00:00:00 – 00:00:06
[The Science and Art of Obstetrics]
00:00:06 – 00:00:17
[Laparotrachelotomy: Low, cervical cesarean section, by Joseph B. DeLee, M.D. and M. Edward Davis, M.D.]
00:00:17 – 00:00:25
[Taken at the Chicago Lying-In Hospital, Fox Movietone Scientific]
00:00:25 – 00:00:38
[…]
00:00:38 – 00:00:57
[Dr. DeLee appears, no audio present]
00:00:57 – 00:00:59
[Dr. DeLee:] …in eighteen hundred and five.
00:00:59 – 00:01:02
And he did the operation,
00:01:02 – 00:01:04
he did the operation twice.
00:01:04 – 00:01:06
Both of the patients died,
00:01:06 – 00:01:09
but he realized that it was a step in advance,
00:01:09 – 00:01:14
and recommended it for all cases requiring abdominal delivery.
00:01:14 – 00:01:17
The mortality of the classic cesarean section
00:01:17 – 00:01:21
has improved as time has gone on,
00:01:21 – 00:01:24
and it did not seem that we needed
00:01:24 – 00:01:27
a better method of abdominal delivery.
00:01:27 – 00:01:31
But, our ideas of what was good also improved.
00:01:31 – 00:01:38
In 1870, the mortality of 15 percent in Cesarean section was not bad.
00:01:38 – 00:01:42
In 1900, the mortality of four percent was considered excellent.
00:01:42 – 00:01:48
In 1930, a mortality of one percent is too much.
00:01:48 – 00:01:53
Therefore, when in 1906 Fritz Frank of Bonn
00:01:53 – 00:01:58
introduced the operation of Osiander,
00:01:58 – 00:02:02
the low cervical incision, it was eagerly seized
00:02:02 – 00:02:07
by the German operator, and its use has been spread over Europe
00:02:07 – 00:02:11
and now in the United States, it likewise
00:02:11 – 00:02:15
is receiving recognition.
00:02:15 – 00:02:17
The principle of the new operation
00:02:17 – 00:02:22
is that the incision is made in the lower uterine segment,
00:02:22 – 00:02:23
the neck of the uterus,
00:02:23 – 00:02:26
and not in the fundus.
00:02:26 – 00:02:29
And all the superiority of the new operation
00:02:29 – 00:02:38
grows out of this fact.
00:02:38 – 00:02:42
There are two kinds of low cervical Cesarean:
00:02:42 – 00:02:47
one where the incision being made just above the pubis,
00:02:47 – 00:02:49
approach to the lower uterine segment
00:02:49 – 00:02:54
is gained by cutting through the peritoneal cavity.
00:02:54 – 00:03:00
This is called the intraperitoneal method.
00:03:00 – 00:03:03
The other kind is where the incision is made
00:03:03 – 00:03:06
just above the pubis, and the peritoneum
00:03:06 – 00:03:10
is pushed upward towards the navel…also the bladder.
00:03:10 – 00:03:13
And the bladder is pushed to the side,
00:03:13 – 00:03:16
and an area of lower uterine segment exposed,
00:03:16 – 00:03:19
sufficiently large for the delivery of the baby.
00:03:19 – 00:03:22
This is called extraperitoneal method,
00:03:22 – 00:03:25
the general peritoneal cavity not being opened.
00:03:25 – 00:03:29
The majority of men prefer the direct route,
00:03:29 – 00:03:32
the intraperitoneal method.
00:03:32 – 00:03:37
The indications for the low cervical Cesarean section
00:03:37 – 00:03:41
are exactly the same as for the classic Cesarean section.
00:03:41 – 00:03:44
But owing to the safety of the low operation,
00:03:44 – 00:03:49
we can extend the field in which it may be done.
00:03:49 – 00:03:51
Now it is a fact that in the United States,
00:03:51 – 00:03:55
too many Cesarean sections are being done.
00:03:55 – 00:03:59
And it is also a fact that if the new operation
00:03:59 – 00:04:02
were generally practiced, the total number
00:04:02 – 00:04:05
of Cesareans done in the United States would be reduced.
00:04:05 – 00:04:10
I shall have occasion to refer to this point later on.
00:04:10 – 00:04:15
The contraindications to the operation are very few.
