Ernest Watson Cushing.

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in the Royal Maternity Charity of London, we are met on the
threshold of our inquiry by the complete absence of the CsesareaD
section. During those years we delivered no less than 40,000
women, and among these deliveries no indication for CsBsarean
section presented itself. The explanation of this remarkable fact
is a simple one. It is explained by the absence of pelvic de-
formity in the metropolis of London. This absence is undoubt-
edly due to the improved and still improving hygienic conditions
under which the poor of London exist. It must be further borne
in mind that year by year they are recruited by many thousands
of destitute alien immigrants who might be supposed to furnish a
certain number of cases of pelvic deformity. Among these 40,-
000 deliveries, only 228 cases required the assistance of forceps,
and of these 228, only one woman died. We therefore find that
forceps are required in only 5 per thousand of all cases of labor.
Among the same nimiber version was called for in 52 cases, and
here also only one woman died. Craniotomy was required in
only 14 cases out of the 40,000, which sufficiently proves the rari-
ty of pelvic deformity. '

The figures given of the Eoyal Maternity Charity may be re-
garded as trustworthy and accurate. They are under the control
and supervision of the Registrar-General of Births, Deaths and
Marriages, and it is well known that this functionary watches

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deaths of mothers in childbed with the most zealous care. The
conclusions at which I arrive are:

(1) As regards symphysiotomy I consider that the operation
has not justified its existence, and I cannot help thinking that in
a few years the eminent obstetricians who have been advocating
it, will abandon its use.

(2) Induction of premature labor, within certain limits, will
always hold a recognized and useful position among obstetric

(3) And lastly we are forced to the conclusion after a careful
study of the latest figures which have been published on Csesarean
section, that it is a scientific and justifiable operation, and that it
will be more widely resorted to in the future, as the science of
obstetrics advances, than it has been in the past.


Ever since 1877, when Bouchard and Gimbert revived the
use of creosote in the treatment of tuberculosis, which Reichen-
bach had advocated in 1833, the profession has been making a
more or less extensive use of this remedy. A long list of authori-
ties, including such men as See, Powell, Yeo and Solis-Cohen, are
on record as approving its use. Prof. Sommerbrodt claims that
he has succeeded in obtaining the quantity in the blood which de-
stroys the growth of tubercle bacilli which Guttmann demon-
strated to be one part in two thousand.

Whether this be possible or not, it is certainly true that medical
men generally believe that in some cases benefit has come from
the use of creosote in this dread disease. The great diflSculty has
been to give the drug in large enough amounts or for a sufficient
length of time, for the stomach almost invariably rebels.
Hence the efforts which have been made to attain the same re-
sults by inhalations of subcutaneous injection. Both of these
methods are so irksome to the patient, friends and physician, that
it is with pleasure that all will welcome the combination of Malt-
ine with creosote recently introduced. The value of Maltine in
digestive disturbances is everywhere well known and will, we
doubt not, lead to a wide trial of this new combination. Should
it be proven that sufficient quantities of creosote can thus be ad-
ministered without gastric disturbance, the manufacturers will
have placed us under other and still greater obligations than

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Third Session, Amffterdain, Aujr. 8-12, 1899.




Walcher's paper, published in 1889, on the variability of the
conjiigata vera, being of practical interest, gave a new direction to
previous researches on the mobility of the pelvic articulations. I
feel obliged to state here, that, according to some authors, the merit
of having made practical use of the current ideas concerning the
mobility of the pelvic articulations is not due to Walcher, the po-
sition he describes having been recommended in difficult labors,
by Scipione Mercurio (1595) according to some, by Sebastian
Melli (1721) according to others." Allowing the question to pass
whether Melli might possibly have copied the design of Mercurio,
I wish to observe that neither the one nor the other can have had
in view enlargement of the pelvic dimensions, as in their day the
mechanism of the sacro-iliac articulations was unknown. More-
over it ought to be said that though the positions described by
Mercurio and Melli have some analogy with Walcher's, there is
nevertheless a fundamental difference, as in the former the lower
extremities of the woman are always supported, whilst in the latter
they are hanging, and by their weight draw the anterior pelvic
ring downward and forward. I have examined 62 women during
the puerperal state, successively in Melli's and in Walcher's posi-
tion. In 17 cases exact mensuration of the diagonal conjugata
gave no difference, in the other 45 cases there was a difference
from one to eight millimeters in favor of Walcher's position. Re-
searches on five feminine cadavers gave the same result for the
conjugata vera. Therefore I think, and Pestalozza is of my opin-
ion, that the position with hanging thighs, ought to bear Walcher's

