Report of a Successful Caesarean Section. BY HENRY D. FRY, M.D., WASHINGTON ». C. EEPEINT FEOM VOL. XV. (Snjttccofogtcaf 1890. [Reprinted from the Transactions of the American Gynecological Society, September, 1890.] REPORT OF A SUCCESSFUL CESAREAN SECTION. By Henry D. Fry, M.D., Washington, D. C. I was called Sunday, February 9, 1890, about 8 o’clock in the evening, to see a dwarf who had been in labor thirty-six hours. The date of her last menstruation was April 20, 1889 ; the date of expected confinement, January 27, 1890. The patient had partaken sparingly of nourishment for three or four days preceding my visit, and had slept little for several nights. During Sunday she had kept up on whiskey alone, having drank about one pint. Her pulse was 144, and sublingual temperature 99.4°. The pulse had considerable volume and strength; its rapidity being due, in great measure, to nervous perturbation. The uterine contractions were of the character which primi- parce frequently experience for some hours without producing marked exhaustion. The abdomen was large and prominent, and the uterine tumor was felt to undergo rhythmical contraction and relaxation. The child presented by the head and occupied the left occipito- anterior position. The head was above the pelvic brim and pro- jected well over the symphysis pubis. By auscultation the foetal heart-sounds were audible to the left of the umbilicus. Digital examination revealed the vulva and vagina soft, moist, and distensible. The cervix was situated high and was not effaced, the os and cervical canal being dilatated only sufficiently to admit the index finger. All the diameters of the pelvic cavity were diminished, and that of the diagonal conjugate measured about one inch and a half. 2 SUCCESSFUL CAES A RE AN SECTION. Recognizing the necessity for Caesarean section, steps were taken for immediate action. Full directions were given for the preparation of the room, and the patient was ordered a warm soap-bath, a Vaginal douche of bichloride of mercury solution, and an enema to move the bowel, x left at 9 o’clock to make my arrangements, and returning at 11, the patient was ether- ized and the operation begun at 11.55. The bladder was evacu- ated with a catheter, the hair shaved from the pubes, and the field of operation made aseptic in the usual manner. Every effort was made to secure asepsis by preparation of the hands, instruments, sponges, etc. The following gentlemen were present: Drs. S. C. Busey, W. W. Johnston, A. F. A. King,W. M. Sprigg, and R. M. Ellyson, and I wish to express my gratitude for their assistance. To Drs. Sprigg, Ellyson, and H. B. Deale I am greatly indebted for faithful attendance during the after-treat- ment. An incision was made through the linea alba from the umbil- icus to within one inch and a half of the symphysis. The peri- toneal cavity was opened aud the incision carried through and two and one-half inches above the umbilicus. The uterus was lifted out of the abdominal cavity and the parietes held in close apposition to its sides. An elastic ligature was next passed be- hind the organ and adjusted around the cervix. This was held loosely in the hands of an assistant, who stood prepared to tighten it at a moment’s notice. A large sponge was placed at the lower angle of the wound to prevent blood or amniotic fluid from enter- ing the peritoneal cavity. Before incising the organ an unsuccessful attempt was made to locate the position of the placenta, which proved to be attached to the anterior wall, and was cut directly upon in opening the uterus. Bleeding, which had been trifling, now started freely, but was immediately controlled by the constriction of the elastic ligature. The placenta separated from its attachment and was removed. The infant was delivered by the head, which .presented at the lower third of the opening. It was asphyxiated, and without doubt would have been lost but for the skilful attention of Drs. Busey and King. HENRY D. FRY. 3 The tension of the elastic tube was removed and bleeding was slight. The uterine cavity was cleansed of blood-clots and shreds of membrane, sponged and dusted with iodoform. The uterine wound, which was about five and one-half inches long, was closed with thirteen deep and fifteen superficial sutures. Silk was used for both, the superficial ones being fine. The deep stitches passed down to, but not through, the endometrium; the superficial approximated the peritoneal edges, which were in- verted. No fluid escaped into the peritoneal cavity during the opera- tion, nevertheless it was irrigated with boiled water at a temper- ture of 115°. The irrigation had a good effect in producing firm uterine contraction. Hypodermic injections of ergot were also administered. The abdominal wound was next closed with deep and super- ficial silk sutures. The time occupied from the beginning of the operation to the removal of the child was six minutes, and it was completed in full, in one hour. The patient was transferred to bed in excellent condition and without the slightest indication of shock. In fact, it was ob- served that her pulse was better than before the operation. She was wrapped in blankets, and bottles of hot water were applied to her extremities. During the remainder of the night she slept some, complaining of nausea, and vomited a few times. During the day of the 10th her pulse varied from 108 to 118, and her temperature from 99° to 100.4°. She complained greatly of thirst and begged for water, but nothing whatever was per- mitted by mouth for seventeen hours. Rectal injections of warm salt-water and beef-tea were given. The urine was drawn every six hours. Monday night was passed comfortably, and Tuesday the pulse the temperature ran about the same as the day previous. In the afternoon the administration of calomel triturates was begun and repeated every two hours. On Wednesday (third day) the bowels moved twice. Thursday night the patient was restless, and Friday (fifth day) her condition was not so satisfactory. At 7 in the morn- ing her temperature was 100.7°, at 10, 101.5°. The abdominal 4 SUCCESSFUL CAESAREAN SECTION. wound was examined and looked in excellent condition. A disagreeable odor of the lochial flow was detected for the first time. The cervix was small, and os closed. Believing the unfavorable symptoms were septic and due to deficient drainage of the uterine cavity, the cervical canal was thoroughly dilated with steel instruments and the cavity of the uterus explored and then irrigated with a 2-per-cent, solution of carbolic acid. No clots or debris were found in the uterus. The immediate effect of the manipulation was to run up the temperature to 104°, but it soon began to fall, and at 7 o’clock in the evening was 99.8°. From this time the lochial discharge was regular and free from odor. The temperature did not rise again, and the patient had an uneventful convalescence. Antiseptic vaginal douches were administered for some days. The baby, a well-developed and hearty boy, is at present four months of age. The mother is entirely recovered. I have since obtained the following information concerning her : She is the sixth of eight children—all girls. Her parents are of American descent, and they lived upon a large farm, possess- ing every advantage of healthy surroundings. Her sisters are all living and healthy. She was a feeble child and did not walk until eighteen months old. Her height is forty-five inches. Judging from the conformation of the skull and the incurva- tion of the long bones, she had been evidently a subject of rickets in early life. The measurements of the external pelvic diameters are: Distance between the anterior superior spines of ilia ... 71 inches. “ “ middle of crests of ilia 5f inches. “ “ of external conjugate ..... 5J inches. “ “ great trochanters Ill inches. The upper portion of the sacrum projects forward between the ilia, causing a marked depression at the corresponding part of the back. The greatest diameter between the iliac crests is at the anterior spines. The variety of deformity is the flattened, generally contracted pelvis.