itttljfCitpoflmgork CoUese ot S^^v^itim& anb ^urgeon;^ Hitirarp Digitized by tine Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookofobstetOOwrig A TEXT-BOOK OF OBSTETRICS BY ADAM H. WRIGHT PROFESSOR OF OBSTKTRICS, UNIVERSITY OF TORONTO OBSTETRICIAN AND GYN.«COLOGIST TO THE GENERAL HOSPITAL, TORONTO, CANADA IVITR TWO HUNDRED AND TWENTY- FOUR ILLUSTRATIONS IN THE TEXT NEW YORK AND LONDON D. APPLETON AND COMPANY, PUBLISHERS 1908 Copyright, 1905, by D. APPLETON AND COMPANY PRINTED AT THE APPLETON PRESS NEW YORK, U. S. A. A TEXT-BOOK OF OBSTETRICS BY ADAM H. WRIGHT PROFESSOR OF OBSTETRICS, UNIVERSITY OF TORONTO OBSTETRICIAN AND GYN.ECOLOGIST TO THE GENERAL HOSPITAL, TORONTO, CANADA WITH TWO HUNDRED AND TWENTY- FOUR ILLUSTRATIONS IN THE TEXT NEW YORK AND LONDON D. APPLETON AND COMPANY, Publishers 190^ Copyright, 1905, by D. APPLETON AND COMPANY PRINTED AT THE APPLETON PRESS NEW YORK, U. S. A. e -J a S3 TO WILLIAM OSLER KEGIUS PROFESSOR OF MEDICINE AT OXFORD PROFESSOR OF MEDICINE, JOHNS HOPKINS UNIVERSITY BALTIMORE A GOOD PHYSICIAN" A KIND FRIEND "There are many speculations in Literature, Philosopliy, and Re- ligion, which, though pleasant to walk in, and lying under the shadow of great names, yet lead to no important result. They resemble rather those roads in the Western forests of my native land, which, though broad and pleasant at first, and lying beneath the shadow of the great branches, finally dwindle to a squirrel track, and run up a tree." —Longfellow, Hyperion. "I am not only ashamed, but heartily sorry, that, besides death, there are diseases incurable : yet not for my own sake, or that they be beyond my Art, but for the general cause and sake of humanity, whose common cause I apprehend as my own. ' ' — Browne, Religio Medici. PREFACE This book has been published at the request of students and fellow practitioners. An intimate association with students and physicians and a careful stud}^ of their wants have convinced me that a work on Obstetrics should be practical in the broadest sense of the word. I recognize the fact that students have learned anatomy and physiology before they commence the study of obstetrics, and I have therefore given only a summary of facts anatomical and physiological which are important from an obstetrical stand- point. While the brief chapters on anatomy and physiology are intended especially for students, the main portion has been written for both students and physicians. In my endeavors to be practical I have adopted chiefly clin- ical methods. I desired to avoid the "lecture style" in writing; but I have to acknowledge that my dogmatic manners as a teacher, and a considerable amount of egoism, are evident in many parts. As an excuse for this, I shall follow Herman in quoting the words of Bacon : " The manner of the tradition and delivery of knowl- edge which is for the most part magistral and peremptory . . . in a sort as may be soonest believed and not easiliest examined ... in compendious treatises for practise ... is not to be disallowed." By abbreviating certain chapters and abstaining from theori- zing, I have been able to devote considerable space to the proper treatment of very important subjects without making a large book. The description of the management of normal labor has been made as nearly complete as possible, no detail, great or small, being overlooked. The importance of exact and correct knowl- vi PEEFACE edge of normal labor with all its preventive possibilities is perhaps better appreciated on this continent than in older countries, be- cause a kind Providence has thus far mercifully preserved us from the licensed midwife. In the consideration of pathological and operative obstetrics an effort has been made to give full and definite directions for the treatment of all the emergencies which arise in the practise of midwifery. The pathological conditions arising in pregnancy, labor and the puerperium, and the relationship between them and such diseases as tuberculosis, appendicitis, heart disease, syphilis, gonorrhoea, nephritis, general toxaemia, etc., have beeri. fully dis- cussed. The Book is divided into two parts : I. Physiological Ob- stetrics; II. Pathological and Operative Obstetrics. In making such a division, which is done partly for teaching purposes, it is not presumed that a definite line always separates the normal from the abnormal in midwifery. Part I contains the subjects of the third-year course; Part II contains those of the fourth-year course in the University of Toronto. I am indebted to Dr. Fothingham, Dr. Mcllwraith, Dr. Fenton, Dr. MacMurchy, Dr. Goldie, Dr. R. H. Muhin and Dr. Malloch for kind assistance in connection with the reading matter, and also to Dr. Edmund E. King, who took charge of the preparation of the illustrations, and was assisted by Dr. E. M. Walker. We have used chiefly the specimens and material in the University Museum and the Burnside Lying-in Hospital. The cuts illustrat- ing the repair of lacerations of the pelvic floor and perinseum are reproduced from drawings from life in the Burnside, by Dr. Walker. I have to thank Dr. Howard Kelly, Dr. Whitridge Williams and others, for some illustrations which I have bor- rowed. I have also to thank my Publishers, and especially Dr. Broome, for valuable suggestions, and for unvarying kindness and courtesy. Adam H. Wright. 