Si..; COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD RECAP HX641 67860 RG524 L38 Talks on obstetrics. ■ON OBSTETRICS LaVAKE mmam tKQrl^A 13B" Columbia ©nibersiitp in tfje Citp of i^eto gorfe College of ^ftpsicianfi anb burgeons 3^eferente Ilitirarj) ^iH Presented Sy k DR. WILLIAM J. GIES M to enrich the liSrary resources available to holders ofthe GIES FELLOWSHIP in Biological Chemistry ERRATA Page 35, line 3 — Read entrance instead of Page 51, line 26— Insert meat after '^eat." Page 70, line 17 — Insert or after **day.'' ' entrace. ' ' Digitized-^by the Internet Archive in 2010 with funding from Open Knowledge Comrhons http://www.archive.org/details/talksonobstetricOOIava TALKS ON OBSTETRICS TALKS ON OBSTETRICS BY RAB THORNTON LA VAKE, M.D. Instructor in Obstetrics and Gynecology, University of Minnesota; Obstetrician-in-Charge of the Out-Patient Obstetric Department of the University of Minnesota ; Associate Attending Obstetrician and Gynecologist to the Minneapolis City Hospital; Obste- trician-in-Charge of the Out-Patient Obstetric Depart- ment of the Wells Memorial Dispensary; Obste- trician to the Swedish and Abbott Hospitals, Minneapolis; One Time Assistant Resi- dent Obstetrician to the Sloane Hos- pital for Women in New York. ST. LOUIS C. V. MOSBY COMPANY 1917 Copyright, 1917, By C. V. Mosby Company Press of C. V. Mosby Company St. Louis PREFACE In presenting this little book to undergrad- uate students and to practitioners, I wish to make it clear that it is intended as a mere sup- plement to the textbooks and is in no way a substitute for them or comparable to them. I wish to acknowledge my indebtedness to the following men who have directly aided me in all my work since my association with them by their continued courtesies, interest, and advice. To Dr. J. C. Litzenberg, Head of the Depart- ment of Obstetrics and Gynecology at the Uni- versity of Minnesota, who has ever given me free access to all cases and records at the Uni- versity Hospital and aided me in my work in the Out-Patient Department in every way pos- sible. To Dr. F. L. Adair, Chief of Staff in Obstet- rics and Gynecology on the University Division of the Minneapolis City Hospital, and Dr. Pot- ter, the pathologist and bacteriologist of that institution, who have extended the greatest courtesies in my service and made it possible for me to use in mv work all clinical material 10 PEEFACE and records and all the most advanced labora- tory aids that such a competent laboratory staff and well appointed hospital can offer. To Dr. J. Warren Bell for care in pernsing the manuscript and for his helpful criticisms. All opinions expressed are the result of my personal studies, experiences, and judgment to date, and I alone stand sponsor for them. E. T. LaVake. Minneapolis, Minn. CONTENTS CHAPTER I Sepsis .17 CHAPTER II Toxemias of Pregnancy 41 CHAPTER III Hemorrhage in Obstetrics 74 CHAPTER IV Heart Lesions and Tuberculosis 108 CHAPTER V Forceps 112 CHAPTER VI PoDALic Version 122 CHAPTER VII Prolapse of the Cord 126 CHAPTER VIII Breech Delivery 129 CHAPTER IX Delivery of Twins 132 CHAPTER X C^.SAREAN Section 134 CHAPTER XI Occiput Posterior Positions 140 11 12 COITTENTS CHAPTER XII Face Presentation 144 CHAPTER XIII Brow Presentation 146 CHAPTER XIV Rules in Obstetrics 149 FOREWORD The aim of this book is to group the material of obstetrics so that the field may lie before the student as a picture, having in the fore- ground the most important problems and grouped in the background the lesser problems arranged according to their relative impor- tance. Thus it may stand as a frontispiece to the study of obstetrics in much the same man- ner as do some of the frontispieces to Dickens' works in which subsidiary characters and scenes are grouped around the central themes recalling to mind at a glance the basic actions of the work. Thackeray, in the prefatory lines to his in- imitable ^^Book of Snobs'' remarks that ^Svhen men commence an undertaking they are pre- pared to show that the absolute necessities of the world demand its completion." I do not wish to furnish an example of the humor of this remark. Familiarity with the standard textbooks by Berkeley and Bonney, Bumm, Cragin, Davis, DeLee, Edgar, Hirst, Jewett, Peterson, Wil- liams, and others, makes it quite apparent that 13 14 FOKEWOED additional encyclopedic textbooks mil not be an absolute necessity for a few years at least. However, after the necessary study of such books, the student is likely to come away with a picture of obstetrics made up of the anatomy, physiology and pathology of pregnancy, labor and puerperium, together vntla. operative tech- nic, laid out according to order of exposition rather than according to frequency of occur- rence and importance of incidence and sequelse. The more startling conditions and procedures are more likely to impress themselves upon the memory than are the final results. This book attempts to correct this frequent lack of per- spective on the part of the student. These talks are merely printed chats similar to those often held with students during the hours of waiting while on out-patient cases. They have taken form from observations of my own experiences, especially my mistakes, and those of others, called to my attention in the course of out-jjatient and hospital clinics and in private practice. The conclusions reached and stated are purely personal and regarded by me as such only They have proved of value to me and may aid those not giving their entire at- tention to this branch of practice. INTRODUCTION A book which is designed to be neither a text- book nor a compend is unique. Dr. LaVake in this little volume has stuck to his text and has done what he set out to do ; to emphasize some of the commoner complications of obstetrics arranged in the order of their im- portance and presented in a familiar ** chatty" way. He has not tried to tell all about even the subjects treated; but in a few *' talks," has at- tempted to give a perspective that will help to establish the relative importance of certain problems. He has entertainingly presented some very important facts which are necessary to the successful practice of obstetrics. Here is a book which sets in relief important facts, establishes relative values, and will stim- ulate the reader to further study and more care- ful obstetrics. J. C. LiTZENBERG, M.D. 15 TALKS ON OBSTETRICS CHAPTER I SEPSIS The prevention of sepsis is by far the most important problem in obstetrics. General mor- tality statistics show that sepsis kills almost as many parturient women as do all other causes put together. In the United States alone it may be computed that approximately seven thousand five hundred women die an- nually from this dread complication, and that severe sepsis arises in about one in every hun- dred parturient women on an average through- out the country. The incidence of mild sepsis would be far in excess of the latter figure. Let it not be thought that this tremendous toll can be accounted for by the immense number of cases imperatively demanding obstetric opera- tions and other interferences. This is clearly shown by the fact that in maternity hospitals, where the number of abnormal cases demand- ing interference would naturally be above the 17 18 TALKS ON OBSTETRICS average found in general practice, the incidence of sepsis is approximately one in two hundred cases. The clear conclusions to be drawn are that either the average aseptic technic is poor or that meddlesome interference is rife. The beginner nearly always pictures the patient as dying from exhaustion due to mal- position of the passenger, obstruction in the passage, lack of propulsive forces, hemorrhage, etc., and in his worry and impatience is inclined to unnecessary interference, failing to see the dread specter, sepsis, at his elbow. There will always be a small mortality rate attendant upon the accidents of childbirth, a tragedy in every case, but nothing can equal the tragedy of death by sepsis in what should otherwise have been a normal case. The prevention of such a catas- trophe should be foremost in the mind of every physician in the conduct of every case. We should remember that Nature has had to deal with sepsis from time immemorial and has so provided against it from an anatomic stand- point that without interference this complica- tion is almost inconceivable. From an evolu- tionary standpoint Nature has seemingly or- dained that it were better for the future of the race that all women with marked deform- ities should die without propagating their kind SEPSIS 19 than that normal women should die of sepsis. Modern obstetric methods should make it pos- sible to save the great majority of deformed women and their offspring without prejudicing the lives of the normal women. Malpositions and obstructions are not com- mon, neither are the mortal accidents of labor as compared to the incidence of infection. The history, signs and symptoms of the patient, together with perfection in pelvimetry and ab- dominal and rectal examinations make the pres- ence of such abnormal conditions possible of determination with almost perfect accuracy without infringing upon Nature's guards against infection. Let sepsis be the specter and not the advent of other untoward conditions in which, if suspected, time is generally ample in which to get the advice of others before at- tempting to aid Nature and possibly doing irreparable damage where Nature might other- wise have consummated delivery without un- toward or fatal results to child, mother, or both. Death is not the only danger in sepsis. Many women recover only to be potential invalids for life. We may postulate from statistics that for every woman dying of severe sepsis three recover. A case coming under my observation recently will illustrate what recovery may 20 TALKS ON OBSTETRICS mean. This woman, eight years ago, after a very easy and normal labor in which, however, vaginal examinations were freely made, de- veloped a sepsis which kept her bedridden for thirteen months. The left hip became involved in a nontnberculous, septic process which re- sulted in a permanently stiff hip with the thigh adducted to snch a degree that in the second pregnancy the question arose as to whether it would obstruct the birth of the child. Throm- bosis of the external iliac vessel on the left side resulted in a practically useless limb which for the last seven years would break down in ulceration at any point after pressure or slight injury. She had been correctly advised to have this leg amputated, but had not as yet followed the advice. After seven years of dragging around on crutches the patient presented her- self five months pregnant, with a stiff adducted useless limb, a severe lumbar compensatory sco- liosis, and a terrible dread of the coming labor. During all these years she had been practically incapacitated for household duties, a great suf- ferer and a source of infinite anxiety to her family. The family was not wealthy and the fact that her former illness had cost the family over three thousand dollars for which they had had to run in debt, added to her worry. This is SEPSIS 21 only one example of so-called recovery from sepsis. Cases of chronic invalidism resulting from pathologic processes in the pelvis, endo- cardium and kidneys following sepsis are not infrequent. The case just cited is of so much interest, especially from the standpoint of the value of external examinations and the danger of rou- tine vaginal examinations in labor, that I will give the history of her second pregnancy and labor. She presented herself in the fifth month of gestation. At that time, careful pelvimetry and internal pelvic examination, together with a good skiagraph of the pelvis, gave no signs of obstructive deformity. During the seventh and eighth months she suffered from a severe pyelonephritis of the right kidney, with large quantities of pus in the urine and chills and rise of temperature two or three times a week. Under hexamethylenamin and copious intake of water this improved greatly in the last month of pregnancy. One week before labor she had an acute otitis media and the ear was discharg- ing at the time of labor. For one month before labor and all during labor no vaginal examina- tions were made. Eectal and abdominal exami- nations showed a vertex presentation and an 0. L. A. position. Very short normal labor and 22 TALKS ON OBSTETRICS normal puerpermm. In this case, in the pres- ence of a pyelonephritis, vaginal examinations would have been especially dangerous. Vaginal examinations are dangerous in all cases, in most cases unnecessary and an example of meddle- some interference. How may we reduce to a minimum the in- cidence of sepsis ? At the present time four great factors may militate against the prevention of sepsis : 1. Failure of the public to realize the neces- sity of special surroundings and care for the parturient woman. 2. Failure of attendants in not giving explicit directions to pregnant women. 3. Poor technic and meddlesome interference on the part of attendants. 4. Poor technic on the part of nurses. It should be our aim to combat these four causes of sepsis. Let us try by every means to impress upon the public the necessity of procuring for the parturient woman as ideal surroundings as the public now demands for other surgical cases. This is being attempted in lay journals, women's clubs and by verbal and written in- structions of physicians to their patients. It SEPSIS 23 has been my personal practice to give to each woman coming under my care a booklet urging the best surroundings. It has been my expe- rience that most women, from unscientific hear- say, are imbued with unnecessary dread rather than by the saving fear which should inspire them to procure an accurate knowledge of safe- guards in pregnancy and labor. Written in- formation and instructions remove this depress- ing dread and in the large majority of instances gain the earnest cooperation of the patient and her family. Physicians are asked daily as to the relative safety of the home and the hospital in labor. It should go without saying that this decision should be rendered entirely with regard for the safety of the mother and child and not for the benefit to the physician. No physician with an accurate knowledge of bac- teriology, modes of infection and technic of operative procedures will gainsay that a hos- pital especially equipped and making provision for the immediate isolation of infected cases and attended by those not coming in contact with infectious diseases, is the place of greatest safety for the woman in labor. It is obvious that if the physical conditions of the hospitals are such that direct or indirect communication 24 TALKS OIT OBSTETRICS can exist between normal obstetric cases and infected cases, medical or surgical, the home, properly equipped, is the safer environment. The abnormal cases should all have ideal hos- pital surroundings. At the present time it is apparent that we must weigh the dangers on both sides and decide each case individually according to the possibilities of home and hos- pital conditions and the degree of normality of the case. Many women likely become infected because of the lack of explicit instructions regarding the birth canal. In proof of this fact I would re- call two normal labors followed by an almost fatal sepsis. In these cases no vaginal exanii- nations, instrumentations or stitches were used upon which the blame might be placed. One admitted intercourse during labor and the other gave notice of the accession of labor by tele- phoning that she considered the birth imminent because she could feel the child's head. This woman had been making frequent vaginal ex- aminations upon herself. The intelligence and station of both these women speak for the ne- cessity of explicit directions. It is our duty to act as sanitary engineers and as far as we are able rid the immediate en- vironment of the birth canal of foci of infection. SEPSIS 25 We should also aim to discover all remote foci of infection in the patient and eradicate them if possible or plausible. Especially is this perti- nent to the oral cavity, which in some patients is as dangerous and inimical to their safety as are discharging ears, empyemas and what not. Concerning the danger of systematic infection through the mouth and the important relation of the care of the teeth to the general health, we will discuss subsequently at greater length. The patient should have definite instructions as regards bathing. Tub baths up to the ninth month and then spray baths. Why not tub baths in the last month? We know that the normal bacterial content of the vagina and its acid media are inimical to pyogenic bacteria. If pyogenic bacteria do gain access and survive, the natural drainage flow of the secretions from within outward tends to render the upper vagina less infested than the lower vagina. To say that nothing should enter the vagina dur- ing the last month is merely setting an arbitrary period during which time Nature may render the vagina as aseptic as possible. The tub bath is surely capable of floating organ- isms from without in, or of carrying organisms from the lower to the upper part of the vagina, especially when the perineum is relaxed from 26 TALKS ON OBSTETRICS former labors and the introitus is patulous. Before removing a piece of bone from a severe comminuted compound fracture we surely would not prepare the patient by giving a tub bath. This is clearly an exaggerated simile and yet the principle is the same. The man who treats the birth canal as he would an un- infected compound fracture is playing safe with infection. A frequent question from patients is whether or not they should take douches. I believe that the danger of introducing infection with the douche as given by the patient overbalances its possible efficacy in washing out or killing bacteria. It may wash the bacteria up into the cervical canal, and therefore it is safer to advise the patient not to use douches in the last month, because of the danger of infection. Patients should be advised to wear closed underclothes during the last months of preg- nancy to protect the vulva from dust and as the pressure on the bladder during the last months compels more frequent urination, it is well for them to carry clean paper covers for the toilet seats which they may have to use. In taking all these precautions we are doing nothing more than a sanitary engineer would SEPSIS 27 do in protecting an area from possible con- tamination. To all well-trained physicians the necessity of aseptic technic is clearly manifest, but to many it does not seem so clear that the anat- omy of the vulva together mth its close proximity to the anus diminishes the pos- sibility of perfect asepsis. This should ever be kept in mind in relation to the dangers attend- ant upon vaginal examinations, manipulations and instrumentations. It may suggest itself that the reason why so many women suffer and die of sepsis is that many are attended by people who are not phy- sicians. Undoubtedly this fact may account for many fatalities. We must depend upon the education of the public for the abolishment of this cause. It cannot be gainsaid, however, that sepsis often follows the physician, so let us confine our attention in this discussion to our- selves. As mentioned once before, if every careful and well trained obstetrician will review his cases and recall even the large number requiring imperative interference in which no sepsis resulted, in the face of the average frequency of sepsis, the deductions can only be that either the average aseptic technic is poor or that meddlesome interference is rife. 28 TALKS OTT OBSTETRICS Both deductions, I believe, are correct, but I believe we err in not laying greater emphasis upon the danger of meddlesome interference. I am convinced that we would lower markedly the incidence of infection by universally dis- continuing the routine vaginal examination in labor and substituting the rectal examination. Needless to say, upon the technic would depend the frequency of infection f ollomng the vaginal examination, but even with the best surround- ings, the most careful men and the best technic, no doubt we have all seen sepsis develop where vaginal examinations alone could be blamed. That the seriousness of tliis procedure is well knoT\m is evidenced by the fact that even in those hospitals and clinics, throughout the country, where the routine vaginal examina- tions are taught and used, each examination is charted in order not only to follow the prog- ress of the case, but in order to partially place responsibility if sepsis ensues. The routine vaginal examination is wrong and no amount of charting can make it right. If infection en- sues, nurses are often blamed. This is often a specious and unjust judgment. If the patient has followed our instructions that nothing should enter the vagina during the last month of pregnancy, together with our other protec- SEPSIS 29 tive instructions, and we have followed the in- structions ourselves and permitted no vaginal manipulations during the