1836. Coe and Gueniot both mention cases in which Cesarean section had

been twice performed with successful terminations as regards both mothers and children. Rosenberg tabulates a number of similar cases from medical literature. Cases of Cesarean section by the patient herself are most curious, but may be readily believed if there is any truth in the reports of the operation being done in savage tribes. Felkin gives an account of a successful case performed in his presence, with preservation of the lives of both mother and child, by a native African in Kahura, Uganda Country. The young girl was operated on in the crudest manner, the hemorrhage being checked by a hot iron. The sutures were made by means of seven thin, hot iron spikes, resembling acupressure-needles, closing the peritoneum and skin. The wound healed in eleven days, and the mother made a complete recovery. Thomas Cowley describes the case of a negro woman who, being unable to bear the pains of labor any longer, took a sharp knife and made a deep incision in her belly--deep enough to wound the buttocks of her child, and extracted the child, placenta and all. A negro horse-doctor was called, who sewed the wound up in a manner similar to the way dead bodies are closed at the present time. Barker gives the instance of a woman who, on being abused by her husband after a previous tedious labor, resolved to free herself of the child, and slyly made an incision five inches long on the left side of the abdomen with a weaver's knife. When Barker arrived the patient was literally drenched with blood and to all appearance dead. He extracted a dead child from the abdomen and bandaged the mother, who lived only forty hours. In his discourses on Tropical Diseases Moseley speaks of a young negress in Jamaica who opened her uterus and extracted therefrom a child which lived six days; the woman recovered. Barker relates another case in Rensselaer County, N.Y., in which the incision was made with the razor, the woman likewise recovering. There is an interesting account of a poor woman at Prischtina, near the Servian frontier, who, suffering greatly from the pains of labor, resolved to open her abdomen and uterus. She summoned a neighbor to sew up the incision after she had extracted the child, and at the time of report, several months later, both the mother and child were doing well. Madigan cites the case of a woman of thirty-four, in her seventh confinement, who, while temporarily insane, laid open her abdomen with a razor, incised the uterus, and brought out a male child. The abdominal wound was five inches long, and extended from one inch above the umbilicus straight downward. There was little or no bleeding and the uterus was firmly contracted. She did not see a physician for three hours. The child was found dead and, with the placenta, was lying by her side. The neighbors were so frightened by the awful sight that they ran away, or possibly the child might have been saved by ligature of the funis. Not until the arrival of the clergyman was anything done, and death ultimately ensued. A most wonderful case of endurance of pain and heroism was one occurring in Italy, which attracted much European comment at the time. A young woman, illegitimately pregnant, at full term, on March 28th, at dawn, opened her own abdomen on the left side with a common knife such as is generally used in kitchens. The wound measured five inches, and was directed obliquely outward and downward. She opened the uterus in the same direction, and endeavored to extract the fetus. To expedite the extraction, she drew out an arm and amputated it, and finding the extraction still difficult, she cut off the head and completely emptied the womb, including the placenta. She bound a tight bandage around her body and hid the fetus in a straw mattress. She then dressed herself and attended to her domestic duties. She afterward mounted a cart and went into the city of Viterbo, where she showed her sister a cloth bathed in blood as menstrual proof that she was not pregnant. On returning home, having walked five hours, she was seized with an attack of vomiting and fainted. The parents called Drs. Serpieri and Baliva, who relate the case. Thirteen hours had elapsed from the infliction of the wound, through which the bulk of the intestines had been protruding for the past six hours. The abdomen was irrigated, the toilet made, and after the eighteenth day the process of healing was well progressed, and the woman made a recovery after her plucky efforts to hide her shame. Cases like the foregoing excite no more interest than those on record in which an abdominal section has been accidental, as, for instance, by cattle-horns, and the fetus born through the wound. Zuboldie speaks of a case in which a fetus was born from the wound made by a bull's horn in the mother's abdomen. Deneux describes a case in which the wound made by the horn was not sufficiently large to permit the child's escape, but it was subsequently brought through the opening. Pigne speaks of a woman of thirty-eight, who in the eighth month of her sixth pregnancy was gored by a bull, the horn effecting a transverse wound 27 inches long, running from one anterior spine to the other. The woman was found cold and insensible and with an imperceptible