Porro's operation : introduction to a discussion in the Section of Obstetric Medicine / by Clement Godson.

  • Godson, Clement, 1845-1913.
Date:
1884
Catalogue details

Licence: Public Domain Mark

Credit: Porro's operation : introduction to a discussion in the Section of Obstetric Medicine / by Clement Godson. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    Table III, showing Indication for Operation. Rickets 89 Fibroid of uterus... r> Malacosteou 27 Cancer of cervix ... Dwarf pelvis 4 Atresia vagime ... 2 Eoberts’s pelvis ... 1 Partial rupture of uterus ... l Pelvis deformed from accident 1 In extremis 3 Arthritis deformans 1 — Osteo-sarcoma of pelvis 1 Total 138 Table IY, showing Causes of Death, Septic peritonitis 24 Strangulation of intestine 1 Septicaemia ... 9 Embolism (following phlegmasia Peritonitis ... 14 dolens) 1 Shock Hi Loss of blood and carbolic acid poi- Tetanus 3 soning 1 Secondary lnemorrhage 2 Ketraction of pedicle ... 1 Pneumonia and bronchitis (pre- Anaemia 1 existing) ... 2 Cerebral aneemia 1 Haemorrhage from pedicle (pri- — mary) 1 Total ... 77 Table Y, showing number of Cases in which Pedicle was dropped in, and of those in which it was kept out, with Result to Mother. No. of Cases. Eecovered. Died. Intraperitoneal 13 3 10 Extraperitoneal 125 58 (17 133 ill 77 Dr. Heywood Smith (London) gave the following particulars re- garding a case of Porro’s operation performed by him (Case 117 in Dr. Godson’s table). The patient was E. C., aged 20, single, of stru- mous cachexia, and very rickety. Labour began on the morning of January 6th, 1S83. The “ show ” began on the morning of the 7th, and the midwife felt the cord presenting. On the 8th, the mem- branes ruptured at 7 a.m. The medical officer of St. Giles’s work- house, where she was admitted at 9.30 A.M., found the funis cold and perforated. Dr. ILeywood Smith arrived at 1.45 P.M., and attempted to deliver with the cephalotribe, and also with crani- otomy-forceps, but, finding it impossible, he decided on performing Porro’s operation. The operation was commenced at 4.15, and occu- pied about an hour. The uterus was drawn out of the wound before it was opened ; the stump of the cervix was secured with a serre- nceud. The operation was performed under carbolic spray. The patient did fairly well, the temperature not rising much till the third day (102.2°), but she succumbed to a low form of peritonitis on the fourth da)7. Mr. Lawson Tait (Birmingham) congratulated Dr. Godson on being, so far, the only successful performer of the operation in Great Britain. Of course he could not agree with Dr. Godson in his estimate of Listerism. He was in the habit of doing four or five abdominal sections every week, and he had a mortality which was not ap- proached by any user of the Listerian method. Dr. Grigg (London) congratulated Dr. Godson on the success which had attended his case. He thought that the difference be- tween Porro’s operation and Dr. Godson’s was so great, that the lat- ter might almost be called a new operation. Dr. Grigg’s experience of Caesarean section had been so unfavourable, that any operation which gave a fair chance of success should be hailed with gratitude. He had performed Porro’s operation once, and a modification of it twice. The latter cases were most unfavourable, and the surround- ings of the first were equally bad. Still, from the experience gained in these cases, he felt sure that, with the modifications pro- posed by Dr. Godson, success might be fairly reckoned on. The mode adopted by Dr. Godson, of tearing the uterus across, he strongly approved, and especially the non-removal of the placenta and the keeping the pedicle externally. Wire wTas apt to cut through. He regarded Mr. Lawson Tait’s modification of Koeberle’s serre- nceud as an improvement, and would certainly use it if called on again to perform the operation. The chief danger in Porro’s operation was division of the ureters. In his own cases, he had been fortunate enough to avoid this accident. In Dr. Godson’s mode of operating, this danger was much reduced, if not entirely removed. Dr. Lloyd Roberts (Manchester) said that all must feel grateful to Dr. Godson for the able manner in which he had brought this subject before the Association. He had almost made this operation his own in this country, his case being the only successful one here to mother and child. Dr. Roberts’s experience in cases suitable for this operation had been acquired from cases in which the Caesarean section had been performed. Yery often, the Caesarean section had been done under the most unfavourable circumstances; still the statistics showed as good results as in Porro’s operation. Hitherto, Porro’s operation had been mostly performed in large cities with every appliance at hand, and by the best operators; still the patients died of shock, of haemorrhage, and of septicemia. No doubt, with