cokrT«H'icVErEi'f|^S£ HX64168182 RG524 R332 Practical midwitery^ RECAP ^(umbia ®nibersiitp in tfje Citp of iJefco gorfe (College of ^i)^iitian& anb burgeons Br. ebtuin |!3. CraQin IS59-1918 Cyfi^X^-yxxjO^iyU^^ %,%. Digitized by tine Internet Arciiive in 2010 witin funding from Open Knowledge Commons http://www.archive.org/details/practicalmidwifOOreyn PRACTICAL MIDWIFERY A HANDBOOK OF TREATMENT EDWARD REYNOLDS, M.D. Fellow of the American Gynecological Society, of the Obstetric Society of Boston, etc.; Assistant in Obstetrics in Harvard University; Physician to Out-Patients of the Boston Lying-in Hospital, etc., etc. WITH ONE HUNDRED AND TWENTY-ONE ILLUSTRATIONS NEW YORK AVILLIAM WOOD &: COMPANY 1892 Copyrighted, 1892 WILLIAM WOOD & COMPANY PEEFACE. "\ 1 riTH all the literary activity which has of late prevailed in * obstetrics, it is a curious fact that there has hitherto been no attempt to render the technical details of obstetric practice readily accessible to the student. The necessity of making the general principles of treatment intelligible to the dullest reader, of course, compels the more extended text-books to omit its minor details, and a five-years' experience in the superintendence of the practical work of the advanced students of the Harvard Med- ical School, in their daily attendance upon by far the largest ob- stetrical clinic in America, has fully demonstrated to me the im- portance of this deficiency in our literature. This volume is the result of that experience, and is an attempt to furnish to students and inexperienced practitioners a full description of those prac- tical details of conduct which are necessary to the management of every case of gestation, labor, or the convalescence therefrom. It further aims to supply to such men a concise description of at least one method of dealing with each of the emergencies of ob- stetrical practice. If it appears to settle moot points of practice dogmatically, and without privilege of jury, the fault has been intentionally committed, in the belief that a clear description of one justifiable plan of treatment is likely to be of more immediate benefit to an inexperienced practitioner than an extended discussion of the rela- tive advantages and disadvantages of many methods; and be- cause the book is mainly intended for the use of those who have already assimilated the more comprehensive but perhaps less definite information, which it is the province of the systematic text-books to supply. I have thought it best not to embarrass so elementary and un- pretentious a work with a load of bibliography and citations of iv PREFACE. authority. t>ut I uiu plad to take the opportunity of acknowledg- ing here ujy obligations to the works of Lusk, Cazeaux, Schroder, and Galabin; to the authors of Hirst's American System of Ob- stetrics; and to many others whose jjast labors have aided me in my own. My thanks are also due to Drs. R. W. Lovett and C. W. Town- send, for much kind assistance in the revision of the manuscript and its preparation for the press, and to Dr. F. H. Brown for the preparation of the index. Boston, May 20th, 1891. CO:^TEE"TS. PREGNANCY. CHAPTER I. Diagnosis of Pregnancy. PAGE Histoiy and inspection of tlie patient. — Examination of the abdomen and breasts. — Vaginal and bimanual examination. — Diagnosis of tlie stage of pregnancy in months. — Diffei'- ential diagnosis between pregnancy and abdominal tumors. — Pregnancj' complicated by tumors. — Tumors complicated by pregnancy, 1 CHAPTER n. Calculation of the Duration of Pregnancy, and the Devel- opment OP the Fcetus in the Successive Calendar Months OF Pregnancy. Calculation of the duration of pregnancy. — Prolonged preg- nancy. — Development of the foetus by calendar months, . 14 CHAPTER III. The Functional Disorders of Pregnancy, and the Manage- ment OF Normal Pregnancy. Hygiene and care of pregnancy. — Special disorders of the several organic systems during pregnancy— the circulatory, diges- • tive, urinarj', nervous, and locomotive systems, . . 19 CHAPTER IV. Intercurrent Diseases in Pregnancy, Vai'iola. — Scarlatina. — Rubeola. — Erysipelas. — Typhoid. — Pneu- monia. — Pleurisy. — Phthisis. — Cardiac diseases. — Cholera. — Intermittent fever. — Icterus. — Syphilis. — Hysteria, . . 41 CHAPTER V. The. Obstetric Complications op Pregnancy. Hydatidiform mole. — Extra-uterine pregnancy. — Abortion, mis- carriage, and premature labor. — Fibrinous mole. — Malposi- tions and abnormalities of the uterus. —Diseases of the ovum, 47 vi CONTENTS. LABOR. CHAPTER VI. Classification of Labor. Diagnosis of Presentation and Position. PAGE Classitication of labor. — Normal and abnormal, natuial and unnatui'al. — Vertex, brow, face, breech, footling, and trans- verse. — Diagnosis of jjresentations and positions. — Abdom- inal inspection, palpation, and auscultation. — Diagnostic signs by presentations, 69 CHAPTER VII. Antisepsis and Preparations for Labor. Antisepsis. — Importance. — Technique. — In tenement-house prac- tice. — Preparations for labor. — The lying-in room. — The ob- stetric bag. — Preparations for delivery. — Bed. — Dress of the patient, 83 CHAPTER VIII. Normal Labor. Physiology and mechanism of labor in anterior positions. — Man- agement of normal labor, occiput anterior. — Fii-st stage. — Second stage. — Preservation of the perinseum. — Delivery of the body. — Third stage. — Duties after labor. — Care of child, 91 CHAPTER IX. Delayed Labor. General principles of the management of difficult or delayed labor in the anterior positions of vertex presentations. — Ex- haustion of the foetus. — Exhaustion of the mother. — Uterine exhaustion. — Bandl's ring. — Constriction rings. — Delayed 8i"st stage. — Inertia uteri. — Rigidity of the os. — Delayed second stage. — Inertia. — A rrest from increased resistances. — * Choice between version and forceps. — Delayed third stage, 115 OBSTETRIC SURGERY. CHAPTER X. Preparations for Operation. Artificial Dilatation of the Os. The Induction of Abortion, Miscarriage, and Prem.\ture Labor. Antisepsis. — Anaisthesia. — Position of the patient. — Catheteriza- tion. — Artificial dilatation of the os. — Barnes' bags. — Manual dilatation. — Induction of abortion, miscarriage, and prema- ture labor. — JustiDcation. — Prognosis. — Technique, . . 135 CONTENTS. Vll CHAPTER XI. Forceps. PAGE Choice of forceps. — Short forceps. — Long forceps. — Axis-traction forceps. — Forces of the forceps. — Anaesthesia. — Conditions which justify tlie application of forceps. — Contra-indlcations. — Low forceps. — Prognosis. — Indications. — Technique. — High forceps. — Prognosis. — Indications. — Technique. — Ap- plication of axis-traction forceps, 148 CHAPTER XII. Version. Pelvic version. — External method. — Cephalic vei'sion. — Exter- nal method. — Bipolar method. — Podalic version. — Bipolar method. — Internal method. — In head presentations. — In transverse presentations. — Difficulties and complications of version. — Indications for version. — Contra-indications, . 169 CHAPTER XIII. The Destructive Operations. Craniotomy. — Indications. — Instruments. — Craniotomy to the fore-comiug head.,— To the after-coming head. — In face pres- entations. — Decapitation. — By Braun's hook. — By Rams- botliam's knife. — By the combined use of these instruments. — By the kuife-ecraseur. — Exenteration, .... 186 CHAPTER XIV. The Abdominal Operations. Cjesarean Section. Porro-Muller Amputation. Laparo-elytrotomy. Indications for the abdominal delivery. — The three operations. — Prognosis of each. — Technique of each. — Choice between them in individual cases. — Sterilization dui-ing the section, 196 ABNORMAL. LABOR. CHAPTER XV. Labor in Posterior Positions of the Vertex.* Physiology and mechanism of labor in posterior positions of the occiput. — Management of posterior positions. — Operative treatment of high arrest of tiie head in posterior positions. — High forceps in posterior positions. — Management of the low head in posterior positions. — Promotion of flexion and rotation. — Reversed forceps. — Low forceps in posterior posi- tions. — Low forceps in persistent posterior positions, . 208 * See foot-note to page 208. VIU CONTENTS. CHAPTER XVI. Abnormal Presentations. Brow, Face, ani> Transverse Pres- entations. Prolapsed Extremities. PA(iK Brow presentations. — Meclianism. — Prognosis. — Management. — Much-moulded brows. — Unmoulded bi-ows. — Face presenta- tions. — Mechanism. — Prognosis. — Management. — Chin an- terior, high and low. — Chin posterior, high and low. — Breech presentations. — Mechanism. — Prognosis. — Management, — Natural breech labor. — Rapid extraction of the breech. — Methods, high and low. — Extraction of the body. — Difficult extraction of the after-coming head and arms. — Manage- ment of footling presentations. — Transverse presentations. — Mechanism. — Prognosis. — Management, — Pi-olapsed ex- tremities, 221 THE PATHOLOGY OF LABOR. CHAPTER XVII. Contracted Pelvis. Intra-pelvic Tumors. Atresia. Contracted pelvis. — Diagnosis. — Simple flat. — Generally con- tracted flat. — Justo-minor. — Treatment. — Estimation of size of child. — Classification by degrees of deformity. — Intra- pelvic tumors. — Fibro-myomata. — Ovarian cysts. — Vaginal hernia. — Vesical Calculi. — Pelvic exostoses. — Atresia va- ginte. — Atresia Uteri, 244 CHAPTER XVIII. Eclampsia. Pathologj'. — Premonitorj' Symptoms. — Description of the at- tacks. — Prognosis. — Treatment. — Prophylaxis. — Treatment during pregnane^'. — During labor. — Puerperal eclampsia, . 264 CHAPTER XIX. Hemorrhages Before and After Delivery. Placenta Previa. Concealed Accidental, and Post-partum Hemorrhage. Placenta prsevia. — Classification. — Prognosis. — Diagnosis. — Treatment. — During pregnancy. — In labor.— Method in- fluenced bj' variety of praivia. — Concealed accidenal haemor- rhage . — Etiology. — Prognosis. — Diagnosis. —Treatment. — Post-pailum liajmorrhagQ. — Haemorrhage from lacerations. Diagnosis. — Treatment. — True post-partum haemorrhage. — Treatment. — Prophylaxis. — Arrest of haemorrhage. — Treat- ment of collapse from luemorrhage. — After-care, . . 271 CONTENTS. IX CHAPTER XX. The Accidents of Labor. PAGE Presentations of the funis.— Prolapse of the funis.— Short funis. — Sudden death of the mother during or after labor.— Car- diac disease.— Inversion of the Uterus. — Rupture of the Uterus. — Vesico-vaginal Fistula:. — Lacerations of the Cervix. — Lacerations of the perina3um. — Rupture of Blood- vessels and emphysema, . 289 CHAPTER XXL Multiple Pregnancies. Abnormalities and Malformations of THE FcETUs. Accidents to the Fcetus. Multiple pregnancies. — Conduct of labor. — Locked heads. — Abnormalities of the foetus.— Monstrosities. —Anencephalia. — Imperforate anus and i-ectum. — Meningocele. — Encephalo- cele.— Spina bifida. — Hydrocephalus. — Composite monsters. — Other abnormalities. — Accidents to the Foetus. — Asphyxia neonatorum. — Forceps marks. — Facial pax-alysis. — Fractures of the skull.— Meningeal haamorrhages.- Fractures of the arms. — Of the thighs, . 309 THE PUERPERITJM. CHAPTER XXIL Normal Convalescence. Rest and quiet. — Binder. — Position in bed. — Post-partum chill. — After-pains. — Ventilation. — Cleanliness. — Ana3mia. — Routine of treatment. — Diet. — Bowels. — Micturition. — Breasts. — Uterus. — Lochia. — Visits. — Length of puerperium, 326 CHAPTER XXin. The New-Born Child. Care of the normal infant. — Selection and care of wet-nurses. — Artificial feeding. — Diseases and malformations of the new- born child, ...... . ... 338 CHAPTER XXIV. Care of Premature- Infants. Prognosis. — Care of seven-months children. — Of eight-months children. — Maintenance of body heat. — Food. — Gavage, . 351 X CONTENTS. CHAPTER XXV. h.emorrhaoes. pelvic compucations of the t'onvalescekce. Intercurrent Diseases. PAGE Secondary ha?moiThages. — Placenta succenturiata — Fibro- mj'oniata. — Vulvo-vaginal thrombosis. — Suljinvolution. — Malpositions. — Cellulitis. — C^'stitis. — Hiomorrhoitls. — Pneu- monia. — Scarlatina. — Erysipelas.— Malaria. — RheumatLsm. — Delirium tremens. — Diseases of the urinary system, . 357 CHAPTER XXVI. Diseases of the Breasts. Galactorrhcea. — Scanty secretion. — Sore nipples. — Phlegmons and abscesses. — Varieties. — Treatment. — Operative treat- ment. — Arrest of lactation. — Galactocele. — Milk fistula, . 368 CHAPTER XXVII. SEPTic.a:M:iA. Symptomatology and diagnosis. — Treatment. — Local. — Consti- tutional. — Septic peritonitis. — Phlegmasia alba dolens, . 38o CHAPTER XXVm. The Insanity of Gestation. Etiology. — Insanity of pregnancy. — Of parturition. — Of the puer- perium. — Of lactation. — Pregnancy of the insane, . . 397 LIST OF ILLUSTRATIOl^S. PIG. PAGE 1. Diagram of Schultz, 15 2. Binder for pendulous abdomen, 40 3. Hydatidiform mole, 47 4. Fibrinous mole, 60 5. Positions of examining hand, 77 6. Sliape of anterior and lateral fontanelles, .... 79 7. Charts illustrating the value of antisepsis, .... 84 8. Diagrams illusti-ating the action of the membranes in dilating the os, 93 9. Diagrams illustrating the mechanism of rotation in anterior positions, 95 10. Diagram illustrating the mechanism of expulsion, . . 96 11. Expulsion of the shoulders ,97 12. Position of tlie hands in tying the funis, .... 109 13. Credo's method of expi-ession, 110 14. Retraction of the uterus, 118 15. Bandl'sring, 119 16. Constriction i-ing about the neck, 120 17. Introduction of the second finger in manual dilatation of the OS, 140 18. Method of fastening the intra-uterine bougie in place, . 145 19. Sawyer's forceps, 14S 20. Forceps of Levret and Smellie, 148 21. Forceps of Hodge and Wallace, 149 22. Forceps of Simpson and Elliott, 149 23. Axis traction, 151 24. Tarnier's axis-traction forceps, 151 25. Breus' forceps, 153 26. Diagram of forces illustrating axis-ti'action, . . . 152 27. Reynolds' axis-traction rods applied to the Vienna forceps. 153 28. Introduction of the forceps, 158 29. Method of grasping the forceps, 160 30. Position of the operator during the perineal stage of for- ceps operations, 1C3 XU LIST OF ILLLSTUATIONS. KKi. 81. DiajjTiain of the position of the blades in oblique apphcu tions at tho superior strait, 32. First stage of bipolar vei*sion, ..... 33. Second staj^e of bipolar version 34. Second part of first stage of bipolar version, wlien th head is extended, 35. First part of second stiige of bipolar version, when th head is extended, 36. Third stage of bipolar version 37. Method of grasping the foot, 38. Neglected transverse presentation, .... 39. Indirect method of seizing a foot, .... 40. Direct method of seizing a foot, 41. Direct nietliod of seizing a foot, 42. Version by combining traction on the foot with upward pressure on the occiput, 43. An expedient in transverse presentations, . 45. Simpson's craniotomy scissors, 46. Braun's cranioclast, 47. Wire of decollator adjusted for craniectomy, 48. Braun's decapitating hook. Ramsbotham's knife, 49. Reynolds' decollator, 50. Suture of uterine wound, . . . . 51. Diagrams illustrating the difficult entrance of posterior positions, 52. Diagrams illustrating the mechanism of rotation in pos terior positions, ........ 53. Diagram illustrating the mechanism of expulsion, face to pubes, 54. Diagrams showing the correct and faulty methods of as suming tlie genu-pectoral i)osition, .... 55. The vectis, 56. Application of reversed forceps, 57. Method of applying traction in low-forceps operations in posterior positions 58. Motion of the handles of tlie curved forceps during the i"o tation of the head 59. Diagram showing the effect of the compressive force of the forceps in promoting rotation, 60. Moulding of the head in brow presentations, 61. Mechanism of rotation in posterior positions of the face, 62. Lateral flexion of the trunk during the expulsion of the breech, ......... 63. Proper and improper direction of traction upon the thigh, G4. C'atheter threaded for use as a porte-iillet, . LIST OF ILLUSTRATIONS. Xlil FIG. PAGE 65. Method of grasping the pelvis, 233 66. Combined traction upon face and shoulders, . . . 234 67. Deventer's method of extraction, 235 68. The Prague method, first stage, 238 69. The Prague method, second stage, ..... 239 70. Tlie Prague method, chin to the front, .... 240 71. The pelvimeter 246 72. The normal inclination of the symphysis pubis. Diminution and inci'ease of the angle between the sj'mphysis and the pelvic brim, 247 73. Variation in the subtraction for the calculation of the true conjugate, 248 74. Characteristics of the simple flat pelvis (diagrammatic), . 248 75. Characteristics of the generally Qontracted flat pelvis (diagrammatic), ......... 249 76. Characteristics of the justo-minor pelvis (diagrammatic), . 249 77. Diagrams illustrating the difference in the configuration of the head when extracted by forceps and version, , . 254 78. Apparatus for hot-air bath, 270 79. Suture of bleeding vessels in the cervix, .... 281 80. Closure of the sinuses in a retracted uterus, . . . 281 81. Patulous condition of the sinuses in a relaxed uterus, . 281 82. Bimanual massage of the uterus, 284 83. Use of the catheter as a funis repositor, .... 291 84. Inversion of the uterus, 295 85. Replacement of the inverted uterus, first method, . . 296 86. Lusk's method, 296 87. Noeggerath's method, 296 88. Perineal laceration of the first degree, 299 89. Diagrammatic section through a laceration of the second degree, . 300 90. IMuscular retraction of laceration of the second degree, . 300 91. Typical laceration of the second degree; diagrammatic representation of the same, 301 92. Diagram of a tear of the second degree after retraction, . 301 93. Laceration of the third degree, 302 94. Suture of a laceration of the first degree, .... 302 95. First step in the suture of lacerations of the second degree, 304 96. Second step in the suture of lacerations of the second degi'ee, 304 97. Rapid method of repairing a laceration of the second de- gree ; view of the completed suture, .... 305 98. Insertion of the rectal sutures in a laceration of the third degree, 305 99. First variety of locked heads in twins, 811 100. Second variety of locked heads in twins, . . . .311 XIV LIST OF ILLUSTKATIONS. no. PAGE 101. Sylvester's method of artificial respiration, . . . 319 102. First position ill Scliultze's nu'tliud 320 103. Second position in Scliultz»rs method, 320 104. First position in the author's method 321 105. Second position in the author's nx.'thod, .... 332 106. Lateral pressure on anterior thigh during expulsion of a posterior position of the breech, 324 107. Credo's incubator 353 108. Tarnier's incubator, 354 109. Mi-s. Bailej''s breast pump, 370 110. Acme nipple shield 370 111. Fii-st motion in massage of breast, 376 112. Second motion in massage of breast, 376 113. Diagram of Garrigues' breast bandage. .... 377 114. Garrigues' breast bandage in position, 377 115. Boston Lj-ing-in Hospital breast bandage, .... 378 116. Dr. Cliadbourne's breast bandage, 379 117. Crepe-lisse dressing for breast, 380 118. Diagrammatic section of a parenchymatous abscess of the breast, 382 119. Bozeman's double-current intra-uterine catheter, . . 389 120. Position of the simple tube in intra-uterine irrigation, . 389 121. Mund6's placental curette 39] PRACTICAL MIDWIFERY. PAET I.— PEEGl^ANOY. CHAPTER I. DIAGNOSIS OF PREGNANCY. The diagnosis of pregnancy during the earlier months is diffi- cult and sometimes impossible, even when the fullest examination has been allowed, and after all the resources of the specialist have been exhausted; but during the later months it becomes pi'ogressively easy, until at term and in uncomplicated cases a mistake is rarely excusable. " The signs from which a diagnosis of pregnancy can be made, may be divided into three classes, those obtained from the history given by the patient, from inspection of* the exposed breasts and abdomen, and by the vaginal and bimanual touch. Such information as can be obtained from history and from ordinary inspection without derangement of the clothing, is at- tainable in all cases, but is never sufficient for a positive diagnosis, both on account of the inherent weakness of subjective evidence and because the rational signs of pregnancy are so well known to the laity ; and, moreover, because the patient so frequently has an object to gain by deception. Vaginal examination, digital and bimanual, may afford the means of making a positive diagnosis, in exceptional cases, as early as the end of the eighth week ; and the proof so obtained usually becomes positive by the end of the third month, at all events if the physician is given the opportunity of making re- peated examinations ; but the practice of this method of physical examination is rarely to be advised unless the circumstances of the patient render the attainment of an early diagnosis of great, social or medico-legal importance. I 2 PKACTICAL MIDWIFERY. Kxniiiiiiation of tlie Ijrejusts Jiiui abdomen occupies a middle position between the other methods, both in vahie and jxccessi- l)ihty. At the latter end of i)re^;naney, inspection, palliation, and auscultation of the abdomen, in connection with the signs furnished by the breiusts, will usually permit of a positive diag- nosis, and can then usually be obtained. In the early stages of pregnancy, up(jn the other hand, this examination Ls apt to excite nearly ;us much opposition as the vaginal touch, and is, moreover, at that period, of far from positive value. The physician's conduct when a diagnosis is a.sked for, must consequently vary greatly in proportion to the varying social status of the patients, and with the stage to which jiregnancy has at that time advanced. AVhen he is consulted early in preg- nancy by married women, who, for one rea.son or another, wish to be assured of the probabilities of their condition, it is .seldom or never wise to propose a vaginal examination, and it is usually best to confine one's self to .such evidence as can be obtained by questioning the patient. It is then, however, necessary in all cases to give an extremely guarded opinion, since it must be re- membered that women who desire children, are peculiarly prone to accejit the most cautious statements as fully equivalent to a positive assurance, and that nothing covers a i^hysician with more widespread ridicule, than a supposed inability to diagnose the pregnant condition; which, moreover, offers for his solution a proljlem which varies from most medical questions, in that the result must always be publicly known. AVhen, however, such patients ask for an opinion at a period Avhen a positive diagnosis can be reached by palpation, i.e., during the sixth and seventh months or later, it is usually easy to obtain the opportunity for such an exannnation, by reminding the patient of the undoubted fact that it is a distinct advance in her interests if her attendant is permitted to assure himself, not only of the fact of pregnancy, but of the presentation, position, and life of the child at as early a period as possible. On the other hand, in the case of a patient whose unmarried condition, or other social circumstances render an early decision a matter of jirime importance, the only course which is consis- tent with wisdom, is to firndy decline to express any shade of opinion without a vaginal examination, which under such cir- cumstances will usually be readily granted. It must, however, be remembered that the diagnosis of pregnancy is always depen- dent upon the coincident appearance of all the symptoms of the condition, rather than upon any one pathognomonic sign, and to attain a knowledge of the relative value Avhich these signs and symptoms possess, it is necessary to study them in detail. PREGNANCY. History and Inspection. Amenorrhcea. — The absence of the accustomed catamenial pe- riod is usually the first sijj^n which attracts the attention of the patient to a suspicion of her condition. Its value is impaired by the fact that it is not uniformly present ; cases being occasionally observed in which apparently normal menstruation occurs throughout the whole or greater part of pregnancy, but the ut- most scepticism is always the best rule of conduct in these cases, which are often of pathological origin, while on the other hand, actual amenoi'rha3a may be due to a variety of other causes. The fact remains, however, that where the patient has been exposed to conception and was jireviously regular in her menstrual habits, the non-appearance of two or more successive catamenia is always strong presumptive evidence of pregnancy. The more usual causes of amenorrhcea when not dependent on pregnancy are chlorosis; and anaemia, whether this be siuiple, or due to the presence of chronic wasting disease such as cirrhosis, phthisis, Bright's disease, etc. In women who are still nursing, or are habitually irregular, the evidence furnished by this sign is, of course, of little or no value. The non-appearance of one or more catamenial periods may also be due to any unusual fatigue or excitement, such as grief, overwork, or the onset of insanity; it is not infrequent among newly married women, as a result of a pelvic excitement caused by the recently adopted marital relation ; and in unmar- ried woman who have imprudently exposed themselves, is often referable to an excessive fear of px'egnancy. Nausea and Vomiting. — An almost equally prominent symjD- tom of pregnancy, and one equally well known to the laity, is the digestive disturbances of the first four months, which usually appear in the form of nausea and vomiting, limited especially to the early hours of the day. This symptom, is however, by no means constant, so that its absence possesses but slight negative importance ; but its presence in connection with amenorrhcea, is, if chlorosis, severe anaemia, and Bright's disease can be excluded, strongly suggestive of pregnancy. Salivation. — The excessive salivation which is sometimes no- ticed is rather less constantly present than nausea and vomiting. Its absence is of even less importance ; its appearance has about the same significance. Breasts. — A sensation of Aveight and fulness in the breasts, and perhaps the appearance to the eye of an increase in their size, are more or less constant accompaniments of pregnancy, the change being commonly better marked in primipanB than 4 PKACTKAL illOWIFEHV. ill iiiultiparsB. The latter patients not infrecjuently dream, dur- ing the early months of pregnancy, that they are nursing a baby. Qi'iCKKXixo. — The perception of the foetal movements by the mother is commonly termed (juickening. If actually present it is of course dijignostic, but this is a point upon which women are prone to deceive themselves, and its presence as a suljjective symptom consequently jm)sscssos but little value; indeed, it has been well said, that probably no woman ever imagined lierself pregnant without feeling distinct foetal movements. It may be I)erceived, especially by women of a sensitive organization, as early jis the middle of pregnancy, and sometimes in the course of the fourth month. Leucorhhcea. — A marked increase in the vaginal .secretions is an almost constant accompaniment of pregnancy, Ijut may be due to many other conditions and possesses little or no diagnostic value. Sexsatioxs During Coitus. — Certain Avomen believe them- selves able to distinguish a fruitful from an unfruitful coitu.s, by their perception during the connection which they believe to have been eventful, of certain i^eculiar, voluptuous, or other sensations which they have never felt at any different time. The value to be placed upon such statements nuist always depend upon the physician's estimation of the particular jjatient's powers of obser- vation. Gait. — If the patient be made to take a few steps under the eye of the physician- close observation of her gait may sometimes furnish evidence of value. Pregnant women are prone to assume a backward pose, and a certain carefulness of step, from a very early period of gestation. Alteration of Figure.— Where the physician has been pre- viously familiar with his patient he may sometimes be able to observe at an early period a characteristic change of figure, which is often of considerable diagnostic importance during the later months. This consists in an enlargement of the breasts, and in an increased antero-posterior prominence of the abdomen with but little corresponding increase in the lateral diameter. In estimating the value to l)e derived from observation of the above list of symptoms, it should never be forgotten that they are all so well known to the laity that many patients are able to construct a history which is most ingeniously calculated to deceive the physician; that their value as evidence is only cunuilative. becoming more and more marked in proportion as a larger and larger number of symptoms are present; and that in early preg- nancy a diagnosis should never be made from this class of symp- toms alone. PREGNANCY. Examination of the Abdomen and Breasts. Breasts. — The changes in the breasts due to a previous preg- nancy are never entirely effaced, and their examination is, there- fore, ordinarily of much greater value in primiparse than in those who have already borne children. The breasts of a virgin con- tain little, if any, glandular tissue which is perceptible to the touch. The nii5i:)les ai'e small, and the skin of the nipples and areolae is of a delicate pink color ; the areolar papillae are not or- dinarily noticeable. With the ado]ition of an active sexual life, the nipples become more prominent, the areolae begin to show a bi'own jDigmentation, the ai'eolar papillae become evident ; and with the supervention of pregnancy, all these changes become much more marked, so that within the first few months, the prominence of the papillae, the distinctive brown discoloration of the areolae and nipples, and the presence to the touch of distinctly glandular tissue are easily distinguished. A few drops of milk may often be expressed from the nipple during pregnancy, but the jjresenee of milk in the breast is not alisolutely conclusive, as it may sometimes, though rarely, be found during puberty and the menopause, exception- ally at the catamenial periods, and occasionally in the presence of uterine or ovarian neoplasms. Abdomen. Inspection. — A certain brown pigmentation of the linea alba is commonly observed in pregnancy, especially in brunettes, but may occur in so many other conditions as to be of little differen- tial value. An increase in the antero-posterior diameter should be perceptible in spare subjects at about the end of the fourth month, the comparatively slight increase from side to side, being an important i:)oint in the diagnosis, since most other enlarge- ments of the abdomen result in a symmetrical increase; a state- ment which is esi^ecially true of the distention from tympanites, which is so frequently seen in women, and against which the physician should be constantly on his guard when consulted upon this suljjeet, by women whose fears or desires have impi-essed them with the belief that they are not improbably with child. Palpation. — Deei^ palpation in the i^ubic regions will often en- able the observer to i-ecognize in the median line the fundus of the uterus, and to distinguish it by its shape, consistency, and median position from ovarian tumors, and other abdominal neo- plasms, since at the end of the eighteenth week the uterus is usually sufficiently enlarged to permit recognition of the fundus by abdominal palpation above the symphysis pubis. In advanced 6 PHACTICAL MIDWIFERY. pret»nanc'y abiloininal palpation luay lu' enrirely sufficient for the e.stabli^hiueiit of a positive diaj^nosis l)y rt'cot^iiition of the char- acteristic slia[)e of the fciitiis. It is always necessary to tlie i)roper i)erformance of this exam- iation that the clotliiny: of the patient should be so far loosened or removed that the whole alxlonien is exposed, or at most cov- ered by a sinj,de thickness of cloth. The patient should lie upon her back and with the knees slightly drawn up, so that the abdo- minal walls maybe rela.xed to the utmost degree possible; the physician should stand by her side, facing toward the feet, and "with a gentle, steady motion should press the ulnar borders of the hands deeply into the abdomen upon each side of the uterus, until the body of the organ is made to rest between the hands. One hand is then held immovable while the other makes inter- mittent i^ressure against the tumor, in the effort to distinguish its contour and consistence. The jDregnant uterus yields to the examining hands a sense of elasticity which closely api^roaches an obscure fluctuation, and which is as much separated on the one hand from the extreme hardness of a fibro-myoma, as its partly solid contents are, upon the other hand, from the uniform resist- ance of an ovarian cyst. If the pregnancy has advanced beyond the sixth month, recognition of the various foetal meudjers can usually he attained, though with less distinctness than in palpa- tion when performed at term. Should the body in question alter its shajje and consistency while under examination, from an ob- long, soft, or elastic mass to a more or less firmly resistant organ, it may be taken for granted that the alteration in question is a contraction of the pregnant uterus, this being one of the most valuable of all the signs which can be gained by abdominal palpation. Detection of the Fcetal Movemexts.— During the latter part of pregnancy, the examining hand often detects the move- ments of the ffotal limbs; but this sign, though valuable, is not cer- tain, as it may be very exactly simulated by irregular and localized spasmodic contractions of the abdominal muscles, especially in hys- terical women, and in those who suspect themselves to be with child, and long for confirmation of their hopes. It may also be imitated by an irregular uterine contraction — a i)henomenon which is more likely to occur in cases where the contents of the uterus are pathological, as, for instance, in hydatidiform mole. AuscULT.VTiON.— This method of examination furnislies us with two points for observation : the .so-called placental or uterine soufHe. and the .'Jounds of the fo'tal heart. The uterine souffle is an intermittent sound, exactly synchron- ous with the mother's pul.se. which is jjrobably due to the in- creased circulation in the uterine arteries, and was formerly PREGNANCY. 7 thought to be pathognomonic of pregnancy, but is now known to occur in many otlier enlargements of the uterus. Its absence is suspicious, in alleged pregnancy, after the fourth or fifth month ; its presence is suggestive, but nothing more. The detection of the foetal heart, beating at a speed in no way allied to the rate of the maternal pulse, is, if observed by the ex- perienced ear, one of the two distinctive signs of pregnancy, since it can exist in no other condition. It has been heard at the end of the fourth month of utero-gestation, but is not commonly per- ceptible before the middle or end of the sixth. It is classically described as resembling the ticking of a watch when concealed beneath heavy bed-clothes, and when once heard is thereafter usually recognized, but except in a few instances, where the double heart sound is clearly perceptible, is not easily described for the benefit of those who are unfamiliar with it. It may sometimes be heard with much distinctness over the greater jjart of the whole abdomen, or may again be limited to a single spot of small extent. It is usually heard over the back of the foetus, and m head presentations slightly below the umbili- cus; and since left positions are decidedly the more frequent, its most common site is along the line from the umbilicus to the left anterior superior iliac spine. It should be listened for at first in the neighborhood of this line, but if it is not heard here, the line of search should be made to sweej) gradually around the abdo- men into the right flank, covering, so far as possible, every inch of the surface. Its absence cannot, however, be fully demonstrated by a failure to hear it at any single examination, since the posi- tion of the child not infrequently so alters the transmission of its heart sounds as to make them inaudible at one time and particu- larly distinct at another. Its recognition can never be positively decided upon unless the observer is able to determine its fre- quency by count, and thus differentiate it from transmitted sounds due to the maternal pulse. The foetal heart may frequently be heard with the naked ear applied directly to the abdomen, but is more easily found by the aid of a binaural stethoscope, which should be furnished with a wide mouth. In the use of the instrument for this purpose, a point of much j^ractical importtince is the fact that the applica- tion of the fingers to the stethoscope is often sufficient to divert the transmission of such feeble sounds as the foetal heart, and thus render them inaudible ; for which reason the mouth of the stethoscope should be moistened to prevent its slipping upon the abdominal walls, and the instrument should be steadied by the motions of the head, without the aid of the hands. The recognition of the foetal heart during early pregnancy by vaginal auscultation has been suggested but is seldou\ practised. I'KACTICAL MIDWIFEKY. Vaginal and Bimanual Examination. Inspection. — By inspection of the vaginal orifice we are en- abled to note two things; firstly: the shape and condition of the hymen, if present; secondly: the coloration of the vagina. In women who have had intercourse the hymen is commonly lacerated, but a crescentic or even an annular hymen may be so distensiljle as to permit the passage of a full-sized male organ without visible laceration, and the existence of a non-distensible hymen with a small orifice is not of necessity absolutely exclusive of pregnancy, as numerous cases of impregnation without pene- tration have been reported. The existence of such a state of affairs would, however, of course, render pregnancy extremely im- prol)able, and if, in such cases, any further examination seems necessary, it should be strictly limited to the bimanual rectal touch, at least until the existence of pregnancy has been demon- strated beyond a douV^t. A blue discoloration of the vestibule and of the anterior jjor- tion of the vaginal wall has been described as present in the ma- jority of cases after the middle or end of the third month, and as absolutely diagnostic of pregnancy and likely to occur in no other condition. It is certainly frequently present, but the ma- jority of authorities are now agi'eed that it not infrequently fails to appear until late in pregnancy, and that it moreover has been found in other and pathological conditions. Its value is then that of suggestion, rather than of evidence. Digital Examination. — The vagina of pregnancy is sou)e- what relaxed, moist, and softened from an early period, but these changes are rarely sufficiently pronounced to furnish evidence of real value. The alterations of the cervix and of the uterine body, however, often supply evidence of the first importance. The index finger, or if the size of the introitus permits, the first two fingers, should be thoroughly greased with vaselin or some other lubricant, and gently passed within the vagina to their full length. They should note in entering, the size and di- rection of the orifice, the firmness of the external parts, the condi- tion of the rectum, Avhether empty or filled with fjeces, the length and width of the vagina, and the amount of its secretion. The palm of the hand should at first be turned upward with the ex- ternal fingers extended across the mons veneris to enable the observer to explore thoroughly the anterior part of the pelvis. The palm should next be turned downward, by rotation of the wrist upon the forearm, and the external fingers allowed to lie between the nates, when liy gentle pressure ui)ward and back- ward, the perinjcum may be sufiiciently retracted to enable the PREGNANCY. 9 physician to note the width and shape of the sacrum, and in contracted i)elves may permit him to reach the promontory. The finger tij^s should then be made to pass slowly forward, until they meet the cervix, which is not infrequently foiind high ui^ and well toward the rear of the pelvis. The shape and jjatency of the external os should now be noted, and the consistency and length of the vaginal portion of the cervix, which during advanced pregnancy becomes distinctly softened and shortened. Its condi- tion, however, always depends largely upon the existence or non- existence of previous pregnancies. The cervix of a primipara preserves its more or less conical shape, and the os is normally small and rounded, but the cervix as a whole is of a softer con- sistency than in the non-pregnant state. The os is seldom or never patulous, and the cavity of the cervix is usually Dccupied by a more or less abundant mass of thick stringy mucus. Among multipara, on the other hand, the external os is usually freely patulous during pregnancy, the finger penetratmg in most cases into the cervix and nearly to the internal os, and in some cases finding that also sufficiently open to permit the finger to come in contact with the membranes, or to detect the foetal head; which latter condition is, hoAvevei", rare in any but advanced pregnancy. By the vaginal touch we are also able to obtain that most val- uable of all evidence, the sign known as ballottement. This is obtained by placing the pulp of the finger in contact with the body of the uterus and vertically below it, then imparting to it a sharp u^iAvard movement and afterward holding it immovably fixed in position. If the uterus be pregnant, the contained foetus, being a little heavier than the amniotic fluid which surrounds it, is urged u^Dward by the impulse of the finger, and in settling doAvn to a dependent position a feAv seconds later, gives to the finger a distinct tap Avhich cannot be simulated under ordinary circumstances by any other condition.^ Ballottement is best obtained by examination while the pa- tient is standing, and its absence can never be considered estab- lished until after an examination in that position; it can then occasionally be obtained as early as the end of the third month, and usually by the end of the fourth. BiMAXFAL Touch. — The combination of the vaginal touch Avith the assistance furnished by pressure from the other hand, constitutes the method commonh' knoAvn as the bimanual. By ' A slightly enlarged and prolapsed ovary, or a small pedunculated, subperitoneal fibroid may furnish a false ballottement; but the existence of these pathological conditions, and their exti'a-uterine situation, should always be detected by the bi- manual touch. 10 PKACTICAL .MIDW iri.JCV. this examination we are enabled to appreciate any alteration in the shape or size of the uterus. An increase of the l)otly of the uterus in all diameters, antero- posterior as well as lateral, unaccompanied by any corresponding increase in the size of the cervix, and combined with the charac- teristically soft and " boggy " feeling of the latter, may sometimes be perceived at the end of eight, or even six weeks of utero- gestation, and though not sufficiently marked at that period to be conclusive, is, when taken in connection with the existence of rational signs, very strong evidence of the existence f)f pregnancy. If circumstances permit the observer to watch the gradual in- crease in size of the uterus from week to week, and month to month, it is often possible to make a fairly positive diagnosis at a comi^aratively early period. The alteration in the shape of tlie uterus known as Hegar" s sign is not difficult of perception, and is of great value. Hegar describes it as an enlargement of the body of the uterus in such a way that this overhangs the cervix, especially in front, as a distinct ridge mai'king the junction of the body and cervix; ac- companied by a distinctly boggy sensation in the lower uterine segment. This alteration should always be sought for, and if found is one of the most important signs obtainable. Ether. — In cases in which the diagnosis is rendered obscure by rigidity, or great thickness, of the abdominal walls, or by involun- tary resistance on the part of the patient, the administration of an aniesthetie will sometimes smooth away all obstacles, and in cases in which the question assumes much medico-legal or other importance this resource should always be called to our aid be- fore a i^ositive opinion is declared. Diagnosis of the Stage of Pregnancy in Months. This can never be more than fairlj'^ approximate, and must de- pend mainly on an estimation of the size of the uterus and child by external palpation, or in the early months by bimanual ex- amination, this sign being taken in connection with such evidence as can be gathered from the history. In the course of the fourth lunar month the fundus of the uterus rises above the symphysis pubis, and in the fifth month it is half way between the symphysis and the umbilicus, which lat- ter point is reached about the end of the sixth. In the eighth month it is nearly half way between the navel and the ensiform cartilage, at the end of the ninth month almost at the cartilage, and in the latter half of the tenth month, conmionly sinks for- ward and downward, until it reaches a point not far distant from that at which it was found at the end of the eighth; this subsi- PREGNANCY. 11 dence is dxie to the passage of the head from the abdomen into the pelvis, and is generally nmch more marked in fa-st than in subse- quent ijregnancies, in which latter the head seldom enters the pelvis until after the beginning of labor. During the later months an experienced observer can fre- quently obtain considerable information by bimanual estimation of the size of the child. Diagnosis of the Previous Existence of Pregnancy. The physician is sometimes called upon to answer the ques- tion as to whether or no a given woman has ever borne a child. The question when it arises is usually of medico-legal importance, and is one which should be answered only after the most careful scrutiny. Its decision must rest uiDon the evidence furnished by inspection of the genital canal, by the bimanual touch, and by examination of the breasts and abdomen. The changes in the nipples and areoljB which have been pre- viously described as characteristic of pregnancy should first be looked for. The existence of fine radiating cutaneous scars, due to previous distention of the breasts, if present, furnishes distinctive evidence. Scars due to the opening of previous mammary abscesses possess the same significance, in the absence of any other reason for their presence. Similar cicatrices in the skin of the abdomen should always be looked for, and in parous w^omen are almost invariably found, at least if the previous pregnancy has advanced as far as the end of the seventh month. ExAMiJf ATio:jf Per Vagi2^am. — If the woman has ever borne a child, a vaginal examination should establish the non-existence of the hymen as such, and the presence of the carunculiB myrti- formes ; more or less relaxation and distention of the whole of the vaginal canal ; the increased size and altered shape of the uterus due to a previous parous condition ; the possible scar of a i^re vi- ous laceration of the perinseum, and lastly, the existence to a greater or less degree of laceration of the cervix — an accident which is avoided by an extremely small proportion of parous women ; indeed the passage of an ovum no more developed than is usual at the third month, frequently leaves a distinctly per- ceptible laceration of the edge of the external os. It is, however, necessary to avoid confounding this last condi- tion with the eversion of the margin of the os, which is some- times seen in virgins who have been the subjects of chronic endo- cervical catarrh ; and it is always w^ell before expressing an opinion of medico-legal importance, to exclude the possibility that a slight laceration may have been caused either by previous treatment of a cervical stenosis or pinhole os, or by the extrac- 12 PKACTICAL MIDWIFERY. tiou of a uterine imlypus or other tumor from a non-pregnant uterus. Differential Diagnosis of Pregnancy. The differentiation of the XDregnant uterus from other abdom- inal tumors can only be made by physical examination, and may occasionally present considerable dilliculty. The establishment of i)regnancy depends upon the decision that the enlargement of the abdomen is due to an enlargement of the uterus, and then that this is due to pregnancy and to no other cause. The oidy tumors whose existence is likely to lead to mistakes are ovarian cjsts, fibro-myomata of the uterus, and the enlarged tube of an extra-uterine i:)regnancy. ' Ovarian Tumors. — An early pregnancy is to be differentiated from a small ovarian cyst only by the bimanual touch, and then frequently requires the administration of an anjesthetic. The diagnosis is to be made by the establishment of the extra-uterine situation of the tumor, and by a demonstration of the unenlarged uterus at its side. In addition, though the consistency of an ovarian cyst varies greatly with the degree of its distention, it is always different from that of the unimpregnated uterus. An ovarian cyst of large size may be distinguished from an advanced pregnancy by the fact that ovarian new growths pre- sent far less defined outlines than the pregnant uterus, and sel- dom occupy the median line; that they ordinarily yield distinct fluctuation, that no fcetal parts can be found by palpation, and no foital heart heard on auscultation of the tumor. Not infre- quently, and especially if the patient is examined in the upright position, the outlines of the non-i^regnant uterus can be perceived by the examining finger below the tumor, though usually in some abnormal position. In case of doubt, the two conditions maj' be differentiated by the difference in the rate of growth, and by the non-appearance of labor at the time when it would have been expected. Fibro-Myom ATA.— Slight enlargements of the non-pregnant uterus from the presence of interstitial fibroids, may sometimes give rise to the suspicion of early pregnancy; the distinctive points are, however, the greater hardness of the uterus when the eidargement is due to the presence of myom.ata, the aV)sence of Hegar's sign, the fact that such a uterus is almost always lisym- nietrical, and tliat the tumors are seldom single and therefore usually present a more or less loViulated outline. Large fibroids may usually be distinguished from advanced pregnancy with the greatest ease by their hardness and irregular • For the differential diagnosis of extra-uteriue pregnancy, see page 52. PREGNANCY. 13 shape, but the complication of jji-eviously existent flbroifls by pregnancy may be extremely difficult of recognition. Pregnancy Complicated by Abdominal Tumors. When pregnancy is complicated by a co-existent and previously unsuspected abdominal tumor, the recognition of the latter be- fore delivery is only possible when it is rendered accessible by being crowded into pi'ominence below the increasing uterine tumor, or when it can be felt as an accessory enlargement in one or the other flank. When such a tumor is already known to exist, any sudden and rapid increase in the size of the abdomen should always suggest the possibility of its complication by an intercurrent pi-egnancy, and should lead to a careful attempt at abdominal palpation of the uterine body. When pregnancy occurs in a uterus already the seat of fibroids, the tumors usually grow with extreme rapidity, but no positive recognition of the complication can be secured until the foetal, heart sounds become audible or ballottement can be obtained. CHAPTER IL CALCULATION OF THE DURATION OF PREGNANCY, AND THE DEVELOPMENT OF THE FCETUS IN THE SUCCESSIVE CALENDAR MONTHS OF PREG- NANCY. The first essential for the determination of the duration of pregnancy is our ability to fix the date of its beginning, but the circumstances of the case are such as to make this practically im- possible in the great majority of cases, and, indeed, even if, in a given case, it can be safely estimated that the i^regnancy has originated from a single coitus of known date, the time of the oc- currence of impregnation may jjrobably vary within somewhat Avide limits. It has been found by observation that the pregnan- cies of animals, in which the date of coitus can be accurately known, vary in duration by an average of about twenty jjer cent of their total length. For these reasons it is usual to calculate the duration of preg- nancy by taking the date of the last menstruation previous to pregnancy as that from which to start the computation. Statis- tics taken from a large number of cases show tnat eighty per cent of all Avomen are delivered at a date within one week of two hundred and eighty days from the close of the last menstrua- tion; the exact day of parturition being probably decided by numerous small, accidental, mental or i:)hysical causes. But as most women are uaore exact in their account of the day on which menstruation begins, it is customary to estimate the duration of pregnancy by the addition of two hundred and eighty-five days to the date at which the last menstruation began. It was formerly thought that conception could be avoided, in almost all cases, by aV)stinence from coitus during the first few days after and Ijefore menstruation, but recent observations tend to show that ovulation may be and probably usually is, entirely independent of menstruation, and that impregnation may conse- quently occur in any part of the menstrual month. A very strong argument in support of this view may be drawn PREGNANCY. 15 from clinical observation of the fecundity of the Jewish race; it being well known that Jewesses almost invariablj' observe to this day the directions of the Mosaic law which forljade connection until after the bath of purification, a ceremony which is observed upon the seventh day after the cessation of the menstrual flow. Menstruation is, moreover, fixed by the Mosaic law as lasting at least five days ; so that Jewish women are restrained from con- nection during at least twelve days of the twenty-eight, and in cases of jirofuse menstruation, of coui'se possibly much longer; notwithstanding which fact the fertility of the race is a matter of proverbial knowledge. The possibility that conception may not have occurred until Fig. 1.— Diagram op Schultz. just before the pei'iod which was expected but failed to appear, explains readily the frequent occurrence of cases in which delivery Is delayed until about three weeks after the date at which it was expected; in.stances which are so frequent that it is a matter of practical observation that if a woman passes her time by one week the probable date of delivery should be set at about a fort- night later. The tAvo hundred and eighty days which are considered to be the average duration of pregnancy correspond to ten lunar months, and in most women to ten menstrual periods, a time which approaches so closely to nine calendar months that the I'ule originated by Naegele, to count forward nine months, or 16 PRACTICAL MIDWIB^ERY. wlijir unioiints to tlie same thiii/^, backw.ml three months from the (late at which the last ment-tniation began, and add to that date Ave days for the probable duration of the catanienia, has become the usual method of calculation. This method is exact for seven months in the year, but owing to the irregularities in the length of the calendar months, is not as exact for the re- mainder. It is, therefore, usually a convenience to consult the well-known figure of Schultz, which, or its equivalent, is included in most physician's visiting lists. An api)roximate check upon this reckoning may be effected by observing the date of quickening, which is most often noticed at the end of about twenty-two weeks. The perceptive powers of different women vary so greatly, however, that this furnishes us, at the best, with a very loose method of reckoning. Some confirmatory evidence can be obtained by observing the size of the uterus, but the whole matter is unfortunately one in which great accuracy is absolutely unattainable, and which is one of the constant hetes noirs of every practising physician. It will, however, conduce greatly to the comfort of the physician to make the best calculation possible himself, rather than to accept the date which the woman or her friends have previously fixed upon. Prolonged Pregnancy. The possibility of an abnormally prolonged pregnancy is a question which is frequently raised in medical practice, and which sometimes becomes of medico-legal importance. The weight of authority tends strongly to discredit the i^ossibility of the extension of the period of pregnancy to a length greater than three hundred days, and it is highly probable that even this limit is a somewhat large estimate of the true duration of pregnancy. This statement must, however, be qual- ified by an acceptance of the possibility that conception may have occurred twenty or more days after the date commonly taken as the beginning of pregnancy, i.e., the occurrence of the last menstruation, and it is, moreover, possible that we may be further misled l)y the existence of an irregularity in the length of the intermenstrual period immediately Ijefore the occurrence of conception. Even the few well-observed cases of prolonged preg- nancy are probably due to such causes, and the physician who preserves an attitude of scepticism toward such reports will rarely be mistaken. The nearest approach to credibility belongs to cases where an amenorrhoea of unusual duration is followed by the birth of an unusually large and very fully developed child. PREGNANCY. 17 Development of the Foetus in the Successive Calendar Months of Px-egnancy. As it is often necessary for the obstetrician to judge of the duration of i^regnaucy by the appeai-unee of a recently expelled footus, it is well to bear in mind the main points which form the basis of such an opinion. First Month. — So few specimens of the human ovum, expelled during the first two months of pregnancy, have been thoroughly studied and the variations in those were so great, that the examination of an ovum of less than two months' develop- ment, is rather a matter of importance to the embryologist than of practical value to the accoucheur. Second Month. — By the end of the second month the ovum is of the size of a hen's egg; the embryo measures from two-thirds of an inch to an inch in length; the chorionic villi are more abundant in the neighborhood of the umbilical cord ; ossification begins in the lower jaw and clavicle, and the three divisions of each extremity are clearly indicated. Third Month. — At the end of the third month the embryo is from three to three and a half inches in length and weighs about an ounce ; the chorionic villi have mostly disappeared and the placenta is small but well developed ; the neck is now differen- tiated and the ribs are visible; spiral turns appear in the cord; the mouth is closed by the lips, points of ossification appear in most of the bones ; and the first indication of nails appears ; the sex is indistinguishable. Fourth Month. — At four months, the foetus measures from four to six inches in length, its weight being from three to four ounces; the mouth, eyes, ears, and nose begin to assume their proper shape ; the sex is distinguishable, hair begins to form upon the scalp, and the foetus makes slight movements with its limbs. Fifth Month. — At the end of this month, the foetus is about ten inches long, and weighs in the neighborhood of twenty ounces; the eyelids separate, fine lanugo appears over the whole surface of the body, and the movements are more distinct. Sixth Month. — The foetus measures from fourteen to fifteen inches, and weighs from thirty-five to forty ounces ; the skin is still red and wrinkled, but is covered with vernix caseosa; the" child moves its limbs, and may cry feebly at birth, but seldom or never survives. It is, however, right that every child which breathes and cries should be treated as though its life might possibly be preserved. Seventh Month.— At the end of this month, the foetus mea- sures sixteen to seventeen inches and its weight averages about: fifty ounces, though in this, great variation is the rule; the pupiL 2 lb PKACIK A). .Mll>\\ IKKKV. lary inonibrane is f^oiie fnjiii tlic eyes, uiul the luiir on tlie head is well (ieveloped : the lanugo luis ili.sapi)eared from the I'aee, and the nails are well formed, but do not yet reach the tips of the fuigei*s; in boys, at least one testicle is usually found in the scrotum. Many such children survive with proper care. Eighth Month.— At the end of the eighth month the nails have reached the ends of the Angers, the body is rounded, and the face has lost its senile aspect. Eight-months children can be di.^itinguished from tho.'^e born at full term, only by tlieir small size and lethargy. The greatest care is required to pre- serve theii" vitality CHAPTER III. THE FUNCTIONAL DISORDERS OF PREGNANCY, AND THE MANAGEMENT OF NORMAL PREGNANCY. The state of pregnancy occupies an intermediate position between the conditions of chronic disease and those of ordinary health. The whole physiology of the pregnant woman is being subjected to a series of changes, that produces, in the majority of cases, a symptomatology which differs from that of disease in degree rather than in kind ; so that a normal pregnancy may be defined as one in which the disorders of the various organic systems do not exceed normal limits. Hygiene and Care of Normal Pregnancy. In the management of normal pregnancy the physician should aim to limit his attentions to the proper regulation of the habits and general hygiene of his patient, and should encourage her to endure the discomforts of her condition so long as they remain within the limits of health, avoiding all unneces- sarily active treatment; but since this line of action implies, of necessity, an accurate knowledge of the various disturbances incidental to pregnancy, it is impossible, in describing its man- agement, to Avholly separate the normal and abnormal; for which reason it is convenient to open the subject by a descrip- tion of the general hygienic precautions which should be adopted, and afterward to take up in detail the disorders of the various organic systems, defining the normal limit, so far as possible, under each heading. Hygiene of Pregiyanct.— If a pregnant woman is to remain Avell nourished, the extra energy necessarily expended in the formation of the tissues of the embryo must, of course, be pro- vided for by an increased absorption of nutritious material. In some women the increased demand is supplied by a quickened activity of the processes of assimilation, but in most eases the requirement is met by an increased ingestion of food, i.e., an improved appetite, which is most marked during the later months, when the growth of the child is most rapid; and since the diminished abdominal space proper to this period makes the 20 PRACTICAL MIDWIFERY. ingestion of unusually full meals uneonifortable and even perni- cious, it is a general rule that pregnant women should be advised to satisfy their increased appetites by partaking of food at shorter intervals than usual, rather than by taking an increased quantity at each meal. They may, with advantage, be urged to take up the habit of drinking a glass of milk or taking a cup of coffee before rising, and .should be instructed to take light lunches in the middle of the morning and afternoon, in addition to the regular meals; many women also find that their sleep is im- proved, and that faintness in the morning is decrea.sed by a light supper in the evening; and some such habits of life should always be recommended. No restriction of diet is necessary, other than to advise a preponderance of simply cooked, easily digested, nutritious materials. Constipation is especially to be avoided, and should be com- bated by regulation of the food and, if necessary, by the use of cathartics. Frequent bathing of the whole skin is particularly to be enjoined. The increased metabolism of pregnancy involves an increased activity of the excretory organs; and nothing is more certain to encourage disturbances of the kidneys than the increased work thrown upon these organs by the inactivity of the skin, Avhich is itself due to an imperfect removal of the worn- out epidermis, and a consequent clogging of the excretory ducts by their own secretions. The water used should be lukewarm, excessively hot or cold baths being almost equally harmful. Muscular exercise forms a very important part of the prepara- tion for labor, in itself distinctly a muscular ijerformance by no means inaptly comparable to the feats of endurance for which athletes undergo a long course of training, and it is therefore im- portant that every jjatient should be encouraged to take, during pregnancy, as much light exercise as can be performed without undue fatigue; but violent exercises and those Avhich involve jarring motions of the body should be especially forbidden, the shock occasioned by jumping from even low elevations being an especially connnon cause of miscarriage. An abundance of fresh air is of the first importance; but unless the patient is able to walk freely, is often secured with difficulty, since the constant jarring incident to the motion of a carriage is frequently pro- ductive of fatigue and of a sense of weight and aching in the back, and is then distinctly to be avoided. Railroad journeys of any length should be avoided during pregnancy. The absence of avoidable care and responsiliility is especially to be desired, since the strain of social, educational, and business cares during pregnancy predisposes in the most marked degree to the excite- ment of the various nervous and mental disorders which fre- quently complicate the condition. PREGNANCY. 21 The increased leucorrhtea of pregnancy makes frequent batliiuf^ of the external genitals absokxtely necessary to comfort, and prompts most women to the use of vaginal injections, which are jjermissible if the water used is neither hot nor cold, and does not exceed a half pint in quantity. Coitus during pregnancy is not necessarily hai'mful, indeed, many Avomen seem to be possessed with a special desire at this period, but excessive indulgence is an extremely frequent cause of miscarriage, and it is always best to avoid connection during the weeks in which the patient would have menstruated if not pregnant. Its frequency should properly be regulated by moderate restraint of the desires of the Avoman, and not, as is too frequently the case, by the appetite of her husband. The dress, during pregnancy, should be loose, all tight lacing should be absolutely avoided, heavy skirts should be forbidden, and all the clothing of the lower part of the body should be buttoned to a special waist worn beneath the di*ess, in order to relieve the abdomen of its weight and secure its dependence from the shoulders. The corset is necessary to the comfort of many women and especially to those whose breasts are large and pendulous ; it may, however, be well replaced by a linen waist which furnishes the necessary support to the breasts without exercising pressure upon the abdomen. Such garments are now commonly sold in most cities, or can be manufactured in the household. So soon as the increased prominence of the abdomen removes the skirts from contact with the thighs, a pair of warm drawers should be recommended. Circular garters should be absolutely forbidden on account of their tendency to produce or increase varicosity, and should be replaced by the elastic sus- penders now commonly worn by women; these should, however, during pregnancy, be attached to the waist already referred to, rather than to the belt with which they are commonly fitted. The shoes should be broad and easy, and furnished with low flat heels. Pressure upon the developing nipples should be i^revented by looseness of the clothing, and if necessary, by the adoption of a nipple shield, but massage and pulling upon the nipple should be avoided, not only as injurious to the nipple itself, but on account of its tendency to jjrovoke uterine contractions. Lacta- tion during pregnancy should be discouraged on account of its tendency to disturb the digestion of the nursing child. The patient should be encouraged to lie down several times daily, and her sleep should be carefully watched, mild hypnotics being frequently necessary during the later months. The urine should be examined in every case, and as a routine measure dui-ing the sixth or seventh month of pregnancy, and ^2 PRACTICAL MIDWIFERY. slioiiltl suspicious symptoms arise, the examination should be freiiueutly repeated. The patient should be instructed to send for her physician at once upon the appearance of any abdominal pain, of even the slightest stain of blooii upon her linen, of persistent headache or dizziness, of any epigastric pain, or on the recurrence of nausea after the usual vomiting of early pregnancy has disappeared. She should be cautioned to avoid lifting or stretching; i.e., hang- ing pictures, placing a dress upon a high nail, etc. ; she must be warned of the danger incident to even the slightest blows ujion the abdomen, such as may be occasioned by the unguarded motions of a child, or of her husband when asleep; and if a primipara, should V>e informed that the pains of labor often closely resemble an attack of colic. Special Disturbances of the Several Organic Systems During Pregnancy. Circulatory System. AxiEMiA. — Microscopic examinations of the blood of pregnant women have long ago estaVjlished the fact that a mild antemia is a constant element of that condition, and that it is only in ag- gravated instances, where evident loss of strength is observed, that the anaemic state assumes any jDathological importance. As a consequence of anjemia many pregnant women are subject to occasional attacks of syncope, an occurrence which need cause no alarm, unless the attacks are of long duration or extremely frequent. The same may be said of those somewhat annoying symptoms, dyspnoea and palpitation of the heart. As a consequence of antemia. also, the majority of j^regnant women find themselves the subjects, during the later months, of a slight, more or less transient, oedema of the ankles, finding, for instance, that it is necessary to wear loo.se boots, and that if to- ward the end of the day the boots are removed it is difficult to replace them. So long as the oedema is confired to the feet and ankles it is probably of angemic origin and is of no importance, but its occurrence about the hands or face should always excite the attention of the physician, and is sufficient ground for an examination of the urine. (Edema of AXjEmic Origix. — This is rarely sufficiently pro- nounced to need special treatment. If extreme, it is more likely to be relieved by general tonic and hygienic treatment, than 'by depletion in any form, since that would only increase the hydrse- mic condition upon which it is dependent. The ana?niia of pregnancy may, in rare cases, and most frequently in multipara?, take on a distinctly pernicious form, in which there is progressive PREGNANCY. 23 loss of strength, emaciation, and all the classical symptoms of I^rogressive, pernicious anjemia, but this type arises by slow gradations from the ordinary form and no sharp line can be drawn between them. 'rreatmeiit of Amvmia. — The first and most important rule of treatment is that, to be effective, it must be undertaken during the early stages of the affection. The cause of the disease, i.e., pregnancy, being non-removable under ordinary circumstances, the most that can be hoped from medicinal or hygienic treatment is the arrest of the disease. There is but little hope of its im- Ijrovement until after delivery has been accomplished. To this end the patient should be put under treatment as soon as the classical symptoms of anaemia become distinctly prorninent ; and this is of si^ecial importance in ease the patient is showing weak- ness in any other direction, most of the other affections of preg- nancy being dependent, to some extent at least, upon a distinctly anaemic element ; a statement which is especially true of the uri- nary and nervous complications. The treatment of the pernicious form of anaemia varies from that of the simple form only in the fact that it is necessary to carry out all the precautions in a more stringent manner, and that the increased importance of the condition makes the preferences of the patient distinctly less well worth consulting. As in the ordinary forms of anaemia, the first rank among medicinal agents must be ascribed to the various preparations of iron, the value of which may be increased by the addition of arsenic, but in the anaemia of pregnancy the adoption of proper dietetic and hygienic precautions is of even more im- portance than medicinal treatment. Avoidance of unusual exer- tion, or mental fatigue and disquietude, and the assimilation of an abundant quantity of nourishment are prime factors in treat- ment, but the digestive condition of the pregnant woman is such that it is rarely possible for her to obtain sufficient food by the ingestion of three large meals daily, as is the rule in health ; it is therefore the best rule of conduct to prescribe the use of small quantities of the most simple nourishment at short intervals. Simple animal foods, such as milk, eggs, and raw oysters (if the season permits), are to be preferred, but may be combined with smaller quantities of the simpler farinaceous foods, such as puddings, and bread not too recently baked, Avhich if toasted should be but slightly browned and not buttered. These should be administered, in all cases, mid-way between the meals, and in extreme cases should be given in small quantities as often as every half-hour, or even every fifteen minutes. It is surprising to see how large a quantity of nourishment will sometimes be taken readily in this way bj' patients who are so devoid of ap- petite as to be utterly unable to eat the ordinary full meal. 24 riiACTlCAL AllDW IIKICV. TliP fluid preparations of iron are rarely well borne by the stomachs (»f patients of this clatis. The redneecl iron or some similar preparation, in the form of a pill, combined, if necessary, with one-sixtieth of a grain of arsenic, and given three times a day, is in general the best prescription. It is of course of the utmost importance to secure a free move- ment of the bowels, at least once daily, 'as no proper assimilation of food is likely to go on in the presence of constipation. A suflQcient amount of open air should be prescrilied for all cases in which it can be obtained without undue fatigue. If driving is for any reason inadmissible, it is often Aell to dress the patient wannly and expose her to the sun before an open window once or twice daily, for a period of from half an hour to an hour, and in extreme anjemia the imjiortance of an absolute avoidance of muscular exertion cannot be too strongly enjoined. The fact that the pernicious anaemia of gestation is distinctly dependent ujjon pregnancy and terminates with it, of course suggests at once the question of the propriety of the induction of premature labor, miscarriage or abortion, l>ut this question is to be answered in the case of ana;mia, as in most other pathological conditions during i^regnancy, In* the consideration that there are two lives involved, and that that of the child must not be sacri- ficed till it is reasonably certain that any further prolongation of gestation would involve the loss of both lives; and it is not until the strength of the mother has been so far reduced that her ability to sustain the burden of pregnancy to its natural end becomes doubtful, that this question should be raised ; but when once a doubt exists it should then be decided only after consultation with one, or preferably two, other physicians. Varicosities. — One of the most annoying of the occasional ac- companiments of pregnancy is the gradual development of vari- cosity to a greater or less degree, in one or both of the legs and ankles. Though not a constant symptom it is unfortunately extremely common, and if it does occur is usually progressive, increasing in amount with the increased duration of pregnancy, subsiding after delivery in part, but seldom entirely, and usually recurring in a more and more marked form with each successive pregnancy. Dilatation of the veins of the vulva and vagina is less common and usually occurs only in the jiresence of a some- what excessive varicose condition of the extremities. The dilated veins of either locality may reach a point at which rupture threatens, but this is fortunately rare. In cases in which rupture does threaten, the patient should be furnished with a small pad of folded linen to which a strap and buckle have been sewn, and shown how to apply it over a bleeding point, that she may be prepared for the emergency in case it should arise. PREGNANCY. 25 Treatment of the varicose condition should be undertaken early, not only for the sake of preventing any increase of trcjuble, but also bec^ause the existence of even slight varicosities exposes the patient in many eases to considerable dragging pain, and sense of fatigue in the affected member; but during pregnancy no decrease of the varices can be expected, and indeed a complete arrest of the increase is unlikely. The only effective treatment is that rendered by mechanical support of the dilated veins, and this can be secured, either by the use of the elastic stocking, commonly manufactured by dealers in surgical appliances, or by a properly constructed flannel bandage. The stocking is the more comfortable, the more elegant, and tVie less effective. It is also a decidedly expen- sive luxury. If used it should be constructed to fit the individual limb, after due measurement either by the physician or by an experienced maker ; and in the latter case it is essential to success that the physician should i:)ersonany inform the manufacturer of the localities at which pressure is most to be desired, it being especially necessary to avoid all constrictions above the seat of the varicosity. The flannel bandage, though less comfortable, and more troublesome to apply, has the advantage of inexpensiveness, and of greater efficiency. It can be made by the patient, but the physician should be careful to give her accurate and detailed instructions about its preparation. It is better that it should be made from cheap rather than from expensive fiainiel, owing to the greater elasticity of the former. For a patient of ordinary size, one and one-half yards of flannel should be cut upon the bias, into strips of not less than four inches wide and not more than five ; the pieces should then be stitched together by simple basting, without turning the edges. It should be rolled up before using and should be applied tightly from just above the roots of the toes to a point as near the groin as possible, whether the varicosity is confined to the low^er part of the leg or extends over the whole member; care being taken to make the pressure rather less above than in the lower portion of the leg, and to avoid lo- calized constrictions. Whichever appliance is used should be put on before rising from bed in the morning, and should be taken off only after re- tirement for the night, so that the veins shall never be unsup- ported Mobile the patient js in the erect position. The rubber bandage that is occasionally' used is mentioned only to condemn it. Its macerating effect upon the skin, and the itching which it causes, render it unfit for use in this affection. Thrombosis. — Thrombosis of the veins of an extremity or in the pelvis may occur as a consequence of the stasis of pregnancy, 26 PRACTICAL MIDWIFERY. l)ut is more common after delivery, Jiiul then usually in cases in which antisepsis has not been strictly observed. The treatujent of thrombosis ilurinfj: pre^^nancy consists mainly in the strict avoidance of any motion of the affected limb, in order to lessen the danger of embolism; and in order to secure strict local rest it is essential that the patient's whole body should be as far as possible motionless, it being well known that motion of one part of the body almost invariably involves some action of the whole muscular system. So soon then as thrombosis is suspected the l)atient should be put to bed and urged to preserve the utmost quietude possible — a precaution which must be maintained until sufficient time has jjassed without extension of the trouVjle, to warrant a belief that organization of the clot has occurred, and that the danger of embolism is past. When the detachment of an embolus takes place, the gravity of the situation depends entirely upon the functional importance of that i)ortion of the body at which the detached clot lodges, and the treatment is conducted upon the same principles as in any other case of embolism, the only obstetrical indication being that if miscarriage occurs spontaneously, labor should be expe- dited as far as jDOSsible. Vulvo-vaginal thrombosis, the only form which merits especial description, occurs much more frequently after delivery, and will be fully described in the section w^hich treats of the puerperium. H.liMORRHOlDS. — Haemorrhoids not uncommonly appear dur- ing pregnancy, but are seldom troublesome unless during the last few weeks or at the time of delivery. An attack of painful lijemorrhoids during pregnancy must be treated upon the same lines which would be taken at any other time, with the single exception that the treatment must always be confined to mild and palliative measures, since any operative treatment would expose the patient to the dangers of an un- necessary abortion. HEMORRHAGE. — Bleeding during pregnancy is distinctly rare unless from obstetrically pathological causes, such as placenta prsevia, hydatidiform mole, attempted abortion, etc. Should it occur in the absence of these conditions, the existence of endo- cervical disease, of a uterine polypus, of extreme congestion from prolapse, or of some other pathological condition should be sus- pected, it being probaV>le that the majority of reported cases of menstruation during pregnancy are due to some such cause. Digestive System. Dyspepsia. — Dyspepsia as such is a not infrequent accompani- ment of pregnancy, but when uncomplicated by nausea rarely assumes importance, or needs any treatment other than that PREGNANCY. 