month before, dur- ing or just subsequent to labor, and no gon- orrheal infection obtains, then and then only may we turn to the nurses for an explanation, in the advent of sepsis in the normal case of labor. It is perfectly surprising what niceties of diagnosis the rectal examination allows. Prog- ress of labor, dilatation of the cervix, presen- tation, position, prolapsed cord, and often pla- centa previa, can be diagnosed with accuracy. When the examination is completed, subsequent imperative operations such as Csesarean sec- tion, forceps, etc., may be instituted without the danger of a previously introduced infection. The examinations may be repeated and the progress of labor followed accurately, and al- ways with the same freedom from the danger of infection. This applies not to the few, but to every one of us even under the Avorst possible conditions. If obscurity still holds after care- fully combined rectal and abdominal examina- tions, which may occur in exceptional cases, we still have the vaginal examination to fall back upon and can enter into the elaborate technic that its danger warrants. In this con- 30 TALKS ON OBSTETRICS nection let me say that careful abdominal ex- aminations are too often neglected. I believe that the general use of the routine rectal ex- amination instead of the routine vaginal ex- amination, for diagnostic purposes in labor, would reduce the incidence of infection to as great an extent as did the introduction of the use of sterile rubber gloves in the vaginal ex- amination and labor. In the rectal examination it is hardly necessary to emphasize the use of rubber gloves to prevent contamination of the hand, which would militate against asepsis in the subsequent scrubbing up for the use of the sterile delivery gloves. It is not necessary to mention all the errors of judgment in respect to interference in labor with consequent liability to sepsis, but in the face of histories of cases and physical findings, it would be neglect not to emphasize that most prolific source of sepsis, invalidism and prepa- ration for subsequent surgical operations; namely, the indiscriminate use of forceps. This is such an important subject that I wish to make it the topic of a separate talk. We now come to a consideration of a most potent factor in the prevention of sepsis; namely, scientific nursing. Obstetric nurses should be especially well trained in bacteriology SEPSIS 31 and the basic principles of asepsis. In no other surgical branch of nursing is this knowledge of more importance. This is most apparent when we consider the postpartum nursing. The day will come when we will have only special nurses for this branch of surgery. Considering the intimate contact of the nurse with the patient from the beginning of labor to the end of all danger in the puerperium it is especially es- sential that she realize the danger of coming from an infectious case to a case of labor. She should realize that whereas the patient is at least partially immune to the bacteria in her usual environment, she may quickly succumb to virulent bacteria foreign to her environment. Considering the long and intimate contact of the nurse and the patient, it is even more dangerous for a nurse to come from an infec- tious case than for a physician, although both should be equally deprecated. Be sure to in- quire about this in regard to each nurse. I have several times had the experience of finding that a nurse, a friend of the family and engaged for the case months beforehand, not wanting to disappoint the patient, would come to the case directly from a case of tonsillitis or what not, even leaving the case she was on from a mistaken sense of duty. Some of these cases 32 TALKS ON OBSTETRICS have had to be delivered by instnimentation followed by extensive repair. Imagine the dan- ger to which we would subject such a patient if we allowed this nurse to prepare the patient, assist in the delivery, and follow up the after- treatment. This danger may be reduced by early instructing patients that their surround- ings in labor are essential to their safety and in: particular that their nurse should be one having had special training and not having come from an infectious case. Only under these two conditions will a nurse who is a friend of the family be acceptable. This militates against the oldest living female member of the family who in the past has so frequently been entrusted mth the duty of assisting the physician. In the majority of cases it assures the earnest cooperation of the patient and her family in obtaining the best surroundings and assistants. Special instructions should be given to nurses to preclude certain slips in technic which may be encountered. When a patient comes in labor she should have a spray or sponge bath and not a tub bath. The nurse should see that she empties her bladder, should give her an enema, and then prepare the vulva by shaving or clipping, followed by cleansing and an exter- SEPSIS 33 nal sterile douche, after wliich preparation a sterile vulva pad should be applied and held in place by a T-binder. "Where the ster- ile pad has not been held on in this manner, 1 have often seen it drop on the floor or elsewhere and have seen the patient pick it up and put it in place again. The patient should be definitely told by the nurse not to touch the vulva throughout labor. We will not go into general nursing technic, but one other point does need emphasizing, however, and that is that you acquaint yourself with the technic of the hospital to which you may send your case. See that no inexperienced nurses are allowed to change the vulvar pads in the puerperium. The changing of the vulvar pads and the care of the patient after urination and defecation approach in seriousness a major surgical dress- ing. Women have often brought to my atten- tion the differences of technic used by nurses and the technic of certain unskilled nurses has been such a source of worry to them that they have expressed a dread at not having their regular nurse attend them. In histories of otherwise normal labors many patients have stated their opinion that the accession of a **milk leg" was due to carelessness in nursing. 34 TALKS ON OBSTETKICS We cannot be too careful in seeking to elim- inate this possible factor. In carefully watching the tendencies of stu- dents and others in their handling of a delivery, three errors stand out conspicuously as tend- ing to increase the possible incidence of sepsis. 1. Lack of care in carrying out the most rigid aseptic technic that textbooks and good clinics teach and a tendency to place too much con- fidence in antisepsis. (After a clear contami- nation a man mil smsh his gloved hand around in an antiseptic solution and proceed with per- fect confidence.) 2. Not appreciating the fact that the average normal first labor lasts eighteen hours and sub- sequent labors from twelve to fourteen hours. In consequence they are apt to become over- anxious after a few hours, especially when deal- ing with hypersensitive women and under the importunities of anxious relatives and friends, think that something must be wrong even when they feel sure that their abdominal and rectal examinations show that ever3i:hing is normal, and as a result they are led to make many vag- inal examinations and are too prone to think that operative delivery will be necessary. 3. They forget the basic fact that the slow noninstrumental delivery tends to limit the SEPSIS 35 number of lacerations and that every lacera- tion means an extra channel for the possible entrace of infection. The mention of lacerations brings to mind a stage in labor at which point infection is easily introduced. In watching the conduct of some labors you will notice that men, in the last part of the second stage, will soil the right hand by coming in contact with the anus, in the endeavor to protect the perineum when the head and shoulders are passing over it. After the birth of the baby they will then rinse off the hand in some antiseptic solution and proceed to make vaginal examinations in the search for cervical or perineal lacerations. "Why more women are not infected after this maneuver is hard to ex- plain. It suggests a corroboration of St. Ansehn's treatise, ** Truly there is a God, al- though the fool hath said in his heart. There is no God." Cervical tears should be left alone unless imperative demand for repair is made by severe hemorrhage and most perineal tears can be recognized without entering the vagina. Keep out of the vagina if possible, and if entrance is imperative, change to a clean glove and do not rely on the antiseptic value of a rapid immersion in any antiseptic solution. No gynecologist would think of doing otherwise 36 TALKS ON OBSTETRICS in operating for secondary repair of the peri- neum. After suturing the perineum we can test the competency of the perineum as well by rectal examination as by vaginal examination. We should all aim to correct these tendencies as they exist in ourselves. No subject in ob- stetrics warrants more attention and detailed care than this subject of asepsis. By taking thought we may not be able to add a cubit to our stature, but by taking thought in obstetrics we may greatly reduce the occurrence of sepsis, that dread specter that stands at our elbow in every case, normal and abnormal. If all prophylactic measures have proved of no avail, the next great problem for the exer- cise of judgment is the treatment of sepsis. Here let us remember that as Nature's safeguards are the best in the prevention of sepsis, so is her treatment. Give Nature a chance undisturbed and she will bring about better results than will rapid interference on our part. Let hemorrhage and drainage be the only indications for interference. It is part of the technic of every labor to examine the mem- branes and placenta carefully to see that large masses have not been retained to obstruct drainage. If masses have been retained, let the fact set us on our guard, but do not attempt SEPSIS 37 to remove them unless hemorrhage or blocking of the cervical canal with lack of drainage makes it imperative. In most cases they will come away by themselves in a few days and we have not then imposed the added danger of the possible introduction of infection. Do not give donches which may spread any existing infec- tive material to regions othermse normal. If masses have been retained and subsequent hem- orrhage or marked closing of the cervix with symptoms render it imperative to act, with the greatest aseptic care remove the same with the gloved finger or with a large dull curette see- ing to it that this procedure disturbs as little as possible the leucocytic barrier that Nature has undoubtedly thrown around any iufective focus present. In the great majority of cases no interference will be found necessary. Each and every one of the follomng general therapeutic measures is important as an aid to Nature in effecting a cure: 1. Placing the patient in the Fowler or semi- sitting posture, to promote uterine drainage. 2. The administration of fluid extract of er- got, one dram three times a day, to contract the uterus and close the sinuses against infection, always keeping in mind, however, that too much 38 TALKS ON OBSTETRICS ergot may close the cervix and interfere with drainage. 3. Due attention to the bowels and plenty of water to flush out the system by all the chan- nels of elimination. 4. Forced feeding with easily assimilable nourishing food with the addition of brandy or whisky, the latter acting both as a food of high caloric value and as a stimulant. 5. Treatment in the fresh air and sunlight. If the process localizes, do not incise until definite fluctuation obtains. If the patients are to recover at all at least three out of every four cases presenting marked areas of induration will clear up without pus formation. It is a common tendency to want to resort to incision too quickly in the presence of induration. I have again and again seen areas of induration incised without obtaining pus, with a resulting healing of the incision and with a final breaking down and fluctuation at a point far distant, the incision of this fluctuating mass resulting in proper drainage and a cure. Too early incision may only spread the infection. Without fluc- tuation let the process alone and depend solely on general supportive measures as outlined above. It is well for every man to view a puerperal SEPSIS 39 rise of temperature as an infection and not set stock on nervous causes. A frequent mis- take, however, is to become panic stricken and think of immediate interference before one has satisfied himself by a thorough physical and laboratory examination that puerperal infec- tion is alone the cause of the rise of tempera- ture. If puerperal infection is the cause, let hemorrhage and lack of drainage be the only indications for immediate manual interference. Whatever the cause, free catharsis will often bring our anxiety to a sudden end. If after a cathartic the temperature does not fall to nor- mal and remain there, look upon the condition as puerperal sepsis and institute appropriate treatment until marked lesions elsewhere make it clear that we are dealing with another con- dition. Even then consider that this lesion may be only another complication. The greatest consolation that an obstetrician can have in the face of a sharp postpartum rise of temperature is the knowledge that he could see no slip in the aseptic technic, that he has made no vaginal examinations, nor has been compelled to use any operative procedure and that the absence of perineal lacerations necessitated no repair. I designate perineal lacerations to emphasize the belief that where- 40 TALKS ON OBSTETRICS as all perineal lacerations should be repaired immediately, the only indication for immediate repair of the cervix should be hemorrhage. The latter belief is based on three reasons: first and foremost, the predominance of the risk of sepsis over the amount of good actually ac- complished ; second, the frequent amazing nat- ural restitution of cervices markedly damaged; and third, the distortion of the cervix after labor may lead us to sew too much with a result- ing permanent distortion or stricture of the cervical canal. In going to every case let us remember that sepsis kills almost as many women as do all the remaining complications of pregnancy put together. Measures for its avoidance should run as a warp throughout all the procedures of obstetrics. As such they should be con- sidered in reference to all subsequent subjects discussed. CHAPTER II TOXEMIAS OF PREGNANCY Pre-Eclamptic Toxemia and Eclampsia. Next to sepsis the toxemia of pregnancy re- sulting in eclampsia kills more women than all remaining complications. General statis- tics show that twenty-five per cent of the deaths in pregnancy are due to this condition, and in maternity hospitals the percentage often runs as high as forty per cent. It is a frightful com- plication and every woman should be looked upon as a possible eclamptic and all precautions taken right from the start to guard against the condition or at least to recognize its ap- pearance at the earliest possible moment in order to institute immediate treatment. Zweifel aptly called eclampsia a disease of theories and we must admit that today its basic cause has not been incontrovertibly proved. With the autopsy findings in liver, kidney, etc., together with the signs and symptoms in life, all are familiar. These have given us clues for treatment. Other clues to treatment have been 41 42 TALKS ON OBSTETRICS given by experimental evidence and the results of empiric treatment founded upon theories more or less substantiated by correlated facts. Every man must establish in his mind at least a temporary theory, deduced from all known observations, in order that he may have some foundation upon which to base his prophylaxis and treatment. Upon my present belief in the following fac- tors in the rationale of the production of pre- eclamptic toxemia and eclampsia, do I base my procedures : 1. Insufficient elimination of toxins gen- erated in the fetus or at the placental site, coincident with the increased strain thrown upon the maternal organs from the necessity of assimilating and eliminating for both the fetus and herself. 2. Infection. 3. Mild asphyxia. Given a pregnant woman. The growing fe- tus throws upon the excretory organs of the mother, possibly previously damaged by dis- eases such as scarlet fever, etc., double the normal load. The excretory organs may be further damaged by ba^jteria or their toxins from foci of infection in teeth, tonsils, colon, etc. The basic toxin causing the condition TOXEMIAS OF PKEGNANCY 43 arises either from the fetus or from the pla- cental site. Upon the amount and rapidity of the generation of this toxin and the ability of the excretory organs to excrete it, depends the occurrence of eclampsia. The lesions in the liver, kidney, heart, etc., caused by the toxin also increase the deleterious effects upon the patient. The demands for oxygen by the rapidly growing fetus, especially in the last two or three months of pregnancy, together with a decrease in the normal powers of oxy- genation on the part of the mother caused by pressure on the abdominal organs with result- ing stasis, and caused by pressure on the dia- phragm with decreased lung expansion and in- terference with the heart, produce a low grade asphyxia in the mother. This asphyxia lowers the resistance of the organs to the attack of the toxin and increases the extent of the lesion in the liver and kidneys. The asphyxia increases the blood pressure by acting on the adrenal glands and causing an increased amount of adrenalin in the blood. The asphyxia likewise manifests itself in the increase in the acidity of the hydrogen-ion concentration with the varying degree of acidosis. Based upon such a rationale of the produc- tion of eclampsia, the following broad lines of 44 TALKS ON OBSTETKICS prophylaxis and treatment would suggest them- selves : 1. Protect the excretory organs by nonirri- tating food and keep the channels of elimina- tion, skin, bowels and kidneys active. 2. Eradicate as far as possible or plausible all foci of infection. 3. Combat asphyxia by fresh air and all methods for promoting deep breathing and keeping up the general circulation. 