VAGINAL C,ESAHEAN SECTION, one of the newest of the various obstetrical operations, is one whose indications are: normal size of child and pelvis; pregnancy at or near term; malignant growth of uterus or other obstructing tumor which renders its delivery safe through the vagina and whose persistent presence renders its removal justifiable. Under these conditions the vaginal ("cesarean hysterectomy has been recom mended by Piihrssen. The technique of the operation is as follows: After thorough asepsis, the anterior and pos terior cul-de-sacs are dissected up and the arteries and bases of the broad liga ments either angiotribed or tied oft. The cervix and lower uterine zones are now split up on two to four sides ex tending above the internal ring. The membranes are then ruptured, the child is delivered, the placenta extracted, and the hysterectomy finished "lege arils' as in the non-pregnant woman.
Less dangerous than the classical Caesarean section is an operation by which, in spite of closure of the cervix, and without opening the peritoneum, a living child may be delivered by the vagina. The portio is exposed by a large speculum, and. sagittal openings having been made in the anterior and posterior vaginal vaults, the bladder and vesical fold of peritoneum and that of Douglas's pouch are detached from the cervix and lower segment of the uterus, which are then divided in the median plane. After the bleeding has been ar rested by ligatures, the hand is intro duced and the child extracted. The operation is indicated when, with an un dilatable cervix. the mother's life is im periled by circumstances which may be improved, or set aside, by emptying the uterus; for example, in severe eclampsia or urremia; in cases of serious internal haemorrhage from a normally-situated, but prematurely-displaced, placenta; in grave pulmonary or cardiac disease; in the interests of the child, when the con dition of the mother is expected to prove rapidly fatal; and, finally, in patho logical conditions of the cervix (stenosis, rigidity, myoma, carcinoma) or of the lower segment of the womb (patholog,ical bulging). In new growths of the cervix
the operation may be supplemented by vaginal hysterectomy, which, directly after delivery, can be performed in a few minutes. by Dover's method. Dfihrs sen (Berl. klin. Woch., p. 530, '96).
Surgical Measures Indicated in Fetal Obstruction.—These are all destructive to the child; they are, however, conserva tive, since they are preservative to the mother. In actual practice our first duty is to the mother, and under no condition should danger to the child influence the accoveheur in increasing the danger to the mother, unless, of course, the full consent of both parents is obtained. Where mother and baby have equal chances, those chances should be well weighed and operative influence esti mated. In all difficult and prolonged labor cases in which many operators have examined and many instruments have been used, and operations have been attempted and failed, the child as a result of these prolonged, fruitless, and severe manipulations has often suf fered so severely as to have been nearly or already sacrificed. In such cases, a de CRANIOCLAST.—The use of the cranio clast we have given up entirely, since the instrument, at least in our hands in difficult cases, has repeatedly pulled out, making it a sort of osteoclast.