Changes in the pelvic dimensions. — Antero-posterior dimenr
sions. When a woman is placed on a table, with the head and

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shoulders slightly elevated and the buttocks somewhat projecting
beyond the edge, a cushion being placed under the sacrum, the
thumbs being placed on the superior iliac spines, whilst an assist-
ant places the lower extremities first in the lithotomy and then in
the horizontal position, finally abandoning them to their weight,
the following is observed.

The iliac spines describe part of a circle in a forward and down-
ward direction, the lumbar lordosis increasing at the same time.
Moreover, when the lower extremities being in complete extension
are allowed to hang downwards, the iliac spinal action continues
without the lumbar lordosis being further increased. There is
first an increase of pelvic inclination, limited by the tension of the
ligamentum longitudinale anterius and the intervertebral joints.
By this tension the sacrum is fixed. The anterior pelvic arch be-
ing drawn further downward, the effect will not be perceived for
the entire pelvis, but only for the iliac bones, which change place
in the sacrum. The transverse axis for the movement of the iliac
bones lies behind the second sacral vertebra. This axis being situ-
ated under the promontory, the symphysis must be removed from
the promontory by the rotation, whilst it approaches the point of
the sacrum; the sagittal diameter of the brim being.consequently
increased and that of the outlet diminished. This action of the
iliac bones is limited partially by the sacro-iliac articulations,
partly by the posterior ligament, and somewhat by the muscles of
the abdominal wall and by the psoas.

I need not say that pregnancy will be, generally, favorable to
this dislocation of the iliac bones, but I ought to add that indi-
vidual conditions may diminish, even in pregnant womeji, this mo-

At the present moment there is no doubt that the conjugatavera
increases progressively, when a woman is brought successively in
the lithotomy position, the obstetrical position and Walcher's po-
sition. Difference of opinion exists only as to the degree of the
augmentation. According to the researches of Walcher, Diihrs-
sen, Fothergill and Kiister, the increase of the conjugata varies
from eight to fifteen millimeters. Of those who object to those
elevated ciphers I quote Vamier, who says that there ought not to
be made a comparison between the dimension found in the lith-
otomy position, never used in obstetrics, and that of Walcher, but
between the measures found in the latter and in the obstetrical

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position. In this way an increase of two or three millimeters ad
maximum can be obtained, according to his researches. Later ex-
periments of Fehling contradict partially Vamier's pessimism.
The results of cadaver-experiments by Walcher, Klein^ Vamier
and Pinard, and Kiittner being incongruent, and on the other
hand the clinical observations of Kalt, Wehle and others, showing
a considerable increase, I resolved to make some researches for

In 102 women, nearly all in the second week after confinement,
and the others in an advanced state of pregnancy, I have measured
with the finger with the utmost exactness, the diagonal conjugata
in the lithotomy position, in the obstetrical position and in Wal-
cher's position. By the change of the first position into the third
I have found an increase in the average of 7.5 millimeters, maxi-
mum 17, minimum 2 mm. Between the first and the second posi-
tion the difference was on the average 1.9, maximum 5, minimum
nmi. Between the second and the third position (101 cases) the
average of the increase was 6.1, maximum 12, minimum 2 mm.

The mensuration in the five female bodies gave smaller diflFer-

Is it true that the increase of the conjugata vera corresponds ex-
actly to that of the diagonal conjugata. According to Klein the
conjugata vera is less, according to Kiittner more increased than
the diagonal conjugata. In the five bodies I examined the dif-
ference between conjugata vera and conjugata diagonalis was the
same in all three positions.







