ANDISON: (½ESAREAN SECTION.,

CAESAREAN SECTION*

A. -W. Andison, M.D., M.R.C.O.G.(Lon.)Winnipeg, Man.

IN reeent years, due largely to improvementsin technique the safety of Caesarean section

has markedly increased. This has resulted in

a widening of its indications, so that todaythere are few obstetrical complications whichmay not, on occasion, be best dealt with byabdominal section. Cephalopelvic dispropoi-tion, while still an important reason for itsperformance, does not exceed by such a widemargin the other indications in any series ofcases. But while this might suggest a greatlyincreased incidence of the operation, actuallythis need not 'be so., With the more frequentemployment of trial labour as a means of deal-ing with cases of apparent disproportion, manypatients who formerly might have been de-

livered by elective Cesarean section are todaybeing allowed to deliver themselves vaginally.On the other hand, having confidence in the out-come for the mother, we can give more con.

sideration than was formerly possible to thefetus. So we find Caesarean section being done,and justifiably, 16or some cases of prolapsedcord, for types of placenta previa other thancentral, and for certain cases of malpresenta-tion. Cesarean section is now a safer, methodof delivery for mother as well as for her child,than a difficult forceps extraction.As a basis for the remarks in this com-

munication I wish to use a series of Caesareansections performed during the six years 1940to 1945 by myself, or by a resident doing theoperation with my assistance. The cases are158 in number. Of these, more than half were

performed in the Maternity Hospital of whichI had the complete charge; the remainder were

done in three other hospitals to which I actedas consultant. This is a very modest seriesand too small to warrant any detailed statisti-cal analysis. I wish to use it therefore merelyas a starting point for some reflections on theplace of Caesarean section in modern obstetri-cal practice.At the outset, let us consider whet should

be the incidence of CoesarEan section in any

* From the Department of Obstetrics and Gynscology,University of Manitoba, Winnipeg, M'an.

Division of Obstetrics and Gynsecology, WinnipegClinic, Winnipeg, Main.

well run maternity hospital. According toStander, it should not exceed 4% and in privatepractice it should be much lower. There are

not a few institutions where this figure isgreatly exceeded and rates as high as 8 or 10%.are reported from some hospitals in the UnitedStates and in Great Britain. One cannot butbelieve that such figures as these indicate a

distorted view of the place of Caesarean sectionin midwifery. When one considers that one

woman in ten or twelve is delivered by an ab-dominal operation, one is forced to concludethat a valuable procedure and obstetriciansthemselves are being brought into disrepute.It needs to be emphasized and re-emphasized,that delivery by Casarean section is still a

more dangerous method for the, mother thandelivery per vias naturales for one still en-

counters doctors, not to speak of patients andtheir relatives, who consider it the simplest wayout of any difficulty that-may develop in mid--wifery. Reports from various centres showmaternal mortality rates as high as 5%o. Ac-cording to Aleck Bourne the mortality risk ofCaesarean section even in selected cases, is fourtimes that of labour. In a study of cases per-

formed at the Winnipeg General-Hospital madeby Ross Mitchell in 1938, the death rate fromCaesarean section was 6 times that of thegeneral rate. In a recent detailed study ofCaesar-ean section mortality made by Dieck-mann of Chicagoi it is claimed that in favour-able circumstances ana when the operation isdone by skilled operators the maximum totalmortality rate should be 0.5 to 1%o, still ap-

preciably higher than the rate for vaginaldeliveries.There is not only the question of mortality to

be taken into account. There is a good deal ofevidence to suggest that the performance ofa Caesarean sectionoreduces a patient's fertility.Even apart from this, once a section has beenperformed, there is a strong likelihood that thenext pregnancy will have to be terminated bythe same method, when, in very many cases

sterilization will be carried out as well. More-over there are few obstetricians 'who willpermit their patients to undergo more thanthree sections. It follows, then, that if a

woman has a section for her first pregnancy,the size of her family is likely to be seriouslyrestricted.

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In six years in which I was ill charge of thleMaternity Hospital of the Prestoni Royal Ini-firmary there were 113 sections in 5,133 cases,or an incidence of 2%Ho and in the last year ofthe series there were only 17 sections in 947cases, that is, a frequeniey of only 1.8%. Thisfigure includes all cases, booked anid emergency.

