woman lived in poverty, and weighed but sixty pounds; she also presented in her legs some evidences of having been rickety in early childhood. When taken in labor under the care of Dr. Jarrot, of Florence, she in time was seized with convulsions, for which he gave her two grains of sulphate of morphia, which, not relieving her, he called upon me, and at my suggestion administered two more grains hypodermically, after which the convulsive movements ceased. I saw her for the first time on the morning of February 20th, 1885, and found her breathing heavily. Her abdomen was tympanitic above the uterus, and there were no uterine contractions, these having ceased suddenly, giving rise to the belief that she may have ruptured her uterus. The os uteri was found of the size of a twenty-five cent piece, and the tissues relaxed; there was but little hemorrhage. We decided, under all the difficulties of the case, to deliver by Cæsarean section. (Fig. 1.) FIG. 1. At the time of the operation the woman had been more or less in labor for thirty hours, and twenty-two hours had passed since she had taken any morphia. She had a feeble pulse of 118, a respiration of 20, and her extremities were cold; being unconscious, no anesthetic was used. An incision six inches long was made in the median line, and nearer to the umbilicus than the symphysis pubis, the flexure and anchylosis of the lower extremities making this necessary. The distended intestines were with much difficulty kept back, and were punctured in several places with a hypodermic needle to evacuate the gas. The incision of the uterus led into a rupture of the lower part of the body and cervix, opening the organ to the extent of about eleven inches, six inches of which were by incision. Although laceration was believed to have taken place, it had not been postively located until cut into by the knife. After the uterus was opened the fœtus was seized by the left arm and delivered, and the cord cut and tied. The uterus, in its contractions, now presented under the eye the curious phenomenon of inversion, the right anterolateral portion, to which the placenta was attached, being driven through the uterine wound with the disk firmly adherent. (Fig. 2.) Although an effort was made to detach the placenta, it seemed only to become more firmly fixed as the convexity outward increased and the parts became consolidated by contraction. Finding the placenta immovable, I with my two thumbs placed on either side of the cord at its origin, and my fingers spread out over the back of the uterus to antagonize them, readily indented the protruding portion, which, being started, became restored by a spontaneous movement. The uterus now contracted normally, and the placenta was gradually separated, the mouths of the blood-vessels being closed so perfectly that it was difficult to distinguish its former site. The uterine wound was closed by thirteen silk sutures, but a portion of the rent in the neck was not sewed up, it being inaccessible because of its position under the right thigh; after the organ had fully contracted, the laceration was not distinguish able. The patient lost but little blood from the operation, but when the abdomen was opened it was found to contain a considerable quantity mixed with amniotic fluid. The foetus was not weighed, but was above the average size. After the uterine wound was closed, I cleansed the abdominal cavity thoroughly and closed the wound with ten sutures. When half had been passed, the patient exhibited very unfavorable symptoms, and ether was administered hypodermically; an order was given to place bottles of hot water around her, but, regardless of instructions given prior to the operation, they had not been provided. As the last abdominal sutures were being passed she died. There were no symptoms indicative of opium poisoning, but the shock and depression resulting from the rupture of the uterus (which was the main reason for the operation) were so great that we believed from the first that the chances for recovery were as ten to one against her. I am indebted to Dr. Harris for the following interesting facts and observations; "Of the 136 Cæsarean cases in my note-book, but one other died during the operation, which was performed in New York city in 1860 upon a patient nearing the maturity of gestation, but not in labor, who had been for six hours in convulsions. In no other American case is there a record of uterine inversion. This may be partly accounted for in your own by the extreme length of the uterine opening. As the organ had been a long time in a quiescent state and partly emptied, any slight traction upon the cord in removing the fœtus might indent the flaccid uterine wall and favor inversion if muscular contraction was at that moment revived. I do not remember to have seen any similar accident recorded of any foreign case. Your operation increases the list of American dwarf cases to 27 and the deaths thereof to 20; twelve children were delivered alive; the number of Cæsarean operations in the United States is upon the increase, but their proportionate mortality much more than keeps pace with the growth in number. From April 7, 1884, to April 20, 1885, there were eight operations, all fatal but the last, and all of the children perished; six of the cases were reported to me by letter. Of the 136 American cases, 58 have not yet been published, and but a very small fraction ever will be by their operators." Since January 1, 1875, there have been 32 operations in the United States, saving 8 women and 14 children. In the preceding decade, 1865–1874, there were also 32 operations, saving 8 women and 10 children. From 1855 to 1864, 27 operations, with 12 women and 11 children saved; and from 1845 to 1854, inclusive, 23 women operated upon, saving 13 of them and only 7 children. We are certainly retrograding in the measure of success, due very largely to delay; of the last 50 operations, 9 were performed early and 41 late; hence the number of deaths both of women and children. Since my operation there have been two women subjected to the same method of dealing. I learn from Dr. Harris these cases have not been published yet. One case was under Dr. Lungren, of Toledo, a homœopathic surgeon-woman four and a half days in labor, membranes ruptured two days, child dead two days, woman exhausted, respiration 36, temperature 102 1-5, pulse 130, recovered 33. Single, Irish, primipara, 4 feet 11 inches; strumous, weight 94 pounds, date, April 19, 1885. The other operator was Dr. Parrish, of Philadelphia, September 20, 1885. Woman white, multipara, 35, German, forty-two hours in labor, membranes ruptured thirty hours. Three febroids in lower segment of the uterus, pulse 124, much exhausted, had been under care of a midwife; operation in Philadelphia hospital. Woman died in twelve hours of exhaustion and septicuma, child dead and putrid. Uterine wound treated after Sauger's method. From January 1st, 1880, to present time, there have been in the United States twenty Cæsarean operations; of the women, five were saved; eight children were delivered alive, of which one lived only four hours and one thirty-two hours. Dr. Lungren saved two of the five women and one child. How SHALL THE PRACTITIONER DISINFECT HIS HANDS ?A thoroughly efficient disinfection of the physician's hands, remarks the Therapeutic Gazette, is more than a matter of personal cleanliness; it is an absolutely required, though often neglected, protection of his own person and the safety of his family, friends and patients. There being no dissenting voice as to the necessity of this by no means irksome precaution, the only question that can arise in this respect is, what method of disinfection insures the greatest success? The present state of bacteriology must convince even the most skeptic and conservative physician that soap and water exercise not the slightest influence over the microbial organisms, and that the true antiseptic agents have to be resorted to. Foster, of Amsterdam, made some special researches in this field (Pharm. Centralblatte, May 28, 1885) with the view of ascertaining the relative worth of carbolic acid, boric acid, chloride of zinc and iron. He gained the conviction that the ordinarily used two and one-half per cent. solution of carbolic acid, and even Billroth's plan to wash the hands in muriatic acid and ten per cent. phenol in glycerine, were insufficient to sterilize the hands, that is, prevent microbic growth on them. The only process that Forster found absolutely reliable was recently recommended by Koch, of Berlin, which consists in a solution of corrosive sublimate having a strength of seven to fifteen grains to two pints of distilled water. The simplicity of the manœuvre and its unquestionable prophylactic power will go far to recommend Koch's wash to the American practitioner.—Boston Med. and Surg. Journal. |