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Episiotomy in Midwifery Practice.

BY T. GRISWOLD COMSTOCK,
A.M., M.D., PH.D.

Master in Obstetrics (Vienna), St. Louis.

As a preliminary the following question is in order: Is the operation of episiotomy warranted, in order to save the perineum from a traumatic rupture, that is worse in its consequences than a section, or cut made with a sharp bistoury?

It sometimes happens that we have in labor a rigid and tense perineum with a great strain upon it, so that it is enormously distended, and still the head can not glide over it, without lacerating it, and making a gap that heals with difficulty. We will presume in such a case that the obstetrist has applied hot cloths to the perineum, in order to relax it as much as possible, and that he has given gelsemium internally and other remedies, but all to no purpose, as the vulvar ring is really too small for the child's head to pass.

We will now suppose a case that may occur to any practitioner, where the head has pressed against the perineum for a long time, and has produced a congested condition in its tissue, and we have there really, a contusion. When, with the advent of another pain the perineum

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gives way, and is torn, it is not in a favorable condition to heal, but if we make two cuts laterally, with a sharp knife or scissors, we substitute a surgical incision (if I may so term it) for the impending laceration that the head will make when it passes; and, a laceration situated always in the antero-posterior direction, through the raphé extending down towards the anus. This rupture is not in so favorable a place for the healing process, as when it is situated midway in the posterior quadrant of the vulvar circle, this being the place, where we elect to make the incisions, for the operation of episiotomy.

INDICATIONS FOR THIS OPERATION:— Whenever, in the judgment of the obstetrician, a rupture of the perineum is unavoidable, and the perineum is great. ly distended, and pushed forward abnormally by the head of the child, in order to relieve the great strain upon the recto-vaginal septum, incisions may be made laterally. Such a strain may happen even to a primipara in a normal labor, indeed here it may be applicable; but such an operation is especially indicated in occipito-posterior positions, where the occiput can not be turned under the pubis, and the head must be born in a position exactly antipodal to the normal.

ADVANTAGES OF THIS OPERATION:We will suppose a case of labor, where rupture of the perineum is inevitable, and when it occurs, as we have before stated, it follows the raphé, and the retraction of the transverse perineal muscles after completion of the labor, will naturally favor a gaping of the wound, that will interfere very materially with immediate union.

The incised wound made by the surgeon-obstetrist, differs materially from a lacerated wound made by the child's head pressing against the perineal structure; the former will heal readily, but the latter is managed with much more difficulty, and is indeed more liable to be affected from septic influences, if accidentally the woman is exposed to anything of the kind, or even if she has complications that may cause her to have a slow getting up.

TECHNIQUE OF THIS OPERATION:After the woman has been in labor with strong pains for some hours, and the second stage seems about to be completed, that is to say, with the advent of another pain the head will probably be expelled; and we will suppose in such a case, that the perineum is tense, and greatly strained, and the obstetrist decides in his judgment that the head will certainly be forced through by another pain, and in order for it to pass, the perineum must be ruptured; at that moment, and during a pain, the incision should be made. The index finger with a bluntpointed bistoury should be inserted within the ring of the vulva, and the external skin of the ring should be drawn back as much as possible, and then a section should be made, extending a little more than half an inch (Prof. Lusk says, three-fourths of an inch). The same kind of an incision should be repeated on the opposite side. Some obstetrists use angulated scissors to make the sections, and they will be found to be very practical whenever they may be preferred. We have made the operation, in an emergency, with an ordinary bistoury out of a pocket-instrument case. After such incisions are made, the tension is relieved, and soon the head will be delivered. When the placenta has passed, and the woman has recuperated (say within not more than an hour or two

after the delivery), we should turn her on one side, in the semi-prone position, and proceed to introduce sutures through the incisions, using iron-dyed silk, or cat-gut, and thus close them at once. Dressings are to be made to the wounds with non-alcoholic calendula, laying over them borated cotton, dusted with iodoform (or iodoform gauze,) and in our experience such cuts have always healed without further trouble.