In the 158 cases there were three maternaldeaths, a relatively high rate of 1.9%.

The first of these occurred in a woman of 26, ad-mitted to hospital at the 24th week in her first pregnancybecause of congestive heart failure, the result of arheumatic infection. She made a reasonably good re-

covery with rest in bed and digitalis, but was keptin hospital continuously until the onset of labour.About the 34th week her cardiac condition began todeteriorate and at the 35th week she started in labour.Although the baby was small, it was consideredadvisable to spare the mother the exertion attending avaginal delivery, so a lower segment Casarean sectionwas performed under local anasthesia and a living child,weighing 2 pounds 15 ounces was delivered. Themother's condition was not satisfactory throughout theoperation and shortly after its conclusion left ventricu-lar failure became evident and death occurred threehours later.

The second maternal death was in the case of a womanwho had already had one classical Caesarean sectionbecause of disproportion. At the second operation, doneunder ether anwsthesia prior to the onset of labour, theabdomen contained very many adhesions, making expo-sure of the lower segment very difficult, therefore aclassical incision was made and a living mature childwas delivered. The mother made an apparently satis-factory recovery and was afebrile. On the eighth day,while sitting in bed nursing her baby, she suddenlycollapsed and died within a few minutes. Autopsyconfirmed the obvious clinical diagnosis of a largepulmonary embolus.

The third fatal case of the series was the only one tooccur in my own hospital. The patient was a bookedcase, a primigravida admitted at the 34th week. Shehad last attended the ante-natal clinic about 10 dayspreviously, when nothing unusual had been noted. At7 a.m. on the day of admission she was found lyingunconscious on the floor of her home and was sent into hospital as a case of eclampsia. On admission shewas stuporous, there was a moderate cloud of albuminin the urine, the blood pressure was 150/90, no cedemawas present and the fetus was alive. She was given aquarter grain of morphine, but as the case presentedsome rather unusual features the usual routine treatmentof eclampsia was withheld pending further observation.Three hours later it was noticed that the pulse ratehad fallen to 52 and the patient roused herself suf-ficiently to complain of pain at the back of the neck.The true diagnosis was now apparent; a lumbar puncturerevealed almost pure blood in the subarachnoid space.As the day went on her condition deteriorated furtherand in the evening convulsive seizures supervened,Cheyne-Stokes respirations developed and it was obviousthat a fatal outcome was to be expected. With thepatient in a moribund condition, a classical Caesareansection was done under local anesthesia and a livingmale child, weighing 3 pounds 12 ounces was delivered.The mother expired 4 hours later; autopsy revealed aruptured congenital aneurysm of the middle cerebralartery. The child was successfully reared.

I believe that in such circumstances as these aCaesarean section done on a dying patient is to be pre-ferred to the post-mortem Cesarean section usuallyadvocated; certainly the prospect for the child is betterif the former is chosen.

In the series presented, 19 of the sectionswere of the classical type, the remainder, or 88%,were done through the lower uterine segment.The latter operation was used routinely for elec-tive cases as well as for those in labour. Theclassieal incision was reserved for patients inwhom the lower segment was inaccessible becauseof markedly pendulous abdomen, the capacityof the belly being extremely reduced as a resultof spinal deformity, or because of extensive ad-hesions. To argue here the advantages of thelower segment Cawsarean section should be super-fluous. To all modern obstetricians the classicaloperation is practically obsolete. Yet in spiteof the years of preaching the superiority of thelower seginent operation, notably by DeLee inAmerica and Marshall in England, there are

still too many classical operations being per-performed. It has been demonstrated repeatedlythat the maternal mortality for classic sectionis 3 to 4 times that of the lower segment opera-tion in the hands of the same operators. In theseries I present there was no death from puer-peral sepsis, even though in many instances themembranes had been ruptured for as long as

48 hours and even up to 84 hours.I cannot imagine any valid reason for failing

to employ the low segment operation as a routine.Technically it is only slightly more difficult thanthe classical section. It involves working in a

somewhat less accessible field, and requires theelevation of a peritoneal flap before incising theuterine musculature. It therefore takes a littlelonger time, but is a neater procedure, involvesless blood loss and is more satisfying to thesurgeon, apart altogether from its advantage tothe patient, than the old "smash and grab"classical operation. I have taught many hos-pital residents (within a reasonably short time)to do the operationl proficiently.