Walchee memorizes the ancient doctrine, taught by Ambroise
Par6 and Severinus Pinacus, i. e., the expansion of the pelvis dur-
ing labor. This doctrine, contradicted by Andreas Vesalius was
finally refuted by Hendrik van Deventer, the founder of the doc-
trine of the contracted pelvis. Since his time the pelvis is consid-
ered as a solid ring, as long as the symphyses ar6 intact. In 1804

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van Wy gives as his opinion that the base of the sacrum is dislo-
cated backwards after symphyseotomy, whereas G. Vrolik, in
1807, defended an opposite view.

Luschka proved (1850) that the pelvic joints are real articula-
tion, pregnancy and labor increasing their mobility by the juici-
ness of the cartilages and ligaments.

Next, H. Meyer (of Zurich) has proved that rotation of the iliac
bones on a transverse sacral axis is possible, nnd Korsch demon-
strated, in his thesis (1881) that the pelvic dimensions may be aug-
mented up to 3 — 10 millimeters.

The researches of Budin and Balandin, on living women, prove
a mobility of the pelvic articulations, allowing an enlargement of
the pelvic dimensions, although almost insignificant in the brim.

Walcher then mentions his own researches, begun in 1885 on
dry pelves, in which he found that the antero-posterior diameter
of the brim is changeable, as soon as the sacro-iliac articulations
allow however slight a movement. He could not continue his re-
searches until 1889, and then he perused them in vivo. He
started from the idea that it might be possible to obtain an en-
largement of the conjugata vera, if the iliac bones could be made
to rotate forward and downward. To obtain this rotation he made
use of the thighs as a lever. As the ligaments of Bertini prevent
an excessive displacement of the femora with regard to the iliac
bones, these will be obliged to displace themselves, and to make a
rotation as soon as an effort is made to exceed the limit formed by
the Bertini ligaments. When the sacrum is fixed, an enlarge-
ment of the antero-posterior diameter will be obtained in this way.

Walcher's ideas were confirmed by his researches. He could
make the conjugata vera vary about eight millimeters, and he pub-
lished his results in the Centralblatt fiir Gynaekologie, 1889, No.

When a woman at full term is placed on the border of a table
in such a way that the thighs are lifted against the abdomen, the
promontory is more easily to be reached than in the dorsal posi-
tion. In six cases the length of the diagonal conjugata was

by Froschle, I para, 10.3 centimeters.

Brockel, II para, 10.2 centimeters.

Stockburger, IV para, 10.2 centimeters.

Heckel, ^ I para, 10.4 centimeters.

Bischoff, IV para, 10.2 centimeters.

Hetzler, III para, 9.7 centimeters.

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Lowering then the thighs as much as possible he found that the
promontory was dislocated backwards. Subsequent measure-
ment then gave the following result:

Froschle, 11.1 centimeters, i. e., a difference of 9 millimeters,
Brockel, 11.6 centimeters, i. e., a difference of 13 millimeters.
Stockburger, 11.0 centimeters, i. e., a difference of 8 millimeters.
Heckel, 11.2 centimeters, i. e., a difference of 8 millimeters.

Hetzler, 10.5 centimefers, i. e., a difference of 8 millimeters.
Bischoff 11.5 centimeters, i. e., a difference of 13 millimeters.

When the pelvis is only moderately contracted, the promon-
tory cannot be reached when the thighs are lowered.

The diagonal conjugata is therefore not a constant, but on the
contrary a variable dimension.

He could demonstrate this variability in a woman who died of
eclampsia and found a variability of the conjugata vera of eight

The publications of Zalasky and of G. Klein confirmed the es-
sential part of Walcher's results. However, Klein thought he
might substitute the thighs by a weight attached to the anterior
pelvic wall. This is erroneous, because the action of the femora
as levers then fails.. Still Klein found once a difference of eleven
millimeters. The differences stated by Walcher are, on the aver-
age, greater on account of his experiments being made on preg-
nant women, whilst Klein made his experiments on cadavers of
every kind.

