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Successful Postmortem Cesarean Section
SUCCESSFUL POSTMORTEM CESAREAN SECTION .JOHN
Y.
KELLY, M.D.,• GROSSE POINTE, MICH., AND HEBERT (}.WINSTON, ScARSDALE,
M.D ..
N. Y.
(From the Division of Obstetrics and Gynecology of the Metropolitan Hospital and the Nell: York Medical College, New York, N. Y.)
pOSTMORTEM cesarean section is a rare occurrence in medical practice and ... is successful even less frequently. It is the purpose of this paper to give a brief review of its history and incidence, and present two case reports with the purpose of emphasizing the importance of this rare procedure when the occasional opportunity arises. Postmortem cesarean section was probably the first major surgical operation undertaken in the history of mankind. Successful procedures of this type are narrated in the legends of the Romans, probably because the Roman Law of Numa Pompilius decreed that any woman who died during pregnancy should have her child removed from the abdomen prior to her burial. Graham, 1 in his history of gynecology and obstetrics, relates that such famous names as the mythical Bacchus, the philosophers Gorgias and Trismegistes, the soldier Scipio Africanus, and the physician Asklepios, delivered by his father Apollo from the womb of the dead Koronis, were all products of this successful procedure. Published articles and reports of this operation have been collected from as far back as the eighteenth century. In an excellent review, Duer 2 in 1879 reported a total of thirty-six successful postmortem cesarean sections during the eighteenth and nineteenth centuries. We have collected an additional st>venty-five cases from the literature of the twentieth century. TABLE
l.
CArSES OF MATERNAL DEATH IN 111 POSTMORTEM CESAREA;>~ SECTIONS WITH INFANT SURVIVAL
----~---~-----~
CAl:SE OF DEATH
-------------
Eclampsia Tuberculosis Cardiac Hypertensive cardiovascular disease Rheumatic heart disease Accident (traumatic skull fracture, etc.) Pneumonia (plus pneumococcic meningitis, lJ Aneurvsm Dissecting aneurysm Ruptured syphilitic aneurysm Spinal anesthesia Bulbar poliomyelitis Cholera Peritonitis (fulminating, etiology unknown) Gangrene of the neck Unknown Total *Present address. Allmiinna Barnbordshuset, Stockholm ii, S\Yeden.
203
;\'llMBER OF CASES
39
:n
5 4
3 2
1
3 2 2 1 1 ];l
111
204
KELLY AND WINSTON
Am.
J.
Obst. & Gynec. July, !95<>
The total number of reported successful postmortem cesarean seetions in the available world literature is one hundred and eleven cases. These easPs and the respective causes of death arc listed in Table I. To these cases we wish to add two case reports, which describe our experiences with this problem. CASE 1.-A. R., a 30-year-old gravida ii, para 0, Puerto Rican woman, was first admitt;>d to Metropolitan Hospital on April 12, 1952, in acute congestive heart failun• and with evidence of small pulmonary infarction and residual evidence of subacute rh('umati<· a<'tivity. The diagnosis by our eardiologist was rheumatic. heart disease with mitral insuffit'i'm'·y and stenosis, enlarged heart, regular sinus rhythm, and congestive heart failurP, Class Ill. She was placed on digitalis, mereurial diuretics, sodium restriction, bed rest, awl antibioticR, and responded well enough to treatment to be discharged on May 12, 1952. She did fairly well on our Home Care Service until Aug. 28, 1952, when mild failure again supt>rvened and she was readmitted to the hospital servke. It was learned at that time that she was pregnant, her last menstrual period having oecurred on April 14, 1952. Adjustment in the dosage of digitalis resulted in some improvement in the cardiac status. The attending phy,;ieians on the medical service advised interruption, but the patient and her husbautl would not permit interruption of the pregnancy on religious ground~. Rigid management, including digitali~, mercurial diuretics, sodium restriction, absolute bed rest, and close rooperativP management vlith the medical service were maintained. At the time of admittance, the physical examination showed a well-developed, wellnourished Puerto Rican woman who appeared to be in moderate distress. The respirations were 24 per minute and a slightly productive cough was present. 