The precise limit at which the dangers of delivery through the pelvis rise to the level or exceed those from Caesarean section is not easy to determine. It depends partly upon the size and ossification of the child’s head, and largely upon the experience and dexterity of the operator.
The indications of premature labor in pelvic deformities may make the operation justifiable.
Michaelis extracted a small child through a pelvis measuring but 1 1/2 inches in the conjugate diameter.
From 1777 to 1849, 65 pubiotomies are recorded, saving 44 mothers (32.4 per cent. mortality) and 24 children (64 per cent. mortality). From 1868 to 1880, 50 operation, by three operators, saved 40 mothers and 41 children-a mortality of 20 per cent. and 18 per cent. respectively. From 1880 to 1886, Morisana had, out of 18 cases, only 10 recoveries. But with a perfected technique, and by practicing strict antisepsis, better results were obtained, and the last report by Caruso showed in 22 operations 22 recoveries and 20 living children.
From a late report of pubiotomy, in 44 cases all the mothers recovered but one, with a loss of 5 children.
Pubiotomy is on trial. The opinions of eminent specialists differ. Some cases have not resulted well. Schroeder, Fritsch, A. Martin and Runge treat it with silent contempt. Kehrer, Zweifel and Winckel condemn. Kehrer writes that it always results in permanent invalidism.
Winckel says: “The good results expected from this operation have not been obtained, but lacerations of the bladder, injuries to the sacro-iliac joints and necrosis of the pubic bones have been plentiful.”.
Pubiotomy not admissible in Roberts’s in Roberts’s or Nagle pelvis.
The so-called Sanger’s stitch is the best, but be it known to all men that our own Lungren even folded in the peritoneum so as to keep the peritoneal surfaces in contact. He not only did this, but described it in print several years before Sanger, so that everybody could read how he did it.
The Galbiatis knife for pubiotomy.
A ruptured uterus occurs once in 4000 cases. Hugenburger estimates the mortality from ruptured uterus at 95 per cent.; Carl Braun at 86 per cent.
Spaeth, writing before the conservative operation of Sanger had changed the results of practice, said that there had not been a single case in the lying-in hospital in Vienna during the century in which the mother had survived.
Baudon, writing in 1883, said: “In Paris there has been one successful case in eighty years, though in the present century the opposition has been performed on as many as fifty women.”.
Leopold says: “The danger to the mother increases directly as the time since the rupture, and the forces used in attempting delivery, those factors leading to exhaustion form haemorrhage or infection. The child dies very soon after the rupture. The mother may show considerable shock within a very short time, but quick assistance and successful control of the haemorrhage can save the woman, and allow a favorable prognosis in the most severe tears, where the woman is seen at once.
Rupture of the uterus anteriorly at the vesico-uterine fold is more frequent than has been generally supposed. A rupture at this point does not necessarily produce severe haemorrhage.
Dr. R.P. Harris reports nine women whose wombs had been ripped in advanced pregnancy by the horns of infuriated cattle, with the survival of four women and four children.
In another report of six cases of self-inflected Caesarian section, five of the women recovered.
In repeated operations, shall the incision be through the first? Not unless there are no adhesions.
If the urine must be drawn, have the vulva, particularly the vestibule and orifice of the urethra, antiseptic.
After Caesarian section, would it not be well to ligate the Fallopian tubes for the future safety of the woman, and thus have no repetition of Caesarian section?.
To avoid post-partum uterine relaxation, operate early.
Vaginal drainage is not always necessary.
Consider Hews, from very ancient times, practiced hysterotomia, now called Sectio Caesaria.
The Greeks were acquainted with the operation of removing the child while the mother was alive, and named it hysterotomia.
The first case recorded with anything like circumstantial minuteness is that done by a sow gelder (Chatneur of Seigerheusen), who operated on his own wife. .
Kehrer recommends that the uterus be opened at the level of the internal os by a transverse incision, thus avoiding the placenta and a gaping uterus.