30 Gerhard Street, E., Toronto, Canada. CONTENTS PART I PHYSIOLOGICAL OBSTETRICS CHAPTER I. -Anatomy The pelvis .... The female reproductive organs External organs Internal organs The mammse or mammary glands II. — Physiology .... Ovulation .... Menstruation .... Conception and generation III. — The Embryo and Fcetus IV. — Pregnancy .... Foetus in utero Changes in the maternal organism Diagnosis of pregnancy . Signs and symptoms Differential diagnosis of pregnancy Duration of pregnancy . Diagnosis of previous pregnancy Pelvimetry .... Description of pelvimetry Hygiene and management of pregnancy -Physiology op Labor The expelling powers Stages of labor ... Methods of examination Mechanism of labor First position or left occipito-anteri The other vertex positions VI. — Management of Normal Labor General directions . The onset of labor . First stage of labor Management of the second stage of labor V.- PAGB 1 1 6 6 7 14 15 15 16 16 18 30 30 30 38 39 48 51 53 54 55 61 65 65 71 72 77 78 83 85 85 92 98 105 Vlll CONTENTS CHAPTER PAGE VII. — Normal Labor {Continued) 121 Third stage of labor 121 Care of mother immediately after labor .... 132 Management of the babe immediately after labor . . . 135 Methods of artificial respiration ...... 136 Anaesthetics in labor 142 VIII. — The Puerperal State ........ 146 General conditions ........ 146 The care of the mother ........ 153 The condition and care of the babe ..... 160 Artificial feeding ......... 163 Care of premature infants ....... 166 IX. — Face Presentations, Breech Presentations, Multiple Pregnancies .....*.... 169 Face presentations . . . . . . . .169 Management . 172 Brow presentations . . . . . . . .175 Breech presentations ........ 175 Mechanism and management 177 Multiple or plural pregnancies 185 Twins 185 PART II PATHOLOGICAL AND OPERATIVE OBSTETRICS X. — Diseases of Pregnancy Salivation or ptyalism Dental caries and toothache Derangement of the stomach Disorders of intestines . Enteroptosis or gastroptosis Diseases of the circulatory system Diseases of the respiratory organs Nervous diseases ..... Paralysis of pregnancy Diseases of the skin .... XI. — Diseases of Pregnancy {Continued) Prolapse of the uterus . . . . Anteversion and anteflexion of the uterus Retroversion and retroflexion Incomplete retroversion or incomplete retroflexion Hernia of the uterus Leucorrhoea .... Pruritus vulvae 192 192 193 194 197 199 200 202 202 206 207 210 210 211 213 217 218 218 220 CONTENTS IX Painful mammary glands Myofibromata with pregnancy Diseases of the decidua and ovum Pathology of the chorion Hydatiform mole or vesicular mole Diseases of the amnion Hydranuiion, hydramnios or polyhydramnios OJigo-hydramnios .... XII. — Intercurrent Diseases of Pregnancy The acute infectious diseases Typhoid or enteric fever Scarlatina Erysipelas Measles Smallpox Pneumonia Cholera Tetanus Tetany Influenza Malaria Rheumatism Bronchocele Haemorrhages Lead poisoning Mercurial poisoning Tobacco poisoning Factory employment, pregnancy and childbirth Appendicitis Tuberculosis Cardiac diseases Syphilis Gonorrhoea . XIII. — Diseases of Pregnancy and the Puerperium Diseases of the kidneys Nephritis Diseases of the bladder General toxarnia of pregnancy Eclampsia ...... Acute or chronic nephritis with eclampsia XIV. — Extra-Uterine or Ectopic Pregnancy Primary ectopic gestation Haemorrhages due to ectopic gestation . Secondary ectopic gestation . Diagnosis of ectopic gestation Differential diagnosis of tubal pregnancy Growing pregnancy, full-term pregnancy, dead pregnancy 221 222 225 226 226 228 228 231 232 232 232 234 235 236 236 237 237 238 238 238 239 239 240 240 240 240 241 241 242 249 257 265 269 272 272 273 280 283 294 306 310 313 316 321 322 327 329 X CONTENTS CHAPTER PAGE XV. HEMORRHAGE BEFORE, DURING, AND AfTER LaBOR . . 333 Haemorrhage before labor 333 Accidental haemorrhage 333 Treatment for external accidental haemorrhage . . . 338 Treatment for concealed accidental haemorrhage . . . 340 Placenta praevia . . . . . . . , .341 Treatment of placenta praevia ...... 343 Haemorrhage from cancer of the cervix .... 348 Haemorrhage from a ruptured varix of the vagina or vulva 349 Post-partum haemorrhage ....... 349 Primary post-partum haemorrhage ..... 349 Treatment . . . . . . . . . . 351 Secondary post-partum haemorrhage ..... 355 XVI. — Abortion or Miscarriage 359 General considerations ....... 359 Threatened abortion ........ 362 Inevitable abortion ' . . 362 Treatment . . : 362 Other varieties of abortion ....... 372 Deciduoma malignum or chorio-epithelioma .... 372 XVII. — Prolonged and Precipitate Labor ..... 374 Prolonged labor 374 Causes of prolonged labor 376 Dry labor .......... 377 Treatment of dry labor ....... 382 Difficult occipito-posterior positions ..... 385 Treatment 387 Labor obstructed by faulty conditions of the soft parts . 392 Precipitate labor ......... 397 XVIII. — Malpresentations and Abnormal Conditions of the F(ETUS 399 Shoulder, arm, and transverse presentations . . . 399 Abnormalities ......... 403 XIX. — Abnormal Conditions of the Uterus, its Contents, and THE Mammary Glands . . . . . .410 Rupture of the uterus . . . . . . . . 410 Inversion of the uterus . . . . . . .416 Retention of the placenta and adhesions of placenta . . 418 Mastitis 420 XX. — ^The Emotional Element in the Puerperal Period and Puerperal Insanity 427 Effects of emotional disturbances ..... 427 Puerperal insanity ........ 430 XXI. LiSTERISM AND OBSTETRICS 433 Puerperal fever or puerperal septic infection . . . 435 Nature of puerperal infection ....