'rhe radial pulse and apex ratt> were 120 per minute at bed rest, there was a one plus pretibial and sacral edt>ma with inoist post-tussive rales at the left base. The blood pressure was 110/80. The heart was enlarged both to the right and to the left, while a harsh systolic aud a presystolic apical murmur were present. The liver was palpated 4 fingerht·eadths below the right costal margin. Tht' uterus was enlarged to approximately 4¥2 months' size. A chest x-ray revealed moderate enlargement of the heart in all diameters with a;!centuation of the pulmonary eonus segment and some pulmonary congestion. The blood serologic test for syphilis was positiw. The blood group was A and the Rh factor was positive. The cardiac regime was augmented by the utilization of intramuscular aminophylline, more frequent mercurial injection, and intermittent ammonium chloride therapy. A course of antisyphilis therapy was institutPd with the use of penieillin G. The patient improved but intermittently developed signs and symptoms of incipient cardiac decompensation. An increase in digitalis dosage wa~ ahandoriPd due to manifestations of toJ~;icity. The patient's progress was relatively satisfactory until she was about 30 weeks pregnant when again incipient failure occurred. In an effort to ensure a more rigid sodium restriction, a rice diet was instituted. This resulted in some improvement in her body status. Her weight gain had been held to approximately 8 pounds. On Dec. 20, 1952, a 2 pound weight gain in 24 hours was noted. Mercuhydrin, 2 c.c., was immediately given intravenously. Three hours later respiratory distress became more marked and frank pulmonary edem!l. appeared. She was approximately 32 to 33 weeks pregnant at this time. Vigorous therapeutic measures were instituted in collaboration with the medical servic<>, including pressure oxygen by mask, morphine, aminophylline, 50 per cent glucose intravenously, dry phlebotomy, and wet phlebotomy ( 500 c.c.). Pressure oxygen through alcohol, by the technique of Luisada, was instituted and while some improvement occurred it was not market! and was only transient. Imminence of fatal outcome was obvious and preparations for agonal cesarean section were made. \Vithin 45 seconds after death had been pronounced by three physicians, a 1,500 grar:1 depressed female infant waR delivered hy classical cesarean section. Resuscitation was successful and the baby wa~ transferred to the prepared incubator. The baby progressed well and now at 3 years of age is a normal healthy little girl. A postmortem examination of thE' mother was performed and revealed rht'umatic heart disease, mitral stenosis with a very tight orifiee, pulmonary edema, old pulmonar,v infar<>tion, and chronic passive congestion of the liver, spleen, and kidne,vs.
Volume n Number l
SUCCESSFUL POSTMORTEM CESAREAN
SECTION
205
CASE ~.-B. 0., a 37-year-old Negro woman, gravida v, para ii, who had had ~ abortion~. was first seen in the Metropolitan Hospital Obstetrieal Clinic on Aug. 25, 1954. Her last normal menstrual period had been on Jan. 14, 1954. The chief romplaints were incr<'a~iug dyspnea for three months and the presence of a ''lump'' in the nt:ek and a '• big lump·· in the breast also present for three to four months, for which she had sought treatment from two local '' doetors'' without success. The patient wa~ immediately admittt>d to thf' Metropolitan Hospital for diagnostic workup and therapy. The positive physical findings included the presence of a 4 em. hard right supraelavicular node, a nodular, indurated 10 em. mass in the left breast, large distended vein~ cowring th•' anterior cht>st, rhonchi and coarse rilles throughout the lung fields, a uterus enlarged to th•• size of a i to i% months' pregnancy, a regular fetal heart rate of lH in an orthopnPi<: 1i.) pound Negro woman. The diagnostic hospital workup included biopsies of the right supraclavicular nod<' au•l left breast mass, both of which showed small-cell carcinoma of the breast; chest x-rays whil'h showed mediastinal widening, atelectasis of the base of the left lung, extensive irregular densities in both lung fields and pulmonary congestion, and a single fetus of apprnximatt.'ly j to nl! months. size.
