CAESAREAN SECTION Willi the (Report of a Case. BY GEORGE HAVEN, M. D. Reprinted from the Boston Medical and Surgical Journal of February 21, 1895. BOSTON: DAMRELL & UPHAM, PUBLISHERS, 283 Washington Street. 1895. 3. J. PARKHILL & CO., PRINTERS BOSTON CjESAREAN section, with the report OF A CASE.1 BY GEORGE HAVEN, M.D. Pelvic deformity begins when the true conjugate falls below four inches, and the difficulty of delivering a living child through the pelvis at term increases as the diameter decreases, and becomes impossible when the conjugate measures three inches or less. The size of the child in all cases should be estimated so far as possible, and of special moment is the size, hardness and compressibility of the head. Delivery is accomplished in the lesser degrees of contraction by nature, forceps or version. In the greater degrees of contraction three methods are to be considered : first, emptying the uterus during the early months of pregnancy; second, induced labor at the seventh or eighth month ; and, third, the major obstetrical operations, namely, craniotomy, Porro, symphyseotomy, and Caesarean sec- tion. I do not wish in this paper to consider the subject of abortion, and shall confine myself to induced labor and the major operations. It is clearly our duty to select the operation which offers the best ultimate result for mother and child. How far respect for fetal life should determine the method is a matter to be decided by the family, operator, and in Roman Catholic families by the priest. It is, however, safe to say that no operator will destroy fetal life if other methods of procedure offer which are equally, or almost equally, safe for the mother. Induced labor is by no means an absolutely safe operation for the mother, and the fetal mortality is very large. In twenty-three cases of induced labor, at the 1 Read before the Obstetrical Society of Boston, December 15,1894. 2 Boston Lying-in Hospital, 19 children died. Selecting the cases which are on the records subsequent to the introduction of antisepsis, or, in other words, the cases occurring since 1885, we have one maternal death in 12 cases or a mortality of between eight and nine per cent. Dr. Theodore Wyder, in an exhaustive article in the Archiv fur Gyncekologie, Band 32, reports 225 cases operated upon since the introduction of anti- sepsis. Of these 12 died, or a mortality of 5.3 per cent.; and the fetal mortality was a little under 50 per cent. This is distinctly less than Winkle's esti- mate of 66 per cent, for the fetus. With our in- creasing knowledge of asepsis, I have no doubt that the maternal mortality can be reduced, but fear that it can never be eliminated. The fetal death-rate, with improved methods of caring for the child, may also be reduced but must remain very high. Craniotomy is fatal to the child, unless we accept a report which comes from the West, where the brain substance was replaced and the child lived. The maternal mortality, quoting once more from Wyder, is about five per cent., and his table is made up of the following cases: 104 cases are from the Berlin Poly- clinic, with six deaths, ora death-rate of 5.8 per cent. ; 35 cases are from the Halle Clinic, with two deaths, or a death-rate of 5.7 per cent.; 76 cases are from the Leipsic Polyclinic, with four deaths, or a death-rate of 5.3 per cent.; in all, 215 cases with a mortality of 5.6 per cent. In the Lying-in Hospital there have been 15 perforations with one death, or a percentage of about six. The latest figures by Leopold place the mortality at two per cent. I shall only speak of Porro's operation in passing, as the mortality is so high that I think it will only be under- taken in cases where hemorrhage cannot be controlled, or where for some other reason the Caesarean section is contraindicated. The mortality in the United States, quoting from Dr. Robert P. Harris, is 61 per cent. ; 3 in Italy it is between 38 and 50 per cent., and in Ger- many it is claimed to be only a little above 10 per cent. Symphyseotomy has already been spoken of by Dr. Jackson, and his paper has so exhaustively and so ably treated the subject that it leaves nothing for me to add. This brings me to the subject of my paper, Caesarean section. Schroeder says, that the first authentic case of Cae- sarean section was that of Trautmann in 1610. Much greater antiquity has been accorded the operation, but apparently without sufficient data. The section is in- dicated when delivery by the natural passage is impos- sible, or of extreme danger to mother and child. This may be caused by deformity of the pelvis, intro-pelvic growths, or advanced malignant disease of the cervix. For many years the mortality, 80 per cent, and over, which attended the Caesarean operation, led to its prac- tical abandonment, and we have to thank asepsis and Sanger for its present splendid showing. The former, as through it the danger of opening the abdominal