Rupture of the uterus, with a report of seventeen cases

I)It.

CATXISS (closing) .-This study W:IS based on 12.iO V:ISCS only. T am sort’! It is true that the accuracy of :I study of this n’rw not more available. kind groxs with the increasing number of cases and that it is highly desirable tc 11:trc a minimum of 4000 for ;ln analysis such as this. JVith a lnrgrr series the l”‘obable errors are much sm:lller and the rcli:rbilit,v of tllc coefficients is t,llrrch: increased. The size of the coefficient itself is not a f:lctor as to it,s rcliahilit~y. rtl fact, tllrrc arc very few iustances in biologic variables xherc one will get :1 coefficient as high as 0.3 to 0.6. Tllr real test of a rocfficirnt is its relation to its probnhlc error. If the coefficient is four times its probable error there is not’ 1norc than om! challcc in n thousand of its being incorrect. tlbat

thc~re

Dr.

LaVake spoke of dctermiuing the probable duration of l:~hor heforehand. was my sole idea in introducing this study and I am convinced, as a result of this work, that one cannot estimate accurately the length of labor from the relation of the size of the baby to the size of the pelris, from the age or stature Tllc only information of value of t.llr mother, or from the stage of’ prcgnanc~. in f&mating the length of labor, is the length, thickness, and the ronsistrncy of the ccwis. Of course, WC know little about what the labor pains will be like, esccpt~ as Dr. LaVnkc has pnintcd out,, that hrredity may give us some idea. Witll a multipara, of course, the character of pains in previous labors is of great value. Dr. Potter spoke of the long labors in the seventh nud rightli pregnxncics. Frequent childbearing does tend to produce weak and ineffective labor pains in this group of patients. The general average is not different, however, from the second, third, or fourth labors. Dr. Royston referred to the prolonged labor with nccipitopost,erior position. 1 p~rp(~ly avoided the question of presenatation because the study was already ton long, without adding this additional variable. That

h.

I.

W.

POTTER,

Buffalo,

N. Y., read

a pap&

Uterus, with ELReport of Seventeen Cases. page

389, February

erltitled Rupture of the (For original article set

imle.) DISCURAION

T)R. .I. P. GREENHILL, CIII~-AGO, ILr,.--Nat,urally, rupture of the uterus having occurred 17 times in the experience of one individual is very unusual. At the Chicago Lying-in Hospital and its Dispensaries, in an experience of over 50,000 labors, we had only six cases of rupture of the uterus from all causes. Strange to say not one of the ruptures followed a cesarean section. Sixteen of the seventeen ruptures which Dr. Potter saw, followed abdominal delivery and I assume that all of these were cesarean sections of the classic type. As you all know, the incidence of rupture of the uterus after the classic operation is far greater than it is after t,he cervical one. Holland repnrted an incidence of 16 per cent in a small series and in a series of over 1,100 cases collected in t,he British Isles, hc found the incidence of rupture in a subsequent pregnancy or labor to be 4 per cent,. Rupture of the uterus following the low, cervical cesarean section is very unusual. Altogether in the entire world literature there have been reported only 22 ruptures after the cervical operat.ion and it is safe to say that at least ;?O,OOO of these operations have been performed. IIence the frequency of rupture after these operations is rory small. Furthormorc, all but three of these accidents occurred during active labor when the patients were under observation. On the other hand, a large proportion of the ruptures which occurred after the classic operation took place during pregnancy under unfavorable circumstances. For example, Holland makes the statement that among 84 ruptures, 48 of these catastrophies occurred during labor, vhilc 36 or almost 4.3 per cent took pl:xcc during prrgmtncy. Dr. I’otter’s mortality

was very low as compared to be congratulated.

