writer believed that the different operations, with their potential dangers should be presented to the family, permitting them to decide as to the method. His views have changed somewhat in this regard; the untutored minds and judgments of the members of the family too often are incapable of passing opinions; now he would lay down the essential facts as they seemed best for the interest of those concerned. In conclusion, the writer would deprecate the Cesarean section performed with inadequate assistants, faulty surroundings and makeshift facilities; the writer has had ample opportunity of testing an emergency Cesarean section under trying circumstances, and feels strongly that it should not be done unless there be very pressing indications. 412 NORTH STATE STREET. SIX CASES OF CESAREAN SECTION.* BY JOS. B. DELEE, M.D. Mrs. D., age Case I was referred to me by Dr. Guy Gowan. 28, II-para, Irish, Catholic; had a hard instrumental delivery at her first labor with a complete laceration of the perineum. The cervix and roof of vagina sloughed out, leaving a narrow fistula leading up into the uterus. An unsuccessful secondary perineorrhaphy left a rectovaginal fistula. A few months later patient had gangrenous appendicitis and after operation a large hernia. developed in the scar Patient is now pregnant at full term, and labor has been in progress for 12 to 15 hours. The bag of waters ruptured. Examination. Abdominally; large child, head 12 cm., slightly contracted pelvis. C. D. 12 cm. Bispinous 10 cm. False promontory, bones large and heavy. Signs of rachitis. Vaginally; no cervix can be felt. The vagina ends in a single vault, in the apex of which a small lump of tissue can be felt. No cervix or os is discoverable. The vagina is full of feces and gas. In view of the difficulties of extracting the large child through the scarred uterus and vagina, and the dangers of general infection in producing so much traumatism in the presence of so much fecal matter, it was * Chicago Gynecological Society, March 17, 1905. diameter of C. V. IO cm. deemed wiser to remove the child through the abdomen, and amputate the uterus if it was found impossible to dilate the sinus from above. The child's interests were likewise considered better in an abdominal delivery. The section was typical. The uterovaginal fistula on the uterine side would admit a fine toothpick. It could not be rapidly dilated. The uterus was atonic and hemorrhage very profuse, so the amputation of the uterus was performed. A piece of the lower uterine segment formed the stump, as it was not considered advisable to remove any more of the vagina, and the bladder relations were disturbed There was hardly any broad ligament at the base, and it was with difficulty that the vessels were found, owing to the distortion produced by the scars. The child was a female weighing 9 lb. The mother rallied poorly from the operation, and 6 hours later was in bad condition, with a running pulse at the wrist and 192 heart beats counted with a stethoscope. Extreme pallor and prostration. Saline solution had been given on the operating table. Acting on the assurance that there was no internal hemorrhage, only rectal saline solution was given, without other stimulation. and patient gradually recovered. Primary union in the wound. Good lactation. Mother and babe throve. Case II referred to me by Dr. R. Graves. Mrs. S. II-para, age 26, Italian. First labor craniotomy, with extensive lacerations. Patient has a flat rachitic, kyphoscoliotic pelvis. Spines, 26; crests, 25; trochanters, 30; C. D. to false promontory. 8; C. V. 6 to 7; bi-ischiatic, 10; sacrum convex from side to side and upper half convex from above downward. Head projects 1 inch in front of the pubis. Labor lasted 8 hours. Cervix, 4 fingers, half of head in pelvis, the anterior half arrested on the pubis. Conservative Cesarean section. Female, 6 lb. Smooth recovery for both. Case III referred to me by Dr. Trenchard. Mrs. J., age 33, primipara, German. Flat rachitic pelvis of high degree of contraction. C. D. 8 cm. CV 6 to 6. Head high above promontory makes a visible tumor over pubis. A very marked granular vaginitis is present, with a profuse green, purulent, foul-smelling discharge, Porro Cesarean section. No complications. Smooth recovery for both. Case IV referred to me by Dr. White. Miss H., colored, age 18, primipara, kyphoscoliotic flat rachitic pelvis, also generally contracted. Patient is a rachitic dwarf, and is afflicted with acute gonorrhea. Porro Cesarean section, leaving one ovary and part of the tube. No complications at time of operation, but patient ran a ten days' course of high fever. The wisdom of removing the uterus was thus proven. Male, 7 lbs. throve at the breast. Case V is one treated 2 years ago in the service of the Chicago Lying-in Hospital Dispensary, and whose case was reported at the meeting of this society shortly after. Mrs. F., Italian, born in Naples, Catholic, age 34. Her first, second and third labors were normal and easy. The fourth was long, terminated by a physician, and the chiid, though small, was dead. She then came to America. Her fifth labor was slow, but normal, with a small, living child. Her sixth labor was the one referred to, terminated by myself, by version and craniotomy. The measurements are: spines, 25; crests, 28; trochanters, 28; Bandelocque, 19; C. D., 91; C. V., 