Observations on the use of local anesthesia in gynecologic operations

CHICAGO GYNECOLOGICAL SOCIETY

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bettered, even during these last ten years. Edward Reynolds, in 1907, presented a paper before this Society showing the great advantage of primary over secondary cesarean sections; he has been credited with being the father of the principle that the only safe time for a section was before labor. I feel there may be no question but that the postoperative reaction discomforts are less following low cervical sections in comparison to the classic, but, at times, I have had classic sections on women who had little or no postoperative discomfort. In one woman, on whom I did two sections, there was little or no discomfort, so she refused to remain in bed the allotted time. From the day of operation she wandered about the ward. I reported 92 classic sections in 1922. I analyzed them in this manner: (a) those before labor; (b) those in labor; (c) those in labor with membranes ruptured. Tables were made of the high and low temperatures and high and low pulse rates for ten days, averages were made and from these, average graphs were made. It was clearly evident that there was comparatively little difference between the pictures in these graphs of those not in labor and those who were in labor, but there was a markedly increased postope:tative thermal reaction in those women .whose membranes had been ruptured for a period, even for a short time. After reading my paper one of the audience told me I would not have had such a thermal curve if I had used the low cervical section on all my women, and he is identified with some points which have enormously improved the technic of the operation. He had just before reported a series of low sections. I took the seven eases of his series which had been longest in labor and with the longest period with membranes ruptured, treated them in the manner described above and took my seven worst cases of comparable type. When the graphs were produced. my seven cases showed the low cervicals to be infinitely worse as regards the height of the thermal curves, and the duration of the fever. When I sent this graph to him his comment, in reply, was: "You forget that there is far more tissue traumatism in a low cervical section than in a classic.'' My whole contention is this, there is less peritoneal reaction after a low cervical than a classic, therefore the postoperative disturbances are less than in a classic section. As to the relative safety of the two, this is still a moot question. The classic has one advantage certainly in that it takes less time. The one way to prove the problem is for individual operators to take alternate cases without any selection, and do one series of low cervicals and the other by classic technic. I believe the results would be equally favorable.

F. H. FALLS read a paper on the Observations on the Use of Local Anesthesia in Gynecologic Operations. (For original article sec

DR.

page 310.) DISCUSSION DR. CAREY CULBERTSON.-Dr. Falls has frankly said that he is offering these observations a~ one doing gynecologic work and not using local anesthesia as a routine procedure. In taking up the discussion of this subject, I offer my remarks in exaetly the same way. As a matter of fact, my observations on local anesthesia are those of one who does not use it on every occasion or make a fetish of it or try to make use of it to the exclusion of other methods. My experience with local infiltration anesthesia began years ago when Webster started to do cesarean sections by this method. Prior to that he had done an occasional case in which general anesthesia was contraindicated, an occasional laparotomy ur an occasional low or plastic~ operation. But when he started to do cesarean sections under local anesthesia, it worked so well that he carried it out in a lung series of cases already reported.

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A:M:ERJOAN JOURNAL OF OBSTETRICS AND GYNECOLOGY

In my own experience, I lutve used local anesthesia, preceding the innltration with scopolamine and morphine, using it fir~t in cases in which general anesthesia was contraindicated, but extending indications until confidence was gained, until now it is often a method of choice. Basic technical principles which Dr. Falls haR laid down are those which we have followed for yvhiclt I favor. Unless the paravaginal tissues are well saturated this is apt to he painful. DR. JOSEPH L. BAER.-Having been at Michael Reese Hospital since 1904, I saw some o:f the early work in local anesthesia wltich Dr. L. A. Greensfelder had introduced when he 1·eturned from Europe with the ''Schleich mixture.'' .!<'rout that time on, in the surgical wards, infiltration anesthesia has had vogue until today. In the last few years we have taken up spinal anesthesia. I like this particularly :for gynecologic work. '\Ve find the operative iield is so comp!Ptely exposed, the abdominal musculatme being completely 1·claxeLl and the bowel cviIapsed, that it seems to be the method of choice. In selecting cases :for intiltra· tion anesthesia, we invariably think of cardiacs and nephritics. Here spinal aneRthesia may be just as useful. DR. J. P. GREENHILL.-At the Chicago Lying-in Hospital local anesthesia was employed in 55.1 per cent of the 87 4 cervical cesaTean sections performed from July, 19151 to July, 1929. During the last year 92 per cent of all the c&sarean sections were performed entirely under direct infiltration anesthesia. The latter rather than spinal anesthesia is preferred berause it is safer and has given excellent results. The total mortality for the 87 4 operations was 1.26 per cent and this low mortality at least in part is attributed to the use of local anesthesia. There were only two deaths from pneumonia in this large series and both oceurred after the use of ether. Local anesthesia has been found very helpful in gyne-

PHILADELPHIA OBSTETRICAL SOCIE'I'Y

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cologie work also, especially for plastic operations. In my experience direct infiltration with novocaine solution r11akes dissection of the tissues an easy task. DR. H. 0. JONES.-It seems to me that before deduction can be arrived at a comparison of the mortality and morbidity should be made under the different types of anesthesia. In our service we never ,use spinal or local anesthesia. We are willing to compare our mortality and morbidity under ethylene-oxygen and ether anesthesia with that obtained from either spinal or local anesthesia. Except in a very few selective cases no spinal anesthesia is used and local anesthesia has not been used at all. DR. FALLS (closing).-I should have sa1u ..:;na..:; 've use ten drops of 1:1000 adrenalin to the ounce. We infiltrate the sheath of the rectus and the peritoneum. Dr. Culbertson brought out an important point concerning elderly women. They are especially well adapted to the rnethoU. VVe have seen then1 sleep during a procidentia operation. Concerning the question of its use in episiotomies, we have used it not so much to reduce pain when the incision is made because most of our patients get ether or gas, while the head is coming down, but to have its effects during the repair of the episiotomy when we have discontinued the ether and gas. We have noticed in perineorrhaphies as Culbertson also mentioned, that there is no question but that it takes more novocaine solution than it does in anterior colporrhaphy. Anterior colporrhaphy requires very little to completely anesthetize the area. In order to do a perineorrhaphy an additional injection into the n1uscle is often necessary. I have not mentioned spinal anesthesia in the paper because I do not use it very much. This is a discussion on local anesthesia. It is a study of what happens when you use local anesthesia for various types of gynecologic operations, including the ordinary major abdominal operations with adhesions, which is the factor I was most interested in. Cesarean section should not be done under local anesthesia, unless you have a contraindication for general anesthesia. I see no reason for subjecting the patient to the psychic strain of local anesthesia needlessly. The question as to whether it is ever necessary, as Dr. Jones brought out, is a personal one. He is satisfied 1;vith ethylene and can do anything he wants with it. I feel that is true in the great majority of cases, but there is an occasional case where I feel that local anesthesia is safer. One should understand hov~. . to use it and have considerable experience vr:ith the method so that one will not be handicapped in using it on the case in which it is especially indicated.

PHILADELPHIA OBSTETRICAL SOCIETY STATED MEETING, MARCH 6, 1930

DR. CLrFFORn B. LuLL described a Fetal Monstrosity which presented

an interesting problem in delivery.

(See page 421.)

H. j, TUMEN read a paper (by invitation) entitled The Association of Polycythemia with Occlusion of the Inferior Vena Cava. (For

DR.

original article see page 417.) DISCUSSION DR. EDW_lliD A. SCHUMANN.-The question of secondary polycythemia as the result of the obstruction of the vena cava was an interesting speculation, but