The introduction of symphyseotomy (1893) caused new investi-
gations to be made. At the Congress of German obstetricians at
Breslau (1893), Diihrssen and Fehling adopted the position with
hanging thighs, the advantages of which were confirmed by obser-
vations taken in Leopold's clinique by Wehle. Walcher will not
discuss the unparliamentary attack made by Vamier. In the last
years a great number of papers were published, almost all favor-
able for Walcher's ideas.


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For the answer to this question, it will be necessary to first ex-
amine operative results, and we have therefore to discuss, first,
the evolution of antisepsis, the part it has to play and its limita-
tions; second, the important modifications undergone by the tech-
nique in use of late years, and to point out how necessary it is to
be a thorough surgeon, in order to practice surgery with success.


The Development of Antisepsis. With Lister's method began
the revolution, which created the possibility for future perfection
in technique, but it was not flawless, and is not so yet. In the ber
ginning, all danger was supposed to come from the air and from
the invasion of wounds by atmospheric germs. Carbolic acid
then reigned supreme, and this first period has been termed "em-
pirical," — not entirely without reason. Afterwards came a time
of more exact researches into the various causes of infection and
the preventive measures to be adopted. Morphological investi-
gation and experiments in vitro, became the law. This was the
era of scientific credulity, when nothing more was aimed at, be-
yond making use of the best laboratory-antiseptic for sick-room

It was not longj however, before the discovery was made, that
the very best antiseptic in vitro, does not retain its value for clini-
cal purposes, and that laboratory prognoses were not always to be
relied upon. It was found that the use of antiseptics was not only
inefficient but at times dangerous. Hence, it gradually became
more or less discredited, whilst sterilization by heat has been daily
gaining favor. This brings us to the present time.

The utilization of heat for the destruction of germs, and for
sterilizing instruments and dressings, originated with Pasteur and
has well nigh attained perfection; its assistance in the struggle
against infection is not to be denied.

Should it be considered as a new method? It is asserted to be so,
by a class of surgeons who own that antisepsis has been exchanged

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for asepsis. It strikes me that here must have been confusion of
ideas. Asepsis is the aim, antisepsis the way. Heat has been sub-
stituted as much as possible, for powders and solutions, but heat,
in itself, is only the most powerful antiseptic. I will therefore
continue speaking of the "antiseptic" method. Moreover heat is
not adaptable to all purposes, and we cannot do without other
antiseptics as well.

It cannot be asserted that the utilization of heat has simplified
matters. On the contrary, sterilization can only be obtained bv a
very complicated and eiixpensive apparatus, demanding the most
careful manipulation.

It is a great mistake to suppose, as some do, that so-called asep-
sis is nothing more nor less than ordinary cleanliness; we can
safely aver that the continual effort to attain asepsis by every
means, has brought forth the most admirable results.

The boundary line of antisepsis must now be traced. We are
enabled, to a certain extent, to prevent ourselves from carrying
infection to our patients, but as personal asepsis does not destroy
the existence of bacteria, we are fighting with unequal weapons
against preexistent infection. For instance, if in course of ab-
dominal salpingotomy, the purulent sack should burst, "contami-
nating the peritoneum by its contents," if the matter be particu-
larly infectious, the patient will die, whatever may be done to
avoid fatal results. It can, however,, also happen that when in
similar cases, the focus be carefully cleansed and drained
with gauze, the patient recovers, after a few bad days. How are
we to explain this? It may be that the pus was less virulent; or
that the organism defended itself, no share in the recovery being
due to ourselves.

This notion concerning the powers of self-defence in the organ-
ism has rectified the absolutism of the earlier ideas on the subject
of micro-organisms (the specific gravity and degrees of virulency
in microbes). Bacteriologists have acknowledged its importance,
and shown its mechanism, by demonstrating phagocytosis. The
living organism is able to defend itself, it beats off attack, when
not in a debilitated condition, and armed with all its resisting-
power. If this is not the case, hope is lost. We should not ex-
pect too much from 'datura medicatrix," and when in an en-
feebled condition should give it the support that is wanted. Su^
gical art is now called upon, and the importance of technique

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stands revealed. Antisepsis is the same for everyone and de-
mands only passive obedience to certain rules. On the contrary,
technics vary, and are subject to personal aptitude.

