CAESAREAN SECTION


Caesarean section with its perfection in detail of operation and splendid results is of modern date. It is true that it has a history dating back no Numa Pompelius who “forbade the burial of pregnant women in whom the operation had not been performed.” We have no early authentic statement that Caesarian section was performed upon living women.


HISTORICAL AND STATISTICAL.

LEISHMAN says that Caesarean section with its perfection in detail of operation and splendid results is of modern date. It is true that it has a history dating back no Numa Pompelius who “forbade the burial of pregnant women in whom the operation had not been performed.” We have no early authentic statement that Caesarian section was performed upon living women. Though no mention is made of it by the old writers, such as Hippocrates and others, yet its great antiquity is admitted.

The first mention of Caesarian section is in the Chirurgia Guidonis de Cauliaco, published in the middle of the fourteenth century, and here only after the death of the mother. It was performed the first time on a living woman in 1500 by Jacques Nufu on his own wife. At first no attempt was made to close the uterine wound, for all of the attention seems to have been given to the manner of closing that of the abdomen. In 1769, Libas was the first to close the uterus with sutures after the operation, but this proceeding was lost sight of until 1828, when it was carried out by Dr. Frank E. Pollen, who first used the silver wire suture for the uterine wound.

Sir F. Gould, in 1742, is the first British author who notice the operation and says it may be performed “either while the mother is living or after her death”.

The Caesarian operation meant one of three different proceedings, viz.:.

First.-Cutting the os when hard fibrinous deposits are found around it, or when other conditions exists which necessitate its opening and enlargement; this is vaginal Caesarian section.

Second.-Abdominal Caesarian section for the removal of the foetus from the abdominal cavity, or ectopic gestation.

Third.-Caesarian section where the incision is made through the abdominal and uterine walls for the extraction of the foetus.

In abdominal section there are three conditions which indicate the operation, viz.:.

First.-When the foetus is alive and the mother died in labor, or in the last two or three months or pregnancy.

Second.-Where the foetus is dead but cannot be delivered in the usual way on account of the deformity of the mother or the disproportionate size of the child.

Third.-When both the mother and child are living, but delivery cannot take place from the same cause as in the second example.

History records the bitter opposition to the operation as well as the strenuous efforts made to support it during the seventeenth and nineteenth centuries. To-day it is an accepted operation under existing conditions with results favorable.

The conditions which warrant the operation are largely disputed. In Germany it is asserted that where the conjugate diameter of the brim is only 21/2 inches. Americans say that craniotomy can be performed where the diameter is only 1 1/2 inches, but the conjugate is not the test.

Cazeau thinks the operation is indicated when the pelvic contraction measures five centimetres (two inches), and Tarnier is of the same opinion. DePaul prefers the Caesarian section when the pelvic contraction is only six centimetres and the child is alive.

Scanzoni would even prefer the operation for a living child if the contraction was only eight centimetres. This diameter may be from 1 1/2 to 2 1/2 inches and other conditions exist which demand the procedure. These conditions may be a shelving brim, an exostosis, a fibroma, pelvic bones, spondylolisthesis, placenta praevia, the kyphotic pelvis, the scolio-rachitic pelvis, the Roberts pelvis, the osteo-malacia pelvis, or the ruptured uterus. Moreover, the operation is indicated in cases in which the mother prefers the operation rather than to sacrifice the life of the child; also in cases of death of the mother while the child is viable.

The following statistics by Schroeder up to 1874 gives the percentage of deaths at 54 per cent. Dr. Robert P. Harris gives the following statistics of operation: In North America, 135 cases with 60 cures; in England, 141 cases, 25 cures.

He further states that in 120 operations in this country the percentage of cures in the country was 62 1/2 per cent.; in the small towns, 34 per cent., and in the cities 33 per cent. The same authority, in a report dated September, 1886, gives the results of Caesarean section performed when the condition was favorable, viz.: saves, 75 per cent. of the mothers in this country and 80 per cent. of the children. it further gives a statistical report as follows:.