cavity has been reduced to a practical no per cent. ; and the latter for teaching us how to do the operation, and for dispelling the belief that, owing to the contrac- tion and relaxation of the organ, suturing the uterine wound was not to be thought of. Much has been written as to time of election, whether we should wait until the pains begin, and also how much dilatation should be present, or whether we should operate at our convenience any time during the last days of pregnancy. Dr. H. C. Coe believes that the best time to operate is before labor has begun, and his opinion is strengthened by that of Dr. Robert P. Harris. Personally, I can see no object in waiting, and believe that results will be better if we thoroughly prepare the patient for operation, and then operate at our convenience. The argument that we may have a dangerous hemorrhage in cases where labor has not be- 4 gun, is, I think, false ; and one of the strongest proofs to the contrary is to be found in cases where, for one reason or another, the uterus is emptied during pregnancy but before the advent of labor. There are hundreds of such cases ; and I have never yet heard of one where the organ did not contract, and of very few where hemor- rhage, to any alarming extent, was present. The other argument against the operation of election was that the cervix, being undilated, would not permit free drainage. I believe this to be also a mistake. The cervical canal is always open, and is usually, during the last few days of pregnancy, so soft and dilatable always with multi- parte that the point of the finger can be introduced through it. This certainly gives sufficient outlet for all fluids, and moreover, a strip of gauze can be pushed from the uterine cavity down through the cervix into the vagina, giving all the needed drainage. One other point, about which much has been written, is whether the uterus should be opened outside or in- side the abdominal cavity. Both methods have warm supporters. I think, however, that the consensus of opinion is that it should be opened outside, Dr. H. A. Kelley to the contrary. Many cases where the uterus has been opened inside have later, on account of hem- orrhage, necessitated the removal of the organ to the outside. The cleanliness of the abdominal cavity is much better cared for when the uterus is outside ; in fact, it need not be in the slightest degree soiled. The patient should, if possible, enter the hospital several days be- fore the operation. The total amount of urine passed in twenty-four hours should be noted, and a careful examination of the secretion made. If there is any diminution in the amount, she should be encouraged to drink as much water as possible, and should have some mild diuretic. The skin must be in good condi- tion, and hot baths are to be recommended. Her bowels must receive careful attention, and the rectum should 5 be emptied by enema the day before the operation. The abdomen is to be scrubbed with green soap and peroxide of hydrogen, to be covered with a soap poul- tice for two or three hours, to be followed by a cor- rosive one which remains in position until the lime for operating. The vagina is scrubbed with soap, and washed out with peroxide of hydrogen and corrosive sublimate, and lastly packed lightly with aseptic gauze. The bladder should be emptied just before the oper- ation. Four assistants are needed ; one to etherize, one to handle instruments and sponges, one to hold the uterus, and one to take care of the baby. The instruments are to be sterilized, and the assistants' hands and arms treated as in preparing for any lap- arotomy. The incision is in the linea alba, and should be long enough to admit of easily taking the uterus outside. Hot sterilized towels are placed arouud the organ, and, if possible, the placental site determined ; if it cannot be, an incision should be made through the uterine wall, in the median line, just below the top of the fundus, and extend down for about three and a half inches. A rubber ligature is placed lightly round the uterus at the cervical junction, not to be used save in case of grave hemorrhage. One assistant places both hands around the uterus, and in this way controls hemorrhage. If the incision exposes the placenta, it should be rapidly separated, and the child removed by grasping it around the neck, and given to an assistant. The uterus is now freed from any remnants of placenta and membrane. Deep sutures are introduced about half an inch from the wound, and going down to the mucous lining of the organ, but not through it, and between these superficial sutures unite peritoneum to peritoneum. The number of sutures will depend upon the length of the incision, and will vary from three or four to eight. The material best suited for this pur- pose is braided silk, and should be of a size sufficient 6 to insure against breaking. The abdominal wound is to be closed with