However, it must be admitted that onle doesencounter trouble more often in the lower seg-ment section. In some cases where the fetalhead is deep in the pelvis, it is no easy matterto dislodge it upwards and through the uterineincision, and it may take all the strength ofone s hand and forearm to accomplish. In suchcases as these, and also where the fetal head islarge, the uterine incision may extend to a seri-ous degree, making subsequent suture veryawkward. In the same circumstances one maytear into the greatly dilated veins of the broadligament, with resultant furious hawmorrhage.

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A very interesting error one can make is, in a

case where labour is well advanced and thecervix is almost fully dilated, to mista.ke theposterior lip of the cervix for the lower marginof the uterine incision. This may sound absurdand appear to justify censure for gross eareless-ness, but it is easy to do. It is a recognizeddanger and is described in Marshall's monographon lower segment Cesarean section.

Placenta prLevia is often conceded as.an in-dication for doing a classical section, even bythose who admit the superiority of the more

modern operation. With this I cannot agree.

If the lower segment method is safer -for cases,

say, of disproportion, it is more so for placentaprevia cases, since these patients have usuallyhad one, and often more than one vaginal ex-

amination before they reach the theatre tableand the risk of infection is correspondinglyincreased. What is the objection to the lowersegment operation in placenta pravia? Simplythat if the placenta is located on the anteriorwall one will encounter severe haemorrhage incutting through it. But surely the same situa-tion, i.e., the placenta underlying the uterineincision, is just as likely to be met with inclassical sections when the placenta is normally

situated in the upper segment. While it maybe a little more troublesome, it does not greatlyincrease the difficulty of the operation. More-over, the lower segment operation has the ad-vantage in those instances of placenta preeviawhere there is profuse bleeding from theplacental site after the placenta has been de-livered,-since the bleeding point can be accur-

ately distinguished and the haemorrhage checkedby appropriately placed sutures.

The most important advantage of using thelower segment operation is that it permits one

to intervene with safety after the patient hasbeen in labour. This means that in cases where,before labour, one is in doubt as to a successfuloutcome for vaginal delivery, ont can give thepatient a trial of labour. Since the great ma-

jority of such 'women do deliver themselvesvaginally or can be delivered by a relativelyeasy forceps operation, the'result is that one

does fewer sections, and many patients are

spared abdominal' delivery. The obstetricianwho does only elective sections (and if he doesnot practice the lower segment operation all hissections must perforce be elective, the risk ofsepsis following classical sections during labour

being prohibitive) may declare that his judg-ment is so accurate that he can select without-error, prior to labour, those cases that willdeliver vaginally and those who will not. I wishto state firmly, no matter who he is that makessuch an extravagant claim, that he cannot besure. He will 'always have a significant per-

centage of errors. In cases of moderate dis-proportion it is impossible to distinguish thosethat will require section and the others that willnot. I never cease to be amazed at the degreeof disproportion that can be overcome, granteda co-operative patient and strong uterine con-

tractions. In so many of the most unlikely cases

will an uncomplicated vaginal delivery ensue.

Of the cases here reported 67 were elective andoperated upon before the onset of labour, whilein 65 labour had been in progress a variablelength of time when the section was performed.In the remaining 26 cases the patient was notin labour but there had been ante-partumhawnorrhage.

ANRESTHESIAEther anesthesia was used more often than

any other ancesthetic agent, in 68 cases, induc-tion being by ethyl chloride or chloroform.Ether is far from being the best anaesthetic butit is often the only one available, when one hasto depend on house surgeons or general practi-tioners to administer the anasthetic. The par-

ticular objection to ether in Ceesarean sectionis that it makes for poor retraction of the uterinetmuscle following delivery, so that there is oftenvery free bleeding; one has to introduce one'shand into the upper part of the peritoneal cavityto grasp the uterus to express the placenta andto apply massage or compression, an undesirableprocedure when there is a possibility that thecase is infected. In many ways a general etheranaesthetic throws an additional burden on a

patient who needs all the energy she can summon

for her recovery.