Caesarean operations of the United States. 144.

Women saved, 37 1/2 per cent, 54.

Children living when delivered, 64.

First 50 operations saved, 54 per cent, 27.

Last 50 operations saved, 24 per cent, 12.

Operation for decade ending Dec. 31, 1885, 25.

Women saved, 48 per cent, 12.

Children living, 13.

Operations for decade ending Dec. 31, 1865, 24.

Women saved, 45 5/6 per cent, 11.

Children living, 10.

Operations for decade ending Dec. 31, 1875, 36.

Women saved, 27 7/9 per cent, 10.

Children living, 11.

Operations for 10 1/2 years, ending Aug. 1, 1886, 37.

Women saved, 21 2/3 3/7 per cent, 8.

Children living, 16.

Late operations, nearly 84 per cent. of this.

division 31.

The late Dr. S.S. Lungren, of Toledo, O., collected reports of all cases on the same woman. On 48 women the operation was performed 119 times; 8 mothers only have died and 40 have been saved.

“The time most favorable for the operation is that which just precedes or immediately follows the rupture of the membranes; for at this time the os is well dilated and the uterine contractions, which have already exists for some time, acquire a more regular and intense character. If one operates much earlier than this, the uterine contractions after the operation are apt to be insufficient, and if much later, the danger to the child is considerably increased.”.

Statistics very: one report gives the advantages of an operation during or before the close of the first day of labor to be 73 per cent. of women and 86 per cent, of children, while Lusk says only 81 per cent. of women are saved.

Dr. Harris gives statistics as follows:.

Operations Cures.

24 hours before labor had commenced, 7 7.

34 hours before labor had commenced, 7 4.

34 hours before labor bad commenced, 10 1

Radfoot gives statistics of 100 cases as follows:.

Operations. Cures. .

24 hours before labor, 24 7.

24 hours after labor, 76 9.

Kayser’s statistics in relation to the rupture of the membranes is as follows:.

Mothers. Children.

Cases. cures. Cases. Cures.

Before or 6 hours after, 39 20 39 34.

7 to 24 hours after, 35 24 32 25.

More than 24 hours after, 38 13 37 19.

Of Porro’s operation the results for the first few years were very unfavorable. it is reported that the mortality of mothers was 58 per cent. For the period of five years to the close of 1889, from all countries-the general result is of 158 operations-there were 47 deaths-a mortality of 29 per cent. Italy, who gave us the Porro operation, and has thus far led all countries in the number of her Porro-Caesarean sections, has made the least satisfactory progress in reducing the percentage of deaths.

Caesarean operations in the United States where the obstruction was due to pelvic fibroids, 13.

Caesarean operations in the United States where the obstruction was due to pelvic fibrous tumors, 1.

Caesarean operations in the United States where the obstruction was due to pelvic exostosis, 8.

Women recovered in uterine fibroid cases, 4.

Women recovered in pelvic fibroid cases, 0.

Women recovered in pelvic exostosis, 4.

Children living in uterine fibroid cases, 5.

Children living pelvic fibroid cases, 1.

Children living pelvic exostosis, 5.

Time in labor in uterine fibroid cases, 42 hours to.

15 days, 9.

Time in saved cases: 9 1/2 hours, 14 hours, 3 days, 4 days,

respectively, 4.

Time not stated, but labor prolonged, 2.

Time in labor in pelvic exostosis cases, 24 hours.

to 3 days, 6.

Time in saved cases: “a few hours;” 12 hours, 24 hours and.

38 hours, respectively, 4.

Uterine fibroids, cases saved, 30 1/1 0/3 per cent.

Pelvic exostosis, cases saved, 30 per cent.

MODIFICATIONS OF THE OPERATION.