with

tile

usual

mortality

for

ruptured

uteri

and

l1P is

DR. PAUL TITUS, PITTSBURGH, I’s.-Because 1)~. Potter is nt his best when some one seems to disagree with him, I venture to take issue with one of his stat{‘This is that pituitary extract should uerer be used for inductiou of labor, JJJcJlts. 011 thr basis of tile int,imation being that this may c:luse rupture of the utc*rus. :L fairly large series in which it was used with castor oil and quinine for the ther:lpcut,ic inductiou of labor according to the teaching of Watson :oJtl also CVilliums, I UJJJ thoroughly convinced that its judicious use is accompanied by lltl sue11 risk. By this T ~nwll its administration before labor Il:ts begun Y0k’l.V to aid in tile induction of labor, emphasizing that it is ifcst:lntly to lye ~lineontinued if 1:lbu1 p:iio.s begin. ‘I’~IIJS there is :L dist,inction bctwcen giving minute do%? by 1J)‘pOdeJ’JlJiC iJljeCt~iOl1 (11’ b!, I~fofbauer ‘s nilSill application as n part of :L Cuursc of tJ’eat!JJ~?Jl~ to bring 011 aud its use during labor to increase the forcr of the uterine contractions. hbor, 1 subwr.ilw completely to a dictum against its use at ally time during actual 1abo1 Ijut do not believe it is harmful if given as outlined before labor has begun. I brlic~~e that a11 a~mlysis of this work which Dr. Potter has presented brings out two facts ; first, that he should not condemn and advise the discarding of a practice t Iut has proved valuable in the IJnnds of many competent men solely because a nlisnlrdcrstandillg of its proper application may occnsionnlly hare resulted in its illjudicious use; second, that frequent OCCIIJ~JIC~ of ruptured uterus folloGng ~~Y~I~I’~:Iu scetion in one’s practice suggests that tlic techuic of thca section is open to question. I, for one, have long l)ecn conrinccd that the lower uterine segment cesarc:~n section has many ndvnntages over the older classical section and tll:rt rupture is JJJUCIJ less likely to occur in subsequent pregnancies if the scar is in the ~~~rvcr, JJOJJcOJltraCti~C pOrtion of the uterus than if it is in the fImduS. m.

1s. w.

SCHOENECK,

~I’RACUSK,

x.

T.-I

IWIlt

to

diSCUSS the

SCpaKItiOll

Of

the scar in the so-called classical section. The litcraturc has shown that this occur8 much more frequently than we were wont to expect. In our rmm Of S.&On mhich come for SubSequeJJt dCliWry, me make it a point to go over the line of uterine incision by abdominal palpatiou. This procedure is followed out in hope that Ii--e may detect these incomplete ruptures before the onset of labor. Having done this over a period of ~enrs. nncl .lmring found no break in 1,111’ iucisions, WC fame to the couclusion that tllerc must bc something in our method c,f closing the wound which avoided separation. 411 iJJ
584

AMERICAN

JOURNAL

OF

OBSTETRICS

AND

(‘1YSECOLOGY

digestive disturbance. I watched her for a few weeks and considered it necessary to take out the appendix. We found a subacute appendicitis and her convalescence was absolutely normal. What we could see of the uterus through the incision appeared perfectly normal. She went on for the next three months, with no digestive disturbance whatsoever, picked up in weight and was in every way in excellent condition. I was called at midnight later on and found her suffering with vomiting, diarrhea, a certain amount of shock, and very definite pain in the upper abdomen. This had followed a very injudicious meal that evening. There was no distention At the end of another twenty-four of the abodmen and no tenderness anywhere. hours she went into labor and delivered herself normally. I’or the following four or five days convalescence was perfectly normal. The bowel movements were not quite as free as they had been and she began to complain of a little digestive disturbance. There was no elevation of temperature. Food was withheld for about two days suspecting we might have a pseudoileus, although her general appearance was good. When she began to take food again there were symptoms of intestinal obstruction. After a few days the abdomen was opened and found full of a foul smelling blood and she died of embolus about two days later. DR. E. M. LAZARD, Los ANGELES, CALIFORNIA.-At the General Hospital in Los Angeles we have had our share of ruptured uteri brought in and an occasional a neglected case which ruptured during the ease brought in with an obstruction, I well remember one ease a number of years patient’s later labor in the hospital. ago that was brought in at midnight. That woman had had two normal deliveries. Her third baby had been delivered by cesarean section, because of too large a baby; she had had two prolonged labors following the cesnrean section and was brought in at the eighth month of her third pregnancy following cesarean section, having ruptured the uterus twenty-four hours before being brought in. She gave a history of having gotten out of bed to go to the lavatory and of having fallen back on the bed in a faint from severe pain. She was sent into the hospital twenty-four hours later in extreme shock with all the evidences of ruptured uterus. We operated as soon as we could get consent but before the patient had been fully anesthetized she died. A postmortem examination was done. The fetus, placenta, and membranes were free in the abdominal cavity; there was a rupture through the scar of the cesarean section that had been done a number of years before; although the uterus had gone through two pregnancies and difficult labors and withstood them without any trouble; this time rupture had occurred before she went into labor at all. DR. A. M. MENDENHALL, INDIANAPOLIS, IND.-I would like to supplement Dr. Potter’s remarks by saying that wit,hin the last year I have made considerable study of the cases of ruptured uteri due to pituitary extract, 90 of which I was able to obtain. The fact I want to bring out is that in a great many instances, and not following cesarean section, we found that there were pathologic lesions in the uterine wall that had not been suspected. In other words, we must look for diseased uterine walls in case of ruptured uterus. DR. JAMES E. DAVIS, ANN ARBOR, MICII.-I have in my collection ten ruptured uteri. One of these is rather an unique case, different from any Dr. Potter has reported. This uterus had ruptured between the fourth and fifth months of pregnancy through the midpoint at the fundus. It was the placental type, as Dr. Potter has classified these different ruptures. The placenta was slightly protruding through the thinned-out wall and within the abdominal cavity there was a large adherent clot. There was evidence of a large peritoneal hemorrhage. The patient died. Microscopic examination of the uterus showed just what Dr. Mendenhall has been speaking of. There was a marked hyaline degeneration at this part of the uterus. This patient was suspected of having an induced labor by criminal intent