4. Combat the manifestation of acidosis by alkaline salts and food. 5. In extremity, remove the products of con- ception as rapidly as is consistent with freedom from shock and the integrity of the soft parts of the mother. Before leaving the theory of toxemia to go into the minutiae of prophylaxis and treatment let me briefly enumerate certain observations from clinical material and animal experimenta- tion that should be of interest to every student in attacking this interesting problem. Note the following points: The evident relief following delivery in most cases of toxemia, which would point either to a toxin elaborated by the fetus or the placenta. One of the most suggestive articles that I TOXEMIAS OF PREGNANCY 45 have read concerning a toxin elaborated by the placenta was written by James Young, of Edinburgh, appearing in the Journal of Obstetrics and Gynecology of the British Empire, July, 1914, entitled ^*The Etiology of Eclampsia and Albuminuria and Their Eelation to Accidental Hemorrhage." Young believes that thromboses in the ovarian and uterine vessels cause hemorrhages or areas of necrosis in the placenta according as veins or arteries are occluded, and that the toxins generated in the autolysis of these areas are the toxins basically responsible for the toxemia. He goes so far as to suggest that a postpartum eclampsia may warrant an exploration of the uterus for retained portions of the placenta. Before condemning his theory, read his article and observe your cases. Coupling Young's theory with the theory of the infectious origin of eclampsia, note the close connection between most thromboses and in- fection and in your cases note the high per- centage of toxemia of pregnancy and accidental hemorrhage in which definite foci of infection can be demonstrated. In relation to asphyxia from pressure, note that toxemia occurs most frequently in primip- ara, multiple pregnancies and hydramnios, in 46 TALKS ON OBSTETRICS other words in those generally subjected to the greater pressure. That primipara are subjec- ted to greater pressure than multipara can be postulated from the fact that in primipara the lightening occurs earlier than in multipara in whom the abdominal walls have been previously stretched. Note that two of the beneficial effects of delivery may arise from the conse- quent relief of pressure and the throwing of the child on its own mechanism for oxygen- ation. Note the experiments in chloroform poison- ing in which lesions are found in the liver and kidneys identical mth those found in certain cases of eclampsia. Two poisons giving the same lesions may be amenable to the same ther- apeusis. We may learn three things from these experiments: the danger of giving chloroform to a toxic woman and thereby increasing the lesion; that experiments on rats point to the fact that an asphyxia obtaining in the presence of a circulating poison such as chloroform, causes an increase in the liver and kidney lesions ; and that the diet that protects the liver cells in chloroform poisoning is one high in car- bohydrates and low in proteid and fat, es- pecially low in the latter. May we not apply TOXEMIAS OF PREGNANCY 47 these facts in fighting the toxin causing pre- eclamptic toxemia and eclampsia? Note the similarity, early brought out by various writers, between the kidney lesions of sepsis and eclampsia. Note the presence of acidosis in certain cases of eclampsia and then follow the work of Martin Fischer on the relation of edema to acidosis, with the advice as to the use of the salts best calculated to overcome the edema. In this con- nection note the use of magnesium sulphate. In connection with edema note the contention of such a man as Zangermeister that eclampsia may be caused by edema of the brain. In relation to asphyxia and the increase in the liver and kidney lesions note the early em- piric use by Stroganoff of oxygen in the eclamp- tic seizures. Note the experiments of Cannon showing that asphyxia will increase the output of ad- renalin, thereby causing a rise in blood pres- sure and an increase in the coagulability of the blood, both of which are found in eclampsia in the latter months. I am turning the mirror here and there in the various fields of experimentation and clini- cal observation in the hope that the student may get some suggestive reflection from the 48 TALKS OK OBSTETRICS angle at which he is viewing the subject, which may give him some cine for new stndy and observation. No field in obstetrics offers a greater field for stndy and research and each case shonld be studied intensively from every conceivable standpoint, in the determination to discover some more successful method of pre- vention or treatment than now obtains. To return to prophylaxis and therapy. With our present knowledge how should we set about to limit the ravages of this complication? We should use every possible method for educating the public to the fact that women should place themselves under care as early as possible in pregnancy. This can best be done by furthering the propaganda for pre-natal care. Mothers will do more for the care of their offspring than they will do for themselves. The pregnant woman should be given a thor- ough physical examination. Special attention should be given to locating foci of infection. The teeth should be thoroughly examined and the patient specifically advised to see her dentist and remain under his care throughout pregnancy. All visible signs of destruction and infection in the oral cavity should be treated. If the patient gives a history of rheumatic manifestations, such as muscular TOXEMIAS OF PREGNANCY 49 pains, neuritis, etc., we should go farther and have the teeth in which the nerves have been killed, x-rayed. Be suspicions of all crowned teeth. *^ Uneasy lies the head that wears a crown. ' ' If symptoms of local inflam- mation or systemic absorption obtain, and ab- scesses are found, advise the removal of those teeth, care being taken to extract only one at a time to avoid a severe reaction from the auto- vaccination. In the face of definite signs and symptoms of infection and absorption, I believe the retention of these abscesses to be more dangerous than their removal. If definite signs do not exist and it is decided to leave the teeth alone, watch that woman with especial care for the accession of toxemia. To me the removal of all obvious foci of infection means prophy- laxis against sepsis, toxemia, miscarriage and accidental hemorrhage. Concerning the latter two, more later. It is fairly obvious at least that the clearing up of the oral cavity will re- lieve the kidneys of much unnecessary strain. If oral sepsis can cause nephritis in the non- pregnant, it should be more likely to do so in the pregnant woman. In the face of any infec- tion, such as pyelonephritis, pyorrhea, etc., ev- ery physician should watch his patient with especial care for the accession of toxemia. 50 TALKS ON OBSTETRICS Nearly every student asks, **Wliy this empha- sis on infection?^' First, I have not yet seen a case of eclampsia in which a focus of infection, and generally a marked one, conld not be dem- onstrated. I have seen case after case develop a toxemia in which, working on this theory, I had looked for toxemia with especial care. I have seen cases that a week before delivery showed no signs of toxemia in nrine and blood pressure, but started to show an albuminuria and continual rise of blood pressure three days before delivery. They were placed immediately on treatment and even then just got over the rope, as it were, their urine boiling nearly solid at delivery, the blood pressure high and with everything ready to assist delivery if convulsions obtained. As I say, I suspected these cases because of evident foci of infection which could not be cleared up. Second, notice the number of eclampsia cases running a tem- perature when first seen and thus not ac- counted for by manipulation; third, note the number of multiparse with toxemia who have had previous normal pregnancies and labors, but who give definite histories of symptoms of infection occurring since the last labor and especially during the pregnancy in which the toxemia occurs. These are the reasons why TOXEMIAS OF PEEGNANCY 51 I have come to emphasize the possible role of infection. Give explicit directions that the bowels should move once a day, and instruct the pa- tient to notify yon if persistent constipation exists. Not only do free bowel movements re- move excretory products and bacteria and their toxins from the system, that wonld otherwise have to be removed by the kidneys, bnt they tend to prevent injury to the intestine due to large hard fecal masses trying to pass obstruc- tions caused by unusual pressure condition with resultant infection of the blood stream. That colon bacilli gain entrance to the blood stream is evidenced by the frequency of hematogenous infection of the kidney. Obstruction from pres- sure must also disturb the normal balance of bacterial life in the bowel with the generation of particularly toxic products. The bowels should be kept active by fruit, coarse cereals and vegetables, and if necessary by aperients. The patient should be instructed to drink from six to eight glasses of water daily to aid in flushing out the kidneys, bowels and skin. The skin should be kept active by bathing. The patient should be instructed not to eat more than once a day. With the object of preventing a low grade 52 TALKS ON OBSTETRICS asphyxia she should be in the fresh air and sunlight as much as possible, and exercises and massage should be used to promote the general circulation. The hemoglobin con- tent of the blood should be estimated and in- creased if need be by the administration of iron compounds in addition to the iron obtained in the diet. The patient should have definite instructions to have the urine examined at stated intervals. Once a month for the first six months and once a week after that until delivery. More fre- quently, of course, if the accession of untoward symptoms demands. The blood pressure should be taken with in- creasing frequency toward the seventh month and after. A rising blood pressure or any blood pressure above 150 mm. should be looked upon with suspicion and the patient watched very closely. The blood pressure often gives a warning of the onset of toxemia before evi- dences are present in the urine. Women should be instructed to notify the physician immediately upon the accession of any possible signs of an approaching toxemia; persistent headache, disturbance of vision, edema of feet, hands or face, scanty urine, pains in abdomen and nausea and vomiting. TOXEMIAS OF PREGNANCY 53 Prophylaxis and early recognition are the keynotes in attacking this condition. The immediate treatment of a beginning tox- emia is merely an accentuation of the prophy- lactic treatment. View every case of albuminuria with suspi- cion, but you will find that many will prove to be transitory under the simple treatment of rest in bed, milk diet for a few days, free catharsis daily by means of magnesium sulphate and a copious intake of fluid. If no improvement results: See to it that the patient is in a well-venti- lated sunny room, and prevent circulatory sta- sis by the assumption of the dorsal, prone, and knee-chest positions together with massage and calisthenics. See that the teeth are kept clean. Have den- tal treatments continued at the home if neces- sary. Produce free catharsis by the administration of one ounce of magnesium sulphate every morning and give a glass of water every hour. Increase the alkalinity of the blood by giving organic acids such as lemonade or orangeade. Diuresis may be increased by administering Imperial Drink; cream of tartar, drams three; sugar of milk, drams four; lemon juice, one 54 TALKS ON OBSTETRICS ounce; sugar, one ounce; dissolved in three pints of boiling water. This may be taken in- stead of the water alone. Many patients seem to weaken considerably on solely a milk diet if used for any length of time. Place on a cereal, whey, and sugar diet, with a free use of buttermilk if the patient can take it. In giving nourishment the object is to give a diet high in carbohydrate, with enough proteid to sustain the nitrogen equilibrium, and very low in fat. The use of cereals, whey, skimmed milk or buttermilk and sugar fulfills these conditions. (Opie and Alford in an arti- cle appearing in the Journal of the American Medical Association, March 21, 1914, give ex- perimental data which lead them to believe that carbohydrates may be found to influence favorably the course of pathologic conditions caused by chloroform and pregnancy, whereas, fat may cause grave trouble. We know the deleterious action of high proteid.) Wash out the lower bowel daily with high colon irrigation, taken in the knee-chest posi- tion, and containing one per cent sodium bicar- bonate. This removes toxins and tends to re- duce acidosis. Keep the skin active by sponge baths, avoid- ing any chilling of the patient. TOXEMIAS OF PREGNANCY 55 Assure plenty of sleep. By the use of these methods of treatment, many cases will either clear up entirely or can be carried through delivery without the acces- sion of eclampsia. When should we consider emptying the uterus ? I believe the following danger signals will prove as valuable as any: Examine the urine once or twice daily as the gravity of the case demands. Use the acetic acid and heat test and allow the test tubes to stand in a rack so that the depths of the pre- cipitates may be compared from day to day. If the albumen rises to fifty per cent by volume when the patient is on treatment, consider seri- ously hastening the emptying of the uterus. If the urine of the patient contains more than eighty per cent albumen by volume when first seen, consider the induction of labor. If, on the other hand, when the patient is first seen, she has not been on treatment, and the albumen content is below eighty per cent by volume try the result of intensive treatment for twenty- four hours. It will then sometimes fall below fifty per cent and you may be able to carry that patient through delivery without need for inter- ference. Following this rule has kept me from 56 TALKS ON OBSTETRICS interfering in many cases in which normal de- livery without the accession of eclamptic seiz- ures proved the wisdom of the delay. Don't forget the danger of sepsis in interfering. The albumen content alone, however, is not a safe criterion. Even if the albumen content is low and the blood pressure keeps rising un- der intensive treatment, it is not safe to allow it to stay above 180 mm. for long without inter- fering. If it reaches 200 nun. one should almost surely interfere. At the accession of convulsions the uterus would better be emptied as quickly as is con- sistent with preserving the integrity of the soft parts of the mother and by a method which will result in the least shock. Fortunately in many cases we find that Nature has attempted to induce labor, and that the cervix is soft and beginning to dilate. Why not let Nature take her course in every case and not in- terfere? Believing that the ultimate toxin causing the condition is being produced either in the fetus or in the placenta, the sooner the uterus is emptied the better for the mother. Experience shows that delivery tends to ter- minate the condition. I have personally come to use two other pos- sible indications for delivery; the accession of TOXEMIAS OF PREGNAITCY 57 eye disturbances with definite lesions visible in the eye grounds and beginning indications in the heart that the toxin is producing marked changes, such as marked irregularity, where previously the heart rhythm has been normal. There is one other type of case to which I would call your attention. This is the primip- ara who begins to have an increasing toxemia a month or two before term. If she is allowed to go much over three weeks with a severe tox- emia and you then attempt to induce labor es- pecially if she has a long hard cervix, this woman will almost invariably die before you have effected delivery. It seems as if the se- vere contractions of labor must force the toxin into the blood stream, and her organs have been so profoundly affected by the severe toxemia of the previous weeks that a fatal termination is rapid. I do not believe that these severe tox- emia cases should be allowed to go without in- terference for much over three weeks and then if a long hard cervix prevents a rapid delivery, I believe we should do a Cesarean. In most cases the albumen and blood pres- sure will help the decision as to interference, but I know of no condition in which so many factors must influence the decision and where it is so impossible to give definite rules. In the 58 TALKS ON OBSTETRICS long run, I believe the attention to the albumen and blood pressure rules as given above will result in the greatest success. When we have decided that the uterus should be emptied, w^e must remember in our proce- dure not to do anything that will injure, produce shock or lower the recuperative power of the patient. If the cervix is soft and dilatable with the fingers, do a version and breech extraction if the head is not engaged. If the cervix is di- lated and the head tightly engaged deliver with forceps. If the cervix is not dilatable with the fingers, insert a Yorhees bag and allow the cervix to dilate and soften sufficiently to permit manual dilatation. Eapid forcible dilatation of a more or less rigid cervix with delivery, otherwise known as accouchement force, is dangerous for the mother because of shock, and lacerations with increased danger of infection. If labor has not begun, induce it with bougie and gauze packing if necessary, but if a Vorhees bag can possibly be inserted I be- lieve it is better to use it in preference to other methods. Do not rupture the membranes, as the drainage of liquor amnii may make a sub- sequent version dangerous or impossible. With a long rigid cervix and a live child in the pres- ence of a rapidly increasing toxemia or fre- TOXEMIAS OF PREGNAITCY 59 quent convulsions, I believe a Caesarean is indi- cated. These patients are poor risks for Caesarean section, but the strain of a long labor with a rigid cervix is as hard on the mother as the strain of Caesarean section, and the Caesarean empties the uterus immediately and the toxins are not forced into the general circu- lation by the contractions of the uterus. The vaginal Caesarean should be performed only when the child is small. If you will watch the vaginal Caesarean at term or before this if the child is large, you will likely agree that it is a more serious operation than the abdominal Caesarean. Remember the lesions of chloroform poison- ing and never use chloroform in any procedure in toxemia. Use ether. Do not use chloroform to try to limit the convulsions. For this rely on chloral and eliminative measures. Many cases of postpartum convulsions and death may be due to delayed chloroform poisoning per se or by increasing the lesion already caused by the toxemia. It has been stated that chloral will produce the same lesions as chloroform. The experiments of J. Gardner Hopkins pub- lished in the American Journal of Obstetrics, Vol. Ixv, No. 4, 1912, would disprove this state- ment. Hopkins believes *Hhat it is impossible 60 TALKS ON OBSTETRICS to produce by the administration of chloral hy- drate necroses in the liver similar to those found in delayed chloroform poisoning and eclampsia, and that chloral hydrate produces no histologic changes in the kidneys." Do not fear the administration of chloral hydrate. Give the patient oxygen in the convulsions to aid in overcoming the asphyxia. If the woman is progressing rapidly in labor, do not interfere and thereby increase the chance of infection, unless the great severity of the condition demands. Put the woman in a quiet, dark, well-ventilated room, and watch for the possible accession of convulsions with a mouth- gag ever ready to prevent injury to the patient. If you are seeing the patient for the first time and free catharsis has not already been ob- tained, produce free catharsis with magnesium sulphate if the patient is conscious or if un- conscious by croton oil, drops three, placed on the back of the tongue. Give an initial dose of chloral hydrate, grains thirty, by mouth or rec- tum as it is possible, and repeat this dose every four hours according to the amount of restless- ness shown. Put the patient on a Murphy drip containing one per cent sodium bicarbonate and six per cent glucose. If she cannot retain this fluid TOXEMIAS OF PREGNANCY 61 give the one per cent bicarbonate solution by hypodermoclysis, great care being exercised to make sure of the sterility of the solution and the aseptic technic. Alternating every eight hours give a high colon irrigation of nine gallons of tap water, and a hot pack. Be sure, however, not to give the hot pack unless the woman is absorbing plenty of water, otherwise the sweating will concentrate the toxin in the blood and do more harm than good. If the severity of the case demands, just as soon as the cervix has dilated sufficiently so that one can finish the dilatation with the fin- gers and do a version with breech extraction, or can apply the forceps, the woman would bet- ter be delivered immediately. After delivery keep the woman on the same general treatment until marked subsidence of symptoms warrants its discontinuance. Before delivery do not bleed the patient for high blood pressure, especially if you are not prepared to give a normal saline infusion of an amount equal to the amount of blood taken. The average case will do better without the phlebotomy because it is impossible to tell how much blood the woman will lose at delivery and the delivery in addition to the phlebotomy may 62 TALKS ON OBSTETRICS bring the blood pressure too low, with conse- quent death. In watching these cases it seems to me that cases that have not been bled re- cover more rapidly than those who have. If it seems imperative to reduce the blood pressure, use the fluid extractum Veratri hypo- dermically, beginning mth five minims and re- peating every four hours for a pulse over one hundred in rate and three minims for a pulse over eighty. The Veratrum both slows the pulse and lowers the blood pressure. I have followed carefully the use of phlebotomy and Veratrum and have seen them used with appar- ent success, but I could seldom bring myself to believe that either was the deciding factor in the recovery. Of the two, however, I would fa- vor Veratrum, as I have never seen it do harm, but I have seen cases where I felt sure that the phlebotomy before labor in addition to the loss of blood at labor reduced the blood pressure to too great an extent mth evident bad results. One t^^e of case definitely demands a phle- botomy and that is where we have a dilated right heart with beginning edema of the lungs in the face of high blood pressure. It will be noticed that I have not mentioned the use of morphin. I have used it again and again according to the Stroganoff method. My TOXEMIAS OF PREGNANCY 63 own results and observations on the cases of others, lead me to favor the emptying of the uterus. An initial dose of morphin, grain one- fourth, may aid in reducing restlessness, but when it is used to the extent of reducing the frequency of the respirations, I believe we are doing possible harm by increasing the as- phyxia. It may slow the rapidity of the labor which should not be sought. Morphin does not reduce the reflex irritability of the cord early in its action as does chloral. I do not believe it will inhibit convulsions as will chloral. If the patient is mentally restless or if apparently suffering from severe pain, use the morphin to attempt to relieve internal stimulation as we relieve external stimulation by placing the woman in a quiet dark room. Stroganoff pre- sents some wonderful statistics which should compel the attention of every student. His method also has the advantage that the danger of sepsis by interference is eliminated. How- ever, it is my personal belief that all things being equal in two cases of eclampsia that woman will have the better chance for life who is delivered the sooner, provided we use the best aseptic technic and use no measures that will produce shock. 