“It has fulfilled what was predicted of it, but has produced, in many instances, what was not expected-injuries of the bladder, stretching of the sacro-iliac articulations, and caries of the anterior wall of the pelvis. May this be forever entombed!” Notwithstanding the above, from so conservative and experienced a man as Winckel, we are obliged to keep up with the changes and experiences of this present age.
Recently, under the advantages of superior surgical skill, combined with our practical experience of aseptic procedures, some encouraging results are said to have been attained form this operation. An interesting article upon the operation in question, giving statistics and results, may be found in the April number of the Medical Century, Chicago. Obviously, the advantage to be gained is in saving the integrity of the peritoneum and the uterine wall. We therefore hope for this operation would seem to consist in tardy rearticulation of the divided symphysis. With suitable surgical, pelvic constraint, and requisite avoidance of locomotion, this difficulty may possibly be reduced to the minimum.
The operation known as episiotomy, while not a novelty or anything new, has recently been brought into more pronounced notice, as a means of relief, to prevent laceration of the perinaeum. The operation is very simple, consisting in making lateral incisions into the labia. It has been called “the young practitioners’ operation.” This is an unjust fling against it. it is an operation practiced in the best lying in institutions in Germany. We first learned it when a pupil of Prof. Braun in Vienna, and have had occasion to practice it occasionally for the past thirty years.
Any mode of management which so safely and simply prevents the dire disaster of perineal rupture ought not to be lightly esteemed. These lateral incisions repair soon with or without trifling surgical assistance. It may be advisable in some cases to apply catgut sutures. In this place we have a word to say as to the time for surgical repair of a lacerated perinaeum. In olden time repair was postponed almost indefinitely, and only attempted in very bad cases.
A great deal of the work the gynaecologist has to do, is caused by the injuries that happen during parturition. To protect the perinaeum during the passage of the child’s head and shoulders, is the duty of the skilled accoucheur. Laceration of the perinaeum, unrepaired, cause untold miseries to women, and render their lives wretched. They are liable to occur in labors where instruments are not employed, or they may result from their unskilful use. But such accidents often happen to the most experienced and skilful obstetrist, and the circumstances of the case may be such that they cannot be avoided. After every labor the accoucheur should (before leaving the lying-in room) carefully examine the vulva by an ocular inspection to assure himself of its exact condition. If rupture of the perinaeum has occurred, it is his duty to repair it at once.
This should be done as soon after the delivery as may be practicable-within the first six hours if possible; it is unsafe to wait longer than sixteen hours. However, in two case in my own experience, the operation proved a success, when made twenty-four hours after the delivery. The consensus of opinion of the authorities in midwifery the world over, now insists upon the immediate repair of a perinaeum ruptured during labor. In giving this opinion so positively, it may be supplemented by the statement, that there are exceptions to this rule-the circumstances of the case may be such that the primary operation will be contraindicated.
An operation for laceration of the cervix during labor, may with entire propriety be deferred beyond the puerperal state, and yet its immediate repair is already advised by some experienced obstetrists.
Saturating the vulva with hot oil, to be kept hot by frequent application of compresses out of hot water, has recently come into much use and favorable notice as a simple and practicable means for relaxing the unyielding parts, threatened with laceration. This is to be practiced just when the head is ready to pass through the outlet.
To Dr. Thomas, of new York, belongs the credit of having recently introduced and practiced a modification of the Caesarean section as a substitute for craniotomy. Early in the present century, Ritgen, Sir Charles Bell, Raudeloque, and others conceived and suggested the plan of which the industry and skill of Dr. Thomas have made a practical illustration. It is known as laparo-elytrotomy. Its object is to effect delivery in pelvic deformities without craniotomy, and at the same time save the integrity of the perinaeum and the uterine wall; an object and result most devoutly to be wished for by every cautious and conscientious practitioner.
No prudent surgeon ever passes his knife through these parts without a painful misgiving, with all the precautions against sepsis. The initial incision in this operation, is made an inch above Poupart’s ligament. The by a cautious dissection and separation of the peritoneum from its sub-cellular connection, it is pushed up so as to enable the surgeon to dissect down to the cervical end of the vagina, which is freely cut laterally (across) so as to reach the foetal head through the os and deliver above the symphysis pubis.
Anatomical familiarity with the parts, a steady hand, and a bright eye, render the operation by no means difficult; and while statistics are by no means all that might be desired, in the way of favorable results, yet the operation promises well, as a dernier resort. In extenuation of any unfavorable result in this and kindred cases, it should be borne in mind, that surgical interference is usually deferred until the bodily vitality of the mother is so low, that the simplest surgical operations are liable to terminate disastrously.
Occipito-posterior position of the foetal head in labor, has of course been liable to occur at any time since labor and child- bearing came to be a fact. Yet, it does not seem to have received careful recognition and systematic attention until recently. According to Dr. Uvedale West, who studied the subject very carefully, it seems to have occurred 79 times in 2585 labors; all of the labors being exceptionally difficult. The failure of recognition seems to grow out of a seeming obscurity of the parts in the matter of examination.
I remember at a medical society one evening, the manakin with the foetal head in this position under cover, was presented for opinion, from several men of ability and experience, not one of whom recognized or diagnosed the position correctly.
Practically, the state of the case consists in the failure of the occiput is situated posteriorly at the promontory, while the forehead and face are at or under the symphysis, presenting the very longest diameter that can be made of the face and cranium, to one of the shorter pelvic diameters. A marked peculiarity of such cases is, that the chin instead of being pressed down upon the sternum is drawn as far away as possible; this fact serving as an important element in the matter of diagnosis.
There modes of management have been suggested. The first is to leave the case to the efforts of nature, under the hope that a spontaneous rotation of the occiput may bring it under the symphysis and so terminate the labor as one of the normal varieties. And, what is remarkable, not a few of such cases thus terminate favorably by the unaided powers of nature.
The second is to make pressure upon the frontal bone so as to bring the chin to its normal position on the sternum, while making oblique lateral pressure on the head under the symphysis, with a view of inducing rotation of the occiput towards the symphysis. In fine the manipulations of the accoucheur should be such as to constantly favor flexion of the head, which will facilitate the descent of the occiput, and resist the descent of the forehead, by pushing it towards the sternum, keeping it in a constant state of flexion.
The third method is to deliver with the forceps with the occiput-posteriorly. In the main, experience will show from the results of any or three modes, that it were much more lucky to have escaped the case altogether, than to be responsible for its management.
The question whether it is ever a legitimate operation to destroy the child’s life to save the mother, is one that must be answered. We will not discuss it in extenso, for we could easily write many pages upon it.
To sum up, a case may occur, where the labor has been greatly prolonged, where the mother’s pulse is very rapid and weak, and the temperature so high as to indicate danger from complete exhaustion, that may terminate suddenly with death, unless she is relieved by an immediate and rapid delivery. Added to this, the pulsations of the foetal heart being very faint- indeed, almost inaudible-and, consequently, the absolute indications of the Caesarean section are absent.
In such a dilemma, when the mother cannot last much longer, if the obsterist (who we will suppose is an expert as a surgeon) elects to make a rapid Caesarean section-either by the Porro, or Sanger method, in all probability the result will be fatal to both mother and child. Either craniotomy or embryotomy must be a last resort. So many objections are made to this serious operation, that the practitioner must be certain that there is nothing left but a resort to it. A short time since, we were in consultation with a celebrated practitioner (an ex-professor)in a case of lingering labor, with Occipito-posterior position, where the head was impacted, and rotation could not be made.
