Tvqi (EalU^ of pijiiHtrtattH an&^ttrg^nna 4-28-13-10: l&tUrmu Sitbrarg ifciidne. By- ^^uJ-^-uJOi^ n^ Aj , -2^/u£ J*(/ Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/obstetricsurgeryOOgran J ^ftsjs^ rlk Obstetric Surgery. EGBERT H. GRANDIN, M.D., Obstetric Surgeon to the New York Maternity Hospital; Gynaecologist to the French Hospital, etc. ; GEORGE W. JARMAN, M.D., Obstetric Surgeon to the New York Maternity Hospital ; Gynaecologist to the Cancer Hospital, etc. With Eighty=Five Illustrations in the Text and Fifteen Photo= graphic Plates. 'Or, ^ PHILADELPHIA : THE F. A. DAVIS COMPANY, PUBLISHERS. LONDON : F. J. PvEBMAK 1894. COPYRIGHT, 1394, BY THE F. A. DAVIS COMPANY. [Registered at Stationers' Hall, London, England.] Philadelphia, Pa., U.S.A.: The Medical Bulletin Printing-House, 1916 Cherry Street. PREFACE. The key-note of this volume is election in obstetric surgery. The results which are daily secured in general surgery through resort to timely operation are obtainable in obstetrics if the same principle be held in view. This volume, further, being Avritten from a teaching basis, is necessarily imbued with the personality of the authors, and is, therefore, not burdened with literature references and sta- tistical data. The latter have alone been introduced, when necessary, in order to assist in the elucidation of some disputed point. The illustrations have been prepared and selected with the special end in view of teaching graphically. The works of Barnes, Charpentier, Lusk, Cazeaux, and Oscar Schaeffer, in particular, have furnished many of the wood-cuts, and the authors hereby express their obligation. The photographic plates have been prepared from nature under the personal supervision of the authors. On the basis of honest desire to promote progress in obstetrics, this volume is offered to the medical profession. September, 189J:. (iii) CONTENTS. INTRODUCTION. PAGE Obstetric Asepsis and Antisepsis, 1 CHAPTER I. Obstetric Dystocia and its Determination, 9 CHAPTER II. Artificial Abortion and the Induction of Premature Labor, . 34 CHAPTER III. The Forceps, . . 12 CHAPTER lY. Yersion, 93 CHAPTER Y. Symphysiotomy, . . .120 CHAPTER YI. The Cesarean Section, , . . . . . . .132 CHAPTER YII. Embryotomy, . 146 CHAPTER YIII. The Surgery of the Puerperium, 163 CHAPTER IX. Ectopic Gestation, 193 Index, ........... 203 (V) LIST OF ILLUSTRATIONS. FIG. PA&E 1. Normal female pelvis, 9 2. Beaudelocque's pelvimeter, 10 3. Martin's pelvimeter, ............. 10 4. Schultze's pelvimeter, .11 5. CoUyer's pocket pelvimeter, 11 6. Justo-major pelvis, 18 7. Generally equally contracted pelvis (justo-minor), 19 8. Flat non-rachitic pelvis, 20 9. Flat rachitic pelvis (mild grade), 21 10. Flat rachitic pelvis (high grade), 22 11. Generally contracted flat rachitic pelvis, 23 12. Roberts's pelvis. The transversely contracted pelvis, 24 13. The kyphotic pelvis, showing narrowing in the transverse diameter and length- ening in the conjugate, 25 14. Non-rachitic scoliotic skeleton, 26 15. Rachitic scoliotic skeleton, ........... 26 16. Spondylolisthetic pelvis, 27 17. The osteomalacic pelvis, 29 18. Obliquely distorted pelvis of Naegele, 80 19. Osteosarcoma of the pelvis, 32 20. Steel-branched dilator, 41 21. Uterine curette, 41 22. Ovum forceps, 42 23. Glass irilgating tube, 42 24. Fi-itsch-Bozeman catheter, ............ 42 25. Edebohl's speculum, 43 26. Cervical tenaculum, . . . . 43 27. Intra-uterine dressing forceps, .45 28. Barnes's bags, •■•........... 66 29. McLean's bag, .............. 66 30. Marx's incubator (closed), 70 31. Marx's incubator (open), 71 32. Elliott forceps, 72 3.S. Hunter forceps, 73 34. Lusk-Tarnier forceps, 73 35. Jewett's axis-traction forceps, ........... 74 36. Showing Reynolds's traction rods in position, 75 37. Introduction of the left blade of the forceps, 79 38. The left blade introduced ; the right blade (in outline) ready to be introduced, . 80 39. The forceps adjusted and ready to be locked, 81 40. Showing the direction of the line of traction, . 83 41. Showing direction of traction in face presentation, . . . ' . . . .86 42. Tarnier forceps applied to the thighs, 88 43. Incision of the cervix, ............ 89 44. Application of medium forceps, 90 (Vii) viii LIST OF ILLUSTRATIONS. FIG. PAGE 45. First stage of bipolar version, 102 46. Grasping the knee, 103 47. Representing first act of extraction, ^04 48. Version in head presentation, 106 49. Completing the version, 107 50. Impacted shoulder, 108 51. Introduction of the left hand to bring down the posterior (left) leg, . . . 109 52. Showing direction of traction, 110 53. Method of releasing the cord, Ill 54. Disengagement of the posterior (right) arm, 112 55. Showing direction of traction, 113 56. The child is lifted over the perineum and the occiput passes from under the sym- physis, 114 57. Chin arrested at symphysis, 115 58. Forceps applied to after-coming head, 116 59. The bulging of peritoneum and of bladder into the opening at the joint, . . 133 60. Galbiati-Harris Knife. (Harris's modification), 124 61. Showing deep suture passed, the loops not cut, 138 62. The same, the loops cut, 138 63. Suture of uterine wound, 139 64. Braun's trephine, 148 65. Blot's perforator, " . .148 66. Martin's trephine, 1*9 67. Scissors-perforator, l*^ 68. Braun's cranioclast, 149 69. Effect of the cranioclast on the foetal skull, 151 70. Lusk's cephalotribe, 154 71. Tarnier's basiotribe, 1'54 72. Bone-forceps, • ^^'^ 73. Crochet and blunt hook, 157 74. Braun's hook or decollator, 15° 75. Delivery of trunk after section of head, 159 76. Locked twins, 160 77. Sutures inserted on one side of a lacerated cervix, 166 78. Insertion of sutures. (After Hegar.), 1*^1 79. Laceration through the sphincter. Sphincter sutures in place, . . . .172 80. Repair of a vesico-vaginal fistula, l'''^ 81. Simon's specula, ' . . . 175 82. Transverse rupture of the uterus, l'^9 83. Cleveland's ligature-carrier, 1"''' 84. Emergency Trendelenburg posture, 198 LIST OF FULL-PAGE PLATES. PAGE Plate I. — Measurement of distance between the spines, . . . .12 Plate II. — Fig. 1. Measurement of Beaudelocque diameter. Fig. 3. Measurement of Beaudelocque diameter in case of pendulous abdomen, 13 Plate III.— Fig. 1. Determination of the diagonal conjugate. Fig. 2. Depression of the uterus so as to determine adaptability of pre- senting part to the pelvic brim, 14 Plate IV. — Introduction of the left blade of the forceps, ... 79 Plate V. — Fig. 1. Towel applied to handle of Hunter's forceps. Fig. 2. Bilateral incision of the perineum (episiotomy), .... 83 Plate VI. — Showing method of grasping the foot, 109 Plate VII. — Extracting the posterior leg, 109 Plate VIII. — Extracting the posterior arm, . . . . . . 113 Plate IX. — Head impacted at the outlet. Admitting air that the child may breathe, 115 Plate X. — The child is lifted over the perineum and the occiput passes from under the symphysis. An assistant makes suprapubic pressure, 115 Plate XI. — Traction while the head is in the ti-ansverse diameter of the pelvis, 116 Plate XII. — Application of the forceps to the after-coming head, . . 116 Plate XIII. — Method of grasping the child's body in performing in- ternal rotation, US Plate XIV. — Fig. 1. Trephining the before-coming head. Fig. 2. Per- foration of the after-coming head, . . . . . . 150 Plate XV. — Insertion of Braun's decollator, 158 (ix) Obstetric Surgery. INTRODUCTION. OBSTETRIC ASEPSIS AND ANTISEPSIS. It is only within the last decade that obstetric surgery has progressed toward the scientific eminence to which it may justly lay claim to-day. Before the advent of tlie era of antisepsis and asepsis, before the fear of handling the uterus had been swept away, the forceps and version were the only operations which came within the ken of the average practitioner, and the results from resort to these were anything than matters to be proud of. So-called childbed fever was virulent not alone after spontaneous labor at term, but also after resort to any and all obstetric operations. To-day the scene has radically changed. Septicaemia after labor is justly considered as due, in almost every instance, to faulty asepsis ; gradually bettering attempts are being made to educate the student with a practical knowledge of the entire range of obstetric surgery, and extra stress is being laid, as it should be, on the absolute necessity of studying the pelvis of the pregnant woman before the advent of labor, so as to be in a position to take advantage of that operative procedure, where any is indicated, which is best not alone for the woman, but which also takes into account the welfare of the child. Whilst, then, more accurate educational methods enter as factors in the science of obstetrics as practiced to-day, the fundamental reason why mortality rate has been lowered is the recognition of the culpability of the man who neglects the laws of cleanliness (1) *2 OBSTETRIC SURGERY. (asepsis and antisepsis) thronghout the conduct of labor and during- the puerperal state. Lack of cleanliness (asepsis and antisepsis) will ruin the most expert technique, and. therefore, a thorouo-h oroundmo' in the fundamental laws of cleanliness as applied to obstetric work is essential to the undertaking of any of the surgery of the art. Antisepsis is simply the means of certifyins: to asepsis (cleanhness). The whole question has been needlessly compli- cated by the introduction of scores of chemical agents which possess, to a greater or less degree, the power of rendering inert the micro-organisms which exist in. or may be conveyed to, the human body. It is possible to secure asepsis without resorting to antisepsis, but. in order to surround surgery with every possible safeguard, these chemical agents must be looked upon as abso- lutely essential, The point to be remembered in obstetiic surgery is that too free indulgence in antisepsis may do harm even whilst it aims at good. The nature of many of the antiseptic agents on which we must needs rely is poisonous to the human body. Therefore the corollary must be borne in mind that overzealous- ness in matters of antisepsis may injure and kill, even as lack of asepsis may be followed by similar effects. Obstetric asepsis is secured through attention to (a) the person of the accoucheur, the nurse, and assistants; (b) the lying-in woman; (c) the instruments and accessories. ('-0 Asepsis of the Accoucheur axd Attexdaxts. It being absolutely proven that septiceemia is heterogenetic, — that is to say, does not originate within the body. — it is the bounden duty of all who come in direct contact with the lyhig-in woman to keep themselves not alone clean, but also free from those acute infectious elements which, through inoculation, breed sepsis. The ideal obstetrician, like the ideal surgeon, should avoid seeing patients suffering from certain of the acute infec- tious diseases, such as scarlet fever and diphtheria ; and. except in absolute emergency, should have nothing to do with post- OBSTETRIC ASEPSIS AND ANTISEPSIS. 3 mortem examinations. These rules of conduct should be abso- lute with the expert obstetrician, wlio, from recognized standing, is liable at any time to be called upon to give advice in the minor emergencies of labor or to act as chief in major operative obstetrics. Barring spontaneous or operative traumatic lesions, the risk the lying-in woman runs is septic infection at the hands of her immediate attendants. The general practitioner of necessity must perform obstetric work even whilst his routine duty calls for attendance on scarlet fever, for instance. The greater, therefore, the precautions he should take to bathe thoroughly, to change his garments, to wash his hair and beard, to asepticize his hands before going from such diseased states to a woman who is about to perform a physiological act. In the event of his time being occupied to a great degree with attention to patients sick from any of the acute infectious dis- eases, so that he finds it difficult to take the simple and yet most essential precautions mentioned above, then it is wise, to say no more, for the time being to refuse to attend labor cases, else, as has too frequently happened, one puerpera after another will be diseased, if not killed. Tlie man who makes post-mortems frequently is a death-dealing obstetrician, and the careless gen- eral practitioner may become such. It has been well said, and cannot be emphasized too strongly, that puerperal sepsis means faulty technique, — that is to say, one or more of the attendants are to blame. There is no shifting the responsibility on nature. Sucli general measures as have been noted apply with even greater force to the nurse. She will come more frequently in contact with the woman, and, if careless, is even more likely to septicize. If ignorant, as outside of large centres she is apt to be, she may even now, in this aseptic age, fill grave-yards as she did in the past. It becomes, therefore, the duty of the physician to investigate the previous occupation and where- abouts of the nurse his patient has engaged, and to insist on her practicing the most rigorous antisepsis as regards her clothing and person. Asepsis is not sufficient for the average nurse ; she 4 OBSTETRIC SURGERY. must be provided with antiseptics in order to cause her to approximate cleanhness. It goes without saying- that she should never be allowed to attend the lying-in woman if she has been, "vvithin at least a week, in attendance on one of the acute infec- tious diseases. The rigid rules about to be noted as applicable to the care of the obstetric hands are to be enforced with her even as they must be with the physician. In the lying-in room the physician should remove his coat and roll up his shirt-sleeves above the elbow. Since, aside from instruments, the hands are most likely to septicize the woman from direct contact, great care must be exercised to render them aseptic. If the physician has recently been in contact with any infectious material, thorough washing in soap and water and scrubbinof in bichloride solution will not suffice to render these hands aseptic. Under such conditions the following method must be resorted to : The hands and arms are scrubbed for at least ten minutes in hot soap and water, the latter being fre- quently changed. Especial attention must be paid to the finger- nails, under which the infectious elements are most prone to lodge. The hands and the arms are next covered with a hot saturated solution of permanganate of potash, and are then immersed in a hot saturated solution of oxalic acid until the stain of the permanganate has entirely disappeared. The oxalic acid is next removed by soaking the hands in hot sterilized water. If the physician be at all suspicious about the nurse, she should be compelled to resort to the same process under his direct supervision. It has been proven by* culture experiments that this method of treating the hands renders them absolutely free from micro-organisms. Under ordinary conditions, where the physician is sure of his freedom from infectious material, this elaborate process is not necessary. It will suffice to scrub the hands in hot soap and water, and next to immerse them in a 1 to 1000 solution of bichloride of mercury. They are then washed in alcohol. After OBSTETRIC ASEPSIS AND ANTISEPSIS. O this sterilization of the hands the physician must avoid touching anything which has not been similarly sterilized. Before proceeding to the performance of any obstetric manipulation, the physician should cover his clothing with a clean sheet, which may be found in even the households of the most indigent. (b) Asepsis of the Lying-in Woman. Thorough asepsis of the genital tract of the woman is most essential, and, at the same time, most difficult to secure. These organs must be rendered surgically clean, and yet the means resorted to must be such as will not injure the protecting coat of epithelium. It is very questionable if douching of the geni- tals is sufficient for asepsis. The antiseptic agents thus em- ployed at best only come in contact with the superficies. The vagina, in particular, is rendered aseptic with difficulty. It is in the depths of the rugosities that the micro-organisms lodge. Before undertaking any surgical manipulation the following means should be resorted to : The external genitals are to be scrubbed with hot soap and water, and next washed with a solution of bichloride (1 to 1000). If the required manipu- lations are in the vagina, a new tooth-brush should be inserted into the canal, and this should also be scrubbed with soap and water. It is next to be scrubbed with a solution of bichloride of mercury (1 to 1000). In the event of the proposed operation being a symphysi- otomy or a Caesarean section, the pubes must be shaved, the skin thoroughly washed with soap and water, then washed with bichloride solution (1 to 1000), and finally with alcohol or with ether. After any manipulation in the uterus, in order to certify to perfect post-operative technique, the entire genital tract should be douched with bichloride solution (1 to 5000). There is risk of poisoning if sti'onger solutions than this are used in the uterus. 6 OBSTETRIC SURGERY. (c) Asepsis of Instruments and Accessories. The elaborate processes wliich are in use in hospitals obvi- ously cannot be resorted to in private practice. Just as thorough asepsis, however, as regards instruments, may be secured if these instruments have been carefully cleansed by the physician before they are taken to the woman's house. Instruments which have been scrubbed with soap and water, and next boiled for ten minutes in a 1-per-cent. solution of carbonate of soda (the com- mon washing-soda), may be deemed aseptic. This asepticism, however, is destroyed if they are then placed in the average obstetric bag, which contains bottles and cotton, and, from old age, micro-organisms of every possible genus. The sterilized instruments must be wrapped in a sterilized napkin or towel before they are placed in the bag, and imme- diately before use must be again washed in hot soap-suds and next boiled in the 1-per-cent. soda solution. In every household the washing-soda will be found, as well as the pot in which to boil them. The instruments may be used directly from this soda solution or else may be first transferred, with aseptic hands, into a 5-per-cent. solution of creolin, — a solution which is an efficient antiseptic and yet will not injure the instruments as does bichloride. This creolin further answers the purpose of an emollient. If there is one thing more dangerous to the patient than another, it is the vaselin which it is customary to use as an emollient. The vaselin-pot should, once and for all, be banished from the lying-in chamber. If newly opened it may not contain micro-organisms, but when it has been repeatedly exposed to the air, and possibly has been used scores of times, it will be found a veritable culture-medium for bacteria. Creolin will answer as a lubricant for the finger and for the instruments, and this should be the only lubricant allowed in the lying-in room, unless the physician prefers to use sterilized oil. As far as is possible the physician should avoid using rub- ber instruments. It is difficult to render them sterile. The stronger antiseptics will ruin them, the weaker will not asepti- OBSTETRIC ASEPSIS AND ANTISEPSIS. 7 cize them. Prolonged boiling may sterilize them, but often at the expense of their integrity and, therefore, of their utility. Glass catheters and glass irrigating-tubes should be selected. These may be boiled, and thus be rendered safe to use. The metal catheter, which the average nurse will produce with pride, should be taken from her and returned only when she leaves the case, and then with the injunction to either throw it away or to lock it up and to forget it. Many a case of puerperal cystitis has been traced to the use of this relic of pre-aseptic days. During the performance of an obstetric operation sponges should not be used. This is another article which should have no foothold in the modern lying-in room. Sterilized towels and sterilized gauze or absorbent cotton should take the place of the sponge. In every household, no matter how humble, there is an oven, and in this towels and gauze may be baked. If the oven is lacking, there always exists a means for boiling them. For purposes of irrigation boiled water should be used. To this creolin may be added to make a 2-per-cent. solution, except where it is essential to see the irrigated portion, and then, since the milk-white creolin solution will obscure vision, bichloride solution (1 to 5000) must be substituted. Ligature and suture material must be absolutely sterile. In view of the difficulty of obtaining sterile catgut it is wise never to use it. The ideal suture is silk-worm gut. If this be boiled for ten minutes in creolin — 5-per-cent. solution — it is rendered aseptic, and is further rendered pliable. Obstetric sur- gery being often emergency surgery, the operator has not the time to prepare beforehand his catgut and silk so as to feel certain about them. Further, since the major portion of ob- stetric work falls to the lot of the busy general practitioner, his precedent preparations must be as simple as is consistent with absolute asepticism. If these simple rules for securing asepsis of the lying-in woman and her surroundings are followed, the morbidity rate 8 OBSTETRIC SURGERY. and mortality rate in private practice will approximate those which are secured to-day in maternity hospitals, where the mortality rate has been reduced to a fractional percentage, and where morbidity from sepsis is practically abolished. We have endeavored to emphasize our belief, and this is the current be- lief, that the lying-in w^oman is septicized solely through personal contact. By this we mean that the atmosphere is not a factor, and that the infectious material does not originate in the body of the woman. The sole exception to this latter statement is where, during the progress of labor or during obstetric manipu- lation, a pyosalpinx, for instance, ruptures. Such an event may lead to septic infection of the woman, but then the sepsis cannot be properly considered an obstetric epi-phenomenon. Aseptic and elective obstetrics rob labor of its terrors and the puerperal state of well-nigh its sole risk. CHAPTER I. OBSTETRIC DYSTOCIA AND ITS DETERMINATION. A SCIENTIFIC knowledge of the configuration of the female pelvis and of the methods of estimating its capacity is an essen- tial prelude to the practice of midwifery. The surgical side of the art, in particular, rests its results on accurate pelvimetry. The fate of the woman and of the foetus is intimately linked with the expertness of the physician in determining, before or at the time of labor, the probable capacity of the pelvis in its Fig. 1.— Normal Female Pelvis. relation to the estimated size of the foetus. A consideration, therefore, of the surgical means at our disposal for assisting labor or for facing its emergencies, must be preceded by a care- ful study of the pelvis, normal and abnormal. Furthermore, the pelvis is not the only element in the problem which is to be solved. An approximate idea of the size of the foetus which is to pass through the birth-canal is also to be secured. It is essential, therefore, to precede the surgery of parturition by a description in brief of the anatomy of the obstetric pelvis and of the general physical features of the foetus. (9) 10 OBSTETRIC SURGERY. The pelvis is formed by the union of the ossa innominata with the sacrum. The sacrum is connected with the vertebral column above and with the coccyx below. The resulting canal is larger above than below, and is flattened to a degree from in front backward. The superior, wider portion constitutes the greater pelvis, the inferior and narrower portion the lesser pelvis. The pelvis is further subdivided into a number of Fig. 2. — Beaudelocque's Pelvimeter. Fig. 3.— Martin's Pelvimeter. straits, the entrance into the canal receiving the name of su- perior strait, the median portion constituting the middle strait, the exit from the canal the inferior strait. It is the determi- nation of the measurements in various directions of these three portions which is termed pelvimetry, and the resultants consti- tute the diameters of the pelvis. The diameters of the pelvis are to be obtained both externally and internally, and the former stand in a certain relation to the latter. OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 11 Instruments for the Determination of the Pelvic Diameters. The best-known pelvimeter is that devised by Beaude- locque. In view of the fact, however, that the instrument should be portable, the Martin pelvimeter will be found prefer- able. It should ever be remembered that the pelvimeter is as Fig. 4. — Schultze's Pelvimeter. Fig. 5.— Collyers Pocket Pelvimeter. indispensable to the obstetrician as is the microscope to the physiologist, and, therefore, that it should be associated with pregnancy in his mind as the forceps is with labor. (Figs. 2, 3, 4, and 5.) External Diameters of PEL\^s. The following external diameters are of chief obstetric significance : The distance between the anterior superior spines of the ilium, that between the crests of the ilium, that between 12 OBSTETRIC SURGERY. the trochanters, that between the spinous process of the last lumbar vertebra and the centre of the anterior surface of the pubic bones (the diameter of Beaudelocque). These are the essential measurements which are to be obtained by means of the pelvimeter. The objection which has, over and over again, been made to this instrument, that the patient will object to the exposure which it entails, will not hold, for the reason that there need be none, as the patient is covered by a sheet; and, instead of there being objection made, the patient will have a higher opinion of the physician who evidently is taking every requisite precaution for her future safety. It cannot be emphasized too strongly that the physician is to-day not guiltless who, whenever it may be, does not practice pelvimetry. (See Plates I and II.) In using this or any similar instrument the utmost care must be exercised to adapt the points of the blades accurately to the soft parts (as is purposely shown in the plates), and, in in- stances where it is of considerable importance to determine with great accuracy the exact measurements, it is advisable that these should be taken by two persons independently. These external measurements, of course, give us purely a relative idea of the internal, but, occasionally, a slight diminution beyond the nor- mal in one or another diameter, may turn the scale in favor of one over another obstetric operation. The following external measurements may be taken as nor- mal in the average case, although it should ever be remembered that the estimated capacity of a given pelvis depends on the estimated size of the foetus which must pass through it : — Distance between the spines, . . 