A SUCCESSFUL CASE 
OF 
LAPARO-ELYTROTOMY, 
WITH REMARKS ON THE 
Indications, Dangers, a\d Results of the Operation. 
BY 
WALTER R. GILLETTE. M.D„ 
VISITING PHYSICIAN TO N. Y. LYING-IN ASYLUM, OBSTETRIC SURGEON TO 
MATERNITY HOSPITAL, VISITING PHYSICIAN TO CHARITY, 
AND ST. FRANCIS HOSPITALS. 
Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Vot. XIII., No. I., January, 1880. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1880. A SUCCESSFUL CASE 
OF 
LAPARO-ELYTROTOMY, 
WITH REMARKS ON THE 
Indications, Dangers, a\d Results of the Operation. 
BY |/ 
WALTER R. GILLETTE. M.D., 
VISITING PHYSICIAN TO N. Y. LYING-IN ASYLUM, OBSTETRIC SURGEON TO 
MATERNITY HOSPITAL, VISITING PHYSICIAN TO „ 
AND ST. FRANCIS HOSPITALS. 
Reprinted from the American Journal of Obstetrics and Diseases 
of Women and Children, Vol. XIII., No. I., January, 1880. 
NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES STREET. 
1880. A SUCCESSFUL CASE OF LAPARO-ELYTROTOMY, 
WITH REMARKS ON THE 
INDICATIONS, DANGERS, AND RESULTS OF THE OPERATION. 
BY 
WALTER R. GILLETTE, M.D., 
Visiting Physician to N. Y. Lying-In Asylum, Obstetric Surgeon to Maternity Hospital, 
Visiting Physician to Charity, and St. Francis Hospitals. 
I was called November 8tli, 12 p.m., to the N. Y. Lying-In 
Asylum, to see Mary Ii., get. 23; married ; native of Scotland, 
who was in labor with her first child. The House-Physician, Dr. 
Coughlin, informed me of the general characteristics of the woman, 
and that he thought there was a narrowing of the superior strait 
of the pelvis to the extent of two inches. 
Looking at her lying upon the obstetric couch, she appeared to 
be a woman in vigorous health, plump and dwarfed. She gave 
the history of having always been healthy, and seemed to have no 
knowledge of her rachitic condition. She merely thought she 
was small in stature. She was four feet four inches high by mea- 
surement. Her femora were incurvated and shortened ; her tibiae 
long and straight, and set in the middle of the foot, as it were, the 
heel projecting making it look like a bird’s foot. Lying upon her 
back, she had somewhat the appearance of a turtle in the supine 
position ; the pubic region being broad and flattened, and the 
perineal region broad. She said she had had more or less pains 
for a week, but that the waters had discharged eighteen hours 
previously, since which time she had been in recognized labor. 
Upon external examination, the uterine tumor was noticed as large, 
partially anteverted, and freely movable above the superior strait. 
There was no fetal heart-sound to be heard; auscultation reveal- 
ing only the general crackling and hissing of air in the uterine 
cavity, such as may be heard in those cases of so-called emphyse- 
matous uterus, and dependent upon the decomposition of a dead 
fetus from which the waters have been drained off for a long time. 
Upon digital examination, the inferior strait was discovered 
capacious and expanded, so that, having anesthetized the patient, 
I was permitted to introduce my whole hand into the pelvic cavity 
with ease. This was shallow, and led directly to the superior 
strait, which was reduced in its whole antero-posterior diameter 
to a slit one and a half inches in diameter. 4 
Gillette : A Case of Laparo-Elytrotomy. 
Through this the lips of the os uteri were pouting and beyond 
the strait the os seemed dilated about the size of a silver dollar. 
In the os was a caput succedaneum, through which could be felt 
a presenting part, which I recognized as the cephalic extremity, 
but could not determine whether it was the vertex or face. 
Recognizing the necessity for immediate delivery by laparo- 
elytrotomy or Cesarean section, I sent for my colleague, Dr. H. 