My experience with spinal anesthesia has beenlimited; in only five of my cases was it used.Like many obstetricians I have been wary of itbecause of its condemnation in obstetrics byDeLee, who believed that pregnant women were

peculiarly sensitive to spinal analsthesia and thatto it alone could be attributed l1o of maternaldeaths from Casarean section. But it has beenpointed out before now that it is as important todistinguish among the different drugs used forspinal anelsthesia as it is among those used for

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inhalation aneesthesia. One would hardly con-

demn all forms of general antesthesia becausethere have been deaths from chloroform. Thereis good uterine retraction and very little post-partum heemorrhage with spinal ancesthesia andthese advantages make it a valuable method.A large p'ercentage of my cases were done

under infiltration anaesthesia. The actual num-

ber was 64, or 40%o. The drug used was novo-

caine 0.5%o and between 250 and 300 c.c. was

the amount usually required. In many respectsthis is the ideal mode of anaesthesia for Cm-sareaa section. Certainly no death due to itsuse has ever been reported. The uterine re-

.traction which occurs is most striking, thereis very little blood loss, often as little as 2 to4 ounces, and the placenta separates withoutdelay so that it can be withdrawn by steadytraction on the umbilical cord. It is thus themethod of ehoice if the patient has alreadysuffered from blood loss. There is never any

difficulty in resuscitating the fetus, whichusually cries as soon as the head is delivered.The postoperative course is undisturbed by any

complications due to the anwesthetic, there isusually no vomiting and therefore no strainput on the sutures. With its use one is assuredthat no additional handicap has been imposedon the patient's recovery. It is the method ofchoice in cardiac disease, in cases where thepatient comes to operation tired out due toneglect in a long drawn-out labour, in diabetesand in eclampsia. A diabetic patient can haveher usual breakfast, go up to the theatre an

hour or two later, be delivered under infiltra-tion anesthesia, then be returned to theward to have her usual dose of insulin followedby lunch, with no untoward disturbance. Ineclampsia, I am sure that a good part of theextremely high mortality associated with Cae-sarean section for that condition can be as-

cribed to the use of general anwsthesia. It isimptrtant to realize, of course, that in very fewcases of eclampsia is a Casarean section indi-cated, and I intend to discuss these indicationslater, but if an operation has to be done, localanesthesia is the only method to be considerea.

Local is not a suitable form of anaesthesiafor all patients. One would not select it whereany additional intra-abdominal procedure iscontemplated, such as removal of fibroids or

ovarian cysts. It is possible to ligate the tubesunder local anesthesia after first infiltrating

between the layers of the mesosalpinx, or

alternatively the patient can be given pento-thal a minute or two before the sterilizationis commenced. In the case of a very nervous,

apprehensive patient one would naturally con-

sider some other form of anamsthesia, althoughit is surprising how well behaved most women

are when they are told beforehand the advan-tages for themselves and their baby from hav-ing a local anwsthetic. Just before theoperation is commenced one can administermorphine gr. 1/6 or omnopon gr. 1/3. I havehad good success with demerol 100 mgm. com-

bined with scopolamine gr. 1/150 given 45minutes preoperatively, and another 100 mgm.

demerol with scopolamine gr. 1/450 admin-istered as the operation is commenced. Somepatients will remain asleep almost throughoutthe operation and have no recollection of itafterwards under this sedation.The operation takes a rather longer time

(usually an hour or slightly less, I find) underlocal anaesthesia than when other methods are

employed and of course one must exercise theutmost gentleness. It entails greater strain on

the operator but this is well worthwhile.More recently I have had the opportunity of

doing a group of sections, 18 in number, undercyclopropane anaesthesia. It has no depressingeffect on the patient, there is excellent uterineretraction and not a great deal of blood loss.The high percentage of oxygen given with thegas means that the fetus is generally in goodcondition. Despite this theoretical considera-tion there are occasions when the fetus seems

adversely affected and I had one case wherethe fetus was stillborn after an elective opera-tion when there had been no undue difficultyin delivery. It appears that pituitrin shock isgreatly accentuated when it occurs under cyclo-propane anxesthesia and may cause a fatality.Therefore one should use only pitocin or

preferably ergometrine, as an oxytoxic agentwhen using this form of anaesthesia.

