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.
DISCUSSION.
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.