pulse. The small intestines were lying between the thighs and covered with coagulated blood. In the process of cleansing, a male child was expelled spontaneously through a rent in the uterus. The woman was treated with the usual precautions and was conscious at midday. In a month she was up. She lived twenty years without any inconvenience except that due to a slight hernia on the left side. The child died at the end of a fortnight. In a very exhaustive article Harris of Philadelphia has collected nearly all the remaining cases on record, and brief extracts from some of them will be given below. In Zaandam, Holland, 1647, a farmer's wife was tossed by a furious bull. Her abdomen was ripped open, and the child and membranes escaped. The child suffered no injuries except a bruised upper lip and lived nine months. The mother died within forty hours of her injuries. Figure 19 taken from an engraving dated 1647, represents an accouchement by a mad bull, possibly the same case. In Dillenberg, Germany, in 1779, a multipara was gored by an ox at her sixth month of pregnancy; the horn entered the right epigastric region, three inches from the linea alba, and perforated the uterus. The right arm of the fetus protruded; the wound was enlarged and the fetus and placenta delivered. Thatcher speaks of a woman who was gored by a cow in King's Park, and both mother and child were safely delivered and survived. In the Parish of Zecoytia, Spain, in 1785, Marie Gratien was gored by an ox in the superior portion of her epigastrium, making a wound eight inches long which wounded the uterus in the same direction. Dr. Antonio di Zubeldia and Don Martin Monaco were called to take charge of the case. While they were preparing to effect delivery by the vagina, the woman, in an attack of singultus, ruptured the line of laceration and expelled the fetus, dead. On the twenty-first day the patient was doing well. The wound closed at the end of the sixteenth week. The woman subsequently enjoyed excellent health and, although she had a small ventral hernia, bore and nursed two children. Marsh cites the instance of a woman of forty-two, the mother of eight children, who when eight months pregnant was horned by a cow. Her clothes were not torn, but she felt that the child had slipped out, and she caught it in her dress. She was seen by some neighbors twelve yards from the place of accident, and was assisted to her house. The bowels protruded and the child was separated from the funis. A physician saw the woman three-quarters of an hour afterward and found her pulseless and thoroughly exhausted. There was considerable but not excessive loss of blood, and several feet of intestine protruded through the wound. The womb was partially inverted through the wound, and the placenta was still attached to the inverted portion. The wound in the uterus was Y-shaped. The mother died in one and a half hours from the reception of her injuries, but the child was uninjured. Scott mentions the instance of a woman thirty-four years old who was gored by an infuriated ox while in the ninth month of her eighth pregnancy. The horn entered at the anterior superior spinous process of the ilium, involving the parietes and the uterus. The child was extruded through the wound about half an hour after the occurrence of the accident. The cord was cut and the child survived and thrived, though the mother soon died. Stalpart tells the almost incredible story of a soldier's wife who went to obtain water from a stream and was cut in two by a cannonball while stooping over. A passing soldier observed something to move in the water, which, on investigation, he found to be a living child in its membranes. It was christened by order of one Cordua and lived for some time after. Postmortem Cesarean Section.--The possibility of delivering a child by Cesarean section after the death of the mother has been known for a long time to the students of medicine. In the olden times there were laws making compulsory the opening of the dead bodies of pregnant women shortly after death. Numa Pompilius established the first law, which was called "les regia," and in later times there were many such ordinances. A full description of these laws is on record. Life was believed possible after a gestation of six months or over, and, as stated, some famous men were supposed to have been born in this manner. Francois de Civile, who on great occasions signed himself "trois fois enterre et trois fois par le grace de Dieu ressucite," saw the light of the world by a happy Cesarean operation on his exhumed mother. Fabricius Hildanus and Boarton report similar instances. Bourton cites among others the case of an infant who was found living twelve hours after the death of his mother. Dufour and Mauriceau are two older French medical writers who discuss this subject. Flajani speaks of a case in which a child was delivered at the death of its mother, and some of the older Italian writers discuss the advisability of the operation in the moribund state before death actually ensues. Heister writes of the delivery of the child after the death of the mother by opening the abdomen and uterus. Harris relates several interesting examples. In Peru in 1794 a Sambi woman was killed by lightning, and the next day the