A System of Operative Surgery, Volume 4 (of 4)

by Unknown

The instruments required are those given on [p. 5].

When the patient is under the influence of ether and the bladder emptied with the catheter, an incision is made in the linea alba from the umbilicus to the pubes. The belly-wall of a woman advanced in pregnancy is very thin, and, unless the surgeon be cautious, the knife will come in contact with the uterus before he is aware of it.

The uterus lies just under the incision, and the operator ascertains that it lies centrally (often the uterus is somewhat rotated to the right or left), and then makes a free incision through the uterine wall and extracts the fœtus and placenta; as the uterus contracts, he slips his left hand behind the fundus, and grasps the uterus near the cervix, and effectually controls the bleeding. The assistant passes a large warm flat dab into the belly to restrain the intestines and omentum. The uterine cavity is sponged out, and the finger passed through the os uteri into the vagina in order to ensure a free passage for blood and serum.

The incision in the uterine wall may be closed either by a double or a single set of silk sutures. When two layers of sutures are employed, the first set involve the mucous and adjacent half of the muscular layer[;] these sutures should be fairly close together, for they not only bring the parts into apposition, but they restrain the bleeding. A second row of silk sutures is now inserted, including the serous coat and adjacent half of the muscular layer. These threads should not be tied too tightly, as the tissues of a gravid uterus are soft and easily tear. In closing the uterine incision the surgeon should not spend time vainly in endeavouring to stanch the bleeding from the edges of the incision; this is best effected by dexterously inserting and securing the sutures.

The recesses of the pelvis are carefully cleaned by gentle sponging, and the parietal incision is closed as after ovariotomy.

The dressing varies with the fancy of the operator; a piece of sterilized gauze and a square of Gamgee tissue held in position by a many-tail of flannel firmly applied is all that is necessary.

Although Cæsarean section is one of the simplest operations that can be performed on the pelvic organs, it formerly had a very high mortality; but since the principles of asepsis have been thoroughly established the death-rate from this operation has been so reduced that it varies from 4 to 10% according to the skill of the operator; indeed the results are so good in the hands of careful and skilful men that on recovery from the operation the patient may reconceive, and there are conditions in which the patient is desirous to produce more children with the knowledge that they must be extricated by Cæsarean section. There are many instances on record of women being submitted to this operation twice, and some thrice; and at least two patients have undergone this operation four times (Sinclair). In view of the fact that a woman after being submitted to Cæsarean section may reconceive, it has been urged (especially by Sinclair) that the anterior surface of the uterus should be attached to the abdominal wall in such a manner as to promote the formation of adhesions, so that when the patient needs to be submitted to ‘repeated Cæsarean section’, the adhesions resulting from the primary operation will so shut off the operation area from the general peritoneal cavity, that the uterus may be opened and the fœtus and placenta extracted by a practically extraperitoneal operation. This question has been discussed in an able and comprehensive paper by Wallace, and also by Sinclair.

There is one great danger which women run by becoming pregnant after Cæsarean section, namely, rupture of the uterus. Some cases illustrating this accident have been reported. This accident has been discussed by Wallace.

Although a few writers, particularly Wallace, consider that all Cæsarean sections should be performed with a view to ulterior pregnancy, this is not the opinion of the majority, for there are many women who, having passed such an ordeal once, have no desire to do so again, and ask for something to be done to prevent its possibility in the future. This involves what is known as ‘sterilization’.