The Cesarean Section and its 
Substitutes 
BY 
CHARLES P. NOBLE. M.D. 
Surgeon In Charge, Kensington Hospital 
for Women, Philadelphia 
REFRINTEIi FROM 
The American Journal of Obstetrics 
Vol. XXVII., No. !i, 181)3 
NEW YORK 
WILLIAM WOOD & COMPANY, PUBLISHERS 
1893 THE CESAREAN SECTION AMD ITS SOBSTITUTES. 
No better evidence of the marvellous development of surgery 
during the past ten years exists than the status of the Cesarean 
operation then and now. At that time surgeons and obstetri- 
cians were only fairly beginning to realize the errors of the past 
and to be intluenced by the successes obtained in abdominal 
surgery. Undoubtedly the modern successful revival of the 
operation is to be attributed to the introduction of the principle 
of antisepsis into surgery. The boldness in operating and in 
reasoning about operations, which grew out of the successes made 
possible by this principle, led men to throw off the shackles of 
the past and to apply the light of the present to this as to all 
other operations. The result has been to show that success in 
Cesarean section depends upon the same principles which under- 
lie success in all operations, and that the operation, instead of 
being “the most dangerous in surgery,” is to be classed among 
the comparatively safe operations, having a scarcely greater in- 
herent mortality than ovariotomy. 
It is my purpose in this paper to discuss briefly the present 
status of the Cesarean section and the principles underlying its 
successful performance, and to consider it in its relation to its 
substitutes, puerperal hysterectomy, symphysiotomy, and em- 
bryotomy. 
The statistical method of establishing the status of an opera- 
tion is the one usually followed, but, as is well known, it is open 
to many objections and can yield anything but reliable results. 
First there is the difficulty of securing the entire number of cases, 
and then the greater difficulty of knowing the condition of the 
patients at the time of operation, and then the difficulty of 
1 Read before the Philadelphia County Medical Society, November 9th, 1892. 2 
NOBLE : THE CESAREAN SECTION 
estimating the degree of skill of the host of operators included 
in the table. Hence, even if the table includes all the cases, it 
simply demonstrates the results of good obstetrics and good 
surgery together with bad obstetrics and bad surgery—results 
which are worthless for the purpose in hand. I believe a better 
method is to study the subject in its general aspects, and to con- 
fine our study of statistics to those of a few well-known operators. 
In a typical Cesarean operation done before labor, or during its 
first stage, we have the following conditions to deal with: The 
patient is a healthy woman, in good condition, with a healthy 
peritoneum, a healthy uterus with aseptic contents, and with a 
non-infected birth canal. Under such favorable conditions an 
abdominal surgeon would expect the best results from any ope- 
ration not unduly prolonged and not accompanied by serious 
hemorrhage. Ovariotomy under these conditions has yielded 
the best results. Experience has sliowm that pregnant women 
are good subjects for anesthesia and for operations in general. 
The technical details are easily under the control of an expert. 
The incisions are made under the guidance of the eye, and the 
suture ligatures are likewise so placed. Hemorrhage from the 
wound is thus easily controlled by the surgeon, and hemorrhage 
from the placental site is controlled by the action of the uterus 
itself. Hence the dangers, theoretically, resolve themselves into 
the possibility of infecting the peritoneum by the surgeon’s 
hands, instruments, etc., and of hemorrhage due to non-action 
of the uterus. The first accident should never happen, and prac- 
tically it very seldom does in careful hands; and the second is 
even more rare, as the uterus only fails to act when its muscle 
is exhausted by long hours of labor. The theoretical consider- 
ations involved would indicate that the inherent dangers of the 
operation are slight, and the results obtained by the best opera- 
tors amply bear this out. For example, Sanger has had nine 
operations without a death. Zweifel did thirteen operations in 
Leipzig without a death, then operated on a case having a dead 
and putrid fetus and lost it. Eight operators in Leipzig, includ- 
ing Sanger and Zweifel, had thirty-six cases with two deaths, 
one of which was referred to above. The results of Leopold, and 
Cameron of Glasgow, are similar. They saved the mothers who 
were in good condition, and lost only those wdiose condition be- 
fore operation indicated such a result (the later results of Leo- 
pold and Cameron are not obtainable). In this country there AND ITS SUBSTITUTES. 