00:04:15 – 00:04:17
In a woman with a pendulous belly,
00:04:17 – 00:04:22
it may be hard to get access to the lower part of the abdomen
00:04:22 – 00:04:24
to make the incision.
00:04:24 – 00:04:26
And if you are going to do a Porro,
00:04:26 – 00:04:29
it is hardly worthwhile to do the low operation.
00:04:29 – 00:04:33
But if at any time you have to do the old classic,
00:04:33 – 00:04:37
make it as low in the uterus as possible so as to get as many
00:04:37 – 00:04:43
of the advantages of the low operation as are to be had.
00:04:43 – 00:04:58
Now a few words about the surgical anatomy.
00:04:58 – 00:05:04
Here is a model of a woman at term, but not in labor.
00:05:04 – 00:05:07
Here is the cervix, and here the lower uterine segment,
00:05:07 – 00:05:11
which is about nine centimeters long.
00:05:11 – 00:05:16
This is variable, but it nearly always is long enough for you
00:05:16 – 00:05:19
to extract the baby through it.
00:05:19 – 00:05:23
Here is the loop peritoneum over the lower uterine segment,
00:05:23 – 00:05:26
and here is the fascia, this white line,
00:05:26 – 00:05:29
the fascia that extended from the vagina
00:05:29 – 00:05:35
upward, and loses itself towards the fundus of the uterus.
00:05:35 – 00:05:39
It is about this point that the grey seam is located.
00:05:39 – 00:05:42
You will hear a great deal about the grey seam
00:05:42 – 00:05:50
during the operation.
00:05:50 – 00:05:55
Here is a model of a woman who has been in the second stage
00:05:55 – 00:05:57
for a long time.
00:05:57 – 00:06:00
And you can see how long and thin the lower uterine
00:06:00 – 00:06:03
segment and cervix are.
00:06:03 – 00:06:05
They are fully 15 centimeters long,
00:06:05 – 00:06:10
and the lower uterine segment almost invites you to cut into it.
00:06:10 – 00:06:13
When you do your first low cervical,
00:06:13 – 00:06:15
select the place where the labor has
00:06:15 – 00:06:18
been on for a considerable length of time.
00:06:18 – 00:06:21
And that makes it much easier.
00:06:21 – 00:06:23
You see how thin it is.
00:06:23 – 00:06:25
Here is the peritoneum again,
00:06:25 – 00:06:29
and here is the contraction rate.
00:06:29 – 00:06:36
Now gentlemen, a few words about local anesthesia.
00:06:36 – 00:06:41
It is particularly well-adapted to the low cervical cesarean section
00:06:41 – 00:06:44
And I prefer it to the spinal anesthesia,
00:06:44 – 00:06:47
indeed to general anesthetics, too.
00:06:47 – 00:06:50
No one can deny that spinal anesthesia
00:06:50 – 00:06:54
is more dangerous than a local infiltration.
00:06:54 – 00:06:57
And since we can, in 90 percent of the cases,
00:06:57 – 00:07:00
succeed with local infiltration anesthesia,
00:07:00 – 00:07:02
this should be the method of choice.
00:07:02 – 00:07:04
And I have here in my hand the instruments
00:07:04 – 00:07:07
that we use at the Chicago Lying-In Hospital.
00:07:07 – 00:07:11
They facilitate the operation, but ordinary syringes
00:07:11 – 00:07:14
will do the work just as well.
00:07:14 – 00:07:19
We use a novacaine-cocaine solution, one half of one percent,
00:07:19 – 00:07:22
And we add two minims of adrenaline
00:07:22 – 00:07:25
to every ounce of the solution.
00:07:25 – 00:07:29
We use seven or eight ounces, sometimes nine or ten,
00:07:29 – 00:07:31
and we have never had any cases of poisoning,
00:07:31 – 00:07:33
or any trouble whatever.
00:07:33 – 00:07:37
After the baby is born, a quarter of a grain of morphine
00:07:37 – 00:07:41
and 1/150th of scopolamine are given.
00:07:41 – 00:07:45
Solomon said that you should have an understanding heart.
00:07:45 – 00:07:48
And this will help you a great deal in your
00:07:48 – 00:07:50
operating under local anesthesia.
00:07:50 – 00:07:54
No tugging, no pulling, no jarring of the patient.
00:07:54 – 00:07:57
Gentleness all the time, and you will succeed.
00:07:57 – 00:07:59
Now gentlemen, let us proceed to the amphitheater
00:07:59 – 00:08:02
where we will do the operation.
