CESAREAN SECTION IN VIRGINIA IN THE PRE-ASEPTIC ERA, 1794-1879 By JOSEPH L. MILLER. M.D., LITT.D.

THOMAS, WEST VIRGINIA

O FAR as the records show, the Rush, Shippen, and others, and to have first successful cesarean section been “a thorough anatomist and most in the was done excellent surgeon.” After settling in in the backwoods of Virginia, Virginia he was married 011 April 8, Sthe oldest English settlement in Amer1793,­ to Elizabeth Hog, daughter of ica. Major Peter Hog, who was a graduate of I he operation was performed by a the University of Edinburgh, a pioneer pioneer doctor on January 14, 1794, lawyer in the Valley, an officer in the in the Valley of Virginia. The mother French and Indian War, and first Clerk survived for more than a quarter of a of the Rockingham County Court. century, and the daughter to the ripe In due course Mrs. Bennett came to old age of seventy-seven. In the eighty- her first and only confinement. Owing five years following this case to the be­ to non-delivery due to a contracted pel­ ginning of the aseptic era in surgery and vis or other obstruction, not now in modern technique, we find records known, assistance was called in the per­ of nine additional cases in Virginia. son of I)r. Alexander Humphreys, a I he results of these ten cases were three well known physician of Staunton, and living mothers, one of whom died preceptor of Ephraim McDowell, at eleven years later following a second this time a student at Edinburgh. After cesarean, but of a pre-existing disease, consultation and an unsuccessful at­ and six living children, two of whom tempt at a forceps delivery, it was de­ died a few minutes after delivery, no cided that but two courses were open to doubt from the long delayed operation. them—craniotomy or cesarean section. There may have been other cases but Mrs. Bennett, thinking she would die these are all that can be substantiated anyway, insisted that the be saved by the reports of the operators, their rec­ if possible. Dr. Humphreys refused to ords, or the evidence of reliable eye wit­ do the operation so Dr. Bennett pre­ nesses. pared to do it himself, and did perform it, Dr. Humphreys, however, staying to Case Reports and Operators assist. Unfortunately, Dr. Bennett did Dr. Jesse Bennett was born in Frank­ not report the operation to any medical ford, Philadelphia County, Pennsyl­ publication during his lifetime, but he vania, on Ju>y 10, 1769. In 1792 he set­ did leave some record of it, which has tled in Rockingham County, Virginia, come to light in recent years. A few for the practice of his profession. He is years after his death, when his sister-in- said to have read medicine in the office law, Mrs. Nicholas Hawkins, who was of a prominent Philadelphia physician, present at the operation, was asked why and then to have had a course of study he had never reported it, she said that at the University of Pennsylvania under she had heard him say that no strange doctors would believe that operation “Memoirs on the Cesarean Operation” could be done in the Virginia back- with Dr. Bennett’s autograph on the woods and the mother live, and he’d be title page and on the margin of the text some notes he had made of the opera­ tion he had done on his wife. These with Dr. Knight’s data give us a good account of the operation. Dr. Knight was born and reared within a mile of Dr. Bennett’s home, and was nearly twenty years old when Dr. Bennett died. Knowing the neigh­ borhood tradition of the operation, as soon as he had graduated in medicine, Dr. Knight sought to verify it and gather the details from all living who knew about it. These were: Dr. Ben­ nett’s daughter, the wife of Dr. Enos Thomas; Mrs. Bennett’s sister, Mrs. Nicholas Hawkins; and a Negro serv­ ant, both of whom had been in the room at the time of the operation. The details as given to him are here pre­ sented. Mrs. Bennett was given a large dose of laudanum which put her to sleep. damned if he would give them a chance She was then placed on a table made of to call him a liar. Also, on another oc­ two boards laid on a couple of barrels, casion, that “no doctor with any feel­ and with one sweep of his knife Dr. ings of delicacy would report an opera­ Bennett laid open the , partly tion he had done on his own wife.’’ incising the . This he rapidly en­ The operation was first reported in a larged and quickly lifted out the child “History of the Great Kanawha Val­ and en masse. After control­ ley” (1891), the medical section of ling the hemorrhage he remarked, which was written by Dr. A. L. Knight, “This shall be the last one,” and pro­ one of the most prominent physicians ceeded to remove both , or in of the Kanawha and Ohio Valleys; and the language of one of the witnesses, by myself in the Virginia Medical “he spayed her.” The wound was then Monthly (January, 1929), with more closed with stout linen thread such as complete details of the operation given is used in making heavy clothing. This me personally by Dr. Knight, who was was probably the , as my father’s family physician. About two it was not then the custom of the sur­ years after the publication of my sketch geons to suture the uterus. Dr. Ben­ of Dr. Bennett, his great granddaughter, nett’s own record is very terse, but whom I had known for many years, especially interesting as giving the con­ gave me a book of his ■which she had re­ valescence. Following Baudelocque’s cently found in the attic of the old home record of twenty-four case reports of where they lived. It was Baudelocq ue’s “The operation performed with sue- cess,” Dr. Bennett wrote: “25th. i4janv be said that his operation antedates by 1794 J.B. on E.B. Up 9 Feb1' Walked thirty-three years that of Dr. John Rich­ 15 Feb" Cured on 1 March.” Further in mond of Newtown, Ohio, which being this chapter Dr. Bennett underscored the following significant remarks of Baudelocque: This operation is not essentially mor­ tal ... if he had not introduced a catheter into the deepseated collection of matter which threatened the most dread­ ful consequences, Mr. Bacqua, like many others would have failed in attaining the end, which he proposed to himself, and would have furnished an additional arm to the adversaries of caesarean operation, in making them acquainted with an­ other victim . . . we can scarcely prom­ ise ourselves to save one in ten. Dr. Bennett lived a long and useful life and died at his home on the Ohio River on July 13, 1842. About three years after the of his daughter he moved with his family and those of his brother and sister-in-law, who with his wife had inherited nine thousand acres of land on the Ohio River from their father Major Peter Hog. This land was located in what is now Mason County, after the formation of which in 1804 Dr. Bennett was a justice of the first court, a major and surgeon in the county militia, member of the Virginia Assembly, a surgeon in the U. S. Army in the “Whiskey Rebellion” and the War of 1812, and a witness in the trial less than two hundred miles from Dr. of Aaron Burr for treason. For several Bennett’s home affords speculation as to years after his removal to the Ohio whether Dr. Richmond may not have River he was the only physician in a known Dr. Bennett, or at least have radius of fifty to seventy-five miles of his heard of his successful operation and home, and after others came, his repu­ so have drawn courage to proceed with tation was such that he was called far his own case. The done and wide in consultation, particularly by Dr. Bennett preceded by seventy­ in surgical cases. There are many inter­ eight years that done by Dr. Robert Bat- esting and humorous stories of the old tey of Georgia, who is given credit as doctor, but scarcely appropriate for rep­ the first to advise and remove non-dis- etition here. eased ovaries. Before leaving the old doctor it may The next cesarean of which we have record was done in the village of Occog- Esq., of Fairfax, myself, and three or non, Virginia, in June, 1828, by an four citizens of the village, whose names irregular practitioner, and reported to I do not recollect. The epigastric the American Journal of Medical Sci­ was divided, but secured without diffi­ ences eight years later by Dr. M. L. culty. Not more than one or two ounces Weems, a regular physician who was of blood was lost, none of which was from the uterus. The uterus contained the re­ present but did not assist in the opera­ mains of a foetus in a half dissolved state, tion. He writes: many of the bones being detached and The operation was performed by an bare; a large proportion of the soft parts empiric who then enjoyed an extensive had been dissolved by putrefaction and practice in the adjoining county of Fair­ discharged by the . fax, but is now no more. I was present at On removing the remains of the foetus the operation, but for reasons which will the internal surface of the uterus for sev­ be obvious to all, refused to participate eral inches around the os uteri was found in it. All the particulars that could be lined by a crust of osseous matter which known by any but a physician, were formed a perfectly smooth continuous familiarly known to all the citizens of surface except at the os uteri, where there the village. The subject of the case was— was an opening sufficiently large to ad­ Payne, a mullato, aet. about 25, of the mit the finger. The crust was about half middle stature, well formed, and the a line thick, possessed considerable mother of 3 or 4 children. Her labours strength, and adhered firmly to the uterus. were represented as having been severe. The was well formed and capa­ I11 the spring of 1827 having completed cious. The uterus showed no disposition the 9th. month of her she was to contract. The wound was closed in the taken with severe pains, which continued usual way, except two or three stitches 2 or 3 days and left her undelivered. At were taken to close the incision in the that time she was seen by Dr. Thornton, uterus. At the next dressing the wound a highly esteemed practitioner of Dum­ appeared unfavorable, but after the third fries, who afterwards informed me that dressing it continued to improve. The from a hasty examination he had con­ woman remained free of fever, said she cluded her pregnancy extra-uterine, but was getting better every day, and was as he was compelled to leave her immedi­ elated with the hopes of a speedy re­ ately, and could not visit her again, he covery. She continued to improve until had not a sufficient opportunity to form about the middle of the second week, a satisfactory opinion. From this time when she violated the rules of diet by tak­ she continued about every four weeks to ing animal food and drinking cider, di­ have a return of her pains, which gen­ rectly after which she was seized with fever and the usual symptoms of violent inflam­ erally lasted for two days, and then left mation of the uterus and peritoneum, and her as before. This state of things con died in about forty eight hours after the at­ tinned until June, 1928, at which time I tack. . . . was invited to witness the operation, In the present case we may safely say and saw her for the first time. She was that the change of structure was the re­ now very much emaciated and experi­ sult of . That the woman enced an offensive discharge from the had laboured under inflammation of the vagina, and had been more haressed by m.m. of the uteri, as proved by the the pain. Her patience was entirely gone severity of her previous labours, as there and she was anxious for the operation. was no mechanical obstruction to deliv­ This was performed by the oblique ery. This case, I think, should tend to les­ section in the presence of Wm. G. Mason. sen the dread entertained towards the , for notwithstanding peritonitis. The duration of the phlegm­ this operation was performed in a rough asia was a month, during which time the and improper manner, and under every fluid contents of the uterus escaped, the

disadvantage, both as to time and state of abdomen shrunk, and the vaginal dis­ the patient, yet there was afterwards every charge became very offensive. reason to hope for a successful issue up On the 6th November the os admitting to the time of the patient’s imprudence. two fingers I made persevering efforts to dilate it and introduce the hand. The I he next case in our list is that of cranial bones denuded of the scalp, rough Dr. Brodie Herndon of Fredericksburg, and sharp, rested on the uterine aperture. who described it as follows: These attempts failing, ergot was freely Mrs. Russell, white, aet. about thirty, given which occasioned unequival pains moderately robust, mother of several chil­ and procured the expulsion of a very dren, fell into labour on the evening of putrid placenta. The patient continued Oct. ist, 1845. During the night, pains to waste, the discharge filling the room which had been paroxysmal became per­ with stench, and had an irritating fever. manent and there supervened tenderness On the 16th of November it being now to pressure, vomiting, and high vascular manifest the woman must die without re­ disturbance. The labour gave place to lief I determined on the Cesarean opera­ tion. She was placed on a table and the phia at night, and quinine and nour­ catheter introduced. An assistant gather­ ishment in the day the case did very well. ing up transversely a large fold of the ab­ Fhe wound united by adhesions in nearly the whole extent. The woman is now—3 months since the operation—quite well. Passing from the mainland of Vir­ ginia to the Eastern Shore we find the next case in Northampton County. In 1856 Dr. William G. Smith of Eastville reported in full a cesarean section which he performed on April 17, 1855, with the assistance of his son, Dr. Charles Smith, and Drs. George T. Yerby and Thomas Bagwell, whom he had called in consultation. His report is too long to repeat in full, but may be abstracted as follows: Dr. Smith and his son were called the day before to see a twenty-three year old Negro servant in strong labor for eight hours with her second pregnancy. She had aborted with the first one in March, 1853, which had been followed by puerperal fever and violent inflamma­ tion of the vagina. Upon examination Dr. Smith found a total occlusion of the dominal integuments, I thrust a bistoury vagina about one inch inside the , through them, and cutting outwards, with the exception of an opening the made at one stroke an incision of the full size of a goose quill, which evidently length required. With the scalpel divi­ had been sufficient for the exit of her sion was cautiously made at the upper menstrual discharge and ingress of the point of the wound of all the tissues in­ male sperm. Her expulsion pains were cluding the uterus, which was found ad­ herent to the parietes. The finger being severe, and it was thought the present­ introduced, the incisions were extended ing part must be low in the pelvis, but upon it laying open the parts from the could not be felt due to the rigidity of umbilicus to the . A full sized putrid