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- Incorporating
The Kansas City Medical Index-Lancet

An Independrut Alonthly Magazine



No. 11

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Original Contributions

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number, but of a sufficient variety to be interesting, and I trust instructive.

During the last few years many surgeons, ( EXCLUSIVELY FOR THE MEDICAL HERALD.1

having sharp knives, have been looking for an opportunity to deliver a baby surgically. On the

face of things it is one of the most spectacular WHY CESAREAN SECTION ?*

operations of surgery and exceedingly simple to A. B. SOMERS, M. D., Omaha, Neb.

perform, but from what I have seen it is per

formed altogether too frequently on women Why Cesarean Section-Conclusions

either in a poor condition or when some other (Traditional.

method of delivery should have been chosen. Cesarean {Historic previous to 1882.

In Omaha I know of seven women who died Sanger and asepsis.

during 1916 following cesarean section, most of | Vaginal.-Duhrssen, 1895.

them having been done by leading men, and while (Death of mother.

I have no record of all the operations performed Abso Major deformity of pelvis.

during this period I think the fatalities must have Extreme disproportion.

been 25 to 30 per cent of the cases. There is Tumors.

some risk of cesarean section being over-done on (Stenosis.

account of poor judgment in selection of cases. (Improved prognosis for mother During my experience cesarean has been Indications or child.

modernized and made a strictly up to date operaPlacenta previa with close cer tion to a greater degree than ever before. Orig

Tetany of uterus, close cervix.

inally cesarean section was done wholly on dead Relative Abruptio placenta close cervix.

or dying women in the interest of the unborn Prospective difficult labor child. I have had no experience with this class woman unfit.

of cases but two years since a pregnant woman Heart insufficiency.

fell on the street of Omaha, was picked up unEmergencies.

conscious and hurried to her home. Dr. Mack (Possible infections.

of Omaha was called and arrived about fifteen

minutes later. He found the woman dead, did Exhaus- (Loss of blood.

an immediate cesarean and saved a live baby girl Contra. tion Prolonged labor.

that is alive and well today. indications Waters ruptured for long time.

The next step in cesarean was practically in | Eclampsia.

the interest of the baby as the maternal mortal| Toxemia of several weeks standing.

ity was nearly 100 per cent. These were the Serious kidney lesions.

cases where pelvic deformity was so great that (After labor begins, ideal.

it was impossible to deliver a child even after {By appointment, precludes emergency

embryotomy had been performed. This was | conditions,

before the days of aseptic surgery, the uterus was

not sutured and the cases were little removed I am not a surgeon, but I have been a teacher from the class of dead or dying mothers so far of obstetrics for fifteen or twenty years and for as actual results were concerned. But occasionthe last ten or twelve years I have been called ally both the mother and child would be saved. quite frequently in an advisory capacity by some of our leading men to help determine on the ad

In 1882 with the limited knowledge of asepsis visability of cesarean section.

of that day Sanger conceived the idea of suturing This article briefly summarizes my experience

orience the uterus after section and from that day cesarand covers twenty-five or thirty cases, not a large

ean has become one of the recognized operations

to be performed in the interest of both mother *Read before the Medical Soc cy of the Missouri Valley. and child.


After recommending multiple incisions of the histories of previous labors with disastrous recervix as a method of opening the close cervix in sults to the baby. I have seen numerous such 1890, Duhrssen in 1895 successfully performed cases giving a history of difficult labors with vaginal cesarean and saved both patients.

forceps extraction or version, resulting in a dead During the last ten or twelve years both the baby. I was called to see one woman who had Sanger and Duhrssen operations have been per- had four dead babies as a result of delivery. I fected to a high degree and have become the saw another woman whose baby was permanently established operations of the present time. defective as a result of difficult delivery. There The mortality statistics of value at the pres

being no contra-indication these cases are ideal ent time do not extend back ten or twelve years. for abdominal section, if resorted to as a primary I have had no experience with extra peritoneal operation by a skille

operation by a skilled operator with surgical cesarean and hence omit that subject from the environment, there should be no mortality for 1 present discussion. Having two methods, va- either mother or child. ginal and abdominal cesarean established as legi

It should always be borne in mind, however, timate methods of emptying the uterus surgically that efforts at delivery by

that efforts at delivery by natural passages, rein the interests of mother and child, it is well to peated examinations, any examination only 119discuss the applicability of the two methods. der strict asepsis, early rupture of membranes.