abdomen was opened by official command and a living child was extracted. The Princess von Swartzenberg, who was burned to death at a ball in Paris in 1810, was said to have had a living child removed from her body the next day. Like all similar instances, this was proved to be false, as her body was burned beyond the possibility of recognition, and, besides, she was only four months pregnant. Harris mentions another case of a young woman who threw herself from the Pont Neuf into the Seine. Her body was recovered, and a surgeon who was present seized a knife from a butcher standing by and extracted a living child in the presence of the curious spectators. Campbell discusses this subject most thoroughly, though he advances no new opinions upon it. Duer tabulates the successful results of a number of cases of Cesarean section after death as follows:-- Children extracted between 1 and 5 minutes after death of the mother, 21 " " 10 and 15 " " " " " " 13 " " 15 and 30 " " " " " " 2 " " 1 hour " " " " " " 2 " " 2 hours " " " " " " 2 Garezky of St. Petersburg collected reports of 379 cases of Cesarean section after death with the following results: 308 were extracted dead; 37 showed signs of life; 34 were born alive. Of the 34, only 5 lived for any length of time. He concludes that if extracted within five or six minutes after death, they may be born alive; if from six to ten minutes, they may still be born alive, though asphyxiated; if from ten to twenty-six minutes, they will be highly asphyxiated. In a great number of these cases the infant was asphyxiated or dead in one minute. Of course, if the death is sudden, as by apoplexy, accident, or suicide, the child's chances are better. These statistics seem conscientious and reliable, and we are safe in taking them as indicative of the usual result, which discountenances the old reports of death as taking place some time before extraction. Peuch is credited with statistics showing that in 453 operations 101 children gave signs of life, but only 45 survived. During the Commune of Paris, Tarnier, one night at the Maternite, was called to an inmate who, while lying in bed near the end of pregnancy, had been killed by a ball which fractured the base of the skull and entered the brain. He removed the child by Cesarean section and it lived for several days. In another case a pregnant woman fell from a window for a distance of more than 30 feet, instant death resulting; thirty minutes at least after the death of the mother an infant was removed, which, after some difficulty, was resuscitated and lived for thirteen years. Tarnier states that delivery may take place three-quarters of an hour or even an hour after the death of the mother, and he also quotes an extraordinary case by Hubert of a successful Cesarean operation two hours after the mother's death; the woman, who was eight months pregnant, was instantly killed while crossing a railroad track. Hoffman records the case of a successful Cesarean section done ten minutes after death. The patient was a woman of thirty-six, in her eighth month of pregnancy, who was suddenly seized with eclampsia, which terminated fatally in ten hours. Ten minutes after her last respiration the Cesarean section was performed and a living male child delivered. This infant was nourished with the aid of a spoon, but it died in twenty-five hours in consequence of its premature birth and enfeebled vitality. Green speaks of a woman, nine months pregnant, who was run over by a heavily laden stage-coach in the streets of Southwark. She died in about twenty minutes, and in about twenty minutes more a living child was extracted from her by Cesarean section. There was a similar case in the Hopital St. Louis, in Paris, in 1829; but in this case the child was born alive five minutes after death. Squire tells of a case in which the mother died of dilatation of the aorta, and in from twenty to thirty minutes the child was saved. In comment on this case Aveling is quoted as saying that he believed it possible to save a child one hour after the death of the mother. No less an authority than Playfair speaks of a case in which a child was born half an hour after the death of the mother. Beckman relates the history of a woman who died suddenly in convulsions. The incision was made about five minutes after death, and a male child about four pounds in weight was extracted. The child exhibited feeble heart-contractions and was despaired of. Happily, after numerous and persistent means of resuscitation, applied for about two and a half hours, regular respirations were established and the child eventually recovered. Walter reports a successful instance of removal of the child after the death of the mother from apoplexy. Cleveland gives an account of a woman of forty-seven which is of special interest. The mother had become impregnated five months after the cessation of menstruation, and a uterine sound had been used in ignorance of the impregnation at this late period. The mother died, and one hour later a living child was extracted by Cesarean section. There are two other recent cases recorded of extraction after an hour had expired from the death. One is cited by Veronden in which the extraction was two hours after death, a living child resulting, and the other by Blatner