D. Nicoll, and Dr. S. B. W. McLeod, of the consulting staff. 
Upon their arrival, they examined the case, agreed in the diag- 
nosis, and, with me, considered it a proper one for the operation 
of laparo-elytrotomy. The patient was anesthetized, and by the 
illuminating aid of a dim gas-burner and a candle, I commenced 
the operation, at 3.15 A.M., by the usual incision, namely, from 
the anterior superior spinous process of the ilium of the right side 
to the symphysis pubis. There was no difficulty in cutting down 
to the desired point, but it seemed to me I embarrassed and com- 
plicated the operation by not calculating properly for the sunken 
and retrogressed pubic bone, and thereby making my incision too 
low down. Two vessels were ligated and one twisted, and the 
hemorrhage was not serious. Passing the sound into the vagina, 
I pushed its point up to the opening in the flank, and, cutting 
down upon it, made the communication with the vagina complete. 
Enlarging the opening thus made by laceration, I introduced my 
fingers, and recognized through the os the face presenting in the 
right mento-iliac position. I dilated the os manually as much as 
I could, but it was extremely rigid and hard, and could not be 
pulled open sufficiently even with the blunt hook, whereupon I 
incised it slightly by means of a curved scissors. 
Dr. McLeod now drew the uterus over to the left, so as to bring 
the long axis in a proper direction for delivery through the open- 
ing, and I attempted to apply the forceps. I introduced and 
applied the left-hand blade without difficulty, but was utterly 
unable to apply the right-hand blade. This was, no doubt, due to 
the position of the fetus, which was jammed down by the spastic 
rigidity of the anteverted uterus against the iliac and pubic bones, 
with the head and face flexed upon and against the right shoulder. 
I could not depress the handle sufficiently to make the curve of 
the blade embrace the head. Dr. Nicoll also made the effort un- 
successfully. I then determined to turn and deliver by the feet. 
With great difficulty I succeeded in getting hold of the right 
knee—the only one I could reach—and pulling it down part-way, 
applied the blunt hook, and delivered the leg. Here I stopped; 
for, with all the force that I could apply that was compatible with 
the integrity of continuity of the leg, and with all the assistance 
which Dr. hTicoll and Dr. McLeod could give in external mani- 
pulation, and by endeavoring to push up and dislodge the head 
toward the left, I was unable to complete rotation. I then per- 
formed craniotomy, and evacuated the brain, hoping in this way 
to reduce the size of the head, so that it could be pushed up out 
of the way. This was of no avail, for the contraction of the ute- 
rus was so great that, upon traction, the flaccid, yielding body of Gillette: A Case of Laparo-Elytrotomy. 
5 
the (lend fetus only doubled the more, and jammed more tightly, 
notwithstanding our most ingenious efforts. I tried to get the 
left foot, knowing that if I once could make traction on it, and 
get the pulley action on the left shoulder, I could most undoubt- 
edly cause the child to rotate, and break up the wedge. This I 
was utterly unable to do, for I could not reach it. 
I then did what I might better have done at first: put on the ce- 
palotribe, crushed the base of the cranium, pushed the presenting 
leg up, and making traction after reapplying the instrument, and 
with the aid of a cranioclast holding upon the scalp, delivered 
without difficulty. The placenta immediately followed, together 
with the fetid grumous discharges that were pent up behind the 
decomposing fetus. This I regretted; I should have much 
preferred delivering it through the vagina, and thus avoided the 
danger of infecting the wound with septic matter, but it gave me 
no option. The uterus contracted at once, and there was no 
hemorrhage of account. The wound in the flank was stitched 
together with eight sutures (silver), dressed with adhesive plaster 
and cotton batting over all, and the patient put to bed, with hot 
bottles at her feet, and eight drops of Magendie administered 
hypodermically, along with ergot. She did comfortably well all 
this day (Monday, Nov. 9th), suffering in no way. The tempera- 
ture did not go above 101 F. The pulse, however, was rapid. 