silk or silkworm-gut; ergotine (five to ten minims) is given subcutaneously, and the patient placed in bed. There is usually very little nausea following the operation, and in many cases the mother is able to nurse her baby. Before reporting the case upon which I operated 1 wish to speak of the statistics of the operation. The result of Sanger's operations from 1880 to 1888 showed a mortality of 17.9 per cent. A report comes from Leipsic of 38 cases with three deaths, or eight per cent. I have collected 40 cases, operated upon in the United States since 1888, and of these nine died, a mortality of 22£ per cent. Of the nine deaths one case was operated upon without any antiseptic precau- tions ; one had been in labor six days, and had had for- ceps and version tried ; another had advanced malignant disease, and was dying at the time of operation ; still another had been in labor two days, and had had forceps and version. This is true of a fifth, and the sixth death was in a case where labor had lasted five days and where the woman was septic. These cases should not properly be counted. If we omit them, we have three deaths in 34 cases, or a death-rate of be- tween eight and nine per cent. It is also interesting to note that all cases operated upon in hospitals re- covered, save one, and this was the case of advanced malignant disease. I think we can then assume that in all properly selected cases the mortality is not greater than nine per cent., and that in cases operated upon at the time of election, in hospitals, the mortality will be very much below nine per cent. We then have Caesarean section with a mortality of nine per cent., craniotomy with a mortality of five per cent., and induced labor with a mortality of five per cent. ; in other words, Caesarean section is, taking all cases, nearly twice as dangerous for the mother as craniotomy or induced labor. Undertaken Case. Operator. No. Preg. Previous Operations. Age. Labor. Conjugate. Inches. Cause of Operation. Uterus. Antiseptic. Mother. Child. Where. Reference. 1 W. H. Lusk In labor Probable HgCl. Well Well Hospital Trans., Gyn., 1888 deformity 2 W. H. Lusk In labor Carcinoma •• Ditto of uterus 3 W. H. Lusk 64 days 24 Outside cc ll Dead •• Ditto 4 W. H. Lusk 26 Gen. cont. pelv. ll li Dead c* li Med. Jour., New York, 1889 5 J. S. Hawley Sixth 32 Carcinoma of vagina Carbolic Dead (nearly so when op). ll •• Ditto 6 J. E. Alien Several Tried forceps and 35 6 days 2J Outside Dead Home Am. Jour, of Ob., New misc. version before Cae- sarian operation Exhausted HgCl2 York. 1889 7 J. M. Hays Fourth Craniotomy Flat pelvis il N. C. Med. Jour., 1889 8 H. H. Vinke Tried forceps and version before Cae- sarian operation 20 2 days Gen. cont. pelv. il •• li Well il Med. Assoc., Mo., 1889 Ditto 9 Seth Hill Ditto 21 2 days 10 D. H. Fay 36 hours Exhausted 1J Gen. cont. pelv. Outside Well ll Trans. Gyn.. 1890 11 H. A. Kelley First 26 2 weeks 2i Inside ll ll Am. Jour, of Ob., New Exhausted York, 1890 12 F. M. Donohue First 30 5 days Fibroid cc li Dead W 6 Ditto 13 H. A. Kelley Fourth 2 craniotomies Not in labor Rachitic fibroid ll ll cc Well Hospital Ditto 1 misc. tumor 14 H. A. Kelley 24 il Ditto 15 H. A. Kelley Third Forceps 26 Flat pelvis ll i< Ditto 16 D. Logaker Twelfth 40 30 hours Tumor cc It Home Med. and Surg. Rep., 1890 17 A. H. F. Biggar Fourth 3 craniotomies 28 Rachitic pelvis •• if 11 Hospital Med. Rec., New York, 1890 18 A. H. F. Biggar Third 34 5 days Septic HgCl2 Dead Dead Well Home Ditto Med. Jour., New York, 19 R. A. Murray Second 25 3 days 3S Impacted shoul- Well Hospital Exhausted der, gen. cont. oelvis 1890 20 H. C. Coe First 34 Rachitic. Outside CC Trans., Gyn., 1891 21 H. C. Coe Second 37 Fibroid. CC ll CC Ditto 22 Henry Gibbons 24 hours 24 a Home Occident. Med. Times, 1891 23 J. N. Bartholomew Second 17 2 Rachitic pelvis Inside Carbol., 5% ii •• CC Med. Jour., New York, Gen. cont. pelv. 1891 24 H. A. Kelley 2 craniotomies 3 C c HgCl2 ii Hospital Ditto 25 H. A. Kelley 36 3 Rachitic pelvis ll Ci Johns Hop. Bui., 1891 26 H. C. Coe 22 34 Gen. cont. pelv., Outside cc CC a ll Internat. J. S., New result of accid't York. 1891 27 H. C. Wyman First Deformed pelv. Dead Dead Home Med. Rec., New York, 1891 28 Seth Hill 1 week Gen. cont. pelv. a Well Well Proceedings Can. Med. Soc., 1891 29 J. H. Corstens First 24 3 Outside i* Hospital Am. Jour, of Ob., New York, 1892 30 P. H. Ingalls Second 33 24 hours Exhausted 24 Gen. cont. pelv. •• i1 Ditto Med. Press, New York, 31 William Goodell Twelfth 32 Carcinoma Inside cc •• •• of uterus 1892 32 C. Kellock Flat pelvis Home N. C. Med. Jour.. 1892 Dwarf 33 T. G. Thomas First 20 2d stage 2 5-6 Gen. cont. pelv. n •• ii Hospital Med. Rec., New York, 1892 34 A. H. F. Biggar Fifth 3 craniotomies 28 cc u ll n Ci ii Ditto 35 A. H. F. Biggar Fifth 3 craniotomies 34 Same patient il u n li Ditto as No. 34 Am. Jour, of Ob., New 36 G. S. Mitchell First 24 2 days 14 Tumor Outside ii •• Home Exhausted York, 1893 37 M. L. Wescheke 36 Several days Deformed. Soap Dead Dead ll Pacific Med. Journal, Emergency San Francisco. 