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.
The length of time occupied was twenty-five minutes; the birth was “dry” in this eight and one-quarter pounds. At the first operation the father positively objected to the removal of the ovaries. It was thought best not to do so at this time, not only on account of most intimate adhesions of the abdominal parietes to the uterus, but from the enfeebled condition of the mother resulting from labor having continued for thirty hours, and the uncomfortable journey to the hospital during a severe winter might. Prof. J.C. Standers determined the foetal heart- beat as 128, prognosticating a boy. The case made a good recovery, despite some bronchitic and erysipelatous symptoms, and returned home in the usual state of bodily vigor. The boy was christened as a point of remembrance of the method by which rescued, Caesar, and was a thrifty, well-nourished child.
The doctors, [resent, besides the college seniors, were Drs. J.C. Sanders, H. Pomeroy, J.K. Sanders, Martha A. Canfield, G.W. Meredith, H.D. Bishop, G.B. Haggart and Emily Barnes.
SUGGESTIONS.
Antiseptic thoroughness is essential in every detail, including the care of the abdomen and vagina.
Chloroform is preferable, especially with Junker’s improved apparatus.
Ether in certain conditions may be safer. If possible, prevent vomiting, as it might open the uterine sutures. To prevent vomiting after an anaesthetic, have a good movement of the bowels.
Trendelenburg’s position is not very desirable in sectio Caesaria.
If the operation is at the election of the surgeon, the most suitable time is before the membranes are ruptured and when the os has dilated in size equal to a silver dollar.
Tait’s method with a rubber cord around the cervix uteri to stop the haemorrhage, and lifting the uterus outside of the abdomen to extract the child, are of great advantage.
If rubber cord is used, beware of secondary haemorrhage. The incisions should be six or eight inches in length, beginning three inches above the pubes, and extending above the umbilicus.
In cutting through the abdominal wall, secure all bleeding vessels before incising the uterus.
If the uterus is not lifted out of the abdomen let the assistant press the abdominal walls on each side of the incision down against the uterus, thus retracting the wound edges and pressing the uterus still prominently into the wound opening.
Before lifting the uterus out, insert three or four log sutures of silk through the upper part of the incision, so that the abdomen may be temporarily closed before extracting the child.
Let the incision into the uterus correspond with the abdominal opening, but shorter.
Avoid entering the uterus through the placental site. If the placenta should lie in the line of incision (placenta praevia Caesareana) run the fingers between it and the uterine wall, find its margin and break through the membranes there and grasp the feet and extract, as before.
Do not cut the placental tissue, thus bleeding the child in placenta praevia Caesareana.
Deliver by the feet.
If the uterus is not lifted out of the abdomen before delivery of the child, it may be done afterwards for the purpose of inserting the stitches.
There are three dangers-shock, haemorrhage and sepsis. Haemorrhage may be controlled by manual compression of the uterus or cervix uteri.
Sutures should be thoroughly antiseptic.
Don’t use a continuous suture in the uterus.
If the contents of the uterus are septic, turn the uterus out of the abdomen before the delivery of the child.
The reason the uterus was not sutured in the early times was largely due to the persistent existing superstition with regard to the alternating contractions and relaxations of the uterus which forbade the employment of the uterine sutures. Even Porro at one time considered that the contraction of the uterus necessitated its entire removal. Now his operation has been restricted to within narrow limits.
Suturing the uterus largely adds to the good results.
Caesarian section should be always, if possible, elective, not the dernier resort. Per via naturales may not always be the best way. In mismanaged cases Porro’s operation is preferable. Foetal mortality is greater in this country, the hospital weight of infants being about seven and a half pounds; in private rooms in Europe the average is six pounds.
Thanks to the great discovery of the source of the sepsis and of its preventive means, this “Opprobrium Chirugae” has to- day assumed and is destined forever to maintain its place as one of the begin and most serviceable resources of art.
Caesarean section will yield as good results as those now given by coeliotomies.
May we not consider this operation in praevia totalis or even partialis? In placental praevia vaginalis,. if the os is rigid form fibrosis, the haemorrhage profuse, the presentation lateral, the cord prolapsed and not reducible, or the foetus evidently suffering, immediate recourse to the Caesarean section should be had.
If the cord was prolapsed, and, after reposition, still descended, the os being partly dilated and not dilatable- dangerous haemorrhage continuing meanwhile-the Caesarean section would be unquestionably indicated for the safety of both mother and child.
The perforation of the living child is not longer justifiable.
Where there is a viable child, is not Caesarian section preferable to craniotomy.
Craniotomy and embryotomy are performed too often. It soon may become a lost art, or it will be relegated to its proper place as an operation on the dead foetus to save the mother, and not to destroy the child.
Craniotomy is a more difficult operation than Caesarean section.
Dr. Osborn, in the celebrated case of Elizabeth Sherwood, extracted a child through a pelvis measuring 3/4 of an inch in the narrowest portion.
