TWO SUCCESSFUL CASES OF THE 
CONSERVATIVE CESAREAN 
SECTION. 
-BY 
Charles Jewett, A. M.,M. D., 
Professor of Obstetrics and Diseases of 
Children in the Long Island College 
Hospital. 
Reprinted from 
The New York Journal of Gynecology 
and Obstetrics. 
March, 1892. 
New York: 
M. J. Rooney, Printer and Stationer, 
1329 Broadway. Reprinted from The New York Journal of Gynaecology and Obstetrics, March, 1892. 
TWO SUCCESSFUL CASES OF THE CONSERVATIVE 
CAESAREAN SECTION. 
Charles Jewett, M.D. 
The operations referred to in the title of this paper were both 
done in December last at the Long Island College Hospital. The 
first patient was a woman of English birth, aet. thirty-two years. 
With the exception of a chronic nephritis, she was apparently in fair 
health. No important uraemic symptoms appeared at any time, 
yet, twice after the operation there was partial suppression of urine 
which was promptly relieved by moderate doses of diuretine. The 
only outward signs of bony deformity were her small stature (4 ft. 
6 in.-137.2 cm.), and a lumbo-sacral kyphosis, the summit of 
which corresponded to the fourth lumbar vertebra. The character 
of the spinal deformity is shown in the accompanying figure (Fig. 1). 
The compensatory lordosis above pitched the uterus forward, giving 
the abdomen an unusually globular and pendulous shape. The pel- 
vic measurements were: Iliac crests, n1/, in. (29.2cm.); iliac 
spines, ioy2 in. (26.6 cm.); external conjugate, in. (19 cm.); 
symphysis pubis, 2 in. (5.1 cm.) deep; diagonal conjugate, 4y4 
in. (10.8 cm.) ; true conjugate, estimated at 33/4 in. (9.5 cm.); 
coccyx to subpubic ligament, 23/4 in. (7 cm.) ; bisischial diameter, 
2y4 in. (5.7 cm.). The patient was admitted to the hospital in the 
evening of December 1, 1891, labor having begun at 10 in the 
morning. At 12 midnight the waters had drained away and the 
head had sunk well into the excavation ; the os externum was 
dilated to the size of a half dollar and was dilatable ; the child was 
small, the head within easy reach and the case altogether a favor- 2 
Charles Jewett, M.D. 
able one for craniotomy. This operation was determined upon 
after consultation with Dr. Dickinson, of the attending, and Dr. 
Wallace of the consulting staff. This decision, however, was 
reversed on learning that the woman was a Catholic, and the 
Caesarean section was done by necessity in deference to the re- 
Fig. i. 
quirements of her religious faith. The pulse, shortly before the 
operation, was 90 and weak, and the patient showed signs of ap- 
proaching exhaustion. 
Operation.-First incision at 2.11 a.m. ; some difficulty and loss 
of time in applying the cervical constrictor, which was a large, 
thin-walled rubber tube ; placental seat directly under the uterine Two Successful Cases of Conservative Ccesarean Section. 
3 
incision ; hand passed over the left edge of the placenta, and 
through the membranes ; head extracted from the pelvic cavity 
with difficulty, and only after relaxing the grasp of the constrictor ; 
child delivered in four minutes from the time of first incision; 
cord clamped at two points with catch-forceps and cut between 
them ; the child was alive and respiration was promptly estab- 
lished ; the uterus was drawn up into the abdominal wound but 
not out of the abdomen ; the placenta and membranes were 
separated by hand, and the uterine cavity left undisturbed. The 
uterine incision, which, owing to the strong forward inclination of 
the uterus, reached well up on the fundus, was closed with twelve 
deep silk sutures in seventeen minutes from beginning of operation ; 
deep sutures included the decidua ; symperitoneal suture with fine 
catgut ; almost no handling, and no special cleansing of the peri- 
onaeum, a small amount of blood and bloody serum being left in 
the cavity ; abdominal incision closed with ten silk sutures and 
dressed with a thick covering of dry gauze fresh from the steam 
sterilizer; blood-loss no greater than in ordinary labor. The 
tonicity of the uterine muscles was apparently unimpaired by the 
cervical constriction, though a good deal of tension was required 
for a time to control haemorrhage. Retraction promptly followed 
moderate manipulation and the injection of a half drachm of fluid 
ergot under the skin. The patient made a good recovery. The 
lochia remained odorless. There was only a barely perceptible 
meteorism for a few hours, and at no time any evidence of sepsis. 