•• 436 How does the infection take place . . . . • 437 CONTENTS XI CHAPTER Bacteriology .... Varieties of puerperal infection . Pathology Symptoms of puerperal infection Treatment of puerperal infection XXII. — Puerperal Infection (Continued) Phlegmasia alba dolens Gonorrhoeal infection XXIII. — Deformities of the Bony Pelvis and Injuries to the Child During Delivery Causes and forms of deformity Contracted pelvis Treatment Injuries to child during delivery Abnormalities and diseases of the new-born child XXIV. — Obstetrical Operations .... General considerations .... General operations ..... Repair of lacerations of the genital canal . Lacerations of the vagina .... Lacerations of the pelvic floor and perinseum Induction of abortion .... Induction of premature labor Accouchement force ..... Cervical incisions ..... Version ....... XXV. — Obstetrical Operations (Continued) . Delivery with the forceps .... Indications ...... Kinds of forceps ..... The Milne Murray axis-traction forceps The Porter Mathew axis-traction forceps . XXVI. — Major Obstetrical Operations Csesarean section Porro's operation Hysterectomy Symphysiotomy Operation for ectopic pregnancy Embryotomy PAGE 438 440 443 445 455 473 473 476 480 480 482 484 489 491 496 496 499 508 509 510 519 520 522 528 530 534 534 535 539 543 546 559 559 560 561 561 563 563 LIST OF ILLUSTRATIONS Abdomen of primipara showing strise. (Fig. 189) Accidental haemorrhage. (Fig. 125) ..... Accidental ha?morrhage, concealed. (Fig. 126) Anencephalus, with meningocele and spina bifida. (Fig. 134) Artificial respiration, Byrd's method (first part). (Fig. 91) Artificial respiration, Byrd's method (second part). (Fig. 92) Artificial respiration, Sylvester's method (first part). (Fig. 89) Artificial respiration, Sylvester's method (second part). (Fig. 90) Bags, Voorhees' dilating. (Fig. 183) Balloon, Champetier de Ribes. (Fig. 181) Balloon, Champetier de Ribes, ready for introduction. (Fig. 182) Bandage, many-tailed, applied for phlegmasia dolens. (Fig. 167) Bandage, many-tailed, partially applied. (Fig. 166) Bandage, many-tailed, T-bandage. (Fig. 165) Barkpr, Fordyce. (Fig. 154) .... Basylist, Simpson's, articulated. (Fig. 222) . Basylist, Simpson's, disarticulated. (Fig. 221) Belly, pendulous, of a multiparous woman. (Fig. 44) Bladder, empty after labor. (Fig. 98) Bladder, empty before labor. (Fig. 64) Bladder, full after labor. (Fig. 99) Bladder, full before labor. (Fig. 65) Blood, normal. (Fig. 163) . Blunt hook, Braun's. (Fig. 223) . Blunt hook, Braun's, decapitation with. (Fig. 224) Bossi's dilator. (Fig. 184) Breast of pregnancy. (Fig. 149) . Breast, mastitis. (Fig. 150) Breech presentation. (Fig. 62) Cancer of the cervix with pregnancy. (Fig. 129) Cancer of the cervix with pregnancy, showing embryo. (Fig. 130) Cephalotribe, Tamier's. (Fig. 220) Cervix, manual dilatation of. (Fig. 180) Chair, Soudan labor. (Fig. 77) . Chair, Soudan woman in labor in. (Fig. 78) Chair, Soudan woman in labor in. (Fig. 79) Chart, abnormal involution line. (Fig. 96) . PAGE 536 334 335 401 139 140 137 138 527 525 526 476 475 474 434 568 567 36 150 108 151 108 470 568 569 428 421 422 77 347 348 567 524 119 119 120 148 XIV LIST OF ILLUSTEATIOKS 118) (Fig. 119) Chart, abnormal involution line. (Fig. 97) . Chart, high temperature after curettement. (Fig. 155) Chart, high temperature from acute indigestion. (Fig. 161) Chart, influenza. (Fig. 160) ..... Chart, normal involution line. (Fig. 95) Chart, puerperal syphilitic fever. (Fig. 117) Chart, "queer" from unknown causes. (Fig. 159) Chart, rise of temperature from sore nipples. (Fig. 151) Chart, septicaemia. (Fig. 158) Cord, cutting the. (Fig. 88) ... Cord, umbilical, section through. (Fig. 22) . Cranioclast, Braun's. (Fig. 218) . Cranioclast, head crushed by. (Fig. 219) Decidua reflexa, diagram showing formation of. (Fig. 17) . Decidua reflexa, diagram showing formation of. (Fig. 18) . Ectopic gestation, broad ligament or extraperitoneal. (Fig. 123) Ectopic gestation, interstitial, rupture. (Fig. 120) . . , Ectopic gestation, rupture of tube, corpus luteum. (Fig Ectopic gestation, rupture of tube, thickened decidua. Ectopic gestation, uterine decidua. (Fig. 122) Embryos from second month. (Figs. 27 to 29) Embryos from fourth and fifth weeks. (Figs. 23 to 26) . Embryo, transverse section through. (Fig. 19) Exomphalos. (Fig. 139) Face presentation, delivery of head in. (Fig. 103) Fibroids, pregnancy with numerous. (Fig. 113) . Fibroids, obstructing pregnancy. (Fig. 114) Foetal circulation. (Figs. 37, 38) Facing Foetuses, composite of, at two, three, five, seven and nine months. (Figs. 30 to 34) 25 Foetus, macerated. (Fig. 142) 409 Foetus, meningocele. (Fig. 141) 408 Foetus papyraceous. (Fig. 109) . . 187 Foetus, with ascites. (Fig. 133) 400 Forceps, articulated (Mathew). (Fig. 205) 547 Forceps, blades and traction rods held in hands before application (Mathew). (Fig. 206) 548 Forceps, front view of blades and rods (Mathew). (Fig. 203) . . 545 Forceps, introduction of first blade (Mathew). (Fig. 207) . . .549 Forceps, introduction of second blade (Mathew). (Fig. 208) . . 550 Forceps, introduction of right blade. (Fig. 212) 554 Forceps, left blade in place. (Fig. 211) 553 Forceps, lock of English. (Fig. 199) 542 Forceps, lock of French. (Fig. 200) 543 Forceps, locked. (Fig. 213) 655 Forceps, locked, Pajot's maneuver. (Fig. 202) 544 Forceps, locked and block and handle adjusted (Mathew). (Fig. 209) . 