The rôle of frontier america in the development of cesarean section

w ITH the present year the so-called modern era of cesarean section concludes its first half-century; and were one asked in what respect obstetrics has advanced most conspicuously during these five decades, one might fittingly point to the revolutionary changes which have occurred in the indications, the technic, and the prognosis of the eesarean operation. Throughout the greater part of the nineteenth century, cesarean section was the most fatal of surgical procedures. In Great Britain and Ireland, the maternal mortality from the operation had mounted in 1865 to the appalling figure of 85 per cent. In Paris, during the ninety years ending in 1876, not a single successful cesarean section had been performed. The results in Germany, Austria, and Italy were so poor that the newly introduced operation of Porro, which included hysterectomy as well as removal of the child, was superceding the old and almost universally fatal cesarean section; the Porro procedure, it was claimed, saved more than half of the women subjected to it. As late as 1887, Harris noted that cesarean section was actually more successful when performed by the patient herself, or when the abdomen was ripped open by the horn of an infuriated bull. He eoNected nine such cases from the literature with five recoveries, and contrasted these with twelve cesarean sections performed in New York City during the same period, with only one recovery. In the face of such results, it is not surprising that many obstetricians of the nineteenth century doubted the wisdom of ever resorting to cesarean section, and predicted that the operation would shortly lapse into desuetude. The turning point in the evolution of eesarean section was clear-cut and decisive. It was the appearance in 1882 of a monograph by Max Siinger, then a twenty-eight-year-old assistant of Crede in the University Clinic at Leipzig. The title of the work, “ Der Kaiserschnitt bei Uterusfibromen nebst vergleichender Methodik der Seetio Caesarea und der Porro-Operation,” scarcely suggested its real purpose, which was to recommend in cesarean section the routine employment of carefully placed uterine sutures. “The salient consideration in the proposed improvement of the classical cesarean section,” he urges, “is without doubt the treatment of the uterine wound”; and through two hundred pages he evolves, amplifies and substantiates this same theme. The history of the uterine suture, the advantage of the buried uterine suture, the best material for sutures-these were a few of the many aspects of the subject which received detailed attention. In particular, Ringer deprecated the growing tendency to abandon the old classical cesarean section in favor of the new Porro procedure, since he believed that careful coaptation of the uterine wound with sutures would obviate all difficulties and permanently establish the superiority of the older operation. Such views were new, for neither in Europe nor in England had uterine sutures been considered necessary. His opinions were at variance, moreover, with the dictates of the most experienced operators of the time--and, let us remind ourselves, Singer’s experience had been limited to but one successful case. His contentions, however, were supported by