3 
have been no large series of operations. Drs. Kelly and Lusk 
have had four each. Dr. Kelly saved all, although one case was 
desperate at the time of operation. Dr. Lusk lost one unfavor- 
able case. The Kensington Hospital for Women (two cases by 
Kelly and two by myself) and the New York Maternity Hospital 
have each had four cases and saved all. 
These statistics are quoted simply as illustrating what has been 
accomplished. Better results can be obtained in favorable cases, 
as the above include a certain number of unfavorable cases—that 
is to say, some bad obstetrics, and even some bad surgery; for 
example, Zweifel’s fatal case was unfit for the classical operation, 
and should have had the Porro operation or panhysterec- 
tomy. 
An advocate is said to harm his cause by stating it too 
strongly, but I feel that the facts in the case justify and fortify 
the statement that the Cesarean section done by the expert 
before or early in labor is scarcely more dangerous than the 
average of labors as at present conducted in our great cities. 
Undoubtedly the average mortality of the operation as done 
heretofore is many times greater, but it cannot be too strongly 
insisted upon that this represents the mortality, not of the 
operation, but of the bad obstetrics and the bad surgery which 
heretofore has largely prevailed. 
Operators are in agreeirkent concerning the principles govern- 
ing success in this operation, with three exceptions. The points 
agreed upon are: 1. The diagnosis should be made during 
pregnancy and the operation determined upon, and the patient 
should be put in good condition for operation. 2. The opera- 
tion should be done with the same antiseptic and other care 
given to other celiotomies. To achieve the best results it must 
be done by an expert. 3. The after-treatment should be the 
same as after celiotomies in general, modified by the treatment 
necessary for the puerperal state. 
The points at issue are: 1. Should the operation be done be- 
fore labor, or early in the first stage of labor ? 2. Should the 
uterus be turned out, or incised in situ ? 3. Should the uterus 
be constricted by rubber tubing to control hemorrhage during 
operation, or should manual compression be employed? 
The first point is the most important. Desiring to avail my- 
self of his extensive knowledge of this subject, I have asked Dr. 
Robert P. Harris, of Philadelphia, who was a very early advo- 4 
NOBLE : THE CESAREAN SECTION 
cate of the Cesarean operation before labor, to give me his opin- 
ion, which follows : 
“My studies of the Cesarean section commenced in 1869 and 
have been continued, with some interruptions, ever since, dur- 
ing part of which interval I have witnessed many operations 1 
and watched the cases into recovery, having seen but two die, 
and these had a bad prognosis. My first object in study was to 
discover why some reported cases of our country recovered and 
why others in much larger number died. In time I became 
thoroughly convinced that the seeds of death were sown, as a 
general rule, before the knife was used, either through pre-ex- 
isting disease or the result of parturient exhaustion and change. 
This was made to appear much more decidedly after it became 
the practice to close the uterine incision by sutures in all cases, 
such as has been done in the last ten years upon seventy women 
in the United States. It was then made to appear that delay in 
operating prevented a rapid uterine union and favored the pro- 
duction of peritonitis, sepsis, and nerve shock ending in death. 
Finding the value of early operating, I made it my special mis- 
sion to urge upon all operators to make their celio-liysterotomies 
as soon after the invasion of labor as possible; and it has been 
the acceptance of, and action upon, this belief that has led so 
largely to the reduction of our mortality in America. In fact, it 
has become a general belief that if a woman has no organic dis- 
ease and is operated upon directly after labor has begun, she has 
a very fair prospect of recovery; and our records plainly estab- 
lish this fact. 