in which one hour had elapsed after death, when the child was taken out alive. Cases of rupture of the uterus during pregnancy from the pressure of the contents and delivery of the fetus by some unnatural passage are found in profusion through medical literature, and seem to have been of special interest to the older observers. Benivenius saw a case in which the uterus ruptured and the intestines protruded from the vulva. An instance similar to the one recorded by Benivenius is also found in the last century in Germany. Bouillon and Desbois, two French physicians of the last century, both record examples of the uterus rupturing in the last stages of pregnancy and the mother recovering. Schreiber gives an instance of rupture of the uterus occasioned by the presence of a 13-pound fetus, and there is recorded the account of a rupture caused by a 20-pound fetus that made its way into the abdomen. We find old accounts of cases of rupture of the uterus with birth by the umbilicus and the recovery of the woman. Vespre describes a case in which the uterus was ruptured by the feet of the fetus. Farquharson has an account of a singular case in midwifery in which abdomen ruptured from the pressure of the fetus; and quite recently Geoghegan illustrates the possibilities of uterine pressure in pregnancy by a postmortem examination after a fatal parturition, in which the stomach was found pushed through the diaphragm and lying under the left clavicle. Heywood Smith narrates the particulars of a case of premature labor at seven months in which rupture of the uterus occurred and, notwithstanding the fact that the case was complicated by placenta praevia, the patient recovered. Rupture of the uterus and recovery does not necessarily prevent subsequent successful pregnancy and delivery by the natural channels. Whinery relates an instance of a ruptured uterus in a healthy Irish woman of thirty-seven from whom a dead child was extracted by abdominal section and who was safely delivered of a healthy female child about one year afterward. Analogous to this case is that of Lawrence, who details the instance of a woman who had been delivered five times of dead children; she had a very narrow pelvis and labor was always induced at the eighth month to assure delivery. In her sixth pregnancy she had miscalculated her time, and, in consequence, her uterus ruptured in an unexpected parturition, but she recovered and had several subsequent pregnancies. Occasionally there is a spontaneous rupture of the vagina during the process of parturition, the uterus remaining intact. Wiltshire reports such a case in a woman who had a most prominent sacrum; the laceration was transverse and quite extensive, but the woman made a good recovery. Schauta pictures an exostosis on the promontory of the sacrum. Blenkinsop cites an instance in which the labor was neither protracted nor abnormally severe, yet the rupture of the vagina took place with the escape of the child into the abdomen of the mother, and was from thence extracted by Cesarean section. A peculiarity of this case was the easy expulsion from the uterus, no instrumental or other manual interference being attempted and the uterus remaining perfectly intact. In some cases there is extensive sloughing of the genitals after parturition with recovery far beyond expectation. Gooch mentions a case in which the whole vagina sloughed, yet to his surprise the patient recovered. Aetius and Benivenius speak of recovery in such cases after loss of the whole uterus. Cazenave of Bordeaux relates a most marvelous case in which a primipara suffered in labor from an impacted head. She was twenty-five, of very diminutive stature, and was in labor a long time. After labor, sloughing of the parts commenced and progressed to such an extent that in one month there were no traces of the labia, nymphae, vagina, perineum, or anus. There was simply a large opening extending from the meatus urinarius to the coccyx. The rectovaginal septum, the lower portion of the rectum, and the neck of the bladder were obliterated. The woman survived, although she always experienced great difficulty in urination and in entirely emptying the rectum. A similar instance is reported in a woman of thirty who was thirty-six hours in labor. The fundus of the uterus descended into the vagina and the whole uterine apparatus was removed. The lower part of the rectum depended between the labia; in the presence of the physician the nurse drew this out and it separated at the sphincter ani. On examining the parts a single opening was seen, as in the preceding case, from the pubes to the coccyx. Some time afterward the end of the intestine descended several inches and hung loosely on the concave surface of the rectum. A sponge was introduced to support the rectum and prevent access of air. The destruction of the parts was so complete and the opening so large as to bring into view the whole inner surface of the pelvis, in spite of which, after prolonged suppuration, the wound cicatrized from behind forward and health returned, except as regards the inconvenience of feces and urine. Milk-secretion appeared late and lasted two months without influencing the other functions. There are cases in which, through the ignorance of the midwife or the