Case 1. Primipara about forty years of age. prolonged efforts at delivery on the part of near full term, gave every indication of impend

mother, or general exhaustion of mother for any ing eclampsia. After two or three days' treat

reason are contra-indications to cesarean section. ment, it was decided to bring on labor. This was

I recommended a cesarean in one primipara, done by introducing a bag into the cervix. Labor

a rachitis dwarf, with justo-minor flat pelvis; the came on promptly and the woman went into con

operation was a success in every way and she vulsions. Vaginal cesarean was performed and subsequently gave birth to a living child northe child delivered by version, died very shortly

mally. In two cases I have known of normal after, recovery of mother uneventful.

labor following cesarean, so "once a cesarean" Remarks: Being a toxemic case, I believe

does not mean “always a cesarean" in my ev.

perience. I know of no bad results from labor that the concensus of opinion would favor the

following a cesarean. With few exceptions vaginal rather than abdominal method so far as the mother was concerned, as being less liable

primipara should be put to the test of labor in to produce serious kidney lesions. In this case

these conditions, but the test should not be unthe efforts at cervical dilatation contra-indicated

duly prolonged, then cesarean will not be called abdominal section on account of danger of infec

for except in cases where the presenting part tion. Another point of interest in this case is

does not enter the pelvic cavity. All my cases

in this class have given 100 per cent recovery. that labor often becomes an exciting cause of

Cases III-IV-V. Unterine tetany. Of this convulsions in an eclamptic woman and must

series Case III primipara was seen in consultaalways be carefully considered in these cases.

tion at or near full term, with tetany of uterus, If we consider the interests of a full grown hemorrhage, close cervix and impending convulchild there is no doubt that the vaginal method

sions with a dead baby. Diagnosis, eclampsia of is more disastrous, especially when delivery is

uterus, ablatio-placente. Urinary findings gave complicated by version.

all the evidence of acute nephritis. Abdominal Case II. Primipara 36 years of age, 26 weeks cesarean appeared to be the only way to deliver pregnant, profoundly toxemic with every indica- this woman alive. She died six weeks later of tion of impending convulsions. It was decided kidney lesions. There was no drain put into the that welfare of baby being non-viable should be cervix and as a result the cervix had to be didisregarded and the woman be promptly deliv- lated two days later to allow drainage to take ered and vaginal cesarean was given the prefer- place. ence of methods. The mother made a complete Case IV. Primipara was under our own obrecovery but it was many months before her servation and at about the 36th week she sudkidneys were restored to a normal condition. denly developed albumen in urine with headache

Remarks: Labor either induced or normal and other toxemic symptoms. She also develoften precipitates convulsions in toxemic cases. oped prolonged severe uterine muscular pain This was the result in Case I and I believe that that required full doses of morphin to relieve. Case II would have gone into convulsions with She was placed in the hospital where the urinary the advent of labor. The child being non-viable findings were albumen and casts. There was there was nothing to consider only the interests high blood pressure and the uterine pain deof the mother.

veloped into continuous contraction (tetany). Doubtless the major number of cases indicat- With my previous experience staring me in the ing cesarean are in justo-minor flat pelvis or face, I feared ablatio-placente. We decideed on extreme disproportion. These women present immediate delivery. The entire uterine muscle,

upper segment, lower segment and cervix being nancy without pain, very slight dilatation of involved in spasm, the cervix being very close cervix. Diagnosis, placente previa. Mother in and resistant, abdominal section seemed our only good condition except for loss of twenty or more choice of methods. The operation was performed ounces of blood. Baby alive. Effort made to under ether, a living child delivered and the bring on labor by packing cervix with iodoform mother made an uneventful recovery.

gauze under very strict aseptic precautions. Remarks: We consider eclamptic conditions Uterus did not respond after two days and cesand kidney lesions a contra-indication to major arean performed, both patients made an uneventoperations, but to our certain knowledge the ful recovery. conditions had existed for less than two weeks Remarks: In our opinion, any other method in this case and the result confirms our opinion of delivery would have incurred far greater risks that no permanent damage had been done to for both mother and child. In future labors unthe kidneys.

usual care should be given this mother on acI am satisfied that the duration of these con- count of scar. ditions are of as much vital importance as their Case VIII. Primipara, pelvis obstructed with severity. In brief, a mild degree of toxemia or ovarian cyst, decided to let patient go to full kidney lesion extending over a prolonged period term, do cesarian and remove cyst at same time. is more serious than a more pronounced degree Both patients recovered. Subsequently this extending over a brief period.