After the eighth day an occasional slight rise of temperature occurred 
which was controlled by quinine. Five grains of calomel were 
given toward the end of the second day and followed with a saline. 
The abdominal sutures were removed on the tenth day. Uterine 
involution was slow, but the woman was ready to leave the hos- 
pital by the end of four weeks, except for a sciatica which detained 
her for some time longer. The child was a female, weighing five- 
and-a-quarter pounds. The head measurements were : Bi-parietal, 
3*/2 in. (8.9 cm.); O. F., 41/\ in. (10.8 cm.); O. M., 5'/^ in. (13.3 cm.) 
The second case .was that of a German immigrant, set. twenty 
years. She was transferred to the maternity from the medical 
wards with the following history : Subject to frequent hysterical 
paroxysms with occasional convulsions ; the attacks were fre- 
quently followed by semi-coma, lasting for days; badly nourished, 
owing to anorexia and frequent emesis ; ejecta at times contained 
considerable quantities of blood. A notable feature of this case 
was the irregular and excessively high flights of temperature, which 4 
Charles Jczvett, M.D. 
several times before operation mounted to 107°, once to no° F. 
The temperature would generally fall in an hour or two nearly or 
quite to the normal without treatment (see temperature chart, 
Fig. 2). The pyrexia was believed to be mainly of neurotic origin ; 
some days before operation barely perceptible signs of beginning 
consolidation were detected at the apex of one lung, which were 
attributed by Professors McCorkle and West, who kindly examined 
the patient, to a slight broncho-pneumonia. The lung cleared up 
in two or three weeks after operation, and the trouble was at no 
time sufficiently marked to be regarded as a factor in the high tem- 
perature. There was also an intense stomatitis, with patches and 
ulcers on the mucous membranes of the mouth and throat, attended 
with copious salivation and partial or complete aphonia. Post- 
cervical glands indurated. A careful laryngoscopic examination by 
Dr. W. F. Dudley substantially confirmed the diagnosis of syphilis 
in the second stage. 
The patient was of slight figure, 4 feet 6'/2 inches (138.5 cm.) in 
height, and with no bony deformities except in the pelvis, which was 
extremely flattened. Pelvic measurements were : Crests, io1/, in. 
(26 cm.) ; iliac spines, io3/4 in. (27.2 cm.) ; external conjugate, 61/, 
in. (159 cm.) ; diagonal conjugate, in. (8.3 cm.) ; depth of 
symphysis pubis, 2*/4 in. (5.7 cm.); true conjugate estimated at 2l/2 
in. (6.4 cm.); pubo-coccygeal diameter, 2*/4in. (5.7 cm.); bisischial, 
2% in. (5.7 cm.). Labor pains began at 1 p. m. , December 16, and 
about the end of the sixth month of gestation, or a little later. 
Fundus well above the umbilicus; waters escaped at 6 p. m ; at 
9.15 the cervix was not effaced and admitted one finger with diffi- 
culty ; while a piecemeal extraction of the foetus or cephalotripsy 
would have been possible, craniotomy through a pelvis so narrow 
at both inlet and outlet would have been an awkward and difficult 
operation, to say nothing of the long delay that would have been 
necessary owing to the unyielding condition of the soft parts. 
Caesarean section was therefore decided upon mainly in the interest 
of the mother, though not wholly without hope of a viable child, 
Drs. Wallace and Hyde, of the consulting staff, and Dr. Dickinson 
concurring. Temperature immediately before operating, io88/8° F., 
pulse, 98. 
Operation.-First incision at 10.41 p.m. Troublesome protrusion 
of intestines from tympanitic distention; provisional uterine ligature 
of large, thin-walled rubber tube, as before; placenta attached 
anteriorly ; left edge separated and child delivered in four minutes, 
alive and breathing but not viable; uterus lifted out of the abdo- Two Successful Cases of Conservative Ccesarean Section. 
5 
Fig. 2. 6 
Charles Jewett, M.D. 
men ; membranes separated with difficulty ; uterus closed with ten 
deep sutures in fourteen minutes from beginning of operation ; 
decidua not included in the sutures; symperitoneal sutures of silk ; 
no flushing and almost no cleansing of the peritonaeum ; some 
blood and bloody serum left in the cavity ; abdominal incision 
closed with ten silk sutures ; dressing as in the first case ; thirty 
minims of fluid extract of ergot were given hypodermically ; tem- 
perature at close of operation, 983/.0 F.; pulse, 90. The condition 
of the patient after operation was very soon better than for weeks 
before. The abdomen was distended on the second day but im- 
mediately became flat after repeated and copious evacuations of 
the bowels with calomel and salines, and the tympanites did not 
return. The meteorism would probably have been avoided 
altogether had not the bowels been confined for one or two days 
before the operation. The temperature soon resumed its custom- 
ary oscillations but there was no bad symptom attributable to the 
abdominal section. At the date of this reading the patient is 
rapidly gaining weight and in better health than at any previous 
time since her admission to the hospital. I am in duty bound to 
say that these patients are much indebted to the skilful services ren- 
dered by the efficient house surgeon, Dr. John O. Polak, both dur- 
ing and after operation. 
