ON 
GASTRO-ELYTROTOMY 
BY 
HENRY J. GARRIGUES, A. M., M. D., 
BROOKLYN, N. Y., 
FELLOW OT THE AMERICAN GYNECOLOGICAL AND NEW YORK OBSTETRICAL B00IBT1M. 
1 REPRINTED FROM THE NEW YORK MEDICAL JOURNAL, 
OCTOBER AND NOVEMBER, 1878.] 
NEW YORK: 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1878. TO 
THEODORE GAILLARD THOMAS, M.D., 
THE REINVENTOR, IMPROVER, AND SUCCESSFUL PER- 
FORMER OF GASTRO-ELYTROTOMY. ERRATA. 
Page 7, fifth line from bottom, for "lacunae," read "lacunar." 
Page 8, second line from bottom, for " 1835," read " 1825." 
Page 13, eighth line from bottom, for "1824," read "1825." 
Page 27, ninth line from top, for "vagina," read " bladder." ON GASTRO-ELYTROTOMY. 
The fearful mortality resulting from the Caesarean section 
has given rise to the ardent desire of finding a substitute that 
might give better chances for the recovery of those women 
whose conformation is such that it does not allow the passage 
of the foetus through the pelvis. Therefore were invented, on 
the one hand, symphysiotomy (Sigault, 1768), and its offspring, 
pubiotomy (Stoltz) pelviotorny (Galbiati), and, on the other, 
gastro-elytrotomy, or laparo-elytrotomy. The first of these 
operations was at one time quite in vogue, and is still mentioned 
in all text-books, although abandoned long ago as entirely 
worthless, except in Italy.1 The other was noticed so little 
that it was invented three times in different countries be- 
fore it was reinvented in this country, and came into notoriety 
through the splendid results obtained by Dr. Theodore Gaillard 
Thomas, of New York, and his follower, Dr. Alexander J. C. 
Skene, of Brooklyn, New York. 
1 During the last five years symphysiotomy was performed nineteen 
times in the hospital of Naples. Fifteen patients recovered; four died. 
of the children died.-(" Annales de GynGcoIogie," vol. viii., p. 317; 
reported in Howitz's "Gynecological Communications," vol. i., No. 3, p. 
114, Copenhagen, 1878.) 4 
History.-Medico-historical researches are difficult in a 
young country, in which, in spite of laudable efforts and great 
progress, the scholar looks in vain for the facilities afforded 
by the large public libraries of European cities. In order to 
ascertain the true history of gastro-elytrotomy, I have been 
obliged to bring under contribution the private and public 
libraries of New York, Boston, and Washington, nay, even to 
have recourse to the libraries of Copenhagen (Denmark). Even 
those most interested in the operation know little about its 
history. Most books on midwifery do not even mention the 
operation. The few that do, all give more or less erroneous 
descriptions of its performance and its results. It is therefore 
absolutely necessary to go to the original sources in order to 
get accurate and complete information on the subject. 
The history of this operation may naturally be divided 
into two parts-the age of projects and attempts, in which 
we find Joerg, Bitgen, Physick, L. A. Baudelocque, and 
Charles Bell ; and the age of fulfillment, belonging to Drs. 
T. G. Thomas and Skene. 
The first group may again be divided into those who 
merely proposed the operation-Joerg, Physick, and Charles 
Bell-and those who tried it-Ritgen and Baudelocque, Jr. 
Before going further it will be necessary to say what is the 
character of the operation, for the above-named authors and 
surgeons have by no means all advocated or tried the same 
procedure; but there is something common in their aim which 
makes a unit of the different plans and attempts. All try to 
avoid opening the ~body of the uterus, as done in the Caesarean 
section, while some open the peritoneal cavity, others not; 
some incise the vagina, others the neck of the womb, or both 
together. 
First Period-Projects and Attempts.-As early as 1806 
the German obstetrician Joerg1 proposed to make the Caesarean 
section in such a way as to avoid the incision of the body of 
the womb. After having incised the abdominal wall in the 
'Joerg, "Versuche und Beitriige geburtshulflichen Inhalts," Leipsic, 
1806, p. 263 ; " Handbuch der Geburtshulfe," 1807, sec. 384, and new edi- 
tion, 1833, sec. 512. 5 
tinea alba, he advises to open the vagina, and, if this does not 
give space enough, the os uteri, by an incision, and extract 
the child through this artificial opening. He felt justified in 
making this proposition from the experience of several accouch- 
eurs who had seen the child pushed through a rupture in the 
vagina into the abdominal cavity. He had only once per- 
formed Caesarean section, on a dead woman, and in that case 
he saw that he could extract the child very easily by incising 
the lower part of the uterus only. He thought that an in- 
cision here would be less dangerous and wrould heal more 
readily than the artificial opening in the middle of the 
uterus. 
To Joerg, then, belongs the honor of having first enriched 
science with a proposal falling under the head of gastro-elytrot- 
omy ' but, in the first place, he never tried his plan in prac- 
tice, and, next, his plan, as it is, is open to a good deal of 
criticism. First, he incises the peritonaeum, in which respect 
he is inferior to most of his successors. Second, he makes the 
incision in the middle line, which would leave a comparative- 
ly great distance to the point in which the deep incision is to 
be made, and from which the child shall be taken, and dimin- 
ish the advantage gained by tilting the uterus on one side 
during delivery. Third, if he had carried out his plan of in- 
cising the side-wall of the vagina, and carrying up the incision 
into the neck of the womb-in other words, making a longi- 
tudinal incision in the direction of the axis of the pelvis-he 
would have endangered the ureter of the corresponding side 
very much. Fourth, if, as in his second proposition, he incised 
only the lower segment of the womb in front, he would, in- 
deed, avoid the ureter and the large uterine vessels, but, on 
the other hand, he would incise a part much less contractile 
than the body of the uterus, and, consequently, the vessels 
divided would be apt to give a fatal haemorrhage. 
In 1820, Ritgen,1 another German professor, took a great 
step forward, proposing to operate without opening the peri- 
tonaeum. He acknowledges his obligation to Joerg on one 
1 Ritgen, "Die Anzeigen der mechanischen II tilt en bei Entbindun- 
gen," Giessen, 1820, pp. 406-7, and 441-446. 6 
hand, and to Abernethy and Cooper on the other, the first 
having proposed the incision of the vagina, the two others 
having taught how to ligate the external iliac artery without 
opening the peritonaeum. He regards the time following close 
upon the spontaneous rupture of the- membranes as the most 
favorable for operating. Before the rupture the vagina is too 
little extended, later the head has too much difficulty in passing 
the os on account of the resistance offered by the pelvis. Yet, 
even if the head be already fully engaged in the os, or still 
more advanced, the operation is still indicated. If the vagina 
has ruptured spontaneously, the same incision ought to be 
made through the abdominal 'wall, including the peritonaeum. 
On account of the greater distance between the rectum 
and the ilio-pectineal line, the-incision ought to be made on 
the right side. The patient is placed on her back, the sacral 
region considerably elevated on a firm cushion, the head, 
neck, and shoulders raised on pillows, and the thighs and legs 
stretched out. 
He describes the modus operandi in these words: " 1. The 
accoucheur takes his place at the right side of the pregnant 
woman, introduces a male catheter, pushes the bladder toward 
the left side, and gives it in charge to an assistant. Another 
assistant, standing at the left of the woman's chest, places 
one of his hands flat in the middle line, under the umbilicus, 
the other toward the left, and draws the uterus toward himself 
and away from the right side of the pelvis, by doing which he 
also puts the skin to be incised on the stretch. 2. A semi- 
lunar incision is made from the region of the crista ilii to 
the neighborhood of the symphysis pubis, at a distance of 
barely an inch from the bones in this region. 3. Next, an 
incision is made through the muscles in the same direction, 
and with the precaution not to injure the peritonaeum. Ar- 
teries that may have been severed, such as the epigastric, the 
abdominalis (superficial epigastric), and the circumflex iliac, 
are immediately tied. 4. Now the areolar tissue, which lies 
under the peritonaeum, is to be separated with the fingers, the 
handle of the scalpel, or, if it can be safely done, with its edge, 
and thus the peritoneal cavity undermined, in order to come 
behind the walls of the vagina. 5. Then the operator intro- 7 
duces Frere Gome's sonde d dard, the stylet drawn back, into 
the vagina, and applies the point of the instrument against 
the wall of the vagina so as to raise it above the middle of the 
tinea innominata (or ileo-pectinea) of the right side. At the 
same time the assistant who lifts the abdomen draws the 
uterus vigorously away from the iliac and pubic bone, thereby 
exposing as much as possible of the deeper parts of the vagina. 
6. The operator now pushes the stylet of the sound through 
the vaginal walls, protecting the surrounding parts with the 
thumb and the fore and middle finger of the left hand. 7. 
When the stylet has perforated the wall, a probe-pointed bis- 
toury is passed down along its groove, and the vagina opened 
toward the urethra, which must not be wounded. Then the 
stone-sound is withdrawn and the incision extended toward 
the rectum, as far as it can be done without injuring this 
organ, using the fore-finger of the right hand as a guide. 8. 
When this incision has been successfully performed, so as to 
leave a curtain of vaginal wall two or three inches long hang- 
ing down from the right half of the uterine neck, this curtain 
is to be divided in the middle with a pair of scissors, up to the 
edge of the uterus. 9. Next, the wound is covered with a fine 
piece of linen soaked in warm oil, and the operator awaits the 
passage of the child through the wound, during which the 
womb must be drawn vigorously upward and toward the left. 
If necessary, the vaginal portion of the uterus may be incised 
on the right side, in order to facilitate the passage of the child. 
10. After the expulsion of the foetus the wound is cleaned, 
and the skin and the muscles brought together by interrupted 
sutures and strips of adhesive plaster. The wound in the 
vagina is first left alone, and later only moistened with injec- 
tions of conium. A suitable bandage ought to be applied in 
order to prevent a ventral hernia." lie says that he did not 
lay much stress on the unavoidable injury to the artery and 
veins running through the lacunae of the vagina, the artery 
being so small that, when entirely cut, it soon ceases to bleed, 
and the venous haemorrhage being likely to be arrested by the 
compression exercised by the body of the child moving forward, 
by the contraction of the womb during the expulsion of the 8 
foetus, or being easily checked, as he hoped, by tamponing the 
wound with a sponge. 
Ritgen not only gave this detailed plan, so rich in excel- 
lent suggestions, but the following year, October 21, 1821, he 
had the courage to subject his views to the test of experience. 
As we learn as much from failures as from successes, and as 
the description of this first essay of gastro-elytrotomy is only 
found in an old German journal,1 accessible to few of my 
readers, I deem it useful to translate it in extenso. 
"The wife of Joan Peter , of , thirty-seven and 
a half years old, a woman of small stature and very delicate 
constitution, with dark eyes and hair, was delivered ten years 
ago of a living girl. The labor was difficult and the child 
was taken with the forceps. The woman gave birth to a 
second child, a boy, on the 24th of October, 1815, and this 
time the labor was a very easy one. The same was the case 
on the 15th of February, 1818, on which day she was again 
delivered of a boy. 
" In the year 1819, in consequence of all sorts of depressing 
emotions, a cold and damp dwelling, as well as bad food, she 
began to sicken. Her complexion became pallid and finally 
earthy. She lost flesh, and her gait became so uncertain that, 
toward the end of 1820, she could no more leave her bed. 
" The physician who attended the patient, Dr. , diag- 
nosticated the disease as beginning osteomalacia, and warned 
her against becoming pregnant. Pregnancy occurred, how- 
ever ; and, when in due time he was called in to deliver her, 
he found the bones of the vertebral column and the pelvis dis- 
torted, the lumbar vertebrae turned inward and toward the 
left, the sacrum much curved at its lower end, the pubis 
turned inward and upward, the symphysis pubis sharply pro- 
jecting, and the horizontal branch of the right pubis bent in- 
ward. The bones of the pelvis had not reached that degree 
of softening which allows the application of the forceps. Not 
long ago the same physician had succeeded in extracting two 
children, whose mothers suffered from still greater narrowness 
1 " Heidelberger klinische Annalen," vol. i., Heidelberg, 1835, p. 266, 
•ej. 9 
of the pelvis, but in those two cases the pelvic bones were 
already so flexible that they yielded to the pressure of the head 
seized with the forceps, and allowed it to pass. 
" The inward deflection of the pubis, which caused the head 
of the child to overtop the pelvic brim in this place, made the 
doctor particularly expect success from gastro-ely trotomy. He 
therefore applied to me in order that I might myself perform 
the operation as proposed by me. 
" Accompanied by Dr. , I repaired immediately to the 
house of the parturient woman, where we found the necessary 
number of assistants. She appeared to me exactly as de- 
scribed by Dr. . I found her very thin, with small, rather 
quick pulse, but without fever. She was entirely resigned as 
to the pain and the possible result of the operation. She 
wished only to have the child saved, and complained of great 
weakness. Labor pains had begun in the forenoon of the pre- 
ceding day, had disappeared toward evening, had set in again 
during night, and increased until five o'clock in the morning. 
Since then they appeared with intervals of eight to five min- 
utes. By external and internal examination, I verified the 
statement of Dr. in regard to the conformation of the 
pelvis and the vertebral column. The womb was normally 
shaped, the fundus and body lying more in the left, the neck 
more in the right side of the mother. The os was felt soft 
and swollen, and presented a dilatation of two and a half inches 
in diameter. The occiput of the child was directed toward the 
right sacro-iliac articulation, and the left parietal bone over- 
topped the right pubis of the mother, which was bent inward. 
Although the promontory was very easily reached on account 
of the curvature of the sacrum, the head stood pretty high, 
because the projection formed by the last two lumbar verte- 
brae prevented it from descending. With the hand and my 
pelvimeter I made out the measures of the pelvic brim 
ppetty accurately as they were found after the death of the 
patient. 
" I wished to delay the operation until the head was passing 
through the os, in order to be able to extract the child quickly 
after having made the incision, but the great weakness of the 
patient made it dangerous to wait for this. The bowels and 10 
the bladder having been emptied, and the patient having 
taken an opiate, the operation was begun at 10 a. m. The 
patient was placed on her back, on a solid table covered with 
a mattress, pillows, and a large piece of oil-cloth. All pre- 
cautions usual in Caesarean section were taken, and the neces- 
sary instruments at hand. 
"I made the incision through the skin on the right side in 
the way prescribed above, and likewise that through the mus- 
cles. The epigastric artery, that had been cut, was tied, and 
the walls of the vagina exposed on the right side, the areolar 
tissue being easily separated with the fingers. I passed the 
handle of my wooden pelvimeter into the vagina, pressed the 
knob of this instrument against the roof of the vagina, and 
raised it at the point where the pubis was most bent inward. 
Having charged the first assistant with holding the pelvimeter, 
I incised the vagina at the raised point with a convex knife, and 
dilated the opening with the probe-pointed knife, guided by 
the forefinger of the left hand near up to the urethra, the in- 
cision extending one inch and a half in length. The bleeding 
from the vessels severed in the vaginal wall was quite insig- 
nificant, and stopped immediately by itself. 
"Next I dilated the incision one inch and a half backward, 
but I had scarcely incised the last inch when a stream of blood 
filled the wound and poured out, whilst another traversed the 
vagina. Without delay I pushed a sponge soaked in cold 
water which lay near by into the wound, thereby checking 
the haemorrhage immediately and perfectly. Now we waited 
for the next labor pain, which was weaker than the preceding 
ones, and did not move the child forward rn any perceptible 
degree. I resolved, therefore, to incise the os uteri during 
the next pain, and extract the head of the child ; but, on 
withdrawing the sponge, the blood came again rushing out so 
violently that I was obliged to desist from this intention, and 
replace the sponge in the vagina. We resolved, if possible, to 
leave the expulsion of the child to Nature's own efforts, the 
sponge stopping the haemorrhage completely. Therefore, half 
an hour was spent in restoring the patient, and furthering 
labor pains by the administration of wine, tincture of cinna- 
mon, etc., but the contractions of the uterus had entirely 11 
ceased, and the strength of the patient was failing fast. In 
order to save the child, that still made lively movements, im- 
mediate help was necessary. It was feasible to perform pubi- 
otomy, and on account of the softened condition of the bones 
a ready yielding of the sacro-iliac symphyses without any 
rupture could be expected ; but, on the other hand, the sponge 
which checked the bleeding would thereby loose its hold, and 
the child would not be born immediately. Neither could a 
return of the haemorrhage from the vaginal wound be avoided 
by podalic version. While we were consulting as to the course 
to be adopted, the patient fainted. I examined the interior 
of the vagina, but did not find any extravasation of blood 
there. The patient having rallied, I quickly seized the knife 
and performed the ordinary Caesarean section. Within a few 
moments I extracted a large boy, having all the signs of a vig- 
orous life. I made the Caesarean section in the direction pro- 
posed by Stein, Jr., beginning at the right of the umbilicus, 
and carrying the knife near to the middle of the left horizon- 
tal branch of the pubis. 
"No ligature was needed after the incision through the 
muscles and before opening the peritoneal cavity. The in- 
testines did not protrude after the opening of this cavity. 
The bleeding from the uterus was trifling. While I handed 
the child to the midwife, Dr. had approached the pa- 
tient, and, when I returned to her, he had already withdrawn 
the after birth. I sawr that the womb had by no means con- 
tracted fully. I therefore passed my right hand through the 
oblique wound in the uterus, and placed my left hand on the 
fundus uteri, which was intact, and endeavored to make the 
womb contract in the way recommended by Wigand. This 
succeeded after a few minutes. Then the parts surrounding 
the contracted womb were examined, and no extravasation of 
blood into the abdominal cavity was discovered. Now the 
sponge wTas removed from the wound in the vagina, and, as I 
had expected, no more blood flowed from it. Next, the ab- 
dominal walls were united at both incisions with sutures and 
straps of adhesive plaster going round the whole abdomen. 
Finally, a many-tailed flannel bandage was applied round the 
abdomen, and the patient brought to bed a little before 11 12 
o'clock. She had recovered somewhat, and rested content- 
with having given birth to a healthy child." 
The family physician insisting on the application of wool- 
en cloths soaked in an infusion of resolvent herbs, made with 
wine and used as hot as the patient could bear them, while 
Ritgen held them to be very dangerous in regard to internal 
haemorrhage, the latter withdrew from active participation in 
the treatment of the patient, and continued only to watch it. 
As the prescriptions do not present anything of interest, I 
will not reproduce them here, and merely give the description 
of the further course of the case. The night between October 
1st and 2d the patient was quiet, free from pain, and slept 
pretty well. In the morning of the 2d her pulse was rather 
quick and very small. She was very weak, No fever pres- 
ent. The lochial flow was scanty. The night between the 
2d and 3d was passed without sleep. After two loose pas- 
sages her strength lessened till morning, w'hen she again ral- 
lied somewhat and became a little feverish. The urine was 
passed wdthout any disturbance. Toward 10 a.m. the abdo- 
men began to swell, the patient became restless, and the fever 
augmented. The meteorism seemed especially to be seated 
in the colon. The patient's strength diminished, while the 
distention of the abdomen increased, and breathing became 
ve.iy difficult. The heat was all the time very moderate. 
Toward evening it disappeared altogether, and death ensued 
at 8 p. m. 
Post-mortem examination forty-eight hours after death. 
