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section. In five hundred and ten instances, the mother has recovered and has been discharged from the hospital in good condition, except five recent cases whose recovery is assured-now convalescing. The maternal recovery is 89.3% of the cases operated upon. The post-partum day of discharge of these cases is something of an index of how they recover. The later cases show considerable reduction in the number of days of post-partum care. Thus we find by taking the average day of discharge by hundreds, considerable progress has been made. They are as follows:

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If we were able to exclude several cases whose recovery was complicated and prolonged some of them remaining over seventy daysthe average day of discharge would be much reduced. It is very near the fourteenth day in the majority of cases.

DEATHS OF MOTHERS.

Sixty-one women have died following this operation, a maternal mortality of 10.7% from all causes. We may say that a very large proportion of these deaths occurred in spite of rather than because of Cesarean section. Thus, there is a group of thirteen cases of toxemia of pregnancy and eclampsia who died after this operation. Their condition was such that they must have died under any plan of treatment.

There are two classes of so-called border line cases. First: the clean, uncomplicated cases in whom there is a contracted pelvis or other moderate obstruction in the birth canal or a marked disproportion between the capacity of the pelvis and the child which is to be delivered. In these cases it becomes a matter of very good judgment whether a trial labor shall be allowed or some form of vaginal delivery be attempted or whether they shall be delivered by Cesarean section. We see a considerable number of women who have contracted pelves in whom we must decide that delivery shall be by Cesarean section if we rely upon pelvis measurements alone. Yet a large proportion of such women have small children capable of being easily molded and are delivered spontaneously or by low forceps operation. In another class of cases of rather limited number, we find the pelvis of normal size and in some instances, above the normal size, and yet the fetus is so large, the bones of the fetal head are so thick and unmoldable, there is such a disproportion between the capacity of the pelvis and the fetus that abdominal Cesarean section

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is the only safe way of delivery. Pelvic measurements alone can be relied upon only as a guide rather than final in judging these cases. There is another class of border line of cases. This class gives us a very high morbidity and mortality in mother and child. We refer to these women, in our service, who have been long in labor, some times with membranes ruptured, or in whom the trial labor has been allowed for an unwarranted time. Many vaginal examinations have been made or it may be some form of vaginal delivery has been attempted; labor has been persisted in until the mother is exhausted, the fetus compressed and in poor condition. These are apt to be the cases in whom the disproportion between the fetus and pelvis is small, the vertex partially engaged or the obstruction may be in the lower part of the pelvis. Such cases are rarely badly infected, but they are poor Cesarean risks. Or the cases may come under our care as emergencies after having been long in labor with membranes ruptured, or in the care of midwives and usually later in the care of private physicians who attempt forceps delivery. Such patients may be admitted in very good general condition, yet already infected, or they may be in poor general condition, very much exhausted and also infected. We are bound to care for such cases as we find them. How shall we manage them? Whatever course we pursue we know that the mortality and morbidity for mother and child must be very high. Some will say that we should do a craniotomy, destroy the child and thus save the mother. It may be said with truth that many of these unborn children are already dead or nearly so; or they may be in good general condition but already so infected with the same germ which jeopardizes the life of the mother, that, though born in good condition, they soon die from sepsis. If these contentions covered the whole situation, craniotomy would be the only justified mode of delivery in these cases. But craniotomy is neither a safe nor an easy operation. In fifteen hundred consecutive cases, one-half from the Out-door Department and one-half from the In-Door Department, craniotomy was found necessary one hundred and twenty-two times. Nineteen mothers died, a maternal mortality of 15.5%. Symphysiotomy is no longer an operation to be considered, pubiotomy is less often employed than formerly. The so-called extraperitoneal Cesarean section is on trial. The scope of this paper does not permit us to go far into details concerning the outcome of these cases delivered by Cesarean section, but a considerable number of them, though they experience a stormy and protracted puerperium, recover.

This second class of border line cases is capable of being very materially reduced. In many of these women the indications for Cesarean section are present and positive from the beginning of labor or before. This should be appreciated, and they should be operated upon while mother and child are yet in good condition. It should be more generally recognized that delay is dangerous; that delivery by high forceps or difficult

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version even in hospital surroundings and in the hands of the most skilful and experienced obstetricians are among the most dangerous operations known to surgery. Under even these conditions the results are too often deplorable. Many of us know to our sorrow what the results are in the hands of the unskilled in unfavorable surroundings. The children are apt to be born dead as they are severely injured. The mothers who survive, there are many who do not, are made invalids for the remainder of their days in too many instances. Yet prior to the birth of their child they had the right to look forward to a strong and healthful existence. A homicide occurs in a community, possibly two vicious lives are involved. One of these lives is already disposed of. The police, the legal machinery, the press and public opinion are at once set in motion to save or destroy the other life. Time, public treasure and legal skill are employed without stint. A knowledge of the crime is spread to the limits of our country.