woman delivered a full grown child by normal Case V. A multipara, three living children, labor. about 40 years of age, sent in from the country in Case IX. Primipara developed insufficiently the last month of pregnancy. She gave a history of kidneys during last six weeks of pregnancy of a sudden severe hemorrhage with pain about with albumen casts, dropsy. The condition of two weeks previous. Fetal movements disap- the mother became so critical that immediate depeared. She consulted no physician until one livery seemed imperative and cesarian section day previous to her coming to the city. On

was the method chosen. The baby lived and is examination there was high pulse tension, al

ere was high pulse tension, al- well today but the mother died about two months bumen and casts in urine, absence of fetal pulse later of acute kidney conditions. and movements with board-like hardness of uter

If I had this case to do over again I would ine muscle. Entire muscle including lower segment in a state of firm tonic painful spasm. Full

try some other method of treatment on account

of kidney lesion. Major operation being contradoses of morphin failed to relieve the spasm.

indicated. Vaginal cesarian had not been popuDiagnosis, ablatio-placente, uterine tetany,

larized at this time and if performed would very dead baby. Abdominal section seemed the only

likely have resulted disastrously to the child. It safe method of delivery of mother, the child al

is possible that medical treatment with induced ready dead. The operation was performed and

labor would have been a safer method than operthe mother made an uneventful recovery and re

ative procedures. turned to her home in good health. Case VI. Mitral Stenosis. This patient, a

In my entire experience, the mortality has primipara, consulted us previous to marriage as

been two mothers, both being toxemic cases with to the safety of child bearing. An older sister

kidney complications that resulted disastrously had died of heart complications following a

about two months following delivery. first labor. We gave her three alternatives : re

Case X. Primipara 45 years of age, married main single, be sterilized by removel of tubes, or fourteen years. Long, firm, close cervix. Scar risk a cesarean section. She got pregnant very where uterine fibroid had been removed, another promptly following marriage. She was watched palpable fibroid in uterus. Decided that risks carefully during pregnancy. At one time she to mother and child were sufficiently great in went to bed in a hospital for three weeks on this case to justify a cesarian delivery. Operaaccount of decompensation. At the thirty-ninth tion performed near full term and both patients week of pregnancy she was delivered by ab

saved. I believe that any one of the three condidominal section and sterilized by removel of

tions; scar in uterus, palpable fibroid, and long, tubes. Both patients made uneventful recover

close cervix in a primipara forty-five years of ses and are in good condition today, four years age were sufficient justification for cesarian.

I have seen one baby fatality from morphin Remarks: Mitral stenosis is the most serious narcosis, the mother having had by direction of heart lesion confronting child-birth and in this the operator 14 gr. of morphin hypodermically, instance it was considered advisable to let the fifteen minutes before taking anesthetic. woman take no chances by going into labor or I believe all cesarian patients should receive even getting pregnant again.

a minimum amount of anesthetic extending over Case VII. Primipara taken with sudden se- a minimum length of time. vere hemorrhage during last month of preg- I have seen two cases of great difficulty in


recussitating the baby after prolonged profound The doctor mentions the sterilization of a woman anesthesia.

because she has to have a cesarean section. In the

case reported by him a man would be perfectly justiAn article by Franklin S. Newell of Boston, in fied in sterilizing her, so that she could not become Journal A. M. A. for February 24, 1917, consid pregnant again, because of her heart action. But if ers cesarean in a very comprehensive manner.

a woman is normal, other than her pelvis, if she has

a normal heart and lungs, I do not see why simply CONCLUSIONS

because she has a pelvic deformity she should be 1. Cesarian section is always an emergency opera

denied the privilege of offspring, or why we should tion.

be justified in recommending sterilization. I have a 2. More skill required to determine what to do than little woman on whom we have performed two how to do it, provided the operator is an abdominal surgeon.

cesarean sections. She had a justo-minor pelvis, and 3. Should be a primary not a secondary operation. she has given birth to two hale, hearty children, and

4. Toxemia of several weeks standing or serious kid in the middle of next month she expects to be deliv. ney lesions, a contra-indication. (My only mortality has been from kidney lesions.)

ered of a third by the same route. Their convales5. Possible infections a contra-indication,

cence is usually uninterrupted and uninteresting, and 6. Exhanstion of mother from any cause a contra why should we deprive them of this privilege if it is indication. 7. Ideal time after labor begins. Uterine contrac

their desire to have children? tions safeguard against hemorrhage, facilitates separation of membranes, insures drainiage by dilating cervix D. C. BROCKMAN, Ottumwa: I was very much and reduces dangers of infection to a minimum.