“ Although the importance of early operating to recovery has 
been demonstrated, it has been found to be quite difficult to se- 
cure the patients in proper season for.this, and it has only been 
accomplished in a small proportion of cases, even in our large 
cities. A labor of at least an hour or two was for a long time 
11 have been present at three Porro operations and visited two more cases in 
their convalescence. One woman died who had albumin in her urine; the 
rest recovered. I have been present at eight Sanger-Cesarean operations, and 
many times visited a ninth woman in her convalescence, which was a battle for 
life against a taint of syphilis. One woman with a very unfavorable prognosis 
died. I made an autopsy in the case of a rachitic dwarf in 1885, upon whom 
the old Cesarean operation was performed in 1835 and in 1837. One child is 
now 57 ; the other died when 43. The mother was 76. I saw the girl and boy 
in their early childhood on several occasions. I have thus taken a special in- 
terest in fifteen Cesarean deliveries, from which there were thirteen recoveries. AND ITS SUBSTITUTES. 
5 
thought to be an essential element of success, in order that ute- 
rine contraction should be certain to follow the use of the knife, 
and drainage he secured by having an open cervix. Where an 
operation was determined upon prior to labor, the inconvenien- 
ces of a night call and of securing proper assistance at night were 
a serious obstacle to immediate action, especially in cases at a 
distance from the operator’s residence. This was so much felt ro 
be an inconvenience that Dr. Anna E. Broomall upon one occa- 
sion slept night after night at the Woman’s Hospital, so as to be 
on hand to operate directly after labor was announced. She ope- 
rated in the middle of the night and saved mother and child. 
This was in May, 1889. She woidd not wait for labor now. 
“ It has long been known that an evacuating wound of a preg- 
nant uterus, especially where gestation is far advanced, will be 
followed at once by a contraction of the organ quite as marked 
as where it has occurred normally in labor. This has been very 
remarkably exhibited in cases of horn-rip Cesarean delivery, 
some of which date a number of years back, and under which 
ten women and seven children were saved out of fourteen sub- 
jects between the years 1530 and 1S88, ten of the casualties hav- 
ing occurred during the present century. 
“ M*y attention was first drawn to this fact of contraction in a 
practical way in September, 1880, when 1 saw the late Dr. Elliott 
Richardson, of Philadelphia, perform a Porro operation upon a 
woman, eight and a half months pregnant, at a selected time. 
We had considered the case of this dwarf in consultation, and 
the operation took place in accordance therewith and was fully 
successful. 
This was the first of a series of Porro and Sanger Cesarean 
operations that have been performed in this country in which 
there was no delay in uterine contraction after the removal of the 
fetus. This operating at a convenient, selected time has been 
objected to in Europe because of two deaths that occurred under 
it in the experience of Prof. Hector Treub, of Leyden, within 
the last five years, through the uteri having failed to contract. 
“ His first operation was upon a primipara of 28, in whom he 
completed a Sanger section under cervical compression made 
with an Esmarch elastic tube. When this tourniquet was re- 
moved the uterus filled with blood, and, the hemorrhage proving 
beyond control, the operation was converted into a Porro and 
the stump dropped in. The woman died of anemia in three 6 
NOBLE : TIIE CESAREAN SECTION 
days. Here I believe the uterine atony was due to the paralyz- 
ing effect of the elastic tourniquet, which is far less safe and re- 
liable than manual compression. In April, 1886, Dr. Emilio 
Fasola, of Florence, Italy, had the same difficulty in a case where 
tubing was used upon a woman ten hours in labor, and was 
obliged to exsect the uterus after completing the first Sanger ope- 
ration in Italy. lie wisely treated the stump externally, and the 
woman recovered. 
“ Prof. Treub’s second operation is much more unaccountable in 
its results, as the tubing was not used, and still the uterus showed 
but a trace of contraction under hypodermic injections, massage, 
and faradization. The woman was a rachitic dwarf, four feet 
five and a half inches high, 41 years old, and pregnant for the 
fourth time. The operation was completed under the Sanger 
method, but the woman died from the previous blood loss soon 
afterward. Against this one case we place fourteen operations 
in this country in which the fetus has been extracted through a 
uterine incision, where the women were not in labor when the 
abdomen was opened, and where prompt uterine contraction fol- 
lowed the evacuation of the amniotic fluid. 
