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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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