OBSTETRIC SURGERY.

BY JOSEPH EVE ALLEN, M.D., AUGUSTA, GA.

The scientific obstetrician of the present day has to be a surgeon, for the conditions he ordinarily meets with in practice, as well as all unusual accidents and emergencies, have to be treated according to principles that govern in surgery. During the past twenty-five years all progress in obstetrics has been along surgical lines, and it is certain that the achievements of the future lie also in this direction. The man, therefore, who would keep up with his profession and treat his patients according to the latest science, must bring to bear in midwifery practice everything that characterizes and makes successful the work of the modern practitioner of surgery.

The brilliant results that are now attained in obstetric surgery are due entirely to precision in diagnosis and rigid asepsis in technique. Before exact methods of diagnosis were known and the necessity for absolute cleanliness in operating recognized, the fear of puerperal fever prevented handling of the parturient uterus and effectually barred all advance in operative obstetrics. The average obstetrician was limited in conservative procedures to version and the forceps, while infantile life was sacrificed to a frightful extent by frequent resort to the perforator and the knife.

In preaseptic times few lying-women escaped some form of infection, and delivery was often accomplished by methods now known to have been improper. Puerperal fever was regarded as a specific affection and frequently raged with epidemic violence, sweeping off thousands of victims,

or leaving them permanent invalids suffering with chronic septic inflammations.

In lying-in hospitals the usual mortality from septicemia was from two to ten per cent. and even higher, and childbirth in such wards was justly looked upon as almost certain death.

The experience of the City Lying-in Hospital of London, which was made the text of Dr. Godson's address before the British Gynecological Society at its last annual meeting, is the common history of all such institutions. This hospital is one hundred and twenty-four years old, and it was quite a common occurrence for it to be closed on account of puerperal fever, while many thousand pounds have been spent in structural alterations, remodeling, demolitions, and rebuildings, carried out under the superintendence and advice of the best sanitarians of the day. All efforts had, however, failed to bring about more than temporary reduction of the death-rate prior to the time when the great discoveries of Semmelweiss and Lister wrought such a revolution in practice. In 1880 the mortality in this institution was one to nineteen. In 1886 the use of antiseptics was begun and that year 480 women were delivered without a single death.

The statistics of other public maternities also demonstrate the inestimable benefits arising from change of methods. Thus Leopold in 1887 records 3,089 deliveries, in cluding many operative cases, without a death from septic infection. Slawiansky reports 176,646 labors occurring in Russian hospitals with a mortality of three-tenths of one per cent. and a morbidity of eight and five-tenths per cent. The Boston Lying-in Hospital in 1891 records 550 deliveries with no death. The Sloan Maternity of New York had one septic death in 3,000 cases, and the New York Maternity 957 deliveries with no death from infection.

Now, owing to the adoption of clean methods, the danger of sepsis is obviated, the number of conservative operations has greatly increased and embryotomy on the living child is seldom practiced, and perhaps is never justifiable. In well managed lying-in hospitals puerperal fever is a thing of the past, and a woman is here much more secure against the perils and dangers of childbirth than she could possibly be in the best of private homes.

While in hospitals maternal and infantile mortality has wonderfully diminished, the death-rate in private practice is still appallingly high. According to insurance reports quoted by Reynolds, in 2,183 insured women, 197 or 9.03 per cent. died of puerperal causes, and seventy-five per cent. of these deaths were from septicemia. Dr. Cullingworth, in a recent address before the Obstetrical Society of London, shows that the mortality from puerperal fever throughout England and Wales is just the same as it was before the beginning of the era of asepsis. In America examination of the mortuary reports of any of our cities will disclose many deaths from puerperal septicemia disguised as malaria, typhoid fever, la grippe, etc.

Unfortunately death-rates do not by any means show the full extent of the evil done by infection, because for every fatal case about ten patients survive the puerperium to drag out a miserable existence and furnish material to the gynecologist.

It is a lamentable fact that at present at least threefourths of the deaths in childbirth outside of hospitals are absolutely preventable. This is a terrible indictment of the general practitioner, suggesting gross ignorance and negligence, and urgently calling for radical reform in obstetric methods usually practiced. The reasons for this state of affairs are many and various. Thus many of the older physicians only half accept, and do not follow, the teachings of the new school. In the education of students

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opportunities for actual bedside demonstrations are comparatively rare, and hence the importance of strict asepsis in midwifery is not so fully impressed and emphasized it is in surgery. Many excuse their shortcomings by pretending belief in the exploded doctrine of autoinfection, claiming that a parturient woman may infect herself, and that hence troublesome precautions are ineffectual and useless. Others, quoting the aphorism of the distinguished Dr. Blundel, that "meddlesome midwifery is bad," depend upon nature to bring their patients through. While some say that labor is a physiological process, and hence requires no special care or attention. Certain physicians claim to be aseptic, but forget that much depends on minute detail, and quiet their consciences by washing their hands in water containing a few drops of creolin or carbolic acid, leaving everything else to the nurse, and then glibly assert that every precaution has been observed.

The truth is the crude and imperfect methods commonly practiced are ridiculous imitations of real aseptic midwifery, and no accoucheur can do safe and thorough work who practices in this way and has not trained himself to manage every labor case according to strict surgical principles.

DIAGNOSIS.

To the obstetric surgeon accurate diagnosis is very essential, for upon it is based the whole matter of election in operative procedures. The physical examination which should be made of every pregnant woman long before the beginning of labor furnishes him information that is invaluable. By it it is possible to decide as to the necessity for interference and to select that method of delivery which best subserves the interest of both mother and child. This. examination prevents such mistakes as that of attempting delivery by forceps in cases suited only for version, or

craniotomy where symphyseotomy or some other operation would better meet the indications. The obstetrician is thus also saved the embarrassment of having to face complications for which he is unprepared, or abnormal conditions which it is too late to remedy. Without this previous knowledge, he is often obliged to do for his patients not that which is best, but that which is most available.

The improved means of diagnosis now at our disposal make it possible to accurately determine the capacity of the pelvic canal and its relation to the fetus which has to pass through it. This gives exactness to treatment and removes the operations of obstetric surgery from the category of emergency operations, in which until recently they were classed, and makes them elective operations, thus very much enhancing the chances of success.

The preliminary examination, in order to be of value, must be conducted in a systematic manner and should include auscultation, palpation, and pelvimetry. Every orof the body should be investigated and a careful chemical and microscopical study of the urine made.

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The following case record is given as a convenient form for cases in private practice, as it is not so complicated as the forms generally used in lying-in hospitals.