Ten grains of quinine every six hours were ordered. The catheter 
was passed into the bladder, and urine passed through it. Through- 
out this case the catheter has been passed at proper intervals, and 
with invariable success. The bladder was not opened, as was the 
case in four out of the seven previously reported operations of 
laparo-elytrotomy. Nothing of special note occurred until Tues- 
day, Nov. 10th, 4 a.m., when she woke from her sleep complain- 
ing of colicky pains in the abdomen. Morphine was administered. 
There was no elevation of temperature above 101° F. At 10 a.m., 
she was tympanitic, although not complaining of pain. Quinine was 
administered in doses before mentioned, and hot flax-seed poultices 
applied over the abdomen. The wound looked well, and was ex- 
uding but little dark blood from the second external suture. 
At 3 p.m., I introduced a rectal tube and considerable wind 
passed off with great relief. Temperature at this time 100° 
F. I could not pass the tube above the superior strait, for 
the reason that the promontory of the sacrum jutted so far for- 
ward, and the whole strait projected, so that I could not flex the 
tube to an angle sufficient to let it pass. Morphine was given 
her again at this hour. At 8.30 p.m., I called and found her in 
opium narcosis. The respirations were down to seven per 
minute, very irregular and stertorous. She was aroused to con- 
sciousness with difficulty. The doctor said he had given her 
another hypodermic injection of morphine at 6 p.m. I remained 
with her two hours, rousing her and administering coffee and 
stimulants, until the respirations rose to twelve per minute, 
when I went home, leaving instructions not to let her respirations 
fall below this number. Wednesday, Nov. 12th, 10 a.m., she was 6 
Gillette : A Case of La/paro-Elytrotomy. 
progressing favorably, simply drowsy and lethargic from last 
night’s narcosis. Temperature 100°. Wound looked well. In the 
evening, everything was favorable, and in response to an enema of 
soapsuds, she discharged a great quantity of wind and was re- 
lieved. Thursday, 13th, temp. 99°. Friday, 14th, lactation com- 
menced; temperature 102°, no pain or tympanites. In the evening, 
the temperature was down to 100°. At midnight, she had a chill, 
and upon my visit Saturday, 15th, at 11:45, the temperature was 
99£°, though the wound looked sloughy and was exuding fetid 
broken-down blood and pus. I immediately removed all the 
sutures, giving vent to a quantity of fetid liquid, and applied a 
poultice of flaxseed meal, carbolic acid, and brewers’ yeast. 
Bowels moved twice this evening naturally, and the patient was in 
a good general condition; quinine, whiskey, and milk freely given. 
Saturday, 16th, about the same temperature continued at 100° 
until 10:30 p.m., when it went up to 103°. 
At 9 a.m. 17th, it was down to 99°, and the patient was perfectly 
comfortable. It is needless to report the daily progress of this 
patient toward recovery from this date, as the temperature has 
hardly risen above 100°, and there has been no disturbance to occa- 
sion the least alarm or worry. The wound, Nov. 21st, has cleaned, 
and is in the process of repair by granulation. There was no 
peritonitis. The tympanites was simply due to the empirical dose 
of morphine, which we are so apt to administer after obstetric 
operations, and which, by paralyzing the muscular coat of the 
intestines, must result in the non-discharge of gases, and their 
consequent accumulation with distention of a tympanitic quality. 
The variations of her temperature were due to emotional causes, 
as she was exceedingly cross and disobedient. There was hardly 
an untoward symptom other than the sloughing condition which 
the wound took on at the fifth day. 
I think I made a mistake in closing the wound originally, for 
the purpose of getting union by adhesion. It would seem hardly 
to be looked for that such union could take place under the 
circumstances, as it is quite impossible to bring the walls of such 
a wound in coaptation by the methods at hand. Aside from this 
difficulty, it had been bathed and saturated by the decomposed 
fluids which had poured from the uterus at the moment of deliv- 
ery of the fetus and placenta. 
Much time, trouble, and danger would have been avoided if I 
had treated it as an open wound antiseptically, with a drainage 
tube passing through the wound into the vagina. The conditions 
of such a wound are most admirable for drainage, the opening in 
the vagina being at its most dependent point. 