64 TALKS ON OBSTETRICS All cases should be treated at a hospital, if possible. The child should be fed artificially until the toxic symptoms have cleared up in the mother. All patients should be watched for the pos- sible accession of postpartum eclampsia and nurses should be instructed to report the earli- est appearance of headache, scanty urine or marked somnolence. After the delivery of a toxemic woman, the blood pressure and the urine should be followed for months, not only to direct appropriate treatment, but because of the significance of the findings in their bearing on the advice to be given in reference to the danger of a future pregnancy. If the blood pressure and urine return to normal very slowly over a period of months, it is well to advise an interval of at least three years before attempting pregnancy again. If the blood pressure and urinary find- ings rapidly return to normal, it seems quite safe to attempt pregnancy after one year. In both instances, however, I believe she should not attempt pregnancy until all foci of infec- tion have been eradicated. The teeth and ton- sils should be examined again and all proce- dures taken to remove any focus of infection. The frequency with which, after this procedure, TOXEMIAS OF PREGNANCY 65 albumen will disappear from the urine leads me to believe that much of the transitory al- buminuria of pregnancy may come from foci of infection. This transitory albuminuria was probably obtained before pregnancy and was brought to the attention in pregnancy by the routine frequency of examination. Such a course of clearing up foci of infection will oft- times result in the attainment by the patient of better health than she has enjoyed in years and a future pregnancy need not be dreaded. Pernicious Vomiting Under the caption of toxemias of pregnancy must be included the pernicious vomiting of pregnancy which at times results in death. Fortunately this form of early vomiting is not very common. The minor forms of early vomit- ing, however, are frequent and a source of much discomfort to the patient and perplexity to the physician. All are familiar with the classification of causes into reflex, neurotic, and toxemic. It is probably not wide of the mark to believe that the early vomiting of pregnancy even in its mildest form results from a toxemia and that the reflex and neurotic elements merely aggra- vate the condition. 66 TALKS ON OBSTETRICS Three fairly plansible nltimate origins of the toxin suggest themselves: A toxin generated from a pathologic devel- opment of the corpus Inteum of pregnancy. A toxin developed from autolysis of areas in the developing decidna caused by interference in the blood supply in the rapidly developing organ. A toxin, a foreign protein representing the male element of the developing ovum. As in pre-eclamptic toxemia the ultimate na- ture of the toxin is a matter of conjecture. Thus our treatment must be guided by the re- sults of clinical observation, and the results of autopsy findings together with such experi- mental data as may bear upon the subject in an indirect way. The follomng facts may give us guides for treatment : At autopsies of fatal cases of pernicious vom- iting, we often find lesions of the liver similar to those found in delayed chloroform poison- ing and acute yellow atrophy of the liver. These lesions are a central necrosis of the liver lobule with a fatty degeneration extending with diminishing intensity to the periphery of the lobule. Experimental chloroform poisoning gives these lesions in animals. It may be fair TOXEMIAS OF PREGNANCY 67 to assume that any treatment that will diminish the extent of the lesion in experimental chloro- form poisoning may also diminish the extent of the lesion caused by a toxin producing identical lesions, whatever that toxin may be. Experi-^ ments point to the fact that fresh air and oxy- gen, and a high carbohydrate diet will tend to^ limit the liver lesions of chloroform poisoning. Let lis use these data in pernicious vomiting. In cases of pernicions vomiting an acidosis is present. If it is the result of starvation, we should seek to overcome it by feeding. "We can also attempt to overcome it by the administra- tion of salts such as sodium bicarbonate and by the administration of glucose. It is, of course, a well recognized fact that the removal of the products of conception will bring about a cure provided it is done before the toxin has produced irreparable damage. Few cases necessitate abortion and it should be a last resort. The problem as to when an abor- tion is indicated is a difficult one. Many women have died because a therapeutic abortion was not performed soon enough and on the other hand the frequent recovery without abortion after the most serious symptoms and the pos- sibility of malingering on the part of the pa- tient make one hesitate to induce abortion. It 68 TALKS ON OBSTETRICS is to be hoped that we may some day have a test by which we may recognize in time the cases imperatively calling for interference. To turn to actual treatment. Eecognizing the possible aggravating factor of reflex irrita- tion, we should make sure that pelvic relations and conditions are normal. Most likely all have seen cases improve markedly after the reposi- tion of a retroflexed uterus. "We should see to it that the rectum is not loaded with feces and relieve all conditions likely to cause local circu- latory disturbance. Though these are factors to be considered I believe they are the least important. The aggravating influence of the mind is an undoubted fact. Counting out positive malin- gerers who desire if possible to force an abor- tion, there are countless women who because of fear of labor, fear of economic conditions in the home, fears engendered by difficulties in past pregnancies, etc., are rendered mentally unsta- ble and apprehensive and this neurotic condi- tion increases to sometimes an alarming extent the symptoms originated by the causative toxin. It has been my experience that psychotherapy will relieve more patients than any other rem- edy. Try to find the source of the worry and overbalance it with well chosen counter sugges- TOXEMIAS OF PREGNANCY 69 tions. I have often failed in this and seen the patient recover with remarkable rapidity under the guidance of some Faith cure. The response to suggestion is too frequent and too marked to be a coincidence. Next to psychotherapy, fresh air seems to be the most efftcient remedy. Its rationale is likely the better oxygenation of the blood with increased oxydizing and destruction of the toxin, affording protection to liver and kidneys. Stimulate and equalize the circulation by light exercises in the open air or by judicious mas- sage if necessary. Let the diet be high in carbohydrates, bal- anced in proteids and very low in fats, cereals, sugar, buttermilk, etc. Ofttimes the taking of food before rising will mitigate the morning nausea. Light meals at frequent intervals are better than larger meals at longer intervals. The excretory channels, bowels, kidneys, and skin should be kept in their highest state of ef- ficiency. We should see to it that the patient's teeth are in good condition and that she is not swal- lowing large quantities of pus resulting from pyorrhea or caries. The worst case of pyor- rhea that I have ever seen was present in the mouth of a woman who eventually died of per- 70 TALKS OjST obstetrics nicioiis vomiting. Her liver gave the appear- ance of acute yellow atrophy. Whatever the basic cause of the lesion certainly the swallow- ing of huge quantities of pus may have has- tened the outcome. In the drugs given by mouth such as cerium oxalate, etc., that are said to allay the nausea and vomiting I believe you will lose confidence. It is my opinion that if they act at all it is through suggestion. Better the psychotherapy alone without a drug that may have a deleteri- ous effect upon the digestive processes. If psy- chotherapy is not sufficient sedative, turn to bromids and chloral given by rectum. Twenty grains of sodium bromid dissolved in one-half cup of warm water and given by rectum twice a day every four or six hours according to the necessity of the case will often prove of great value. If this is not effective, add ten grains of chloral hydrate to each dose of the bromid. Avoid the use of drugs if possible and regard them as mere adjuvants to tide the patient over until with fresh air and high carbohydrates and under the influence of rest the patient has over- come the toxin whatever it may be. The severe cases are confined to bed and cannot retain fluid or solids given by mouth. These patients must be fed by nutrient enemas. TOXEMIAS OF PREGNANCY 71 Introduce fluids by means of tlie Murphy drip. The solution thus given should contain five per cent sodium bicarbonate and six per cent glu- cose. Thus we may introduce fluids, attempt to reduce the acidosis and may seek to protect the liver and kidney cells by the carbohydrate con- tent which will also tend to overcome acidosis caused by starvation. High colon irrigations are important to re- lieve the lower bowel of possible toxic products. Acting on the supposition that the corpus luteum has some share in the causation of the toxic process, it has been given hypo- dermically and good results reported, es- pecially by Hirst. The fact that this nausea and vomiting comes at the time when there is a change going on in the corpus luteum, sug- gests so forcibly a possible dependence upon abnormal internal secretion from that source that all literature bearing on the subject should be followed closely. As to when a therapeutic abortion should be advised, it is still a question of judgment. Close observation of the general condition of the patient, together with the findings of the degree of acidosis as evidenced in the ammonia coefficient in the urine and the way it responds to psychotherapy, fresh air and forced feeding 72 TALKS OIT OBSTETRICS and the administration of salts such as sodium bicarbonate can be our guides in rendering this judgment. In performing the abortion, if in consultation the same has been deemed necessary, play safe and do not use chloroform as an anesthetic. It may increase lesions possibly already present. Before closing this subject, I would like to offer a suggestion. Acting on the supposition that the male element in the developing fetus may act as a foreign protein and cause the symptoms in the mother if their proteins are widely divergent, I would suggest the possi- bility that we might gain some helpful informa- tion by testing the mother's and father's blood for hemolysis and agglutination in the very se- rious cases as we do before transfusion. It is certainly true that the husband is not a safe donor in many instances. In a severe case of pernicious vomiting when the question of the advisability of doing a therapeutic abortion is a moot one, on all the evidence at hand, this ag- glutination and hemolysis test might be of great benefit in aiding the decision. Though I can as yet offer no definite statement as to the validity of the theory or give enough evidence pro or con in relation to the actual help given, by such a test to make it in any way decisive, TOXEMIAS OF PREGNANCY 73 I will say that it is my belief, at present at least, that in a borderline case the presence of agglutination and hemolysis would increase my leaning to the side of the advisability of thera- peutic abortion. In regard to this theory postulating the pos- sible toxic reaction of the male element of the fetus upon the mother, certain observations are interesting for consideration. Does not the condition recall somewhat the symptoms en- countered in the struggle to elaborate anti- bodies or antitoxins! May not a rapid abate- ment of symptoms connote that a probable bal- ance may have been reached? Concerning the probable difference in a wom- an's reaction to different male elements, ob- serve the difference in the pregnancies with first and second husbands. With one the early vomiting may be absent or negligible and with the other serious. It has been said that pernicious vomiting is less frequent in England and Germany than in America. With due consideration for the neu- rotic differences, cannot the more frequent marriage of divergent strains in the United States offer an explanation? Such speculations are justified here only by the interest of all students in the problem to be worked out in the future. CHAPTER in HEMOEEHAGE IN OBSTETEICS In covering sepsis and the toxemias of preg- nancy we have covered seventy-five per cent of the causes of death in the present day practice of obstetrics. We wiU now take up a group of conditions marked by hemorrhage, which con- ditions are responsible for approximately fif- teen per cent of the deaths in obstetrics. They are: 1. Postpartum hemorrhage. 2. Placenta pre\T.a. 3. Accidental hemorrhage. (Premature sep- aration of the placenta.) 4. Ectopic pregnancy. 5. Euptured uterus. 6. Abortion and miscarriage. Postpartum Hemorrhage Serious postpartum hemorrhages, though al- ways to be guarded against by preparation and technic, are fortunately comparatively rare. If we designate every case as a postpartum 74 HEMORRHAGE 11^ OBSTETRICS 75 hemorrhage that shows sixteen ounces by weight of hemorrhage, it is a comparatively frequent condition. This is done in some rec- ords. If one will measure the blood and follow these cases closely, he will see that it is mis- leading to so designate a postpartum hemor- rhage as some women will show general signs of too much hemorrhage when they have lost less than sixteen ounces and a great many women will show no general signs after losing more than sixteen oimces. When I speak of serious postpartum hemorrhages as being com- paratively rare, I consider them from the stand- point of general symptoms of loss of blood re- quiring treatment, irrespective of the exact amount of blood lost. In eight years I have seen only ten cases. Three were due to failure of attendants to watch the uterus for one hour after the delivery of the placenta, three were due to retained portions of the placenta and occurred within an hour of the delivery of the child and necessitated manual removal, two were due to the division of the cervical artery, and the remaining two to atony of the uterus following a severe and long drawn out labor. It is very important to examine the placenta after its delivery to make sure that no cotyle- dons are left in the uterus. If portions have r? 6 TALKS ON OBSTETRICS remained in the nterus, that patient should be watched closely and all preparations made for possible interference, made necessary by hem- orrhage. Most of these remnants will come away without the necessity for interference. Many men make this an absolnte indication for immediate interference, but unless a man can be morally certain that his surroundings assure a perfect aseptic technic, I do not believe that he is justified in doing so. From the standpoint of sepsis the manual removal of the placenta is one of the most dangerous procedures, more dangerous than a version because the maneuver is not carried on within the amniotic sack which oifers some protection, but the hand comes into immediate contact with the uterine sinuses. After the birth of the child, the nurse should place her hand over the uterus and give warn- ing if the uterus balloons up more than is nor- mal. She should not massage the uterus. I have several times seen this maneuver result in a retained placenta, the cervix contracting and prohibiting the exit and the massage not allow- ing the normal collection of blood behind the placenta which aids in its ultimate expulsion. After the birth of the placenta, the nurse should hold the uterus and if the placenta has come away intact, ergot should be given. The HEMORRHAGE IN OBSTETRICS 77 nurse should hold the uterus for one hour and should massage it if it becomes flabby and soft. If it tends to remain flabby the ergot should be repeated as often as necessary. If under mas- sage and ergot it will not contract down and hemorrhage ensues, use a sterile intrauterine douche with the water at a temperature of from 115° to 120° Fahrenheit. In every delivery the essentials for giving this sterile douche should be prepared for emergency. If the uterus still balloons up tremendously, insert one hand in the uterus and massage the uterus bimanually v/ithdrawing the internal hand as the uterus contracts down. As a last resource pack the uterus tightly with sterile gauze, afterward continuing the ergot and massage if necessary. Be sure that the hemorrhage is not coming from a perineal or cervical laceration. If it is, of course, immediate ligature is indicated. I be- lieve that hemorrhage is the only indication warranting the immediate repair of the cervix. If general sign^ and symptoms of hemor- rhage obtain, the stoppage of the hemorrhage must be followed by the administration of flu- ids by mouth. Murphy drip, hypodermoclysis, or transfusion as the urgency for quick replen- ishment of fluids demands. In every case, normal or abnormal, the nurse 78 TALKS ON OBSTETRICS should watch the pulse at frequent intervals and note any general signs and symptoms of hemorrhage, such as pallor, air hunger, feeling of f aintness, etc. The pulse is a good index and every rapid thready pulse should indicate the administration of fluids. Before leaving every case the physician should satisfy himself that the woman is flow- ing normally, that the uterus is normally con- tracted and hard, and that the pulse is not ris- ing in frequency. He should make it a rule to remain with every woman for at least one hour after the birth of the placenta. Placenta Previa A painless, apparently causeless hemorrhage occurring in the last trimester of pregnancy should bring to mind immediately placenta previa. It is important to be instantly alive to the gravity of the situation and to remem- ber that under the best treatment about one in every six women with this complication dies and that the fetal mortality runs as high as seventy-five per cent. Go to that case with supplies ready to pack the vagina if hemor- rhage demands. A differential diagnosis must be made between this condition and acciden- tal hemorrhage and a threatened miscar- HEMORRHAGE IN OBSTETRICS 79 riage. The absence of pain points to pla- centa previa and the finding of a boggy mass, the placenta, in the lower nterine segment impinging on the cervix, clinches the diag- nosis. Needless to say it is ofttimes a difficult diagnosis to make. It is often impossible to make a definite diagnosis nntil the patient has been under observation for some time. In making the diagnosis do so if possible by means of the rectal examination. Eemember that sep- sis attendant upon lapses in aseptic technic in the vaginal examinations and subsequent treat- ment is responsible for many deaths in this complication. It is obvious that the hospital offers the safest environment for the observa- tion and treatment of these cases. The first hemorrhage rarely exsanguinates a woman, but the second may and all prepara- tions should be made to meet this contingency. As to treatment let us take up in order the lateral, marginal, partial and complete vari- eties of placenta previa. Let us first consider those cases of lateral placenta previa that manifest themselves for the first time in labor. The descent of the head often stops the hemorrhage in these cases mak- ing interference unnecessary. If interference is necessary, ofttimes the artificial rupture of 80 TALKS ON OBSTETRICS the membranes will stop the hemorrhage by al- lowing the presenting part to descend and act as a tampon. If this does not suffice and the cervix is dilated sufficiently or is dilatable with the fingers, forceps or version is indicated ac- cording to the engagement of the head. If a breech presents under these conditions, draw down a foot. In the lateral, marginal and partial varieties, when interference is necessary and the cervix is not dilated, the following courses of treat- ment may be used according to conditions and equipment; packing the cervix and the vagina with gauze and repeating the packing when the hemorrhage soaks through until the cervix is sufficiently dilated to allow of a podalic version and the bringing down of a leg to act as a tam- pon ; packing the cervix and vagina mth gauze until the cervix is sufficiently dilated to admit of the placement of Vorhees bags in increas- ing sizes which will tampon the placenta against the uterus sufficiently to stop the hem- orrhage and wiU dilate the cervix until it is possible to do a podalic version and draw down the leg to act as a tampon ; the use of the Vorhees bags until the cervix is completely dilated and either a forceps operation may be HEMORRHAGE