then in her twenty-ninth year, the second in January 1830, the third in March 1832, and the fourth on the 27th June, 1836. The second operation was performed by Wiedemann, of Kiel, and scarcely lasted five minutes; nor does it appear that the patient’s sufferings were very great, for the application of sutures on this occasion elicited more complaint than all the operations put together.[100]

History. Although the early records of the CÆsarean operation are not very distinct, still we possess sufficient data to pronounce it of very considerable antiquity. The earliest mention of it shows that it was at first used merely for the purpose of saving the child by extracting it from the womb of its dead mother, a law having been made by Numa Pompilius, the second king of Rome, forbidding the body of any female far advanced in pregnancy to be buried until the operation had been performed.

The mythology of the ancients refers to two cases of an exceedingly remote period where a living child was taken from the dead body of its mother: these were the birth of Bacchus and Æsculapius; but as these traditions are so enveloped in allegory and mystery, it is difficult to come to any other conclusion than a mere inference of the fact: one circumstance, however, connected with the birth of Bacchus is curious, viz. that his mother Semele died in the seventh month of her pregnancy.

The oldest authentic record is the case of Georgius, a celebrated orator born at Leontium in Sicily, B. C. 508. Scipio Africanus, who lived about 200 years later, is said to have been born in a similar manner. There is no reason to suppose that Julius CÆsar was born by this operation, or still less that it derived its name from him, for at the age of thirty, he speaks of his mother Aurelia as being still alive, which is very improbable if she had undergone such a mode of delivery. We would rather prefer the explanation of Professor NaegelÉ, viz. that one of the Julian family at Rome had been delivered ex cÆso matris utero, and had been named CÆsar from this circumstance, so that the name was derived from the operation, not the operation from the name.

“The earliest account of it in any medical work is that in the Chirurgia Guidonis de Cauliaco, published about the middle of the fourteenth century. Here, however, the practise is only spoken of as proper after the death of the mother.” (Cooper’s Surg. Dict.) Among the Jews, however, it appears to have been performed on the living mother at a very early period; a description of it is given in the Mischnejoth, “which is the oldest book of this people, and supposed to have been published 140 years before the birth of our Saviour, or, according to some, even antecedently to this period. In the Talmud of the Jews, also, their next book in point of antiquity, the CÆsarean operation is mentioned in such terms as to render it extremely probable that it was resorted to before the commencement of the Christian era. In the Mischnejoth there is the following passage, ‘In the case of twins, neither the first child which shall be brought into the world by the cut in the abdomen, nor the second, can receive the rights of primogeniture, either as regards the office of priest or succession to property.’ In a publication called the Nidda, an appendix to the Talmud, there is the following remarkable direction: ‘It is not necessary for women to observe the days of purification after the removal of the child through the parietes of the abdomen.’” (Introduction to the Study and Practice of Midwifery, by W. Campbell, M. D. p. 260.)

The first authentic operation upon a living woman in later times was the celebrated one by Jacob Nufer, upon his own wife, in 1500, after which, owing to its fatal character and the strong feeling against it, it was performed but rarely: still, however, sufficient evidence existed to mark its occasional success and urge its repetition in similar cases; and from what we have already stated, the history of the last twenty years shows that its results have rapidly become more and more favourable, so that in the present day it can be no longer looked upon as an operation of such extreme danger and almost certain fatality, as it was in former times.[101]