FOR several years progress in the art of obstetrics has been mainly along surgical lines, until so much operative work now pertains to the complete practice of this branch, that he who expects to rely upon himself in the hour of emergency must possess surgical skill. Moreover, requirements for the successful practice of obstetrics are daily becoming more exacting. Midwives and incompetents will ultimately be driven out of the field by the lash of public sentiment.
Symphyseotomy.-The old operations of Sigault, known as symphyseotomy, which had quite a run in the latter part of the last century, has been received in this our day by the Obstetric School of Naples, and thus far has a good record. In this country it has been employed but a few times, but the sentiment of accoucheurs appears to be friendly toward it.
It is only occasionally appropriate, and probably far less frequently in this country, and especially in the west, than in the more densely settled countries of Europe, where pauperism is more prevalent, and the people are harder worked and more poorly fed.
Ever since the original operation of Sigault fell into desuetude, obstetrician have busied themselves in efforts to devise methods for reducing the size of the fetal head to correspond to pelvic dimensions, and as a result, thousands of foetal lives have been sacrificed for want of the very expedient which had been cast aside.
It is unnecessary for me to sway that the secret of our success with Sigault’s operation to-day is found in cleaner methods and finer technique.
For some years Caesarean section has been the standard operation for in which the antero-posterior diameter of the brim was reduced as low as 2 3/4 inches; but recently a living child has been delivered by means of symphyseotomy when the diameter was only 2 2/3 inches. The wonderful improvement in obstetrical results which this affords is at once apparent when we consider the vast difference in point of mortality between the two operations, Caesarean section and symphyseotomy. Nor is maternal life preserved at the expense of subsequent misery, for according to the reports thus far made, there are no disabling effects produced in the woman as the result of temporary disarticulation of the pubic bones.
Still we are recollect that the operation is yet on trial, and should lay corresponding restraint on our enthusiasm. The true value of it can better be told in a twelve-month.
After the os uteri has become fully dilated, and futile attempts have been to deliver with the forceps, or as soon as we find that the foetal head is unquestionably so decidedly out of proportion to the size of the pelvis delivery of a living child cannot be effected, the time has arrived for the performance of symphyseotomy.
The field of the operation is prepared in the usual manner (which preparation should include shaving the mons veneris and vulva), and an incision is made about two inches long in the median line, the lower limit of it being a point just above the clitoris. A few fibres of the rectus muscle are separated from the pubes on either side of the median line, and the finger is passed down along the posterior surface of the symphysis. Using the finger as both director and protector, a curved probe-pointed bistoury is then made to severe the articular soft structures, including the sub-public ligament, great care being exercised to avoid wounding the other structures.
The articular surfaces are gently separated a few lines, the wound is examined for bleeding points, these being secured with fine catgut, temporary gauze packing is used and the forceps are applied. Delivery should be practiced with great care, and during traction effort the trochanters should be supported by the hands of an assistant.
After delivery of the placenta the gauze is removed, the control of all bleeding assured, the articular surfaces are brought together and held by silkworm-gut sutures through the fibrous structures along the face of the bones, which fall within easy reach, and then the external wound is closed. In exceptional cases it may be wise to practice drainage for twenty-four hours. A tight bandage should be applied to the hips and firmly secured. The recumbent posture should be enforced for about four weeks.
The Caesarean Operation.-I am not aware that there has been any improvement worthy of mention in the technique of the Caesarean operation or its modification during the past year; but the sentiment is becoming nearly universal that the operation should be regarded as elective in the matter of time.
Formerly, the custom was to resort to surgical interference only after labor had been well established, and that, too, even in cases wherein delivery per vias naturales had been recognized as impossible.
Without pausing here to note the objections which have been made to early interposition, I may be allowed to emphasize the advantages arising from ante-partum operation, viz.:.
1. A better opportunity for deliberate and painstaking preparation on the part of the operator is afforded.
2. Daylight can be assured.
3. The patient can be more thoroughly prepared.
4. The vital powers of the woman have not become seriously impaired.
In view of the bearing of exact pelvic and cranial measurements on the selection of the most suitable operation for an individual case, I should not omit to direct your attention to the demand for more frequent use of the pelvimeter and careful estimate has established.
Sanger vs Parro.-Caesarean section, pure and simple, as practiced by Sanger, and Caesarean section as modified by Porro, are still rivals for surgical favor. In Italy, where it originated, the Porro operation is by far the most popular, while in Germany Sanger’s operation is in greater favor. the surgeons of this country have exhibited a preference for the latter method, though some of the best operators are outspoken in their preference for the former. Dr. Robert P. Harris, whose statistics are most elaborate and reliable, believes that Americans have food reason for preferring the improved Caesarean operation, inasmuch as twelve out of twenty-eight Porro subjects, up to the present time, have died, against five out of the last twenty- eight delivered under the other method.
On the other hand, “our success,” says Dr. Joseph Price, who has thus far produced the best statistics of personal abdominal work which the world affords, “in supra-vaginal extra-peritoneal hysterectomy for fibroids, and the low mortality accompanying the operation has assured our faith in the Porro operation.” “Hysterectomy should be performed,” he continues, “wherever the Caesarean section is necessary.” Thus the controversy goes on, but out of the din and smoke of the tumult we gather indications of the advantage of the Porro over the Sanger operation for the use of the average surgeon and gynaecologist outside of hospital walls.
It is more easily and expeditiously performed, and, what to my mind commends it still more, the possibility of future impregnation is prevented. The sentimentality in which some indulge, and the amiability which would encourage reproduction by such women of weak, deformed, and usually dependent children, should be discountenanced. The record which Rosenburg found of thirty-six cases wherein Caesarean section has been performed from two to five times on the same woman, is to my mind deeply revolting.
As in the case of supra-vaginal hysterectomy under other circumstances, some late operators have treated the stump according to various intra-abdominal or intra-pelvic, of not strictly intra-peritoneal, methods, but the ordinary operator will still prefer to fasten the stump at the abdominal opening.
Caesarean Operations vs. Craniotomy.-The accoucheur who possesses surgical skill will hereafter reserve his perforator, his craniotomy forceps, and his cephalotribe for use only upon the dead foetus, for, with the child still living, abdominal section and symphyseotomy are the operations to be considered. Upon a dead foetus, in a pelvis measuring in e excess of 3 or at the least 2 1/2 inches, such instruments will afford occasional aid, but not elsewhere. This is the dictum of late obstetrical authorities, and yet I can conceive of an occasional case in the experience of those who have no surgical skill themselves and cannot readily summon those who do possess it, wherein an exception to this rule may properly lie.
The practitioner who is inexperienced in surgery of the abdomen, but who is accustomed to obstetrical manipulation, will be instruments than with the knife; and to such cases, with an environment decidedly unfavorable so for as concerns consultative facilities, rigid rules cannot be applied.
Ischio-Pubiotomy.-I should not fail to refer to a congener of symphyseotomy known as Farabeuf’s a operation, which consists of section of the pelvis at a point about 2 inches to the right or left of the symphysis pubis, according to the direction of the pelvic contraction. It is intended for cases of obliquely contracted pelvis, wherein symphyseotomy would be comparatively ineffectual. The most recent example of this operation, of which I have seen a report, is from the clinic of Prof. Pinard, of Paris.