27 directed to the palliation of discomfort ; ' during the later months, however, and after the disai)i)earance of nansea and v^oniiting, dyspepsia in the form of a burning- pain tlu'ough the whole upper digestive tract may cause considerable annoyance, but this symptom when present is usually due to an over-acidity of the gastric or other digestive secretions, and is generally best com- bated by the use of alkaline remedies. Prophylactic treatment during the earlier months is of con- siderable importance. It is well known that pregnant women are liable to considerable variations m appetite, and often long for indigestible and improper substances; chalk, charcoal, slate pencils, high or even rotten meat, and excessively acid food being the most common objects; such patients should, however, be encouraged to subdue these abnormal inclinations, as their in- dulgence paves the way for the occurrence of dyspepsia at a later period. When gastralgia is troublesome, the most agreeable, and on the whole, the most successful drug is the carbonate of magnesia. The patient should be furnished with a lump of this chalk-like substance, which she should keep in her pocket and should nibble whenever the necessity arises. Mildly alkaline mineral waters and the subnitrate of bismuth may also prove of vahie. Nausea and Vomiting. — Nausea, most marked in the morn- ing and often accompanied by vomiting, occurs during the tirst three or four months of most pregnancies. It is often productive of extreme discomfort to the patient, and may even assume the so- called uncontrollable form. It usually appears during the second month, but is sometimes seen within the first few weeks; it normally disappears at some time during the fourth month, but may cease before that time with the most unexpected sudden- ness. Its recurrence at a later period is distinctly abnormal, and is always suggestive of eclampsia. If the vomiting is not sufficiently constant to cause distinct emaciation it may be considered normal and left untreated, and the patient should then be encouraged to endure her discomfort in the expectation of its disappearance at the usual time, but when the vomiting becomes so incessant as to make it impossible for the patient to absorb a proper quantity of nourishment, and results in pi'ogressive emaciation and loss of strength, the condi- tion is of the utmost importance, the prognosis is grave, and the consideration of treatment opens questions of the utmost delicacy. Treatment op the Uncontrollable Vomiting of Preg- nancy.— The treatment of this affection separates itself naturally ' A symptom which should not be confounded with those of dyspepsia is the sudden occurrence of severe epigastric pain— a plieuomenon which should always suggest the possibihty of impending eclampsia. 28 PRACTICAL MIDWIFERY. into tliree divisions : the first embraces the hygienic management autl the various metlKuls of forced nourishment, is sometimes sutlicient by itself, is aijplicable to all cases, and should always be i)ursued during the whole course of the alfection ; the second confines itself to the treatment of uitercurrent gastric disease and of local disorders or malpositions of the cervix and uterus; and the third consists in the induction of abortion. DiKT AND Gexeual Caue.— It is inadvisable to attempt to treat such cases by the temporary deprivation of food which is so often valuable in the management of vomiting after surgical opera- tions, in gastritis, etc., as here the danger of fatal loss of strength outweighs any lirosjject of relief from such a method; on the contrary, and from the time that nausea begins to be trouble- some, it is important that the jDatient should take food in small quantities at short intervals, and at the moment when it seems most likely to be retained. In some cases it is possible, by the administration of small quantities of nourishment innnediately after vomiting, to secure sufficient absorption to keep up a fair degree of strength; the best preparations being those of the simple albumens which are capable of absorption with a minimum degree of exertion of the digestive organs ; milk, milk mixed with lime-water or soda-water, Koumyss, Matzoon, raw eggs, either alone or mixed with milk, expressed beef-juice if obtainable, raw oysters in the season, or defibrinated blood, being kept at hand and administered as often as possible, without paying nxuch regard to the sensations of the patient, the size and frequency of the dose being determined solely Ijy observation of the amount which is retained. In combination with this forced feeding it is of the utmost importance to secure quietude, vomiting being often niore decreased by the maintenance of rest in a horizontal position than by any other single means. When the stomach refuses to retain a sufficient quantity of nourishment, temporary supi^ort may sometimes be gained by the use of rectal enemata. These should consist of milk, eggs, or expressed beef-juice, should not exceed three to four ounces in quantity, and are rarely retained if given oftener than once in six hours, though in a few cases it is possible to give them as often as once in three to four hours. It is im- portant that these injections should be given quite slowly and gently, that the patient's iiosition should be unchanged for some time after the injection, and that the anus should be supported by pressure from without by a towel held in the hands of the nurse, for a period of from five to ten minutes. The observance of these little precautions often makes the diflference between success and failure. A large variety of medicinal substances have been recommended PREGNANCY. 29 for the treatment of this condition, few of which have, however, stood the test of jjractical trial. Those which are best known are the oxalate of cerium in five-grain doses, i^referably combined with the subnitrate of bismuth in doses of from five to ten grains; the use of bicarbonate of soda dissolved in soda-water in the propor- tion of one drachm to a quart siphon and taken fi'eely, is highly recommended by Fordyce Barker ; and when all other medicinal treatment fails, relief is sometimes obtained, oddly enough, by chewing spruce gum. In some cases the application of cold to the cervical vertebrte, and to the epigastric regions, gives con- siderable relief. Treatment op Local and other Organic Diseases.— It is always important in the treatment of these cases to make it a I'ule to endeavor, from the moment that nausea begins, to dis- cover some assignable cause for the trouble. To this end the urine should be examined to exclude organic and functional disease of the kidneys, and the physician should subject the patient's whole system to careful sci'utiny in order to satisfy himself that the nausea is really the peculiar vomiting of preg- nancy, and not due to some intercurrent condition. In a certain proportion of cases, moreover, the true nausea of pregnancy is dependent upon local uterine conditions which can only be determined by thorough specular and digital examination. It is probable that such lesions are frequently present in cases where the digestive disturbances never exceed normal limits, but it is certainly a clinical fact that when they are found in connec- tion with severe vomiting, this symptom is frequently relieved by local treatment of the uterine lesions. Erosions of the Vaginal Surface of the Cervix. — This affection is usually found on or about the everted lips of the lacerated cervices of multipara, but may occur upon the surface of the primiparous cervix. If it is found, the surface should be carefully dried with absorbent cotton and then thoroughly brushed with a ninety-flve-per-cent solution of carbolic acid, or with a solution of nitrate of silver of a strength of sixty grains to the ounce. The relief of extreme congestion, as evidenced by an unusu- ally deep purple color of the vaginal walls and surface of the cervix, by the use of glycerin tampons or small, moderately hot, douches (100° to 105° F.), may be of distinct service in allevi- ating the vomiting, and under such restrictions the use of douches seldom results in an interruption of pregnancy. Malpositions of the Uterus. — The correction of any prolapse which may be present, and even the elevation of a uterus which merely occupies a somewhat low position in the pelvis, is some- times followed by the most happy results. Another and well- known cause of the vomiting of pregnancy is the existence of a 30 PRACTICAL MIDWIFERY. retroversion, a condition which is especially dangerous on ac- count of its tendency to result in prolongation of the vomiting to an uniluly late period of pregnancy, and in incarceration of the uterus within the pelvis, and below the ]>roniontory of the sacrum. Should any such displacement be found, its immediate rectification should be the first step in treatment and is often followed by complete relief. ' Even in the absence of such lesions it has been fouml that the vomiting is frequently relieved by making a dilatation of the cervix, though why this should follow is still a matter upon •which conflicting theories are held. Strange as it may seem, the occurrence of abortion after this ojDeration is a rare accident, pro- vided that the dilating instrument is not passed beyond the in- ternal OS, and that the membranes are not ruptured. Relief is sometimes obtained in this "way, even though the cervix be patulous, and the internal os not especially small. Dilatation may be performed by the insertion of the index finger into the cervix, the pulp of the finger being pressed into the internal os, but not allowed to pass through it; but a preferable method is the use of the ordinary expanding steel dilatoi's. These should, however, be used only through the speculum. The patient should be placed in Sims' jDOsition, the os exiiosed, and the length of the cervix measured by the passage of a full-sized uterine sound through the cervical canal until arrested by the internal os. The dilators should then be passed to the same depth and very slowly expanded till the internal os is sufficiently patulous to permit the easy passage of the finger through it and into contact with the membranes, when the operation is complete. Artificial Abortion. — All the above-described methods having been given a fair trial and having failed to afford relief, the final question of the propriety of a resort to artificial abortion becomes prominent, and is alwaj's a difficult pi'oblem to decide. On the one hand is the consideration that if abortion is resorted to sufficiently early it never fails to relieve the vomiting and to place the patient in a position in which a rapid convalescence is to be expected ; and that if it be too long delayed, that is if th« patient is already in a condition apiu'oaching collapse, the added exhaustion of even a three-months labor is extremely apt to be fatal. On the other hand it is a fact that the most distressing vomiting may cease abruptly at any moment without apparent cause, and that in that case speedy recovery is also to be expected, even though the patient is already in a condition of extreme ex- haustion. The gravity of the situation is of course increased by the early ' For a description of the operation of replacement see page 03. PREGNANCY. 31 appearance of exhaustion, and diniinished Ijy the maintenance of a fair degree of strength until near the point when a spontan- eous disapiDearanee of the vomiting may be looked for. The solution of the question must in any case depend to a certain degree upon the religious beliefs of the individual family, and upon their estimate of the relative value of maternal and ftBtal life. It is the jiractitioner's duty to set the facts clearly before them, and to abide by their decision ; but the question is so momentous that it is always wise to submit the case to the best consultants obtainable before expressing an oi^inion. Among Protestant phj^sicians and in Protestant families it is genei'ally considered the best practice to advocate abortion when all other treatment has failed ; when the vomiting is so incessant as to prevent the retention of a sufficient amount of nourishment, and shows no indications of decrease; when rectal alimentation has failed; when the patient's condition is growing worse day by day, and the pulse is steadily at or above one hundred and twenty beats per minute and still rising ; but it is important to remember that patients are constantly lost by over-conservatism in the most skilled and experienced hands ; that the final collapse often comes on rapidly, and that when the condition of constant vomit- ing is succeeded by real exhaustion and rapid pulse, the question which comes up is usually, not — " When shall abortion be done ? " —but — " Shall abortion be done now, or not at all ? " It is perhaps unnecessary to again remind the practitioner that this is an operation which can never be undertaken without manifest im- propriety, unless after formal consultation with one, and pre- ferably two other physicians, and after due examination of the patient by each consultant. Saliyatiox. — The excessive secretion of saliva which is usual in pregnancy is commonly slight, seldom causes trouble, and only rarely amounts to positive discomfort. In the rare cases in which this is excessive, treatment unfor- tunately offers but little hope of relief. The frequent use of small doses of atropia has been recommended as permissible, but for the sake of the child and of the woman's general health, should be avoided if possible. Some relief is occasionally afforded by the frequent and persistent use of a solution of tannic acid as a mouth wash. Co^fSTiPATiox. — There is, during pregnancy, an especial tend- ency toward habitual constipation and an accumulation of txcal material in large quantities — a condition which is probably due to an arrest of peristalsis as a refiex result of the mechanical pressure exerted by the enlarged uterus upon the intestines, and it is of extreme importance to the well-being of the patient, not only during pregnancy, but also during the puerperium, that this 32 PRACTICAL MIDWIFERY. ai'cniimiliition should be reclufed to tho least possible ininiinura, a result which eaii l)e obtaiueil in most cases only by the hal)itual use of some mild cathartic- from the time at which constipation is first noticeil. Aiiionj; the large list of cathartics there are but few which can be used habitually without producinji: toleration, and the neces- sity of increasing the dose ; and prominent among these are aloes and cascara sagrada, the two drugs which are most valuable in the constipation of pregnancy. The best form in which to jjre- scribe aloes for patients who are able to take pills is the officinal pil. aloes et ferri, one pill t. i. d., the combination of aloes and iron being peculiarly suitable to the conditions of pi'egnancy. If this dose should prove too large for the individual patient, it is better to decrease the size of the pill rather than to diminish the fre- quency with which it is taken. Some patients also find it easier to take two pills of half the officinal size at a dose, than to swallow one of the usual size. With patients who are unable to SAvallow pills we may resort to the elix. rhamn. pursh. co. (N. P.) in dose of from ten minims to a drachm immediately after each meal, or to the following prescription, Tr. aloe socot., Elix. tarax. co., aa 3 ij. M. S. Two teaspoonfuls after each meal. Urixart System. Urine. — It was formerly thought that tlae existence of free albumin in the urine of pregnant women was a normal occur- rence, but it has been lately found, by careful observation of a large number of cases, tliat it occurs in only twenty per cent of all cases, at least if the slight traces due to admixture of the urine with the leucorrhoeal secretion, and to the lesser grades of cystitis be excluded from the list ; and it has further been observed that one hundred women with all^uminuria yitld, upon the chances, nearly four times as many cases of eclampsia as an equal number of women in whose urine albumin is not found. The occurrence of casts is always pathological and suggests the gravest danger, even though they be of small size and merely hyaline or fine gi'anular. Throughout pregnancy it is not uncommon to observe a tend- ency toward concentration of the renal secretion, a symptom wdiich is always suggestive of danger and which should always indicate watchfulness and appropriate treatment. In hysterical women and in some other cases also, an increase in the quantity and a deci'ease in the specific gravity is also frequently observed PREGNANCY. 33 — a condition which, Hko all variations from the normal, is to be suspected, and is suflficient ground for careful supervision of the patient. An increase in the frequency of urination is usual from the time that the distention of the uterus begins to exert an in- creased pressure upon the bladder. These normal variations differ only in degree from pathological alterations which are dependent upon the existence of distinct functional disturbances of the secreting tissues, and though the question of the origin of these functional disturbances and even of distinct nephx'itis during pregnancy, is a subject which still furnishes matter for much discussion and difference of opinion among theorists, the clinical fact remains, that pregnant women are peculiarly subject to disturbance of the renal function, a dis- turbance which may be sufficient to give rise to that most serious of all obstetrical complications, eclampsia. The approach of this danger is signalized by the appearance in the urine of the symp- toms characteristic of acute or subacute parenchymatous nephritis, i.e.^ a decreased secretion of urine, with diminished total solids, and the appearance of casts and of albumin, in amount varying from a large trace to a quarter, or even one-half of one per cent, or more, according to the degree of severity of th3 trouble. These alterations of the urine are accompanied by a symptomatology closely analogous to that which precedes an impending uraemic convulsion in ordinary Bright's disease ; the symptoms especially worthy of observation being frontal head- ache, frequently described as a dull pain immediately behind the eyes, disturbances of vision or of hearing, severe epigastric pain, recurrence of nausea and vomiting during the later months, and general oedema ; it being noted, however, that the occurrence of oedema in the lower extremities possesses here but little signi- ficance, on account of its occurrence in pregnancy in the absence of renal trouble, but that oedema of the hands, face, and eyelids is of marked significance. The oedema rai-ely needs special treatment, but may excep- tionally become so extreme as to cause distention to such a degree as to threaten rupture or sloughing of the skin, which extreme distention is most common about the labia and vulvar orifice. (Edema of the vulva must be endured unless it becomes so extreme as to threaten gangrene, in which case it is usually rapidly relieved by multiple puncture with a surgical needle. This procedure is, however, open to the objection that it may furnish a point of origin for sepsis and that it usually precipi- tates labor. Some comfort may sometimes be obtained by the application of vaselin and warm cloths. CEdema of the ankles is best treated by the application of a proper bandage, and by rais- ing the feet during the night. General oedema, if the patient be 3 o-i PKACTICAL MIDWIFEKY. in {^ood condition, is often fj:re;itly relieved ))y free eatharsis, best oljtained Ijv the administration of salines. Further discussion of these symptoms and of their significance Avill, however, be omitted here on account of their reappearance in the section upon eclampsia; it being more convenient, and more conducive to clearness, to group together the eclampsia of pregnancy, labor, and the puerperium, in a chapter especially devoted to that purpose. Vesical Symptoms. — During the early months of i)regnancy, as the uterus enlarges and increases in weight, and before its size is sufficient to lift it alcove the brim of the pelvis, it not uncom- monly exerts sufficient ijressure ui^on the posterior wall of the bladder to seriously diminish the capacity of that viscus; and, un- doubtedly aided by reflex influences, produces in some cases a con- siderable inci-ease in the frequency of micturition. This symptom, which, though inconvenient to the patient, is purely temporary ; admits of ho treatment, must be endured, and commonly becomes less annoying by the end of the third, or middle of the fourth month. From that time on, though moderate frequency is com- mon, it is usually not sufficient to excite complaint, until it again becomes troublesome during the later months. At a period which varies from the end of the seventh to the beginning of the ninth month, the increase of the uterus becomes so great that the pos- terior wall of the bladder, closely attached as it is to the anterior surface of the uterus, is so far drawn upon and elevated in the abdomen, as to change the shape of the bladder from an approx- imately spherical form, to that of a flattened bag. Its anterior and posterior walls are now separated from each other by but a short distance, and are so crowded between the enlarged uterus and the abdominal wall that the sphincter is unable to resist the abnormal pressure. The frequency of urination at this time may be so great as to occupy almost the whole attention of the patient. It is, however, a symptom which again must be en- dured, and for Avhich no appropriate treatment is possible. In occasional cases the frequent repetition of the act of urina- tion may excite cystitis — a phenomenon which is probably likely to occur only in bladders which have been the seat of previous inflannnation. When cystitis is present it is to be recognized by the characteristic signs in the urine, i.e., an increase in alkalinity, decomposition of the urine soon after its passage, and the pres- ence in the sediment of large quantities of pavement epithelium from the bladder Avail, together with, in extreme cases, an ad- mixture of fresh blood. The only treatment usually necessary is the administration of mild alkaline and demulcent drinks, such as or PREGNANCY. 35 Potass, brom., Potass, chlorat., .... aa 3 i. Extr. tritici repen., . . . fl. § iv. Aq. caiuph. Aq., aa 3 ij. M. S. Teaspoonful in water three times daily. Elix. buchu et pot. acet. (N. F.), 3 iv. M. S. Teaspoonful in water three times daily. Excoriation. — The frequent passage of urine, especially if cystitis has been established, may produce an excoriation of the vulva and internal surfaces of the thighs, which is closely similar to that sometimes caused by an acrid leucorrhoea, and which may be the occasion of an intense pruritus. This trouble is best treated by carefully drying the parts with absorbent cotton or some other soft material after each urination, and then covering them thickly with a stiff vaselin. If this treatment be carried out Avith sufficient thoroughness to eflficiently protect the skin from con- tact with the urine, it commonly yields prompt relief, though little can be expected from it unless the patient be gifted with sufficient intelligence and perseverance to devote herself closely to following the instructions given her. Nervous System. Neuralgias. — Whether the cause of the affection be the hy- drgemia of pregnancy, the presence in the blood of one or more substances which in ordinary health ai-e pi'omptly excreted, or whatever other reason may be assigned for its occurrence, it is certainly a fact that pregnant women are peculiarly liable to the functional derangeulents of sensation familiarly known to us un- der the name of neuralgia. These neuralgias may be found in any of the sensory nerves, but are especially common in two situations : in the regions supplied by the fifth or trifacial nerve, and by the nerves whose origin is in the pelvis. Trifacial or other general neuralgias should be treated upon the principles familiar in general medicine, there being but one special ob- stetrical indication, or rather contra-indication, to be observed. The neuralgia being dependent upon pregnancy, and therefore limited in its duration, no operative or other radical treatment should be allowed, and it is especially necessary to forbid the in- cautious extraction of teeth for the cure of persistent toothache during pregnancy, unless an examination of the mouth discloses the existence of an intercurrent dental caries. Neuralgia of the other branches of the fifth nerve, and of the cutaneous nerves in general, may be treated by external applications of aconite, cam- 30 PRACTICAL MIDWIFERY. phor, or chloroform liniments, or of the menthol pencils now so familiarly used; but in this, as in other chronic and painful affections, the use of such sedatives as morphia or chloral is al- ways to be avoided so far as possible; and if morphia be used, it is best given by hypodermic injection, and only by the physician himself. Neuralgias of the nerves which traverse the pelvis, and of the great sciatic nerve in particular, are not uncommon in the later months of pregnancy, and are undoubtedly due t.o the effects of mechanical jjressure upon the nerves themselves by the enlarged uterus or fcetal head. Though they usually disappear with the tenuination of pregnancy, they are still of some moment, for the reason that they furnish in some cases the origin and starting- point of permanent and ti'oublesome sciaticas. Treatment upon general principles may and should be employed, though it is usually of comparatively little value; but an attempt at postural alteration of the foetal position may, if successful, so far relieve the pressure as to cause the disappearance of the neuralgia.' Pruritus. — Pruritus, either of the cutaneous surface in gen- eral, or when limited to the genital organs, may occur in preg- nancy as a pure neurosis and without visible alteration of the skin. When it is general or confined to the distended abdominal walls, relief may occasionally be obtained by keeping the skin constantly covered with cloths moistened in a solution of bicar- bonate of soda or by prolonged bathing in the same solution. Cloths wet with linimentum saponis co., to which chloroform may be added in the proportion of a drachm to an ounce, or in a 1 : 100 cai'bolic acid solution may also afford relief; especially if at the end of each application the whole affected surface is thoroughly rubbed with vaselin. Pruritus of the vulva and its neighborhootl, if unaccompanied by any local pathological conditions, should be treated in the same way, but it is in most cases, even when unaccompanied by excoriation, in reality due to the existence of an acrid leucorrhoeal discharge. Any active local treatment of this affection l)eing not without its risks during pregnancy, the measures already spoken of under the head of cystitis should be first applied in all cases, but after the failure of these milder measures it is allowable, if the patient's discomfort be extreme, to permit the bi-daily use of gentle, tepid, vaginal injections, though the quantity of water used in these injections should never exceed a half-pint. They may best be composed of a solution of borax in the strength of a teaspoonful to a pint, or of a solution of tannin of similar strength. Should this treatment fail, it is probable that the vaginal leucor- 1 See treatment of posterior positions of the occiput, page 311. PREGNANCY. 37 rhcea is distinctly dependent upon, and excited by, an acrid cer- vical discharge. In such an event a speculum examination should be made, and if erosions be found upon the vaginal portion, its surface should be painted with a solution of nitrate of silver, of a strength of thirty to sixty grains to the ounce; or a small tampon soaked in glycerite of tannin, in simple glycerin, or in glycerin to which powdered alum has been added, should be placed against the cervix and allowed to remain there over night. The tampon should always be small,- and is best applied by the physician through the speculum. No application to the endo- cervical mucous membrane is ordinarily advisable. Abdominal Pains. — Abdominal pains, when not referable to an imperfect action of the bowels, are either due to the stretching of old inflammatory adhesions among the pelvic organs or to pressure upon, or other functional disturbances, of the abdominal nerves, and must be endured, there being no effective treatment for them. Muscular Cramps. — Some pregnant women are much troubled by frequent attacks of cramp in the extremities, which usually come on at night, and may often be prevented by gen- eral massage, administered just before their retirement for the night. Insomnia.— Insomnia is often a prominent symptom, espe- cially among women wdth unduly developed nervous systems. It should be endured, in all cases, until it reaches a point at which it is evidently causing distinct depreciation of health, mental or physical, and although it is then deserving of treatment, the greatest caution should be used in the administration of hypno- tics, on account of the danger of the formation of a habit which is especially to be dreaded in i^atients who have already shown a tendency to insomnia when in the non-i^regnant state. If, how- ever, it should become marked enough to produce evident ner- vous exhaustion, recourse must be had to the milder drugs of this class, of which the bromides of potassium and sodium are the most commonly used, the bromide of sodium being thought to produce less gastric and intestinal irritation. If either bromide is used it is best given in small doses of from five to fifteen grains, repeated several times during the latter part of the day, as, for instance, at five, eight, and ten p.m. ; rather than in one dose at bedtime. Sulphonal, grains v.-x., given at bedtime alone, or at eight P.M. and bedtime, is useful to many patients. Urethan, gr. XX. at bedtime, is of value in some cases, and is probably less objectionable than either of the other hypnotics mentioned. In obstinate cases Avith much nervous irritability, and especially in the presence of marked headache, the following mixture is fre- quently very valuable : 38 PRACTICAL MIDWIFERY. Pot. broiu., 3SS. Clilor. liydrat., .... 3 ij. Extr. liyosc, '^v. vi. Aq., ; iv. M. S. Teaspoonful at 8 r.M. and bedtime. Mental Condition.— A state of mind peculiar to pregnancy, and which is distinctly a symptom of pregnancy, is not inf retiuently the cause of mucli discomfort to the patient and her family; and it is always important to emphasize to them the fact that the alteration in character and in temper which is ajjparent to every- body is not to be visited upon the patient as a voluntary change, but is a distinct and involuntary symptom of her condition. Not infrequently a patient, naturally good-natured, becomes, during pregnancy, irritable and suspicious to an extreme degree; often developing a desire to avoid her most familiar and dearest friends and relations, Avhich is probably due to an effort to sj^are them annoyance, and to a knowledge of the fact that self-restraint is easier in the presence of strangers. This curious phenomenon appears most commonly at about the middle of pregnancy, in- creases gradually, may terminate by a sinular decrease or may disappear suddenly, but more frequently lasts throughout the whole pregnancy if it has once appeared. It may deepen into the insanity of pi'egnaney, is always a reason for anxiety, may persist during the whole or greater part of the pueri:)erivim, and does not improve the pi'ognosis for the patient's mental state in after-life. In case a tendency of this kind has been noticed, and is on the increase, the greatest watchfulness should be observed. The patient should be surrounded by cheerful, and if possible by unfamiliar and impersonal attendants. Every effort should be made to divert her mind and to keep her in public and anmsed, as much as may be possible Avithout undue fatigue. She should be given, herself, a full explanation of the existence and cause of the phenomenon, and should be urged to use the strongest mental effort to control it. Her i^hysician should direct his efforts mainly toward acquiring her entire confidence, that there may be at least one person who is able to comfort and relieve her, and who is in a position to discuss confidentially all the things Avhich dis- quiet her, and to give an authoritative assurance of the visionarj' character of the griefs and embarrassments which surround hor. In marked cases it is essential that his visits should be frequent and regular, and it is best that the necessity for such attendance should be explained, not only to the patient, but to the husband or other responsible relatives. With the exception of the administration of hypnotics to com- bat sleeplessness, more freely than in other conditions, there is PREGNANCY. 39 no special treatment for this state beyond the watchfuhiess already si)okeii of. Cutaneous Affections. — Brownish discolorations of the skin of the forehead and other portions of the body ai'e not unu- sual during pregnancy, but commonly disappear after delivery, and need occasion no alarm. Locomotor System. Distention.— During the later months of pregnancy the rapid increase in the size of the uterus produces an increase in the ab- dominal pressure, which by elevation of the diaphi-agm and con- sequent encroachment on the thoracic space may pi-oduce dysp- noea, which is, however, rarely of sufficient amount to need special notice, being commonly about equivalent to that which is so frequently observed in ansemic girls. This increase of ab- dominal pressure may also cause obstruction of the venous cir- culation, to a degree suflBcient to give rise to oedema, or to increase that which ah'eady exists. The rapid increase of weight which is common at this period may also so far distui'b the patient's bal- ance as to make her unwieldy, and liable to falls. This is espe- cially likely to occur in the presence of multiple pregnancy, or of an undue quantity of liquor amnii. Where the undue distention is due to multiple pregnancy, no treatment is possible, unless it should become so extreme as to call for the induction of premature labor, which in such cases would not improbably appear spontaneously. When due to hy- dramnion it demands the treatment proper to that condition. Relaxation and Softening op the Pelvic Synostoses. — Relaxation of all the ligamentous connections of the pelvic bones is proper to pregnancy, but ordinarily produces no effect, unless it be a feature in the joroduction of the characteristic gait. If extreme, it may give rise to considerable difficulty in locomotion — an annoyance which may usually be lessened or relieved by the application of a proper belt. This should not be less than three inches broad, should be made of leather, canvas, or other firm material, and should be applied around the pelvis in the space between the iliac crests and the ti'ochanters. Relaxation op the Abdominal Walls.— This is most likely to occur in women who have borne several children, and usually only when the confinements have followed each other with consid- erable rapidity. It gives rise to the malposition known as ante- version of the pregnant uterus, in which the fundus may reach, in extreme eases, a position below the symphysis, or may even rest upon the thighs, this displacement being rendered possible by the distention of the tendinous central raph(5 and overlying 4(J J^JtACTICAL MIUW IFEliV. skin, after separation of the recti muscles. It is productive of much fatifjfue and roper bimler, such as is shown in Pi{^. 2. The es- sential iJoints ill the application of this bandaj^e are that it should Fig. 2.— Binder for Relaxed Abdomi.nal Walls. be drawn firmly around the pelvis in the space between the trochanters and iliac crests and that it should be sufficiently high in the back to give firm support in the direction of the dotted lines in the figure. CHAPTER IV. INTERCURRENT DISEASES IN PREGNANCY. Pregnant women are equally liable with others to many of the ordinary diseases which afflict mankind; and since a large proportion of these diseases are influenced in their clinical course by pregnancy, or themselves exert an unfortunate influence upon its duration, it is highly necessary that every obstetrician should be equipped with a competent knowledge of the special relations between general disease and the practice of midwifery. The Exanthemata.— Continued high temperature is by itself unfavorable to the continuance of pregnancy, but the exact amount of effect observed, depends greatly on the individual disease which is the cause of the pyrexia. Variola. — Small-pox, if mild, is often survived by both pa- tients ; but if severe is almost inv9,riably fatal to the child, and usually to the mother; the confluent form of variola commonly resulting in the death of both patients. Scarlatina. — Scarlet fever is a very dangerous complication of pregnancy, and one which is usually fatal to the child, even though the mother survives; the death of the child in such cases, of course, usually precipitating miscarriage. In mild cases the prognosis for the mother is but little altered by her pregnancy ; in severe cases the exhaustion of a probable miscarriage, and an increased liability to scarlatinal nephritis, endometi-itis, metri- tis, ovaritis, and other inflammations of the pelvic organs, ren- ders the prognosis distinctly worse. Treatment is unaltered and the induction of labor should be avoided. Rubeola. — Measles almost invariably causes abortion or mis- carriage, and usually results in the death of the child, unless it occurs Avithin the last few weeks of pregnancy. It has almost no danger for the mother. Erysipelas. — The prognosis of erysipelas is about equivalent to that of measles. Typhoid Fever. — When this disease occurs during pregnancy it is followed by miscarriage in all but the most extremely mild cases, and even in those the life of the child is rarely preserved. The prognosis for the mother is only altered by the fact that to the exhaustion of typhoid is superadded the exhaustion of par- 42 PRACTICAL MIDWIFERY. turition and the iJiU'i-perimii, but this factor may be safflcieiit to turn the scale, and always increases the gravity of the projjrnosis ; which becomes worse in jjroportion as the advancement of prejj:- nancy augments the exertion of labor. The treatment is un- altered except that the question of the induction of labor be- comes a prominent one. It may be taken for granted, in all but the most extremely mild cases, that the life of the child is neces- sarily to be lost, and it is therefore evident that the physician's chief object should be to secure the occurrence of labor at that period of the disease at which it will be least harmful to the mother. It is, on the one hand, extremely unwise to subject the patient to the fatigue of a prolonged or difficult induction of labor, and on the other, it is much better for her to undergo the exhaustion of parturition at a period when her vitality is still comparatively good; l)ut the exact period at which labor should be induced must be determined in each case by a careful consid- eration of the mothers condition, in connection with the probable behavior of the uterus during the induction of labor, an estimate of which can be obtained only by a vaginal determination of the rigidity of the cervix, and of the degree of irritability of the uterus, these facts being considered in connection with the past history of the patient, if a multipara. The occurrence of a spon- taneous miscarriage is always to be hoped for, as much the more favorable event. PxEUMO^'iA. — Acute lobar pneumonia is a somewhat frequent complication of pregnancy, being a disease to which pregnant women seem to have an increased susceptibility. It is almost in- variably fatal to the child, and its dangers to the mother are increased by the diminished thoracic space due to crowding of the abdominal organs by the enlarged uterus and the consequent elevation of the diaphragm. The induction of labor is rarely wise, owing to the fact that in a large i^roportion of cases the sudden disappearance of the intercurrent disease allows parturition to take place during con- valescence, and at a period when the mother is much better able to bear it. The later the period of pregnancy at which pneu- monia appears, the worse the prognosis for mother and child. Pleurisy. — The course of pleurisy is but little aflfected by the existence of pregnancy, and on the other hand this disease rarely exerts any injurious effect upon the course of gestation. Phthisis. — Tuberculosis, whether thoracic, abdominal, or gen- eral, exerts but little influence on the course of pregnancy, even in the somewhat advanced stages; the nutrition of the child be- ing sometimes curiously good, although the emaciation of the mother may be extreme. Labor in phthisical patients is usually very easily accomplished on account of the laxity of the soft PREGNANCY. 43 parts. The fcetns is not infrequently weak, is generally small, and sometimes badly nourished. The induction of labor is rarely justifiable; patients in an almost hojjeless condition sometimes delivering themselves with extreme ease, and making a surpris- ingly rapid, temi)orary improvement — an improvement which is, however, often followed by an equally rapid decline. In case the destruction of the pulmonary tissues is so extensive as to cause extreme dyspnoea during labor, it is always proper to ter- minate delivery as soon as the os is well dilated ; and operative interference is then usually easy, but is comparatively rarely necessary. The influence of pregnancy on phthisis is a matter on which there is still some conflict of authority; the old opinion that phthisis was favorably influenced by pregnancy still having some adherents ; but the more modern view is that phthisical patients should avoid jDregnancy if possible, for their own sakes as well as for that of the community, which certainly needs no in- crease of individuals with an hereditary predisi^osition to tuber- culosis. In patients of phthisical family history but previously healthy, the disease not infrequently appears during pregnancy or the puerperium, or shortly after the occurrence of an abortion. Cardiac Disease. — Du.ring pregnancy, the heart undergoes a physiological hypertrophy, which is required as a compensation for the increased arterial and venous pressure incident to the development of the uterus. Even with a normal organ, this hypertrophy fails to entirely overcome the obstacle to the cir- culation; and the dyspnoea and oedema, which are so common during the later months of pregnancy, are undoubtedly, at least partly, of cardiac origin. When the heart is the subject of pre- existent valvular disease, these symptoms usually become severe ; and in extreme cases such a condition may occasionally lead to the appearance of sudden and severe pulmonary congestion, oedema, ascites, albuminuria, or metrorrhagia. The foetus is not infrequently feeble and poorly developed, and may even die in utero of impaired nutrition, the result of an imperfect placental circulation. Mitral lesions are more danger- ous than aortic ; and of mitral lesions, stenosis is by far the more dangerous. Acute endocarditis has, during pregnancy, a marked tendency to assume the ulcerated form ; pericarditis is not per- ceptibly affected ; the majority of women with valvular cardiac disease pass through pregnancy without serious harm, though they visually suffer extreme discomfort. Treatment. — Rest, freedom from care, and a free use of digitalis and iron, are all of great value in preventing an increase of trouble and in tiding the patient along till her pregnancy reaches 44 PRACTICAL MIDWIFERY. its natural end. In very rare cases tlie mothers life may he so seriously threatened as to render the induction of premature labor advisable. Cholera. — The prognosis and treatment of cholera are but little influenced by the coexistence of pregnancy. Its duration is so brief that it has either killed the patient (^r has disappeared before the pelvic organs are awakened to activity. Statistics show that from one-third to one-half of the patients attacked re- cover, and that of these about one-half subsequently abort, most of the children being born dead, even though the period of viabil- ity has been reached. Intermittent Fever. — Repeated oUservations have estab- lished the fact that pregnant women are equally, if not more, liable to attacks of this disease than are the non-pregnant, and it is highly i:»robable that in juany instances the foetus undergoes attacks which are synchronous with those of the mother. The intermittent fever of pregnant women differs, however, from the ordinary form, in the fact that during its persistence a continu- ous mild pyrexia is usually observed, the paroxy.sms being, of course, marked by increase of fever. It is highly probable that wonien who are the victims of this disease are more liable to abortion, miscarriage, and premature labor than other patients ; but this increase of liability is prob- ably not great. The supervention of labor arrests the attacks, but they usually recur during the puerperium, which appears to be especially favorable to their occurrence when a predisposi- tion to the disease exists, and this even in eases in which they have failed to appear during the existence of pregnancy. It has been objected to the usual treatment by quinine, that the powers of that drug as an abortifacient renders its use during pregnancy improper. The constant experience of the profession in malarial regions, casts, however, grave doubts upon its pos- session of this proi^erty, and it is now usual to treat intermit- tent fever during i^regnancy exactly as it is treated at other times. Icterus. — Jaundice during pregnancy may occur in two forms ; ■a mild icteric condition, or the so-called severe icterus of preg- nancy. In the first form the symptoms are mild and the pulse slow, usually less than a hundred. In the grave foi'm the symp- toms are severe from the start, the j^ulse is high, usually above one hundred and twenty, and exhaustion to an extreme degree occurs early, and grows rapidly worse. The mild form is of but little importance, and exerts no influence on pregnancy: the severe form always causes abortion, followed by severe and usu- ally fatal collapse. The distinction between the two forms can only be made clinically after the lapse of some little time, and PREGNANCY. 45 even then they are to be distinguished only by the severity of their syiniitoius. The treatment is syniptoniatie, and is in no Avay different from that of icterus in the non-pregnant state. Syphilis. — When pregnancy occurs during the active stages of syphihs the course of the disease seems to be much aggravated by the pregnant condition, and tliere is an especial tendency to- ward the occurrence of mucous lesions, which are also of unusual duration and severity. The usual treatment should be at once and energetically entered upon, but controls the disease with much less cei'tainty than among other i^atients. In such cases pregnancy usually terminates in the early months by a spon- taneous abortion, and this is generally followed by a decrease in the severity of the symptoms, at least if treatment be systematic- ally pursued. During the primary and secondary stages of syphilis, and in fact, during the fli'st three to five years after the occurrence of the initial lesion, abortion is the rule, and delivery at term a comparatively rare exception. In general in syphilitic patients, successive abortions occur at later and later periods, to be finally followed, should conception again take place, by the birth of a living child at term. Such children may present some evidences of inherited syphilis at birth, or may be apparently healthy ; and in this latter event, may either develop symptoms of the disease with fatal or non-fatal results shortly after birth, or may con- tinue healthy. A systematic administration of mercury and the iodides from the date from which conception is suspected, offers the only- basis of hope for the prolongation of pregnancy to term, and oc- casionally results in the birth of living children. The possible transmission of syphilis to the child by a previ- ously diseased father, without propagation of the disease to the mother, remains a question of some doubt, but is still held to occur, for which reason the administration of anti-syphilitic treatment during the whole of pregnancy is always to be recom- mended for any case in which miscarriages have previously oc- curred, and in which either parent is known to have been in- fected. If the mother has been subject to the disease, such treat- ment is proper as a matter of routine, even though no symptoms are apparent at the time ; since abortion not infrequently occurs as a consequence of syphilis when no other evidences of the dis- ease are present. Hysteria. — Hysteria has no effect upon the progress of preg- nancy. The influence of pregnancy on hysteria, on the other hand, varies greatly in different cases. It is pi'obable that in those instances where the hysteria is due in whole or in part to an imperfect development of the pelvic organs, it may be greatly 46 PRACTICAL iUDWIFERV. ameliorated, or even cured, ))y the increased nutritiroductive sj^stem are rarely followed by this accident, and may be iDerformed if sufficient indications exist. Operations upon the genital tract,, including operations upon the breasts, are followed by abortion in the large majority of cases, and this although the extent of" the wound may be slight; such operations should, therefore, 5 66 PRACTICAL MIDWIFERY. never be ijerfonned unless in the presence of imperative neces- sity, either on account of the existence of serious risk to the life of the niotlu.'r if the operation ))e deferred, or because the pres- ence of a new {j:rowth or other pathological condition oilers an in- superable obstacle to delivery. Cancer of the Cervix.— Cancer of the cervix is likely to in- crease rapidly during pregnancy, and if at all extensive is best removed by the curette or by amputation of the cervix so soon as the child has reached the i:)eriod of viability, on account of the serious and even fatal hsemorrhage which may follow upon the laceration of such tissues during paj'turition. OvARiAX Cy.sts. — Intra-pelvic ovarian tumors may frequently be raised into the abdomen by a i)ro2:)er taxis, and if this be pos- sible should be left undisturljed until after the termination of pregnancy, unless their growth is sufficiently rapid to threaten miscarriage ^jer se; but if this is the case, the immediate perform- ance of laparatomy is justified by the number of cases, now considerable, in which such an operation has failed to interfere with pregnancy, and in view of the liability to miscarriage with- out operation. Trauma. — The results of accidents bear about the same rela- tion to pregnancy as those outlined above for surgical operations ; the chance of miscarriage being pi'oportional to the extent of the injury, and to its anatomical proximity to the pregnant uterus. In the after-treatment of operations, and in the ti'eatment of ac- cidents among pregnant women, absolute resti'iction to the re- cumbent position and a free use of opiates are to be especially enjoined. Both accidents and surgical operations are less well borne at the periods when the catamenia Avould naturally have occuiTed than at other times, and are especially likely to be followed by miscarriage at the third or seventh month. If a surgical opera- tion is indicated during pregnancy, it should always, if possible, be deferred until the period of viability is reached. Diseases of the Ovum. Endometritis. — This disease rarely originates during preg- nancy, but the continuance of a pre-existent intra-uterine inflam- mation is thought to be a frequent cause of 1>lighted ovum and adherent placenta. It can rarely be diagnosticated during preg- nancy, but is said to be accompanied by undue sensitiveness to the movements of the child. The catarrhal form of endometritis is supposed to be the cause of the affection known as hydrorrhoea gravidarum. The exist- ence of this disease is signalized by the discharge at varying in- PREGNANCY. 67 tervals, during the middle or later months of pregnancy, of a thin albuiiunous fluid, in quantities which vary from a drachm to several ounces; discharjj;es which are unaccompanied by pain, and never followed by miscarriage. The affection is of no patho- logical importance, and no ti-eatment is indicated. Hyuram^'ION. — The condition known as hydramnion is essen- tially the presence of an abnormal amount of liquor anniii, and has been accounted for by many different theories, about which considerable difference of opinion still prevails. It is not infre- quently coexistent with foital monstrosity. The discomfort due to it must be endured until the mother's existence is actually threatened by an embarrassment, or partial arrest, of circulation or respiration as a result of distention. It may then be treated by puncture of the membranes, or by an as- piration of the uterus through the abdominal walls. This latter operation, if done with sufficient care and with absolute asep- sis, should be ordinarily attended by no danger ; and is usually the better treatment, since it may be followed by a continuance of pregnancy to term. The puncture should be made at that sjDot at which it seems least likely to injure the foetus — a point which can usually be determined by careful palpation; and the withdrawal of liquor should be stopped as soon as the distention is definitely relieved, in order to minimize the risk of exciting labor. Death of thb Fcbtus.— Death of the foetus may result from any general disease of sufficient severity. When it results from acute illness it is usually succeeded by prompt abortion, but a foetus Avhich dies a slow death from chronic affections is often re- tained in utero for a considerable length of time, and may even be carried to full term. It is sometimes important to be able to diagnosticate the occui*rence of foetal death, which is usually accompanied by more or less marked symptoms. Pregnant women are frequently alarmed by a disappearance of the foetal movements, which is due to some change in the posi- tion of the child that makes them imperceptible to the mother for a period of a few hours or days. This intermission of the movements is by itself of no importance, but possesses some sig- nificance when it occurs in connection with other symptoms. Cessation of movement due to the death of the child is often preceded by an increase of movement, probably of convulsive origin. Death of the child is frequently followed by swelling and tur- gescence of the breasts, accompanied in some cases by the appear- ance of milk, and followed by a marked decrease in their size. The patient frequently complains of malaise, fatigue, and general lassitude, and sometimes of a sensation of weight and coldness in (58 PRACTICAL MIDWIFERY, the abdomen. If the hea-rt-soirnds have been previously heard, their continued absence is highly sufxf^estive, but it must be re- membered that they, like the fcwtal movements, are normally subject to apparent disappearances for short periods. When death occurs, an eml)ryo of not more than two months' development is often wholly absorbed, but after that period, ab- sorption is rare, and maceration is the rule. Maceration is an aseptic decomposition, and the macerated tissues rapidly become so soft and flabby that the foetus when laid upon a level surface assumes a flattened form under the influence of gravity, in the same manner that would be observed in a bag partly filled with fluid. The epidermis is loosened and peels off at the lightest touch. The foetus emits a stale, sickly sweet odor, easily distin- guished from the odor of putridity. The presence in utero of a macerated foetus never causes sep- tic absorption ; if, however, air be admitted to tlie surface of the membranes, or the germs of ordinary decomposition be brought into contact with them in any way, true putrefaction rapidly comes on. and under these circumstances, or when a previously macerated foetus is exposed to the air after delivery, the foul gases of decomposition are rapidly evolved, the body swells, a green color appears, and the characteristic odor is shortly perceptible. Should such decomposition occur in utero, absorption of septic poison by the mother is by no means unlikely. PAET II.— l^OEMAL LAJBOR. CHAPTER VI. CLASSIFICATION OF LABOR. DIAGNOSIS OF PRESEN- TATION AND POSITION. Classification of Laoor. For pui'poses of description it is usual to arrange labor eases under the head of presentations ; that is, in accordance with the relations which the long axis of the child bears to the long axis of the uterus, Avhether situated parallel to it or at an angle ; and, further, in longitudinal presentations as the cephalic or pelvic end of the child presents at the inlet of the pelvis. The presentations of the head, or cephalic extremity, are the vertex, brow, and face ; pelvic presentations are subdiAaded into breech and footling; transverse into presentations of the trunk and shoulder. Shoulder presentations are again subdivided into l^resentations of the shoulder proper, presentations of the elbow and of the hand. Labor is also divided in two other ways, according to the re- sults which may be expected to accrue from the presentation, into normal and abnormal, natural and unnatural, labor. Nor- mal labor includes presentations of the vertex, and of the vertex only, all others being considei*ed abnormal ; and this on account, not only of the more favorable prognosis which attends on vertex presentations, but because of their relatively great frequency. Those labors in which the delivery is effected by the natural ex- pulsive effoi'ts of the uterus are classified as natural labors ; those in which nature fails, and the delivery is effected by obstetric art, being termed unnatural labors. Each presentation has, further, several varieties known as positions, and named in accordance with the relation between some prominent point upon that portion of the foetus which presents and the various parts of the pelvic wall ; thus the differ- ent positions in presentations of the vertex are named in accord- ance with the position of the occiput in relation to the pelvis ; e.g., occiput left anterior (O. L. A.), when the centre of the occipital 70 PRACTICAL MIDWIFERY. bone is found to be in the left anterior quadrant of the canal; in brow presentations the forehead, i.e., the region of the root of the' nose, is taken as the leading point; e.g., brow left anterior, brow right posterior, etc. ; in face presentations the chin; e.g. ; nientum left anterior (M. L. A.), etc. ; presentations of the pelvic extremity take their name fi'om the position of the sacrum; sacrum right anterior (S. D. A.), etc. ; transverse presentations from that of the scapula; (Sc. L. A.), etc' The importance of the study of posi- tion is far too generally underrated, l:)ut it may be accepted as an axiom that no man is capable of doing accurate and intelligent obstetrics who is not habitually careful to make a diagnosis of position at the earliest possible moment, in all cases which come under his care. In vertex, face, and bx'eech presentations, the long diameter of the presenting part occupies that oblique diameter of the jielvis which extends from the left acetabulum to the right saero-iliac synchondrosis in the great majority of cases; a fact which has been explained as due to the encroachment of the rectum on the other oblique diameter, and in various other ways. About seventy per cent of all cases of vertex presentation are in the left anterior position (O. L. A.), and the majority of the remainder are O. D. P., but it is impossible to make an exact statement of the relative frequency of O. D. P. and O. D. A., for the reason that all O. D. P. positions in which normal rotation takes place, pass through the stage of O. D. A. It is a fact, how- ever, that primary O. D. A. is a comparatively rare position, and that O. L. P. is so rare as to be an obstetrical curiosity. Similarly in face presentations the vast majority of all cases are embraced under the heads of M. L. A. and M. L. P. . In pelvic presentations the long diameter of the presenting part is at right angles to that which terminates in the sacrum, the point after which the positions are named, and in consequence the common varieties are S. D. A. and S. L. P. Transverse presentations are divided into four positions, in ac- cordance with the anterior or posterior situation of the child's back, and with the situation of its head to the right or left of the mother. For the sake of conformity to the nomenclature of the other presentations, these four positions are named after the position of the scapula; that is, with the back anterior and the head to the mother's left, the position is scapula left anterior (Sc. L. A.), with the back posterior, and the head to the mother's left, scapula left posterior (Se. L. P.). As will be seen under the head of management of transverse presentations, this division of them into positions, though somewhat arbitrary, is of eonsidei*- ' The nomenclature adopted is that recoinnieniied by the committee on obstetri- cal nomenclature of the last International Medical Congress. LABOR. 71 able i:)ractieal importance. The study of the action and inter- action of the nieclianical relations which govern the passage of the child thnmgh the pelvis in a given presentation, lies at the foundation of all scientific and exact obstetrics, and the posses- sion of skill as an obstetric operator always, and necessarily, pre- supposes an accurate and i)ractical knowledge of the whole subject of mechanism; but interesting and imporant as this matter may be, it is one which belongs rather to more extended text-books upon the theory and practice of midwifery, than to a concise and purely practical manual like the present, and although it is impossible in many instances to write intelligibly upon treatment without mentioning mechanism, it will be necessary to be con- tent here with a simple description of what happens in each variety of labor, without attempting any extended explanation of its occurrence. Diagnosis of Presentations and Positions. To this end we are fui'nished with two methods of examina- tion of almost equal importance, examination of the abdomen, and by the vagina, which must be described separately. AbDOMIJ^AL IlfSPECTION, PALPATI02f, A]SrD AUSCULTATION. The abdominal examination must be again subdivided into in- spection, palpation, and auscultation. In the use of this method of examination, it is best for the beginner to ignore the possibility of O. L. P. and O. D. A. on account of their great infrequency, and of the excessive complications that an effort at their recog- nition would involve. The value which the individual obstetrician places upon an ab- dominal examination is generally proportionate to the experience which he has enjoyed, and the beginner should be urged to avail himself of every opjjortunity for practising the method, for, while he will find in his early practice many cases in which the obesity of the patient or the rigidity of the abdominal muscles and uterus renders abdominal palpation of no value, a lai'ge number in which the examination is inconclusive, and only a few in which he can attain a clear diagnosis by this means, yet as his experience enlarges, the first class will steadily decrease in num- bers, and the two latter will increase proportionally, if he is faith- ful in practising palpation upon every case which comes under his charge; and the value which attaches to facility in making diagnoses -i^y this means in many difficult operative cases, can only be appreciated by those who possess it. It is eei'tainly a fact 72 PRACTICAL MIDWIFEKY. that to the experienced hand abdoniuial palpation yields results fully as valuable as those which can be obtained by digital exam- ination per vaginam, and that there are but few cases in which repeated examinations during the progress of labor fail to estab- lish a diagnosis by palpation and auscultation alone. Inspection. Inspection is mainly valuable as affording a hint of the exist- ence of transverse presentations and of multiple pregnancy. Palpation. Palpation is the most important part of the abdominal ex- amination; it should be performed only in the intervals between the pains, all jjressure of the hand being intermitted with the ap- pearance of each contraction. The i)hysician should stand by the patient's side facing toward hei feet, and should apply the palm of each hand flat against the corresponding side of the uterus. Throughout the examination it is all important that the motions of the hand should be slow and gentle, any quick or jerky impulse being almost certain to result in rigidity of the abdominal walls and uterus, and thus frustrate the purpose of the examination. Every effort should be made to divert the atten- tion of the patient, to soothe her fears, and to assure her that the examination will not be painful; and it not infrequently hai^pens that the first attempt may be a total failure, while the second will yield satisfactory results, owing to the changed mental condition of the i^atient. The finger tips of each hand should be pressed with a gradual and gentle motion downward behind the symphysis pubis in search of the foetal head, which in cephalic jjresentations is al- most always to be felt in this situation as a marked transverse check to the examining hand, and the fundus should then be carefully palpated as a further means of excluding the possibility of a breech presentation. The head may be distinguished from the breech at the fundus by its greater size and mobility, by its rounded contour as opposed to the tapering form of the smaller pelvis, and by an easily-distinguished sulcus which corresponds to the neck of the child ; but the best evidence of the presence of the breech at the fundus is always the recognition of a head pres- entation by deep palpation behind the symphysis, in which exam- ination care should he taken to note on which side the head is most plainly perceived, since with a well-fixed head the frontal extremity is much the more easily reached, with the extended head but little difference is to be noticed, and in face presenta- tions the occiput is much the most distinct. LABOR. 73 In transverse presentations the differential diagnosis between the head and breech is always of importance, and is to be made by the signs enumerated above. The hands should then be jjlaced along the sides of the uterus and should make gentle but deep pressure toward eac^i other, i.e., with the uterus and child directly between theu* palms, in the effort to estimate the relative resistance afforded by the right and left sides of the uterus, the flat, firm back of the child usually presenting a resistance to j^ressure which is markedly greater than that of the yielding abdomen, and movable limbs. The differing resistances having been estimated, the fingers should be applied to the sides of the uterus, not with the tips deeply indented into the abdomen but with their whole i^almar surface pressed firmly against the uterus ; the hands should then be moved gently wg and down along the uterine wall in the en- deavor to recognize the irregularities due to the presence of the foetal limbs, but during this search it is necessary to guard against the error of mistaking either of the round ligaments for the foetal members. These ligaments are at term of nearly the size of the adult finger, and extend obliquely from the cornua of the uterus, downward, outward, and forward to the pelvic brim; they may be recognized by their situation, and by the jDain of which the patient invariably complains when they are rolled about under the fingers. The existence of small sub-peritoneal fibi-oids is an- other possible source of error. With thin and flaccid abdominal walls, it is sometimes possible by this method to recognize the foetal limbs with the utmost distinctness, but in the majority of cases, an irregularity in the contour of the uterus is all that can be hoped for. Auscultation. Auscultation of the foetal heart gives us confirmatory evidence about the i^resentations and positions,^ informs us of the condi- tion of the child, and is the most impoi'tant sign in the recognition of multiple pregnancy. In interpreting the evidence furnished by this sign it must not be forgotten, however, that owing to the fact that sound is better conducted by solids than bj^ liquids, the exact situation of the foetal heart-sounds corresponds to that portion of the chest which happens at the moment to be in con- tact with the uterine wall, so that its situation may vary tem- porarily with the position of the mother, as one or the other shoulder rests against her soft parts, or may be temjporarily 1 Owing to the oblique position which the shoulders normally occupy, the dividing line between the right and left position of the heart sounds in this and all longitud- inal presentations sliould be that drawn between Ihe umbilicus and the right anterior superior spine of the ilium rather than the median line of the body. 74 PRACTICAL MIDWIFERY. absent (especially wIhmi the patient lies upun her back) owing to the intervention of liciuor aninii between the foetal chest and the physician's ear. In A'ertex presentations the heart is most plainly heard over the back of the child and below the mother's umbilicus;' in breech presentations the heart is heard over the back ; but its greatest intensity is generally above the mother's umljilicus; ■while in presentations of the face, it i* niost readily heard over that portion of the uterus which corresjwinds to the chest of the child, but is again below the umbilicus. In transverse presenta- tions, the heart is usually plainly audible when the back is an- terior, but is often found with difficulty in the posterior varieties, and is of comparatively little value in the diagnosis of i:)Osition. The value of auscultation in the recognition of the condition of the foetus can hardly be overestimated, any fatigue of import- ance being quickly shown by alteration of the rate and regularity of the heart-sounds. In addition to the fretal heart-sounds, the so-called uterine or placental souffle is generally heard, as a soft blowing sound, synchronous with the mothers pulse, and of no practical value. Recapitulation of Signs by Presentations — Ve?-tex. The head is felt behind the symphysis, the breech is at the fundus, the heart is below the umbilicus, and is heard on one side of the abdomen, while the limbs and the more accessible portion of the head are felt upon the other; the position of the heart corresponds to that of the occiput, and the limbs and head to that of the forehead. Face. — The head is felt at the brim, the breech at the fundus; the limbs and heart are found on one side, and the more accessi- ble i^art of the head on the other. The limbs and heart are upon the side to which the chin is directed, and the more accessi- ble portion of the head upon that which corresponds to the back of the child. Breech. — On deep palpation behind the symphysis, the pro- jections of the occiput and face are not found ; the presence of the head at the fundus is recognized by its size and rounded shape, and by the existence of the cervical sulcus; the greatest intensity of the heart is above the umljilicus. The position of the heart corresponds to that of the sacrum, the limbs to that of the foetal symphysis. Tra:xsverse. — Upon inspection the abdomen is found to ho. broad, the fundus to be low, broad, and flat in shape; upon palpation the long diameter of the child is plainly transverse, > See note on preceding page. LABOR. 75 and a large part ' is felt in each iliac fossa. Whether the posi- tion is right or left is known by recognition of the situations of the head and breech. In anterior i)ositions no small parts are ordinarily to be felt, while if the back be posterior, the foital members ai"e usually plainly perceptible through the abdominal wall. In this presentation the results of abdominal palpation are of far more value than anything which can be obtained by digi- tal examination per vaginam. Multiple PREG:jfAA'CY. — If the uterus contain twins this fact may be recognizable at the time of the usual abdominal examin- ation. The size of the uterus is seen to be much larger than is normal, and in some few cases, a depression is perceptible at the fundus in the median line. Upon jjalpation three large parts are usually to be felt, and if one hand be held applied to one of the large parts, while the other hand attempts to move the remaining tAvo, first in one direction and then in another, it is frequently possible to establish the fact that two of the three are connected together, while the third is unaffected, or at most but slightly affected by their motions. It rarely happens that all four large parts are to be perceived, one at least being usually so far pos- terior as to be out of reach. Upon auscultation, two points of maximum intensity of the foetal heart-sounds may be per- ceived, the sounds being less distinct in the space between them. If two observers by simultaneous examination succeed in estab- lishing a difference of rate between the two hearts, the diagnosis of twin pregnancy is conclusively established. Palpation further offers us extremely valuable evidence of the condition of the uterus, whether it is still in a state of normal relaxation between the pains or is beginning to show evidence of fatigue.^ Vaginal Examination. In obstetric work it is usually best to avail one's self of the extra length of the middle finger by employing two fingers for all examinations, except in those cases in which the extremely narrow vulva of a primipara makes the introduction of the second finger painful to the patient. Most American obstetri- cians prefer to examine the patient when in the left lateral decu- bitus, but it is well to accustom one's self to examining in all positions, not only in the interests of the patient's comfort and convenience, but because it is often possible, by changing the decubitus, to reach a portion of the child which has before been unattainable. 1 The festal head and breech are commonly spoken of as large parts, while the foe- tal members are known as small parts. 2 See " Retraction and Constriction Rings." Page 117. 76 PRACTICAL MIDWIFERY. The hand, having been thoroughly disinfected and anointed with the aseptic lubricant, should be introduced under the bed- clothes, which should be held up by the other hand in such a way as to protect them from contact with the examining fingers; these should be placed against the genital cleft, and swept gently forward till they perceive the entrance of the vulva and come in contact Avith the fourchette, carefully avoiding friction against the vestibule and clitoris in the process. As the examining finger enters the vagina, it should notice, successively, the size of the vulvar orifice, the position of the coccyx, the shape of the sacrum, > and the condition of the rec- tum, whether full or empty. These points having been ascer- tained, the finger should be passed ujDward into the posterior fornix, and swept forward over the soft and yielding vault of the vagina in the effort to find the external os, wliieh is usually situ- ated in the median line, and near tlie centre of the pelvis. In case of failure to find it readily, tlie field of the pelvis should be systematically quartered by the exaiuining finger, much after the fashion emiDloyed by a pointer dog in searching a field for game. If the cervix be not yet taken up, it is recognized as a rounded prominence, on the summit of which is found the orifice of the OS, if the patient be a primipara; in multiparje the lacerated and ragged condition of the cervix frequently makes the external OS indistinguishable from an early stage of labor, but the finger may usually, in such cases, be passed into the cervical canal, and will then recognize the presence of the internal os. If the cervix has been wholly taken up, the os is best recognized by i^assing the linger through it, and into the space between the cervix and the presenting part.- The physician's ability to reach the upper portions of the pel- vis is more dependent upon the jjosition in Avliich liis hand is held, than upon the length of his fingers. When it is desirable to reach the upper and posterior i^arts of the jjelvis, the hand should be held in the position indicated in Fig. 5, a, the perineum being strongly retracted by the pressure of the web between the second and third fingers. When the object sought for lies nearer the anterior wall of the pelvis, the position of the hand should be altered by rotation of the fore-arm, into that represented by Fig. 5, h. The space between the second and third fingers is now 1 The author strongly recommends the practice of roughly measuring the conjugate diameter, by reaching upward for the promontory of the sacrum, as a routine mea- sure, at the conclusion of the first examination in each case, and believes tliat many operative difficulties may be avoided bj- this simple procedure. 2 Unless this precaution of hooking the finger about the edge of the os be observed, the beginner is Uable to mistake a fold of the vaginal wall, or in breech presentations the anus, for the os utei'i, both of which mistakes have been made many times by medical students in the presence of the author. LABOR. 77 pressed firmly against the edge of tlie pubic arch, and tlie pulp of the finger is directed anteriorly. The OS having been reached, the finger should note its size, the thickness of its edge, and its consistency, whether hard or Fig. 5 a.— First Position op the Examining Hand. soft ; and by very gentle stretching should endeavor to ascertain: its degree of dilatability ; but in this last manoeuvre it is neces- sary to employ the greatest gentleness in order to avoid the in- Fig. 5 b. — Second Position of the Examining Hand. excusable accident of manual laceration of the os during examin- ation. The characteristically different sensations yielded to the finger by the smooth and velvety cervix, the rough but slippery membranes, and the hairy scalp, is a matter with which it is iui- 78 PRACTICAL MIDWIFERY. portant to Ijecome familiar; for it is easy to recoffiiize these diflfer- euces if the physician has trained himself to observ them in evene a comparatively small number of cases; and the possession of this faculty may preserve him from the danj^erous or even fatal error of making an application of the forceps to the intact mem- branes, or over an undilated cervix. DiAGOxsis OF Pkeskxtatiox.— The diagnosis of presentation by vaginal examination, though ordinarily easy, is sometimes diffi- cult when the presenting part is still high in the pelvis; it would be supposed, a 2^flo>% that the distinction between the hard head and the yielding breech could be made in all cases with the greatest ease, but a considerable experience in the superintend- ence of students has convinced the author that this is a most un- safe and unsatisfactory guide, and some iiersonal experiences have led him to adopt the rule of never permitting himself to diagnose a head unless it is i^ossible to recognize at least one suture, nor to commit himself to the diagnosis of a breech with- out inserting the examining finger into the anus, and recognizing the presence of the coccyx. If the cervix be thin, it may be possible to recognize these diagnostic marks through its substance, but in ordinary cases it is necessary to introduce the finger through the os, in order to distinguish between the different parts of the child. When the two f ontanelles are the only distinctive points within reach, the vertex presents. When the supra-orbital ridges and the bridge of the nose are easily accessible, and the small fontanelle is reached with diffi- culty, the presentation is that of a brow. , The face is to be recognized by the presence of the small and pointed chin, by the insertion of the finger into mouth, and by perception of the nostrils, the eyes, the root of the nose, and the supra-orbital ridges ' in their proper positions. The diagnosis of shoulder presentations is not easily made by vaginal examination during the early stages of labor, but they should always have been recognized "by abdominal palpation be- fore the vaginal examination is made. At the first examination the presence or absence of the caput suceedaneum should be noted, and the character and strength of the uterine contractions should be estimated by observing the tension to which the membranes are subjected during the height of the pains and by observation of the comparative length of the pains and intervals. DiAG]\"OSis OF Position— Vertex well Flexed.— With a vertex presentation and a well-fiexed head, the examining finger, > The siib-occinital ridges may easily be mistaken for the supra-orbital, if care is not taken to search for the other points as well. LABOR. 79 on passing through the os, ordiniU'ily recognizes, not far from the centre of the field, tlie convergence of three sutures (Fig. 0, a) wliich forms the posterior fontanelle,' the recognition of whicli offers positive evidence of a vertex presentation with good flexion, but affords no more than a hint of the position which may be present. The lambdoidal sutures ordinarily meet at more of an obtuse angle than is formed by the sagittal and either parietal, the occipital bone is commonly overlapped throughout labor by both jiarietals, one of which usually overlaps its fellow, and the ob- servance of these two points may furnish to the expert finger evi- dence of some slight value in determining which of the three bones is the occiiDital ; while the position of the fontanelle as a Avhole in one or the other quadrant of the pelvis gives another hint of the jjosition which is probably present, but these facts are Fig. 6.— Diagrams of the Fontanelles. a, The posterior fontanelle ; 6, the anterior fontanelle ; c, the lateral fontanelle. always in themselves insufficient for any approach to a positive diagnosis. Each of the three sutures, hoAvever, ends in a distinguishing feature, and a diagnosis is to be reached by following as many sutures as possible to their terminations. The sagittal suture ends in the lozenge-shaped anterior fontanelle fi'om which four sutures emerge at right angles and opposite to each other (Fig. 6, b) while each of the lambdoidals terminates in an ear and mastoid process, and in the ivregularly -shaped lateral fontanelle. The lateral fontanelle is often ill-marked and is important only because it is sometimes mistaken for the anterior fontanelle; it is formed by four sutures, which go off at right angles but not op- posite to each other (Fig. 6, c). The mastoid is not always to be recognized with ease, but when well marked is ,of about the size and shape of an adult canine tooth, and is, of course, always situated upon the occipital side of the ear. The flap of the ear must always point toward the occiput unless, as sometimes hap- • It must not be forgotten that during labor the fontanelle exists only in name, be- ing converted, by the crowding together of the cranial bones, into a mere meeting of sutures. 