AUTHORITY FOR THIS PROCEEDING :We were first taught this operation in the Vienna obstetrical clinic under Prof. Braun, and in our practice we have only seen it performed by practitioners in midwifery of the highest standing, and great experience. The operation has, indeed, been caricatured as "the young practitioner's operation," but all we have to reply to that is, that it was first recommended by no less a classical authority than Sir Fielding Ould of Dublin, in 1742*. Notwithstanding we have such high authority for this operation, many of our obstetrical writers fail to even mention it. We are happy to state, that Prof. W. T. Lusk, in his recent most excellent work upon midwifery, describes the operation, and recommends it to be made when no other resort is left to the practitioner, to avoid a traumatic rupture of the perineum, and thereby save the woman much suffering and trouble.

We would be pleased to hear from experienced practitioners, who are subscribers to the MEDICAL BRIEF, and would especially request them to give their opinions not only upon the indications for the operation of episiotomy, but also their experience in labors with occipito-posterior positions.

Detailed cases from members of the profession, of such "vicious" positions, and statistics of the same, would be very interesting and instructive. We certainly can sympathize with any practitioner in the country, who, to his chagrin, recognizes in the lying-in chamber his first case of an occipito-posterior position, where normal rotation has failed, and the occiput has already greatly distended the perineum. In such a case the pains

A Treatise of Midwifery in three parts, by Fielding Ould, Man-Midwife, Dublin, 1742. NOTE.-Obstetrical practice a hundred years ago, was mostly in the hands of midwives.-T. G. C.

are strong, but the head makes no advance and seems to be impacted, when the obstetrist very naturally resorts to the forceps to terminate the labor, with every confidence that he can deliver the head easily and quickly. Theoretically, there is in such a case every indication to use the forceps, and he applies them, and they are easily locked, and he makes traction, but to his astonishment he finds the extraction of the head in this position is a most difficult task, and sometimes impossible to accomplish. In such cases, a country physician requires the assistance of an experienced consultant, and when delivery is effected, even by the most skillful practitioner, laceration of the perineum is liable to be a consequence.

Note! I have used the term "vicious" position, as applicable to occipito-posterior positions of the head, when normal rotation fails and the forehead can not be turned into the hollow of the sacrum, and I think from the dangers, and serious results of such cases, to both mother and child, that such a designation is warranted in practice.

Obstetrical writers have failed to fully explain the dangers and significance, of occipito-posterior positions, when the head fails to rotate, the result in such labors is frequently very serious, and when craniotomy is resorted to, almost tragical. Prof. Algernon Temple, M.D., M.R.C.S. Eng., Professor of Obstetrics, in Trinity Med. College, Toronto, in an exhaustive article, read before the International Medical Congress, at Washington, 1887, says, in speaking of the way that such cases are passed over by most obstetrical writers, "these labors are called natural in our text-books, while to my mind they are dissimilar in almost every respect, and they might well be placed under the same heading as preternatural labors."

I think, from the above authority, that I may transcend the bounds of former obstetrical classifications, and designate this position as a "vicious

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one.

JABORANDI is recommended by Prof. Waugh in erysipelas. The dose is twenty-five drops of the fluid extract, continued until diaphoresis is produced.

Definition, Etiology, Morbid Anatomy, Symptoms, Diagnosis, Prognosis, and Treatment of Pulmonary Phthisis.

(Continued from page 368.)

DIAGNOSIS.- Pulmonary phthisis is chiefly distinguished from other affections of the chest by physical signs. Other important diagnostic features are, night-sweats, the character of the cough, which generally occurs in paroxysms several times during the twenty-four hours, and also the character of the sputum, which is usually in large quantities, and, in some cases, lung tissue may be detected in the expectorated matter, which is very foetid. Loss of weight and rapid wasting of the entire muscular system, and more especially the muscles of the thighs, are very important diagnostic points.

Hemoptysis, when present, points strongly to consumption, though it may occur in other affections besides consumption.

Amenorrhea, in girls, with cough and night-sweats, is diagnostic of pulmonary

phthisis. When the voice becomes hoarse and husky, and other symptoms being present that point towards consumption, strengthen the diagnosis.