IN OBSTETRICS 81 consummated or a breech extraction after a version. In placing these bags do not rupture the membranes as the lack of fluid may interfere with the subsequent safety of the version. If it is possible to insert a bag and proper assist- ance is at hand, do not use the gauze. Under present conditions I suppose that the gauze packing followed by the manual dilatation of the cervix and version with breech tamponade or breech extraction is the most universal treat- ment. The bag treatment seems to give a lower mortality for the mother and a much better prognosis for the child. If possible use it every time. In respect to central placenta previa with a live child and in selected cases where loss of blood has not been extreme, evident sepsis is not already present, and we can be fairly cer- tain of the previous aseptic technic used in pre- vious vaginal examinations, if any have been used, I believe that an abdominal Csesarean is the treatment of choice. In a deformed pelvis the absolute indication holds of course. The success of this operation will depend entirely upon the selective acumen of the obstetrician. If the cases are not well selected, I am sure that the mortality rate will be much higher than 82 TALKS ON OBSTETRICS under the bag or the ganze packing treatment. If bags are used in central placenta previa, do not go through the placenta to place the bag, but place it between the placenta and the cervix and when the dilatation is complete go through the placenta rapidly, do a version and breech extraction followed by an immedi- ate manual extraction of the placenta. Have everything ready for an infusion. Accidental Hemorrhage or Premature Separation of the Placenta If called by any woman during the last five months of pregnancy because she has sudden severe uterine pain and she gives evidence of external or concealed hemorrhage, premature separation of the placenta should immediately flash across the mind. The presence of pain militates against the diagnosis of placenta previa and the appearance of the condition be- fore the last trimester speaks against it. The suddenness and the severity of the pain and the absence of premonitory signs, together with the lack of the rhythmic character of labor pains speak against the ordinary miscarriage. Eapid pulse, history of sudden severe uterine pain, signs of shock and hemorrhage open or concealed, an appreciable rapid enlargement of HEMORRHAGE IN OBSTETRICS 83 the uterus and the absence of a boggy mass in the lower uterine segment point directly to premature separation of the placenta. Premature separation of the placenta is a very serious condition. General statistics show that in this condition about one in every three women die and that about three out of every four babies die. Of course, these figures vary greatly according to the extent of the separa- tion of the placenta, but it is well to keep them in mind to impress the gravity of the situation and the need for the best surroundings for the conduct of the treatment. All cases should be taken to a hospital immediately, if the prox- imity of the hospital and the condition of the patient render it possible. Treatment. — Gauze packing from below to stop the hemor- rhage. Abdominal binder to limit if possible the bal- looning out of the uterus above and thus limit the hemorrhage by pressure. Means to hurry the emptying of the uterus and allow us to get at the seat of the hemor- rhage. To hasten the emptying of the uterus, pack the vagina with gauze until the cervix softens 84 TALKS ON OBSTETRICS and dilates sufficiently to permit of the intro- duction of a bag. When the cervix is dilated sufficiently, version and breech extraction or forceps, as conditions dictate. After delivery, manual extraction of the placenta if the hemor- rhage does not cease. Other means for stop- ping postpartum hemorrhage are a douche at 115° to 120° Fahrenheit, and gauze packing. Essentials should be at hand for quick replen- ishment of body fluids after delivery. The hemorrhage may be so severe as to allow of no slow methods of delivery and accouche- ment force or Csesarean, vaginal or abdominal, may offer the only hope for the mother. Can we prevent this complication? Considering the accepted causes ; it is appar- ent that we cannot prevent all falls and blows, nor can we prevent short cord, twins, poly- hydramnios, all toxemias of pregnancy, syph- ilis, rheumatism, endocarditis, etc. However, I want to call your attention again to the previously quoted article, written by James Young, who believes that premature sepa- ration of the placenta is due in many in- stances to a thrombosis of the uterine and ova- rian vessels causing a hemorrhage and a separa- tion of the placenta, from the damming back of blood. We may be able to go a step further HEMORRHAGE IN OBSTETRICS 85 and postulate infection or bacterial toxins as a possible cause of the thrombosis. The last se- vere case of accidental hemorrhage that came under my observation, gave no history of trauma, nor was a short cord or any other ab- normal condition present except the presence of fifteen carious teeth and a marked pyorrhea with a mouth bathed in pus. Note the list of possible causes in any textbook; endocarditis, rheumatism, etc. Eradication of foci of infec- tion will prevent or aid in the cure of many rheumatic manifestations and may it not pre- vent one of the complications, accidental hemor- rhage? It may seem ridiculous to many, to harp and harp on the subject of infection, but I do not believe that facts warrant such an atti- tude of scoffing. The more one studies the dis- ease-processes in plants, lower animals and man, the more one is led to recognize the tre- mendous role played by bacteria. If we err at all, we do so on the side of forgetting too often the great biologic struggle for existence, with its resultant train of pathologic conditions. I believe that the clearing up of all foci of in- fection in pregnant women as far as it is pos- sible or expedient may aid in reducing the in- cidence of accidental hemorrhage. 86 TALKS ON OBSTETRICS Ectopic Pregnancy I was first really introduced to ectopic preg- nancy after having brought in, as an ambulance surgeon, a young unmarried woman with a diagnosis of acute appendicitis. Pelvic ex- amination at the hospital showed the incorrect- ness of my snap diagnosis. Since then I have seen two women operated on for appendicitis which proved to be ectopic pregnancy, two women curetted for incomplete abortion with- out relief because the real condition was ectopic pregnancy, and many women operated on for salpingo-oophoritis and pelvic abscess that proved to be an ectopic. The possibility of an ectopic pregnancy, rup- tured or unruptured, should ever be in one's mind when called to see a woman in the child- bearing period suffering from abdominal pain and uterine hemorrhage. I have fallen down so many times in the diagnosis and seen others do the same, that the only advice I can give is to always keep the possibility of an ectopic in mind, have consultation as soon as it is sus- pected, and rely on your surgical judgment in recognizing conditions warranting an explora- tion if there is a question of diagnosis. I have seen ectopic diagnosed as dysmen- HEMORRHAGE IN OBSTETRICS 87 orrhea, menorrhagia, abortion pyosalpinx, ovarian cyst, uterine fibroid, pelvic abscess, and mistaken for acute upper abdominal con- ditions. Having seen such situations brings forcibly to mind the advantage of early exami- nations where a woman believes she may be pregnant so that a possible ectopic pregnancy or other abnormal condition may be sought for or a normal pregnancy diagnosed. In the presence of pelvic pain and uterine hemorrhage it simplifies matters greatly if you have already diagnosed a nomal pregnancy. I mention this advisedly because I have often been called to a case which appears to be a case of threatened abortion and yet in which the diagnosis of a possible ectopic must be made because I had not seen the woman before. One stands a bet- ter chance of quieting do-WTi a threatened abor- tion if no manual examination is made. If for the purpose of a differential diagnosis pelvic examination must be made, use the rectal if possible to preclude the possibility of intro- ducing infection. (I cannot emphasize too much the value of being expert in making the rectal examination. Not alone in obstetrics and gynecology is it of great value, as one can vouch who has had experience in general hospital training and can recall frequent cases of ap- 88 TALKS ON OBSTETRICS pendiceal abscess diagnosed by rectum and can recall many obscure cases that have escaped diagnosis for days because men have failed to make rectal examinations and thereby failed to find a prostatic abscess that has given the patient no local pain that would call attention to the pelvis. Its use in obstetrics instead of the routine vaginal examination, I am certain, will prevent many cases of sepsis and in gyne- cology it will often give information that the vaginal examination will not give.) In making the diagnosis of ectopic pregnancy, the symptoms and signs to be kept in mind are: some irregularity of menstruation, spot- ting, pains in the pelvis, some enlargement and softening of the uterus with or without other presumptive symptoms and signs of pregnancy, pain on moving the cervix, a feeling as if a stick were sticking into the rectum on defeca- tion, and the finding of a tender mass to any side of the uterus. Eemember that the absence of any one or two of these signs cannot exclude ectopic pregnancy. When the ectopic oozes or ruptures, we may have in addition to the above, signs of internal hemorrhage, shock, and a boggy mass distending the pouch of Douglas. The rup- HEMORRHAGE IN OBSTETRICS 89 tnred ectopic may simulate almost any acnte abdominal condition. The most frequent differentials that one is called to make are abortion, complete or incom- plete, pus tubes, and ovarian cyst. In acute salpingitis the diagnosis is aided by finding no enlargement of the uterus, no pre- sumptive signs of pregnancy, masses on both sides of the uterus, history of infection and positive smears from urethral and cervical dis- charges. Temperature and leucocytosis may aid. It is often a very difficult differential. Under the most thorough examinations, his- tories and laboratory findings, after consul- tation you may operate for ectopic and find a salpingo-oophoritis and vice versa. The key- note to success is knowing when an exploratory should be done. The ovarian cyst in the presence of presump- tive signs of pregnancy, pelvic pain, and ir- regular bleeding makes a differential a puzzling question. When any question exists, the pa- tient should be under observation in a hospital. In determining the presence of a threatened abortion in a uterine pregnancy we may have the knowledge by a previous examination of a normal pregnancy, we may have the rhythmic pains characteristic of labor, or we may find 90 TALKS OX OBSTETPwICS no change in the pelvic organs outside of the enlarged and softened 11161118. In cases where iDregnancy is doubted and de- lay under observation is indicated, the Abder- halden test may prove of valne, but at least when subject to the present possible errors of teclmic. it cannot be depended npon entirely. After all is said and done, in reference to this condition I have come to the following conclusion : The more cases that yon follow in which it has been necessary to make a differential di- agnosis betAveen a possible ectopic, especially before rupture, and other conditions that must be excluded, the less sure you w]]l be of the diagnosis of the exact condition, but the more sure you vill be of the absolute importance of a diagnostic care and acumen and a surgical judgment that can distinguish between the case that can safely be watched closely without im- mediate interference and the case demanding immediate exploratory laparotomy. Rupture of the Uterus This subject is generally so thoroughly drilled into students and the symptoms and signs brought out in such a spectacular and tragic manner that I find that men are likely HEMORRHAGE IX OBSTETRICS 91 to be unduly nervous from fear of it in many cases and ofttimes want to interfere imnecessa- rily thereby courting sepsis. Remember that most cases of rnptnred uterus have resulted from very poor manage- ment. Eemember that only about seven per cent occur in primiparae, the remainder occur- ring in multipara where the uterine wall is more apt to be flabby and thinned out. Re- member that any Ioioaaii abnormality of the uterine wall such as a scar of a previous Cesarean, especially if the Ce?sarean section was followed by suppuration, should make one especially cautious. As gTiards against a possible rupture of the uterus the following rules are valuable : 1. Do not allow the second stage of labor to last much over two hours. If continuous ad- vancement of the head and the good condition of mother and child lead one to extend some- what this two hour limit, watch for the contrac- tion ring and do not let it rise above the mn- bilicus without interfering. If the uterine wall is known to be pathologic, interfere before the two hour limit if it seems advisable and most certainly at the first appearance of a contrac- tion ring. (Do not mistake a full bladder for a contraction ring as I have often seen done.) 92 TALKS ON OBSTETRICS 2. Never give pituitrin in the presence of a contraction ring. 3. Never give pituitrin unless you can be as certain as measurements and examinations will allow that the passage offers no absolute ob- struction to the passenger. Then give it in no larger than five minim doses repeated as often as is necessary or expedient. 4. Beware of attempts at version if the amni- otic fluid has long been drained away and the uterus is firmly contracted around the child. 5. Beware of attempts at version before the uterus is thoroughly relaxed under an anes- thetic. The signs of a possible rupture of the uterus are: Tearing pain, shock, hemorrhage, reces- sion of the presenting part with cessation of labor pains; together with abnormal findings on abdominal palpation. Laparotomy is indicated immediately upon the establishment of the diagnosis. Maternal mortality is about fifty per cent. Abortion and Miscarriage I have placed this condition in the hemor- rhage group to emphasize a cardinal sign in diagnosis and not because hemorrhage is the frequent cause of maternal mortality. The dan- HEMORRHAGE IN OBSTETRICS 93 ger of abortion lies more in sepsis than in hem- orrhage. The appreciation of this fact will save the lives of many women. The majority of hemorrhages, preceded or followed by abdominal pain, in pregnancy are the signs of abortion. From ten to twenty per cent of pregnancies terminate in abortion and the possibility of its accession should be ever present in the mind of the physician when a patient presents for care in pregnancy. A miscarriage is a great disappointment to a mother and the family and the mental de- pression follo\\ing in its train is almost as fre- qnent a canse of subsequent ill health in the mother as the physical results per se. This is especially true if the miscarriage obtains in the first pregnancy. In many such cases the mental anxiety jjroduced by the fear of miscarriage in a possible subsequent pregnancy may become a veritable complication, especially when a sub- sequent pregnancy ensues. I have found that the most effective way to quiet this fear is to tell them that for some reason miscarriage falls to the lot of most every woman once in five pregnancies and that she has suffered her quota of misfortune. I then try to find the cause of the miscarriage as a means of future prophy- laxis. 94 TALKS O:^ OBSTETRICS In regard to prophylaxis. When a woman presents for the j&rst time in pregnancy we shonld aim, by means of specific written in- structions and a thorough physical examination, to guard her against the possibility of mis- carriage. The instructions should caution her as to the danger of overtiring, jolts, jars and straining, especially at the time when menstruation would normally be in progress, at which time the uterus seems especially sensitive to even slight stimuli. She should be cautioned about inter- course at this time and if advisable from the previous history, be advised to remain in bed for a few days. Douches should be interdicted. She should have definite instructions to notify the physician at the advent of an increased vaginal discharge mth a feeling of discomfort in the pelvis, often a precursor of threatened miscarriage, and at the first sign of spotting or definite uterine hemorrhage, or pain in the abdomen. We should seek to protect her as much as possible from worry and mental shock. I re- call one patient who had an abortion beginning at a moving picture show depicting ^Hwilight sleep." Any mental shock should be avoided if possible. HEMORRHAGE IN OBSTETRICS 95 It is not in the lack of care in giving these instructions to our patients that we are likely to err, but in our carelessness in making our physical examinations. Before bringing out the main points in the physical examination, recall to mind the accepted direct and indirect causes of abortion : trauma, mental shocks, de- velopmental anomalies in the fetus that result in its death and subsequent expulsion, local ab- normalities, such as retroversion of the uterus, deep cervical tears, endometrial pathology, etc., and infections. Criminal abortion we will omit from this discussion. A large number of abortions are the result of developmental anomalies, that result in the death of the fetus. These we cannot influence and it is a blessing that Nature has provided this safety valve, as it were, which prevents in so many instances a woman going to term and delivering a living monstrosity. The significance of trauma and mental shocks we have mentioned. Of all other causes, observation has taught me to give the most weight to infection. I am inclined to believe that it is the most important of all causes. I do not mean lues alone, which we all know is a most important cause of abor- tion, but any other infection. 