The last case is my third Caesarean section, all performed in the 
Long Island College Hospital. The first was done in December, 
1883, and has been already reported (N. Y. Med. Jour., August 29, 
1885). It was one of the first operations under the improved 
method of Sanger. The indication was extensive cancerous disease 
of the cervix, also involving the vaginal wall, with little or no 
dilatation of the cervix after twelve hours of active labor. The 
patient was in bad condition at the beginning of labor from pain, 
loss of sleep, frequently recurring haemorrhage and the abuse of 
alcohol and opium, the pulse ranging from 94 to 108 for several 
days before the section. The operation was done during an epi- 
demic of erysipelas in the hospital, and the mother died in forty- 
eight hours of peritonitis. The infection was attributed to a septic 
contact which occurred through the inadvertence of one of the by- 
standers. This operation, moreover, dates back to a time when 
antiseptics were freely used in the peritonaeum. Both the uterus 
and abdominal cavity were carefully cleansed with more or less 
contact of the mercurial solution. The death, I believe, was a 
preventable one. There was no evidence, post-mortem, of sepsis 
in the uterine cavity, and the uterine incision was securely closed Two Successful Cases of Conservative Ccesarean Section. 
7 
throughout The child was living and doing well when it left the 
hospital. 
Remarks.-Several observations of practical interest suggest 
themselves in connection with the two recent cases. I may say, 
first, that the entire procedure in both was made as nearly as possi- 
ble microscopically clean. Instruments were exposed for fifteen 
minutes to dry heat of about 260° F. shortly before use. With the 
exception of the operative field, the patient and immediate sur- 
roundings were covered with cloths and sheets fresh from the steam 
chamber. The hand-disinfection lacked the advantage of the per- 
manganate method, but it was made as complete as possible by 
laborious and long-continued scrubbing with sterilized brushes, 
with the use of green soap, alcohol, and the mercuric iodide solu- 
tions. The sutures, with the exception of the superficial uterine 
sutures in the first case, were of silk, which had been immersed 
for two hours in a soft paraffine wax at a temperature of 260° to 280° 
F., and subsequently sealed in a bottle of alcohol and steamed for 
an hour. A like degree of care was observed throughout, except 
that lack of time prevented any further attention to the room 
(which was the labor-ward) than wetting the floor to suppress 
dust. 
One matter in which practice differs in Caesarean section is the 
provisional ligation of the cervix. The prevention of haemorrhage 
from the uterine incision is more satisfactorily accomplished by the 
use of an elastic rubber tube than by manual control or by the in- 
elastic gauze band of Sanger. The objection to the tube, that it is 
liable to injure the tonicity of the muscles is obviated by employing 
a large tube with thin walls, which spread as it is drawn taut and 
distribute the pressure over a large surface. In the two recent cases 
reported in this paper, though the placental site was incised in both 
and forcible constriction was used, the contractile power of the 
uterus was apparently not in the least impaired. Neither manual 
nor instrumental control of the uterus, however, is absolutely 
essential. 
A vital point in the Caesarean operation is the accurate and 
secure closure of the uterine incision. In numerous fatal cases the 
death has been traced to gaping of the uterine wound and leakage 
of lochia into the peritonaeum. Even a minute fistulous tract has 
been sufficient to cause the death of the patient. The improved 
results of the modern operation are largely due to the attention 
which has been given to the accurate closure of the uterine 
wound. 8 
Charles Jewett, M.D. 
Some difference of practice obtains in regard to the avoidance of 
the decidua in the deep uterine suture. Sanger strongly insists upon 
the necessity for this precaution and cites an experience of Macan's 
in which infection took place from the uterine cavity through the 
needle tract. Zweifel, on the other hand, takes no pains to avoid 
the decidua, and his record is twenty-nine cases with but one death, 
and that a preventable one. Schauta's practice, is similar, and he 
has done fifteen Caesarean sections without a death. The entirely 
buried suture, however, would seem safer, as avoiding all possi- 
bility of secondary infection of the needle tract. The first of my 
recent cases goes to enforce this conclusion. The deep sutures in 
this case were passed into the uterine cavity. While the patient 
made a perfectly good recovery, a few days ago a fistula was dis- 
covered at the lower end of the abdominal cicatrix, which leads 
down, I assume, to an infected uterine suture. 
