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ever, find their way to the asylum.

Patients who show unmistakable symptoms of insanity cannot be too quickly removed to some properly equipped institution. The treatment of such cases depends upon the psychosis. The majority of all of them need eliminatives, good nourishing diet in abundance, forced if necessary, fresh air and

quiet. Very few drugs are necessary. To quiet intense excitement and restlessness, a neutral sheet pack or a continuous neutral bath will often suffice. Occasionally a hypodermic of 1/100 grain of hyoscin hydrobromate will be necessary. These measures, together with some simple tonic, are all the patient requires.

CESAREAN SECTION. HISTORY OF A SUCCESSFUL CASE*

CHARLES HARVEY RODI, M. D.,
Calumet.

The Cesarean section is a surgical operation by which the child is delivered from the uterus by an abdominal section. It is generally assumed that Cesarean section takes its name from Cesar who is said to have been delivered in this way, but authorities do not seem will ing to accept this as a fact.

This section was recommended in cases where pregnant women died undelivered, long before it was resorted to upon the living woman. The Romans had a law ascribed to Numa Pompilius which forbade the burial of a pregnant woman before the fetus had been taken away from her, and this was generally done through an abdominal incision. This wise and prudent law was adopted throughout Christendom, and it still flourishes vigorously in the Roman Catholic Church. Pliny stated that the celebrated Scipio Africanus and Manilius were saved under Numa's law. The precise period at which the operation was first performed on the living patient remains undetermined.

The history of Cesarean section may be said to extend over three periods.

*Read before the Upper Peninsula Medical Society.

The first period lasted from the earliest times to the beginning of the sixteenth century. During this period the operation was occasionally resorted to after the death of the mother in the hope of saving the child, but it is improbable that it was practiced upon the living woman, although several authorities are inclined to believe that certain passages in the Talmud may be so interpreted.

The second period extends from 1500 to 1876, when Porro recommended that the older operation should be supplemented by the removal of the uterus. According to M. C. Lage, the first authentic case was reported by Nicolas de Falcon, in 1491. According to Caspar Bauhin the first Cesarean section upon the living woman was performed in 1500, by Jacob Nufer, a castrator of pigs in Switzerland, who operated upon his own wife, saving her life after she had been given up by mid-wives and barber-surgeons in attendance. It is said that Nufer operated many times, but the fact that the woman had five subsequent spontaneous labors would lead one to believe that it probably was the removal

of an extra-uterine pregnancy from the abdominal cavity. In 1581, F. Rousset published a treatise on this subject with the report of a collection of several successful cases, some of them no doubt cases of advanced extra-uterine pregnancy. This article acquired considerable celebrity and directed the attention of the profession to the possibility of performing the operation upon the living woman. The surgeons were so emboldened by Rousset's monograph that the operation was often performed without any indication whatever, and became so popular that a Dominican Friar affirms that it was as common in France as blood letting in Italy. However a reaction took place. Rousset was viciously attacked, public sentiment changed, and Cesarean section would have fallen into oblivion if Caspar Bauhin had not come to the rescue with fresh proofs in its favor. The first authentic Cesarean section was probably done in 1610 by Trautmann, of Wittenberg, Germany, in a case of hernia of the gravid uterus. It was occasionally performed upon the living subject up to 1777 when symphyseotomy supplanted it, and was afterwards taken up again when the latter fell into disrepute.

During all these years, up to 1882, the mortality was frightful; 75% (Mundé); 54% Mires' Collection of 1,600 cases up to 1867; 52% United States collection by Harris.

For 90 years, between 1787 and 1877, there was not a single successful case in Paris. During all this period the uterus. was simply incised. The uterine wall was not sutured and retraction and contraction of the uterus were relied upon to check and control hemorrhage. The high mortality was due to hemorrhage

or infection.

What is known as the third period began in 1876 when Porro advised amputating the body of the uterus and stitching the cervical stump into the lower

angle of the abdominal wall. This improved method aided in the control of hemorrhage and the prevention of infection, and was so satisfactory that Harris, in 1890, was able to collect 264 operations from the literature. It remained. however for Sänger, in 1882, to still further perfect this method by sewing up the incision in the uterus. This, together with the improved technic at this time, completely changed results, the mortality being greatly decreased, so that today the operation is more practical and can be applied under certain conditions that heretofore would not have been considered because of the danger.

Indications

A pelvis which is so contracted as to offer a serious mechanical obstruction to labor is the most frequent and important indication for Cesarean section. It is absolute or relative; absolute when the contraction is so pronounced that the birth of the child cannot be effected by any other means. Authorities tell us that with a living child and the true conjugate diameter of 25% inches extended to 2 6/8 inches, or less, or a generally contracted pelvis of 234 to 3 inches or less, or in case of a dead child, and the true conjugate diameter 134 inches to 2 inches, Cesarean section is absolutely indicated.

The indication is relative when the contraction is so great as to render · spontaneous labor impossible. If the conjugate diameter is not less than 2 4/5 inches, not an over large child can be delivered after symphyseotomy; if less, it is a hazardous operation unless the head is very small. Symphyseotomy competes here with induction of premature labor in a pelvis whose conjugate diameter measures 2 4/5 inches, or more. Further, the indication is still relative. and Cesarean section enters into competition as an alternative with craneotomy,

when the child is alive and the conjugate diameter runs from 2 or 2% to 3 inches.

In view of the excellent results which now follow Cesarean section, and the fact that the spontaneous delivery of an ordinary full term child is out of the question, when the conjugate vera is. less than 7 centimeters (234 inches) the upper limit of absolute indications has been extended to that point.

