“IN ALMOST ALL CASES in which the Caesarean operation has been performed in this country the patients have died.” So wrote, nearly fifty years ago, that erudite and bold obstetrician who still lives to know that the justice of his criticism has remained undiminished. The Caesarean operation is about as frequently demanded and its results the same.

The most successful operator of the present time is happy if  he can claim an equal success with the German cattle-gelder of the sixteenth century. Our continental neighbours have written of a far larger success, but it has scarcely found credence with those severer critics who have analysed the cases selected.

The Caesarean operation still remains an almost sacrificial one, reversing from necessity the teaching of British obstetrics; for the children thus preserved are comparatively many, the mothers disastrously few. Eighty-five per cent of deaths has been stated by an accurate writer as the probable results in our days.

Probably as much, or more, may be learned from failure as from success. Here is such a failure from the obstetric ward of the Westminster Hospital. It can only be from the faithful record of cases and careful observance of facts that any better rules for guidance can be elicited. 

Woman aged 31, height 3ft 10 inches

SG was a dwarf of 31 years, whose height was but three feet ten inches, and whose figure scarcely presented the outward marks of deformity – fat and muscle had thrown a veil over distortion of bone. She went to offer herself as a candidate for emigration; spent a night on board an emigrant ship; was refused a passage, but returned pregnant. The date thus afforded served to mark the period of her pregnancy on admission into the hospital.

Seven days before she was admitted she had been taken in labour, the pains speedily becoming severe, the liquor amnii escaping early on the third day with prolapse of the funis. No progress other than this being made, the ignorant midwife in attendance left her in alarm, and she remained without assistance of any kind for many hours, when Mr Kempster, of Battersea, was called to her. He performed, with great difficulty,  craniotomy, previously relieving the bladder of a large accumulation of foetid urine; several portions of the foetal skull were removed, but no real progress effected. Labour irregularly continued, the patient’s powers rapidly lessened, and in such state she was brought to the hospital.

Aided by rest and stimulants, she was enabled to bear a minute examination, and the results obtained were: that the soft parts were in a state of sloughing as far as the upper part of the vagina; that the pelvis was so contracted that not two inches of space existed on the anterio-posterior diameter; that the capacity such space might afford was materially lessened by the intrusion of the pubic bone on the left side; that all its measurements were still more distorted by obliquity towards the right side. The pulse was running at 152; the respiration rapid; the abdomen tympanically tense; uterine contractions still occurring feebly and irregularly.

With all her sad suffering and full knowledge of great impending danger, this small woman evinced a large mind, evolving equal patience, hope, and resignation. Indeed, this was the only encouragement, for a more unwelcome case for the Caesarean operation could not be conceived.

Late in the evening some slight rally occurred, enough to mark the moment for the operation, and I therefore performed it. The procedure  may be briefly stated as: free incision into the abdomen, at once exposing the uterus, irregular in form from previous escape of liquor amnii, being moulded by the foetus, save were the placenta unusually placed immediately in front, rendered it more uniform; an incision into the uterus, avoiding the placenta; removal of it and foetus at once; avoidance of all bleeding into the abdominal cavity; compression of the uterus until it contracted; closure of the abdominal wound by suture; cold-water dressing; opium.

Great sense of relief was expressed by the patient as soon as the ceasing influence of chloroform enabled her to judge of herself. Uterine pain ceased; her pulse improved, and she slept; but within twenty-four hours there came the fatal issue in the symptomatic order of vomiting, or rather effortless regurgitation of fluid from the stomach; restlessness; clammy perspiration; surface coldness; death.

Twenty-eight hours after death the body was examined. It was found that the incurvation of the pubic bone so lessened the applied transverse measurements, that the total resultant area was too small to admit of the passage of a very much smaller body than that of the mutilated foetus.

It ought to be added, that assuming the possibility of the patient’s recovering from the effects of the operation, there could have been but little hope of her surviving the great tax upon constitutional resources that must have been imposed by extensive pelvic sloughing.