" The edges of the wounds were without any trace of sup- 
puration, and even without considerable inflammatory swell- 
ing. Here and there the opposite surfaces of the wound 
were slightly glued together, but in several places no union 
had taken place. The peritonaeum did not show any inflam- 
matory redness around the wounds or anywhere on the 
anterior wall of the abdomen. Nowhere in the abdominal 
cavity was there found any extravasated lymph. The in- 
terior surface of the caecum and a small part of the ascend- 
ing colon displayed here and there spots of the size of a 
cent, a red vascular net was discernible. The whole 
colon was much distended with gas. The womb had relaxed, 13 
and measured from the fundus to the mouth eleven inches; 
the body measured almost six inches in width. The wound 
in the uterus was wide open, and filled with coagulated blood, 
thick clots of which also filled the interior of the whole womb. 
The amount of blood contained within the womb w'as esti- 
mated at a little less thau a pound. Above and behind the 
Pelvis or Woman on whom Kitgen performed Gastro-elytrotomy.-Heidelb. kliu 
Anna!., vol. i., 1824. 
BCE, superior strait; D, region of right sacro-iliac symphysis; E, region of left sacro- 
iliac symphysis; C, symphysis pubis; ZZ, depression of right pubic bone; FA G, 
lower border; F B G, upper border of lowest lumbar vertebra. 
Measures in American inches, added by me; A C, 3| inches; D C, 4J; E C, 4/,; diameter 
sacro-cotyloidea, right 2, left, 2T*S. 
womb, extending up to the diaphragm, was found a fluid ex- 
travasation of blood amounting to a little more than a pound. 14 
No traces of inflammation were found around the extravasated 
blood. The other abdominal viscera were entirely normal. 
The large blood-vessels contained very little blood. The cav- 
ities of the head and the chest were hot opened. The vaginal 
wound had not united, the edges having been partly separated 
by the distention of the colon, and no plastic lymph having 
been secreted by them. The pelvis was cut out, and the an- 
nexed diagram of the brim was made from it." 
Ritgen remarks that his incision through the abdominal 
wall, on account of the direction of the fibres of the external 
oblique abdominal muscle, gave little space in width, and that 
he had determined to make a second, from the lower edge of 
the first, along the epigastric artery, downward, when the par- 
ticular circumstances related above prevented him from going 
on with the operation. 
He further thinks that the incision of the os and the neck 
of the womb cannot be avoided in any case. After having in- 
cised the vagina he would not extend the incision into the 
posterior part of its side, in order to avoid the vessel the in- 
jury of which frustrated his first attempt, but go right to the 
uterus. " The best place," says he, "forincising the uterus is 
below the fold of the peritonaeum which is formed when it 
spreads over the round ligament and partially surrounds it. 
By undermining the peritonaeum from below and from the 
side, so as to enter into the interior of this fold, the space un- 
der the ligament, which is only filled with areolar tissue, leads 
to a very extensive part where the uterus is not covered with 
peritonaeum. Consequently, an incision may here be made in 
the uterus without opening the peritoneal cavity, extending 
from the os high up on the body. The ureter adhering to the 
rough surface of the peritonaeum will not be wounded if the 
operator keeps far enough from the peritonaeum with his knife. 
Cooper's hernia knife, which, behind the blunt point, has a 
cutting edge of only one-half of an inch in length, is there- 
fore the most suitable instrument to be used in this locality. 
The incision ought to begin at the os, and may be carried five 
inches upward. We need not say that, as soon as the in- 
cision is made, the child has to be extracted, in order that the 15 
haemorrhage from the opened wall of the womb may be ar- 
rested by the contractions of the whole organ." 
Before criticising any particular point I would call atten- 
tion to the lucidity of Ritgen's description. We follow him, 
both in his plan and in his operation, step by step. Nothing 
is left to conjecture. He speaks with worthy calm of his in- 
vention, and gives honestly all details about his failure. In 
his modesty and simplicity he differs in a striking manner 
from the vainglorious and verbose Baudelocque. It is Ritgen's 
lasting merit to have been, the first to propose gastro-elytrot- 
omy with avoidance of opening the peritoneal ca/vity. Thus 
he is, from an historical point of view, the real inventor of an 
operation that, resuscitated in an improved form, seems to 
have promise of a great future. 
His idea of incising the vagina by following the groove on 
Frere Gome's sonde d dard was not very good. This inci- 
sion would have become almost longitudinal, and we see that 
he wants a transverse incision, since the next step is to make 
a longitudinal one up to the os uteri. In thus recommending 
a _L-shaped incision of the vagina, he took too little notice of 
the vessels running in the parts to be incised, and would al- 
most infallibly have cut the ureter. If he had followed his 
plan of using the forefinger of the right hand as a guide in 
extending the incision, he would have been obliged to cut 
with the left hand, which in so delicate an operation would 
embarrass most operators. In performing the operation he 
arranged it so as to use the left forefinger as a guide, which, 
of course, is the simpler way. By keeping a metallic catheter 
in the bladder during the incision'it will be easier to avoid 
wounding it with the cutting instrument; but it ought of 
course to be withdrawn before the child is extracted or ex- 
pelled, in order to prevent injury to mother and child. His 
recommendation to wait for the child, till it is expelled by 
the unaided efforts of Nature, is not good. The sooner the 
operation can be ended, the better, on account of anaesthesia, 
disinfection, checking of haemorrhage, etc. His operation failed 
in consequence of haemorrhage. The first incision and the ex- 
tension forward one and a half inch succeeded, but in cutting 
backward he caused a haemorrhage that forced him to desist 16 
from his plan. This was evidently due to the vaginal branch 
that is running downward along the border of the vagina from 
the uterine artery. If, instead of cutting, he had torn, he 
would probably have been able to bring his operation to an 
end. Having been unsuccessful in his first attempt, he pro- 
posed alterations in his plan by which he made it more 
unlike the operation as it succeeded in other hands, half 
a century later. He proposed to make the external wound 
T-shaped, which would make it more difficult to heal, and 
weaken the abdominal wall still more, and which later ex- 
perience has proved to be an unnecessary injury. His second 
proposal, to incise the edge of the uterus between the folds of 
the peritonaeum as high up as five inches from the os, is so far 
from being an improvement that I think it is inferior to the 
common Caesarean section. Even if he succeeded in avoiding 
the ureter, he would cut exactly in the part of the uterus 
where the largest vessels are situated, and which has not the 
same contractile power as the part incised in Caesarean section. 
He mentions the circumflex iliac artery among those that may 
be severed by the incision through the abdominal wall ; but 
this vessel is out of the way when the incision is made, as 
prescribed by Ritgen, an inch above Poupart's ligament. It 
takes its course behind the ligament and inside the crista ilii. 
He operated when the os was only two and a half inches in 
diameter. In such a case the os would have to be dilated 
first, which, with our present resources, could be done without 
difficulty. To use the handle of an instrument or a sound for 
lifting up the vagina and incise upon it is not so safe as to 
use the fingers. By following the latter plan the operator is 
enabled to feel for pulsating vessels, and perhaps avoid them, 
as Dr. Skene did. Even when operating on the right side, 
and consequently being obliged to introduce the right hand 
into the vagina, he w'ould be able to make the first incision in 
the vagina with a knife carried in the left hand. But, as we 
shall presently see, other instruments are preferable. 
August 19, 1823, L. A. Baudelocque (" the nephew ") de- 
fended in the Medical School of Paris a thesis called : " Nou- 
veau procede pour pratiquer Voperation cesarienne" and on 
.the 14th of November of the same year he read before the 17 
Cercle Medical a paper on the same subject, published at 
Paris in 1824 under the title: " Nouveau moyen pour delivrer 
les femmes contrefaites a terme et en travail, substitue a V ope- 
ration appelee cesarienne." He called his operation gas- 
★ro-elytrotomy, and conceived such high opinion of its value 
that he says that the Caesarean operation, hitherto so terrible 
for the mother, can no more take her life (p. 10) ! Having 
placed the patient on her back, he advises to make an incision 
along the external edge of the rectus abdominis from the um- 
bilicus extending to two inches above the pubis. This is done 
so as to preserve the peritonaeum intact. Then he ruptures 
the membranes from the vagina. Next he separates the peri- 
tonaeum from the iliac fossa by the linger introduced into the 
lower end of the wound. An assistant lifts the peritonaeum 
and the intestines, while another fixes the uterus. The oper- 
ator introduces his hand into the abdominal wound and feels 
for arteries surrounding the vagina. If he finds any, he ties 
them at both extremities. He feels likewise for the round 
ligament, in order to be able to avoid it later. The bladder 
and rectum are emptied. 
Next he introduces his left hand into the vagina and 
pushes it through the external wound. With the right hand 
he seizes a bistoury and incises the vagina through the exter- 
nal wound, as far below its junction with the uterus as possi- 
ble, and extends the incision to a length of four inches and a 
half. The expulsion of the child is left to Nature, or if not 
expelled it is extracted with a short forceps. 
He proposes, as another method, to comprise the perito- 
naeum in the incisions. He chooses for the operation the side 
opposite to that in which the fundus uteri is situated. He 
removes the placenta through the natural passage after hav- 
ing replaced the uterus. 
In 1844 Baudelocque published a new pamphlet on the 
subject, under the title " Operation cesarienne.-iNytrotc- 
mie, ou section du vagin, precedes, ou non, de la ligature ou 
de la compression de Vart'ere iliaque interne." In this the 
original plan is much modified. He advises (page 11) to 
make an incision extending from a point twenty lines (about 
one inch and three-quarters) outside of the spine of the pu- 
2 18 
bis to another a little above the anterior superior spine of 
the ileum, leaving the round ligament inside. After having 
separated the peritonaeum as described above, he introduces 
between the internal iliac artery and vein a female catheter, 
through the eyes of which is drawn a thread, and ligates the 
artery. Next he thrusts the bistoury from without through 
the side-wall of the vagina beneath the ureter, which is 
found one centimetre (three-eighths of an inch) below the 
neck of the womb; or he introduces a sound with stylet 
(sonde d dard} into the vagina with the left hand, making 
counter-pressure with the thumb and forefinger of the right 
hand, at the place where the point is felt. An assistant 
pushes the stylet forward, and the operator dilates with a 
probe-pointed bistoury, from above downward, the puncture 
made in the vagina. He turns and extracts the child. The 
child having respired, the cord is cut, put back into the 
vagina, and the placenta removed through the normal pas- 
sage. Likewise, both ends of the ligature round the internal 
iliac artery are drawn forth through the vagina. The edges 
of the external wound are brought together with three or 
four sutures that do not comprise the peritonaeum, and the 
■wound is dressed. The patient being replaced on her bed, 
the abdomen is covered with ice for several days, in order to 
prevent peritonitis. 
After laying down this plan for the operation, he reports 
two cases in which he had tried it: 
Case I. (I. c., page 12).-Date of operation not indicated. 
The patient was thirty-six years old, primipara, rickety, only 
a metre (about thirty-nine inches) high. She had first begun 
to walk when eleven years old, and then with a crutch. Dur- 
ing her pregnancy she could only walk on two crutches. The 
brim of the pelvis was very irregular, wider in the right than 
in the left half, with an antero-posterior diameter of two 
inches and a half. The os was four centimetres (little more 
than one inch and a half) in diameter. The waters had broken 
spontaneously, and flowed out in great quantity. The opera- 
tion is described in these terms: 
" I made through the skin of the left iliac region an in- 
cision beginning twenty lines (one inch and three-quarters) 19 
from the spine of the pubis, and ending two centimetres 
(three-quarters of an inch) in front of and a little above the 
anterior superior spine of the ileum. Next I incised, layer 
after layer, the external oblique, the internal oblique, and the 
aponeurosis of tlie transverse muscle. During this incision 
an endless number of small arteries gave blood, and were 
immediately tied. At the lower angle of this incision I made 
a small opening in the transversalis fascia, through which I 
introduced a probe-pointed bistoury, and cut the fascia from 
below upward. Then, passing my left forefinger between the 
peritonaeum and the iliac muscle, I separated this membrane 
from the muscle through its whole extent, down to the vagina. 
The internal iliac artery and vein having been exposed, I 
pressed the point of the bistoury against the external surface 
of the vagina, one centimetre and a half (five-eighths of an 
inch) beneath the ureter, i. e., about twenty-seven millimetres 
(a little more than an inch) below the neck of the womb. 
This simple puncture of the vagina caused such a flow of 
blood that instantly the iliac fossa was filled. I sponged it 
immediately, but it was filled again twice. This loss of blood, 
although not considerable in itself, was sufficient to weaken 
this woman ; we saw her natural pallor increase and her eyes 
turn in their orbits. My assistant tamponed speedily the 
outside of the vagina and the iliac fossa with sponges, and I 
performed immediately hysterotomy, extracting a child that 
had died quite recently. I removed the placenta through 
the wound in the uterus, and united the edges of the anterior 
wall of the abdomen by six interrupted sutures. The wounds 
were dressed simply, a binder applied round the abdomen, 
and the patient brought to bed." 
lie adds that the haemorrhage came from the vaginal veins, 
that he ought not to have been so frightened by it, and that 
compression exercised with a finger on the common iliac ar- 
tery would have stopped it and permitted him to go on with 
the operation. The patient again lost blood during, the in- 
cision of the uterus, and continued bleeding from the lips of 
the uterine wound and from the vaginal veins, until she died 
from haemorrhage. Time of death not indicated. The autopsy 
showed anwmia. 20 
Case II. (Z. c., page 14).-May 6, 1843. Age and number 
of pregnancy not stated. Pelvis ten centimetres (almost four 
inches). Eclampsia. 
" The woman having been placed on a table covered with a 
mattress and sheets, I chose, as in the first case, the left in- 
guinal region. The incision of the skin and the muscles did 
not present anything remarkable except the necessity of apply- 
ing about thirty ligatures. The separation of the peritonaeum 
was very easy. After having separated, with the end of a 
female catheter, the internal iliac artery from the accompany- 
ing vein, I passed under this artery a Deschamp's needle, 
through the eye of which I had drawn a flat thread ; but, at 
the moment I carried it round the artery, the peritoneal sac 
slipped from the hands of the assistant, so that for an instant 
I did not see the point of the instrument, which met the ex- 
ternal iliac artery and pricked it, although the needle was 
rather blunt. A small continuous stream of blood appeared 
instantly, and I was obliged to tie the common iliac artery. 
After having passed the left hand into the vagina, and having 
raised on the tips of my fingers the part of the vagina that 
was to be incised, I perforated it from without with a straight 
and pointed bistoury. Next I extended the incision with a 
probe-pointed bistoury from above downward, in order not to 
injure the ureter. Then passing the same hand through the 
vaginal wound into the uterus, I seized the feet of the foetus, 
whose head presented at the brim, and turned it with the 
greatest facility. The child was dead, the mother having had 
an attack of eclampsia, with loss of consciousness, before I 
performed the operation. As to the after-birth, I extracted 
it through the natural channel, having replaced the cord 
through the vaginal wound. 
" The edges of the external wound having been brought to- 
gether with strips of adhesive plaster, and covered with lint, 
I replaced the patient on her bed. She felt then so well that 
she wanted to get up and take some food. For about twenty- 
four hours she complained of numbness in the left leg. After 
that the numbness disappeared entirely, and the heat returned 
in this extremity so as to become greater than in the right 
leg. Thus, on the third day after the operation, we could 21 
consider Mrs. D. as cured of the ligature of the common 
iliac artery. Nevertheless, this accident prevented me from 
combating, with as much energy as I else would have used, 
the inflammatory symptoms appearing in the abdomen. The 
following day the abdomen was distended, the patient had 
pain in some places, the wound looked bad and smelled slightly 
gangrenous ; normal lochial discharge ; fever. Twenty leeches 
wrere applied to the tender parts of the abdomen, and twelve 
drops of laudanum in a little sweetened water administered 
internally. The next day the tympanites was consider- 
able, vomiting set in, the odor from the wound was much 
more marked, abundant suppuration, fever. Phlebotomy and 
fifteen leeches on abdomen. The blood withdrawn from the 
vein and by the leeches amounted in all to 500 grammes 
(about 16 ounces). In spite of this rather active treatment in 
a woman of so small a stature (height not stated), the inflam- 
matory symptoms increased, the tympanites became excessive, 
although the pain in the abdomen had ceased, and on the 
fourth day Mrs. D. vomited continually, her extremities grew 
cold, her face became blue ; briefly, she was asphyxiated in 
consequence of the distention of the abdomen, and died 74 
hours after the operation. 
" Autopsy.-Distention of bowels ; very slight redness of 
some spots of the peritonaeum covering the intestines; extrava- 
sation of 80 to 100 grammes (about 3 ounces) of yellow serum ; 
no obstacles in the alimentary canal capable of producing 
the tympanites; no union of the vaginal or the external 
wound. All the other organs were healthy. 
"What has caused death ? Is it the slight injection of the 
peritonaeum ? I do not think so. Is it the opium that was 
given to calm the abdominal pain, and that produced the pa- 
ralysis of the intestines, their enormous distention, and death 
from asphyxia ? I think so." 
After this second operation, he proposes (p. 17), as an im- 
provement, to incise skin and muscles to the extent of one 
inch, close up to (rasant) Poupart's ligament, lift the perito- 
naeum in this place in order to ligate the anterior iliac (sfc) 
and the epigastric artery, push the forefinger of the left hand 
between the peritonaeum and the muscles of the anterior wall 22 
of the abdomen, use it as a guide for a probe-pointed curved 
bistoury, and cut in one stroke, from the inside outward, and 
from below upward, the muscles and the skin. This, he says, 
would shorten the operation considerably, because there would 
be fewer ligatures to apply. 
In the same pamphlet (p. 23), Baudelocque proposes two 
other methods. The first consists in an incision in the linea 
alba, as in ordinary Caesarean section. The uterus would pro- 
trude from the abdominal cavity by itself, or, if necessary, it 
should be drawn out with the hands. Incision of the meso- 
rectum and of the posterior wall of the vagina from below 
upward. An assistant might place his forefinger on the ab- 
dominal aorta in order to prevent bleeding during the incision 
of the vagina. After the extraction of the foetus, the edges 
of the external wound ought to be brought together and kept 
in apposition with the instrument invented by Baudelocque 
for the purpose, or with dressing-forceps surrounded with com- 
presses and tied together by the eyes, so as to avoid sutures. 
If there should be any haemorrhage from the vaginal wound 
after delivery, there would be no other resource than to com- 
press for six or eight hours, with a compressor, one or both in- 
ternal iliac arteries (p. 25). 
The other method (p. 24) consists in a transverse incision 
from one anterior superior spine of the ileum to the other, 
through the whole thickness of the abdominal wall, ligature 
of both epigastric arteries, incision of the mesorectum and 
the posterior wall of the vagina, as in the previous method. 
The edges of the external wound are not sutured nor brought 
together by any means, as the inclination forward 6f the 
woman would bring them sufficiently together. 
Although Baudelocque comes after Joerg and Ritgen in 
time, there is no occasion to doubt the originality of his first 
plan. In his first pamphlet (" Nouveau moyen" p. 10), he says 
that, of all those who tried to modify the Caesarean section, no 
one thought of extracting the foetus through the vagina. In his 
second p. 9), he states expressly that he first be- 
came acquainted with Ritgen's proposition in 1826, through a 
German physician. We have no difficulty in understanding 
this. Fifty years ago there was scarcely a Parisian surgeon 23 
who was able to read a German book; and while a German 
periodical (Froriep's " Notizen zur Natur und Heilkunde" 
October, 1824), with that curiosity about everything, wherever 
it takes place, that is so characteristic a feature of German 
science, immediately reported Baudelocque's operation, nobody 
in France had noticed Ritgen's plan and operation. 