80- PKACTICAl. MIDWIFERY. pens, it be folded forward af^iiinst the scalp, a faf^t which is easily recognized if the finger is pjissed backward and forward a few times across the ear. Thus, if in addition to the recognition of the posterior fontanelle, any one of the three sutures has been followed to its termination, a fairly satisfactory diagnosis may be made, and if two of them have been so followed the diagnosis is assured; but it is a good rule that no obstetrician should ever permit himself to apply the forceps without having reached at least two, and preferably three, of these diagnostic points. The Extended Head.— In presentations of the extended head, the anterior fontanelle occupies a position in the pelvis which renders it at least as easily accessible as the occipital, and with extreme extension, the eyebrows and the root of the nose are fre- quently reached. Additional evidence of extension is also fur- nished by the fact that in these presentations the examining finger, in searching for the ear, touches most easily the anterior, and not the upper edge of the helix, while the ear as a whole is more ac- cessible than the mastoid process. The situation of the occiput, of course, gives the name to the position. Brow.— The position in brow presentations is named in accord- ance "with the position of the forehead. Face. — When a presentation of the face has once been detected, the recognition of the position is usually easy, owing to the ease with which the situation oi the pointed chin can be localized. Breech. — Th.Q diagnosis of position in breech cases is not al- ways easy, the soft buttocks being often so much compressed and moulded under the forces of labor as to form a very confusing mass, but it should be made by observing the position occupied by the rough sacral spines, and by the scrotum or vulvar cleft, which should of course be found upon the opposite side of the pelvis ; the best method of diagnosis is, however, by the introduction of the finger into the rectum of the child, when the recognition of the ischial tuberosities and of the tijo of the coccyx is extremely easy, and allows a very accurate localization to be made. The posi- tion of the coccyx, of course, corresponds to that of the sacrum, and to the name which is given to the position. Presentations of the Knee and Elhoio. — The knee may some- times be distinguished from the elbow by the presence of the patella, but since this is small and not always easy of recognitioni it is best to distinguish between these two joints by following the course of the limb to its termination in a hand or foot, as the case may be. Presentation of a Hand or Foot. — If the membranes be rup- tured, a presenting hand or foot may easily be drawn outside the vulva and recognized by the eye; if this be impossible it may usually be differentiated by the touch through the membranes LABOR. 81 by observation of the following points : the foot is to be distin- },^uislied from the hand by the presence of the malleoli and of the prominence of the heel, and by the facts that the great toe is of etiual or greater length than the others, and is placed in the same plane with them ; while the hand is recognized by the absence of the heel, by the fact that it can be placed in direct continuation of the line of the limb to which it is attached, and that the thumb is shorter than the fingers and can be opposed to them. The importance of avoiding rupture of the membranes in such presentations is, however, so great that it is usually best to trust to the I'esults of external palpation. Transverse. — The shoulder is liable to be mistaken only for the breech, from which it may be distinguished by the presence of but one limb in place of the two which are attached to the pelvis, and by recognition of the smooth ridge of the scapula, as opposed to the rough spines of the sacrum, but the recognition of a shoulder by vaginal examination is extremely difficult, and the existence of the presentation is practically ascertained in the majority of eases by external palpation without assistance from vaginal examination. In presentations of the hand it is sometimes possible to make a diagnosis of jiosition by observation of the hand alone ; to this end it is first necessary to determine which hand of the foitus presents, which is best ascertained by attempting to shake hands with the presenting part, the right hand of the foetus coming into position to shake hands with the right hand of the physician, and the left with the left ; if then the presenting hand be turned by rotation of the fore-arm into forced supination, the thumb points to the side on which the foetal head lies and the back of the hand corresponds to the back of the foetus, but in actual practice the attitude of the child so seldom corresponds exactly to any one of the four classical positions that this evidence is of comparatively slight value, and is only to be used as confirmatory of the results of palpation. 6 CHAPTER YII. ANTISEPSIS AND PREPARATIONS FOR LABOR. Importance of Antisepsis.— The value of antisepsis is of late so generally admitted that it may seem unnecessary to dwell upon its importance in any work of the present day. Yet so large a poi'tion of the profession are still indifferent or careless in this matter that a brief statement of the experience of the past few years is not as yet out of place. Among the most strikmg examples of the revolution which has been wrought in the i^ractice of obstetrics by the introduction of antiseptic principles is the experience of Garrigues in the New York Maternity on Blackwells Island. During the twelve months from October 1st, 1883, to October 1st, 1883, the death-rate from septicaemia in that institution reached a per cent of 6.0G, and during the last month of that year, in September, 1883, attained the frightful rate of lo.GO/J of all the women confined. On the first of October, Dr. Garrigues introduced the system noAv in use in most lying-in institutions, and to be described in the latter part of this chapter. During the next three years the total death-rate from septicasmia was as follows : From October 1st, 1883, to October 1st, 1884, . .0059 From October 1st, 1884, to October 1st, 1885, . .0018 From October 1st, 1885, to October 1st, 1886, . .0021 The excellence of Dr. Garrigues' results under this system led to its adoption by Prof. W. L. Richardson in the Boston Lying- in Hospital. In this institution the death-rate had never been so high as in the New Y^'ork Maternity, but from January 1st, 1883, to January 1st, 1884, the death-rate from sepsis Avas 4.58;*. Gar- rigues' system was adopted on the 1st of October, the beginning of Dr. Richardson's service: and from January 1st, 1884. to Jan- uary 1st, 1885, being the first year in Avhich the method was in operation, the septic death-rate fell to 1.05;?. From January 1st, 1885, to January 1st, 1880, it was . .0064 1886, ". " " 1887, 1887, " " " 1888, 1888, " " " 1889, 1889, " " "■ 1890. 1890, " " " 1891, .000 .002 .002 .002' .000 1 One patient each year. LABOR. 83 In addition to the deci'eased death-rate, Professor Richardson says of the convalescence : ' " There has been marked freedom from any tenderness over the uterus or its appendaj^es ; less com- plaint has been made of after-pains, and the general range of temperature has been much lower, rarely exceeding 99'." The charts on pages 84 and 85 show these results in a graphic form. This and similar experiences in many cities and mstitutions have led to a wide -spread acceptance of the fact that the use of antiseptic precautions is essential to the administration of a well- conducted lying-in hospital, but the author's experience in con- sultation practice has given him abundant reason to believe that the mass of the profession still think it unnecessary in private l^ractice, on account of the alleged infrequency of puerperal fever in that field of work. This allegation may be answered in two ways. First : the ex- jDerience of life insurance companies'- shows that of 2,182 insured women, 197 died from puerperal causes (9.03$?), and statistical tables indicate tliat 75$? of the deaths during childbed are due to puerperal fever. The fact that these women are of the class who place insui'ance on their lives, makes it unlikely that any consid- erable proportion of them were hospital patients ; and it is indeed probable that most of these deaths occuri*ed among the better " classes of society, and in the practice of at least fairly competent physicians. Secondly : an all important point that is generally lost sight of is the fact that the death-rate from septicaemia is only one of its many and far-reaching results. When the pro- fession has learned that for every death from septic absorption, we may reckon large numbers of cases of mild sepsis, the majority of which w^-eck the after-health of then* victims ; when the gen- eral practitioner has been taught to know that the income of the gynaecologist is largely dependent upon the dirty tinger-nail of the obstetrician, and that the chronic ill-health of many of his own patients is dependent upon his personal carelessness while in attendance upon their past labors, we shall hear less often the boast that Dr. So-and-so during his large experience has never seen a case of septicaemia, in spite of his neglect of antisejjtic pre- cautions — a remark which is to-day practically eqviivalent to the statement that that iDhysician is unable to recognize the presence of mild sepsis. Few men who have not been specially trained in this particular line realize how largely the milder complications of the puerperal state are dependent upon imperfect antisepsis, ' See " Antiseptics in Obstetric Practice,'" Boston Medical and Surgical Journal, Vol. 16, No. 4, p. 73. - System and tables of life insurance from the experience and records of thirty life offices. Levy W. Meech. 84 PRACTICAL MlDWIFEIiY, and how iiniforinly its stringent observance is followed by a rapid and uncomplicated convalescence; while even among those who have grown to believe in the great importance of a strict use of antiseptics, there is still, unfortunately, much ignorance of the details of the technique of their employment in obstetrics. Tkchnique.— Since the first introduction of the antiseptic I)ractice, the whole tendency of progress has been toward greater and greater simplification of its details ; and that is to-day the best sj'stem, which, while affording complete protection to the patient, is most easily and conveniently applied by the physician. The system which is now in use in the obstetric institutions aijove re- ferred to, and in the private practice of the great majority of fy* lOO' /Oi° mi' ICH° lOS' 'Oi f^ To? lOl' lOi' iCi' ' lot' lOS' lOt fos' '0<,' Fig. 7.— Graphic Representation of the Septic Percbntages. LABOR. 85 ff /w' '01° ''^'*' ' 31? "/ \ ,. 1885 \ 10 H- v; /Oi' /0¥' /OS"' /Ob' ?9' /oc' /or ected to assure the patient that everything is all right, ?.e., that the head presents, and no unusual difficulty is to be appre- hended, and if for any reason it is impossible to give this assur- ance conscientiously, the greatest care should be exercised to avoid any direct statement that anything is wrong ; but if a mal- presentation or other abnormality exists it is essential to the l^hysician's reputation that the husband or other responsible rel- > It is always well to leave the obstetric bag in another room, as the sipht of the instruments, and the sound made by rattling them together in withdrawing any article from the bag, will often give a nervous patient the impression that some severe operation is in immediate contemplation. laborI 99 atlve should be informed of it at once, being directed at the same time not to tell the patient. One of the first questions asked of the physician in most cases is al)out the i:)robab]e duration of labor, but this can only be ausAvered by the assurance that all progress is dependent upon the quality of the pains, and that that is always so uncertain that it is imi^ossible to offer an opinion of value upon the point of time. It is usually best to give the most hopeful view possible to the patient, without committing one's self to an exact state- ment; but if the question is asked, not by the patient, but by the husband or other members of the family, it is usually prefer- able to state the case as it appears, without disguise, since an as- surance to them that the labor is likely to be short and easy is liable to be interpi'eted as a confession of ignorance in case of subsequent delay. The conditions which make rapid f)i'ogress probable are the existence of strong pains at regular and not very long intervals; ' the facts that the os is soft and a considerable degree of dilata- tion has been reached in a short time ; that the head is not very high in the pelvis; that the presentation is normal; that the membranes are intact and bulge freely through the os; and that the patient, if a multipara, has had a history of raj)id confine- ments on previous occasions. The opposite conditions of course jDredispose to delay. It is rarely necessary or indeed advisable for the physician to remain in the house continuously during a long first stage, and the question whether to remain within call at any given stage of dilatation must always be answered by an estimate of the amount and rapidity of the progress which has been made up to that time. If true labor is present, it is seldom wise to absent one's self for more than a few hours at a time. It is best that the first visit should be of at least an hour's duration, and that before leaving, the physician should make a second examination in order to be able to judge of the rapidity of progress. In all cases the early stages of dilatation consume much more time than the later, and it may be laid down as a general rule that continuous presence is seldom necessary with primiparse until the os has reached the size of a silver dollar, though with a multipara it is unsafe to be long absent after the size of a silver quarter has been attained. - 1 The best type of pains is when the intervals average about two minutes and the pains about three, but this is seldom attained imtil during the second stage. 2 The amount of cUlatation is usually reckoned by comparisou of the size of the os with standard coins, thus the os reaches successively the size at which it admits the tip of the finger, the size of a silver ten-cent piece, of the silver quarter, half-dollar, and dollar, or is said to be half or two-thirds dilated, after which any further prog- ress is estimated by the length of the portion of the cervix which is still to be felt ; thus we may say that an inch or half-inch of cervix still remains. lUU PRACTICAL .MlDWlKEi; V. Under normal circuuistauces the treatment of the first stajjje is largely expectant. The ijhysician should maintain an attitude of watchfulness, should hold himself in readiness to detect the first signs of delay or abnormality, and should refrain from inter- ference so long as steady progress is being made. With sufficient care a diagnosis of presentation and position can usually be made at the first visit, and the importance of an early diagnosis can hardly be exaggerated, since malpositions which could be corrected with entire ease at an early period of labor, may often, if neglected, require the most serious obstetri- cal operations. In case the first examination fails to afford a satisfactory diag- nosis of the presentation or position, it should be repeated at short intervals until that object has been attained. If, as occa- sionally hai^pens, repeated abdominal and vaginal examinations fail to afford a satisfactory diagnosis, the conduct of the physi- cian must be determined by the progress of the case ; if dilata- tion and descent go on with normal rapidity, he is usually justi- fied in waiting for the rupture of the membranes, without resort- ing to any more heroic means of diagnosis; but if the diagnosis of presentation or even of position is unknown, and the progress of the case is unsatisfactory, the attendant is always justified in a somewhat early resort to the more efficient methods of diagno- sis, which will be referred to under the head of difficult or delayed labor. If, after full dilatation has been accomplished, the membranes fail to rui^ture siDontaneously, they shouUl be torn by the attend- ant, and this should be done in the interval between pains, since jjerforation of the membranes and the consequent sudden escape of the liquor amnii during a contraction might easily result in jDrolajise of the cord, an accident which seriously compromises the safety of the child. If the head is well engaged, the presenting part of the mem- branes should be ruj^tured by gentle scratching with the nail of the examining finger, or by seizing a portion between the tips of two fingers and tearing it by a gentle twisting motion. Shf)uld these methods fail, a disinfected pro1>e, director, or even hair- pin may be passed through the membranes, under the guiilance of the finger. If the head is free above the brim, and a direct rupture is thought to be unsafe, on account of its likehhood to produce a prolapse of the cord, recourse may be had to rupture of the mem- bro.nes at some distance above the brim by the insertion of a catheter. The best instrument for this purpose is a male Eng- lish webbing catheter, furnished with a wire stylet. The catheter should be softened in warm water, and the last inch of the stylet LABOR. 101 should be bent at an angle. The instrument should be gently and cautiously inserted between the membranes and the uterine wall, to a height of several inches above the os, and then sharply rotated in the direction which will force its bent end into and through the membranes. The withdrawal of the stylet will then permit the escape of such a quantity of liquor as may be judged sufficient to produce enough retraction of the uterus to insure contact between the breech and fundus; and when the retraction has produced an engagement of the head, a direct rupture should be resorted to ; this partial withdrawal of the waters also often excites the uterus to renewed activity, by decrease of its disten- tion. During the first stage it is unwise to annoy the patient by too frequent examinations, and the physician should endeavor to so time them that he can confidently expect to note some differ- ence in the jDatient's condition with each repetition. Each ex- amination should include an auscultation of the foetal heart, since it must not be forgotten that the obstetrician is always in charge of two patients, and is responsible for the life of the foetus as well as for that of the mother. The position of the patient during the first stage should depend largely upon her own preference. Labor usually progresses more I'apidly if the patient retain the erect position, and if from time to time she moves about the room, but tliis should not be in- sisted upon, if it is evidently fatiguing to the woman, nor is it usually best to require its continuance after the pains become so severe that the patient feels the necessity of support during their presence. • During labor few patients are conscious of apjjetite or rfeady to take food, but during long first stages it is always important to prevent exhaustion and faintness, by an occasional adminis- tration of broths or other simple nourishment ; though in view of the possible necessity for etherization it is well to prohibit milk and solid food. The physician should remember to absent himself from time to time in order to permit the patient to pass urine, and he should inform himself if this is done, since there is no more com- mon cause for delay than the presence of a distended bladder, and in case of any question as to the completeness with which the patient has emptied her bladder it is, therefore, always best to pass the catheter. The general principle which should l)e observed throughout the management of the first stage of labor, is non-interference with the process so long as normal progress is present, and a careful Avatch for the advent of exhaustion. The patient should be urged to avoid unnecessary effort, and should be especially cautioned against all voluntary bearing down dur- 102 PRACTICAL MIDWIFERY. ing the contractions — an effort which during the first stage can be productive of notliing but fatigue. In addition it must not be forgotten tliat wliile jjliysical exliaustion is promptly signalled by a rising i)ulse, there is in all women a capacity for fatigue of the nervous system, which must be guarded against with equal care ; and the existence of which is to be gathered from the behavior and general aspect of the patient, and from her mental condition, rather than from any i)hysical signs. The sudden and marked appearance of extreme irritability, nervousness, and short temj^er on the part of a commonly good- natured woman is, during labor, a phenomenon of some signifi- cance, and may culminate, if neglected, in uterine inertia, eclampsia, or even in the insanity of jiarturition. The gradual supervention of irritability is, upon the other hand, a matter of small importance. The treatment of nervous exliaustion in labor consists in the arrest of its cause by the rajjid termination of labor, should that be necessary, and in the use of nervous sedatives. For this pur- pose two drugs stand pre-eminently above all others. During the earlier portion of the first stage, and when there is in all probability a considerable length of time still before the woman, hydrate' of chloral is often of the greatest value, especially as the existence of labor affords a toleration for this drug in doses which would be dangerous or even fatal to the non-parturient woman. The best method of using it is the administration of fifteen grains, if given by the mouth, or twenty by the rectum, in a so- lution of checkerberry water, or other vehicle, to be repeated twice, if necessary, at twenty-minute intervals; but this total of fifty* grains by the mouth, or sixty by the rectum, should never be exceeded. The second or third dose is followed, in the ma- jority of cases, by drowsiness and sleep of some hours' duration, after which the patient commonly arouses in a greatly refreshed condition, and labor often proceeds with considerable rapidity. If, on the other hand, the os is already tolerably well dilated, the pains strong and regular, and the second stage at hand, it frequently happens that chloral fails to afford relief, so that in such cases it is usually better to withhold this drug, and substi- tute for it the obstetric use of ether, which is its administration to the point of toleration of pain, without loss of consciousness, in contra-distinction to its surgical use to full anjesthesia. The patient should be furnished with a cone or folded towel, and al- lowed to give the ether to herself, being placed, however, in such a position that the cone will drop as soon as the grasp of her hand relaxes. The physician or nurse should sit by her side in readiness to restore the ether to her whenever the pains arouse the desire to reneAV it. Ether given in this way has, in the ma- LABOR. 103 jority of cases, little or no ill ellect upon the progress of laVjor, and may be administered for many hours to the great comfort of the patient and without ill results.' Secoa'D Stagk. — We are usually warned of the beginning of descent by a marked change in the cry of the patient during her pains, for whereas the cry of the first stage is that of an irritated, discouraged woman who despairs of any relief, it is replaced, on the advent of descent, by a peculiar groan expressive of bearing- down effort, and frequently full of renewed energy. So soon as this change is joerceived or when vaginal examination demon- strates that full dilatation has been accomplished, every effort should be used to encourage the bearing-down elTorts which were before prohibited. The patient, if previously about the room, should be put to bed, and a rope or folded sheet should be tied to the foot of the bed near her feet, so as to furnish a fixed point upon which she can pull during her pains, an effort which is agreeable to most women, and which encourages voluntary efforts by fixation of the costal origins of the auxiliary abdominal mus- cles; she should be encouraged to hold her breath and bear down throughout the whole of each contraction, caution being taken, however, to prevent her making such violent efforts as to exhaust her muscular powers too soon. Throughout the second stage examinations should be made with sufficient frequency to enable the physician to form an ac- curate judgment of the rate of progress;^ he should also from time to time estimate the amount of force w^hieh is being ex- pended, by observation of the increase of the caput succedaneum, and of the tension of the abdominal walls and uterus ; and, in addition, should note the rate of the mother's pulse and of the foetal heart at each examination. If progress is normal or slow, the patient must be urged to keep ui) or increase her voluntary efforts, and encouraged with the hope of speedy relief and by the assurance of constant ad- vance; but if, on the other hand, the adaptation between mother and child is easy, if the pains are powerful, and in the judgment of the attendant there is more danger of undue precipitation and of laceration of the soft parts than of delayed labor, she should be instructed to avoid effort and taught to open the mouth and 1 Whatever claims may be urged for the use of chloroform for surgical anaesthe- sia during labor, its greater dangers make it less valuable for this continuous use than is its rival, ether. 2 In estimating the progress of descent it is highly important to avoid the error of confounding the lowering of the vertex which follows upon growth of the caput and moulding of the head during labor, with an actual descent of the jiresenting part, which latter movement can only be correctly judged by passing the finger as high upas possible between *^he head and pelvic wall in order to estimate the height in the pelvis of the girdle of contact, i.e., of the greatest diameter of the head. 104 PRACTICAL MIDWIFERY. to draw her breath in sliort (luick gasps like a pantinp: dog, dur- ing the continuance of each pain, tliis rapid action oJ tlie chest l)reventing the use of the accessory muscles. If even with these measures too rapid jjrogress still threatens, the administnition of ether to the point at Avhich the contractions are lessened by the anaesthetic is always projjer and advisable. Preservation of the Perineum. — When the head begins to press against the pelvic floor and the perineum is seen to bulge out- ward during the acme of each pain, the stage of expulsion is at hand, and with that begins the most important function of the Ijhysician during normal labor; «.fe., the preservation of the perineum. The percentage of cases in which laceration of the perineum necessarily occurs is very variously estimated and must always depend, not only upon the method employed, but on the skill of the individual accoucheur. The various forms of technique which have been and still are employed by one or another school of obstetricians are too many for enumeration, but any method which is to be successful must combine certain pre-requisites ; it must avoid direct compression of the perineum between the pre- senting part and the hand of the ol)stetrician, or any other sub- stance ; must he able to check the advance of the head absolutely and at any moment; and finally mu.st put it in the jiower of the attendant to guide the movements of the presenting part in that direction which is at the moment likely to decrease the tension on the mother's soft parts in the highest possible degi'ee ; for it must be remembered that abrupt movements of descent, even though of small extent, are far more likely to produce laceration than marked but gradual progress, and that the change of direction which aceomioanies the stage of exjiulsion is effected ])y the re- sistance of the muscular layers of the i^elvic floor and perineum, so that laceration of these tissues is in effect a failure upon their part to j)ossess the degree of strength requisite for the jiroper l)erformance of their functions, and is to be prevented l)y rein- forcement of their efforts by the added power of the obstetrician's hand as it urges the head forward and against the pubic arch. Even though we eliminate the many methods which are be- coming obsolete and Avhich are thought at the present day to be improper, so many excellent plans remain, that all that can be admitted here is a description of those which have been most successful in the author's i^ersonal experience. Position of the Patient. — It shoud be premised that the proper preservation of the perineum invariably involves a certain amount of exposure of the jjatient's person, and that while it is the duty of the attendant to avoid all unnecessary denudation of his patient, it is distinctly necessary to lay aside the mock mod- LABOR. 105 esty which prohibits such exposure as is condueive to the proper perforiiianee of ills (hity. Upon the ('or)tinent of Europe it is customary to deliver women in the dorsal deculjitus, but this luethod, liowever excellent if the delivery is effected upon a special obstetrical chair, or with the patient in the lithotomy position, and each leg in charge of an attendant, has many dis- advantages when the patient is confined upon an ordinary bed. Bellvery Upon the Side. — In this country and in England the majority of obstetricians prefer the left lateral position with the thighs well flexed upon the body, and the upper knee supported by a pillow. If the patient is delivered in this attitude the Vjut- tocks should be brought to the edge of the bed, and the shoul- ders placed sufUciently far from it to allow tlie physician to sit iipon the bed opposite the position of the lumbar region. His coat should be removed and his shirt sleeves rolled up to the shoulder. The hands and arms having been thoroughly disin- fected, the left arm should be passed over the patient's abdomen and between the thighs, so that the finger tips, and later the palmar surface of the hand, may be i3laced upon the vertex in a position to arrest the movement of expulsion. The edge of the fourchette is then constantly under the eye of the physician, a point of the utmost importance ; while his right hand is at liberty to wipe the mucus from the head and vulva ; to test the condi- tion of the perineum by the insertion of the finger between the head and the vaginal outlet; and finally as the head crowns, should be used to prevent extension and a consequent undue strain upon the perineum, by pressure upon the forehead through its tissues ; this pressure, being made, not upon the centre of the perineum where laceration is likely to occur, but upon its lateral portions which are thicker and practically safe. Then, as the edge of the great fontanelle appears at the fourchette, the right hand is able to prevent recession of the head and urge it forward, or as it is commonly termed, "shell the head out," by applying pressure to the face, through the tissues immediately below the tip of the occyx, and in the axis of the vaginal outlet; i.e., di- rectly forward. Another Method. — The great advantage of the method which has just been described is the opportunity which it offers of fix- ing the patient's position, and making it difficult for her to move away from her attendant during the great pain of expulsion. Its disadvantage is the fact that the left hand, upon which the great strain of resisting the expulsive efforts is placed, works in a disadvantageous position, so that, unless the muscular develop- ment of the physician b^ distinctly greater than that of his pa- tient, he may find his physical force insufficient for the task. When this is the case, or when the patient is so far anaesthetized lOG PRACTICAL -MIDU IKKKV. tliut voluntary luovi'iiieiits of lier body are unlikely, she should be placed in the same position, but the attendant should place himself in a chair facing the vulva. The palmar surface of his right hand should then be placed directly against the emerging occiput, in which position the whole force of the arm and shoul- der can be exerted in direct opposition to its advance, while the left hand may be used to steady the patient by a grasp upon the upper part of her thigh and the iliac crest. Since it will, how- ever, in the later stages Ije needed for the control of extension and for forward pressure upf>n the forehead through the tissues about the anus, it is better, if the patient is not etherized and is uncontrollable, to direct the nurse to place herself upon the bed in such a position that she is able to prevent the patient from drawing away fi'om the physician. Rectal Expression of the Head. — In cases where the natural efforts fail to couipletely overcome the resistance of the perineum, the release of the head may usually Vje effected by inserting the first and second fingers of the left hand into the rectum, and with them exerting i^ressure upon the frontal end of the head. This mancBuvre is not, however, usually successful until the head has advanced so far that the rectal fingers are able to seize the supra- orbital ridges, or preferably the edge of the upper jaw. In this latter position a living child almost invariably begins to suck the fingers w^hich it feels within its mouth, and is of course liable to draw in and swallow more mucus and liquor amnii than is de- sirable ; for which reason the fingers should be shifted as soon as possible to a jjosition in which they grasp the chin instead. When this grasp has once been effected the head is so thoroughly within the conti'ol of the hands and its motions of advance or recession can be governed with such complete facility that when lacei'ation seems probable, it is distinctly advisable to administer ether in obstetrical degree from the beginning of the stage of expulsion, and to increase the dose as the head advances, to such an extent that Avhen the rectal fingers obtain control of the head the ether can be pushed to full surgical ana^sthesiji within a few moments, during which the head can be held immovable. All the forces of expulsion and resistance are then under the control of the accoucheur, and he possesses facilities for the avoidance of laceration Avhich can be obtained in no other way. Avoidance of Haste. — Whichever method is emjiloyed, it may be laid down as an axiom that suflBcient caution and slowness in the delivery of the head will always save the perineum ; to which must be added the very necessary corollary, that while the above statement is true theoretically, in practice the golden mean be- tween unnecessary delay with its increase of suffering to the mother and of danger to the baby, and the undue haste which LABOR. 107 results in laceration, is no easy matter; and that the most skilful obstetrician will inevitably fail to save the i)erineinu in some cases; but it is worth remembering that the majority of lacera- tions are clue to the production of a slight nick during the early part of the stage of expulsion, which insignificant tear is con- verted during the distention of the orifice by the emerging head into an extensive laceration, and that it is of the utmost impor- tance to watch and superintend each motion of the presenting part from the time that it first rests against the jierineum. An unduly long- perineal stage distinctly increases the risk to the child, but although the life of the child is always of far gi'eater value than the external tissues of the mother, it remains a fact that in reality comparatively few children are lost during the process of expulsion, and it is probably the better practice for the young obstetrician to pay more attention to the mother's tissues than to the chances of the foetus, it being far more probable that he will fall into the error of undue hurry than of too great delay. During the whole process of delivery the fourchette should be carefully watched, and the head should be allowed to descend slowly and gradually during each ijain until the tension of its edge pi'oduces a faint and narrow white line, by compression of its capillaries, but the moment the least indication of this con- dition is observed, all progress should be arrested during the continuance of that pain, and until the head recedes in the succeeding interval. This process of alternate advance and recession and of watchfulness against undue tension of the perineum should be continued until the edge of the anterior fon- tanelle appears in sight ; the head should then be restrained from recession by pressure over its frontal end, should be allowed to advance until the white line of pressure appears at the fourchette, and then held immovable until the gradual distention of the tis- sues effects its disapi^earance ; an advance of from one-quarter to one-eighth of an inch will then usually cause its re-appear- ance, when progress should again be arrested during its continu- ance. This process of careful, gradual, and guarded advance should be continued until the fourchette is seen to slip over the prominence of the forehead and retract across the face, at which moment the great majority of lacerations occur; as it approaches the watchfulness of the attendant should be redoubled. As the motion of retraction begins, the hand which covers the occiput should rotate it slightly toward the side to which it was origin- ally directed in order to remove the projecting nose and chin from the median line, where the danger of rupture is gi-eatest ; while at the same time the hand which governs the frontal end should push the Avhole head vigorously forward in order to pro- mote its expulsion and lessen the tension of the tissues. 108 PRACTICAL MIDWIPEEY. Care of the Cord. — The emergence of the chin is followed in the uiajoi'ity of cases by a short period of uterine inertia, during which the obstetrician should wipe the vaginal mucus from the eyes of the child, if possible before they are opened ; his little fin- ger shovUd then be inserted in the mouth in order to sweep from the throat any nuicus which may have been inspired ; after which a finger should be passed rapidly along the neck of the child and across its shoulders in search of the cord, which in quite a large proportion of eases is looped in one or more turns about the neck and shoulders. If the cord is found in this situa- tion the looser of the loops should be withdrawn from the vulva and pulled dcnvnward over the occiput of the child, or i^ushed back over the shoulders if this is easier. It naay occasionally happen that the cord is so tightly twisted that its length is in- sufficient for either of these manreuvres ; in such a case it should be cut with scissors between a double ligature, but this proced- wve should not be resorted to until several efforts without it have been unsuccessful, as the necessity for its performance is one of the things which must be borne in mind but is not likely to occur. The author has never seen an instance in Avhich it was necessary. During this procedure the attendant must, however, hold himself in readiness to check a too rapid advance of the shoulders if the contractions again set in, it being probably a fact that a larger number of perinea are torn by the shoulders than by the head. Delivery of til e Body. — If the cord is not about the neck, or after it has been released, the finger should be passed across the chest of the child in search of the jierineal hand, for if the arms of the child are flexed in the normal manner across the chest, one or the other hand is usually within I'each of the fingers. If both are accessible, that which is attached to the perineal arm should be selected, but if either hand can be drawn doAvn by traction upon its wrist until the fore-arm and elbow sweep across the fourchette, the release of the corresponding shoulder is at once effected, and the remainder of the trunk may always be extracted without further difficulty, the advantage of this manoeuvre being the fact that the bulky shoulders pass the perineum piece by piece and not all at once, thus greatly lessening the strain. If neither hand is within reach and if the shoulders do not start under the influence of the natural forces within a few minutes after the birth of the child, the right hand should seize its head, the neck lying between the second and third fin- gers, which seize respectively the occiput and chin; it should then be drawn forward and upward in the curve of Carus, while the left hand, applied over the anal region, urges the perineal shoulder forward. If this effort does not succeed, its failure is LABOR. 109 probably due to the arrest of the anterior shoulder behind the pubic arch. In such a case it should be swej^t rapidly back- ward until the posterior side of the neck places the perineum slightly upon the stretch, when very slight traction downward will usually release the anterior shoulder, and a repetition of the upward and forward traction will then invariably effect the de- livery, but during this process the perineum must be under the most careful watch of the eye and hand. After the extraction of the shoulders the head and body should be swept upward across the mother's abdomen in the curve of Carus, while the left hand guards the perineum against pressure from the hips and heels, for while a perfectly intact i^erinuem can scarcely be torn by the hips or feet, it is possible for these parts to convert a nick into a serious laceration. During the extraction of the child and from the moment it emerges from the vulva the hands of the nurse should be ap- FiG. 13.— Position of the Hands in Tying the Funis. plied to the fundus of the uterus and should follow it down in its retraction, but without force unless demanded by the physician ; and should be retained in position in readiness to prevent re- laxation of the uterus by friction and kneading of the fundus, from that time until the patient is adjudged to have passed beyond the danger of immediate post-partum hemorrhage and is ready for the binder. If these precautions be faithfully followed, the loss of a suflQcient quantity of blood to affect the pulse is an al- most unheard-of accident. Ligature of the CorcZ.— After the delivery of the child its fauces should be again cleared of mucus and if no cause for hurry exists the physician should wait for the cessation of pulsation in the cord before tying it. When pulsation ceases, a stout cord or bit of narrow bobbin should be tied tightly around the cord at a point about two inches from the umbilicus, and secured with a double knot, in tying which care should be taken that the hands should rest against each other (Fig. 12), as separation of the cord at the umbihcus has been known to follow the twitching con- 110 PKACTICAL MIDWIFERY. sequent upon }>reakinfc of tlie cord when tlie hands are being forcibly drawn apart. The bal)y .should then be wrapt in a warm woollen elotli and laid in some jiosition where it can neither fall upon the floor nor be stepped upon, while the attention of the attendants is directed to the mothei-. Third Htaye. — The expulsion of the child is usually followed l)y a period of uterine inertia of from one to ten minutes. During this time the uterus should be guarded by the hand and very gentle friction should be used to prevent relaxation and encour- age contraction : and all in.sertion of the fingers into the vagina .should be conscientiously avoided, there being no advantage in their enti-ance and its avoidance being a point of importance in the prevention of septicaiuiia. Credo's Method of Expression.— The expulsion of the pla- centa may occur spontaneously, but it is in the majority of cases Fig. 13.— Expression of the Place.nta. effected more rapidly and to better advantage by the use of Crede's method of expulsion. This procedure has fallen into disrepute with some schools of obstetrieans, but it seems prob- able that their disapproval is largely due to neglect of the re- strictions which Crede originally laid down. Expulsion should never be attemj^ted in the interval between uterine contrac- tions, and the degree of force employed should never exceed a very moderate amount. It is essential that the abdominal wall should be so far depressed as to allow the fundus of the uterus to rest in the holloAv of the hand, the fingers being behind it and the thumb in front (Fig. 13). The hand when in this position should compress the fundus at the moment when LABOR. . Ill a contraction is felt, tlie pressure l)ein<:r exerted only by the palm and the l)aseof the fingers and thumb, their tips merely steadying the lower portion of the uterus, and at the moment this pressure is exerted a rapid but gentle downward impulse should be given to the uterus as a whole. In skilled hands the release of the placenta is frequently accomplished by the first efToi't at expul- sion, and if the method be carefully applied it rarely fails of suc- cess in any hands after a few repetitions. When the jjlacenta passes into the vagina, and a sudden decrease in the bulk of the uterus is ol^served by the hand, it should cease to compress the fundus and should urge the placenta to the vulva by a continu- ance of the downward pressure. As the placenta emerges it should be urged forward by pressure behind the perineum with the dis- engaged hand, the conversion of a nick into a laceration being perfectly possible even at this late moment if this precaution is not observed. As the placenta passes the vulva it should be seized and gently twisted by the hand, but no tractile force should be allowed. This movement converts the fragile mem- branes into a tough and twisted rope which is not liable to tear, and permits their complete extraction. Ergot. — As soon as the iDlaeenta has been delivered it is custom- ary to administer to the patient a drachm of the fluid extract of ergot — a proceeding which is undoubtedly unnecessary in many cases but is productive of no harm and is always a wise precau- tion. After the extraction of the secundines they should be ex- amined in order to discover any abnormalities of the placenta, or incompleteness of the membranes, which may be evidence of their partial retention in utero. ' After the expulsion of the placenta the patient should be warmly covered uj) and should be allowed a few minutes' rest, and the uterus should be guarded by the hand until it has re- mained unrelaxed for at least fifteen minutes. A slight chill is not uncommon at this time, and though sometimes alarming to the patient, is of absolutely no importance. Exnmiiiation of the Perineum. — At the termination of labor the physician should ahvays examine the perineum, in view of the possibility of an undiscovered laceration, and this examin- ation should be conducted by inserting the finger into the rec- tum and everting the posterior vaginal wall through the vulva, in order to facilitate the detection of any intra-vaginal tears, which are extremely common and productive of at least as great loss of support as can be attributed to any external laceration."^ 1 If the membranes be extended and examined by transmitted light, the possible existence of a retained placenta succenturiata may be demonstrated, if present, by the existence in tlieir substance of large blood-vessels which terminate abruptly at the torn edge. 2 g^g rupture of the perineum, page 2uy. 112 PRACTICAL MIDWIFERY. Duties of the PhysiciiDi afttr lAihor. — Btd^ Binder, etc. — The process of eleaiiiug up the bed and patient is properly the pro- vince of the nurse, but since the physician is not infrequently called upon to perform it, in eases of premature lalior, or where no nurse has been engaged, it is essential that he should be fa- miliar with its details. The patient should never be allowed to turn upon her side before the application of the binder, unless the abdomen is guarded by the hand, since its relaxed walls afford the fullest possible opportunity for the entrance of air into the vagina, or even into the cavity of the uterus, in case the patient should accidentally turn herself into Siuis" position. The vulva and neighboring skin should be carefully wa.shed with the corrosive solution; an intra-vaginal injection should be given, and any vaginal or pubic hair which has been soiled by blood or other discharges should be carefully trimmed away with the scis- sors. The vulvar pad should be applied, and the draw sheet and soiled clothing removed with all possible care to avoid unneces- sary exposure of the patient, after which the binder should be applied. This should be long enough to meet across the pa- tient's abdomen, and sufficiently wide to extend from below the trochanters to the lower ribs; the patient's knees should be placed closely together, the lower edge drawn as tight as possible and secured with a large safety pin, and the remainder of the binder should then be drawn and pinned together firmly but without excessive compression. The ends of the vulvar pad or napkin should be secured to the binder and the patient covered with a fresh sheet. The physician should remain in the house for at least an hr>ur after the birth of the child, and should not leave the patient under any circumstances until her pulse has fallen to about the normal range, i^ost-j^artum hemorrhage being extremely rare with the pulse less than eighty, and almost unknown with less than sixty beats per minute. Care of the Baby. — The mother being comfortably arranged in bed, the baby should be washed and dressed, and, though this is again the duty of the nurse, it is a matter with the details of which the physician should be thoroughly conversant. A woollen cloth should be held across the lap, and should be used to cover the baby as thoroughly as possible during the process of wai^h- ing. The vernix caseosa should be thoroughly softened with oHve oil, especial care being taken to completely expose the deep wrin- kles which are common about the neck, groin, and other joints of a well-nourished V:)aby. The whole surface should then be rap- idly and thoroughly but gently washed with a soft sponge and pure castile soap and water at a temperature of from 90 to 95 F. The dressing of the cord immediately after delivery is considered LABOK. li;] by many patients to be the province of the physician, and he should at all events always i"e-exanune it before the child is clothed, in order to make certain that the ligature is sufficiently tight. The cord and the neighboring skin should be carefully washed with an antiseptic solution, carefully dried, and enveloped in absorbent cotton or in soft dry linen. If the cloth dressing is used, a hole should be cut in the middle of a square piece of old linen, and the cord should be passed through the hole until the cloth rests against the skin, when it should be wrapped securely around the cord, and held in i^laee by the belly-band. No grease need be used, but a very small quantity may be smeared around the edges of the hole if it is demanded. The popular practice of l:»rowning the cloth in the oven is perhaps to be recommended, as an efficient sterilization. If the cord is dressed aseptically and no moisture is subsequently allowed to approach it, it rap- idly dries up into a hard, shrivelled body, which separates in from five to ten days, and leaves a dry and thoroughly healed sur- face behind it. The clothes provided for the baby vary greatly with the social conditions of the jjarents, but, although the children of the wealthy are often provided with extra garments, the various forms of dress are always based upon the same general plan ; and it is be- lieved that the following list comprises all the necessai-y articles, Avhich should be adjusted to the infant in the order in which they are described : The first garment to be adjusted is the belly-band, which should be a strip of flannel wide enough to extend from the pubes to the axillae, and sufficiently long to be wrapped twice around the trunk. It sliould be w^ound snugly, not tightly, around the whole body, and secured in position by four small safety pins. After the first ten days this flannel band may preferably be rei:)laced by a cylindrical knitted or woven band, not unlike a section of the leg of a thick stocking, which possesses tlie advan- tages of rendering unduly tight pinning, and consequent com- pression of the chest, impossible, and of dispensing with the use of pins. The binder being in jDOsition, the next garment which should be placed upon the baby is a short undershirt. This is often made of cotton, but it is better that it should be woven and similar to the undershirts of adults in all respects, except that it should button down the Avhole front, rather than be drawn over the shoulders. The shirt is followed by a garment kno'wn as the pinning blan- ket, which, as ordinarily made, consists of a large piece of flannel slightly gathered at one end and attached to a strip of cotton. If this form of pinner has been provided, the cotton strip should be wrapped around the chest and secured by safety pins. The 8 114 PRACTICAL MIDWIFERY. flannel skirt will then l)e rolled several times around the limbs and will project far below them. Its end should he turned over and secured to itself opposite the knees of the infant by a large safety pin. This garment may, however, be better rei)laced by one made wholly romptly successful, this happy result is so rare, and the dangers which attend its use are so much greater than those which follow the employment of forceps, that the free use of ergot while any portion of the ovum remains within the uterine cavity is unhesi- 12G PRACTICAL MIDWIFERY. tatingly condemned by all modern authorities, at least in labor at term or ilurinj;; the last three months of gestation. Some high authorities permit themselves to administer ex- tremely small (ten-minim) doses of the fluid extract of ergot at intervals of twenty minutes in cases of simple uterine inertia in Avliich the os is practically dilated, and where they feel certain that the rapid delivery of the child is prevented by nothing but the aljsence of vigorous contractions; but all agree that its use must be followed by the maintenance of an extremely careful Avatch ujion the fcvtal heart, and that the obstetrician nuist hold himself in readiness to apply forceps without delay if any indi- cation of an alteration of its heart-beat occurs. Although the guarded use of ergot in this manner may, in a few selected cases, be allowable to experts, the danger of an er- roneous diagnosis of the cause of delay is so exti*emely great, that the accoucheur who permits himself to emijloy it assumes a far gi'eater responsibility than is involved in the application of high forceps to an easy case; while the reckless use of this di-ug. which is still extremely common, is a relic of more ignorant times which must be unhesitatingly condemned. lliyidlty of the CercLv. — Rigidity of the cervical tissues may be due either to an over-development or an over-activity of their muscular elements, or to the existence of an organic alteration of their substance, i.e., a stenosis. If no mechanical obstacle is detected by an examination under ether, and if the rigidity of the OS disappears, to be re-established after the recovery of the patient from anaesthesia, the failure of progress is i^robably due to a muscular spasm of the circular fibres of the cerAix and a consequent undue resistance to the efforts of the dilating wedge. This condition is almost uniformly ovei'come by the administi*a- tion of chloral in fifteen- to twenty -grain doses, repeated at twenty-minute intervals to a maximum of fifty grains, or by the obstetric use of ether described under Normal Labor. If no mechanical cause for the arrest is discovered, and if the rigidity of the os does not disappear under full surgical anaes- thesia, it may be admitted that true rigidity of the cervix is present. This, when recognized, may usually be overcome by gentle manual dilatation, Avhich in such cases need not be carried to the degree of complete expansion, since a very moderate stretching often produces a change of condition, which permits dilatation to progress under the force of nature. ^lalpreaeutation^, etc. — If a malpresentation is found it should be rectified at once if possible, since its persistence untreated must necessarily lead to the supervention of retraction or of a spasmodic rigidity of the uterus. If the delay proves to be due to a disproportion between the size of the head and the pelvis LABOR. 127 the obstetrician should be stimulated to the closest possible ob- servation of the progress of labor, in order to be ready to oper- ate, if that should prove to be necessary, before the appearance of any serious degree of exhaustion. In general, it may be said that, Avhen the question of opera- tion arises during the first stage, the conditions which should in- cline one toward a conservative policy are, a small size of the os, rigidity of the cervix and other soft tissues, a satisfactory condi- tion of the pains, and the fact that fairly good, if not satisfactory, progress is still present; while absolute arrest in the pi-esence of a large and increasing caput, full dilatation or dilatability of the cervix, an elastic perineum, and rapidly increasing failure of the uterine forces are arguments in favor of the necessity of inter- ference. DELA.YED Second Stage. The management of delay in the second stage of labor practi- cally resolves itself into the question of the expediency or inexpe- diency of operative interference at any given minute ; and since the risks of delay and interference both decrease in proportion to the amount of descent which has been effected, it is necessary at the stai't to divide the consideration of delay in the second stage into sub-stages, in accordance with the height of the head in the pelvis. This is determined by the relation which the greatest diameter of the head bears to the pelvic walls; i.e., according to the zone of the pelvis which is occupied by the girdle of contact between the head and pelvic walls. When the greatest diameter is above the inlet the head is said to be free above the brim ; when the greatest diameter occupies the strait itself, the head is said to be engaged at the brim ; Avhen the girdle of contact occupies a posi- tion between the superior and the inferior straits, the head is in the excavation ; when the girdle is found at the inferior strait, the head is low ; when the greatest diameter has passed the inferior strait and the perineum is distended by the vertex, the head is said to be on the perineum. Although delivery when the head is in the excavation is more difficult and attended by somewhat greater risks than when it is at the inferior strait or upon the perineum, the difference in risk is so much more greatly altered by the fact that it has or has not passed the brim that it is cus- tomary to divide the question into the consideration of high and low operations, the Ioav including all cases in which the greatest diameter is below the superior strait. In normal pelves, and with occipito-anterior positions of the vertex, delay in the second stage is, as before, due either to rela- tive feebleness of the pains in opposition to a normal adaptation between the head and pelvis, or, upon the other hand, to unduly 128 PRACTICAL MIDWIFERY. great resistances in the face of normal uterine forces. In the second case the resistances may be increased, either by abnormal rigidity of the soft tissues of the mother, or by undue size and firmness of the foetal skull. Inertia in the Second Stage. — High Arrest from In- ertia. — The diagnosis of inertia during the second stage of labor is to be made by the exclusion of any obstructive elements in the case on high examination, under ether if necessary, and by the fact that the feebleness of the contractions has existed from the start. When delay, high, is due to relative inertia of the uterus, the expedients recommended for the treatment of inertia in the first stage should be given a fair trial; but since tne dangers of interference are considerably decreased l)y the dis- appearance of tli6 cervix, and because operations undertaken for the relief of mere inertia with no more than normal resistances are uniformly easy, it is ordinarily proper to resort to an opera- tive delivery whenever there has been an absence of jjrogress of from three to four hours' duration, or at the least indication of failure in the powers of mother or child. When the operative delivery of a normal head, arrested by simple inertia at the brim of a normal pelvis, has been decided upon, the choice between forceps and version must depend to some considerable extent upon the preferences of the individual operator and the preponderance of skill which he has acquired in one or the other operation. Easy forceps operations, however, if performed with a reasonable degree of adroitness, should in- volve but little risk to mother or child, while the life of the child may occasionally be lost in the most simple versions by prema- ture compression of the cord or by some difficulty in the extrac- tion of the arms, for which reason the iDreferenee should usually be given to forceps in this class of cases. The relative indication for forceps over version increases with the firmness of the peri- neum and other soft parts, and is of course more marked in primiparee than in multiiDarse. Loto Arrest from Inertia. — When the contractions have been sufficiently powerful to effect the descent of the head into the excavation, but die away and are succeeded by an absence of progress at the inferior strait, the risks of the performance of a probably easy low-forceps oi:»eration are so small that it is usu- ally proper to complete the delivery by instrumental means, after an hour has i:)assed without any increase in the descent. Such action is justifiable, not only on the ground of humanity to the mother, but because it is found by experience that, although it may result in a slightly increased luimber of lacerations of the peri- neum, it decidedly decreases the percentage of still-l)orn children. High Arrest from Increased Resistances.— When at LABOK. 129 any time after the eflfacement of the cervix the high head has failed to make any advance during a full hour of strong labor, it is good practice to i^ass the half-hand into the vagina, under ether if necessary, and thus enable one or two fingers to pene- trate sufflciently high to make an accurate and complete exami- nation of the position and relations which the head as a whole bears to the pelvis. If such an examination demonstrates the absence of any abnormal conditions, and establishes the fact that the delay is due solely to the unusual size and firmness of the head, it is proper to definitely lay aside all thoughts of operative interference until it is indicated by the actual or impending ex- haustion of one or the other patient. It frequently happens that a head which was at the start, to all appearances, so dispropor- tioned to the pelvis as to afford but little reasonable hope of its delivery by the uterine efforts alone, be omes so greatly modified during a few hours of strong labor as to pass the brim under the force of nature only, before the powers of eitlier patient fail. It is, moreover, a well-established fact that the moulding of pro- longed labor is far better borne by the child than is an immediate and forcible reduction of the bulk of its head during a rapid in- strumental extraction. Such delay is, however, always sufficient cause for anxiety, and should excite the obstetrician to the main- tenance of an unusually close watch for the appearance of .ma- ternal, uterine, or foetal exhaustion. When the fcetal heart or maternal pulse begins to rise steadily, or when previously regular and intermittent pains become irregular and tonic, it may be taken for granted that the delivery of a living child by natural labor has become improbable. When the foetal heart- beat permanently increases in rapidity it is important that the child should be promptly delivered; since, if operation is delayed, it must, not improbably, be even- tually undertaken at a time when the vitality of the child has be- come distinctly less, and when its chances of survival are there- fore much decreased, and because it may be taken as an axiom in midwifery that, though the pi'eservation of the maternal soft parts is an object of the first importance, it is always inferior in value to the foetal life. When the maternal pulse and tempera- ture are steadily rising, an operation is indicated in the interests of both patients; since it is unlikely that powers which have be- gun to flag before the head has passed the superior strait will be sufficient to perform the large amount of work which still re- mains to be done, and if an operative delivery is to be necessary it is far better that it should be performed while both patients are in comparatively good condition. Moi'eover, Avhen the gen- eral strength of the mother has once failed it is highly improba- ble that the uterus will long remain in a normal condition; and, 9 130 PRACTICAL MIDWIFERY. as a matter of clinical experience, an increase in the maternal pulse and temperature is almost invariably followed, after a short interval, by the appearance of an in-egularity or tonicity of the uterine contractions which is highly diagnostic of the ap- pearance of prematui-e retraction of the uterus. Choice between Foroe2)s and Version in High Arrest from In- creased Resistances. — The discussion of the relative advantages of version and the forcei:)S in each of the many cases in which a high ojDeration is indicated is one that in itself might fill a vol- ume, and the choice is, moreover, one which must, after all, be decided in most cases by the skill and predilections of the indi- vidual operator, and by <^areful balancing of the conditions of the individual case. All that can be attemi^ted here is to de- scribe briefly the conditions which are favorable or unfavorable to one or the other oi^eration. In anterior positions of uncomplicated vertex j^resentations, in normal jaelves, the choice dejiends on the degree of engage- ment which has already been effected, and on the condition of the uterus and soft parts. Fixation of the Head. — If the head has become fixed at the brim the application of forceps is comparatively easy, while the introduction of the hand for version is more difficult than with a free and movable head. A free head is therefore favorable to version, and a fixed head to forceps. If at the time of ojieration the greatest diameter of the head is already in, or nearly in, the superior strait, the greater part of the resistance to the passage of the forecoming head has been already overcome; and the head is, moreover, in all probability so far moulded to the posi- tion in which it finds itself, that its rapid alteration during ex- traction, to the configuration necessary for the passage of the after-coming head will expose the child to grave risks of intra- cranial injury. This condition is therefore a strong indication for the use of forceps rather than version. Constriction Ring. — When a dry uterus has retracted upon the child, or a constriction ring is present, the use of forceps is far less difficult and dangerous than version. Bandl's Ring. — When BandFs ring occurs in the presence of an undiminished quantity of waters, and in a pure state, forceps should be preferred, unless the child is very freely movable and the head l^ut lightly engaged ; if it is complicated by the presence of a constriction ring, version is rarely safe, or even possible. Rigid Soft Parts. — If the cervix or vagina is small and rigid, "the use of the forceps permits of their gradual dilatation during "the slow advance of the head, while the rapid extraction which is necessai-y in the delivery of the after-coming head exposes them to much greater risk of serious laceration. LABOR 131 The importance of each of these conditions in the individual case should be carefully estimated before the decision is made; but it should be remembered that while the jDerformance of ver- sion renders a subsequent resort to forceps impossible, a previous tentative application of forceps is no hindrance to the subse- quent jDerformance of version. The careful and skilful applica- tion of forceps, and the .use of gentle traction to determine the probability of so effecting the descent of the head, should be at- tended by little or no risk to either mother or child. The introduction of axis-traction has greatly widened the field for instrumental delivery. Low Arrest from Increased Resistances.— When the uterine contractions have been sufficiently powerful to effect the passage of the superior strait, but are unable to overcome the resistances of the inferior strait and of the soft tissues of the pelvic outlet, the only consei'vative operation possible is the applica- tion of forceps. The risks- of this low operation, even when per- formed for over-tight adaptation, are comparatively so small that it may be properly undertaken, not only on the appearance of the least perceptible amount of exhaustion on the part of either patient, but as a matter of routine whenever the second stage has already consumed two hours and progress has been absent for one hour. Delated Third Stage. Delay in the expulsion of the placenta may be due to com- plete or partial atony of the uterus ; to the presence of a spas- modic closure of the internal os, or of a spasmodic constriction ring in some other portion of the uterus ; and, finally, to the ex- istence of morbid adhesions between the placenta and the uterine surface. Inaction of the uterus is usually attended by the appearance of post-partum hemorrhage, and the immediate removal of the placenta is then essential to its arrest ; if the relaxation of the uterine muscle is not followed by this complication, it may be endured without injury for prolonged periods of time; but it should be an invariable rule that the uterus should be closely guarded by the hand of the obstetrician, or by a trained assist- ant, during the whole period which intervenes between the de- livery of the child and the expulsion of the placenta. • The danger of the occurrence of haemorrhage in such a condition of uterine relaxation is, moreover, so great that if, at the end of an hour spent in attempts to excite uterine contractions and express the placenta, all efforts to this and have been unavailing it is usu- ally better to remove the secundines manually. 133 PRACTICAL MIDWIFERY. The presence of spasmodic constriction or of abnormal adhe- sions of the placenta is to be diagnosed mainly by the failure of Credo's method of expression, when systematically and persever- ingly applied by an experienced hand. When the uterus re- sponds promptly to the hand, an expert operator may occasion- ally be justified in manual removal of the placenta after the failure of a comparatively small number of efforts at expression; but the best rule for the young accoucheur is that gentle efforts at ex- pression should be persevered in for at least an hour before the hand is allowed to invade the uterus in search of the placenta. If expression fails, the fingers of the half-hand should be in- serted into the vagina and passed into the cervix, in an attempt to reach the lower edge of the i^lacenta, when this can be drawn into the os. Gentle traction upon its substance, in combination with expression from above, will sometimes supi:)ly sufficient force to release it from a sj^asmodic ring, or may even separate slight adhesions ; but there is so much danger of lacex'ation of its substance, and of the retention of portions of the placenta or membranes, after the use of this method, that none but the most gentle tractions should be allowed. If this fails, and the immediate removal of the placenta is warranted by the presence of haemorrhage, or by prolonged re- tention, the fingers should be formed into a cone, should be passed gradually and without force into the uterus, and caTried to the fundus, if possible between the membranes and the uterine wall, upon the side opposite to the placenta. They should then be swept across the fundus until they reach the edge of the pla- centa, when, if no pathological adhesions are present, the entire after-birth may usually be swept into the world in advance of the hand ; if, however, its surface is adherent to the uterus, the adhesions must be divided bj' gentle sawing and sci'aping mo- tions of the fingers, care being taken that they are so directed that any laceration which may occur shall be at the expense of the placenta, and not of the uterine wall. The tissues of the jjlacenta may be distinguished from those of the uterus by their greater softness and their lack of contractability when excited by the pressure of the fingers. Should the adhesions be exten- sive and the separation difficult, the risks of the retention of small fragments of the placenta in utero are decidedly less than those which attend upon unnecessary wounding of the intra- uterine surfece, since such fragments are usually cast off with the lochia, and fail to cause any symptoms of importance if full antiseptic precautions have been observed. The manual removal of the placenta should invariably be followed by an antiseptic intra-uterine douche, since the intro- duction of the whole hand and the use of the finger-nails in in- LABOR. 133 flictiiig fresh wounds upon the uterine surface makes the opera- tion the ]nost dangerous of obstetric manipulations, in so far as the production of sepsis is concerned. In tlie majority of cases in which manual removal of the placenta is necessary, the elasticity of the perineum is so much inci'eased, and its sensibility is so much diminished by the dis- tention due to the delivery of the child, that tolerably resolute women are able to endui-e the pain of the operation without anaesthesia. In cases in which the pain is extreme the adminis- tration of ether or chloroform is usually permissible; but its use should not be pushed to any unnecessary degree, on account of the increased liability to relaxation of the uterus and post-partum ha?morrhage, which probably attends its employment during this stage of labor. PAET III.— OBSTETEIC SUEGEEY. CHAPTER X. PREPARATIONS FOR LABOR. ARTIFICIAL DILATA- TION OF THE OS. THE INDUCTION OF ABOR- TION, MISCARRIAGE, AND PREMATURE LABOR. Preparations for Operation. Antisepsis. — Obligatoiy as is the observance of strict anti- septic precautions in all cases of normal labor, this necessity is even more imperative when operative procedures are contem- plated. No added precautions are, however, necessary, except a cai'eful disinfection of any instrument which is to be used, and the use of a thorough vaginal douche as a preliminary to any operation ; since the introduction of a clean hand or instrument through anything but an equally clean vagina is manifestly un- scientific and unlikely to exclude sei^ticfemia. Disinfection of Instruments. — This may be effected by their immersion in corrosive sublimate or carbolic acid solutions, by boiling, or by exposure to dry heat. Corrosive sublimate, though a most efficient antiseptic, corrodes metallic instruments, but those which have been well nickelled are so slightly affected that their pohsh can be restored with but little effort. Carbolic acid, in the proportion of one part of the acid to twenty of water, is however, an efficient germicide, and, if at hand, should be pre- ferred, since its action upon metal is extremely slight ; the instru- ments should, however, be left in the solution for at least ten minutes before being used. Dry heat is seldom easily attained, and possesses the disadvantage that it is efficient only at temper- atures which are more or less injurious to the temper of steel in- struments. Soft catheters and forceps with wooden handles are injured by boiling; but if the forceps are provided with handles of metal or hard-rubber there can be no more efficient or convenient method of sterilization than their immersion in boiling water for from twenty minutes to half an hour ; and this is the only method which can be relied upon in the disinfection of more complicated instruments. Whichever method is used, it must not be forgot- 136 PKACTICAL illDWIl'EKV, ten that ordinary, or luacroscoijic, cleanliness is an essential pre- liminary to proper disinfection. Catheters should not only he imiuersed in the disinfectant solution, but care should Ije taken to see that the fluid has access to the interior as well as the out- side of the tube; and it is well to rinse the instrument in simple Avater before passinj^ it into the bladder, since the strong disin- fectants are sometimes capable of exciting cystitis by merely chemical irritation. AXjKSTHKSia. — The use of antesthetics during obstetrical op- erations is in this country so nearly universal" that any extended discussion of the proi^riety of their use is unnecessary. The ad- vantages of anaesthesia are twofold — first, the avoidance of pain and anxiety, and the accompanying nervous exhaustion of the patient; and, second, the diminished or abolished danger of abrupt movements, at inconvenient moments, which results from their use. During delivery by forceps the obliteration of the uterine jjains is sometimes a disadvantage, but during other op- erations it is almost uniformly to be desired. It must, however, be remembered in this connection that if ana-sthesia is used at all it must always be carried to the fullest surgical degree, since partial loss of consciousness not only fails to annul pain, but de- prives the patient of her normal self-control, and renders the occurrence of dangerously abrupt movements almost a certainty. The choice of anaesthetics is practically restricted to chloro- form and ether. It is generally admitted that the dangers of chlorofoi'm are far less in midAvifery than in its surgical use; but this absence of risk, though relatively great, is by no means abso- lute, and the advantages of ether for prolonged administration are very real; while the greater care which must be exercised in the administration of chloroform, and the possibility of intrust- ing the ether sponge to an untrained assistant during normal la- bor or minor operations, are so great a convenience as perhaps to turn the scale, and this especially since the patient's perception of the discomforts of the first stage of etherization are distinctly lessened by the distraction of her attention due to the presence of the pains of labor, so that it is often possible to carry its ad- ministration to complete anaesthesia without the provocation of any marked symptoms of discomfort. The mo.st certain method of effecting this very desirable end is to intrust the sponge at first to the hands of the patient, in the manner recommended for the alleviation of pain during normal labor, and then gradually increase the dose until consciousness is insensibly lost. It is probable that tlie physiological effect of either anaesthetic is so far antagonized by the presence of the pains of labor that the dose necessary for complete an?esthesia is considerably in excess of that which would be required by the same patient in the ab- OBSTETRIC SURGERY. 13? sence of pain ; and it is certainly often observed that a patient who has failed to attain complete anjesthesia during the process of delivery sinks into profound unconsciousness as soon as the pain has been annulled by the escape of the child ; a fact which, though ordinarily unproductive of evil, should never be forgotten during the administration of ether to patients with feeble consti- tutions or weak hearts. Position' of thk Patient.— The attitude in which the pa- tient is placed varies with tlie nationality of the operator; in England, the lateral decubitus is still preferi-ed ; but on the con- tinent of Europe, and in America, the lithotomy position, with the patient lying across the bed, the hips well over its edge, and each leg held by an assistant, is ahuost uniformly chosen; and its adojDtion will always be assumed here unless some statement is made to the contrary. The i3hysieian should always remember to protect the edge of the bed by drawing the rubber sheet well over it, and to lay a number of old rugs or comforters on the carpet underneath it, in order to prevent soiling by either liquor amnii or blood. The l^ro vision of hot and cold watei-, ice, ergot, brandy, etc., already recommended for normal labor, is of course of especial impor- tance in operative cases. Catheterization. — All obstetrical operations should invari- ably be preceded by an evacuation of the rectum and bladder; the administration of an enema of soap and water is sufficient for the one, but the use of the catheter during childbirth some- times presents some little difficulty, and must be described in de- tail. The abundance of the vaginal secretions during labor and the puerperium makes it difficult to pass the cathether by touch without introducing into the bladder some jDortion of the vaginal secretions — an accident which is almost invariably followed by the production of cystitis ; for which reason, the catheter, in obstetri- cal work, should always be passed under the guidance of the eye. The form of instrument which should be used is by no means unimpoi'tant ; during the puerperium, soft rubber catheters, or those made of woven raw silk, are unobjectionable and distinctly the least disagreeable to the patient; but during labor short fe- male catheters and all soft instruments are mere abominations, whose use should never be i^ermitted, the only instruments fit for use at this time being the silver, or stiff English webbing, male catheters, of medium size, i.e., 20 to 25 French, 8 to 12 English. The labia should be separated, and the neighborhood of the meatus carefully cleansed with a corrosive-sublimate solution.' 1 The normal prolapse of the anterior vaginal wall during labor sometimes hides the meatus at the bottom of a fold, but it can always be found by following the median line backward from the clitoris. 