“Cases of uterine atony such as that of Prof. Treub’s second 
must be so rare that we do not feel inclined to weigh it against 
the many advantages to be gained by an operation before labor 
and at a convenient, selected time. Cases of cancer of the cer- 
vix uteri must not get into labor, if they are to recover, and two 
that I have seen operated upon before there were any pains did 
remarkably well. If we are to choose between operating before 
labor and not being able to do so for some hours after it has be- 
gun, let us take the little risk of atony, and do so at a selected 
hour, rather than run the multiple dangers of delay.” 
The advantages of operating at a fixed hour, with patient, 
room, assistants, and operator ready, instead of doing an emer- 
gency operation, decided me in favor of operating before labor 
in the case of Mrs. C., September 28th, 1S92. I was also led to 
this conclusion by having seen its advantages in two cases ope- 
rated upon before labor by Dr. Kelly. 
To my mind the one objection to operating before labor is 
that the issue of the labor in some cases might prove the opera- 
tion unnecessary. But this should occur only in the hands of 
one unskilled in pelvimetry and in estimating the relative size of AND ITS SUBSTITUTES. 
7 
head and pelvis, and lienee is rather an argument for counsel in 
diagnosis than against operation before labor. In the future it 
seems likely that symphysiotomy will supersede the Cesarean 
section in cases of contracted pelvis with a conjugate above two 
and three-quarter inches. If this proves true this argument 
likewise will fall to the ground. The anomalous case of Treub 
alone stands against the method. Hypodermics of ergotin and 
strychnine, given before operating, should lessen the risk of 
hemorrhage which he encountered. 
The question, Should the uterus be turned out or incised in 
situ? I would answer by saying, do not turn it out. Turning it 
out complicates the operation by requiring a long incision, giv- 
ing a large surface for the radiation of heat, favoring displace- 
ment or escape of the bowels, and requiring a longer time in su- 
turing the wound. With a little care blood and liquor amnii 
can be kept out of the peritoneal cavity ; and even should this 
not be accomplished, both are aseptic and can easily be sponged 
or washed away. 
The question, Should the uterus be constricted with a rubber 
ligature to prevent hemorrhage during the operation? I would 
answer in the negative. Experience has proven that the risk of 
paralyzing the uterus in this way is not imaginary, and has 
shown, in the hands of others, that the practice is unnecessary. 
I have seen four Cesarean operations, and in them hemorrhage 
was readily controlled without the tube. 
The only other point in the technique that I shall touch upon 
is the sutures. In my opinion silk is the best material. It can 
be made aseptic by boiling, and has many well-known good 
qualities. Enough deep sutures (about seven) should be intro- 
duced to control bleeding from the wound. They should be 
drawn fairly tight. About twice as many superficial sutures 
should be introduced to insure a neat approximation of the 
edges of the wound. In my judgment it is best to introduce 
them in the regular way, and not after the manner of Lembert. 
I have used the method advised in two cases, the first in April, 
1890. Dr. Kelly and others now advocate this method. Its ad- 
vantages are that time is saved, and that these sutures assist in 
controlling bleeding from the lips of the uterine wound. 
The Porro Operation.—The relative merits of the classical 
and of the Porro-Cesarean section are still under discussion, 
with the majority favoring the classical operation because of its 8 
NOBLE : THE CESAREAN SECTION 
supposed greater safety. Dr. Harris tells me that the statistics 
of the two operations are in favor of the classical operation, 
whether the results are taken of all cases in a given year, or the 
results of the best operators advocating the two methods. This 
evidence is of value, but to me it indicates rather a difference in 
the condition of the cases and in the skill of the operators than 
in the relative danger of the two operations. In typical cases 
both operations should give almost perfect results. The fact 
that the results under the Porro operation are not so good as 
under the classical operation, I believe is to be explained on the 
ground that the Porro is the operation of election in cases seen 
late, in cases already septic, and in cases complicated by fibroid 
tumors. My own objection to the Porro operation in typical 
cases is that it unnecessarily robs a woman of her womb and 
ovaries, and takes away from her the power of bearing children. 