585

AM. ASSN. OBST., GYNEC., AND ABD. SURG. but the cervix was intact, the membranes were intact, abortion having been attempted.

and there was no evidence of

DR. POTTER (closing).-Fifteen of these cases I operated upon. One case was never operated upon; she was attended by a midwife. One ease was operated upon by another doctor seven or eight years ago. That makes the number of ruptures fifteen in over 1700 eases. Now rupture does occur from pituitrin and I still maintain that pituitrin should not be used. Dr. Titus can use it successfully because he understands its use. The trouble is that the men I see using it do not follow out instructions but administer 2 or 3 cc. at once. Regarding the type of section in these cases, the technic was the same in each case. Each uterus was packed with gauze, the wound closed with three layers of catgut, and pituitrin was put into the uterine muscle after the uterus was emptied, and sutured. In spite of this we had these ruptures. I wanted to report these eases because I know they occur and that other men also have them. I did not do the low operation because I do not like it. DR.

MIKLOS

entitled original

TEMESVARY,

Budapest,

Hungary

(Guest),

read a paper (For

A Rapid Nonsurgical Means for Aiding Childbirth. article see page 267, February

issue.)

DR. TEMESVARY.-That is not a contraindication so far as the size of the fetus is concerned. If the heart pathology is not very marked forceps can be used if necessary. DR. AND-

bile.

(For

CROTTI, Columbus, Ohio, read a paper entitled original article see page 356, March issue.)

Cecum MO-

DR. JAMES W. ‘KENNEDY, PHILADELPHIA, PA.-When we have a better understanding of the function and reactions of the peritoneum we will have better knowledge of many of the abnormalities of structure, location, form, and organic relations of intraabdominal organs. In our enthusiasm over physicochemical methods of study, we should not forget the importance of structural development. I find authors in discussing the mobile ceeum very often make the statement that the mesentery of the cecum fails to become fixed or fused with the posterior abdominal wall. It is my understanding that the cecum has no mesentery, so in discussing this subject of mobile cecum we must more accurately consider the mesentery of the ascending colon. When au organ has once formed a mesentery and later becomes a retroperitoneal or partially retroperitoneal organ, it probably loses its mesentery in one of two ways. Either the peritoneal planes which cover the mesentery and also help constitute it, spread apart and thus permit the ascending colon to be mushroomed, so to speak, against the posterior abdominal wall and thus become a partially retroperitoneal or fixed organ, or, one peritoneal side of the mesentery becomes fused with the parietal peritoneum and thus fixes the organ. This later solution of fixation of the colon, I believe, is the popular view. * * * * That mobile cecum has become a well-recognized entity, Dr. Crotti’s discussion has well brought out, and further, he has pointed out the great frequency with which the appendix has been removed, whereas, the floating cecum has been at fault. I feel in a large percentage of cases the floating cecum can be diagnosed by clinical history and physical signs. One need not worry about the appendix as that can be taken care of at the same