7; bi-ischiatic, 6. The sacrum is sharply curved and the rami pubis are so close together that it is almost impossible to insert two fingers between them. The pubis can be grasped like the handle of a dipper; it is "beaked." Osteomalacic pelvis of high degree. Patient entered the hospital in labor, and was operated on before the classes of Northwestern. The conservative section was performed without incident. Then the ovaries were removed. (Unfortunately these were destroyed so that sections could not be obtained, to confirm Fehling's findings in osteomalacia.) The child was a male weighing 6 lbs. It lived. The recovery of the mother was interrupted by an abscess in the wall of the uterus, probably from infected catgut, but the uteroabdominal scar was firm, and up to one year no hernia had developed. Case VI was another from the service of the Chicago Lying-in Hospital Dispensary and her case, too, has already been reported before this society. This is her second Cesarean section. Mrs. H., age 28, IV-para, Prussian Jewess, has a generally contracted flat rachitic pelvis. C. D. 10; C. V., 8; bi-ischiatic, 5. Craniotomy was performed on the first child, after preparations for symphyseotomy had been completed. Reason for desisting was bad condition of child. Cesarean section was done in the second labor. Recovery complicated by infected silk, which suppurated for 8 months. During this period an abortion occurred, spontaneously. The fourth pregnancy was the present one and the labor occurred at full term. The omentum was adherent to the abdominal wall and also to the uterus, requiring some time in separation. Transverse fundal incision (made also the first time on this patient) and 91 lb. boy delivered alive. Cried at once, which is unusual, and in this case probably due to slow delivery. Operation otherwise not unusual. Patient rallied well, but soon symptoms of obstruction of the bowels appeared. Obstipation, vomiting, prostration, pulse 132, respiration 60, hiccough, tympany. The tight binder was loosened and immediately the symptoms ameliorated. The bowels moved within 10 minutes and the patient was out of danger in two hours. Recovery of both mother and child perfect. These six cases, in which all mothers and babes lived, added to four others already reported, make in all ten cases of Cesarean section. Of these 9 mothers recovered and 9 babies lived. One child died in 16 hours under symptoms of acutest sepsis, though the mother recovered. It had fever of 101° when delivered. The one case that died was one that had been in labor three days, had been examined under ether three times, and who had a solid tumor of the ovary blocking the pelvis completely. The technique of the operation was varied but little in each case. The transverse fundal incision was used only twice. There is no advantage in it. The uterus was amputated three times, once for obstruction to the lochial flow and twice because of a severe vaginitis. One ovary was left in each of these cases to preserve the ovarian function as long as possible. The uterus was delivered through the incision in all the cases, but the abdomen was closed in three layers and no hernia has developed in any of the cases. Altogether the results encourage one to extend the field of Cesarean section. 34 WASHINGTON STREET. A STUDY OF FOUR HUNDRED CASES OF TUBERCULOSIS IN CHILDREN.* BY SAMUEL S. ADAMS, A.M., M.D, In this paper it is my intention to deal with tuberculosis affecting the brain, the lungs and the abdominal viscera. This will necessarily exclude a large number of cases of tuberculous affections, more especially those of the lymph-glands, the bones and joints. The cases here analyzed have been under the observation of my colleague, Dr. G. N. Acker, and myself, and our predecessors in the Children's Hospital, District of Columbia, and are, unfortunately, not always accurate in detail. The hospital was established on a small scale in 1870 and considerably enlarged in 1878. I have been on continuous duty, except six month in 1880, since 1876, and have availed myself of the courtesy of my colleague to familiarize myself with many of the cases not under my own supervision. From nearly thirty years' experience with tuberculous patients, much knowledge of tuberculosis and its treatment has been gained and, though my ideas may seem pessimistic, nevertheless the conclusions drawn are not the outcome of theory, but the deductions drawn from cases "under control"-to use a laboratory term. The children have varied in age from early infancy to fifteen years; but the maximum age was fixed at 12 years about 15 years ago, and white infants under two years have only been admitted since 1894. Age seems to influence the location of the tuberculous process in the white and black. The white infant and young child is much more susceptible to tubercular meningitis than the negro; but tubercular peritonitis is quite common in the negro and rarely seen in the white child. Frequency. As to the frequency of tuberculosis in young children, the statistics of numerous clinicians preclude the possibility of reaching a definite percentage. Positive results, however, are significant as to the seat of the tuberculous process. In Holt's 119 personal cases, under 3 years, the lungs were affected in 99 per *Read before the Washington Obstetrical and Gynecological Society, February 17, 1905. |