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.