551 PAGE 149 441 451 450 147 268 449 423 448 136 23 565 566 19 19 326 317 314 315 324 24 24 20 406 172 223 224 28 LIST OF ILLUSTRATIONS XV Forceps, Mathew's axis traction, parts sciparated. Forceps, ordinary lonjj;, introduction of left blade. Forceps, side view of blades and rods. (Fig. 204) Forceps, Simpson's, cephalic curve. (Fig. 197) Forceps, Simpson's, pelvic curve. (Fig. 198) Gertrude baby suit. (Fig. 93) Head, birth of. (Fig. 71) . (Fig. 72) ■ . (Fig. 73) . (Fig. 74) . (Fig. 75) . (Fig. 76) . (Fig. 35) (Fig. 36) (Fig. 214) (Fig. 210) Head, birth of. Head, birth of. Head, birth of. Head, birth of. Head, birth of. Head, child's, at term Head, child's, at term Head, controlling passage of through vulva. (Fig. 66) Head, controlling passage of through vulva. (Fig. 67) Head, presentation. (Fig. 61) Hegar's sign. (Fig. 47) Holmes, Oliver Wendell. (Fig. 157) . Hydatidiform mole. (Fig. 115) Incarceration of retroflexed pregnant uterus. (Fi Labor, room prepared for. (Fig. 63) Leg-holder, Robb's. (Fig. 201) . Leucocytosis. (Fig. 164) Leucopoenia. (Fig. 162) Lithopsedion, ectopic gestation. (Fig. 124) Lithotomy position, patient prepared for operation 112) (Fig. 192) Lithotomy position, parts partially exposed. (Fig. 193) Lord Lister. (Fig. 152) Murphy binder. (Fig. 102) . Nabothian glands. (Fig. 13) Os, parous external. (Fig. 12) Os, virginal external. (Fig. 11) Ovum, human. (Fig. 15) Palpation, abdominal, deep pelvic grip. (Fig. 60) Palpation, abdominal, fundal grip. (Fig. 55) Palpation, abdominal, Mcllwraith's grip. (Fig. 58) Palpation, abdominal, Pawlic's grip. (Fig. 59) Palpation, abdominal, second umbilical grip. (Fig. 57) Palpation, abdominal, umbilical grip. (Fig. 56) . Pasteur, Louis. (Fig. 156) Pelvic floor and perinseum, sutures in tears. (Fig. 171) Pelvic floor, distended, showing superficial muscles. (Fig. 70) Pelvic floor from above. (Fig. 68) Pelvic floor from below. (Fig. 69) Pelvic floor, sutures in tear. (Fig. 170) Pelvic floor, tear, bilateral. (Fig. 169) PAGE 556 552 546 542 542 141 113 114 115 116 117 118 26 26 109 110 76 43 447 227 213 92 543 471 469 331 539 539 432 158 10 9 9 13 76 73 75 75 74 73 446 513 112 111 112 512 511 XVI LIST OF ILLUSTEATIONS Pelvic floor, tear, correct result after tying suture. (Fig. 175) Pelvic floor, tear, fault after tying suture. (Fig. 173) . Pelvic floor, tear on right side. (Fig. 168) . Pelvic floor, tear, suture improperly introduced. (Fig. 172) Pelvic floor, tear, suture properly introduced. (Fig. 174) Pelvimetry, antero-posterior measurement. (Fig. 51) . Pelvimetry, intercristal measurement. (Fig. 50) . Pelvimetry, interspinous measurement. (Fig. 49) Pelvis, normal female. (Fig. 1) . Pelvis, normal female, showing diameters of superior strait. (Fig. 2) Perforation of head. (Fig. 217) ..... Perforator, Simpson's. (Fig. 215) .... PerinEeum, tear extending into rectum, sutures. (Fig. 177) Perinseum, tear extending into rectum, some sutures tied. (Fig. 178) Perinaeum, tear extending into rectum, all sutures tied. (Fig. 179) Perinseum, tear, sutures. (Fig. 176) Placenta, battledore, foetal surface. (Fig. 137) Placenta, battledore, maternal surface. (Fig. 136) Placenta, being expelled. (Fig. 82) Placenta, diagram of. (Fig. 21) . Placenta, double. (Fig. 135) .... Placenta in uterus after birth of child. (Fig. 80) Placenta prsevia, (complete). (Fig. 128) Placenta praevia, (incomplete). (Fig. 127) Placenta separated and pushed partially into vagina. (Fig. 81) Placenta, velamentous insertion. (Fig. 138) Placental site near fundus. (Fig. 83) . Prague method of extracting the head. (Fig. 104) Pregnancy, five weeks. (Fig. 39) . Pregnancy, two months. (Fig. 40) Pregnancy, three months. (Fig.41) Pregnancy, five months, showing placenta and sack containing foetus (Fig. 42) Pregnancy, five months, cord around neck and arm. (Fig. 140) Pregnancy, full term, showing placenta and sack containing foetus (Fig. 43) Scissors, Smellie's. (Fig. 216) .... Section, sagittal, of a new-born babe. (Fig. 3) Section, sagittal, of a five-year old girl. (Fig. 4) . Section, sagittal, of a nine-year old girl. (Fig. 5) Section, sagittal, of an adult female pelvis. (Fig. 6) Semmelweiss. (Fig. 153) .... Sheet sling, first stage in making. (Fig. 194) Sheet sling, second stage in making. (Fig. 195) Sheet sling applied. (Fig. 196) Shoulder-jaw traction. (Fig. 105) Shoulder-jaw traction. (Fig. 106) LIST OF ILLUSTRATIONS xvii Shoulder-jaw traction. (Fig. 107) Simpson, Sir James Y. (Fig. 94) . Smallpox, babe died in utero from. (Fig. IIG) Snively breast-binder. (Fig. 100) Snively breast-binder, applied. (Fig. 101) . Snively stocking-drawers. (Fig. 190) . Snively stocking-drawers, pattern. (Fig. 191) Tamponade, uterine after labor. (Fig. 145) Triplets from two eggs. (Fig. 110) Triplets from three eggs. (Fig. Ill) Tubal abortion. (Fig. 121) .... Tubal mucosa, longitudinal folds of. (Fig. 14) Twins, locked. (Fig. 132) .... Uterus and appendages of a young child. (Fig. 8) Uterus and appendages of a fourteen-year old girl. (Fig. 9) Uterus and appendages of a twenty-one year old multipara. (Fig. 10) Uterus, bimanual examination showing bellying. (Fig. 46) Uterus, bimanual examination showing no enlargement. (Fig. 45) Uterus, complete inversion. (Fig. 148) .... Uterus, height at different periods of pregnancy. (Fig. 48) Uterus, lined by decidua containing a seven-day ovum. (Fig. 16) Uterus, partial inversion, external view. (Fig. 147) Uterus, partial inversion, internal view. (Fig. 