1. Porro’s Caesarean section; ovaro-hysterectomy; amputation of the uterus and ovaries immediately after the performance of Caesarean section, the stump being fastened at the lower angle of the abdominal wound.

2. Thomas’s operation; laparo-elytrotomy.

3. Porro-Muller operation. In this the uterus is brought out of the abdominal incision, an elastic ligature is applied around the cervix at the level of the internal os, and the uterus is then incised and the foetus extracted.

4. Porro-Veit operation. Modification of Porro’s operation by dropping the stump into the pelvis.

5. Sanger’s operation, sero-serous.

6. Pubeotomy.

NECESSARY STEPS IN THE OPERATION.

First.-Care for the patient in every particular, as in coeliotomy.

Second.-The abdominal incision should be sufficiently long to permit the lifting of the womb out of the abdominal cavity.

Third.-Protect the exposed uterus with hot clots.

Fourth.-Have a heavy rubber tubing passed around the cervix uteri, and tie in a single knot loosely; it may be useful in case of haemorrhage.

Fifth.-Surround the lower part of the uterus with sterilized or medicated gauze, thus preventing soiling the abdomen.

Sixth.-Open the uterus and remove the child and placenta.

Seventh.-If severe haemorrhage occurs, seize the uterus with the hands and, gently or otherwise, contract it. Ergot may be necessary; or, tighten the rubber tubing.

Eighth.-After cleaning the cavity of the uterus, close the uterine incision with sutures. Silver, silk, or catgut may be used, adopting one of two ways, viz.:.

1. The deep suture, avoiding the mucosa, with superficial intervening suture. 2. The sym-peritoneal suture, or the sero- serous of Sanger.

Ninth.-Close the abdominal wound with silkworm-gut suture, after the manner of coeliotomy, and the usual antiseptic dressings.

CLINICAL CASES.

CASE I.-Caesarian section. Mother and child saved.

Mrs. A. Salter, a German, of Salineville, O., aet. 28, weight 65 pounds, height 4 feet; husband’s height, 4 feet 9 inches. This is her fourth impregnation; in the three previous gestations the lives of the children were sacrificed at full term by craniotomy.

The parents were desires of having a living child, and the mother was willing to assume the risk of a Caesarian section.

Two weeks before the time of the completion of term Mrs. S. came to the Huron Street Hospital, in Cleveland, O. At the completion of her gestation, at 7 A.M., December 15, 1886, labor pains began and continued till 9 o’clock in the evening of the same day. Prof. J.C. sanders was in constant consultation during the day and up to the time of the completion of the operation. Prof. Sanders, after his first careful examination of the patient, believed that by turning the foetus in utero a living child could be born.

At 9 at night, when the os was dilated to the size of the silver dollar, and before the membranes had ruptured, the doctor decided that it would be impossible to deliver the child alive per vias naturals-a wall of bone, the shelving brim of the pelvis, obstructing the passage, and the conjugate diameter being less than two inches. Anticipating his decision, every preparation was ready for the operation. The babe was living, and the heart-beats were 135 per minutes. The Loylen mixture was used, and in fifteen minutes after beginning the operation a living girl babe was extracted from the womb through the abdominal and uterine walls. The operation was performed in the operation-room of the hospital, before the senior class of the Homoeopathic Hospital College and other physicians.

The Method of Operating.

The patient, assistants, nurses, instruments, dressings, room and furniture were all carefully prepared for the operation. None were admitted who had been dissecting or were in attendance on any contagious or suspicious cases within forty-eight hours. The usual coeliotomy incision was made, beginning two inches above the symphysis pubis and extending to a point beyond the umbilicus, and in depth down to the peritoneum. When the bleeding was stopped the peritoneum was opened, exposing the uterus. An assistant held the uterus in position by placing the hands on either side of the womb. The sides of the peritoneum, coming in contact with the uterus, were packed with sterilized, gauze, thus protecting the peritoneal cavity from the entrance of fluids.