138 PRACTICAL MIDWIFERY. The tip of the catheter should then be .shpped into the meatus, and the forefinger of one hand should be passed into the vagina, and should watch the passage of the instrument along the pos- terior surface of the pubic wall to its point of contact with the head. In some cases no obstacle is encountered here, but in the majority of instances, the passage of the catheter into the blad- der is greatly facilitated by making moderate pressure upward and backward upon the presenting part. The entrance of the instrument into the bladder is signahzed by the escape of a jet of urine; but it is essential to success that its progress should not be arrested here. If a rigid instrument is used it should be passed on until the operator ascertains by his tactile sense that its tip has reached the highest point of the bladder, stretched as that vlscus is to an extreme height in the abdomen, by its at- tachment to the anterior wall of the distended uterus ; Vjiat if the much preferable English webbing catheter is employed the stylet should be withdrawn as soon as the instritment is within the bladder, and the catheter itself should then be pushed in until its hilt is at the meatus. If in this position no urine comes, the instrument should be gradually withdrawn until the flow is ob- served to start, held in position until this ceases, and again with- drawn gradually, when a further flow is usually observed. This process is to be repeated until the catheter has been entirely withdrawn. Too great care cannot be exercised in the evacuation of the bladder, since, if even a small quantity of urine has been left be- hind, it may during the subsequent manipulations of delivery settle into the lower portion of the bladder, which may then, by prolap.se of the anterior vaginal wall, form a .sac below the head, and if such a sac is formed it is almost certain to be caught be- tween the advancing occiput and the pubic wall, when, its con- nection with the urethra being cut off, the force of delivery is not unlikely to result in the production of that most annoying of aU obstetrical accidents, the formation of a vesico- vaginal fistula. Artificial Dii/Atation of the Os. The delivery of the child, whether effected by art or by the natural forces, presupposes the existence of complete or nearly complete dilatation or dilatability of the os; but, since it may exceptionally be necessary to perform any operation in the pres- ence of a partly dilated cervix, we may be obliged to precede any of them by the preliminary operation of its dilatation. It is there- fore proper to open the discussion of operative obstetrics by a description of the methods which should be emijloyed for this purpose. OBSTETRIC SUKGERY. 1B9 Two methods are at our disi^osal — the use of Barnes's dilating bags, and of the intelhgent efforts of the human hand. The Eng- hsh obstetricians, following the example of the illustrious in- ventor of the dilators, are little prone to manual dilatation; but in Germany and America the many provoking annoyances and the frequent failures of Barnes's bags, in comjDarison with the certainty and efficiency of manual dilatation, have led to the abandonment of their use, unless in exceptional cases. Bar2,-es"s Hydrostatic Dilators.— If the dilating bags are used, the tip of a uterine sound should be inserted into the pocket on the side of the smallest bag, which should then be folded around the sound, thoroughly greased, and passed into the eer^-ix until its Avaist is gTasped by the os. It should then be held in position by a pan- of forceps and distended with a weak solution of corrosive sublimate until the os has been raised to as high a degree of tension as is judged wise; it is then left in situ until expelled by the contractions of the uterus, when the same process is repeated -with the next larger bag. The objec- tions to theu" use are that they can but seldom be used until a certain degi-ee of dilatation is already present ; that when the subsequent failure of dilatation is due to inefficiency of the pains they frequently fail to excite contractions which are sufficiently strong to secure dilatation; and that, on the otiier hand, when the delay is due to rigidity of the os in the presence of good la- bor, the bag will not infrequenth' rupture, without effecting dil- atation. Their action is never sufiiciently prompt to be of use in a pressing emergency; and, as they are at present made, the largest size fails to raise the os to a degi'ee of dilatation sufficient for the i:)erformance of any operation. ilAXUAL Dilatation:. — The operation of manual dilatation, though easy and often invaluable, is no light procedure, and must even be regarded as among the gravest of obstetrical opera- tions. It not only exposes the patient to increased danger of septic absorption, but. if clumsily performed, is almost certain to result in lacerations of the cervix, or even of the uterus or its vaginal attachments. If used as a prehminary to a forced de- livery it adds greatly to the gTavity of the other operation pro- posed. It should never be undertaken without grave considera- tion, and then only under full surgical anaesthesia and with every convenience which can be afforded by the position of the patient and the presence of competent assistants. In fact, al- though this operation affords to the skilful obstetrician his most valuable resource for the induction or acceleration of labor, and although its careful performance seldom results in any accident of importance, the occuiTence of any clumsiness or the use of undue force dui'ing the procedure is attended by such immediate 140 PKACTICAL MIDWIFERY. and disastrous consequences that the inexperiencd accoucheur should not permit himseh' to employ it without consultation with some older practitioner, unless in the face of a most pressing emergency. Everything being in readiness for the performance of the op- eration, and the dorsal surface of both hands being thoroughly anointed with aseptic vaselin, one hand should be placed upon the fundus of the uterus, and throughout the operation should make downward pressure upon it through the abdominal wall, in order to guard so far as possible against the pro- duction of any undue tension upon the vaginal at- tachments of the uterus; while the fingers of the other hand should be formed into a cone and gentlj' inserted through the vulva until the first joint of the fore-finger can be passed within the os.' This finger should then be hooked around its edge, and should exert gentle downward traction, while a cautious effort is made to pass the tip of the second finger be- side it (Fig. 17); and this effort should be main- tained until the first joints of both fingers are fully within the circle of the os and placed side by side, in which position they pre- sent the greatest surface to it. Throughout the per- formance of this operation it should be remembered that the os uteri is not simply an elastic band, nor capable of distention to any marked degree after the manner of a piece of rubber, but is, on the other hand, living tissue which can be dilated only by the relaxation of the circular fibres of the cervix, and that this relaxation is the result of a gradual mus- cnleiv fatigue due to their long-continued exei'tions against the obstacle opposed to their contractions by the presence of the fin- ger. For this reason, so soon as the edge of the os is distinctly subject to even slight tension the motion of the fingers should be arrested, and they should be held firmly rii situ until the os 1 Should the os resist the entrance of the finger, it may be necessary to trust to the action of a bougie or to resort to the cautious use of steel dilators to effect a preliminary dilatation ; but this is seldom necessary. Fig. 17.— Introduction of the Second Finger IN Manual Dilatation of the Os. OBSTETRIC SURGERY. 141 is felt to relax around them. So soon as this occurs they should be again advanced until the former slight tension is re-estab- lished, and then again arrested until relaxation occurs. This process may occupy many minutes, and frequently subjects the hand of the operator to extremely painful muscular cramps, but cannot be hurried, with any proper regard to the safety of the patient. This portion of the operation is by all odds the most dif- ficult and painful to the operator, who rapidly loses all power of controlling the motions of the fingers which are subjected to the uterine pressure. It may occupy from a few minutes to several hours, in all but the easiest cases is so extremely fatiguing as to necessitate a frequent change of hands, and may often prove im- possible unless a second operator is present to sujDply the place of the first and afford him needed rest. It occasionally happens that after the insertion of the first finger the introduction of the second proves almost impossible. In such cases the steel dilator may be inserted by the side of the first finger, and very cautiously expanded ; or the temporary use of a Barnes bag may be resorted to, either alone or by the side of the finger, until the necessary increase of size has been at- tained. When the first joints of two fingers are in position the withdrawal of the second finger until only its tip is within the circle will usually permit the immediate introduction of the tip of the third finger by its side, when the process of intermittent dilatation must be repeated with the third, and finally with the fourth, finger. When the os permits the easy introduction of the third joints of four fingers placed side by side, the thumb should also be introduced. The os should then be placed gently upon the stretch by expansion of the hand, which should again be re- tained immovable until relaxation occurs and permits its grad- ual passage upward until the os is about the wrist; but at this stage of the operation the precautions against undue haste should be, if possible, redoubled, since the moment at which the projecting knuckles pass the os is that at which laceration of the cervix is most likely to occur, and because if any but the gen- tlest upward pressure is permitted at this time, the tension upon the vaginal attachments becomes dangerously severe. Throughout the operation the occurrence of even the least degree of uterine contraction should be a signal for instant quietude of the hand, which, however painful its position, must then be retained immovable until the labor pain has passed away. When the extended hand has been passed within the lower uterine segment it should be gently closed into a clenched fist, in which position it attains its greatest circumference, and should then be gently drawn downward against the os, in imita- tion of the production of dilatation by the natural progress of 143 PRACTICAL MIDWIFERY. the head. When the clenched fist can be passed freely backward and forward through the os, the fullest dilatation which can be reached by artificial means has been attained. ^ If the mem- branes are unruptured at the commencement of the operation every effort should be used to avoid their accidental rupture and the premature escape of the waters, especially if there is any pos- sibility that version may be necessary. When dilatation of the os is to be succeeded by the perform- ance of version, the fullest dilatation possible must always be at- tained; but when it is undertaken as a preliminary to the appli- cation of forceps, it is not necessary, and seldom or rarely wise, to attempt to secure full dilatation ; on the contrary, when the size of the os is such as to permit the easy passage of the blades, it is usually best to leave its further expansion to be effected by the passage of the head. Induction of Abortion, Misca.rbiage, and Premature Labor. Conditions which Justify the Induction of Abortion. — Artificial abortion is indicated in two classes of cases — (1) when delivery of a viable child through the natural passages is impos- sible, and the induction of abortion offers any advantage to the raother as compared with delivery at full term; (2) when the mother's life is materially endangered by some pathological con- dition incident to pregnancy, and is likely to be saved by its im- mediate termination. The consideration of the first class of indi- cations, and tlie comparison of tlie relative advantages of the induction of abortion or premature labor with craniotomy and the Caesarean section, falls more properly under the treatment of contracted pelves, and is fully discussed there. The indications which group themselves under the second class are also described in detail elsewhere, under the heads of the incurable vomiting of pregnancy; incarceration of the pregnant uterus; albuminuria or eclampsia; haemorrhage during pregnancy; hydramnion; anaemia, chorea, and the other general or systemic diseases; to which must be added the occurrence of actual or incipient in- sanity during pregnancy ; but it is proper to remind the physi- cian here that in all these cases, except insanity, the dangers 1 When the presence of some grave emergency renders a rapid dehvery a matter of urgent necessity, and the resistance of the cervix is so great that it becomes evi- dent that the mother's life will be lost before sufficient dilatation can be obtained, it may occasionally be proper to incise the cervix with a blunt-pointed bistoury at three or four points, to a depth of perhaps a quarter of an inch, when further dila- tation is usually rapidly possible ; but since this procedure exposes the patient to exceptionally grave risks of extensive laceration, it is only justifiable in the face of the most urgent and immediate danger. OBSTETRIC SURGERY. 143 which threaten the mother are no less serious to the child, whose life is dependent u^Don hers, and that it must always be the most grave of mistakes to sacrifice both lives by an unduly protracted effort to preserve the less valuable of the two. The occurrence of insanity during pregnancy opens a question of much ethical interest, and one upon which there may be much honest differ- ence of opinion; but it is probable that, in view of the almost inevitable inheritance of the child, the great majority of physi- cians would admit the right of the mother to sacrifice the foetus for the sake of the preservation of her own mental balance. The induction of premature labor may occasionally be indicated, in the interest of the child, in cases in which the life of the foetus has been habitually lost at some period within the last two months of previous pregnancies; but the difficulties which attend the diagnosis of such a condition are so great that but few successful cases have been recorded. Prognosis of Premature Labor, Miscarriage, aivd Abortion. — Although the work of the professional abortionist is one of the most prolific causes of the ill-health of women, and is attended by no insignificant mortality, the induction of artificial abortion or miscarriage should, in skilful and aseptic hands, in- volve no risk to the maternal life, and, in the absence of previous pelvic derangements of inflammatory origin, should seldom or never produce local troubles of importance. The prognosis of induced premature labor should differ but little from the prog- nosis for labor at term, so far as the mother is concerned. The foetal mortality is that of premature children in general. Apter-Treatment. — The care of convalescence after the per- formance of artificial abortion differs in no way from that already recommended in the description of inevitable abortion. Technique of the Induction. — Among the means which have been recommended for the initiation of labor, the use of drugs, such as ergot, quinine, and jaborandi, of prolonged hot- water douches, catheterization or faradization of the uterus, puncture of the membranes, dilatation of the cervix, and me- chanical distention of the vagina are the most prominent and deserving of mention. The only drug which can be considered to possess any value in this connection is ergot ; but even that can seldom be relied upon to initiate the pains, its chief value being to sustain the action of the other expedients; and even when it is used for this purpose it should be restricted to cases in which the child is dead or not yet viable, on account of the fact that its use produces a state of tonic contraction, which if pro- tracted usually results in the death of the foetus by embarrass- ment of the utero-placent^l circulation. Hot-water douches are somewhat inefficient, and are also useful mainly as adjuvants. 14-4 PRACTICAL MIDWIFERY. If they are employed at all, the quantity of water should be large, and the temperature should be the highest which the patient can endure. The use of faradic, or even galvanic, electricity, through a vaginal or intra-uterine electrode, has lately been rec- ommended, but has not yet been shown to justify the claims of its advocates. The choice between the other measures must be decided by the i^eriod of pregnancy at which the induction of la- bor is desired, and by a consideration of the physiological pro- cesses by which their several effects are produced. For clinical purposes, the process of the induction of labor may be divided into the provocation of pains, and the acceleration of labor after contractions have been aroused — a classification which materially assists in the choice of the methods which should be used at any given moment ; but whichever method is adopted, the whole pro- cedure should be conducted under the most rigid antisejitic pre- cautions, including a jireliminary flushing of the vagina with a 1:1,000 solution of corrosive sublimate or 1:60 of creolin, which should be repeated at the expiration of twenty-four hours if the delivery has not been sooner accomplished. Abortion. — During the first three months of pregnancy the element of haste is rarely important, and the chief desideratum is then to choose a plan which will probably result in the expul- sion of the intact ovum ; and, though many methods are permis- sible, catheterization of the uterus is perhaps most generally pre- ferred. A small solid bougie, about No. 12 French, and with a very flexible tip, should be carefully introduced into the os, passed well within the uterus in the most gentle manner and if possible without rupture of the membranes, and then retained in situ by the insertion into its external end of a catheter stylet Avhich has been bent to an acute angle and is retained in position by the attachment to its other end of a tape tied about the waist of the patient (Fig. 18) and by a T-bandage placed over the vulva. Both bougie and stylet should, of course, be new. The vagina should be thoroughly distended with sterilized cotton pledgets, introduced through a Sims' speculum, and the patient should be given about twenty minims of the fluid extract of ergot every four hours. If at the end of forty-eight hours no descent of the ovum has been produced, it is probable that the decidua are abnormally adherent ; that the uterus is extremely unresponsive to stimulus, or that the membranes have been rup- tured during the introduction of the bougie, and that the bulk of the ovum has been thereby so much diminished that the uterus is unable to expel it. In either case it is perhaps best to resort to puncture and free separation of the membranes with a uterine sound or other rigid instrument, which should be passed to the fundus of the uterus, and swept about in all direc- OBSTETRIC SURGERY. 145 tions to insure the rupture of the ovum, or at least a thorough loosening of its attachment to the uterus; after which, under the use of ergot and the tampon, the expulsion of the foetus may be confidently expected. Another, and perhaps a preferable, method is the mechanical dilatation of the cervix, which at this period is best effected by the use of a branching steel dilator, which should be inserted into the cervix in such a manner that its tips project but little beyond the internal os, in order to avoid laceration of the ovum — an accident which, with care, may usu- ally be escaped. When the dilator is in position the cervix should be gently stretched until the os admits the finger freely, when the vagina should be packed and ergot administered, as before recommended. Should this method fail, a subsequent re- FiG. 18.— Method of Fastening the Intra-uterine Bougie in Place. sort to the bougie or to rupture of the membranes is always pos- sible. If after any of these procedures the expulsion of the ovum is followed by troublesome and persistent bleeding, it is probable that some portion of the decidua is still unexpelled, in which case the interior of the uterus should be thoroughly scraped with a blunt wire curette, and swabbed out with Churchill's tincture of iodine. The cervix is usually at such times sufficiently patulous- to permit the passage of a small instrument, but may if neces- sary be again dilated by the steel dilator, or by the use of Hanks'^ graduated sounds. The patient should be kept in bed, and the- most rigid antiseptic precautions should be observed throughout the employment of these and all other methods for the induc- tion of abortion or labor. Miscarriage. — If pregnancy has advanced to more than three lO 146 PRACTICAL MIDWIFERY. and less than seven months, the expulsion of the intact ovum is hardly to be hoped for, and it is therefore less necessary to avoid an operative rupture of the membranes during this period. It is usually best to begin by the introduction of a bougie ; but if this is not followed by a prompt ajDpearance of regular pains, it is generally best to rupture the membranes with the sound, and then support the action of the decreased intra-uterine pressure by the introduction of a vaginal tampon and the administration of ergot. Premature Lahor. — Fi'om the beginning of the seventh month, or perhaps a little earlier, a new element enters into the problem, since the life of the child now assumes imijortanee. It must be remembered that the vitality of premature children is small, and that their resistance to the exhausting effects of the pressure of prolonged labor is very slight ; it is therefore important to use every effort to secure as complete dilatation as possible before the rupture of the membranes, in order to avoid, at once, any direct pressure of the uterus upon the child, and the delays of a dry la- bor ; and for the same reason the slower methods of induction are to be avoided. At this period of pregnancy it is usually easy, by the exercise of due care, to introduce a bougie without injury to the membranes ; and in some cases this simple procedure is in it- self sufficient. If the first bougie fail to excite contractions, the insertion of one or more similar instruments beside it is some- times followed by the desired result ; but, since the cervix is often still rigid and unprepared for parturition, and since many women show great jiower of resistance to the induction of labor at this time, it is usually best, Avhen catheterization is not promptly efficient, to proceed at once to the procedure x>o.i' excellence for the induction of labor during the last two months, or for the acceleration of labor at term — dilatation of the cervix by manual or other means. "When this operation is used for the induction of labor it is usually best to stop the process of artificial dilata- tion when the os has been raised to the size of a silver dollar, and trust the remainder of the labor to the efforts of nature, which then seldom fail ; but, since it is by no means an unknown occur- rence to find the os recontract and the contractions disappear, the physician should remain by the bedside, or should at least visit the patient frequently, from this time on, and, if labor fails, should again dilate the os, and this time to a degree sufficient to permit the passage of the head. The membranes should then be ruptured, the head made to engage by pressure from above, and held in position by extei-nal pressure until some progress is per- ceived, when the further course of the case is closely similar to labor at term ; but, since it is a fact that premature children resist the pressure of carefully conducted operative delivery much bet- OBSTETRIC SURGERY. 147 ter than that of prolonged labor, the attendant should be some- what more ready to interfere than in ordinary cases. Delivery by version may be effected with ease in most cases, but the use of forceps is usually to be preferred, since these feeble infants are greatly exhausted by the necessarily rough manipu- lations of version. CHAPTER XL FORCEPS. Choice of Forceps. — Before entering upon the technique of forceps operations it is necessary to say something about the choice of instruments. So many varieties have been described by various obstetricians that it is impossible even to mention any but the most important, and those which are most typical of a class. The instruments in common use may be divided into three classes— short forceps, long forceps, and those furnished with axis-traction attachments. Short Forceps. — Short forceps are intended for use when the head is at the pelvic outlet, and have a cephalic but no pelvic Fig. 19.— Sawyer's Forceps. Fig. 20. — a, Smellie's Forceps ; 6, Levret's Forceps. curve. Their only advantages are the small space which they occupy in the obstetrical bag, and a slightly greater ease of adap- tation ; but since a pair of short forceps alone is never a sufficient equipment, they are practically an extra luxury, and are now but little used. The preferable form of short forceps is that known as Sawyer's (Fig. 19). Long Forceps. — Long forceps are intended for use in any portion of the obstetric canal, and possess both pelvic and ce- OBSTETRIC SURGERY. 149 phalic curves. Among the instruments most commonly used we may still trace the influence of the two original types, the Levret and Smellie models (Fig. 20). Smellie, aware of the necessity of high-forceps operations, but strongly impressed with their dan- gers, sought to lessen the risks by shortening the handles and so reducing the compressive power. Levret, on the other hand, pre- ferred to equip himself with a powerful instrument and trust to his own discretion for caution in its use ; and instruments but Fig. 31.— Forceps op Hodge, a, and Wallace, b. Fig. 22.— a, Simpson's Forceps ; b, Elliott's Forceps. slightly modified from the original model of Levret are still used in France, but are now seldom seen in this country. Among the forceps which stand high in the esteem of the profession in America, the Hodge and Wallace instruments follow the type of Levret (Fig. 21), while Simpson's, Elliott's, and the Vienna for- ceps (Fig. 22) tend rather to that of Smellie. Hodge's forceps is shorter, lighter, and more graceful than the original French model, and the f enestrse are wider ; but it retains the long metallic handles and the French, or pivot, lock. Wallace modified Hodge's instrument by adapting to it the peculiar blades devised by Davis, of London. Both are excellent models and have many admirers. Simpson's forceps, the most widely known of all of those which follow the Smellie type, has longer shanks and a shar^Dcr cephalic curve than the Hodge or Wallace instruments. It is fitted with an English, or mortise, lock, the 150 PRACTICAL MIDWIFERY. handles are shorter, are made of wood, are furnished with trans- verse slioulders for the upper or traction hand, and with inden- tations to fit the fingers of tlie hand wliieli grasps tliem. This model, though excellently well qualified tor seizing the head in any ijosition, and for use as a tractor, is not capable of very for- cible comiDression, a condition which is perhaps a great advan- tage for the majority of operators. Braun's modification of Simpson's, the so-called Vienna forceps, differs from it only in the material of the handle, which is made of hard-rubber moulded around the shank, and in some slight alterations in the weight and proportions of the instrument. The well-known ElHott forceps are a long, highly curved, and somewhat heavy modification of Simpson. Their distinguishing feature is the ex- istence of a thumb screw by which the separation of the handles can be regulated; a device which, though sometimes a conveni- ence, is distinctly unnecessary, and extremely diflBcult to keep clean. A few operators, who believe that non-festrated blades are less likely to injure the soft tissues of the pelvis and head, have constructed instruments upon this plan ; those of Winckel and McLean being the best known ; but the advantage claimed for these models is probably counterbalanced by their encroach- ment upon the already scanty pelvic space. The choice between these various types of instruments is reg- ulated largely by fashion, and by local i^rejudice ; and it is un- doubtedly true that it is far more important that the individual instrument should be well made, than that it should follow one or the other plan. The points which should be most carefully sought for in any forceps are well rounded, blunt edges; firm, well-tempered blades ; strong shanks with but little spring ; and close but not too tight adjustment of the locks; and, other things being equal, the English lock is decidedly preferable to the Prench. Until recently it could be truly said that the possession of a single pair of good long forceps was amply sufficient for all the needs of ordinary practice ; but to this it is now necessary to add that the operator who intends to do high forceps, and wishes to give his patients all the advantages of modern resources, must possess, in addition, some form of axis-traction instrument ; and can only be possessed of a comi^lete equipment within the com- pass of a single forceps, by adopting one of those models which are furnished with accessory axis-traction appliances ; and which are so little modified that the blades when divested of their axis- traction rods, ai'e still suitable for low operations. Axis-traction Forceps. — It has long been known that when the forceps is applied to the head at the superior strait, and trac- tion is made upon the handles, the line of effort is such that. OBSTETRIC SURGERY. 151 under the most fa vox-able circumstances, a large portion of the force expended is wasted in compression of the head against the tissues of the anterior pelvic wall (Fig. 23). From an early date many efforts have been made to altef the line of traction, eithei' Fig. 23.— Axis Traction. by bending the handles backward, or by attaching rigid traction arms of similar effect ; but the exact line in which traction should be applied varies so much with the varying presentations and positions of the head, and with the variations in the form of in- FiG. 24.— Tarnier's Axis-traction Forceps. dividual pelves, that the line of traction furnished by any rigid instrument is likely to be little less erroneous in a given case than is that of the simple instrument; and the advantages of these forceps proved to be so slight that none of them ever attained any wide popularity. It remained for Tarnier to invent the first really useful axis-traction instrument (Fig. 24), by adapting to 152 PRACTICAL MIDWIFERY. the ordinary forceps a pair of curved rods, attached to the blades at a point close to their grasp upon the head, by. a freely mova- ble joint. "With this appliance, if traction is made in an even ap- proximatelj' correct direction, the head moves automatically in the direction of least resistance under the influence of the me- chanical forces involved; and the delivery is consequently effected by the expenditure of the least possible degree of force,' and it is a noteworthy fact that all the successful instruments which have followed his first model, including the many modifi- cations which he has himself produced, have been mere attempts at simplification of his device, without any essential alteration of Fig. 25.— Breus' Forceps. Fig. 26.— Diagram of Forces Illustrating Axis-traction. If the line c represents the amount and direction of the traction force •which is applied to the handles of the forceps, the line b represents the amount of force ■which is utilized in extracting the head, and the Une a that -which is wasted in compressing it against the pubes. its plan; with the single exception that the forceps of Breus (Fig. 25), which is now so widely used in Germany, varies from that of Tarnier in having dropped axis-traction as such; and retains as its sole essential feature, only the movable joint be- tween the head and traction handles ; which Breus considers the only valuable element in these instruments. Tarnier's original model possessed two antero-posterior curves, was unnecessarily complicated, and was soon modified by its au- 1 It is to be noted that the force actually expended in effecting delivery is the same ■with either instrument ; because the excess of power required by the simple forceps, over that -which is necessary with an axis-traction instmment, is all expended in grinding the head against the maternal tissues, and in directly obstructing progress (Fig. 26). OBSTETRIC SURGERY. 153 thor, whose latest model (Fig. 24) is one of the most graceful and convenient yet devised. One of the best known of American in- struments, Lusk's modification of Tarnier, on the contrary retains the extra curve ; but though this instrument is undoubtedly con- venient for use in some difficult high cases, its greater difficulty of application makes it less valuable for general use. Simpson's axis-traction forceps is merely a somewhat long and heavy Simp- son forceps, to which axis-traction rods have been attached by a screw and nut. Its sole objection is that it is difficult to clean. Felsenreich has improved upon this instrument by attaching the rods to the blades by the joint commonly used in surgical scis- sors, and by supplying a detached compression screw which fits into a slot upon the handles; the forceps itself being practically unmodified, and i^erfeetly fit for common use. The author has used for some years with much satisfaction an appliance (Fig. 27) which was devised in accordance with the belief that it is a Fig. 27.— Reynolds' Axis-traction Rods Attached to the Vienna Forceps. decided advantage to the general practitioner to use one pair of forceps, with the curves of which he is thoroughly familiar, for all emergencies ; and that it is a practical advance to supply an axis-traction attachment, that can be applied to any pair of for- ceps of which the practitioner is already possessed, without the necessity of making any alteration in them. This contrivance consists of a pair of steel rods, which terminate at their upper ends in fiat buttons intended to engage in the lower extremity of the fenestra; and at their lower ends in hooks, which are re- ceived by rings connected with a transverse traction-handle. A seiDarate compression screw for fixation of the handles, is a con- venient but not an absolutely necessary accessory. The instru- ment is simple, and easily cleaned; and, when the rods are at- tached to the forceps, is similar in all respects to the Simpson model. The rods may be hooked into the blades after the latter have been adjusted to the head, but most operators prefer to place them in position before making the application. ■ 154 PRACTICAL MIDWIFERY. Axis-traction is of value only while the head is still above the inferior strait, and is consequently a^jplied only to long forceps. Forces of the Forceps. — The forceps is an instrument capable of exei*ting three different forces ; those of traction, com- pression, and leverage. Traction is the essential power of the forceps. It is for the application of this force that the instrument was devised ; and operators of limited experience will act most wisely by limiting their use of the forceps to this force alone. Comjjression of the head by forced approximation of the blades is a force which is never entirely absent ; since a certain amount of it is essential to a proper grasp of the presenting part, but the amount of compression which is thus incident to the use of the instrument is fortunately.never injurious. The injudicious use of an improper amount of compression is of course harmless to the mother, but exposes the child to the most serious risks of fatal injury; and is indeed the only element in the use of forceps which can be injurious to the child. The amount of comiDression which the foetal head can sustain without injury is largely dependent upon the diameter to which that force is applied ; and it may be laid down as a rule that com- pression of the bi-parietal diameter to the extent of any more than half an inch is seldom harmful, if not continued without interruption for more than two minutes. Compression in the occipito -frontal diameter is almost equally well borne, and to about the same degree; but diminution of the oblique diameters of the head, i.e., those drawn from either side of the brow to the opposite side of the occipit, is far more likely to be productive of in tra-cranial injury; though, even in this situation an intermit- tent compression of no more than half an inch, is comparatively safe in the majority of cases. Uninterrupted compression or an intermittent approximation of the blades, beyond the above amount, is, however, so highly dangerous that the greatest care must always be taken to avoid its unintentional use ; while in the rare cases in Avhich the operator finds himself obliged to re- sort to a more extreme degree of comx^ression, he should always feel that he is subjecting the child to a desperate chance for its life. The cephalic curve of all good forceps is so blunt, that when the blades are applied to the sides of any ordinary head, the handles are so nearly in contact that a dangerous amount of compression is impossible ; but if for any reason it is impossible to secure such an application, and the handles of the forceps are found to be widely separated, when the instrument is in place, the force of traction must necessarily expose the child to grave danger of undue compression, unless special precautions are OBSTETRIC SURGERY. 155 taken. With the ElHot forceps this danger may be avoided by so setting the thumb screw, whicli is their special feature, that it is impossible to exercise a greater degree of compression than is considered safe. The same object may be equally well attained with other models, by the insertion of a folded towel between the handles. Leverage is a force obtained by lateral or antero-posterior pendulum movements of the handles. By the use of leverage, it is sometimes possible to overcome an arrest which has resisted simple traction; but it is so difficult for the operator to estimate the amount of force which he is employing, and the danger to the tissues of the mother is so extremely great, that the use of this method is distinctly inadvisable to any but the most expert operators; and the beginner may feel sure that by the time his exi:)erience justifies him in attempting the use of leverage, he will find himself so fully impressed with its dangers that he will re- serve it for a last resource. Rotation of the head by the forceps is closely analogous to the employment of the pendulum movement ; and is indeed in effect a species of levei'age. Forced instrumental rotation is so ex- tremely likely to be followed by extensive laceration, and its safe performance implies so accurate an adjustment of the blades and so instinctive a knowledge of the position of their tips, that its use should be restricted to experienced operators ; but even the beginner must be cai-eful to avoid disturbing the mechanism of delivery by the prevention of rotation ; that is, whenever forceps are applied before rotation is completed, the operator should bear carefully in mind the direction toward which the head will natu- rally turn, and should be ready to permit, or indeed favor, its occurrence. Antethesia ijf Forceps Operations.— It is probable that the skilful use of forceps is but very slightly more painful than normal delivery ; and the presence of the pains in an unether- ized patient may greatly facilitate the extraction of the child ; but most patients feel so much dread of any operative interfer- ence, that its performance without ether is likely to be attended by a very undesirable amount of nervous exhaustion. All women are, moreover, prone to attribute any pain which they may feel during the performance of an operation to the efforts of the phy- sician; and to resent its infliction by unguarded movements, which may often result in unnecessary laceration. It is there- fore customary, in all but the crudest practice, to administer an anaesthetic before making even a low application of the forceps, unless some special contra-indication exists; and it is rarely wise to attempt even the simplest of high operations without the use of ether or chloroform. If anaesthesia is not employed, the for- 15G PRACTICAL MIDWIFERY. ceps should be warmed before being introduced ; and in any ease, the extei'nal surface of the blades should be thoi'oughly anointed with an aseptic lubricant. CoxDiTioxs Which Justify the Application' of For- ceps. — These ai'e : a presentation of the cephalic extremity of the f ffitus, or of the full breech ; ruptured and retracted membranes ; an OS so far dilated as to permit the easy introduction of the blades, and the existence of a possibility of delivering a living child. Con'tra-in'DICATIoxs. — Forceps should never be api)lied to the hydrocephalic head ; nor to the head of a dead child, unless the operation promises to be easy. They should never be used on a putrid foetus, nor upon a perforated head. The diminished size of the perforated head makes the forceps extremely liable to slip from its surface ; an accident which is almost certain to re- sult in the production of extensive laceration. The use of the forceps upon hydrocephalic or putrid heads is rendered danger- ous by the uncertainty of its grasp, and should be avoided, not only for this reason, but on account of the absence of any objec- tion to the performance of craniotomy. Classification^ of Forceps Operations. — The forceps may be applied to either extremity of the foetus when engaged in any portion of the i^elvic canal ; but the severity and the tech- nique of the operation vary so greatly with the amount of prog- gress ah'eady effected, that it is necessary to consider the apph- cation of forcej)s to high and low heads under sejiarate headings. The methods of application should, moreover, be so radically altered in accordance with the varying presentations and posi- tions of either presenting part, that it seems most conducive to •clearness to describe the general principles which should be fol- lowed in all forceps operation under the head of the anterior positions of vertex presentations, high and low, to Avhich the remainder of this chapter will accordingly be devoted ; while the api^lication of forceps to other presentations, and to posterior positions of the occiput, will be considered in the chapters de- voted to the general management of those cases. Skill in the use of forceps, that is, the instrumental extraction of the child with a minimum degree of force and a minimum amount of danger to both patients, is almost wholly dependent upon a careful imitation, throughout the oj^eration, of the mech- anism of natural labor in the given presentation and position; since with ordinary adaptation it is impossible for the head to jjass the pelvis by any other method, unless under the influence of an extreme and unnecessary degree of force. The quality of an operators work will, therefore, depend essentially upon the cor- rectness of his diagnosis of position ; and it should be an invaria- OBSTETRIC SUKGERY. 157 ble rule, that his last act before applying forceps should be an. effort to obtain an accurate perception, not only of the quarter of the pelvis in which the occiput lies, but of the exact direction of the sagittal suture, and of the situation of the parietal bosses. The importance of avoiding any mistake in this matter is so great that it is a safe rule that forceps should never be apiDlied unless- both fontanelles, or one fontanelle and an ear, have been surely recognized ; and, as a last step before operating, the catheter should be passed; and the operator should himself listen to the foetal heart, in order to form an estimate of the condition of the child, and of the amount of delay which he may permit himself in the effort to conserve the perinseum. Low Forceps i?^^ Anterior Positions.— Prognosis.— The ai^plieation of forceps, when the head is within the excavation, and the occiput is anterior, is distinctly a minor operation ; and should not increase the gravity of the outlook for either mother or child, except as concerns a slightly increased risk of laceration of the perinseum, and such slight risks as may appertain to anaes- thesia. Indications for Low Forceps in Anterior Positio7i.— The risks being so slight, it follows that the application may be made for comparatively slight indications. The practice of dif- ferent accoucheurs varies widely, but it is probably safe to say that when the second stage of labor has existed for two hours, and the rate of progress is such that there seems to be no probability that spontaneous delivery will occur within the next hour, the foetal death rate is on the whole smaller if immediate delivery be resorted to than if such cases are left to nature. Technique. — The forceps may be applied in two ways: the blades may be so introduced as to be adjusted exactly to the sides of the head, or they may be so placed as to lie against the- sides of the pelvis, without regard to the position of the head. Either of these applications may be made by two methods; the forceps may be passed directly into the position which they are expected to occupy, or each blade may be introduced opposite to a sacro-iliac synchrondrosis, and then swept around the sides otthe head into position. The application to the sides of the head is perhaps the more difficult, but possesses two great advantages. When the instru- ment is so placed it has much less tendency to disturb the normal mechanism of labor, and it moreover exposes the child to a greatly decreased risk of injury from comjDression. It may occa- sionally happen in difficult operations that an inexperienced op- erator will find it difficult to place the forceps accurately over the parietal bosses, but such cases must be rare in low applica- 158 PRACTICAL MIDWIFERY. tions to the anterior occiput ; and in low arrest the accoucheur should never feel satisfied with any other application. In anterior positions the direct method of application is usu- ally easy, and should generally he preferred; since it exposes the tissues to a nhniniuni amount of friction against the instrument, and to a uunimum risk of laceration. The patient being in ijosition, and all preparations being made, the operator should lock the forceps outside the vulva in order to avoid a mistake in the choice of blades, and should place them outside the vulva, in the position in which they will lie when ap- plied to the head; i.e., with their transverse axis at right angles to the line of the sagittal suture ; he should then select the left blade, that is, the blade which passes to the left side of the mother's pelvis, and Avhose handle is grasped by the left hand of the operator. The handle of the forceps should then be lightly Fig. 28. — Introduction of the Forceps. seized by the thumb and two fingers of the left hand, in the man- ner in which one holds a pen ; two or more fingers of the right hand should be passed as high as is possible without undue force between the head and pelvic walls opposite to the parietal boss over which the blade is to pass, and if any portion of the cervix be still recognizable, should be inserted within the os. The forceps blade should hang loosely from the fingers by its own weight; should be passed through the vulva along the palmar surface of the vaginal hand, and should be urged onward by pres- sure with the right thumb against its heel. The edge of the blade should rest in the groove between the fingers, so that, as the tip advances they are able to receive an accurate percep- tion of its double curves, and to estimate the probable position of the tip during the entire process of introduction (Fig. 28). The common mistake of j^oung ojjerators is to attempt to push the blade onward in the straight line of its handle ; the beginner OBSTETRIC SURGERY. 159 should therefore endeavor to bear in mind the fact that its prop- er Introduction re(iuii-es a constant renienibranoe of its com- pound curve ; and tliat the handle must not only be gradually and smoothly depressed in obedience to the pelvic curve of the instrument, but must be simultaneously rotated upon its own axis in order to insure a constant and close application of its cephalic curve to the tissues of the scalp.' During the whole process of introduction the tip should be in close contact with the ffjetal head, the forceps should be allow^ed to guide itself, and no force should be used. If the blade is ar- rested it may be taken for granted that its failure to advance is due to the fact that the tip has been given an improper direction and is pressing too hard against the maternal soft parts or the foetal scalp. In such an event the use of force can only result in injury to one or the other; but progress will at once be made, without increased pressure upon the handle, so soon as gentle movements of adjustment have guided the tip into the proper situation. When the first blade is in position its handle should be given to an assistant, who must hold it with the palmar sur- face of his hand uppermost, in order to keep his wrist out of the way of the operator, and must be careful to maintain it in exactly the position in which it Avas given to him. The second blade is then introduced in the same manner on the opposite side of the head, and during its passage into position its movements should be so guided that when it reaches its final resting place its handle is directly opposite to that which is already in place ; the posi- tion of the first handle being the guide for the introduction of the second. If the blades are exactly opposite each other, the forceps will lock without force ; but if this does not occur, it is better to remove the second blade and re-apply it than to use any but the most minute movements of adjustment, any eversion of the forceps tips by rotation of either blade on its long axis being an experiment which is especially dangerous and to be avoided. During the locking of the forceps the operator should be careful that no portion of the vulva, or vulv^ar hair, is pinched within the lock of the instrument, this being an accident which is pro- ductive of the utmost pain to the patient if unetherized, and which may moreover result in the production of serious contu- sions. At the conclusion of the application, if the blades lie in the proper position, with each parietal boss and its corresponding ear included within a fenestrum, the handles should meet each 1 The peculiar spiral movement of the instrument can best be appreciated by placing the edge of one blade in the groove between the first and second fingers, pushing it gently onward without any attempt to guide its movements by means of the fingers which control the handle, and then watching the course of its tip. 160 PRACTICAL MIDWIFERY. other -vvithont force; but if they remain slij^htly separated, it is probable that the head has been chisped, not by the biparietal, but by one of the long oblique diameters; and should this be the case it is usually better to remove and readjust the instrument, than to subject the child to the increased risk of compression which this application involves. If the indirect method of application is chosen, each l)lade should be introduced, and passed to the full height necessary, in the space opposite the sacro-iliac articulation, or at any other point in the pelvis which seems to afford abundant room ; and should then be swept into position on the sides of the head, by pressure with the internal fingers on the edge of the blade ; care being taken that the whole surface of its cephalic curve remains closely applied to the head throughout the whole manffiuvre. When the instrument has been satisfactorily adjusted to the Fig. 29. — Method of Qraspikg the Forceps. head, the left hand of the operator should grasp the handle with its palmar surface uppermost; and the right hand should be placed over the head with its palmar surface downward, and with the shanks of the forceps lying between its second and third fingers (Fig. 29). The first tractions should be gentle, and gradually applied in order to test the security of the grasp which the forceps have taken upon the head, and thus guard against the possibility of its slipping in case an error in diagnosis has been made. When the operator is fully satisfied that the insti'ument is unlikely to slip, he should increase his efforts until the maximum force which he thinks advisable has been attained ; should maintain them at that height for a space of from one to two minutes, and then gradually allow them to decrease, in imi- tation of the natural pains. When the forceps have been applied through the partly di- lated cervix, the amount of tractile force which is applied should be estimated by ocular or digital observation of the degree of ten- OBSTETRIC SURGERY. 161 sion to which the edge of the os is subjected, precisely as is done in the preservation of the perinaeuni ; and in case the cervix should be found to be so rigid as to obstinately resist dilatation, or if the usual bilateral laceration is seen to begin, antero-posterior divi- sions of the edge of the os to a depth of from one-fourth to one- half of an inch usually determine the advent of laceration in that situation; and are expedient, because antero-posterior lacerations usually heal spontaneously during the puerperium. If the for- ceps lie in an oblique diameter, the operator should be especially careful that his grasp upon the handles opposes no obstacle to that rotation of the forceps with the head which is sure to take place as soon as the resistance of the pelvic floor is met. If the blades have not been adjusted to the sides of the head, the han- dles should be gently separated during the intervals, in order to intermit all compression, and thus permit the head to rotate be- tween the blades. The first tractions should be directed as far backward as the perinseum permits ; but as this is put upon the stretch by the advance of the head, the handles should move gradually upward, their axes being directed a little higher after each successive traction. The proper direction for each traction is determined by the extent to which it distends the perinseum, and by the amount of pressure which exists between the occiput and pubes ; and may be learned with accuracy by the occasional passage of one finger between the head and pubes during trac- tion. The ideal line of force is always that which holds the head in contact with the anterior pelvic wall, and but lightly applied to it. When the occipital protuberance appears under the symphysis, the shanks of the instrument should be steadied by the right hand, while the left changes its grasp, and seizes the handle with its dorsal surface upwards. The operator should then stand opposite the patient's left buttock (Fig. 30) ; and while still con- tinuing gentle traction directly upwards, should sweep the han- dles forward toward the mother's abdomen, in the curve of Cams; thereby extracting the head by a mixed movement of descent and extension, during which the sub-occipito-bregmatic diameter describes an arc of a circle around the lower edge of the pubic ai'ch as a centre, the right hand observing and controlling the movement by pressure upon the forehead through the tissues in front of the anus, in the manner described under normal labor. When the edge of the fontanelle is at the fourehette the plans, adopted by different operators vary. Some prefer to control the head by retaining the forceps in position, believing that the effort to remove them before delivery is completed is likely to be itself productive of laceration, while others think that this dan- 1 1 162 PRACTICAL MIDWIKEHY. ger is more than counterbalanced by tlie relaxation of the tissues Avhich results from the extra space j^ained by the removal of the instruments. If this latter method is chosen, two fingers of the right hand sliould be inserted into the rectum and should have reached the chin before the blades are taken off; and during their removal the advance of the head must be controlled by pressure with the right thumb against the occiput, if this be possible, or by the hand of an assistant. The forceps should then be unlocked, and the left hand should withdraw Avhichever blade seems the less firmly fixed ; the motion of Avithdrawal being the reverse of the spiral curve Avhich Avas followed in the introduction. Should the blade first selected be arrested when partly Avithdrawn, it should Fig. 30.— Perineal Stage of Forpep.s Operations. be steadied by an assistant until the removal of its fellow, when it will probably be released by the additional space gained ; if, however, one or both blades are firmly held, it is better to relin- quish the attempt to withdraAV them, rather than to use any force, since either of them might be looped about an ear, and any force might result in its laceration. If the operator prefers to conclude the extraction by means of the forceps he sliould continue his tractions with them, in the curve of Carus, watching the perineum closely, preserving flex- ion both by means of the forceps and by pressure on the fore- head over the tissues about the anus, forcing the head to hug the symphysis as closely as possible, and constantly holding himself in readiness to cheek any unduly rapid advance, by backward pressure with the instrument, or by applying the fin- gers of the right hand to the occiput. OBSTETRIC SURGERY. 163 High Forckps.— Prognosis. — The application of high for- ceps in anterior positions differs from the low operation in that, so far from being a trivial matter, it is in every sense a major op- eration, which exposes the mother to grave risks of serious laceration and involves necessarily a chance of serious comj^res- sion to the foetal head, which results, in the hands of the best operators, in a by no means inconsiderable f'X!tal mortality. Incl/cations.— The opei-ation should never be undertaken un- less some pathological condition renders the dangers of delay to mother or child distinctly greater than the risks of operative intei'ference, or unless the arrest of progress is so complete that there seems to be no prospect that the head will pass the superior strait under the force of nature, and the exhaustion of one or the other patient is already imminent. The discussion of the various pathological conditions which may justify immediate delivery must be relegated to the chap- ters devoted to those complications. The best rule for the application of high forceps for the treat- ment of simple delay is that, when the caput is large and increas- ing, when the foetal heart or maternal pulse is steadily and per- ceptibly rising, and no progress has been made for at least an hour, the forceps should be api>lied ; but, in view of the greatly increased foetal death rate when the operation has been delayed until exhaustion is already present, it should be an invariable rule that the physician should maintain a most careful watch over the condition of the foetal heart whenever the progress of the head through the superior strait is anything but satisfactory. The difficulties of the high applications are often so great that, unless in exceptional circumstances, it is distinctly unwise to at- temxjt any high operation without the use of surgical anesthesia; and the question of the choice between forceps and version in the treatment of high arrest is frequently so intricate a problem that it is usually wise for an accoucheur of small experience to summon a consultant before interfering in such a case. Technique of High ApiMcations. — In high, as in low, oper- ations the api^lication of the blades to the iDoints of election at the sides of the head is distinctly an advantage to the child as well as to the mother; and with proper care a persistent and skil- ful operator will rarely or never fail in making such an applica- tion in normal pelves. The difficulties are, however,' sufficiently 1 The importance of an exact application to a high head, and the extent to which the tips may encroach upon the maternal tissues in oblique applications, with one of the accidental disadvantages of such inaccuracies, is well exemplified by a case in which the author had occasion to perform a high forceps operation without ether, and failing to apply the forceps accurately to the sides of the head at the first at- tempt, made traction with the blades iu correspondence to the sides of the pelvis. 164 PKACTICAL MIDWIFEKY. great to deter many excellent authorities from recommending the attempt to the inexperienced; but the diminished percentage of lacerations and the decrease of fu3tal mortality, due to such ex- actitude, is also so great that the author believes that every ob- stetrician should teach himself to apply the forceps in this way in all cases; an art which can only be learned by making persist- ent efforts to attain it in every case which comes under observa- tion. This course is, moreover, rendered justifiable by the fact that the danger of injuring the mother's tissues by moderately jn-olonged efforts to secure an accurate adjustment is extremely slight so long as the operator is able to restrain himself from the temptation of attempting to overcome obstacles by force; that is, so long as he remembers that the only possible obstruction to the advance of the blade is that its tip is so lolaced that it is in un- duly firm contact with either the maternal or foetal tissues, and that if the tip is i^roperly directed between the two there is noth- ing to oppose its onward movement. If several such efforts to attain an accurate adjustment to the sides of the head have merely resulted in securing an oblique position of the instrument, it is allowable, in high arrest, to pro- ceed with the extraction with the instrument in that position. The forceps will then be so applied that the anterior blade is in contact with the temporal region, Avhile the lambdoidal suture of the other side is opposed to the fenestra of the posterior blade (Fig. 31) ; in which position the compressive force of the forceps tends in itself to produce rotation. The application of the forceps to the head at the superior strait by the direct method is rarely possible, and the indirect must generally be adopted. The anterior blade is so much the more difficult of application that it is customary to introduce this first in all cases. Its adjustment is then more easy than if it were complicated by the i^resence in the vagina of the shank of the posterior blade. The patient being in position and everything in readiness for the operation, the physician should lock the forceps and turn them into the diameter which they are expected to occupy, out- Having assured the patient that the operation would not be attended with excessive pain, he was much chagrined to hear her scream with agony during each traction, complaining that she was tortured with excruciating pains which extended from one hip to the corresponding knee. In the belief that some projecting part of the blades must be exerting pressure upon the intra-pelvic portion of the sciatic nerve upon that side, the blades were removed and reapplied to the sides of the head, when a somewhat forcible extraction was performed without any recurrence of unbearable pain. The case also suggests the possibility that a clumsy operation may occasionally be the starting-point of the intractable sciaticas which not infre- quently make their appearance shortly after labor, and which may then continue for many years. OBSTETRIC SURGERY. 165 side the vulva, and should then select the blade which is to be anterior. Two fingers of the hand which has the same name as the position should be passed within the cervix, and should find the spot at wliich there is the greatest s^jace between the head and the posterior surface of the symphysis. The fingers having been passed as high as possible into this space, the anterior blade should be introduced between their palmar surface and the head, should be passed into position under the guidance of their sense of touch, and should then be urged forward to a situation over the parietal boss by pressure with the internal fingers upon the convex edge of the fenestrated portion. The fingers of the other hand should then be passed within the cervix and urged high as is possible, without the use of force, into the space between the head and the sacro-iliac notch, on the other side. The posterior O^^ Fig. 31. — Action of the Compressive Force op the Forceps in Promoting Rotation. blade sliould then be passed into position under their guidance, and adjusted to a position opposite to its fellow. It must be noticed that in O. L. A. positions this rule leads to the introduction of the right blade first, and that, owing to the construction of the lock of most forceps, it is necessary to intro- duce the second or left blade behind the shank of its fellow, a proceeding which is much facilitated by temporarily drawing the first handle toward the left thigh of the mother ; in O. D. A. posi- tions no such special precaution is, however, necessary. If the liead is already engaged in the superior strait, it is only necessary to avoid the use of any force, which might alter its position; but if, at the tim^when tlie instruments are applied, the head is still fi'ee above the brim, it is usually important that it should be held in position by external pressure from the hands of an assistant, in order to prevent the occurrence of partial rota- tion during the application of the forceps. Should the forceps, after the application of both blades, fail to lock, that blade which seems to be in fault sh.ould be partly withdrawn, and gently moved, during its reintroduction, into a lOG PRACTICAL MIDWIFERY. position which forrespoiuls witli that of its ft'llow ; but, in high for- ceps especially, all attempts at forcible apposition of the blades, when in position upon the head, must be unhesitatingly con- demned. If the instrument has been successfully applied to the sides of the head, the handles will be found in close approx- imation; but if the application is oblique they will be separated by a greater or less interval, in which case the head is always ex- Ijosed to serious risks of undue compression ; and if the grasp is such that the handles are separated by more than the amount which will allow a half-inch of approximation to the blades, it is always best to adjust a folded towel between the handles, in such a way that a greater compression than this is impossible, before any traction is made. If the application was oblique the forceps should be removed and readjusted to the sides of the head as soon as it has entered the excavation. As in loAv operations, the first traction should be gentle, grad- ual, and tentative, and intended more to test the grasp of the instrument and the ijossibility of its slipping than to advance the head. When the security of the blade has been ascertained and serious tractions are begun, they should be directed as far backward as the perineum will allow^; but, as will be seen by a glance at figure 23, traction in the axis of the superior strait can never be attained by simple pulling ui^on the handles of the ordi- nary instrument ; and if axis ti'action be not employed, it is al- ways best that one hand should be placed upon the shanks of the instrument near the vulva, and should be used to make downward pressure, while the other grasps the handles near their extremity, and exerts traction at an angle of about -io to the horizon, thereby combining an outward pull with a backAvard leverage between the hands, in such a manner that the resultant of the force employed is as nearly as possible in the desired direc- tion. This effort should be continued until the p*issage of the head through the superior strait makes the remainder of the ex- traction a low operation. A successful application of this method of traction requires, however, not only a high degree of operative skill, but considerable nuiseular strength ; and the author l)elieves that the obstetrician who performs a high-forceps operation with- out axis-traction forceps when such an instrument is at hand distinctly fails to offer his patient one of the most important ad- vantages of modern obstetrics; and this the more certainly from the fact that the recent simplifications in axis-traction models render them easily amenable to the use of any physician who is qualified to perform any serious obstetrical operation. Apjilication of Axis-Traction Forceps. — The application of the modern forms of axis-traction instruments requires little additional description. In Tarnier's latest model and in Lusk's OBSTETRIC SURGERY. 167 modification of Tarnier the traction rods are so shortened as to lie flat against the blades until the application has been con- cluded ; but with most other forms it is necessary to lift the rod which is attached to the. female blade over the other handle be- fore locking the instrument. If the author's rods are employed in connection with the ordinary forceps they may be attached to the fenestra with the forceps already in position, in all but extremely high applications— arid even in these the attachment is usually easy if made before the forceps are locked — but most operators prefer to place them in position before the blades are introduced, when the application is exactly similar to that of Simj^son's instrument. When the instrument is in position the transverse bar is at- tached to the rods, and the handles are grasped and compressed by the hand to the desired degree. The compression screw is then tightened to that position, but no further, any approxima- tion of the handles by the use of the screw being always highly dangerous on account of the impossibility of estimating properly the amount of force so obtained, and the ease with which a fatal degree of compression could be applied.' The traction bar is SAvept backward so far as the perineum will allow, and traction applied to it alone. As the head advances the handles are seen to rise slowly in the curve of Carus, and their upward movement should be followed by a similar altera- tion of the line of traction. In operating with the unmodified instrument, the French school of obstetricians consider artificial rotation by the forceiDS at the brim as sometimes justifiable; but most American and German operators think that even the most exjoert are unwise in permitting themselves to use any force but that of simple trac- tion while the head is still high; and nothing should tempt the inexperienced accoucheur to permit himself the use of any pendu- lum movements or to make any attempt at rotation by the for- ceps while any part of the head is still within the uterine cavity. If axis-traction rods are used, flexion and rotation of the head take place automatically under the guidance of the mechanical forces of the obstetrical canal, and require no special care upon the part of the operator; the only precaution necessary being that the tractions should be intermittent, and that the compres- sion screw should be released during the intervals. Some operators prefer to complete the extraction with an axis- traction instrument, but the expediency of this course of action 1 If traction is made upon the rods at a time when the handles of the instrument are not held in position either by the screw or by the hand of the operator, the only result is the immediate removal of the forceps, unless the lock is of the French form. 1G8 PKACTICAI. MIDWIFERY. is very doubtful. Not only does the special value of such instru- ments decrease with the advance of the head and become least at the inferior strait, but the presence of the rods and the greater bulk of most axis-traction models necessarily expose the tissues of the i^elvic wall to increased danger of laceration ; so that it is usually better to remove the axis-traction instrument when the head reaches the inferior strait, and complete the delivery with the simjile forceps. CHAPTER XII. VERSION. The term version is applied to all operations by whicli the long axis of the child is changed in its I'elation to the long axis of the uterus. The operation is divided into three varieties — pelvic, cephalic, and podalic version — each named after the part which is to be brought to the inlet ; and is performed by three methods, the external, the internal, and the combined or bipolar. Pelvic version is rarely performed, and then only by the external method. It is indicated in cases in which it is known at the beginning of labor that a breech-presentation is desirable and that some other presentation has occurred, as in a transverse presentation in a fiat j)elvis ; but, after external version becomes impossible, internal or bipolar podalic version should generally be preferred. External Method. — Version by the external method should ex- pose the mother to no added risk, but is liable to be fatal to the child by causing displacement and consequent compression of the cord. It cannot be performed after the presenting part has en- gaged, nor after the escape of the waters ; it is much facilitated by lax abdominal and uterine walls, and by a condition of free m.obility of the child, but, under opposite conditions, may be Tendered possible by the free administration of an anaesthetic. If the performance of pelvic version by the external method be determined upon, the bladder and rectum should be emiDtied— as in all obstetric operations — the patient should be placed upon her back, and the operator should stand by her side, and facing her. After carefully mapi^ing out the iDosition of the child, he places one hand flat ujDon the abdomen, with its palmar surface as nearly as possible over the sacrum of the foetus, and the other in the same manner over the forehead; and then, by simultaneous pushing movements of both hands, he endeavors so to change the position of the child as to convert it first into a transverse and then into a pelvic presentation. If a pain comes on during this process all movement of the hands must at once cease, and the operator must direct his whole attention to the attempt to hold what he has already gained. Gentleness and patience are essential to suc- cess, as hasty or rough manipulations always excite contractions i;U PRACTICAL illDVMFEKV. and so defeat their own purpose. Wlien the breech has been brought to the inlet it must be held there by the hands, or, if this becomes too tedious, by a properly adjusted binder and com- presses, until it has become engaged in the superior strait. The version may sometimes be aided by placing the patient, at the beginning of the operation, upon the side to which the breech is turned ; for as the fundus sinks to that side it carries the breech with it, and so tends to move the head toward the opposite iliac fossa. The subsequent treatment is that of an ordinary breech case. Cephalic Versiox. — Theoretically, cephalic version should be performed in all uncomplicated cases of breech or transverse presentation ; in practice it is, however, limited to cases in which the diagnosis is made early, in which there is no necessity for rapid delivery, and in which the other conditions are favorable to the performance of version by the external or bipolar method, for cephalic version by the internal method is usually more diffi- cult and dangerous than internal podalic vei-sion. External JletJiod. — The performance of cephalic version by the external method differs in no Avay from the description of exter- nal version already given under the head of Pelvic Version. If cephalic version be indicated, and the use of the external method be possible, it should always be preferred, as being the least med- dlesome and dangerous operation. Bipolar Method. — In regard both to efficiency and to possible risks, bipolar version occupies an intermediate position between the external and internal methods. The conditions which make external version practicable render bipolar version easy, but it can often be performed when the external method is no longer possible, and with far less interference with the processes of na- ture than is necessary to the performance of internal version at an early stage of labor. A moderate degree of engagement of the presenting part makes bipolar version more difficult, but is not necessarily a bar to its employment. Cephalic version by the bipolar method is usually restricted to cases of transverse presentation in Avhich the liquor amnii has not yet drained away and the presenting part is but lightly en- gaged. A prolapsed arm, unless previously replaced, would pre- vent its employment. Anaesthesia is not always necessary, but is al ways an advantage. Of the various methods Avhich have been pi'oposed, that of Braxton Hicks is alone employed at the present day. After the bladder and rectum have been emptied, the hand which is of the same name as the position {e.g., O. R. A. = the right hand) is introduced into the vagina, and two fingers are passed through the os to the presenting part, which we assume OBSTETRIC SURGERY. 171 to be a shoulder ; this is gently raised and moved toward the feet by the fingers of the internal hand, care being taken not to rup- ture the membranes if they are still intact. So soon as the shoul- der rises, the external hand begins to press the head toward the inlet until it can be received and guided to the os by the tips of the internal fingers ; it is then retained in its new ijosition by the pressure of the external hand, while that which was internal is withdrawn from the vagina and used, if necessary, to complete the version by making upward pi'essure on the breech through the abdominal wall, as in external version ; or the internal hand may be able to retain control of the head, while the other is transferred to the breech. After the completion of the operation the head must be re- tained in position by external pressure, as after external version ; or, if the os be sufHeiently dilated, the membranes may be rup- tured, in order to hasten the fixation of the head. The remainder of the delivery is left to nature. PoDALic Version. — Podalic version is indicated in most trans- verse presentations ; in most brow and many face presentations, and in some other malpresentations of the head when arrested high; in some cases of contracted pelvis, often in high arrest of the head in a normal pelvis, whether from inertia uteri or from too tight adaptation ; and, in general, under any circumstances which call for the immediate delivery of a high head, unless the use of forceps be preferred. It may be performed by either the combined or internal methods, but is of course beyond the power of external version. Bipolar Method. — This operation is not much used in head presentations, because podalic version is now generally followed by immediate extraction, and therefoi'e presupposes a degree of dilatation which admits of the introduction of the entire hand, but it is of value in some cases of placenta prsevia in which there is profuse flowing at an early stage of labor. In such cases it is useful, both because it can usually be completed with less loss of time than is consumed in the preparation of the os for internal version, and because, after its completion, the pressure of the half-breech against the os is usually sufficient to control the . haemorrhage until full dilatation has been accomplished. It may, however, be used in any case in which the mobility of the foetus is unimpaired at the time of operation. Its performance is rendered more easy by the use of an anaes- thetic, which should be given to full surgical anaesthesia. In this country the patient is usually placed in the lithotomy position, in which case she should lie across the bed, with the buttocks well over its edge. Each leg should be held bj' an assist- ant, and the oi^erator should sit between them. The full observ- 172 PRACTICAL MIDWIFERY. ance of all possible antiseptic precautions is as nece««sary as in in- ternal version. The exact position of the child and its extremities is carefully made out by abdominal and vaginal examination, and, the rectum and bladder having been emptied, the hand of the same name as the position is passed into the vagina until two fingers can be in- serted into the os to their full length. The fingers then raise the head and push it gently to the side toward which the occiput is turned, while the other hand pushes the breech by external ma- FiG. 32.— First Stage of Bipolar Version (Galabin). nipulation in the opposite direction (Fig. 32). This process is continued as long as the head remains within reach of the hand. The fingers are then moved toward the breech in search of a knee, which, unless the normal flexion of the child has been lost, is by this time well within reach (Fig. 33). The knee is distinguished from the elbow by the fact that it points toward the head, while the elbow points to the breech. The presence of the patella may also be recognized in some cases, and, if found, is of course conclusive. If by cliance a foot be reached before the knee and surely recognized, it should at once be seized. The foot is distinguished from the hand by the pres- OBSTETRIC SURGERY. ITS ence of the malleoli and of the prominence of the heel, and by the fact that the great toe is of equal or greater length than the others, and placed in the same plane with them, while the thumb is shorter than the fingers and can be opposed to them. It may sometimes happen that the head becomes extended under the pressure of the internal hand, and thus passes out of reach of the fingers before the external hand has been able to de- press the breech sufficiently to bring the knee within their reach (Fig. 34). In this case the fingers next come in contact with the shoulders and chest, which must be urged upward and onward toward the head, while the external hand continues to press the Fig. 33. — Second Stage op Bipolar Version CGalabin). breech down until the knees are within reach. So soon as a knee is recognized, the membranes should be ruptured, if still intact, and a finger hooked around the knee. The hand which has de- pressed the breceh is then applied to raise the head, while the internal fingers draw the knee to the os (Fig. 35). When the knee is fairly in the vagina and under control, the foot should be brought down and examined, to guard against the possibility that an error has been made by mistaking an el- bow for a knee. The version is then completed by traction upon the leg, in combination with external pressure upon the . head (Fig. 36). After the completion of the version, the treatment is that of a ordinary footling case. 174 PRACTICAL MIDWIFERY. Podalic version by the bipolar method is seldom performed in transverse presentations, for, until it has become impossible, bi- FiG. 34. — Second Part of First Stage op Bipolar Version, when the Head is Extended (Galabin). polar cephalic version is generally to be preferred. In case it is done, the position at the beginning of the operation is that rep- FiG. 35. — First Part of Second Stage of Bipolar Version, when the Head is Extended (Galabin;. resented in Fig. 34, and the procedure is in every way that which has just been described. OBSTETRIC SURGERY. 