PROGNOSIS.-The prognosis in any given case of pulmonary phthisis depends very much on the amount of damage the lungs have sustained. Though, as a rule, the prognoses are unfavorable in a large majority of cases that come under the care of physicians. There are several modes in which consumption may end in complete recovery, namely, by absorption of the tubercular deposit, the calcification of the caseous products, and the cicatrization of the cavities.

In a few cases, the disease is said to be self-limited, and ends in recovery without any treatment.

TREATMENT.-The treatment of pulmonary phthisis may conveniently be considered under four heads, namely, climatic, hygienic, dietetic, and medicinal.

Climatic Treatment.-There is no one climate that suits all cases of consumption. The most important feature in this treatment is a change from one climate to another. A dry, high situation, as a rule, is more suitable for consumptives

than a low, damp one. Colorado, California and Florida are thought to be suitable places in the United States for consumptives. If the patient resides in a cold climate, it will be well to send him to a warm and mild climate, and from a warm to a cold climate in some cases will be beneficial. Of course, we can not discourse this subject in an article for a medical journal. We only give it a passing notice, as it is only our intention in this article to give the treatment we generally employ in cases of consumption.

Hygienic Treatment.—This consists in abundance of exercise out of doors, during all seasons of the year, staying in-doors only when the weather is inclement. Sporting of all kinds, such as fishing, hunting, etc., are beneficial to a large majority of consumptives in the first stage. Patients with consumption should keep regular hours and sleep at least onethird of their time. They should bathe regularly, and go well clad in the winter months. Suffice it to say that the laws of hygiene should be scrupulously observed.

Dietetic Treatment.-The most important object to keep in view in the dietary treatment of phthisical patients, is that the amount of food taken into the stomach is digested and assimilated. It is not the amount or quality of food taken, it is what is thoroughly digested and assimilated that nourishes the whole physical economy, and to accomplish this object it is very essential that the function of the stomach, liver and kidneys should receive the physician's careful attention. The diet of phthisical patients should consist largely of fatty material and the amount should be pushed as far as the stomach will digest. Of fatty food I prefer rich cream. Butter should enter largely into the diet of consumptives, as well as meats of all kinds, provided the digestive powers are not materially impaired. Vegetables and fruits of all kind may be allowed in moderate quantities. It is also essential that starchy food be taken in sufficient quantities. In this disease alcoholic stimulants play an important role, probably more than in any other chronic affection. As a rule, they should be given just before or with meals. In regard to quantity, no definite

rule can be given, it depends on various things connected with each individual case, and the physician should, by carefully observing the effects, ascertain the quantity of any given stimulant necessary for each case. Of the numerous stimulants that have been used in phthisis, there is, probably, none equal to pure whisky or brandy.

Medicinal Treatment.-The medical treatment of phthisis consists in the application of the various therapeutical agents to cure or mitigate the disease. This is an affection, as all physicians know, that we have no specific remedy for, though there are many drugs that are thought to influence the course of the disease very much by improving the general health. There is one agent that is universally employed in phthisis, and that is cod liver oil, which is more properly a food than a medicine. It is preferred by some in its crude state, and by others in an emulsion, and the form I prefer to administer cod liver oil in is the preparation known as Hydroleine, which is more readily taken by patients than any other preparations that I have ever used. If cod liver oil is given alone, the pale is the best, and the dose I generally give is from a teaspoonful to a tablespoonful, and it should be given just before or after meals. As a vehicle the compound tincture of gentian or the tincture of columba are probably the best.

There are many other agents that are thought to act more favorably in the course of consumption even than cod liver oil; namely, iron, quinine, strychnine, arsenic, and the hypophosphites. These agents act beneficially by improving the bodily nutrition. Any drug that improves the general health is useful in phthisis.

There is one agent that has proved of more therapeutical value to me in the treatment of consumption than any other, and that is carbonate of ammonium. It should be given in from three to five grain doses, three times a day dissolved in water and mixed with simple syrup, and it is well to combine it with some of the simple bitters, or better, the tincture of nux vomica. Of course, this agent does not rank with cod liver oil, the different fats and oils, and the vari