96 TALKS OlsT OBSTETRICS If you will follow your cases carefully you will find that the laity believes so universally in the traumatic factor in miscarriage that a woman mil often give a very vague history of trauma that is likely to throw one o:ff his guard. It reminds me of the history of trauma that a mother mil give when she describes the beginning of a limp in a child with a tuber- culous hip. In many of these abortions I feel certain that infection of some sort is the causa- tive factor and I feel that a physician is not doing his duty to his patient if the history of a previous abortion does not prompt him to look for foci of infection in addition to lues. Lues must, of course, be excluded, but I have in a great many instances excluded lues to the best of my ability by history, signs, and a number of Wassermanns on man and wife, have ex- cluded local factors, trauma and neuroses, have been morally certain that artificial means had not been used, and found carious and abscessed teeth and infected tonsils, which, especially in the presence of symptoms of infection such as neuritis, muscular rheumatism, endocarditis, etc., made me suspect the oral and throat in- fection as the origin of the abortion. It seems fair to assume that bacteria from abscessed teeth, tonsils, etc., that can form emboli in mus- HEMORRHAGE IK OBSTETRICS 97 cles and nerves and cause rheumatism and neu- ritis, can cause abnormal conditions in the de- cidua with consequent abortion. We know the action of the bacillus abortus in cattle. We know that any infectious disease can cause an abortion in woman. Whether it does so by killing the fetus directly or indirectly by caus- ing pathology in the decidua with the resultant death of the fetus is of more pathological than practical interest. I personally believe that the decidua suffers first. Those of us who work with experimental laboratory animals, such as rats for example, know that we are often handicapped in our work by the frequent abor- tions resulting from infection. I believe that infection of any type, anywhere situated, may cause abortion by infarction or elaboration of toxins. Needless to say it will not always do so any more than diseased teeth and tonsils will always cause rheumatic conditions. Even if you don't believe it, keep it in mind in care- fully going over your cases. Concerning infection, I would recall a case coming under my observation lately. She was two months pregnant and suffering from acute and rapidly progressing tuberculosis of the lung. It was the opinion of three physicians that a therapeutic abortion should be per- 98 TALKS ON OBSTETRICS formed. This she refused and went on to de- livery. The point of especial interest in this case was not her refusal to take advice, but her previous history. Within a year and one-half previous to her present pregnancy she had aborted twice. No history of trauma in either abortion. The tuberculosis lesion was not dis- covered until the third pregnancy, but it seemed fairly certain that it had existed in the previous pregnancies. "What I want to emphasize is that not only should a woman be given a careful, thorough physical examination in applying for the first time in pregnancy, but that a history of previous abortion should lead every phy- sician to take especial care in the search for foci of infection other than lues. The time to discover infection is before or between preg- nancies. Following an abortion, a physician should seek for and advise the removal of all foci of infection, such as diseased tonsils, ab- scessed teeth, etc. Search for tuberculous le- sions. If you do not do so, and she has an ac- tive process, she may not be so fortunate as to abort in the subsequent pregnancy and the ac- tive process may either call for a therapeutic abortion or may cause the death of the mother in or shortly after labor. All pregnant women should be sent to their HEMORRHAGE IN" OBSTETRICS 99 dentists and all foci of infection discovered. At- tention to the teeth in pregnancy will negative the old adage, **for every child a tooth,'' and the majority of women will reach delivery with better teeth than they had at the beginning of pregnancy. If infection is found, the question arises as to whether it is safe to work on a woman's teeth in pregnancy. All open infec- tions can be treated without danger by fre- quent, short, nontiring, painless methods. If pyorrhea is present the dentist should exercise great care in manipulating the gums so as not to get a severe reaction from auto -vaccination. When it comes to eradicating root abscesses, the question is more difficult of decision. In cases giving a history of previous abortions or toxemia of pregnancy and where definite local or general signs exist, pointing to the teeth as a possible cause, such as rheumatism, neu- ritis, nephritis, etc., I never hesitate to advise extraction. The most painless method should be used. I counsel the family that the reten- tion of these abscesses is of more danger to the patient than the possibility of a miscarriage. It is a well known fact that pregnant women stand major operations well with the exception of cervical and hemorrhoid operations, and that abortion is likely to ensue only when infection 100 TALKS OIT OBSTETRICS takes place. In abdominal operations in preg- nancy, if the corpus luteum is not disturbed, abortion is not likely to take place unless infec- tion ensues and then about forty per cent will abort. Even fibroids may be removed from the pregnant uterus without imtoward result. Seemingly the infection and not the operation per se is the danger. The same applies to den- tal operations. In this connection a prominent dentist related to me a story of an experience, arising in his early practice. A woman applied for treatment of a condition that required an extensive dental operation. This was per- formed under ether anesthesia with success. After the operation she made the remark that ^^she hoped that would fix it." Upon inquiry as to what she meant he was informed that she was pregnant and had sought treatment in the hope that it would bring about a miscarriage. It did not do so. This is not a plea for the advisability of extensive dental operations, however. If extractions are decided upon, only one tooth should be extracted at a sitting, a week, ten days or two weeks interval elapsing before the next extraction to allow for reaction as we do in giving autogenous vaccine. The reaction is often much the same. So far, I have seen only one case in which a threatened abor- HEMORKHAGE IN OBSTETRICS 101 tion immediately followed. This was in a highly neurotic woman. Her history of a past abortion, the presence of definite rheumatic symptoms obtaining from a time previous to her abortion and the presence of a large root abscess made it seem wise to counsel extraction in spite of her highly neurotic temperament As she recovered consciousness from the gas anes- thesia she said she had been through labor. In about five minutes she began to have pains, and within a half hour she began to flow. Under appropriate treatment the threatened abortion subsided. Marked and rapid improvement in her general health followed the draining of this abscess. Such a case would suggest the wise precaution of being on hand to administer im- mediate treatment for threatened abortion if it should become necessary. An initial dose of morphin before the anesthetic could do no harm. Use local novocaine anesthesia where it is pos- sible or expedient. Some patients dread the thought of being conscious and should have gas anesthesia or analgesia. In studying gas an- esthesia I have often found from subsequent questioning or from voluntary statement of the patient that there was a predominance or marked accentuation of a previous fixed idea in the dreams under the anesthetic. In the case 102 TALKS ON OBSTETRICS of threatened abortion cited above, I believe we were dealing with a psychic shock produced by the intensity of the dream tinder the anes- thetic. It is obvious that an incarcerated uterus may cause an abortion. Do not think, however, that because of this fact every retroverted u.terus should be replaced in early pregnancy. Most of these uteri will rise out of the pelvis as the uterus enlarges. Watch the uterus care- fully if it is retroverted, but do not insert a pessary unless observation makes it seem ab- solutely necessary. I have seen several abor- tions foUoAving manual reposition and the in- stallation of a pessary. Other possible local factors in abortion : deep laceration of the cervix, endometritis, etc., it is obvious must be remedied before pregnancy. It is possible for the obstetrician to render a great service by being especially careful and thorough in making his physical examination. Many women never go to a physician unless in pregnancy and his findings may be the means of correcting many morbid processes which the family physician has never been given the op- portunity to detect. Diagnosis and Treatment — The great major- ity of hemorrhages during pregnancy are signs HEMORRHAGE IN OBSTETRICS 103 of abortion or miscarriage, threatened or inevi- table. Pain is a concomitant sign. Granted said signs, if the physician has previously di- agnosed a normal pregnancy, it is better not to make an examination, bnt place the patient im- mediately npon treatment for a threatened abortion. Both the rectal and vaginal exami- nations may by irritation increase the tendency to abort and the vaginal examination increases the danger of infection. Concerning infection, the late Dr. John B. Mnrphy, of Chicago, told the story of his being called to a case of obvious threatened abortion, placing the woman npon treatment, and leaving without making an ex- amination. The next morning he was met at the door by the husband who said that his serv- ices would not be needed as they had called a real doctor who had made a vaginal examina- tion. Several days later Dr. Murphy passed that way and saw crepe upon the door. The moral is apparent : Why take the chance of in- fecting the woman, if it is not necessary. Many times a di:fferential must be made. In my experience, in the early months of preg- nancy, the differential lies between threatened, inevitable or incomplete abortion, ectopic preg- nancy, pus tubes and ovarian cyst; in later months, miscarriage, accidental hemorrhage 104 TALKS ON OBSTETRICS and placenta previa. The history, symptoms and signs differentiating these conditions are covered in other Talks. In making the exami- nation nse the rectal first and then if in doubt nse the vaginal examination exercising the greatest care in the aseptic technic. For purposes of treatment, abortions and miscarriages are classified as follows: Threat- ened, complete, incomplete and septic. Threatened Abortion. — Up to the last mo- ment treat these cases as threatened abortion. A patient may lose a pint of blood and still go on to normal labor. Put the patient to bed, give morphin one- fourth grain by hypo, or rectal suppository con- taining powdered opium, grain one, and bel- ladonna, grain one, to relieve pain and muscle spasm. If pain continues, repeat the supposi- tory every six hours. Rest in bed one week after the cessation of bleeding. Counsel again as to care in not overdoing and the avoidance of strain especially at the time when menstruation would normally obtain. Make a complete phys- ical examination after the bleeding has ceased, to see if there is any accounting for the condi- tion. If in spite of treatment, abortion becomes in- evitable, make no vaginal manipulations ex- HEMORRHAGE IN OBSTETRICS 105 cept to pack the cervix and vagina in case of severe hemorrhage. Remove packing in twelve hours, when the products of conception will usually be found on pack. Do not enter the uterus after abortion or mis- carriage, unless continuation of bleeding and a patulous cervix make it evident that the abor- tion or miscarriage has not been complete and sufficient time has elapsed to preclude the prob- ability of natural expulsion and restitution. If you conclude that the uterus must be emptied either use the gloved finger as a curette or use the largest dull curette compatible with intro- duction through the cervical canal. A small curette is more likely to furrow the decidua without complete removal and more likely to perforate the uterus. After curettage pack the uterus with gauze. This promotes contraction of the uterus, inhibits bleeding and upon re- moval in twelve to twenty-four hours, small particles of decidua possibly remaining will most likely come away with the gauze. If there is any question as to the asepsis, do not pack the uterus. If dealing with septic abortion, put the pa- tient in the Fowler position, ice bag on hypo- gastrium, give ergot by mouth or hypo, fresh air and sunlight, forced feeding and tonics. 106 TALKS 01^ OBSTETRICS Do not curette. By so doing the leucocytic barrier may be broken down with resulting in- crease in danger of general sepsis. This rule must be abrogated in the face of severe bleed- ing. Light blunt curettage may here be insti- tuted, care being taken to interfere as little as possible with a possible leucocytic barrier, and always remembering that these septic uteri are extremely soft and easy to perforate. In all cases be sure that the cervical canal is allowing sufficient drainage. If infection localizes in the pelvis with in- duration, do not incise unless definite fluctua- tion is present. Failure to wait for fluctua- tion is a frequent error. In cases of miscarriage where instrumenta- tion is admitted or suspected and signs of se- vere sepsis are present, with the delivery of the fetus not imminent, the best results are ob- tained by dilatation of the cervix and extrac- tion. Here, emptying of the uterus reduces its size, and the contraction aided by ergot tends to close the avenues through which the infection may gain entrance and the leucocytic barrier has a smaller area to cover. Eapid recovery usually follows this drainage. Such a proce- dure is often made imperative in missed abor- tion followed by toxemia or infection. HEMORRHAGE IK OBSTETRICS 107 Before closing let me bring to your attention the subject of miscarriage or premature labor on or about the seventh month when the vi- ability of the child is probable. Treat these cases by rest in bed and elevation of the foot of the bed, using morphin with great caution. Be especially careful in your use of morphin, if the premonitory signs of increased dark vaginal discharge have been in evidence for several days prior to the accession of pronounced signs of premature labor. This vaginal discharge generally presages changes in the decidua making premature delivery inevitable and if morphin is used, a probable viable child may succumb upon birth to depression of the re- spiratory center. One should be as certain as possible that the birth is not imminent and if uncertain only small doses should be used. CHAPTER IV HEART LESIONS AND TUBERCULOSIS Heart lesions and tnbercnlosis are the cause of about seven per cent of the maternal deaths in present day obstetrics. I will merely men- tion some of the other possible remaining causes ; such as, diabetes, carcinoma, embolism, pneumonia, etc. I believe that all pregnant women with heart lesions or who have had active tuberculosis, should have the best counsel obtainable to decide the question as to the advisability of therapeutic abortion. In the cases with heart lesions that have given serious symptoms and signs of decompensation, especially in the near past, or at the time give even minor evidences of decompensation under normal exertion, and in all cases with active tuberculosis or with lesions that have been active within two years I side with those of my consultants who advise therapeutic abortion before the fifth month. I do this because of the apparent jeopardy and the mortality in these cases, because of the un- certainty of all such cases, and in spite of the 108 HEART LESIONS AND TUBERCULOSIS 109 fact that many patients will refuse the advice and will possibly pass through pregnancy and labor without serious untoward symptoms. It will aid to know the relative seriousness of various heart lesions and apply this knowledge to the extent of the lesion of the case in hand, it will aid the judgment to go into all the past history minutely and seek for all the past signs and symptoms of decompensation, and to es- timate the present reserve strength of the heart by various tests, but in the final analysis of each case results show that even a fairly defi- nite prognosis is hard to give. I must admit that fortified with literature, with discussions with other men concerning their observations, with actual experience of my own cases, and with all the best consultation that a patient can afford, I approach each case with no assur- ance as to its outcome. The same applies to tuberculous patients. In tuberculosis I do not necessarily mean the immediate outcome, but the later effect upon the mother, and I am here referring to those patients who either have active lesions or who have had active lesions within the past two years. Needless to say that after giving a serious prognosis we are often agreeably surprised at 110 TALKS 01^ OBSTETRICS the result and onr opinion is held more or less in contempt by the family after a most normal and happy outcome. Do not be misled by these cases, however, and remember that a man should not urge a risk that he would not advise in his own family. It seems to me that in fev/ other obstetric prob- lems is judgment more liable to error. Always have consultation in these cases irrespective of whether you favor therapeutic abortion or not. It goes without saying that no man should perform a therapeutic abortion in any condition until his opinion as to its necessity has been corroborated by at least two men of unques- tioned professional standing. As to the treatment : In addition to medicinal treatment and general measures throughout pregnancy, all special obstetric treatment should aim to make these labors as easy for the patient as possible, and all aids to delivery should be used, according to conditions and judgment, that will result in the least strain and shock to the patient, such as assistance by forceps, version or what not. These are two of the general conditions that may add indications for the imperative need for interference. In tuberculosis, I doubt the advisability of in- ducing labor after the fifth month. The end HEART LESIONS AND TUBERCULOSIS 111 result will be questionably different from labor at term, helped by every aid at our command if necessary. It may result more disastrously. In heart lesions, on the other hand, decom- pensation may make an induction after the fifth month imperative. All things being equal, how- ever, I believe that labor at term will give as good results as the premature induction of labor for other than imperative symptoms of decompensation. CHAPTER V FOECEPS The obstetric forceps, mthout which few men would care to practice obstetrics today, a blessing to humanity when used with discrimi- nation, like all other good things can become a curse if used indiscriminately, and this curse makes itself manifest in the mother by fatal hemorrhage or shock and by frequent unnecessary sepsis, invalidism and preparation for subsequent surgical operations; and in the child by great increase in the percentage of mortality and injury. In any large clinic hardly a week passes in which some woman does not present herself, either terrified at the thought of having to pass through another labor or to obtain treatment for injuries sus- tained at a previous labor and giving a history much like the following: At the birth of her first child, after being in labor for three or four hours, during which time several vaginal ex- aminations were made, her physician at first thought that the baby would have to be turned, but decided finally to use forceps. She was 112 FORCEPS 113 told that it was a very difficult delivery. She was delivered of an injured or dead child, suf- fered severe lacerations that required many stitches, and had a protracted puerperium ac- companied by chills and fever. Since this labor she has never felt well. On physical examina- tion the following findings are obtained : Badly lacerated perineum, cystocele and rectocele, deep tears in the cervix, and pelvic adhesions the results of previous pelvic infection. What facts obtained in her history and physical ex- amination would lead one to suspect that for- ceps might not have been necessary in this case? Measurements of the pelvis, both inter- nal and external, show that she has a large roomy pelvis with no inlet or outlet contraction and we find upon inquiry that her child had not been unusually large. "When one considers that the average length of a first labor is eighteen hours, the necessity for using forceps at the fourth hour, though possible, is rather doubtful. The extremely deep tear in the cervix would lead one to suspect that dilatation of the cervix had been rapid and forcible rather than slow and gentle, which latter method is not likely to result in deep tears. We are even led to sus- pect that the forceps may have been applied before the cervix was completely dilated. From 114 TALKS ON OBSTETRICS the fact that version was considered, we are led to suspect that forceps were applied to a floating head or that the accoucheur did not recognize a normal position with an engaged head. That infection ensned would point to a slip in technic, bnt granting the best asepsis, it shows the danger of any vaginal manipula- tion and instrumentation. This is only one of many histories suggesting the indiscriminate use of forceps. In the face of textbook expositions and pres- ent day clinical teaching it should not be neces- sary here to go into the minutise of aseptic tech- nic, but granting the most careful personal asepsis and aseptic preparation of the patient, two dangerous tendencies are brought to my attention every day; first, the tendency to place too much confidence in antisepsis; and second, the tendency to forget the fact that the anatomy of the vulva and the vagina makes it almost impossible to count on thorough asep- sis. Men forget that when we enter the vagina, though we do so by sight and avoid all other contact, we are still facing the danger of carry- ing virulent bacteria from the lower to the up- per part of the vagina or into the uterus itself. Not only should we perfect ourselves in the best methods, but we should remember the f alii- FORCEPS 115 bilities of the best technic. In our fight against bacteria we should not become too confident of onr own prowess. General surgeons have long since reached this attitude in regard to the probing of wounds. No general surgeon, wor- thy of the name, would thrust his hand or an instrument the length of an obstetric forceps blade across a possible area of infection into the depths of a wound, unless for the most ur- gent indications. Men frequently ask me how it is possible that this danger of sepsis can be so imminent when they have read in this book or that that so and so uses forceps in nearly one-third of his cases or one-fifth as the case may be, and reports excellent results. Do not allow yourselves to be overconfident because some of our ablest obstetricians use forceps in a high percentage of their cases. Remember that they get a relatively greater number of difficult cases than the average man, that their clientele is made up of a higher percentage of oversensitive, neurotic women, weakened by luxury, which will necessarily increase the fre- quency of indications for the application of for- ceps ; and do not forget that not only are these men especially skilled in the use of forceps and exceptionally well-trained and careful in their aseptic technic, but that they work under the 116 TALKS ON OBSTETRICS best conditions that science and money can ob- tain and with the most skilled and reliable as- sistants. Now and then you will hear a man advocate the early nse of forceps to hasten delivery in the speciously creditable attempt to relieve women of pain. As a sole indication, surely this is an error of judgment in the face of pres- ent day methods of obtaining the same result without danger. The judicious use of chloral and morphin, if absolutely necessary in the early stage of labor, and the use of nitrous oxide gas and oxygen, administered by an ex- pert in the latter part of labor (may begin gas when the cervical canal is obliterated and the external os dilated to the size of a dollar), to- gether with the judicious use of pituitrin (three to five minims in repeated doses hypodermic- ally), in the second stage of labor if no real ob- struction exists, will permit of normal delivery in most cases with a minimum of pain, no dan- ger of infection, and less danger of laceration than if forceps were used. Certainly the judi- cious use of morphin and pituitrin need not be elaborated, as medical literature is replete with advisory articles on this subject. In relation to the use of chloroform in obstetrics it is well to keep in mind the danger of delayed chloro- FOECEPS 117 form poisoning. Never use it in cases giving signs of toxemia. The greater a man's knowledge and experi- ence the more exacting and searching becomes his zeal, in the interests of both mother and child, in trying to eliminate the necessity for the nse of forceps. In the same measure, how- ever, does his zeal increase in searching for and recognizing immediately, imperative indi- cations for their use. In the nse of forceps two mistakes stand out conspicuously, spelling disaster in many in- stances; namely, the attempts to deliver by forceps when the cervix is not fully dilated or potentially so, and the attempts to deliver a child by applying forceps to a floating head. Outside of the danger of trauma to mother and child these procedures frequently mean the sub- sequent substitution of other measures to con- summate delivery with increased danger of sepsis in proportion to the increased number of manipulations and the number and extent of the lacerations. In relation to dilatation of the cervix, give Nature and time a good chance and then if nec- essary use bags to complete the dilatation, but do not attempt to deliver by forceps with an xmdilated cervix. 