4. Finally, with Alessandrini, of Milan, Pinard advocates the Porro operation in case of rupture of the uterus. The cases cited by Halbert sma, and the results given by Jolly in his thesis, seem to justify this opinion.
As for the indication from the presence of fibrous and cancerous tumors, we have discussed it elsewhere.
To resume, then: Porro's operation, like the Caesarean, should be one of absolute necessity, and whenever we have the choice between it and another, it is to the other that the preference should be given.
[The results obtained of late years through the improved Caesarean sec tion, have led most authorities to practically reject the Porro operation, except in case of rupture of the uterus, which makes the Porro an opera tion of necessity, where it is not possible to use the uterine suture.
We are again indebted to the labors of Dr. Robert P. Harris for the more recent statistics of this operation, and its modifications, which we append below.
In many of the cases in this table the maternal death was due to the fact that the operation was deferred too long, and since the compilation of the table the total number of operations has been increased to 164. " Deducting from this number 3 moribund cases, and 14 in which the stump was dropped and proved fatal in 10, we have remaining 147 cases with 44 per cent. maternal recoveries." (Harris.) In regard to the various methods in vogue for the delivery of the child per alnlominem, Harris sums up the question so tersely and justly, that we append his remarks: " The Caesarean section and the Porro are largely dependent for success upon the condition of the patient at the time it is performed. If then a timely, elective, and pre-arranged Cesarean operation must have an unfavorable prognosis because of the physical condition and poverty of the subject, can much more be anticipated from the Porro im provement under the same disadvantages? Laparo-elytrotomy may prove less fatal than either, because it neither wounds the uterus nor opens the peritoneal cavity." To sum up this question in the light of to-day's knowledge, we would say: Perform laparo-elytrotomy if the conditions essential to its perform ance are present; not, perform the modified Caesarean section with deep muscular and sero-serous superficial sutures; reject the Porro or its modifications except in the presence of rupture of the uterus where the uterine suture cannot be used; above all, operate in time, before exhaus tion has set in, and pay strict attention to scrupulous cleanliness.—Ed.] Preliminary Precautions.—These are identical with those applicable to ovariotomy or the Caesarean section.
The operation is divided into four stages: 1. Incision of the abdominal wall.
2. Incision of the uterus, and extraction of the foetus.
3. Amputation of the uterus and ovaries, and formation of the pedicle.
4. Dressing of the abdomen.
Incision of the Abdomen.—Tho incision should extend from 11 to two inches above the pubes to one to two inches above the umbilicus, to one side of which it passes. The peritoneum is divided on a director.
Incision of the Uterus and Extraction of the Fcelus.—The uterus is brought close to the abdominal wall, and is incised layer by layer. The membranes are ruptured, and the foetus extracted.
Muller brings the uterus externally, and applies an elastic ligature around the cervix at the level of the internal os, and then only does he open the uterus and extract the fcetus. This is the method which Rein followed in his experiments on animals.
Instead of the ligature, Litzmann and Fehling use Esmarch's bandage.
Resorted to by Litzmann, Breisky, G. Braiin, Tarnier, Tibone, C. Braun, Chiara, and others, MiiRees modification has given good results only in the hands of Breisky. It can be only used in easy cases, for it may result in tears or injury of the peritoneum, and hence in peritonitis.
Amputation of the Uterus and Ovaries, Formation of the Pedicle. Porro incises the uterus in position, and it is only after extraction of the foetus that he draws it out by means of long ovarian forceps. He then passes a trocar through the uterus, at the junction of the body and the cervix, and through this two metallic wires, which are twisted the one to the right and the other to the left. Ile then amputates.
Tarnier and Championniere pass a steel needle through the uterus at the same junction, and a second, at a slightly higher level, perpendicu larly to the first. A wire loop is passed around the cervix, underneath these needles and including the ovaries and tubes, and this is twisted, and the uterus is amputated about inch above the wire. , The peritoneal cavity is then cleansed, and the pedicle is fixed in the lower angle of the incision in the abdominal wall. The abdominal incision is united by metal lic sutures. The dressing is the same as after ovariotomy.
Schlemmer (Stuttgart, 1881) objects to the Porro operation, on the ground that it is immoral, since it removes all 'possibility of further con ception, and therefore might be abused.
Muller, whose thesis is simply an eloquent plea in favor of the Porro operation, is compelled to admit the bad results of this operation, and that they are not much more satisfactory than those from the classic section. lie ends his conclusions in the following words: " The day when a large number of cases prove to me that, by means of modifications of the classic section, we have obtained as sure a guarantee against hemorrhage and sepsis as is offered by the utero•ovarian amputation, then I will be the first to declare against the Porro operation. Until then I will remain a partisan in its favor, seeing that I have personally tested its advantages." Notwithstanding these words of Muller, the tendency to-day is to re turn to the classic section, and the search is always in the direction of im proving the technique of this operation.