10 to 10^ inches. Distance between the crests, . . 10^ to 11 inches. Distance between the trochanters, . 12 to 12^ inches. Diameter of Beaudelocque, .... 8 inches. The most important of these external diameters is that of Beaudelocque. By means of this €xternnl conjugate we are enabled to approximate the true conjugate, — that is to say, the diameter of the pelvic inlet, — the distance from the PLATE I. H fc_^.fe^jB 1 1 1 ■ ^^^^^^^^ T^^ g /MM I 1 H ^^^^P^ ri ^Kk^^ "'^«l ^^^ / '"ig '^ ^ % » 1 2 — 1^ ^^B »v ^ j^**- H "■■'5, ^^ ■ 1 I '■- mi^ " - ^^HH BBp^' '*i^^^ ^ "' ^3 ■ " • ' ' ■? Measurement of Distance between the Spines. PLATE II. Fig. I. — Measurement of Beaudelocque Diameter. Fig. 2. — Measurement of Beaudelocque Diameter in Case of Pendulous Abdomen. OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 13 upper margin of the pubic symphysis to the promontory of the sacrum. In general it may be stated that a mean deduction of three inches from the measurement of the external conjugate will give us that of the true conjugate. As regards the other external diameters, suffice it to say that diminution below the foregoing measurements, which represent a mean from a large number of pelves examined, should always be a source of thought and solicitude to the physician. This matter will be amply considered under the heading of the various operations. Internal Diameters of Pelvis. Many instruments have been devised for determining the internal diameters. The finger and, if need be, the hand of the physician best subserve the purpose. Obviously, the hand can only be used under anaesthesia ; but in every instance where the determination of the internal diameters is of moment in the selection of one operative procedure over anotlier, in view of the almost absolute safety of anaesthesia, this should be resorted to. In the vast majority of cases, however, digital pelvimetry yields us sufficiently exact information in regard to the capacity of the pelvis. This should be practiced as a routine measure in every case. We may tlius determine the diagonal conjugate, and, this having been obtained, the true conjugate is readily ascer- tained by deducting the estimated depth of the pubic symphysis. The transverse and oblique diameters may also be thus approx- imately measured. To perform digital pelvimetry the patient should occupy the dorsal position, witli tlie nates on the very edge of the bed or couch. The index and the middle finger of the right hand are introduced into the vagina, the perineum being de- pressed as much as possible. The aim of the fingers is to reach the junction of the sacrum with the last lumbar vertebra, for it is the distance from this point to the lower margin of the sym- physis pubis which yields the diagonal conjugate. If the sacral promontory cannot be reached, the inference is safe that the 14 OBSTETRIC SURGERY. pelvis is normal as regards its antero-posterior diameter. If the promontory can be reached, then the wrist is carried upward until the edge of the index finger rests against the pubic sym- physis. The index of the other hand notes this subpubic point, the fingers are withdrawn, and, by means of a tape-measure or the pelvimeter, the distance from the end of the middle finger to the noted point on the edge of the index is measured. This measurement is the sacro-subpubic or the diagonal conjugate diameter. (Plate III, Fig. 1.) According to the estimated depth and obliquity of the sym- physis in a given case, it is necessary to deduct from one-fourth to one-half an inch from this measurement, in order to obtain the dimension of the sacro-suprapubic or true conjugate of the pelvis. In taking the above measurement it should be remembered that occasionally the first sacral vertebra projects over the second, forming a false promontory. To avoid mistaking this for the true sacral promontory, it is only necessary to depress the perineum or to carry the fingers as high upward as possible. Then, in the event of the existence of a false promontory, the true will be found above it. The transverse and the oblique diameters of the pelvis cannot be measured with the same exactitude as the conjugate. As a general rule, it may be stated that, when the promontory cannot be reached in a symmetrical pelvis, labor at term is pos- sible with a foetus of average size. If there be a -suspicion, how- ever, of a deviation from the normal in the pelvis, then the welfare of the woman and the foetus calls for anaesthesia, in order that the entire hand may be inserted into the vagina, so that the capacity of the pelvis may be determined. This point cannot be emphasized too strongly. The scientific determina- tion of the operative procedure to be elected in the presence of an abnormal pelvis depends on pelvimetry as accurate as pos- sible. The instruments which from time to time have been devised for the purpose of internal pelvimetry cannot take the PLATE III. Fig. I. — Determination of the Diagonal Conjugate. Fig. 2. — Depression of the Uterus so as to Determine Adaptability of Presenting Part to the Pelvic Brim. OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 15 place of the finger and hand ; further, outside of maternity hos- pitals these instruments will rarely be at the disposal of the practitioner. Usually, fortunately, the careful measurement of the external diameters of the pelvis and the accurate estimation of the true conjugate will give 'a sufficient estimate of the capacity of the pelvis. Where the estimate thus obtained falls below the normal, we repeat, manual pelvimetry under anaes- thesia is called for. Further, in the presence of a contracted pelvis, we thus not alone note the capacity of and shape of the pelvis, but we also — and this is of equal importance — may form an approximate idea of the size of the foetal presenting part. (Plate III, Fig. 2.) Whilst the hand is in the pelvis the uterus may be depressed, and the facility with which the presenting part is likely to engage within the pelvic inlet may be noted. Far too little stress is laid on the relation which the foetus bears to the canal through which it must pass into the world. A given pelvis may be large enough, although diminished in all its diameters, for a foetus below the average size, and the reverse is equally true. Could we solve as approximately the size of the foetus as we can the capacity of the pelvis, the surgical side of obstetrics would be much simplified. As yet, however, we may only form an imperfect and relative idea of the ease wdth which the foetal presenting part will enter the pelvic canal. In general, however, if a foetus can engage at the pelvic inlet the chances are that it can engage at the outlet, unless, indeed, the alteration in shape of this outlet is marked enough to be deter- mined even by digital pelvimetry. Aside from the conjugate, the internal diameters of the pelvis which the practitioner should estimate in the average case are as follow, with the dimensions necessary for the birth of the average foetus : — Diameters. Brim. Cavity. Outlet. Transverse, 5 in. 5 to 5^ in. 4| in, Oblique, . 4^ to 5 in. 5 to 5^ in. 4| in, Conjugate, . 4^ to 4^ in. 4| in. 5 in. 16 OBSTETRIC SURGERY. It will be noted from these figures that in the normal pelvis the transverse diameter is widest at the brim and nar- rowest at the outlet ; the obhque is widest in the cavity and narrowest at the outlet; the antero-posterior is widest at the outlet and narrowest at the brim. Therefore, a foetus of average size, engaging normally at the brim, can pass without assistance through the cavity and emerge at the outlet, if the estimate of the pelvic capacity do not fall below these figures. Where the obtained measurements are below these figures, we are in face of an abnormal pelvis, and the degree of abnormality in relation to the estimated size of the foetus must be carefully weighed before we are in a position to determine the measures, if any, which are requisite for the safe conduct of the labor. A further measurement to be taken is the circumference. This is chiefly of importance in determining asymmetry of the pelvis. ^ The circumference may be secured by means of a tape- measure. Failing this the pelvimeter may be utihzed by meas- uring each lateral half separately. This latter method will best enable us to secure knowledge in reference to pelvic asymmetry. Before entering into a consideration of deviation of the pelvis from the normal, it is essential to recall briefly the aver- age dimensions of the foetus at term, for, as already stated, the practitioner must take into account in his estimate not alone the probable capacity of the given pelvis, but also the probable size of the body which must pass through this pelvis. The weight of the average foetus at term varies from 6i to 7i pounds, and the length is about 20 inches. The chief diam- eters of the foetal head, with their measurements, are : — Occipito-frontal, Occipito-meiital, C erv ico-bregmatic , rronto-mental, . Suboccipito-bregmatic, Biparietal, , 4| inches. 5^ inches. 3| inches. 3^ inches. 3^ inches. . 3| inches. It should ever be remembered that during the course of OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 17 labor some of these diameters, owing chiefly to tlie presence of the fontanelles, are capable of diminution, always, however, at the expense of others. In tlie course of a normal labor the molding of the foetal head as it descends flexes and rotates in the pelvis, results in diminution of those diameters which adapt themselves to the most favorable diameters of the pelvis, and the corollary is that in case of abnormal pelvis the aim of the attendant should be to guide the longest diameters of the fcetal head into the longest diameters of the pelvic canal. Such an aim presupposes accurate knowledge of pelvic configura- tion, and hence a further reason for accurate pelvimetry in every case. The problem before the physician is rarely a simple one, and as we pass from a consideration of the normal pelvis to that of the abnormal pelvis this problem becomes all the more complex. General Considerations of Abnormal Pelves. On the accurate determination, as far as possible, of the degree of pelvic abnormality in relation to the estimated size of the foetus depends the scientific selection of the operative pro- cedure which offers the fairest chance both to the woman and to the foetus. Only through the deliberate election, in a given case, of a determinate operative procedure can the physician plead that he has done his whole duty by the two beings whose welfare depends on his skill. The midwifery of the present differs in many respects from that of the past. In no respect is the difference more striking than in the growhig tendency to elect the proper operation before, in the face of maternal and of foetal exhaustion, it is forced upon us. Careful inquiry into the antecedents of the patient; inspec- tion, Avhere need be, of the general configuration of the body, — data of this kind are essential aids in the determination of the nature of pelvic abnormality. Diseases of early life, such as rachitis and marasmus, almost inevitably leave their impress on the pelvis, — an impress which superficial pelvic examination 18 OBSTETRIC SURGERY. mav not reveal. — -but the knowledge of Avhicli ^vill nra-e the physician to brina' all his skill to bear on a more carei'ul and thorough examination of the pelvis. The abnormalities of tlie female pelvis may be conveniently divided into minor and major, cummon and uncommon. In the United States the major delormities are rarely met witli. l)ut their determination is a far simpler matter than that of the minor deviations from the normal. It i- in the latter class of cases that extreme accuracy is refpii>ire. since at times shades of dif- erence may turn the =rale in favor nf one or another operative Fig. 6. — ^Justo-Major Pelvis. procedure. In instances of major deformity the 'choice of oper- ation will ordinarily be limited, in tlie presence of a foetus of avera£:e size, within a very narrow ran2"e. The varieties of pelvic deformitv and the salient character- istics of f-ach are as follow: — /. Jusio-Mojor Felc'i.^. — The ecpaaliy erdara'ed pelvis is of obstetric significance only in so far as it may lead to precipitate labor or to prolapse of the funis. It is not a variety of pelvic abnormality Avliich is at all likely to rail for operative inter- ference. Extfrrnal pjelvimetrv will readily diagnosticate the con- OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 19 dition, seeing that the diameters obtained exceed the measure- ments which have been stated as normal. The diagnosis, therefore, is chiefly of value as warning the attendant of the possible complications just mentioned, in order that he may be prepared to meet tbem. Precipitate labor may mean, for the woman, post-partum hsemorrhage, inversion of the uterus, lacer- ation of the genital tract, and prolapse of the cord may entail foetal death. // TJieJasto- Minor Pelvis. — This form of pelvic deformity is of infrequent occurrence. The external configuration of the patient and her antecedent history may give us no clue to its presence. It is only through careful pelvimetry, external and Fig. 7. — Generally Equally Contracted Pelvis ( Justo-Minor) . internal, that tbe diagnosis, ordinarily, may be readied. All the diameters of the pelvis are diminished to a greater or less degree, and it is apparent how essential it is to determine the amount of diminution in order to elect the proper operative procedure in any instance where the estimated size of the foetus suo-"-ests that assistance will be needed. In general, it mav be stated, that in the presence of this variety of pelvic deformity,, certainly in all but the lesser grades, it is advisable to explore the pelvis manually (under anaesthesia), in order to determine, as approximately as possible, the length of the transverse and oblique diameters from the brim to the outlet. In reported instances the diminution in the diameters has amounted to an 20 OBSTETRIC SURGERY. inch and over. Early recognition of this type of pelvis, there- fore, might suggest the induction of premature labor : if tlie time for this operation had elapsed the question of choice between forceps and version might arise ; in the extreme decrees of contraction the deliberate election of svmphvsi- otomv, the Caesarean section, or of embryotomy would offer as alternatives. III. The Flattened Pelvis. — This abnormality of the pelvis may be met with, like the preceding, in women of normal ex- ternal configuration and of healthy antecedents. It is a type of pelvis very frequently found, so much so, indeed, that many authorities rank it as the most frequent variety of deformity. Fig. 8.— Flat Xon-Kacliitic Pelvis. The etiological cause can rarely be definitely stated. This pelvis is found amongst all classes, the wealthy as well as the poor, amongst those subjected to privations in ii>fancy and to toil before maturity, and those who are reared Avitli tenderest care from the start. Pelvimetry alone, in the vast proportion of cases, will reveal the abnormality, and that its recognition is important is apparent when we recall the well-known fact that this deformity is a frequent source of the most deplorable results in childbirth. The diagnosis of this form of pelvic deformity rests on the fact that there is narrowing in the external conjugate whilst, as a rule, the other diameters are normal. The transverse diam- OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 21 eter may be increased ; there is no pelvic asymmetry. ' The true conjugate measures, generally, about three inches. From a surgical stand-point, bearing these characteristics in mind, the recognition of this form of pelvic deformity tells the physician that his aim, in case of difficulty in extraction, should be to guide the largest diameter of the fcetal presenting part into the largest diameter of the pelvis. In other words, labor through this type of pelvis requires constant watchfulness on the part of the accoucheur. It is only by not trusting to nature overmuch that deplorable results, chiefly from the foetal side, may be avoided. Here, again, the question of the election of version or forceps will often be forced on the physician. Pig. 9.— Flat Rachitic Pelvis (Mild Grade). IV. The Racliitic Pelvis. — In certain sections of Europe the rachitic type of pelvis is very commonly met with. In the United States, except among our foreign-born population, this pelvis is infrequent compared with the simple flat pelvis. The external conflguration of the woman may or may not suggest the presence of rachitic deformity. Inquiry into the early history of the patient will, however, generally give the requisite clue. Often, in marked instances, the appearance of the patient is characteristic ; the size is dwarfed ; the abdomen prominent ; the gait clumsy ; the sacrum is flattened externally in outline ; a variable amount of spinal deviation may be present. External 22 OBSTETRIC SURGERY. pelvimetry will reveal, as a rule, diminution (slight in the minor degrees of deformity) in the measurements between the crests and the spines. The external conjugate is always diminished. These results call for internal pelvimetry under ansestliesia, for the hand alone, exploring the pelvis, can give us sufficiently accurate data as to the degree of deformity. The pelvic capacity will be found to be generally limited. The pelvis is often asym- metrical. The most marked internal change is due to the downward sinking of the sacrum, the result being approximation of the promontory to the symphysis. This antero-posterior shortening Fig. 10.— Flat Rachitic Pelvis (High Grade). may be compensated by a slight increase in the transverse di- ameter, but this is not the rule in the typical rachitic pelvis. The pubic arch is generally widened. The total result of these alterations is a pelvis with contraction at the brim, whilst the outlet may be normal or slightly widened. In the extreme degree of this deformity the approximation of the sacral promontory to the symphysis may be such as to practically divide the brim of the pelvis into two portions. The importance of the recognition of this pelvis before labor, is at once obvious. The contraction at the brim neces- sarily interferes with the normal engagement of the foetal pre- senting part! The safety of the foetus, certainly, depends OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 23 therefore on the diagnosis of the deformity before long-continued efforts — leading to maternal and foetal exhaustion — at engage- ment have been made. Here, again, it is evident how accurate pelvic exploration before labor may teach the physician that his patient has a pelvis where the judicious election of one or another obstetric operation will redound to tlie safety of the child if not always, in this deformity, of the mother. In minor degrees of the deformity, even, the foetal head cannot enter the pelvic brim obliquely (as is normal). The physician, for instance, if he recognize this, may conclude that the chances Fig. 11.— Generally Contracted Flat Rachitic Pelvis. for the foetus are better if he perform version and guide the largest diameters of the head through tlie largest of the pelvis. The brim once passed, there will be rarely difficulty in the further progress of labor in the pure rachitic type (mild) of pelvis. The pelves, the characteristics of which have been tersely passed in review, constitute the varieties with which the prac- titioner will ordinarily come in contact. As a rule, these pelves, except the higher grades of rachitic deformity, rarely suggest themselves from inspection of tlie general configuration of the patient. The varieties which are next to be considered are of 24 OBSTETRIC SURGERY. rare occurrence, certainly in English-speaking countries, and, as a rule, the appearance of the woman at once suggests the ex- istence of pelvic deformity. Accurate pelvimetry, however, is none the less requisite, seeing that due recognition of the exact deformity may, the time being opportune, point infallibly to the necessity of the induction of premature labor or even to arti- ficial abortion, in order to avoid at term embryotomy of the living foetus in instances where the indication for the Csesarean section is not absolute, and yet, where this operation cannot, for one or another reason, be deliberately elected, (a) Tlie Transversely Contracted Pelvis. — This type is also known as Koberts's pelvis from the fact that he first described it. Fig. 12. — Roberts's Pelvis. The Tiansverselj- Contracted Pelvis. It is an uncommon variety of pelvic deformity, only about thirteen instances being on record. Tlie chief internal cliar- acteristic of this pelvis is its division into two li^lves antero- posteriorly. This is due to progressive narrowing of the transverse diameter from the brim to the outlet. The conjugate diameter, on the other hand, differs but little, if any. from tlie normal. The sinking of the sacrum into the pelvis is marked, the posterior superior spines are close together, and the iliac bones project greatly posteriorly. {h) The Kyphotic Pelvis. — Inspection of the patient and the antecedent history will at once suggest this deformity. The etiological cause is Pottos disease, and, according as this disease has affected one or another portion of the spinal column, the OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 2o anterior deviation of the column is in the dorsal, lumbar, or sacral region. The effect of the spinal deviation on the pelvis is variable. In general, however, the pelvis offers the following characteris- tics : The true conjugate is increased, the transverse diameter is lessened at the brim, diminished in the cavity, and still more so at the outlet. The sacrum is carried upward and backAvard ; the pubic arch, as a rule, is narrowed. Where Pott's disease has developed in infancy, the total result, as regards the pelvis, is Fig. 13. — The Kyphotic Pelvis, showing Nairo\\ing in the Transverse Diameter and Lengthening in the Conjugate. that its growth is arrested. This pelvis, in general, will call for the induction of premature labor, for at term the choice will almost necessarily lie between the Csesarean section and embry- otomy, except in an instance of very small foetus. (c) TIw Scoliotic Pelvis. — It is essential to differentiate two types of scoliotic pelvis, — the rachitic and the non-rachitic, — for the characteristics are markedly different. In case of the non-rachitic scoliotic pelvis the diminution in the diameters is only exceptionally great enough to prevent delivery at term. The chief characteristics of the pelvis are : 26 OBSTETRIC SURGERY. The side of the pelvis toward which the spinal column deviates is flattened to a greater or less degree. As a result one of the oblique diameters is shortened, but the other may not be altered. The pelvic inlet is chiefly the seat of contraction. The rachitic scoliotic pelvis, on the other hand, presents alterations which differ in degree according as the rachitic Fig. 14. — Non-Rachitic Scoliotic Skeleton. Fig. 15. — Rachitic Scoliotic Slieleton. changes have supervened in early infancy or later. Leopold states the following as the striking characteristics of this pelvis : There is considerable shortening of the true conjugate owing to the projection forward of the sacral promontory. There is greater or less asymmetry of the pelvis according to the degree of lateral curvature of the spinal column. The symphysis of the pubes is deviated toward the side opposite the scoliosis. OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 27 At the pelvic inlet there is contraction on the side of the scoliosis and widening on the other, whilst at the outlet the reverse holds true. The antero-posterior diameter is here dimin- ished, but more to the same degree than the true conjugate. In the usual variety of scoliosis the dorsal vertebral column is curved toward the right, and the compensatory lumbar curve is toward the left ; the pelvic capacity, therefore, is ordinarily diminished on the right. If the foetus can be borne spontane- ously, it must be through the wider (left) half of the pelvis, Fig. 16.