00:08:02 – 00:08:05
Now Mrs. Herman, we are ready to start.
00:08:05 – 00:08:06
Don’t be afraid.
00:08:06 – 00:08:09
It will hurt just a little when the baby comes.
00:08:09 – 00:08:11
I’ll prepare you.
00:08:11 – 00:08:14
If any of my work should give you pain, say ouch.
00:08:14 – 00:08:20
But don’t move.
00:08:20 – 00:08:29
Pubis.
00:08:29 – 00:08:37
Navel.
00:08:37 – 00:08:42
We use a very fine needle to make a wheel in the skin.
00:08:42 – 00:08:57
Then the big needle doesn’t hurt when it goes in.
00:08:57 – 00:09:05
Inject the novocaine into the skin itself, and, of course,
00:09:05 – 00:09:24
into the fascia right under the skin.
00:09:24 – 00:09:29
Inject as you move the needle in and out.
00:09:29 – 00:09:30
Do you feel that?
00:09:30 – 00:09:32
[Patient:] No.
00:09:32 – 00:09:33
[Dr. DeLee:] Do you feel that?
00:09:33 – 00:09:35
[Patient:] No, Doctor.
00:09:35 – 00:09:36
[Dr. DeLee:] That’s good.
00:09:36 – 00:09:39
You’re going to see the grey seam,
00:09:39 – 00:09:45
where the loose peritoneum of the uterus becomes firmly adherent.
00:09:45 – 00:09:48
See how loose it is here?
00:09:48 – 00:09:55
…but I prefer the scissors.
00:09:55 – 00:10:06
[…]
00:10:06 – 00:10:10
On this drawing, you see where the clamps go,
00:10:10 – 00:10:14
and how the scissors cut the lower uterus in the front.
00:10:14 – 00:10:20
On this pelvis, you see how the forceps are to be applied,
00:10:20 – 00:10:22
and the head delivered.
00:10:22 – 00:10:26
See the hammer effect of the forceps.
00:10:26 – 00:10:36
Slowly, no hurry.
00:10:36 – 00:10:39
Now Mrs. Herman, the baby is about to come.
00:10:39 – 00:10:41
Be brave.
00:10:41 – 00:10:42
Don’t squirm.
00:10:42 – 00:10:44
Breathe quietly.
00:10:44 – 00:10:49
And in a very few moments, you will hear the baby cry.
00:10:49 – 00:10:55
[…]
00:10:55 – 00:10:58
I am putting my finger in the baby’s mouth
00:10:58 – 00:10:59
to bring it to the front.
00:10:59 – 00:11:00
Be careful,
00:11:00 – 00:11:10
you can injure the little mouth.
00:11:10 – 00:11:13
Wipe out the baby’s mouth because if it gasps,
00:11:13 – 00:11:20
it might suck in the liquor amnii.
00:11:20 – 00:11:28
[Baby crying]
00:11:28 – 00:11:32
Lift the forceps blade under the lip of the womb.
00:11:32 – 00:11:42
Be very careful of that.
00:11:42 – 00:11:47
Take lots of time, very slowly and gently.
00:11:47 – 00:11:52
All the instruments have been removed from the womb.
00:11:52 – 00:11:53
Slow…
00:11:53 – 00:11:56
Take lots of time.
00:11:56 – 00:11:57
No hurry.
00:11:57 – 00:12:39
[Baby crying]
00:12:39 – 00:12:41
Be ready to [INAUDIBLE].
00:12:41 – 00:12:49
Carmen, will you have a lap sponge [INAUDIBLE]
00:12:49 – 00:12:54
[Baby crying]
00:12:54 – 00:12:57
Now Mrs. Herman, you go to sleep.
00:12:57 – 00:13:00
You have a fine, healthy baby.
00:13:00 – 00:13:04
And also, you had a hypodermic.
00:13:04 – 00:13:09
Gentlemen, we will now proceed to the repair of the womb.
00:13:09 – 00:13:13
In this animated drawing, which Mr. Carlson made,
00:13:13 – 00:13:22
you will see the course of the suture.
00:13:22 – 00:13:38
Avoid the mucosa.
00:13:38 – 00:13:43
Swing the needle around.
00:13:43 – 00:13:46
Now in the upper part of the uterus,
00:13:46 – 00:13:50
the muscle is much thicker and is likely to retract up
00:13:50 – 00:13:55
into the body of the uterus.
