On Craniotomy: Mr. Cox's Case of Cæsarian Section
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Transcript of On Craniotomy: Mr. Cox's Case of Cæsarian Section
BMJ
On Craniotomy: Mr. Cox's Case of Cæsarian SectionAuthor(s): Frederick CoxSource: Provincial Medical and Surgical Journal (1844-1852), Vol. 8, No. 35 (Nov. 27, 1844), pp.543-544Published by: BMJStable URL: http://www.jstor.org/stable/25498246 .
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CRANIOCTOMY. S43 small veins w're observed to contain globules, which miorvd '
tardily as possible, and sometimes stopped entirely, A circulation equally' lo was maintained in the larger ves'l ofthe part ,The web was then
punctired thr-b h, and the circulation was unaffected
by the niury." T'he right web was then examined, and the circula
tion was there found to be equally slow.' The diameter 4o the vessels was natural where circulation was ob
servable; but where it had ceased and the vessels were empty, no capillaries were to be seen. The vsible vessels. were equally few in both feet. The web was then punctured through. The animal made a vast effort at escape.
For a minute the circulation ceased altogether. It wat soon re-established with increasing velocity, and was shortly as rapid as in health, both around the
puncture, and in each of the divisions of the web. After an interval the circulation was retarded around the. puncture, but continued to be rapid elsewhere.
In an hour the circulation was proceeding as before in the sound limb, but had made no advance in the other.
Five hours later the circulation was still brisk, and
generally difsed in the healthy web; brisk in several pats, tardy in others in the' paalysed. Fifteen hours
ltet the circulation was nearly equalized, and nothing new was obseivable.
A little reflection will show that these results are of some importance. They involve the discovery that the sensitive nerves at their termination, though not
Dssentiai ! to the maintenance of the 'capillary circu lation, may, neverthe ss, exert an important influence over it when they are excited. Their influence is local, for had it been reflected in a manner to increase the force of the heart, it would have been felt in the
web of both feet equally. It would thus almost seem that an afilux of nervous power to a part, as in
vital turgescence or blushing (iX.), exerted an affinity for the blood.
That the blood should traverse the capillary vessels unchanged, as authenticated by several observers, if such a fact be capable of ocular demonstration, must not be passed over unnoticed. The change of blood. from arterial to venous is a chemical phenomenon, and is caused, on the authority of Liebig, (' Theory of Respiration,") by a conversion of peroxide of iron into carbonate of protoxide in the capillary vessels. If these changes are suspended animal temperature ceases to be generated in the part.
The bloodglobules coalesce during congestion, not owing to reduction of animal heat; for they do not immediately coalesce even on removal from the vessels themselves; not indeed until they have been isolated for a sufficient length of time to become obnoxious to chemical changes; an agency which pro bably gives rise.to their coalescence in congestion ?
The arrest of secretion is best explained by a consi deration of the fact, that remora and stasis are condi tions of the circulation best calculated to favour secre
tion, ald that in active congestion the torrent of the circulation is increased. The influence which the condition of the nerves exerts will be examined under the head of inflammation.
(To be costiWed)
ON CRAN1OYOMY : MR. CO "'CAtS `OF t $AlIAN SECTION.
TO THE EBMTOR OF THE PROVINCIAL MDICAL AXp
SUBxIAL: JOURNAL.
SIR, I am tempted- once more to trouble you, requesting
you to allow the insertion of the following :explana. tory remarks relative to my recent case of Csara
operation, called forth by the letters of Mr. -Kinrla and Dr. McEgan. I must premise that I by no meas
regret the appearance of th ese s ehrvations; on the other hand, I am pleased to see them, my object in
publishing the case being to elicit, if it shbod ean. mand sufficient interest and attention, the. opimi A of
my professional brethren. It is by controersie.; pon difficult and doubtful points of practice, that science is
advanced,. and the truth established; and as lenga the dispute is carried on in a fair and gentlemanly spirit, it matters not who goes to the wall, the great human family being the gaisers. I am much pleased with the generous tone of Mr. Knowles's remai4c.; it is pleasant to have such a man for an opponent, and it
must be very delightful to find him our ally. A fair estimate of the success or failure of an operation or
plan of treatment, can of course never be obtained unless all the cases are honestly laid before thepro fession. It unfortunately happens that too many are
apt to withhold the unsuccessful and make known only those of fortunate termination, letting the world into the secret only of what- .
" Strangely visited people, The mere despair of surgery,. they'cre."
To my thinking, the man who' would shrink f*ro the fulfilment of an unpleasant obligatim his duty imposes on him, solely from the consequence to :hime
self, is unfit -to practice thatprofemion, tagreat win of which is the prolonging of human life, ?idX tei relief of human suffering; and the sooner he employshis talents in another sphere, the more conducive will it be to the dignity of his profession and the best interests of humanity. I must say it too often happens that censures and critiques follow the publication bf unsue. cessful eases from men not altogether qualified by years and experience to issue them. PFrom men, who, to speak figuratively " Never set a squadron in the field, " Nor the division of abattle knows " More than a spinster; unless the bookish theorick," Now for a few words in my own defence.-Mr.