The uterus was entered by an incision, eight inches in length, in the medium line on the interior surface. Fortunately, the “placental site” was not in danger of being encroached upon by the knife, which brought to view the translucent membranes enclosing the fluids which cushion the babe in its casket like a bird in the egg. a natural contraction of the uterus, observable by all, ruptured the membranes; the fluid escaped when the infant, doubled upon itself, was expose to view and the closest approach to the great mystery of life-the marvel of maternity-it is possible to have enjoyed was seen by those who reverently witnessed the operation.

Some strong men actually wept in witness of the depth of emotion caused by what so few have ever seen and what no man could see without being profoundly moved-a sight as powerful to move the heart as the view that Moses had of Deity. Every other feeling was completely subordinated to that sentiment of reverence and wonder which would be natural on being permitted to see what is transpiring on another of the inhabited planets. The presentation was natural. The feet were seized and the babe lifted from the womb and given to Prof. J.C. Sanders and Dr. L.W. Sapp to care for. A gasp and a lusty squall, assuring us all of the safety of the babe, elicited a round of genuine but subdued applause and an exclamation of delight from the father.

The cord was secured, after-birth and membranes were carefully removed; the uterus was gasped and made to contract. The patulous coellum uteri did not need a drainage-tube. The cavum uteri was gently cleaned and the uterus closed with animal ligatures, after Sanger’s method. The abdominal cavity was cleaned, the abdominal incision closed with silk sutures, the toilet of the abdomen completed, and the another put to bed. After a few moments she recovered consciousness and found by her side a living girl babe. With motherly instinct she drew her child closely to her heart and greeted her darling with the exclamation, “Mein babe,” a salutation that could but feebly express the depth of her mother’s love and devotion to those who did not know the risk she had run to save the babe’s life. The mother and babe were the recipients of devoted and sympathetic attention by the hospital, and both returned to Salineville after the usual uneventful convalescence of a coeliotomy.

CASE II.-Caesarian section.

Mrs. R.T., American, aet. 34, mother of two living children. From the beginning of her labor was assisted by a midwife for sixty hours. At this time Drs. J.C. and J.V. Winans, of Madison, O., were called, and the midwife retired from the case. The condition of the patient was so alarming that Dr. Winans immediately summoned Drs. A.L. Gardner and L. H. Tillotson, of Painesville, O. It was supposed that large doses of Ergot had been given by the midwife. I was summoned by telegraph and arrived at two in the morning, and found the patient in a state of collapse with suspected symptoms of a ruptured uterus and a non-visible child.

Section Caesarian was determined upon and performed by the light of a kerosene lamp. The uterus was found longitudinally ruptured at the lower third anteriorly, the amniotic fluid escaping into the abdominal cavity, but the membranes, placenta, and child were in utero. Perhaps from the weakened condition of the patient at the time of the rupture and the syncope following the escape of fluid into the abdominal cavity, all uterine contractions had creased. No doubt, if the labor pains had been severe the contents of the uterus, or the greater part, would have been found in the abdominal cavity.

The operation was, in every was, similar to Case I., with this difference, that the rupture which was slightly to the right of the median uterine line, was enlarged; the torn edges were trimmed, and the uterus closed by two sets of animal sutures, the deep going to the mucosa,,and the superficial approximating the peritoneal borders. The surroundings were unfavorable for successful operation-the woman was moribund,the 13-pound foetus dead, and the nursing incompetent. The patient lived but a few hours.

CASE III.-Porro’s Operation.-Mrs W.N.K., a German aet 43, living in Akron, O., and mother of two living children. Dr. O.D. Childs had attended her in previous labors. No uterine examination had been made by Dr. Childs since the birth of her last child till the beginning of the third labor.