118 TALKS ON OBSTETRICS In relation to a floating head, if after abdom- inal manipulation and the assumption of the Walcher position the head fails to engage, bet- ter by far do a podalic version if it is possible and deliver by breech than apply forceps to a floating head and attempt to deliver. Here use high forceps with craniotomy if necessary, only as a last resort. If absolute dispropor- tion exists between passage and passenger ac- counting for the nonengagement of the head, the child is alive and we can be sure of the previous nonintroduction of infection by vagi- nal examinations, a selective Csesarean is indi- cated. Such cases bring home the value of the routine rectal instead of the routine vaginal examination. If sepsis exists or the child is dead, podalic version if possible and crani- otomy if necessary, is indicated in the interest of the mother. Having assured oneself as far as possible by mensuration that the passage offers no in- surmountable barrier to the birth of the pas- senger, with the cervix completely dilated and the head firmly engaged and in a position al- lowing of delivery, certain indications must dictate the need for forceps. Under the above conditions of passage and passenger if the child is advancing and shows no evidences of danger- FORCEPS 119 Oils pressure such as weak irregular heart sounds of markedly increased or decreased fre- quency, especially the latter, and the mother shows no local signs requiring quick action such as hemorrhage, contraction ring reaching to t^e umbilicus, pressure edema or bladder paralysis, no general signs and symptoms of hemorrhage or exhaustion, such as weak rapid pulse, etc., and no constitutional condition ex- ists bespeaking aid, such as severe heart or kidney disease, eclampsia or tuberculosis, the use of forceps is contraindicated. The slow delivery by tending to limit lacerations opens up fewer channels for the admission of infec- tion and noninterference introduces no infec- tion. Toward those men who say that they have used routine vaginal examinations and forceps for years and years and never had an untoward result, one can only show that deference due also to the men whose cases never show a lacer- ation. Their technic must be phenomenal. Statistics, however, might modestly suggest the added element of good fortune. Surely they will admit that in general the obstetrician who guards his patient against the importunities for or actual attempts at meddlesome inter- ference shows greater wisdom and prowess 120 TALKS ON OBSTETRICS than he who hastens to a display of his technic no matter how faultless or successful it has proved in the past. Before applying the forceps, run over in your mind the mnemonic originating with Dr. S. E. Moore, one time Teaching Fellow in Obstetrics at the University of Minnesota. This is called the A.B.C.'s of forceps application. Each letter stands for two things to be done. Let A stand for Application and Amnion. In other words, before attempting to apply the forceps deter- mine the position of the head, lock the forceps, hold them up, and figure out the application, and be sure that the membranes are ruptured. Let B stand for Bladder and Bowel. See to it that they are emptied before attempting to de- liver by forceps. Let C stand for Cervix and Cord. Be sure that the cervix is dilated and that you pass within the cervix in the introduc- tion of the blades and be sure that a prolapsed cord is not within the grasp of the forceps. This is a very clever and helpful nmemonic. Do not attempt to apply the forceps until the patient is well under an anesthetic. In delivery take plenty of time and do not think that you must deliver the baby with one pull. In beginning the gradual traction with the right hand, keep the fingers of the left hand FORCEPS 121 on the head to see that the forceps are not slip- ping. Let the pull be slow and steady and un- lock the forceps at from one-half to one minute intervals. Let the progress simulate as nearly as possible normal delivery, for the sake of both baby and mother. As soon as the head is under control, remove the forceps and deliver as in a normal delivery. CHAPTER VI PODALIC VERSION One of the most frequent questions in out- patient teaching is, ^^What are the indications for podalic version?" Before going into details, I would repeat a statement made by an old country practitioner who had over twenty-three hundred obstetric cases to his credit. * ^In the face of abnormality or perplexity never forget to weigh the possible benefits of version. It has brought me more success in difficulties than all other obstetric procedures barring medium and low forceps. Never forget podalic version. ' ' Make this per- sonal and let it always ring in your ears and see if you do not have many opportunities for feeling grateful for this advice. Let us first take up the contraindications to an attempt at version: 1. Where our examinations show that the marked disproportion between the pelvis and the fetal head will not allow of the delivery of the after coming head. (We are here consider- 122 PODALIC VERSTON 123 ing the case of a live child where craniotomy is not indicated in the interest of the mother.) 2. When the head is firmly engaged. (Deep anesthesia may permit disengagement.) 3. When a high contraction ring exists, with a thick upper uterine segment and a thin stretched out lower segment. The version is here likely to cause rupture of the uterus. 4. When the amniotic fluid has long been drained away and the uterus is firmly con- tracted around the child. Here again we are running a great chance of rupture of the uterus. Podalic version should immediately suggest itself in oblique and transverse presentations. Version is a possible resource in face, brow and persistent occiput posterior positions with arrest at the inlet. Consider version in all cases where there is no absolute disproportion between the pelvis and fetal head and where the presenting part will not engage. In such a case do not consider high forceps, except as a final resort, with per- haps craniotomy. I am of the personal opinion that there is rarely a case in obstetrics in which high forceps might be used on a floating head that would not better be delivered in some other way. Consider version to hasten deliverv as in 124 TALKS ON OBSTETRICS eclampsia and premature separation of the pla- centa; as a means of tamponade in placenta previa; when prolapsed cord will not stay replaced; and in deformed pelves of a minor variety where the internal conjugate is not below 8 cm. In such cases if previous labors have proved disastrous and resulted in a dead child, and abdominal Caesarean section un- der selective conditions can be performed, I would prefer it to version. This applies also to primipara in which the fetal mortality of version is high. I am stating conditions in which it may be considered and perchance sur- roundings may make it the measure of choice or necessity. Version is indicated in those cases which would demand a Csesarean were it not for in- fection or a dead child. Here delivery may be consummated if necessary by craniotomy. Before doing a podalic version be sure that the bladder and rectum are emptied and that the patient is well relaxed under the anesthetic. In conclusion let me mention several prac- tical points in the technic where I have seen men fall down. Be sure that you are inside of the amnion. Be sure that you grasp a foot and not a hand. (The heel is the distinguishing feature.) Grasp the anterior foot. If the head PODALIC VERSION 125 obstructs in pulling down the foot, abdominal manipulation with the free hand will aid in pushing the head to one side. Do not withdraw your hand from inside the uterus until you have completed the maneuver, no matter how much thinking you have to do or how many at- tempts you have to make before you have suc- ceeded in drawing down the foot. It is obvious that the withdrawal and reinsertion of the hand will increase the chances of infection. Draw the foot down with the heel facing the operator so that the fetal back will face the front. See that the cord is not prolapsed before withdraw- ing hand. CHAPTER VII PROLAPSE OF THE CORD Thougli this complication is less likely to oc- cur when a normal presenting part, in normal position, is engaged snugly in the pelvis before the advent of labor, always seek for it in every labor in making yonr rectal examinations. Make it a rnle to examine all patients as soon as possible after the rupture of the membranes. The out rushing fluid may carry the cord with it. If it is diagnosed before the rupture of the membranes, keep the hips elevated until the membranes rupture and the part is engaged. If, after rupture of the membranes, the cord is found to be prolapsed, do not interfere if the cord does not pulsate and the fetal heart sounds are absent unless the complete dilatation of the cervix will allow of rapid delivery by forceps or breech extraction and you feel sure that the child gave evidences of vigor only a short time before. If the fetal heart sounds are present or the pulsation of the cord can be made out, try the following procedures: With the woman in the 126 PROLAPSE OF THE CORD 127 knee-chest or Trendelenburg position try to push back the cord with the finger. In vertex positions it is sometimes possible to hang the cord on the ear and thns keep it back. If re- placement by the finger fails, you may try the technic of replacing mth a catheter which has a tape drawn through the eye. If the cervix is completely dilated and the head engaged, after replacement of the cord, apply forceps and draw the head being careful not to include the cord in the grasp of the forceps. If the cervix is not completely dilated, and the head is either not engaged, or not so firmly engaged but that it may be pushed back, and the cord will not re- main in place after reposition, do a version and deliver by breech. If the breech presents in the first place pull down a foot and thus tampon the cervix snugly after replacing the cord. It may be necessary to dilate the cervix with a bag before any maneuver is possible. I have made it a rule not to temporize mth this complication and if I have the least diffi- culty in keeping the cord replaced, where for- ceps cannot be used, I pull do^vn a foot as soon as possible and deliver by breech. It has been found that where forceps cannot be used, the delivery by breech gives only one-half the fetal mortality of the vertex delivery. 128 TALKS ON OBSTETRICS All things being equal, the earlier the diag- nosis the greater the success. Do not forget to examine for a prolapsed cord as soon as possible after the rupture of the membranes. CHAPTER VIII BEEECII DELIVERY A goodly share of men are likely to be over- perturbed in the presence of a breech presenta- tion, and if not well versed in the rectal and abdominal examinations and imbned with a saving fear of the vaginal examination, the life of the mother is more likely to be endangered by unnecessary vaginal examinations at fre- quent intervals than by the results of the deliv- ery itself. Although the breech is not an ideal dilator, in most instances it succeeds very well if you give it time. Do not be anxious. The danger lies in the increased mortality of the child and this danger does not usually arise until the cervix is dilated and the child has passed through the cervix as far as the navel. In dry labors, of course, the child may be in danger at an earlier period. Here Vorhees bags may take the place of the membranes in dilating the cervix. The average breech will need no interference. Count on a longer delivery than in a vertex 129 130 TALKS ON OBSTETKICS case, which should average eighteen hours for a primipara and from twelve to fourteen for a multipara. Do not be perturbed if the breech case lasts longer than this so long as the child and mother are doing well. The prog- ress of dilatation of the cervix and descent of the breech can be well made out by rectal exam- ination; and the mother's pulse, and observa- tion for the contraction ring and auscultation of the fetal heart will keep one in close touch with the condition of mother and child. Be sure to have someone present who can push down on the af tercoming head through the abdomen to aid when you are using the Smellie- Veit maneuver. Only five minutes should elapse between the passage of the child's navel through the cervix and the birth of the head. Have tubs ready for resuscitation. Don't forget to keep the child's back rotated to the front and to see that the arms are not caught behind the head when attempting to de- liver the shoulders. Keep the exposed portion of the child cov- ered with a moist warm sterile towel to prevent stimulation of the breathing before the head is born. If the breech becomes impacted and the ad- BKEECH DELIVERY 131 vance stops, we may push up the breech and pull down a foot, which is possible of accom- plishment in a great majority of instances. To prevent this possibility of an impacted breech, which occurs more often in primiparse than in multiparse ; in a primipara when a footling pre- sents, when the cervix is sufficiently dilated to grasp the foot, pull the latter do\\m. When the foot is pulled down, allow ample time for the complete dilatation of the cervix before at- tempting extraction. If you do not, the cervix will contract around the neck and prevent the quick delivery of the head. In impacted breech where the breech cannot be pushed back and a foot drawn down, the procedures in order of choice are: Finger in the groin, fillet around the groin, and, as a last resource, Braun's hook. In these procedures fractures are common even with the greatest care. We are seldom called upon to use them. Most breech deliveries are consummated without the advent of complications. The main considerations are to watch the condition of mother and child as in any other delivery, and to work up the technic of delivery from the time of the birth of the navel, until you are sure of precision and rapidity combined with gentle- ness to preclude injury to the child. CHAPTER IX DELIVEEY OF TAVINS During the delivery of twins the question is often asked, ' ^ Should we interfere in the deliv- ery of the second child and if so what are the indications?" I believe that we should never interfere unless we find an abnormal presenta- tion of the second child, a prolapsed cord, or some indication on the part of mother or child demanding interference as in any other de- livery. After the birth of the first twin sever the cord between two cord ties as always, and then treat the second delivery just as you would in any delivery. Make sure of the normality of the presentation and position and the absence of a prolapsed cord. Watch carefully for hem- orrhage from the placenta and watch the fetal heart sounds at frequent intervals in order to detect weakness at the earliest possible mo- ment. If all is well, leave the case alone. The great majority of cases will need no in- terference and where it is indicated speedy and proper interference mil in most cases be suc- 132 DELIVERY OF TWII^S 133 cessful. I do not believe we are v^arranted in artificially rupturing the second bag of waters and doing a version and breech extraction ac- cording to a time schedule simply because indi- cations might arise to call for interference later. Such a procedure may be open to argu- ment under ideal conditions where the most perfect asepsis may be assured. Personally I do not believe in it even under these conditions. But surely such a procedure is not warranted under the conditions that confront many physi- cians in the country and poor city districts. The danger of infection is too great. Granting careful watching for indications for interfer- ence, I do not believe that early interference according to a fixed time schedule will assure a higher percentage of uninjured and living second babies than the rule of not interfering except for definite indications. Many men seem to have been more impressed in their studies with the danger of interlocking and other abnormalities than with the normal- ity of the great majority of twin deliveries. In all cases of abnormalities remember the rule, **Push up what you don't want and pull down what you do want. ' ' CHAPTEK X CESAREAN SECTION This operation is so spectacular and thus seems to leave such an indelible impression on a student's mind and the well selected cases in clinics give such a high percentage of success that from the remarks of students it becomes obvious that many men do not realize the care with which these cases are selected in point of definite indications for Csesarean and in point of ruling out risks of previously introduced in- fection. At the beginning of this discussion I would like to emphasize the fact that where keen selective care is not exercised in choosing cases for Csesarean the mortality mil mount to tAventy-five per cent or even higher and thus the Cesarean will hold forth a worse prognosis than almost any other form of interference. I am, of course, speaking in the interest of the mother who should be considered before the child in all cases. With a live child the two absolute indications for Csesarean are: 134 CESAREAN- SECTION 135 1. Absolute disproportion between the pas- senger and passage. 