00:13:55 – 00:13:58
[Observer;} What kind of suture material do you use, Dr. DeLee?
00:13:58 – 00:14:02
[Dr. DeLee:] We use number two catgut for the first row.
00:14:02 – 00:14:05
The second row, we use number one.
00:14:05 – 00:14:17
And for the peritoneum, number one.
00:14:17 – 00:14:20
Very important to get a good apposition here,
00:14:20 – 00:14:24
in order to have a firm scar in the lower portion
00:14:24 – 00:14:36
of the fundus and the cervix.
00:14:36 – 00:14:45
Don’t catch the gauze in the needle.
00:14:45 – 00:14:48
Pull it out a little there.
00:14:48 – 00:14:51
The complications of the third stage…
00:14:51 – 00:14:54
very seldom is there post-partum hemorrhage
00:14:54 – 00:14:56
in laparotrachelotomy,
00:14:56 – 00:14:59
especially if you use local anesthesia.
00:14:59 – 00:15:01
And we give ergot 15 minutes
00:15:01 – 00:15:04
before the baby is born, and a [INAUDIBLE]
00:15:04 – 00:15:06
pituitary right afterwards.
00:15:06 – 00:15:09
If there should be hemorrhage, we pack the uterus.
00:15:09 – 00:15:11
But I do that as a routine.
00:15:11 – 00:15:13
And if you wanted to give pituitary
00:15:13 – 00:15:20
as it’s been necessary, inject it under the peritoneum as…
00:15:20 – 00:15:22
I put it under the peritoneum.
00:15:22 – 00:15:25
because if the solution is infected and makes an abscess,
00:15:25 – 00:15:32
the abscess is not open into the peritoneal cavity.
00:15:32 – 00:15:36
Some accoucheurs believe that placenta previa is not
00:15:36 – 00:15:40
a good indication for laparotrachelotomy.
00:15:40 – 00:15:45
But our experience in 40 cases without mortality
00:15:45 – 00:15:47
proves the contrary.
00:15:47 – 00:15:52
There are three or possibly four things that must be remembered.
00:15:52 – 00:15:56
In the first place, in anemic cases
00:15:56 – 00:16:00
precede the operation by a transfusion of blood.
00:16:00 – 00:16:04
And second, save blood throughout the whole course
00:16:04 – 00:16:05
of the operation.
00:16:05 – 00:16:07
Don’t waste any.
00:16:07 – 00:16:11
Third, deliver the baby by version and extraction,
00:16:11 – 00:16:16
and proceed slowly so as not to do any tearing.
00:16:16 – 00:16:19
Fourth, clamp all the bleeding vessels,
00:16:19 – 00:16:23
and hold them securely clamped until they are sutured.
00:16:23 – 00:16:28
Now gentlemen, do not fear the difficulties
00:16:28 – 00:16:29
that you might encounter.
00:16:29 – 00:16:32
The field is open before you,
00:16:32 – 00:16:35
and you can meet the emergencies as they arise.
00:16:35 – 00:16:40
The hemorrhage, you can control by the ordinary tools and surgical method.
00:16:40 – 00:16:45
And mechanical difficulties are overcome by taking time,
00:16:45 – 00:16:49
and by art instead of strength.
00:16:49 – 00:16:53
Let me again recommend the low cervical cesarean
00:16:53 – 00:16:59
or laparotrachelotomy, as well as the local anesthesia.
00:16:59 – 00:17:03
Any of the difficulties, an ordinarily skilled surgeon
00:17:03 – 00:17:04
can overcome.
00:17:04 – 00:17:07
And if you will perform this operation as a routine,
00:17:07 – 00:17:11
I am sure that you will cut your mortality in half.
00:17:11 – 00:17:16
What are the particular features of the low cesarean
00:17:16 – 00:17:18
that make it so superior?
00:17:18 – 00:17:24
As I said before the operation, these points of superiority
00:17:24 – 00:17:27
grow out of the fact that the incision is
00:17:27 – 00:17:29
in the lower uterine segment.
00:17:29 – 00:17:40
And I will now give you 10 of these points of superiority.
00:17:40 – 00:17:45
The first point is that the incision is in the lower
00:17:45 – 00:17:47
part of the abdomen.