Surgical and radiological consultants agreed that the extent of the neoplasm was t•"; great to undertake specific therapy for it, so the treatment consisted of bed rpst, ~Pdation. oxygen via tent as needed, usually 2 to 3 hours each day, and prophylactic antibiotie~. Th•• patient's conditioll improved symptomatically on this treatment and during the next four weeks she was comfortable and relatively asymptomatie save for occasional bouts of dy~pm•a and hemoptysis which were treated with oxygen and aminophylline. She was also known to have had asthma for six years. During this time in the hospital, equipment for agonal <~esarean section was always readily available in case of sudden demise. The plan of th0rrtpy included allowing the gestation to proceed to approximately 38 weeks, if possible. to provid•• maximal chance for survival of the fetus, at which time the patient was to be delivrreo] by elective cesarean section followed by a surgical castration to be pprformed at the samo• tinw. with a course of palliative deep x·ray therapy to follow. Howewr, on Sept. 25, 1954, at exactly 36 weeks of gestation, the patient's condition suddenly began to deteriorate and over a period of 4 hours increasingly severe dyspnea and hemoptysis rapidly developed which did not respond to vigorous therapeuti(] methods, including pressure oxygen by mask passing through alcohol after the technique of Luisada, morphinP, aminophylline, 50 per eent glucose intravenously, and dry and wet phlebotomy ( 600 ,...... i. Despite the attempts to control the acute pulmonary <•d.ema, the patient died. After death was pronounced by three physicians, a rapid classical cesarean section was perforn~<•cl and a depressed :.?,160 gram female infant was delivered 3 minutes after the patient's
Comment The ral'e suceess in the past with postmortem cesarean seetion has letl to opinions that the procedure is not justified. The pessimism with whieh it is described by Sullivan and his group 3 and Eastman,• however, does not coincide with our experience. It is our contention that a more enthusiastic attitude toward postmortem cesarean section is indicated today because of the improved
206
KELLY AND WINSTON
Am, ]. Obsr. & Gynec. July, 1956
methods of infant resuscitation and care of premature infants which have contributed to an increased fetal salvage rate. Eastman 5 made note of tho infrequency of survival of the baby when death of thE' mother is due to ohronic wasting diseases, especially when the terminal stage is associated \Vith cyanosis. Greenhill 6 likewise commented on the greater frequency of a successful result when the maternal death is due to acute conditions. It is precisely in the less acute situations, however, that opportunity to perform the operation is more likely to occur and adequate preparation for the procedure including incubator and resuscitation equipment can be made available. The stipulation has been made that the operation should not be done if the husband's permission has not been obtained. Greenhill quoted Bacon as having proved that permission is not necessary, although he stated its desirability. Lattuada7 and Whiteside 8 discussed the medicolegal aspects and convincingly asserted the necessity of performing the procedure even despite the husband's refusal of consent. They also raised the question whether the physician is morally, if not legally, culpable in not performing the operation. The article of Lattuada contains an interesting discussion of this aspect of the problem and is highly recommended. One statement in particular is impressive: ''No individual has the right to deliberately and intentionally take the life of another or to deprive anothe1· of the right to live. The obligation to save human fetal life, when it can be done without destroying or jeopardizing another life, is absolute.''
Summary Postmortem cesarean section has been reviewed. One hundred and eleven successful postmortem cesarean sections have been collected from the world literature since the eighteenth century and a tabulation of the causes of maternal deaths has been detailed. The history of the operation has been briefly presented. The necessity for the more frequent performance of the operation has been outlined and the medicolegal aspects have been discussed. Two additional and illustrative cases of successful postmortem cesarean section are presented from our obstetrical experience at the Metropolitan HospitaL We wish to express our gratitude to Dr. Clair E. Folsome for his suggestions and encouragement.
Bibliography 1. 2. 3. 4. 5. 6. 7. 8.
Graham, H.: Eternal Eve, New York, 1951, Doubleday & Company, Inc. Duer, E.: Am. J. Obst. 12: 1, 1879. Sullivan, C. L., Minkel, H., Campbell, E., and Graham, J.: Postgrad. Med. 14: 329, 1953. Eastman, N. J.: Williams Obstetrics, ed. 10, New York, 1950, Appleton-Century-Crofts, Inc.; editorial comment, Obst. & Gynec. Surv. 4: 665, 1949. Eastman N. J.: Editorial comment, Obst. & Gynee. Surv. 6: 538, 1951. Greenhill, J. P.: Principles and Practice of Obstetrics, ed. 9, Philadelphia, 1947, W. B. Saunders Company. Lattuada, H. P.: Am. J. Surg. 84: 212, 1952. Whiteside, G. W.: Am. J. Obst. 73: 105, 1916.
References for Remainder of Case Reports 1. Bacon, C. .S.: Surg., Gynec. & Obst. 12: 168, 1911. 2. Baden, E. E., and Baden, W. F.: AM. J. 0BS1'. & GYNEC. 66: 202, 1953. 3. Bohmer, J.: Doctor's thesis, Berlin, 1908, R. Treukel.
