The Caesarian section or operation; also called hysterotomia, and hysterctoma-tocia. It is the operation whereby the foetus is extracted from the uterus through the teguments of the belly. It is called the Cesarean operation, from Julius Caesar, who is said to have been brought into the world this way; or from Caeso, who was the first thus taken from his mother's womb.

There are three cases wherein this operation may be necessary. - 1. When the foetus is perceived to be alive, and the mother dies, either in labour, or in the last two months. 2. When the foetus is dead, but cannot be delivered in the usual way, from the deformity of the mother, or the disproportionate size of the child. 3. When both the mother and the child are living, but the same difficulty attends as in the second case.

Many instances have occurred, in which it has been said that both the mother and child have lived after this operation, and the mother borne children by the natural passages. Heister gives a very distinct account of this operation in his Surgery; and of its success in his Institutes of Surgery, p. xi. § 5. cap. 113. See also Mem. de lacad. Roy. de Chirur. vol. i. p. 623. ii. p. 308. Edinb. Med. Essays, vol. v. art. 37 and 38.

Notwithstanding the many successful cases given by different authors, still it appears very probable that most of them have been extra uterine, if we consider the very rare success which has attended the operation in cases where the foetus has been extracted really from the uterus; for in almost every case which has occurred in England, the operation has proved fatal. It was, however, performed by Mr. James Barlow, of Chorley, Lancaes . 302 C A J

Cashire, where the foetus was taken from the uterus by the Caesarean operation, the woman was preserved, and recovered her perfect health. See Dr. Haighton's Inquiry concerning the true unci spurious Caesarean Operation; and Mr. Barlow's Account in the Medical Reports and Researches, 1798. It is singular, that in the old authors it is said to have been performed frequently with success, and, in some instances, repeatedly on the same woman. We must confess, that we feel no little scepticism on this point, though we cannot see what reason there should be for imposition. The dangerous nature, however, of the operation, even in the best hands, with every assistance, forbids us to believe that it could have succeeded by the rudest means.

To determine the necessity of the operation, the size of the pelvis should be carefully examined. It has been supposed, that if the aperture in any direction was less than two inches, or two inches and a quarter, delivery was impracticable. It has, however, been more lately found, that in a pelvis of an inch and three quarters, delivery with the crotchet might be effected, and, in some instances, even through a less aperture. Delivery, therefore, should scarcely in any instance be considered as hopeless; and almost every attempt should have failed before the Caesarean section is practised.

If the woman is exhausted and in a dying state while the child is alive, we should certainly attempt to save the latter; but, in general, the life of the mother is by far of the greatest importance. When the child is dead, we should at least wait till we find every effort with the crotchet has failed; though in this difficult emergency, we must occasionally balance between the probability of success in delivery, and the only possible chance the woman can have by attempting the operation before her strength is too far exhausted.

It should not be recommended if the woman is living before she falls into labour, and yet it must be attempted before she has suffered much by her ineffectual throes; for when she is much reduced, the operation is almost sure to be fatal.

To perform this operation, having previously injected a clyster, lay the woman on her back, place a pillow under her right side, to turn the uterus as much as possible on the left; then the operator must make a longitudinal incision, beginning as high up as the navel, on the outside of the linea alba; and carrying it down in an oblique direction towards the ileum, he must cut carefully through the muscles of the belly, and through the peritonaeum. He must then introduce a finger into the abdomen, which must be carried along before the point of the knife, in order to prevent the vagina from being wounded. The incision is usually directed to be on the left side, for fear of wounding the liver, though there seems to be more danger of the omentum, or a flexure of the intestines; because as the uterus rises up, it carries the viscera above it, and to each side, but the omentum is frequently found lying between it and the parietes of the belly. The incision into the uterus must be longitudinal, and as long as the external wound will admit, taking care not to wound the Fallopian tubes; the child must be taken out at the incision, and after it the placenta and membranes; blood must be absorbed with sponges: the wound in the uterus must be left to nature, for by its contraction it will be brought into about an inch and a half in length. The external wound is to be sutured with the interrupted stitch, and then to be dressed as in general. If any considerable vessels arc cut through, they should be taken up. We have already observed, that this operation is highly dangerous and very generally fatal. The danger sometimes arises from its having been too long delayed, often from internal haemorrhage, but more generally from the inflammation excited, and the irritation occasioned, by the access of the air.

In the Lond. Med. Observations and Inquiries, vol. iv. p. 261, is an instance of this operation, which, though unsuccessful, merits attention. In this case the incision was made on the right side; and it was observed that the woman complained but little during the operation, except when the needles passed through the peritonaeum in making the sutures: and that the uterus seemed very little sensible of any injury done to it. It is noticed in the remarks on writers who have described this operation, that there is very little satisfaction to be obtained from them; that all they relate is very vague; and that it is indifferent on which side the incision is made, further than as some present circumstance may determine; that the haemorrhage spoken of by Heister is not so much to be dreaded as he intimates; that the course of the linea semilunaris, as nigh to the outer edge of the rectus muscle as possible, seems to be the most eligible place for the operation.

Pare, Guillimeau, Rolfincius, Hoorne, Mauriceau, Solingen, and some others, are violent opposers of this operation; but they only object to it in certain cases, where they thought the practitioners too rash in the attempt. As a substitute for it, the section of the symphysis of the pubes is proposed. (See Pubis ossa). Another proposal has been lately offered, that in women whose pelves are distorted, and labour supposed to be impracticable, an attempt should be made to bring on delivery at the end of the seventh month. This, however, is an expedient highly difficult and dangerous, though less so than the operation. It involves, however, many considerations not strictly medical, which we must not pursue in this place. See also an Account of the Caesarean Section by Dr. Vaughan of Leicester. Bell's Surgery, vi. 446. White's Surgery, 451. Osborne's Essays on the Practice of Midwifery. Denman's Midwifery.