It has been amply demonstrated that second or third Cesarean 
operations are more safe than the primary operation, which it- 
self is no longer dangerous. Hence I am opposed to depriving 
women having deformed pelves of their fertility, whether by the 
Porro operation or by operations on the tubes or ovaries. The 
burden of proof as to its value rests with those who advocate 
this needless sacrifice of the sexual organs. 
The Porro operation and panhysterectomy I would reserve 
for atypical cases. When the pregnancy is complicated by large 
fibroid tumors, or when the uterus is septic, or when the operator 
is called in late, after the uterus is exhausted by long labor, I 
believe the advantages of hysterectomy are manifest. In the 
first case the patient is cured of the tumor at the same time, with- 
out greater and at times with less risk. In the second case the 
infected uterus is removed and the many dangers of puerperal 
sepsis avoided. In the third case the dangers of atony of the 
uterus and possible post-partum hemorrhage and of sepsis (well 
known to be rare in this class of cases) are likewise avoided. In 
my judgment the field of the Porro operation and puerperal pan- 
liysterectomy embraces these three classes of cases. In these 
cases the advantages of these operations over the classical ope- 
ration are so obvious as not to require an argument. I have 
personal knowledge of two deaths from the classical operation 
which I believe could have been avoided by the Porro. These 
cases were operated on late. 
Symphysiotomy.—The operation of symphysiotomy gives AND ITS SUBSTITUTES. 
9 
promise of being a great boon to women with deformed pelves. 
The record of fifty-four cases with fifty-three women and forty- 
eight children saved (Harris) commands our admiration. Even 
the one maternal death was due, not to the operation, but to me- 
tro-peritonitis following a long labor. The operation, however, 
as a practical fact is too new to us in America to enable us to 
have fixed opinions concerning its practical value. If, however, 
the claims of its advocates prove true, especially if the pubic 
joint heals soundly, rapidly, and well, certainly symphysiotomy 
will displace the Cesarean operation done for fiat pelves with a 
conjugate above two and three-fourths inches, and also for cer- 
tain cases of generally contracted pelvis and of osteomalacia ; 
and, moreover, it will take away the old excuses which have 
been used to justify embryotomy on the viable child in the past. 
Personally I welcome the operation of symphysiotomy on this 
account. 
Embryotomy.—Embryotomy has been an operation always 
hard to justify when done on the viable child. The Homan 
Catholic Church condemns it and holds the operator morally 
guilty of homicide. The decalogue condemns it. It has been 
justified on the ground that it is better to kill one than to permit 
two to die. This condition no longer exists, with the modern 
Cesarean operation and with pubiotomy recognized. It is no 
longer a question of killing one to save the other. With proper 
management both can be saved. I find myself in positive dis- 
agreement with those who say that the child should not be con- 
sidered, but only the mother, and who justify themselves by say- 
ing that without the intervention of art the child will die as 
surely as though its brain should be broken up by the perfo- 
rator. The dictum of the profession, especially in England, 
France, and America, has so long been in favor of embryotomy 
that time and facts, and the earnest advocacy of a more humane 
and life saving practice by those who are convinced that sym- 
physiotomy and the Cesarean section should take the place of 
embryotomy on the viable child, will be needed to establish a 
better practice. That embryotomy on the viable child will soon 
be condemned as universally as it is now defended I do not 
doubt, and I hope that every one convinced of the rightfulness 
of this principle will speak out and disregard the traditions and 
prejudices of the past. If this be done the final day of the sac- 
rifice of the innocents will be at hand. 10 
NOBLE : THE CESAREAN SECTION AND ITS SUBSTITUTES. 
