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DISCUSSION.

Dr. Jordan: Dr. Morris has covered the ground so well in his excellent paper that it seems there is little to be added. Before I knew that he had prepared a paper on this subject, I concluded the report of a case of my own in a group of cases which I expect to report at the present session.

There are one or two points in connection with the management of cases of Cesarean Section which differ somewhat from the text-book descriptions. Dr. Williams urges very strongly to open the uterus in the cavity of the abdomen. Sơ far as my knowledge goes, it is far preferable for me to deliver the uterus before opening it. I fail to see how we can do any harm, for you are then in command of the situation. The matter of locating the placenta may be ignored entirely. As in Dr. Morris' case, I struck the center of the placenta exactly. The location of the incision is also of secondary importance. Some favor incision from tube to tube in the top of the uterus. I think this is merely a matter of choice. I fail to see any advantage in that over the anterior incision. Heretofore the rule has been to use silk in closing the walls of the uterus and to close the peritoneum with cat gut. I have used silk, and but rarely cat gut. I think it is a good idea to pull the omentum down behind the uterus. It is also wise to have a physician ready to resuscitate the child. It seems that there is some interference with respiration and they are sometimes very slow to breathe. That was so in my case.

Dr. Talley: I have very little to say on this subject, because I have had no experience in doing Cesarean Section. I assisted Dr. Morris in the second operation. I was present when he did his third operation. I want to bear out what he says in regard to hemorrhage. The text-books, Kelly and also Williams, in the latest work on Obstetrics, say that the hemorrhage is very insignificant and that it is not necessary to use any means of compressing the arteries. In the second case of Dr. Morris, he was going on that suggestion in not pressing the uterine arteries and the hemorrhage was frightful until the arteries were pressed and the bleeding thus controlled. I think it is very important to deliver the uterus and to have a large constricting band around the broad ligament in such a way that you can control the hemorrhage unless you have some one to hold the arteries. Undoubtedly some cases are lost on ac

count of the hemorrhage, because these sinuses are so large that they simply flood, and it only takes a little while to lose enough blood to produce a serious condition in the patient.

I believe this operation is becoming so successful that it should not be looked upon as being an operation of last resort, -yet it is so to such an extent that patients are allowed to go on where they have a contracted pelvis or tumor or obstruction to normal delivery until they have worn themselves out in labor before it is determined to do Cesarean Section.

When a student in the Charity Hospital, in New Orleans, a Cesarean Section was done on a little woman who had a contracted pelvis and had been in labor several days before they decided to do the operation. She was completely exhausted before the operation was done and consequently, she died. I think the conditions which lead to the necessity for this operation should be earlier recognized and the patient advised to undergo the operation sooner, when it is perfectly plain that she cannot give birth to the child normally.

Dr. Mason: There is one point about this paper which I think needs special stress and that is the use of the pelvimeter. I have had one case of Cesarean section which terminated fatally for the mother and child, for the reason that the pelvimeter was not used. I was called to see this case and the physician said that he had been consulted and had been laboring all night trying to deliver the woman. I found that the woman had a markedly contracted pelvis. It was perfectly plain that it was impossible for any foetus to be delivered. She was badly lacerated from various attempts at delivery, and by turning and by the use of forceps. Her condition was such that something had to be done. We decided the best thing, under the circumstances, was a Cesarean Section. It was done without difficulty, but she did not survive. All the trouble could have been prevented if she had been taken in hand a few days before; for a careful examination and the use of the pelvimeter would have shown that normal delivery could not take place. No primipara should be allowed to progress far without the use of the pelvimeter.

Dr. Palmer: I was very anxious to hear this paper of Dr. Morris' discussed at some length by men who have done this class of work. I think the majority of the medical profession pay but little attention to obstetrical work, especially obstetrical