pleased with the able paper the doctor has given us. 8. The danger of uterine scars depends on the scar. I have an objection to one of his statements, which If the uterine incision is clear cut, the edges carefully coaplated and sutured with the most rigid asepsis and

in this particular case was probably justifiable; that no infective complications following, the scar will stand is, he did a cesarean section for placenta praevia the test of a labor of normal severity. On the other hand, after the cervix had been dilated. If we knew posian obstructed labor with powerful muscular contractions

tively, that the uterus was not infected, it might have or a version might be disastrous. It is well to have such a patient in a hospital under skilled care and be prepared been done. He might have known that; I do not. for emergencies,

For that reason I think that that part of the paper

should be criticized. As a general statement, no man DISCUSSION

has any right to do cesarean section without doing F. B. DORSEY, Keokuk, Iowa: When we coni: the Poro Muller operation on a case where the cervix pare the gravity of a cesarian section with the results has been packed. If he did the packing himself may obtained, both to the mother and the child, with de- be he has confidence in himself; I haven't that confiliveries under certain circumstances that are at- dence on him, or anyone else. tempted and accomplished, we are decidedly in favor Another subject of great importance is the hemorof cesarian section.

rhages-accidental hemorrhage-separation of the plaWe have had quite an extensive experience in centa. I feel in these cases the abdominal operation cesarean section. If we read our text-books and the should be done as soon as possible. description of the various operations advised, we may I think the general practitioner should be more think it is a very complicated operation, but to a careful about the statements he makes to his pa. skilled abdominal surgeon it is one of the most tients. Six weeks ago a man came to me to have simple, I think, of operations in connection with the a premature delivery done upon his wife because she abdomen.

had such hard labors in two former cases. The doctor We are all acquainted with the disastrous effects told her that she never would be delivered of another on the mother where posterior rotation takes place. child unless it was done prematurely. I said, “Bring It means the inevitable use of the forceps, and with it your wife over and let me see her, and if there is any the inevitable destruction of the pelvic floor to a condition there that precludes an ordinary delivery greater or less extent-usually greater. We cer

we will do cesarean section." I found she had a tainly would not think of performing manual dilata. normal pelvis and was a big woman. I told her to tion under the conditions that the doctor mentioned stay in town and go to the hospital when the time in his essay, because of the time consumed and the

came, which she did, and was properly delivered danger to the mother as well as to the child.

well as to the child


The normally. These are statements that the ordinary danger to the mother and to the child, if this opera

practitioner has no business to make. But with the tion is performed under proper circumstances and indication that the doctor mentioned, where it was conditions, is almost nil. In his report of some ten

a question of the election between premature labor or twelve cases the doctor has had but two deaths and cesarean section, I would always decide in favor and those were not due to the operation, but to the

of cesarean. I don't think he touched on that. poisonous constituents from the kidneys. In my ex

In regard to Dr. Dorsey's case, after the woman perience I have had three deaths: one from exhaus- had been in labor 84 hours of course it absolutely protion. The woman had been in labor for 84 hours, hibits cesarean section. I was called not very long with a funnel pelvis, and it would have been better ifago into such a case. The woman had been in labor I had arrived about two hours later, both for the 36 hours. The forceps had been applied after 34 doctors and perhaps for the patient, too. The other hours, and the child had been dead for 12 hours. We two deaths were due to uraemic toxemia, the patients performed a craniotomy and delivered the baby. dying from three to five weeks after delivery.

Any work done on the cervix precludes absolutely I think the day is not far distant when cesarean cesarean section, unless the doctor is positive that section will be a popular operation under conditions there is no infection. When a woman has such & demanding it, when we get a fuller view of it—when defect that it is going to be difficult to deliver her we recognize how little danger it is to the woman, she should be sent to the hospital. I take issue with and very small mortality to the child, and the fact the doctor that cesarean section is always an emergthat it does not leave a woman impaired for future ency operation; I think it should be very largely a labors. As recited by the doctor, because a woman remedial operation. We can induce labor whenever we has one cesarean section does not mean that for her want it; we can induce contractions; and everything it is a cesarean section always; that is not the case being prepared for section makes a very simple in my experience.

operation of it, and I very greatly prefer to make it

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