IMAGE EVALUATION TEST TARGET (MT-3) 4r L<»- 1.0 I.I III 2.0 1.8 1.25 1.4 J4 ^ f^" _ ► Photographic Sdences Corporation # lO^ ,\ s i\ V \ % .V ^ <> %^ 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 m / W.r CIHM/ICMH Microfiche Series. CIHM/ICMH Collection de microfiches. Canadian '.mitute for Historical IVIicroreproductions / Institut Canadian de microreproductions historiques ft Technical and Bibliographic Notes/Notes techniques et bibliographiques The Institute has attempted to obtain the best original copy available for filming. Features of this copy which may be bibliographically unique, which may alter any of the images in the reproduction, cr which may significantly change the usual method of filming, are checked below. Coloured covers/ Couverture de couleur I I Covers damaged/ D D D D D D Couverture endommagie Covers restored and/or laminated/ Couverture restaur^ et/ou pelliculAe I I Cover title missing/ Le titre de couverture manque □ Coloured maps/ Cartes giographiques en couleur D Coloured ink (i.e. other than blue or black)/ Encre de couleur (i.e. autre que bleue ou noire) Coloured plates and/or illustrations/ Planches et/ou illustrations en couleur Bound with other material/ Relii avec d'autres documents Tight binding may cause shadows or distortion along interior margin/ La re liure serrie peut causer de I'ombre ou de la distorsion le long de la marge intdrieure Blank leaves added during restoration may appear wirhin the text. Whenever possible, these have been omitted from filming/ II se peut que certaines pages blanches ajout6( j lors d'une restauration apparaissent dans le texte, mais, lorsque cela itait possible, ces pages n'ont pas 6t6 filmdes. Additional comments:/ Commentaires supplimentaires; L'Inst'tut a microfilm^ le meilleur exemplaire qu'ii lui a 6ti possible de se procurer. Les details de cet exemplaire qui sont peut-dtre uniques du point de vue bibliographigue, qui peuvent modifier une image reproduite, ou qui peuvent exiger une modification dans la methode normale de filmage sont indiquAs ci-dessous. □ Coloured pages/ Pages de couleur □I Pages damaged/ I Pages endommagies I I Pages restored and/or laminated/ D Pages restaurdes et/ou pellicul^es Pages discoloured, stained or foxe( Pages d6color6es, tacheties ou piqudes Pages detached/ Pages ddtachdes Showthrough/ Transparence Quality of prir Qualiti in^gale de I'impression Includes supplementary materii Comprend du materiel suppldmentaire Only edition available/ Seule Edition disponible r~n Pages discoloured, stained or foxed/ I I Pages detached/ r~~| Showthrough/ I I Quality of print varies/ n~1 Includes supplementary material/ I I Only edition available/ Pages wholly or partially obscured by errata slips, tissues, etc., have been r'ifilmed to ensure the best possible imagr;/ Les pages totalement ou partleilement obscurcies par un feuillet d'errata. une pelure, etc., ont 6t6 filmdes d nouvoau de facon d obtenir la meilleure image possible. This item is filmed at the reduction ratio checked below/ Ce document est filmA au taux de reduction indiqu6 ci-dessous. 10X 14X 18X 22X 26X 30X J 12X 16X 20X 24X 28X 32X The copy filmed here hes been reproduced thanks to the generosity of: IVIedicai Library IVIcGill University ■Montreal The images appearing here are the best (quality possible considering the condition and legibility of the original copy and in keeping with the filming contract specifications. Original copies in printed paper covers are filmed beginning with the front cover and ending on the last page with a printed or illustrated impres- sion, or the back cover when appropriate. All other original copies are filmed beginning on the first page with a printed or illustrated impres- sion, and ending on the last page with a printed or illustrated impression. The last recorded frame on each microfiche shall contain the symbol —»•( meaning "CON- TINUED"), or the symbol V (meaning "END"), whichever applies. INAaps, plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: L'exemplaire film6 fut reproduit grice h la ginArosit6 da: Medical Library McGill University ■Montreal Lee imeges suivantes ont it* reproduites avec le plus grand soin, compte tenu de la condition at de la nettet* de l'exemplaire fWtni. et en conformity avec les conditions du contrat de fiimage. Lee exemplaires orlginaux dont la couverture en papier est imprimte sont film6s en commen9ant par le premier plat et en terminant soit par la dernlAre page qui comporte une empreinte d'impression ou d'HIustration, soit