INDICATIONS

When we come to consider the indicationsfor Casarean section in this group of cases, wefind, as is to be expected, that more were donefor disproportion than for any other singlecause. The total number in which this was theindication was 60. Of these, 34 were performedafter a trial labour and 26 were done as

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elective operations. In this latter group 11 hadalready had a previous section for dispropor-tion and 2 had a malpresentation as well as

pelvic contraction, so that in only 113 cases was

the operation done before the onset of labourbecause of gross disproportion alone. Two ofthese were done on the same patient, allachondroplasic dwarf with a diagonal coii-

jugate of 21/4 inches. Another patient was 3 ft.8 in. in height due to Pott's disease of thespine. A third had gross lunibar kyphosis andscoliosis with a pendulous belly. There was

one, a primigravida of 41, with a markedlycontracted outlet. I mention these to make itquite clear that our general policy was to giveall save very few patients a chance to demon-strate whether or not they could deliver them-selves vaginally. There are circumstanceswhen it is not possible to conduct a trial oflabour. A trial of labour means that a patientmust be under close and accurate supervisionby the obstetrician, in the constant care ofmidwives experienced in the management ofsuch cases. If the patient is in a hospital tenmiles away from the centre where one is direct-ing a busy obstetric practice, one cannot see

her as often as a proper test of labour demands,and one will be forced to do an elective opera-

tion on a woman who might otherwise havebeen given an opportunity to deliver herselfwith a fair prospect of success.

In 21 cases of the 158 the operation was

performed for the sole reason that the patienthad already had one, and in 2 instances, twoCaeesarean sections. This raises the question as

to whether a patient should be allowed to havea vaginal delivery when she previously hashad an abdominal section. In the opinion ofmany obstetricians of repute, the reply to thisquery is "No, she should not". The objectionto vaginal delivery subsequ-ent to section is,

obviously, that the risk of rupture of theuterine scar greatly exceeds the risk of a sec-

tion done before term in favourable surround-ings. But this doctrine carries with it thecorollary that the size of the family must berestricted to only one, or at the most, two more

children in addition to the first one born byCesarean section, since the same obstetriciansadvise that sterilization be carried out afterthe second section and insist on it after thethird. This is a condition refused by many

mothers.

I can only answer from my own experience.I can report a series of 34 vaginal deliveriesconducted under my charge in 33 patients whohad had a prior section; one patient had twochildren vaginally after her first operation.In seven of these the section had been throughthe lower segment of the uterus, in the re-

mainder it had been of the classical type. Thedanger of rupture is estimated to be ten timesas great (4%co) in cases coming within the lattercategory. In twelve cases the operation hadbeen done for cephalopelvic disproportion. Insome instances the subsequent child had a

smaller birth weight, but in not a few it washeavier than the first infant. The indicationfor the first section in the remaining patientswas; malpresentation (breech) 5 cases; pla-centa pr2evia, 5 cases; toxaemia, 2 cases; pelvictumour, 1 case; and in 6 cases the reason forthe operation was not known. Three patientswere delivered vaginally after 2 previous sec-

tions, in one case done for disproportion, inone for an unknown reason, and in the thirdbecause of tonic contraction.

This last case was the only one in which rupture ofthe uterus occurred. I performed her first Cfsareansection when she was admitted with tonic uterine con-traction, with a retraction ring and imminent uterinerupture. When she returned pregnant a second timethe fetus was a very large one (10 pounds) and a secondsection was done. At the close of the third pregnancyit was considered that the fetus would pass throughthe pelvis without difficulty, and as it proved, it did so.Labour was uneventful but the fetus was stillborn andshortly afterwards signs of intra-abdominal heemorrhagebecame apparent. Laparotomy revealed a rupturethrough the old uterine scar. The error in judgmenthere was to allow a uterus whose lower segment had beenso extremely overstretched on a former occasion to gointo labour; one could not expect a strong scar fromsuture of such a thinned-out uterine wall.