the obstruction. It was decided to per­ child was readily extracted. The opera­ form a cesarean section if her pains did tion lasted half an hour, and was per­ not “effect a rupture and separation of formed in the presence of Drs. Brown, the walls of the vagina’’ by the next Wallace, Wellford and McGuire. Only morning. Dr. Charles Smith stayed with one large artery was tied and that in the her all night. When Dr. Smith and the integuments. There were no utero-pla- consultants came the next morning they cental vessels; the uterus did not contract in the least and remained a large flaccid “found her a good deal exhausted from sack. It was sponged out and the integu­ the violent pains she suffered during ments brought together with stitches and the night, but there was not the slight­ straps. The patient took an anodyne, and est change in the relation of the parts. a few hours after expressed herself as feel­ Drs. Yerby and Bagwell concurred in ing much more comfortable. With mor­ the opinion that delivery per vias natu- rales was impossible, and that the Caesa­ distressing. She died on the sixth day rean operation offered the only chance and the doctor remarks “no doubt mor­ for relief.” Following catheterization tification had ensued.” The child was and chloroform anesthesia Dr. Smith living fifteen months after the opera­ incised the from one inch tion and as healthy as any other child of below the navel downward for six his age. inches, exposing the fundus uteri and Returning to the mainland we find upper part of the bladder. The uterus that the next three cases were all op­ was then incised for the whole length erated on during the same year, 1856, of the first incision, and the protruding two in Richmond, and one in Norfolk. membranes ruptured, allowing the On May 12, 1856, Dr. Charles S. breech of the foetus to present. The Mills of Richmond was called to attend head was impacted in the pelvis, but a negro servant in labor twenty-four delivered with some difficulty, “and a hours with her first child. She was a fine living child was thus saved.” After rachitic dwarf three feet nine inches an easy delivery of the placenta the tall. The owner’s regular physician had uterus was sponged out and recommended a premature delivery sev­ . . . immediately visible contractions eral months previously, but this had not of that ensued. The edges of the been done. On examination Dr. Mills external incision were then brought to­ found “the promontory of the sacrum gether, and held by gentle pressure for projecting across the pelvis above the several minutes, to allow the escape of pubis having a space between the two fluids from the uterus while it was con­ scarcely wide enough to allow two fin­ tracting. The external wound was then gers to pass.” The cervix, admitting one dressed with four sutures, strips of adhe­ finger, presented an arm or a leg. Two sive plaster, and cold water dressings. A hours later he ruptured the membranes bandage of light linen was secured mod­ and brought down a leg and with con­ erately tight round the abdomen. . . . siderable force attempted to force the The time occupied from making the first “body into the pelvis.” Not succeeding, incision until the edges of the wound he sent for help in the persons of three were brought together, was just six min­ utes. The hemorrhage from the wound other prominent physicians, Drs. was very inconsiderable, not exceeding Deane, Drew and Bolton. After their four ounces. Valuable assistance was ren­ examination an attempt was made by dered by Drs. Bagwell and Yerby, by Dr. Bolton to eviscerate and deliver, keeping a constant and gentle pressure but with two fingers through the supe­ upon the sides of the abdomen, to pre­ rior strait he could not pass any instru­ vent protrusion of the intestines, none of ment for this purpose, so a cesarean was which were seen during the operation. decided upon. She was given a third of a grain of Under chloroform anesthesia the ab­ morphia, to be repeated in one hour. dominal wall was incised along the linea Following the operation the patient was alba from an inch above the umbilicus comfortable; her pulse was 120. A de­ to two inches above the pubis, passing tailed report of her condition three around the navel. “A large quantity of times every day is given. She did well serum escaped.” The uterine contrac­ for over a day but by the end of the tions brought it up through the wound, second day the abdomen was swollen when it was incised for seven inches and and tender; wound suppurating; pulse the placenta and child easily delivered. hard and rapid; nausea and vomiting The fetus was asphyxiated but easily resuscitated. After the uterus was firmly case, which was mentioned in the Vir­ contracted and the hemorrhage had ginia Medical Journal at the time, but been stopped by manual stimulation, no full report was made until 1877 the clots were removed; the incision when Dr. Drew reported the details to was closed by six or eight interrupted Dr. Robert P. Harris of