-^poiidylolistlietic Pelvis. and in a given case, where the scoliosis is right-sided, the phy- sician in his manipulations should remember that it is within the left half of the pelvis that he can alone work. (c/) SiDondyJolistJietic Pelvis. — This pelvis results from the sliding downward of one or more of the lumbar vertebrae on the first sacral vertebra, forming a false promontory anterior to and below the true. The result is marked narrowing in the conjugate, — to such a degree, in extreme cases, that the foetus cannot enter the pelvic cavity. The deformity was first described 28 OBSTETRIC SURGERY. by Kiliaii. Neugebauer has most elaborately studied it, and, as a result of his analysis of forty-three cases, he reaches the conclusion that the deformity is not the result of a dyscrasia, but of the physiological weight of the trunk. This explana- tion, however, hardly accords with the data furnished by the museum specimens, seeing that in the majority there is evidence of the destruction of one or more of the lumbar or sacral verte- brae, suoo-estin"' Pott's disease as a causative factor. The recognition of the deformity offers no difficulty. The contour of the lumbar spine at once suggests deformity, and digital internal pelvimetry reveals the nature of the obstruction. This form of pelvis, if detected early enough, calls for the induction of preniature labor. At term the indication for the Csesarean section may be absolute. (e) Funnel- Shaped Pelvis. — This variety is so exceedingly rare as to call for but passing notice. The name accurately describes the appearance of the pelvis. There is slight contrac- tion in all the diameters at the pelvic inlet, and this narrowing increases progressively to the outlet. Recognition is easy if internal pelvimetry be not neglected, and, again, we have a pelvis where wise conservatism will counsel the induction of premature labor, for at term the choice will almost inevitably lie between the Csesarean section and embryotomy. (/) The- Osteomalacic Pelvis. — The disease causing this deformity usually develops after puberty, appearing, as a rule, during the gravid state. The early stages of the disease are characterized by the presence of acute pain in the limbs and pelvis, and this symptom during pregnancy should suggest the development of the disease, and should call for careful pelvic mensuration by means of the entire hand. The disease is very rare in the United States. In Italy and in certain portions of lower Germany it is frequently met with. The etiological causes are the same as those of rickets ; but, except in advanced cases, the external configuration of the woman will not suggest the pelvic deformity. OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 29 The characteristics of the osteomalacic pelvis are : The bones, in general, are softened ; the sacrum is small, the promon- tory sinking- into the pelvis and approximating the symphysis. The lumbar vertebrae, in consequence, approach the pelvic brim. The rami of the pubes bend inward, the pubic angle being sharply acute and shaped like a beak. The external measurement between the iliac spines is less than normal, and that between the crests exceeds that between the spines. As a rule, the outlet of the pelvis is narrower than the inlet. AVhilst the conjugate diameter may be only slightly narrowed, the Fig. 17. — The Osteomalacic Pelvis. transverse is considerably so at the brim and more so in the cavity and at the outlet. In the slighter degrees of deformity due to osteomalacia, internal pelvimetry by the entire hand is absolutely essential not alone for accurate diagnosis, but also for determining the extent to which the softened pelvic bones can be made to yield to pressure. It is very essential to determine this latter point, for on this depends the determination of delivery i^er vias naturaJes with safety to the woman. In many of the reported instances of osteomalacia the indications for Ceesarean section 30 OBSTETRIC SURGERY. have been absolute. Of 72 cases collected by Litzmann, 38 could not be delivered naturally. It is also to be remembered that the disease is aggravated in successive pregnancies. If recognized in time, the osteomalacic pelvis calls for the induction of premature labor; in aggravated instances, for arti- ficial abortion. If determined only at term, whilst the pelvis may yield sufiiciently to allow of the delivery of the foetus, in the vast proportion of cases the physician will be called upon to elect either embryotomy or the Csesarean section, — here, as Fig. 18.— Obliquely Distorted Pelvis of Naegele. always prior to maternal exhaustion, the result of ineffectual efforts at delivery. (g) The Oblique Ovate Pelvis. — This form of pelvic de- formity was first described by 'Naegele. As a rule, the woman off"ers no external signs. The broad characteristics of the pelvis are the diminution of one oblique diameter associated with ankylosis of one of the sacro-iliac synchondroses. The pelvis is asymmetrical, one side of the sacrum is lacking in development, and the bone is pushed toward the affected side. The pubic symphysis is obliquely opposite the sacrum. The arch of the OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 3i pubes is narrowed. The true conjugate is, as a rule, longer than normal; the transverse is narrowed at the brim, and this narrowing increases progressively toward the outlet. Pelvic mensuration of the lateral halves will reveal the asymmetry. In aggravated instances the rule as regards the external configuration will not hold. The woman limps, one hip is higher than the other, and deviation of the pubes is marked. In such an instance the following measurements, which are the same in a normal pelvis and shorter on the affected side in the oblique ovate pelvis, should be taken as assisting in diagnosis : From the tuberosities of the ischium to the opposed posterior superior spines of the ilium ; from the anterior superior to the opposite posterior superior spines ; from the spinous process of the last lumbar vertebra to the anterior superior spines. These measurements may readily be taken with the pelvimeter. The oblique ovate pelvis is of not infrequent occurrence. The neces- sity of recognition is apparent from the statement that in a series of instances collected by Litzmann, 22 out of 28 women died and out of 41 children 31 were lost. Such results are ex- plainable alone on the assumption that the variety of deformity was not recognized before term. This pelvis calls strictly for the induction of premature labor in order to avoid the choice at term between the Csesarean section and embryotomy. Only ex- ceptionally, and then in the lesser degree of the deformity, can spontaneous labor at term occur, or will, at this time, version or the forceps be safe for the woman. Symphysiotomy is contra- indicated. (7i) Pelves Deformed hjj Tumors. — The presence of tumors within the pelvic cavity obviously interferes with the progress of labor and may even render delivery by the natural passages impossible. These tumors may be bony projections (exostoses), osteosarcomata, carcinomata, fibroids of the uterus, ovarian cysts ; such, at least, are the common varieties. According to. the size of these tumors will vary the obstetric operation requi-. site for delivery. Ordinarily their presence may be detected. 32 OBSTETRIC SURGERY. only by exploration of the pelvis ; hence a further reason for the rule already dwelt upon, — the necessity for examining the pelvis of every gravid woman at an early date of gestation. Such a rule, if ordinarily followed, and if its necessity be recognized by every woman, will, time and again, result in the choice of a minor operative procedure, — such as artificial abor- tion or the induction of premature labor, in instances where, if the woman be only examined at term, the indication for the Csesarean section may be absolute. Further, in case of pedicu- lated fibroids, for instance, the risk resulting from impaction within the brim may be avoided where the woman is seen in the early stage of gestation, seeing that, at times, manipulation Fig. 19. — Osteosarcoma of the Pelvis. in the proper position — the knee-chest — may enable the phy- sician to push the growth above the brim ; and in case of an ovarian cyst, for instance, the advisability of abdominal section for its removal might well be forced on the physician. The osseous, cancerous, sarcomatous tumors which spring from the walls of the pelvic cavity will, as a rule, if not de- tected till term, call for embryotomy or for the Caesarean sec- tion, possibly for the Porro operation. It must be recognized as unscientific, to say the least, to attempt delivery by either forceps or version where the foetus is estimated at average size and the tumor narrows the pelvis sufficiently to warrant the assumption that delivery Avithout mutilation is problematical. OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 33 Aside from the death of or injuries inflicted upon the child by attempts at forceps extraction, the trauma the woman would necessarily be subjected to is a distinct contra-indication. From this analysis of the salient characteristics of deformed pelves it is apparent how helpless the practitioner may be, at the term of gestation or when labor is advanced, if, for one or another reason, he has neglected or it has been impracticable to estimate the capacity of tlie pelvis either at an early stage of gestation or before the onset of labor. Without the data obtainable through pelvimetry and ex- ploration of the pelvis, it is impossible to elect the obstetric operation, where one is demanded, which best subserves in a given case the interest of the two beings whose safety depends on the acquired knowledge and expertness of the accoucheur. In practical obstetrics, the forceps, for example, is too often used in instances where accurate pelvimetry will teach that it is contra-indicated. The major obstetric procedures are too fre- quently delayed until maternal and foetal exhaustion is immi- nent or present. The facts on which stress has been laid teach the necessity of deliberate election of every obstetric operation, and it is from this stand-point that these operations will be considered. CHAPTER II. ARTIFICIAL ABORTIOX AXD THE IXDUCTIOX OF, PREMATURE LABOR. The term " abortion"' is applied to instances where the ute- rus is emptied of the product of conception either spontaneously or artificiallv before this product has reached that stage of devel- opment wlieii it is fitted for extra-uteriue life. Artificial abor- tion, therefore, is performed purely in the interests of the woman. Premature labor, on the other hand, when induced, carries with it tlie assumption that the foetus is capable of surviving apart from the mother, — that is to say, that this foetus has reached wliat is termed the viable age. This operation, then, is resorted to both in the interests of mother and child, although ordinarily those of the former chiefly urae the physician to resort to it. Tiie induction of premature labor is. in general, an elective operation ; artificial abortion is usually forced on the physician. The factors calling for the one operation are usually different from those calling for the other, and the method of procedure also ditfers. It is useful, therefore, to consider the subjects apart. (ti) Artificial Abortion. Tlie diseases and anomalies which justify artificial abortion are: 1. Advanced pulmonary and cardiac disease. 2. The pernicious vomiting of pregnancy. 3. Penal disease. -1. Per- nicious anaemia. 5. Chorea. 6. Absolute pelvic contraction or occlusion of the genital tract by tumors, etc. 7. Irreducible displacements of the uterus. 8. Hsemorrhage from placenta prtevia. hydatid mole. etc. Bearing in mind strictly the fact that artificial abortion is performed purely in the interests of the ^voman. we will con- sider these indications seriatim. 1. Advanced Palmonary and Cardiac Disease. — At a glance it is apparent what an untoward effect gestation, if (34) ARTIFICIAL ABORTION. 35 allowed to advance, must have on the life-limit of a woman in an advanced stage of phthisis or with serious cardiac lesion. The vital force of the woman is being actively expended in fighting the disease which shortly will kill her when, in addition, the extra burden of supporting foetal growth for nine months is thrown upon her. If such a woman be allowed to go to term, even if she can withstand the strain of pregnancy and of labor, the duration of her remnant of life has unques- tionably been shortened, and she will rarely have the satisfac- tion of leaving behind her a healthy babe. Wise and justi- fiable conservatism, therefore, counsels the artificial arrest of pregnancy as soon as detected, in case of advanced phthisis and of a cardiac lesion which has progressed to the stage of dilatation. The indication may be said to be absolute in the former instance ; in the latter only when the heart has begun to dilate, since otherwise the physiological cardiac hypertrophy of ^Dreg- nancy will enter as a compensatory factor, and enable the woman to reach term with safety, and, likely enough, not deteriorated in general health. 2. The Per-nicious Vomiting of Pregnancy. — This indica- tion may be called absolute only after the recognized general and local remedies have been tried. Eectification of a uterine displacement, applications of solutions of nitrate of silver to the cervix, digital or instrumental dilatation of the cervix, regula- tion of the diet and of the function of the intestinal canal, the internal administration of drugs (oxalate of cerium in large doses, ingluvin, minim doses of ipecac or of phenic acid), — such, briefly stated, are the chief measures on which depend- ence may be placed for the relief of pernicious vomiting. Only after such means have been tested does artificial abortion suof- gest itself as justifiable. It should then be deliberately elected. The physician should not wait until the emaciation is extreme, the pulse is rapid, and the fever of exhaustion sets in. On the occurrence of phenomena of exhaustion, the operation may fail 36 OBSTETRIC SURGERY. in its object. — the saving of maternal life, — and generally emptying of the uterus is postponed too late. The fact that the vomiting, even when of the so-called pernicious type, in many instances ceases spontaneously at the third month, whilst a cause for hope, should never blind the physician to such a degree as to lead him to expectancy oveiiong. Whilst, as a rule, artificial abortion, under this indication, is rarely called for, it is safer not to wait until the vital forces of the woman are at too low an ebb. 3. Renal Disease. — The co-existence of renal disease and of pregnancy is most unfortunate. Aside from the strong prob- ability of the development of eclampsia if the pregnancy be allowed to continue, the extra wear on the kidneys associated with gestation inevitably tends to shorten the woman's life if she be allowed to go to term. This in particular holds true of the parenchymatous form of nephritis. In a given case, if under absolute milk diet and the administration of iron and diuretics the amount of albumin in the urine do not decrease, artificial abortion should be resorted to. In the event of better- ment from the side of the kidneys, then, under constant watch- fulness, the woman might be tided over until tlie child is viable, and often to term. 4. Pernicious Anaemia. — This indication will rarely offer for the reason that the affection is only exceptionally met with, and then conception is a rarity owing to the lack of function of the ovaries. In the event, however, of pregnancy supervening on this depraved condition of the blood, artificial abortion is justifiable as soon as it becomes apparent that the auEemia, not- withstanding the recognized remedies, is becoming deeper. To wait longer is to aggravate the disease, only to obtain a foetus incapable of extra-uterine life. 5. Clwrea. — Pregnancy has a deleterious influence on chorea. In all the reported instances the choreic movements have become aggravated often to an extreme degree. Nature sometimes asserts herself and abortion is spontaneous. On the ARTIFICIAL ABORTION. 37 other hand, it cannot be positively predicated that emptying the uterus will modify the chorea favorably. The indication, there- fore, for artificial abortion is not an absolute one. The opera- tion should be resorted to only in extreme instances, and then only in the hope that it may prove a remedial measure. Barnes's statistics prove that gravid choreic women often die of the dis- ease, and that the foetus rarely survives. It should further be remembered that in a few recorded instances chorea associated with pregnancy has merged into one or another variety of insanitv. 6. Ahsolate Pelvic Contraction or Occlusion of the Genital Tract by Tumors^ etc, — By absolute pelvic contraction is under- stood that degree of pelvic deformity which will not even permit of the induction of premature labor with viable child. This will be amply considered when the subject of premature labor is discussed. As soon as determined, artificial abortion is indi- cated in order to save the woman the risks of the alternative operations at term, — the Csesarean section or the Porro. Until the results from these operations are of such a nature as to prove no greater mortality rates than that after abortion, the duty of the physician, unless the woman deliberately elects the major operations, is to empty the uterus. The same view may be taken of instances of cicatricial contraction of the vagina of such high degree as to preclude the successful induction of premature labor. The tumors which come under consideration, aside from exostoses, are fibroids in the lower uterine segment, epithelioma of the cervix, impacted ovarian cysts. Exostoses, if sufficiently prominent to occlude the pelvis to a degree incon- sistent with the successful induction of premature labor, will always call for artificial abortion unless, again, the woman elects the Csesarean section at term ; fibroids in the lower segment of the uterus do not, as a rule, interfere with the development of the uterus to the term of foetal viability, at any rate ; but at this date, and later, the choice will necessarily lie between enuclea- tion of the fibroid per vaghiam before delivery can be effected 38 OBSTETRIC SURGERY. or else the Csesarean section or the Porro. Enucleation of a fibroid by the vagina is at best a formidable operation, and be- comes all the more so in the presence of the vascularity asso- ciated with pregnancy. To say nothing of the risk of septi- c£emia during the puerperium, the safety of the woman is best subserved by emptying the uterus at an early stage, unless, again, in full view of its risks, she elects the alternative operations at term. It is understood, of course, that an ovarian cyst impacted in the pelvis cannot be removed through abdominal section without first emptying the uterus ; therefore, the proper course to pursue is to induce abortion, and at one and the same time to remove the cyst by one or another of the recognized methods. Epithelioma of the uterus, whenever discovered, should be re- moved either by high amputation or by vaginal hysterectomy. In either event the gestation will be interrupted ; so that artificial abortion is forced on the physician, and not elected. Advanced carcinoma of the lower uterine segment, when complicated by pregnancy, becomes all the more serious the longer the gestation is allowed to continue. The chief risk the woman runs is that from sudden profuse hsemorrhage ; but, seeing that the woman may be made more comfortable by a partial operation, this should be resorted to even though it interrupt gestation. At term delivery per vias naturaJes might be possible without fatal result to the woman ; but this being problematical, active inter- ference is justifiable before the child is viable,- Fortunately women with advanced carcinoma rarely conceive. It is a recognized surgical rule, to-day, to remove an ovarian cyst as soon as it is discovered. If pregnancy co-exist, ovariotomy may be performed and the gestation not interrupted. This is exceptional in the favorable case, when the tumor is not impacted in the pelvis. In the latter instance the maternal chances are better if the uterus be first emptied lege arils, and the ovariotomy be performed afterward. Obviously the phy- sician should be on his guard lest, during the process of abor- tion, the cyst rupture. Puncture of the cyst by the vagina as ARTIFICIAL ABORTION. 39 an elective measure cannot too strongly be condemned. Whilst such a measure will diminish the size of the tumor, and thus, perhaps, enable the gestation to advance nearly or to term, with resulting- viable foetus, puncture, however aseptically performed, carries with it the risk of suppuration of the cyst, in which event neither abortion nor ovariotomy might avail to save the woman. Obviously, where the obstructing tumors are so large as to interfere with access to the uterine cavity, it ceases to be a question of even artificial abortion, and the physician is called upon to decide upon the relative risks of interference surgically with the tumor before or at term. Where the risk is equal the latter period should, of course, be selected, since the child is then given a chance. 7. Irreducible Displacements of the Uterus. — No displace- ment of tlie uterus uncomplicated by adhesions must be con- sidered irreducible so as to require artificial abortion until replacement under auEesthesia, with the woman in the knee- chest position, has failed. Simpler metliods are, of course, first to be tested. Impaction of the gravid uterus below the promon- tory of the sacrum may simulate an adherent uterus ; but if the Avoman assume the knee-chest position and the cervix be drawn downward by means of a tenaculum inserted into the anterior lip, reposition may, as a rule, be effected if the displacement be uncomplicated. In an instance of this nature, if seen before tlie third month, emptying- of the uterus will rarely be called for. It is the adherent fundus which generally will give rise to trouble. Unquestionably, in many of these instances, the adhe- sions stretch and enable the uterus to rise above the brim ; but where this does not occur, gentle attempts at manual stretching of the adhesions having failed, artificial abortion should be resorted to before the uterus, developing asymmetrically, — in case spontaneous abortion do not occur, — causes grave symp- toms from the side of the bladder, possibly leading to rupture of the organ. 8. Hcemorrliage. — The slight discharge of blood which not 40 OBSTETRIC SURGERY. uncommonly complicates the early months of pregnancy will never call for artificial abortion. Rest in bed with appropriate remedies — such as the viburnum prunifolium and, perhaps, an opiate ; removal of the cause, such as a small submucous polyp — will, as a rule, suffice to check what at times is simply an attempt at periodical menstruation. It is the haemorrhage met with between the third and sixth months of gestation which may warrant abortion. Haemorrhage at this period should always suggest a low attachment of the placenta, and, when profuse enough to threaten maternal exhaustion, it is conserva- tive to empty the uterus rather than to endeavor to tide over the patient until the foetus has attained viability. Such, briefly outlined, are the complications of early preg- nancy which chiefly will call for artificial abortion. This oper- ation should never be determined upon without the advice of a consultant. The risk to the woman where the operation is carefully performed is slight, presumably always slighter than that she is subject to if the gestation be not interrupted ; but no physician, except in strict emergency, should induce an abortion without the support of one or more consultants. He will thus be amply protected against scandal and legal process, should either arise. In view of the fact that artificial abortion is an operation which is forced upon the physician, when the indication presents, the object is to empty the uterus as rapidly as is consistent with the welfare of the woman. The method of procedure about to be described is peculiarly applicable to gestation which has not advanced beyond the third month. After this period, the foetus and its adnexa being larger, and fuller dilatation of the cervical canal being therefore requisite, the metliod to be de- scribed under the subject of the induction of premature labor is to be selected. The administration of so-called abortifacients and resort to electricity are proposed methods for the induction of abor- tion which are so problematical in their results as not to be ARTIFICIAL ABORTION. 41 worthy of trial. Tamponing the vagina, associated with the administration of ergot, was a method formerly greatly in vogue. It should be rejected, however, because it is slow in action, un- certain in its results, and difficult to maintain aseptically. The sponge tent for dilating the cervix cannot be too strongly con- demned, on the ground that the chances of sepsis following its use are very great. It should ever be borne in mind that the operation is performed in the interest of the woman, and that the one risk the physician subjects her to is sepsis. OPERATION FOR THE INDUCTION OF ABORTION. The instruments strictly requisite are : A steel-branched uterine dilator, a uterine dull curette, an ovum forceps, an intra- Fig. 20.— Steel-branched Dilator. uterine irrigating tube, the finger. These instruments should be carefully sterilized. The intestinal canal should be thoroughly emptied by enema, and the bladder by catheter. The external genitals and Fio;. 21.— Uterine Curette. the vagina must be thoroughly asepticized. Douching will not accomplish this. Both the genitals and the vagina .'^hould be scrubbed with soap and water, and then washed with a 2-per-cent. solution of creolin or a 1 to 5000 solution of 42 OBSTETRIC SURGERY, bichloride of mercury. Thus alone may the rugosities of the vagiua be rendered aseptic. If the operator prefer continuous irrigation during Ins manipulations tlie creolin solution answers Fig. 22. — OTTim Forceps. admirably, since it will not injure the instruments and will not poison the patient. The liands of the operator and of his assist- ant should be scrupulously scrubbed with soap and Avater, and Fig. 23.— Glass Irrigating Tube. then carefully washed in a solution of bichloride of mercury. These details are called ibr in order to avoid septic infection of the patient. — the risk, we would repeat, which the woman is Fig. 24. — Fritsch-Bozemau Catheter. subjected to. As a rule, it is desirable to anaesthetize the patient. The operation, when resorted to at alh must he thorough, and it is difficult to secure this if the patient be struggling and complaining. The patient is placed upon the ARTIFICIAL ABORTION. 43 table in the lett lateral or dorsal position, according to the preference of the operator. We prefer the dorsal position because all the necessary steps are best followed in this position, and because, furthermore, the uterus is under better control. Fig. 25. — Edebolil's Speculum. A speculum is inserted into the vagina, and, the cervix having been exposed, a tenaculum is inserted into the anterior cervical lip to steady the uterus. The steel dilator is passed into the cervix beyond the in- Fig. 26.