This operation is the eighth that has been performed in the 
interests of obstetric surgery. To Dr. T. G. Thomas the 
profession is indebted for the brilliant surgical ability and 
admirable courage with which he introduced a surgical pro- 
cedure which, unlike Cesarean section, must in principle and Gillette : A Case of Laparo-Elytrotomy. 
7 
practice be considered pre-eminently conservative. The two 
cases of Dr. Thomas, three by Dr. Skene, one by Dr. Dime, 
of Sheffield, Eng., one by Dr. Edis, of London, and the one 
here reported, are worthy of a serious consideration, inasmuch 
as it must soon be determined to what exact class of cases the 
operation is adaptable. Looking at it from the standpoint 
of its results, so far it may be considered as having been re- 
markably successful. It will be remembered that Dr. Thomas’ 
first operation was performed upon a moribund woman in the 
interests of her child solely, and with the result of saving 
the child. True it lived but two hours, but the cause of its 
death was not in the slightest degree associated with the oper- 
ation, as it died of inherent non-developmental causes. The 
operation must, therefore, be considered a success in that it 
demonstrated that the operation was feasible, and had accom- 
plished its purpose. The second case was favorable to both 
mother and child, both living. Dr. Skene’s three operations 
were undertaken and carried out with results that were prom- 
ised and foreseen. His first operation was performed in the 
case of a woman who had already undergone the most serious 
obstetric procedures, and when she was in a condition when 
almost any further endeavors must appear hopeless. She had 
been forty-eight hours in labor, with a pelvis of two and a half 
inches in diameter. Version and craniotomy had been fruit- 
lessly performed, and her general condition was such that it is 
hard to conceive that any successful delivery to the mother 
could be accomplished under the circumstances. In the light of 
his two succeeding successful operations, is it unfair to pre- 
sume that laparo-elytrotomy would have saved both the mother 
and the child in the first case, if it had been performed earlier, 
before the patient had been brought to death’s door by protracted 
and exhausting efforts at manual and instrumental delivery ? 
The case of Dr. Hime was fatal from causes entirely inde- 
pendent of the operation. The patient had cancer of the 
vagina and rectum, between which two passages there was a 
large fistulous opening. The vaginal canal was narrowed to 
about two inches by cancerous disease. There was a continu- 
ous stinking hemorrhagic discharge from the vagina and rec- 
tum, and, in addition to this fearful local condition, she was a 
chronic alcohol drinker. “ A thin, ill-nourished woman, with 8 
Gillette: A Case of Laparo-Elytrotomy. 
a large fatty liver, fatty heart, and a face indicative of her 
intemperate habits.” In this case, the doctor operated almost 
solely in the interests of the child and saved it, and chose 
laparo-elytrotomy, “ considering that the consequences of Cesa 
rean section in sncli a case must probably be immediately fatal 
to the mother.” The autopsy showed that there had been no 
hemorrhage after the operation, the peritoneum was intact, and 
so was the bladder. The uterus was well contracted, and no 
damage done except in the tissues intentionally incised. Such 
a case as this surely cannot be quoted as an argument against 
the operations performed. Dr. Edis’ case was “ performed as 
an alternative to embryotomy in a case of pelvic deformity.” 
The patient had anchylosis of the right hip-joint, was a flabby, 
unhealthy subject, with extremities that were edematous, and 
became livid under anesthesia. Forceps had been applied in 
vain; and when Dr. Edis was called, “ a huge thrombus was 
distending the right labium. The operation was performed in 
the interests of the child which was saved; there was little 
hemorrhage, and the bladder was torn on the right side. The 
result to the mother, in the doctor’s judgment, would have been 
the same if Cesarean section or cephalotripsy had been per- 
formed. It is extremely unfortunate that this operation was 
inaugurated abroad upon two such hopeless cases, but its per- 
formance in each case was a demonstration of the preference 
of the operators for laparo-elytrotomy over Cesarean section and 
embryotomy, the usual and heretofore established methods of 
delivery in cases of such a desperate and hopeless nature. 
My operation was performed solely in the interests of the 
mother, as the child was recognized as dead and decomposed. 
