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.
In order to make the result of this operation satisfactory, as it appears to me, the greatest care will be requisite, owing to the presence, at the site of section as designated, of the obturator nerve which supplies adductor muscles of the thigh. In measurements recently made on the cadaver, I find that the point of exit of this nerve, at the upper and inner margin of the obturator foramen, is just 2 inches form the symphysis. The obturator vessels are also found at the same point. To go to the outer side of this opening would materially diminish the danger of section, but the operator must recollect that that the nerve there lies close to the lower border of the horizontal ramus of the pubis.
If section is made at a nearer point the body of thee pubis alone will be cut, and, owing to proximity of this line of incision to the symphysis, the special advantage of the operation over symphyseotomy will be measurably diminished. The best point for section is probably about 2 1/2 inches fro the symphysis. The direction of the section will be downwards and somewhat inwards, the chain saw cutting first the transverse and then the descending pubic rami. Of course, the obturator nerve can be avoided by careful adjustment of the saw about the transverse ramus.
Pyrexia in the Puerperium.-Advanced notions concerning the treatment of puerperal pyrexia have been maintained and strengthened. I have frequently seen the temperature in the puerperium run up to 103 degree and 104 degree for a few hours and then subside under the influence of simple remedies, and therefore great haste in the matter of operative interference is by me discountenanced. But when the temperature is disposed to remain high, or when there is a decided rigor at the beginning of the pyrexia, with no explanation traceable to disturbance distant from the pelvis, little time should be allotted to the expectant plan of treatment. First of all, let the vagina be washed out with a gentle stream of hot boiled water.
If the symptoms do not improve within a few hours, or if the temperature is only temporarily lessened, the uterus should be carefully washed out with plain boiled water, ample provision being made for the return of the fluid. Then seizing the cervix with a pair of bullet forceps and drawing it downwards until is within easy reach, the uterine cavity should be wiped out repeatedly with pledgets of absorbent cotton or iodoform gauze. If this should fail to give more than temporary relief, the organ should be curetted and packed with either iodoform or sterilized gauze, the end of the strip being allowed to trail into the vagina for drainage purposes.
If up to this point the manipulation has been done with due regard to asepsis, the packing may safely be left twenty-four hours, and subsequently renewed if required. It may be unnecessary to say that all this manipulation would better be left undone unless it be done with strict regard to perfect cleanliness. A thoroughly clean vulva and vagina and uterus are absolutely essential, and the fingers of the operator, the instruments, and the packing material must be above suspicion.
If at the end of twenty-hours after packing the temperature does not approach normal, and the other symptoms do not evince corresponding improvement, we are left to infer that the cause of the disturbance, while originally within the tract which has been thus treated, has now located itself within the lymphatics, the veins, the tubes, or has invaded the peritoneal cavity. When this is true some practice laparotomy without delay, but, in view of the results of such operations, as shown by reliable statistics, I would still withhold my hand for a season, men while hoping to obtain from our deep-acting remedies results unlooked for by Old-School practitioners. This relegates laparotomy, in such cases, to the place of a dernier of a resort.
Episiotomy.-I am convinced, from what I have seen and heard, that the operation of episiotomy is far more commonly used than formerly. About three or four years ago I appealed to several of operation, and was surprised to find how few had become familiar with it in a clinical way. At that time I had resorted to it a few times, but of late I have had rather frequent recourse to it.
Whereas it was my former custom to make several small incisions on either side of the vulva, I now make but one on each side, and that of sufficient depth to give the needed circumference. The authors who mention the subject at all usually advise that the incisions be made with a knife, and that we leave the integument intact or nearly so; but this is not my practice. When the perinaeum is bulging, and the vulvar circle is tense, with every certainty of laceration, I slip the scissors under the thin margin and cut outwards and backwards from a half to three- quarters of an inch. By this means the vulvar circumference is greatly augmented and the perinaeum is saved.
After delivery of the secundines I put two or three catgut sutures into each wound, and the result is usually a perfect vulva. I confess to a partiality for this operation, and have yet to meet the case wherein I have had occasion to regret any resort to it. Immediate Repair of Parturient Lacerations.-The demand for immediate attention to lacerations involving the vulva and vagina is becoming more imperative, while some teach and practice immediate suturing of even cervical rents. Surely the time is ripe for declaring that the accoucheur who fails to suture vulvar rents is guilty of gross neglect. Nor should one be allowed to escape censure under the plea that anything short of an extensive laceration is not reckoned by him as a laceration.