Cohnstein recommended that the whole uterus should be turned out of th abdominal wound, and that the opening should be made on its posterior aspect while the aorta is being compressed. He says the uterine tissue is thickest behind, and therefore less like to gape.
Do not use the utero-parietal suture.
Let an abdominal bandage be worn for months after coeliotomy.
Let the operation be thoroughly and quickly done.
To secure union or healing without put is the highest attainment of a surgeon, and counts for more than the brilliant operation.
The operation may be brilliant and skilful, but success depends on the proper preparatory and subsequent care.
Caesarean section is an easy operation.
DISCUSSION.
THE CHAIRMAN: The gentleman who was appointed to lead in the discussion of this paper is not present. The paper, therefore, will be in the hands of the Congress at once, and I hope we may have it discussed. I have the pleasure of introducing to you Dr. Streeter, who will open the discussion.
J.W. STREETER, M.D.: I don’t mean this discussion to go by default. it is to me a very interesting paper. I was not prepared to discuss it secundum artem, but there are some points I desire to emphasize. I am delighted with the record made by our friend, and I think we all have a right to be proud of him. I was also glad to hear that my old friend from Toledo had done such good work in this direction. It seems to me that the Caesarean section is growing, that the demand for it is growing, and the advisability of it is growing, and just in proportion as the doctors and the people become educated to what seems to be the wisest plan for women in extremis, just so soon will they submit to an early operation, and it seems to me it is the early operation that is bound to be successful.
Most of these cases which the doctor narrated were upon women in extremis; two of them were premeditated cases. I believe, as he says at the end of his remarks, Caesarean section is an easy operation. it is an easy operation, but in a majority of cases it is done when the woman is so far exhausted, so extreme in her debility, that her chances are not at all good. The trouble is not in the operation, but in deferring to a time when the woman does not have a reasonable chance for her life. If we can educate ourselves and our patients to a belief that there is surgical aid in these extreme cases of pelvic deformity, that it is a reasonably safe remedy, just so soon have we done them and ourselves a very great service.
It is only a few years since, if a case of Caesarean section was performed in Europe, it was heralded all over the world; and if it was done in this country, Europe knew it by telegraph. Now it is done throughout the country and in the backwoods, and successfully done. it is a wonder, too, that it is done so successfully, because, as I said before, most of the women ar half moribund before the operation is commenced. You would not by preference operate in that way. Discover these deformities. if you can, in time, and set the time to operate, and make it a premeditated case. Make every preparation for it, and it will be as simple and as satisfactory in its results as laparotomy. I am very much obliged to Dr. Bigger for his careful paper.
THE CHAIRMAN:While waiting for another, I might interject a word with regard to a double Caesarean section. This was performed on a woman, and she recovered. A silver suture was used in the uterus. The doctor told me all about this, so that I speak advisedly. He used the silver wire in the uterine wall, twisting in and leaving it; and when he came to do his second operation on the same woman, three or four years later, he found the silver sutures there in a perfect state, bright and clean. The uterus had gone on in its expansion and the silver wire had not caused any trouble. He had to perform this second operation at the peril of his life-a drunken husband threatening to kill him if she died, and he determined then and there that he would never perform it on her again; so he did what was unknown at that time, and I haven’t heard of it having been done anywhere since; he ligated the Fallopian tubes, and so stopped the business.
E.H. PRATT, M.D.: It has been a long time since I have delivered babies, but at one time I was doing it at quite a rapid rate. I never killed a child to save a mother. I have been called upon to deliver them after they have been killed-been called in counsel.
The valuable part of this paper to me lies in the suggestion of preventing craniotomy. It is very rare that we will ever come across that; there ever occurs a cases of rupture of the uterus into the peritoneal cavity at confinement. I have never encountered one in my personal experience, no have I ever come in contact with a medical gentleman that has reported such a case to me.