The suture material which best serves the purpose and is now 
generally adopted, is that which is the most easily prepared and 
the most convenient in use, viz., silk. While the ideal suture is one 
that will hold securely for the required length of time and then be 
absorbed. Thes'e conditions are not wholly met by catgut. Soft 
catgut has been responsible for several deaths by yielding too soon, 
and hard chromic gut has little advantage over silk in point of ab- 
sorbability ; moreover, a serious defect in catgut, however prepared, 
is the comparative insecurity of the knot. 
Another moot point is the superficial uterine suture. The half- 
deep superficial suture which has been used by Zweifel, Kelly, and 
others is an important saving of time. Yet there is a certain sense 
of security in completely closing the peritonaeum in a welt over the 
deep sutures as is still practiced by Sanger. 
Conspicuous points in the technique of the Caesarean operation 
are the treatment of the uterine and the peritoneal cavities. It is the 
practice of Sanger and others after the separation of the placenta 
and membranes to scrub the cavity with a fold of gauze. In my 
recent cases the uterine cavity was left literally untouched after 
peeling off the membranes, and this seems to me the more rational 
procedure in the absence of infected fluids. The endometrium is 
left aseptic after removal of the secundines, and antiseptic douching 
or scrubbing is not only uncalled for but injurious. Even decidual 
shreds, in the absence of sepsis, are better left to be cast off with the 
lochia. A septic uterus on the other hand should not be trusted to 
the conservative operation at all, but should be amputated. Two Successful Cases of Conservative Ccesarean Section. 
9 
A careful peritoneal toilette is generally deemed essential in this 
operation as is the common rqle in other laparotomies. In the two 
recent cases above reported, little attempt was made at cleansing the 
peritonaeum. A small gauze compress was passed once in front and 
once behind the uterus to make sure that no accumulation of bloody 
fluid remained in the ctils-de-sac. In both cases, and especially the 
second, the uterus and surrounding surfaces of peritonaeum were 
everywhere soiled with blood when the abdomen was closed. The 
extreme care generally required in cleansing in other laparotomies 
is here, I believe, unnecessary. A healthy peritonaeum, such as 
we usually have to deal with in a Caesarean section, is less injured 
by a little blood, even if not absolutely aseptic, than by much 
sponging. The peritoneal epithelium is removed by sponging or 
handling, or even by irrigation, and the resisting power of the peri- 
tonaeum is impaired, to say nothing of increased risk of adhesions. 
In the Caesarean operation, with care to prevent the entrance of 
much blood and liquor amnii into the abdominal cavity, the usual 
peritoneal toilette may be almost wholly omitted. 
Foreign authorities and most others, so far as I know, have 
fixed upon the end of the first labor period as the preferred time for 
operating. This is done on the assumption that the establishment 
of labor before operating is essential to subsequent retraction of the 
uterus and to free lochial drainage. An experience, however, of 
several cases operated before labor, to say nothing of a large num- 
ber of deliveries by cattle-horn lacerations, which have been followed 
by sixty-nine per cent, of recoveries (Harris) is sufficient to show 
that this assumption has no foundation in fact. The obvious advan- 
tage of operating with deliberate preparation before the rupture of 
the membranes and with the patient in full strength furnish a strong 
argument for an appointed time, if possible, shortly before the 
expected date of labor. 
The main conditions of success in Caesarean section are, obviously, 
asepsis, and the accurate suture of the uterine wound. Reasonable 
rapidity, however, is important, and, as Harris observes, the length 
of time should not exceed three-quarters of an hour if the best re- 
sults are to be expected. To these conditions I am disposed to add 
the early use of saline catharsis after operation. In the two recent 
cases a small dose of calomel was given and followed by salines 
soon after the first expulsion of flatus from the bowel. My experi- 
ence, not alone in these cases, but a somewhat extensive one in 
analogous conditions, leads me to place a high value on early resort 
to peritoneal drainage by the intestines. 10 
Charles Jewett, M.D. 
In conclusion, I submit that laparo-hysterotomy under modern 
methods is a relatively benign abdominal section. Its technique is 
one of the simplest in abdominal surgery, and the patient, in timely 
operations, is in comparatively good condition. Is it not reasonable 
to expect that the results of Caesarean delivery in relatively healthy 
women shall fully equal or exceed the best records of laparotomy in 
disease?