On the other hand, it seems very likely that Baudelocque, 
before he operated on the living subject, knew all about Rit- 
gen's plan, even if he did not know that he had tried it in 
practice. At least, it looks very suspicious that he does not 
indicate the date of his first operation, and that he made the 
transverse abdominal incision as advocated by Ritgen, and 
not his own, longitudinal, along the external border of the 
rectus muscle, although he expressly says in his first pam- 
phlet that no other part of the abdomen answers so good a 
purpose for the external incision as the outer edge of the 
rectus muscle. 
Passing to the consideration of the value of his plans and 
operations, we notice, first, their great number and diversity. 
Altogether, there are no less than six different methods: 
1. Longitudinal incision at outer edge of the rectus mus- 
cle, without opening the peritoneal cavity. 
2. The same incision comprising the peritonaeum. 
3. Oblique incision from the spine of the pubis to the an- 
terior superior spine of the ileum, without opening the peri- 
toneal cavity. 
4. The same with previous ligature of the external iliac 
artery. 
5. Longitudinal incision through the tinea alba and the 
posterior wall of the vagina. 
6. Transverse incision from the anterior superior spine of 
the ileum on one side to the opposite, and longitudinal incision 
of the posterior wall of the vagina. 
Of all his methods he prefers the last p. 25). 
Consequently, he abandons the most important point, namely, 
not to open the peritoneal cavity. Even in his first pamphlet, 
which is by far the better, although not so important as the 
second, since it proposed only a plan that had not yet been 
tested in the crucible of experience, he lays most stress on avoid- 24 
ing the uterus, and aceords only secondary importance to spar- 
ing the peritonaeum. 
Accordingly, Baudelocque occupies a position midway be- 
tween Joerg and Ritgen, with the disadvantage of being their 
successor. As to good description of cases he is much inferior 
to Ritgen. Most of all, he is inferior to him in so far as Ritgen's 
case was one undoubtedly fit for the operation, while at least 
one of his was not. In the first the mother might, perhaps, 
have been saved by using the cephalotribe, with which he had 
himself enriched the obstetric art. In the second, both might 
perhaps have been saved by employing other means. He says 
himself, in his particularly confident way, that he would have 
extracted the child alive if he had operated the evening before, 
the eclampsia not having taken place then. But why would 
he then have operated, since her pelvic brim was four inches 
in diameter, and since he does not indicate the least abnor- 
mality in her labor except the eclampsia ? 
The child being dead, and no deformity found in the 
mother, it is singular to read the conclusion he draws from 
this operation : " The result of this operation," says he, " re- 
moves every doubt as to the possibility of extracting a living 
child, through an incision made in the vagina, even in the 
worst conformation of the pelvis " (Z. c., p. 17). He might as 
well have added that the death of the mother being due to 
opium, proved the innocuousness of the operation, in itself, 
to her. 
Now we will examine his plans and operations more in de- 
tail. His first incision along the outer edge of the rectus mus- 
cle would, by far, not make the separation of the peritonaeum 
so easy as that along Poupart's ligament, proposed by Ritgen, 
and adopted in practice by Baudelocque. Nor would it be 
so easy to tilt the uterus sufficiently over on the side to 
make the os present in the abdominal opening. These two 
disadvantages are by no means counterbalanced by the fact 
that the epigastric artery is out of the way. This artery can 
either be tied without any harm, or avoided altogether. As 
for the vaginal incision, his advice to tie arteries that may be 
in the way, before making the incision, sounds plausible 
enough, and ought to be kept in mind by future operators ; 25 
but it is another question if it would be possible to tie them. 
On the other hand, it is a useful recommendation to make 
the incision as low as possible, i. e., as far from the uterine 
neck as possible, for thereby he not oidy avoids the ureter and 
Douglas's pouch, but he comes to the part of the vagina in 
which there are the fewest vessels. If the contraction of the 
pelvis be great, it may be difficult to deliver the placenta 
through the vagina. It is better to withdraw it through the 
wound. 
In his third method, he makes the incision in the abdomi- 
nal wall begin one inch and three-quarters outside'of the spine 
of the pubis. By so doing he would avoid the epigastric 
artery, and the modern operations have proved that this may 
be done; and then it is of course better to do it. At the 
same time he avoids cutting the round ligament, part of which 
protruded and had to be tied and removed in Dr. Thomas's 
second operation. As this organ contains a small arterial 
twig, and seems to play a part in adjusting the uterus to the 
penis during coitus, thereby facilitating conception, it is of 
course better to spare it if it can be done without sacrificing 
greater interests. Baudelocque's advice to feel for the liga- 
ment, in order to avoid it, is of no use in practice. A point 
of much greater importance is his advice to ligate the internal 
iliac artery. We will not lay too much stress on the criticism 
pronounced by Fate when, in trying to tie.the internal iliac, 
he wounded the external, and was obliged to ligate the com- 
mon iliac artery. Even apart from this unlucky accident, the 
advice is not a good one. The pelvis being full of arteries 
with numerous anastomoses, it is very doubtful if the ligature 
of the internal iliac would prevent haemorrhage from arteries 
'cut in the vagina. Next, it would be a difficulty more for the 
operator, and likely to lessen the chances of the operation be- 
coming popular with obstetricians. It would be a serious com- 
plication of an operation already grave enough. In his second 
operation, he says that the wound became gangrenous; perhaps 
in consequence of the ligature of the common iliac artery. 
Finally, the recent operations have shown that it is not neces- 
sary to interfere with the iliac vessels at all. His alternative 
to use the sonde a dard instead of his fingers seems to be 26 
borrowed from Ritgen, as well as the direction of the ab- 
dominal incision, although he does not admit owing him any- 
thing. As stated above, I do not, however, consider this an 
improvement. The incision will become too longitudinal. 
It is better to feel the arteries with the fingers, and the less 
we use the knife in the vagina the better. 
His advice to turn and extract the child instead of waiting 
till it is expelled is of course a great improvement on his first 
plan, and his last proposition of covering the abdomen with 
ice-bags in order to prevent peritonitis is excellent. 
We will now consider his first operation. Since the os 
uteri was only an inch and a half, it ought to have been 
dilated before operating; if it was incapable of being so, this 
would constitute a contraindication for gastro-elytrotomy. 
It is difficult to understand how Baudelocque can have 
been obliged to ligate an "endless number" of arteries, and 
in his second case " about thirty." Ritgen met with no bleed- 
ing, although he only ligated the epigastric artery. Drs. 
Thomas and Skene only forcibly compressed the external or 
subcutaneous epigastric artery (private communication). The 
only arteries of importance enough to have a name which can 
be wounded during the incision through the skin and the 
muscles are the internal epigastric (A. epigastrica stride, s. 
inferior}, and the superficial epigastric (A. epigastrica super- 
ficialis, s. abdominalis sub cutanea}. Even if a few muscular 
branches should spout, they would scarcely require ligature; 
torsion or temporary compression would be more expeditious 
and sufficiently safe. 
The most noteworthy point in Baudelocque's first opera- 
tion is the fact that, on making a simple puncture with a nar- 
row bistoury in the vagina, he met with a haemorrhage that 
made him give up the operation and have recourse to Caesarean 
section; but his own remarks on the subject, as found above, 
seem to prove that he might have gone on. Nevertheless, this 
experience, combined with theoretical considerations, engages 
us to try to avoid all sharp instruments in the vagina. If the 
surrounding parts are covered with a wet compress, it must 
be possible to incise the vagina with the galvano-cautery, or 
the thermo-cautery brought to red heat. If these instruments 27 
be not at hand, common red-hot cautery-irons may be 
used. The hand in the vagina must then of course be pro- 
tected by a wet napkin, or some wooden instrument used 
in its stead. 
In his second case, Baudelocque operated again on the 
left side, although there was no reason for so doing, and 
although lie says himself in 'LVmtw moyen" that the right 
side is to be preferred, on account of the greater distance be- 
tween the vagina and the rectum. The left side presents only 
this advantage, that the operator introduces his left hand into 
the vagina, and cuts with the right; but, in operating on the 
right side, he may either cut with the left hand, as Dr. 
Skene did, or have an assistant raise the vagina, as Dr. 
Thomas did. 
When he says that he made the vaginal incision from 
above downward, this means probably a direction parallel to 
the ureter and the bladder. lie does not indicate how long 
he made the incision, but in his " Nouveau moyen n he says 
that it ought to be four and a half inches, and this can 
only be obtained in the antero-posterior and somewhat 
oblique direction. Besides, he says here expressly that the 
incision is to be transverse, and in the upper third of the 
vagina. 
It is curious that Baudelocque tries to deny the fact 
that his patient succumbed to peritonitis. His theory that 
twelve drops of laudanum, containing even in the stronger 
preparation used in France only one and one-fifth grain of 
opium, paralyzed the bowels and killed her by asphyxia, will 
not find much favor in a country in which Dr. Alonzo Clark's 
treatment with enormous doses of morphia is regarded as the 
best cure for peritonitis. Not improbably the prostration due 
to gangrene contributed to the bad result. But, since the few 
lines he devotes to the report of the autopsy do not even al- 
lude to gangrene, it may also be that the odor perceived dur- 
ing life arose from othei* causes. It may be that septicaemia 
played a part in the process that killed her. If she died as- 
phyxiated from the meteorism, it is noteworthy that nothing 
was done to relieve this dangerous symptom. Nowadays 
we would resort to puncturing the intestine with the hypo- 28 
dermic syringe-which had not yet been invented when Bau- 
delocque operated-besides other means, such as large doses 
of bismuth, turpentine, a long tube introduced through the 
rectum, etc. 
His fourth method, previous ligature on the anterior iliac 
and the epigastric artery, is far from being an improvement. 
According to Sappey 1 and to the true relative situation of the 
two iliac arteries to one another, the anterior is the external ; 
his advice to ligate the epigastric, which is a branch from it, 
separately, must be founded in fear of haemorrhage from 
the distal part of the main vessel. This ligature of the 
external iliac is entirely superfluous, and constitutes a serious 
complication, the more so as the second incision, accord- 
ing to Baudelocque, must be preceded by the ligature of the 
internal iliac. 
His fifth method, incision in the tinea alba and the poste- 
rior wall of the vagina, is inferior to those hitherto considered. 
Not only the peritonaeum is opened, but to such an extent 
that the uterus protrudes, and we know, from Spencer Wells's 
ovariotomies, that as soon as the incision exceeds five inches 
mortality increases with every additional inch? Next, the vagi- 
nal incision is made in a place that would render both turning 
and the application of forceps impossible. If there came haem- 
orrhage from the vaginal wound it would be beyond control, for 
it is more than doubtful if the patient would be able to stand 
the compression of one or both internal iliac arteries, which 
Baudelocque calls the only resource. He is not correct when 
he says that the mesorectum is cut, this name designating the 
short mesentery found behind the upper part of the rectum. 
He means, evidently, the fold of the peritonaeum forming 
Douglas's pouch. 
His sixth and last method is the least good of all, as it not 
only opens the peritoneal cavity to a large extent, and makes 
the awkward vaginal incision just mentioned, but leaves the 
peritoneal cavity entirely open. 
As for results, they could not be worse, all four lives inter- 
ested in the two operations having been lost. 
1 Sappey, " Traite d'Anatomic," vol. i., part 2, Paris, 1850, p. 471. 
2 Spencer Wells, "Diseases of the Ovaries," London, 1872, p. 352. 29 
If I have been obliged to criticise Baudelocque rather se- 
verely, it ought not to be forgotten that he always has the 
merit of having been one of those who originally, and without 
knowing that the idea was not new, conceived the plan of 
avoiding both the peritoneal cavity and the uterus in perform- 
ing gastro-elytrotomy. He has also carefully studied every 
point of the anatomy bearing on the operation, and is, in this 
respect, more explicit than any othei* author on the subject. 
The next author we have to deal with is an American. In 
a letter from Dr. W. E. Horner, adjunct professor in the Uni- 
versity of Pennsylvania, dated September 28, 1824, and in- 
serted in William P. Dewees's " A Compendious System of 
Midwifery" (seventh edition, Philadelphia, 1835, page 598), 
we find the following statement: " More than two years ago, 
it (the Caesarean operation) being then a matter of particular 
inquiry with me, I was struck by the following proposition of 
his (Dr. Physick) in regard to it, which made a very strong 
impression on me, and the justness of which I have ever since 
been extremely anxious to verify by dissection." He next 
describes how, in the body of a woman in the sixth month of 
pregnancy which he dissected, by drawing moderately at the 
bladder, the peritonaeum leaves the cervix uteri " after the same 
manner that it does in the unimpregnated state," and goes on : 
" Dr. Physick, founding his idea upon a similar observation 
made in early life, during the dissection of a pregnant woman, 
proposes that in the Caesarean operation an horizontal section 
be made of the parietes of the abdomen, just above the pubes. 
That the peritonaeum be stripped from the upper fundus of 
the bladder, by dissecting through the connecting cellular 
substance, which will bring the operation to that portion of 
"the cervix uteri where the peritonaeum goes to the bladder. 
The incision, being continued through this portion of the 
uterus, will open its cavity with sufficient freedom for the 
extraction of the foetus. All of which the doctor supposes 
may be done by a careful operation, without cutting through 
the peritonaeum. . . . Dr. Physick proposes that the operation 
be performed with a moderately distended bladder, and that a 
catheter should be introduced previously, to ascertain its situa- 
tion." 30 
Physick, then, had also, probably without knowing any- 
thing about Kitgen's plan, published two years earlier, con- 
ceived the idea of avoiding the peritoneal cavity in making 
Caesarean section. As he does not aim at incising the vagina, 
his operation does not properly fall within the scope of gastro- 
elytrotomy ; but it is so nearly related to it by trying to avoid 
the body of the uterus and the peritonea] cavity, that it may 
be warrantable to discuss it in this disquisition. The place 
he chooses has considerable disadvantages. The dissection of 
the peritonaeum from the bladder is a much nicer anatomical 
undertaking than to separate it from the iliac fossa. Next, 
the neck of the womb has to be incised, with the unavoidable 
haemorrhage. He would not obtain room enough for extract- 
ing the foetus without extending the separation of the peri- 
tonaeum to part of both iliac fossae. The opening being in the 
middle line, he would not be able to facilitate its exit by tilt- 
ing the uterus, as when it is made on the side. Finally, he 
would have a severe suppuration going on all around so sensi- 
tive an organ as the bladder. Probably Physick has doubted 
himself of the feasibility or value of this plan, since he never 
published it. 
The last author of this period is Sir Charles Bell. In his 
" Institutes of Surgery," being a guide for students who at- 
tended his lectures, published in 1837,1 after relating a Caesa- 
rean operation in which he acted as assistant, he continues: 
" On such a case (one in which the mother cannot be saved 
by the operation of embryo-ulcia) recurring, time and oppor- 
tunity being given for the performance of the operation, I 
would recommend the following precautions: 
" 1. That the incision through the abdominal wall should 
be made in a direction from the crest of the pubes obliquely 
outward. The epigastric artery would require to be tied. 
u 2. Press up the peritonaeum-a matter not difficult in the 
pregnant state of the uterus-and reach the vagina or uterus 
under the peritonaeum. 
" 3. Getting at the vagina, or certainly the lowest part of 
the uterus, make a small incision-introduce a finger-dilate 
1 American edition, Philadelphia, 1840, p. 341. 31 
slowly, imitating in this the natural labor; there would be 
neither pain nor danger by delay. 
" 4. Break the membranes, and, if the action of the uterus 
should be as strong as I have seen it in the last case, permit 
the head to advance; if not, seize and deliver by the feet, as 
in the operation of turning. 
" [Would not such a procedure avoid the breach of the 
peritonaeum ? Would it not avoid the fatal haemorrhage which 
is consequent on the incision into the body of the uterus ? 
Would it not give a better chance of recovery than an in- 
cision into the belly of the woman ?] " 
It is impossible to know if this idea originated entirely 
with Sir Charles himself, or if he knew anything about his 
predecessors. He says neither the one nor the other. It 
sounds as if the idea were his own. But, on the other hand, 
there were so many ways by which some knowledge of the 
subject might have reached him. Even apart from German 
works and Baudelocque's pamphlets, there are Velpeau's criti- 
cism in his " Traite de Fart des accouchements," 1829, trans- 
lated into English by Meigs, 1831; Dubois's article in the 
celebrated " Dictionnaire de Medecine," 1834 ; and Dewees's 
" Compendium of Midwifery," 1830. All these publications 
were comparatively recent when Bell published his " Insti- 
tutes." When we think of the easy intercourse between Lon- 
don and Paris, even in those days, he may have heard some- 
thing about Baudelocque's plan and first operation. His 
silence on the subject would not contain any unfairness, when 
we remember that the work in which his plan is proposed is 
a brief memorandum for surgical students, and that Caesarean 
section always has been a very rare operation in Great Britain. 
However this may be, Bell announces at least one idea 
that is entirely new, and that an excellent one-I mean his 
advice to make the incision in the vagina so small as just to 
admit the finger, and then use this for slow dilatation. This 
shows that Bell, more than any of the other surgeons hitherto 
considered, understood the danger of cutting into these deep 
parts, rich in vessels and little accessible. 
The result of this inquiry into the old history of gastro- 
elytrotomy is, then, that it has been invented twice, or perhaps 32 
three times-by Ritgen, Baudelocque, and Charles Bell-and 
performed once-by Baudelocque-the patient dying from 
peritonitis, and the child having died before the operation. 
Authors' Opinions. 
The opinions expressed on the plans and the essays by 
authors form part of the history of the operation, and may 
guide others in the deliberations on the subject, although 
many of these remarks have lost much of their value, since the 
second period has been so remarkably successful. For clear- 
ness's sake I will divide the authors into two groups, those 
who upon the whole are in favor of the operation, and those 
who are against it. 
Kilian,1 in speaking of gastro-elytrotoray, called it " a 
method of decided importance, even if so far without any en- 
couraging results." 
Meygrier 2 says that " Baudelocque's process deserves the 
attention of practitioners." 
Jacquemier3 devotes many pages to the description of the 
different methods, and discusses the subject rather fully. He 
says that most of the objections put forth against the opera- 
tion are founded on the consideration of the peritonaeum in 
the non-pregnant woman, " but, if we," says he, " think of the 
changes occurring in consequence of the development of the 
uterus, we cannot forbear to accord more serious attention to 
it." The examination of the body of a woman who had died 
during labor convinced him of the feasibility of the operation. 
He advocates a longitudinal incision through the vagina and 
the neck of the womb, made in front of the vessels running on 
the lateral parts of these organs, and ends by the following 
judgment: "Doubtless the extensive separation of the peri- 
tonaeum and the severed tissues would expose the patient much 
1 Kilian, " Operative Geburtshiilfe, 2te Aufl., Bonn, 1849, vol. ii., p. 
714. 
2 Meygrier, "Midwifery Illustrated." Translated from the French, 
with Notes, by Sidney Doane, New York, 1833. 