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9. .1 0.
11. .12. 13. H. 15. I fl. I i. l.'i.
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Campbell, A. M., and Miller, .T. V.: J . .Mi<·higan M. Sor·. 30: ll:l:l, J 9:i l. Chamorro, T.: Semana med. 2: 733, 1942. Chappaz, G., and Dazy, R.: Bull. Assoc. gynec. ei ohst. 2: 41:3, 1\l;iO. Dobbs, E. H.: \Vest Virginia M. J. 44: 80, 194S . Fallon, M. J.: Boston M. & S.•T. 195: 929, 192ti. GhosP, S. K.: Calcutta M. J. 37: 303, 1940 . Hanar, ,J.: Am. J. Obst. Bull. Lying· In Hosp. N. f. 73: 1046, 1916; 10: :ns, l91fl. Harrison, D. A., Shelton, .T. H., and Carrithers, C. l\L: J. A. M. A. 110: 2066, 19.3.~ . Heppner, .M.: .J. A. M. A. 72: 727, 1919. Hoffman, P.: West Virginia M. J. 31: 78, 1935. Holden, R. T.: M. Ann. District of Columbia 1: 63·64, 1932. Johnson, R. 0., and Frank, T.V.: AM. J. 0BST. & GYN!i:C. 53: 3±.1, 194-i. Kerr, Mumo J. M., and Moir, J. 0.: Operative OhstPtrics, Hal timor!•, 19ii0, William~ & Wilkins Company. Kronick, M.: New England J. Med. 243: 933, 1950. Kupfer, K.: Doctor's thesis, Leipzig, 1927, E. M. Loffier. Lacomme, L.: Bull. Soc. gynec. et obst. 28: 393, 1939. Linzenmeier, G.: Med. Klin. 16: 439, 1920. Meneghini, T.: Atti. Soc. ita!. di ostct. e gynec. 35: :120, 19:3\J. Moran, R. .1.: Ne\v England J. Med. 227: 988, 19..J:2. Moran, T. A.: J. Iowa M. Soc. 31: 195, 1941. Morgan, .J.: Lancet 2: 132, 1940. (}ldfield, 0.: -J. Obst. & Gynaec. Brit. Emp. 28: 5i0, 19~1. Pfaff, 0. G.; Trans. Am. A. Obst. & Gynec. 29: +:!, l9lll. Phaneuf~ L. G.: An1. J. Surg. 35: 446, 1937. PrPgnell, G.: .r. Missouri M. A. 39: 177, 194:3. Purdie, A. vV.: Gen. Practitioner 15: 3+7, 1945. Rider, F.: Nebraska M. J. 16: 474, 1931. Roberts, H. G.: Brit. M. J. 1: 829, 1925. Roemer, H.: Zentralbl. Gynlik. 62: 295, 19~lS. RoHin, I.: Lancet 1: 820. 192'l. Rutherford, N. J.: Glasgow M. J. 128: 12, 1937. Sr:hopps, M.: Berl. klin. Wchnschr. 55: 221, 1918. Schwartz, .J.: A~!. J. 0BST. & GYNEC. 62: 539, 1951. Simmons, .T. M., and Ellis, H. B., Jr.: AM .• T. 0BS1'. & GYNI<:C. 57:004, 194-fl. Sproull, 0. T.: Ohio M. J. 13: 169, 1917. Stone, M.. J.: New York M. J. 118: 571, 192:>. Talisman, M. R.: A~r. ,J. 0BS1'. & GYN~<:c. 68: i'1 i, 195-1. 'rietsz,•, K.: Med. \Velt. 9: 1077, 1935. 'I'itus, P.: The Management of Obstptrii' Diffir·ultiP~, ••d. :l, St. Louis, 1945, Th" t ', \' Mosby Company. Torpin, R.: 'l'reatise on Obstet.rii'al Lal>or, .\ugusta, Ga., Hi4R, Ohstrtri<'al aud
G:
Y.
KELLY, M.D.,• GROSSE POINTE, MICH., AND HEBERT (}.WINSTON, ScARSDALE,
M.D ..