00:17:47 – 00:17:50
All the surgeons know that the lower abdomen
00:17:50 – 00:17:55
is more resistant to infection than the upper abdomen.
00:17:55 – 00:18:01
The intestines and the omentum will rarely come into view,
00:18:01 – 00:18:02
and are not touched.
00:18:03 – 00:18:07
Therefore, shock is small,
00:18:07 – 00:18:12
and there is less tendency to vomiting after the delivery,
00:18:12 – 00:18:15
and to ileus.
00:18:15 – 00:18:20
The spill is located right around the womb
00:18:21 – 00:18:23
and has very little distribution,
00:18:23 – 00:18:29
which also helps prevent shock, ileus, and nausea
00:18:29 – 00:18:31
and vomiting.
00:18:31 – 00:18:33
The cervix, in which the incision is made,
00:18:33 – 00:18:39
is more resistant to infection, being used to it.
00:18:39 – 00:18:44
Every gynecologist knows how much the cervix can stand.
00:18:44 – 00:18:54
I will now show you this on another chart.
00:18:54 – 00:18:57
This chart shows the delivery…
00:18:57 – 00:19:00
shows the uterus a few hours after delivery.
00:19:00 – 00:19:05
As you see, the cervix shrinks and drops into the pelvis,
00:19:05 – 00:19:08
out of the general peritoneal cavity.
00:19:08 – 00:19:10
This was point five.
00:19:10 – 00:19:19
Point six. In this chart you see the uterus a few hours after delivery.
00:19:19 – 00:19:23
And as you will notice, the wound in the cervix
00:19:23 – 00:19:27
has dropped down into the cavity of the pelvis, far away
00:19:27 – 00:19:32
from the general peritoneal cavity.
00:19:32 – 00:19:36
That was point five in the list of superiority.
00:19:36 – 00:19:41
One of the greatest advantages of the low incision
00:19:41 – 00:19:46
lies in the security of the scar in subsequent pregnancies
00:19:46 – 00:19:47
and labors.
00:19:47 – 00:19:52
Only a few cases of rupture of the scar during pregnancy
00:19:52 – 00:19:54
have been put on record.
00:19:55 – 00:19:59
And the number of ruptures of this scar during actual labor
00:19:59 – 00:20:02
is only a small fraction of those
00:20:02 – 00:20:07
that occur after the classic cesarean section.
00:20:07 – 00:20:11
The reason for this security from rupture
00:20:11 – 00:20:15
is easily seen by a reference to these charts.
00:20:15 – 00:20:21
In this operation, the wound is in the lower uterine segment,
00:20:21 – 00:20:24
which is at rest and can heal in peace.
00:20:24 – 00:20:30
It is not disturbed by the turmoil going on in the fundus above.
00:20:30 – 00:20:36
Compare that wound with this, after the classic cesarean section.
00:20:36 – 00:20:40
Here, the wound is in the fundus,
00:20:40 – 00:20:43
which is in a constant state of unrest.
00:20:43 – 00:20:47
The uterine contractions, the afterpain,
00:20:47 – 00:20:49
keep up a constant motion,
00:20:49 – 00:20:53
and sooner or later, one of these stitches or more
00:20:53 – 00:20:59
[INAUDIBLE] will tear, and let the cut, the lochia
00:20:59 – 00:21:05
and bacteria into the wound and into the peritoneal cavity.
00:21:05 – 00:21:08
Point of superiority, number seven.
00:21:08 – 00:21:10
In the old classic cesarean,
00:21:10 – 00:21:14
the lochia has a chance to seep through the uterus
00:21:14 – 00:21:20
into the general peritoneal cavity, causing peritonitis.
00:21:20 – 00:21:23
In the new operation, the low cervical,
00:21:23 – 00:21:27
the lochia is prevented from seeping through,
00:21:27 – 00:21:31
and is confined to the neighborhood of the cervix
00:21:31 – 00:21:35
and under the bladder.
00:21:35 – 00:21:39
Should infection occur, which is not common,
00:21:39 – 00:21:44
see how easy it is to drain the area that is infected.
00:21:44 – 00:21:48
Either you can pull the cervix down with a vulsellum
00:21:48 – 00:21:50
and make an anterior colpotomy,
00:21:50 – 00:21:54
thus reaching the abscess under the bladder,
00:21:54 – 00:21:58
or you can burrow a finger through the stitches,
00:21:58 – 00:22:00
into the abscess.