3 Jacquemier, " Trait6 des accouchements," Paris, 1846, vol. ii., p. 
503, seq. 33 
to diffuse suppurations of the subjacent areolar tissue, to 
peritonitis, to the inflammation of the veins and the lymphat- 
ics of the womb and the pelvis, to which the puerperal state 
particularly predisposes ; but it cannot be denied that, in 
avoiding the incision of the peritonaeum, and the entrance of 
blood from the cut vessels, and of the uterine secretions into 
its cavity, the woman would be preserved from the most com- 
mon and the most active cause of death." 
Horner,1 after having described Physick's operation, adds: 
"It is evident that, if this be a practicable operation, it will 
diminish immensely the tendency to peritoneal inflammation, 
and will, in fact, put it on a foundation of danger very closely 
allied to the taking up the external iliac artery, near its origin, 
by taking aside the peritonaeum." 
Blundell, 2 after relating, though not quite accurately, 
Charles Bell's plan, says : " This dilatation is likely to prove of 
more easy accomplishment, because the substance of the ute- 
rus is, perhaps, naturally of a somewhat yielding and obsequi- 
ous kind, and it is not altogether impossible that this method 
of procedure may be found desirable, not only in those cases 
in which the placenta chances to cohere to that part of the 
womb which corresponds with the abdominal incision, but in 
every instance in which the Caesarean delivery is requisite. 
This proposal, however, requires consideration. Contusions 
and lacerations might, not without reason, be apprehended. 
By dilating in this manner we should diminish the extent ot 
the uterine incision." 
I have not been able to obtain Duchateau's remarks on 
Baudelocque's original plans; but, since they were published 
as an appendix to "Nouveau moyen" it is likely that he was 
in favor of the operation. 
The unfavorable judgments are more numerous and more 
decided. 
" Revue'medicdie franchise et etramgere" Paris, 1824, page 
155, insists on the necessity of repeated trials on the cadav- 
er on pregnant women, and demands the proof that the vagina 
1 Dewees's " Compendium," p. 599. 
2 James Blundell, " Principles and Practice of Obstetricy," by Thomas 
Castle, Washington, 1834, p. 355. 
3 34 
is sufficiently distensible, that no important vessels are injured, 
that the detachment of the peritonaeum is not a greater injury 
than its incision in two places, that the injury of the perito- 
naeum and the vagina is less dangerous than that of the womb ; 
finally, that the rent in the vagina will not extend into the 
womb. 
Velpeau,1 after having stated Ritgen's procedure, some- 
what inexactly, adds : " In the first place I cannot perceive 
how it would be possible to incise the apex of the womb with- 
out cutting the serous membrane with which it is enveloped ; 
then the difficulties inherent in this proceeding, added to the 
detachment which would be produced in the iliac fossa, do 
not appear to me to be of a nature to render the operation at 
all less serious than those which have been mentioned " (other 
methods for Caesarean section). Of Baudelocque's plan he 
says that he " can scarcely believe that it will be found prac- 
ticable in a majority of cases, or that the laceration of the vagina, 
in addition to the disturbance necessarily occasioned in the 
iliac fossa or in the excavation, would be less redoubtable than 
the simple and methodical incision of the peritonaeum and 
womb, such as may be performed in ordinary hysterotomy." 
As for Physick's suggestion, he finds that it is "little worthy 
of its inventor, and does not deserve the trouble of being dis- 
cussed." 
The great Paul Dubois, who so longtime governed French 
obstetrics as an autocrat, treats the subject in an addition made 
to Desormeaux's article on Caesarean section, in the " Diction- 
naire de Aledecine ou Repertoire General des Sciences Medi- 
cates" 2d edition, Paris, 1834, vol. vii. He thinks that the 
new methods of Ritgen, Baudelocque, and Physick, "without 
offering any advantage, present difficulties and dangers from 
which the other methods of Caesarean operation are exempt." 
He censures especially the place of the incision in a part of 
very small dimensions and of difficult access, so rich in ves- 
sels and possessing so little retractility that a serious haem- 
orrhage is almost certain to supervene. 
'Velpeau, "Elementary Treatise of Midwifery." Translated by 
Meigs. Philadelphia, 1831, p. 514. 35 
Cazeau,1 one of the most esteemed of modern obstetricians, 
says: " If the incision in the peritonaeum could be avoided, 
effusions of blood or of sanious or purulent matter into its 
cavity would not take place, and the patient be protected 
from the most efficient cause of death. This advantage is un- 
fortunately so fully balanced by the difficulties of the opera- 
tion, by the number of vessels wounded, and by the inflamma- 
tion liable to follow the extensive separation of the perito- 
naeum, that the method is now entirely abandoned." 
Moreau3 insists likewise on the dangerous inflammations 
that are likely to follow the detachment of the peritonaeum, 
and asks who will guarantee that this membrane, after hav- 
ing been raised, is not torn during the passage of the child ? 
IQ ay, he goes so far as to question the possibility of carrying 
this method out in practice. 
Bedford3 mentions Joerg, Ritgen, and Baudelocque, and 
gives an exact description of the latter's plan as modified in 
his third ifiethod, and finishes by declaring that to him this 
operation is " the very reverse of plausible." 
Tarnier,* like Moreau, questions the feasibility of the 
operation, repeats the criticisms of his predecessors, and de- 
clares it to be still more redoubtable than gastro-hysterotomy, 
wherefore it " has been completely abandoned?* 
In the "Nouveau dictionnaire de medecine," edited by 
Jaccoud and other celebrities, in Paris, 1867, vol. vi., p. 697, 
J. A. Stoltz gives an incomplete summary of Ritgen's, Bau- 
delocque's, and Physick's contributions, which he stamps as 
eccentricities. According to him it was easy to foresee that 
there would not be room enough for extracting the child, and 
that the incision of the vagina and lower segments of the 
uterus would meet with insurmountable difficulties. 
1 Cazeau, " Theoretical and Practical Treatise of Midwifery," fifth 
American, from seventh French edition, by William R. Bullock. Phila- 
delphia, 1873, p. 1038. 
3 Moreau, " Trait6 des accouchements," Paris, 1841, vol. ii., p. 356. 
3 Bedford, "The Principles and Practice of Obstetrics," New York, 
1861, p. 640, foot-note. 
* Lenoir, S6e et Tarnier, "Atlas compl6mentaire de tous les trait6a 
d'accouchernents," Paris, 1865, p. 276; quoted by Masson: "DelaGas- 
tro-61ytrotomie." These pour le Doctorat, Argenteuil, 1878, p. 29. 36 
Naegele-Grenser1 states briefly what had been proposed 
or essayed by Joerg, Ritgen, Physick, and Baudelocque, and 
holds it to be superfluous to go into detail about the dangers 
and difficulties attending gastro-elytrotomy. 
I am not prepared to say that this is all that has been 
written on gastro-elytrotomy in its first period, but it is all I 
have found while searching in all the works on obstetrics I 
have been able to lay hands on in public and private libraries. 
The great majority do not mention the operation at all; most 
of those that do so, condemn it; a few only are timid defenders. 
It had been entirely abandoned and almost forgotten. No 
practical obstetrician had ever thought of it for a generation, 
even when grappling with the most desperate case. Thus 
stood things when Dr. Thomas, unacquainted with its exist- 
ence, invented it again in an improved form, and inaugurated 
the second period of its history. 
Second Period. Fulfillment.-It is a curious fact that, 
half a century after Ritgen's operation, the little town of 
Yonkers, on the border of the Hudson River, should be the 
first place in which the word gastro-elytrotomy sounded again 
after the long interval elapsed since the operation had been 
tried for the last time. In 1870 Dr. T. G. Thomas read be- 
fore the Medical Association of that place a paper entitled : 
" Gastro-Elytrotomy, a Substitute for the Caesarean Section." * 
He had then twice essayed it on the cadavers of non-pregnant 
women, and once (February, 1870) on that of one in the latter 
part of the ninth month of pregnancy, and had performed one 
operation on the living subject, which he reported in these 
terms: 
Case I. "Gastro-elytrotomy performed on a living woman. A living 
child delivered.-Within a month from the time of the experimental opera- 
tion just recorded, I was called in great haste by Dr. T. C. Finnell to a case 
which he was attending with Dr. Richardson, under the following circum- 
stances. The patient, a multipara aged about forty years, and at the end 
of the seventh month of utero-gestation, had been suffering from pneu- 
1 Naegele's " Lehrbuch der Geburtshiilfe," 7te Auflage, bearbeitet von 
Greaser, Mainz, 1869, p. 411. 
2 American Journal of Obstetrics, vol. iii., No. 1, May, 1870. 37 
monia for a week or ten days, and was now in articulo mortis. Dr. Fin- 
nell intimated to me that he could wait only a short time for me, for, as 
the woman was fast becoming comatose, he deemed it his duty to perform 
the Caesarean section in the interest of the child, which might prove viable. 
I hastened to the patient's house, and found everything in accordance with 
what has been stated above: the patient, almost entirely pulseless, was 
cyanosed, breathing with a loud laryngeal rattle, and almost entirely un- 
conscious. A rapid consultation was held between Drs. Finnell, Richard- 
son, Jas. L. Brown, Walker, Lynch, and myself, and it was decided that 
the child should be at once removed by abdominal section. 
" The patient being placed upon a table, anaesthesia was produced, so as 
to quiet her restlessness and jactitation, with a few inhalations of ether. 
I then passed my hand up the vagina and dilated the cervix slowly and 
cautiously, so that at a three-quarter distention no injury was done to its 
tissue. With a bistoury I then cut through the abdominal muscles, the 
incision being carried from the spine of the pubis to the anterior superior 
spinous process of the ilium. The lips of the wound were now separated, 
and by two fingers the peritonaeum was lifted with great readiness, so that 
the vagino-uterine junction was reached. The vagina was now lifted by 
a steel sound passed within it, and cut, and the opening thus made was 
enlarged by the fingers. The cervix was then lifted into the right iliac 
fossa by the blunt hook, while the fundus was depressed in an opposite 
direction. I then passed my right hand into the iliac fossa and introduced 
two fingers into the uterus, while the left hand, placed on the outer sur- 
face of the uterus, depressed the pelvic extremity of the foetal ovoid. The 
knee was readily seized, and delivery easily and rapidly accomplished. 
The child was born alive, but was a badly-developed, harelipped, and, as 
I before stated, premature infant. It lived about one hour, during which 
time the rite of baptism was administered to it. The mother, the wound 
in whose abdomen was closed by interrupted suture, died about the same 
time as the child. 
" In completing the recital of this case, I need hardly point out the fact 
that the fatal issue for mother and child which occurred should not in the 
slightest degree be imputed to any inherent imperfection of the operatiou 
itself. It was unquestionably due to these two circumstances which char- 
acterized this individual case: first, that the woman was moribund when 
the operation was undertaken ; and second, that the child was premature, 
undeveloped, and probably depreciated in strength by the toxaemia which 
had for days aftected its mother in consequence of pneumonia. I think 
that I am correct in saying that al the gentlemen present agree in the 
belief that nothing connected with its delivery could in any way have in- 
jured the child's prospects for life. The liquor amnii was unevacuated up 
to the moment when version was practised, and not an instant's delay, or 
the expend ture of any, even the slightest, force was developed as a possi- 
ble cause of death. The child died, as we so often see premature children 38 
die, of want of cerebro-spinal and ganglionic nerve-power to maintain the 
functions of life in its new relations." 
Five years later Dr. Thomas incidentally spoke of this- 
operation in the New York Obstetrical Society,1 and, in 
speaking from memory of a thing done at so remote a date,, 
quite naturally committed some small mistakes, of which only 
one merits mention. He said that he enlarged the opening- 
in the vagina with the scissors, while in the original paper it 
reads "with the fingers" and, as we shall presently see, this 
is a point of great importance, as it contains the clew to Dr. 
Thomas's success. 
Eight years after this operation, Dr. Thomas performed 
another: 
Case II? " Laparo-elytrotomy successfully performed for both mother 
and child.-On the 3d of December, 1877, I was requested by Prof. 
James W. McLane to see with him, at the Nursery and Child's Hospital, 
a woman who had been taken in labor some sixteen hours before. She 
resided in Harlem, about four miles distant, and had been attended there 
by Drs. Farrington, Dwyer, and Shrady, who, finding the pelvis so much 
contracted as to require an operation, had sent for Dr. McLane, and at his 
suggestion she was brought to New York. The labor at this time was far 
advanced, but her surroundings at home were so unfavorable that this was 
deemed the wiser course. 
" The woman was Irish, twenty years old, married, and a primipara. 
She was very small and undeveloped; one leg was contracted and bent, 
and the thigh firmly flexed on the abdomen. The pelvis at the superior 
strait had been estimated by Dr. McLane, Dr. G. A. Sabine, and the other 
gentlemen above mentioned, at 2| inches in the conjugate diameter, 
though I question whether it measured more than 2|. At the outlet, the 
conjugate diameter was long, while the transverse was estimated at 2| 
inches. 
" The question as to operative procedure, up to the time of my arrival, 
had been between evisceration, the child presenting by the breech, and 
Caesarean section, the preponderance of opinion being decidedly in favor 
of the former. I proposed, as a compromise, laparo-elytrotomy, and, this 
being decided upon, Dr. McLane very kindly requested me to perform the 
operation. 
" The patient being anaesthetized and laid upon a table, I cut through 
skin and adipose tissue from the superior spinous process of the ilium, 
1 American Journal of Obstetrics, vol. viii., p. 326, August, 1875. 
1 Ibid., vol. zi., p. 240, April, 1878. 39 
along the upper edge of Poupart's ligament to the spine of the pubis on 
the right side of the body. Then I cut through the muscles, and, coming: 
down to the peritonaeum, lifted this, and touched the vagina. Dr. McLane 
now passing his finger through this canal and pushing it upward, I cut- 
down upon it near the uterine junction. Then inserting my two index- 
fingers, I tore the vaginal wall downward. Immediately the uterus, con- 
tracting strongly, forced the breech of the child into the iliac fossa, and, 
hooking the index-fingers into the groins, I rapidly delivered. The child 
was asphyxiated, but by sharp slapping it soon recovered and cried lustily. 
From this time onward it did perfectly well. 
" The wound having been thoroughly cleansed of blood-clots by forcing 
carbolized water through it by means of a Davidson's syringe, was closed 
by silver sutures throughout. No vessels were tied, and thus no foreign 
substance was left within it. 
" The duration of the operation, from the time of the first incision to its 
completion, was thirty-five minutes. After its completion, the patient 
was put to bed, given an opiate, confined to fluid diet, and kept perfectly 
quiet upon the back. 
"From this time the history is compiled from Dr. Beckw'ith's notes. 
" December J^th.-Patient slept well last night, quieted by morphia ad- 
ministered hypodermically. At 8 a. m., temperature 99°, pulse 132. 
Milk given every two hours. 7 p. m., temperature 102°, pulse 140. 
" 5th.-8 a. m., temperature 99f °, pulse 124; 7 p .m., temperature 100°, 
pulse 128. 
"Urine does not pass through catheter kept in bladder, but escapes per 
vaginam. A fistula evidently exists. 
"6th.-9 a. m., temperature 101°, pulse 136. Wound washed out by 
vaginal injection of carbolized water every eight hours; water forced 
out through abdominal wall freely. 10 p. m., temperature 101f°, pulse 
128. 
"7tA.-8 a. m., temperature 102f°, pulse 128; 7 p. m., temperature 
98|°, pulse 116. 
"8th (sixth day since operation).-8 a. m., temperature 98|°, pulse 108. 
Urine flowing now freely through catheter. When vagina is injected, 
very little water flows through wound. Up. m., temperature 100|°, 
pulse 116. 
"9th.-8 a. m., temperature 98f°, pulse 124; 8.30 p. m., temperature 
101°, pulse 124. < 
" 10th.-8 a. m., temperature 99f °, pulse not recorded; 9 p. m., tem- 
perature 98f°, pulse not recorded. 
" 11th.-9 a. m., temperature 103°, and at 10 a. m., 104f°. As patient 
had lived in a very malarious district, rise of temperature was regarded as 
due to miasmatic poisoning. Quinine was given in scruple dose, and at 
7 p. m. temperature was 100°. 
"12th.-9 a. m., temperature 101|°, pulse 124; 8 p. m., temperature 
103|°, pulse 128. 40 
" 13th.-8 a. m., temperature 101f°, pulse 112; 8 p. m., temperature 
98f°. 
" llfth.-8.30 a. m., temperature 98f-°, pulse 92 ; 7.30 p. m., tempera- 
ture 98f °, pulse 88. 
" Patient very steadily and certainly improving. December 15th, tem- 
perature taken every two hours, 98f°, pulse from 92 to 104. 
"From this time the patient went on steadily to complete recovery, the 
wound healing by second intention, the solution of continuity being filled 
up by granulations. 
"It is in my mind a question whether the rise of temperature was due 
to miasmatic poisoning, or to septicaemia. My impression is that the 
former condition produced it, as it was markedly controlled by quinine, 
freely administered. 
" On the 20th day after the operation, the bladder, which was undoubt- 
edly injured by the operation, recovered its retentive power, the catheter 
was removed, and patient thenceforth passed her urine voluntarily. 
" On the 25th day after the operation, one end of the round ligament 
protruded from the wound, which had now nearly healed throughout its 
length. This was ligated and cut off. 
" On January 3d, thirty-two days after operation, the wound, which was 
originally five inches long, measured in length two and a half inches, and 
in depth half an inch. Vaginal examination showed on right side an 
opening with sharp, falciform border extending into iliac fossa, one inch 
in extent. 
" On this date the patient was discharged cured. She and her child 
have since done perfectly well." 
Dr. Thomas, in the paper read before the New York 
Academy of Medicine, on the 21st of March, 1878, from 
which the last-mentioned case is taken, declares 1 that, until 
some time after he had essayed it on the cadaver, he was 
fully under the impression that the idea had originated with 
himself, and, although he spoke of it freely with his profes- 
sional friends in New York, none of them were able to correct 
his error until he mentioned it to Dr. Emil Noeggerath, who 
remembered having somewhere read of Ritgen's operation. 
After having seen, in the preceding chapter, how entirely the 
idea had been abandoned, nay, forgotten, this is easily under- 
stood by any one who is acquainted with the peculiarities 
incidental to life in this metropolis, that, in fact, contains 
two millions of inhabitants, widespread over different islands 
and part of the continent, and who knows what claims are 
1 L. c., p. 230. 41 
laid on the time of a man of such a skill and such a fame as 
Dr. Thomas. Already, in his first publication on the sub- 
ject, he gave such historical data about previous attempts as 
he had been able to obtain from Kilian's, Dewees's, and Vel- 
peau's works. 
I think it is fortunate that Dr. Thomas was unacquainted 
with the difficulties encountered by his predecessors. Had he 
known the unsuccessful operations of Ritgen and Baude- 
locque, it is very likely that he never would have tried a plan 
that, in their hands, had proved so utterly a failure. As it is, 
prompted by his genius alone, he went to work and tried the 
idea originated in himself, and a splendid success put him in 
a place in vain aspired to by others. And why did he suc- 
ceed? His operation is identically the same as that essayed 
fifty years before by Ritgen, except in this respect, that he 
did not cut backward in the vagina, but tore the vaginal 
wall as soon as he had made an incision large enough to ad- 
mit his two index-fingers. This is by far the safer process, 
for by being torn the blood-vessels of the vagina are much less 
likely to bleed. Spontaneous ruptures of the vagina seldom 
give rise to dangerous haemorrhage. They may nevertheless 
do so exceptionally, and we have seen that Baudelocque met 
with a haemorrhage the moment he thrust his bistoury into the 
vaginal wall. Although in his case it does not seem to have 
warranted him in desisting from the operation, a troublesome 
haemorrhage may occur, and it is therefore better to make the 
first incision bloodless by using the cautery, as suggested 
above. 