2. Interposition of pelvic tumors, which in each individual case in consultation have been considered as insurmountable obstructions. Eemember that the great majority of tumors will be passed by the presenting part and will not prove to be insurmountable barriers. Concerning the borderline cases of pelvic contracture and tumors remember that in the first pregnancy at least all women should be given a test of labor. Many of these cases are deceptive and one will often be surprised and many times slightly embarrassed to see a labor consummated naturally if not precipitately where all preparations have been made for a most probable selective Csesarean. Over enthu- siasm for the Csesarean has undoubtedly re- sulted in many unnecessary performances of the same, as is sometimes proved by subse- quent normal deliveries. On the other hand, through failure to make accurate measure- ments, and careful examinations, many women have undoubtedly suffered unnecessarily and many babies have been lost because a Csesarean has not been the operation of choice. Remember that every vaginal examination or instrumentation makes the woman a poorer 136 TALKS ON OBSTETRICS risk for a subsequent Csesarean section. This accentuates the great value of the rectal ex- amination. Also remember the great danger of placental bacteriemia with subsequent gen- eral sepsis if the operation is performed much over twenty-four hours after the rup- ture of the membranes. All these consider- ations may make the choice of the operation a matter of the nicest judgment. Few men have not seen mortalities eventuate because of fail- ure to weigh the chances, and a live child ob- tained followed by the death of the mother. In selected cases of the complete variety of placenta previa, the Csesarean may give the highest percentage of success, but if the keen- est judgment is not used in choosing these cases I feel positive that the maternal mortality will be infinitely greater than when other methods of delivery are used. The same holds for the few cases of premature separation of the pla- centa where the urgent need for immediate de- livery may seem to render the choice of a Csesarean imperative. In those cases of severe toxemia where, with- out the definite indication of pelvic contracture, the long hard cervix and imperative indications for rapid delivery may make the operation one of possible choice, the decision is a very difficult CiESAREAISr SECTION 137 one. In well selected cases results certainly make it justifiable. From observation of those instances where women conceive for the first time late in life and present pelves of questionable size and tis- sues of questionable elasticity, and where in all probability it will be the only child they can have because of the close proximity to the probable end of the childbearing period, I be- lieve that the indication for a selective Cgesa- rean may hold. These women should, of course, always be given a trial of labor as it is well known that many of these women deliver with- out trouble. I hesitate to mention this possible indication for Csesarean, although I believe in it thoroughly, because unless acted upon with the greatest care and conservatism it would un- doubtedly result in much abuse and great harm. I am convinced that at present too many Cge- sareans are performed unnecessarily, but on the other hand, I am sure that with greater care in pelvimetry, discrimination and selective judgment on the part of the profession in the future, this operation will save many lives. In relation to the choice between the vaginal and the abdominal Csesarean, I believe that the former is justifiable only when the child is 138 TALKS ON OBSTETRICS small. AYhen the child is near term I have never yet seen the vaginal Csesarean performed that I haven't been impressed with the fact that from all appearances it was a mnch more shocking operation for the mother and most certainly increased the danger to the child. I could never see why the abdominal route were not the safer from the standpoint of asepsis. Consideration of Csesarean section should impress the following obligations : 1. The obligation to measure every pelvis carefully, especially the pelves of primiparse and those giving histories of previous difficult and disastrous labors. 2. The obligation to examine for any tumor obstruction in every case, so that if a Csesarean is definitely indicated or proves to be after a trial of labor, all preparations can be made for its performance before the condition of the mother or child contraindicates its use. 3. The obligation to so conduct our examina- tions in labor that if Caesarean must be resorted to, it can be undertaken without the fear of infection previously introduced. Become ex- pert in the use of the rectal examination, and do not use the vaginal examination except when doubt makes it absolutely necessary. CiESAREAN SECTION 139 4. The obligation to remember that unless the keenest selective judgment is used in choos- ing cases for Cesarean section, the maternal mortality will be higher than in the use of other accepted methods of delivery. CHAPTER XI OCCIPUT POSTEEIOE POSITIONS Do not be disturbed when you have made a diagnosis of an occiput posterior position. Sta- tistics show that eighty per cent will rotate an- teriorly, if you but give them time, and that three out of every four of the remaining twenty per cent that remain posterior will be born spon- taneously with the face toward the symphysis. You may never see one requiring operative interference because of the posterior position. I do not say this to lull you into a feeling of false security, but rather to introduce more calm to deliberations in the presence of an occiput posterior diagnosis. The most frequent error that I have encountered in such deliberations is the tendency not to allow sufficient time for na- ture to complete the anterior rotation. Be sure that you are dealing with an absolute arrest or that indications call for imperative procedures before you attempt interference. If you do not follow this advice you are likely to en- counter trouble unnecessarily that you will 140 OCCIPUT POSTERIOR POSITIONS 141 never forget. It is frequently one of the most difficult situations to be met in obstetrics. The average time of delivery will be length- ened from three to four hours by this position. Don't forget this, and give these women every chance in the world to deliver naturally. You will often be surprised when you have just about given up all hope of natural delivery, to see or feel the head suddenly rotate anteriorly with subsequent very rapid delivery. I have several times barely finished a talk on the diffi- culties of persistent occiput positions when the woman delivered, with perfect ease, a full term baby i\ith the head in the posterior position. What shall we do, however, when we meet the exceptional case that imperatively calls for interference because of arrest in the posterior position? Eealize that you have a real man's job before you. Do not be misled by the con- fidence and ease with which experts attack these cases and accomplish excellent results. "When you read that the Scanzoni or any other maneuver to rotate the head with forceps is simple, remember that what the writer means is, that it is simple for him. The average man would be about as successful as he would be if he attempted to play the Beethoven violin con- 142 TALKS ON OBSTETPvICS certo after reading an article by a virtuoso. These maneuvers in any but expert hands will kill most of the babies and will either sacrifice or maim for life a good share of the mothers. About the only time that the average man achieves even apparent success with these ma- neuvers is when the head would have rotated any^vay and would most probably have been born naturally had he given nature time. General rules of attack are : 1. Try to rotate the head anteriorly with the hand. Flex the head at the same time. 2. If the head will not remain in an anterior position after flexion and rotation, try a podalic version, if there are no contraindications. Ver- sion in primijparse results in a high fetal mor- tality and may result in serious lacerations in the mother, but I believe that in average hands it mil meet with greater success than vnll high forceps manipulations. High forceps may be the operation of necessity. 3. If the head is well down and rotated di- rectly posterior, apply the forceps with a pelvic application as in the ordinary low or mid for- ceps and deliver the head in the posterior po- sition. As three out of four of these posterior rotations will deliver spontaneously I am sure OCCIPUT POSTERIOR POSITIONS 143 that this method will meet with the greatest success. 4. If the head remains posterior in the oblique diameter, manual rotation or version is impos- sible, and if the aid of an expert cannot be ob- tained, make a pelvic application and draw the head dowTi allowing it to rotate anteriorly or posteriorly as it will and changing the applica- tion as often as the rotation of the head makes it expedient. This is a difficult procedure at its best and craniotomy may be necessary to con- summate delivery, but I feel sure that it will result in fewer fetal injuries and deaths and fewer maternal lacerations and deaths than will forced anterior rotation with forceps according to any method in the hands of any but experts. I believe that anyone will agree with me on this point after he has seen results of forcible for- ceps rotation as used by men of average expe- rience. CHAPTER XII FACE PRESENTATION When you encounter a face presentation, if the chin points anteriorly leave the case alone. In all probability spontaneous delivery will take place though the labor may be prolonged. If the chin is posterior, as soon as the di- latation of the cervix will permit, attempt to convert the face presentation into a ver- tex. With the woman well relaxed under an anesthetic, with one hand in the vagina flex the head by pushing up on the chin, while with the free hand you push down on the occiput through the abdomen. An assistant must at the same time flex the body of the child by pressing against the chest of the child through the abdomen. This is easier done than one would imagine. It does not hold forth the dan- ger of version, as you introduce nothing far into the uterus to increase the volume of the contents, and the range of motion for the child is not so great as in version. It may thus be done with impunity long past the time when a version would be contraindicated. After this maneuver it is obvious that a right mental pos- 144 FACE PRESENTATION 145 terior position becomes a left occiput anterior position. If for some reason you fail in this maneuver try a version, especially if the chin faces directly to the rear. The chances of suc- cess in these maneuvers will depend directly upon the stage of labor in which the diagnosis is made and the results emphasize the value of careful examinations at the beginning of labor. If in posterior chin positions, conversion to the occipito anterior positions fail and ver- sion is impossible, the chin may rotate ante- riorly when it reaches the pelvic floor. I have never seen a case that could not either be changed to a vertex, turned by podalic version or which did not rotate anteriorly with a spon- taneous delivery or a delivery aided by forceps. In the event of the chin remaining posterior, textbooks tell us to attempt to rotate the chin anteriorly mth the hand or the forceps. In such a rare contingency, if the hand rotation were not successful, especially where the chin points directly posterior, I doubt if the slender chance of delivering a live or uninjured baby by forceps rotation attempted by any but the most expert would warrant the infinitely greater chance of severe injury to the mother. I would favor craniotomy after the most careful and limited trial. CHAPTER XIII BBOW PRESENTATION The man who understands the mechanism and management of face presentations will know what to do with brow presentations. Both face and brow presentations are due to conditions either limiting the normal flexion of the fetal head or franldy favoring extension. The brow is the presentation about midway be- tween the normal occiput and the frank face presentations. Brow presentations are infre- quently encountered because by the time we first see a case that has begun labor with the brow presenting, it has either resolved itself into a normal vertex presentation by flexion or into a frank face presentation by extension. This fact gives us a good hint for use in treat- ment ; namely, when a brow presentation is di- agnosed early in labor allow time for it to re- solve naturally into a vertex or a face presenta- tion. The management then follows the indica- tions for those presentations. If the brow presentation gives no indication of early resolution, try to convert it into a ver- 146 BROW PRESENTATION 147 tex by flexion of the head and body as in a frank face presentation when the chin lies in a posterior position. If this fail, attempt a ver- sion, providing absolute contraindications do not exist. We should see to it that we do not allow the brow presentation to persist to the stage when version would be contraindicated, without an attempt at interference. If the chin points or rather lies anterior and does not re- solve into a face presentation with the chin to the front, I have done a version rather than run the chance of converting to a posterior occip- ital position by flexion and then having to run the chance of a persistent occiput posterior. If attempts both at conversion to a vertex and podalic version fail, see what Nature may accomplish and then if necessary apply forceps. I am now speaking of a contingency that I have never had to meet. If such should arise I Avould perform a craniotomy early in the attempt at forceps rather than run a chance of seriously injuring the mother. In certain selected cases Csesarean section or hebotomy might be indicated. In the cases that I have seen, the brow was either in the right posterior position and flex- ion of the head and body easily converted them to the occiput left anterior position or a ver- 148 TALKS ON OBSTETKICS sion could be performed. These cases brought home to me and emphasized the importance of early diagnosis and correction as soon as no evidence was given of natural resolution into occipital or frank face presentation and before firm engagement and molding of the head or the early drainage of the amniotic fluid might make both the correction to a vertex or a ver- sion impossible. CHAPTER XIV RULES IN OBSTETRICS 1. Early pelvimetry and pelvic examination, which, with an accurate past history of the pa- tient, will allow of classification in respect to the coming delivery, as normal, doubtful or positive in relation to the need of interference. 2. Thorough physical and laboratory exam- ination, to determine that there are no possible contraindications for entering the contest, such as active tuberculosis, severe heart or kidney lesions, or marked diabetes. 3. Clear up all manifest foci of infection as far as is possible or plausible. 4. Give explicit directions to patient as re- gards general health measures such as exercise, diet, baths, fresh air, water intake and atten- tion to bowels. 5. Give explicit directions to the patient as regards measures aimed at the avoidance of a possible miscarriage. 6. Give the patient a written list of signs at the accession of w^hich she should notify you immediately. Such are: Persistent headache, 149 150 TALKS ON OBSTETRICS edema, disturbance of vision, persistent consti- pation, vaginal bleeding or spotting or abdom- inal pain and vomiting. 7. Insist on frequent and stated examina- tions of urine and blood pressure. 8. Make no vaginal examinations during tbe last month of pregnancy, or during labor or early puerperium unless the results of abdom- inal and rectal examinations leave one in doubt. 9. At the beginning of labor determine care- fully by abdominal and rectal examinations, the presentation and position. 10. Examine by rectum for a possible pro- lapsed cord immediately after the rupture of the membranes, especially if it is not definitely known that the position and presentation are normal and the presenting part well engaged. 11. Remember that the average length of the first labor is about eighteen hours and of sub- sequent labors from twelve to fourteen hours. 12. Do not interfere unless definite indica- tions on the part of the mother or child demand. It is well to bear in mind the approximate two hour limit for the second stage of labor. Con- ditions may prompt its curtailment or ex- tension. 13. Use the most careful and accurate asep- RULES IN OBSTETRICS 151 tic technic yourself and guard against errors of assistants and physical surroundings. 14. Do not allow your patient to be catheter- ized unless you feel that it is absolutely neces- sary. It is a serious operation calling for the best aseptic technic. You must catheterize as a routine just before the use of forceps or the performance of version. Give hexamethylen- amine for a few days following catheterization. 15. Never use chloroform in any procedure when a woman gives any signs or symptoms of toxemia. INDEX Abdominal Caesarean in treat- ment of central placen- ta previa, 81 indications for, 137 Abdominal examination, 29 Abortion, 89, 92 causes of, 95 diagnosis, 102 hemorrhage in, 92 induced, in pernicious vom- iting, 67 treatment, 102 Accidental hemorrhage, 82 Acidosis in eclampsia, 47 in pernicious vomiting, 67 Anesthesia during pregnancy, effect of, 101 Asphyxia as cause of toxemia, 42 Bacteria, entrance of, into vagina, 25, 26 in toxemia, 51 Bathing in pregnancy, 25 Baths, spray, 25 tub, 25 Bimanual massage of uterus, 77 Blood pressure in toxemia, 50 Bowels, care of, in sepsis, 38 in toxemia, 51 Breech delivery, 129 presentation, 129 Brow presentation, 146 C Caesarean section, 134 indications for, 134 in toxemia, 57, 59 Causes of toxemias in preg- nancy, 43 Cervical tears, 35 Chloroform, contraindicated in cases of toxemia, 59 use of in labor, 116 poisoning, experiments in, 46 Convulsions, during labor, treatment of, 60 emptjdng the uterus in, 56 Cord, prolapse of, 126 D Delivery, breech, 129 Dental operations during pregnancy, 99 Diagnosis during labor by rectal examination, 29 153 154 INDEX Diet in pernicious vomiting, 69 in toxemia, 51, 54 Douche, contraindicated, 37 in pregnancy, 26 sterile, in postpartum hem- orrhage, 77 Drainage after labor, examin- ing for obstructions to, 36 Drugs, use of, in labor prefer- able to forceps, 116 E Early care in pregnancy, 48 Eclampsia, 41 acidosis in, 47 causes of, 42 prophylaxis of, 44 treatment of, 44 Ectopic pregnancy, 86 diagnosis of, 86 rupture of, 88 symptoms of, 88 Emptying the uterus in tox- emia, 58 Enemas, nutrient, in perni- cious vomiting, 70 Ergot, extract of, in sepsis, 37 Ether» use of, in cases of tox- emia, 59 Examination, physical, in pregnancy, 48 rectal, 29 vaginal, 28 Face presentation, 144 Feeding in sepsis, 38 Floating head, delivery in cases of, 118 Foci of infection, eradication of as prevention of sepsis, 25 in toxemias, 48 Forceps, dangers in use of, 112 directions for use of, 120 in obstetrics, 112 Fowler posture in sepsis, 37 H Heart lesions in obstetrics, 108 Hemorrhage, accidental, 82 treatment of, 83 due to premature separa- tion of placenta, 82 in abortion, 92 in obstetrics, 74 in placenta previa, 78 postpartum, 74 causes of, 75 treatment of, 76 Infection as factor in abor- tion, 96 as factor in accidental hem- orrhage, 85 entering through lacera- tions, 35 INDEX 155 Instructions to patients, need of, 24 to pregnant women, 94 Interference, indications for, 56 sepsis due to, 18 Invalids caused by sepsis, 19 Labor in hospital, 23 in home, 23 Lacerations as point of infec- tion, 35 Lues as cause of abortion, 96 M Magnesium sulphate, use of, in eclampsia, 47 Male elements acting as for- eign proteins causing pernicious vomiting, 72 Massage of uterus, 77 Miscarriage, 92 at seventh month, 107 Morphin, use of, in labor, 116 Murphy drip in convulsions in labor, 60 N Nursing in obstetric cases, 31 O Obstetric forceps, 112 nurses, 30 Obstetrics, hemorrhage in, 74 rules in, 149 sepsis in, 17 Occiput posterior positions, 140 rules of attack, 142 Operations during pregnancy, 99 Oral cavity, infection of, in pregnancy, 48 Packing uterus for postpar- tum hemorrhage, 77 Perineal tears, 35 Pernicious vomiting, liver le- sions associated with, 66 of pregnancy, 65 treatment of, 68 Phlebotomy, 61, 62 Physical examination in preg- nancy, 48 Pituitrin, use of, in labor, 116 Placenta, hemorrhage due to premature separation of, 83 manual removal of, as cause of sepsis, 76 toxin elaborated by, 45 Placenta previa, 78 diagnosis of, 78 symptoms of, 78 treatment of, 79 Podalic version, 122 indications for, 122, 123 Positions, occiput posterior, 140 Postpartum hemorrhage, 74 156 INDEX Pre-eclamptic toxemia, 41 Pregnancy, bathing in, 25 douche in, 26 early care in, 48 ectopic, 86 pernicious vomiting in, 65 prophylaxis in, 94 toxemias of, 41 Premature separation of pla- centa, 82 prevention of, 84 treatment of, 83 Preparation of patient for la- bor, 32 Presentation, breech, 129 brow, 146 face, 144 Prolapse of the cord, 126 Prophylaxis in pregnancy, 94 in toxemia, 44 Psychotherapy, 68 Puerperal infection, 39 Puerperal rise of temperature indicative of infection, 39 E Eectal examination, 28, 29 Retroverted uterus in preg- nancy, 102 Rules in obstetrics, 149 Rupture of ectopic pregnan- cy, 88 Rupture of uterus, 90 prevention of, 91 signs of, 92 S Scientific nursing in obstet- rics, 30 Sepsis, causes of, 22 due to interference, 18 in obstetrics, 17 in obstetrics, frequency of, 17 invalids caused by, 19 prevention of, in obstetrics, 17, 22 treatment, 37 Septic abortion, treatment of, 105 Spray bath in pregnancy, 25 Sterile douche in postpartum hemorrhage, 77 T Teeth, care of in pernicious vomiting, 69 in pregnancy, 99 Therapeutic abortion, 72 advisability of, in tubercu- losis, 110 Toxemia, emptying the uterus in, 58 of pregnancy, 41 causes of, 42 prophylaxis in, 44 symptoms of, 52 Toxin elaborated by placenta, 45 Treatment of pernicious vom- iting, 68 of sepsis, 37 of toxemia, 44, 54 INDEX 157 Tub bath in pregnancy, 25 Tuberculosis in obstetrics, 108 Twins, delivery of, 132 U Uterine drainage. Fowler pos- ture to promote, 37 Uterus, rupture of, 90 Urine in toxemia, 50, 55 V Vaginal Csesarean, indications for, 137 Vaginal examinations, 28 contraindicated, 22 Version, contraindications, 122 indications for, 123 podalic, 122 Vorhees bag, 58 in treatment of placenta previa, 80 W Water in sepsis, 28 Whisky in sepsis, 38 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE C28(l 140)M100 La Vake L38