I believe that practical men will still find a place for embry- 
otomy. It will be done in preference to the Cesarean section or 
symphysiotomy: 
1. On the dead child. 
2. On human monsters and cases of hydrocephalus. 
3. In cases seen latehy the surgeon, when the fetus is believed 
to be non-viable, whether by long pressure from delayed labor 
or by undue or violent efforts at delivery by the forceps. In 
such cases embryotomy will be considered as against symphysi- 
otomy or hysterectomy, and will, I believe, be elected at the pre- 
sent time. 
4. In cases of labor remote from assistance. This class, how- 
ever, should be sharply limited to emergency cases; and it is to 
be hoped that symphysiotomy will prove sufficiently easy of per- 
formance to supplant embryotomy in almost all such cases. 
Conclusions.—1. Cesarean section in typical cases is a safe 
operation. 
2. It should be performed preferably before labor, and not later 
than the first stage of labor. 
3. The classical operation is to be preferred to puerperal hys- 
terectomy in typical cases, because it is equally if not more 
safe, and because it preserves the fertility of the woman. 
4. Puerperal hysterectomy is to be preferred in certain atypi- 
cal cases : (a) Cases, seen late, in which infection of the birth 
canal and atony of the uterus are to be feared, (b) Infected 
cases. (c) Cases complicated by large fibroid tumors of the 
uterus. 
5. Symphysiotomy will probably supersede Cesarean section 
done for the relative indication. 
6. Embryotomy is no longer justifiable on the living viable 
child as an elective operation. 
2134 Hancock street. MEDICAL JOURNALS 
PUBLISHED BY 
WILLIAM WOOD & COMPANY. 
MEDICAL RECORD. 
A WEEKLY JOURNAL OE MEDICINE AND SURGERY. 
Edited by GEORGE F. SHRADY, A.M., M.D. 
Price, $5.00 a Year. 
The Medical Record has for years been the leading organ of the medical 
profession in America, and has gained a world wide reputation as the recog- 
nized medium of intercommunication between the profession throughout the 
world. It is intended to be in every respect a medical newspaper, and contains 
among its Original Articles many of the most important contributions to 
medical literature. The busy practitioner will find among the Therapeutic 
Hints and in the Clinical Department a large fund of practical matter, care- 
fully condensed and exceedingly interesting. Medical News from all parts 
of the world is supplied through special correspondents, by mail and telegraph; 
New Publications and Inventions are reviewed and described ; and in the 
Editorial Department matters of current interest are discussed in a manner 
which has established the Medical Record in the estimation of the whole 
profession as a thoroughly independent journal and the most influential publi- 
cation of its class. 
The AMERICAN JOURNAL OF OBSTETRICS 
AND DISEASES OF WOMEN AND CHILDREN. 
Price, $5.00 a Year (Issued Monthly'). 
This is not a special journal, as such are usually understood. As it gives 
special attention to lines which, more than any other, go to form the everyday 
experience of the general practitioner, its scope of usefulness is very wide. 
The original articles appearing in its pages are selected wutli a view to their 
practical value and general interest, and include many contributions from 
writers of wide celebrity and established reputation. 
The Journal is not the organ of any society, being entirely independent, 
and consequently free to select for publication only such matter as will be most 
useful to its subscribers. 
Society Proceedings, Book Reviews, and Abstracts of current literature 
in its scope are carefully prepared features which and to the completeness of 
the Journal. 
In order to add to its usefulness and attractiveness, special attention is 
given to the matter of illustrations, and all articles admitting of it are copiously 
illustrated by every available means. In fact, the Journal is presented in a 
form of typographical excellence unequalled by any other medical journal. 
A specimen copy will be sent free, if desired. 
Medical Record (Weekly), .... $5.00 a year. 
American Journal of ObHtetrics (Monthly), - 5.00 a year. 
And when mailed to the same address and paid for according to our terms: 
Medical Record and Journal of Obstetrics, - $9.00 a year. 
PRICES AND CLUB RATES: 
At the above low rates only when paid in advance to William Wood & Company of 
their Agents, NOT the Trade. 
WILLIAM WOOD & COMPANY, 43, 45, & 47 East 10th Street, New York.