Philadelphia, sutures and dressed with a broad cir­ who was collecting data on all American cular bandage. The patient soon recov­ cesarean sections. ered from the anesthesia, and her pulse The patient was a nineteen year old and general condition were regarded as negro dwarf with a deformed pelvis and favorable. A grain of opium was given a conjugate diameter of one and a quar­ and ordered repeated every hour until ter inches. The mother lived four days the patient was asleep. Dr. Mills gives and died in convulsions two hours after a detailed daily report for the next two having eaten a large dish of apple dump­ weeks. Her pulse varied from 96 to lings. Her previous condition is not 128; no mention is made of fever. Her stated. The child survived, and after his main complaint seems to have been gas accidental death in 1876 an interesting pains from constipation, the pain and account of the case was written by Dr. distention being always relieved by L. S. Joynes. calomel and enemas. Everybody in Richmond remembers Six days after operation the stitches little Bob, the crippled newspaper boy, were removed because of a skin irrita­ who used to hobble around our streets tion, and adhesive strips were substi­ selling newspapers. The poor fellow has tuted. By this time “the wound seems met a sad fate as the following letter will to have healed in its upper third, and show: along the remaining portion the adhe­ “Dear Sir: Bobby Moore, the little col­ sion has taken place in the inner tis­ oured boy who went to New York last fall sues, but the skin has not united. No from your place to sing and dance, was opening remains in the abdominal cav­ drowned today at 3 o’clock while bathing at Gloucester, N.J. four miles from here. ity.” I saw him taken from the water dead. The treatment from the beginning Respectfully, Dr. T. W. Weeks.” had been opium as needed; warm poul­ Bob, like McDuff, was not of woman tices to the sides of the abdomen; a but­ born but “ripped from his mother’s termilk, tea and cracker diet; and calo­ womb”—not “untimely,” however, as mel and enemas as indicated. Eighteen McDuff declares to have been the case days after operation she developed a with himself. In other words, Bob was phlebitis in the left femoral , which delivered by the cesarean operation in the kept her in bed several weeks longer. A year 1856 by Dr. Edward C. Drew, then month after operation Dr. Mills said of in this city. . . . Bob was a diminutive the child, “it has not had a moment sick­ specimen of humanity, in height probably ness since its birth, and no medication not exceeding two and a half feet, and whatever. It is a fine, hearty child and we are informed that he was drowned in water not over that depth. Few of those rather above the average sized chil­ who saw him every day on the street dren.” Eleven years later Dr. Mills op­ imagined that when taken from our midst erated upon this same patient. The case by the “Variety Manager” he was nearly is reported subsequently in this article. twenty years old. He was quite stunted A few weeks after Dr. Mills had op­ in growth and his body and limbs were erated, one of his consultants, Dr. Ed­ hardly larger than those of a child of ward C. Drew, operated upon a similar seven years. His legs were short and crooked, apparently from the effects of which a close examination will show to be rickets, and so nearly useless in locomo­ largely due to an excessive thickness of tion that he was compelled to use crutches the . She died in a house of prosti­ with which he swung his body forward tution. rather than walked. That he “could dance Eleven years elapsed before we find a jig as well as anyone,” as stated in the Dispatch seems hardly creditable. He record of another section in Virginia. moved about briskly, however, in plying This was in Richmond on October 8, his vocation as a newsboy and seemed to 1867, when Dr. Mills operated upon enjoy life in his way as much as those the same negro dwarf on whom he had more favored by nature, and fortune. operated in May, 1856. She was five The third Virginia cesarean in 1856 months pregnant and had been severely took place in Norfolk, and the only ac­ ill for a week or more with dysentery count we have of it is that of Dr. Robert and peritonitis; she had been in labor P. Harris of Philadelphia as follows: for two days before Dr. Mills operated. The child lived a few moments after I regret that I cannot yet state who was extraction, and the woman died of the the operator in this case, as letters of in­ pre-existing disease four days after the quiry sent twenty-one months ago remain operation. Query: Was the “dysentery unanswered; but the fact of the operation having been performed is clear, as we and peritonitis” caused by having taken have the skeleton of the woman and skull some drastic abortifacient? This possi­ of her foetus in the museum of the Ob­ bility was not mentioned by Dr. Mills. stetrical Society of this city. The woman The last two cases to be mentioned in was a white