N. Y.
(From the Division of Obstetrics and Gynecology of the Metropolitan Hospital and the Nell: York Medical College, New York, N. Y.)
pOSTMORTEM cesarean section is a rare occurrence in medical practice and ... is successful even less frequently. It is the purpose of this paper to give a brief review of its history and incidence, and present two case reports with the purpose of emphasizing the importance of this rare procedure when the occasional opportunity arises. Postmortem cesarean section was probably the first major surgical operation undertaken in the history of mankind. Successful procedures of this type are narrated in the legends of the Romans, probably because the Roman Law of Numa Pompilius decreed that any woman who died during pregnancy should have her child removed from the abdomen prior to her burial. Graham, 1 in his history of gynecology and obstetrics, relates that such famous names as the mythical Bacchus, the philosophers Gorgias and Trismegistes, the soldier Scipio Africanus, and the physician Asklepios, delivered by his father Apollo from the womb of the dead Koronis, were all products of this successful procedure. Published articles and reports of this operation have been collected from as far back as the eighteenth century. In an excellent review, Duer 2 in 1879 reported a total of thirty-six successful postmortem cesarean sections during the eighteenth and nineteenth centuries. We have collected an additional st>venty-five cases from the literature of the twentieth century. TABLE
l.
CArSES OF MATERNAL DEATH IN 111 POSTMORTEM CESAREA;>~ SECTIONS WITH INFANT SURVIVAL
----~---~-----~
CAl:SE OF DEATH
-------------
Eclampsia Tuberculosis Cardiac Hypertensive cardiovascular disease Rheumatic heart disease Accident (traumatic skull fracture, etc.) Pneumonia (plus pneumococcic meningitis, lJ Aneurvsm Dissecting aneurysm Ruptured syphilitic aneurysm Spinal anesthesia Bulbar poliomyelitis Cholera Peritonitis (fulminating, etiology unknown) Gangrene of the neck Unknown Total *Present address. Allmiinna Barnbordshuset, Stockholm ii, S\Yeden.
203
;\'llMBER OF CASES
39
:n
5 4
3 2
1
3 2 2 1 1 ];l
111
204
KELLY AND WINSTON
Am.
J.
Obst. & Gynec. July, !95<>
The total number of reported successful postmortem cesarean seetions in the available world literature is one hundred and eleven cases. These easPs and the respective causes of death arc listed in Table I. To these cases we wish to add two case reports, which describe our experiences with this problem. CASE 1.-A. R., a 30-year-old gravida ii, para 0, Puerto Rican woman, was first admitt;>d to Metropolitan Hospital on April 12, 1952, in acute congestive heart failun• and with evidence of small pulmonary infarction and residual evidence of subacute rh('umati<· a<'tivity. The diagnosis by our eardiologist was rheumatic. heart disease with mitral insuffit'i'm'·y and stenosis, enlarged heart, regular sinus rhythm, and congestive heart failurP, Class Ill. She was placed on digitalis, mereurial diuretics, sodium restriction, bed rest, awl antibioticR, and responded well enough to treatment to be discharged on May 12, 1952. She did fairly well on our Home Care Service until Aug. 28, 1952, when mild failure again supt>rvened and she was readmitted to the hospital servke. It was learned at that time that she was pregnant, her last menstrual period having oecurred on April 14, 1952. Adjustment in the dosage of digitalis resulted in some improvement in the cardiac status. The attending phy,;ieians on the medical service advised interruption, but the patient and her husbautl would not permit interruption of the pregnancy on religious ground~. Rigid management, including digitali~, mercurial diuretics, sodium restriction, absolute bed rest, and close rooperativP management vlith the medical service were maintained. At the time of admittance, the physical examination showed a well-developed, wellnourished Puerto Rican woman who appeared to be in moderate distress. The respirations were 24 per minute and a slightly productive cough was present. 