As my chief motive for composing this dissertation is to 
enable the reader to form a clear opinion of gastro-elytrotomy, 
by comparing the old operations with the recent ones, and there- 
by to contribute to dispel the dread with which it has been 
surrounded by the damaging verdict pronounced against it by 
great authorities, I think it useful to make such additions to 
the description given by Dr. Thomas as I am enabled to by 
his own kindness, in answering certain questions put by me, 
and as he has authorized me to publish. He did not extend 
his incision precisely up to the spine of the pubis, by doing 
which he would have cut the epigastric artery. He made it 42 
at some little distance, say an inch, above Poupart's ligament, 
and did not extend it to the mesial line, exactly as recom- 
mended by Baudelocque, who places the inner angle of the 
abdominal wound at one inch and three-quarters above and 
outside of the spine of the pubis. Dr. Thomas did neither 
see nor cut the epigastric artery. As for the superficial ar- 
tery, of the same name, which necessarily is cut, he merely 
applied temporary compression to it by a holding-forceps. 
The first incision in the vagina was made at some distance 
below the neck of the uterus, perhaps an inch or an inch 
and a half. This point is of importance, since an opening 
immediately below the os would injure the ureter. He made 
the incision just large enough to get through, and then he tore 
with his index-fingers, one turned toward the os uteri, the 
other toward the descending ramus of the pubis. Thus he 
aimed at making a longitudinal rent. He cannot state what 
shape it took, but he feels certain that it becomes stellate 
when the child passes. Else he does not think it would be 
possible to get it through. He tore only enough to insert the 
tip of his fingers, put together as for dilating the os. While 
the band passes the fissure tears more, and finally, during the 
passage of the child, it tears still more. It is of course impos- 
sible to tell what direction the branches of the rent will take ; 
this is the hazardous part of the operation, but the result 
so far shows that the risk is much smaller than in Caesarean 
section. He neither saw nor felt the iliac vessels. In his first 
operation he removed the placenta per vias naturales ; in the 
second, through the abdominal wound. 
To Dr. Thomas, then, belongs the glory of having been the 
first who performed gastro-elytrotomy so as to extract a living 
child from a living mother in his first and of hav- 
ing brought both mother and child to complete recovery in his 
second operation. In both cases the operation was perfectly 
indicated, the alternative being in the first Caesarean operation, 
on account of the mother's moribund state, and her physician's 
unwillingness to let her die undelivered ; in the other, either 
Caesarean section or an embryotomy that would have been 
extremely difficult and dangerous to the mother, on account 
of the breech presentation, combined with considerable coarc- 43 
tation of the pelvis, and which, besides, would have cost the 
child's life. 
The last, but by no means the least important, performer 
of gastro-elytrotomy we have to deal with is Dr. Skene. 
Between Dr. Thomas's two cases, he has performed the opera- 
tion no less than three times with the greatest success: 
Case I.1 Gastro-elytrotomy, performed in the interest of the mother 
after perforation of the head of the child.-"Dr. Charles Corey was called 
to see the patient on Saturday morning, March 21, 1874. He then learned 
that she was aprimiparaat full time. Her general health had been fair for 
years; she was rachitic when a child, and did not walk until she was over 
five years of age. Labor began on the night of Friday, the twentieth. 
The os uteri was dilated, but the head, the presenting part, was wholly 
above the superior strait. 
" When the os became fully dilated, the doctor ruptured the membranes, 
but the head did not at all engage in the pelvic cavity. Drs. Andrews and 
Filrgang were called in consultation, and it was decided to try version. 
"At three o'clock on Sunday morning the operation was tried, but was 
found to be impossible, owing to the shortness of the antero-posterior di- 
ameter of the pelvis, which was not more than two and a half inches in 
diameter. At eight a. m., of the same day, delivery by craniotomy was 
undertaken, but, after perforating the head, that also was abandoned be- 
cause of the oedema of the parts and the narrowness of the pelvis. I saw 
the patient in consultation with the gentlemen named, at two p. m., on 
Sunday, about forty-eight hours from the time when she was taken in 
labor. Gastro-elytrotomy was proposed and agreed to by all the gentle- 
men present, as the only means of giving the patient a chance for her life. 
It was also believed that if she died-which in all probability she would- 
she would be relieved from the severe labor-pains which still continued. 
At this time she was suffering from exhaustion. Her pulse was rather 
feeble and over one hundred and thirty. She was anaesthetized, and I 
operated with the assistance of the gentlemen in attendance, and Dr. 
George Cushing. The general rules laid down by Prof. Thomas were fol- 
lowed, and I can testify to the truth of his statement that the operation is 
exceedingly simple, and may be performed with rapidity and certainty, 
for, although the operation was unknown to me in every sense, except the 
description of it which I had read, I was able to make the dissections and 
deliver the child and placenta in ten minutes, and without making any 
haste. The patient came out from the anaesthetic very well, and remained 
free from pain afterward. The exhaustion and shock were but slightly in- 
creased by the operation, but they gradually became more marked, and 
she died seven hours after the operation. 
' New York Medical Journal, 1874, vol. xx., p. 401. 44 
" There are several observations which I made during the operation, 
which are of sufficient importance to be worthy of special mention. The 
incision through the skin and superficial fascia was made from the spine 
of the pubis to the anterior superior spinous process of the ilium, as di- 
rected by Prof. Thomas. This I found to be longer than necessary. The 
muscles were then divided a little more than two-thirds of that distance. 
The opening made appeared to be rather small, but I found that it stretched 
with the greatest facility, and was therefore ample. 
" The finger was used to raise up the vagina at the point where it was 
opened. I believe that this method is preferable to using the sound, as 
directed by Prof. Thomas. I was able in this way to avoid a large vessel 
which 1 felt pulsating. The finger was also used in place of the blunt 
hook to draw the cervix up to the right iliac fossa, while the fundus was 
carried to the left side. 
" In place of delivering the child by version, as recommended by Prof. 
Thomas, I seized the occipital bone with the craniotomy forceps, and ex- 
tracted the child with'the greatest ease. At the same time I had the or- 
dinary obstetric forceps, at hand, and satisfied myself that I could have 
applied them to the head and delivered with more facility than I could by 
performing version. 
" The experience afforded by this one case has fully convinced me that 
the operation should take the place of Caesarean section, and in deformity 
of the superior strait it should be tried in place of craniotomy when the 
life of the child could be saved by doing so." 
Case II.1 Gastro-elytrotomy performed successfully for mother and 
child.-" Mrs. F., aged 31 years, born in England. She is rachitic, and, in 
giving her history, stated that she was unable to walk without support until 
eleven years of age. At twenty-five years of age her physician delivered 
her by performing craniotomy, after which she made a slow recovery, and 
was confined to her bed for six weeks. Some time after that she was de- 
livered at the seventh month. The child lived only a few minutes. When 
she came to this country her physician gave her a letter stating the nature 
of her former confinements, and also that she had a deformed pelvis. This 
letter she brought to me in 1872, when I found that she was again pregr 
nant. She expressed a strong desire to have a living child, and, upon 
examining the pelvis, I resolved to let her go until the beginning of the 
ninth month, when I proposed to induce labor, in the hope of obtaining a 
living child. Accordingly I brought on labor in the first week of the ninth 
month, and found an arm presentation. Version was performed with 
great difficulty, owing to the fact that the antero-posterior diameter 
of the superior strait was not more than two and three-quarters (2f) 
inches. 
" By using strongHraction, and extreme pressure over the uterus, depres- 
sion of one of the parietal bones was produced, and thereby a small child 
1 American Journal of Obstetrics, February, 18*76, vol. viii. 45 
was delivered, which lived for several months. Metritis followed, and she 
suffered great pain in her back and limbs. There was also partial paralysis 
of the limbs, which slowly disappeared. Altogether it was five weeks be- 
fore she recovered. At that time she was strongly advised to give up 
child-bearing. Some time ago she called upon me and stated that she was 
pregnant, and urged me to save her child if possible. I told her, if she 
would take the risk, I would give her what I believed to be the only cer- 
tain chance of having a child, and also the possibility of saving her own 
life. She cheerfully accepted the proposition, and expressed her deter- 
mination to go to full time. 
" I gave the history of her case to Prof. T. G. Thomas and asked his ad- 
vice and assistance. His kind reply was that he would be at my service 
at any time. Late in the afternoon of October 28, 1875, she called at my 
office, and, on examination, I found her at full time, the os uteri dilatable, 
and that she had slight uterine contractions. 
" She was ordered to go home and to let me hear from her late in the 
evening. At ten o'clock her husband reported that she had slight pains, 
but was about the house and felt comfortable. I gave directions to call me 
during the night if her pains increased, and not to wait longer than four 
o'clock in the morning. Labor progressed, but, being unwilling to disturb 
me, they did not call me until six a. m. on the 29th. I then found that she 
had good labor pains, and that the os uteri was almost fully dilated; the 
membranes were unruptured, and an arm and the cord were presenting. 
I could feel the cord pulsating through the membranes, and the fetal heart 
was heard distinctly. I sent in all haste for Prof. Thomas, but most un- 
fortunately he was engaged and could not come. I also sent for Drs. Co- 
rey, Cushing, and Stuart. While waiting for my medical friends, I was in 
constant dread that the membranes would rupture and the cord become 
compressed so as to destroy the child. 
" I felt sure that I could not restore the cord and keep it in place when 
there was an arm presentation, and I dreaded the death of the child, which 
would have decided in favor of delivery by embryotomy, an operation 
which, under the circumstances, would have been difficult and very dan- 
gerous to the mother. Fortunately the membranes remained intact until 
my friends came. At nine o'clock, I performed gastro-elytrotomy, accord- 
ing to the method of Prof. Thomas, the best, indeed the only, authority on 
this operation. I opened the abdominal wall and also the vagina, before I 
ruptured the membranes. I then delivered by performing version. 
" Having reason to believe, from the character of the fetal heart action, 
that the circulation of the child was slowly becoming interrupted, I made 
great haste to deliver as soon as I ruptured the membranes. 
" The child, which weighed ten pounds, was slightly asphyxiated, but 
was easily restored. 
"The time occupied, from the beginning of the operation until the child 
and placenta were delivered, was fifteen minutes, five minutes longer than 
my former operation. The extra time required was owing to slight 46 
haemorrhage, caused by making the incision in the abdominal wall lower 
down than was necessary, and also by having to restore the prolapsed arm, 
and deliver by version. 
"There was no shock or vomiting after the operation, and no haemor- 
rhage, primary or secondary, worthy of notice. 
"Several hours after the operation, Dr. Stuart, in passing the catheter, 
discovered that the bladder had been opened. The opening in the vagina 
had been extended so as to enter the junction of the urethra and bladder, 
on the right side. 
" I am satisfied that the bladder was not wounded at the time when I 
opened the vagina, but that it occurred during delivery. 
"If I had had more time, and could have permitted the parts to distend 
gradually, the wound in the bladder would not have been made. It was 
unfortunate, if not bad management on my part, that I did not detect the 
wound in the bladder at the time of the operation, for then a few stitches 
could have been easily introduced and the catheter worn until the opening 
closed. 
" When I became aware of the accident, I was unwilling to anaesthetize 
my patient again and submit her to the operation of closing the wound, 
because I feared that I might cause haemorrhage. 
" The second day the temperature went up, and she became quite tym- 
panitic, but there was no tenderness to indicate peritonitis. 
" The symptoms were due mostly, I believe, to a slight metritis, such as 
she had after her other confinements. These conditions continued for 
about four days, but the temperature did not at any time exceed 102°, and 
the pulse did not go beyond 120. On the sixth day, the tympanitis was 
relieved by an injection containing mint-water. 
"Morphine was given at night to secure sleep, and quinine was used in 
the day in the hope of preventing malarial fever, which had troubled her, 
off and on, for years. From the sixth to the tenth day her condition was 
remarkably good. Her pulse and temperature were normal, her appetite 
good, and she had a scanty secretion of milk. 
" On the tenth day she sat up in bed, contrary to our expressed wishes, 
but was apparently no worse for it. 
" In the afternoon of the eleventh day she had a chill, followed by fever 
and free perspiration. She was quite well on the morning of the twelfth 
day, but the chill and fever were repeated in the afternoon. 
" Quinine was freely given on the following day, and there has been no 
return of chills or fever. She believes that this part of her trouble was 
a return other familiar ague, and I believe that her diagnosis was correct. 
" The external wound healed by first intention, except at the two central 
stitches, where there was suppuration. Both the abdominal and vaginal 
wounds were completely healed on the fourteenth day. On the fifteenth 
day she sat up in a chair while her bed was being made, and, with the ex- 
ception of the opening in the bladder, she was as well as one of her consti- 
tution could be at that date after confinement. At the end of three weeks 47 
she went out riding, and continued in good health from that time. On 
November 28th, I closed the small vesico-vaginal fistula, and two weeks 
afterward dismissed her well and sound. January 15, 1876, she is well, 
and nurses her strong, healthy baby. 
" Finally, I wish to state positively that I believe the injury done to the 
bladder was the fault of the operator, not of the operation, and that I could 
avoid that accident in future. I am also satisfied that I could not have, 
under the circumstances, delivered that patient in any other way, with 
more safety to herself. I trust that the history of this case (the first suc- 
cessful one on record) will aid in placing the operation among the chief 
triumphs of obstetrical surgery, to the honor of Professor Thomas, whom 
I believe to be its author." 
Case III.1 Gastro-elytrotomy performed, successfully for mother and, 
child, four days after beginning of labor. Lordosis. Anchylosis of both 
hip-joints. Previous pelvic peritonitis.-" The subject of this history is 
an unmarried Bohemian girl, thirty-seven years of age. She became preg- 
nant, but concealed her condition from her relatives, with whom she lived, 
up to the full period of gestation. This she was enabled to do by being 
herself very much deformed in body. 
"She was taken in labor on Tuesday, the 19th of June, 1877, and soon 
after the membranes ruptured ; at least, this much was learned from sub- 
sequent inquiry. Her labor pains continued, but she did not disclose her 
true condition, nor did her friends suspect what was her trouble; but, 
becoming alarmed at her continued sufferings, they sent for Dr. S. Schinit- 
zer on the morning of Friday, the 22d. The doctor found that she was 
pregnant at full term. The membranes were ruptured, the liquor atnnii 
completely drained off' and the uterus contracted firmly round the child. 
The dilatation of the os uteri was only sufficient to admit the point of the 
finger. 
" The patient was much below the average size, emaciated, her complex- 
ion sallow, and her skin dry and ill-conditioned in appearance. There 
was a well-marked forward curvature of the spine in the lumbar re- 
gion ; the sacrum was nearly straight, and formed a right angle with the 
axis of the spinal column; the symphysis pubis was deeper than normal, 
being about two inches. The antero-posterior diameter of the superior 
strait was said by Dr. Schmitzer to be one and one-fourth inch, and 
I am confident that it did not exceed one and one-half inch. The 
thighs were flexed to nearly a right angle to the body, and held there by 
anchylosis of the hip-joints. The knees could not be separated more 
than an inch and a half. The left lower extremity was four and three- 
fourths inches shorter than the right. A number of deep scars about 
the hips indicated the previous existence of large abscesses. These, ex- 
1 American Journal of Obstetrics, vol. x., p. 623, October, 1877. With, 
two woodcuts after photographs. 48 
isting in connection with the anchylosis, led to the conclusion that she 
formerly had had the hip-joint, disease on both sides. 
"Dr. Schmitzer, finding the conditions described, satisfied himself that 
normal delivery was impossible. He then called Drs. Frickenstein and 
Weber to see her in consultation. These gentlemen agreed with the doc- 
tor regarding the deformity and the difficulties in the way of delivery. 
" I saw the patient with Drs. Schmitzer and Alexander Hutchins at six 
p. m., on Friday, the 22d. She was then partially relieved from pain by 
a dose of morphine, which was given to her in the afternoon. The os 
uteri was still undilated beyond about half an inch. From the character 
of the presenting portion, as observed through the walls of the uterus, it 
was presumed to be the vertex. 
" In consultation we agreed to first dilate the cervix, and then deliver by 
gastro-elytrotomy; but, as the patient was not having severe pains, and 
we were not then prepared to operate, we concluded to wait until morn- 
ing, when we would have daylight. In the mean time dilatation of the 
os could be attended to. Early on the following morning, Saturday, Drs. 
Schmitzer and Hutchins began an artificial dilatation of the os, which was 
found to be a most difficult task. Owing to the deformity of the patient, 
the cervix was flexed backward so as to bring its axis to a sharp angle 
with the axis of the uterus, and there was not room enough in the pelvic 
cavity to permit bringing the cervix forward on a line with the body of the 
uterus. It was therefore almost impossible to pass the dilator through 
the internal os. After prolonged manipulation, dilatation to the extent 
of two and one-half inches was effected. 
"At ten a.m., on Saturday, the 23d, four days from the time labor be- 
gan, we were prepared to operate. In selecting this method of operating, 
we were guided by the fact that craniotomy was impossible under the cir- 
cumstances, not alone because of the narrow superior strait, but also from 
the fact that the axes of the uterus and vagina were at right angles, which 
made it impossible to use the necessary instruments for delivery in that 
way. This statement will be indorsed by Drs. Schmitzer and Hutchins, 
who tried to dilate the cervix. Caesarean section was suggested by the 
difficulties in the way of gastro-elytrotomy; but we preferred to encoun- 
ter the obstacles rather than open into the peritoneal cavity and uterus of 
the patient. The condition of the patient just before the operation was 
not encouraging. Her skin was dry and hot, tongue coated, temperature 
102|°, pulse 98. Indeed, the operation was beset with difficulties from 
beginning to end, and on that account I will give the several steps in brief 
detail. 
" To reach the point for incision parallel to and a little above Poupart's 
ligament, it was necessary to raise up the abdomen and retract the soft 
parts of the thigh as much as possible. The parts being thus brought 
into view, the abdominal walls were divided through the tegumentary and 
muscular layers. This was accomplished without much trouble; but, on 
reaching the region of the peritonaaum, I encountered the products of a 49 
previous inflammation, which obscured all the normal anatomy. I have 
always believed that a previous pelvic peritonitis would greatly compli- 
cate this operation, and have dreaded that such a case might fall to my 
lot, and in this case I fully realized my expectations. The peritonaeum, 
iliac fascia, bladder, and vagina were all glued together by plastic mate- 
rial, which rendered the normal tissues unrecognizable. This, and the 
space between the flexed thigh and the large abdomen being very narrow, 
made the difficulty of manipulating very great. The vagina also was nar- 
row and unyielding, so that it could not be forced upward to guide us in 
the right direction. In this part of the operation there were three points 
of danger to be guarded against: 
" First.-Wounding the peritonaeum. There is no danger of doing this 
when the parts are normal, for then the peritonaeum can be easily recog- 
nized and lifted up from the other tissues with perfect facility ; but in this 
case everything was changed in appearance and character, and in place of 
easy-sliding tissues we had lymph and adhesions, both difficult to manage. 
11 Second.-I had learned, by former experience, that to open the vagina 
too near the symphysis pubis gives rise to the danger of the incision ex- 
tending into the bladder during delivery. 
"And Third, if the incision is made too near to the walls of the abdo- 
men, there is danger of wounding the circumflexa iliac artery. 