dwarf, only 3 feet 6 inches this paper occurred on the coast in 1875 high, with a reniform, rachitic pelvis, and 1879. which deflected backward at the sacro- The first patient was an Irish woman, vertebral angle, and having a conjugate aged twenty-one, scarcely four feet tall. diameter of one and three quarter inches, She was married, a primipara and on and a transverse of four and a half inches. May 1, 1875, she consulted Dr. James How long the woman was in labour, how Parrish of Portsmouth as to the possi­ long survived the operation, and what bility of her being delivered at term, she died of have not yet been reported. Craniotomy was attempted before cae­ and was advised to have an sarean section, and the foetal head bears produced at once. For religious scruples the mark produced by a pair of Smellie’s this was declined. She went into labor scissors in the posterior part of the left September 10, 1875, and called a mid­ parietal bone; but it was found impossible wife “who used ergot freely.” Later Dr. to manipulate, in consequence of the axis Charles McAlpine was called and on of the superior strait striking the abdomi­ the 14th he called Dr. Parrish, who nal wall one inch or two above the sym­ found her exhausted and with a pulse physis pubis—the angle of inclination be­ of 120. He operated and removed a tween the vertebrae and pelvis, usually dead fetus. The woman died eight about 150° being brought to a straight hours after operation, death being at­ line. tributed to hemorrhage from postpar­ The dwarf bears the evidence of rickets, in an anterior bending of the ossa hu­ tum gaping of the uterine wound. The meri, just above the elbows; but her lower obstacle to natural delivery was a de­ extremities are straight and strongly formity of the pelvis connected with built. In life she is said to have been quite ankylosis of the right hip , the fat. She was of feeble intellect, although thigh being fixed nearly at right angle the head is apparently well developed, with the pelvis. The tenth and last case in the period cold, windy day,” Dr. Boutelle returned covered by this paper was operated with Drs. W. Semple and J. H. Peck as upon in the old town of Hampton by assistants. The girl’s mother and friends Dr. J. T. Boutelle on January 20, 1879. insisted that an attempt be made to de­ He was called on the 19th after the pa­ liver through the vagina before pro­ tient, a twenty-two year old negress, ceeding with the operation. She was had been in labor more than two days anesthetized and “with considerable with a midwife attending her. He found difficulty forceps were carefully intro­ her in “pretty fair condition, pulse of duced and applied to the head. Trac­ good strength, but rather quick.” Exam­ tion was then made not with any ex­ ination disclosed pectation of delivery, but rather to see . . . the outlet very narrow, the rami whether the head could be brought any of the pubes making an acute angle, and lower. It was found to be immovable the tuberosities of the ischia only two and and the forceps were removed.” a half inches apart. The mucous mem­ A six inch incision in the linea alba brane of the vagina greatly thickened, and was then made, the intestines were crossed by two or three fibrous bands pushed back, and the uterus was which projected like ridges. The bands opened, the upper end of the uterine were very firm, feeling like cartilage, the incision touching the lower border of upper one nearly completed a circle, and the placenta. An arm presented but at first I took it to be a rigid partially was pushed back and the foetus deliv­ dilated os uteri. Just above this band the vertex of the child’s head presented at the ered by the feet. “The uterus was ex­ upper strait feeling pointed and elongated. tremely dilated, showing no tendency to Another ridge passed longitudinally from contract, and hemorrhage was pro­ the outlet upward on the posterior aspect fuse. I put a piece of ice in the uterus of the vagina crossing the circular ones, and gave a hypodermic of fluid extract and a large vesico-vaginal fistula existed. of ergot in the thigh.” With more ice On inquiry I learned the patient had been in the uterus it contracted considerably delivered by craniotomy five or six years “but not enough to close the incision previously after a labour of eight days— from which blood poured furiously.” three physicians being present—and that After suturing the uterus with three silk the midwife on that occasion had cut stitches and compressing it with his some portion of the vagina with scissors hands, it contracted more and the hem­ before the doctors were summoned. orrhage ceased. He then sutured the Dr. Boutelle gave her a third of a abdominal wound except at the lower grain of morphia and went home, re­ angle, through which he brought out turning several hours later with Dr. the ends of the uterine sutures and in­ Semple as consultant. They decided serted a greased cloth tent. The ab­ that in view of the narrow outlet and domen was dressed with a