CESAREAN SEcTioN.—When for any reason the pelvis is rendered, by tumor or contraction, impassable for the un born child, dead or alive, we have an absolute indication for the performance of a Cmsarean section. The operation is indicated when there is a small pelvis with a large child, and, occasionally, when the maternal parts are not dilated and the patient's condition demands an immediate delivery, as, for instance, in placenta prvia or eclampsia. Again, carcinoma in a pregnant uterus at times justifies this operation plus a total hys terectomy; so does a severe case of ante partum sepsis. In the relative indica tions a living child, before the operation is undertaken, is a sine qua non.
The limitations for this operation have already been given; the advisability and the necessity of such must always rest with the operator.
The newest incision recommended by Fritsch is one that extends, not through the centre of the uterus, but transversely from one horn to the other, a little be low and anterior to the fundus. Its ad vantages are the absence of important vessels above as compared to those in the lower uterine zone, the smaller wound, the ease of extraction, and the minimum danger from hernia of the abdomen, be cause of the higher situation of the ex ternal incision.
Technique of Caesarean sec tion: Strict antisepsis, four assistants; incision six inches, equal distance above and below umbilicus; seize uterus by left upper cornu. lift out, close incision partly above; place rubber tube around cervix, crossed but not tied, to be tight ened as necessary. Incise uterus in median line, clamp bleeding vessels, avoid lower segment, incision four to five inches: if placenta is on anterior Nvall cut through it; if waters have not broken avoid soiling peritoneum. Intro duce right hand, extract child by head if possible, if not by extremities; tie cord, divide, give child to assistant. Remove placenta if loose, if not insert sutures, but do not tie until placenta, now having loosened, is removed. Cer vix should be open; silk No. 4 for deep suture in uterus, finer sutures for super ficial, one suture for each inch; peri toneum united by broad surfaces. An sutures tied, elastic ligature gradually removed; abdomen closed. Do not curette uterus. Woman allowed up in three weeks. II. G. Garrigues (Med. Rec., Feb. 1. '96).
Advantages of a trans\ erse cut across the uterus at the fundus. In a recent. operation the abdominal incision was made so that the navel was in the centre of the cut. Hernia is less common after a high incision. The placenta was quickly and easily extracted without bleeding: the child's legs were readily grasped: the womb quickly contracted, seven sutures closing it completely. The incision was about 3 V, inches long. Rapid followed.
In operating upon the uterus the anat omy of the vessels is such that bleed ing is best controlled when the uterus is incised transversely to its long axis, at the fundus. At the level of the tubes and ovaries the incision should be longi tudinal to secure the vessels most read ily. Fritsch (Centralb. f. Gynii.k., No. 20, '97).
Though the transverse fundal incision bleeds but little, the fmtus cannot always be extracted through it. The necessity for a vertical incision in addition causes so much damage to the uterus that it becomes safer to remove that organ than to close the double wound by sutures. Hence the conservative aim of the oper ator is completely defeated when a "Fritsch incision" will not allow of the extraction of the fmtus. Steinthal (Cen tralb. f. Gynlik., No. 14, '93).
Slinger's conservative Cmsarean section performed 25 times. Of IS patients that recovered 5 have already become preg nant again. Transverse incision along the fundns is disapproved; the wound in that case heals badly. as the vascular supply is interfered with by the sutures, secondary infection is very probable, and there is a greater chance of visceral adhesions than when the incision is longitudinal, facing the parietes. Most essential point in Cesarean section is accurate and safe union by suture of the longitudinal incision. Speedy union of the uterine wound is of first importance. This must be effected by three layers of sutures, so that the edges are kept to gether as closely as possible in spite of stony or contractions of the uterine muscular tissue. A deep layer of sutures should be passed, the ends of which are brought out into the uterine cavity and tied there against the decidua. Then a middle set, and afterward a more super ficial set, are passed into the muscular coat and tied on the surface of the uterus. Everke (Wiener med. Woch.. No. 51, '98).