" We succeeded in avoiding the peritonaeum and important vessels, but 
unfortunately the bladder, which was drawn upward and to the right by 
old adhesions, was wounded. That is not very surprising when it is 
remembered that in making this portion of the dissection I was guided 
mostly by the sense of touch, and the parts were so crowded together and 
changed in appearance as to be almost unmanageable. The point at which 
the bladder was wounded was just opposite the anterior superior spinous 
process of the ilium, a place where one would not expect to find it. 
" When the cervix uteri was reached through the opening in the abdom- 
inal wall and vagina, we found dilatation sufficient to admit the points of 
the four fingers. Manual dilatation was then made and soon completed. 
The only difficulty experienced was in getting the fingers between the 
child's head and the uterus, so firmly was the latter contracted. The 
head presented transversely, with the occiput to the left side. Delivery 
»by version has been advised in this operation, and was thought of in this 
case, but was ruled out as being impossible, owing to the firm contraction 
of the uterus. Deciding to deliver with the forceps, we proceeded to use 
them. Here we encountered another perplexing difficulty. The thigh 
stood up in front of the opening in the abdominal wall and the os uteri, 
and prevented the introduction of the instruments. After some awkward 
manipulating, we succeeded in grasping the head, and then delivery was 
easy and speedy. The placenta came away without trouble. There was 
very little heemorrhage; the wound was closed with silver sutures and 
dressed with cotton wadding, secured by adhesive straps. 
" The child was markedly asphyxiated, due, no doubt, to the continued 
4 50 
contraction of the uterus so long after the escape of the liquor amnii. 
It was restored after the vigorous employment of artificial respiration. 
It was well developed, healthy in appearance, and weighed pounds. 
Drs. S. Schmitzer, Hutchins, Corey, Cushing, and Hunt were present and 
gave their counsel and assistance in the operation. 
" She recovered from the anaesthetic promptly, and showed no symptoms 
of shock, nor did she complain of pain or discomfort. On the day fol- 
lowing the operation her pulse was 94, and her temperature had fallen 
from 102|° (which it was at the time she was delivered) to 100°. The 
catheter was used frequently in order to keep the bladder from being fully 
distended. 
" Drs. Schmitzer and Hutchins observed that, after a few days, the quan- 
tity of urine retained in the bladder became less and less, and at the same 
time the urine was seen to escape from the vagina. 
"The introitus vaginae was small and firmly contracted, which prevented 
free drainage, causing the urine to accumulate in the vagina and ■well up 
through the abdominal wound. 
" A rubber tube, perforated with small holes for about two inches at 
one end, was introduced into the vagina for the purpose of draining off 
the urine. It answered well, and for twenty-four hours the urine flowed 
continuously and freely into a urinal, and all appeared to progress well 
for a time. The patient, unfortunately, was ignorant, obstinate, and un- 
manageable. Her mental obliquities and angularities were, like those of 
her body, well marked. After a day or two she became dissatisfied with 
the drainage-tube and would not let it remain any longer in the vagina. 
Every time that the doctor placed it there, she would withdraw" it and 
throw it away, and no argument could persuade her to do otherwise. 
The urine, from this time, flowed freely from the abdominal wound, and 
occasionally from the vagina. Owing to the disagreeable disposition of 
the patient, it was impossible to keep her clean or comfortable. Her ap- 
petite was good, her bowels moved regularly, she slept well on small 
doses of morphine at bedtime, and her pulse and temperature were nor- 
mal, but it was difficult to keep her wounds in good condition. She was 
cared for by her sister, who, although willing, was not skilled as a nurse, 
and, besides, she had her household duties to perform. 
" Such being her surroundings, we concluded to send her to the hospital, 
and on the fifth of July, two weeks after delivery, she was taken there. 
She made the journey to the hospital, about three miles, very comfortably. 
When admitted, her condition gave evidence of want of proper nursing. 
The wound was healed except at the outer portion near the anterior su- 
perior spinous process of the ilium, where the fistulous opening was. 
Around the opening the parts were foul and covered with a superficial 
slough. Most of the urine escaped from this opening. There was also 
a free purulent discharge. 
" She was placed upon tonic doses of quinine, and a little morphine at 
bed-time to relieve an uneasy restlessness. The wound, vagina, and blad- 51 
der were kept thoroughly clean by the frequent use of carbolic acid and 
water. A stream was passed from the wound in the side through the 
vagina and then reversed. The bladder was also injected; the stream 
being carried in through the urethra and made to escape through the 
vagina and abdominal opening. 
" To keep the wound in the best condition for healing, a rubber tube 
was introduced into the fistulous opening in the side, and it made good 
drainage when the patient could be persuaded to keep it in place, but she 
often pulled it out. After a few days the house physician succeeded in 
passing a perforated rubber tube from the abdominal opening out through 
the vagina and left it there. This made perfect drainage. Sometimes the 
urine would flow from one end of the tube, and sometimes from the other, 
according to the position taken by the patient, and she was unable to re- 
move this tube, which was a great advantage. 
"From this time the abdominal wound healed rapidly, and the drainage- 
tube was finally removed about the third of August. The urine flowed 
then from the vagina only. To drain the vagina, a hard-rubber bulb with 
a stem wTas used, which answered very well to carry off the water. The 
bulb was olive-shaped, and perforated closely with small holes. To the 
stem of the bulb a small flexible tube was attached which conveyed the 
urine to a vessel. A rubber urinal was obtained for her which she could 
wear while walking around, but for some reason, which no one could 
understand, she would not use it. 
" Most of the time since the operation the bladder has retained more or 
less urine, and at this stage of her progress the house physician noticed 
that it began to retain more and more, showing that the fistulous opening 
was closing. Improvement in this direction continued until the twelfth 
of August, when the bladder had fully regained its pow'er of retention, 
indicating that the fistula had closed. 
"At this date (August 12th) her health is as good as it ever was. In 
short, the recovery of the mother is complete, and the baby, which was 
left at home, prospered for a time, but died when eighteen days old, 
from bad feeding and care. 
" The notes here given of the case while in the hospital are brief ex- 
tracts taken from the clinical records kept by the resident physician, Dr. 
McPharlin, to whose skill and constant care her complete recovery is 
largely due. 
" In reviewing this case of gastro-elytrotomy, the second successful case 
on record, so far as I know, I may say that a more unfavorable case for 
operating could not well be imagined. 
" The conditions of the patient in every particular relating to the opera- 
tion, and the want of facilities for after-treatment, were such as to thor- 
oughly test the merits of this method of delivery. Certainly, greater dif- 
ficulties than were here encountered are not likely to occur in the fu- 
ture history of this operation." 52 
Availing myself of my personal acquaintance with Dr. 
Skene, I have several times questioned him about the details of 
his operations, and am, through his kindness, enabled and au- 
thorized to add the following items. In his last operation he 
did not see the epigastric artery at all, while in that preceding 
it he saw it and the accompanying vein, like the embroidered 
lines on the back of a glove, and pushed them inside and up- 
ward. The superficial or external epigastric was cut and tem- 
porarily compressed with a holding-forceps in every case. He 
did not twist or tie a single vessel. The external incision did 
not extend down to the spine of the pubis, but ended above it. 
He had made the incision rather too near to Poupart's liga- 
ment, which, in his last operation, necessitated the extirpation 
of a large inguinal gland. He thinks it best to keep even more 
than one inch above the ligament. The peritonaeum separated 
in the first two cases as easily as a rabbit is skinned. The pul- 
sating vessel, which he felt before incising the vagina in his 
first case, was felt running in the direction of a prolonged 
radius from the os uteri outward. He made his incision in 
front of it, but is not sure if he tore it, as it may have staid 
intact in the posterior part of the vagina. He introduced his 
right hand and cut with the left. He cut in a direction par- 
allel to the ilio-pectineal line. He estimates the distance from 
the utero-vaginal junction at scarcely half an inch in the 
centre, but greater tow'ard the symphysis and the rectum. 
The incision was just long enough to admit the end of both 
fore-fingers. He introduced them perpendicularly to the in- 
cision, and applied the force in the direction of the vaginal 
axis. This gave a transverse rent, which he extended by ap-_ 
plying his fingers in the same way, in different places, nearer 
to the symphysis, and then nearer to the sacrum ; thus mak- 
ing a rent that he saw distinctly in his first two operations, 
but not in the third, on account of the deformity of the pa- 
tient, and the disturbance caused in the tissues by previous 
inflammation. It was ragged, but had no branches; it was 
simple, not stellate, and about three inches long. He was 
surprised at the facility with which the wall tore. On ac- 
count of the elasticity of the tissue the hand entered easily 
through this opening without tearing it more. In his second 53 
case he carefully examined the vaginal rent after 
looking for vessels, and he is positive that it was a simple 
transverse rent. On account of this he doubts if it is possible 
to perform the operation on the left side, as the distance from 
the rectum to the bladder is smaller on this side than on the 
right. He did not see nor feel the large iliac vessels, which 
were covered by the uterus. 
The indication seems to have been absolute in the first 
case, since not even craniotomy was thought practicable, on 
account of the narrowness of the pelvis, combined with the 
cedema of the genitals, although cephalotripsy is not men- 
tioned. In the third case the indication was unquestionably 
an absolute one, on account of the great contraction of the 
pelvis. In the second it was only conditional; but the opera- 
tion was justified by the experience from the patient's former 
deliveries, and her great desire to have a living child. 
When Dr. Skene formulates as a general indication that 
gastro-elytrotomy should be " tried in place of craniotomy, 
when the life of the child could be saved by so doing," I think 
he goes too far. This operation being much more hazardous 
than cephalotripsy, cranioclasis, and decollation, under favor- 
able circumstances, it ought only to take the place of opera- 
tions by which the foetus is broken up, if these operations, in 
the given case, would present particular difficulties, as in Dr. 
Thomas's second case. Under circumstances favorable for 
■craniotomy or embryotomy, gastro-elytrotomy would only be 
justifiable in the hands of those who absolutely refuse to kill 
the foetus, and who consequently either would expose the 
woman to greater danger by non-interfering, or by Caesarean 
operation ; but this is not good obstetric practice. 
Apart from the regard to the greater safety to the mother 
in cases in which difficult embryotomy, in the wider sense, 
would be the alternative, gastro-elytrotomy may also be justi- 
fiable, like Caesarean operation, if the woman is willing to un- 
dergo the operation, and great interests, such as the preserva- 
tion of a dynasty, or the entailment of a large estate, etc., are 
at stake. Since it is less dangerous than Caesarean section, it 
is even warrantable to let the interest of the child weigh more 
than when the latter operation is contemplated. 54 
It is fortunate that the only man who, besides Dr. Thomas, 
has performed this operation since its reinvention, had never 
witnessed the experiments and the operation performed by 
the latter. By performing the operation three times, and 
once even under the most difficult circumstances, Dr. Skene 
has proved that it is fit to become the common property of the 
profession. What has succeeded in Brooklyn, at the hands of 
a man who had merely read Dr. Thomas's description of his- 
operation performed in New York, may as well succeed in 
any other part of the civilized world, provided that he whe 
undertakes it is capable of operating at all. According to the 
unanimous testimony of all who have tried it, it is not even a 
difficult operation. Ovariotomy, an operation in which the 
unforeseen plays a much greater part, and in which often 
the greatest difficulties are met with, has been performed 
successfully numbers of times by village doctors. How much 
more readily then may gastro-elytrotomy be undertaken, an 
operation that indeed is dangerous, but in which the danger 
is much Jess under the control of the skill of the operator! 
This must of course not be misconstrued as if I meant that 
anybody can do what Dr. Skene can do, who is a consum- 
mate surgeon. I only mean to say that the operation in itself 
is not one of those that demand such shill that they necessarily 
can he performed only by few men. There cannot be any 
serious difficulty in the first part of the operation, the abdomi- 
nal incision and the separation of the peritonaeum. The 
only delicate point, to cut the fascia without wounding the 
peritonaeum, is not so difficult as to incise the hernial sac with- 
out injuring the gut, the first two being separated by cellular 
tissue and often fat, while the latter are in contact. The sec- 
ond part may be made comparatively safe by opening the 
vagina with the actual cautery and then tearing. If the rent 
extends into the bladder, experience has shown, in Dr. Thom- 
as's second and Dr. Skene's third case, that the fistula may 
heal by itself. If it does not, and the operator does not feel 
competent to close it, this part may be performed later by 
another. In order to ascertain, immediately after the opera- 
tion, whether a fistula has been formed or not, I should advise 
to inject lukewarm milk into the bladder, which would enter 55 
the vagina, and would be easily recognized by its color. The 
rupture may then be united at once by a few stitches. 
It is likewise fortunate that the few cases hitherto operated 
on in America have varied so much that they prove that the 
operation, with proper modifications, is practicable under dif- 
ferent and even the most trying circumstances. The child 
has presented by the head, by the breech, by the arm and 
cord; there has been considerable narrowness of the pelvis 
and anchylosis of both hip-joints; and the woman has been 
delivered by version, extraction, and forceps. 
It appears from the above that there is some difference be- 
tween the statements of Dr. Thomas and Dr. Skene as to the 
important question of the size and the shape of the vaginal rent. 
But one thing has become entirely dear: both applied the force 
in precisely the same direction, although with different aim. 
It is, therefore, likely that the result was the same, and that 
the chief direction of the rent was one parallel to the brim 
of the pelvis. The chief direction of the muscular fibres fa- 
vors the separation in this oblique line. I have tried myself 
to tear the vagina on the cadavers of non-pregnant women, 
after having made a small incision below and parallel to the 
ureter, and applying the force perpendicularly against the 
edges as in the operation. The opening became only longer, 
but retained its chiefly transverse direction, and did not tear 
at all in the direction in which the force was applied. If I 
made an incision in the direction of the longitudinal axis of 
the vagina, and tore, the rent retained indeed also this direc- 
tion, but tore with less facility. Thus it seems that we can de- 
cide the direction of the rent by the direction in which the in- 
cision is made. Whether the rent will become stellate or not 
will, probably, to a great extent, depend upon the rapidity 
with which the foetus is expelled or extracted. As it is impos- 
sible to tell in what direction, and to what extent, the branches 
might go, thereby endangering not only the bladder, that actu- 
ally has been invaded, and the wound in which is of less con- 
sequence, but the ureter and the peritoneal cavity, which 
might prove fatal, it must be safer to try to avoid them. 
Intimately allied to this question is that about the possi- 
bility of operating on the left side. We have seen that Bau- 56 
delocque did so in both his cases, and was able to extract the 
foetus through the wound in the second. But he cut, and 
could consequently give his incision so oblique a direction that 
he obtained room enough ; but cutting is so hazardous that it 
has to be avoided in future, and the question is then if tearing 
will give as good results on the left side as on the right. It 
appears likely from my experiments, but it has yet to be 
proved in practice. I shall hereafter show that there is plenty 
of room, although the rectum lies in this side of the body. 
Dr. Thomas says that his last patient will almost surely re- 
turn within a year,1 and that he would repeat the operation. 
He would then have an opportunity to examine this impor- 
tant question on the living subject. I w'ould also call to 
this point the special attention of those who may be fortunate 
enough to have at their disposal the body of a woman who 
has died at term. Let them by all means try the operation 
on the left side, and cut below and parallel to the ureter and 
the line of connection between the bladder and the vagina 
(see Fig. 2), but not more than absolutely necessary to intro- 
duce their two fingers, and then tear. This is the point 
that, more than any other, needs investigation now; the feasi- 
bility of the operation on the right side having been put be- 
yond a question by the success of Drs. Thomas and Skene? 
1 L. c., p. 245. 
9 I have just received Masson's "Th&se: De la Gastro-61ytrotomie," Ar- 
genteuil, 1878, which contains (page 48) the report of an operation made 
on the cadaver, April 12, 1877, by Budin and Th6venot. They operated 
indeed on the left side, and extracted a rather large child with great facil- 
ity, and the following dissection showed that the peritonaeum, as well as 
the bladder and the rectum, was intact. They found, like their predeces- 
sors, that it was easy to detach the peiitonaeum, and reach the vagina. 
Two fingers of the left hand were introduced into the vaginal canal, and 
fixed a little in front of (or below) the scarcely perceptible ring formed by 
the fully dilated os uteri. They made the incision between these two fin- 
gers separated from each other. The vaginal wall seemed so thick that 
the operator for a moment questioned if he did not incise the uterus. The 
incision was extended a little forward and backward, in order to give pas- 
sage to the hand and the child. This, as well as Baudelocque's second 
case, gives good hope of the feasibility of the operation even on the left 
side; but as they made the whole opening by incision, we cannot draw any 
positive conclusion as to tearing. 57 
Name. 
When we look in Dunglison's " Dictionary," 1 under the 
head of Gastro-elytrotomia, we should think that it is a very 
common operation, since it bears no fewer than five names- 
Gastroelytrotomia, gastrelytrotomia, gastrocolpotomia, lapa- 
rocolpotomia, laparoelytrotomia-but this can only be regard- 
ed as a display of philological scholarship. When we take the 
thing historically, it looks a little different. The operation 
was called by its first inventor, Ritgen, in 1820, Bauchscheiden- 
schnitt, which, Grecized, would be either gastro-elytrotomy 
or laparo-elytrotomy. Baudelocque, its second inventor, called 
it gastro-elytrotomie in 1823, and in his second publication, 
in 1844, elytrotomie. Dr. Thomas, its last inventor, called it 
gastro-elytrotomy in his first paper (1870), and so did Dr. 
Skene; but in his last paper (1878), Dr. Thomas called it la- 
paro-elytrotomy and substituted this word for gastro-elytroto- 
my in reproducing the earlier publications. 
The whole question is of little account, and Dr. Thomas 
has certainly, more than any other living man, the right to 
name the child. From historical grounds, it would be right to 
keep the name given by Ritgen ; but as it is German, it has 
to be translated, and may be translated in both ways. As one 
of the two was used originally by Baudelocque, and later by 
Dr. Thomas himself, it seems to me to be preferable, so much 
more so as there cannot be said anything against it. raa-Trjp 
signifies as well abdomen as stomach. Gastrotomy signifies 
indeed the opening of the stomach, while laparotomy is the 
opening of the belly (XaTrdpa, properly the flank, the soft part 
between the ribs and the iliac crest); but as a term designating 
an incision through the stomach and the vagina would be 
meaningless, and as gastro-hysterotomy is much more used 
than laparo-hysterotomy for Caesarean section, it seems better 
to call its substitute gastro-elytrotomy. 
Statistics, Dangers, Indications, and Contra-indications. 
There can of course not be spoken of any statistics for the 
first period. The operation was in two cases given up, and 
1 Robley Dunglison, " Dictionary of Medical Science," Philadelphia, 
1874. 58 
Caesarean section performed, resulting for the mother in death 
from haemorrhage. In Ritgen's case, the child survived; in 
Baudelocque's it was dead. The operation was only per- 
formed once-the mother died from peritonitis-the child had 
died in consequence of the mother's eclampsia. The same 
condition, besides a defective modus may have exer- 
cised some influence on the result for the mother. 
During the second period, five operations have been per- 
formed-four of the children were born alive, and three of 
the mothers are still living. But the record is still much bet- 
ter, when we remember that the fifth child had had its head 
perforated before the operation, and that both of the mothers 
who were lost were in a dying condition when it was under- 
taken. 
Of the children, one died shortly after birth, being only a 
seven months' deformed foetus; another after eighteen days, 
from want of care. 