My opinion is that if all other circumstancesare favourable, it is reasonably safe to allow a

patient who has had a previous lower segmentoperation to go into labour on a subsequentoccasion if the postoperative course had beencomparatively afebrile. A history of uterineinfection would imply a weakened scar. Inthe case of a former classical section, as wellas selecting for vaginal delivery only thosewhose recovery had been uneventful, I wouldendeavour, by soft tissue radiography, to

determine the position of the placenta. If thisis found on the anterior wall I would certainlydo a repeat section just before term, since theimplantation of the placenta over the old scar

renders it liable to rupture. Moreover, theplacenta can be adherent to the scar and the

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patient's life may be endangered by postpartum haemorrhage, while in removing theplacenta manually in such circumstances thereis a grave risk of passing one's hand throughthe uterine wall in its thinned-out portion.Heart disease was the indication for Cao-

sarean section in four patients, one of whomhad a subsequent repeat operation and steriliza-tion. In all of these the cardiac condition was

rheumatic in origini, and there was considerablereduction in the heart's reserve. The more one

sees of patients with heart disease associatedwith pregnancy, the less one is inclined toresort to an operative method of delivery.have seen a patient who had to walk very

slowly the few yards from the hospital en-

trance to the consulting room couch, becauseof extreme shortness of breath, deliver herselfnormally of a seven pound child, with no un-

toward symptoms whatever, after a shortlabour. Almost every midwife can remarkglibly and cheerfully that "heart patients haveeasy labours" and, to a point, this is true.Nevertheless there are some cases (in theirselection one will naturally be guided'by thephysician), who are not fit to bear the strainof labour and are best dealt with by section.Local anaxsthesia is excellent for these mothers.

Section was chosen as the mode of deliveryin three cases in whom extreme rigidity of thecervix developed with consequent prolongationof labour. Almost always this condition can

be satisfactorily dealt with by general sup-

portive treatment including the judicious use

of sedatives. In one instance operation was

made necessary by fetal distress, in another byextreme distress of the mother, even thoughthe fetus was known to be dead, while in thethird case the patient had already had a Cae-sarean section and a rupture of the scar was

feared.In seven cases section was performed be-

cause of the presence of pelvic tumour. Thiswas a uterine fibroid in four instances. Suchtumours in the great majority of cases havelittle, if any, effect on the course of labour andonly rarely cause obstruction. It is only whenthe fibroid is situated very low on the posterioruterine wall, so as actually to underlie thefetal head, that interference through the ab-domen is called for. If a fibroid so placed isvery large it can also cause a malpresentationwhich is an additional indication for operation.

If a pedunculated fibroid is found which calleasily be removed at the tinme of the sectioni,it is wise to do so, but large intramural fibroids,

it is generally conceded, are best left alone.There were three cases of ovarian cyst occupy-

ing the pelvis prevrenting descent of the fetus.Such tumours should be removed when firstdiscovered earlv in pregnancy, 'but if they are

not found until the gestation is far advancedthere is some disagreement among obstetriciansas to their management. My own opinion isthat the patient should be permitted to go

practically to term and that then a Casareansection should be performed as well as removalof the tumour. The entire situation can thusbe dealt with at the one operation. Othersclaim that one should remove the ovarianitumour no matter how late in pregnancy it isfirst discovered. Then the patient is allowedto go into labour spontaneously and deliverherself or be delivered with forceps early in

the second stage. By this means, it is true, thewoman is spared a scar in her uterine wall,but it is a heroic form of treatment. The onlytype of case I would manage in this way is

one which has been neglected, and is poten-tially infected on admission.

Caesarean section was done for toxemia ofpregnancy on only 3 occasions, and in only 2cases of eclampsia. These are conditions whichare best managed more conservatively, usuallyby induction of labour. Many Americanobstetricians perform section on a considerablenumber of patients with pre-eclamptic toxemia,especially if prodromata of convulsions are

present. But patients should not be permittedto progress to such a stage without induction,and even so late as that it is possible to avertthe seizures with sedatives. I resort to sectiononly in the case of elderly patients of lowfertility or if some other complication ispresent. The high mortality of section foreclampsia is now everywhere acknowledged butI believe there are rare cases where it isjustified. These are patients in whom the fitshave been adequately controlled by sedationfor twenty-four hours or so, yet there is per-sistent deep coma with no indication of theonset of labour. I have seen such cases as thisdie, even though vaginal delivery may haveeventually taken place. In two cases of this

description I have done Caesarean section under

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local anasthesia, with survival of the motherin both instances. One fetus was stillborn.