Upon examination, he found a very large intra-mural fibroma, situated at the junction of the neck with the body of the womb, Consultants were called, and every effort made to deliver by forceps, or by turning the child, or by changing the position of the woman, but no advancement was made. The membranes had ruptured 18 hours after labor set in. I was summoned by telegraph, and arrived forty-eight hours after labor began. Dr. Childs says the child had been deal three days.

The condition of the woman was not very good. I made every reasonable effort to deliver and failed. Could not get even an entrance to the womb, owing to the displacement of the os upwards and behind the symphysis tubes, as well as from the undilatable os from the fibrinous deposit. Porro’s operation was performed, in all respects similar to Case I., with this difference, that after the babe and placenta were extracted, the neck of the womb was clamped with Keith’s clamps, the uterus with the fibroma and adnexa were removed and the stump dressed, extra-peritoneal. The fibroma weighed 11 1/2 pounds and the child 11 pounds.

On the tenth day after the operation there was profuse haemorrhage of the stamp, and before the physician arrived the woman was in a state of collapse and shortly died. If the patient had been in the hospital, the haemorrhage might have been stopped. If the rubber ligature, since introduced, had them been used, the result might have been different.

CASE IV.-Ectopic gestation, in many respects similar to Sectio Caesaria. Miss H., an American sewing girl, aet. 22, a patient of Dr. I.F. Baughman, of Akron. O., after a railroad accident, first noticed a lump in the right ovarian region. Action was brought against the railroad company, who settled the claim without litigation. The tumor continued to grow. Fifteen months after the railroad accident, and seventeen months after the cessation of the menses with the assistance of Drs. Baughman, O.D. Childs, J.W. Rockwell, Wm. Murdock, and R.B. Carter, coeliotomy was performed at the rooms of the patient. She refused to go to a hospital. The tumor, which filled the abdominal cavity, was adhered to the parietal peritoneum and abdominal viscera.

The incision was in the median line of the abdomen. It required very careful dissection to avoid the intestines, which were closely adherent to the entire circumference of the uterus; the walls of the sac were thick and resembled uterine tissue. Within the cavity was a dead foetus, which was removed from its placental nidus. The extensive adhesions of the cyst were not disturbed, but the edges were stitched to the abdominal opening; glass drainage-tubes were placed both in the abdominal and placental cavities.

The child, a boy, weighed 18 pounds; the nails were so long that they curled around the fingers and toes. Its conception was seventeen months previous to the time of the operation. The child was in a good state of preservation, but we were not able to elicit any information from the mother as to the exact time of the death of the child. The room, bedding, furniture, and surroundings, were very uninviting, in fact everything indicated a picture of squalor; notwithstanding al these conditions, the patient slowly recovered and subsequently married.

CASE V.-Sectio Caesaria repeated on same woman. Mother and two children living. Mrs. A. Salter, same women as reported in Case I., from Salineville, O., aet, 34, six years after the first Caesarian section became pregnant, making in all her fifth impregnation. At the seventh month of gestation she came to Cleveland for consultation. With Professor J.C. Sanders as consultant, she was advised to return to her home, and in two weeks before the completion of the gestative period she was to enter the hospital and be prepared for the Caesarian section. On February 16, 1893, at 3 P.M., two or three weeks before the expected time, while at her home at Salineville, labor began, and at 3 A.M., December 17th, they took a train for Cleveland.

They came in a day-car, 75 miles, the pains lasting until her arrival at 7 A.M. By a mistake, I did not learn of her arrival on the morning train, and the consultation preceding operative measures occurred at 4.30 P.M.; at 5 P.M., twenty-six hours after the rupture of the membrane, I began the operation before the medical class of the college. The method was the same as the first Sectio Caesaria, following the old line of incision. The old operation had resulted in the adhesion of the entire uterine length to be abdominal wall. The method of suturing the uterus was different owing to adhesions of the uterus to the parietal peritoneum; the deep sutures around the tissues included the abdominal and uterine walls down tot he mucosa, and the superficial sutures merely the abdominal walls down to the peritoneum.

H F Biggar