— Cervical Tenaculum. ternal os, and the canal is slowly stretched to the extent of an inch and a half to two inches. The cervical muscle is made to yield to the applied pressure; the aim is not to rupture the cervix. Owing to the hypersemia and softening of the cervix, 44 OBSTETRIC SURGERY. which, as a rule, is present even in the early months of preg- nancy, dilatation to this extent will ordinarily be possible. The instruments are then to be removed, and the next step is the extraction of the ovum. The best of all instruments for the loosening of the ovum, the breaking up of the foetus, and for the removal of the debris is the aseptic finger. It is sentient, and therefore it is less likely to do harm than any instrument. We are operating to protect the interests of the woman, and, therefore, must take every pre- caution to see that these interests are not endangered. In the average case of abortion under the third month it is possible to empty the uterus by the finger alone, provided the physician proceeds as follows : The woman should be anaesthetized. The fundus of the uterus is grasped through the abdominal wall, and the organ is depressed deeply into the pelvic cavity in the axis of the inferior strait. The other hand is introduced into the vagina, and the index finger is inserted to the fundus of the uterus, slowly, in order to obtain greater dilatation than has fol- lowed the use of the dilator. The ovum is then carefully pealed from its connection with the uterus. Up to the second month of gestation it may ordinarily be removed in its entirety. Beyond this period it is usually necessary to break up the ovum by the intra-uterine finger, and this may be accomplished with- out great difficulty, provided the external hand firmly controls and steadies the uterus. In instances where it is not possible to depress the uterus sufficiently to enable the finger (the hand being in the vagina) to reach the site of the ovum, the long uterine curette takes the place of the finger. The instrument, however, should be used simply to loosen the connection of the ovum with the uterus, the after-extraction being accomplished either by means of the ovum-forceps or by the finger. The manipulation is as fol- lows: The curette seeks to penetrate between the ovum and the uterine wall, the external hand being conscious of and tlius indirectly controlling the action of the instrument. When dis- ARTIFICIAL ABORTION. 45 lodged in this manner, if the finger cannot complete removal, the ovum-forceps should be used to grasp and to extract it. The haemorrhage from these manipulations is, as a rule, considerable, but the external hand grasping the uterus may soon cause efficient contraction. When satisfied that the uterus has been thoroughly emptied, a |-drachm of ergot or 10 minims of ergotole should be injected into the nates, the intra-uterine tube should be inserted into the cavity of the uterus and the organ washed out either with a 1 to 5000 solution of bichloride of mercury or with a 3-per-cent. solution of creolin. The last step, and we believe a most important step, is the insertion to the fundus of a sterilized-gauze drain. The object of this drain is twofold : At times, owing to Fig. 27.— Intra-uterine Dressing Forceps. flexion at the level of the internal ,os, drainage from the uterine cavity is imperfect and the retained secretions might give rise to septic symptoms ; furthermore, no matter how exact our asepsis, an error in technique may creep in, and, if local sepsis should develop, we want above all things free external drainage, in order to avoid, as far as is possible, extension to the Fallopian tubes. This drain, therefore, is prophylactic in its aim. It can do no harm, and it may be the means of preventing serious damage. The steps detailed will answer for the induction of abortion and lor its completion in the average case under the fourth month. Occasionally, however, the cervix is rigid, and then the steel-branched dilator and the finger cannot secure ample- enough dilatation. In such an event many practitioners resort 4:6 OBSTETRIC SURGERY. to t'ry.t- : '"U": for t'le rea-o:: already stated and again emphasized, t:.:;- :':,- -py„_^i- r-ri":: cliI.i.o: "ue rendered aseptic, we emphatically cc;.u-i:;:. ::.:- a_-i.: ; :i:cj,;Ji:-i; as well all other terms of tent), and we c-:-.;-. :.d the following procedure : The external geni- tr,"^ ■:. ^. ::^:: v _::.m having been rendered aseptic in the manner w.^- ■:.::\ :, awtj.t upuu, the cer^dx is exposed through a speculum aid -:r.uiied by a tenaculum. As much dilatation as possible is secured by the steel-branched dilator, and then the cervical canal and the lower ur: r: -meut is packed by means of the intra-uterine dressing ibrcep- vir^i sterihzed gauze. At the end of from six to eight hours tL- _a ize may be removed, when, as a rule, the cervical canal will be found sufficiently patulous for the finsrer or else the cervical tissues have been sufficiently softened by the gauze to enable the steel-branched dilator to act efficiently. The further steps are similar to those already detailed. There remain for consideration those instances where the cervical canal is not accessible to the dilator, owing, as a rule, to the marked retroversion of the uterus with or without ad- hesions. It has been recommended, in such instances, to punct- ure the uterus through the rectum, the object being to tap the amniotic sac, which procedure will result in spontaneous abor- tion. This method should never be resorted to, owing to the absolute certain tv of canwiiio- pjroducts of infection into the uterus. The recturn canr.ot be aseptir^ized as may the vagina. The aim of the method Avill be as well subserved by tapping through the vasfina. car- h-::.2^ taken to avoid any large vessels and al-'> ^'■..■: ure>tral triai;-le. Very rarely will such a step be nece— : ' . :. .''v.r\>:^i-. and if resorted to the method must be called an u.:.:-:-.: ::. - ae. In the face of an emercrency suggesting it, it is wise to wei2"h the alternative step. — abdominal section, the breaitiai^ up of trie adhesions, and reposition. 2>^/' o.hdorninem. of the 'i':e:u-. Artihcial abortion, if performed aseptically. and if elected before the woman is at too low an ehb from tlie affection indi- INDUCTION OF PREMATUEE LABOR. 47 eating the operation, ought not to have a mortahty rate. Haemorrhage we may control ; sepsis is avoidable by the steps of the operation we have advocated ; shock need be feared only when the physician sees the patient too late or trusts to expect- ancy overlong. The after-treatment of cases where the phy- sician has been called upon to induce abortion is similar to that which is applicable to the puerperium after delivery at term. The woman should remain in bed for about a week, not neces- sarily in the recumbent position, however. If there be no contra-indication from the side of the heart, and if the disease which called for the induction of abortion will permit, it is de- cidedly advantageous for the patient to sit up in bed according to her fancy, for thus the vagina drains to better advantage. If the operation has been performed aseptically, there will be no call for either vaginal or intra-uterine douching. Where a gauze drain has been inserted into the uterine cavity, it may be removed at the end of sixty hours ; and if there be no evi- dence of local sepsis, it need not be re-inserted. If, notwith- standing all our aseptic precautions, sepsis develop, its surgical treatment will be in accordance with the rules to be emphasized in the chapter dealing with the surgery of the pathological puerperium. (h) The Induction of Premature Labor. Obviously, the indications for the induction of abortion hold with equal, if not greater, stringency in case of the induc- tion of premature labor. The object to be attained, however, is twofold. Both the interests of the foetus and of the woman are to be considered. Exceptionally, as will be noted, those of the former alone call for the operation. From the side of both the woman and of the child, the chief indications for the induction of premature labor are: 1. Contracted pelves^. 2, Haemorrhage. 3. Eclampsia. From the stand-point of the child alone the indication offers where, in a previous labor, the foetus has died a short 48 OBSTETRIC SURGERY. time before term as a result, frequently, of disease of the pla- centa, sucli as fatty degeneration. Here, by electing premature labor in a succeeding pregnancy a few weeks before term, at a period when, from the decrease in fcetal movements, it may be inferred that death is imminent, the physician may succeed in obtainino- a livin"- child. 1. Induction of Premature Labor in Case of Deformity of the Pelvis. — Deformity of the pelvis of varying grade is by far the most frequent indication for the induction of premature labor. The aim is a most beneficent one, seeing that the major obstetrical operations — the Caesarean section, symphysiotomy, and embryotomy — are thus often avoided. As Robert Barnes, with a certain amount of truth, puts it, spontaneous labor may supersede the forceps, the forceps may supersede version, version craniotomy, and the Csesarean section may be eliminated. Whether it is desirable or not tliat craniotomy sliould supersede the Csesarean section will be considered later, as also the effect of the resuscitation of symphysiotomy. In the instances under consideration, the problem for the physician to solve is most complex. He must determine as accurately as possible the term of gestation, in order to speak with any degree of authority in regard to the chances of viability of the child. He must estimate the probable size of the foetus in relation to the degree of pelvic contraction in a given case. He must bear in mind the degree of molding 'to which the diameters of the foetal head are susceptible within safe limits. He must, lastly, ever be conscious of the fact that in deferring the operation overlong in the interest of the child he may be increasing the risks which the woman runs. It is thus apparent how difficult it is to select just the right time for the induction of premature labor from an elective stand-point. The determination of the stage of gestation so as to insure fcetal viability is not a simple matter. In almost every instance there is likely to be a margin in error of at least a fortnight. Where the exact date of the cessation of menstruation can be INDUCTION OF PREMATURE LABOR. 49 ascertained, the rule of adding seven days and counting buck three months, in order to approximate the term of gestation, is exact enough only in the lesser grades of pelvic deformity; for here, if the error of a fortnight creep in, at best the child has not passed the seven and a half months of gestation. Where the interests of the child, on the other hand, demand the induc- tion of premature labor at the seventh month, at least, the difficulty in determining this date might lead us to resort to the operation before the term of viability or else beyond it, when, in either event, the operation, so far as the child were concerned, would be a failure. The two hundred and twentieth day of gestation may be taken as the lowest limit when, with the improved means at our disposal (the coiiveiise, or incubator), a chance of the child being reared exists. Error in our data below this period may be taken as being fatal to the child. Not only, therefore, is it essential to obtain as accurately as possible the date of the cessation of the last menstruation, but also that of quickening. The first sensation of foetal motion occurs from three to three and a half months after conception, in some cases not till the fourth month. Here, again, is a chance of error of a fortnight. But, by weighing the probable date of conception against the date of perception of foetal motion and comparing this with the height of the uterus above the pelvic brim, the physician is, at any rate, unlikely to err against the term of viability. It will be remembered, of course, that the general statement of the height of the uterus at various stages of gesta- tion is subject to modification in the presence of a contracted pelvis. Whilst, normally, the fundus of the uterus is on a level with the umbilicus at the sixth month of gestation, and about two fingers' breadth above this at the seventh month, in case of contraction chiefly at the pelvic brim these relative situations will be a trifle higher. Thus, at the sixth month the fundus may occupy the position which normally it would at the seventh. Having determined as accurately as possible the date of 50 OBSTETRIC SURGERY. conception, the next factor is the estimation of the size of the foetus wliich must pass through the given contracted pelvis. The size of the foetus can, of course, only be relatively estimated. The best guide at our disposal is that furnished by Ahlfeld, and the value of this guide at best is very limited. From extended study, Ahlfeld concluded that the long axis of the foetus lying flexed in the uterus is nearlv half the entire leno-th of the foetus when extended. To determine the axis in utero of the foetus, one arm of a pelvimeter is placed in the vagina in contact with the foetal presenting part, and the other arm is placed on the abdomen at the site of the fundus over the other end of the foetus. Multiplying the obtained measurement by two, the total length of the fcetus is obtained. According to Ahlfeld, the length of the extended foetus bears a certain definite relation to the period of gestation. Thus: From the 38th to the -IrOth week of gestation the length of the intra-uterine foetal axis varies from 9| inches to 10. The total length of the fcetus, therefore, is about 20 inches. From the 35th to the 38th week the intra-uterine axis varies between 8| and 9| inches. The length of the fcetus is 18 J to 19 J inches. From the 30th to the 35th week the intra-uterine length varies from Si to 8f inches, and the total length of the foetus is 16 to 18 inches. From the 25th to the 30th week the intra-uterine length varies from 7 to 8i inches, and the mean total lengtli of the foetus is about 15 inches. Ahlfeld further determined that this length' of the foetus stood in the follo^vino■ relation to the weia-ht: — Weight. Length. At the 40th week, . . -61 pounds. 19-^ inches At the 38tli Tveek, 6|- pounds. 19^ inclies At the .36th ^veek, 6;^ pounds. 18| inches At the 35th week, 6 pounds. ]Ti inches At the 34th week, 5^ pounds. 17^ inches At the 33d week. 4i pounds. 16| inches At the 80th week. 4^ pounds. 16^ inches At the 28th week. 3^ pounds. 15| inches INDUCTION OF PREMATURE LABOR. 51 The data furnished by tliese researches of Ahlfeld, whilst only of approximate value in estimating the size of the foetus, are still of great assistance in determining tlie period at which labor should be induced. An important factor lacking, how- ever, is the average size of the foetal head at various stages of gestation. The diameter of the foetal head of the greatest im- portance is the biparietal. As the result of many measure- ments made by Budin, Tarnier, Stolz, and others, the average length of this diameter at various stages of gestation is: at term, about 31 inches ; at 8J months, about 3.-i inches ; at 8 months, about 3.2 inches; at 7J months, about 2.96 inches; at 7 months, about 2.75 inches. The foetal head, further, may be safely compressed to the extent of about 0.4 inch. Remembering' this de^rree of safe compressibility, having estimated the size of the foetus and the stage of gestation, the next important element in the problem is the determination of the degree of pelvic deformity present. Before passing, however, to renewed reference to this, we will state the method of estimating the adaptability of the foetal presenting part to tlie pelvic canal which answers every pur- pose for private practice, and which commends itself, also, on account of its simplicity. As long as the foetal presenting part can enter the pelvic brim, obviously the time for the induction of premature labor may be deferred ; but just as soon as the presenting part, engages with difficulty, the time is ripe for interference. Every week, therefore, the physician should examine his patient for the purpose of determining the above fact. Intro- ducing one or more fingers into the vagina, he presses the fundus of the uterus downward in the axis of the pelvic inlet and the fingers in the vagina are able to appreciate the ease with which the presenting part adapts itself to the pelvic brim. If need be, the patient should be examined under anaesthesia. (See Fig. 2, Plate III.) By reference to Chapter I the method of determining the 52 OBSTETRIC SURGERY. pelvic diameters and the characteristics of the chief varieties of pelvic contraction will be recalled. Taking the length of the conjugate of the brim as our guide, seeing that it is the in- ternal diameter of the pelvis which alone can be determined with any degree of accuracy, and remembering that in a given case tlie capacity of the pelvis may be approximately estimated best by examination by the entire hand under anaesthesia, we may, with Charpen tier, formulate the following general rules, which are the result of an extended study of the reports of numerous maternities and clinics : — If the conjugate is at least 3 J inches, the biparietal diameter of the foetal head at term being of inches (compressible to the extent of about 0.4 inch), then, in multiparse, labor should be induced between 8J to 81 months, according to the estimated size of the foetus and the difficulty in delivery offered by former labors. In primiparse, since, in general, the child is smaller, it is safe to wait till a week before term. Where the conjugate is 3.35 inches premature labor, both in the multipara and in the primipara, should be induced at 8 to 8| months. Where the conjugate is 3.12 inches, labor is to be induced between 8 and 8| months at least. AYhere the conjugate is 2.95 inches, labor is to be induced between 7J and 8 months. Where the con- jugate is 2.75 inches, labor is to be induced between 7 months and 7 months and 3 weeks. Where the conjugate is 2| to 2.36 inches, labor must be induced as near the seventh month as practicable, and certainly no later than 11 months. Below 2.36 inches tlie indication for the induction of premature labor does not exist. To resort to it would necessarily entail an embry- otomy, and this carries risk to the mother and subserves not the child. At this point, then, the indication for artificial abor- tion in contracted pelves begins. It is to be remembered that the figures just given hold good only for the foetus estimated to be of the average size, and for a pelvis which ranks under the flat type or, possibly, the generally contracted type. The prognosis for the child is better, under INDUCTION OF PREMATURE LABOR. 53 the measurements given, if the pelvis be of the former variety than if it be of the latter. In general, of course, the special type of pelvis will alter the indication. All that we aim to do here is to state the general indications which serve as guides in the election of the period at which premature labor should be induced in the face of pelvic deformity. It is impossible to lay down special rules, since each case must be studied from its special stand-point. 2. Hcemorrhage as an Indication for the Induction of Pre- mature Lcd)or. — Haemorrhage occurring after the fourth month of gestation should always awaken the suspicion of placenta prsevia. There is little agreement amongst obstetrical writers as to the advisability of inducing premature labor on the appear- ance of the first hsemorrhage due to faulty implantation of the placenta. A careful study of this question, in the light chiefly of the mo e modern statistical data, warrants the following state- ments, which assist in reaching a conclusion sound in practice, seeing that it takes account of the interests both of the woman and the child. As has been noted under the subject of artificial abortion, in rare instances the hgemorrhage due to faulty insertion of the placenta occurs as early as the fifth month of gestation. As a rule, however, it is within the six weeks preceding term that hsemorrhage appears. Usually the first haemorrhage is not profuse enough to endanger either the woman or the child. It may be taken, however, as nature's danger signal, warning the alert physician that a second hsemorrhage may at any time occur, and in such amount that not alone will the child probably die before delivery, but that the woman as well will be seriously en- dangered. Instances of this nature are extreme ones, but in no given case can it be predicted that such will not be the issue of the second hsemorrhage. Unquestionably, through enforced rest in bed, the woman may often be tided to term and deliver}'- be safely accomplished for the child as well as for the woman ; but even during rest in bed profuse hsemorrhage may occur, and this too at a time when the physician may not be in ready reach 54: OBSTETRIC SURGERY. of the woman. All authorities are agreed that the excessive ma- ternal mortality of the past was due, in part, to faulty methods of treatment, in part to delay in resort to active measures. The maternal mortality has varied from 32 to 9 per cent, and the infantile from 50 to 85 per cent. The modern method of treat- ment has given a maternal mortality, in the hands of various observers, of from 1 to 4 per cent., whilst even the infantile mortality has been lowered. The facts, then, at our disposal prove clearly that by any and all methods the child suffers excessively, whilst for the woman there is a choice in method. The question may be summed up as follows : The risk to the woman increases progressively to term after the first hsemor- rhage. On the occurrence of this haemorrhage the child is viable. Renewed haemorrhage simply risks viability. The interests of the child, therefore, are not subserved by expect- ancy. Those of the woman are actually imperiled. The teaching is sound, therefore, which says : On the occurrence of the first haemorrhage, whether profuse or not, elect the induc- tion of premature labor. The earlier the haemorrhage, the greater the chance of the placenta being implanted centrally. It is central implantation which at term subjects the woman to the greatest risks and holds out but very slim chance for the child. 3. Eclampsia as an Indication for the Induction of Prema- ture Labor. — Absolute statement in regard to this indication is not wise owing to the very just diversity of opinion amongst experienced obstetricians. To reach an approximately accu- rate conclusion it will be necessary to sharply differentiate the instances where eclampsia seems imminent and those where convulsions have developed. Albuminuria is an almost constant forerunner and accom- paniment of eclampsia. Such, at least, is the rule with but rare exceptions. The albuminuria may or may not be dependent on organic renal disease, and in the latter instance it may or may not lead to organic disease. The question, therefore, which the INDUCTION OF PREMATURE LABOR. 55 physician has chiefly to face is the immediate risk to mother and child if pregnancy be allowed to progress to term, remembering that in- no given case can it be predicated that the emptying of the uterus will ward off the convulsions, and also that the inter- ference with gestation may excite convulsions. The problem, it is evident, is most complex. Still, the following considera- tions help toward its solution. In the vast majority of instances, the development of eclampsia leads to premature labor. If we do not shut our eyes, then, to nature's teachings, it seems wise, in the presence of eclampsia, to resort to such measures as will hasten the empty- ing of the uterus instead of to such as will tend to protract the gestation. The latter course, certainly, will avail naught to the child, for its life is directly imperiled by the first eclampsic attack, and, should it survive this and labor not occur spontane- ously, its chances of living through further attacks are all the less. As regards the woman, if spontaneous premature labor do not occur during the first attack, experience teaches that the liability to further attacks is greater if the uterus has not been emptied tlian where it has. The first attack exhausts the woman, if it do no more. The second attack adds to her ex- haustion and may kill. Therefore, in the presence of eclampsia it may be stated that, in general, nothing is gained by endeav- oring to protract gestation and everything may be lost. One of the recognized methods of treatment of eclampsia is deep anses- thesia protracted, if need be, for hours. During this anaesthesia resort to the measures we shall shortly consider will empty the uterus possibly of a live child, for at the period of gestation under consideration the child is viable ; otherwise it becomes a question of artificial abortion, — a subject already considered. Where convulsions are imminent, there is even greater diversity of opinion as to the advisability of inducing labor. Whilst apparently imminent, they may never occur; the induc- tion of premature labor may not ward them off; indeed, the measures necessary for induction may provoke convulsions. In 56 OBSTETRIC SURGERY. the face of this fair statement of fact, what ground is there for advocating- the operation 1 Supposing that, in spite of resort to the recognized methods of treatment of albuminuria, in particular absolute milk diet combined with iron, the albumin increases in amount, headache and visual disturbances appear, dropsy to a greater or less de- gree sets in. The woman has reached the seventh month ; the child is viable, and the foetal heart certifies that it is alive. It may be safely predicated that the chances are that this woman will have eclampsia before or at term, during labor or afterward. If she do before the onset or the completion of labor, the child's chances of survival are very slight. Meantime the woman risks aggravation in the renal symptoms and condition, disturbances of vision more or less permanent, puerperal mania, and puer- peral paralysis. Now, if the operation of inducing premature labor be elected at the period under consideration, the child's chances are better even if, as tlie result of tlie manipulations, eclampsia is induced ; for, as already stated, in the presence of eclampsia rapid emptying of the uterus is advisable. As for the woman, medical and dietetic treatment having failed to arrest the progress of albuminuria (the usual forerunner of eclampsia), the induction of premature labor may save her the complications just enumerated, to any and all of which she is liable if the pregnancy is allowed to go to terra. Should eclampsia develop as the result of the necessary manipulations, labor having been started it may be more quickly ended than if emptying of the uterus is forced upon the physician by the spontaneous occur- rence of convulsions. As the case has been stated, therefore, the immediate and the remote welfare of the woman calls for the induction of premature labor in instances where the development of eclamp- sia is feared; and this fact should outweigh the argument, from the side of the child, that its chances of survival are less the earlier before term it is born, whether spontaneously or arti- ficially. To be born in the midst or at the expiration of an INDUCTION OF PREMATURE LABOR. 