par le second plat, selon le cas. Tous les autres exemplaires orlginaux sont fllmte en commenpant par la premiere page qui comporte une empreinte d'impression ou d'illustration et en terminant par la dernlAre page qui comporte une telle empreinte. Un dee sym'^oles suivants apparaltra sur la dernlAre image de cheque microfiche, selon le cas: Se symbole — <^ signifie "A SUIVRE", le symbols y signifie "FIN". Les cartes, planches, tableaux, etc., peuvent Atre fllmte il dee taux de rMuction diffirents. Lorsque le document est trop grand pour dtre reproduit en un seui clich«, 11 est film« A partir de I'angie supArieur gauche, de gauche A droite, et de haut en bas, en prenant le nombre d'images nicessaire. Les diagrammes suivants illustrent la m^thode. 1 2 3 1 2 3 4 5 6 Ca-C ^ IS^.g.A A CASE OF CONSKRVATIVE CilSEKEAN SECTION. BY WILLIAM GARDNER, M.D., Professor of Gj-niecology in McGill University ; Gynrecologist to the Royal Victoria Hospital, Montreal, With Reiiort of Previous History, BY DAVID J. EVANS, M.D., Lecturer in Obstetrics, McGill University, Montreal. Reprinted from the Montreal Medical Journal, December, 1900. / A CASE OF CONSEEVAL^IVE CESAREAN SECTION.* BY William Gardner, M.D,, Professor of Gyniticology in McGill University ; GynsEcologist to the Royal Victoria Hospital, Montreal, With Report of Previous History BY David J. Evans, M.D., Lecturer in Obstetrics, McGill University, Montreal. ,0n September 24th, 1900, I was called by Dr. Morphy of Lachine to see Mrs. K. S., aged 29 years, Ilpara, who was shortly expecting her confinement. Dr. Morphy informed me that two years previously he had delivered her of twins at the seventh month of pregnancy, after per- forming version. The extraction in each case was only accomplished with the greatest difficulty, and both children were born dead. On examination, I found the patient to be an undersized, well-nour- ished woman. She presented no evidence of rachitis in the long bones of the limbs or in thorax or head. The heart and lungs were normal. The abdomen was greatly distended, the fundus uteri reaching to the ensiform cartilage. The umbilicus was prominent, the flanks full, and the skin uver the abdomen presented the usual pigmentation and hnete albicantiae. Foetal movements were observed. On palpation, the excavation of the pelvis was found to be unoccupied. The foetus was in an oblique position, the head resting in the left iliac fossa, while the breech could be felt at the fundus to the right of the middle line. The foetal back was directed posteriorly, which would ac- count for the fact that at no time could the foetal heart sounds be heard in spite of repeated auscultation. Pelvimetry. — The pelvic measurements were as follows: — A. II., 11 inches; If. II., lOJ inches ; Ext. conjugate, ^ inches : Diagonal con- * Read before the Montreal Medico-Chirurgical Society, Oct. 19, 1900. jugate, 3J inches; Conjugate vera, 3 inches (estimated). By vaginal palpation Uie proinintory could be easily reached. The sacral ahij pro- jected forward into the brim, thus causing a sharp bend in the posterior part of the iliac bones. The lower part of the sacrum and coccyx were sharply bent and projected forward into the pelvic cavity. The pubic bone was thickened in its upper part, further tending to obstruction of tlie pelvic inlet. Diagnosis. — A diagnosis of Hat rachitic pelvis with marked obstruc- tion of the inlet, was made. An attempt was made to bring the foetal head into position over the pelvic inlet but without success, as the head seemed to be particularly large. In view of the peculiar projection into the brim of the alse of the pacrum and the posterior -parts of the iliac bones, and the sharp forward bend of the lower part of the sacrum and coccyx, it was deemed im- posible to deliver the child through the natural passages, and therefore it was thought best to recommend Csesarean section in preference to symphysiotomy. Accordingly, that afternoon the patient was removed to the Eoyal Victoria Hospital and placed under the charge of Dr. Wil- liam Gardner. Beport of the operation. The case was ideally favourable for the saving of both mother a^d child and conservation of the uterus. The woman was pregnant to full term and had been examined only by Drs. Morphy and Evans besides myself, in each case presumably with aseptic precautions. She was admitted to the gyuagcological ward of the Koyal A'ictoria Hospital on the evening of one day. At four o'clock the next morning labour had commenced. Foetal heart sounds could