physician, prolapsed pelvic organs are mistaken for afterbirth and extracted. There have been instances in which the whole uterus and its appendages, not being recognized, have been dragged out. Walters cites the instance of a woman of twenty-two, who was in her third confinement. The midwife in attendance, finding the afterbirth did not come away, pulled at the funis, which broke at its attachment. She then introduced her hand and tore away what proved to be the whole of the uterus, with the right ovary and fallopian tube, a portion of the round ligament, and the left tube and ovarian ligament attached to it. A large quantity of omentum protruded from the vulva and upper part of the vagina, and an enormous rent was left. Walters saw the woman twenty-one hours afterward, and ligated and severed the protruding omentum. On the twenty-eighth day, after a marvelous recovery, she was able to drive to the Royal Berkshire Hospital, a distance of five miles. At the time of report, two years and six months after the mutilation, she was in perfect health. Walters looked into the statistics of such cases and found 36 accidental removals of the uterus in the puerperium with 14 recoveries. All but three of these were without a doubt attended by previous inversion of the uterus. A medical man was tried for manslaughter in 1878 because he made a similar mistake. He had delivered a woman by means of the forceps, and, after delivery, brought away what he thought a tumor. This "tumor" consisted of the uterus, with the placenta attached to the fundus, the funis, a portion of the lateral ligament, containing one ovary and about three inches of vagina. The uterus was not inverted. A horrible case, with similar results, happened in France, and was reported by Tardieu. A brutal peasant, whose wife was pregnant, dragged out a fetus of seven months, together with the uterus and the whole intestinal canal, from within 50 cm. of the pylorus to within 8 cm. of the ileocecal valve. The woman was seen three-quarters of an hour after the intestines had been found in the yard (where the brute had thrown them), still alive and reproaching her murderer. Hoffman cites an instance in which a midwife, in her anxiety to extract the afterbirth, made traction on the cord, brought out the uterus, ovaries, and tubes, and tore the vulva and perineum as far as the anus. Woodson tells the story of a negress who was four months pregnant, and who, on being seized with severe uterine pains in a bath, succeeded in seizing the fetus and dragging it out, but inverting the uterus in the operation. There is a case recorded of a girl of eighteen, near her labor, who, being driven from her house by her father, took refuge in a neighboring house, and soon felt the pains of child-birth. The accoucheur was summoned, pronounced them false pains, and went away. On his return he found the girl dying, with her uterus completely inverted and hanging between her legs. This unfortunate maiden had been delivered while standing upright, with her elbows on the back of a chair. The child suddenly escaped, bringing with it the uterus, but as the funis ruptured the child fell to the floor. Wagner pictures partial prolapse of the womb in labor. It would too much extend this chapter to include the many accidents incident to labor, and only a few of especial interest will be given. Cases like rupture of an aneurysm during labor, extensive hemorrhage, the entrance of air into the uterine veins and sinuses, and common lacerations will be omitted, together with complicated births like those of double monsters, etc., but there are several other cases that deserve mention. Eldridge gives an instance of separation of the symphysis pubis during labor,--a natural symphysiotomy. A separation of 3/4 inch could be discerned at the symphysis, and in addition the sacroiliac synchondrosis was also quite movable. The woman had not been able to walk in the latter part of her pregnancy. The child weighed 10 1/2 pounds and had a large head in a remarkably advanced stage of ossification, with the fontanelles nearly closed. Delivery was effected, though during the passage of the head the pubes separated to such an extent that Eldridge placed two fingers between them. The mother recovered, and had perfect union and normal locomotion. Sanders reports a case of the separation of the pubic bones in labor. Studley mentions a case of fracture of the pelvis during instrumental delivery. Humphreys cites a most curious instance. The patient, it appears, had a large exostosis on the body of the pubes which, during parturition, was forced through the walls of the uterus and bladder, resulting in death. Kilian reports four cases of death from perforation of the uterus in this manner. Schauta pictures such an exostosis. Chandler relates an instance in which there was laceration of the liver during parturition; and Hubbard records a case of rupture of the spleen after labor. Symphysiotomy is an operation consisting of division of the pubic symphysis in order to facilitate delivery in narrow pelves. This operation has undergone a most remarkable revival during the past two years. It originated in a suggestion by Pineau in his work on surgery in 1598, and in 1665 was first performed by La Courvee upon a dead body in order to