175 Internal Method. — This operation diflfers from those previously described in that its perfonuance presupposes a degree of pre- paration of the soft parts which permits of an immediate extrac- tion after the completion of the version. If preceded by artificial dilatation of the os, it is capable of effecting a rapid delivery in almost all cases, and at any period of pregnancy or labor. It is the most generally valuable of all obstetric operations ; as Barnes says : " If we were restricted to one operation in midwifery as our sole resource, I think the choice must fall upon turning. Probably no other operation is capable of extricating patient and practitioner from so many and so vari- FiG. 36.— Third Stage of Bipolar Version (Galabin). ous difficulties. " It is our main operative resource in eclampsia, placenta prsBvia, concealed haemorrhage, and many other of the gravest obstetrcial emergencies. Internal version is not, however, an indifferent operation. It exposes the mother to grave dangers, both of injury to the tissues by too rough manipulati— Perforation.— The fingers, or the half -hand, should be passed to the head, behind the symphysis, with their palmar surfaces downward. The scis- sors should be passed along it, and adjusted by the finger tips to a position in which the axis of its point is perpendicular to the por- tion of the skull against which it impinges, or is directed slightly toward the hand, the latter position being the better, because m the event of its slipping it might then be arrested by the fin- gers, instead of burying itself in the vaginal wall or uterus. The surface of one of the flat bones should be chosen for perforation, rather than one of the sutures or fontanelles, since the hole is then less likely to be lost. The perforator is forced against the bone by carefully guarded pressure, accompanied by a slight bor- ing motion, and is passed through its substance until its prog- ress is arrested by its projecting shoulders. The catch which holds the handles apart should next be loosened, and the blades separated to the widest jjossible angle: they should then be closed, and rotated to a position at right angles to the first ; again widely opened, and, while still extended, rotated in all directions, In order to convert the hole into the largest aperture obtainable. If the trephine is preferred, it is best to choose one which is furnished with a cephalic curve; it should be passed to the head under the guidance of the fingers, and throtighout the perfora- tion its position should be watched by one hand of the operator, OBSTETRIC SURGERY. 180 the other steadying the shank of the instrument, while an assist- ant turns the crank. The scissors, or, if the operator prefers, some smaller metallic in- strument, should next be passed into the head until it comes in contact with the base of the skull, and if possible enters the foramen, and should be swept around in all directions, in order to thoroughly break up the cerebral centres of organic life ; since it is important to effectually destroy the life of the child before its delivery, in order to avoid the very unpleasant accident of the birth of a perforated but living child. Evacuation of the Brain. — In cases where the pelvic space is so extremely small that the head must be reduced to the least possible minimum before its passage, it is well to emi^ty the cranial cavity by washing out the brain with a large stream of Avater, injected into the interior of the skull with a syringe and a large catheter, or some similar apparatus ; but in ordinary cases this precaution is unnecessary. Extraction. — The medulla having been broken up, one fin- ger of the operator should be inserted into the aperture in the skull before the scissors are withdrawn, as a neglect of this pre- caution may sometimes lead to considerable difficulty in finding the site of the perforation. The male blade of the cranioclast should be passed through the perforation and its handle steadied by an assistant. The female blade should then be passed over the external aspect of the head. In vertex presentations, this blade should be adjusted, if possible, to the face of the child, which is not only the most solid of the accessible portions of the skull, but is furnished with soft tissues which are more abun- dant than those of the scalp, and are therefore better able to permit an efficient burying of the external blade in their substance. Should want of space prevent this application, a position over the occiput should be selected, as this is the only other portion of the skull which affords a solid hold for the cranioclast. The male blade should then be so rotated as to permit the locking of the instrument ; and the handles should be brought into close approximation by a forcible use of the compression screw; when steady, persistent traction will usually result in an advance of the head, which is immediately signalized by the oozing of the brain substance through the hole in the skull ; but during the whole extraction, the operator's fingers should be kept in the vagina and should watch the edges of the perforation, to prevent any tearing of the maternal tissues by projecting spicuia of bone. Throughout the extraction the operator should so manage his force, that it may be promptly relaxed, whenever the tissues are felt to be giving away. Difficult Extractio^t.— If the pelvic space is markedly i"JU rilACTICAL illDWIFEKY. suiiiU, as compared with the iiulivuhial skull, it maybe necessary to lessen the bulk of the head by deliberate teariiijj: away of the cranial bones, before the extraction is attempted. This may be done by the cranioclast, but is better executed by the crani- otomy forceps; which should be introduced under the guidance of the finger, witb one blade between the scalp and skull and the other inside its cavity ; when by a rotatory movement, under the guidance of the finger, the bones may be successively broken off and removed, piecemeal, until nothing is left but the face and the base of the skull; the soft tissues of the cranial vault Ijeing left as nearly intact as is possible, in order to pro- tect the ragged edges of bone, -svhich might otherwise inflict in- jury upon the vagina and lower uterine segment. The head should then be extended by the hand until the face presents at the brim, when the solid blade of the cranioclast may be intro- duced into the mouth or below the chin, its other blade applied over the forehead, and the blades approximated by the compres- sion screw until their outer edges are separated from each other by but little more than two inches. Since the width of the base of the skull rarely exceeds three inches, it is evident that by this uianoiuvre the perforated head may be extracted through all but the most extremely contracted pelves. If, after such an oper- ation, it proves difficult to engage the shoulders in the superior strait, the craniotomy scissors should be i^assed into the thorax through the supra-clavicular space, and followed by the cranio- clast, which should take its grasp over the upper portion of the spinal column. In extreme cases it may be necessary to precede the extraction of the body by a preliminary evisceration, or by an amputation of the arm at the shoulder-joint. The method above described is usually to be preferred in diffi- cult extractions after craniotomy, but it may sometimes be ad vantageously replaced by the process of crushing the base of the skull with the eephalotribe after perforation and evacuation of the brain have been performed. The best forms of eephalotribe are those of Hicks, Blot, and Lusk ; but this instrument is rarely found except in the hands of specialists engaged in large consul- tation practice, who need no directions for its use; and its em- ployment is, moreover, so seldom advisable that its further dis- cussion is here unnecessary. Extraction of the perforated child by version and manual delivery of the after-coming head is occasionally recommended as preferable to the use of the cranioclast, but this i.s an unsafe operation, the objections to it being that craniotomy is seldom performed while the uterus is in a condition which renders ver- sion a matter of indifference in the interests of the mother, and that this operation must always expose the maternal tissues to a OBSTETRIC SURGERY. 191 considerable risk of injury from tlie broken cranial bones during the passage of the liead along the uterine wall. It is a convenient precaution to place a pail, partly filled with water, upon the floor beneath the patient's buttocks, in order to receive the usually large amount of blood and brains which pour forth from the vulva ; and into this the child may also be dropped after its delivery. Although the perineum is often necessarily lacerated during the i^erformance of very difficult craniotomies, its preservation is, with care, ordinarily f)Ossible ; and the importance of this ob- ject should never be forgotten. After delivery it is usually best in all but face presentations to so arrange a cap over the child's head as to render it presentable, and prevent unnecessary shock to the feelings of the family — a precaution which should always be recommended to the nurse by the physician. Craniotomy to the After-Coming Head.— If, after ver- sion or the extraction of a breech, the after-coming head is found to be so firmly arrested as to resist all reasonable efforts toward its delivery by the usual methods, the performance of craniotomy is our only resource. When this becomes necessary, the body of the child must be drawn sti-ongly downward toward the floor by an assistant, in oi'der to engage the head fii-mly and to bring the occiput within easy reach. Two fingers of the operator are then passed up to the skull behind the symphysis pubis, the craniotomy scissors are guided up to the occipital bone be- tween the fingers and the skull, and are driven through it, the maternal tissues being effectually protected by the operator's fingers. ' The operation is ordinarily exti'emely easy, and the only other precaution to be observed is that care should be taken to see that the point of the scissors laas actually reached the occiput before it perforates the skin, in order to avoid the long, tortuous canal which necessarily follows the passage of the perforator through the tissues of the neck and throat, and through which the cerebral substance escapes with much less ease. The extrac- tion of the diminished head may often be accompished by the application of combined traction to the face and shoulders in the usual manner; but unless this effort succeeds at once, the cranioclast should be placed in position over the most accessible portion of the cranial vault, and used for supplementary traction. It rarely happens that a pelvis which is capable of affording passage to the intact body offers any excessive resistance to the perforated head. Craniotomy in Face Presentations.— In face presenta- tions the perforation should be made through an orbit or through the frontal bone ; but if the orbit is selected, great care 192 PRACTICAL illDWIFEKY. must be taken to pass the perforator well within the cranial cavity before the eranioclast is applied, Craxiectomy.— Many complicated instruments have been devised for lessening the bulk, of the head by the removal of portions of the base of the skull ; but if this procedure is neces- sary, it can be equally well accomplished by passing the chain of a powerful ecraseur, or the wire of the author's decollator, under the chin of the child, and around the head to the edge of the small fontanelle (Fig. 47). The adjust- ment of the noose is effected either Vjy carry- ing it upward over the face upon the tips of the fingers or by the use of a porte-fillet ; on tightening the wire the whole face and base of the skull are separated from the remainder of the head. Decapitation, IxDiCATioxs — I jfSTRUMENTS,— Decapita- tion is only indicated in extreme impaction, after long-neglected presentations of the shoulder. Such cases are only likely to arise in the practice of untrained midwives, and. are therefore very rare in this country. The steps of the operation are the division of the neck, the extraction of the body, and the ex- traction of the head. It may be performed by means of Braun's decapitating hook, Ramsbotham's knife, the author's sharp 6craseur or, in case of necessity, by an ordinary c'craseur, or even with scissors. Braun's hook (Fig. 48) should be made with a metal handle, since the wooden handle with which it is occca- sionally provided is extremely liable to split during its rotation,. Ramsbotham's knife (Fig. 48) should not be made of very highly tempered steel, since a blunt edge is quite sufficient for the division of the soft foetal tissues, and a very fine and brittle edge is certain to break upon the bones. Reynolds' decollator (Fig. 49) is in effect a large and powerful ('craseur, the distal extremity of which terminates in a crescentic chisel edge, which under the traction of the wire loop is readily forced through the tissues of the neck, the pressure and counter-pressure being applied to opposite surfaces of the child, so that the operation exposes the tissues of the mother to no added strain. It is ac- companied by a modification of OUivier's porte-fillet, intended to assist in the adjustment of the wire around the neck. Tech xiQUE.— Whenever it is possible, and whichever instru- ment is used, the operation should be preceded l)y the extraction of an arm ; or, if one is already prolapsed, it should be secured Fig. 47.— Reynolds' Decollator Adjusted TO THE Head for Craniectomy. OBSTETRIC SURGERY. 193 by a fillet and drawn strongly downward, and toward the side to which the breech is directed, by an assistant ; in order to make the neck as accessible as possible. Brami's Hook.— The bladder should be emptied with espe- cial care ; the instrument should be passed, under the guidance of the finger, behind the neck, and turned forward until it is in position about the neck, when its point should be met by the finger. The hook should next be drawn strongly downward, and Fig. 48.— a, Braun's Decapitation Hook; h, Kamsbotham's Decapitating Knife. Fig. 49.— a. Reynolds' Decollator; b, Porte-flUet. rotated until its tip is buried in the tissues of the shoulder ; ' and then, while strong traction is made upon the handle by both hands of the operator, the instrument should be sharply rotated through an arc of one hundred and eighty degrees, when the neck will be heard to snap. The bladder is protected from injury during this manoeuvre by the fact that the point of the hook is already buried in the foetal tissues, and that it is, moreover, turned away from tlie bladder. The soft parts are then divided by torsion, the instrument ■ Not against the occiput, from the hard surface of which it is liable to glance- daring rotation. 13 194 PRACTICAL MIDWIFERY. beiny: drawn lirmly downward, and rotated until the neck is com- pletely torn away: but throughout this process one hand should be held in the vagina, to guard its tissues from the injury which might be caused by a sudden yielding of the neck. Raniabothanis Knift. — The knife is introduced between the neck and symphysis, that its point may be away from the blad- der. When it is in position around the neck, its tip is met by the finger, which should be retained in position while the neck is divided by a gentle sawing motion, combined with downward traction. The Combined 0/;>erai/o7i.— The objections to the hook are that the division of the soft parts is a prolonged and tedious opera- tion, during which the already overstrained soft parts of the mother are subjected to considerable force from their friction against the surfaces of the child during traction and torsion. The objections to the knife are that, while its division of the soft IDarts is speedy and almost forceless, it is lial^le to break against the vertebrte or to cause considerable delay and annoyance in finding an intervertebral notch. If the operator possesses both instruments, a much preferable method of division is to break the neck with the Braun's hook, and, after its Avithdrawal, efTect the division of the soft tissues by means of the knife. The Knife Ecraseur. — A loop of No. 18 piano wire is drawn into position about the neck by a stout, thi*eaded catheter, or by the porte-fillet su])plied with the instrument. The ends of the wire are then secured to the ecraseur, and the operator satisfies himself that no maternal tissues are included in their grasp; the wire is put slightly on the stretch, the fingers of the operator's left hand are placed upon the i^oints of the instrument, and his right hand guides the handle ; while an assistant draws the in- strument into position by turning the crank at its lower end. When the instrument is in jiosition, the division of the neck is accomplished within a few seconds and without the application of any force whatsoever to the tissues of the mother. In the absence of special instruments, the vagina should be ■distended by a large Suns' speculum, a stout cord should be passed around the neck, and should be drawn as far downward as jjos- sible, under the guidance of the eye. The tissues may then be cautiously divided with a pair of long, stout scissors, continuous traction being maintained on the cord throughout the operation; or after the passage of the cord around the neck, the vaarina and cervix may be protected by the insertion of a large cylindrical speculum, the end of which should be placed against the neck, when the head maj'^ be separated from the shoulders by a to-and- fro, sawing traction upon the ends of the cord. Extraction.— After the decapitation has been effected, the OBSTETRIC SURGERY. 195 cut sui'faee should be protected by covering it with the palinar surface of the fingers, in order to avoid»laceration of the vaginal walls by projecting fragments of bone; and the body of the child may then be readily withdrawn, by traction upon the prolapsed arm. The head is then turned into a position in which the di- vided vertebras occupy the centime of the lumen of the vagina, and is extracted by the forceps, cephalotribe, or cranioclast, care being take to pi-event any rotation which would bring the di- vided vertebrae into contact Avith the soft tissues of the mother. Exenteration. In transverse presentations where the neck is so high as to be Inaccessible, and in delivery of the fore-coming body where the disproportion between the child and pelvis is unusually extreme, it may sometimes be necessary to reduce the bulk of the body by removal of the abdominal viscera before extraction is possi ble. This should be done by opening the abdominal wall with scissors, passing the hand through the wound and tearing out the liver and intestines. The half -hand should then be passed through one of the natural openings in the diaphragm, and made to tear through its substance; when the heart and lungs can be torn from the thorax. If in transverse presentations the chest only is accessible, the ribs should be severed with the scissors; and care should be taken that their projecting edges are covered, during extraction, by the intervention of the soft parts. Extraction after ExEiiTTERATiOJ^. — In transverse presen- tations a half -hand or the blunt hook should be forced through the tissues of the back, and hooked around the vertebral column, or this may be grasped by the cranioclast ; the child is then ex- tracted by direct traction, which causes the lessened body to bend upon itself. If the space gained by evisceration permits the in- troduction of the hand into the uterus, and the performance of internal podalic version, without the use of undue force, this should be preferred. CHAPTER XIV. THE ABDOMINAL OPERATIONS. C-s;sAREAN Section, Porro-MI'ller Amputation, Laparo- EliYTROTOMY. Indications for the Section.— The Caesarean section, or any one of the abdominal operations, may be indicated by con- traction of the pelvis to a degree which makes the delivery of the child by the natural passages impossible or extremely dangerous ; by obstruction due to malignant disease of the cervix ; or to im- movable, benign intra-pelvic tumors ; it may very exceptionally be advisable on account of incomplete atresia of extreme degree. Operations. — Among the various abdominal operations for the delivery of the child, but three are worthy of mention in modern obstetrics — the Sanger modification of the classical C;esa- rean section, the Porro-Miiller amputation of the uterus, and Thomas's operation of laparo-elytrotomy. In the Sanger Caesa- rean section, the abdomen and uterus are opened in the median line ; the child is delivered, and the uterine wound is closed by deep inter-muscular, and superficial sero-serous sutures. In the Porro-Miiller operation the abdomen is opened in the median line, the uterus is opened, and, after the removal of the child, is amputated, with its appendages, at about the junction of the cervix and body, and the stump is then sutured to the lower corner of the abdominal wound. Laparo-elytrotomy is per- formed by making an incision parallel to Poupart's ligament, stripi^ing up the peritoneum, opening the vagina, and delivering the child through the wound, above the brim of the pelvis. Prognosis of Abdominal Beliceri/.— The prognosis of all of the forms of abdominal delivery varies so greatly with the con- ditions of the individual case that it is impossible to form a true conception of its gravity, or to indicate the line of conduct which should be pursued in determining the choice between perforation and each of the forms of abdominal delivery, without first con- sidering the consequences of the latter operations when per- formed at the time of election, and late in labor. The conditions which predispose to a high mortality are the existence of exhaus- tion from prolonged labor; the presence of debilitating organic disease on the part of the mother; and lastly, but most impor- OBSTETRIC SURGERY. 197 tant, the existence, or not, of previous attempts at delivery per vaginani. Cjesarean Section. — The recent improvements in the tech- nique of abdominal surgery, and Sanger's introduction of an ac curate adaptation of tlie uterine wound by sero-serous sutures, have greatly lowered the former enormous mortality of the Caesa- rean section ; but even this operation, when performed late in labor, and after unsuccessful attempts at extraction by version, forceps, or perforation, has resulted in a mortality of 40%. Upon the other hand, in a recent ' analysis of the literature of the world, conducted with the idea of determining the prognosis of this operation under favorable conditions, it was discovered that up to August, 1888, thirty-nine Csesarean sections had been performed bj' thirty o^oerators under the following conditions : The perform- ance of the operation, during the first twenty-four hours of labor, in the absence of maternal disease other than deformity of the pelvis, uncomplicated by previous attempts at extraction by the natural passages, and with the use of sero-serous sutures. The result of these thirty-nine sections under favorable conditions were that all the mothers recovered ; and that of thirty -nine chil- dren who were alive at the beginning of the operation thirty-eight were saved ; '^ the fcetal death rate being thus much less than can be claimed for any other of the serious obstetrical operations, and the maternal mortality absolutely nothing ; and this, in spite of the fact that the majority of the operators were performing this operation for the first time. The difference in mortality between early and late interference by the Csesarean section is thus so great that the importance of avoiding delay and attempts at inter -pelvic extraction, in cases which are like to require the sec- tion, cannot be too strongly urged ujDon the profession. PoRRO-MuLLER Amputation.— Although the statistics of the Porro-Miiller operation are greatly influenced by the time of its performance, the shock of the operation is at best so much more severe than that of the Csesarean section that it is but seldom performed till late in labor, and has been almost uniformly re- served for desperate cases in which the condition of the uterine tissues is such that it is unwise to allow them to remain. Its mortality in all the reported cases is about 46^. Laparo-eLiYTROTOMT. — Thomas's operation has so far been performed only fourteen times. Six cases wei'e operated upon early in labor and in the absence of organic maternal disease. Six children were saved, and five mothers ; one died of septic peri- 1 Still unpublished. 2 Dr. R. B. Harris permits me to state that although he has not had occasion to pursue this special investigation into the statistics of the subject, its results are in in a general way in thorough accord with those of his own researches. 108 PRACTICAL MIDWIFERY. touitis on the eighth day. Laparo-elytrotomy in favorable cases lias then yielded a ileath rate of IG.Gr*; but the number of cases is extremely small, the only death was from a cause which it should be i)ossible to prevent, and we may hope that in the future its record will be j^reatly improved. Of the reiuaininfj eight cases which were operated on under unfavorable circum- stances, one had been forty-eight hours in labor, craniotomy had been performed, and the patient had a feeble pusle of 130; one had cancer of the recto-vaginal septum, was intemperate, and died delirious; a fourth w'as in feeble health, and oedematous; a fifth was moribund at the time of operation ; the sixth had been a week in labor and died of septicaemia; all six mothers were lost. The two remaining cases, though unaffected by disease, had l)een in labor, respectively, four daj's, and a week ; the latter case had been subjected to craniotomy, and the child had been allowed to remain in utero until it was putrid; yet both mothers and the living child recovered. Nine of the fourteen children were alive when the operation was undertaken ; two were delivered living, but died within a few days; seven were saved. Out of seven al- most desperate cases, the operation has thus saved two mothers, or nearly 30;/, and half the children. Technique of the Abdominal Operations. The Cjesarean Section. — The necessity for the operation should be determined if possible by careful measureiuents of the pelvis, and by estimation of the siae of the head, before labor begins, or during the first stage. No attempts at deliv- ery per vias naturalen should be permitted ; the vagina should be thoroughly douched at the beginning of labor with a 1 : 3,000 corrosive-sublimate solution or with a 1 : 40 creolin emulsion ;■ it should then be exposed with a Sims' speculum, its walls should be thoroughly scrubbed with a wad of absorbent material soaked in the antiseptic solution and a somewhat larger wail wet with the solution should be placed in the vagina, and should remain in position until the time of operation. The section should not be undertaken until the os has become dilated to the size of a silver dollar; since it is highly important that the cervix should remain sufficiently patulous to permit the free escape of the fluid during at least the first forty-eight hours after labor. The al^domen should be thoroughly scrubbed with hot soap and water; dried; and scrubbed with ether to remove the fatty se- cretions of the skin; scrubbed with creolin or corrosive sub- limate; and covered with a large pad wet with the same anti- septic solution, which should remain in position for fi-om eight to ten hours. The instruments, the sponges, and the hands of OBSTETRIC SURGERY. 199 every one who is to approach the patient should be rendered tlioroughly asei)tic. Tlie oi)eration has been performed successfully by the light of a tallow candle and with one untrained assistant ; but the best of light and the presence of at least four trained assistants are much to be desired. The patient should be laid upon a table, and her whole body warmly wi-apped in blankets, the abdomen only being exposed. Everything in the immediate neighborhood of the abdomen should be covered with towels wet with a 1 : 40 carbolic-acid solution; the operator should stand upon the right side of the patient, with the instruments upon a taVjle near his left elbow. The first assistant should stand opposite; the second should stand behind the first and should assume the care of the sponges; the third should etherize; and the fourth should hold himself in readiness to perform any service that may be required of him during the operation, and to take charge of the baby after it is delivered. Instruments. — Twelve round, and twelve thin, flat sponges of selected sizes should be provided.' The instruments necessary are knives, scissors, dissecting forceps, retractors, six to twelve small compi'ession forceps, neadles and needle holder, a Koeberle serre-nceud or some ecraseur which can be used as a substitute for it in compressing the pedicle, pins for transfixing the stump, a thermo-cautery, a sheet of rubber gauze, and a piece of large, soft rubber tubing, or preferably the elastic band which is sup- plied with Esmarch's rubber tourniquet. The bladder and rectum should be carefully emptied. The incision should be made about an inch to one side of the linea alba, and should extend from about the umbilicus to within one and one-half inches of the symphysis pubis ; if the woman is at term, it must be at least seven inches long; and if it is necessary to enlarge it, the extension should be upward. The skin and cutaneous fat should be divided by bold, free sweeps of the knife; the sheath of the rectus muscle should be divided, and its fibres separated with the point of a director or the handle of a scalpel ; bleeding points should be compressed with catch forceps; and the posterior sheath of the rectus, and the transversalis fascia should be carefully divided. The subperitoneal fat should then be separated with a blunt instrument, when the peritoneum may be recognized as a thin, transparent membrane which can be readily moved to and fro over the uterus, which is faintly visible through it. The peritoneum should be raised with a pair of dis- • The sponges may be advantageously replaced by bags of cheese-cloth of proper size and shape, loosely filled with Berlin worsted which has been rendered absorb- ent by prolonged boiling in soft soap and water, or in a solution of dilute caustic potash. 200 PRACTICAL MIDWIFERY. secting forceps, care being taken that nothing else is included in their grasp; and a small incision should be made, when the es- cape of a little fluid will demonstrate the fact that the peritonejil cavity has been opened. The incision should be slightly enlarged with a knife or pair of scissors ; and the finger should be intro- duced, and used as a director on which to extend the incision in the peritoneum to the full length of the cutaneous incision, care being taken that the bladder is not injured in opening the lower angle of the womb. The fingers and thumbs of the first assist- ant should then be placed around the loAver uterine segment, beneath the head of the child, or the elastic Ugature may be made to surround it, in order to exert compression if it should be nec- essary. The uterus may tlien be opened in situ, or the abdominal wound may be extended upward, and the uterus lifted from the abdomen through the incision. In either case the hands of the unoccupied assistant should carefully hold the abdominal parietes in apposition with the uterus, in order to prevent ex- trusion of the intestines, and the entrance of liquor amnii into the abdomen. If the uterus is lifted from the abdomen before it is opened, the contamination of the cavity by blood and liquor amnii may be effectually prevented by cutting a hole in a sheet of thin elastic rubber, and drawing it over the uterus, in imita- tion of the dam commonly used by dentists. The uterus should be incised in the median line, to a length of about six inchs, the ends of the cut being about equidistant from the fundus and cervLx, both of which should be avoided on ac- count of their greater vascularity. If the hjemoiThage is not ex- cessive, compression of the lower uterine segment should be avoided in the interests of the foetus and of the maternal tissues ; but if the incision bleeds profusely, the uterine circulation should be arrested by digital compression of the circumference of the lower segment in the space between tlie head and pelvic brim, or by the elastic ligature ; the incision must then be completed rap- idly. If the membranes present in the incision, tliey should be ruptured ; if the placenta presents, it should be peeled off, or the fingers passed through its substance, and the child seized, if possible by the head, and rapidly extracted ; if the head is inac- cessible the feet should be seized, and the child should be turned and delivered. The cord should be torn, and the child handed to an assistant who is competent to deal with asphyxia. The placenta should be at once manually extracted, when the uterus will usu- ally contract promptly. A hypodermic injection of ergot should be given: the uterine cavity sliould be emptied of clots and, if hsemorrhage continues, should be swabbed out with dilute acetic acid, tincture of iodine, or, in extreme cases, with a dilute solu- tion of persulphate of iron (Monsel's solution). OBSTETRIC SURGERY. 201 The abdominal cavity should be cleansed with sponges at- tached to spon{?e -holders and passed to the bottom of Douglas's fossa, or by the injection of a gallon or more of warm boiled water. The uterine wound should be closed by interrupted inter- muscular, and superficial sero-serous sutures of aseptic silk or cat- gut (Fig. 50). The i^eritoneum should be drawn slightly toward the wound on either side, deep sutures of medium-sized silk or catgut should be inserted at from one-fourth to one-third of an inch from the edge, and should pass through the entire thickness of the uterine wall, with the exception of the mucous membrane, to emerge at a similar distance upon the other side. These should then be tied, care being taken at the time to see that the peri- toneal edges are turned into the wound and lie in apposition; where they should be held by interrupted superficial sero- FiG. 50. — Suture of Uterine Wound, a. Sero-serous suture; 6, intermuscular suture. serous sutures of very fine silk or catgut, placed no more than half an inch apart ; the uninterrupted suture is ill adapted to the closure of the uterine wound, since the shortening of the wound which occurs with each contraction of the uterus must necessa- rily loosen any continuous suture. The abdominal cavity should be again cleansed bj' a copious injection of warm water, and the abdominal wound closed by silk or silver-wire sutures. A dry antiseptic dressing, a tight binder, and the usual obstetric vul- var pads should be applied, and the patient should be put to bed and warmly covered. A. special nurse should be j^rovided, who should never leave the patient alone for an instant during the first ten days or a fortnight ; since many cases have been reported in which death was due to separation of the wound, or to internal hjemorrhage, caused by the patient's sitting up in bed or rising from it during a temporary absence of the nurse. If the recovery from ether is followed by excessive vomiting, 202 PRACTlCAh ."MIDWIFKIiY. it should be tre.'ited by the frequent udiiiiuistration of very suiuU (one- or two-drachm) doses of strong black cofTee, or champagne, or of brandy poured upon cracked ice; in ease of need, a dose elvis at the sides of the extended head, when further jjrogress is impossible without oi>erative release of the anus, and the child is subjected to a risk of delay which materi- ally lessens its chance of survival. One other and extremely important duty remains; from the time that the breech enga^^es in the pelvis until the cord Ls within reach of the finger, the obstetrician should maintain an uninter- mittent watch upon the fcetal heart, in order to detect the earli- est indication of an alteration of the circulation of the child by compression of the cord against the pelvic walls. If any j^ersist- ent alteration of its rhji:hm is noted, the conservative ix)liey hitherto adopted should be instantly abandoned, and rapid de- livery resorted to. since if the cord has been once subjected to pressure its circulation is almost certain to be totally arrested during the further progress of the case; and if interference is likely to be necessary at all. it is far better that it should be un- dertaJcen while the child's vitality is still unimpaired. Rapid Extraction of the Breech— High Arrest.— When the breech is arrested at the superior strait until the signs of exhaustion of one or the other patient appear, or when rapid delive^^• becomes necessary by reason Qf some pathological condi- tion which threatens the lives of mother or child, five methods of securing descent are applicable. Traction may be made upon the groin with the finger, the fillet, or blunt hook, forceps may lie apphed to the breech, or the hand may be inserted into the uterus and made to bring down a leg. for use as a handle with which to make traction. Use of the Finger. — If the finger reaches the groin with suflB- cient ease to make traction effective, this procedure is always preferable to all oth«rs ; but it is unfortunately seldom possible in high interference, unless where some pressing danger necessi- tates the immediate delivery of a distinctly small breech. The Blunt HooT<. — Both the fillet and blunt hook can usually be applied to the groin without especial difficulty in any portion of the pehis, and both are fairly effective means of traction ; both, however, labor under the disadvantage of subjecting the tissues of the child to great risk of injury; the blunt hook, when skilfully used, being perhaps the less dangerous. The blunt hook should be passed up under the guidance of the finger, between the an- terior hip of the child and the horizontal ramus of the puljes, until it can be so rotated that its point passes between the child's ABNORMAL LABOR. 229 thigh and abdomen. The finger should then be passed between the thighs and brought into contact with tlie point of the hook, which should then be settled downward by slight traction until it fits snugly against the hip joint, and the fingers should be kept in contact with the tip thi'oughout the extraction, in order to guard the soft parts from injury so far as possible. The line of traction should be directed slightly toward that side of the mother on which the sacrum of the child lies (Fig. (38), since trac- tion in any other direction is extremely likely to result in fracture Fig. 63. — Proper and Improper Direction of Traction Upon the Thigh. Proper direction ; b, improper direction. of the femur; an accident which is especially frequent in sacro- posterior positions. The Fillet. — The fillet may be made of a piece of broad tape (preferably linen, on account of its greater strength), or of a wide strip torn from a silk handkerchief. The best fillet known is, however, that made by passing a stout cord through a piece of rubber tubing about three-eighths of an inch in diameter. The fillet may occasionally be passed through the groin by the un- aided fingers, but in all except the most simple cases its adjust- ment in this manner is impossible. Several ingenious porte-fillets have been devised, but their place is equally well filled by a very simple device which can be readily improvised at the time of operation. A large English webbing catheter is threaded with a double loop of strong but 230 PRACTICAL MIDWIFERY. narrow bobbin, and its stylet is bent to the shape of the blunt hook {Fig. G4). The catheter is passed into the groin, the finger draws down the projecting loop of string until the end of the fillet can be knotted within it, and, by traction on the string, it is drawn close to the tip of the catheter. The instrument is then removed by a reversal of the process by which it was introduced, when the fillet settles into position in the groin. The use of the fillet is as liable to result in fracture of the thigh as is that of the blunt hook, and the same precaution must be observed as to the direction of trac- tion. Forceps to the Breech. — Until within the last few years it was commonly stated that the ijresenta- tion of any part of the foitus ex- cept the head was an absolute con- tra-indication to the use of forceps; but it is now known that if this in- strument is accurately adjusted to the breech its use is rarely produc- tive of any injury to the child, and it is perhaps the most eflfective means at our disposal for the rapid delivery of the pelvic extremity. If the position of the breech is dis- tinctly oblique the tip of one blade should lie against the upper sacral vertebrae, while that of its fellow should be pressed into the flexor surface of the most easily accessible thigh. If the position of the hips is transverse, each tip should impinge upon a femur just beyond or above the great trochanter, which then furnishes a firm hold for the blades. Application of the Forceps. — The forceps should be placed in an approximately correct i^osition upon the breech; the hand should then be passed into the vagina until the finger-tips can touch the exact spots at which the tips of the blades should lie ; when an accurate adjustment is easily attained by direct move- ment of the tips of the blades with the internal fingers. The small size of the tapering breech, in comparison with the diam- eters of any pelvis through which a living child can be extracted, renders this manoeuvre extremely easy. When the forceps are once in position, the handles should be brought together suffi- ciently tightly to ensure a firm compression, which should then Fig. 64.— Use op the Catheter AS A Porte-fillet. ABNORMAL LABOR. 231 be inaiiitaiiied without intermission until the deUvery of the child. The ordinary forceps are better adapted to this applica- tion than any special forms which have been devised; but the advantages of axis-traction ai"e perhajis more fully a^jparent in high arrest of the breech than in any other obstetric operation. Extraction of a Leg. — The introduction of the hand to bring down a leg i-equires no special description, other than that all the precautions proper to a version should be observed, and that the operator should be careful to ascertain the position of the coi"d and thus avoid the production of an unnecessary prolapse. The leg when exti*acted should be wrapjjed in an aseptic towel and traction made upon it in a line which should at first be di- rected as far backward as the perineum allows, in order to draw as nearly as possible in the axis of the superior strait ; but, as the breech descends, the line of traction swings forward until as the hips clear the vulva it becomes nearly vertical. As soon as the knee is well outside of the vulva the grasp of the hand should be shifted to the thigh, as traction on the lower leg is apt to overstrain the ligaments of the knee-joint. If there is any difficulty in bringing the breech to the vulva, its delivery may be assisted by hooking a forefinger into the other groin as soon as it is within reach, and, as it distends the peri- neum, it should be drawn well forward and every effort made to prevent a laceration, precisely as is done in the delivery of the foi'e-coming head. When the second knee appears at the vulva, it should be drawn along the side of the child and toward its back until the foot can be released by flexion of the leg upon the thigh ; but during this process traetioin upon the shaft of the femur must be avoided, as it is always likely to cause fracture. Care should also be taken to bend the knee only in the natural direction. After the entrance of the breech into the excavation, the use of the finger is often readily possible, and the use of the fillet and blunt hook becomes easier and somewhat less dangerous, as is also the case with the forcejDs ; manual extraction of the leg is usually then impossible. Choice of Methods. — In high arrest the use of the finger is sel- dom possible. The fillet and blunt hook are so likely to injure the child's groin that when the breech is high and movable and the uterus is in a relaxed condition, the choice should ordinarily rest between forceps and the extraction of a leg. The latter is then, upon the whole, the easier operation, and generally the more efficient, since, in addition to furnishing a convenient handle, the extraction of one leg greatly diminishes the size of the breech; but if the breech is firmly engaged and the uterus is so far retracted as to resi.st the introduction of the hand, the use of 232 PRACTICAL MIDWIFERY. the forceps should be i)referred. Tlie only objection to its em- ployiiient is the argument that it is likely to result in laceration or sloughinj^ of the soft parts of the child — a statement wliich lia« been clearly refuted V)y the fact that in actual practice no such results have been seen. It rarely fails to deliver the breech in any case in which delivery is i^ossible, unless both legs are fully extended across the abdomen and chest, in which case, as was originally pointed out by Barnes, the lower extremities act as a spHnt to the body, and prevent it from assuming the serpentine curve which is necessary to the delivery of the hips. In this condi- tion the extraction of a foot is the only expedient wliich is likely to be successful. In low arrest the preference should be given to the finger, and in the event of its failure the forceps should be applied. Extraction of the Body. — When the hips have cleared the vulva, and the popliteal spaces appear, the legs should be extracted by hooking a finger into the holloAv of each knee successively, and draAving them along the child's side toward its back, thus flexing the knee and bringing the foot to the vulva. When both legs have been released, one thigh should be grasped by the fingers of each hand, while the thumbs lie along the sacrum (Fig. 65), the line of traction should again be directed as far backward as the perineum allows, and the back of the child should be I'otated gently to the front during each of the remaining tractions. A towel wrung out of a warm corrosive solution should still be wrapped around the breech, both to prevent slipping and be- cause contact with the air is likely to induce jDremature respira- tions. As soon as the umbilicus appears at the vulva, a finger should be passed into the vagina and the cord drawn gently downward until enough has been gained to prevent any further dragging upon the navel. If the arms remain folded upon the chest it is an easy matter to hook a finger successively into each elbow and extract them: but if, as is usual, they become extended above the head by fric- tion against the Avails of the canal, their release becomes a more difficult matter. In easy extractions it is generally possible to bring the slioulders outside the vulva by simple traction upon the thighs; the body of the child is then dropped toward the floor and drawn as far backward as the perineum alloAvs; and two fingers are then passed over one shoulder and along the upper surface of the arm to the bend of the elbow. The arm is pushed downward and backward across tlie face of the child by pressure in the bend of the elbow, and, as the elbow appears at ABNORMAL LABOR. 233 the vulva, the fingers slide along the forearm to the hand and easily sweep it outside the vulva. The other hand of the operator then repeats the same proce- dure with the other arm. The child is then laid astride of one forearm, and the hand which belongs to it is passed into the vagina until its first and second fingers He upon the canine fossse of the child, while the Fig. 65.— Method of Grasping the Pelvts (Lusk). other hand is hooked over the shoulders, with the neck between its first and second fingers, and their tips upon the supra-clavicular region. The assistant then presses the head downward by supra- pubic pressure in the axis of the superior strait, and both hands of the operator make simultaneous traction, as nearly as possible in the same direction, the internal hand at the same time exert- ing itself to preserve the necessary flexion of the head (Fig. 6G). As the head emerges the line of traction sweeps forward in the curve of Carus, until at the end of the extraction the body of the 234 PRACTICAL Mn>WlFEKY. child rests upon the other forearm and along the abdomen of the mother. When the mouth appears at the vulva, all hurry ceases, and the operator's efforts should be directed to the preservation of the perineum. All traction should cease, the upper hand should promote flexion by restraininj^ the descent of the occiput, and the other should be used t(j shell out the head by pressure on the forehead through the perineum, or, if necessary, by pa.ssing two fingers into the rectum. This, Avhich is known as the method of extraction by com- bined traction upon mouth and shoulders, may sometimes be re- placed with advantage by the method known as Deventer's (be- FiG. 66.— Combined Traction Upon Face and Shoulder."?, cause introduced by an obstetrician of that name about the year 1715). This method was warmly advocated by Deventer, but fell into disuse and was practically forgotten, until within the last two years it has been revived and highly jiraised by several promi- nent American obstetricians. It is so simple and rapid a proced- ure that it is worthy of trial in any case in which the shoulders can be brought readily into view. By this method the after-coming head and the extended arms are extracted together, by simple traction on the feet and shoul- ders. When the shoulders appear at the vulva the body of the child is swung sharply backward, the feet are grasped by one hand and the shoulders by the other, and both hands make trac- tion simultaneously, and directly toward the floor (Fig. 67). By ABNORMAL LABOR. 235 tliis mancBUvre the arms, which lie by the side of the head, are pressed against the yielding and elastic sacro-sciatic ligaments, the chin is arrested by the pelvic floor, extension occurs, the occi- put appears at the vulva, the head is born by extension, and the arms follow. The advocates of the method believe that it never tears the perineum, and my own rather limited experience with it certainly supports this somewhat astonishing claim. The ease and rapidity with which delivery can sometimes be effected by this manoeuvre is very surprising ; but it is as yet a Fig. 67.— Devknter'3 Method of Extraction. comparatively untried measure, and further experience may de- velop contra-indications to it. It is certainly inapplicable when the head and arms are arrested at the superior strait. After the delivery of the child the uterus should be watched by an assistant, and every precaution taken against post-partum haemorrhage, which is peculiarly likely to follow a rapid empty- ing of the uterus under the profound surgical anaesthesia which is proper and necessary in the performance of version. Unless the child has reached the stage of pale asphyxia and feeble heart, it is well to hold it suspended by the feet for some 2o(J PRACTICAL MIDWIFERY. minutes after delivery before cutting the cord. This promotes the return of blood to the brain, permits the normal influx of ljU)od from the placenta, tends to drain away inspired li(iuor amnii or mucus, and is in itself a valuable method of resuscita- tion. In case it is thought necessary to jiroceed at once to more active treatment, time can often be saved by breaking the funis near the vulva, and at such a distance from the child that its end can be readily compressed by the hand which holds the infant. A broken cord rarely bleeds, and can be tied at the proper distance after all hurry has ceased. Difficult Extraction of the After-comixg Head axd Arms. — The difficulties met Avith in extraction are due to: (a) Arrest of the head and arms at the superior strait ; (h) arrest of an arm behind the occiput ; (r) closure of a constriction ring or of an imperfectly dilated os aljout the neck ; or (d) to arrest of the head, l:)y its excessive size, by extension, by a rigid perineum, or by contraction of the i^elvis. Arrest of the Arms at the Stiperior iSti'ait. — When the child is large, or the transverse diameters of the pelvis are diminished, the wedge formed by the head and arms is often too large to pass the superior strait. In such a ease the release of the arms must be effected before the head can enter the pelvis. The extraction of the ai-ms from the superior strait is a nmch more difficult matter than their release after they have entered the pelvis, and is effected by a different mancBuvre. The arrest occurs at or about the time when the points of the scapulse ap- pear at the vulva, and before the back is wholly turned to the front. If such an arrest is felt, and unless it can be overcome by very moderate efforts, all traction should be stopped, and the thorax should be grasped by both hands, pushed slightly upward to relieve the impaction, and rotated, if necessary, until the antero-posterior diameter of the child is nearly, if not quite, transverse to the pelvis. The feet should then be seized by the hand w-hich corresponds to the back of the child and drawn firmly upward and to that side, toward the groin of the mother. This answers the double purpose of drawing the posterior arm further into the pelvis and of making room for the passage of the operating hand into the vagina. The free hand is then rap- idly passed along the abdomen of the child to the posterior shoulder, and one or two fingers are passed along the arm and hooked into the bend of the elbow, which is then drawn down- ward, and across the face, into the vagina. The hand is then swept out of the vulva by pressure upon the forearm, applied as near to the wrist as possible. The feet are then drawn downward, and to the same side as before ; the same hand is passed over the abdomen to the anterior ABNORMAL LABOR. 237 shoulder, and an atteiii[)t is made to pass two fingers behind the symphysis to the bend of the elbow. If the elbow is reached, it is to be drawn downward across the face, as was the posterior arm; but unless this attempt is at once successful, the hand should be withdrawn, and the back of the child should be ro- tated across the front to the other side, so that the retained arm ] )eeomes posterior. This rotation may be effected either by grasp- ing and turning the thorax with both hands, or by drawing the prolapsed arm forward between the labium and the back of the child. The hand which before entered the vagina then draws the feet upward and to the side, while the other hand is passed over the abdomen to the elbow, and draws down the arm in the manner already described. If the hand passed over the abdomen fails to find the posterior elbow, it may sometimes be reached by seizing the feet in that hand, drawing them strongly upward and to the other side, pass- ing the hand which before held the feet along the back of the child to the posterior shoulder, and thence along the back of the arm to the elbow, which, as before, must then be pressed down across the child's face. In rotating the child it must always be remembered that the articulations of the neck are so arranged that, if the point of the chin be carried behind the point of the shoulder, dislocation of the atlas upon the axis is the result. For this reason the thorax should be pushed strongly upward whenever an effort at rotation is made, in order to free the head from the superior strait ; and the hands of the assistant should watch the head, that he may warn the operator if it fails to follow the shoulders. Arrest of an Arm Behind the Occiput. — It sometimes happens that the head rotates with the shoulders, but the arm is detained behind the pubes by friction against the walls. In such a case the arm crosses the nape of the neck, and, if traction is made, becomes jammed between the occiput and the symphysis. If the accident is discovered before traction has been made, prompt rotation in the reverse direction may unlock the arm ; and in this case this reversed rotation should be continued until the arm be- comes posterior, ?.e., through 180°; but unless the first attempt unlocks the jam, the child will probably be lost, and it is then per- haps best to make direct traction upon the shoulders, in the hope of extracting the head and arm together, at the risk of fractur- ing the humerus, after forewarning the bystanders that this must be the result, and that it is done in the interests of the child. Closure of a Constriction Ring, or of an Imperfectly Dilated Os, about the Neck. — The stricture of the canal formed by either of these conditions may embarrass the release of the arms, but 238 PRACTICAL MIDWIFERY. does not otherwise affect the Jibove-clescribed nianojuvre, excei)t that any abrupt or too forcible movements of the hand whilt' within the uterus are even more dangerous in these cases than in others; the extraction of the head from the constricting band is, however, often a matter of great difficulty. Any attempt to overcome this obstruction by force exposes the mother to the most imminent dan- ger of rupture of the uterus; and, though steady traction upon the mouth and shoulders should be given a fair trial and may effect di- latation in time to save the child, it is in these cases that the application of forceps to the after-coming head is most often indicated. There can be no doubt of the truth of Lusk's observation that " the forceps will sometimes bring the head rapidly through the cervix, when traction upon the feet only serves to drag the uterus to the vulva.*' Care should, however, be taken that this rapidity be not so great as in itself to cause serious laceration. Arrest of the Head at the Stipe- rior Strait hy Reason of Unusual Size of the Head. — Most German and American obstetricians believe that the use of combined traction upon the face and shoulders is the best method to adopt in arrest of the after-coming head, at any point in the pelvis, and it should certainly be the first method tried in any given case ; but as cases frequently occur in which the head can be de- livered with far greater ease by a rapid alternation between two or more methods than by the continued use of any one alone, it is, for this reason if for no other, well to be familiar with all the methods which have been found to be of value. The Prag7(e Method. — This manoeuvre is often of service in effecting the engagement of the head and its initial descent into the superior strait. This is especially true in certain forms of Fig. 68.— The Prague Method: First Stage (Lusk). ABNORMAL LABOR. 239 contracted pelvis, and to oi)erators whose muscular strength is inadequate to the really severe strain which is sometimes im- posed upon the internal hand in the use of the combined method at the brim; but it is usually inferior to the combined method after the greatest diameter of the head has passed the superior strait. Like all methods of manual extraction, it is greatly in- creased in value by the application of proper supra-pubic pres- sure by an assistant. ■The Pragite Method: Second Stage (Lusk). In its performance the feet are seized by one hand and the body drawn as far backward as the perineum allows; the other hand is then hooked over the shoulders, and traction is made by both hands simultaneously (Fig. 68). As the head enters the ex- cavation the body is swung rapidly upwai-d, and the remainder of the delivery is accomplished by upward traction on the feet, while the hand upon the neck promotes flexion by retarding the descent of the occiput (Fig. 60). 240 PRACTICAL MIDWIFERY. If by any clumsiness on the part of the openitor the abdomen of the child has been directetl to the front durinjj^ the liberation of the arm, and the chin is therefore arrested at the symphysis, the Pi-aj^ue method should be used throuj^hout. In this case the direction of the first traction should l^e nearly horizontal, and, as the occiput descends, the body of the child should be raised until, when the head emerges from the vulva, the Ime of traction is nearly parallel to the mother's aljdomen (Fig. 70). The cliief disadvantage of the Prague method lies in the fact that all the force exerted by the operator is expended upon the child's neck, and that the amount of force which can be safely applied is therefore less than in the combined method. Forceps to the After-coming Head at the SujJerior Strait. — The use of the forceps is generally believed to be the most power Fig. 70.— The Prague Method: Chin to the Front (Lusk). ful and certain means of overcoming difficult cases of high arrest of the after-coming head. The operation is, however, often diffi- cult, and the time occupied in the application of the forceps may be of vital importance to the child. IMoreover, there are but few cases in which a skilled operator, aided by efficient supra-pubic pressure, fails to deliver by manual extraction ; but as such cases do occasionally occur, the forceps should always be at hand be- fore version is attempted. If forceps be used, the body should be raised to a nearly verti- cal position, and the forceps should be passed into place upon the sides of the head beneath the abdomen of the child. An axis- traction model should be preferred. This is especially emphasized by a recent case in which a living child was delivered with ease by axis-traction forceps, after manual extraction and the ordi- ABNORMAL LABOR. 241 nary Vienna forceps had successively failed to deliver, though in the hands of a skilled operator. Arrent from Extension of the Head. — This condition is rare unless in improperly conducted extractions, and when it occurs may often be overcome by internal press\ire upon the face of the child, aided by supra-pubic pressure upon the forehead ; but if these measures fail, the body should be swept upward over the mother's abdomen, when traction upon the shoulders will draw the occiput over the i)erineuu], Fig-. 70). If forcejjs are neces- sarj% they should be applied under the child's Vjody, and should extract by the same mechanism. Arrest at the Inferior Strait or on the Perineum. — Cases in which manual extraction by the combined method fails to over- come a low arrest are extremely rare, but if forceps be required the application and extraction are always easy. Arrest Due to Contraction of the Pelvis. — In the ordinary- forms of contraction the arrest is always at the brim, and after the head has passed the superior strait the subsequent delivery is easy. Justo-minor Pelvis. — A breech presentation should never be allowed to persist as such in a justo-minor pelvis, but if it has not been corrected the inevitable arrest of the head at the supe- rior strait should be met by extreme flexion, and the application of forceps, to be followed by craniotomy if not promptly suc- cessful. Flat Pelves. — In all flat pelves, and in flat pelves only, the head enters the superior strait in the transverse diameter, and the passage of the strait is most easily effected in a somewhat ex- tended position, in which the bi-parietal diameter is received by one of the sacro-iliac notches, while the lesser bi-mastoid diameter is opposed to the contracted conjugate ; if, then, the hand, when it is passed into the vagina for combined traction, finds the head transverse, it should allow extension to go on until the face be- gins to approach the side wall of the pelvis, or until the greatest diameter of the head has passed the supei'ior strait ; and when this has occurred flexion should be promptly restored, and rota- tion and delivery will then rapidly follow. In siraf)le flat pelves the application of forceps to the after- coming head is rarely successful after manual extraction has failed; but in pelves of the universally contracted, flat type, if the transverse diameter is mai-kedly diminished, the mechanism approaches that of a normal or justo-minor pelvis, and, if the breech pi-esent, and efforts at manual extraction of the head fail> the application of the forceps may be tried. Management of Footling Presentations.— The treat- ment of footling cases is in no way different from that which is i6 2-i2 PRACTICAL MIDWIFEKY. proper to the whole breech, with the single exception that, if rapid extraction is necessary, there can be no question as to choice of operation. Transverse Presentations. Mechanism.— Spontaneous delivery is rarely possible in trans- verse presentations at term. The mechanism Ijy which it can occur with very small children has been explained already on page 177, under Version in transverse presentations. ProGtNOSIS. — The prognosis of transverse presentations for mother and child is entirely dependent upon the date of their recognition. If they are recognized at the beginning of labor, and before the rupture of the membranes, the prognosis to the mother is in no way worse than that of normal labor, while the prospects for the child are but very slightly altered ; but when such presentations are unrecognized, and are permitted to pro- ceed until general retraction of the uterus sets in, they can be relieved only by a version, which is certain to subject both mother and child to the most grave dangers ; or by a destructive operation, which sacrifices the child in the interests of the mother. Management of Transverse Presentations.— If, at the time when the presentation is diagnosticated, the membranes are unruptured and tlie presenting jDart is unengaged, four opera- tions are possible, external or bipolar cephalic version and ex- ternal or bipolar pelvic version, and they should be i^referred in the order in whicla they are given. If bipolar version fails, resort must be had to the immediate performance of tlie internal po- dalic operation. If tlie condition of the uterus is such that this operation is thought to be too difiBcult or too dangerous to the mother to be proijerly justifiable, decapitation or exenteration must be resorted to. Prolapsed Extremities. Presentation of the Head and Hand. Mechanism AND Prognosis. When the hand prolapses by the side of the head, it is most commonly placed at one end of the bi-temporal diameter; its presence then commonly results in delay, from the increased size of the presenting part, and may occasionally inter- fere with rotation. The prognosis is that of the operative treat- ment which may be necessary. Management. — The i^resentation is unlikely to be detected until there has been sufficient delay to warrant a high examina- tion ; when it is discovered, an attempt should be made to push ABNORMAL LABOR. 243 back the hand with the finp^ers, and, if this fails, forceps should be applied to the head, when the friction of the pelvic wall will usually delay the hand, while the head advances under the force of the instrument. In this application great care must be taken to avoid including the hand, wrist, or forearm in the grasp of the blades ; for such an error would sui'ely result in the production of one or more fractures. In the less common cases in which the hand is prolapsed by the side of the occipital end of the head, that part is frequently delayed by its presence, while the comparatively unobstructed sinciput descends. This motion, of course, results in the produc- tion of extension, which may even proceed to the establishment of a' brow presentation. If the accident is detected before marked extension has occurred, it should be treated by an at- tem.pt to replace the hand and the application of forceps, or by version. If marked extension is already present at the time when the diagnosis is made, the obstetrician should endeavor to replace the hand and flex the head manually, unless prolonged labor has already effected the configuration of a brow. In this case, or if an attempt at reposition fails, he should resort to ver- sion. Presenta-Tions of the Head and Foot.— This presenta- tion is decidedly more rare than that of the head and hand. Their consequences and treatment are identical. PAET Y.— PATHOLOGY OF LABOE. CHAPTER XVII. CONTRACTED PELVIS. IXTRA-PELVIC TUMORS. ATRESIA. Contracted Pelves. The almost universal neglect of pelvimetry by American phy- sicians is commonly excused on the ground that these deformi- ties are seldom or never seen among American women : but this view is undoubtedly erroneous, and is the result of an ignorance which is properly held by European authorities to be a standing reproach to the profession of this country. In a recent analysis of the percentage of contracted pelves among the native and foreign-born women of the out-patient de- partment of the Boston Lying-in Hospital/ it was found that nearly two out of every hundred American-born women showed some evidences of contraction, though it was usually slight, and was in every case of the justo-minor type ; while among the foreign- born women of the clinic the proportion of deformity reached nearly six per cent. It must be admitted that an attempt to manage such cases without a knowledge of their pecuharities must often lead to unnecessary loss of foetal life and laceration of the maternal Tis- sues ; and it is evident that a competent knowledge of these mal- formations is necessarily of great value to physicians whose practice lies among the foreign-born population of our cities, and that even those whose obstetric opportunities are limited to our native women are not safe in wholly neglecting the study of contracted pelves. Diagnosis. — Unfortunately there are few external peculiari- ties which can guide us to a suspicion of the existence of i^elvic deformities. So far as such warnings do exist they are to l^e found in an excessively small size of the patient, or in the pres- 1 Tran . Amer. Gyn. Soc, 1890. PATHOLOGY OF LABOR. 245 enee of narrow hips in tall, slender women ; in relative shortness of the limbs; in lameness due to diminished length of one leg; in abnormal curvature of the spine or undue hollowness of the back, which suggests the probability of an excessive inclination of the pelvis ; and m the history of a previous rachitis. The ex- istence of any such peculiarity is always sufficient reason for a careful pelvic examination during the later months of preg- nancy ; and this will be but seldom resisted by the patient if the necessity for its emi^loyment is plainly represented to her. Dur- ing labor, several conditions of much more moment in pointing to the existence of contraction may be observed. In the first stage the head rarely engages early, and it is often difficult to reach any presenting part; the non-descent of the head prevents the complete occlusion of the lower uterine segment and, if the membranes be elastic, results in the protrusion of a long sausage- like bag through the jjartially dilated os, while after rupture the whole or greater part of the liquor amnii is not infrequently at once discharged, to be followed usually by more or less re-contrac- tion of the cervix, which is no longer subjected to the action of the intra-uterine forces, since the head is unable to press against it. If the head is relatively large enough to form an efficient (obstacle, the progress of active labor without advance of the presenting jjart renders the patient peculiarly liable to the oc- currence of constriction or retraction rings, after the appearance of which but little is to be hoped for from a longer continuance of natural labor. Malpresentations and prolapse of the cord are relatively common; and further and still more suggestive evi- dence is to be derived from the alterations of mechanism charac- teristic of the dififerent types of deformity. Among the many pelvic malformations usually described but three are of sufficiently frequent occurrence in Amei'ica to be worthy of mention — the symmeti'icalh^ contracted or justo- niinor; the simi^le flattened; and the flattened, generally con- tracted pelvis. The differential diagnosis between these forms must depend upon a careful external and internal measurement, and on an internal palpation of the pelvis in question. Of the external measurements, three only are of practical value. These are the distance between the anterior superior spines of the ilium, the greatest distance between the external surfaces of the iliac crests, and the external conjugate diameter, or " Diameter of Baudeloeque." The only internal measurement which can be accurately taken is the diagonal conjugate at the brim, from which by proper subtraction the true obstetrical conjugate can be calculated. The internal examination should, however, always include a thorough and extensive palpation of the walls ■of the pelvis, if possible by the half-hand. 24G PRACTICAL MIDWIFERY. The height of the promontory above the brim, tlie length and degree of inclination of the symphysis, the dei)th of the ilio-sacral notches, and tlie degree of curvature of the iho-pectineal hue, the amount of curvature of the sacrum, and the length of the pelvic axis as a whole should also be observed. The determination of these points is largely a matter of judgment, and dependent upon experience; for which reason it should be the routine hal)it of the student to i:)ractise this examination upon every parturient woman Avho comes within his observation; and he who adopts this rule for every normal pelvis in which the administration of ether makes it possible, will rarely fail to form a conclusive diag- nosis of the form of contraction with which he is dealing, when confronted by a contracted pelvis. Uxternal Measurements. — The external measurements of the pelvis can only be taken with accuracy by means of a ijelvimeter Fig. 71. — The Pelvimeter. (Fig. 71). The distance betAveen the spines of the ilium is to be measured by placing the tips of the instrument against the anterior superior spines, just external to the origins of the recti- femoris muscles, and is normally, in American women, about ten inches. The distance between the iliac crests is obtained by placing the points against their external aspects, and then moving them backward and forward until the point of greatest distance is found. This diameter averages about ten and three-quarter inches. The external conjugate diameter is taken by so placing the pelvimeter that one point is pressed against the upper edge of the symphysis pubis, while the other rests in the median line below the spine of the fifth lumbar vertebra, a point which may be roughly stated as being that which gives the smallest measure- ment obtainable from any jioint of the median line in this im- mediate neighborhood. It is on the average about seven inches long, but these last two diameters are liable to considerable vari- ation in accoi'dance with the varying stoutness of the patient; the distance between the spines l)eing the less affected, while the external conjugate is distinctly unreliable, in all but thin women. PATHOLOGY OF LABOR. 247 Internal 3Ieasure?nents.— The length of the diagonal conju- gate diameter is obtained by the passage of two fingers into the posterior cid-de sac, when, by pressing them onward and as much upward as possible, the tip of the middle finger is made to reach the promontory of the sacrum ; the radial edge of the index is then liressed closely against the lower edge of the symphysis, and their point of contact is marked off Ijy the nail of tlie other index finger. The two fingers which have been used in the measure- ment ai'e then withdrawn from the vagina with as little altera- tion of their position as is possible, and the length of the diagonal conjugate is ascertained by mea- suring them with the pelvimeter. The fingers of the half-hand are tlien made to palpate the entire Fig. 72.— Calculation of the True Conjugate from the Diagonal Conju- gate, a, Normal inclination of the symphysis to the pelvic brim; b, diminished angle between the symphysis and the pelvic brim; c, increased angle between the symphysis and the pelvic brim. internal surface of the true pelvis so far as it can be reached, and to note especially the length and degree of inclination of the inner surface of the symphysis, and the height of tlie prom- ontory above the brim, in order to form an accurate estimation of the shape of the triangle (Fig. 72) from which the true conju- gate is to be calculated. It has been found by experience that the amount which should be subtracted from the diagonal conju- 248 PRACTICAL MIDWIFERY. gate to obtain the conjugata vera varies ordinarily Vjetween one-half and three-quarters of an inch. It is evident (Fig. 73) that this variation must grow less with a decrease in the inclination or length of the synii)hysis and with a diminution in the height of the promontory, and that it increases as these characteristics are reversed; but the exact amount to be de- ducted in the individual case must depend largely upon the judgment and experience of the obstetrician. When the inclination of the brim and the height of the promontory are normal, one-half inch should be subtracted if the length of the symphysis- is less than one and a half inches, and three-fourths if it exceeds that length. Simple Flat Pelvis. — This variety of malformation is most common among the Irish portions of our population, though it is not uncommon among the Germans. In it the external trans- verse measurements {i.e., those between the spines and crests) are but little if at all decreased, while the external conjugate is distinctly lessened. Internal palpation shows the transverse Fig. 73.— Variation in the Subtraction from the Di- agonal Conjugate in Ac- cordance with the Vary- ing Height and Inclination OP the Symphysis. / cO^ Fig. 74.— Characteristics of the Simple Flat PEL\ns (exaggerated). The dotted line represents the normal pelvis. space to be ample, and the sacro-iliac notches of about normal depth ; the symphysis is .short, and the angle of its inclination to the brim is normal or diminished; the longitudinal curve of the sacrum is markedly increased, the promontory is low, and the pelvis as a whole is short (Fig. 74). The inferior strait is but lit- tle if at all diminished in size, and the obstacle to labor is wholly, or almost wholly, at the brim. The head enter.s such a i)elvis in the transverse position, and is commonly extended at the brim ; PATHOLOGY OP LABOR. 249 Tjut it regains flexion upon entering the excavation, and its pro- gress is subsequently normal. In breech jM-esentations, or after version, the head enters transverse, but the narrowed conjugate then receives the bitem- TlG. -Characteristics of the Generally Contracted, Flat Pelvis (exag- geratecl). The dotted line represents the normal pelvis. poral diameter, while the wider biparietal corresponds to the greater space opposite one ilio-sacral notch. Traction upon the body causes slight extension of the head until the resistance of the conjugate has been overcome, when flexion must again recur to permit the passage of the excavation and of the inferior strait. Fig. 76.— Characteristics of the Justo'MINOR Pelvis (exaggerated). The dotted line represents the normal pelvis. Geis^erallt Contracted Flat Pelvis. — This pelvis is most commonly seen in this country among English and Ger- mans. The general characteristics of these pelves are the same as those just described, but the external transverse measurements are here decreased, though to a somewhat less extent than the external conjugate. An internal palpation shows the transverse space at the brim to be correspondingly diminished (Fig. 75). The obstacle to labor is mainly at the superior strait ; the head 250 PRACTICAL MIDWIFERY. enters transversely, but the pressure upon the sinciput cdiim-- ([uent on the diminished transverse space renders extension ies> likely to occur. JusTo-MiNOR Pklvis. — This pelvis, which is in Europe the most rare of the familiar forms, is in America the most connuon, and is the only type which is found with any fretjuency amonf^ our native women. In justo-minor pelves the promontory is high and the sacrum long and straight ; the symphysis is long, and the angle of its inclination to the brim is increased. The shape of the inlet is round, the sacro-iliac notches are shallow, the axis of the pelvis is long, and the external measurements are symmetrically decreased (Fig. 76). The ob.struction to labor is not limited to the superior strait, but continues through the Avhole pelvis. The mechanism is that of early and complete Hex. ion, with occasionally a delay in rotation from decreased incli- nation of the inferior pelvic planes. Treatment of Contracted Pelves. Variation in the Size of the Child.— If all of the heads of unborn children were of uniform size and consistency, the division of contracted pelves into classes would be easy, and the determination of the treatment which should be adopted would be a mere matter of pelvic measurement ; but in practice the in- dications vary Avidely in accoi'dance with the variation in the size and ossification of individual fuetal heads, as Avould indeed be expected when it is remembered that the normal variation in the size of the child at term can hardly be stated within lesser limits than from five and a half to tAvelve pounds: while the con- sistency of its cranial bones may vary from that of stiff card- board to almost the rigidity of a metal plate. The difference in the size of premature children at the same period is perhaps even greater than obtains at term. The variation of the results of labor in pelves of given size and shape in accordance with the varying size of the child is well shown by the following tabulation of a series of thirty-nine un- selected cases. ' Eight simple flat pelves Avith conjugates of three and three- quarter inches resulted in no craniotomy, four versions, one for- ceps, and three normal labors. Four justo-minor pelves with conjugates of four inches re- sulted in no craniotomies, three forceps, and one normal labor. One generally contracted flat pelvis Avith a conjugate of four inches resulted in version. ' Many of these women were delivered in subsequent labors by the natural efforts, after the induction of labor. PATHOLOGY OF LABOR. 