surgery. The operation of Cesarean Section may not be one with which many physicians are familiar. Many men will never be called upon to do any work of the kind. I recently had a case. It brought to my mind the importance of being prepared to do all such operations, and how easily, with the proper preparations, most any man can do work of this kind successfully and save many lives as well as many babies. One of the principal points, I think, is the matter of elective operations. A great deal depends upon that point. I do not think that any physician should undertake to wait upon a primipara until he is perfectly familiar with her history as to whether there is any indication of the disease of the bony structures of the pelvis or any trouble of that kind. On examination of the primipara, we can always tell whether it is possible, or probable, to deliver, and to tell whether the operation may be necessary, and we can warn the patient of the trouble that may come, and be prepared to meet it when it does come. On the 23rd of February, I was summoned to do an operation supposed to be a Cesarean Section. The patient was the mother of several children and had been operated upon for sarcoma. I reached the patient at nine and found that she had been twentyfour hours in labor. The expression of her face showed intense pain. An examination showed that the pelvis was completely filled with a bony tumor. There was hardly space between the iliac fossae to pass your finger, and no chance to reach the cervix. I had only two hours between trains. Finding that the husband of the woman had been told what to expect, he was anxious for the operation and, in the limited time allowed, the woman was prepared in a way that sounded more like vengeance than surgery. The operation was done. We prepared her as best we could and the operation was commenced and finished in a few minutes. We removed a twelve and a half pound baby girl. The uterus was very skillfully handled by my assistant and the hemorrhage amounted to nothing. The baby, as soon as delivered, was turned over to the assistant physician. The uterus was closed rapidly with cat gut sutures. The abdomen closed in layer of cat gut and silk sutures, and the patient took a meal soon afterwards. It is my opinion that if a woman as thoroughly exhausted as she was, could be operated on and her life prolonged and the life of the baby saved then, this procedure should commend itself to us more strongly.

Dr. Burns: Dr. Morris has read a very elegant paper. I have had no personal experience, but I have seen four operations performed. I believe that a high incision is better than a low incision. A high incision when the uterine cavity is approached contracts down below the abdominal wall. I do not think that hemorrhage amounts to very much in Cesarean Section. If it is a reasonable amount I believe it is beneficial. Another point about taking the uterus out of the abdominal cavity; bring it up into the field of the incision and press the abdominal wall against the uterine wall and control the hemorrhage in that way. So far as the hemorrhage is concerned, I de not think it amounts to very much.

Dr. Lupton: I had the pleasure of assisting Dr. Morris in these cases. The gentleman who has just preceded me says he does not think it necessary to control the hemorrhage. I say you had better control the hemorrhage. In the first case, very little blood was lost; in the second, the hemorrhage was very severe. In the third, there was very little hemorrhage. i think it likely that this may have had something to do with the termination of the cases. The pressure of the arteries as a means of controlling the hemorrhage is a very important matter. So far as the pelvimeter is concerned, I wish to say that I think it a very important thing. All these three cases were measured immediately. The first case had already been in labor for some time. In the others, we knew we would have to do a Cesarean Section. I think it is best to wait and see what happens when a woman comes into labor. I recall one-case which I had where I felt sure a Cesarean Section would have to be done; the mother was a very small woman and the father was a fully developed man. It so happened that the woman went to full term and had a very small child which she delivered spontaneously without any trouble whatever.

Dr. Morris (in closing): As regards the term of gestation and operating when it is terminated, I stated that that was only advisable when the operation was absolutely necessary. In doubtfu! cases, on the contrary, as Dr. Williams says, it is best to wait for the bearing down pains before doing the operation. The only objection to delivering the uterus is the larger incision. In elective cases, where examinations have been made, I can see no necessity for the delivery of the uterus.

In the majority of cases, however, there is always a reasonable possibility of an infection within the uterine cavity.

I thank you very much, gentlemen, for the liberal discussion.

ABDOMINAL PAIN.

BY EDMOND MORTIMER PRINCE, M. D., Coleanor.
Member of the Medical Association of the State of Alabama.

The subject of abdominal pain is one that should be of no less interest to the general practitioner than to the surgeon, for it is through the advice of the general practitioner that the cases manifesting this symptom seek the surgeon for relief; and should the general practitioner fail to appreciate its importance, the life of some useful man or woman may be the forfeit.

Abdominal pain is a symptom of many diseases and the time spent in the careful study of the causes which manifest themselves by the expression of pain in the abdomen will prove of inestimable value to those applying to us for its relief. It is today of greater symtomatic importance than it has been at any time in the past. Until the daring surgeon invaded the then sacred abdominal cavity, little was known as to the cause of abdominal pain, as it was not possible in many cases to know the relationship existing between the pain manifested and the disease giving rise to the pain. We now endeavor to locate or account for the cause of the pain and do not, as was often done in the past, attribute it to an over-indulgence in something that pleased the palate and administer an opiate for its relief. Abdominal pain is Nature's signal that some pathologic condition is taking place in the abdomen and it is almost criminal to mask this symptom with opium.

We too often see patients brought to the operating table in the last stages of a fatal peritonitis when a proper interpretation of the pain that the patient had complained of for the past few days would have resulted in an earlier diagnosis, proven of life saving value to the patient, and caused the world at large

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