Knowles says, " It is much to be regretted that the consultation was deferred until eleven o'clock." I
will just give him a little insight into the difficulties that beset a country practitioner. About nine p.m., on the night the woman was taken in labour, I sent to
my friend Mr. Williams, of Guilsborough, five miles
distant; he was not at home; thinking he might have
gone to dinner at Northampton, I sent again, bidding my servant await his return, if expected, or, if iir. Williams were at a case, to follow him. He was attend
ing a lady four miles from home, and coula not obey
my summons. It was now between one and two o'clock a.m.; I then sent to Lutterworth, another
eight miles distant, but fruitlessly.' Mr. Colson felt diffident about acting without a third opinion, and so
did-I, for we did not arrogate to o0uhrsvei the belief
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544 CURA$I0OTOMY.
th t we were Nestors in age. or wisdom accordingly Mr. Colston himself started to Har-orough, another
eight miles, and returned with Mr. Francis. How had
the pbor 'woitrdu been all this tine ? Why, truly she
had had pains allnight, but of tdch a character that I
have seen many women bear the kind two or three
days in a first labour without anything like exhaustion, and such as would not advance the child much, even in a capacious pelvis; and she had slept at intervals. Mr, Francis thought the pelvis a little larger than I did, and after much thinking and anxious speculation, we
agreed to attempt delivery by embryotomy, as affording the best chance for the mother. And ndw for autho
rities to justify the attempt; The pelvis was from one inch and a half to one inch
and five.eighths in the short, and as large as usual in
the long diameter. Dr. Osborne did deliver a woman
whose pelvis did not exceed one inch and a half in the
sort diameter, and she lived. Mr. Knowles suspects D. OsbOrne was wrong in his measurement; I do not
iee' ;ythe correctness of his judgment or veracity bshiold be doubted, and* must claim him as an autho
rityon my side. IThe talented and accomplished Dr.
Lee,-in his recently published lectures says, (showing a
pelvis to his class), " When you look at this distorted
pelvis from malacosteon, which measures only one
Inch and three quarters from the last lumbar vertebra
to the sympbysis pubis, and know that two children, it the full period, were drawn through it, without
destroying the mother, you may conclude that few
cases of distortion can possibly occur, where you will not ultimately succeed in effecting the delivery with
the crotchet." ? Now the pelvis, in this case, measured, when in the dissected state, one eighth of an inch more' than in mine, and surely not more than mine in the
living woman; and here let me observe, that the man
who pretends to such exquisite sense of touch, that he
ean tell to the eighth of an inch the size of a pelvis, with the fingers necessarily cramped, possesses a trea
sure that Ido not, nor many of my brethren lay claim to.
Dr, Lee again says, "Wherever thepresenting part can
be reached, Qt apply the perforator and crotchet, an
attempt should always be made to deliver, and the
Cassarian operation reserved for those cases in which the distortion is so great that the os uteri and pre senting part are entirely beyond reach." Again, says the same high authority, " I would draw an entirely different conclusion, and in all cases, whatever the
degree of distortion might be, either in the brim or outlet of the pelvis, attempt to deliver by embryotomy where the presenting part could be reached by the
finger, and the crotchet applied." Mr. Barlow says,
" where the pelvis is from two and a half inches to one and a half, delivery should be
completed byembryotomy." I could quote other autho rities to justify the practice, but I consider the opinion of so eminent an accoucheur as Dr. Lee, a host; while the fact of his having twice delivered a woman posses sing a pelvis certainly not larger than in my case, at the full time, is a triumphant refutation of the assertion, that it is an impracticable proceeding. Mr. Knowles himself says, that " when the sacro-pubic diameter of the pelvis does not amount to one inch and three
quarters, delivery can rarely be effected by craniotomy, wigl any probability of safety to the mother." We are to iifer f(rm a th4j that be thinks it may sWe.ow
be successful with a pelvis one eighth of an inch larger than Brooks's. I must say this seems to me, drawing a very fine distinction, one that reads nicely, but can
not be of practical value, unless it were possible to
define exactly to a line the size of the pelvis and the
child's head, neither of which can be done. As Mr.
Knowles considers craniotomy may sometimes be suc
cessful with a pelvis of such a size, I contend every woman should have the chance and benefit of the sometimes.
Dr. McEgan principally condemns my practice, because he is an enemy to needless craniotomy. Why, no sane man would ever perform it, if he were certain
it was needless; but, very few, perhaps none-unless
fond of displaying and puffing great surgical deeds, would hesitate to adopt it in a case of doubt, and give the mother the benefit of the doubt.
I must ever be an enemy to the Cesarian section, from a conviction of the 'almost insurmountable
changes attending it. I must honestly confess, that I
do not believe Brooks would have recovered, had
delivery by craniotomy not been attempted, because,
although of course that operation tended to weaken
her, neither my colleagues nor I considered her more
than temporarily depressed by it-indeed, in half an
hour, she was as cheerful, and her pulse as good, as
ever. I firmly believe, had the operation been per
formed twelve hours 'earlier, she would have sunk just as rapidly, for the prostration following it is not one
of degree, depending on the previous strength of the
patient altogether, but the effect of a tremendous
shock caused by an almost certainly fatal operation, which must be and has been felt, alike by the feeble
and the strong, by the giant and the dwarf. I con
tend the Caesatian section should never be reforged
to while any reasonable chance remains of delivery
by other means. I have proved,-at least I think so,
that craniotomy holds out a reasonable chance of suc
cess; and in my case it was tried. Dr. Lee's case and
statements put my mind at rest as to the correctness
of the proceeding, and justify the deed to myself, and
I hope, to many of my professional brethren. I am
convinced the poor woman would have died under any circumstances, even had the Cesarian operation alone
been performed and performed earlier, and then I
should have expected, and certainly should have met with a host of assailants, for not having given my
patient the chance of delivery by embryotomy. This is just one of those cases of difficulty and nicety that, terminate as it will, is sure to be condemned, and I comfort myself with' the conviction, that it is more
consistent with human nature to censure and condemn
than justify or palliate, while I am strong in the belief
that in medical affairs it is much easier to criticise the
doings of others in dangerous and difficult situations, than to act for themselves in similar emergencies.
I remain, Sir, Your much obliged servant,
FREDERICK COX. Welford, Nov. 15, 1844.
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