While here I want to add a word in favor of the primary operation for laceration of the perinaeum. You know the rule is here, as everywhere else in surgery, to close the wound, if possible, and obtain primary union. The reasons have well been given already. If done promptly, the results are justifiable. I know there are men here who have operated a hundred times to my one, and are competent to operate much better; but so far as I am concerned, I have never seen a failure after the primary operation. I saw one partial failure where I was not able to take the after-treatment myself, and it might have happened if I had been.
MARTHA G. RIPLEY, M.D.: I only wish to say that having spoken against operations, I do not wish to be thought entirely opposed to them. I believe in the primary operation, and with a large obstetrical practice, I must have some cases that need operation. The primary operation is the best one, in my opinion, and I am surprised to hear that somebody’s opinion is there was never a successful case seen yet. If my patients were here, I think there would be successful cases seen.
As to the new idea that has recently been promulgated in the medical magazines in regard to primary operations upon the cervix, I should not feel justified in performing one with my present knowledge, with the parts in the condition that they must be after parturition. I hardly believe it would be the thing. But the primary perineal operation is the one that I have done, and done immediately.
J.W. STREETER, M.D., of Chicago: I would not say a word this afternoon on this subject or any other, were it not that I believe that it is quite an important one, and that, so far as it is possible for us, we should settle it in our own minds and be consistent at least. It seems to me that we are too far advanced in surgical knowledge, in pathological knowledge, in our ideas of sepsis and antisepsis, to revert to the old method of allowing nature to do the work which art can do a great deal better. The perinaeum should be sewn at once when it is torn. There is hardly an exception.
I once used a common needle and linen thread when I was too far away from silk and suitable instruments, and it was not a success. In every other instance in my experience-which has not been a very limited one-the primary operation has been successful. If successful, why not do it every time?.
The laceration of the cervix, the primary repair of which is done in some of the German hospitals, is a surgical exploit, and that is all there is of it. Nine-tenths of lacerations of the cervix will repair themselves so that they gynaecologists will never find them. I can imagine a case now and then where it would be wise to take a few stitches; but ordinarily, as I said before, it is a surgical exploit which will never general in private practice.
J.C. WOOD, M.D., of Ann Arbor: As to perineal operation or an operation on the pelvic floor, I experimented for some time with the flap-split operation, and was delighted with it so far as restoring the perinaeum was concerned. I found out, however, by experience, that in those cases where there was decided relaxation of the pelvic floor, with rectocele, that it did not fulfil the indications, so that by degrees I simply extended the flap-split until I separated the tissues to the crest of the rectocele, even if the crest was near the cervix uteri.
Then, instead of dissecting out the tissue, I found, by experiment, that if the tissues were brought together underneath the superior flap, that if the tissues were brought together underneath the superior flap, that it accomplished the desired end, that it gave us a posterior pillar, which, instead of being in the way, was a most valuable supporting medium. If the perinaeum is to be restored, I make my outside incisions exactly as in the Tait flap-split method, If it is simply to overcome the relaxation of the pelvic floor, I make my incision high up, simply underneath the vaginal mucous membrane, make my dissection with the finger, and the whole thing can be done in two or three minutes, and bring the underlying surfaces together with a continuous catgut suture passed through the vaginal mucous membrane, the sutures being entirely passed through the vagina. The result, I think, will be surprising to those of you who will experiment with this operation.
DR. GREEN closed the discussion as follows:.
Three has been so much said upon the subject of immediate repair of laceration, that it is hardly worth while for me to replay; but, it is a subject to which we cannot give too much emphasis, and it is useless for a man to put his theories against another’s experience; and when I hear a mn condemning the immediate repair of a lacerated perinaeum, I have but one thought in my mind, and that is, that he is theoretical and not practical. When a man says he has repeatedly examined cases that have been operated upon and were faulty in their results, I must say it has not been properly done.
I have seldom seen a failure, and I have been doing this ever since I commenced the practice of medicine. In my earlier operations it was not well done, and I failed, probably, in 40 per cent of my cases; but, after studying over the causes of these failures, they disappeared.
In regard to the rupture of the cervix, I believe the writer states that a rupture of the cervix often occurs at the same time, and why not repair it as well? Whenever I am called upon to operate upon a lacerated perinaeum, I always examine the cervix, and if the cervix has been lacerated I draw it down and repair it at the same time. We cannot neglect any of those things that will benefit a patient who is under our care.
In regard to the draw-string operation, I have operated a number of times with that. It is imperfect, does not give good results, and the reason is, principally, that it shortens the anterior vaginal wall and destroys the parts that we attempt to restore.
I have also performed Tait’s operation a number of times, and I find that faulty. The fault is in not removing the flap. A portion of the flap protruding into the vagina cases more or less deformity, and I have found better results by removing the flap than when I left it. Why should not the flap be removed? You have got to dissect these structures down to the muscular tissue. If you simply denude a part, you will not get strong union. That structure is cicatricial. It is devoid of circulation, and why not remove it? How do you know that a nerve fibre may not be pinched in that scar? If you know anything about orificial surgery, you know it may, and you know it is bad surgery to leave a scar tissue anywhere.
In respect to the subinvolution of the vagina, etc., the Doctor is wrong in his anatomy. The parts have been over- distended. The blood vessels have lost their support. There has been exudation of matter there that has become organized, the parts are thickened, and the whole thing is the result of the want of support which has been taken from the vagina.
In regard to the suggestion made by Dr. Mcdonald I accept that.
The following question was asked of Dr. Green:.
“How many hours may elapse before it is too late to sew up the perinaeum after labor?”.
DR. GREEN: That depends very much upon the accoucheur. If the man is one who is given to antiseptic methods, the operation may be delayed for several hours; but, ordinarily, if it is not done at once, if several hours elapse, the tissues becomes swollen, and probably have become infected, and it will not do to sew the perinaeum up after the lapse of ten or twelve hours, as he is liable to have failure.
THE CHAIRMAN: There is a little confusion in regard to the primary operation upon the cervix. Do you wish the Congress to understand that you operate upon a torn cervix at the time, or, were you referring to a secondary operation? Do you repair the perinaeum and also the cervix at the time of the accident?.
DR. GREEN: When I am called upon to repair a lacerated perinaeum, and immediate repair I mean, I always examine the cervix, and if I find a lacerated cervix and it is my judgment that that can be mended at the time, it is my habit to sew it there and then. Sometimes it will not unite, but often it does. Where the labor has been perfected, and where the parts are greatly bruised and ecchymosed, it is probably not necessary to do it, as it will not unite; but, in my experience, a reasonable number of cases will unite, and save the patient a secondary operation for laceration of the cervix.
