Part 17 (2/2)
During the last fifteen or twenty years the operation has become remarkably successful in the hands of the German pract.i.tioners, 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 Caesarean Operation has been and continues to be performed where British pract.i.tioners 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 repet.i.tion 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 circ.u.mstances 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 Caesarean Operation_.)[98]
The difficulty of deciding upon the operation according to the indications of the Continental pract.i.tioners, is much more perplexing than according to that which is followed in this country: the question here is, can the child under any circ.u.mstances be made to pa.s.s _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 circ.u.mstances 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 pa.s.sage 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. Circ.u.mstances may nevertheless occur where the pelvis is so narrow that the child cannot be brought even piecemeal through the natural pa.s.sage: in this case, even if the child be dead, the operation becomes unavoidable.
Under the above-mentioned circ.u.mstances, 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 circ.u.mstances, 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 circ.u.mstances. 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 circ.u.mstances, 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 pa.s.sages 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 pa.s.sages, &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 pa.s.sages.
(Richter, _Anfangsgrunde 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 circ.u.mstance 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 r.e.c.t.u.m 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 a.s.sistants are necessary, ”two to prevent the protrusion of the intestines, and a third to remove the placenta and foetus.” (_Neue Zeitschrift fur 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 a.s.sistants, 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 Caesarean 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 haemorrhage: 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 pa.s.sing 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 v.a.g.i.n.am. 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 Caesarean operation are not very distinct, still we possess sufficient data to p.r.o.nounce 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 aesculapius; 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 circ.u.mstance, 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 Africa.n.u.s, who lived about 200 years later, is said to have been born in a similar manner. There is no reason to suppose that Julius Caesar 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 Naegele, viz. that one of the Julian family at Rome had been delivered _ex caeso matris utero_, and had been named Caesar from this circ.u.mstance, 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 Caesarean 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 pa.s.sage, '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 repet.i.tion 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]
CHAPTER IV.
ARTIFICIAL PREMATURE LABOUR.
_History of the operation.--Period of pregnancy most favourable for performing it.--Description of the operation._
Perhaps the greatest improvement in operative midwifery since the invention and gradual improvement of the forceps is the induction of artificial premature labour for the purpose of delivering a woman of a living child, under circ.u.mstances of pelvic contraction, where either the one must have been exposed to the dangers and sufferings of the Caesarean operation, or the other to the certainty of death by perforation, or at least where the labour must have been so severe and protracted as to have more or less endangered the lives of both. It consists in inducing labour artificially, at such a period of pregnancy that the child has attained a sufficient degree of development to support its existence after birth, and yet is still so small, and the bones of its head so soft, as to be capable of pa.s.sing through the contracted pelvis of its mother.
_History._ Few improvements have met with more violent opposition, or have been more unjustly stigmatized or misrepresented, than artificial premature labour, and it redounds, not a little, to the credit of the English pract.i.tioners that they have not only had the merit of its first invention, but with very trifling exceptions, have been the great means of bringing it into general practice and repute.
To the late Dr. Denman we are under especial obligations in this respect; for, although himself not the inventor of this operation, he, nevertheless, was one of the first who widely recommended it to the profession, and actively promoted it by the powerful support of his name and writings. ”A great number of instances,” says he, ”have occurred to my own observation of women so formed that it was not possible for them to bring forth a living child at the termination of nine months, who have been blessed with living children, by the accidental coming on of labour when they were only seven months advanced in their pregnancy. But the first account of any artificial method of bringing on premature labour was given me by Dr. C. Kelly. He informed me that about the year 1756 there was a consultation of the most eminent men in London, at that time, to consider of the moral rect.i.tude and advantages which might be expected from this practice, which met with their general approbation. The first case in which it was deemed necessary and proper, fell under the care of the late Dr. Macauley, and it terminated successfully.[102] Dr. Kelly informed me he himself had practised it, and among other instances mentioned that the operation had been performed three times on the same woman, and twice the children had been born living.” (Denman's _Introduction to the Practice of Midwifery_, 2d ed. vol. ii. p. 174.) Since this the observations of Mr. Barlow, Dr. Merriman, Mr. Marshall, Drs. J. Clarke, Ramsbotham, &c. &c., have afforded an ample body of evidence in its favour, and have, we trust, tended not a little to diminish the frequency of perforation. On the Continent it experienced a very different reception, being regarded as immoral, barbarous, and unjustifiably endangering the life of the mother and her child. In France, although at first successfully adopted by a few pract.i.tioners, (_Sue_,) its farther progress was completely stopped by the powerful opposition of Baudelocque, and by the plausible though erroneous objections which he made against it. A similar course was pursued by Gardien and Capuron, and even by the celebrated Madame la Chapelle, all of whom have taken a singularly incorrect view of it and a.s.sign it a totally different object to that which is intended: the very name which they have given to it of _Avortement artificiel_, plainly shows how little they have understood of its real character.
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