146) Uterus, pregnant, section of, after retraction. (Fig. 54) Uterus, pregnant, section of, before retraction. (Fig. 53) Uterus, pregnant seven months, front wall removed. (Fig. 85) Uterus, pregnant seven months, placenta and membranes turned to left. (Fig. 86) . Uterus, pregnant seven months, posterior wall removed. (Fig. 87) Uterus, pregnant seven months, showing hei; lopian tubes. (Fig. 84) Uterus, seventeen days pregnant. (Fig. 20) Vagina ballooned. (Fig. 7) . Vagina, rupture of. (Fig. 143) Version, bipolar podalic. (Fig. 188) Version, external cephalic. (Fig. 185) . Version, internal podalic. (Fig. 186) Version, transverse presentation. (Fig. 187) Vulvar pad. (Fig. 52) .... Walcher's position. (Fig. 214) ght of fundus above Fal- PAGE 184 142 236 156 157 537 538 414 188 189 319 12 399 8 8 9 42 41 417 44 19 416 415 69 68 127 128 129 126 21 7 411 533 530 531 532 63 556 PART I PHYSIOLOGICAL OBSTETEICS CHAPTER I ANATOMY GENERAL DESCRIPTION The Pelvis. — The bony pelvis consists of four bones, the ossa innominata, the sacrum, and the coccyx. In early life the os innominatum has three bones, the ilium, the ischium, and pubes, Fig. 1. — Normal Female Pelvis (Williams), x ^. united by a Y-shaped piece of cartilage with its center in the acetab- ulum. These unite at about the twentieth year. The last lumbar vertebra is important, especially in cases of deformed pelvis. The pelvis is divided into two parts; the upper, or false pelvis — that 2 ANATOMY portion above the brim ; the true pelvis — that portion below the brim. The brim, or inlet, is formed by the upper margin of the pubes in front, the ilio-pectineal line on either side, and the upper and anterior margin of the sacrum behind. The cavity of the pelvis is bounded by the sacrum and the coc- cyx behind, the pubic bones in front, the inner surfaces of the innominate bones with the sacro-sciatic ligaments and the muscles attached to them at the sides. The outlet is lozenge-shaped and is bounded behind by the sacro-sciatic ligaments converging to Fig. 2. — Normal Female Pelvis showing Diameters of the Superior Strait (Williams). x ^. the tip of the coccyx, at each side by the tuber ischii, and in front by the rami of ischia and pubes converging to the lower margin of the symphysis pubis. The pelvic brim is sometimes called the superior strait; the outlet, the inferior strait. Differences in Sexes. — The female pelvis differs from the male in the following respects : it is shallower, wider and less funnel- shaped, smoother, thinner, weaker; the fossa of the ihum is gen- erally smaller and shallower ; the rami of the pubes and ischia are more everted; the pubic spines are farther apart; the diameters at the inlet are greater, especially the transverse; the inlet is rounder and the pubic arch more open. The plane of the brim, in the erect position, is more nearly GENE IJ AT. DESCRIPTION vortical than liorizontal. ]t niakos an aiv^lc of sixty degrees with the liorizoii. 'I'lic promontory of the sacrum is about 3f inches (9 cm.) above the i)ul)es when the body is erect. In pregnancy, or in the case of a large abdominal tumor, the pelvic inclination is diminished. Articulations of the Pelvis. — Sdcro-iluic syitchrondrosis. The bones are united by cartilages, but in adult women, especially in pregnancy, a synovial membrane intervenes and a small degree of movement is allowed. Sy7nphysis Pubis. The fibro-cartilage is thi(!ker in front than behind and a small synovial membrane is foimd in the back part. Sacro-c occygcal Ariiculation. There is a cartilage and a synovial membrane between sacrum and coccyx. During preg- nancy, cartilages and fibrous structures be- come swollen and softened ; the syno- vial cavities become extended and the mobility increased. Pelvic Planes. — These are imaginary levels at any portion of the pelvic circumference of the inlet, cavity, outlet, etc., of the pelvis. Plane of Inlet, or Brim. This extends from the top of the sacrum to the most prominent point of the symphysis pubis. Median Plane. This extends from the center of sacrum to the center of the symphysis pubis, etc. Plane of Outlet, This extends from the lower part of the sym- FiG. 3. — Sagittal Section, Five-year-old Girl. ;, uterus; 6, bladder; v, vagina slightly distended with a tampon. (Primrose, Tor. Univ. Museum.) AXATOMY physis pubis to the lowest point of the sacrum, etc., or the lowest point of coccyx, according to some. Axis of Pelvis. — This is an imaginary line indicating the course of the center of the foetal head as it passes through the pelvis, some- times called the circle of Carus, although it is not really a circle nor an arc of one. On the inner sur- face of the ischium there are two planes separated by a hne passing from the ilio-pectineal eminence to the spine of the ischium, called the anterior and posterior planes of the ischium. Two other planes are formed by the inner surface of the pubic bones in front, and by the upper portion of the sac- rum behind, both directed downward and backward. These planes, in conjunc- tion with the spines of the ischia, are supposed by some to assist in rotating the fcetal head in delivery. The Pelvis in Infancy and Childhood. — The pelvis is funnel- shaped, and the pubic arch forms a more acute angle; the tubera ischii are relatively nearer together than in the adult. It is small even in proportion to the size of the child. The iliac fossae are flatter, more upright, and their surfaces look more