They are in the books, and Dr. Biggar very kindly furnished us with illustrations if that class of cases, but they are so rare, and when they do occur the collapse is so extreme, that Caesarean section simply offers a forlorn hope that is doomed before you touch it; and it is so rare that the report is of no avail to us. But it is so frequent that children are too large to be born in the natural way, and they have to be killed or die from very prolonged labor, that the practical suggestion of doing Caesarean section to save the life not only of the mother but also of the child is a very valuable part of the paper.
This is the age, I think, of abdominal section; it is the age of going into the abdominal cavity with impunity. I would like to relate one experience which I think would have saved not only the life of the child but also of the mother, if the doctors had acted upon the knowledge which this paper makes common to us.
I was called to a neighboring town, in my earlier surgical career, when I was not as old or as brave or as competent in any particular as I am present. A woman had been in labor. It was among the poorer classes, it was the very centre of squalor. They were, an unhappy, quarrelsome family, as well as a half-starved, half-clothed, and ball-frozen family. It was cold weather, and yet they had no fire in the house. The woman had been in labor for a week. She was a hunchback, and also had a distorted pelvis, so much so that it was impossible to even get three fingers as far as the uterus. It happened to be a leg presentation; the feet came down first, and the doctors pulled the child away piece- meal.
They got away one leg and then the other leg, and then the head itself. The woman had been trying to deliver that head when I saw her for one week, and they asked me to come and perform Caesarian section. I went out three prepared for Caesarian section, at the same time having confidence that , by book or crook, I could get the remains of that child out of the pelvic cavity. I went with all the instruments at my command, but was unable to strike the head by any instrument with me, and so I was compelled to do Caesarian section.
I performed it in the midst of that dirt and squalor and the uncomfortable surroundings, to the best of my ability. It was not an antiseptic operation. The conditions were not favorable to it. What surprised me at that time, was the thickness of the walls of the uterus. I expected to find a tissue-paper wall, thin and wasted away. Instead of that, the walls of the uterine cavity were fully two inches thick.
I opened the walls and removed the head and after-birth and the blood which gushed very rapidly at first as I went through the uterine walls, stopped itself under the uterine contractions. I had no difficulty in checking the haemorrhage. I stitched the uterus and the abdomen, and left the patient in the care of an exceedingly incompetent nurse. I am satisfied now, if I had taken the precaution to take a nurse with me I would have saved the woman. She lived one week without fever or chills, or any trouble whatsoever, but at the end of the week there occurred a family row, and she got out of bed take a hand in the now. The result was, she died in forty-eight hours.
DR. BIGGAR: Perhaps some of the gentlemen in the audience have also performed successfully, or otherwise, Caesarian section, or knew of the skill of Dr. Lungren, and what he did.
We have a late case in this city by Professor Ludlam, and we have a new case by our good friend and Institute-President, Dr. McClelland. I do not see Dr. Ludlam, nor do I see Dr. McClelland, but, perhaps, if their names are called, they will spontaneously appear.
THE CHAIRMAN: Ladies and gentleman, Dr. Ludlam is here.
R. LUDLAM, M.D.: Concerning the case which I reported a little while ago, I suppose that everybody reads the Clinique, and if they do, intelligently, they must be familiar with the case which I had the honor to conduct. The chairman of the bureau has requested me to give the details of the case, and therefore I will repeat myself with your permission.
I might say, by way of premise, that so far as I know, my case is the only one that has ever been made in this country because of uterine fibroid.
Briefly, the case was one of pelvic obstruction by a fibroid which laid below the child, and which twisted the cervix out of place so it never came down and was not accessible in any way, shape or manner form below. Another peculiarity of the case was, arisen as we discovered the fibroid within the pelvis we also discovery; or had evidence to believe, that the patient was pregnant and at about the fourth month. The diagnosis, however, could not be absolute. I recommended, under the circumstances, the making of an exploratory incision so that the complicated conditions might be plain, and it might appear then as to what would be best, whether to remove the foetus, to remove the uterus-I mean by way of Paen’s operation-taking the tumor along with it or not, or to leave it until term.
So at the fourth month, as I recollect, we made an exploratory incision through the abdomen, as usual, and came down to the pregnant uterus lying off to the right side. The appearance of the uterus, the thickness of the wall, made us feel, though we did not touch it much I assure you that the patient was pregnant. The fibroid could be felt below the brim of the pelvis. It was therefore deemed practically impossible or impracticable that the labor should be consummated under the circumstances , but I said with plenty of space for this uterus to develop, with a good position of the organ, with the fact that this tumor does not involve its capacity at all, why not let it go on to term.
A reason, and very weighty, too, under circumstances, was that the parents were said to be very desirous to have a child. The father and mother prospectively were happy with the idea of having a child, and I determined if any means could secure that end, those were the means they desired. So with this backing, with the under standing that the incision was exploratory, the wound was closed, and we decided to await events.
I am sure that during the next to the last half of the period of gestation we were all quite anxious as to the outcome of this case. We recommended exercise in the open air, plenty of good food, and all the sort of thing, and in the most natural way she rode about the country and had a good time until term, and then we were to be notified directly there was any appearance of the signs of labor.
I remember very well one evening coming home from one of my lectures with my assistant and found a call to go forty miles in the country by the very fast train. We had less than an hour’s time to pack up our duds and get to the train. We reached the place about one o’clock in the morning and went to this little private hospital and got ready to look the case over. The waters had been discharged; the cervix could not be felt or found at all; the pain had subsided with the discharge of the water. We had a consultation with Dr. Clark, who was looking after the patient and was to assist us in this matter, and did, very kindly. We resolved, at my suggestion, that we would not wait until daylight lost the pains should come on and constitute an obstacle.
We made a window in that uterus and got the little rascal out of the window safely for himself-or herself, as it turned out-and the mother. We went at it at 2 o’clock in the morning under gaslight, and I should like to have had z photograph of the scene. Not for any advertising purposes-God forbid-but as a sort of reminiscence of the way the thing was done.
We made in incision of twelve inches over the abdomen, and an eight-inch incision through the uterus; came down through the membranes, went through them very gently and quickly, for there was no time to waste nor time to discuss, and no talk. I had instructed my assistant, Dr. Stetler, who was on hand, and in a lively way, too, I assure you, to the that chord, if they ever got at it and the youngster was alive, as quickly as possible. The chord was tied after a manner that I recommend in emergencies and haste when you want delivery. He snapped two forceps across the chord. They were gauged forceps.
He snapped one here and one there, and a pair of scissors went between, and a great deal more quickly than I can tell it, the baby was off to be resuscitated. When the baby cried, which was while we were delivering the after-birth, we heard the sound which was music to us and to the new mother. The short of this is, that the mother made a prompt and excellent recovery. The child weighed eight pounds, and I suppose she is going to Sunday-school, now.
H.F. BIGGAR, M.D.: In regard to the previous report, I would say: in a ruptured uterus it was the first I knew anything about, and the suspicion of it was the syncope. Some writer has said – and it is embodied in the paper-that a ruptured uterus occurs once in four thousand times. This is from the Vienna report. I do not know that it is found as often as that. it is merely a statistic that is given; but another writer says that a rupture of the uterus occurs, with a proper delivery of the child, more frequently than is known by the obstetrician. What data he may have for saying so I do not know, but it is so asserted.