save the child, and afterward by Plenk, in 1766, for the same purpose. In 1777 Sigault first proposed the operation on the living, and Ferrara was the one to carry out, practically, the proposition,--although Sigault is generally considered to be the first symphysiotormist, and the procedure is very generally known as the "Sigaultean operation." From Ferrara's time to 1858, when the operation had practically died out, it had been performed 85 times, with a recorded mortality of 33 per cent. In 1866 the Italians, under the leadership of Morisani of Naples, revived the operation, and in twenty years had performed it 70 times with a mortality of 24 per cent. Owing to rigid antiseptic technic, the last 38 of these operations (1886 to 1891) showed a mortality of only 50 per cent, while the infant-mortality was only 10 2/3 per cent. The modern history of this operation is quite interesting, and is very completely reviewed by Hirst and Dorland. In November, 1893, Hirst reported 212 operations since 1887, with a maternal mortality of 12.73 per cent and a fetal mortality of 28 per cent. In his later statistics Morisani gives 55 cases with 2 maternal deaths and 1 infantile death, while Zweifel reports 14 cases from the Leipzig clinic with no maternal death and 2 fetal deaths, 1 from asphyxia and 1 from pneumonia, two days after birth. All the modern statistics are correspondingly encouraging. Irwin reports a case in which the firm attachment of the fetal head to the uterine parietes rendered delivery without artificial aid impossible, and it was necessary to perform craniotomy. The right temporal region of the child adhered to the internal surface of the neck of the uterus, being connected by membranes. The woman was forty-four years old, and the child was her fourth. Delay in the Birth of the Second Twin.--In twin pregnancies there is sometimes a delay of many days in the birth of a second child, even to such an extent as to give suspicion of superfetation. Pignot speaks of one twin two months before the other. De Bosch speaks of a delay of seventeen days; and there were 2 cases on record in France in the last century, one of which was delayed ten days, and the other showed an interval of seven weeks between the delivery of the twins. There is an old case on record in which there was an interval of six weeks between deliveries; Jansen gives an account of three births in ten months; Pinart mentions a case with an interval of ten days; Thilenius, one of thirteen days; and Ephemerides, one of one week. Wildberg describes a case in which one twin was born two months after the other, and there was no secretion of milk until after the second birth. A full description of Wildberg's case is given in another journal in brief, as follows: A woman, eighteen months married, was in labor in the eighth month of pregnancy. She gave birth to a child, which, though not fully matured, lived. There was no milk-secretion in her breasts, and she could distinctly feel the movements of another child; her abdomen increased in size. After two months she had another labor, and a fully developed and strong child was born, much heavier than the first. On the third day after, the breasts became enlarged, and she experienced considerable fever. It was noticeable in this case that a placenta was discharged a quarter of an hour after the first birth. Irvine relates an instance of thirty-two days' delay; and Pfau one of seven days'. Carson cites the instance of a noblewoman of forty, the mother of four children, who was taken ill about two weeks before confinement was expected, and was easily delivered of a male child, which seemed well formed, with perfect nails, but weakly. After the birth the mother never became healthy or natural in appearance. She was supposed to be dying of dropsy, but after forty-four days the mystery was cleared by the birth of a fine, well-grown, and healthy daughter. Both mother and child did well. Addison describes the case of a woman who was delivered of a healthy male child, and everything was well until the evening of the fourth day, when intense labor-pains set in, and well-formed twins about the size of a pigeon's egg were born. In this strange case, possibly an example of superfetation, the patient made a good recovery and the first child lived. A similar case is reported by Lumby in which a woman was delivered on January 18th, by a midwife, of a full-grown and healthy female child. On the third day she came down-stairs and resumed her ordinary duties, which she continued until February 4th (seventeen days after). At this time she was delivered of twins, a boy and a girl, healthy and well-developed. The placenta was of the consistency of jelly and had to be scooped away with the hand. The mother and children did well. This woman was the mother of ten children besides the product of this conception, and at the latter occurrence had entire absence of pains and a very easy parturition. Pincott had a case with an interval of seven weeks between the births; Vale 1 of two months; Bush 1 of seventeen days; and Burke 1 with an interval of two months. Douglas cites an instance of twins being born four days apart. Bessems of Antwerp, in 1866, mentions a woman with a bicornate uterus who bore two twins at fifty-four days' interval.