a larger experience, the mortality would be reduced. He thought Dr. Godson’s suggestion of making the uterine incision in a transverse direction a good one, as by this means there was less danger of wounding the uterine artery. The further suggestion of leaving the placenta attached to the uterus was an important one, as it reduced the risk of blood entering the peritoneal cavity. Dr. Godson seemed to hope much from strict Listerism in these cases ; but Dr. Roberts did not attach much importance to this. Dr. Ward Cousins (Southsea) referred to the critical moment of the operation—the opening of the uterus—when the danger of haemorrhage was extreme. Dr. Godson had the skilled assistance of Mr. Knowsley Thornton, who grasped the neck of the uterus during the laceration of the body of the organ, and removal of the child. As all operations could not command the enormous advantage of skilled assistance, he suggested the application of the clamp, at least with partial closure, at this stage of the operation. Its ap- plication of course could be greatly helped by lifting up the uterus out of the pelvis. The instrument described by Mr. Lawson Tait appeared admirably adapted for that purpose. There was no fear of this wire cutting through the tissues, and causing hemorrhage ; but Dr. Cousins thought that, even with the smallest wires, hemor- rhage might be avoided by very slowly closing the ccrasewr. He had often taken half an hour during serious operations in tightening the wire. Dr. Walter (Manchester) drew attention to the importance of deciding between Porro's operation and Cesarean section, plus re- moval of the uterine appendages; for he believed that simple Cesarean section ought not to be performed without recollecting the chance of the occurrence of future pregnancy; and, therefore, in those cases where the deformity for which the operation was un- dertaken was so great as to prevent a child from being delivered through the natural passages by the induction of premature labour, he thought it the duty of the operator to prevent future pregnancy. Hence it was very essential to decide between the mortality of Porro’s operation, and that attending removal of appendages along with Caesarean section. Dr. Walter alluded to a case of Caesarean section performed at the North Staffordshire Infirmary by Mr. Alcock, about two years ago. In this case, the woman recovered rapidly, but he heard that she had since died in America, having again undergone Caesarean section. Had Porro’s operation been well known when she was under Mr. Alcock’s care, the woman might yet be living. Dr. Ogilvie Grant (Inverness) said that, while acting as a clinical assistant under Professor Breisky of Prague, he saw two cases ; one case before the operation had been performed, and the other case afterwards. Professor Breisky’s remarkable statistics had been mentioned by Dr. Godson ; the mother and child recovering in all four cases operated on. One point on which Dr. Breisky insisted was to undertake the operation immediately before labour com- menced; he carried out antiseptics to the most minute detail, and did not use drainage. Dr. Godson, in reply, said that the wire attached to Koeberle’s serre-nceud was not a steel one. It was a very soft thick wire, metallic, like Mr. Tait’s, but equally unlikely to cut through the pedicle. He would take care to examine Mr. Tait’s instrument; and if he saw advantages in it over Koeberle’s, he would certainly adopt it. The wire employed was a matter of choice with either instru- ment. He trusted that Mr. Tait’s remarks might deter future operators from adopting the intraperitoneal treatment. The value of antiseptics he would not enter upon ; he would merely say that the employment of them, at all events, ensured cleanliness, which otherwise would be frequently neglected. It would be impossible to compare the statistics of the old Caesarean with the Porro’s opera- tion. There were scores of Caesarean operations performed in vil- lages and remote parts which, proving fatal, had never been heard of; while, on the other hand, it was almost certain that his (Dr. Godson’s) table contained, with very few, if any, exceptions, all the Porro’s operations that had occurred over the whole world. In reply to Dr. Ward Cousins, Dr. Godson said that, having so eminently skilled an assistant, he deputed to him what, under other circum- stances, he should have done himself. The operator could equally well grasp the uterine neck to control haemorrhage while applying the wire of the serre-nceud with the other hand, the assistant attend- ing to the child. No vessels were tied ; everything was included in the loop of the serre-nceud, and all above it was cut off. Amputa- tion of a ruptured uterus was not a Porro’s operation ; there was no Caesarean section in it. The advantages and disadvantages of this operation required special consideration.