00:22:00 – 00:22:05
Or, what is most common, nature helps you
00:22:05 – 00:22:12
in that the pus burrows under the bladder, around the bladder,
00:22:12 – 00:22:15
through the cavity urethras.
00:22:15 – 00:22:18
And by taking out one, two or three of these stitches,
00:22:18 – 00:22:20
you can let the pus out,
00:22:20 – 00:22:28
and usually, healing is very rapid and complete.
00:22:28 – 00:22:30
For comparison, see where the infection
00:22:30 – 00:22:36
would travel after a classic cesarean section,
00:22:36 – 00:22:44
beginning here in the endometrium,
00:22:44 – 00:22:53
all through the peritoneal cavity.
00:22:53 – 00:22:58
Adhesions are common after the classic cesarean section,
00:22:58 – 00:23:02
and the reason is very plain.
00:23:02 – 00:23:06
Then the infection and pus is in the intestines and the omentum.
00:23:06 – 00:23:11
On the other hand, after the low operation,
00:23:11 – 00:23:13
adhesions are very rare,
00:23:13 – 00:23:15
and you can see why.
00:23:15 – 00:23:19
The wound is dropped down into the pelvis, far away
00:23:19 – 00:23:21
from the general peritoneal cavity,
00:23:21 – 00:23:25
and the omentum almost never comes down so low,
00:23:25 – 00:23:27
the intestines hardly ever.
00:23:27 – 00:23:33
And when the bladder fills, the peritoneal line of suture,
00:23:33 – 00:23:36
that little line of suture I showed you at the operation,
00:23:36 – 00:23:39
drops down into a deep cul-de-sac
00:23:39 – 00:23:42
and is further protected.
00:23:42 – 00:23:45
Finally here, but there are many other reasons.
00:23:45 – 00:23:49
The classical cesarean section is only safe
00:23:49 – 00:23:51
when it is an operation of election.
00:23:51 – 00:23:53
We can give a woman a good test of labor,
00:23:53 – 00:23:57
and then perform a low cervical cesarean section.
00:23:57 – 00:24:00
And therefore, by giving a woman a test of labor,
00:24:00 – 00:24:03
a great many cesareans will be unnecessary,
00:24:03 – 00:24:06
and thus, the total percentage in the United States
00:24:06 – 00:24:07
will be reduced.
00:24:07 – 00:24:12
Now gentlemen, in conclusion, I have here the mortality statistics
00:24:12 – 00:24:16
of the United States Census Bureau in Washington.
00:24:16 – 00:24:19
And from these tables we can learn
00:24:19 – 00:24:25
that over 500 women die from cesarean section every year.
00:24:25 – 00:24:28
This is an enormous number, and brings upon us
00:24:28 – 00:24:31
the opprobrium of the community,
00:24:31 – 00:24:34
when our statistics of maternal mortality
00:24:34 – 00:24:37
are compared with those of other nations.
00:24:37 – 00:24:42
If laparotrachelotomy was generally practiced in the United States,
00:24:42 – 00:24:47
I am sure that most of this mortality would be reduced.
00:24:47 – 00:24:49
And this is the reason that I have spent
00:24:49 – 00:24:53
a great deal of time, a great deal of effort,
00:24:53 – 00:24:55
and not a little money in spreading
00:24:55 – 00:24:58
the gospel of the low cervical cesarean section,
00:24:58 – 00:25:02
or laparotrachelotomy.
00:25:02 – 00:25:23
[bells ringing]
00:25:23 – 00:25:27
Ladies and gentlemen, it is now six years
00:25:27 – 00:25:30
since the picture which you just saw was published.
00:25:30 – 00:25:34
And I am going to tell you what has happened to the operation,
00:25:34 – 00:25:37
laparotrachelotomy, during this time.
00:25:37 – 00:25:41
But first, I want to show you those babies.
00:25:41 – 00:25:49
Boys, will you come in?
00:25:49 – 00:25:52
I believe that Cesones do better
00:25:52 – 00:25:57
mentally and physically than children delivered from below.
00:25:57 – 00:26:07
Attention, salute, left face, march.
00:26:07 – 00:26:09
What has happened to the operation
00:26:09 – 00:26:11
during these six years?
00:26:11 – 00:26:14
Several modifications have been suggested,
00:26:14 – 00:26:16
and we have tried them.