57 eclampsic seizure at the eighth month or at term imperils its existence fully as much as, with our modern methods of rearino- premature infants, its chances of survival are relatively great. Modern opinion is tending toward the acceptance of this view. liusk protests against postponing resort to the induction of premature labor until the grave symptoms (chiefly cerebral) which precede eclampsia develop. Tarnier, of the French school, holds practically the same opinion. The opponents of this view are certainly many, and their names carry weight; but a careful estimate of the question, both from the stand-point of the woman and of the child, forces on us the conclusion that, dietetic and medicinal measures having failed to ameliorate the symptoms which precede eclampsia, the best interests of both are subserved by the election of premature labor. Such, briefly outlined, are the indications for the induction of premature labor. In determining the best method for per- forming the operation, the fact must never be lost sight of that the intent of the operation will ordinarily be to save the woman the greater risk she suffers if allowed to go to term, and also to obtain a living child. To amply satisfy this intent in the indi- vidual case, the operation, where election is possible, should be postponed to as near term as is absolutely consistent with the interest of the mother, for thus the chances of the infant's life are increased. Further, the method selected should be one which, while the safest for the woman, takes into full account the phenomena of normal labor, since thus alone are the inter- ests of the child fully subserved. Again, in view of the fact that the child has not attained full maturity, ample preparation should be made beforehand for the rearing of the immature child. Finally, the physician should be prepared to meet every emergency which labor at term miglit involve; for premature labor may call, before it is completed, for any of the obstetric operations (the forceps, version), and its completion may be followed by the same complications as labor at term (h£emor- rhage, adherent placenta). 58 OBSTETRIC SURGERY. METHODS FOR THE INDUCTION OF PREMATURE LABOR. Many of the methods which have been proposed for the induction of premature labor are purely of interest from an his- torical stand-point. Such, for instance, is the administration of medicinal agents, — ergot, rue, quinine, cinnamon, and the like. These drugs will not provoke contractions, although some of them will intensify action when contractions are in force. Again, it has been suggested to start the expulsive action of the uterus by injecting water or air between the membranes and the uterine wall. Such a procedure would doubtless be effect- ive, but should not be countenanced, since it is likely to rupture the membranes, thus imperiling the child, and since it may prove fatal to the woman from the entrance of air into the uterine veins. Vaginal irrigation with hot water is slow and uncertain in action, and, if prolonged, may give rise to local conwstion. unfavorable alike to woman and foetus. As will be noted, this method, within limits, is useful as preparatory to other methods, in that by means of it softening of the cervix mav be assisted. Electricity is of value only as an adjuvant for hastening labor through re-enforcing contractions when tliese have once been started. Used alone, this agent is very prob- lematical in effect, and highly uncertain as well. There are left for consideration the following five methods: 1. Puncture of the membranes. 2 Tamponing the vagina. 3. The injection of glycerin. 4. The insertion of an elastic bougie between the membranes and the uterine wall. 5. Mechanical dilatation of the cervix. 1. Puncture of the Memhrnnes. — This may be accomplished in two ways, — by direct puncture through the cervical canal ; by insinuating a uterine sound on a sharpened goose-quill between the uterine wall and the membranes and tapping the membranes high up by projecting the quill over the stylet. This method was formerly highly in favor with the Vienna school. INDUCTION OF PREMATURE LABOR. 59 Puncture of the membranes Avill certainly induce labor, and, where aseptically performed, the method may be ranked as safe for the woman. The method, however, is open to the objection that it does not imitate natural methods, and there- fore may imperil the child. In the course of normal labor premature rupture of the membranes invariably leads to tedious labor, and this may entail both maternal and foetal exhaustion. Our aim should be to maintain the dilating water-wedge intact. This is the sound rule of practice in the course of spontaneous labor at term. Similarly, in case of the induction of premature labor, an operation resorted to in the interests of the child as well as in those of the woman, tlie object should be to maintain the membranes intact, in order to avoid a protracted first stage of labor, with its concomitant risks. Therefore, puncture of the membranes should be dismissed from consideration as a means of inducing premature labor. 2. Tamponing the Vagina. — Thorough tamponing of the vagina by means of aseptic tampons will unquestionably, in course of time, provoke uterine contractions, and the more speedily the nearer the woman is to term. The method, if aseptic throughout, carries with it no risk either to the woman or the child, but it is slow in action. Days may elapse before effects on the uterus are noted. Now, when speaking of the indications under which the induction of premature labor was justifiable, we have noted tliat in pelvic contraction, for in- stance, it was highly important not to err in the date assigned for the operation, and that under the best possible conditions there existed a chance of error of at least a fortnight. Obvi- ously, no method should be selected for the induction of prema- ture labor which carries with it the strong probability of greatly magnifying this chance of error. The selection of such a method is not fair to the child. Neither under other indications is it fair to the woman. If eclampsia threaten, for instance, and the physician determines that labor should be induced, he cannot afford to place dependence on a method which may not 60 OBSTETRIC SURGERY. prove eft'ective for days. There exists, indeed, but one indica- tion under which the tampon might fill a place, and this is in the event of premature labor being indicated by haemorrhage, due, likely enough, to faulty placental insertion. Here the tampon prevents further hsemorrhage whilst the cervix is di- lating sufficiently to warrant resort to the next step in treat- ment. The colpeurynter of the late Karl Braun is an excellent agent for tamponing the vagina in such an instance, but it can never fill the place of the aseptic gauze, in private practice cer- tainly, for the reason that it is made of rubber, — an agent which deteriorates with certainty in course of time, and can therefore not be depended upon as to quality. Further, it is not as strictly aseptic as sterilized gauze. When the tampon is indicated it should be inserted under the strictest asepsis, and with the patient in the knee-chest or in the left lateral position, for thus alone can the vaginal fornices be efficiently packed. An iodoform or borated gauze inserted in a continuous strip forms the best tampon. If uterine con- tractions be not established within thirty hours the strip should be removed, the vagina douched wdth 2-per-cent. creolin solution or with 1 to 8000 solution of bicliloride, and a new strip in- serted, unless the cervix is found sufficiently dilated for resort to methods the aim of which is to empty the uterus rapidly. 3. Injections of Glycerin for tJie Induction of Premature Labor. — This method has recently been highly commended in Germany, and on the few occasions when it has been tested in this country the success has been fairly uniform. The cases on record are too few to admit of positive statement. In our own hands success has not been marked, but when we tested it the technique had not been perfected as it has -at the present. Glycerin, when injected into the uterus between the membranes and the uterine wall, acts by causing exosmosis from the amni- otic sac. There is a profuse secretion of "fluid fi'om the uterus, and concomitantly uterine contractions set in. The method of procedure is the following : — INDUCTION OF PREMATURE LABOR. 61 The external genitals and the vagina having been rendered thoroughly aseptic, a sterilized gum-elastic catheter is insinuated to the fundus, between the membranes and the uterine wall. The woman is then placed in the knee-chest or in the left lateral position ; the catheter is connected by means of a sterilized rub- ber tube with a glass funnel, and into the funnel is poured sterilized glycerin. Under the influence of gravity this flows into the uterus. The catheter is carefully withdrawn, and the vagina is tamponed with sterilized gauze. The woman should maintain the lateral position for a number of hours, otherwise the glycerin will flow from the uterus and the effects of the in- jection will be nullified. Uterine contractions should be evolved in the course of a few hours, otherwise the procedure will have to be repeated. Instead of the glass funnel a syringe may be used for injecting the glycerin. It goes without saying that every precaution should be taken against the injection of air into the uterus. The objections to this method which suggest themselves at the present are that it is uncertain in its action, and therefore, where the indication calling for the induc- tion of premature labor is an urgent one, the physician is scarcely justified in taking the chances of failure. A further objection is the risk of rupturing the membranes during the in- troduction of the catheter, — an accident which, should it occur, places the welfare of the child in an unfavorable light. Further, recent data would seem to prove that nephritis may result. The future, however, may speak with more favor for this method than, at the present, we are inclined to grant it. 4. The Insertion of an Elastic Bougie between the Mem- hranes and the Uterine Wall {Krause's Method). — The method of inducing labor by the introduction of an elastic bougie be- tween the membranes and the uterine wall is probably resorted to with greater frequency than any other. The bougie acts as a foreign body, and at a variable interval provokes uterine action with certainty. The method is safe for the woman, provided proper asepsis accompany the insertion of the instrument. There 62 OBSTETRIC SURGERY. are weighty objections against it, however. In the first place the presence of the bougie in the uterus may not induce labor for some days, and exceptionally not at all, unless it be rotated in the uterus with the aim of separating to a degree the attach- ment of the membranes. When the induction of premature labor has been duly elected by the physician, nothing is gained by awaiting what in any case may prove the slow action of the bougie; and, for reasons already amply considered, delay may mean the loss of the child. Further, in introducing the bougie (a step not always easy of performance) the membranes may be ruptured, and this accident it is very desirable to avoid in the interest chiefly of the child and partly also of the woman. Ro- tation of the bougie within the uterus is objectionable: first, on account of the possibility of injuring the placenta, with resulting hsemorrhage (perhaps of the concealed type, — so fatal both to the woman and to the child), and, secondly, on account of the risk, again, of rupture of the membranes. Lastly, it is not a very easy matter to asepticize the bougie. Soaking in weak antiseptic solutions will not suffice, and soaking in strong- will injure the bougie. The material of which the bougie is constructed forbids its subjection to the most reliable method of obtaining asepsis, — exposure to dry heat. It is evident, there- fore, that this method is not an ideal one ; still, it is the best at our disposal, and, where the emergency calling for the induction of premature labor was not a very urgent one, this method has answered well. In case of urgency, however, it must be supplemented by a further step, wliicli we will shortly describe. Technique of Krause''s Metliod. — The instruments requisite are a speculum (preferably the Sims), a steel-branched dila- tor, and a tenaculum. The external genitals and the vagina having been tlioroughly asepticized, the woman is placed in the left lateral position, and the cervix is exposed through the speculum. The tenaculum is inserted into the anterior lip of the cervix to steady the uterus, and the cervical canal is dilated to the extent of a half-mch by the steel-branched INDUCTION OF PREMATURE LABOR. 63 dilator. This step is requisite in order to enable the passage of the bougie with least risk of injuring the integrity of the membranes. The asepticized bougie is then carefully in- sinuated to the fundus, between the membranes and the uterine wall. A tampon of sterilized gauze is inserted into the vagina to keep the bougie from slipping from the uterus. The woman is put to bed and remains there until uterine contractions are evoked. In the event of these contractions not supervening within twenty-lour hours, the bougie must be removed, the vagina douched with creolin solution, and, if the emergency is still not pressing, a second sterilized bougie is inserted. If uterine contractions have been evoked, then, if the emergency be not pressing, the progress of labor is left to nature. In the event of a complication arising calling for speedy delivery, the pliysician may resort to the method shortly to be described. 5. Dilatation of the Cervix as a Means of Inducing Pre- mature Labor. — With this method as a working basis, labor may be induced and completed within fairly normal limits, with less risk to the woman and the child than by any other method. Under this heading, then, the operation for the induction of premature labor will be described. The operation having been elected, ever — except in strict emergency — under the support of a consultant, the physician will ordinarily have ample time to thoroughly cleanse the intes- tinal canal by the administration of one or another laxative, or, failing sufficient time for this, the lower bowel, at any rate, should be emptied by a copious enema. Convalescence from any obstetrical operation is favored Avhen the great emunctory of the system is neither clogged nor torpid. The bladder is emptied and the field of operation is carefully asepticized as fol- lows : The labia and vestibule are thoroughly washed with soap and water, and then with a 2-per-cent. creolin or with a 1 to 5000 sublimate solution. By means of a small tooth-brush the vagina is similarly prepared. Simple douching of the vagina is not sufficient, since the folds of the canal cannot thus be ren- 64 OBSTETRIC SURGERY. dered aseptic. The physician, and whoe^ er assists him. should scrub his hands with soap and water, and next immerse them in a 2-per-cent. cr-^'^lin or n.i a i to "2000 sublimate solutiou. The instruix. ■"..:- nLLOSsary are the Ibllowing : A Sims speculum, an intra-uterine forceps, a tenaculum, a steel-branched dilator. These are to be carefully disinfected beforehand, and at the time or use mar he nlaced in sterilized water or in an antiseptic solutiun, accoiuini, tL> :ne preference of the individual operator. About two yards of sterilized gauze, two inches in width, are also needed. Such ar^"^ ^b^- precautions which are strictly essential in order to 2'na: '. :b- ^^'oinan a^'ainst her main risk, — septic infec- tion. Tbc b. 1 ^ /. 1 b vinu oeeu em] itied, the woman is placed in the loi: '._.:■. rul nc>-ibon, the speculum inserted, and the ten- aculum fixed in the anterior cerAical lip. In rare instances it may be necessary to dilate the cervical canal to the extent of half an inch before proceeding to the next step ; this, however, will prove the exception beyond the seven and one-halt months of gestation, owing to the softened condition of the cerAucal tissues at this period. The steriUzed gauze is grasped by the packing forceps and carried into ^he cervix up to and not beyond the internal os. The cervical ^ :;. J is thus progressively packed full, and the remainder of tb'::- 2'auze is utilized to tampon the upper vagina. The object of the gauze is twofold; it will in all probability excite utoriiie contractions, but. if it do not, it mechanically lanates tne c^r^vix to a sufficient degree to enable the next step to be resorted to. The patient is placed in bed, and, in tb^r evc-nt of the presence of the gauze being painful, a suppository '^-f two o-yai-v of cod^rine may be inserted into the rectum, AVibnin tcv. to twenty-i-'ir I'^urs the gauze will prob- ably excite contractions, with tb^ -i^-at^-r certainty the nearer tb- w-jinan is to term. The pby-ician's duty now becomes ex- n :^ r.t '-':■ artive. according to the emei^encv wliich has de- munb'-.. t:ie induction of premature labor. In the event of the in^brcation for rapidly terminating labor not being urgent, the INDUCTION OF PREMATURE LABOR. 65 gauze is removed, under aseptic precautions, and the labor may be allowed to progress toward its natural termination. The physician's duty is purely passive, even as it is during the prog- ress of normal labor. This applies particularly to instances where labor is induced in the presence of a contracted pelvis, where the lapse of even twenty-four hours has no untoward effect on either tlie woman or the child. Here, until full dila- tation of the cervix, artificial aid is only called for under stringent indication from the side of the woman or the child, such as hsemorrhage or evidence of fcetal heart-failure. It is absolutely essential to maintain the integrity of the membranes, since, the cervix once dilated, the safety of the woman or of the child, or the degree of pelvic contraction may call for the deliberate election of version. In the event of contractions not having been induced, if no emergency requiring specially active measures be present, the physician, under strict asepsis, may insert another strip of gauze ; but if the indications be pressing, the cervical tissues have been dilated to a degree by the gauze, and have been softened so that it is possible to resort to the next step in the operation, which, in the vast majority of cases, will give the physician full control of the case. The aim of the step to which we now pass is to secure full dilatation of the cervix or, in any event, sufficient dilatation to enable the physician to resort to version, the conditions under the premises being still favorable for this operation. According to whether the indication for interference be urgent or not, the physician may elect one of two procedures, — the first, in case delay of a few hours seems allowable ; the second, if delivery is necessary within as brief a space of time as is consistent with inflicting no damage on the cervix and lower uterine segment. Both measures entail mechanical dilatation of the cervix. The first method consists in the use of Barnes's hydrostatic bags or their essential modification, McLean's bags ; the second depends on the use of the hand, a method not highly favored 66 OBSTETRIC SURGERY. because of the objectionable and erroneous term applied to it, — accouchement force. The difference between Barnes's and McLean's bags is that the former has but one compartment, removal being necessitated for the insertion of progressively larger sizes. McLean's bag, on the other hand, has two compartments, so that when the cervical canal has been dilated to the full extent of one com- Fig. 28.— Barnes's Fig. 29.— McLean's Bag. partment the other may be brought into action without removal of the bag. The method of usins: these hvdrostatic dilators is the fol- lowing: The vagina and the external genitals having been asepticized, and the bag and the forceps having been similarly treated, the bag is seized in the grasp of the forceps, and, under the guidance of one or two fingers in the vagina, it is inserted into the cervical canal just beyond the internal os. If uterine contractions are present the attempt at insertion should be- INDUCTION OF PREMATURE LABOR. 67 made in the interval of the contractions, in order to avoid pos- sible rupture of the membranes. The bag- being in place, the forceps is withdrawn, the rubber tube of the bag is connected with a Davidson syringe, and the bag is distended with sterilized water. The object in using sterilized water is to avoid septi- cizing the uterus, in case the bag should rupture. The rubber tube is then clamped and the patient is put to bed. Ordinarily, after the lapse of two hours, the cervical canal has been dilated to the full extent of the single compartment of the McLean bag^ and the tube of the second compartment is connected with the syringe and similarly distended with sterilized water. In about an hour more the cervix has been sufficiently dilated to enable the physician to resort to delivery of the foetus, prefer- ably by version, if the integrity of the membranes has been maintained. It is at once obvious that this method will not answer where the emergency requiring interference is urgent, as, for instance, in case of placenta prsevia or eclampsia. Here time is an important factor, and a more rapid method is called for. Of late years a method of rapid dilatation, called by the French the accouchement force^ has been resuscitated from unmerited oblivion, and in the presence of the emergencies just noted it offers the best aid to the woman, and also about the only hope for the child. The reason why the method fell into disuse and has been reprobated by obstetricians generally up to a compara- tively recent date is because of the name which was applied to it. The fact is that absolutely no force need be used or is used in securing dilatation. The method depends for its success on the well-recognized fact that any muscle in the body will yield to continuously applied pressure. The procedure is, of course, tiresome to the operator, but the clinical results which may be secured through timely resort to it will amply compensate. The technique is the following : The woman being deeply anees- thetized, and the genital tract having been thoroughly asep- ticized, the hand is introduced into the vagina and the index 68 OBSTETRIC SURGERY. finger is inserted into the cervical canal. Steady pressure is maintained, and shortly it will be found possible to insert the middle finger. Progressively thus finger after finger is inserted, until the entire hand has been introduced. The fist is then doubled and in a few minutes the remaining obstacle to dilata- tion will be found to yield and the physician can at once take the subsequent steps requisite for delivery. We would again impress the fact that this method should be reserved for strict emergency. The risk the method subjects the woman to is laceration of the cervix, the rent from which mi"ht even extend into the lower uterine segment. This major accident should not, however, occur unless the cardinal rule is neglected, which is to use absolutely no force, but to cause the cervix to yield to the applied pressure. In the event of a minor laceration of the cervix occurring, the immediate operation on the cervix should be performed. This will be described in its proper place. Both these methods — the use of the hydrostatic dilators as well as manual dilatation — evoke uterine contractions as well as dilate the cervical canal. These methods constitute at the pres- ent the ideal ones of inducing labor. They fulfill every requisite indication. They are aseptic. They start labor by the natural method, by evoking uterine contractions without the possible sacrifice of the child through premature rupture of the mem- branes ; as a rule, they enable delivery to be effected within fairly normal limits. They necessitate, of course, the constant attention of the physician after the completion of the first step, the provoking of uterine contractions, but, as noted under indi- cations, such attendance is requisite in order to fulfill strictly the aim of the operation, which is the safety both of the woman and the child. At any time it may become necessary to interfere actively in the interests of either. The first stage once com- pleted, labor is ended spontaneously or by forceps or version, according to the individual case. Prognosis. — The prognosis of the operation for the indue- INDUCTION OF PREMATURE LABOR. 