not be heard, but movements were unmistakable. At eleven o'clock of the morning of the same day when operation was commenced, the os was of the size of a silver dollar. No attempt of any kind to deliver had been made and the temperature was normal. The operation was thus, in the full sense of the word, elective. I was most ably assisted by my colleague, Dr. Garrow of the Surgical Department, and Dr. Casselman, my House-Surgeon. The incision in the abdominal wall, six or seven inches long, was two-thirds of its length below and the other third above the navel. In doing this my experience amply bore out that of others — how easy it is to wound the uterus. One comes unexpectedly soon through the ab- dominal wall. Palpation before operation led to more than a suspicion of anterior implantation of the placenta. Palpation of the exposed uterus showed that this was beyond a doubt. Statistics show this posi- tion of the placenta in 50 per cent, of the cases. Dr. Garrow making pressure on the abdominal walls around the uterus, T 8 a six-inch incision was made in the anterior abdominal wall. Dr. Cassel- man was directed to control by finger pressure any large bleeding points and, if necessary, to compress the uterine arteries by grasping the cervix. Tlie incision ex])osed the placenta. It was rapidly peeled off to the right, tlio membranes ruptured, the child's feet grasped, and extraction effected. Tiie cord was pulsating strongly. It was clamped by two artery forceps and divided between them. The child was skillfully resuscitated by Dr. Evans. The uterus was now delivered through the incision. It did not con- tract satisfactorily and, as bleeding was going on, the placenta was de- tached and extracted, and kneading and friction of the uterus were kept up while the uterine sutures were being put ir. But the womb did not contract until hot water had been dashed over it and normal salt solution had been injected under the breasts. The loss of blood was somewhat alarming, and I thought it might be necessary to amputate the uterus to prevent the woman from bleeding to death. Interrupted silk sutures, a centimetre apart, were used to close the uterine wound. On the serous surface the needle was entered about a quarter of an inch from the edge of the incision and brought out just short of perforating the mucosa. Each suture was tied as soon as passed. After cleansing the abdominal cavity, the abdominal wall was closed by silk-worm gixt sutures through all the layers. Eecovcry though complete was tedious. About the ninth day the temperature rose a little and the right thigh and leg became painful in the course of the saphenous vein, but there was no swelling. A little later a small indurated, tender mass appeared inside the brim of the pelvis on the right side. At the exan. -ation of the woman before her discharge all morbid signs and symptoms had disappeared. The uterus had undergone complete involution and was movable. The child was suckled throughout and throve perfectly. In reflecting on the events of the operation some thoughts are upper- most. The fact that the application of hot water was promptly followed by contraction of the uterus, seems to favour the idea that it might have contracted sooner if it had been kept inside the abdominal cavity while the incision was being sutured. The anterior implantation of the ])lacenta doubtless conduced in a measure to the free bleeding. The in- cision of the uterus here must have interfered with as complete con- traction as elsewhere. The advocates of Fritsch's fund^.l incision would doubtless find in this case a favourable argument. I have no experience of it, but in the next case of similar position of the placenta I shall be disposed to adopt it. In my experience of Cajsarean section this is the first case indicating. r / or rather I should say denmnding, conservative methods. I am inclined to think It IS the first successful conservative Cesarean section in this city if not in the Dominion. If T am correct, the fact speaks volumes lor (he rarity of those conditions of impaired nutrition which brin--- about contracted pelvis. This woman had lost all her previous childr'en and was naturally an.xious lor oil'spring. The fact that she is left in a con- dition for subsequent pregnancies is naturally a matter for satisfaction to the operator if not to the patient. In watching the case one could not help seeing that the sum total of suffering was much less than in normal labour m a normal condition of the birth-canal. i I '4 / I /