Suture of such wounds must be thorough, since otherwise the operations will prove unsatisfactory.
Asepsis.-Essential progress is being made by the great body of obstetric practitioners in the direction of thorough cleanliness in midwifery practice, but there is till much room for reform in this direction. The slackness of man by accoucheurs is truly appalling. Filthy instruments and filthy fingers appear to be the rule rather than the exception. Both students and practitioners need education along this line.
L.C. GROSVENOR, M.D.: I don’t know, Mr. President, that I have anything to say to, this able paper. I have enjoyed it intensely. It is as full of met as a nut, and I am very glad to see our Homoeopathic obstetricians coming clear to the front on these very important subjects.
MARTHA G. RIPLEY, M.D.: I was very much pleased with the paper, and doubt if I shall be able to add anything to it. I wish to say that within a year or two I have had what I consider a very important method of using the forceps. I have never seen it mentioned in any work-in fact, it is directly in opposition to the rules that were given me for the use of forceps. In my obstetrical box I carry two sizes of forceps, the medium and the short, the very small. I have those small forceps with me at every case, and in cases where I fear a laceration of the perinaeum when the head bulges on the perinaeum, when I come to that point I stretch it.
If I fear that the outlet is not sufficiently large, and I judge it impossible for the head to pass, then I take my scissors and make the last operation spoken of, on each side. When there is any pain and the ligaments are stretched, I make a cut on each side from a quarter to a half an inch, as I think best, putting in fingers as they are needed. That is very much better than is laceration of the perinaeum. I like that operation very much in case I fear there is to be a laceration. Now, to avoid a laceration, I have worked over the perinaeum and stretched it and dilated it as much as possible; then when there is no pain, I put in my small forceps.
If a pain comes, I stop. I work when there is no pain, when every part is relaxed. I can get then the best results. I have tried it in hundreds of cases, and I can avoid a laceration of the perinaeum many times; and if I delivered with the forceps when there was pain, I would get laceration. I will say this: the patients are not frightened by the word forceps. I say to them, “I have a little pair of spoons here that will help. I will shorten the operation.” I think mine are the Higbee forceps -the smallest size you can find.
It has been said that you can use large forceps as well. I want to say that sometimes I can get along better without any forceps; but when you depend upon delivering without the pain and expulsive efforts, of nature, you have got to use a little force. Sometimes I get along without using any forceps. You cannot use force without pain:.
DR. HINGSTON: Almost the last words of one of the doctors was that he believed that it was almost a rule, rather than the exception, that obstetrical cases were attended without any care as to asepsis. Now, in my discussion of the paper before this one, I rather supposed that the people here thought that I was one of that class, and I don’t believe I look like a very dirty man. I am heartily in concord with the opinion that the greatest aseptic condition should be adhered to; and when I remarked that I thought it was perhaps better to stay out of the vagina than to go into it under certain circumstances, I don’t want to be understood that that was my method.
On the contrary, if I had had time to finish, I would have said that after I go away from my cases, I insist that the nurse shall leave them alone-keep out of that domain. I permit none of these antiseptic washings that we have here recommended in the journals and elsewhere, to be carried out every day or twice a day. On the country, I believe that if we do not have trained nurses, we had better keep the nurse away from that domain. Let us make the vagina as aseptic as possible. Let us be as cleanly as possible. These are my views on this subject, and I was glad that this paper camp up after the other one, because I felt that I was misunderstood.
H.E. BEEBE, M.D.: The measures recommended are all very good, but I think it is quite well proven that of later years laceration of the perinaeum is more frequent when the shoulders are passed than when the head is passed.
SHELDON LEAVITT, M.D., in closing the discussion, said: I have nothing of importance to add, though I might say a few words with regard to the use of the forceps as mentioned, more especially by Dr. Ripley. These short forceps-these very short forceps-are a convenience, to say the least. The use of emollients, as mentioned by Dr. Ripley, is an excellent practice; but we must give what Graves demanded-the tincture of time, in which the perinaeum may accommodate itself to the size of the foetal head.
But the cases of which I spoke, in which episiotomy is desirable, are those in which we have given the time, and the vulvar opening is hard and unyielding, and the head out of proportion to it. Under these circumstances, where laceration is received, from the experience which we have had, we may introduce the scissors and make the incision to which I have alluded.