69 tion of premature labor obidously will vary according to the indication which requires it. If resorted to in the presence of eclampsia or placenta prsevia, the result both for woman and child is necessarily more unfavorable than when, the emergency not being an extreme one, the physician has time at his disposal for the due election of each and every step. Everything, further, it should be re-iterated, depends on the careful observ- ance of strict asepsis. Whilst the prognosis should be guarded, in general it may be stated that the operation should not have a mortality rate. Election of the operation and asepsis are the key-notes of success. As regards the child, its chances of survival are the less the earlier the stage of gestation at which the operation is resorted to. Under the tliirty-sixth week the infant can only be reared through the exercise of every possible care. In hospital prac- tice, with modern appliances, it ought to be possible to save, at the thirty-sixth week (the ninth lunar month), fully 85 per cent, of the children. This has been accomplished by means of the incubator and forced feeding. At the Paris Maternity, 30 per cent, of children at the sixth month have been thus reared, 63.6 per cent, at seven months, and 85.7 per cent, at eight months. These figures refer to calendar months. In private practice, and particularly in country districts, it is not possible to always obtain an incubator, and the physician must do the best possible by means of an improvised incubator, such as an oven, the temperature being maintained at about 90° F. Re- cently, an inexpensive and portable incubator, so simple in construction that trained intellect is not necessary for its man- agement, has been devised by Marx, of New York, and the hope is that before long every physician who contemplates the induction of premature labor will take steps to secure one in advance. This incubator consists of a box made of well-seasoned hard wood, 21 inches long, 20 inches wide, and 14.4 inches high, lined throughout with sheet zinc, between which and the 70 OBSTETRIC SURGERY. wood is a layer of sheet asbestos. It is divided by a partition into two unequal portions, one of which, sliglitly wider than the other, is the incubator proper, the other containing the heat- generating apparatus. This latter is a copper boiler of the capacity of one quart, resting on a tripod, underneath which is a Bunsen burner or an alcohol-lamp, which supplies heat to the water. Passing from the boiler through the partition and wind- ing about the coils over the V-bottom of the incubator portion Fig. 30.— Marx's Incubator (Closed). is a ^-inch pipe about 10 feet in length, terminating in a free vent outside the box. The steam thus received in a suita- ble vessel, condenses and gives us an index of the condition of the boiler. The top of the boiler projects through the box and is closed by a metal cap, which unscrews so that the V-boiler may be readily replenished with water. In the incubator proper there is a well-padded basket suspended so that its INDUCTION OF PREMATURE LABOR. 71 bottom is about 5 inches above the coil of the steam-pipe. A glass plate sliding in grooves acts as a cover, which may be par- tially or entirely withdrawn to aid in the ventilation, which is supplied by numerous holes drilled in the walls of the box. A thermometer is fastened horizontally to the top of the basket, immediately beneath the glass slide. This simple apparatus commends itself on account of its Fig. 31.— Marx's Incubator (Open relative cheapness, thus bringing it within the reach of even people of moderate means in whose families the operation of the induction of premature labor becomes an operation of election. Even so, we question whether, outside of maternity hospitals and the homes of the well-to-do, it will often be practicable to rear infants under the thirty-second week of gestation, in view of the necessitv of having- an attendant to watch the incubator night and day. CHAPTER III, FORCEPS. It is not intended here to enter into the history of the subject at all, nor to describe the various instruments and their modifications which are in general use. The special modifi- cation of the instrument is of very much less service than an accurate knowledge of the use of the instrument. Uecognizing the fact that traction is the essential power of forceps, it will appear that any instrument which is easily kept clean, easily adjusted to the child's head, and which is rigid enough to pre- Fig. 32.— Elliott Forceps. vent slipping, will be the instrument which will meet the greatest number of requirements. Numbers of instruments have been devised, which, though not perfect, will so nearly meet these requirements as to leave little to be desired. A forceps which is in very general use, and which is capable of being adapted to a large number of cases, is Elliott's (Fig. 32). This is a long, well-curved, and somewhat heavy instrument, which has an adjustable screw in the handle, by means of which the amount of pressure on the head can be regulated. While this is a convenience, it is no easy matter to keep the screw aseptic, and the same end may be gained by placing a folded towel between the handles of instruments not furnished with this attachment. An instrument which is not in very general use, but which (72) FORCEPS. 73 undoubtedly possesses merit, is known as Hunter's (Fig. 33). This instrument, having almost no handle, is grasped by means of a bar formed by the locking of the two blades. A firm pur- chase is attained in this way, and the hand is so near the head Fig. 33.— Hunter Forceps. of the child that but little leverage force is possible. The short- ness of the handles renders this forceps easy of application. In addition to possessing some instrument Avhich will meet the requirements mentioned, the operator who wishes to be prepared to meet emergencies must, of necessity, supply him- self with some instrument which will permit him to make use of the principle of axis-traction. This can be found best perhaps Fig. 34.— Lusk-Tarnier Forceps. in the instrument as devised by Tarnier and modified by Lusk (Fig. 34). The disadvantages of this instrument are that it is heavy and adds an amount of weight to the obstetric bag which is objectionable.. It is somewhat expensive, thus deterring some from supplying themselves with it. The axis-traction rods 74 OBSTETRIC SURGERY. which have been devised by Eeyiiolds (Fig. 36) possess the advantages of being light, taking up but little room, and are comparatively inexpensive. They may be attached to any pair of fenestrated forceps. This contrivance consists of a pair of steel rods, which terminate at their upper ends in fiat buttons in- tended to engage in the lower extremity of the fenestra ; and at their lower ends in hooks, which are received by rings connected with a transverse traction handle. The appliance is perfectly Fig. 35. — .Jewetf s Axis-Traction Forceps. simple, and any operator can easily apply it to his ordinary for- ceps. They may be fastened to the forceps-blades either before or after the blades have been adjusted to the child's head. Traction is not the only force of which the forceps is capable, for compression and leverage are coincident to a greater or less degree. In order that the forceps may not slip, a certain amount of FORCEPS. 75 compression is necessary when traction is being made. It is wise to remember this specially in those cases where the opera- tion is prolonged, in order that injury may not result to the child. From time to time the instrument should be unlocked and the handles slightly separated, thus liberating the foetal head. The forceps is not used for this compression force ; it is simply an unfortunate condition, without which traction cannot be made. It is better that traction should be of an intermittent character, if for no other reason than that the head may be re- lieved of this necessary compression at least every two minutes. Most authors hold that any form of leverage to be obtained Fig. 36.-=-Showino; Reynolds's Traction Rods in Position. by forceps is not only objectionable, but absolutely harmful. The use of the swinging or pendulum motion during traction may easily result in dangerous consequences to the mother, and should not be attempted. Without any doubt, a very slight up-and-down motion will facilitate the extraction ; but it must be borne in mind that, at the same time, the free ends of the forceps may be plowing into the maternal soft parts. Direct traction is fraught with so little danger to the mother, and will so certainly be successful in those cases where the forceps is indicated, that it would be better never to resort to this pendulum motion. Instrumental rotation should not be attempted, for maternal injury is almost certain to result. 76 OBSTETRIC SURGERY. However, it is necessary for the physician to bear in mind that if the forceps has been appUed before rotation has taken place he must be careful not to prevent it by rigidly holding his instrument. Indications. — It would be almost impossible to mention all the indications for the application of the forceps. In a general way it may be said that inability of the mother's expulsive forces to overcome the obstacles to delivery is one of the most frequent indications. Secondly, any cause which requires that the delivery should be accomplished rapidly, either in the interest of the mother or the child, provided, for other reasons, that the forceps is not contra-indicated, makes its application justifiable. Forceps should not be applied to the hydrocephalic head, a decoraposiug foetus, nor npon a perforated head. If applied to the hydrocephalic head or one that is decomposing, it will almost certainly fail to hold, and. even if successful, the end gained is not commensurate with the risk of injury to the mother. The perforated head can be better handled with a cephalotribe. Forceps should not be applied until the os is three-quarters dilated or dilatable, nor until the membranes have ruptured and retracted. If the membranes have not retracted, there is the possibility tliat they may be grasped by the forceps and placental detachment occur. The actual size of the os is of less importance than its dilatability. Forceps should not be applied until the elasticity of the cervix justifies the easy introduction of the blades. There must be no mechanical obstruction on the part of the pelvic canal which will prevent the delivery of the child without unusual force. Carcinoma of the cervix, inasmuch as the cervix is rendered so pliable, is a contra-indication to the application of forceps. Forceps should not be applied where the foetal head and the pelvic canal are so disproportionate that the probability of delivering a live child seems small. FORCEPS. 77 Finally, forceps should not be applied until the head has engaged. In regard to the time which should be allowed to elapse before the obstetrician resorts to instrumental delivery, it must be remembered that it is a question of conditions, and not min- utes or hours. Undoubtedly many women would escape that condition of pelvic relaxation, which is so often seen, following tardy deliveries, if forceps were used before the muscles entering into the pelvic floor were paralyzed from overstretching. As soon as it is evident that the vis a tergo is not sufficient to over- come the resistance, then forceps should be applied. Another very safe rule to remember is: whenever the head fails to recede after a contraction of the uterus, forceps should be applied. The failure of the head to recede after a contraction shows that undue pressure is being made on the soft parts of the pelvic canal. Ancesthesia. — Although it is probable that the extraction of the child with forceps is but slightly more painful than nor- mal delivery, yet it is rarely justifiable to apply forceps until the patient is thoroughly under the influence of the ansesthetic. The danger Avhich may result from some sudden motion on the part of the woman is greater than the danger of the anaesthetic, to say nothing of the increased ease of extraction on the part of the obstetrician. Chloroform is so much more rapid in its efl'ects, and leaves so little to be desired as an ansesthetic, that it is preferable to ether. The patient should be anaesthetized to the surgical degree before the instrument is applied. Many authors hold that the application of forceps is only justifiable in head presentations. Undoubtedly it will seldom be necessary to apply it to the breech, but there are con- ditions which will render the application of forceps to the full breech very advantageous. It is absolutely necessary to make a correct diagnosis of the position of the child and the causation of the tardy natural delivery before the application of forceps. Before the examina- 78 OBSTETRIC SURGERY. tion is made which is to determine these points, it is better that the obstetrician have everything in readiness, so that no delay may occur. He should see that the usual heart stimulants are at hand. An hypodermatic syringe and fluid extract of ergot, together with other oxytocics, should be in readiness. The in- strument should be sterilized and placed in a basin containing 1 to 100 creolin solution. Inasmuch as in forceps cases repeated digital examinations are made, it is wise to exercise unusual care in rendering the hands aseptic. They should be thoroughly scrubbed with soap and hot water, and afterward immersed in 1 to 1000 bichloride-of-mercury solution for five minutes. The patient should be anaesthetized and turned across the bed so that the hips will extend well over its edge ; the knees can be held by two assistants sitting on either side of the patient. The anaes- thetic should be given into the hands of a physician who will have no other duty to attend to. The external genitals and vagina should be cleansed with soap and water and a soft scrubbing-brush, and afterward douched either with 1 to 3000 bichloride-of-mercury solution or 1 to 100 creolin solution. After palpating the abdomen, one hand should be passed into the vagina if the head is high, and witli two fingers the operator should carefully palpate the fontanelles. If there be any doubt about their relation to the pelvic canal he should seek an ear, and finding it will enable the diagnosis to be made certainly. At the same time he can determine if any obstruc- tion on the part of the mother exists. The foetal heart-sounds should be listened to, for their character will enable him to de- termine somewhat the eftects of tardy delivery on the life of tlie cliild. The forceps is usually applied wdiile the patient is on her back, though some prefer the left lateral posture. The bladder and rectum should be emptied before any operative procedure is undertaken. The operator, having assured himself of the exact position PLATE IV. 1^3 i ^ ■ ( 33« ^^ ^_^ ^,^^''" •<:' - ~~~~~~-- B-"" "^"^ Fig. 78.— Insertion of Sutures. (After Hegar.) A, A, intra-vaginal sutures ; b, b, external sutures. more sutures. Silk-worm gut answers admirably, and, if need be, a few interrupted sutures of catgut may be inserted. These sutures, if, aseptic, may remain in place for a week or ten days. If there exist much oedema of the pelvic floor, the result of pro- tracted labor, the precaution must be taken to tie the sutures a trifle tighter than is the rule for plastic work ; otherwise, on the disappearance of the oedema, the sutures will be relaxed and deep union will not be secured. 172 OBSTETRIC SURGERY. Where the laceration has been so extensive as to involve" not only the pelvic floor, but also the sphincter ani and the recto- vaginal septum, there is all the more call for the imme- diate operation, and the procedure is proportionately more com- plicated. It is above all things important to bring together the torn ends of the sphincter ani, for otherwise the woman will suifer from incontinence of faeces to a greater or less degree, and will, in consequence, inevitably require the secondary operation. In this operation we still prefer the silk-worm gut for suture Fig. 79. — Laceration tliroiigli the Sphincter. Spliincter Sutures in Place. purposes. It holds just as well as silver wire, and is a source of less discomfort to the woman. The iirst stitches to be inserted are the rectal. The needle is inserted below the margin of the tear and is carried deeply outward so as to grasp the torn ends of the sphincter. It circles around the recto-vaginal septum and emerges at the opposite side, grasping the other end of the sphincter. As a rule, two sutures are requisite to secure the sphincter muscle, and when inserted these may be tied. The laceration of the pelvic floor is then repaired according to the method just described. THE SURGERY OF THE PUERPERIUM. 173 Exceptionally, the laceration occurs directly through the perineum, giving rise to what is termed central laceration. In case of this accident, the method of procedure consists in converting the central laceration into a complete, by slitting through the bridge of tissue remaining between the laceration and the pelvic floor, and then repairing the lesion after the method described. If the steps of the operations just described are aseptic, the management of the puerperal state does not differ materially from the normal. It is unnecessary to administer vaginal douches, since the non-septic lochia will not interfere with union. The old-time rule of keeping the bowels constipated is not deemed good practice to-day. The comfort of the puerpera demands that the intestinal canal should not be allowed to become clogged, and the perineal tear is more likely to heal from the depths if we take precautions to prevent hardened fsecal matter from collecting in the rectal cul-de-sac. It is a good rule, therefore, to order a saline laxative within twenty- four hours after delivery, and thereafter every day, so as to secure copious liquid evacuations. The coaptated surface may be kept powdered with iodoform, aristol, or boracic acid, and the nurse should be strictly enjoined to exercise scrupulous cleanli- ness of the external genitals. For the first few days the woman had better be catheterized, or else, and this we prefer, when she passes water it should be under the administration of a weak creolin or bichloride douche. It is very questionable if the normal urine will interfere at all with primary union. In the event of the primary operation proving a failure, the woman should be advised to submit to the secondary opera- tion as early as may be, for the longer she waits the greater the cicatricial tissue, and the more aggravated the rectocele and possibly the cystocele which will form. 174 OBSTETRIC SURGERY. Fistula. Only exceptionally, nowadays, are fistulse of the genital tract encountered, for the reason that their chief causes are not allowed to act. Protracted labor was formerly responsible for the majority of fistulse. Traumatism, except in the presence of a major degree of pelvic contraction when surgical interference Fig. 80.— Repair of a Vesico-Vaginal Fistula. was demanded, was rarely a causative factor. It is only when a fistula forms as the result of surgical interference that the ])hysician, in the capacity of accoucheur, will be called upon to perform immediate operation. The fistulse which result from prolonged pressure of the foetal presenting part on the pelvic floor rarely make themselves evident until a number of days THE SURGERY OF THE PUERPERIUM. 175 after labor. The process is purely one of sloughing in these latter instances. Of course, here, as well, it is eminently neces- sary to take measures for repair of the lesion as soon as the con- dition of the woman will allow, since the formation of extensive cicatrices will render the operation most difficult and the result problematical. Fig. 81.— Simon's Specula. In vieAv of the difficulty of the secondary operation for fistula, it may at first sight seem useless to attempt repair im- mediately after delivery. When we remember, however, the untoward sequelae of both urinary and fsecal fistulse, and the re[)eated attempts which are often requisite before union can be secured after the secondary operation, there is little need of dwelling further on the desirability of aiming at primary union. 176 OBSTETRIC SURGERY. The main reason why the primary operation is difficult is the impossibility of placing the recently-delivered puerpera in the best position for performing the operation, particularly Avhen the fistula affects the bladder. This, indeed, will prove a distinct contra-indication when the fistula is seated high up ; but when the lesion is low enough down to enable the physician to bring it into view without placing the woman in the genu-pectoral position, the attempt at primary repair should always be made. Kectal fistulse may ordinarily be exposed with less difficulty than the vesical. The steps of the operation either for rectal or vesical fistulee do not differ from those requisite for the performance of the sec- ondary operation. To prevent the lochia from trickling down and interfering with the field of vision, it suffices to pack the upper portion of the vagina with sterilized gauze. Since there is no cicatricial tissue and, consequently, no special tension to he overcome, silk-worm gut will answer for suture purposes. If the fistula is at all accessible with the woman in the dorsal position, the edges are made tense by traction with a tenaculum, and the sutures are inserted one after another from one edge of the fistula out at the other. The same care is requisite, as in the secondary operation, not to pass the stitches through the vesical wall. Coaptation of the torn edges must be accurate and the stitches must be tied more tightly than in the secondary operation, because when any oedema present has disappeared the stitches will otherwise become relaxed. The after-treatment will not differ from that of the normal puerperium. The bowels should be kept fluid, and where the lesion has involved the bladder the catheter should be passed at least every six hours for five to six days. As is the rule for the puerperal state, the catheter must be passed by sight, and this is preceded by careful disinfection of the external genitals and the vestibule. If the sutures be aseptic they will not suppurate, and they should be left in place for fully two weeks. Should the primary operation fail, the woman should be advised to have the secondary operation performed without overmuch delay. the surgery of the puerperium. 177 Rupture of the Uterus. E-upture of the parturient uterus constitutes one of the most fatal as well as most alarming of the obstetric complica- tions. There is scarcely an emergency wliich calls for more rapidity of judgment and of action ; for, as will be noted, on prompt differential diagnosis and equally prompt treatment the life of the woman depends. The accident, fortunately, is an infrequent one, and Avill become all the more so as the benefits of strictly elective obstetric surgery become uniformly recog- nized. The etiological factor cannot be always positively deter- mined. In many instances rupture may be traced directly to the premature and injudicious administration of ergot; again, the causal factor is the attempt to drag a foetus through a pelvis where attention to the ordinary rules of pelvic mensuration will teach that delivery by one or another method is alone possible ; further, a by no means infrequent factor has been protracted labor with consequent thinning of the lower uterine segment ; and, finally, the operation of embryotomy through a greatly- contracted pelvis may be associated with rupture of the uterus. In certain instances none of these factors can be held responsible when, in default of a better reason, we must consider that the uterus has become weakened at a certain point, and has simply given way at the point of least resistance. There are two varieties of rupture of the uterus, and on their differentiation depend both the prognosis and the treat- ment. These varieties are complete rupture and incomplete rupture. The complete rupture is intra-peritoneal ; the incomplete rupture is extra-peritoneal. The clinical history will ordinarily enable the physician to differentiate the variety of ru])ture and the importance of accurate differentiation will shortly be apparent. Incomplete rupture of the uterus may occur into either of the broad ligaments, or into the utero-vesical space, or into the 178 OBSTETRIC SURGERY. cul-de-sac of Douglas. In any case the tear does not extend into the peritoneal cavit}^ Complete rupture of the uterus necessarily invades the peri- toneal cavity associated with, in general, the escape of the foetus in part or in whole into this cavity. In incomplete rupture the shock is not as great and the loss of blood is limited by the capacity of the cavity into which it is effused. In complete rupture with extrusion of the entire foetus into the peritoneal cavity the shock is great, and the hseraor- rhage which may take place is only limited by the amount of blood the patient has to lose. Where a portion only of the foetus is extruded, the amount of blood lost may be checked by the portion of the foetus which is not extruded acting as a tampon. The signs which lead to diagnosis of rupture of the uterus are like those which are associated with haemorrhage. These signs will vary in intensity according as the haemorrhage is sud- den and great or slow, even though gradually progressive. Shock, rapid pulse, pallor, sighing, eventually syncope, — such are the symptoms which should awaken the keen anxiety of the phy- sician. The only positive way of making the differential diag- nosis between complete and incomplete rupture is to insert the hand into the uterus, excepting, of course, in those instances where the foetus escapes into the peritoneal cavity, when, so to speak, the diagnosis is made for us. If the rupture is incomplete, surgical treatment is not demanded, certainly at the outset. The proper course to pursue is one of expectancy. Where the rent extends from the angle of a lacerated cervix into the base of the broad ligament, the haemorrhage, in great part, comes from the circular artery, and this may be checked by carrying a suture around the artery and tying it. AVhere the rent involves the broad ligament or the anterior or the posterior cul-de-sac^ the firm tamponade with sterilized gauze may check the haemorrhage and limit its THE SURGERY OF THE PUERPERIUM. Vl9 extension. Often, however, the blood will continue to be effused until it has dissected the cellular tissue as far as its anatomical boundaries in the given region will allow. In other words, the condition becomes one of hsematoma — ante-uterine, retro-uterine, or lateral — into the broad ligament. Later on, if the hsematoma do not become absorbed, or if, through some faulty technique, suppuration set in, surgical interference may Fig. 82.