Williams, at the American Gynecological Society, advocated that the relative indication be likewise broadened in appropriate cases and that the upper limit be placed at 8.5 centimeters (3 1/3 inches) to 9 centimeters (31⁄2 inches), in generally contracted pelvis. He says in cases of this kind the course of labor will depend upon the size and consistency of the head and the character of the uterine contractions. Given two women with pelves the same size, one may have spontaneous labor, while the other may require Cesarean section for delivery. In the latter case the operation is taken primarily in the interest of the child, instead of resorting to high forceps, version or craniotomy.

The

patient is allowed to go into labor, to complete the first, and enter the second stage. In most cases the head engages and spontaneous delivery follows. On the other hand, if signs of engagement are wanting after one hour of strong second-stage pains the propriety of performing Cesarean section should be considered, provided the patient has not been subjected to repeated vaginal examinations, is in good condition, and is in the hands of a competent operator. By so doing, nearly all the children will be saved and quite as many mothers as after difficult high forceps operations or craniotomy. If, however, these conditions cannot be fulfilled. Cesarean section becomes a very dangerous procedure, and should not be considered. In such cases the patient should be allowed

to continue in labor until a definite indication for its termination arises, when high forceps, version or craniotomy should be resorted to, according to the exigencies of the particular case.

Cesarean section on the living woman should be undertaken in cases in which there is no prospect that the fetus, even after embryotomy, can be extracted by the natural passages with less danger to the mother. In pelves about 25% inches in diameter, with a living child, and 134 inches to 2 inches, with a dead child, Cesarean section is necessary to save the mother's life. Here the indication is absolute, because no other less dangerous alternative presents itself.

In pelves whose conjugate diameter is over 25% inches, symphyseotomy, the induction of premature labor, or embryotomy, being simpler and safer for the mother, must be considered. Here the indication is relative.

If the conjugate diaineter is more than 24 inches, it is always possible, by means of craniotomy, to bring away the child through the natural passages. If the child is dead, perforation is preferable, if alive, one has to choose between perforation and Cesarean section. Zweifel expresses the opinion of today in the following words: "Cesarean section must be preferred to craniotomy in these cases, because it renders it possible to save the life of both mother and child."

Donohue (American Jour. Gyn. and Ped, August, 1903), says: "Conservative Sänger, Cesarean section should be performed in cases of (1) complete placenta previa; (2) placenta previa in the absence of severe hemorrhage or rigid os; (3) when there is a history of previous operative delivery; (4) it should be considered in all cases in which version is indicated, if a reasonably skilled surgeon is available and only an ordinary obstetrician; (5) all these indications are based on a probable viable

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due to some other cause, as cancer, or the presence of a tumor in the pelvic cavity. Every practitioner should be able to form a fair estimate of the amount of contraction of the pelvis, to say before labor has begun, or during the early stages of labor, that the diameter of the pelvis is or is not less than three inches. Not only should he be able to form an estimate of the amount of contraction, but he should be qualified to form an opinion as to whether it will be impossible for the child to pass, and also whether, under the difficult circumstances under which he may be placed, it would not be better to prepare for Cesarean section or to send the patient where Cesarean section could be safely performed, rather than to extract a mutilated fetus through a minimum diameter.

With a diameter of 25% or 234 inches, where engagement of the head is impossible, no one should hesitate to advise Cesarean section, although there will always remain cases, as where the child is dead or a subject of hydrocephalus, in which craniotomy may be resorted to.

Experience alone will enable one to avoid extreme measures. In cases where the conjugate diameter is 3 inches, the skilled practitioner will weigh the chances between premature induction of labor and symphyseotomy. There can be no question that Cesarean section is a highly dangerous operation, but the danger it should be remembered depends, for the most part, on delay, and death most frequently results not so much from the operation as from injudicious and prolonged attempts to extract the fetus. through a deformed natural passage. Success depends upon prompt interference before the patient is exhausted, as then there is less danger from hemorrhage, delayed shock or peritonitis.

Contraindications

Cesarean section should never be per

formed when the child is dead or in serious danger, or if the mother is infected, in poor condition, or with surroundings. that render an aseptic operation impossible. Under such circumstances, craniotomy is the operation of choice. Cesarean section should not be undertaken unless a living child is earnestly desired. Again it is usually contraindicated when the patient has been subjected to repeated vaginal examinations during labor, by one whose technic is questionable, even though no signs of infection are apparent at the time. If, however, Cesarean section should be decided upon under these circumstances, the entire uterus should be removed after the extraction of the child,

Operative Technic

Conservative Cesarean section when undertaken for the absolute or even for the relative indication, if previous labors have repeatedly ended in the birth of dead children, should be performed at an appointed time, a day or two or, even longer, prior to the expected onset of labor. In many instances it happens of course that the patient is not seen until well advanced in labor. Moreover in border cases sufficient time should be given to demonstrate what nature will do. Frequent vaginal examinations should be avoided. If the head does not engage after one hour of strong second stage pains and there appears no likelihood of spontaneous delivery, the Cesarean section should be promptly performed as the prospects for recovery diminish rapidly with every hour after the onset of the second stage of labor. History of a Case of Successful Cesarean Section

Mrs. M., aged 29 years; height 54 inches. Her father, a Frenchman, was tall. Her mother, a German, is a woman of ordinary height; one brother died of phthisis, one brother and two sisters are living.

Nine years ago, she was delivered of a male

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