Aside from the interest in the operation it was, unlike any of 
the cases of Thomas and Skene, Ilime and Edis, of striking pecu- 
liarity, in that after laparo-elytrotomy the greatest difficulties 
were encountered in the delivery. Thus I attempted forceps, 
version, and craniotomy, and finally had to deliver by cephalo- 
tripsy and extraction. It was hardly to have been expected, 
after I had successfully brought the head into the wound in 
the flank, that such difficulties could be encountered in its 
delivery ; and in this is the lesson of this case, that laparo-ely- 
trotomy presents but few of the facilities of Cesarean section, 
although it is free from most of its dangers, and that the Gillette : A Case of Laparo-elytrotomy. 
9 
armamentarium of the obstetrician, in performing this opera- 
tion, must in the future be increased beyond his scalpel, sound, 
and ligatures, and blunt hook, to that of the forceps, cranio- 
tome, cranioclast, and cephalotribe. The presence of a dead, 
decomposing, and flaccid fetus in a uterus long drained of its 
waters, in a state of spastic rigidity, is a complication which 
will perhaps need the intervention of one of these instruments. 
If in the future I should meet such a complication as the 
one related, I would at once resort to the cephalotribe. This 
I learned in this case, though a priori I had no reason to 
believe I could not deliver by forceps or version. I cannot 
conceive of the same difficulties to delivery existing with a 
living or recently dead clpld, where its firmness and elasticity 
would give the assistance of leverage in version, and point 
(Tappui in the application of forceps. 
Perhaps it is too early to specify the domains of this operation 
from the eight cases reported, but considering it from ift stand- 
point of safety and in the light of its beginning, does it not offer 
far more hopeful results than the Cesarean section or embryo- 
tomy ? Thus, in eight laparo-elytrotomies, four mothers have 
been saved, and six children delivered alive. Notwithstanding 
the fact that the four fatal cases were considered hopeless 
before the operation commenced, can Cesarean section, which is 
classed as a conservative operation, show more brilliant results ? 
Eliminating these four cases, as we properly should, can 
Cesarean section make so favorable a showing ? 
Does embryotomy, essentially sacrificial to the child, show 
any equal result with its mortality of thirty-three and a third 
per cent to the mother ? 
What are the dangers of this operation as compared to those 
of gastro-hysterotomy ? Dr. Thomas has summed up the chief 
dangers of this procedure to be : 1st, peritonitis ; 2d, metritis; 
3d, hemorrhage; 4th, shock; 5th, incarceration of intestines 
in uterus ; 6th, septicemia. The dangers in laparo-elytrotomy 
are from: 1st, hemorrhage ; 2d, shock ; 3d, septicemia. 
Now, it is a very suggestive fact that, notwithstanding the 
recognized danger from hemorrhage, in the nine cases of 
laparo-elytrotomy reported (and this includes the case related 
by Dr. J. T. Everett, of Stirling, 111., in the Oct., 1879, 
number of this Journal, of laparo-elytrotomy for the removal 10 
Gillette: A Case of Laparo-Elytrotomy. 
of a calcified fibroid of the uterus), so far there has been no 
such accident, and possibly future experience will eliminate 
this danger almost entirely. Certainly we expect no serious 
hemorrhage from the cut epigastric, which we can always 
ligate, and the congerie of vaginal arteries, which must be 
invaded in opening the vagina, thus far have not given us 
serious hemorrhage, probably because they have been lacerated 
instead of cut. 
The danger from shock is almost nil, and from septicemia 
no greater than that which obtains in any incised wound, open 
to drainage and antiseptic treatment. 
In considering the future of-an operation that has had in its 
inception such brilliant results as laparo-elytrotomy, while we 
must necessarily be cautious and conservative, we nevertheless 
have reason to be sanguine, for nothing yet has occurred in its 
practice which can be other than recommendatory, and in 
weighing all its possible dangers with those of embryotomy 
and gastro-hysterotomy, which have been before the profes- 
sion for centuries, we can see no reason why it must not 
advance to a position and practice which will render sacrificial 
obstetric surgery one of the rarest of procedures.