This result is not only most remarkable in a dangerous 
operation undertaken in the gravest cases of obstetric prac- 
tice, but it becomes still more so when we compare it with 
the results of Caesarean section. Of course nobody can fore- 
see what experience will show to be the real statistics of 
gastro-elytrotomy when it has been performed often enough 
to exclude the influence of chance. It is not likely that the 
result will continue so good as it has been in the five opera- 
tions hitherto performed according to Dr. Thomas's method. 
But in order to know if it is right or wrong to try it, we 
must consider the result so far obtained. The statistics 
of gastro-elytrotomy have the great advantage of being com- 
plete, while others regarding operations performed many 
times are based on literary sources in which successes are 
more frequently reported than failures. Thus all general 
statistics published on Caesarean section are entirely fallacious, 
although, even as they are, they show the great danger of the 
operation. The most recent collection of the kind, that of 
Mayer, shows in 1,605 women a mortality of fifty-four per 
cent.; the same figure was obtained by Michaelis, while Kay- 
ser even found sixty-two per cent.1 Dr. Robert P. Harris, of 
1 Spiegelberg, " Geburtsbulfe," Lahr, 1878, p. 852. 59 
Philadelphia,1 has gathered eighty-nine operations performed 
in the United States. Of the mothers thirty-eight lived and 
fifty-one died, or 57.3 per cent. Of the children forty-four 
were born alive, thirty-eight continued living some time, forty- 
seven were born dead, i. e., 51.6 per cent. The author in- 
sists justly on the comparatively favorable results obtained 
when the operation is performed within twenty-four hours 
after the commencement of labor, but even under these cir- 
cumstances the results are inferior to those hitherto obtained 
by gastro-elytrotomy. If we take more limited localities, 
where it is easier to ascertain the results of Caesarean section, 
the report is by far darker. Joulin 2 states that it has been 
performed sixty-seven times in Paris since the sixteenth cen- 
tury, and six women only escaped death. The last success- 
ful operation was performed by Lauvergeat in 1787. During 
this century twenty-six operations have beenperformed without 
a single success. Spath 3 says that there has not been a single 
case in the Lying-in Asylum of Vienna, during this century, 
in which the mother survived. Stadfeldt4 has collected the 
cases reported in the three Scandinavian countries during the 
last twenty-five years. They were-for Sweden five, for Nor- 
way ten, for Denmark four. Of the nineteen women only one 
survived. Of the children six were dead before the opera- 
tion ; of the remaining thirteen eleven were born alive, and 
ten continued to live for some length of time. In New York 
and its suburbs there has only been one operation resulting in 
the survival of both mother and child, since the incorporatiou 
of " Nieuw Amsterdam " in 1621/ 
It has often been said that the experience gained in ovari- 
otomy would render the results of Caesarean section better, but 
the prediction is yet to be fulfilled. Spath makes the above 
statement in reporting four cases operated on by himself, 
1 American Journal of the Medical Sciences, April, 1878, vol. cl., pp. 
336-342; July, 1878, vol. cli., pp. 69-76. 
2 Joulin, "Trait6 complet d'Accouchement," Paris, 1867, p. 1092. 
3 Wiener med. Wochenschrift, January 26, 1878. 
4 Stadfeldt, "Det mekaniske Misforhold under Fodselen " (The Me- 
chanical Disproportion in Childbirth), Copenhagen, Denmark, 1872, p. 156. 
3 Thomas, " Comparison of the Results of Caesarean Section and La- 
paro-elytrotomy in New York," New Yokk Medical Journal, May, 1878. 60 
which all proved fatal. Ovariotomy has been steadily per- 
formed in the Scandinavian countries these last fifteen years, 
with very fair results, and we have just seen what has been 
obtained in Caesarean section in those parts. Spiegelberg, who 
has only operated after ovariotomy had become a common 
operation, has performed Caesarean section five times, and 
never succeeded.1 
Even if we take the crude facts of the six only operations 
of gastro-elytrotomy ever performed, and not even make any 
allowance for a perforated head, we have for the mothers 
three recoveries, three deaths, or 50 per cent.; for the chil- 
dren, four born alive, two dead, or 33 per cent. Even these 
entirely unjust figures compare favorably with those of Cae- 
sarean section ; and while the first are complete, the latter 
are utterly incomplete. Thus even statistics ought to engage 
obstetricians to give gastro-elytrotomy a fair trial. But the 
number is so small that the proportions may be altogether 
changed by a single new case. Let us therefore compare the 
operations themselves. 
The first step, the incision through the abdominal wall to 
the peritonaeum, is identical in both as to danger. The 
second step in gastro-elytrotomy, the separation of the perito- 
naeum, is, by all who have tried it on the woman at the end of 
pregnancy, declared to be easy. I have myself found it very 
easy on the cadavers of non-pregnant women. The third step, 
the incision of the vagina, may be made almost safe by using 
cauterization and tearing instead of cutting, and has even 
been performed in the latter way without causing haemorrhage. 
In the vagina there are comparatively small vessels which may 
bleed or may not, and which in the last six operations out of 
eight, which are all those in which the operation has been at 
all attempted, in fact have not bled. Should they do so, there 
would still be a fair chance that the haemorrhage would stop 
after delivery, as it did in Ritgen's case, or might be con- 
trolled by ligature, temporary compression, the tampon, the 
actual cautery, or styptics. In the body of the uterus, on the 
contrary, there is the certainty of cutting the large sinuses, be- 
sides the additional possibility of encountering the placenta. 
1 Spiegelberg, I. c., p. 853. 61 
'As to primary hemorrhage, then, the danger is much greater 
in Caesarean section than in gastro-elytrotomy. The fourth 
step, the extraction of the child, has proved easy in all cases 
excepting one, in which there was great deformity, and even 
then the difficulty was overcome. In Caesarean section this 
step is sometimes rendered very difficult and dangerous to the 
child, by the contraction of the womb around its neck. The 
fifth period comprises all the time from delivery to recovery or 
death. This is the most dangerous period in gastro-elytrotomy, 
but even here the dangers are less than in Caesarean section. 
The peritoneal cavity not being opened, the patient is less like- 
ly to die from shock. Incarceration of intestines, which may 
occur in Caesarean section, is excluded in its rival. Metritis is 
not more likely to occur in gastro-elytrotomy than in any other 
difficult labor, and is of course infinitely less likely to follow 
than in an operation by which a large wound is made through 
the wall of the uterus. Peritonitis may indeed occur, as it 
did in Baudelocque's case ; but, the peritoneal cavity remain- 
ing intact, it is much less likely to occur than in Caesarean 
section, in which the cavity is opened to a large extent, and 
the membrane wounded by two large incisions. A necessary 
sequel of gastro-elytrotomy is cellulitis, but this is in its na- 
ture not so fatal as peritonitis. Septicemia is a danger com- 
mon to both ; but while in Caesarean section, besides originat- 
ing in the wounds, it may be the consequence of blood being 
decomposed in the peritoneal cavity after the operation, in 
gastro-elytrotomy the latter danger does not exist, and the 
whole wound is accessible to thorough disinfection. Secondary 
hemorrhage may occur in gastro-elytrotomy, but would prob- 
ably be controllable by ligature, styptics, or tampon; in 
Caesarean section it occurs often on account of the relaxation 
of the uterus, and is fatal. 
Thus the a priori argument, as well as the results hitherto 
obtained, are in favor of the new operation. 
The same may be said in regard to the new modification 
of Caesarean section, by which the whole supra-vaginal uterus 
is extirpated, as done by Porro, Spath, C. Braun, and P. 
Muller.1 
1 Centralblatt fur Gyniikologie, 1878, No. 5, vol. ii., p. 98. 62 
Dr. Thomas has only proposed gastro-elytrotomy as a sub- 
stitute for Caesarean section, and declined to discuss it in 
relation to embryulcia in the New York Academy of Medi- 
cine. The operation is much too new to enable us to have 
even an approximate idea of the fatality inherent in it. Only 
when this is known will it be time to give exact rules as to 
when it is indicated. As yet we can only point out when it 
ought to be tried. Now, Dr. Parry,1 in a paper on " The 
Comparative Merits of Craniotomy and the Caesarean Section, 
in Pelves with a Conjugate Diameter of Two and a Half 
Inches or less," has shown that, in the hands of the most skill- 
ful operators, craniotomy performed under these circumstances 
gives no better results than Caesarean operation. He has tab- 
ulated TO cases, of which 26, or per cent., were fatal. Dr. 
Harris2 has grouped together those of his cases of Caesarean sec- 
tion that had occurred in cities and large towns, where they 
may be supposed to have had similar advantages as to skillful 
treatment. They number thirty-two, with a saving of twenty 
women and sixteen children, i. e., the mortality among the 
mothers was 37| per cent., and among the children 50 per 
cent. Thus the mortality among the women upon whom crani- 
otomy was performed was almost exactly the same as when 
Caesarean section was performed ; and while in the former all 
the children were sacrificed, in the latter fifty per cent, were 
saved. Under these circumstances it would therefore also be 
warrantable to try gastro-elytrotomy instead of craniotomy. 
Bad cases of embryotomy, especially those in which it 
would become necessary to take away large parts, such as the 
liver and the lungs, will be likely to prove much more dan- 
gerous to the mother than gastro-elytrotomy, apart from the 
sacrifice of the foetus. Thus the operation may be undertaken 
even when the child is dead, and to the mother's sole benefit. 
After having pointed out cases in which the operation ought 
to be tried, we may also call attention to circumstances in 
which it would be contraindicated. The operation cannot be 
repeated on the same side, as it would be impossible to sepa- 
rate the peritonaeum, and lift the vagina. When the head is 
1 American Journal of Obstetrics, 1872, vol. v., p. 644. 
3 American Journal of the Medical Sciences, April, 1878, p. 323. 63 
wedged into the pelvis, so that it cannot be pushed up, the in- 
cision of the vagina becomes impossible. If some solid tumor, 
for instance a fibroid, fills up the vagina, the same is the case. 
If the obstruction takes place in the uterus itself, as in cases of 
fibroid or cancer, the operation is of course contraindicated ; 
likewise in cases of atresia or coarctation of the vagina, be- 
cause this organ would not be distensible enough. 
Anatomy. 
It is not my intention to give a description of all the parts 
interfered with in gastro-elytrotomy, but it may be well to re- 
call certain points of the regional anatomy, and to add certain 
facts that will in vain be sought in treatises on anatomy. 
I think the simplest way will be to treat the subject exactly 
in the same order as the operation is performed. 
1. Abdominal Incision.-By beginning the incision one 
inch and three-quarters above and outside of the spine of the 
pubis,1 we avoid the round ligament and the epigastric artery. 
During the incision of the skin the external epigastric or 
superficial abdominal artery is severed. It is a small branch 
that starts from the femoral an inch or less below Poupart's 
ligament, and runs in front of it in the subcutaneous cellular 
tissue up to the umbilicus. 
The external dbligue muscle is aponeurotic throughout the 
incision except just above the anterior superior spine of the 
ilium, where the fleshy part may be reached. 
The fibres of the internal dbligue run almost horizontally 
in this locality; those of the transversalis descend a little. 
These two muscles are fleshy in the greater part of the wound, 
but aponeurotic toward its inner extremity. 
The rectus muscle is not interfered with. 
The transversalis fascia is rather thick and dense in this 
locality. It is separated from the underlying peritonaeum by 
a layer of areolar tissue in which often is found a deposit of 
1 This is the term by which English and French anatomists (Gray, 
Sappey) designate the small protuberance in which the ilio-pectineal line 
ends inward and forward, while German anatomists (Holstein, Krause) 
call it tuberculum pubis. Holstein uses spina pubis for designating the 
anterior border of the pubis. 64 
fat. In the pregnant state this tissue becomes much looser 
still than in the non-pregnant, so that it allows the fascia and 
the peritonaeum to be separated with great facility. • 
The epigastric artery starts from the anterior and internal 
circumference of the external iliac, one-quarter of an inch 
above Poupart's ligament, runs between the transversalis 
fascia and the peritonaeum downward, forward, and inward, 
about half an inch, to the ligament, turns here upward and 
inward, passes in front of the round ligament, inside of the 
internal abdominal ring, behind the inguinal caiial, outside of 
the internal inguinal fossa. Next it passes behind the pos- 
terior layer of the sheath of the rectus muscle, and enters 
finally the muscle itself. It crosses the round ligament at 
right angles. Generally it will not be reached by the in- 
cision ; but since Dr. Thomas cut off a protruding piece of 
the ligament in his second case, he came in close proximity 
to the artery, and Dr. Skene once laid it bare without in- 
juring it. 
The circv/mflex iliac artery starts from the external iliac, 
opposite or a little below the epigastric, runs between the 
peritonaeum and Poupart's ligament to the anterior superior 
spine of the ilium, and continues its course inside the crest. 
Thus this artery does not come under the knife; but in sepa- 
rating the peritonaeum it will be between the back of the fin- 
gers and the ligament. It is a vessel of small calibre, that 
has not even been noticed by the operators. 
2. Lifting of the Peritonaeum.-Beyond Poupart's liga- 
ment the transversalis fascia is continued as the iliac fascia. 
It adheres in front to the peritonaeum by exceedingly loose 
areolar tissue. It covers the internal iliac and psoas muscles, 
between which the crural nerve is situated. At the inside of 
the psoas muscle, between the peritonaeum and the fascia, 
lies the external iliac artery, extending from the upper end 
of the sacro-iliac articulation to Poupart's ligament. It has 
the corresponding vein on its inner side throughout on the 
left side of the body, and during the greatest part of its 
course on the right side, but in the uppermost part on the 
right side the vein lies outside the artery and crosses be- 
hind it. 65 
The internal iliac or hypogastric artery runs, from the 
point where it separates from the external, forward and down- 
ward, and then it dips perpendicularly into the excavation of 
the pelvis, in front of the sacro-iliac articulation. It is only 
from three-quarters of an inch to one inch and a half (2-4 
centimetres) long (Sappey *), accordingly not favorable for 
ligature. The corresponding vein runs behind it and inside 
of it. 
3. Vaginal Incision.-First of all it must be remembered 
that the operation is only performed toward the end of preg- 
nancy and when the pelvis is narrow. Consequently the 
whole uterus with the foetus is above the pel/vic brim. The 
vagina becomes so enlarged during pregnancy that, although 
it is drawn up to the brim by the ascending uterus, it forms 
large folds in order to be large enough to give passage to the 
child. Its wall becomes thick, but its tissue very loose, so 
that, although highly dilatable in the unimpregnated state 
even, it becomes still more so during pregnancy. The same 
is the case with the areolar tissue that binds it to the sur- 
rounding parts. Thus the whole organ may be lifted more 
or less considerably out of the pelvis and the operation per- 
formed above the pelvic brim. Even in the unimpregnated 
state of women who have borne children, it can easily be 
lifted a couple of inches up from the position it holds by 
gravity. The vagina has a thin external layer of cellulo- 
librous tissue interspersed with elastic fibres. The bulk of it 
is formed of muscular fibres spreading like a fan from the 
region of the sacro-iliac articulation above and the pubis be- 
low, as shown by Rouget.' When a small incision is made 
parallel to the ureter and torn, it keeps the same direction. 
Innermost is the mucous membrane. 
The vagina is rich in vessels. On either side comes a 
branch called the vaginal artery, directly from the hypogas- 
tric. Besides, the trunk of the uterine artery runs in the 
upper fourth of its borders up toward the uterus, sending 
down a branch along the border to anastomose with the first. 
1 Sappey, "Trait6 d'Anatomie descriptive," vol. i., part 2, p. 472. 
2 Courty, "Maladies de 1'Uterus," Paris, 1866, p. 59. 
5 66 
Other arterial branches are derived from the inferior vesical, 
the internal pudic, and the hoemorrhoidal arteries. 
The veins accompany the arteries, and form a pretty 
close venous network all over the walls, but are especially 
numerous at both extremities of the canal. On either side of 
the upper end of the vagina is found the utero-vaginal plexus, 
which receives the blood from the vaginal plexus below and 
pours it into the uterine vein or veins above. 
This disposition of the vessels, apart from other considera- 
tions, makes it desirable to make the vaginal incision as low 
down as possible. 
The relations to other organs are of the greatest impor- 
tance. Behind the vagina is Douglas's pouch. This part of 
the peritoneal cavity varies somewhat in depth ; generally it de- 
scends seven-eighths to one inch (twelve to fifteen millimetres) 
on the vagina; sometimes it scarcely touches it, but in other 
individuals it is in contact with it to the extent of one 
inch and a quarter (three centimetres) below the uterine 
junction.1 
Below the cul-de-sac the vagina is in contact with the 
rectum, separated from it by a fascia descending from the pel- 
vic fascia and loose cellular tissue. 
The antero-superior surface of the vagina is, in its upper 
part, bound by loose connective tissue to the Madder on a 
surface that has the shape of a heart. In the lower or an- 
terior part the boundary line of this surface runs parallel to 
and a little outside of the trigonum vesicate. In the upper part 
it follows the outline of the vagina, from which it passes over 
to the cervix. The distance from the internal opening of the 
urethra to the neck of the womb is one inch and a quarter 
(3.2 centimetres). The bladder extends five-eighths of an 
inch (1.5 centimetre) up on the cervix (see Fig. 2). It is 
very liable to be reached by the vaginal rent, if the latter is 
made too high up or too horizontal. The lower part of the 
antero-superior wall carries in the middle line the urethra. 
In the uppermost part, a little outside of and behind the 
bladder, lies the ureter. 
1 Sappey, I. e., vol. iii., p. 221. 67 
Fig. 2.-Natural Size. 
a, Ureters; b, utems ; c, Fallopian tube; d, ovary ; e, round ligament; F, broad ligament; 
g, connective tissue; A, bladder (antero-superior part taken away to show attach- 
ments) ; i. vesical opening of ureter ; j, inneraperture of urethra; A, urethra ; I, vagina ; 
m, incision and rent in gastro-elytrotomy. 
The course of the ureters is not described with the accuracy 
needed for the science and practice of gastro-elytrotomy and 
other operations on the female pelvic organs in any anatomy 68 
I know of. I have therefore examined it myself on the cada- 
ver, and am thus enabled to correct or supplement what I 
have found in the works of Luschka,1 Sappey," Savage,3 etc. 
The ureter does not lie in the broad ligaments. It does not 
keep the same direction on reaching the wall of the bladder, 
and it does not lie close up to the cervix. 
The ureter is the continuation of the renal pelvis. It lies 
behind or under the peritonaeum, imbedded in very loose con- 
nective tissue, and is much longer than the direct line be- 
tween its two ends. The left ureter begins somewhat higher 
up than the right. The distance from the starting-point of 
the right ureter from the renal pelvis horizontally to the left 
ureter I have found to be two inches and a half (6.4 centi- 
metres). From this point they go, excepting slight windings, 
parallel with one another down to the spot where they cross 
the iliac vessels, so that the distance between them at this lat- 
ter point is likewise two and a half inches (6.4 centimetres). 
