CÆSAREAN SECTION, WITH REPORT OF AN UNUSUAL
CASE. *

By CHARLES T. Howard, M.D., F.A.C.S., Boston.

For many, many years Cæsarean section was performed as an operation of necessity. When all other methods of delivery had failed, the abdomen was opened and the foetus removed. The mortality of both mothers and infants was enormously high and none but the most daring undertook it. Of late years the situation has markedly changed and today Cæsarean section is an operation of election, and is being performed much more frequently and for much broader indications than it was ten or even five years ago, and I fear at times without proper discrimination.

The time has come when each one of us must have definite convictions as to the safe limitations of this operation. I have tried to formulate the indications for my own guidance.

I have tabulated the cases in the Massachusetts Homoeopathic

In 1913

2 cases

12 cases

15 cases

In 1914 (to Oct. 31) 29 cases

The indications for operation were:

Contracted pelvis of one type or another, 35 cases. Of these three mothers died from peritonitis, one baby was stillborn, and five died while still in the hospital.

Placenta prævia, 9 cases.

the babies were stillborn.

The mothers all lived and two of

Eclampsia, 6 cases. Of these four mothers died, two babies were stillborn and one died later.

*Read before the Boston District of the Massachusetts Homœopathic Medical Society, November, 1914.

AL

It is only just to our statistics to say that three of the four who died were moribund and operated upon without any anæsthetic whatever. No thought was entertained of saving the mother, the baby alone being considered.

Toxæmias of pregnancy, 8 cases; of which one mother died from peritonitis, two babies were stillborn, and two died before leaving the hospital.

Fibroid of the uterus, I case: mother and baby both living. The total mortality of these 59 cases has been 8 mothers, 7 babies stillborn, and 8 babies died in the hospital, a maternal mortality of 13.55 per cent. In order to arrive at just conclusions. as to the risk of the operation I feel that we should eliminate the three moribund eclampsia cases. This makes a true mortality of the operation as 8.92 per cent, all from peritonitis.

It is a fact well recognized by all who have had much experience in this line of work that the mortality rate increases more or less in proportion to the length of the time that the woman has been in labor before operation. Our group of cases must consequently be considered an unfavorable series, inasmuch as the average duration of labor (taking all cases where the time was given on the labor sheet) prior to operation was 46 hours.

The statistics for the Boston Lying-In Hospital as given by Greene in the Boston Medical and Surgical Journal for July 30, 1914, were 231 Cæsarean sections, with a loss of 17 mothers, making a mortality of 74 per cent. In the same article the statistics of the New York Lying-In are given as 352 cases, with death of 38 mothers: a little more than 94 per cent.

I have given these statistics for the purpose of showing that the operation of Cæsarean section is not one to be advised lightly or one to be undertaken without positive ideas as to what cases should be so treated. I feel that unquestionably the operation has been performed many times when other methods would have been better and attended with less risk to the mother. In the enthusiasm of delivering a woman without pain in a most spectacular fashion we are apt to forget that the dangers of the operation are considerable. We must not ignore a mortality of approximately 8 per cent.

Now there are three conditions which today most generally are considered indications for Cæsarean section,-contracted pelvis, placenta prævia, and eclampsia. There are, of course, cases of fibroid or other tumors obstructing the outlet which call for Cæsarean section, but the three causes enumerated are the

common ones.

In cases with a markedly contracted pelvis I think everyone.

The

will agree that Cæsarean section is absolutely indicated. question comes only in those cases where the contraction or deformity is slight and the possibility of spontaneous delivery has to be considered. Unfortunately, the practice of obstetrics is still an Art instead of a Science, and we have no way of determining the exact dimensions of the child's head in utero and deciding whether or not it is possible for it to be pushed through the bony canal of the pelvis. We must consequently rely upon as careful pelvic measurements as we can get, and in the light of past experience judge whether or not the patient can be delivered without too much traumatism. By the use of the high forceps, of course, many babies can be dragged through a comparatively small pelvis, but it is always attended with considerable danger to the mother and infant. Furthermore, we must consider the morbidity subsequent to a high forceps. Many a woman has awakened from the ether to find a dead baby and to discover later that she was a semiinvalid. Compare the after results of high forceps deliveries with the after results of Cæsarean section, and the balance is all in favor of the Cæsarean.

Placenta prævia. For many years this complication has been the bete noir of the obstetrician. The centrally implanted cases have been treated by perforation of the placenta and version, bringing down a leg to cause pressure on the placenta and control hemorrhage, in the marginally implanted cases early rupture of the membranes and the introduction of a dilator bag to control the hemorrhage.

