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Case IX. Woman, not in labor, died of broken cardiac compensation. A Cesarean section was immediately performed. The child was badly cyanosed at birth with the heart going at about forty. There was no effort at respiration with prolonged attempts at resuscitation and the child succumbed.
Case X. The author's case. Woman died of cerebral hemorrhage, verified at autopsy. She was not in labor, and was admitted with cerebral pressure symptoms. The urine showed none of the findings of eclampsia. The house surgeon was watching her closely and incised the abdomen and uterus immediately after death. A living child was delivered that cried at once, and weighed 3500 grams. It was later discharged from the hospital in excellent condition.
To summarize, three babies were stillborn. It is probable that the death of all these children occurred before the death of the mother. Four babies were born with hearts feebly beating, but there was no attempt at respiration with prolonged efforts at resuscitation. One baby gave a few feeble gasps and died shortly after delivery. One baby slightly asphyxiated at birth, died on the sixth day of peneumonia. One baby badly asphyxiated at birth, left the hospital living and well; and one, crying spontaneously at delivery, was also discharged living and well.
This is perhaps the largest report of this operation from one clinic, and shows in a general way what may be expected as to the success of post mortem delivery by Cesarean section taking them as they come. Numerous individual successful cases are to be found in the literature, but it is quite to be suspected that unsuccessful cases are rarely reported.
DeLee (5) states that a fetus will live five to twenty minutes after the death of the mother, and that reported cases of longer periods are not authenticated. The length of time of survival depends on the suddenness of the mother's death. The child lives longer if she died of apoplexy, accidental hemorrhage, eclampsia, or very acute infection, than if the agony is prolonged, as in tuberculosis, heart disease, etc. Since the mother uses up the child's oxygen, the latter usually dies first.
Women in a cataleptic state have been subjected to this operation, the operator believing them dead, the first incision proving the contrary. Such a swoon or catalepsy may explain the long lapse of time in some reported cases between the apparent death of the mother and a successful post mortem Cesarean section.
In the cases herewith presented the longest interval between the death of the mother and the delivery of a living infant was seven minutes. One delivered after eight minutes gave a few feeble gasps and died shortly after birth. One delivered after an interval of twenty minutes had a feebly beating heart but never made any attempts at respiration.
The obvious observation is that the success of the operation depends very much upon the promptness with which it is done.
Criticism may be made that the operation is unnecessarily performed
when the baby is dead. If a fetal heart slows and finally stops during an ordinary labor we are pretty well justified in concluding that the baby has perished. But there are not a few living babies born in the usual manner whose fetal heart it has been impossible to auscultate. Several most valuable minutes may be lost while trying to get the fetal heart after a mother's death, it may be too faint to hear. So that unless we have positive proof that the baby is dead, when the mother succumbs it is justifiable to proceed at once to post mortem Cesarean section. Except in operating upon the dying woman, which class of cases this paper does not intend to include, and where in rare instances recoveries have been reported, asepsis and the time necessary to assure it may be ignored. With any cutting instrument at hand the abdomen and uterus are quickly and freely incised and the child extracted. The uterus has occasionally been observed to contract after the extraction of the child.
The second point to be emphasized is the importance of persisting in prolonged efforts at artificial respiration as long as any intermittent contraction can be appreciated in the baby's heart by pressing the fingers up under the left costal margin. The children are almost invariably born in severe asphyxia and great patience is required in their resuscitation.
1. Monats. f. Geb. u. Gyn., suppl. 1862, Bd. xviii, S. 112.
2. Amer. Jour. Obst., Vol. 12.
3. Festschr. f. Podensky, Moscow, 1914.
4. Surg. Gyn. & Obst., Jan. 1911.
5. Text-book of Obstetrics.
A REPORT ON FOUR CASES OF RUPTURED PELVES.*
WILLIAM A. MORGAN, M. D.
To those particularly interested in obstetrics, the condition of a ruptured pelvis, although undoubtedly exceptional, is at once both interesting and complicated, a condition worthy of our most serious attention.
The articulation between the pubic bones is an amphiarthrodial joint formed by the junction of the two oval articular surfaces. The cartilage lying next to either bone is hyaline in character but soon becomes more fibrous in structure and the bones are held in apposition by five ligaments of which the anterior and subpubic are very dense and thick.