1893 38 A. Worcester 1 craniotomy, 1 version, at 8 mos. 34 hours 41 Gen. cont. pelv. Inside HgCl, Well Well Hospital Boston Med. and Surg, Jour., 1893 39 A. P. Dudley Third 2 craniotomies 2| ,. « Post Grad., New York, 1893 40 George Haven Third 1 craniotomy, 1 verson. Forceps 35 Not in labor 2§ Outside •• - - - 4 7 in proper surroundings and by skilled operators, I doubt very much whether the mortality is greater, and the fetal mortality is wonderfully less. It is a pity that statistics are so disappointing. Men prove whatever they wish, and in collecting statistics take many cases which should be omitted ; for in- stance, if it is wished to prove that craniotomy or induced labor is much safer than Caesarean section, we have but to include all the cases of which I have spoken as unfit for the operation, our mortality im- mediately rises and the proof we wish is forthcoming. I shall end this paper by reporting a case which I had the pleasure of operating upon in July, 1894. E. F., born in England, thirty years old, of slight build, weight about one hundred pounds, entered the Boston Lying-in Hospital on the 10th of July, 1894. She was a patient of Dr. George G. Sears, and was referred by him to the hospital. She was pregnant for the third time. Her first pregnancy was ter- minated by craniotomy, which was followed by sepsis, and she made a very slow recovery. The second was terminated by a very difficult version, subsequent to high forceps, by Dr. Edward Reynolds. The result in both cases was a dead child. Her pelvis was carefully measured by Dr. William L. Richardson, Dr. Charles M. Green and myself with the following results : spines 9 in., crests 10 in., trochanters 10§ in., the true conjugates 2-g in. The conjugate was apparently less than at the preceding delivery. The reason for this has not been determined. It must be stated here that she came to the hospital two months before the operation, seeking an induced labor, but was advised against it by Dr. William L. Richardson, as the danger was con- sidered about equal to that of Caesarean section, and she was very anxious to have a living child. I shall make no comments upon the pelvis, save to say that it was too small to allow of but two opera, tions, Caesarean section and craniotomy. She was pre. 8 pared for operation by the method already spoken of, and at 11.15 A. M., Sunday morning, July 15, 1894, she was given ether. She was on the table at 11.30. Drs. E. Reynolds, C. W. Townsend, J. W. Bartol, and Harlow assisted, and Drs. Richardson and Green were present. First cut in the abdominal wall 11.33, abdominal cavity opened 11.34. Uterus delivered from abdominal cavity Ligature round neck of uterus Uterus opened Placenta delivered 11.38 and 45 seconds. Baby delivered 11.38 and 55 seconds. Membranes delivered 11.39 and 20 seconds. Sutures begun in uterus 11.42, finished at 12.04. Sutures begun in abdominal wall 12.07, finished 12.19. Patient in bed 12.35. There was no bleeding from the abdominal incision. Thickness of abdominal wall was about one-half inch. The bleeding from the uterus was very slight after the first gush, which was apparently merely the blood held in the organ. After the sutures were in position there was no bleeding. The abdominal cavity was not washed out, and the organ was merely replaced after suturing and the abdominal walls united. A subcutaneous injection of ergotine was given. The patient had in the evening an enema of bromide of potash. She was for a day or two more or less hy- sterical, was given bromide and champagne. The baby was nursed from the beginning, and gained steadily in weight. The mother was up in three weeks and left the hospital in four weeks. Her temperature chart is uninteresting. There was a slight rise during the first forty-eight hours, to be followed by a practically normal chart. Her pulse was never above 100. I saw her a short time ago. She was well, and had a remarkably healthy and fine son. The baby's initial weight was eight pounds. I am indebted to Dr. Courtney for preparing the table of cases. -THE BOSTON MedicalandSurgical Journal. A FIRST-CLASS WEEKLY MEDICAL NEWSPAPER. PUBLISHED EVERY THURSDAY. Two Volumes yearly, beginning with the first Nos. in January and July. But Subscriptions may begin at any time. This Journal has been published for more than sixty years as a weekly journal under its present title. Still it is incumbent upon this Journal, no less than upon others to assure its patrons from time to time, as the occasion arises, of its desire, ability, and determination to meet all the requirements of the most active medical journalism of the day, without sacrificing any of that enviable reputation which is an inheri- tance from the past. 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