The value of antisepsis is, within narrow limits, absolute; the
value of the technics is relative and unlimited. It depends on the
operating hand and on the directing head.

Evolution of Technique. The great technical improvements
have been rendered possible by the use of ancesthetics, exact
hemostasis and antisepsis.

Instruments, Amongst the numerous inventions under this
heading, that our time has produced, the greater quantity can safe-
ly be consigned to oblivion. We acknowledge the value of artery
clamps, and are much indebted to the Trendelenburg position, but
as for the rest, we do not place too much reliance on instru-
mentary innovations. The best results are obtained by the sur-
geon who knows how to use his hands and his common sense.

Surgical ability in the widest sense of the term, is comprised in
the three chief qualifications: dexterity, ingenuity and judgment.

Dexterity varies in its nature — some possess the gift by birth,
others never acquire it, and most manage to do so, and to develop
it by practice. Anyone can observe this by himself. An able
surgeon operates quickly, so as to minimize the dangers of a long
operation, i. e., greater chances of infection, hemorrhage, shock,
etc., although quickness of execution should never be allowed to
encroach on careful operating.

The ingenuity of gynecologists has opened several entrances
to the pelvic organs, and taught us various methods of proceeding,
although it must always be remembered that for methods, as for
instruments, excess does not mean riches.

The history of operative treatment of pelvic diseases, fibroids
and Uterine cancer, etc., shows how important is the choice of the
Operative Way. To make sure of selecting well, we must have
broad views on the subject. *^ot one of us has the right to be
imperfectly educated.^'

Methods continue to become more and more simplified, and in
that way lies progress. The successive extraperitoneal and intra-
peritoneal treatment of the stump, and total extirpations in the
abdominal operations for fibroid, furnish the example. Another
is found in the application of "pinces a demeure" in vaginal hys-

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Whatever way may be followed, whichever may be the method
chosen, the details of execution will always decide the point. The
true surgeon shows himself, who seems to be operating easily, and
manages to produce the impression that anyone else could do the

Therapeutic Results. — Obviously the best methods yield to the
most favorable results, but it is not to demonstrate this I am now
addressing you, but to speak of the relative value of antisepsis and
technique — assigning to each its share in the final results. I will
not select my examples amongst dangerous operations and merely
remark that, whilst in these many operators ascribe their good
results to antisepsis alone, it is the contrary for minor operations
where the importance of method is greatly exaggerated. The
question concerning abdominal suture and colporrhaphy points to
the conclusion that it matters less what is done, than how.

To conclude, I wish to remark that the union of antisepsis with
improved technique paves the way for conservative gynaecology,
and that in this direction lies the progressive improvement we
hope to attain.







The absolute reliance on the protective power of antisepsis has
been a good deal diminished by exact investigations, as it has been
proved by a whole series of experiments and observations that
elimination of all micro-organisms during the operation, has not
yet been attained.

We can sterilize the instruments and dressings, but no method
has been discovered, at least up till now, that gives us with cer-
tainty, the same result as to the skin of the hands and the part to
be operated on.

A yearns bacteriological research made during a great number
of operations from beginning to end, the skin of the hands as well

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as the operation field, the wound, the instruments, the dressing-
and ligature-material, have given me the following results:

1. There is no way to remove with certitude all micro-organisms
from the hands. The successive use of soap and hot water, of
alcohol, and of a solution of lysol or sublimate, for ten minutes
each, are not suflicient to sterilize the skin with certainty.

For these experiments rigid precautions, as prescribed in
Hagler's method, are necessary to obtain satisfactory results.

Online LibraryErnest Watson CushingAnnals of medical practice → online text (page 64 of 77)