'rhe radial pulse and apex ratt> were 120 per minute at bed rest, there was a one plus pretibial and sacral edt>ma with inoist post-tussive rales at the left base. The blood pressure was 110/80. The heart was enlarged both to the right and to the left, while a harsh systolic aud a presystolic apical murmur were present. The liver was palpated 4 fingerht·eadths below the right costal margin. Tht' uterus was enlarged to approximately 4¥2 months' size. A chest x-ray revealed moderate enlargement of the heart in all diameters with a;!centuation of the pulmonary eonus segment and some pulmonary congestion. The blood serologic test for syphilis was positiw. The blood group was A and the Rh factor was positive. The cardiac regime was augmented by the utilization of intramuscular aminophylline, more frequent mercurial injection, and intermittent ammonium chloride therapy. A course of antisyphilis therapy was institutPd with the use of penieillin G. The patient improved but intermittently developed signs and symptoms of incipient cardiac decompensation. An increase in digitalis dosage wa~ ahandoriPd due to manifestations of toJ~;icity. The patient's progress was relatively satisfactory until she was about 30 weeks pregnant when again incipient failure occurred. In an effort to ensure a more rigid sodium restriction, a rice diet was instituted. This resulted in some improvement in her body status. Her weight gain had been held to approximately 8 pounds. On Dec. 20, 1952, a 2 pound weight gain in 24 hours was noted. Mercuhydrin, 2 c.c., was immediately given intravenously. Three hours later respiratory distress became more marked and frank pulmonary edem!l. appeared. She was approximately 32 to 33 weeks pregnant at this time. Vigorous therapeutic measures were instituted in collaboration with the medical servic<>, including pressure oxygen by mask, morphine, aminophylline, 50 per cent glucose intravenously, dry phlebotomy, and wet phlebotomy ( 500 c.c.). Pressure oxygen through alcohol, by the technique of Luisada, was instituted and while some improvement occurred it was not market! and was only transient. Imminence of fatal outcome was obvious and preparations for agonal cesarean section were made. \Vithin 45 seconds after death had been pronounced by three physicians, a 1,500 grar:1 depressed female infant waR delivered hy classical cesarean section. Resuscitation was successful and the baby wa~ transferred to the prepared incubator. The baby progressed well and now at 3 years of age is a normal healthy little girl. A postmortem examination of thE' mother was performed and revealed rht'umatic heart disease, mitral stenosis with a very tight orifiee, pulmonary edema, old pulmonar,v infar<>tion, and chronic passive congestion of the liver, spleen, and kidne,vs.
Volume n Number l
SUCCESSFUL POSTMORTEM CESAREAN
SECTION
205
CASE ~.-B. 0., a 37-year-old Negro woman, gravida v, para ii, who had had ~ abortion~. was first seen in the Metropolitan Hospital Obstetrieal Clinic on Aug. 25, 1954. Her last normal menstrual period had been on Jan. 14, 1954. The chief romplaints were incr<'a~iug dyspnea for three months and the presence of a ''lump'' in the nt:ek and a '• big lump·· in the breast also present for three to four months, for which she had sought treatment from two local '' doetors'' without success. The patient wa~ immediately admittt>d to thf' Metropolitan Hospital for diagnostic workup and therapy. The positive physical findings included the presence of a 4 em. hard right supraelavicular node, a nodular, indurated 10 em. mass in the left breast, large distended vein~ cowring th•' anterior cht>st, rhonchi and coarse rilles throughout the lung fields, a uterus enlarged to th•• size of a i to i% months' pregnancy, a regular fetal heart rate of lH in an orthopnPi<: 1i.) pound Negro woman. The diagnostic hospital workup included biopsies of the right supraclavicular nod<' au•l left breast mass, both of which showed small-cell carcinoma of the breast; chest x-rays whil'h showed mediastinal widening, atelectasis of the base of the left lung, extensive irregular densities in both lung fields and pulmonary congestion, and a single fetus of apprnximatt.'ly j to nl! months. size.