In this part of their passage they lie in front of the psoas 
muscle. The left ureter crosses the iliac vessels somewhat 
higher up than the right, the left lying in front of the lowest 
part of the common iliac artery, the right in front of the 
uppermost part of the external iliac artery. The right passes 
also in front of the external iliac vein, which here lies outside 
the artery. Consequently the left is also slightly nearer to the 
median line of the vertebral column. From this point they 
diverge, running downward, backward, and a little outward 
on the wall of the pelvis to a point near the spina ischii, at 
which point they are farthest separated from one another, 
namely, about three inches and a half (8.5 centimetres). The 
ureter lies outside the hypogastric artery. They run behind 
the broad ligaments down to the indicated point near the 
spina ischii, and bend then downward, forward, and consider- 
ably inward, so as to converge toward the bladder. They 
1 Luschka, " Die Anatomie des menschlichen Beckens," Tubingen, 
1864, p. 384. 
1 Sappey, " Trait 6 d'Anatomie," vol. iii., p. 494. 
* Savage, " The Surgery, Surgical Pathology, and Surgical Anatomy 
of the Female Pelvic Organs," 2d ed., London, 1870. Pls. iv.-vii. and 
Pl. xii. (Pl. viii., Fig. 1, is correct.) 69 
pass beneath the base of the broad ligaments, lying in the 
abundant cellular tissue found in this locality. They cross 
the cervix at some distance from behind, at an acute angle, so 
as to come in front of it and below it. They lie outside and 
above the anterior part of the side-wall of the vagina, if w'e 
will suppose such a thing to exist, on a spot as large as the 
tip of the linger. On reaching the wall of the bladder they 
turn rather sharply inward and go less downward, until they 
open with a small slit in the interior of the bladder, at the 
outer angle of the trigonum vesicate. From behind they are 
seen to be united by a kind of ridge forming the base of the 
trigonum (Fig. 3). 
I found the following distances : From the ureter, horizon- 
tally, to the horn of the uterus (the starting-point of the 
ovarian ligament), right, three-quarters of an inch (1.9 centi- 
metre), left, an inch and one-eighth (2.9 centimetres); from 
the ureter, horizontally, to the junction of the body and the 
neck of the womb, right, three-quarters of an inch (1.9 centi- 
metre), left, five-eighths of an inch (1.5 centimetre); from 
the ureter to the nearest point of the vaginal portion on either 
side, half an inch (1.3 centimetre); from the ureter where it 
enters the wall of the bladder to the utero-vaginal junction, 
right, three-quarters of an i nch (1.9 centimetre), left, five-eighths 
of an inch (1.5 centimetre); this point is on a level with the 
os uteri; from the opening into the cavity of the bladder to 
the vaginal portion, right, half an inch (1.3 centimetre), left, 
five-eighths of an inch (1.5 centimetre); between both ureters, 
where they reach the wall of the bladder, two inches (5 centi- 
metres); between the two openings of the ureters into the 
cavity, one inch (2.5 centimetres); from the point where the 
ureter passes under the broad ligament to the point where it 
reaches the wall of the bladder, one inch and one-eighth (2.9 
centimetres); the course of the ureter in the wall of the blad- 
der, nine-sixteenths of an inch (1.4 centimetre); from the 
opening of the ureter into the cavity of the bladder to the 
centre of the anterior lip of the os, right, three-quarters 
of an inch (1.9 centimetre), left, one inch (2.5 centimetres); 
these openings lie below the level and considerably in front 
of the vaginal portion ; from the internal opening of the 70 
urethra to the os uteri, one inch and a quarter (3.2 centime- 
tres'). 
These measures are taken from the body of a woman 
about forty years old, who had borne children, and died from 
malarial fever and heart-disease. The abdominal organs were 
healthy. Most of the measures have been compared with 
those on two other bodies, and the differences are of no im- 
portance for our operation. They are represented in Fig. 2. 
If some mathematical spirit should find slight contradictions 
in the measures as stated above when the distance from one 
point to different others is indicated, or between the text and 
the diagram, it must be remembered that the parts measured 
are soft, elastic, and movable, so that they easily give way a 
little even when great care is taken to steady them. As to 
the diagrams, I do not pretend to be a draughtsman, but I think 
that even an imperfect sketch may contribute to the under- 
standing of the operation. All the measures are taken in situ. 
This is absolutely necessary, for the organs are so lax that, 
when examined after removal from the body, all the distances 
appear much larger than in the body; but this shows, on the 
other hand, that in operating we may obtain much more room 
than is shown on the diagrams. Thus I found on a fresh speci- 
men I had removed from the body the following distances: 
From the ureter to the horn of the uterus, 6 centimetres (2f 
inches); from the ureter to the junction of the body and the 
neck of the womb, 4.5 centimetres (If inch); from the ureter to 
the vaginal portion, 2.5 centimetres (1 inch); from the point 
where the ureter enters the wall of the bladder to the vaginal 
portion, 2.0 centimetres (f inch); from the opening into the 
vesica] cavity to the vaginal portion, 4.0 centimetres (1| inch) ; 
between the ureters on a level with the os uteri, 7.0 centime- 
tres (2f inches); on reaching the bladder, 6.0 centimetres (2f 
inches); on opening into the cavity, 3.8 centimetres (1| inch); 
the length of the ureter in contact with the vagina before 
entering the bladder, 2 centimetres (f inch); the length of its 
course in the vesical wall, right, 3.0 centimetres (1| inch); 
left, 2.5 centimetres (1 inch). 
Fig. 2 is somewhat theoretically constructed, that is to 
say, I have made the diagram with the measures actually 71 
Fig. 3.-Natural Size. 
Curve formed by the ureters and the base of trigonum vesicate; a, ureter; b, common 
iliac artery ; c, external iliac artery ; d, internal iliac artery ; e, uterus (appendages cut 
off); f, bladder (dissected from uterus and roof of vagina, a little beyond the base of 
the trigonum)-, g, site of vesical aperture of ureter on the inside (not visible); A, vesi- 
cal aperture of urethra; », base of trigonum; J, incision in bladder ; A, vagina. 72 
taken on the body, putting them down on the paper without 
any consideration of foreshortening. Fig. 3 has been drawn 
exactly as I saw the organ in another subject, fifty-seven 
years of age, with an atrophic uterus. I laid the ureters bare 
from the place where they cross the iliac vessels to the place 
where they pass under the broad ligaments. Next I dissected 
the bladder from the uterine neck and upper part of the 
vagina, and drew it forward in order to show the curve 
formed by the ureters and the base of the trigonum vesicate. 
Then I took away the broad ligaments and cut the bladder 
perpendicularly in the median line, in order to measure the 
distances between the vesical apertures of the ureters and the 
urethra. Finally, I pushed a needle through the vaginal wall 
at the base of the trigonum, in order to ascertain its distance 
from the vaginal portion. After removal of the uterus and the 
vagina, the needle was found to have penetrated just below the 
os. The sketch is in natural size. The measures found in this 
case were: Between the ureters where they cross the iliac ves- 
sels, 6.7 centimetres (2f inches); where they bend inward at 
the bottom of the pelvis, 8.5 centimetres (3-f inches); from the 
vesical aperture of the urethra to the point where the ureters 
bend inward, 5.0 centimetres (2 inches) on either side; from 
the point where the ureters bend inward to the point where 
they cross the iliac vessels, right, 5.5 centimetres (2f inches), 
left, 6.5 centimetres (24 inches); the trigonum vesicate, right 
side, 3.0 centimetres (1-j- inch), left, 2.5 centimetres (1 inch), 
base, 3.7 centimetres (1| inch); from urethra to base, 2.5 
centimetres (1 inch); in all four bodies I have examined I 
have found the same asymmetry of the trigonum, the left 
ureter opening nearer to the urethra than the right; but that 
the left ureter in this case is more distant from the cervix 
than the right seems to be an exception ; the length of the 
uterus, 5.7 centimetres (2| inches); the width at the fundus, 
4.9 centimetres (2 inches); at the os internum, 2.7 centimetres 
inch); midway between os internum and externum, 2.9 
centimetres (1-j inch); from the bladder to the rectum, recti- 
linear measure, left, 6.0 centimetres (2f inches), right, 8.5 cen- 
timetres (3f inches); along the wall of the pelvis, left, 9.5 
centimetres (3f inches), right, 10 centimetres (4 inches); from 73 
the vesical aperture of the urethra to the rectum following the 
brim of the pelvis, left, 15.5 centimetres (6 inches), right, 21.0 
centimetres (8£ inches). 
The ureter lying behind and below, not in, the broad liga- 
ments, it retains its place when the uterus rises during preg- 
nancy. 
Since the ureter only touches the vagina on a small spot 
in the upper and anterior corner, if I am allowed to use such 
an expression, and at some distance from the uterus, we jean 
understand how it is possible to extirpate this organ without 
injuring the ureter.1 
The description will also serve to explain the occurrence 
of fistulous communications between the ureter and the cervix, 
or the vagina. 
In order to avoid the ureter and the bladder, the incision 
of the vagina should be made nearly an inch and a half (3.8 
centimetres) below the uterus, and in a direction parallel to 
the ureter and the boundary line between the bladder and 
the vagina (Fig. 2, m). If this incision appears so small that it 
would be impossible to extract a child through it, I will only 
state that on the vagina of an unimpregnated woman I have 
been able to make it two inches long. When we now bear 
in mind the enormously enlarged proportions we find when 
we explore a woman at the end of the first stage of labor, I 
have no doubt that it may be made twice that length. We 
1 After I had finished my studies concerning the anatomy of gastro- 
elytrotomy, I became acquainted with Freund's description of his new 
method of extirpating the uterus ( Volkmann's klinische Vortrdge, No. 133, 
Leipsic, 1878). In this he refers to a description of the female ureters 
given by himself in the Berliner klinische Wochenschrift, 1869, No. 47. 
This excellent gynecologist has felt the same dissatisfaction with the 
description given by anatomists which has prompted me to investigate the 
subject. I am glad to see that in most points we agree as to the course 
of the ureters. Thus my description may serve to corroborate his, and 
vice versa. When he gives the distance from the ureter to the os uteri as 
4 centimetres or more on the right side, and 2.5-3.4 centimetres on the 
left, and that between the ureters on a level with the external orifice of 
the womb as 7.9-9.8 centimetres, I feel inclined to think that he has 
measured on specimens removed from the body, for, as stated above, the 
distances appear much larger when these lax 'parts are taken out and 
spread on the table. 74 
feel the vagina as wide as the pelvic brim, and the above 
figures show, then, that there is ample room on either side 
between the urethra and the rectum. The tissues incised 
being extremely elastic, the child may be extracted through 
such an opening. 
Operation. 
The bowels having been emptied by an aperient and a 
copious enema, and the os having been fully dilated by Barnes's 
water-bags, if it is not so already, the patient is placed on 
her back, on a long, narrow table covered with a mattress 
or quilts, rubber or oilcloth, and a sheet. The pelvis is 
well elevated on a hard cushion, the head and shoulders 
slightly raised by means of pillows, the' legs stretched out. 
If, from some cause, it has been impossible to dilate the os 
fully by Barnes's dilators, it is now done by the fingers, or if 
that is impossible too, it is dilated later through the abdomi- 
nal wound. The patient is anaesthetized. Since disinfection 
cannot be carried out strictly, and since its administration 
would give some additional trouble, it is scarcely necessary to 
operate under disinfectant spray. 
The operator takes his place at the right side of the pa- 
tient. Besides one who administers the anaesthetic, four assist- 
ants are needed; one on either side of the operator, and two 
in front of him. The first assistant, standing at the left of 
the patient's chest, lays his flat hands under the umbilicus and 
draws the uterus upward and toward the left, thereby putting 
the skin in the right iliac region on the stretch. Counter- 
extension may be made by the assistant placed at the right of 
the operator. A slightly curved incision is made through the 
skin from a point one and three-quarter inches (4.5 centime- 
tres) above and outside the spine of the pubis, parallel to, 
and an inch above, Poupart's ligament, to a point an inch above 
the anterior superior spine of the ilium. This incision may 
also be made in the opposite direction from without inward. 
By a few touches with the edge of the knife the external 
oblique muscle is laid bare, and spouting branches of the 
superficial epigastric artery secured by holding-forceps. The 
abdominal muscles are cut to the same extent, layer by layer, 75 
the external oblique, the internal oblique, and the transversalis, 
the first of which is aponeurotic. The transversalis fascia is 
very carefully hooked up with a fine tenaculum, and the knife 
carried horizontally, so as to make a small opening in it, avoid- 
ing the peritonaeum that lies beneath it, separated from it by 
loose areolar tissue, and sometimes fat. A director is intro- 
duced through the opening and pushed between the fascia and 
the peritonaeum toward the inner and the outer angle of the 
wound, and the fascia is cut. The best instrument for this 
purpose is Key's hernia director, the one which Spencer Wells 
uses when incising the peritonaeum in ovariotomy. It is firm, 
a quarter of an inch (6 millimetres) broad, slightly curved on 
the flat, well-rounded at the end, and has on its concave side 
a groove that stops a quarter of an inch (6 millimetres) from 
the point of the instrument. Next, the operator places the 
pulp of his fingers on the peritonaeum, separating it from the 
transversalis and iliac fasciae, until he reaches the vaginal wall. 
The second assistant, placed at the left of the operator, holds 
the peritonaeum and intestines, applying a fine, warm napkin 
under his hands, in order to be sure not to let them slip. The 
first assistant draws the uterus vigorously upward and toward 
the left, in order to expose the deeper part of the vaginal wall 
on the right side. A female silver catheter is introduced into 
the bladder by the third assistant, placed at the left hip of the 
patient and held in the knowm direction of the boundary line 
between the bladder and the vagina, below the ureter on the 
side on which the operation is being performed. A blunt 
wooden instrument, something like the obturator of a cylin- 
drical speculum, only longer, is introduced into the vagina 
and applied above the linea ileo-pectinea, raising the vaginal 
wrall as much as possible into the abdominal wound. An in- 
cision is made parallel to the ileo-pectineal line and the cathe- 
ter felt in the bladder, as far below the uterus as possible, in 
order to avoid the ureter and Douglas's pouch, and incise where 
there are fewest vessels, cutting down on the obturator with 
Paquelin's thermocautery, the galvano-caustic knife, or simply 
cautery-irons (table-knives), only heated to red heat. The 
surrounding parts are protected by the application of wet 
compresses around the place to be cauterized. The incision 76 
made by the cautery is extended forward toward the sym- 
physis and backward toward the promontory by placing the 
pulp of both index-fingers perpendicularly on the edges, and 
applying the force in different places in the direction of the 
os uteri and the ileo-pectineal line, so as to tear the vaginal 
wall as far forward as is deemed safe in regard to the bladder 
and the urethra, the locality of which organs is ascertained 
by feeling the catheter held by the assistant, and as far back- 
ward as the wound in the abdomen w'ill allow. Now the 
catheter is withdrawn, the membranes ruptured if the liquor 
amnii has not escaped before, the uterus tilted as much as 
possible to the opposite side, and the os drawn with the fore- 
finger into the iliac fossa. 
The operator draws the child through the double wound 
either by simple extraction, or after turning, or by applying 
the forceps, according to the presentation and other particular 
circumstances. The placenta is expelled by compressing the 
uterus, and withdrawn through the wound. 
If bleeding occurs, the operator tries to check it by apply- 
ing ligatures through the abdominal wound, holding-forceps, 
styptics, or cauteries, using a large wooden tubular speculum ; 
or a Sims speculum may perhaps give easier access to the 
bleeding vessel than anything else. If it be impossible to 
check the haemorrhage, the vaginal wound must be firmly 
tamponed from below through the vulva and from the ab- 
dominal wound with cotton pledgets soaked in cold water and 
squeezed, and held in situ by broad straps of adhesive plaster 
round the abdomen, as after ovariotomy. Except in the last 
eventuality, the bladder is distended by injecting lukewarm 
milk in order to ascertain if this organ has been injured. If 
so, the fistula is immediately sewed with catgut, which need 
not be removed. The wound is cleaned by injecting a stream 
of lukewarm carbolized water (2 per cent.), or a solution of 
thymol (2 per thousand), from the vagina and from the ab- 
dominal wound. Next, the edges of the abdominal wound 
are brought together by interrupted sutures, and the lower 
part of the abdomen covered with borated or salicylated cot- 
ton, and surrounded by broad straps of adhesive plaster fas- 
tened to the hips, as in ovariotomy. A pledget of cotton 77 
soaked in carbolized oil (1:10) is applied in the entrance of 
the vagina. 
After-Treatment.-The vagina and iliac fossa are syringed 
every two or three hours, and the plug in the vagina renewed. 
The nozzle of the syringe may be carried through the vaginal 
wound, but the injection ought to be made so carefully as 
not to interfere with the abdominal wound, in -which union 
by the first intention ought to be attempted. Bodily and 
mental rest is to be secured, light nourishment, such as milk, 
gruel, and beef-tea, given according to appetite, pain sub- 
dued by opium, which also will keep the bowels quiet for 
some days. As soon as the temperature rises, or tenderness 
on pressure appears, a couple of large ice-bags are suspended 
above the abdomen, so as to touch it without pressing too 
heavily upon it. Ten-grain doses of quinine, cool baths, or as- 
persion with cold water on Kibbee's fever cot,1 may be need- 
ed. Meteorism is to be combated by tincture of nux vomica 
or capsicum (five drops every hour), by injections of oil of 
turpentine, sulphate of quinine (five grains every four hours, 
Spencer Wells2), or mint water (two ounces of the herb to a 
quart of water, Peaslee 3), by large doses of subnitrate of 
bismuth (gr. xxx.-xl., Koeberle), by the rectal tube, by punc- 
ture of the intestine, especially the transverse colon, or, as 
recently advised by Dr. Jenks, of Detroit, Michigan, by 
standing the patient on her head,4 or by faradization (Wells 5). 
The time required for the performance of the operation 
will of course vary much according to circumstances, and 
will especially depend upon the occurrence or non-occurrence 
of haemorrhage. Bitgen used a little less than an hour, includ- 
ing half an hour spent in waiting for labor pains, and the 
time occupied in performing Caesarean section. Baudelocque's 
1 Thomas, " The Most Effectual Method for controlling the High Tem- 
perature after Ovariotomy," New York Medical Journal, August, 1878. 
' Spencer Wells, " Diseases of the Ovaries," London, 1872, p. 388. 
' Peaslee, " Ovarian Tumors," New York, 1872, p. 503. 
4 E. W. Jenks, " On the Postural Treatment of Tympanitis Intesti- 
nalis following Ovariotomy," American Journal of Obstetrics, July, 1878, 
vol. xi., p. 515. 
• Wells, I. c. 78 
operation lasted one hour.1 Dr. Thomas performed his last 
operation in thirty-five minutes. Dr. Skene used only re- 
spectively ten and fifteen minutes in his first two cases; the 
time employed in the last is not stated. 
As to the time required for recovery, it will to a great 
extent depend on the healing of the abdominal wound by 
first or by second intention. In Dr. Skene's second case both 
wounds were closed on the fourteenth day. In his third there 
remained at that time only a vesical fistula. 
Conclusions. 
1. Gastro-elytrotomy ought, when possible (see contrain- 
dications above), to be performed instead of Caesarean section 
in all cases, and instead of operations by which the foetus is 
broken up, when these would be particularly difficult, espe- 
cially when the smallest diameter of the pelvis measures two 
inches and a half or less. 
2. It does not require exceptional skill or rare instru- 
ments. It is, indeed, less difficult than ovariotomy and her- 
niotomy. 
3. Five assistants are desirable, and four indispensable, 
in order to carry out the above plan? 
1 " Elytrotomie," p. 24. 
4 Dr. Skene, in hia second case, had only three assistants, but then no 
catheter was used.