251 Six simple flat pelves witli conjugates of three and one-half inclies resulted in one craniotomy, three versions, and two nor- mal labors. Two justo-minor pelves Avith conjugates of three and three- quarter inches resulted in two forceps cases. Four generally contracted flat pelves with conjugates of three and three-quarter inches resulted in no craniotomies, two ver- sions, two forceps, and no normal labors. Two generally contracted flat pelves of less than three and one-half inches in the conjugate (2^, 3i) resulted in two craniot- omies. Three justo -minor pelves Avith conjugates of less than three and three-fourth inches (3, 3i, 3i) resulted in three craniotomies. The duty of the obstetrician when confronted by a contracted pelvis must then be to malve accurate measurements, and to diagnose with care the type of its deformity, and thus determine to which class of pelvis it would belong if the child was of aver- age size. He should then estimate carefully the size of the child, and modify the plan of treatment proposed in accordance with his opinion of its size. Estimation of the Size of the Child. — This is to be determined by bimanual palpation of the body through the abdominal walls, and an attempt to thus form an estimate of the probable size and weight of the child. The biparietal diameter which should correspond to this estimated weight should then be learned by reference to the subjoined table: Weight of Child. Size of Biparietal Diameter. Average Period of pregnancy at which these weights and measurements are attained. Correspond- ing Conjugate diameter in Justo-Minor Pelves. Correspond- ing Conjugate diameter in Simple Flat Pelves. 3 -3* lbs. 3i-4 " 4 -5 " 5 -6 " 2|— 3 inches. 3 -Si " 3 -3* " 3*-3| " 32 weeks. 34 36 38 3 inches. 3i " 3* " 3f " 2f inches. 3 " 3i " 3+ " It must be noted that the period of iDregnancy at which these weights and measurements are attained is subject to extreme variations. In generally contracted flat pelves the conjugate diameter which is appropriate to a given head must vary from that rec- ommended for the simple flat and that which is appropriate to the justo-minor type, in accordance with the amount of trans- verse contraction present. The probable consistency of the head should then be estimated by bimanual palpation, both through the abdominal walls and 258 PRACTICAL MIDWIFERY. ■with one hand in the vagina. If the patient be a multipara, the results obtained by i)hysical examination should be contrasted ■with the history of her previous labors; it beinility of delivering a living child, and, lastly, but not less important, upon the choice of the mother and her relatives. If the pelvis is close to the upper limit of the class, and the relative disproportion of the head ' Except that at the lower limit of this class, the chance for the child is so small that the seotiou should often be considered. PATHOLOGY OF LABOR. 257 to it not excessively great, the choice should be given to the more conservative measui'es. If the adaptation is such that, in the judgment of the attendant and his consultants, delivery by ver- sion or the forceps is al:)Solutely impossible, it is important that the prognosis of the case should be fully stated to the family at the outset of labor, and that the choice of methods should be decided upon early, since the results of the modified Csesarean section when performed early in labor, upon cases which have not been subjected to previous attemi^ts at delivery by the natural passages, have been almost uniformly successful, and in marked contrast to the extreme fatality which still exists among late and secondary abdominal deliveries. Cases Been Late in Labor. — If the deformity is not recog- nized until after the performance of unsuccessful attempts at ex- traction through the pelvis, or until uterine exhaustion has su- pervened, craniotomy should be performed, in all cases in which the size of the pelvis makes it possible without extreme danger ; since the high mortality of late sections makes them, only justifi- able in the presence of an absolute indication. If an abdominal operation is necessary, either the Porro-Mtiller amputation, or laparo-elytrotomy is the operation of choice. Treatment — Class c — During Pregnancy.— Wh.Qn a woman, whose pelvis is so highly contracted that the delivery of a living child at any time is impossible, is seen during the early months of pregnancy, the choice must rest from the start be- tween the immediate induction of abortion and a resort to the Csesarean section at term. This question is one which must necessarily be decided by the family or by their spiritual advisers. The duty of the physician is to state the probable results of each course of action in plain terms, and to abide by their decision. In case the mother refuses to consider the Csesarean section, and repeated abortions become necessary, the propriety of sub- mitting her to a laparatomy for the sake of sterilization is a question which in the present state of abdominal surgery should certainly be raised. Most physicians would probably consider that the chance of death to a healthy woman after a careful lapa- ratomy is so slight as hardly to outweigh the risks of health which are necessarily attendant upon frequently repeated abortions. The time has certainly not yet arrived, and perhaps never will, when the success of the section is such that the right of the physician to induce abortion in these cases can be open to serious questions upon ethical grounds; but his action in the premises is so likely to be misrepresented that he should always protect himself by the opinion of a consultant before allowing himself to terminate the pregnancy. At term. — After the child has obtained a size sufficient to ob- 17 258 PRACTICAL MIDWIFERY. struct delivery, the performance of the Csesarean section at the time of election is the only course of action which can be adojited. Intra-pelvic Tumors. The new growths and other enlargements by which labor may be obstructed are fibroid tumors of the uterus, prolapsed ova- rian tumors, retro-uterine intestinal hernia, cancer of the cervix, vesical calculi, and pelvic exostoses. Fibroids.— Fibro-myomata maybe discovered during preg- nancy or labor, by either abdominal or vaginal examination. They appear as irregular nodular excrescences connected with the uterus, and are only liable to be confounded with tense, multilocular ovarian cysts, Avhich, when held in close proximity to the uterus by adhesions or the effect of the intra-abdominal pressure, are sometimes differentiated with difficulty. Fibroid tumors often appear for the first time during pregnancy, and, if connected with the upper part of the back wall of the uterus, are often first noticed after delivery; but more frequently their in- crease during pregnancy is so rapid as to attract then the atten- tion of the patient or her physician. If fibroid tumors are known to exist, the appearance of a sudden and rapidly increasing en- largement of them is always strongly suggestive of pregnancy. Their obstetrical importance depends upon their situation — whether subserous, interstitial, or submucous — and whether con- nected with the upper or lower uterine segment. Subserous Fibroids. — The subserous variety, if small, are of no obstetrical importance; and, even if they are large, the only influence which they exert, is a tendency to the production of premature labor by their encroachment ujjon the already limited space in the abdominal cavity. Interstitiad and Submucous Fibboids.— /?2. the Upper Segment of the Uterus. — The influence of the interstitial and submucous varieties varies with their situation. Those Avhich are attached to the fundus and upper uterine segment compli- cate parturition only by their tendency to produce irregular and feeble pains, and thus prolong labor, which may also be patho- logically painful. They are afterward attended by an increased liability to post-partum haemorrhage, a tendency to the produc- tion of delayed involution, and an increased risk of sepsis from sloughing of the tumor due to the bruising which it may receive during labor, and to the alterations in its blood supply which attend upon the rapid decrease of the uterine circulation dur- ing the puerperium. In the Lower Segment. — Upon the other hand, inter.stitial and submucous fibro-myomata of the lower uterine segment often offer grave obstructions to the exit of the foetus. If small, they PATHOLOGY OF LABOR. 259 are extremely liable to cause malpresentations and malpositions ; if large, they not infrequently so far fill the pelvis as to become incarcerated within the excavation, and may then render deliv- ery by the natural passages impossible. Treatment. — Fibroids of the Upper Segment. — Fibroids which are above the brim may so far lessen the contractility of the utei-us as to necessitate the use of forceps or version ; otherwise they require no treatment. Incarcerated Fibroids, — The Taxis., etc. — When incarcerated intra-pelvie fibroids are discovered during pregnancy they should be at once lifted above the superior strait by gentle tasis, the patient being placed in the knee-chest position. The at- tempt should be repeated after a few days if it proves unsuccess- ful at its first trial. If it succeeds, a re-entrance of fibroids of any considerable size is unlikely; but lest this should occur, the ex- amination should be repeated, and the tumors, if necessary, raised from the pelvis at short intervals until their increased size makes re-entrance impossible. Interstitial fibroids of the lower uterine segment frequently extend, however, into the pelvis only, and are then often neg- lected until the advent of labor renders a vaginal examination necessar j^ The same attempt at raising them from the pelvis by the vaginal or rectal taxis, with the patient in the knee-chest position, should then be resorted to ; but if reasonably jDrolonged efforts of this kind fail to relieve them, the continued use of elas- tic intra-vaginal pressure should be turned to. This may be pro- duced by the inflation of a rubber colpeurynter within the vagina or rectum, by a weak solution of corrosive sublimate. With the exception of the continued use of this expedient throughout the labor and an occasional repetition of the taxis, the case should then be left to nature, since these tumors are largely muscular in their structure, and are subject to the same processes of softening and retraction with which we are familiar in the cervix; and because, by this process, tumors which seem to oppose a hopeless obstacle are usually entirely effaced and withdrawn above the head in the most surprising manner during the progress of labor. Indeed it may almost be laid down as a rule that no intra-pelvic fibroid tumor is capable of affording so hopeless an obstacle to delivery as to be sufficient cause for an early Csesa- rean section. Even though it wholly fills the pelvis, the chances of ultimate delivery by natural labor through the natural pas- sages, after its retraction, are so great that it is better to adopt a conservative policy in the hope of this result,' and to resort to I The author has himself seen, or known personally, four cases of incarcerated fibroids first discovered during labor, three of which were terminated by natural labor, and one by low forceps for failing pains, after the complete retraction of the tumors. :J(J0 PKACTICAL MIDWIFEKV. craniotomy, forceps, version, Porro's (^jerution, or an operative removal of tlie tumor in case of its failure and the appearance of exhaustion. Choice of Operation. — The choice between these operations must depend on the amount of space which has been gained by retraction before exhaustion appears. The patient should be left to the care of nature until her condition warrants a belief that she is unlikely to be strong enough to terminate the delivery her- self. A final effort should then be made to raise the tumor by taxis; if that fails, and the intra-jjelvic space is sufficient to per- mit delivery by forceps or version, one of these ojierations should be done ; or if there is not enough room for the delivery of an intact child, craniotomy may be possible. When exhaustion ap- pears before any considerable retraction has been effected, the choice lies between a vaginal extirpation of the tumor and a Porro's amputation of the uterus. If the tumor is accessible and distinctly pedunculated, it may be readily detached by the use of the scissors or ecraseur. If it is readily accessible and attached to the uterus by a broad base, it may be enucleated by an incision through its capsule, and the removal of the tumor, piece by piece, by the use of the scissors, or of Thomas's serrated spoon, to an extent sufficient to permit the passage of the child. This operation is, however, so difficult and dangerous that it should not be attempted unless the tumor is very readily accessible. When retraction fails and the enucleation of the tumor is thought to be inadvisable, Porro's operation should be iDerformed ; and since the prognosis is greatly influenced by the condition of the patient at the time when it is undertaken, it should be per- formed so soon as a rising maternal pulse gives reason for the belief that the iDatient's strength is unlikely to endure a continu- ance of labor till an. adequate retraction of the tumors has been produced. When abnormal presentations or positions are produced by the presence of small fibroids, the operation appropriate to the presentation should be undertaken as soon as the retraction of the tumor affords space for its performance. When a uterine polypus is discovered for the first time at the conclusion of labor, it should be removed by theecraseur, and its pedicle, if necessary, erased by the curette. Non-pedunculated fibroids should be left untouched, but watched carefully to an- ticipate the occurrence of sloughing, at the first sign of which the necrosed tumor should be thoroughly removed by the large blunt curette recommmended for the removal of adherent secundines. Ovarian Tumors.— Ovarian tumors of snuill or medium size may occasionally become prolapsed into Douglas' fossa below PATHOLOGY OF LABOR. 261 the pregiuant uterus, and, when so placed, constitute an extremely dany:erous complication of laljor. They are to be differentiated from fibroids in a similar posi- tion by fluctuation, when that can be obtained ; by the mobility which they sometimes show, and by the absence of any attempts at retraction during labor. They should be treated by persistent but gentle efforts at taxis, repeated at intervals until symptoms of exhaustion of the patient appear, or until the descent of the head produces a pressure against them which is sufficient to threaten rupture or necrosis. When this danger is thought to be present, the vagina should be thoroughly disinfected, and, the perineum being retracted by a Sims speculum, a carefully disinfected aspirating needle should be introduced into the tumor, and its fluid* contents should be drawn off. If the cyst is multilocular, and the first aspiration reduces its size without completely effacing it, the attempt to raise it from the pelvis by gentle taxis should be again repeated before resorting to further punctures. The operation of aspira- tion exposes the patient, under the most favorable circumstances, to considei-able danger of a general peritonitis from the escape of the cyst contents into the abdominal cavity ; and after such an operation the attendant must hold himself in readiness to relieve this condition by the immediate i:)erformance of a secondary laparatomy for the removal of the tumor, and cleansing of the peritoneum, whenever the symptoms of peritonitis appear. Herxia ixto Douglas' Fossa. — This condition is to be diag- nosticated by the peculiar feel of the tumor, and by its tympanitic note on percussion, if this is possible ; it may be discovered dur- ing pregnancy or may remain unsuspected until the advent of labor. It not only forms an obstruction to the passage of the foetus, but also exposes the patient to grave danger of intestinal obstruction, and should be treated by immediate and persistent taxis in the knee-chest position, if necessary under anaesthesia. Carcinoma Uteri. — When cancer occurs as a complication of pregnancy, its seat is invariably in the cervix, since cancer of the fundus would render iDregnancy an extremely improbable if not impossible event. It should be treated by amputation of the diseased tissues by the ecraseur, scissors, or galvano-cautery during pregnancy, immediately before the expected advent of labor, whenever the extent of the infiltration is sufficiently limited to permit the operation, Avhich is not necessarily followed by miscarriage or premature labor. When the disease is too far advanced to render this treatment possible, the case should be allowed to proceed to term and the child delivered by Ctesarean section, since the hopeless prognosis for the mother renders the life of the child the more valuable of the two. 263 PRACTICAL MIDWIFERY. Vesical Calculus.— A stone in the bladder, when impacted between the head and pubic wall, is sometimes mistaken for an exostosis of the symphysis, from which it is to be differentiated by the use of the urethral sound, and by the fact that exostoses are necessarily immovable, while calculi, though fixed during? the con- tinuance of the pain, are movable in the intervals. The head should be raised, and an attempt made to urf^e the calculus above the brim, by pressure exerted upon it with the fingers through the vesico- vaginal septum. If this is unsuccessful, the stone should be removed from the bladder by an incision through the septum, which sliould be carefully sewn up after labor, and then usually heals by first intention, or, if this fails, can be repaired by a subsequent operation. The operation of litholapaxy is sometimes possible, but is rendered so difficult by the lack of space around the stone as to be usually inadvisable at this time. Exostoses. — Multiple exostoses of the pelvic bones are not extremely infrequent; they usually spring from the sacrum or symphysis; the latter being the less frequent seat. The treat- ment to be adopted must depend upon the dimensions and shape of the pelvic canal. The condition differs from the other bony contractions of the pelvis only in the fact that, if the exostoses are irregular in shape and sharply pointed, the danger of pro- ducing fatal lacerations of the soft tissues during a pelvic deliv- ery may make a resort to an abdominal operation an imperative necessity. Atresia. Atresia Vagiitje. — Atresia of the vagina may be complete or incomplete, congenital or acquired. When complete it is of no obstetrical importance, since pregnancy is then impossible. Congenital atresia is the result of an imperfect development of the external organs of generation. Acquired atresia is due to cicatricial contraction, either after sloughing of the vaginal Avails from prolonged pressure in previous labors, or as the result of deep ulcerations due to dii^htheria, typhoid fever, syphilis, or other exhausting general diseases. Whatever tlie cause of the condition, it should be left un- treated during pregnancy and until the advent of labor, when the presenting part should be allowed to dilate the constriction, under the influence of the uterine contractions, until it is seen that exhaustion of the uterus or of either patient is impending; the ring then should be divided by multiple, preferably lateral, superficial incisions, and the forceps applied. During convales- cence a large-sized glass Fergusson si)eculuin should be kept constantly in the vagina, unless its jjresence prove too irritating, PATHOLOGY OF LABOR. 263 its orifice being plugged with iodoform gauze to avert the danger of sepsis. Atresia Uteri.— In very rare instances the septum of a bi- partite uterus may form an obstacle to the advance of the head. If, in such cases, a small hole is made in the septum by a blunt instrument, it is sure to dilate rapidly under the pressure of the membranes or presenting part. Cicatricial stenoses of the cervix may, very exceptionally, re- quire the same treatment which was recommended for cicatrices of the vagina. CHAPTER XYIII. ECLAMPSIA. Eclampsia is an aflfeetion characterized by the appearance of convulsions, both tonic and clonic in character, associated with the state of pregnancy, labor, or childbed, and not due to independ- ent organic disease. The latter restriction being intended to ex- clude the convulsions of epilepsy, hysteria, and cerebral lesions. Pathology. — Tlie etiology of eclam^jsia has given rise to a great amount of discussion, and the question is by no means thor- oughly settled; the two theories which ai-e most generally es- poused being, first, that it is a condition of toxeemia due to func- tional inefficiency of tlie kidneys ; secondly, that the convulsions are dependent upon an abnormally irritable condition of the central nervous system, produced by the hydrsemia of pregnancy. The advocates of each theory have attempted to prove that all cases of eclampsia can be explained upon their pet hypothesis; but while some few cases may be of almost purely renal origin, and a still smaller number wholly central and entirely uncon- nected with tlie kidneys, it is higlily probable that in the vast majority of cases botli elements are i^resent, and that one or the other predominates in each individual case; and it is certainly true that, whatever the pathological significance of the case may be, botli elements must be recognized in the treatment of almost every patient. Premonitory Symptoms. — In almost every case the advent of convulsions is preceded by a train of premonitory symptoms ; and, though cases not infrequently occur in which no such symp- toms have been noted, it is probable that they have merely been so slight as to be overlooked by the patient. The occurrence of oedema of the feet and ankles is so connnon in pregnancy as to be of no diagnostic importance; but a general wdeiuti, which is most easily detected in the hands and eyelids, is highly suggestive. Another symptom of almost constant oc- currence is a dull headache, which is usually slight and generally frontal, and is frequently described as an uncomfortable feeling just behind the eyes. Dinniess or indistinctness of vision, some- times amounting to almost total amaurosis, is freciuently com- jjlained of. A less common but very noticeable symptom is the PATHOLOGY OF LABOR. 265 sudden appearance of extremely severe epigastric pain, which is usually followed within a few hours by a seizure. Not infre- (lueiitly the attack is preceded by a slightly confused, stupid condi- tion of the mind or by a sudden access of irrital)ility ; but this is often wanting. The changes which appeai- in the urine are more significant than any other signs. It has long been known that a slight amount of albunnn is very frequently found in the urine of pregnant women, but it has only lately been discovered that such women furnish a very much larger percentage of eclampsia than those whose urine is non-albuminurie. A deci'ease in the quantity of urine, especially if it is attended by the appearance of albumin or casts, is highly prognostic of impending eclampsia. Descriptiox ot the Attacks. — When the attack occurs, it appears in the form of a typical epileptiform convulsion. It is ushered in by a few seconds of complete loss of consciousness; and this is succeeded by a spasmodic contraction of the smaller muscles of the face, which gives rise to a peculiarly unpleasant smile, the risus sardonicus of early medical literature. The eye- lids open and shut in rapid alternation ; the eye-balls roll up- ward until the pujpil is barely visible; the head is drawn rapidly from side to side; and the thumb is folded into the palm of the clenched hand, which passes rapidly from pronation to sujDina- tion, and vice versa. In severe attacks the forearms are rapidly flexed and extended over the chest, and toward the termination of the convulsion these clonic motions are succeeded by a tonic opisthotonos ; resj^iration stops, the eyes protrude from the sock- ets, the conjunctivae are deeply injected, the face becomes cyan- otic, and the jaws are clenched, often inflicting serious wounds upon the partially protruding tongue. A temporary rise of tem- perature follows each convulsion. The seizures last for from ten seconds to about two minutes, and are succeeded by a coma of varying depth and duration, from which the patient awakes with no memory of the attack. If the case is left to nature, the convulsion is usually I'epeated after a longer or shorter time, the intervals between successive convulsions becoming j)rogressively less, and the attacks more severe, Avhile life lasts ; each succeeding seizure adds markedly to the gravity of the prognosis for both mother and child. Much doubt exists as to whether the muscles of organic life participate in the attacks or not; but many observers have reported that the uterus not infrequentlj* contracts with extreme force during each convulsion. Progxosis. — It is one of the most fatal of obstetric accidents and is fortunately comparatively rare, being variously stated as occurring in from 1 in 300 to 1 in 500 lal)ors. It may ap[)ear at any period, but is more frequent in the later months of preg- 266 PRACTICAL MIDWIFERY. luuicy, during labor, or in the puerperium. As a rule, the eclamp- sia of labor is the more severe ; but puerperal eclampsia, if the attacks are severe, is rendered very danjj^erous l)y the compara- tive inefficiency of the treatment which it is possible to apply. The mortality varies greatly with the form of treatment adopted and with the severity of the individual case. When the first convulsions are incomplete, last but a short time, are fol- lowed by but brief coma, and are separated by jjrolonged inter- vals, both patients may be saved in the majority of instances by energetic treatment. When the attacks are severe and proUjnged, and the coma is continuous, the prognosis is almost hopeless. As a rule, the gravity of the situation is somewhat closely indi- cated by the completeness of the suppression of the urine. The mortality of untreated cases would be enormously great; even under efficient management it is commonly believed to be as high as from thirty to forty per cent. Treatment. — The treatment is divided into prophylaxis, care of the convulsion, and after-care. Pro2Jhylaxis. — The prophylactic treatment should be promptly instituted whenever any of the premonitory symptoms ap- pear, and is the most satisfactory part of the management of eclampsia. It should aim to attain two ends : first, the restora- tion of tone to the nervous system by securing for the patient complete rest, entire quiet, and the uttermost absence of mental worry, to which a moderate use of such sedatives as bromide and chloral should be added ; second, the prevention of any increase of toxtemia, by restricting the patient to a simple milk diet, and by the administration of the tincture of the chloride of iron in full doses; and, finally, the elimination of poisonous materials from the blood by diuresis, catharsis, and sweating. The urine should be examined frequently to determine both its quantity and quality, since the activity of the treatment must be dependent on its characteristics. The use of any other diu- retic than large quantities of water is of doubtful utility; but the vicarious elimination of urea or other toxic substances, by such sweating and catharsis as the strength of the patient permits, is an object of the first importance. Some form of saline should V)e administered in small quanti- ties several times daily; the choice between Hunyadi water, cit- rate of magnesia, seidlitz powders, and Epsom salts being de- pendent mainly upon the taste of the patient. The use of pilocarpine to ward off impending convulsions has been highly recommended, and strongly disapproved, by authorities of equal reputation. It is, however, rarely if ever necessary as a pro- phylactic, since it can usually be replaced by the milder and more continuous sweating produced by the use of hot-water PATHOLOGY OF LABOR. 2GT bottles or an excessive amount of bed -clothing; in extreme eases, the hot pack or steam bath may be resorted to, or the patient may be placed for twenty minutes in a tub filled with the hottest water which can be borne; but either of these expedients should be followed by her immediate re- moval to an artificially warmed bed, covered by a large number of blankets. The appearance of the premonitory symp- toms of eclampsia during labor should be treated by the admin- istration of chloral in fifteen-grain doses, repeated once or twice at intervals of half an hour; or better, by the prolonged use of ether to a degree of anaesthesia which is sufficient to cause par- tial unconsciousness without annulling pain. It is always a suf- ficient reason for the avoidance of any unusual prolongation of labor, and indeed, if the head is already in the excavation, is enough to warrant the application of forceps. Treatment of Eclampsia during Pregnancy. — With the ap- pearance of convulsions the whole plan of treatment changes. So soon as a convulsion has occurred, a differential diagnosis of its cause should be made. Hysteria is to be excluded by the epi- leptiform character of the seizure ; epilepsy by the history, and by an examination of the urine, which should be immediately drawn by the catheter. If the convulsion was epileptic, a trace of albumin or even a few hyaline casts may be temporarily pres- ent, and the specimen will be light and of a low specific gravity; but after eclampsia it is almost invariably scanty, concentrated, and loaded with albumin, and will contain an abundance of granular, or brown granular, casts. When the seizure occurs during the sixth month of pregnancy, or even earlier, some for- eign authorities recommend a conservative i^olicy; i.e., the use of chloral or other sedatives, combined with diaphoresis by pilo- carpine, the hot pack, or a hot bath, and the free administration of salines, in the hope of avoiding a recurrence of the seizures and of prolonging pregnancy until the child is viable, or even until term ; but although this attempt is occasionally successful, it is generally believed in this country that the risk to the mother is so great as to outweigh the faint chance of prolonging the somewhat problematical existence of a premature child ; and the plan usually adopted here is to imitate the course of nature, which in a large proportion of cases terminates the affair by the spontaneous occurrence of labor. Carl Braun declares he has never known but one patient to recover between the fourth and sixth month of pregnancy, except where abortion had taken place ; and since the induction of labor furnishes a considerable propor- tion of recoveries, it seems to be the only plan which can be rec- ommended for use in Avell-marked cases. Treatment during Labor.— A capable attendant should 268 PRACTICAL MIDWIFERY. remain by the bedside, in readiness to administer etiier at the flr-st i^ign of a second convulsion; should it appear, the ether should be crowded down, and the tongue should be protected from laceration by the insertion of a cork or piece of wood lie- tween the teeth, or better by passing a folded handkerchief be- tween the jaws, after the fashion of a bit, in order to retain it within the mouth. The i)atient should never be left alone for an instant until delivery has been completed, and the induction of labor should ordinarily be begun as soon as the necessary preparations can be made. When but a single convulsion has been observed, and the pa- tient is in fairly good condition, it may seem heroic to recom- mend immediate delivery ; Ijut experience shows that when this treatment is adopted, the mother is usually saved unless the at- tack is very exceptionally severe, and that, when the patients are jjermitted to have a number of convulsions, a large proportion are invariably lost; moreover, each succeeding convulsion greatly diminishes the vitality of the child. When the patient has been suffered to endure convulsion after convulsion, and is completely comatose, the shock of a forced delivery may be immediately fatal, and every precaution should be taken to minimize it : but since a continuance in this condition is necessarily and inevitably fatal, the best chance for the mother rests in immediate and gen- tle delivery under full anaesthesia, though even this chance then offers but little hope. The method to be chosen is not a matter of unimportance; the slower methods, which work by irrita- tion of the uterus, are distinctly to be ad voided, as being likely, in themselves, to excite fresh seizures ; the plan to which preference should almost uniformly be given being surgical anaesthesia and manual dilatation of the os; which should, however, be even more slow and gradual than usual, since the element of hurry which may enter into this operation when indicated by other conditions, e.g., haemorrhage, is absent in eclampsia, and the avoidance or minimizing of local irritation is an object of prime importance. The os should be carried uj) to full dilatation ; and the uterus should be emptied, either l)y version or by the appli- cation of forceps, while the patient is still under ether. Ergot should be avoided both on account of its alleged un- favorable action in eclampsia intrinsically and because some slight post-partum loss of l)lood is not an unfavorable circum- stance in this condition. After the patient has recovered from ether, she should be continously watched by the nurse, i.e., should not be left alone for a single moment until some days have passed ■without a convulsion: and the physician should arrange to be within call as much as possible during this interval. Chloral in doses of from ten to fifteen grains by the mouth, or PATHOLOGY OF LABOR. 2G0 twenty to thirty by the rectum, should be aduiinistered several times daily in all cases except those in which the patient is stolid and quiet and the renal disturbances are extreme, and ether should be given during convulsions. The urine should be drawn by the catheter every six hours unless it is passed at shorter in- tervals naturally. The total quantity should be carefully re- corded and each specimen examined for albumin and casts, since the prognosis in any individual case must depend wholly on the infrequency of the convulsions, the variations of the total quan- tity of urine, and the amount of albumin and casts found. From the time of delivery a mild diuretic, such as cream-of-tartar water' or a weak solution of acetate of potash, should be freely and continuously given. If the pulse be strong and full, and the patient is a vigorous woman, a saline cathartic should be admin- istered as soon as she is able to swallow ; or one-sixteenth of a grain of powdered elaterin may be placed upon the tongue, and repeated at intervals of two hours till the bowels have moved freely. No effort should be spared to provoke profuse sweating, it being a general rule, though not without its exceptions, that patients who sweat freely, recover, while those who do not, die. The most prompt and perhaps the most efficient and safest method is the hypodermic injection of one-sixth of a grain of i^ilo- carpine, to be repeated if necessary once; but this should be combined with a free use of hot-water bottles and of an abun- dance of warm coverings. The objection which has been urged against the use of this drug, that it is jorone to cause oedema of the lungs, has certainly some weight, and, in persons afflicted with any pulmonary disturbances, is a distinct contra-indication to its use; but in the majority of cases the danger seems to be slight. Should pilocarpine fail, or if its use is thought to be too dan- gerous in the individual case, the same effect may be attained by the use of hot-air or steam baths, the apparatus for which can be extemporized in any household with the aid of a joint of stove- pipe. The bed-clothes should be raised above the patient by a cradle, which can be made of barrel hoops if nothing better offers ; or by hanging them across a rope stretched above the bed from its top to its bottom, in imitation of the ridge pole of a tent. They should then be tucked very closely around the edges of the bed, and under the patient's shoulders and neck, the stove- pipe should be passed into the tent which they make, at a point where it cannot burn the patient's body, and a large alcohol or kerosene lamp should be placed under its dependent end (Fig. 77) if a hot-air bath is desired ; or a kettle or other vessel of boil- ing water may be mounted on a large lamp or an oil stove, and 1 This is prepared by putting a small piuch of domestic cream of tartnr into a. tumbler full of drinking water, and is to be preferred to the more active diuretics. 270 PRACTICAL MIDWIFERY. connected with the pipe by thick layers of wet cloth, if steam is to be used; the latter being the more troublesome, but rather the more efficient method. So soon as fairly profuse sweating has been produced, the apparatus may be removed, hot-water bottles jilaced in the bed, and the patient closely and warndy covered with blankets. Nursing should be forbidden, and absolute quiet and seclusion must be enjoined. The plan described has yielded, upon the whole, better results to those who have used it than has any other method ; but several other expedients may occa- sionally be serviceable, and must be described. The use of morphia instead of chloral is popular with many physicians, but is objected to by others upon the very rational ground that its tendency to decrease all the secretions more than counterbalances its superior sedative action. Fig. 78. Apparatus for Hot-air Bath. Veratrum viride in full doses — i.e., Squibb's fluid extract, ten to twenty minims subcutaneously, repeated if necessary in thirty minutes, and continued in five-minim doses by the mouth at intervals sufficiently short to maintain a pulse-beat of not more than sixty to the minute— has been highly recommended, and is especially popular in the southern and western portions of Amer- ica. Venesection has been' frequently recommended both upon theoretical and practical grounds, and should certainly be tried, at least as a last resource and after the failure of other methods, in all cases in which a fatal termmation seems likely, and in which the pulse is full and bounding. Eclampsia during the Pnerperi^im. — Puerperal eclampsia differs from eclampsia during laljor only in the fact that no oper- ative treatment is possible; its treatment is the after -treatment of the eclamiDsia of parturition. Clear as the indications for treatment are in many cases, the affection is any of its forms is always so serious, and its uncer- tainties are so many and so great, that it is a wise plan never to undertake the management of a case of eclampsia alone if a con- sultation can by any possibility be obtained. CHAPTER XIX. HEMORRHAGES BEFORE AND AFTER DELIVERY. Placenta Previa; Concealed Accidental, and Post-par- tum hemorrhage. Placenta Praevia. Placenta previa is the insertion of the placenta into the lower uterine segment, i.e., upon that portion of the uterus which is subjected to distention during labor; and this implantation dif- fers from ther normal status, not only anatomically, but also in its results. A normally situated placenta is only loosened by the ex- treme retraction of the uterus which follows the escape of the child ; but a prsevia is necessarily detached by the expansion of its site during the stage of dilatation. The normal placenta is thus detached at the end of labor and at a time when the mouths of the uterine vessels are closed by the retraction of the muscles ; while a placenta prsevia is separated at a period when the vessels are being drawn widely open by passive distention of the tissues in which they are placed. The natural result is that, in placenta prsevia, the first stage of labor is always complicated by haemor- rhages, which can only be arrested by emptying the uterus, and which frequently reach alarming proportions. Classification and Natural History.— Placenta praevia is divided into placenta prsevia centralis, where the insertion is such that the fully dilated os is completely covered by the pla- centa; placenta prsevia partialis, where the placenta cov- ers only a portion of the fully dilated os ; and placenta praevia lateralis or marginalis, w^here no more than the edge of the placenta is felt in the os when fully dilated. Closely allied to placenta i^rsevia, both anatomically and clinically, is the condi- tion known as low insertion of the placenta, in which it is not inserted into the zone of the uterus which is to undergo dilatation, but does extend into the area immediately continuous with it. This portion of the wall may or may not be subjected to suffi- cient alteration to cause the detachment of the placenta, and has been well called the dangerous zone, in recognition of the fact that, although a low insertion of the placenta does not necessarily 272 PRACTICAL MIDWIFERY. imply the unavoidable hajinorrhaf^es of a true placenta prajvia, it does in/olve a considerable risk of lifeiuorrlia^e, which indeed occurs in a large proportion of these cases. In placenta praivia the insertion of the cord is so frequently marginal or velamentous that a complication of the placenta prut if the physician has neglected to provide liiniself witli tlieni, or is timid about undertalving tlie iuniiediate repair of a deeply lacerated cervix in the face of an existing lifemorrhage, and per- haps witli an insufficient hght and almost useless assistants, the bleeding may be readily controlled by the passage of any foinu of needle backward and forward through the edge of the tear in such a way that the spu/ting artery is entirely enclosed within the suture after its ends have been tied (Fig. 79). In most eases the cervix can be seized by the fingers and drawn suffi- ciently near the vulva to permit the inser- tion of such a suture without the aid of the needle holder. True Post-partum Hemorrhage.— This much more com- mon phenomenon is due to failure of the normal mechanism for its prevention ; and a thorough comprehension of this process is so essential to the rational treatment of all forms of true uterine hcemorrhage that its discussion is a necessary preliminary to any clear and intelligent description of the treatment which should be employed. The separation of the placenta from its uterine attachments necessarily leaves the mouths of the utei-ine vessels in a patent condition, a fact which would always provoke profuse haemor- rhage if this were not prevented under normal circumstances by the fact that the uterine contractions which follow its detach iiient, drive it into the vagina, when its expulsion leaves the Fig. 79. — Suture of a Bleeding Vessel in the Cervix. Fig. 80.— Closure op the Sinuses in A Retracted Uterus. Fig. 81. — ^Patulous Condition of the Sinuses in a Relaxed Uterus. uterus free to retract upon itself; in which condition the vessels are closed by collai^se of their thin walls under the pressure of the muscular fibres which surround them, during the reduction of the area of the placental site Avhich is consequent upon retraction (Figs. 80 and 81). If, however, this retraction fails or, after it has once occurred, is lost from any cause, the uterine vessels remain dilated, and, with their orifices no longer occluded by placental 2S2 PRACTICAL .MIDWIFEKY. tissue, are in a position eminently well suited for the production of hieuiorrliaj?e (Fig. 81). It follows necessarily, as a corollary to this exphination, that the utitural, and only legitimate, method of arresting i)c)st-i)artum hfemorrhage, is by securing prompt con- tractit)n and retractitjn in an empty uterus. Thkat.mkxt.— Prophylaxis. — In the discussion of post-par- tum h;emorrhage, too much emphasis cannot be laid on the im- ix)rtauce of the rule which prophylaxis plays in this connection; indeed, it may be safely said that, in the most careful and experi- enced hands, post-partum htemorrhage in normal labor is an almost unknown oceuiTence, and that, if placenta pr«via, deep and prolonged surgical anaesthesia, jirevious extreme distention of the uterus, and severe collapse of the patient from antecedent causes be excluded, post-partum hcemorrhage can in most cases be traced to some neglect of precaution by the professional at- tendants. It is proper and it is the habitual custom of careful men to place by the bedside in every case of labor, as the period of de- livery approaches, all the articles which are necessary for the treatment of haemorrhage if it should occur. These are : a quan- tity of pieces of ice about the size of a hen's egg, brandy and ether, MonseFs solution of iron, ergot, and the hypodermic syringe, a pitcher of hot water, and a Davidson's or fountain syringe. From the moment that the head distends the perina-um. the hand of an assistant should be placed upon the fundus uteri, and should practise gentle friction upon it from that time until after the delivery of the placenta, and until the emjity uterus has been contracted firmly and without marked relaxation, for at least ten minutes. The physician should, moreover, be careful, in the interest of the prevention of hjemorrhage, to avoid a too rapid extraction of the child in the absence of indications for hurry; indeed, the short time which maybe occupied after the delivery of the head, in feeling for the cord about the neck, wip- ing the eyes, and clearing the fauces of the child, is distinctly advantageous as affording the uterus an opportunity for the retraction rendered necessary by the escape of the heail. After delivery, under normal circumstances, the child .should be given into the care of a bystander, and the hand of the physician or of a trained assistant should keep a careful watch of the fundus of the uterus through the abdominal wall, that he may be enabled to observe the first signs of relaxation. These, when noted, shoulc^ be at once combated by the performance of gentle but rapid, cir- ctdar friction of the uterus with the tips of the fingers, which should i^ass quickly across the anterior surface and, by infold- ing of the abdominal wall, around the fundus. If this motion is not followed by innuediate hardening of the uterine body, apiece PATHOLOGY OF LABOR. 283 of ice should be applied to the abdomen and rubbed briskly about over the uterus; Avhile if any suspicion of possible distention of the bladder is excited either by the history or by abdominal pal- pation, this should be at once relieved by the catheter, since a distended bladder may in itself prevent an adequate retraction of the uterus. The efficiency of ergot in producing tonic retraction of the recently delivered uterus is undoubted, and, since its use is productive of no possible harm, it is the usual cvistom, and the author believes should be the habit of all obstetricians, to ad- minister to the ijatient a teaspoonful of the fluid extract imme- diately after the birth of the placenta. This is to be recommended as a routine procedure, because the action of ergot is too slow to render it of value if its administration is delayed until after the occurrence of haemorrhage, unless it is given hyiDodermically ; a procedure -which it is wise to avoid, in view of the fact that the hyi^odermic use of ergot is not infrequently followed by subcu- taneous abscesses. If it is so used, it should always be injected deeply into the substance of the thigh, as this method decidedly diminishes the risk of subsequent sui^jDuration. The use of ergot by the mouth is occasionally followed by nausea, which is, how- ever, rare if no more than a draciam of the fluid extract is given in about two ounces of cool water. All these precautions should be redoubled whenever there is any special reason to fear post-par- tum haemorrhage. Arrest of Hemorrhage. — Emptying the Uterus. — If from neglect of prophylaxis or other cause, post-partum hsemorrhage occurs, the chief end of treatment is to secure retraction — an end which is, however, attainable by many different means, which are here given in the order of their convenience and efficiency : emptying the uterus, massage, ice, hot water, astringent solutions, electricity. The first essential in every case is the complete emptying of the uterus; that is, if htemorrhage occurs before the expulsion of the placenta, it should be immediately extracted — if possible by the use of Crede's method of expression ; but if this is not promptly successful, by the introduction of the hand. If the afterbirth has been already removed and an examination of the membranes shows them to be entire, the uterus may still have become dis- tended by clotted blood, which may usually be expressed after the manner of Cred(5, but, if not, must be removed manually. Massage of the Uterus. — The uterus being emi^ty, there are many methods of securing and maintaining retraction, but the one first to be described possesses the advantage of efficiency in almost every case and of requiring no apparatus other than the hands of the operator. It is known under the name of bimanual massage of the uterus, and is performed by the insertion of one 284 PRACTICAL MIDWIFERY. hand into the vagina and its passage in the extended position and with the i)ahnar surface directed forward, into the p(jsterior fornix of the vagina, wliile the other hand is applied to tlie fun- dus externahy and crowds the uterus down into the pelvis in order to permit the internal fingers to have the freei'st possible ac- cess to its posterior wall (Fig. 82). The uterus is tlien briskly, but not roughly rubbed between the two hands, which maintain throughout the process gentle pressure toward each other. This nianceuvre tends to control haimorrhage in two ways: first, by the direct pressure of the hands, which holds the walls of the uterus together, over at least a portion of the organ ; secondly, and of more importance, by a stimulation of the uterine muscle, which is partly due to direct irritation of the muscular fibres, but Fig. 82. — Bimanual Massage of the Uterus. is in all probability more directly produced by a mechanical irri- tation of the large sympathetic ganglia which are found along the posterior walls of the parturient uterus. When the uterus has become contracted, this condition may usually be maintained by holding a piece of ice against the ab- dominal wall, in the region over the fundus. In very slight hfem- orrhages, this expedient alone is often all the treatment that is required. Intra-uterine Applications. — If this manoeuvre is not promptly successful, it is usually best to pass rapidly to some other, since while some cases are favorably affected by this method of treat- ment, others yield more readily to different plans. Without withdrawing the internal hand from the vagina, it may again be passed rapidly into the uterus and immediately used, not only to empty the cavity of any clots Avhich may have accumulated within it, but to promote contraction by the presence within the organ of a moving foreign body. If even this is not efficient, a PATHOLOGY OF LABOR. :285 piece of ice may be placed within the cavity, when the muscular fibres usually show their resentment of its presence by a contrac- tion which expels it from the os; but this intra-uterine use of ice should not be too prolonged, on account of its evil effect in low- ering the temperature, and increasing the shock which is already present as a consequence of the loss of blood. For this reason, if the ice is not promptly expelled, it should be withdrawn by the hand, and followed by an intra-uterine in- jection of boiled water, or a 1 : 5,000 corrosive-sublimate solution, at a temperature of about 110-115' F., i.e., at that which is distinctly but not uncomfortably hot to the hand ; the injection being given under the usual precautions against the admission of air to the uterine cavity. The injection of hot water is not only valuable from its ordinary effect in causing contraction of the vessels, but more especially from the stimulation of the muscle which results from the sudden change from the temperature of ice to that of the injected fluid. During the intervals which necessarily occur in the substitu- tion of ice for hot water, or vice versa, bimanual friction should be carefiilly kept up. These measures, if promptly carried out, seldom fail ; but in such an event, the main resource at our dis- posal is the intra-uterine injection of an astringent solution, of which a 1 to 100 watery solution of the officinal acetic acid is de- cidedly the best, or if this is not at hand a mixture of ordinary corrosive-sublimate solution with sufficient vinegar to impart a distinctly brownish tinge to the fluid. Styptics. — If this method fails, and hsemorrhage continues until the patient is in imminent risk of an immediate and sevei-e collapse, the uterus should be again cleared of clots and a ball of absorbent cotton or piece of clean cloth, saturated with the tinc- ture of iodine, preferably Chui'chiirs. or with MonseFs solution diluted with four times its quantity of wcter, should be passed, into the uterine cavity; the advantage of iodine over the iron solution being its more stimulating character, and the lesser lia- bility of causing an extensive thrombosis formation and a con- sequently increased danger of septic infection. Faradism. — If a Faradic battery be at hand, its use, either by placing both electrodes on the abdominal wall, or by the passage of one within the uterus while the other is applied to the abdo- men, may pi'oduce efficient contractions. As an addition to these measures, time may often be gained by compression of the aorta against the lumbar vertebrte, by deep external pressure with the hand through the abdominal wall, the situation of the vessels to the left of the spinal column being borne in mind. The subcutaneous administration of brandy or sul- phuric ether, though contra-indicated during the continuance of" 286 PRACTICAL MIDWIFEKY. most forms of hiin their use is far more than counterbalanced by their effect in promoting contraction of the uterus by stimulation of its muscular tissues. After the cessation of hsimorrhage, the uterus should be care- fully watched by the hand for at least an hour, or until it has been firndy contracted without intermission for at least thirty minutes, both because the weakened state of the system renders a second relaxation by no means improbable, and because a loss of blood which under ordinary circujustances would be unimpor- tant may here be a matter of the utmost gravity ; and so soon as it is judged expedient to dispense with this manual control of the fundus a firm and carefully adjusted binder should be at once ap- plied. If the thickness of the abdominal wall is so great as to pre- vent satisfactory pressure of the binder upon the uterus, this may be obtained by inserting under the bandage a number of folded towels, which should be so adjusted as to completely surround the uterus; or, better yet, a rubber bag partly filled with water, which readily adjusts itself to the conformation of the subjacent tissues; and in the absence of this appliance, its place may be sup- plied by a bag of cloth loosely filled with moistened meal or sand. Treatment of Collapse from Haemorrhage.— If the haem- orrhage has been at all serious, the patient is left in a condition of collapse — that is, of cerebral anyemia — which may require con- stant and close care for many hours or days. In order to encourage the intra-cranial circulation, the foot of the bed should be raised by blocks, and in extreme cases the patient's legs should be held in position above the bed by means of pillows. She should be warmly covered, and the body heat should be carefully main- tained by a free supply of artificial warmth, wdiich is most con- veniently furnished by filling bottles with hot water, and placing them under the bedclothes in close proximity to the patient; but care should be taken that the bottles are tightly corked, and that they are sufficiently well wrapped with flannel to prevent burning of the skin. Free circulation of good' air throughout the room should be carefully provided for, the need of oxygen being urgent. Stim- ulants should be given freely; at first, by hypodermic injections, repeated three or four time^ in order to insure the administra- tion of perhaps two drachms, and later by the mouth or rectum. If the patient has not been anaesthetized, a half-drachm of ether under the skin often acts excellently, but this should not be re- peated more than once. The tincture of digitalis, and morphia by hypodermic injection, are also stimulants of great value in PATHOLOGY OF LABOR. 287 the treatment of collapse. In extreme cases an intra-venous injection of fifteen to thirty minims of the officinal solution of am- monia, diluted with an equal quantity of water, often causes Ijrompt reaction. Transfusion. — The process of transfusion of blood involves so many risks, and its technique is so extremely difficult that, though formerly recommended, it is now but seldom used ; a better pro- cedure being the intra-venous injection of a normal salt solution,, made by dissolving fifteen grains of bicarbonate of soda and a drachm and a half of common salt in a quart of water, at a tem- perature of 100' F. ; this should then be carefully filtered, and l^laced in a clean vessel. A superficial vein should be exi^osed, or, if the patient is so extremely anaemic that the veins cannot easily be found, the radial artery should be laid bare. The vein or artery should be nicked and the point of a fine canula passed within it, toAvard the heart in the case of the vein, or away from it if the artery is used. To the canula sliould be attached a rub- ber tube and funnel, and, the latter being held at an elevation of two or three feet above the vein, the whole quart of salt solution sliould be slowly poured into the system, a careful watch being kept on the pulse in the mean time; the object of the injection being to provide a sufficient quantity of fluid to enable the heart to work to advantage, until tlie tissues can replace the blood which has been lost. The process is not always successful, but has frequently been attended by most surprisingly favorable results. After-care. — The after-treatment of these cases should con- sist of absolute rest, deprivation of society, and the frequent ad- ministration of small quantities of food and stimulants, the best l^reparation being usually egg-nogg of the following projDortions ; two eggs should be broken into a cup, Avell mixed but not beaten up, and strained through a coarse colander; to this should be added enough milk to fill the tumbler, and to the mixture from half an ounce to an ounce of brandy. It should then be given to the patient, in quantities of not more than one-half ounce at a time, every few minutes. In the winter, if fresh oysters can be obtained, their adminis- tration to the patient, raw, may be an efficient and agreeable al- ternative for this diet. ]S^o limit can be placed on the ciuantity of nutriment which may properly be given to a collai^sed patient, the rule being that the largest amount that the i^atient can be induced to swallow will be the most beneficial. The author has known such a patient to absorb in twenty-four hours sixty eggs and three quarts of milk, and then make a sur- prisingly rapid recovery, the same diet in smaller quantities be- 288 PRACTICAL MIDWIFERY. inp: continued for many days; and has seen another case, one of hydatidiform mole, in which, after an extremely severe haemor- rhage, a small and delicate woman took, in addition to consider- able quantities of milk and egg, ninety-six dozen oysters in twelve days. This patient also made a good recovery. CHAPTEE XX. ACCIDENTS OF LABOR. Presentation and Prolapse of the Funis. Presentation of the funis is the descent of the cord in ad- vance of the presenting part and behind the intact membranes. Prolapse of the funis is its entrance into the vagina in advance of the jDresenting part, after the membranes have ruptured. The accident is favored by implantation of the placenta on the lower uterine segment, unusually long cords, the insertio velamentosa, abnormal presentations, hydramnion, multiple pregnancies, and contracted pelvis. The diagnosis of the condition is easy, since no other intra- uterine body resembles the cord, even though it be pulseless, and because no other pulsating body can appear at the os. The prognosis for the mother is not altered by the descent of the funis, but the prospects for the child are extremely bad; more than one-half being lost by compression of the cord and consequent asphyxia, of which thei*e is far more danger in head presentations than in any others. Presentations op the Funis. — Treatment. — If the cord when discovered is already pulseless, the foetal heart should be at once auscultated ; and if this is not heard, an attempt at re- placement of the cord should be made : if this fails, nothing more should be done, the case should be left to nature, and the family informed that the child is dead. If the heart be heard, the presenting part should be immediately raised by upward pressure until pulsation is felt to return in the cord, and carefully retained in its new i^osition until the regularity of the heart-beat is well established before any further treatment is undertaken. The subsequent management of the case must depend upon the degree of dilatation i^resent. In case the os is rigid and but slightly dilated, the patient should be placed in the knee-chest position, in the hope that the influence of gravity may induce suflHcient recession of the presenting part to allow of the replace- ment of the cord under the influence of its own weight. This, position should be maintained as long as the strength of the loa- tient i^ermits, and may be aided, if inefficient in itself, by gentle attempts at replacement of the cord with the fingers; but in suclii 19 290 PRACTICAL MIDWIFERY. circumstances the greatest care should be maintained to avoid rupturing tlie membranes. In case this attempt at rei)lacement fails, the immediate jDerformance of external or bipolar version is to be advised, unless the shape of the i^elvis or some other condi- tion of the case contra-indicates version. This manoeuvre almost invariably causes the return of the cord, and, moreover, in case of failure in this respect, leaves the child in a situation which is es- l^ecially favorable to rapid extraction should that be subsequently necessary. If the OS is well dilated when the accident is discovered, pos- tural treatment is to be recommended when the pulsations of the cord are undisturbed ; but if they have once been arrested, a larger number of children will iDrobably be saved by immediate version, which is here rendered permissible by the existence of dilatation. In the version the head should be made to move away from the side on which the cord has descended, in order to avoid a fresh compression during the operation. The cord usually disappears as the child turns ; but for the sake of safety, the patient should be placed upon the side, with the hips somewhat elevated by a pillow, as soon as the operation is completed, in order to favor retention of the cord, and should maintain that position until the membranes rupture or the breech engages. If version is contra-indicated, a conservative policy is to be ad- vised, in the hope that its pulsations may persist until the cervix has become sufficiently dilated to admit of immediate delivery. The patient should, however, be kept in the latero-prone position and carefully watched during the interval, and frequent if not constant vaginal examination should be maintained in order to detect injurious pressure upon the funis so soon as it occurs. This plan of delaj^ is, however, much less favorable to the child, since, if the membranes rupture while the cord is still presenting, it at once descends into the vagina, and in head presentations its circulation is often promi3tly stopped by the descent of the pre- enting part which usually follows a partial escape of the waters. Prolapse of the Fvnis. —Treatment. — When the cord has once prolapsed, even though its iDulsation be as yet unstoi)ped, no delay should be permitted. The only treatment which is then permissible is either immediate reposition of the cord, or version and rapid extraction; and the choice between these procedures must depend upon the circumstances of the individual case. If the pulsations are regular and strong, and if the os is so small that extraction would be impossible unless it were preceded by manual dilatation, an attempt at reposition should be made, since the time which must be spent in dilatation would seriously compromise the chance of obtaining a living child. The patient in such a case should be placed in the knee-chest PATHOLOGY OF LABOR. 291 r^ position, and the head should be made to recede from the supe- rior strait by pressure with the finders, which should then, if possible, return the cord through the os, and, if successful in this, should urge it entirely beyond the head into the sulcus around the neck. If this attempt succeeds, the patient should turn upon her side and every effort should be made to secure an im- mediate engagement of the head. The uterus should be excited to contraction by manual friction upon the fundus, and supra- pubic pressure should be exerted upon the head through the ab- dominal walls. In most cases, how- ever, digital reposition fails, and in such cases an attempt should be made to replace the prolapsed portion of the funis by instrumental means. Several forms of repositor have been devised especially for this pur- pose, but no one of them is superior to that which can be extemporized from an ordinary English- webbing cathe- ter, which, moreover, possesses the advantage of being always at hand. The catheter should be prepared for this use by softening it in warm water until the stilette can be made to emerge from the eye ; a loop of disin- fected string or narrow bobbin should then be passed between the point of the catheter and the stilette, and the latter should be withdrawn until its tip again enters the lumen of the in- strument, when the loop is pei*ma- nently attached to the eye or the bobbin may be threaded through the catheter as in Fig. 83. The lowest portion of the prolapsed cord should be made to en- gage in the loop, and should then be returned through the os to the uterus, and as far toward the fundus as the length of the catheter permits. The stilette should then be withdrawn, in order to release the catheter from its position within the loop, lest this should of itself arrest the circulation. After the replace- ment is effected, the head should be made to engage as rapidly and firmly as possible, and the catheter should be left in situ until it is expelled with the child, lest its withdrawal should be followed by a recurrence of the prolapse. After reposition by either method, the foetal heart should be carefully watched until it is found to become steady and regular ; Fig. 83.— Use of the Catheter AS A Funis Repositor. 292 PKACTICAL MIDWIFERY. but if the first attempt at instrumental reposition is not success- ful or is followed by prolapse of other portions of the cord, it is better to abandon the hope of success by this method and to proceed at once to dilatation and version, since prolonged efforts at reposition almost invariably result in the birth of a stillborn child. If, at the time the prolapse occurs, the os is almost wholly di- lated or dilatable, it is better to etherize the patient without delay ^nd deliver the child by version ; unless, indeed, the prolai^sed loop is extremely short, when an attempt at its reposition is admissible. When compression has once occui-red, reposition usually fails to save the child, and version is the better operation. When a prolapse of the funis is complicated by the presence of a contracted pelvis, the treatment adopted should be determined by the type of deformity present, since version in the uniformly contracted pelves offers at best but little chance for the child. In presentation of the breech and cord, the danger of compres- sion of the cord is more remote than when the head presents, owing to the smaller size and softer consistency of the pelvic ex- tremitj'. For this reason, if postural treatment fails, it is fairly safe to remain inactive until the os is sufficiently dilatated to per- mit a rapid extraction, provided that the pulsations of the pre- senting loop are carefully watched meantime. In breech presen- tations complicated by prolapse of the cord, immediate extraction is almost always necessary. In face presentations the danger of compression is also com- paratively small during the early stages of labor, but such cases should always be treated by version wlaen complicated by pro- lapse of the cord, since the small size of the presenting part renders it unlikely to occlude the os to a degree sufficient to prevent re- currence of the prolapse after reposition. In oblique and transverse presentations, the danger of com- pression is reduced to a minimum ; and since such cases must al- ways be treated by podalic version, the occurrence of a prolapsed cord does not alter the indications. Short Funis.— Decrease in the length of the cord may be actual, or relative and due to practical shortening from the coil- ing of a really long cord around the neck or other portions of the body. In minor degrees of shortening, the difficulty occurs only after the birth of the presenting part, and is usually easily rem- edied by division of the cord, or by slipping it over the head or shoulders, or, in breech presentations, over the buttock. In the extreme degrees, the diagnosis is seldom made until after the ex- traction of the child, which is usually delivered by operative measures undertaken for the relief of failure of its heart, or for delay from cause unknown. The condition may result in lacera- PATHOLOGY OF LABOR. 293 tion of the cord, separation of the placenta, or possibly in inver- sion of the uterus. The occurrence of the latter accident, though theoretically possible, has not been described, while the two former are by no means serious if they occur, as is usually the case, during the later stages of a rapid delivery. Sudden Death of the Mother During and After Labor. The nervous system of a parturient or puerperal woman is so much more unstable than under ordinary conditions that syn- cope unconnected with haemorrhage and due solely to sudden mental shocks, such as excessive fright or grief, is by no means unknown, and has occasionally proved fatal. It not infrequently occui's after the termination of labor, and is then probably due to a disturbance of the heart caused by the sudden decrease of in- tra-abdominal pressure ; but when so caused, it is rarely produc- tive of permanent harm. The extreme muscular exertion of labor may be the cause of a sudden failure of a fatty or otherwise enfeebled heart — a failure which may sometimes be so extreme as to produce a fatal result. Rupture of the cardiac muscle, or of the aorta or spleen, when already affected by degenerative changes, has also been known to occur during sthenic labor. The most common cause of sudden death at this period is, however, a cardiac or pulmonary embolism. This accident is probably always consecutive to pelvic thrombosis, and generally appears during the later portion of the puerperium and after the development of a milk-leg ; it has, however, been known to follow a thrombosis of the pelvic veins of so slight an extent as to have been unrecognized before the occurrence of the accident, and many then hapjDen early in the puerperium or during labor. Another well-established cause of sudden death is the entrance of air into the uterine sinuses during or immediately after labor. During labor it may be caused by the passage of a catheter be- tween the uterus and membranes. After labor it may be effected by the assumption of the knee-chest or latero-prone position im- mediately after delivery ; since the uterus may then be so flaccid as to be capable of expansion under the negative intra-abdominal pressure, caused by non-support of the distended abdominal walls. For this reason a recently delivered patient should never be allowed to turn upon her face or side unless the abdomen is carefully supported by a firm bandage or the hand of an attend- ant. Treatment. — When death occurs during the later months of pregnancy, or during the progress of labor, it is manifestly the duty of the obstetrician to make every attempt to save the life of 294 PRACTICAL MIDWIFERY. the foetus, that of the inother Ijeing ah-eady lost. If death is as- sured, no harm can be done to the mother, and, remember! iig that in calculating the duration of pregnancy a mistake of several weeks is not uncommon, and that children delivered at slightly less than seven months have undoubtedly been saved, it is right that the family should be urged to give the foetus the benefit of the doubt in any case in which pi'egnancy is supposed to have ad- vanced to six full calendar months. If the cause of death is such that its occurrence can be anti- cipated, a consultation should be called so soon as the mother's death is considered to be certain within a few moments, and the child should be delivered by rapid manual dilatation and ver- sion, or, if the foetal condition is such that the delay necessary for this operation seems likely to be fatal, by the performance of the Ctesarean section.' Such interference is, however, to be avoided in cases in which the recovery of the mother is in any way possi- ble ; since the dangers of abdominal section and the shock of a rapid delivery are almost necessarily fatal to her ; and the means of distinguishing a real from an apparent death are so imperfect as to make the position of the obstetrician one of the greatest delicacy, since the symptoms of death usually relied on for medi- , co-legal or other purposes all require a lapse of several hours after the central decease of the patient. The diagnosis of the reality of the death is seldom difficult when it occurs during jaregnaney as a result of an intercurrent fever or organic disease; but in cases of sudden collapse from heart failure or embolism during labor, it must depend mainly upon the absence of the heart-beat when examined by the stetho- scope, in conjunction with the existence of symptoms which show sufficient cause for its occurrence; ^.e., the sudden appearance of extreme dyspnoea, accompanied by loss of consciousness and an irregularly tumultuous action of the heart, when followed by a cessation of its action which persists during several minutes of close observation, ought to be considered as sufficient evidence of cardiac failure or pulmonary embolism, and actual death. Cardiac Disease. — If a normal heart is auscultated during strong labor, it is usually found that the increased arterial pres- sure, which is caused by the sudden arrest of the enormously de- veloped uterine circulation during the pains, produces murmurs with one or the other heart-sound, which cannot be distinguished from those which are the result of valvular lesions. In view of this fact, it would seem, a priori, that a heart which was the seat ' Rapid extraction through the natural passages is usually fatal to any child which has not reached the eighth month of utero-gestation, and the preservation of a seven months' foetus can hardly be hoped for by any lesser means than the Cassa- rean section. PATHOLOGY OF LABOR. 295 of serious valvular trouble could hardly be expected to preserve its activity under so severe a test. In point of fact, valvular le- sions cause extreme suffering from dyspnoea during labor, but in the majority of cases produce no worse result. Labor in the presence of cardiac diseases is apt' to be rapid, because the soft iDarts are usually resilient and lax. The woman should be permitted to retain the erect position until the mo- ment of expulsion is close at hand ; and in extreme cases, it may even be necessary to deliver her in a reclining position, with her shoulders propped up on pillows, and her buttocks projecting just beyond the edge of the bed. An assistant should stand on either side, and should prevent her from slipping on to the floor by each seizing a thigh in one hand and a foot in the other. Labor should be expedited by every means that is possible. Ether is contra-indicated in the presence of even the slightest Fig. 84. — Inversion of the Uterus. pulmonary complications, and in uncomplicated cardiac disease of extreme degree ; in less severe cases, its use is seldom danger- ous, provided it is skilfully given, and in the smallest possible quantity. Inversion of the Uterus. Inversion of the uterus has been described as a hernia of the body through the os, and the condition is very well characterized by Parvin in the exj^ression " The uterus is upside down and wrong side out." It may be complete or partial (Fig. 84). Causation and Prophylaxis.— Inversion may occasionally be due to irregular, reversed uterine peristalsis, or may occur as the result of the general intra-abdominal pressure when exerted against the fundus of a relaxed uterus, but is usually caused by traction upon the cord, or by efforts at expression of the placenta 296 PRACTICAL MIDWIFERY. when these are applied to the pai-tially or wholly relaxed uterus. Its occurrence is to be prevented by the avoidance of expression durinf^ relaxation of tlie uterus, and by an adoption of the rule never to luake traction upon the cord. Diagnosis. — The appearance of inversion is signalized by ex- cessive pain, severe collapse, and sometimes haiuiorrhage; the occurrence of the latter symptom being dependent upon the exist- ence of complete or partial separation of the placenta. Inspection and bimanual examination will, at once establish the diagnosis. Treatment.— The question of theadvisabihty of the removal of the placenta from its site before the reduction of the inversion, has been variously answered. It is proVjably best to complete the detachment if separation sufficient to cause haemorrhage has already taken place, but to return the uterus and placenta to- gether, if they are still thoroughly adherent ; since in the latter case any attempt at detachment of the secundines may cause a haemorrhage, which cannot be arrested until after the return of the uterus. Fig. 85.— Reduction of AN Inverted Utercs by Primary RETrRN of the Fundus. Fig. 86.— Lusk's Meth- od OF Reduction. Fig. 87.— Noeggerath's Method of Reduction. Replacement is to be effected by making pressure upon the fundus with a hand in the vagina, in opposition to the application of counter-pressure upon the cervix through the abdominal Avail. Three methods may be employed : (a) The fundus may be received into the palm of the liand and an effort made to reduce the her- nia by the return of the lower uterine segment first, and of the fundus later, {b) The hand may be formed into a cone and ap- plied to the centre of the prolapsed organ (Figs. 85 and 8G). (c) Or we may adopt the method described by Noeggerath, which consists in applying jiressure to the region in which one or the other Fal- lopian tube enters the uterus ; that is, in the primary reduction of one lateral half of the prolapse and the subsequent return of PATHOLOGY OF LABOR. 297 the other (Fig. 87). Counter-pi-es.sure on the cervix must be em- ployed in either case. But whichever method is employed, it is essential that after the reduction the hand should be retained in position within the uterus until firm contraction has been excited, since the accident once produced has a distinct tendency to re- cur. Rupture of the Uterus and of the Utero-vaginal At- tachments. Rupture of the body of the uterus may be produced during either natural or artificial delivery. Rupture of its vaginal at- tachments can only result from the use of undue force in the introduction of the hand for version or manual dilatation. The uterus may be torn in a vertical direction, either through the cervix and lower segment, or at any portion of the body; it may also separate along any horizontal line, and this may subse- quently extend at either end in a vertical direction; but the mechanism by which these two forms are produced is essentially different. Vertical lacerations of the lower uterine segment may take place by the extension of cervical tears during rapid extraction of the child by forceps or during manual extraction of the after- coming head. A. too forcible passage of the hand, or of some part of the fcetus, through a constriction ring may also result in the production of a vertical laceration. Other lacerations of the body -are usually due to neglected retraction rings ; and their occurrence is in effect the necessary and ultimate result of excessive thin- ning of the lower uterine segment by retraction of the uterus when xincompensated by descent of the child. The prevention of these ruptures is to be effected by the aj^- plication of operative interference before marked exhaustion of the uterus has occurred, and by the avoidance of force, and the use of counter-pressure, during the elevation of the head in ver- sion. Rupture of the uterus may or may not be attended by a con- siderable loss of blood, but is always accompanied by an extreme collapse. ■ Its dangers are, primarily, immediate death from hfem- orrhage or from simple collapse ; and, secondly, a strong proba- bility of the occurrence of a general peritonitis at the end of from twenty-four to forty-eight hours. A large proportion of the pa- tients are lost. Treatment. — The haemorrhage may usually be lessened or controlled by securing firm contraction of the uterus. If it is profuse, the patient is usually lost before any other treatment can be applied ; but if it is moderate but continuous, it may sometimes l)e arrested and the life of the patient saved by an immediate lap- 298 PRACTICAL MIDWIFERY. ariitomy and suture of the uterus. In the uljsence of hajinorrhujje the treatment must depend upon the situation of the rent and the degree of antisepsis which has been previously observed. If the antisepsis has been careful, and if the rent is low and situated upon the posterior wall so as to favor efficient drainage of the abdomen, a large proportion of ca.ses may be expected to recover under conservative treatment. This should consist of a careful cleansing and disinfection of the parturient canal; the application of an occlusion dressing; the insertion of a drainage tube, if this is thought to be expedient; and the continued use of saline cathartics to a degree sufficient to produce as large a number of watery dejections as the strength of the patient permits, as a jjrecaution against the peritonitis which, in greater or less degree, is almost certain to follow the accident. If there is any doubt as to the thoroughness of the antisepsis observed during labor, or if the situation of the rent be such that thorough drainage cannot be expected, a laparatomy should be done, the abdominal cavity should be thoroughly Avashed out "with some gallons of boiled water, the edges of the uterine wound pai'ed, and sutured by the method of Sanger. The escape of the child or placenta into the abdominal cavity is a fact unfavorable to success by conservative methods; but that this factor is of less importance than the observance of antisejisis and the situa- tion of the rent, is shown by a ca.se reported by Dr. C. M. Green,' in which the placenta, the attached membranes, and a large amount of blood clot were removed from the upper portion of the abdomen in close proximity to the liver, and in which the patient made a rapid and complete recovery without laparatomy. Vesico-vagixal Fistulje. These lesions usually appear during the puerperium as the result of sloughing caused by tlie continued pressure of the head during an unduly prolonged second stage ; and the rei)air is then a matter of gynaecology rather than of obstetrics. When they are produced by laceration of the tissues during operative delivery, they are usually complicated by rupture of the pubic synostosis; in which event the danger of suppuration makes the existence of every opportunity for drainage so important that it is far better to restrict the immediate treatment to the application of a firm bandage around the pelvis in preference to an operative closure of the rent ; and this the more especially since spontaneous union is by no means unknown. In the very rare cases in which lacera- tion of the vesico-vaginal septum occurs during labor, Avithout rupture of the symphysis, the rent should be repaired immedi- » Transactions of the American Gynapcological Society, vol. xiii., 1888, page 209. PATHOLOGY OF LABOR. 