Yet the loss of life, the destruction of homes, permanent disability and the sacrifice of the innocent at the time of childbirth is greater, we believe, than that due to homicide. It goes on silently and is accepted without much complaint, because it always has been as it now is. In the presence of appendicitis the medical and lay public is educated to such a degree that the practitioner who allows this condition to drift on unduly, and if he be not a surgeon, does not seek surgical council, and prompt operation where necessary, surely and justly lays himself liable to unfavorable criticism.

We ask that some such condition shall obtain regarding difficult obstetric cases. To some extent death and injury must ever be associated with childbirth. It is our duty to reduce this death rate and injury to the minimum. This calls for better obstetric teaching, a greater willingness to break away from old methods which have been found wanting, a willingness upon the part of those of us who have not been adequately trained to recognize our limitations. And to remember that time, and vaginal interference or the absence of such interference are very important factors in determining what the outcome of a difficult labor shall be. Abdominal Cesarean section is in no sense a cure-all in obstetrics. It is a very valuable agent and its timely employment will do as much to reduce the mortality and morbidity of which we complain as now occurring in obstetric practice. We report a total maternal mortality of 10.7% following Cesarean section occurring in five hundred and seventy-one operations. This high death rate is made up largely from neglected and mismanaged labors. It is a comparatively simple operation in the hands of those accustomed to abdominal surgery. It is susceptible of proof from our histories that in clean uncomplicated cases delivered by Cesarean section shortly before or soon after labor begins, the maternal mortality is between two and three per cent and there is no fetal mortality in such

cases.

In five hundred and seventy-one Cesarean deliveries five hundred and seventy-seven children were born. Twins seven times. In one case the first twin was born before admission. The second twin had a depressed fracture of the skull from high forceps traction of the vertex against a sharp promontory. The mother was sent to the hospital as a case of rupture of the uterus, which did not exist, and the second child was delivered by Cesarean section.

We count all cases as deaths if they do not live to be discharged alive from the hospital, regardless of the duration of their stay. Of the five hundred and seventy-seven children delivered by Cesarean section, sixty-nine were either still-born or died before leaving the hospitala fetal mortality of 12%.

Twenty-three or 4% were still-born.

From the sixty-one mothers who died following Cesarean section sixty-two children were delivered. Forty-four children lived. Eleven died, and seven were still-born. Eclampsia and toxemia of pregnancy was the indication for Cesarean section in thirty-five cases-twenty-two or 63% of the mothers recovered. Thirteen, or 37% of these mothers died. From these thirty-five cases, thirty-seven children were born, twentysix, or 70%, these children lived. Eleven children, or 30%, were either still-born or died. Four were still-born. Seven died.

Period of gestation in these thirty-five cases

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Placenta previa was the main indication in twenty-one cases; two of these mothers died from sepsis.

21 children were born, of which

14 children lived

4 children died

3 children were still-born

The fetal mortality was due to prematurity.

ACCIDENTAL HEMORRHAGE.

We find three cases of accidental hemorrhage, the mothers and one child lived. One child was still-born-one child was premature and died in a few hours.

REPEATED CESAREAN SECTION.

78 cases have been delivered more than once by Cesarean section 60 the second time

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Rupture of the uterus in labor subsequent to Cesarean section.

This accident occurred in six cases. mothers recovered. Two children lived.

Three mothers died. Three
In these two cases the children

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were in the uterus and alive and were delivered by Cesarean section. Four children were free in the abdominal cavity and dead.

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Main indication for this operation was some form of contracted pelvis or deformity of spinal column in 441 or 79% of the cases, while malecostion is reported by Playfair as being a common indication in England for this operation. We have seen but one case in the Lying-In Hospital.

We find nine cases of some neoplasm occluding the pelvis.
Nine cases following some form of suspension of the uterus required
Cesarean. In eighteen cases an unduly large child was the indication.

THE NUMBER OF THE PREGNANCY.

Para 1, 214 cases

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