— Transverse Rupture of the Uterus. become necessary. Where the rupture is intra-peritoneal the prognosis, in any event, is most gloomy. If the foetus has escaped entirely or in greater part into the peritoneal cavity, the only possible operation is an abdominal section, not in the hope of saving the cliild, but in order to give the woman a single chance of life. There is no time in this emergency for special preparations. The physician must have the courage of his convictions ; he must open the abdomen at once, extract 180 OBSTETRIC SURGERY. the foetus, and treat the uterme rent by sewing it up after the manner pursued in the Csesarean section, or by removal of the entire uterus as is described under the Porro operation. Where tlie rupture is complete, but the foetus has not .escaped into the peritoneal cavity, there is scope for difference of opinion as to the proper treatment. The results from either of the methods which may be selected are the reverse of bril- liant, although possibly of late years one of them has seemed to modify the prognosis for the better. At first thought, immediate emptying- of the uterus and abdominal section would seem to be the desideratum. The fact is, h6wever, that the woman, being in deep shock, abdominal section is simply superadding shock, and the wonder is when any recover. The alternate method is to rapidly extract the foetus and then to tampon the uterus with sterilized gauze ; we thus compress the bleeding-point and per- haps check further loss of blood. Of late years a few cases treated after this fashion have recovered. If we are fortunate thus to check the haemorrhage, the peritoneum will take care of the blood which has escaped within it ; and if the labor has been conducted aseptically and the gauze inserted is aseptic, then, if the woman do not die of shock, she will not die of sepsis. Resort to this method of tamponade is, however, only possible where the intestines have not protruded into the rent. If this has occurred, w'e cannot use the tamponade, because of the uncertainty as to whether or not the gut is strangulated at the uterine rent or through compression by th'e gauze. There can be no choice of procedure in case of intestinal prolapse ; the physician's only recourse is abdominal section. In case of incomplete rupture, where the tampon has been applied, the gauze should be left in situ for from thirty-six to sixty hours. Adjuvant treatmant consists in raising the foot of the bed, bandaging the extremities, giving strychnia in large doses hypodermatically ( J^- grain every two hours, for its stimu- lating effect on the heart), and administering hot 2-per-cent. saline rectal injections. THE SURGERY OF THE PUERPERIUM. 181 A further and very rare form of uterine rupture is what is termed " annular rupture." This consists in separation of the cervix at the utero- vaginal junction, either in whole or in part. The treatment requisite is ligation of the circular arteries in the event of their being implicated in the rent. We next pass to the consideration of the puerperal affec- tions due to septic infection, which may require surgical aid. A point to be noted is that elective surgery is peculiarly appli- cable to these affections, since early treatment of this nature very frequently spares the woman results of the most untoward nature. Endometritis and Metritis. These affections are considered together because the one is the direct consequence of the other. On the prompt recog- nition of a septic endometritis depends the safety of the tubes, ovaries, peritoneum, and not infrequently the life of the woman. There has been, of late years, a radical change in the metiiod of treatment of septic endometritis. The practice long in vogue, of repeatedly irrigating the uterus, has been found utterly inef- ficient as a means of guarding against infection of the Eallopiau tubes, and thence of the peritoneal cavity. AVhilst occasionally, when the local infection is slight and superficial, the repeated douche suffices to limit and to check extension of the process, we are never in a position to state definitely what cases will yield to this method, and, seeing that the aim is to check the septic process in ovo, so to speak, treatment of a more radical nature is favored by tlie majority of obstetricians, particularly since it may be definitely stated that such treatment, whilst most efficient for good, carries with it absolutely no risk to the patient when properly and aseptically performed. The objections to which the douche is open are the follow- ing : No matter how often the douche is administered, all that it can accomplish is to wash the superficies of the endometrium. The germs at work on the surface are rendered inert, but those in the depths are not affected. To attempt to check a septic 182 OBSTETRIC SURGERY. endometritis in this way is very much like trying to quench a fire by sprinkling water on it at intervals. Further, since the douches are always administered witli the addition of some anti- septic, usually the bichloride of mercury, there is imminent risk of poisoning the Avoman, as numerous cases on record prove. Again, each additional manipulation to which the woman is subjected carries with it the risk of additional septic infection. Lastly, the repeated douche entails disturbance of a sick and nervous woman, and this is bad for the morale so necessaiy for convalescence from any affection, in particular where the dis- ease is septic infection, when the aim of all therapeusis is to support the heart. For these cogent reasons the repeated douche has been given up by practically all accoucheurs. The following method, varied in only insignificant detail, has been substituted. On the appearance of foetor of the lochia, which, as a rule, is tlie precursor of developing septic endometritis, a vaoinal douche is ordered, to certifv to the fact that the foetor is not due to a vaginal source. If the foetor persist an intra- uterine douche is administered, to exclude tlie presence of clots or loose fragments of decidua in the uterus. If the foetor then persist the time for action has come; for it must be borne in mind that, as yet, there may be no marked constitutional disturbance, such as chill or elevation of temperature, or even mucli eleva- tion of the pulse-rate. Whenever possible the manipulations about to be described should be preceded by digital examination of the interior of the uterus, since not infrequently the symp- toms awakening our suspicion are due to the retention of a piece of placenta which is beginning to necrose, or to portions of the membranes left bcliind. As a rule, it is not necessary to anses- thetize tlie woman ; but if she is hyperaesthetic or peculiarly nervous, it is better to do so in order to lessen shock, as also in order to enable the procedure to be properly performed. The instruments necessary are a dull and a sharp curette with long handles, a vulsellum, a pair of intra-uterine packing-forceps, and a uterine irrigating-tube. A speculum is not strictly requisite, THE SURGERY OF THE PUERPERIUM. 183 since the manipulations may be performed along the finger, — a practice necessary where the pelvic floor has been repaired. Thoroughness being requisite, however, the physician should never hesitate to sacrifice the restored pelvic floor, if necessary, in order to carefully explore the uterus. Since it is desirable to avoid disturbing the woman as much as possible, we will describe the operation of curetting the puerperal uterus without the aid of the speculum. As a rule, also, we much prefer to use the sharp curette, since when the uterine mucosa is diseased it is absolutely essential to remove it in its entirety ; for thus alone can we certainly eradi- cate the disease process and avoid a repetition of the operation. The risk we subject the woman to is slight compared with that she runs if the operation be not thorough. This risk is per- foration of the uterus. If requisite care be used this risk is slight ; still, it is desirable to have the friends of the woman distinctly understand that the procedure is not a minor one. A fountain-syringe connected with a glass irrigating-tube or with a double-current intra-uterine catheter, and filled with a solution of 1 to 8000 bichloride of mercury, should be sus- pended within reach, and a pint bottle of peroxide of hydrogen should be opened. The hands of the operator, the instruments, and the external genitals of the woman should be thoroughly cleansed ; the woman is brought to the edge of the couch and her legs are flexed on the abdomen. At the period of the puerperal state, when the manipulations about to be described are indicated, the cervical canal is open so that precedent dila- tation will not be necessary. Again, whenever there is any- thing remaining in the puerperal uterus or whenever a septic process exists, the same state of the canal will be found. The index finger of the left hand is introduced into the vagina and placed at the external os. Along this finger the curette is guided into the uterus, absolutely no force being used, until the loop of the instrument reaches the fundus. If digital examina- tion has revealed the presence of a portion of retained secun- 184 OBSTETRIC SURGERY. dine or placenta undergoing degeneration, the instrument is guided to this and firm traction on the handle will remove it. Whilst the left hand is manipulating the handle of the curette, the right hand grasps the fundus of the uterus through the abdominal wall and not only controls it, but is ever conscious of the action of the curette. Herein lies a further value of the method of curetting without the speculum. Where the entire endometrium is involved in the necrotic process, the curette, ever under the control of the external hand, should be made to traverse it, particular care being taken to explore the openings of the Fallopian tubes into the organ. When satisfied that the process is thoroughly eradicated, the curette is withdrawn, the irrigating-tube or the catheter is in- serted and the uterine cavity is washed out, the antiseptic solu- tion being at a temperature of about 115° F. When the fountain-syringe is empty, the peroxide of hydrogen is poured in and the uterine cavity is washed out with this. The catheter is now withdrawn ; a strip of sterilized gauze, about two inches wide and eighteen inches long, is grasped by the packing- forceps and carried into the uterus, the greater portion of the gauze being inserted. This insures free drainage externally. As a rule, considerable depression follows these manipula- tions where anaesthesia has not been resorted to, and, therefore, it is generally desirable to use it. The gauze is left in situ from thirty-six to forty-eight hours, when, after renewed asepsis of the genitals and with aseptic hands the gauze -is removed. The uterus is irrigated with hot 1 to 8000 bichloride, or with 2-per- cent, creolin, and a second strip of gauze is inserted, on this occasion not being packed in, but being placed more as a drain. If the curetting has been thorough it will rarely be necessary to repeat it ; the local septic process is either at an end or it has extended to the parenchyma of the uterus, giving rise to a metritis, or to the tubes and ovaries, giving rise to a salpingitis or to an oophoritis. It is to avoid these untoward complications that it is essential to recognize a septic endo- THE SURGERY OF THE PUERPERIUM. 185 metritis early, and to treat it radically after the manner just described. Whilst the method of curetting through the speculum is not favored by us, since it is indorsed by many, we deem it essential to describe it. The additional instruments requisite are a speculum and a vulsellum forceps. If the operator prefer the Sims speculum, the woman is placed, of course, in the left lateral position, otherwise the Edebohl or the Simon speculum will answer for the dorsal position. After due asepsis the cervix is exposed through the specu- lum, the vulsellum is made to grasp the anterior lip of the cervix, and the curette is inserted by sight instead of by touch. The manner of curetting is exactly similar to the process just described. Frequently, after the curetting, the woman has a chill ; but, as a rule, this has no significance, being entirely nervous in character. If, after the lapse of thirty-six hours, the tempera- ture fall and the pulse approximate nearer the normal (and this fall of the pulse is the chief good omen), the chances are that the operation has been timely and that the woman has been spared extension to the parenchyma of the uterus or to the tubes and ovaries. If, on tlie other hand, the septic phenomena become intensified, then the physician must suspect extension, and his position must become an exceedingly alert one. A sup- purative metritis or salpingo-oophoritis can be met in only one way, and this is through abdominal section. Even then the prognosis is most gloomy, since septic processes of tliis nature are ordinarily associated with deep systemic lymphatic absorp- tion, — an affection against which our therapeutic resources, both medical and surgical, as yet avail but little. If, however, there should be reasonable doubt as to the systemic infection, the physician must not hesitate, but proceed to the one operation which offers the woman a single chance of life, and this is ahdominal section with extirpation not alone of the purulent appendages, but also of the septic uterus. This seems a forlorn 186 OBSTETRIC SURGERY. liope, and so it is ; but the sole alternative in these aggravated types of sepsis is to allow the woman to die of septicaemia ema- nating from the uterus or the appendages, and this course of action is reprehensible, seeing that sometimes, although very rarelv, even such desperate cases recover under the bold use of the knife, Unibrtunately, septic metritis, salpingitis, and oophoritis, when developing during the puerperium, are of such a virulent type and the associated general systemic infection is so pro- found that we can expect but one result, no matter what the therapeusis, and this result is death. The women die not so much because of the local lesions as because of the deep sys- temic infection. Still, since there are now^ and then recorded Ciises where aggressive surgery has resulted in ultimate recovery, in a given case the physician is bound to take into consideration the advisability of resorting to abdominal section. The steps of the operation are similar to those which are called for when total hysterectomy is performed for other causes. The object of the operation being to remove from the body the source of the systemic infection, ablation of the involved organs must be thorough; that is to say, the abdominal cavity having been opened, the entire uterus with the appendages must be removed in accordance with the steps which are laid down in modern treatises on gynaecology. As a rule, there is associated witli metritis and septic appen- dages the next subject we are called upon to consider : — Puerperal Peritoxitis. In considering this affection from a surgical stand-point, it is essential to note the change in practice which the last decade has witnessed, without, however, it must be confessed, any special change in secured results. It is a fact beyond dispute that, no matter what the form of treatment employed, the vast proportion of cases of puerperal peritonitis die. Large doses of opium, saline catharsis, abdominal section, — each of these THE SURGERY OF THE PUERPERIUM. 187 approved methods has an exceedmgly high mortality percentage. It must be remembered that puerperal peritonitis, whether local or general, is due to infection by one or two routes, aside from instances when peritonitis complicates the puerperal state, due to, we will say, rupture of an ovarian or tubal abscess or to a purulent appendicitis. The two modes of infection are either by direct extension from the uterine cavity or by lymphatic absorption. In the former instance the peritonitis is likely to be and to remain local ; in the latter instance it is likely to become general. The systemic infection is by no means so exaggerated, as a rule, in local as in general purulent peritonitis. In general peritonitis the affection is secondary to general systemic infec- tion. Not alone is the peritoneal cavity filled with multiple abscesses, but the lympliatics of the entire system are gorged with the infectious element and deposit it all over the body. The women die no matter what the form of treatment employed, not because of the peritonitis, but because of the deep general systemic infection. It is absolutely essential, therefore, to endeavor to differentiate local from general purulent peritonitis. Frequently this is possible; then, again, the symptomatology of the one suggests the other. The physical signs may be as aggravated, frequently more so, in instances of local as in cases of general peritonitis. And yet, no matter how extremely unfavorable the case may appear, sometimes speedy surgical action reveals a local instead of a general peritonitis, and some- times the women recover. So important is the factor of diagnosis that every means should be utilized toward reaching the desideratum, — a differ- ential diagnosis between local and general peritonitis. Examina- tion of the uterus with the finger to exclude septic focus there ; palpation of the appendages, particularly by rectum, and, in case of doubt, with the assistance of deep surgical antesthesia, — these and every other means should be used to clear the scene. Notwithstanding all these differential diagnostic means, there are a certain proportion of cases where the physician will 188 OBSTETRIC SURGERY. still remain in doubt as to whether he is dealing with a local or with a general peritonitis. Then, in remembrance of the fact that, if the affection be local although simulating general peri- tonitis, the Avoman's chance of life depends, in all probability, on his speedy action, gloomy as is the prognosis, it is his duty to resort to the single therapeutic measure which affords a gleam of hope. It must never be forgotten that surgery is full of sur- prises, and that our finite methods of diagnosis must often be supplemented and aided through resort to most desperate measures. Local peritonitis presents itself under two forms, — as extra- peritoneal and as incapsulated intra-peritoneal. The latter, however, is really extra-peritoneal in the sense that it is shut off from the general peritoneal cavity by adhesions, being originally intra-peritoneal. Etiologically the true extra-peritoneal exudate which may suppurate is not usually associated witli tubal or ovarian infection, whilst the latter form is generally the sequela. This is the main reason why a true cellidar abscess carries a less grave prognosis than the intra- and yet extra- peritoneal variety. The symptomatology of true pelvic abscess — that is to say, of abscess in the pelvic cellular tissue — may be as aggravated in type as the intra-peritoneal form ; and yet the outcome of sur- gical treatment is much more favorable. Whenever the local and the general symptoms point to the existence of pus in the pelvic cellular tissue, the sooner it is evacuated the better. As a rule, the point of election for operating will be the vagina, since it is here that an abscess of this character usually points. The operation is performed as follows : Thorough asepsis of the external genitals having been secured, under the guidance of the aseptic finger in the vagina an aspirator-needle is plunged into the softened exudate at a point close to the cervix, in order to avoid injuring the ureter. Along this aspirator-needle, as a guide, a narrow-bladed knife is passed and the opening into the cavity is enlarged. A steel-branched dilator is next inserted, and the opening is torn wider. The finger is then inserted into THE SURGERY OF THE PUERPERIUM. 189 the cavity, and the different chambers which frequently go to make up the cavity are broken down. The cavity is then irri- gated with bichloride or creolin solution, and next washed out with the full-volume peroxide of hydrogen. A T-shaped rubber drain-tube is then inserted, and through this the cavity is washed out daily until suppuration is at an end. If the cause of the symptoms has been the cellular abscess, in twenty-four to tliirty-six hours the general condition of the woman will have altered materially for tlie better, and as soon as she has thrown off the general sepsis she will rapidly convalesce. Such is the treatment and such the course of events in pure cellular abscess, which, we repeat, may present as aggra- vated symptoms as the intra-peritoneal variety. Earely these cellular abscesses do not point in the vagina, but above Pou- part's ligament. Then the point of election for incision is at this site. The cavity is entered by an incision parallel to Pou- part's ligament, is washed out after the same fashion, and, where possible, a counter-opening is made into the vagina, since thus we obtain better drainage, and, therefore, speedier convalescence. It is the intra-extra-peritoneal variety of abscess which gives the most trouble, both from the diagnostic and the thera- peutic stand-point. General purulent peritonitis, being an epi- phenomenon of general septic infection, has as yet proven rebellious to every therapeutic measure. The woman dies not because she is suffering from peritonitis, but because she is deeply poisoned. The post-mortem findings explain this. Xot only does the peritoneal cavity contain multiple abscesses, but the venous and lymphatic systems are similarly gorged. What then, it may reasonably be asked, is the use of surgical pro- cedure'? Because, as we have already stated, the symptoma- tology of local peritonitis sometimes is suggestive of general peritonitis, and, therefore, abdominal section, even though the case appear of the most desperate type, may reveal a local peri- tonitis amenable to treatment. It must further be remembered 190 OBSTETRIC SURGERY. that peritonitis, associated witli purulent appendicitis, may com- plicate the puerperal state, and here prompt section may result in the saving- of life. In this desperate disease one must have the courage of strong convictions, and operate, even though the battle seem lost before action. We are absolutely assured that nothing is to be gained from therapeutic nihilism, at any rate. The abdominal cavity is opened in the usual way, and, if we are fortunate enough to find a local peritonitis instead of a general, the abscess-cavity is emptied, is washed out with per- oxide of hydrogen (full strength), and is packed with sterilized gauze. If, however, the peritonitis is general and purulent, then the most we can do is to break up the multiple abscess-cavities as far as we can detect them, repeatedly flood the peritoneal cavity with hot sterilized water, and pack the lower part of the pelvis with gauze. If the woman recover, the result is fairly miraculous. If she die, the physician has the satisfaction of knowing that he has done his full duty by his patient and that the result was in no sense due to surgery. Puerperal Mastitis. In the light of our present knowledge, puerperal mastitis must be considered as due to infection. The germs or infectious material gain entrance through the lacteal ducts and cause the inflammatory process which may be aborted or which may suppurate. In the latter event, we have the affection which is termed mammary abscess. Two varieties of mammary abscess are to be differentiated, — the glandular and the sub-glandular. The former is not specially uncommon ; the latter is exceedingly so. The one is readily recognized ; the other is not, running an insidious course and undermining the gland often before its presence is made sufficiently known to call for the recognized treatment. Whilst much may be accomplished in the way of aborting THE SURGERY OF THE PUERPERIUM. 191 suppuration through the use of the ice-bag, or, if the individual prefer, by hot applications, as soon as the physician is sure of tlie presence of pus, the earlier it is evacuated the better for the welfare of the breast. Glandular abscess ought to be recog- nized early; the reverse holds true in case of the sub-glandular variety. And yet this latter form is the one wliicli always even- tually does the most damage to the glandular tissue, and, besides, subjects the woman to the serious risk of perforation into the pleural cavity before there exists at times sufficient evidence of pus to justify incision. In these obscure cases,, when, under the use of ice or heat, the cardinal symptoms of inflammation do not abate, exploration with the aspirator- needle should be resorted to. Of course, this aspiration should be strictly aseptic, otherwise a non-suppurating exudation will be converted into a suppurating. When the aspirator-needle reveals pus, or when there is evidence of pus without aspiration, the sooner the gland is incised the better. The line of incision should be radiating from the nipple outward, in order to avoid injuring more of the lacteal ducts than are already involved in the suppurative pro- cess. The affected breast should be scrubbed with soap and water, then with 1 to 8000 bichloride solution, and finally washed with sulphuric ether. With a clean knife an incision is made through the gland down to the abscess-cavity. When this has been opened, the finger is inserted in order to break up all the cavities into which the abscess is apt to be divided. After thorough irrigation with bichloride, the full-strength per- oxide of hydrogen is poured in and the cavity is packed with sterilized gauze. A firm compression-binder is applied. At the end of twentv-four hours the dressino- is removed, the cavitv is again irrigated, a gauze drain is inserted, and a large sterilized sponge is placed over the breast. A firm binder is applied over all. This method of compression secures close apposition of the abscess cavity-walls and prevents the further pocketing of pus. In the event of there being no evidence from the side 192 OBSTETRIC SURGERY. of the pulse and the temperature of septic absorption, this second dressing need not be changed for a number of days, when the cavity may be found entirely closed. In more complicated cases, where, for instance, a submam- mary abscess has not been recognized in its early stages, the pus may be found to have dissected the entire gland, and then all attempts to save the lacteal ducts are futile. As many counter-openings as are necessary, in order to secure efficient drainage, must be made, and every possible eflbrt is requisite to prevent the pocketing of pus under the pectoral muscle and toward the pleural cavity. As the principles of asepsis as applied not alone to the maternal breast, but also to the infant's mouth before it is applied to the breast, are understood by nurses and exacted by physicians, mammary abscess will become one of the rarest complications of the puerperal state. In large maternity hos- pitals, where the strictest care is required, the fact is that mammary abscess is now rarely met with, and, when it is, the nurse has been at fault, unless the mother has handled her breast with unclean hands. CHAPTER IX. ECTOPIC GESTATION. The subject of ectopic gestation is of prime interest to the general practitioner, for the reason that on his abihty to recog- nize the condition early depends usually the life of his patient. Seeing that the majority of obstetric work falls within the province of the general practitioner, it seems appropriate that ectopic gestation should be considered from its tlierapeutic side in a work dealing with obstetric surgery. We shall not enter into a discussion of the value of elec- tricity in the treatment of ectopic gestation. Sufficient the statement that it seems proven that in its earlier stages the development of the ovum may be checked through the adminis- tration of galvanism or faradism. Our aim will be fulfilled when we have tersely noted the diagnostic points and have laid stress on the surgical treatment of ectopic gestation. We shall consider this subject from the now generally accepted view that primarily all ectopic gestations are tubal. About the tenth week rupture of the tube occurs in one of two directions: (1) into the general peritoneal cavity; (2) into the broad ligament. In the latter event the gestation may or may not continue to term. The surgery of ectopic gestation, therefore, envisages the subject from a number of stand-points : 1. Before tubal rupture. 