Now what are the indications for Cæsarean section in placenta prævia? I believe it to be in all cases of centrally implanted placentæ, or where the placenta is so far over the os that the membranes cannot be reached easily to rupture and allow the pressure of the head or a dilating bag to control the bleeding. I believe it is still wise to follow the oid line of treatment whenever it is possible to reach the membranes and to rupture them. All other cases are suitable for Cæsarean section. In cases treated by perforation of the placenta and version, the infant mortality is approximately 50 per cent. Under Cæsarean section the infant mortality drops to approximately 30 per cent and the maternal mortality to not over 5 per cent, in our hospital, zero, none of the nine mothers dying.

In considering the place of Cæsarean section in eclampsia and the toxæmias of pregnancy we enter upon ground which has been fiercely fought over for a number of years. Tonight I shall not enter into the discussion as to whether the expectant treatment in eclampsia as practised in the Rotunda at Dublin or the rapid delivery is the better. That topic in itself is sufficient for

a paper, and you heard it argued by Dr. Edwin Smith about a year ago.

I am in the camp of those who believe in rapid delivery and shall simply discuss the question as to the place Cæsarean section should hold in rapid delivery of toxic cases. Now, waiving discussion as to the indications for a rapid delivery and granting that all dietetic and medical measures have been employed and still the patient is profoundly toxic or even eclamptic: what shall we do? There are three methods of rapid delivery: mechanical dilatation of the cervix with the application of forceps or version; vaginal Cæsarean, followed by the use of the forceps, or version. and abdominal Cæsarean.

The first method, that is, the mechanical dilatation of the cervix with the application of forceps or version, is a measure which today is limited in scope. It must be remembered that in profoundly toxic cases or eclampsia the cervix is usually not only but slightly dilated, but also that it is of a particularly rigid and unyielding character. Hence manual or instrumental dilatation is a slow, tedious process, taking at least an hour, and if not carried out very slowly apt to be associated with extensive lacerations of the cervix and uterus. Consequently there is a high morbidity among the women who recover from their eclampsia. The maternal mortality is placed by statistics compiled by Dr. John T. Williams, as about 18 per cent, the infant mortality at about 65 per cent. With these figures in mind it would seem, therefore, as if dilatation of the cervix with forceps or version should be limited to those rare cases where the cervix is fairly soft and dilatable, and even then we must have a high infant mortality.

Vaginal Cæsarean section, or what would seem better nomenclature, Dührrsen's section of the cervix, is an operation which tends to meet the rigidity of the cervix in these cases. A transverse incision is made across the anterior lip of the cervix; the bladder pushed up out of the way as in a vaginal hysterectomy, and the cervix is then incised longitudinally up to, or above the internal os. The operation, therefore, takes the place of the mechanical or manual dilatation of the cervix. The baby is delivered by forceps or version. The maternal mortality in 201 cases has been a fraction over 10 per cent. The infant mortality about the same as in rapid dilatation, namely, 65 per cent. It would seem then as if the vaginal Cæsarean was much better than the rapid dilatation. It should be remembered, however, that this operation. is not an easy procedure in a woman at full term where the cervix is carried well up into the pelvis, and under such conditions must be a time-consuming and difficult operation, to be undertaken only

in the hospital under favorable operative circumstances. To me its place seems to be in those cases of eclampsia or profound toxæmias occurring along the seventh month, when we cannot hope to get a living baby, when the cervix is not yet taken up and is rigid and unyielding. For this class of cases I believe we have overlooked a most valuable procedure.

Abdominal Cæsarean, the third of the methods for rapid delivery, covers those cases of eclampsia not covered by the prevous two methods. To put it in a positive rather than a negative phase, it is indicated in cases of eclampsia where the woman is at, or near term, with a rigid, unyielding cervix. For such cases it is superior to the vaginal Cæsarean because of the far better chance of a living baby. It is true that the maternal mortality is higher, but not enough higher in my estimation to justify an increase in infant mortality from 42.2 per cent to 75.4 per cent.

Now to consider the operation itself. All these figures and deductions are based upon the results of the operation as we are doing it today. Let me predict that the results of the next five years will show a much lower mortality than the last five. The great factor today in running up the mortality of this truly wonderful operation is peritonitis. Just why peritonitis follows what apparently should be a clean operation I have only theories to explain. It is a fact, however, and one which looms up prominently in all published statistics. Another fact which also stands. out boldly is that the mortality increases with the duration of the labor previous to the operation, and also in proportion to the amount of vaginal manipulation.

How then are we to improve on results and bring our mortality down to a percentage consistent with other clean abdominal operations? First will come improved technic. Practically all of the major operations have gone through the stage of development that Cæsarean section is going through now. It is true that the operation is old, very old, but it is also true that it is decidedly new in most of its phases. Where it was formerly done only as a measure of last resort it is now becoming more and more an operation of election.

Abdominal hysterectomy, cholecystotomy, appendectomy, gastro-enterostomy have all been through the same trial. It will be the same with Cæsarean section.

In order for it to become an operation of election we must learn to estimate more carefully the relative proportions between the infant's head and the bony outlet. When we have learned to foresee the cases of difficult labor from a contracted pelvis and offer such patients an early Cæsarean before they have been sub