299 ately by interrupted sutux'es; but this must be done with the utmost nicety, and witli all the precautions which are necessary to the secondary operation. Lacerations of the Cervix. The immediate repair of cervical lacerations has been recom- mended by some authorities, and it may be well to bring together the angles of the wound when tlie laceration is so extensive as to reacli the cervico-vaginal junction ; but even then free drainage from the uterus is so important a factor in normal convalescence that complete repair is usually inadvisable; and in lacerations of less extent, it is so difficult to distinguish severe from slight tears during the relaxation of the cervix and lower segment which is usual after delivery, that conservatism seems the better policy. Lacerations op the Perin^eum. Perineal lacerations are usually divided in accordance with, their extent into three classes : lacerations of the first degree, or nicks, in which the four- chette alone is torn, without involvement of the muscles which unite in the perineal body and form the so-called pelvic diaphragm ; lacer- ations of the second degree, or uncomplicated ruptures of the perineeum, including all tears which involve the fibres of the pelvic dia- phragm but do not destroy the recto-vaginal septum; and lacerations of the third degree, those which invade the integrity of the sphinc- ter ani, and divide the recto-vaginal septum to a greater or less extent. Diagnosis.— Classification and Anat- omy.^— At the conclusion of labor, the finger should ahvays be passed into the rectum and made to evert the Fig. Fig. 88 b. Fig. 88.— a. Laceration op the First Degree ; b, Diagramatic Antero- posterior Median Section of the Same. posterior vaginal wall through the vulvar outlet, in order to insure the detection of any laceration which may have taken phiL-e. This examination is rendered necessary by the fact that a large 300 PRACTICAL MIDWIFERY. imiuber of the most important tears are entirely intra-vaginal, and are not likely to be recojjfnized by simple inspection of the external i)arts. The bruised and conjj:ested appearance of the tis- sues innnediately after labor occasionally makes it diflRcult to decide upon the existence or non-existence of a laceration, but the presence of a tear should usually be recognized by a careful search in a good light. If doubt be felt, the suspected surface Fir. 89.— Diagrammatic Antero-Posterior Median Section Through a Lacera- tion OP THE Second Degree. should be lightly dried with a pledget of cotton, when if a tear be present it will be recognized by its rough, irregular surface. Lacerations of the first degree usually take the form of longi- tudinal divisions of the fourchette in the antero-posterior median plane of the body (Fig. 88). The more usual forms of laceration of the second degree are : a tranverse tear immediately within the orifice of the vagina proper ; Fig. 90.— Diagrammatic Section Showing the Retraction of a Laceration of THE Second Degree. and a combination of such a tear with longitudinal, lateral lacer- ations of the lateral walls, extending upward on one or both sides of thevagina.' The transverse lacerations probably occur during the outward and forward extension of the perinjeum as it stretches over the advancing head, and are, in effect, a rupture of the fibrous attachments between the superficial structures and the levator ani. Tlie lower shelf (Fig. 89) contains the superficial fascia and the- Intrinsic muscles of the perinseum ; while the upper and remaining portion of The lacerated body is made up of the median attachments of the levator ani and other muscles, which 'See "The Relations between the Anatomy of the Lacerated Perinsexim and the Mechanics of its Causation.'" Trans. Amer. Gynecol. Soc., vol. 26. 1891. PATHOLOGY OF LABOR. 301 form the pelvic diaphragm. After one of these lacerations has occurred, the habitual contraction of tlie muscles causes a re- traction of the upper portion of the perin^eal body to the position shown by the heavy line in Fig. 90, and results in the production of an irregular raw surface, which might easily be mistaken for a longitudinal tear, but which retui-ns to its true form if its upper edge is seized in the median line, and drawn forward and down- ward. The simple transverse laceration is rarely seen alone, but is complicated in the majority of cases by the extension of one or both of its outer extremities upward along the vaginal walls; these lateral tears being caused by a splitting apart of the pos- Fig. 91 B. Fig. 92.— Diagram of a Tear op the Second Degree after Retractiox. The dotted lines represent the situation of the tissues before retraction. Fig. 91 A. Fig. 90. — A, Typical Laceration of the Second Degree ; B, Diagrammatic Representation of the Same; b, c, the transverse tear; 6, e, and c, e, the later- al prolongations; a, b, the median tear of the lower shelf; the points b' and c' are lost by retraction. terior and lateral portions of the levator ani in the direction of their length (Fig. 91). This form of tear is frequently combined with a median laceration of the lower shelf; in which case the retraction of the separated corners of the fourchette by the con. tractile force of the transversus periniei and constrictor cunni muscles results in the production of an apparently crescentic tear such as is diagrammatically represented by Fig. 93. A complete laceration is practically a complication of the last form by a tear of the remaining portion of the recto- vaginal sep- tum in the medium line through the sphincter ani. The appear- ance of the result is shown by Fig. 93. oiJ-Z PRACTICAL MIDWIFEKV. Trkatmkxt. — Ak a general rule, all lacrerations should be re- paired by sutures as soon after the completion of labor as is convenient. Lacerations of the first degrt^e should Ije so repaired, in order to lessen the area of denuded surface and so diminish the chance of septic absorption, even if the loss of supjjort which may be caused by them is so trifling as to be unimportant. Those of the second degree should be sutured, not only for the same rea- son, but because their non-union entails in most cases subinvo- lution of the vagina, loss of support, and the whole train of symp- toms which are so familiar to the gyniecologist as the result of rupture of the perinaum. Complete laceration must be repaired, not only for reasons of antisepsis and to prevent loss of support ; but also on account of the disgusting condition of incontinence, which is the only possible result of their neglect. Fig. 93. — Complete Laceration of the PERIN.EUM (IN THE ThIRO DeGREE). Fig. 94. — SrruRE of a Laceration OF THE First DEGUEn. The lesser degrees of laceration can usually be satisfactorily repaired without the use of antesthesia if the operation is done immediately after the completion of labor, when the distention and bruising of the tissues which is always incident to delivery renders them comparatively insensitive. Patients in fair condition may usually be anaesthetized with- out special risk for the operation of repair of the perin;eum: but if the condition of the patient is such that the prostration and risk of hsemorrhage, always incident to the administration of ether immediately after labor, render its administration inexpe- dient; or if the tissues are so far bruised or injured that it is thought best to allow them to recover their tone before attempt- ing to bring them together, the operation may be done with equal success, under full surgical anaisthesia, at the expiration of PATHOLOGY OF LABOR. 303 from twelve to twenty-four hours, though some slight freshening of the surface with the curette is usually expedient then. Methodn of litpair. — Tears of the First Degree. — Mere nicks are best treated by the simple suture shown in Fig. 94, in which a lai'ge curved needle is made to enter the external skin about a quarter of an inch from the edge of the wound, and is passed through the tissues above the apex of the tear without appearing in the torn surface, to reappeai- at a corresponding point on the other side. The sutures should be about one-third of an inch apart, and more than two are never necessary. Tears of the 8eco)ul Degree. — The patient should be placed on her back, lying across the bed, and with her knees held by as- sistants. The vagina should be thoroughly syringed out with a corrosive-sublimate or creolin solution, and a large wad of ab- sorbent material, wet with the same solution, should be placed in its upper portion to prevent the trickling of blood over the surface which is to be repaired, and thus afford to the physician a clearer view of the field of operation. The ragged and bruised edges of the wound should be carefully trimmed with scissors, and the surface thoroughly sponged and cleaned of all clots before the insertion of the sutures. The material used for sutures may be silver wire, silkworm gut, catgut, or silk, the choice being a matter of -personal convenience rather than essential, and a me- dium size should be selected. Small tears may be repaired by a large, full-curved needle, and most tears can be repaired, if necessary, by this means or by the use of a large, full-curved Peaslee needle ; but the accurate adjust- ment of extensive lacerations requires the Avhole paraphernalia of the gynaecologist — a variety of needles, large and small, straight and curved, a good needle-holder, retractors, tenaculum, wire- twisters, etc. If the patient is already anaesthetized, or if the administration of ether is not objected to, if a trained assistant is at hand, good light is attainable, and the physician is familiar with the op- eration, these tears are perhans best repaired by one of the method recommended for the secondary operation. The vagina should be held open by lateral retractors, and the divided tissues should be drawn into place by tenacula, in order to enable the operator to observe exactly the position in which they should be brought together. The needle should then be introduced just outside the lower portion of the external tear and close to the median line, and passed up through the recto-vaginal septum, to emerge close to the upper border of the transverse tear at the same distance fro)n the median line, its course being watched by the forefinger of the other hand, which is passed into the rectum for this purpose. The needle should be wholly withdrawn, re- oO-i PKACTICAL MIDWIFERY. entered as nearly as possible at the point of emergence, carried through the tissues ahjng a line parallel to the upper edge of the tear, and brought out through the external skin on the opposite side of the laceration. Similar sutures should be in- serted alongside of the first, and the lateral wings of the tear should be repaired by parallel though shorter sutures, inserted at intervals of about one-third of an inch (Fig. 94). The wound should be carefully cleansed and the sutures tied or twisted, be- ginning with the outer sutures and working inward. After the completion of the operation, the twisted sutures will lie in the shape of a V upon the posterior vaginal wall, and will be entirely within the vulva unless the external shelf of the perineum has also been lacerated, when a few superficial sutures must often be inserted through the skin of the perinjeum (Fig. 96). The opera- tion is most easily performed with long, straight, spear-pointed needles, and requires the use of a needle-holder. Fig. 95. — Suture of a Laceration of Fig. 96.— Insertion of the External THE Second Degree. Sutures in a Laceration of the Third Degree. If circumstances render this operation inconvenient or impos- sible, almost equally good results may be obtained by a more ready method ; and this operation, if done immediately after the conclusion of labor, can usually be performed vrithout anaesthesia, from the greater rapidity with which the sutures can be intro- duced. A large, fully curved needle should be made to enter through the external skin a little in advance of the anus, and three-quarters of an inch from the median line; should be carried with a wide sweep entirely outside the tear, into the ujiper por- tion of the perinaeal body, and made to emerge in a corresponding situation upon the other side. A second suture should be intro- duced at a point about a third of an inch anterior to the flnst, and at an equal distance from the median line, and should be swept upward in the same manner, and to the same height in the recto- vaginal septum ; the whole course of each suture being Avatclied by the rectal finger; a third, a fourth, and, if necessary, a fifth PATHOLOGY OF LABOR. 305 suture should be inserted in the same manner. The sutures should be buried throughout their course, i.e., should not be seen in the wound ; and if the lateral tears are so high or deep that portions of the sutures do appear in the wound, the extensions mxist be repaired by a second set of sutures placed within the va- gina. When all the sutures are in position, those which are ap- plied to the lateral extensions should be brought together first, Fig. 97 6. Fig. 97.— Rapid BIethod of Repair- Fig. 98.— Insertion of the Rectal ING A Laceration of the Second De- Sutures in a Laceration op the Third gree. a, Section showing the position Degree. of the sutures; 6, view after the sutures are tied. from above downward, after which the external sutures should be tied from behind forward over a roll of gauze, care being taken to see that the wound is wholly free of clots when brought to- gether (Fig. 97). Lacerations of the Third Degree. — The condition of the patient in whom the surface of a complete laceration has been allowed to heal over is so unfortunate that an attempt at its. repair should invariably be made. In exceptional cases, in which the condition of the patient does not permit any unnecessary loss of time, a successful result may occasionally be obtained by the 20 306 PRACTICAL illDWIFEKY. method just described for lacerations of the second degree; but the consecjuences of a failure are here so important that it is al- ways better to repair such lacerations by the more exact niethoearance of headache, malaise, and a slight elevation of the 308 PKACTICAL illDWlFEKY. temperature. An oil enema sliouUl then be administered and followed by compound rhubarl) pills or by some of the other cathartics elsewhere recommended, in small and repeated doses.' The necessity for the use of cathartics commonly appears on the fourth or fifth day, and the diet should be restricted to gruels, broths, and eggs until a suitable evacuation has been obtained, after which a gradual change to the usual diet should be per- mitted. If silkworm-gut, silk, or wire sutures have been tied exter- nally, they should be inspected on the sixth and on each subse- quent day, and should be removed one by one as they are seen to loosen. If silk sutures have been used and tied within the vagina, they should be removed upon the eighth or ninth day; wire or silkworm-gut may remain a few days longer ; catgut in any situation requires no attention. The patient should remain in bed for at least two weeks, and after extensive lacerations for twenty or thirty days; since the strain imposed upon the tissues by the erect position and by ac- tive movements at an earlier period may result in the loss of an apparently good union. Rupture of Blood-vessels, and Emphysema. The straining of excessive labor may occasionally produce a rupture of a subcutaneous vein, or lacerations of the superficial alveolie at the apex of the lungs. Rupture of a vein produces a subcutaneous ecchymosis; which, even though extensive, needs no treatment, and resolves spontaneously within the space of a few days. Rupture at the apex of the lungs results in an emphysema of the subcutaneous connective tissue, which spreads rapidly and may produce an enormous swelling of the neck and chest; the tumor crepitates on pressure, and is tympanitic on per- cussion. The accident has no results, except the alarm which it always occasions the patient ; no treatment is indicated, as the tumor always disappears spontaneously. 1 See page 331. CHAPTER XXI. MULTIPLE PREGNANCIES. ABNORMALITIES AND MAL- FORMATIONS OF THE FCETUS. ACCIDENTS TO THE FCETUS. Multiple Pregnancies. The only form of multiple pregnancy which is sufficiently fre- quent to be possessed of practical importance is twins, which occur upon an average once in every two hundred confinements ; triplets are seen once in five thousand ; and the higher numbers with extreme infrequency. The occurrence of twin pregnancy may be due to either of two causes. In the one form, two ova are fertilized by the same coi- tus, or by two connections which occur within a short time of each other; in the other the double foetation is due to the for- mation of a double yolk, or to the complete division of a single yolk, within one ovum. In the first variety the placenta and membranes are originally separate, and if fused during subse- quent gro^-th have no vascular connections; in the second the two children are contained within a single amniotic cavity, and are nourished by a single placenta, the cords being usually sepa- rate. Twins contained in separate amniotic cavities, i.e., those which spring from separate ova, may be of the same or different sexes ; but those which originate from a single ovum are invari- ably of the same sex. Twin pregnancies are usually attended by an excessive devel- opment of the symptoms of distention, and are not infrequently terminated by a spontaneous, premature labor, due to the same causes. Presextatiox. — While a double vertex presentation is the most common, presentations of one vertex and one breech are not infrequent, and all varieties of malpresentations are far more common than in single pregnancy ; malpresentations of the sec- ond child being especially frequent on account of the greater mobility which it enjoj's after the birth of the first. The children are usually small, and not infrequently feeble. CoxDUCT OF Labor. — The first stage of labor is apt to be tedious on account of weakness of the uterine fibre, due to its dis- 310 PRACTICAL MIDWIFERY. tention. In vertex presentations, the descent of the first ehiltl is apt to be nqjid on acconnt of itssmall size; but the first birtli is usually followed by an interval of varyiu}^ length, during which contractions are absent, and the uterine fibre is l)usietl chiefiy in retraction. The birth of the first «liild may be followed by the exijulsion of its placenta, but not infrequently neither placenta is detachQd until after the birth of both children. At the end of from twenty minutes to one or more hours, the second child is ordinarily expelled if the presentation is natural, but its birth may occasionally be delayed for a much longer time by uterine inertia. The distention of the uterus, which is usual in twin preg- nancy, always exposes the patient to a greatly increased liability to post-partum htemorrliage, from the resulting atony of the uterine fibre. If the birth of the first twin is followed by expulsion of its pla- centa, if uterine action fails to appear and the os recontracts, and it appears to be probable that the second child may be retrained in utero for some days or weeks, no active treatment should be adopted ; since numerous cases have been recorded in which the second twin has been carried for some weeks after the expulsion of the first, to be subsequently born with a much improved chance of survival. If, however, the first placenta is not expelled, it is unwise to permit this recontraction, since a prolonged re- tention of the placenta would almost certainly result in the jDro- duction of sepsis, or of haemorrhage, during the interval ; and because, if the child is to be extracted by the efforts of art, it is far better, in the interests of both patients, that this should be done while good dilatation still obtains. The best rule of prac- tice is therefore that, if at the end of an hour the first placenta is undelivered and the uterus shows no signs of resuming its efforts, the child should be extracted by forceps if the head pre- sents, and otherwise by version, either ojaeration being usually extremely easy by reason of the small size of the passenger and the previous dilatation of the passage. Locked Heads. — It usually happens in twin pregnancy that the presenting part of one child enters the pelvis in advance of the other, and if uterine inertia makes it necessary to promote engagement by rupture of the membranes, one of the presenting parts should be pressed into the brim before the rupture is ef- fected ; but if the children are small, it may sometimes happen that the head of the second child enters the pelvis alongside the neck and shoulders of the first. This accident may happen in either of two ways. In double- vertex presentation both heads may engage in the pelvis at the same time, or with one but slightly in advance of the other (Fig. PATHOLOGY OF I>AP.OR. 311 99). In presentations of the breech and head, if the breech is jiennitted to enter first, the liead of the second child may occa- sionally engage in the i)elvis,in advance of the aftex'-condng head of the first, in such a manner that each head is opposite to the ne(dv of the other child (Fig. 100). Neither variety can occur unless both children are small, but either is sure to produce considerable difficulty in si^ite of this fact. In double-head presentations the prognosis is especially bad for the first child, on account of the probability of an interruption of its cerebral circulation, by the pressure of the second child against the vessels of its neck. The treatment of the first variety consists in pushing back one head if possible, and, if this attempt fail, in the application of for- ceps to the first head, and later, if necessary, to the second ; and Fig. 99. — First Variety of Locked Heads in Twins. Fig. 100.— Second Variety op Locked Heads in Twins. this should be followed by decapitation or perforation of the first head, or by perforation of the second in the not improbable event of its failure. The diagnosis of the second form of locked heads is rarely made until after the birth of the first body, when the arrest of the head leads to the passage of the hand into the vagina, and the presence of the second head is recognized. In this variety the first child is almost never saved, and the second very rarely. "With very small children both heads may be ex- pelled by the efforts of nature, the head of the second child being born first, but in almost all cases it is necessary to apply forceps, first to the head of the second child, and then to that of the first. Should forceps fail, perforation of the after-coming head of the first child should be attempted, but is always extremely difficult and sometimes impossible. Its decapitation may sometimes make it possible to push back its head. The head of the second child 312 PRACTICAL MIDWIFERY. should be spared, if this is in any way jjossible, on account of its better chances of hfe. In twin labors, the possibility that the first child may be transverse, and the jjresentation conii>licated by a prolajise of the legs of the second, must never be forgotten. ABNORMAIilTIES OF THE FCETUS. Monstrosities. — That strong mental impressions received by the mother during the course of pregnancy may influence the form of the unborn child has always been a matter of popular belief, but it has been received with the greatest scepticism by the profession. The evidence in support of this view has been, however, gradually increased, by the accumulation of a larger and larger number of authenticated cases, until the probability of its occasional occurrence appears so great that it is certainly wise to use every efifort to prevent women of child-bearing age from the sight of horrible and disgusting malformations and ac- cidents, and especially those who are jjregnant. Among the many congenital malformations which are occasionally seen, those which obstruct labor, and those which result in the production of chil- dren who are so imperfectly developed or so far deformed as to be either incapable of sujjporting life or unfitted for the perform- ance of its usual duties, are alone of obstetrical interest ; all others belonging rather to the domain of orthopedic surgery. The common imperfections which necessarily affect life are an- encephalia, and imperforate anus or rectum. Those which ob- struct labor are meningocele, encephalocele, spina bifida, hydro- cephalus, and the double monstrosities due to an incomplete division of the germinative vesicle. ANEXCEPHAiiiA. — The deformity known as anencephalia con- sists of an absence of the cranial vault and of the greater jDortion, or whole, of the brain; the sella turcica and base of the skull being exposd to view, and covered only by the membranes. The birth of an aneneephalic fcetus is by no means rare; they are usually accompanied by hydramnios; and transverse or breech presentations are not infrequent, though that of the face is rather the most common. If the presentation is transverse or pelvic, the diagnosis is rarely made until after the extraction of the child ; though some such deformity may be suspected from the presence of hydramnios and of other minor abnormalities of the child, such as club feet or hands. If the face presents, the absence of the cranium is usually perceived during the course of the second stage. The body of such a foetus is often large and well devel- oped, and, if the presentation was cephalic, its size not infre- quently occasions considerable difficulty in its extraction — a diffi- PATHOLOGY OF LABOR. 313 culty which is due, in i>art at least, to the lack of preparation of the maternal soft jjarts by the passaj^e of a full-sized head. Such children are occasionally born alive, but, as their continued exist- ence is absolutely iniijossible, no effort should be used to preserve or prolong their lives, and it is distinctly a more fortunate result if they die during the process of birth. Imperforate Anus or Rectum. — In the absence of the anus, the diagnosis is made at sight ; but in the more common varieties of the deformity, in w^hich the anus is normal, and the imperfec- tion of the canal is within the orifice, the diagnosis is seldom made until the failure of the child to pass faeces and the conse- quent distention of its abdomen suggest a rectal examination. The imperfection is not uncommon, and the possibility of such an abnormality should always be borne in mind, and should lead to the passage of the little finger into the rectum of any child Avhich fails to pass meconium within a few hours of birth ; since the only possibility of prolonging its life is by a prompt resort to operative measures. Treatment. — Conservative treatment is of course hopeless; the operative measures in vogue are the passage of a trocar through the obstruction, in the hope of reaching the sigmoid flexure without crossing the peritoneal cavity ; dissection ujjward from the perinaeum in search of the upper portion of the bowel ; and the construction of an artificial anus in the groin or lumbar region; but the discussion of the choice of operation belongs rather to works on surgery than to text-books on obstetrics. Prognosis. — The immediate prognosis is extremely unfavorable ; and even if the operation be recovered from, the subsequent con- dition of the child is so extremely unfortunate that its survival is often to be regretted ; but since permanent successes have been occasionally reported, it should always be undertaken.' Meningocele. — Meningoceles are cystic tumors, outside the cranium and beneath the scalp, communicating with the intra- cranial space, and filled with serous fluid, which may, however, become separated from the cavity of the cranium during the later months of pregnancy. When such tumors are sufficient to cause obstruction to labor, their fluid contents should be removed by aspiration with a small trocar or large aspirating needle. Encephalocele. — Encephalocele differs from meningocele, only in the fact that the sac contains a portion of brain tissue, I A very remarkable case of imperforate rectum in a seven-months' child, re- ported by Dr. Georg'e G. Hayward (Boston Medical and Surgical Journal, vol. vi., No. 20, pp. 407 and 475) suggests the possibiHtj' that the division of a thin partition across the lower portion of the rectum may be followed by a resumption of tlie natural processes of development, the arrest of which is the cause of the deformity; and this opinion, if correct, would make the operation distinctly advisable whenever a premature child is found to be so afflicted. 314 PRACTICAL MIDWIFERY. which is spread out over the contained tluid. The prognosis of encephalocele is always bad, and that of meningo<'ele is only better from the fact that if the coiuumnication with the intra- cranial cavity is very small, it may occasionally become oblit- erated and permit of a recovery. Spina Bifida. — The condition known as spina bifida consists of an aVjsetice of the i)Osterior arches of one or more contif^uous vertebrae, and a protrusion through the space thus formed of a cystic tumor whose serous contents are directly cf)ntinuous with the cerebro-spinal fluid. The tuuior is usually small; when it is sufficient to obstruct labor, it should be emptied by puncture, which may be undertaken without the least hesitation, from the fact that such children seldom live. HYDROCEPHA.LUS. — Hydrocei)halus may be either congenital or acquired, but only the first form concerns us here. It is the result of the presence of an abnormal quantity of the intra-cere- bral fluid, and results in the production of an alinormally large and an unduly flexible head. The fluid is usually contained within the dilated ventricles, and is covered by a thin layer of ex- panded brain substance. Bi-eech presentations are extremely frequent, but the children seldom survive. Labor is natural in about 2~ifo of all cases, a re- sult which is due to the facts that the bones are usually but slightly ossified, and that the sutures and fontanelle are so wide as to permit a ready adaptation of the head to the shape of the passage through which it must be forced. Diagnosis. — In breech presentations the diagnosis is rarely reached until the after-coming head is arrested at the superior strait, when its size and consistency should at once suggest the cause of delay. In head presentations it is usually easy, and is to be determined by perceiving that the curvature of the present- ing xiart is abnormally slight, that the sutures and fontanelles are wide and soft, and that the head is abnormally large Avhen exam- ined by bimanual palliation; in extreme cases fluctuation may sometimes be detected. Treatment. — Treatment should consist of perforation; or puncture and the withdrawal of the contained fluid, l)y a trocar or aspirating needle. The forceps should never be applied to the hydrocephalic head, since they almost invariably slip. In well- marked cases the children never live, and craniotomy may be freely resorted to ; unless the religious feelings of the parents, or some medico-legal relation, such as the inheritance of i)roperty, make it desirable that the child should be born alive, even if it die at once. Composite Moxsters. — Composite monsters occur from a partial division of the germinative area of an impregnated ovum. PATHOLOGY OF LABOR. 315 which if carried to completion would have resulted in the pro- duction of twins, and may consist of a more or less complete fusion of the heads with separate bodies or of united bodies with sepa- rate heads. Fusion of the heads is comparatively rare. When it exists, if the head presents and becomes arrested, the progress of the case differs but little from that of an abnormally large single head; but if the deformity can be proved, perforation should be resorted to in preference to any prolonged efforts at delivery by forceps, since the continued life of such a monster is hardly possible. In any other presentation a foot should be seized, and the body drawn down, until the head is within the reach of the forceps ; this should be delivered by forceps, or by perforation if neces- sary, and followed by the other body. The more common form of fusion of the bodies varies in de- gree from those monsters, on the one hand, which possess eight limbs and two heads attached to a single trunk, to the union of separate children by a flexible band such as existed in the case of the famous Siamese twins. As a general rule, the more com- plete the fusion, the less the chance for the ultimate survival of the children ; but since such monsters not infrequently live, their lives must be respected, though if death be inevitable it is proba- bly seldom regretted. The birth of such a monstrosity is of course only possible when it is of small size. The labors have been natural in about 50;^ of the reported cases — a result which is, however, largely due to the fact of the great frequency of pre- mature labor. If the heads present, the usual mechanism of delivery is the expulsion of one head, while the other is delayed above the brim; delivery of the bodies more or less simultaneously, by a process closely analogous to spontaneous evolution ; and, finally, delivery of the second head. In such presentations the deformity is sel- dom if ever diagnosticated until after delivery of the first head, when the mechanism just described should be imitated by the obstetrician; but if the diagnosis is established before the en- gagement of the head, the children should be turned, breech de- liveries being much the most favorable for the children ; all four feet should be seized, the bodies should be extracted simultane- ously, and, after the release of the arms, should be swept upward over the abdomen of the mother, when the posterior head com- monly enters the pelvis in advance of its fellow, is deUvered first, and is followed by the other. Other Abnormalities of the Fcetus.— An abnormal in- crease of the size of the fcetus may be due to its syunnetrieal en- largement ; to the existence of an abnormally large or over-firmly 316 PRACTICAL MIDWIFERY. ossified head, on a body of moderate size ; or to enlargement of tilt' l)ody, witli a normal head. iSyniiiutrivdl Enlurytnient. — Symmetrical incre;ise of the ff«tus may result, accordinjjj to its dejifree and the size of the indivitlual pelvis, in the necessity for forceps or version, or, in rare cases, for craniotomy. Excessive ossification not infrequently causes a dif- ficulty in the delivery of the head, which is due to the inability of the cranial bones to yield to the moulding processes of labor, and which may result in an obstinate arrest of a comparatively small head. If, at the time when the arrest occurs, the head is already in the excavation, the forceps should be applied, and this the more readily from the fact that such children are usually able to endure extremely powerful tractions with ease, since the brain and cerebral circulation are to a great extent protected from pressure by the non-yielding character of their envelop- ment; but if the head is arrested in or above the superior strait, version is usually the preferable operation, since it is practically certain that a greater or less amount of moulding is a necessary preliminary to the passage of the head, and because this is far more likely to be obtained during the-passage of the after-coming head, for reasons which have been already explained.' Mvcesslve Size of the Body. — Excessive size of the body is not an infrequent occurrence. Delay of the body after the birth of the head justifies the use of a very considerable degree of force in the practice of the ordinary methods of extraction, for the double reason that the soft body of the child is unlikely to cause a serious lesion to the more important soft parts of the mother, and that the risk of injury to the child is less important than the certainty of its asphyxiation if not i^romptly delivered. When the size of the foetaj body is so extreme as to cause arrest of the shoulders at the superior strait while the head is in the ex- cavation, it usually results in the loss of the child by craniotomy, or during prolonged efforts at extraction liv forceps ; it may some- times require the application of the cranioclast or cephalotribe to the thorax and shouldei-s, or, in extreme cases, amputation of the arms and shoulders by means of the 6craseur or decapitating hook or knife. Tumors of the Trunk. — Ascites, anasarca, hydro-thorax, and post-mortem emphysema, or an enlargement of the abdomen due to an imperforate condition of the bladder or ureters, may result in arrest of the l)ody, but the diagnosis is usually made only after the introduction of the hand, and the treatment should always be limited to perforation, since the life of such a child is hopeless. The opening may be made by the use of the scissors, knife, or trocar, according to the accessibility of the obstruction. 1 See page 254. PATHOLOGY OF LABOR. 317 ACCIDKNTS TO THB FCBTUS. Asphyxia Neonatorum. — Asphyxia neonatorum is caused by a deficient oxygenation of the blood, due to compression of the cord during the course of labor, and may be complicated by a depressed condition of the respiratory centres, due to antemia, from compression of the brain. It presents two varieties, or rather degrees of severity— blue asphyxia, in which the pulse is slow and strong, the muscles more or less rigid, and the child cyanosed ; and pale asphyxia, in which the pulse is rapid and feeble, the muscles are flabby, i.e., the head, limbs, and lower jaw drop loosely, and the child is pale and anaemic. The latter form may be complicated by the presence of liquor amnii in the lungs if the cerebral anaemia has been pro- found enough to cause respiration to occur in utero, at a time when the mouth was in contact with the liquor. Blue asphyxia is soon followed by the pale form if respiration is not soon estab- lished. Treatment— Prophylaxis.— The anticipation of asphyxia by means of frequent examinations of the foetal heart with the stethoscope, and prompt delivery whenever it is found to be steadily rising or intermittent ; and care to iiex the wrist of the internal hand during the extraction of the after-coming head to an extent which permits the atmosperic air to have access to the mouth, will greatly diminish the number of cases in which the treatment of asphyxia is indicated. Resuscitation. — The means of resuscitating asphyxiated in- fants consist of expedients for exciting natural respiration, and the various methods of maintaining it artificially. The methods in use for exciting respiration are all founded on the view that, although the first respiration may occasionally be provoked by the alteration of circulation which occurs at birth, it is usually a reflex result of the stimulation of the cutaneous nerves which follows the removal of the child from a warm fluid to comparatively cold, dry air. This belief rests upon the results of experimental research in animals, in whom it has been found that when the uterus is opened and the cord tied, or when the placenta is separated in utero without in any other way disturb- ing the foetus, respirations are sometimes excited by the cerebral antemia which results from the cessation of the utero-placental circulation; but that in the majority of cases, the foetus dies with- out making any attempt to fill its lungs : while, upon the other hand, if the uterus is perforated, and the external skin is scratched or otherwise stimulated, or if the foetus is removed from the uterus and exposed to the air with as little manipulation as possi- 318 PKACTICAL MIDWIFERY. ble and without interference witii its circulation, respiration is uniformly excited, the method of removal beiufj: the most efficient. All methods of artificial resjjiration are attempts to produce expiration by compi'ession of the chest, and inspiration by caus- ing expansion of the chest, by traction on the ribs through the pectorales and other auxiliary muscles. In blue asj)hyxia, the stimulative methods are usually all that are needed; and in the majority of cases, simple stimulation of the external skin is suflBcient to awaken respiration; but great care must always be taken to maintain the body heat throughout the process, and to avoid the exhaustion of too much manipula- tion. The child should be held head downward, the mouth and fauces should be cleared of mucus by the fingers, and the posi- tion should be maintained for some seconds, in order to favor drainage of any liquor amnii which may have been swallowed or drawn into the trachea. The infant should then be completely immersed, with the exception of its face, for several minutes, in the hottest water which can be borne without scalding, removed for a few seconds for a brief plunge into ice-cold water, and then at once replaced in the hot water to prevent a serious loss of heat. If any attempt at respiration is excited during this process, it should be persevered in, and then usually results in the pro- duction of good respii'ation. When inspiration lias become regu- lar and sufficiently frequent, the child should be sharply slapped with the hand or with tlie wet fringes of a towel, until it cries vigorously, in order to secure complete inflation of its lungs ; but care should be taken that its tissues are not bruised, the back and buttocks being the preferable places for the slapping. In the milder cases of pale asphyixa, the same process is often successful; but care should be observed here to hold the child with the head downward, not only during the process of slap- ping, but whenever opportunity ]jeruiits. The inverted position is here of gi-eat value, because it favors the gravitation of blood to tlie head, and consequent relief of the cerebral antemia. Tliis is of the last importance, because, if the first stimulating effect of the deprivation of blood fails to awaken the respiratory centres, their revival is hopeless while the local anaemia continues. In pale asphyxia, especially, all manipulations and rough handling of the child should be reduced to a minimum; since a marked degree of exhaustion is to be expected in all such cases, and the vitality of newborn infants is so slight that a very slight increase of shock may be promptly fatal. If the case appears serious, no great time should be lost in these methods, but artificial respiration should be at once re- sorted to, and maintained until the child breathes regularly with- PATHOLOGY OF LABOR. 319 out aid. In pale asphyixa, uncomplifiated by aspiration of fluid, a large i)r()i)ortion of children may be saved by artificial res^iira- tion, provided that the heart be still beating, and that the inverted position is persistently adhered to. When asphyxia neonatorum is complicated by inspiration of the liquor amnii, the prognosis is extremely grave; but, since apparently hopeless cases are sometimes saved, artificial resj^iration should be perse- vered in for at least half an hour. When the liquor has been in- spired to any considerable amount, the only chance for resuscita- tion of the child is to secure drainage of the fluid by holding it with its head downward for many minutes, assisting the action of gravity by the simultaneous production of artificial respiration. Fig. 101.— Sylvester's Method of Artificial Respiration. expiration. a, Inspiration; b. Artificial Respiration— /S^/Zvei'^er'^ Method. — The child is laid upon a table or other flat surface, with its back slightly arched over a folded towel or other compress (Fig. 101) ; the operator grasps a forearm in each hand, presses them lightly against the lower i^art of the chest to effect expiration; and ex- tends them fully by the sides of the head, in order to cause in- spiration by raising the ribs, by traction upon the origins of the auxiliary muscles. The motions should be repeated from six to ten times a minute. The method has the advantage of reducing 320 PRACTICAL MIDWIFERY. the handling of the child to a mininiuiii, but is somewhat ineffi- cient. iSchultze's Method. — In this procedure the child is suspended by the arms, with its back toward the operator. Each arm is held by a thuuib and forefinger, while the other fingers support the back, as seen in Fig. 102. The child is then swung sharply upAvard into the position shown in Fig. 103, and after a few sec- onds the first position is resumed. In the first position the trac- tion of the head and neck upon the auxiliary muscles tends to elevate the ribs, which in the second are depressed by the forward flexion of the whole body. The method exposes the child to con- FiG. 102.— Schdltze's Method of Ar- tificial Respiration. Inspiration. Fig. 103. — Schultze's Method of Ar- tificial Respiration. Expiration. siderable risk of exhaustion from the somewhat rough handling which it involves ; but it is thoroughly etticient, and is to be rec- ommended for mild cases. AiUhor\s Method. — This i^ossesses the imi^ortant advantage of combining a most efficient artificial respiration with a mini- mum of manipulation, and with a constant maintenance of that most important factor, the inverted position. The pelvis of the cliild is encircled l)y the thumb and little finger of one hand, while the other fingers support the back (Fig. 104). In this position the weight of the dependent head and arms produces the fullest possible expansion of the chest. At brief intervals the other hand is passed across the chest, and the second and third fingers are hooked along the opi^osite sides of PATHOLOGY OF LABOR. 321 the neck, when, by H^ht i)re.ssxire of both hands, the child's body is sharply flexed and the chest is finnly compressed (Fig. 105). This method is especially valuable in cases in which mucus or liquor anniii has been inspired, in which the contained fluid can usually be observed to drip from the mouth and nose under the influence of gravity during each compression of the chest; and when this is seen, the little finger of the anterior hand should be made to clear the mouth and fauces at the end of each move- ment of expiration. FaracUsm. — The application of faradic electricity to the chest is a method of great value and, if a battery is at hand, should be given a trial ; one pole being applied, constantly over the phrenic Fig. 104.— Author's Method of Arti- ficial Respiration. Inspiration. Fig. 105. — Author's Methou of Arti- ficial Respiration. Expiration. nerve, just outside the origin of the sterno-mastoid muscle, and the other brought into momentary contact with any part of the chest, at intervals of from ten to twenty seconds. The contact must be made as brief as possible, since any over-stimulation of the respiratory nerves may result in their i^aralysis; and each inspiration which is produced by the electricity should be suc- ceeded by mechanical compression of the chest between the hands of the operator, to insure the expulsion of the inspired air. 3Ioiith-to-mouth Insufflation and Catherization of the Trachea. — In mouth-to-mouth insufflation the fauces are cleai-ed by the little finger, and the child is laid upon its back upon a table; the face and nose being covered by a thin towel. The operator clears his lungs of residual air, inflates them, and, placing his mouth to the face of the infant in such a manner that both its nose and 21 o'^'^ TKACTICAL MIDWIFERY. mouth are includt'il within it, f^eiitly expels a little air from his lungs. Each inilation must of course be followed by compres- sion of the chest with the hand in order to produce expiration. The method is sometimes valualde, but possesses the disad- vantages that a too vigorous expiration may cause lacerations f»f the pulmonary tissues of the child, and that the air "which is ex- pired from the attendant's lungs often passes through the oesoph- agus into the infant's stomach. Catherization of the Trachea. — The forefinger is passed into the mouth until it reaches the larynx and feels the arytenoid car- tilages, and a small (No. 10 F.) English-webbing catheter is jaassed along its flexor surface, and guided through the glottis. The operator then blows gently into the catheter after having expelled the residual air from his own lungs, taking care, how- ever, that the amount of air which he expires is no more than the small quantity which the chest of a new-born infant is capable of containing. When executed promptly and with sufficient caution against any over- inflation of the infant's lungs, the method is extremely valuable; but the introduction of the catheter is not always easy, and the element of time is of so much importance that the more ready methods are usually to be preferred. Such a catheter should, however, be kept within the oljstetric bag, for use after the failure of other means. It has lately been suggested that when the excitation of Ijreath- ing is difficult, and the heart is perceived to be failing, both pro- cesses may be stimulated by the hypodermic administration of from five to ten drops of brandy or ether; and the suggestion is well worth a trial. During the process of artificial respiration, loss of body heat should be prevented by occasional immersions in the hot water: and when voluntary inspiration has been once excited, a plunge should be occasionally resorted to as an additional stimulating measure. The artificial respirations should be i)roduced at regu- lar intervals until natural breathing is well established. The child should then be warmly wrapped, carefully watched, and handled but little for several days; for even after it has been made to cry vigorously, its future prospects are less bright than those of an un-asphyxiated child, nearly 50^ of such infants dying within the first week. Accidents to the F(Etus During Labor. Forceps Marks. — These may be deep or superficial; the superficial injuries are nothing more than a separation of the scarf skin, due to forcible friction against the blades during their PATHOLOGY OF LABOR. 323 iatroduetion, or to their slipping during traction. Such marks are extremely disfiguring at the moment, but require no treat- ment, and leave no traces of their presence. Any undue compression by the forceps may result in the pro- duction of subcutaneous bruises of the face or scalp. These ap- pear as indurated subcutaneous phlegmons, which feel like hard buttons beneath the skin; like the more superficial marks, they need no treatment, and never result in a scar, unless they ai'e sufficiently extreme to cause sloughing, in which case they may be followed by serious disfigurements. Facial Paralysis. — When the forceps are so applied that the tips compress the facial nerve against the bone at its origin from the skull, the pressure may result in the production of a temporary paralysis of the muscles which it supplies. The affec- tion is usually unilatei-al, and generally disappears, without treat- ment, in less than a week. In the rare cases in which it is bilateral, it may induce an inability to nurse, which, if the act of nursing is not replaced by the injection of milk into the stomach through a soft-rubber catheter, is likely to be fatal. By the use of gavage, it is, however, easy to sustain life until the affection disappears. Fracture of the Fcetal Skull. — This accident is usually a result either of an unduly forcible and rapid delivery of a large head or of some violation of the proper mechanism of labor during an operative delivery. Such children are usually still- born, from injury to the brain; and even if born alive, are apt to die of meningeal haemorrhage within a few minutes or hours. Meningeal Hemorrhages.— The overlapping of the flat bones of the skull which necessarily occurs during difficult labor may result, occasionally in natural but more frequently during operative delivery, in laceration of the dura mater and of the vessels which it contains. Its results depend upon the situation of the tear and the size of the lacerated vessels ; it is more serious when the tear is situated at the base of the skull than in any other situation. When this accident has occurred, the compression of the eere^ bral substance has usually been such that the child is extracted in pale asphyxia. If the injury to the meninges was severe, the diminution of the intra-cranial pressure which is consequent on delivery is usually followed by the rapid production of a hjiemor- rhage which is sufficient to destroy life before respiration starts. In less extensive lacerations, respiration may be excited, but only to become progressively slower and more feeble until death oc- curs; in such cases a post-mortem will disclose the presence of a clot of exti'avasated blood at the base of the brain. When the haemorrhage is insufficient to cause death, the child is usually feeble and apathetic for many days; its recovery may then be o24 PRACTICAL MIDWIFEKY. complete, or it may be followed by the appearance of spastic hemiplegia or other paralyses, either im'mediately or after au in- terval of one or more years. Fractures of thk Upper Arm or Clavicle.— These frac- tures are usually produced during the extraction of the after- coming arms; exceptionally, in difficult extractions of the body in head presentatijons ; the fractures are of course always of the green-stick variety. Fractures of the clavicle may be left un- treated, since they rarely result in any permanent deformity. Fractures of tl:e upper arm would probably unite spontaneously, and are seldom followed by any ill results unless the fracture is Fig. lOG. — Lateral Pressure on Anterior Thigh Dcring the Expulsion of A Posterior Position of the Breech. near one of the centres of ossification ; in which case the subse- quent growth of the bone may be interfered with, and the acci- dent then results in a short arm. The treatment should be eon- fined to straightening the affected bone, and confining it between splints of moderately thicK pasteboard or mere compresses of folded cloth; the arm should be lightly bound to the side, but care should be taken that the bandage is not sufficiently tight to compress the chest and interfere with respiration. Fractures of the Thigh. — These are usually produced dur- ing the extraction of the breech in cases in which the legs are extended across the chest, and the anterior limb is usually the seat of the injury. It will be seen by reference to Fig. lOG that in posterior posi- PATHOLOGY OF LABOR. 325 sitions of the breech, the anterior thifj:h is necessarily exposed to considerable lateral pressure from the edge of the symphysis dur- ing the lateral flexion of the trunk which accompanies the expul- sion of the hips; and it can be readily understood that the mero insertion of the finger into the groin may increase this pressure sufficiently to cause fracture, unless the hips are at the same time pressed backward. Injudicous traction in the direction of the arrow would certainly be followed by the accident. The prog- nosis and treatment are identical with those of fractures of the humerus. PART VI.— THE PUERPERIUM. CHAPTER XXIL NORMAL CONVALESCENCE. Though convalescence from labor is a physiological process, it must not be forgotten that the puerperal woman is not in a con- dition of ordinary health, and that, though the normal puerpera is not ill, she is in a state of markedly unstable equilibrium, in which her sensibility to the conditions of her environment is very greatly increased, and in which very slight external stimuh, either physical or mental, result in enthely disproportionate disturbances of her pulse, temperature, and general condition. Under the most favorable circumstances the pulse is usually slightly high and much more variable than in health ; the tem- I^eratui'e, in the absence of complications, should remain below 99' F., but very slight disturbances of the health may produce a degree of pjTexia which would be entirely unexpected from them at any other time. It is therefore necessary that the cause of every rise in temperature, however slight, should be carefully diagnosticated; the usual reasons for an elevation which is not dependent on sepsis being constipation of the bowels, inflamma- tion of the breasts, a disturbed condition of the nervous system, and mtercurrent systemic diseases. Rest axd Quiet. — The occasional occurrence of a distinctly high temperature during the puerpei'ium, from functional dis- tui'bances of the nervous system, uncomplicated by any other con- dition, is a phenomenon which has been so frequently observed as to be beyond reasonable doubt ; and since the condition of the nervous system is such that very slight causes may produce a marked and lasting excitement, it is an important part of the duty of the attendants of every puerperal woman to guard her rest and shield her from nervous excitement in every possible way. It is for this reason that labors which result in still-born children are apt to be followed by protracted and troublesome convalescence; and for this reason also a rigid exclusion of visi- tors from the room of the patient during the first week is to be THE PUERPEKIUM. 327 recoiiimended : the best plan heiui^ to permit the patient's hus- band to visit her twice daily for a few moments, and her mother, if present in the house, to see her once; both being warned to re- duce their conversation with her t(; a minimum, and to especially avoid all topics which would in any way interest or excite her ; but while this is the proper rule, the conditions of family prac- tice will oblige the physician to relax its vigor in many cases, so long as the convalescence is normal. It should be strictly en- forced whenever the nervous condition of the patient is anything but satisfactory. Nothing exerts a more important influence upon the whole course of convalescence from labor than the manner in which the patient passes the first few hours after the birth of her child. It is to be remembered that at the conclusion of parturition the mother is exhausted, not only by the extreme and prolonged muscular efforts of labor, but by the continued endurance of ex- treme pain ; and that, though she is often excited and exultant, in her sense of relief from pain and possession of the baby, she is nevertheless in urgent need of both physical and mental rest. It is thei'efore important that from the very moment of delivery the room should be quiet, and that the attendants should main- tain a calm, collected, and soothing manner, and should avoid all unnecessary conversation with each other or the patient. The baby should not be urged upon the joatient's attention until she asks to see it; it should then be shown to her for a mo- ment and removed to the next room. The physician should him- self remain within call, and should see that the nurse arranges the dress and bed of the patient, and removes the parajDhernalia of labor, as quickly and quietly as possible; the room should be darkened, the whole house maintained in as noiseless a condition as possible, and the patient urged to make a determined effort to obtain the rest which she so greatly needs. If she seem restless or excited, it is frequently good practice to administer at once a mild hypnotic, such as twenty to thirty grains of bromide. The nurse should be ordered to remain in the next room, and forbidden to absent herself for a single minute from the sound of the patient's voice, that there may be no possibility of her failing to secure aid in case of faintness, secondary haemorrhage, or any other emergency. A recently delivered Avoman so treated sel- dom sleeps profoundly, but Avill doze and rest for many hours; and has a vastly better chance of a normal and comfortable con- valescence, than if she had been subjected to the congratulations and inquiries of bustling friends and relatives. The Bidder. — The use of the binder after confinement is in this country almost universal. It has been strongly objected to by some authorities, on the ground that the compression which. 328 PRACTICAL MIDWIFERY. it exerts tends to produce or favor the production of a low jjosi- tion, or even of a retroversion of the uterus; but thou/^h this ob- jection is certainly valid if the binder is applied with injudicious tightness, it is, on the other hand, probable that a moderately snug bandage relieves the relaxed abdominal walls from the pressure of the abdominal viscera, and thus favors the necessary involution of the abdounnal muscles, and, which is more impor- tant still, ijermits the patient to change her position freely and at will, without that risk of the entrance of air into the vagina or uterus which must otherwise always accompany the accidental assumption of Sims' position, in the relaxed condition of a re- cently delivered woman. Position in Bed. — The position which the puerperal woman assumes in bed is unimportant, so long as it is frequently changed ; but since niany women from fear of injury persistently maintain a constrained position upon the back, unless distinct permission to move about is given them, the i:)hysieian should be careful to inform each patient that she will rest better and convalesce more rapidly if, after the first few hours, she turn frequently from one position to another, provided that the i^erinieum is not lacerated; in which case, even, the nurse should be directed to frequently alter the position of the patient by passive motions; since few things ai'e more unfavorable to physiological rest and to the progress of involution than the discomfoi'ts of an unvaried posi- tion ; and every patient should be informed that the occasional assumption of a lateral decubitus is distinctly an advantage, on account of its tendency to promote free drainage of the accumu- lated lochia from the vagina. . PosT-PARTUM Chill.— A large proportion of patients are sub- ject, within a few minutes of delivery, to a slight chill, which is especially frequent if the emergencies of the case have necessi- tated a somewhat free exposure of the person. The phenomenon is of no importance, and indeed is rather a favorable event than otherwise, since its occurrence distinctly lessens the chance of a post-partum haemorrhage; but as it is likely to alarm the patient, care should be taken to inform her that it is a favorable rather than an unfavorable event. After-pains. — After-pains are due to a continuance of the intermittent contractions after the delivery of the child ; they are therefore likely to be greatest after short and easy labors in which the contractility is only partially exhausted, and least after severe labors; for which reason they are comi)aratively rarely seen in primiparai. They not infrequently occur in a thoroughly emptied uterus, they are always present when the uterine cavity contains clots or ijortions of placenta, and are to be distinguished from adventitious pelvic pains by their intermittent character. The THE PUERPERIUM. ?>2U rationale of their treatment consists in the adoption of measures intended to empty the uterus in order to secure its complete contraction, and in (juieting the pain meantime. The first step in most cases should be tlie application of manual friction to the fundus of the uterus; if the size of the organ is such that it is supposed to contain a considerable quantity of clots, the friction should be followed by an effort at expression, after the manner of Crede ; and when the uterus has been emptied in this way, the Administration of a drachm of ergot, to Avhich ten minims of laudanum has been added, will usually lessen and i^erhaps permanently stop the pain within a short time ; but if the attack has been severe, retraction should be iriaintained by the continued use of ergot, in doses of from twenty to thirty minims, at inter- vals of from four to eight hours, for several days. A useful and comforting additional treatment is the aiDplica- tion to the lower portion of the abdomen of compresses Avrung out of stinging hot water, and frequently changed. Gentle, in- termittent faradization of the uterus may also be useful if a bat- tery is at hand. Ventilation. — The popular impression of the extreme danger of " taking cold " during the first week of convalescence arises, without doubt, from the frequency with which septiesemia is ushered in by a chill, and from the mistaken pathology of former days, which ascribed its occurrence to an accidental exposure of the patient to a draught. In reality, nothing is more important, during convalescence from labor, than a free supply of fresh and fully oxygenated air ; and it is the duty of the physician in all cases to be personally watchful lest the prejudices of the family, or monthly nurse, should expose the patient to the pernicious effects of a foul, ill-ventilated room. Cleanliness. — It is a traditional belief that combing or brushing the hair of a woman during the first week of convales- cence from labor exposes her to inci-eased danger of hfemorrhage, a prejudice which probably arises from the fact that the muscu- lar fatigue caused the patient by sitting up in bed to perform this duty herself would certainly predispose to such an occurrence; but careful arrangement of the hair by the nurse, without allow- ing the patient to rise in bed, can be productive of no harm, and should always be permitted and enjoined. The hands and face should be washed by the nurse at least twice daily; the body should be sponged from top to toe with tepid water at least once daily ; in warm weather, and especially if the patient be stout, the groins, axilla?, and any other folds in the skin should be thickly dusted with baby powder. An.bmia. — Many women, especially among the upper classes, are reduced during pregnancy to a condition of ansemia, Avhich 330 PRACTICAL MIDWIFERY. adds greatly to the exhaustion of the process of parturition, and leaves them in a condition peculiarly ill suited to sustain the fatigues and risks of the puerperal state. This condition, when present, should be steadily combated during pregnancy, though little more can be then hoped for than to arrest its progress; but during the puerperal period, much may be gained by a systematic administration of iron in full doses, as soon as the bowels have been moved; three excellent prescriptions for use at this time being the citrate of iron and quinine, the pil. ferri oxidat. saccha- rat. gr. v., and Austin Flint's saline chalybeate tablets. If the expense of these preparations is of importance to the patient, the tincture of the chloride of iron should be j^rescribed in doses of fifteen to twenty minims three times daily, or the liq. ferri albuminatis; together with an early resort to a generous diet, and a moderate use of stimulants, i^referably in the form of malt liquors, if these are not disagreeable to the patient. RouTi^N'E OF Treatment During Convalescence.— Dur- ing normal convalescence the physician should not only keeiD a record of the pulse and temperature, but should maintain a care- ful supervision of the five functions of defecation, micturition, establishment of the mammary secretion, the involution of the uterus, and the excretion of the lochia; since any abnormal al- teration in the course of the puerperium is necessarily attended by a variation from the normal standard in at least one of these particulars. He should therefore, at every visit, examine the breasts; estimate the size, consistence, and tenderness of the uterus, by abdominal palpation of the fundus; inspect or in- quire about the quantity and odor of the lochia, as collected upon the pads; and ask about the regularity of the bowels and urine. Diet. — The digestion of the puerperal woman is, like all her functions, easily upset, and must be constantly watched. Her appetite is, during the first days of convalescence, usually aljsent, or at best slight, and even later is rarely large. The diet should be light until the bowels have mov^ed. During the first few days there is usually but little appetite, and a diet composed of eggs, milk, and gruel, in small quantities, is usually all that is wise ; but it is generally well to administer a small amount of hot milk, flour gruel, or some similar substance as soon as the patient has become rested from the fatigues of labor. So soon as the bowels have moved and some little appetite appears, the diet should be gradually and cautiously increased at such a rate that before the end of the first week the patient is eating about as usual; but it nmst be remembered that throughout the puer- perium the digestion is likely to be sensitive and easily upset. Indeed, throughout the whole lactation certain articles of diet must be avoided; the best rule being that fleshy vegetables, i.e.. THE PUERPERIUM. 331 those which are rich in starch, such as peas, beans, and potatoes, are not usually well borne, and should be taken in comparatively small quantities ; that fruit should be used sparingly, and all un- cooked vegetables positively forbidden; in addition to which it is a general rule that highly colored vegetables are seldom fit food for nursing women. Bowels.— The bowels ordinarily fail to move spontaneously during the first few days after delivery, and should be opened by a cathartic upon the second, third, or fourth day ; the variar tion being dependent upon the general condition of the patient, and the early or late disappearance of the tenderness due to the distention and contusion of the vulva during delivery. Overlong neglect of this function after labor leads with certainty to the occurrence of headache and the other symptoms familiar to every one as the result of a temporary constipation ; a condition which, during the puerperium, is often attended by an elevation of tem- perature, which is productive of discomfort to the patient, is distinctly likely to retard her convalescence, and predisposes to the appearance of haemorrhoids. An over-prompt evacuation of the enormous amount of fseces which has often been accumulated during the latter part of pregnancy frequently leads, upon the other hand, to considerable exhaustion, and may be extremely painful. The administration of a cathartic should be preceded in most cases by an injection of from one to four ounces of olive oil, and the preferable method is the administration of small but repeated doses of some non-poisonous preparation. That which is perhaps the most generally satisfactory after labor is the officinal pil. rhei CO., gr. v., repeated every three hours to a result, or, in case of a patient who objects to pills, the effervescing solution of the citrate of magnesia, a large wineglassf ul at a dose. MiCTURiTiOisr.— Retention of the urine, due to the altered shape of the previously expanded bladder, which is consequent upon the diminished size of the uterus, and to laxity of the ab- dominal walls, is extremely common during the first few days after delivery. The existence of a distended bladder predisposes strongly to the occurrence of post-partum haemorrhage ; since the still distensible uterus may easily be drawn upward and expanded by the attachment of its anterior wall to the posterior portion of the bladder; and it may, moreover, be productive of extreme dis- comfort and much loss of rest to the patient. Its relief by the catheter not only risks the introduction of lochia into the blad- der, and the inception of septic cystitis with its long train of most annoying discomforts; but, in addition to this risk, if the use of the catheter is once begun, it must generally be continued for many days, while, if the patient can be encouraged to empty the 332 PRACTICAL MIDWIFERY. bladder for the first time herself, micturition is commonly per- formed with ease thereafter. The treatment to be recommended is that, in the absence of lijiemorvhage, the patient should endure the discomfort due to distention of the bladder until it becomes extreme, and that she should then be placed upon a bed-pan, and encouraged in every possible way to pass her water herself. A hot compress should be placed over the supra-pubic region, she should be allowed to hear the sound of running water, and, if necessary, should be helped by the application of supra-pubic pressui*e from the hand of the nurse. She should not be allowed to rise or sit up in bed for the i^uriDose, on account of the risk of secondary haemorrhage which this involves ; but many patients succeed in expelling their urine when they are turned upon the face, or allowed to assume the knee-chest position; and this procedure is, Avith tolerably strong patients, upon the wdiole, preferable to the use of the catheter. Breasts. — Disturbance or interruption of the action of the mammfe is, upon the whole, the most common complication of the puerperium; and their development should always be closely watched until the secretion is fully established. At the first visit after delivery, the breasts should be carefully examined by sight and touch, the presence or absence of colostrum ascertained, and the amount of breast tissue estimated and considered in connec- tion with the constitution and physical condition of the mother; so that the physician niay be enabled to form as accurate a judg- ment as possible of the patient's probable capacity as a wet- nurse. If the nipples have not already been under observation, their condition should be noted; and if any treatment of them is likely to be necessary, it should be begun at once, without Avaiting for the establishment of the milk. In most cases the infusion of green tea in brandy, which was recommended for use during preg- nancy, may be advantageously kept in constant contact with the nipples; and in primiparge, it is often advisable to make a sys- tematic attempt to increase the prominence of the nipples • from the time when the patient first recovers from the fatigues of labor. This may often be effected by insti'ucting the patient or nurse to pull them forward with the fingers in imitation of the action of the baby's mouth, remembering that a too constant handling may produce irritation; or, if necessary, they may be drawn for- wa]"d by the use of gentle suction with the breast pump or by means of a hot bottle. If this latter method is selected, a six to eight ounce bottle should be thoroughly heated by filling it with hot water; when, if this is rapidly poured out, and the bottle quickly applied to the nipple, the condensation of the contained THE PUERPERIUM. 333 air, which occurs during the cooling of the bottle, exerts a quite considerable force of suction upon the nipple. So soon as the initial period of rest is passed, the patient should be directed to give the breasts to the child in alternation, at in- tervals of six hours, until the secretion of the milk is established. This process tends to reflex stimulation of the uterus and pro- motion of its retraction ; distinctly hastens and increases the secre- tion of the breasts ; affords an excellent opportunity of teaching the child to nurse properly ; supplies it, in most cases, with a cer- tain amount of colostrum, which has a beneficial and slightly cathartic action ; and may assist the efforts of the physician to ward off the administration to it, by the nurse or family, of castor oil, molasses and water, or other nostrums. During the first forty -eight hours the child should receive nothing else than what it is able to obtain from the mother's breast ; but if at the expiration of that time it becomes restless and seems dissatisfied, and the bi-easts are still unfilled, it may often be quieted, and probably benefited, by giving it one or two teaspoonfuls of slightly sweetened milk and water, in the proportion of one part of milk to three of water; the dose being^ repeated at intervals of from two to four hours. With the appearance of the milk, the breasts increase rapidly in size, and frequently are so much swollen as to be distinctly painful ; but if this disturbance occurs, it is usually promptly re- lieved by the application of a moderately firm breast bandage, such as is used in the treatment of threatened mammary ab- scesses ; by massage of the breasts ; and by the provocation of a moderate number of watery dejections with saline cathartics. Until within the last few years it has been generally taught that this establishment of the milk was ordinarily attended by the appearance of moderate pyrexia, which should not, however, exceed a temperature of 100°. 5 F. ; but this so-called milk fever is so seldom seen when exact antiseptic precautions have been em- ployed that it may be laid down as an accepted rule that, unless the discomfort of the patient from distention of the breasts is de- cidedly excessive, any pyrexia which may appear at this period is probably due to a mild degree of septic absorption, rather than- to any process connected with the breasts. So soon as any considerable quantity of milk appears in the breasts, the baby should be nursed at intervals of two hours; being applied to one breast only at each nursing, and using them in alternation; but unless the condition of the child is-distinctly poor, its interests, as well as those of the mother, are usually best subserved by nursing it but once between the hours of ten P.M. and six in the morning ; the advantage to the baby being the greater probability that it will obtain a satisfactory quality of 334 PRACTICAL MIDWIFERY. milk if the mother's rest is undisturbed. If, as is common, the milk at this period flows spontaueously from the breast, the nip- ples must be covered by a light compress ; which should preferably be made of linen cloth, and should never be so thick as to pro- mote maceration of the nipples by the production of an unneces- sary amount of warmth. It should be an invariable rule of practice to require the pa- tient to wash the nipples thoroughly with a saturated solution of borax in water, before each nursing ; and it is extremely im- portant that the compress should be changed sufficiently often to prevent souring of the exuded milk — an occurrence which is not only likely to disturb the digestion of the baby in the event of any carelessness in washing the nipples before nursing, but is also likely to originate a fermentation, which by extension along the ducts may provoke the formation of a mammary abscess. !New-born children often fail in their first attempts at nurs- ing; and in such cases dependence should be placed on gentle and frequent repetition of the trials, rather than on a wearying persistence. The mother should be laid upon her side, support- ing the baby's head on her upper arm in such a position that the nijDple is exactly opjjosite its mouth, and so near to it that it has no tendency to fall out. If the nipple is flat, it should be drawn out by the fingers of the nurse or mother, or by the use of a hot bottle, before the child is applied to it ; a few drops of milk should be pressed out of the ducts, and allowed to remain on the nipple, that the baby may get the taste of it ; or a little moistened sugar may be placed in the same position for the same reas'^n ; occa- sionally a change of breasts may result in success. The child may sometimes be made to nurse by gently stroking one of its mastoid processes, while the nipple is in its mouth, it being a curious fact that the action of sucking is frequently induced with- in a few moments by this stimulation, whether the child is at the breast or not. Should the nipple fall from the mouth, it should be at once replaced by the mother, who must give her whole attention to the process. The child should nurse as long as it seems heartily interested in the effort ; but so soon as it begins to mouth the nipple, drops it repeatedly, or in any other way plays with it, it should at once be removed from the breast, for the reason that a longer continuance of nursing at such a time encourages a bad habit of dallying with the nipple, and not infrequently leads to the iiigestion of air, and to consequent disturbances of digestion: in addition to which, such actions are almost infallible evidence that its appetite has l>een satisfied. Utkri'.s. — The uterus should be constantly examined to as- certain its consistency, tenderness, and size from day to day. THE PUERPERIUM. 