forward; the maximum distance between the iliac crests is hardly greater than that between the anterior superior spines. The sacrum is narrower in proportion than in the adult pelvis. The three portions of the innominate bones are not united until about the twentieth year. The pelvis is largely developed at the time of puberty, partly by the development of the different bones and partly by the action of mechanical forces; the wings of the sacrum, especially, grow, making the transverse diameter greater. Fig. 4. — Sagittal Section through Body OF Newly Born Child (Williams). GENERAL DESCRIPTIOX The pressure produced by the weight of the body, transmitted through the sacrum, assists in moulding the bones. The pressure and tension of muscles also assist. The Pelvic Floor. — The structures closing the pelvis form a com- plete diaphragm in which there are three faults or slits (Berry Hart), the urethra, the vagina, and the rectum. The vagina is the most important of these shts, from an obstetrical point of view. The outlet, when com- pared with the capa- cious vaginal cavity, may be likened to the narrow vent of a funnel with a wide mouth (Hunter Robb). The floor of the pelvis includes on each side : the visceral layer of the pelvic fascia (rectal, recto-vesical, and vesical portion) ; the parietal layer of pelvic fascia (also called "deep layer of triangular liga- ment") ; the triangu- lar ligament; the fascia of Colles; the following muscles : coccygeus, pyriformis, levator ani, a portion of obturator internus, deep and superficial transversus perinaei muscles, constrictor vaginae, and external sphincter ani; the skin and subcutaneous tissue. The perineal body (so-called) is the triangular body between the vagina arid rectum, the skin between the two forming its base, about 1 inch (2.5 cm.) in length. The apex is about H inches (4 cm.) above, where the walls of the rectum and vagina unite. The Fig. 5. — Sagittal Frozen Section, Nine-year- old Girl. V, vagina; u, uterus; b, bladder. (Primrose, Tor. Univ. Anatomical Museum.) A^TATOMY following structures are found in this perineal body: the deep fascia (two layers) ; a part of sphincter ani muscle ; a part of levator ani muscle; a part of con- strictor vaginge muscle; the junction of trans versus peri- nsei muscles ; some connective tissue, fat, and subcutane- ous fascia ; and the skin. The sheets of fascia (es- pecially the recto - vesical fascia) are the strongest structures in the pelvic floor and probably form the main support of the pelvic con- tents. The chief function of the levator ani muscle is to pull forward and upward the post-vaginal structures of the pelvic floor, especially the lower extremities of the rectum and vagina, and to form to some extent sphinc- ters for both. Note. — The pelvic floor consists of two parts, the structures of which meet in a median rhaphe. Injuries to the pelvic floor, during labor, gen- erally occur on one or both sides of the median line. Fig. 6. — Sagittal Section through Adult Woman (Kelly), reduced to the Same Size as Fig. 3 for Comparison (Wil- liams) THE FEMALE REPRODUCTIVE ORGANS The female reproductive organs are divided into the external, or copulative organs; the internal, or formative organs. EXTERNAL ORGANS Mens Veneris. — This is the cushion of adipose and fibrous tissue lying over the symphysis and horizontal rami of the pubes. Labia Majora. — These are the two sides of the vulva extending from the mons veneris in front to the fourchette behind, TUK FKMALI-] KKIM.'ODLX'TIVE ORGANS 7 Labia Minora, or Nymphae. — 'I'licso aro two folds of skin (not mvicous inciiibraiu') exist iiiu' insiilc of the labia niajora, uniting anteriorly in the middle line where they I'onn the prepuce of the clitoris. Clitoris. — This is a small erectile tubercle, the homologue of the penis in the male, about half an inch below the anterior commissure of the labia niajora. Vestibule. — This is a triangular surface covered with mucous membrane, bounded at its apex by the clitoris, on cither side by the labia minora, and having at its base the anterior margin of the opening of the vagina. The urethral aperture is situated at, or a little above, the center of the base. Fourchette. — This is the bridge of the skin beliind the vulva. INTERNAL ORGANS Urethra. — This is the canal H inches (4 cm.) in length, through which the bladder is emptied. Vagina. — The vagina is the canal in the pelvic floor which forms the communication between the external and the inter- nal organs of generation. The vaginal orifice lies between the vestibule and the fourchette, and is wholly or partially cov- ered by hymen. The an- terior wall is closely re- lated to the base of the bladder ; the posterior wall to the rectum; the sides to the broad ligaments and pelvic fascia. The vulvo-vaginal glands are situated near the posterior part of the vaginal orifice. The fossa navicularis, sit- uated between the hymen and the perinteum, is a small depres- sion which disappears after child-bearing. Uterus. — The uterus is a hollow muscle, an incubator chamber, for the reception and development of oosperms (Bland Sutton)^ Fig. 7. — Vagina Ballooned by Gaxjze-Pack- ING, SHOWING A LaRGE CaVITY WITH A Small Outlet. ANATOMY ^'' y Fig. 8. — Uterus and Appendages of Young Child (Williams), x f . situated behind the bladder and in front of the rectum. The anterior surface is somewhat flatter than the posterior. In infancy and childhood it is small and