00:26:16 – 00:26:18
But we have found that the method
00:26:18 – 00:26:20
which you saw on the screen,
00:26:20 – 00:26:25
and which was perfected after 14 years of trial, is still the best.
00:26:25 – 00:26:39
For example, the transverse surgical incision, like this.
00:26:39 – 00:26:41
A transverse, curvilinear incision
00:26:42 – 00:26:48
is made above the bladder.
00:26:48 – 00:26:52
We tried the operation 10 times, and gave it up.
00:26:52 – 00:26:57
One severe hemorrhage from the base of the broad ligament,
00:26:57 – 00:27:00
one dangerous extension of the womb,
00:27:00 – 00:27:03
a big baby, twice difficulty
00:27:03 – 00:27:06
in suturing the upper to the lower flap.
00:27:06 – 00:27:09
The upper muscular lamellae
00:27:09 – 00:27:12
had retracted into the funds of the uterus,
00:27:12 – 00:27:19
and one almost fatal pulmonary embolism.
00:27:19 – 00:27:23
The literature records the fact that there are
00:27:23 – 00:27:27
more pulmonary embolisms after the transverse incision
00:27:27 – 00:27:29
than after the longitudinal.
00:27:29 – 00:27:34
We had one embolism in 10 transverse incisions,
00:27:34 – 00:27:40
and we had only one embolism in the 1,800
00:27:40 – 00:27:42
other laprotrachelotomies.
00:27:42 – 00:27:46
The surgeons or gynecologists would be very happy
00:27:46 – 00:27:51
if they could record 1,800 consecutive laparotomies
00:27:51 – 00:27:54
with only one pulmonary embolism.
00:27:54 – 00:28:03
This is the median incision.
00:28:03 – 00:28:08
If the baby is large, you can extend it up or down
00:28:08 – 00:28:09
towards the cervix.
00:28:09 – 00:28:13
If a tear occurs, it does not go into the basis
00:28:13 – 00:28:18
of the broad ligament where the big vessels and the urethra are.
00:28:18 – 00:28:20
If the wound should get infected,
00:28:20 – 00:28:27
the dangerous areas, the big veins, are far away.
00:28:27 – 00:28:30
[Observer:] Doctor, do you still use packing?
00:28:30 – 00:28:31
[Dr. DeLee:] Oh, yes.
00:28:31 – 00:28:34
We pack the uterus routinely.
00:28:34 – 00:28:39
But we are now using acriflavine, iodine,
00:28:39 – 00:28:41
and glycerine on the gauze.
00:28:41 – 00:28:46
I wonder if there really is an antiseptic that does good.
00:28:46 – 00:28:49
But we have a better ergot preparation.
00:28:49 – 00:28:54
It is called ergonovine.
00:28:54 – 00:28:57
Regarding post-operative adhesions,
00:28:57 – 00:29:01
we have done second and third laprotrachelotomies
00:29:01 – 00:29:04
on 345 patients.
00:29:04 – 00:29:08
And we found adhesions to be the exception.
00:29:08 – 00:29:11
Whereas, after the classic cesarean section,
00:29:11 – 00:29:13
adhesions are the rule.
00:29:13 – 00:29:19
And they not seldom cause serious late complications.
00:29:19 – 00:29:22
Fertility, likewise, is not compromised
00:29:22 – 00:29:27
by the low operation as it is by the classic.
00:29:27 – 00:29:31
Rupture of the uterus in subsequent pregnancy and labor…
00:29:31 – 00:29:35
the cervical scar has proven its superiority.
00:29:35 – 00:29:39
There are only three cases on record of rupture of the scar
00:29:39 – 00:29:40
during pregnancy.
00:29:40 – 00:29:44
And during labor, there are less than 50 cases on record.
00:29:44 – 00:29:48
Whereas the classic cesarean is notoriously
00:29:48 – 00:29:50
dangerous in this respect.
00:29:50 – 00:29:54
There are thousands of ruptures to its discredit.
00:29:54 – 00:29:58
[Observer:] Doctor, how about placenta previa?
00:29:58 – 00:30:02
[Dr. DeLee:] We have done 120 laprotrachelotomies
00:30:02 – 00:30:05
in placenta previa without a single death.
00:30:05 – 00:30:10
Some doctors claim that the classic cesarean section
00:30:10 – 00:30:14
is better in this complication.