2. After rupture {a) into the peritoneal cavity; {h) into the broad ligament. 3. During development to term. 4. At term and after term. Essential to any treatment is accurate diagnosis. Before tubal rupture this will rarely be possible beyond strong hypoth- esis. At the time of rupture the symptomatology will ordi- narily establish the diagnosis. Daring development to term and at term the diagnosis is often in doubt, not as to whether ^^ (193) 194 OBSTETRIC SURGERY. pregnancy exists, but as to whether it be uterine or extra- uterine. After term, if the precedent history be clear, the diag- nosis is estabUshed ; but often it may be made only on abdominal section. Before rupture — that is to say, before the tenth to twelfth week of gestation — the diagnosis may be reasonably predicated on the following history: A period of amenorrhoea, associated especially with the reflex disturbances of pregnancy, followed by irregular liEemorrhages. Ordinarily there is a history sug- gestive of precedent disease of the uterus and appendages, and, as a rule, the woman has never conceived before or there has been a period of protracted sterility. On local examination (vaginal and rectal) the uterus is found enlarged, and one or the other tube as well (either in situ or posterior to the uterus). The woman, furthermore, often complains of sharp attacks of abdominal pain, which are the associates of the distension of the tube, or are due to peritoneal irritation from tearing of the peritoneal covering of the tube. This ensemble of symptoms should at once awaken the suspicion of the existence of tubal gestation. It is at this period that galvanism may be resorted to with safety, since it may do good and can only do harm in that its use postpones resort to surgery, if it do not render this unnecessary. The symptoms of rupture vary according as the accident occurs into the peritoneal cavity or into the broad ligament. Accurate differentiation is essential, since there is but one pos- sible line of action in the former event, and this is abdominal section as soon as feasible. The main symptom is collapse of varying degree, with the formation of a tumor in case of rupture into the broad ligament. Where the rupture is intra- peritoneal, the symptoms suggestive of haemorrhage (fainting, sighing, rapid pulse, increasing pallor) are usually more grave than where the rupture is extra-peritoneal. The reverse may hold, however, since the intra-peritoneal bleeding may be gradual and the extra-peritoneal profuse. The precedent his- ECTOPIC GESTATION. 195 tory, however, and the immediate symptoms should certify to the diagnosis almost always so as to lead to the adoption of the proper therapeusis, wliich is immediate abdominal section in case of intra-peritoneal haemorrhage, and expectancy in case of broad-ligament ligemorrhage. The symptomatology of ectopic gestation after primary extra-peritoneal rupture may be self-suggestive as regards diag- nosis, and again may be very obscure. So long as the foetus is alive, the hearing of the heart-sounds and the perception of movements will certify as to pregnancy ; but, usually, short of exploration of the uterus, normal gestation cannot be excluded. After foetal death, whilst the precedent history will suggest the likelihood of ectopic gestation, abdominal section alone, in the vast majority of cases, will clear the diagnosis. The following conditions may simulate intra-peritoneal rupture of ectopic gestation : Abortion, dysmenorrhoea, rupture of some abdominal organ with escape of its contents into the peritoneal cavity, and pelvic peritonitis. The following conditions may be mistaken for extra-peri- toneal rupture of ectopic gestation : Intra-peritoneal rupture of the same condition, heematoma of the broad ligament from other causes, exudate in the cellular tissue of the ligament, and cyst of the broad ligament or abscess within it. In both series of instances, attention to the history and careful physical examination, if need be under an anaes- thetic, will often clear the diagnosis. Peritonitis may be ex- cluded by the elevation of temperature, which exists, usually, from the outset. Exploration of the uterus, together with care- ful bimanual, rectal and vaginal, will exclude abortion, aside from the fact that shock rarely exists in the latter condition, except the woman be hyperaesthetic and hysterical, when it is never deep and progressive, but transient. In case of rupture of some viscus, such as the appendix vermiformis, with escape of its contents, where the depression is extreme, the therapeutic indication is the same as for rupture of a tubal pregnancy into 196 OBSTETRIC SURGERY. the peritoneal cavity. The formation or the presence of a tumor in one or the other broad hgament, no matter what the condition, will lack the urgency calling for immediate surgery. Finally, there are instances where combined uterine and extra- uterine gestation exist, and here, no matter how refined our diagnostic aids, the question can alone be settled by exploration of the uterus, and, in the event of supposed intra-peritoneal rupture, by abdominal section. The diagnosis of ectopic gestation having been made with sufficient exactitude to swerve the judgment of two or more physicians in its favor, the woman must be regarded as subject to a greater or a less imminent risk, according to the period of gestation. The ovum is a parasite of ill omen to its mother, and its destruction or removal is called for when, by so doing, the immediate or the ultimate safety of the woman so requires. Prior to tubal rupture, when the diagnosis is always uncer- tain, arrest of the growth of the ovum by means of galvanism or of faradism is justiiiable. Absorption of so small a mass as the ovum is prior to the eighth or tenth week is perfectly pos- sible, and, if this absorption should not occur, the woman at best is carrying a diseased tube, which at any time when it. seems desirable may be removed by abdominal section. Where, however, the physician is a skilled operator, the immediate and future welfare of the woman is best secured through resort to abdominal section. The steps of the operation are the follow- ing : The abdomen and the pubes having been shaved and the integument having been cleansed by thorough scrubbing with soap and water, followed by 1 to 1000 bichloride solution, the woman is anaesthetized. The bladder is emptied. The instru- ments (scalpel, artery-forceps, ligature-carrier, Peaslee-Hagedorn needle) should be thoroughly sterilized, and the hands of the operator and of his assistants should be scrupulously cleansed. It must be remembered that septic infection is the sole risk the woman runs in the hands of an operator familiar with the technique. ECTOPIC GESTATION. 197 The operation is likely to prove of shorter duration if the woman be placed in the Trendelenburg position. This position may be improvised by tying an ordinary kitchen-chair to the table so as to form the inclined plane. (See next page.) In addition to the instruments, the operator should have prepared at least four large, fiat, gauze pads and one dozen small gauze sponges. A quart-bottle full of 1-per-cent. hot (120° F.) sterilized salt-solution should be ready to irrigate the peritoneal cavity, in the event of threatened collapse from un- avoidable haemorrhage. The peritoneum rapidly absorbs the salt-solution, and it forms our readiest restorative. The usual incision is made down to the peritoneum, about three inches in length, extending upward from above the pubes. Any haemorrhage is checked by torsion of the small vessels. Fig. 83. — Cleveland's Ligature-Carrier. Before opening the peritoneum the operator should emphasize his injunction that absolutely no antiseptics are to be used in the further progress of the operation. The peritoneal cavity having been entered, one or more of the large gauze pads, wrung dry from the sterilized water, are inserted to keep the intestines from the abdominal opening. With one or two fingers the operator liberates the tube and ovary (if adherent) and brings them out of the abdominal incision. The ovarian artery being very vascular, it is desir- able, when feasible, to isolate it and tie it separately with medium-sized sterilized silk. The pedicle is transfixed by the ligature-carrier; a stout, sterilized, Chinese-silk ligature is brought through, the ends are crossed and firmly tied, after the usual manner. The appendages are then removed. 198 OBSTETRIC SURGERY. The tube and ovary of the opposite side are next exam- ined, and, if diseased, are similarly tied otf. The pads are now removed from the abdominal cavity. If the operation has not been associated with haemorrhage, it is not necessary to mop out or to irrigate the field of operation. In case the pulse is flagging, however, irrigation with the salt solution should be resorted to. The abdominal incision is closed by deep silk-worm-gut Fig. 84. — Emergency Trendelenburg Posture. (The inclined plane is formed by an ordinary chair being tied on a kitchen-table.) sutures transfixing all the tissues and including carefully the fascia of the recti. In the event of the woman not being seen until tubal rupt- ure has occurred, the surgical treatment must be immediate if the haemorrhage be intra-peritoneal. The steps of the opera- tion are similar to those just stated, except that, on opening the peritoneal cavity, no time should be lost in grasping the rupt- ured tube and tying it off, for tliis is tlie source of the haemor- rhage. The peritoneal cavity should then be irrigated with hot, sterile salt-solution to act as a restorative and to wash out ECTOPIC GESTATION. 199 the major portion of the blood and clots. What must perforce be left behind the peritoneum will take care of, unless it be septic. Where this possibility is feared, drainage by gauze through Douglas's cul-de-sac is preferable to attempts at drain- age through the abdominal incision. When the diagnosis of rupture into the broad ligament (extra-peritoneal rupture) has been reached the therapeusis should be strictly expectant ; operative treatment is rarely called for. If the woman be kept in the recumbent position until the hsematoma becomes smaller, but little other treatment will be necessary, beyond the self-suggestive means for meeting the greater or less acute anaemia from which the woman is sufFerino-; such as frequent hot water (115° F.), sahne (1 per cent.), rectal irrigation, strychnine hypodermatically (^V grain every three to four hours), etc. Rarely the blood-clot breaks down into pus from septic infection. An opening should then be made into the sac from the vagina. The pus must be thoroughly evacu- ated, the sac washed out with the full-strength solution of per- oxide of hydrogen, and drainage resorted to. In a small proportion of cases the ovum survives the extra- peritoneal rupture and continues to grow. The woman from now until term is in constant danger from the possibility of secondary rupture into the peritoneal cavity. Every day the increasing size of the child and of the placenta adds to the danger of this accident. The life of the woman alone is to be taken into consideration. The chances that development will continue and the child reach full term are small, and even if it should, and be safely removed, it rarely survives the first few weeks, and is rarely, also, perfectly formed. Inasmuch as the continuous growth of the child constantly increases the danger which the woman must encounter, it is the duty of the physician to destroy it as soon as it has been de- termined that development is taking place. If development has continued beyond the fourth month, the death of the child will not increase the woman's safety. The sac may have formed 200 OBSTETRIC SURGERY. adhesions with loops of intestine, and throngh this source sepsis may have entered the system. In such cases it is necessary to carefully watch the woman, and, as soon as any symptoms of sepsis are apparent, abdominal section is to be performed. These symptoms are chills, remittent temperature, rapid pulse. The sac is to be opened, the decomposed foetus is to be removed, and the opening of the sac is to be stitched to the abdominal wall. Usually the placenta will have become freed from its attachments and may be removed at the same time. Should it be adherent, however, it is preferable to allow it to come away in fragments. Free drainage should be maintained. Usually this operation will be practically extra-peritoneal. If the child has reached full term and is alive, a very in- teresting complication calls for decision. The little notoriety wdiich one gains from performing a brilliant operation should not influence the conscientious physician for a moment. jSTeither must sentimental notions carry the least weight in reaching a conclusion. The question to be decided is the following: "Should I operate and possibly save the life of the child, which at best will stand but few chances of surviving, and by so doing greatly add to the dangers of the already-unfortunate mother; or should I delay the operation and thereby permit tlie child to die and the placenta to lose very much of its vascularity, if, indeed, not all of it, and by this delay very much enhance the chance of recovery of the woman T' To those who will look at this question purely from the stand-point of the -s^lDman, and who will consider, as they ought, the ectopic foetus as simply a para- site, the choice will unquestionably be in favor of delay. No one will deny the legitimacy or the imperative necessity of re- sorting to foeticide in the non-controllable vomiting of pregnancy, with the end in view of saving the woman. The belief of Tait, that those who advocate the killing of the child in developing extra-uterine pregnancy are simply " abortion-mongers," is illogical, and must be looked upon as one of those statements which are made in haste and are not retracted owing, possibly, to false pride. ECTOPIC GESTATION. 201 After the child is dead and the placental circulation has ceased, operation carries far less danger to the woman. It is contended by some that no operation should be performed until symptoms supervene, but nature's tedious methods of relief and the many obvious dangers to which the woman must be ex- posed do not seem to justify non-interference. The abdomen should be opened as soon as the placental circulation has ceased (and this is certified to by the absence of placental murmur), the foetus is removed, and the sac is stitched to the abdominal wound. If the placenta is detached and lying free it should be removed, and the sac is drained and allowed to close from the bottom. If the placenta is adherent, no attempt should be made to free it, for it will come away gradually through the abdominal opening. Convalescence is hastened if a vaginal opening can be made at the same time and through-and- through drainage thus established. Under the modern method of treatment we have outlined, ectopic gestation has been practically robbed of its terrors, and the almost absolute mortality rate of the past has been con- verted into the almost certain recovery rate of the present. Once again is the value of election in obstetric surgery certified. INDEX. Abortifticients, uselessiiess of, 58 Abortion, artificial, 34 in absolute pelvic contraction, 3T in case of haemorrhage, 39 in case of tumors, 38 in chorea, 36 in displacements of the uterus, 39 operation for the induction of, 41, 46 in pernicious anaemia, 36 in pernicious vomiting of preg- nancy, 35 in pulmonary and cardiac dis- ease, 34 in renal disease, 36 Abscess, mammary, 190 pelvic, 188 operation for, 188 Accouchement force, 6Y Accoucheur, asepsis of, 2 Anaemia, pernicious, artificial abor- tion in, 36 Anatomy of pelvis, 9 of symphysis pubis, 121 Antisepsis, 1 definition of, 2 Arm, prolapse of, method of rectify- ing, 107 Arms, methods of delivery of. 111 Asepsis, 1 definition of, 2 of accoucheur and attendants, 2 of genital tract, 5 of hands and arms, 4 of instruments, 6 of ligatures and sutures, 7 of lying-in woman, 5 Axis-traction forceps, 73, 74 to the breech, 87 Basiotribe, Tarnier's, 154 Beaudelocque, diameter of, 12 Bipolar version, 101 method of performing, 103 Bladder, danger of injury to, in sym- physiotomy, 123 Braxton-Hicks method of version, 101 Csesarean section, 133 abdominal suture after, 140 absolute indication, 132 dilatation of cervix after, 137 election in, 133 indications, 133 instruments for, 134 preparations for, 135 prognosis of, 144 relative indication, 132 statistical data, 145 suture of uterus after, 138 Catheter, Fritsch-Bozeman, 42 Cephalotribe, application of, 155 disadvantages of, 154 Lusk's, 154 Cephalotripsy, operation of, 153 Cervix, dilatation of, after Csesarean section, 137 lacerated, immediate repair of, 163 after-treatment, 167 contra-indications, 164 instruments necessary, 164 steps of operation, 165 suture material for, 164 manual dilatation of, 89, 102 multiple incision of, 89, 105 Chin, arrested at symphysis, extrac- tion of, 116 Chorea, artificial abortion in, 36 Conjugate, diagonal, 13 true (conjiigata vera), 14 Cranioclast, Braun's, 149 extraction by, 150 Craniotomy of the after-coming head, 152 of the before-coming head, 150 operation of, 148 Crotchet, 157 Curette, uterine, 41 (203) 204 INDEX. Decapitation, 157 deliveiy of bead after, 159 method of performance, 158 Decollator, Braun's, 158 Diameters of fatal head, 16 of pelvis, external, 11 internal measnrements of, 15 pelvic, increase in, by S3-mph3'si- otom}', 122 transverse and obliqne, 15 Dilator, steel-branched, 41 Dilators, hydrostatic, 66 Dystocia, obstetric, 9 Eclampsia, induction of labor in case of, 54 podalic version in, 97 Election, value of, in Caesarean sec- tion, 133 value of, in s^-mphysiotomy, 121 Electricity as a means of inducing labor, 58 Elytrotomy, laparo-, 144 Embryotomy, 146 prognosis of, 161 Endometritis, curetting in, 182 gauze tampon in, 184 objections to douche in, 181 operation for, 1 83 post-operative treatment of, 185 puerperal, 181 Episiotomj', 83 EAisceration, 155 indications for and dangers of, 156 Face presentations, low forceps in, 81 Fistiilffi, 174 after-treatment of, 176 operatiou for repair of, 176 Fcfital head, diameters of, 16 Foetus, determination of eugaoement of, 51 dimensions of, at term, 16 intra-uterine measurement of, 50 length of, 50 manual internal rotation of, 117 in case of occiput posterior, 118 Forceps, 72 ansesthesia for extraction by the, 77 application" of low, 81 of medium, 88 Forceps, compression by the, 75 contra-iudications to the use of, 76 direction of traction in low, 83 Elliott's, 72 forces of the, 74 high, 91 Hunter's, 73 in breech presentations, 77 indications for the, 76 intra-uterine dressing, 45 introduction of left blade of, 79 introduction of right blade of, 80 Jewett's axis-traction, 74 leverage of the, 75 locking of, 80 low, in face presentations, 86 in occipito-posterior, 84, 85 Lusk-Tarnier, 73 medium, dangers of, 89 ovum, 42 position for the application of, 78 prognosis of, 92 Reynolds's tniction rods for, 75 rotation by the, 75 to after-coming head, 116 to breech, 87 Funis, prolapse of, version in, 97 Galbiati knife, objections to, 129 Gestation, ectopic, 193 broad ligament, rupture of, 195 treatment of, 196 development of, to term, 199 treatment, 200 diagnosis of, 193 at time of rupture, 194 before rupture, 194 intra-peritoneal rupture, 194 primary, 195 operation for primary rupture, 197 terminations of, 193 treatment after fretal death, 201 treatment of broad-ligament rup- ture, 199 Glycerin, injections of, for inducing labor, 60 Hffimorrhage, artificial abortion in case of, 39 as a complication of symph3'siot- omy, 129 INDEX. 205 Hsemorrhage, induction of labor in case of, 53 Hands, asepsis of, 4 Head, after-coming, forceps to, 116 arrested at brim, extraction in case of, 115 delivery of, after decapitation, 159 foetal, arrested at symphysis 116 compressibility of, 51 on perineum, method of delivery of, 83 Heart disease, artificial abortion in, 84 Hook, blunt, 15*7 Hunter's low forceps, 73 Hysterectomy, laparo-, 141 after-treatment, 144 indications, 142 technique, 142 Incision, multiple, of cervix, 89, 105 Incubator, 69 Instruments, asepsis of, 6 Jewett's axis-traction forceps, 74 Justo-major pelvis, 18 Justo-minor pelvis, 19 Kidney disease, artificial abortion in, 36 Knife, Galbiati, 124 Krause's method for inducing labor, 61 Kyphosis, 24 Labor, premature, induction of, 47 in case of eclampsia, 54 in case of deformed pelves, 48 in case of haemorrhage, 53 method for, 58 prognosis of, 68 Laparo-elytrotomy (vide Elytrot- omy) Laparo-hysterectoni}^ (vide Hyste- rectomy) Ligament, subpubic, necessity of cutting, in symph^^siotomy, 126 Ligiitures, asepsis of, 7 Lusk-Tarnier forceps, 73 Mastitis, glandular, 191 puerperal, 1 90 subglandular, 192 Membranes, puncture of, for in- ducing labor, 58 Mento-posterior position, symph3^si- otomy.iu, 127 Metritis, abdominal section in case of, 185 extension of sepsis causing, 184 puerperal, 181 jSTurse, asepsis of, 2 Occipito-posterior position, forceps in, 84 manual rotation in, 118 symphysiotomy in, 127 Oophoritis, septic, 186 Osteomalacia, 28 Pelves, abnormal, 17 contracted, symphysiotomy in, 122 deformed, b}^ tumors, 31 induction of labor in, 48 Pelvic version, elective, 96 Pelvimeters, 11 Pelvimetry, 11 digital, 13 Pelvis, anatomy of, 9 circumference of, 16 contraction of, artificial abortion in, 37 diameters of, increase in, by S3'm- pliysiotomy, 122 external diameters of, 11 flat, racliitic, 23 flattened, 20 funnel-shaped, 28 internal diameters of, 13 justo-major, 18 justo-minor, 19 kvphotic, 24 Naegele, 30 oblique-ovate, 30 osteomalacic, 28 rachitic, 21 rachitic-scoliotic, 26 scoliotic, 25 spondylolisthetic, 27 transversely contracted, 24 206 INDEX. Perforator, Blot's, 148 scissors, 149 Perineorrhaphy, after-treatment, 1T3 contra-iudicatioiis, 168 for complete rupture, 172 for partial rupture, 170 Hegar's method of, 170 immediate, 167 instruments requisite for, 169 method of performing, 169 suture material for, 171 Perineum, central laceration of, 173 laceration of, determination of, 168 A'arieties of laceration of, 168 Peritoneum, methods of infection of, 187 Peritonitis, differentiation of local from general, 187 intra-peritoneal, encapsulated, 189 operation for, 190 local, 188 operation for, 188 puerperal, 186 Placenta prsevia, 53 bipolar version in, 102 Porro operation (vide H^sterec- tom}-) Pregnancy, extra-uterine (vide Gres- tation, ectopic) pernicious vomiting of, 35 Puerpei'ium, surger}^ of, 163 Pulmonary disease, artificial abortion in, 34 Quinine to promote contractions, 90 Rachitis, 21 Rej-nolds's traction rods, 75 Roberts's pelvis, 24 Rotation, manual, of foetus, 117 Salpingitis, septic, 186 Scoliosis, 25 Specula, Simon's, 175 Speculum, Edebohl's, 43 Spondylolisthesis, 27 Spondylotomy, 157 Sponges, dangers of using, 7 Suture, uterine, 138 Sutures, asepsis of, 7 S3'mphysiotomy, 120 after-treatment of. 128 amount of gain in diameters by, 122 anatomical considerations, 121 complications of, 128 delivery after, 126 factors controlling, 123 Galbiati knife for, 124 indications, 122 instruments essential for, 124 prognosis of, 130 repair of wound after, 127 statistical data, 130 structures involved in, 122 technique of, 124 subcutaneous method, 125 ultimate results from, 129 Sj'mphj^sis pubis, effect of operation at, 129 mobility at, 128 Tenaculum, cervical, 43 Trephine, Braun's 148 Martin's, 149 Tumors, deforming the pelvis, 31 pelvic, artificial abortion in, 37 Twins, locked, 161 Urethra, danger of injury to, in syva- physiotomy, 123 Uterus, displacements, artificial abor- tion in, 39 management of, after Caesar ean section, 136 rupture of, 177 abdominal section in, 179 annular, 181 prognosis of, 179 suture of, after Csesarean section, 138 tamponade in, 180 treatment of, 178 varieties of, 177 Yagina, asepsis of, 5 hand in, for p.urpose of examina- tion, 99 tamponing, for inducing labor, 59 Yaselin, dangers in using, 6 . . INDEX. 207 "Version, 93 bipolar, in case of placenta prsevia. 102 Braxtoii-Hicks method, 101 by external manipulations, 101 cephalic, 94 combined method of, 101 internal, 105 extraction after, 110 extraction of head, 112 insertion of hand in, 106 rotation of foetus b3^ 94 seizure of foot in, lOT Version, liberation of arm after, 111 nomenclature of, 94 pelvic, 94 objections to, 100 performance of cephalic, 95 podalic, 96 contra-indications of, 97 indications for, 97 preparations for, 99 prognosis of, 119 varieties of, 94 Catalogue of the Publications of THE F. A. DAVIS CO., ^Wledieal Publishers and Booksellefs, 1914 and 1916 CHERRY STREET, Branch Offices: NEW YORK CITY IIT TT. Forty-Second Street. CHICAGO 9 I^akeside Boilding, 214-230 S. Clark Street. F. J. REBMAN, 11 Adam St., Strand, W.C, London, Eng. Order from Nearest Office. For Sale by All Booksellers. Prices of books, as given in our catalogue or circu- lars, include full prepaj^ment of postage, freight, or express charges. 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