the neck is larger than the body. At puberty there is a re- f(\ \ ~^ "^ ' "^ markable development, the uterus increasing about 50 per cent, during men- struation. After the meno- pause it atrophies. The virgin uterus is 2^ inches (7 cm.) long and weighs about 1 ounce (.31 gm.). The uterus is divided into three regions : the fundus uteri, the arched portion above the straight line joining the ends of the oviducts ; the corpus uteri, the portion triangular in shape between the Fallopian tubes and the cervix; the cervix uteri, the lower fusiform portion. Structure. The wall of the uterus is made up of three layers, peritoneal or serous, muscular, and mucous. Peritoneal. The peritonseum passes from the bladder on to the uterus at the isthmus, up the anterior surface of the fundus, thus forming the utero-vesical pouch. It then passes over the fundus, down the posterior surface of the uterus and a small portion of the vagina (less than 1 inch) and then up the anterior wall of the rectum, thus forming the pouch of Douglas. When the bladder is distended the peritongeum on the anterior surface of the uterus is pulled up to the fundus. Normally the utero-vesi- cal pouch and the pouch of Douglas contain no small intestine. Muscular. The muscular wall of the uterus is about \ inch (1 cm.) thick and consists of interlacing bundles of smooth mus- cular fibers. Two layers are described (sometimes three). A thin external, or subperitoneal layer, supplying strands which pass into the ligaments of the uterus ; an internal layer, thick, contin- ^^^ a Fig. 9. -Uterus and Appendages of Fourteen- year-old Girl (AYilliams). x f . TIIK FEMALK KEl'lJODrCTI VE OlKiAXS 9 uoiis with the muscle oi the vanilla. Elastic and ordinary con- nective tissue exists between the muscle bundles. There are spe- cial muscular rinf2;s around the inner ends of the l''allopian tubes, the OS internum, and the os externum. Mucus. The mucosa of the body is about -j^ to jt^ inch thick under ordinary circumstances, but grows thicker before the men- FiG. 10. — Uterus and Appendages of Twenty-year-old Multipara (Williams). x f . strual period. It is implanted directly on the muscular wall without the intervention of a submucous layer. The lining epi- thelium consists of ciliated columnar cells. The glands, crypts, or follicles, single or branched, are tubular, and their openings are visible on shght magnification. The interglandular tissue, composed of tissue of a low or embryonic type, forms the main portion of the mucosa. The mucosa of the cervix is continuous with that of the corpus, there being no definite line of demarcation Fig. 11. — Virginal External Os (Williams). Fig. 12. — Parous External Os (William.s). between them. It is folded, however, to form the arbor vitse — j e., a vertical ridge on the anterior and posterior wall, with branch- 10 ANATOMY ing ridges extending from it. The epithelium is columnar, ciliated on the ridges, but not between them. The glands are racemose and lined by columnar epithelium. Cavity of Uterus. The body is triangular in shape, the open- ings of Fallopian tubes being at the upper angles, and the os inter- num at the lower angle. The anterior and posterior walls are in contact. Its capacity is | to 1 dram. The neck is fusiform. On the anterior and posterior walls are longitudinal ridges, the arbor vitse uterina. The cervical glands are racemose and extend Fig. 13. — Nabothian Follicles; Cyst-like Bodies from Obstruction op THE Ducts op the Cervical Gland j. (Tor. Univ. Museum.) from the surface of the mucosa into the stroma. When their ducts are occluded cysts are formed which are called Nabothian follicles or ovula Nabothi. Blood-Vessels. The ovarian arteries, from the aorta close to the renal arteries (the right ovarian frequently from the right renal artery), pass between the layers of the broad ligament, running tortuously through it to the upper angle of the uterus, where they anastomose with the uterine arteries. In their course branches are given off to supply the ovaries. Fallopian tubes, and round ligaments. The uterine arteries, from the anterior division of the internal iliac, pass between the layers of the broad ligament THE FEMALE T^EPTJODUOTTVE OKOAXS 11 toward the cervix. After ,iii\in.r Ijranches of the uterine. The internal pudic arteries, from the anterior division of the internal iliac, supply the perinaeum. Lymphatics. The lymphatics of the external genitals and the lower portion of the vagina terminate in the inguinal glands ; those of the upper portion of the vagina and cervix in the hypogastric glands ; and those of the body of the uterus in the lumbar glands. Nerves. The nerve supply of the uterus is derived from both spinal and sympathetic nerves, the spinal from the fourth sacral and pudic nerves, the sympathetic from the inferior hypogastric plexus. Ligaments. The round ligaments are two flattened cords, four inches long, one on each side, extending from the upper angle of the uterus upward, outward, and forward, through the inguinal canals to the upper part of the labium majus. The broad ligaments are formed by a double layer of peritonaeum continuous with the anterior and posterior coverings of the uterus at either edge. They run from the uterus to the corresponding side wall of the pelvis in front of the sacro-iliac joint. The idero-sacral ligaments are two bands covered with peritonaeum, passing posteriorly from the upper third of the cervix to the third