compress, a the condition of the vagina, craniotomy thick layer of cotton and a bandage. would probably inflict severe injuries The patient rallied quickly from the on the mother and cesarean section anesthetic, but she was chilled and had would probably be the better operation. a feeble rapid pulse, which improved Her strength being good, they decided upon the administration of ergot and to administer morphia as needed dur­ opium and external heat. Her condition ing the night and wait until the next was good the next day; the wound morning to operate. looked good when the soaked dressings The next morning,” an exceedingly were changed, and there was no bleed­ ing. She died suddenly that night, ap­ tipara in labor with her twelfth child. parently from an internal hemorrhage. Dr. Patterson writes: The child was alive when delivered, I had frequently attended this lady in but breathed only a few times. Dr. her antecedent confinements, and there­ Boutelle remarks: fore had no about her, since I knew her to be strong and healthy, of full One of the chief points of interest in size and well developed pelvis, and that this, as in many other recorded cases, is, her accouchements were easy of perform­ that it was not the severity of the opera­ ance and safe. I found her in active la­ tion, but the lateness of its performance, bour, and on making the primary digital which caused the fatal result. ... At all examination, to my great surprise, was events, to the delay of the first two days unable to find any os uteri. I most care­ must be attributed the inertia of the fully searched in every direction, and in uterus, which was the cause of the violent various postures of the body, for it, until hemorrhage during the operation, and I became satisfied it was not to be found, also of the sudden relaxation and sec­ but that the uterus had undergone some ondary hemorrhage which carried off the organic change, and the os had suffered patient. It is reasonable to suppose that entire occlusion. she might have recovered had it not been He recalled that two years previously for this cause, as she did remarkably well she had had “an active inflammation for a day and a half after the operation. and ulceration of the os uteri, but was While not following the technique of entirely cured by the use of leeches, rest the formidable operation devised by in bed for several months, and cauteriza­ Diihrssen in 1895, and later named Der tion with nitrate of silver, and Church­ vaginale Kaiserschnitt, the three cases ill’s tincture of iodine.” of cervical incision done by Dr. W. A. Dr. F. B. Deane was called in con­ Patterson of Richmond do come under sultation, “and after an equally patient the term of “vaginal caesarean section” investigation, concurred fully in the as used in the eighteenth century, and opinion as to the obliteration of the os as a matter of history are included here uteri, and the necessity and propriety but are not counted in the summary of incising the womb where the os of the results of the ten cases of ab­ ought to be found” before rupture of dominal reported above. the walls of the uterus ensued and His first case was on November 4, death. With a long handled scalpel 1848, on a white primipara twenty-nine through what seemed to be a soft spot he incised the uterus downward towards years old, after a hard and exhausting the recto-vaginal junction, and then “a labor of more than sixty hours had bold cut through its walls towards resulted in only a two inch dilatation. the symphysis pubis. . . . The waters He made “a free incision just behind gushed out, accompanied or rather the symphysis pubis, and one of like followed by several ounces of blood.” kind opposite both the right and left A few hours later she was delivered of a acetabula.” Some forty minutes later healthy child but whose scalp had been she was delivered of a large male in­ lacerated for about an inch by the fant, but owing to a tightly wrapped knife. After the first week of con­ cord around the neck, it was asphyxi­ valescence he passed his finger through ated and lost. the cervix daily, and later a large sized His other two cases were on May 11 metallic bougie was passed through the and July 8, 1855. The first a white mul­ os and cervix into the womb for some time after the suspension of all lochial hour later she was delivered of a feeble discharge, to prevent union by cicatriza­ child that lived four days. “The mother tion. speedily recovered; is now perfectly Dr. Patterson reported that this was well, and makes an excellent wet the second case of complete occlusion nurse.” that he had seen; the first one, who had He remarks upon the rarity of such been attended by another physician sev­ cases in proportion to the total number eral years previously, had died two days of , and concludes that the ob­ later from “gangrene the result of long servation of his own three cases, and continued and useless pressure before the one in consultation, “serve to operation.” strengthen and fortify the practice