00:30:14 – 00:30:17
But we believe just the opposite.
00:30:17 – 00:30:20
We want to make the opening in the uterus
00:30:20 – 00:30:23
over the bed of the placenta, where we can attack
00:30:23 – 00:30:26
a hemorrhage should one occur.
00:30:26 – 00:30:32
You make the incision a little bit higher on the uterus than usual.
00:30:32 – 00:30:35
The bleeding is only marked if the placenta happens
00:30:35 – 00:30:38
to be on the anterior wall.
00:30:38 – 00:30:42
You burrow through the placenta, grab the foot,
00:30:42 – 00:30:45
and slowly bring the breech into the opening,
00:30:45 – 00:30:50
just the same as you do when delivering from below.
00:30:50 – 00:30:54
If, after the placenta is delivered
00:30:54 – 00:30:58
the bed of the placenta bleeds, you simply sew it up like this.
00:30:59 – 00:31:02
You see it is very easy to stop the bleeding.
00:31:02 – 00:31:14
You lip over the bed of the placenta with number 0 catgut.
00:31:14 – 00:31:17
Regarding infected cases, we have not
00:31:17 – 00:31:20
broadened the indication for laparotrachelotomy
00:31:20 – 00:31:24
to cover the frankly infected case.
00:31:24 – 00:31:28
But we have risked it, even when the bag of waters
00:31:28 – 00:31:30
has been ruptured a long time,
00:31:30 – 00:31:33
when several vaginal examinations have been made,
00:31:34 – 00:31:37
when labor has been prolonged, and when forceps
00:31:37 – 00:31:43
has been attempted, providing there was a reasonable amount of cleanliness.
00:31:43 – 00:31:48
The Porro operation is still the best for the frankly infected patients.
00:31:48 – 00:31:52
But, although it is sad to have to say it,
00:31:52 – 00:31:58
craniotomy may still be considered in rare instances.
00:31:58 – 00:32:00
Local anesthesia.
00:32:00 – 00:32:03
Local anesthesia has helped materially
00:32:03 – 00:32:06
to reduce our maternal mortality.
00:32:06 – 00:32:10
It is better than spinal in every way.
00:32:10 – 00:32:13
And even the neurologists are telling us
00:32:13 – 00:32:17
of late diseases resulting from this invasion
00:32:17 – 00:32:19
of the spinal canal.
00:32:19 – 00:32:25
Laparotrachelotomy is the ideal cesarean.
458
00:32:25 – 00:32:29
And experience the world over has justified
00:32:29 – 00:32:32
all the claims we have made for it.
00:32:32 – 00:32:34
You remember I told you that it would
00:32:34 – 00:32:37
cut your mortality in half?
00:32:37 – 00:32:44
Well, look at this chart.
00:32:44 – 00:32:49
City of Chicago, 1934, 490 classics.
00:32:50 – 00:32:53
Deaths, five and a half percent.
00:32:53 – 00:32:59
Laparotrachelotomies, 541, two percent.
00:32:59 – 00:33:04
Germany, classics 438.
00:33:04 – 00:33:07
Deaths, six and four-tenths percent.
00:33:07 – 00:33:10
Laparotrachelotomies, 3,554.
00:33:10 – 00:33:14
Deaths, three and seven-tenths percent.
00:33:14 – 00:33:18
Chicago Lying-In Hospital, 1914 to 1936.
00:33:18 – 00:33:21
Out of 60,000 deliveries-
00:33:21 – 00:33:28
60,000 deliveries-classics 168, deaths six percent.
00:33:28 – 00:33:35
Laparotrachelotomies, eighteen hundred and eleven…one-thousand eight hundred eleven.
00:33:35 – 00:33:38
Deaths, 18 from all causes.
00:33:38 – 00:33:47
Tuberculosis, eclampsia, heart disease, et cetera, one percent.
00:33:47 – 00:33:54
Now ladies and gentlemen, a final word.
00:33:54 – 00:33:58
I believe in view of all these facts,
00:33:58 – 00:34:02
that I may in all fairness ask you this question.
00:34:02 – 00:34:06
Does a man, in performing the old classic cesarean section,
00:34:06 – 00:34:11
when the low cervical operation could be done,
00:34:11 – 00:34:14
does he give his patient all the benefits
00:34:14 – 00:34:21
of modern obstetric art?
00:34:21 – 00:34:35
[Music]