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.

CHAPTER IV.

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