Accidental haemorrhage is another conditionwhich can almost always be safely dealt with bymeasures which result in vaginal delivery, andso in only 2 cases of this series was Casareansection selected as the mode of delivery; in one

because the fetus was still alive despite theclassical picture of combined concealed andrevealed hwmorrhage. Vaginal delivery wouldhave resulted in a stillbirth, whereas actuallythe baby survived. In the other case thecervix was long and narrow, external bleedingwas continuous and profuse, and the patientwas badly shocked. She survived a classicalsection done under local anasthesia.In 26 cases placenta pravia was the indica-

tion for Cwsarean section. In 16 of these theplacenta covered completely the internal os andthis type of case does not need further discus-sion. No other method of delivery ought to beconsidered. In regard to the marginal variety,the more experience I have of these, the ofteneram I inclined to select section as the methodof delivery. There was a time when I pridedmyself that if I could feel even the smallestarea of membrane at the os, I could terminatethe case vaginally with success as far as themother was concerned but I found I had toQmany stillbirths. One can never be sure of theoutcome. The case may be one of marginalplacenta pravia in a multipara, in activelabour with the cervix dilating well, when-theonly treatment used is rupture of the mem-

branes and the baby is born only a few hourslater, yet may be stillborn. If the bleeding isprofuse, if the cervix is undilated, if the pa-

tient is not in labour, if the baby is particularlybadly wanted, I therefore have no hesitationin doing a section for this type of case. In 2instances section was performed for lateralplacenta pravia, but in each there was an ad-ditional complicating feature; in one, a cordpresentation, in the other a transverse lie.

Uterine inertia, though such a trying con-

dition, both for mother and obstetrician, isusually best managed by patience and carefulattention to details in the conduct of the firststage of labour, but where other factors haveas well to be considered section may be a wiseprocedure. In 10 of my patients inerti& was

the indication for operation. In 2 of thesethere was a degree of disproportion present

which could have been overcome by the de-velopment of strong contractions but which,in their absence, sufficed to prevent the pas-

sage of the head through the brim. In an-utherinstance the patient had already had one Cal-sarean section. But in most of this group

operation was resorted to because the patientwas advanced in years (the ages ranging from39 to 44) and was of low fertility (marriedfrom 6 to 18 years, with no previous

pregnancies).Akin to this type of patient are those, 5 in

number, on whom Caesarean section was donesolely because of an unfortunate obstetrichistory of repeated stillbirths or stillbirth withadvanced years. In such cases one should nottake any avoidable risk with the fetus.

Malpresentation of the fetus constituted theindication for section in 19 cases, but in manyof these there was some additional complicationwhich lent weight to the decision to adoptoperative delivery, -for example, a bad obstet-ric history, contracted pelvis, previous Cae-sarean section or low fertility, -and, in the case

of oblique lie, placenta pravia or pelvic tumour.There were 7 cases of breech presentation, 7of oblique lie, 2 of, brow, 2 of face, and 1 ofposterior parietal presentation.

There remains a group of miscellaneous-con-ditions for which Casarean section was donein only one or two instances. in the presentseries. These comprise such conditions as:

diabetes (2 cases); tonic uterine contraction,previoug rupture of the symphysis pubis, dys-trophia dystocia, moribund patient, cord pres-

entation and cord prolapse. The latter may

appear somewhat radidal, but there is a grow-ing opinion among obstetricians that Caesareansection is justifiable in some cases. The manage-

ment of prolapsed cord is almost invariably at-

tended by a high fetal mortality, especially inthose cases in which the cervix is only begin-ning to dilate. If other conditions are favour-able and if the delay in the patient reachingthe theatre table is very short, one can preventa number of stillbirths by performing section.

This discussion makes no claim to be a com-

plete statement of the factors involved in theselection of C&esarean section as a mode ofdelivery. Obviously a topic of such major im-portance cannot be adequately covered in a

single article. I submit the above remarks

simply as an outline of the cases within my

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Canad.M.A.J ANGLIN: SARCOIDOSIS 177Feb. 1947, vol. 56 A

personal experience together with some of theconclusions for which they have formed thebasis.