335 During the first few hours after delivery the fundus is usually but a few inches above the symphysis, but by the end of twenty- four lioui's the retraction of the muscular fibres of the uterine ligaments usually raises the organ, so that the fundus is found at, or nearly at, the umbilicus. From that time on, under nor- mal circumstances, thei*e is a steady decrease in its size and a steady increase in its consistency, until, on or about the tenth day, the fundus can no longer be felt with ease through the ab- dominal wall, and is at last wholly below the level of the sj'ui- pliysis pubis. The progress of this process of involution should be observed from day to day, because subinvolution, or delay in the return of the genital apparatus to its normal state, is a com- i:>lieation which may be sufficient to indicate considerable altera- tions in the management of the convalescence. Under normal circumstances the uterus is a tender organ, and one which is rather unpleasantly sensitive to the touch during the first few days after delivery ; but unless some inflammatory process is present, gentle handling does not cause severe pain. Lochia. — The character of the lochia should be inquired about, or ascertained by inspection of the vulvar pad, at each visit, the jDoints worthy of notice being its amount, color, and odor. During the first three or four days the lochia have a red color, and are usually sufficient to soak the pad more or less thoroughly in from six to eight hours. After the fourth or fifth day the dis- charge is faintly joinkish and much decreased in quantity, and by the end of ten days it should be scanty, of a grayish white or yellow color, and of a creamy consistence. Unduly long i^er- sistence of the red color may be due to the existence of small vaginal or cervical tears or to pelvic congestion ; the reappear- ance of the red color after it has once been lost suggests the pres- ence of a foreign body {e.g., clots or portions of the placenta or membranes) in the uterus, subinvolution, or some malposition. A sudden decrease in the quantity of the lochia, or its total dis- appearance, suggests, according to the concomitant symptoms, either the appearance of sejDsis or an occlusion of the internal OS by retained clots or other substances. Normal lochia have a peculiar, sickish odor, which should be made familiar to the nostrils by constant examinations of the napkins in normal cases. The appearance of a distinctly foul smell, or odor of decomposition, is always strong evidence of present or impending sepsis. A slightly stale odor may precede the appearance of foulness, and should lead to an investigation of its cause : but if the nurse is inefficient, it may not infrequently be due to partial decomposition of the lochia upon the outside of the vulva, or on the thighs, clothing, or bedding of the patient. The matter is, however, one of so much importance that the phy- o'oh riiACTICAL MIDWIFEKY. sician should be prepared to personally investigate any such susi)icious symptom. When the lochia are suppressed, and sepsis can be excluded, hot cloths or poultices should be applied to the lower portion of the abdomen, and erfjot should be fj^iveu in the hoi)e of stimulating the uterus into contraction and forcing it to exjjel the plug. Visits. — The number of visits which the physician should make during a normal convalescence is a matter upon which some difterence of opinion obtains, but the majority of obstetri- cians agree that constant attendance during the first week is of the utmost advantage in forestalling and preventing the acci- dents and complications to which patients are at this period lia- ble. It is the best plan to see every patient at the end of from eight to twelve hours after la})or, and thereafter once daily until the establishment of the milk begins; she should then be seen once, twice, or even three times in each day, as the necessities of the case may make advisable, until the flow is well established ; after which, in normal cases, a visit every second or third day is all that is necessary, and with a good nurse the intervals may be made much longer. Length of the Puerperium. — The puerijerium lasts until the involution of the uterus and adnexa is thoroughly completed, a process which usually consumes a full six weeks. During that period, any long continuance of the upright position imposes an undue strain on the uterine supports; since an unusually heavy uterus must be held in position by partly involuted and there- fore somewhat lax and softened ligaments. This danger, how- ever, decreases with the progress of involution, and an unduly long confinement to bed is distinctly productive of fatigue, dis- comfort, and loss of vigor; which is partly, no doubt, caused by the mental weariness due to its tedium and irksomeness, and partly by the loss of strength due to muscular inaction ; in addi- tion to this, it is certainly a fact that a somewhat scanty secre- tion of milk often increases when the patient is allowed to get up. Hence no rule can be laid down as to the precise length of time that must be spent in bed, but the period must vary in ac- cordance Avith the physical state of the patient, and the necessi- ties imposed upon her by her social condition. The best average rule of practice is as follows: Among the poorer classes the patient should be kept in bed, or at least re- strained from her ordinary work, for as near a period of two weeks as is possible; this being all that can usually be done among working women. Among the l^etter classes, women of su- perior physique should be kept flat in bed until about the twelfth day, when, if the fundus of the uterus is no longer perceptible above the pubes, they may be allowed to assume a sitting posi- THE PUERPERIUM. 337 tion in bed for a few minutes, preferably during one meal; if no considerable fatigue, dizziness, or backache follows this effort, it may be repeated two or three times on the following day. The patient is then allowed to move herself from the bed to a lounge placed close beside it, and is afterward roiled away to another part of the room, while the bed is turned and aired ; but is not permitted to sit up for more than fifteen minutes at a time, and is encouraged to maintain as nearly a horizontal posture as is com- fortable during the remainder of the day. If no ill results follow this indulgence, she is permitted to sit up on the lounge for short periods with increasing frequency, and at the end of three weeks is allowed to walk from the bed to the lounge. During the fourth week she is given the freedom of her room, and during the fifth goes down to one or more meals daily ; she keeps within the house during the whole of the succeeding week, and then resumes her ordinary duties. If, however, circumstances make an earlier release desirable, in the majority of cases there is no great risk is jDermitting a somewhat greater freedom during the last three weeks. If involution is tardy or the general con- dition of the i^atient is poor, a much longer confinement to bed may be necessary or advisable ; the golden rule being that every increase of freedom should be gradual; that the erect position should be assumed several times daily for periods of a few min- utes, rather than once for a longer time; and that every fresh indulgence should be adopted tentatively, and stopped at the first sign of backache or fatigue. Cases so treated are undoubt- edly less liable to subsequent gynaecological disease, and are bet- ter fitted to endure the fatigues of prolonged nursing, than are those who are encouraged to a more hasty resumption of the ordinary course of life. 22 CHAPTER XXIIL THE NEW-BORN CHILD. The care of new-born infants in ordinary health falls neces- sarily within the province of the obstetrician, J)ut it is by no means within the scope of a text-book upon obstetrics to deal Avith the management of the diseases of infancy and childhood; for which reason the present chapter will be limited strictly to the care of normal infants, and to those minor ailments which are likely to arise during the period when the mother still de- mands the attention of the physician, i. c, during the first six weeks of the infant's life. Baths. — The baby should be bathed once daily in warm water, but the bath should not be given inmiediately after nurs- ing. Until the cord has separated, the baljy should be sponged, rather than placed in the water , since any moistening of the cord would interfere with its desiccation. Care of the Funis. — If the cord was originally dressed asep- tically, and is afterward kept dry as long as it adheres, it ordin- arily separates as a dry eschar, and without suppuration. If, however, from any cause, infection occurs, and the cord separates by suppuration, leaving a moist, ulcerated surface, this should be Avashed with warm water and dressed with dry (preferably sterilized) oxide of zinc or powdered starch. This dressing, if undisturbed, usually forms within a few hoursa dry scab, which subsequently separates Avithout trouble. If the cord has been improperly cared for, septic absoriition may occasionally occur, and in such a case the treatment indicated is its immediate sterilization by iodoform or powdered salicylic acid ; but care must be exercised in the use of any antiseptics among neAv-born infants, on account of their feeble A'itality and their greater liability to poisoning by absorption of the anti- septics. Such a child should, further, be given from one to three drops of Avhiskey Ijefore each nursing, and eA'ery care should be taken to insure its procuring a proper amount of food; ?*. e., the inter- vals of nursing should, if necessary, be shortened, and the child encouraged to remain at the breast as long as it can be persuaded to suck. THE PUERPERIUM. 339 Clothin^G.' — The clothing of the infant should be loosely ap- plied. The tight bandaging which some nurses affect, not only- does hai'iu by restraining the movements of the chest, but also tends to produce an injurious intra-aljdominal pressure; which is not unlikely to result in the jiroduction of an umbilical or in- guinal hernia, instead of preventing it, as it is intended to do. Retention of Urine and F^ces. — Mothers and nurses are frequently much alarmed at the supijosed non-appearance of urine or faeces during the first few hours or days of the child's life. If the non-appearance of faeces has been definitely ascer- tained, it should always lead to an examination of the anus and rectum, in view of the possibility of an imperforate condition of the gut; but closure of the urethra is so extremely rare that true retention of urine is seldom or never seen, the fact being that the new-born infant secretes but little urine, and has usually emptied its bladder during the i^rocess of birth; so that if the child seems well, and the external meatus is properly formed, the family may be confidently assured that the absence of urine is purely temporary, and of no importance. Icterus Neonatorum. — Jaundice of the new-born infant is occasionally dependent upon structural lesions of the liver; it is then extremely intense, is associated with rapid emaciation, and presents the appearance of a serious disease, even to inexpe- rienced eyes; but such cases are fortunately extremely rare. Upon the other hand, the minor degrees of icterus are quite fre- quent among poorly nourished infants, and especially among the children of the ill-fed immigrant population of our cities. This common affection is usually associated with a slight loss of weight, but is always temporary and of no importance, and de- mands no treatment. Welght of the Child.— During the first three to five days of its independent life, the child receives, and can absorb, but little nourishment. It usually loses several ounces of its birth- weight during the first few hours, by excretion of urine and faeces, and also probably undergoes a somewhat rapid metabolism dur- ing the process of adaptation to its new condition. The result is an almost universal initial loss of from three to ten ounces, large babies losing more in proportion than those whose original Aveight is less. By the end of from five to ten days, the child should normally regain its birth-weight, and, if well, should from that time gain steadily. This is so distinct a rule that a fail- ure to gain, and more especially a loss of, weight, is, as a rule, at any period of infancy, the first and most significant sign of im- proper nourishment or of the existence of functional or organic derangements. 1 See page 113. 340 PRACTICAL MIDWIFERY. Nothing is more iinportaiit in the cure of infancy than daily "weighing of the child. This should be done as nearly as pussible at the same hour of the day, the most convenient time being im- mediately after the bath, and while the child is still naked. Even then some variation may occur, as the result of a dilTerence in the amount of food ingested, and in the amount of urine and fftjces excreted, day by day. The scales employed should register to ounces, and, if the circumstances of the parents peruut, it is well to purchase a spring dial scale, such as that sold under the name of the " Standard family scale," to be devoted to the use of the baby. The process of weighing may be much facilitated by lashing to the top of the scale a shallow basket, in which the baby can be placed. The daily weight should be entered by the nurse upon a chart or piece of paper, and preserved for the in- spection of the physician, beside the mother's temperature chart. Digestive System. — Sprue.— A. frequent source of alarm to the mother and family is the appearance of white aphthous patches upon the infant's tongue and mouth ; these patches are popularly known under the names of "thrush" and "sprue," and are in reality a low form of vegetable life which develops upon the buccal surfaces as the result of a fermentation which is dejoendent upon the use of a dirty bottle, of fermented milk, or other improper foods. The prophylaxis of the affection is evi- dent. When present, it may usually be removed within a few days by scrubbing the inside of the mouth with a saturated so- lution of borax. The nurse should wrap a piece of soft linen tightly about her forefinger, should dii^ this in the solution, and carefully rub it upon the whole of the affected surface. Regurgitation. — Infants which are being properly fed should regurgitate but little, if any, milk. Should this regurgitation be frequent or abundant, it is usually dependent either upon fer- mentation of the milk within the stomach, or upon too frequent or too abundant feeding; it may also be dependent upon an un- due richness, or other improper composition, of the milk. If it is due to the first cause, it may usually be remedied by careful cleaning of the nipples and the mouth. If it is caused by an un- duly rich milk, it should be treated by increasing the dilution of the food in bottle-fed babies, or by the administration, to nurs- ing infants, of one or two teaspoonfuls of water immediately before putting them to the breast. Bowels. — For the first few days of life, the child's dejections consist of dark green, tarry-like meconium, and then gradually assume the light yellow color, which is characteristic of the fipces of healthy infants. The bowels should move at least once daily; but the appearance of several dejections within twenty-four hours is of no importance, provided that the color and consist- THE PUERPERIUM. 341 ence reuiain normal. Frequency, in connection with a f?reen color and a watery consistence, is usually an indication that the food is in some way unsuited to the digestion. Constipation.— This should be treated by alteration of the food, if an J' impropriety can be detected in it; but if no such cause is found, it must be relieved by methods analogous to those used in adults. The rectum of the infant is so siurocess of absori^tion, in the course of which quite a perceptible ring of bone is deposited around the edge of the extravasations. This ring of bone gradually spreads inward, and results in the formation of a slightly thick- ened spot upon the skull, which thickening may be perceptible on close examination for many yea.rs. Cephalhsematoma are not perceptible at birth, but appear within the first few hours of ex- tra-uterine life, and last about a month. THE PUERPERIUM. 349 Malformations of the Heart.— Malformations of the heart or of the great vessels may be due to their deficient devel- opment or to the persistence after birth of normal fcetal condi- tions. An early arrest of the development of these important organs is seldom compatible with life. The only forms of late arrest of development which are sufficiently common to be worthy of notice are, deficient development of the inter- ventric- ular or inter-auricular septa ; either the ductus arteriosus or fora- men ovale may fail to close during the first few days of life. All of these malformations result in a persistence of the foetal circu- lation. Their causation is obscure. Symptoms. — Among the symptoms of an imperfect circulatory system, the most striking and invariable is cyanosis. The im- portance of this phenomenon is dependent upon its permanency. Transient cyanosis may be a result of asphyxia neonatorum, and is, moreover, common in otherwise healthy children during the first twenty-four to forty-eight hours after birth. It is most marked in the hands and feet, is probably due to a partial per- sistence of the foetal circulation, and disappears spontaneously. The affected parts are cold to the touch, and should be kept warmly wrapped ; no other treatment is needed. Persistent blue- ness is almost invariably the result of cardiac malformations. The transient affection usually appears within a few minutes or hours of birth. Cyanosis which is dependent upon organic lesions appears in the majority of cases during the first week, and usually within the first twenty-four hours ; but in a large minority it is absent until some weeks or even many years of normal life have supervened, and is then usually first observed after some exciting effort or in some debilitated condition. Such cyanosis is usually liable to an occasional paroxysmal increase, and is accom- panied by an increased radiation of heat, tendency to dyspnoea, palpitation, and occasionally haematophilia. Such individuals usually maintain a somewhat feeble existence until attacked by an intercurrent disease, but are then likely to succumb to ex- tremely mild attacks. Treatment. — The treatment should be mainly hygienic. The clothing must be warm, any exposure to draughts or other forms of cold must be carefully avoided, all excitements abso- lutely interdicted, and the diet watched with especial care. The only medicinal treatment which can possibly be of value is the moderate use of alcoholic stimulants, the occasional administra- tion of digitalis, and a resort to hot mustard foot-baths ; and the exhibition of oxygen, during the paroxysms. Malformations of the Lungs. — Deficient development of the lungs or of the lesser branches of the pulmonary arteries may result in deficient oxygenization of the blood and feeble 350 PRACTICAL MIDWIFERY. health. An ante-mortem diagnosis is but rarely possible. Some few cases have been reported in which a structural defect in the diaphragm was followed, after a few good inspirations, by dia- phragmatic hernia of the lungs into the abdominal cavity, fail- ure of respiration, and death. Atelectasis Neonatorum. — Closely akin to non-development of the lungs is the atelectasis of the new-born. This may be due to the plugging of important bronchi by inspired mucus, or to the child's failure to fully inflate its lungs after delivery. It is to be prevented by thorough clearing of the fauces with the little fin- ger before inspiration occurs, and by care to make the child cry loudly immediately after its birth. When atelectasis has occurred, its presence is evidenced by the absence of the respiratory mur- mur over the affected portion of the lungs. It is to be treated by stimulating respiration by any of the methods recommended for use in asphyxia neonatorum, aided by the tem^Dorary sup- port of life by the use of oxygen if necessary. Supernumerary Digits. — Extra fingers and toes are abnor- malities of not uncommon occurrence. Such digits may be at- tached to special supernumerary metacarpal or metatarsal bones, or may be attached by skin only. When extra metacarpal or meta- tarsal bones are present, they should be removed with the finger or toe by a set amputation. When the abnormal member is at- tached by skin and connective tissues only, it may be snipped off with scissors, or allowed to separate by necrosis, after ligature of its pedicle with a thread. In either case, the amputation should be iDerformed within a few weeks of birth, since it is then far less likely to leave a permanent scar than if deferred to a later period. CHAPTER XXIV. CARE OF PREMATURE INFANTS. Prognosis. — Children born before the end of the twenty- ninth week seldom survive ; but since the almost uniform loss of life at slightly earlier periods may, to some extent, be due to the want of care, engendered by a fixed belief in the non-sarvival of such infants, it should be a fixed rule that any child which breathes at birth should be treated as though it were viable. The chances of survival of an individual child depend mainly upon the degree of development to which its internal organs have attained; and since this is more dependent upon the period of utero-gestation than upon the size or weight of the child, its chances of survival are more nearly proportional to the period of its birth than to any other circumstance. The popular belief that eight-months children are less apt to live than those born after seven months of gestation is wholly erroneous ; except in so far as it is founded upon the fact that eight-months children seldom receive the care which is given to those born a month earlier. If, however, the attendants remem- ber that the life of a fairly well-nourished and approximately mature-looking infant of eight months is as much dependent upon scrupulous and painstaking care as is that of a feeble fojtus born four weeks earlier, and accordingly give to it the same minute attention, the proportion of survivals among the former will be much the greater. The usual method of death is either by the sudden appearance of a convulsion, which often comes entirely without warning, or by a progressive asthenia, evidenced by restlessness, refusal to swallow, and the production of a peculiar intermittent moan with each inspiration. If the life of a premature infant is preserved until the natural time of term arrives, and till an increase in its weight and strength appears, its chances of prolonged life are, in most cases, in no way inferior to those of infants born at full time. Nurse. — The three essentials in the care of all premature in- fants are : careful maintenance of the body heat ; reduction of the exhaustion caused by passive motions, i.e., by handling, to a mini- mum ; and a supply of pi-oper food, given in small quantities and 35-i VKACTICAL MIDWIFERY. at correspondinjjrly short intervals. The details which are neces- sary to the attainment of these objects are, however, so numerous that few premature children survive without the advanta^'e of having an intelligent attendant who is especially devoted to their care and has no other duties; for which reason, an effort to secure such a person should be the first and most essential st«p in treatment. The nurse, when provided, should be impres.sed with the un- doubted fact that, although the chances for the chikl improve with every day of its survival, there is yet no safety until it has attained the full period of nine months from conception ; nor then, until it begins to show a substantial gain in weight and strength; but that, on the contrary, uiDtothat time the slightest indiscretion may cause the sudden death of an infant which had previously done exceptionally well. Seven-Moxths Childrex.— Seven-months children should net be washed nor dressed, and should never be subjected to the fatigue of nursing. If such an infant is asphyxiated at birth, its resuscitation should be trusted, mainly, to immersion in hot water with the least possible use of the cold jilunge; since the abstraction of heat by, and the considerable use of, cold water is almost necessarily fatal by shock; while the handling involved in efforts at artificial respiration is necessarily attended by an amount of exhaustion Avhich must seriously compromise its chances. As soon as respiration has been established, such chil- dren must be wrapped at once in previously well-warmed cotton- batting or flannels ; and the further arrangements for preserva- tion of heat, which are to be shortly described, must be at once inaugurated. EIGHT-Mo^'THS Childrex".— Fairly well-developed and vig- orous children at eight months may be rapidly waslied in warm water, with the least possible amount of handling, loosely and quickly dressed, and at once placed under the proper conditions for the preservation of their heat. Seven-months children must be artificiavly fed, preferably with the mother's milk, for many weeks, or until the gain of strength is so far apparent that the muscular exertion of nursing is, in the opinion of the physician, Avithin their ]iowers. Eight-months children, if vigorous, may be put to the breast so soon as the milk appears; but all premature infants must begin to receive nourishment within a few hours after birth, and must be fed or nursed at short intervals, on account of the small amount of nourishment which the capacity of their stomach permits them to ingest at a single feeding. Maixtexance of Body Heat.— Tf no better means can be provided, the lives of many premature infants may be saved by THE PUERPERIUM. 353 a careful supervision of such simple preparations as can be made in any household. A large basket should be thickly lined with heated blankets or other flannels. A number of bottles filled with very hot water should be so arranged around the sides of the receptacle that they can be removed and reinserted without disturl>ance of the infant. The child is wholly covered, with the exception of its face, with well- warmed cotton-batting, and is laid between the bottles ; and the cradle is then covered with a thick blanket, a space at the end which corresponds to the child's head being left open to permit the entrance of air. A thermojueter should be laid beside the child; and one or more of the bottles should be refilled with hot water whenever the tem- perature is seen to fall below^ 87° F. The water should not, on the other hand, be so hot as to raise the temperature of the contained air much above 90^ F. It will easily be seen that the attention necessary to secure this small range of temi^erature is extremely fatiguing, but with i^roper care such uniformity is possible ; and if the other details of treatment are equally well carried out, it will usually save the life of the child. Incubator.s. — When the circumstances permit, much trouble may be saved and better results are upon the whole obtained Fig. 107. — Crede's Incubator by the use of the specially devised incubators; among which Tarnier's and Credo's may be taken to represent the two types which have been most successful. Crede's has the advantage of cheapness and simplicity of manufacture. It requires more con- stant attention than need be given to the Tarnier apparatus, and has been at the same time less successful. The experience of the Boston Lying-in Hospital, in which a modification of this arrangement has been used for many years, shows that the mortality which it yields becomes extremely high with every at- 23 354 PKACTICAL MIDWIFERY. teiupt tliat is made to reduce the amount of attention given to it. Cred('''s apparatus (Fig. 107) consists of a tub or cradle of tin or copper, made with double walls and floor. The space between the walls is filled with heated water, the tub is lined with flannel or cotton-batting, and the child, separately wrapped in the same material, is laid in the middle of the whole, and covered with a blanket. A thermometer is laid alongside the child, and another is passed between the walls through a hole left for the purpose so that its bulb is in the water. Uniformity of heat is attained in the original apparatus by drawing off a ])ortion of the water through a stop-cock, and replacing it with fi-esh, boiling water; EDESTOL. Fig. 108.— Tarnier's Incubator. in the apparatus shown in the illustration, by raising or lowering the gas-jet underneath. In the use of any such open apparatus, it is a matter of great importance to maintain a high and ap- proximately uniform temperature of the room in which it stands. Tarnier s incubator (Fig. lOS) consists of a wooden box with double walls 0.10 to 0.12 centimetres thick, and filled in with sawdust to prevent loss of heat. A central partition divides the box into two compartments, the one for hot water, the other for the infant's cradle. A metal case, of a capacity of about seventy- one litres, fits into the lower compartment, leaving a space of two to three centimetres, between its walls and those of the box, for the free circulation of air from below upward. The capacity of the upper comjiartment is about eighty-six cubic centimetres; there is free circulation of air between it and the lower compart- ment, and it is iu communication with the outer air by means of THE PUERPERIUM. 355 two openings: the one on its upper surface is slmt in by a double plate of glass; the other ojjens laterally hke a door, to afford an exit for the cradle. In each corner of this upper conipart- irient thei-e is a hole for the escape of the heated air fi-oin Ijelow. To the lower compartment, containing the hot watei", a ther- mometer is attached by an upper and loAver tube. When the lamp under this siphon is lighted, the heated water flows through the upper tube into the chamber, displacing an equal amount of Avater, which flows back into the siphon ; thus a current is estab- lished, the temperature of which can be raised to the desired point. In cold weather it has been found necessary to light the lamp three times daily, allowing it to burn each time about two hours. The laiup should be extinguished when the temperature in the lower compartment is about two degrees above the heat desired. The thermometer which registers this should be laid alongside the infant. The temperature should be maintained as near 90° F. as possible, 87° to 90° F. being the extreme limits Avhich are permissible. The children should be wrapped in cotton or loosely clothed, according to their age ; the wrapping should be so arranged that the napkins can be changed fxom five to six times daily, without further disturbance of tlie infant, which sliould never be lifted from the incubator except for nursing, when that is permitted. At the Paris Maternite one-third of all the cliildren of less than four and a half pounds weight have been saved of late years, while at Leipsic the total mortality has been reduced to 18/» ; but in comparing these results it must be noted tliat the Leipsic statistics include children up to six l^ounds. Feeding of Premature I^'faistts.— During the first twenty- four hours it is rarely necessary to administer to the child any- thing more than a little brandy, two minims of which should be given in from ten to twenty minims of warm Avater every two hours. It sliould afterward be fed Avith a medicine-dropper or by gaA'age, two to three fluid draclims of the mother's milk being introduced into the stomacli eA^ery hour. If for any reason the mother's milk cannot be employed, that of a wet-nurse, or prop- erly diluted, peptonized cow's milk, should be used. The method by which tlie food is administered is of great importance ; a pre- mature infant at first swalloAvs Avith difficulty, and, if the food be given by a teaspoon, mucli of it usually escapes through the lips. The prepared milk should be placed in the medicine- dropper; the tip of the tube should be passed into the child's mouth, close to the base of its tongue ; and the milk expressed, drop by drop; this process being repeated until the required quantity has been giA'en. If this method is successful, it may be employed throughout ; but if tlie milk is, eA'en when so giA'en, re- 356 PRACTICAL MIDWIFERY. gurgitated, in part or whole, Tarnier's plan of gavage should be employed. Gavage. — The infant is taken upon the lap, its head being slightly raised, and a soft-rubber urethral catheter, No. 14 to 16 French, is moistened and introduced into the mouth, and per- mitted to pass down the oesophagus by the child's efforts of de- glutition. The milk is then poured slowly into a small glass funnel, which is inserted into the upper end of the catheter, till one or two drachms have been introduced into the stomach, when the catheter is Avithdrawn by a single quick motion, since its slow removal is usually followed by vomiting. If too large a quantity of nutriment is administered in this way, the child may appar- ently increase in size and weight; but this increase is lartrely due to ffidema, which, if allowed to persist, must always result fatally. Two to three fluid drachms is usually well borne, unless by the smallest infants. When a seven-months child is four weeks old, it may be dressed and allowed to nurse ; but, in any case, all the other jireeautions must be scrupulously observed in their full rigor until the calcu- lated time of term is passed, and until the gain in weight and strength which is appropriate to that time begins to appear. CHAPTER XXY. HEMORRHAGES. PELVIC COMPLICATIONS OF THE CONVALESCENCE. INTERCURRENT DISEASES. Secondary Haemorrhage. — The term poet-partum haemor- rhage is usually limited to a loss of blood within the first two hours after delivery. Any later flooding is known under the name of secondary haemorrhage. Such secondary bleeding is commonly announced either by the patient's perception of the escape of blood, or by sudden faintness upon her part. It must not be forgotten that occlusion of the internal os by a clot, and subsequent concealed haemorrhage within the uterus, is by no means unknown ; so that any sudden faintness during the puer- perium should lead to an immediate determination of the size of the uterus by palpation. The treatment of secondary haemor- rhage is in all respects similar to that of post-partum haemorrhage. The uterus should be immediately emptied by expression, or by the internal use of the hand ; contraction and retraction should be secured by friction over the fundus, the use of hot-water in- jections, etc., and maintained by guarding the fundus with the hand and by the use of ergot. Placenta Succenturiata. — It occasionally happens during the development of the placenta that a few chorionic villi at a distance from the placental site persist, develop, and form an auxiliary or so-called succenturiate placenta; in which case the elementary choi'ionic vessels which connect the two placentae also persist and join the umbilical vessels. In such cases it usually happens that the succenturiate placenta is torn away from the membranes and left in utero during the third stage of labor ; an occurrence which can usually be diagnosticated by ex- amination of the membranes by transmitted light, when, if the placenta succenturiata exists, it Avill be seen that large vessels pass off through the membranes, from the circumference of the main placenta, and terminate abruptly in torn extremities. If such vessels are found, their existence is a quite sufficient indica- tion for an intra-uterine search for a subsidiary after-birth. The presence of such a body in the uterus usually I'esults in the pro- duction of a secondary haemorrhage after a variable jDeriod. 358 PRACTICAL MIDWIFERY. The bleeding is partly due to its detachment from its uterine site, and partly to the distention of the uterus by a foreign l)ody. Treatment. — The immediate removal of the suceenturiate is the only rational treatment. The method should be that which would be adopted in retention of the normal placenta. When secondary haemorrhage occurs, the possible existence of a placenta succenturiata should always be remembered, and the uterine cavity should be thoroughly explored for such a body after the removal of the clots which are almost invariably found. Fibroid Tumors.— i)m<7«06is.— Submucous sessile fibroids may give rise during the first few days of the puerperium to no other appearances than an undue size and firmness of the uterus, but become aijparent later, on bimanual examination and the use of the sound, owing to the fact that the involution of the uterus is more rapid and complete than that of the tumor. The other varieties are easily ai^preciated by palpation immediately after labor, by reason of the irregular contour which they give to the organ. Prognosis. — The dangers which their presence involves are those of secondary haemorrhage, and septic absorption from possible sloughing of the tumor by the decrease of circulation due to the jDrocess of involution. The lochia in such cases may be increased and prolonged by heemorrhage due to the tumors, which is especially frequent in the pedunculated, submucous va- rieties, or they may occasionally be scanty and almost without color, Hcemorrhage, if it occurs, is usually slight, but is exhaust- ing from its long continuance. Sloughing results in the produc- tion of a mass of necrosed tissue situated over a thin spot in the uterine wall. It exposes the patient to the danger of septic ab- sorption, and even of rupture of the uterus, during any intra- uterine manipulations that may be undertaken. Treatment. — The treatment of hjemorrhage due to fibroids must consist in ordinary cases of a systematic administration of ergot ; but in case of failure to check the flow by the use of this drug, and of the continuance of the haemorrhage to a point at Avhich the loss of strength becomes serious, the gentle use of the blunt wire curette, under full antiseptic precautions, to be fol- lowed if necessary by an intra-uterine application of Churchill's tincture of iodine, or of diluted Monsel's solution, may result In at least a temporary arrest of the bleeding. The further prog- ress of the case should then be conducted upon the ordinary principles laid down in text -books on gynaecology. When a fibroid is found to be present and a foul uterine dis- charge appears, the possibility that sloughing of the tumor is taking place becomes so great that an intra-uterine examina- tion by the finger should be made, when, if a broken-down condi- THE PUEKPEKIUM. 359 tion of the tumor is found, it should be removed as gently as pos- sible by a cautious and gentle, but thorough and px-olonged, use of the blunt wire curette ; it being remembered that the uterine ■wall at the site of the tumor is probably thin, and is, moreover, often softened by an extension of the necrotic process ; and that the greatest care must be used to prevent opening the peritoneal cavity by a too forcible use of the instrument. VuLVO-VAGiNAii THROMBOSIS.— The accident is caused by a submucous rupture of one or more veins, from the increased venous pressure of labor. The return of the blood from the pelvis is prevented by the occlusion of the veins under the pres- sure of the advancing head during the second stage of labor. If the walls of the veins are weak, the increased pressure may be followed by their rupture and an effusion of the blood into any of the submucous spaces of the pelvis, but the most common site of this accident is behind or at the side of the vagina, in the immediate neighborhood of the vulva; from whence the effusion may extend upward through the connective tissues below the pelvic diaphragm, or outward under the superficial fascia of the perinfeum, groins, or, exceptionally, the abdomen and thighs. Thrombosis may also occur, though very rarely, in the substance of the cervix. If the rupture occurs early in the second stage, and is followed by an immediate effusion of blood, the tumor may be detected during labor, and may often be sufficient to constitute an obstruc- tion to the descent of the head; but in many cases the effusion does not take place until after delivery, and the condition re- mains unsuspected until pain or collapse attracts attention to the possibility of its occurrence. It may appear at any time dur- ing the first twelve hours of the puerperium. The condition may terminate in (1) immediate death from loss of blood without rupture of the tumor; (2) in death by external haemorrhage after bursting of the tumor, which may be the result of simple rupture or of the sloughing of its walls from pressure ; (3) in septicaemia due to sloughing, or to suppuration or necrosis of its contents, without rupture ; (4) in recovery, either by spontaneous absorp- tion of the effused blood, or by union of the surfaces of the cavity by granulation after its evacuation. Diagnosis. — The symptoms which suggest this accident are the appearance of a sudden and severe pain at the side of the vulva, more or less severe collapse without external loss of blood, and, on examination, the presence of an elastic tumor either in the cervix or behind one or the other labium. If the tumor contain fluid blood, it will yield a more or less distinct fluctuation, but after coagulation has occurred it has a somewhat boggy feel. 360 PKACTICAL MIDWIFERY. 2Veatme7it. — If the tumor is found during labor and is not large enough to cause a serious obstruction to the advance of the head, immediate delivery by forceps is mdicated; if, however, the tumor when first discovered is so large as to i^revent the ad- vance of the head, its surface should be incised, the clots rapidly turned out, and the head immediately extracted. This, how- ever, should not be done until the materials necessary for the control of the resulting haemorrhage have been placed in readi- ness. Immediate delivery is indicated in either case ; becc^use the pressure of the head necessarily produces venous stasis, and tliuo favors the increase of the tumor. This same jjressure is, how- ever, sufficient to prevent any immediately serious loss of blood, for which reason no flooding need be apprehended until after the delivery of the child. After delivery, in such cases, the re- mainder of the treatment is precisely similar to that which should be adopted when the incision is made at the time of election. If the tumor is only discovered after labor, or if the delivery of the head without incision is possible, it is best to quiet pain by the administration of opiates; to enjoin absolute quiet in bed, and the avoidance of all straining efforts (for which reason the urine should be drawn by the catheter during the first forty- eight hours) ; to make persistent use of ice poultices, or of the jDressure of a coliDeurynter inserted into the vagina and filled with iced water, in the hope of restraining further hiemorrhage, and permitting the absorption of the effused blood, since this is the most favorable termination possible, and its attainment is often possible if the tumor is small. The case should be carefully watched, and examined at least daily; at the first sign of sloughing, as shown by discoloration or vesication of the surface of the affected labium, or of sui^pura- tion as evidenced by the return of fluctuation, the tumor should be incised. It is better to wait for the advent of these symptoms, not only on account of the chance of absorption, but because an earlier evacuation of the cavity is likely to be followed by a se- vere hsemorrhage, for which reason it is better to w^ait until the vessels have become plugged by clots. After the appearance of suppuration or sloughing, no delay should be permitted, since any further delay can but increase the danger of septic absorp- tion. When interference has been decided upon, a good assistant should be procured, the patient should be placed in the lithotomy position, a plentiful supply of properly i^repared absorbent ma- terial and a quantity of Monsel's solution diluted to the color of sherry wine should be placed at hand. The tumor should be opened by an incision of from two to three inches in length THE PUERPERIUM. 361 along the inner surface of the labium ; the clot should be rapidly turned out, and the cavity syringed with an antiseptic solution ; if haemorrhage occurs, it should be controlled by making j^res- sure on the walls of the cavity with a wad of gauze or absorbent cotton which has been wrung out in the diluted Monsel's solu- tion. It should then be distended by packing it with small pledgets of the absorbent material which have been previously treated with iodoform or with a strong solution of creolin ; the latter being the better, since it is equally efficient as a styptic and deodorizer, and on account of the by no means small danger of iodoform poisoning which attends upon the use of the latter drug in recent enclosed wounds. The packing should be removed at the end of not more than twenty-four hours, and the cavity should be washed out and re- packed. Absolute rest in bed should be enjoined, all action of the bowels should be prevented by the use of opiates, and the urine drawn by a catheter. The diet should be mainly composed of liquids, and of those solid substances which are likely to produce the least amount of faeces, but should always be sustaining, in view of the exhaust- ing effects of the inevitable loss of blood and possible sepsis. PEiiVic Complications op the CoNVAiiESCENCE.— This subject has been almost universally neglected in text-books upon obstetrics, being probably considered unworthy of notice, and a part of the domain of gynaecology ; but the prevention of subse- quent pelvic disease is no inconsiderable portion of the obstetri- cian's duty, and the subject of minor pelvic complications aris- ing in the absence of sepsis is of immediate and practical every- day importance in the management of labor. In speaking of these accidents as independent of sepsis, it must, however, be stated that, although they frequently occur without well-marked septicaemia, they are probably, in fact, always due either to the recurrence of a previous local trouble caused by the strains and contusions of labor, or to a mild degree of septic absorption which is sufficient to cause local inflammation, although not enough to cause a general systemic infection. Subinvolution. — Subinvolution may affect the uterus, vagina, uterine ligaments, and abdominal walls. The delay may be caused by any inflammatory process, of which septic inflam- mations are by far the most common ; or may be due to the in- ability of the ligaments and walls to undergo their normal retrac- tion, owing to the constant strain imposed upon them by a too early assumption of the erect position. It may result, when un- treated, in the production of a chronic pelvic congestion, or in any of the uterine malpositions. It is rarely detected before the completion of the first ten days, 3G2 PRACTICAL illDWIFERY. partly from the inherent conditions of the case, partly because the necessity for the observance of antiseptic precautions ren- ders it unwise to institute a vaginal examination before that time. If, however, at any period during the puerperium or con- valescence, the characteristic symptoms of heat, sense of weight and dragging in the pelvis, return of the red color to the lochia, backache, and indefined pelvic pains appear, a careful examina- tion should be made ; and if the pelvic organs are found to be large, soft, and sagging, treatment should be at once instituted. Treatment. — This should usually consist of the use of hot- water douches, given in quantities of one to six quarts, the pa- tient lying upon her back with her hips somewhat elevated ; the water should be injected from a douche-pan or fountain syringe, under the force of a hydrostatic pressure of not more than two or thi'ee feet, at a temperature of from 100° to 110' F. ; the quan- tity of water and the degree of heat being graduated to just the amount which is productive of a sense of comfort, rather than of fatigue, to the patient. If, as occasionally happens, the use of hot-water douches is followed, in spite of all care, by fatigue, headaches, or exhaustion, they should be discontiued, and the bi-daily insertion of small tampons soaked in equal parts of gly- cerin and water should be employed instead. In case these means fail, and a careful bimanual examination demonstrates the absence of any localized inflammatory condition, the use of faradic electricity is sometimes beneficial. The negative pole should be attached to a large abdominal electrode while the positive is passed into the vagina ; an extremely weak current should be used at first, and should be gradually increased to the highest point which is borne without discomfort; maintained at that maximum for a few moments, and as gradually decreased, the whole stance lasting no longer than ten minutes. The appli- cation should be repeated on every second or third day, glycerin tampons being used in the intervals. The use of ergot in the treatment of siibinvolution has been enthusiastically advocated and as warmly condemned. Its pos- session of any power of initiating and stimulating the process is extremely doubtful; but it is undoubtedly useful as an adjuvant to other means. It may be given in a fluid extract, 20 to 30 minims, three to four times daily, or in two-grain ergotin x^ills with the same frequency. Subinvolution of the abdominal walls is most common after great distention, as in the case of twin pregnancy or hydramnios, and in multiparse. It is important, as being the chief element in determining loss of figure, a matter of no small interest to most women, and also because the alteration of the intra-abdominal pressures due to a pendulous abdomen usually results in the pro- THE PUERPERIUM. 363 duction of pelvic pain after a greater or lesser length of time. Treatment of this condition should consist in the application of constant and firm, though not excessive, support by a properly adjusted binder; in increased duration of the period of confine- ment to bed ; light, quick friction of the abdomen ; massage ; and, in occasional cases, faradization as already described, but if sub- involution, of the pelvic organs is absent, the positive electrode should be applied to the abdominal muscles near their origins or insertion. Malpositions of the Uterus. — Malpositions of the uterus are usually combined with subinvolution, and seldom cause symptoms of importance unless so complicated. Immediately after delivery, the uterus normally occupies a position of considerable prolapse and marked ante version, and during the first twenty-four hours rises to about its normal posi- tion by a process of muscular retraction, in which the ligaments partake equally with the uterus ; but is then so large and heavy that its fundus falls about from side to side as the woman moves. For this reason, if no other, restraint to the dorsal position is in- advisable, since the strain upon the uterine supports which results from this decubitus is not unlikely to result in a relaxed condi- tion of the round and of the upper portions of the broad liga- ments, and may thus initiate the production of a posterior mal- position. So also the over-tight application of a binder may result in the production of a partial prolapse, with or without retroversion. When either of these displacements has existed previous to i>regnancy, it is almost certain to recur unless pre- vented by mechanical treatment ; but if such treatment is adopted during the later portion of the puerperium, the displacement may often be permanently cured, instead of being simply relieved, as is unfortunately so often the case at other times. The diagnosis of malpositions of the uterus must depend upon the previous history of the patient ; upon the appearance of pain in the back, groins, or hips, not permantly relieved by rest in bed ; the reappearance of the red color of the lochia ; and finally, and most important, upon bimanual examination. When the existence of such a condition is suspected, the patient should be examined during the latter part of the second week, and a Hodge pessary of suitable size should be adjusted if a pro- lapse or retroversion is found; but owing to the fact that the vagina may be expected to rapidly decrease in size, the examina- tion should be repeated at intervals of a few days, and the pes- sary should be constantly reduced in size, pari passu, with the involution of the passage. The upper limb of the pessary must generally be of unusual length, in order to prevent the production of a retroflexion, which is likely to occur if the heavy fundus is 364 PRACTICAL .MII'W IKEHY. unsu|)ported and the pressure of the pessary is directed against the middle jjortiun of the still soft and llexible uterus. The pes- saries sold under the name of "patent process" are usually the most convenient for this purpose, from the fact that-tliey can be readily moulded to suit the individual case. Cellulitis. — Diffuse inflanunation of the connective tissues of the broad ligaments, and of the other spaces in the pelvis fac- companied or not by salpingitis), is usually of septic origin; it is, however, not very infrequent in aseptically conducted labors, as the result of the contusion of old inflammatory deposits during labor, but is then probabh* more likely to occur if these inju- ries were originally due to sepsis. The symptoms which should lead to a suspicion of such a con - dition are the appearance of a slight rise in temperature and pulse, accompanied by pain and tenderness on one or both sides. The tenderness is usually less Avell marked over the uterine body, but is increased by passive motion of the fundus. Any such train of symptoms should invariably lead to a careful bimanual examination. If a cellulitis is found, the treatment should con- sist of the administration of saline cathartics in small and re- peated doses, unless the pain be so severe as to require opiates; the application of poultices over the lower portion of the abdo- men; and rest in bed. In non-septic cases this course of treat- ment usually results in resolution of the phlegmon within a few days. Cystitis. — Cystitis during convalescence from labor is usually due to the introduction of lochia into the bladder during cathe- terization, though a mild vesical irritation njay follow a too con- stant use of the catheter. When cysititis has appeared, the use of the catheter should be avoided so far as possible; opiates should be freely administered, preferably in suppositories; diu- retics and demulcent drinks, such as elix. buchu et pot. acet. (N.F.), acetate of potash (gr. xx. in a half-tumbler of water), lithia and Apollinaris water, etc., should be taken frequently and in large quantities; and in severe cases the bladder should be washed out once or twice daily, in the hope of arresting the dis- ease. This is most conveniently done by attaching a full- sized silver or elastic Avebbing catheter to the tube of a foun- tain syringe; a saturated solution of borax being generally the best fluid. The bag of the syringe should be so suspended that the free surface of the solution is not more than twelve to fifteen inches above the pubes of the jiatient ; the catheter should be passed and the urine withdrawn ; the instrument should then be attached to the tube of the syringe, care being taken that neither the catheter nor sj'ringe contains any air, and the fluid allowed THE PUEKPEKIUM. 365 to flow into the bladder until a sense of fulness or discomfort is complained of. At the fu-st indication of this condition, the connection between the catlieter and syringe should be broken, and the injected fluid should be expelled by the patient. This process should be repeated, if necessary, on several successive days; and may often be followed, with advantage, by the in- troduction of from five to ten grains of iodoform suspended in the solution of borax, and injected through the catheter with a small syringe after the withdrawal of all but a small quantity of the previously injected fluid; or, if it be preferred, the iodoform may be incorporated into a small gelatin bougie, which can be introduced into the urethra, and then urged into the bladder by pressure upon it through the anterior vaginal wall. HEMORRHOIDS. — Hajmorrhoids are not an uncommon compli- cation of the convalescence, and are often iDroductive of great discomfort. Treatment should consist in securing free daily move- ments of the bowels ; in the application of the ung. gall, et op. ; and the local use of hot- water compresses ; or of ice poultices, con- structed by mixing ice, broken to the size of a walnut, with a suffi- cient quantity of Indian, rye, or other coarse meal. IXTERCURREXT DISEASES. — Pneumonia.— It is probable that there is a somewhat increased liability to acute lobar iDneumonia during the convalescence from labor; when it occurs the pyrexia is apt to be rather high. The prognosis is rather worse than that of pneumonia in general. It is not infrequently associated with a general septic infection, in which case the prognosis is distinctly bad. The treatment is that of pneumonia. Scarlet Fever. — Scarlatina was formerly confused with the erythematous eruptions which are not infrequent accompani- ments of septic infection, and was then considered an extremely common complication of the convalescence; it is in fact infre- quent. It may be contracted by a puerpera either by the ordi- nary infection localized mainly in the throat, or through a con- tamination of the fresh wounds in the genital tract by the path- ognomonic germs of the disease. "When the affection is vaginal, the stage of incubation is shortened, averaging from twentj'-four to forty-eight hours. The rash is most marked in the neighbor- hood of the vulva, and the appearances which are familiar in the throat, i.e., redness, swelling, and pseudo-diphtheritic patches, are found in the vagina. The diagnosis is to be made from a known exposure to the disease, and the appearance of the rash ; it is sometimes impossible until after desquamation occurs. The disease is not infrequently attended by inflammatory pelvic com- plications. Its prognosis is that of scarlet fever in general, modi- 3GG PKACTICAL illDW IFEKY. fied by the prognosis of any jielvic complications which may be present. Eryaipelas. — Whether erysipelas is or is not identical with sepsis is still a matter of discussion among l^acteriologists, but practically the question is unimportant, since it is universally admitted that the erysipelas is to be prevented b^ strict asepsis, and that when it is present its treatment is identical with that of sepsis. Diphtheria. — The relation of diphtheria to sepsis is identical with that of erysipelas. Malaria. — An increased liability to malaria during the puer- perium is generally admitted, and patients who have already been subject to paroxysms of intermittent fever are almost invariably aflflicted by its recurrence at this period. The type of the disease is occasionally extremely severe, but is ordinarily somewhat light ; its treatment is unaffected. Aente Articular Rheumatism. — A somewhat increa.sed liability to this disease has been alleged, but it is possible that this belief is due to a confusion between septic arthritis and rheumatism. Delirium Tremens. — Labor, like jineumonia and fractures, may be followed in drunkards by an attack of delirium tremens, which, on account of the exalted nervous susceptibility of the puerpera, is usually severe. The treatment should consist of forced feeding, and a moderate use of the bromides and chloral. If circumstances render it possible, the patient should be left untied in bed, but should be prevented from leaving her bed by the constant presence of a trained attendant. The delusions of delirium tremens are invariably those of terror, and a nurse who agrees with the hallucination, and promises ]irotection, is usually successful in quieting the patient : bromide and chloral should be used sparingly. The prognosis of the affection when it once exists is extremely grave, but if the habits of the patient are such that an attack is apprehended, it may often be averted by the administration of moderate doses of liquor from the moment of delivery ; after it is once i:)resent, the expediency of giving alco- hol is doubtful. Diseases of the Urixart System.— The urine of a puer- pera is normally increased, both in quantity and in its percentage of solid constituents; that is, the kidneys are required to perform an increased amount of work during the convalescence from labor: there is, consequently, an a 217-iori probability that any previous renal disease will be subject to an increase of severity at this time, and that such an increase does occur has been substanti- ated by clinical experience. Chronic nephritis is not infrequently first detected at this time, but it is probable that, in most of such THE PUERPERIUM. 367 cases, the disease lias been of long standing, although previously undetected. Septic infection through the lower urethra, and the introduc- tion of foul lochia into the bladder by instrumental means, may result in inflammations of any or all portions of the urinary tract. Partial or complete occlusion of the ureters may follow upon the bruising of pi-olonged or operative labors. CHAPTER XXVI. DISEASES OF THE BREASTS. Galactorrhcea. The term galactorrhcea includes two forms of abnormality — the secretion of a ijathologically large quantity of thin, watery milk, and persistence of the normal secretion after the removal of the baby from the breast. The first form may be very exhausting to the mother, almost invariably results in illness of the child if nursing is persisted in, and usually appears toward the end of a long lactation. The second form is less important but may be extremely annoying to the patient ; it is usually seen in women who have been fine wet-nurses, after the death or removal of the baby. In the first form, weaning of the child, a nutritious diet, the use of iron, complete rest, and light support of the breasts, usu- ally cause the disappearance of the secretion. Atropia and its derivatives are best withheld, because their constitutional effect is seldom desirable for the mother. In the second form the main reliance must be placed upon carefully adjusted and vigorous general pressure upon the breasts, in conjunction with the free use of saline cathartics or the continued administration of moderate doses of atropia ; large, fleshy women with an abundant but not over-rich secretion being generally most benefited by saline derivation, while those of more spare build or less abundant secretion are best suited by the use of atropia. If pressure is necessary it may be applied by a breast bandage or the dressing of contractile collodion de- scribed under mammary abscesses. DiMixiSHED Secretiox OF MiLK. — A diminution in either the quantity or quality of the milk is always dependent upon some deficiency in the general condition of the mother, and can be combated only by careful attention to the details of her gen- eral hygiene, by increase in the amount of fluids ingested, and a highly nutritious diet. Chocolate, cocoa, the heavier beers, oatmeal porridge, eggs, and milk all enjoy a deservedly high reputation for the diet of nursing mothers; but to secure rest, freedom from care, from THE PUERPERIUM. 369 anxiety, and other emotional sources of disquiet, is frequently a niucli more important point in the treatment of the affection. It must be remembered that a long lactation is no slight drain upon the vitality of many women ; and that when the failure of the breasts is secondary to the exhaustion of unduly prolonged nursing, there is but little hope of building up the patient while the secretion continues. An inferior quality of milk is always in- jurious to the baby: and, in such cases, weaning should therefore be recommended and urged to the mother, in the interests of both patients, unless a wet-nurse can be provided. Sore NiPPiiES. The painful and by no means innocuous lesions which are usu- ally grouped together under this head occur most frequently in primipane, and especially in women whose nipples, from the pres- sure of corsets or other causes, have become flattened or otherwise deformed. They ai'e best described under the heads of excoria- tion, fissure of the apex, and fissure of the base. EXCORIATION'S. — Excoriation of the nipple is the result of a maceration of its delicate epithelial covering, produced by the constant flow of milk over its surface, when re-enforced by the friction of the baby's tongue and lips, during the act of nursing. It is especially common during the first weeks of lactation, and results in the production of a raw, papillated, strawberry-looking spot, which may be so large as to cover the greater part of the nipple. It is excruciatingly painful when touched, and frequently becomes covered, during the intervals between the nursings, with small scabs, the removal of which by the nurse, or by the act of nursing, may cause considerable discomfort and sometimes slight bleeding. The affection, like all other forms of sore nipples, is of the greatest importance on account of the liability to septic absorp- tion which it initiates, and of the danger of the formation of a parenchymatous abscess which consequently attends its existence. If allowed to become extensive and inflamed, it may form a most obstinate and annoying lesion ; but if treated early, it may usu- ally be relieved in from twenty-four to forty-eight hours. Excoriations tend to heal rapidly if protected from macera- tion and mechanical irritation, which objects ai'e to be attained by the use of some astringent application or by a temporary dis- continuance of the rough handling which the nipple invariably receives from the baby's mouth. The applications most valuable for this purpose are powdered tannic acid, the compound tinc- ture of benzoin, and the solid stick of nitrate of silver. If tannic acid is used, it should be spread thickly over the affected surface 24 370 PRACTICAL iriDWIFERY. and covered by a bit of linen cloth .sli-^'htly fj:reased with vaselin to prevent stickinj^. The compound tincture of Ijenzoin should be applied in several successive thin layers with a caniel's-hair pencil after the injjple has been carefully dried by a soft bit of linen cloth. If nitrate of silver is used, the solid stick should be applied to the affected surface, but not until both the lesion and the surrounding skin have been carefully dried, since the mois- ture of the excoriated surface is abundantly sufficient for the pur- pose, and a too extensive application of the caustic may only re- sult in an enlargement of the excoriation. Tannic acid labors under the disadvantage that its use pre- supposes that nursing from that breast is to be temj^orarily sus- pended, since the ingestion of the superfluous tannin from the Fig. 109. — Mrs. Bailey's Breast Pump. Fig. 110.— Acme Nipple Shield. nipple would almost certainly disturb the baby\s digestion. If it is employed, the use of the affected breast must be replaced by the bottle, and the nurse must relieve the breast at the end of the usual interval, by milking it with the hand or by a careful use of the breast pump (Fig. 109); the difference to the breast between these processes and that of nursing being that the mechanical irritation of the nipple by the motion of the baby's tongue is done away with. If the nitrate of silver or the compound tincture of benzoin is used, it is, however, possible to continue the use of the affected breast by employing a iiroper nipple shield. My own experience has been that the compound tincture of benzoin, in combination with a nijiple shield, is, if employed early, a thoroughly satisfactory method of treatment for almost every case, and I cannot Ijut believe that the many physicians •who condemn the nipple shield upon the ground that it is refused THE PUEKPEKIUM. 371 by the bal)y owe their failures to a want of proper persistence in its use. [t certainly is a fact that most babies decline at first to nurse the shield; but if it is properly constructed, if it is tightly applied to the breast, and if after the shield is in position it is partly filled with milk expressed from the breast by the fingers of the nurse, a very little persistence in its use is almost always crowned with success. Much, however, depends upon tlie form of shield used; those furnished with a rubber tube should l)e unhesitatingly con- demned, on account of the absolute imjiossibility of securing sufR- eiently exact cleanliness of the tube, and because of the certainty with which their use is followed by the appearance of sprue or of more serious digestive troubles. Two forms only are to be recommended— that known as the " Needham (' Mother, don't you cry')" and that sold tinder the name of the "Acme" (Fig. 110). The two are exactly alike in principle; but the jSTeedham is made throughout of rubber and is someAvbat more complicated than the Acme, which consists of a simple glass shield, to which the ordinary rubber nipple is directly attached. Either form must be taken apart after each nursing, throughly washed, and kept under water in a carefully cleaned tumbler. Fissure of the Summit.— A fissure of the summit is an ex- tension of the natural division between the papillssity for its arrest Vjecomes apparent, the same method should l)e employed; but in such cases the fre- quent relief of over-distention by massage or the breast jjump is usually necessary. GalactoceI/E. — It occasionally happens that a milk duct may become permanently plugged, and result, by dilatation of the gland behind it, in the formation of a cystic tumor filled with milk, which may exeeiDtionally attain an extreme size. The affec- tion is chronic, belongs more properly to surgery than to obstet- rics, and can be treated only by the knife. Milk Fistula. — When a lactiferous duct has been opened by a wound or by the extension of an abscess, a fistula results, which may continue to discharge pure milk, or milk more or less mixed with pus, for many months or years. It may sometimes be closed by i^ersistent compression of the breast; occasionally by the inflammation excited by injections of tincture of iodine or a tAvo-per-cent solution of nitrate of silver, repeated two or more times weekly with a small syringe ; but may sometimes, on the other hand, be so intractable as to yield to nothing but the curette, or even require a dissection of its tract and the removal of the offending acini. CHAPTER XXVII. SEPTICEMIA. Puerperal fever is a term which has been used from time ahnost immemorial to designate the febrile affections of child- bed, but in the light of modern knowledge it should be restricted to cases in which septicaemia is developed by the absorption of foul material through wounds due to parturition. In this sense the words puerperal fever will be used in this chapter. It follows from the definition given above, that puerperal fever must always be due to the introduction of organic germs or their products into the blood of the patient. It is a matter of common knowledge that the usual source of such infection is through defective cleanliness of the hands or instruments of the accoucheur or nurse, one or the other of whom must always be held responsible for the causation of the disease; unless some probable source for an autogenetic origin can be found, for it must not be forgotten that, although such cases are extremely rare, they do undoubtedly exist. The most common cause of an autogenetic sepsis is the per- sistence of a former attack of sepsis, under the guise of a chronic salpingitis, whose quiescent germs may be lighted into activity, if they are expressed by the force of labor from their seat in a partially encapsulated tube into the previously healthy cavities of the uterus or pei-itoneum. If these rare cases are excepted, obstetric septicaemia is a preventable disease; but though this statement is absolutely true in theory, it must not be forgotten that the attainment of absolute asepsis is a most difficult achieve- ment, and that instances of infection do occasionally occur in the practice of the most careful men ; so that it should be said that septicaemia may sometimes be the result of a failure to observe exti'aordinary precautions, rather than of the neglect of ordinary carefulness. In estimating the importance of each case of puerperal fever, two factors must be considered — the amount of constitutional in- fection, or true septicaemia, which is present; and the severity of the local lesion, wliich is the source of that infection. The amount of constitutional impression is, to a considerable degree, independent of the extent and severity of its initial lesion. Lo- 25 386 PRACTICAL MIDWIFERY. cal affections of the most alariuiuK appearance may be accompa- nied by sejjtic absori>tion which is only sufficient to cause a feel- ing of lassitude and depression, with but a slight decrease in any of the secretions, and a very moderate elevation of temperature. Cases of mild infection tend, as a rule, to spontaneous recovery after a variable number of days, l>ut are by no means unimpor- tant, since they often result in an undue prolongation of the con- valescence, and in the jjroduction of chronic pelvic troubles. Upon the other hand, local lesions of the most insignificant appearance are not infrequently followed by a severe and pro- longed sejisis, which may end in recovery, or may terminate fatally either as the result of general exhaustion and a ijarenchymatous degeneration in all of the vital organs, or by the production of metastatic abscesses and distinct pyemia. The form of septicfemia to which Garrigues has given the title of aeutest septictemia is the result of the absorption of a poison of such extreme virulence, or in such overwhelming quantities, that death results from paralysis of the heart before a sufficient time has elajased to j^ermit the production of any visceral degen- eration. Such an attack is fatal within two or three days, and is, fortunately, extremely rare. The local affections which may occur are: decomposition of the lochia or of retained clots; so-called diphtheritic patches upon the vulva, vagina, or cervix; endocervicitis, and endo- metritis; purulent, diphtheritic, or gangrenous luetritis, iiara- metritis, salpingitis, or ovaritis ; pelvic and general peritonitis ; any of which affections may, if untreated, extend into the adja- cent tissues, either by way of the lymphatics, or along the- blood- vessels. The local lesion is always the source of infection, and its progress must be arrested before any constitutional improve- ment can be hoped for. Symptomatology axd Diagnosis. — The first sign which usually awakens the suspicion of the attendant is an elevation of temperature; and though every elevation of temperature during the puerperal period is not due to sepsis, it should always arouse the physician to the use of every effort to account for its appearance. It may be due to a simple reaction after the ex- haustion of labor ; to constipation ; to engorgement or threatened abscesses of the breasts; to acute nervous disturbances, such as puerperal mania; to sepsis; or to the onset of some intercurrent febrile disease of non-obstetric origin: so that the differential diagnosis must rest upon the presence of the other symptoms of obstetric sepsis, and the exclusion of all other possible causes. The ])yrexia of a simple reactionary fever api)ears within twenty-four hours of labor, while the onset of sepsis is rarely seen before the third day. Septicfemia is most likely to appear on THE PUERPERIUM. 387 the third, fourth, or fifth day, and the hkehhood of sepsis de- creases with the distance from that date. A rise of temperature due to constii^ation is commonly grad- ual; that caused by the onset of the more common acute diseases, or by affections of the breasts, is more frequently sudden, and is often attended by a chill. The temperature of sepsis may ap- pear in either form, but a sudden rise attended by a chill is common only in the mo.st virulent forms, and is then accom- panied by a well-marked group of other symptoms. The other symptoms distinctive of obstetric septicfemia are diminution and foulness of the lochia, a decreased secretion of milk, and the appearance of abdominal and pelvic tenderness; but in the presence of a rise of temperature during the puerpe- rium the physician, in addition to searching for these signs of sepsis, should inquire into the state of the boAvels ; should himself inspect the breasts; should examine the throat for tonsillitis, and the chest for ijneumonia or pleurisy ; and should use eveiy effort to exclude the presence of any other general disease. In doubtful cases or when any of the signs of septicemia are present, he should never neglect to make a systematic examina- tion of the genitals, both by sight and touch. The abdomen and breasts should be palpated ; the pad should be inspected, and the presence or absence of a foul odor ascertained ; the vulva should be exposed with a Sims' speculum,' and its whole surface care- fully searched for the so-called diphtheritic patches, which, when found, i^resent the appearance of a fine gray or grayish-white film, Avhich is dotted about over the cei'vix and walls of the va- gina wherever any abra,sion or laceration has been produced during labor. Should nothing abnormal be found in the vagina, a small pledget of disinfected cotton should be introduced into the canal of the cei'vix, in order to detect any foulness of the cer- vical or uterine secretions, which are often markedly affected when the more copious vaginal secretions are but slightly stale. If the result of this examination is negative, the uterus, tubes, ovaries, and broad ligaments should be carefully palpated bi- manually, in order to detect any undue size of the uterus itself, such as might be caused by the presence of clots or portions of the placenta within the utei'ine cavity ; to estimate the amount of tenderness over the uterus and other organs; and to ascertain the presence or absence of exudates in the adnexa. Treatmext. — Treatment should be divided into: first, mea- sures directed to the support and stimulation of the system as a whole, in its warfare against the invading poison ; and, secondly, 1 If well-marked symptoms of septica'inia are present, the probability of reopen- ing a lacerated perinaeum should not be allowed to interfere with a thorongh ex- amination of the vagina. 388 PRACTICAL MIDWIFERY. those which are intended to i^revent any further production of septicsis, £2 Rotation in second stage of labor, 95 in posterior positions, 217 Rubeola during pregnancy, 41 Rupture of the uterus and of the utero- vaginal attach- ments, 297 treatment, 297 of perineeum, 104, 299 Salivation in pregnancy, 3, 31 Scarlet fever during convales- cence, 365 INDEX. 419 Sanger, operation for Csesarean section, 196, 197 Scarlatina during jjregnancy, 41 Schultz's luethod of calculat- ing duration of preg- nancy, 16 method of resuscitation, 320 Septicaemia, deaths from, 82, 83 following laVjor, 385 causes, 385 symptoms, 386 diagnosis, 386 treatment, 387 decomposition of the lochia, 386, 388 pseudo-diphtheritic patches, 386, 388 endocervieitis, 386, 388 endometritis, 386, 388 perimetritis, 386, 391 parametritis, 386, 391 salpingitis, 386, 391 ovaritis, 386, 391 peritonitis, 386, 392 phlegmasia alba dolens, 395 Siamese twins, 315 Signs of pregnancy, 1 Skin, dermatitis neonatorum, 846 Skull, fracture of, in fmtus, 323 Social status of patient, 2 Souffle, placental, 6 uterine, 6 Spina bifida, 314 diagnosis, 314 treatment, 314 Sprue, 340 Spontaneous evolution, 177 Stage of pregnancy in months, 10 Stages of labor, 91 first, 92, 98 second, 94, 103 third, 97, 110 delayed first stage, 123 delayed second stage, 127 delayed third stage, 131 Sterilization in connection with abdominal delivery, 207 of food of child, 345 Styptics in post-partum haemor- rhage, 285 Subsidence of abdomen in preg- nancy, 91 Surgical operations during pregnancy, 65 Sutures, 79 Sylvester's method of resuscita- tion, 319 Syphihs during pregnancy, 45 transmission to the child, 45 as cause of abortion, 54 Tait's method in septic perito- nitis, 392 Tampons in abortion, 58 Tarnier's axis-traction forceps, 151 incubator, 353 Thomas' operation of laparo- elytrotomy, 196, 197 Thrombosis, 25 vulvo-vaginal, 359 Thrush in neAV-born child, 340 Toes, supernumerary, 350 Touch, bimanual, in diagnosis of pregnancy, 1, 8, 9 Toxfemia as cause of eclampsia, 264 Transfusion in post-partum haemorrhage, 287 Transverse presentations, 70, 72, 81, 242 mechanism, 242 prognosis, 242 treatment, 242 podalic version in, 184 Trauma during pregnancy, 66 Tubal pregnancy, 50 Tumors, abdominal, 13 fibro-myomata, 12, 13, 358 ovarian, 12 fibroid, 258 prolapsed ovarian, 258 420 INDEX. Tumors, cancer of the cervix, 66, 258 pelvic exostoses, 258 tumors of the trunk of the fa-tus, 31G cephal-hajmatomata, 348 Twins, 75, 309 Tympanites in supposed preg- nancj', 5 Typhoid fever during preg- nancy, 41 Umbilical vegetations, 348 hsemorrhage, 348 hsematophilia, 348 Urinary system, urine to be examined dur- ing pregnancy, 21, 29 presence of albumin, 32 oedema, 33 vesical symptoms, 33 frequency of micturition, 33, 91 excoriation, 34 urination during labor, 101 full bladder a cause of de- layed labor, 125 vesical calculus, 262 functional inefficiency of kidneys as cause of ec- lampsia, 264 urine to be examined in ec- lampsia, 266, 269 vesico-vaginal fistulse, 298 micturition during conva- lescence after labor, 331 cystitis during convales- cence, 364 diseases of, during convales- cence, 366 Uterus, uterine souffle, 6 size, 10 malpositions as cause of abortion, 55 during pregnancy, 62 abnormalities during preg- nancy, 62 Uterus, abnormalities during pregnancy, prolapse, 62 incarceratifjn, 62 anteversion, 03 retroversion and reti'ollex- ion, 63 incarceration, 63 tM-osions of cervix, 29 malpositions during preg- nancy, 29 uterine inertia as cause of delay in first stage, 123 treatment of inertia, 124 Porro-Milller amjiutation, 196, 197 fibro-myomata, 258 ovarian tumors, 260 hernia into Douglas' fossa, 261 carcinoma uteri, 261 double uterus, 65 hernia of, 65 cancer of the cervix, 66 uterine souffle, 74 uterine exhaustion causing delayed labor, 117 retraction ring, 117 fil:)roid tumors, 358 subinvolution, 361 malpositions, 363 atresia uteri, 263 contraction after labor, 282 inversion of the, 295 causation and prophy- laxis, 295 diagnosis, 296 treatment, 296 rupture of the uterus and of the utero-vaginal at- tachments, 297 condition after labor, 334 Vagina., examination of, in di- agnosis of pregnancy, 1, 8 inspection, 8 blue color, 8 digital examination, 8 INDEX. 421 Vagina, previous existence of I)regnancy, 11 examination in labor, 75 antisepsis in labor, 82, 86 injections in labor, 86 atresia vaginte, 203 vul vo vaginal thrombosis, 359 rupture of theutero- vaginal attachments, 297 vesico-vaginal fistulas, 298 Varicose veins in pregnancy, 24 treatment, 25 Variola during pregnancy, 41 Veetis in posterior jDositions, 215 Venesection in eclampsia, 270 Ventilation during the puer- perium, 329 Version, definition, 169 pelvic, 169 external, 169, 170 cephalic, 170 bipolar, 170, 171 podalic, 171, 176 preparations for, 176 recognition of a foot, 172 hand, 172 knee, 172 elbow, 172 difficulties and compli- cations, 180 rigid OS, 180 partial impaction, 180 Bandl's ring, 181 constriction ring, 181 impaction of the head, 180 impaction of the shoulder, 177, 181 general retraction, 183 indications for version, 184 choice between version and forceps in contracted pelves, 253 Version, contra-indications, 185 in normal pelves, 128, 130 care of the cord, 290 in abnormal presentations of brow, 222 face, 225 breech, 170 transverse, 184, 242 prolapsed extremities, 243 Vertex presentation, 71, 74, 78 extended head, 80 posterior jDositions, 208 mechanism in, 208 management of, 211 postural treatment, 212 operative treatment, 213 use of forceps, 214 use of veetis, 215 reversed forceps, 216 Vesico-vaginal fistula, forma- tion, 138, 298 Vision, imijerfection of, as pre- monitory symptom of eclamp- sia, 264 Visits of physician after labor, 336 Vomiting in pregnancy, 3 diet in, of pregnancy, 19, 28 erosions of cervix in, 29 malpositions of the uterus, 29 artificial abortion for relief, 30 Wasting diseases as cause of cessation of menstruation, 3 Waters, hydramnion, 67 hydrorrhoea, 66 rupture of membranes, 92 early discharge liable to cause hour-glass constric- tion, 119 Weight of the child, 339 Wet-nurses, 343 selection and care of, 343 MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. MEMORANDA. "^1)V-