Surgical and radiological consultants agreed that the extent of the neoplasm was t•"; great to undertake specific therapy for it, so the treatment consisted of bed rpst, ~Pdation. oxygen via tent as needed, usually 2 to 3 hours each day, and prophylactic antibiotie~. Th•• patient's conditioll improved symptomatically on this treatment and during the next four weeks she was comfortable and relatively asymptomatie save for occasional bouts of dy~pm•a and hemoptysis which were treated with oxygen and aminophylline. She was also known to have had asthma for six years. During this time in the hospital, equipment for agonal <~esarean section was always readily available in case of sudden demise. The plan of th0rrtpy included allowing the gestation to proceed to approximately 38 weeks, if possible. to provid•• maximal chance for survival of the fetus, at which time the patient was to be delivrreo] by elective cesarean section followed by a surgical castration to be pprformed at the samo• tinw. with a course of palliative deep x·ray therapy to follow. Howewr, on Sept. 25, 1954, at exactly 36 weeks of gestation, the patient's condition suddenly began to deteriorate and over a period of 4 hours increasingly severe dyspnea and hemoptysis rapidly developed which did not respond to vigorous therapeuti(] methods, including pressure oxygen by mask passing through alcohol after the technique of Luisada, morphinP, aminophylline, 50 per eent glucose intravenously, and dry and wet phlebotomy ( 600 ,...... i. Despite the attempts to control the acute pulmonary <•d.ema, the patient died. After death was pronounced by three physicians, a rapid classical cesarean section was perforn~<•cl and a depressed :.?,160 gram female infant was delivered 3 minutes after the patient's
Comment The ral'e suceess in the past with postmortem cesarean seetion has letl to opinions that the procedure is not justified. The pessimism with whieh it is described by Sullivan and his group 3 and Eastman,• however, does not coincide with our experience. It is our contention that a more enthusiastic attitude toward postmortem cesarean section is indicated today because of the improved
206
KELLY AND WINSTON
Am, ]. Obsr. & Gynec. July, 1956
methods of infant resuscitation and care of premature infants which have contributed to an increased fetal salvage rate. Eastman 5 made note of tho infrequency of survival of the baby when death of thE' mother is due to ohronic wasting diseases, especially when the terminal stage is associated \Vith cyanosis. Greenhill 6 likewise commented on the greater frequency of a successful result when the maternal death is due to acute conditions. It is precisely in the less acute situations, however, that opportunity to perform the operation is more likely to occur and adequate preparation for the procedure including incubator and resuscitation equipment can be made available. The stipulation has been made that the operation should not be done if the husband's permission has not been obtained. Greenhill quoted Bacon as having proved that permission is not necessary, although he stated its desirability. Lattuada7 and Whiteside 8 discussed the medicolegal aspects and convincingly asserted the necessity of performing the procedure even despite the husband's refusal of consent. They also raised the question whether the physician is morally, if not legally, culpable in not performing the operation. The article of Lattuada contains an interesting discussion of this aspect of the problem and is highly recommended. One statement in particular is impressive: ''No individual has the right to deliberately and intentionally take the life of another or to deprive anothe1· of the right to live. The obligation to save human fetal life, when it can be done without destroying or jeopardizing another life, is absolute.''
Summary Postmortem cesarean section has been reviewed. One hundred and eleven successful postmortem cesarean sections have been collected from the world literature since the eighteenth century and a tabulation of the causes of maternal deaths has been detailed. The history of the operation has been briefly presented. The necessity for the more frequent performance of the operation has been outlined and the medicolegal aspects have been discussed. Two additional and illustrative cases of successful postmortem cesarean section are presented from our obstetrical experience at the Metropolitan HospitaL We wish to express our gratitude to Dr. Clair E. Folsome for his suggestions and encouragement.
Bibliography 1. 2. 3. 4. 5. 6. 7. 8.
Graham, H.: Eternal Eve, New York, 1951, Doubleday & Company, Inc. Duer, E.: Am. J. Obst. 12: 1, 1879. Sullivan, C. L., Minkel, H., Campbell, E., and Graham, J.: Postgrad. Med. 14: 329, 1953. Eastman, N. J.: Williams Obstetrics, ed. 10, New York, 1950, Appleton-Century-Crofts, Inc.; editorial comment, Obst. & Gynec. Surv. 4: 665, 1949. Eastman N. J.: Editorial comment, Obst. & Gynee. Surv. 6: 538, 1951. Greenhill, J. P.: Principles and Practice of Obstetrics, ed. 9, Philadelphia, 1947, W. B. Saunders Company. Lattuada, H. P.: Am. J. Surg. 84: 212, 1952. Whiteside, G. W.: Am. J. Obst. 73: 105, 1916.
References for Remainder of Case Reports 1. Bacon, C. .S.: Surg., Gynec. & Obst. 12: 168, 1911. 2. Baden, E. E., and Baden, W. F.: AM. J. 0BS1'. & GYNEC. 66: 202, 1953. 3. Bohmer, J.: Doctor's thesis, Berlin, 1908, R. Treukel.
\ 'uluuw
72
:WI
J\umhe: l
4. 3. fl. i. .>;.
9. .1 0.
11. .12. 13. H. 15. I fl. I i. l.'i.
19. ~U. ~L ~2. :!;),
:!-t :25.
:.l6. :J7. :38. :!~.
:w.
:n.
:5:!. :l:l.
:54. :li).
;ltJ. :11.
:ix.
:w. 411.
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