RWSUMIReflexions basees sur l'exp6rience de 158 cas de

cesariennes en 6 ans. Pas plus de 4% des parturientesdevraient avoir des cesariennes. La mortalite mater-nelle varie de 1 a 5%. Cette operation limite lesnaissances subsequentes a 2 ou 3 enfants. Le procedede choix est la section du -segment inferieur de1 'uterus, meme au cas d 'un placenta pravia, et lemode d'anesth6sie le plus sulr semble etre l'infiltrationnovocainique. L 'anesth6sie g6n6rale sera jout6e s'ily a lieu de faire d 'autres operations concomitantes.Les principales indications de la cesarienne sont ladisproportion cranio-pelvienne, une cesarienne anteri-eure, une mauvaise presentation, certains placentaprevia, les tox6mies, les tumeurs pelviennes et certainscas d 'inertie ut6rine. Toutes ces indications gener-ales sont affaire d 'interpretation et de circonstancesparticulieres. JEAN SAUCIER

SARCOIDOSIS*

Adrian Anglin, M.D.

Toronto, Ont.

THE modern concept of sarcoidosis is that itis a systemic disease in which many tissues,

or any tissue, may be involved. Commonly af-fected sites are the skin, lymph nodes and lungs,but the lesion has been found in the bones ofthe hands and feet, in the mucosa of the mouth,nose and throat, in the tonsils, in the breast, inthe wall of the gastro-intestinal tract, in thesalivary glands, eyes, liver, spleen, kidneys,testicle, skeletal muscles, pituitary gland, centralnervous system and heart.The condition has been variously referred to

in the literature as Boeck 's sarcoid, Besnier-Boeck's disease, Schaumann's disease and benignlymphogranulomatosis.

ETIOLOGYThe etiology of the disease is obscure, and its

nature is disputed. David Reisner1 in an ex-haustive review of 35 cases stresses the not in-frequent occurrence of frank pulmonary tuber-culosis as a late stage in sarcoid of the lung, andon this and other evidence, bases his suggestionthat the disease is of tuberculous origin. Boeck2found a few acid-fast bacilli in a nodule fromthe nasal mucosa of one of his patients and in-oculation of this material into a guinea pigproduced a very chronic form of tuberculosis.

* Read before the Ontario Medical Association onMay 23, 1946.

From St. Michael's Hospital, Toronto, Ont.

He concludes, therefore, that sarcoidosis is anatypical form of tuberculosis. Schaumann3 isof the same opinion, believing that the etiologi-cal agent is probably a benign form of the bovinebacillus. Tice and Sweany4 state that manycases which have been followed for years haveshown a gradual change from the "sarcoid state "to some form of tuberculosis showing both casea-tion and tubercle bacilli, and several writersrefer to the disease as non-caseating tuberculosis.However, the results obtained by the majorityof workers coincide with those of Harrell5 who,in a study of eleven cases, failed to demonstratetubercle bacilli by microscopical examination,cultural methods, or by inoculation of guineapigs, rabbits, mice, rats, and fowl. He suggeststhat sarcoidosis may represent a reaction to thelipoid fraction of a variety of organisms. Manycontinue to believe, however, that it is a specificdisease due to an unknown agent.

PATHOLOGYPathologically, sarcoidosis is characterized by

the appearance in the affected tissues of cellaggregations which resemble miliary tubercles,but which differ from these in that the giantcells tend to be very large and vacuolated, theperipheral zone of lymphocytes being absent orpoorly developed. The nodule is very sharplydelimited and, it is very important to note,caseous necrosis does not occur and tuberclebacilli cannot be found. With aging of thelesion the giant cells disappear and the nodulesare eventually replaced by fibrous tissue.

Because of the presence of tissue changes ofthis type many clinically diverse conditions arenow described as sarcoidosis. These are multiplebenign sarcoids, lupus pernio, benign lympho-granulomatosis, uveoparotitis, regional ileitis,atypical miliary tuberculosis and atypical tuber-culous splenomegaly.

CLINICAL FEATURESSarcoidosis occurs chiefly in young adults. It

runs an extremely chronic, relatively apyrexialcourse, usually uninfluenced by any treatment,although spontaneous regression frequently oc-curs and many cases have been known toprogress to apparent cure. Constitutional symp-toms are rarely severe, but weakness, loss ofweight, joint and muscle pains, cough, shortnessof breath, and pain in the chest have been noted.The eye may be involved, leading to partial oreven, in rare cases, complete blindness. Con-