*Read at a meeting of the New York Obstetrical Society, January 11, 1916. Appears also in Am. Jr. Obst., April, 1916.
Like all similar joints of the body, this one is subject to all of the conditions that might affect the others and among these are fractures or ruptures. They may be traumatic or spontaneous. This accident occurs very infrequently and the principal point of interest is its causation.
Unfortunately our inability to recognize such cause and impending disaster naturally prevents our taking the necessary precautions to avoid it. The condition might also become of interest from a medicolegal aspect, especially if we should maintain that spontaneous rupture is impossible.
In the service of the Lying-in Hospital, there has occurred one case of complete rupture of the symphysis and one case of separation of the
cartilages in which the ligaments remained partly intact or two cases in about 87,000 labors. The condition would appear to be especially rare from these records, but others have reported them as of more frequent
Thus, among the more recent records, DeLee cites about eight cases.
Dr. Brettauer reports one case with infection of the joint and shows how drainage was obstructed by shortening the pelvic girdle or strapping. The patient recovered.
Dr. A. B. Davis reports one case with recovery.
Jolly reports three cases, two of which were discovered at autopsy.
Schaefer reports one case in a para-x produced by the delivery of unusually large shoulders. The diastasis was three cm. in width; an abscess formed in the joint and a firm fibrous union was obtained. Such a result seems incredible.
Strassman reports one case of five cm. separation that was discovered at autopsy, the patient dying of hemorrhage.
Bardeleben reports one case after high forceps when the pelvic girdle gave no relief and finally the bones were sutured.
Huxley reports one case of spontaneous rupture upon the second day post-partum, the left pubic bone remaining higher than the right.
Delestre reports one spontaneous rupture upon the third day postpartum, in a patient nineteen years of age, which became infected and the patient died.
Braun-Fernwald reports three cases in 30,000 labors.
Mayer reports one spontaneous rupture in a patient ten hours post partum.
Rudaux in 1898 collected notes on ninety-eight cases and claimed that twenty-five of these were spontaneous.
Ahlfeld and Schauta collected 114 reported cases.
Hirst states that it occurred three times in 94,149 cases.
According to these figures, the accident occurs about once in 25,000 cases. This, of course, does not include cases of excessive relaxation of the pelvic joint.
I have observed five cases of ruptured symphyses, four of which I beg to present in detail and another occurred in the practice of a colleague but has not yet been reported.
CASE I. Para ii; thirty-one years of age; seven months pregnant. Seventeen months previous to this pregnancy, patient was delivered of a still-born fetus after a very diffcult high forceps operation. Upon examination, the cervix and vagina showed old lacerations and the diastasis of the pubic bones readily admitted the passage of three fingers (or 5 cm. in width). All of the ligaments with the exception of part of the supra-pubic had been torn away. She constantly wore a pelvic belt or girdle of her own design and preferred it to the manufactured belt, several of which she had tried. She was confined with this belt around the pelvis to prevent too great contraction of the voluntary muscles. An easy low forceps operation was performed. Recovery was uneventful. The patient has since been confined and has also been operated upon for prolapsus. At the present time, the patient still has the separation, which causes no trouble whatever. She has gained about thirty lbs. in weight, does not wear a belt or girdle and indulges freely in all kinds of athletic sports (principally with the idea of reducing her weight which is about 190 lbs.)
CASE II. Primipara; twenty-one years of age; admitted to the Lying-In Hospital on July 20, 1914. 1914. Mother died of tuberculosis. Previous history showed that she had the usual diseases of childhood but had never had rheumatism or anything that might have produced a weakened joint. The patient's pregnancy was absolutely normal. She was 153 cm. in height and weighed about 52 kilos. The pelvis was slightly generally contracted with a rather long and short promontory; the true conjugate was 9+ cm. and the pubic arch medium to narrow. Upon
admission, the cervix was one finger dilated and pains were weak and infrequent, ten to twenty minutes. After thirty-six hours of intermittent pains (during the intervals of which she slept), the cervix was fully dilated and three hours later high forceps were applied. The head was in an R. O. A. position above the brim but could be forced down into it by pressure from above. I made a pelvic application of the forceps,