of His second case was that of a negro early vaginal hysterotomy in all such servant, whom he had been called to see cases.” six months previously for a prolapsus The plane of obstetrical practice in uteri, at which time he found “the cer­ Virginia was no lower than that in vix uteri protruding beyond the vulva, other parts of the country, but when we soft, elongated, patulous, so that the think of the terrific damage disclosed finger could pass easily its whole by some of these cases as the result of length.” She was treated by rest in bed previous confinements in the hands of with a “charred wood pessary” and later inadequately trained midwives and in­ “a gilt globe pessary” which was more different practitioners, we wonder why satisfactory. Some weeks later he found more women did not die in . the uterus enlarging and containing In 1870 Dr. Robert P. Harris of Phil­ some solid body, but was unable to say adelphia began collecting from every whether it was a fibrous growth or a available source data of all the cesarean pregnancy, which the girl persistently operations that had been performed in denied. When called in July to deliver the United States. These were gathered her, he found her in active labor, the from the published reports, and from cervix just within the vulva and dilated the operators, if living, or other physi­ “to about the size of a shilling,” and cians and reliable witnesses who knew the head down low in the lower strait. about the cases. By July, 1878, he had Passing the finger through the os he collected records of eighty-nine cases, found the “cervix and parts all around twenty-eight per cent of which had it hypertrophied, thickened and very never been reported in the journals. hard; and it was most obvious that no He carefully excluded all ectopic cases impression was made on the os and cer­ and those in which the foetus had been vix by the parturient throes, and that removed from the general abdominal delivery could never happen in this cavity where it had probably escaped state of things, without a tearing off of from a ruptured uterus. In his report the os and cervix from the body of the in July, 1878, he says: womb.” He then called Dr. Haxall in We have now presented reliable rec­ consultation, who concurred in this ords of eighty-nine operations with a sav­ opinion. Dr. Patterson then passed his ing of thirty-eight women, and forty-four finger as a director and incised the cer­ children delivered alive, of which thirty­ vix for an inch and a half posteriorly, eight are still living after some time. We and a similar incision of the same length have heard of seven more cases through anteriorly. “The substance cut had a correspondents, but satisfactory particu­ hard and gristly feel.” About a half lars have not reached us yet, except as to the results to mother and child. The districts and small villages far from hos­ whole collection would number ninety- pitals and surgeons of known ability. six operations with a saving of forty-three In 1932 Dr. N. J. Eastman published and three-fourths per cent of the women in the American Journal of and children. and Gynecology an article on “The His records show that forty-six had Role of Frontier America in the De­ deformed pelves, most of them being velopment of Caesarean Section,” in dwarfs ranging in height from three which he says: feet two inches to four feet six inches, twenty of them surviving. After analyz­ In Great Britain and Ireland the mater­ ing the entire series Dr. Harris con­ nal mortality from the operation had cludes that with timely operations mounted by 1865 to the appalling figure before the patients are exhausted by sev­ of eighty-five per cent. In Paris during the eral days of labor, and without med­ ninety years ending in 1876 not a single dlesome attempts at forceps and embry­ successful caesarean section had been per­ otomy deliveries, a larger percentage formed. The results in Germany, Aus­ tria, and Italy were so poor that the newly would have been saved. He discusses at introduced operation of Porro, which in­ some length the comparative results of cluded as well as the removal cesarean section in Europe and Amer­ of the child was superseding the old and ica, and is amazed at the vastly greater almost universally fatal caesarean section. success of the American operators, espe­ Indeed it seemed that the farther from cially as the majority of the American civilization the operation was done, the cases were operated upon in the country greater the likelihood of success.

References Am. J. M. Sc., 8:257, 1836. Steth. & Med. Rep., 1:425, 1856. Ibid., n.s. 12:386, 1846. Va. Med. Monthly, 6:186; 370, 1879. Ibid., n.s. 75:313, 1878. Ibid., 3:433, 1876-77. Ibid., n.s. 76:68, 1879. Ibid., 55:711, 1929- Am. J. Obst., 6:650, 1872. History of the Great Kanawha Valley, 2:265, Va. M. ir S. J., 2:264, 1854. 1891. Va. Med. J., 7:203, 1856. Am. J. Obst. 6* Gynec., 24:919, 1932. Ibid., 7:170, 1856. Mss notes by Dr. Bennett, in Baudelocque, Ibid., 6:1, 1856. p. 71, 1801.