sacral vertebra; in each ligament there is a fiat band of muscle running along its outer part. The utero-vesical ligaments are two folds of peritonaeum passing from the sides of the uterus to the bladder and the internal boundaries of the utero-vesical pouch. Anomalies of Uterus and Vagina. — Faulty or arrested develop- ment of Miiller's ducts may cause anomalies of the uterus, the vagina, or of both. The chief varieties are : tderus unicornis, uterus bicornis, the uterus being bifid at upper extremity only; complete double tderus with one vagina ; complete double uterus and vagina; uterus masculinus Oviducts or Fallopian Tubes. — These are tubes situated one on each side of the uterus in upper border of the broad ligament. Each tube is 4+ inches (11 cm.) long and consists of the narrow isthmus near the uterus, the ampulla or wider portion near the 12 ANATOMY ovary, and the infundibulum or fimbriated extremity. The fim- briae run from the fringed edge of the ampulla. One fimbria is attached to the ovary and is called the tubo-ovarian ligament, or the fimbria ovarica. A narrow strip of the lower surface of the tube is in contact with the connective tissue between the two layers of the broad hgament. Each has three coats : external or peritoneal; middle or muscular; internal or mucous lined with columnar ciliated epithelium. The Parovarium or Organ of Rosemnuller. — This is the homo- logue of the epididymis in the male. It is situated in the broad ligament, on either side, between the ovary and the ampulla of the Fallopian tube, and is lined by cihated epithelium. It is composed Fig. 14. — Longitudinal Folds of Tubal Mucosa (Williams) of tubules which converge toward the ovary and are connected by a longitudinal tube, the duct of Gartner. This duct is a rem- nant of the Wolffian duct, and is the homologue of the vas deferens. This organ is originally the paroophoron plus the epoophoron, which are respectively the renal and sexual portions of the meso- nephros in the female. These atrophy in development and the re- mains are called parovarium. Ovaries. — These are two in number, very rarely three, are sit- uated behind the broad hgament on each side at the level of the pelvic brim about midway between the psoas muscle and the uterus. The folds of the broad hgament form a sort of mesentery, the mesovarium attached to the hilum of the ovary. Each ovary is attached to the fimbriated extremity of the Fallopian tube by one fimbria, and is connected with the uterus by the hgament of the ovary. The ovaries are almond-shaped, and H inches (3 cm.) THE FEMALE REPRODUCTIVE ORGANS 13 long, I inch (2 cm.) wide, ^ i^^'^i (^ cm.) thick, each weighing one to two drams (6 gm.). Tlioy are covered by a layer of cyhndrical cells (germ epithelium) unhke the squamous epithelium of the peritonaeum. The outer surface is pale, looking like a mucous surface and not like the glistening peritoneum. " The white line of Farre" is the raised white line of tissue at the junction of the ovary and the broad ligament, marking the junction of the peritonai'um and the layer of germ e]:)it helium covering the ovary. In the ovary there are two portions or zones. A medullary portion or zona vasculosa, consisting of connective tissue, un- striped muscle, and numerous blood-vessels and lymphatics. A cortical, or parenchymatous zone, ^ by the naked eye. They have a cap- ^^^ i5.-Human Owm sule of three layers : the external, or (Reichert). x 6. tunica fibrosa, consisting of COnnec- e.a., embryonic area; v., villi. tive tissue with vessels ; the internal, or tunica propria, consisting of non-vascular connective tissue; and the membrana granulosa, lining the tunica propria. This is the most important layer of the three, being an epithelial Uning which is made up of rounded nucleated cells several layers deep. At points over this membrane the cells are heaped up in a mass (discus proligerus) surrounding the female sexual cell, the ovum. The ovum or ovule is a highly organized cell about 2i)i) inch (.01 mm.) in diameter, and has a structure peculiar to itself. There is a tough, elastic, and transparent investing membrane, called the vitelline membrane or zona pellucida. This surrounds a semifluid protoplasmic mass, the Tjolk or vitellus. In this mass, correspond- ing to the nucleus of an ordinary cell, there is an oval body con- taining a few granules, but more transparent than the rest of the yolk, which is called the germinal vesicle. Among these granules is a spot, corresponding to the nucleolus of a cell — the germinal spot. 14 A^TATOMY THE MAMM^ OR MAMMARY GLANDS These are two large milk glands, situated one on either side, between the two layers of the superficial fascia upon the pectoralis major muscle over a space corresponding to that between the third and seventh rib. Quite a third of each gland hes upon the serra- tus magnus muscle and beyond thfe anterior border of the axilla. The axillary lobe reaches upward in the axilla, to the upper bor- der of the third rib, where it is in contact with the central set of the lymphatic glands. Each gland presents three zones — peripheral, middle, and cen- tral—known as Charpentier's zones. The peripheral one is the larg- est ; it has a smooth white surface, through which the underlying veins are easily visible. The middle zone, or areola, is about ^ inch wide ; its color is pale rose in virgins, slightly darker in brunettes, but this color becomes much darker during pregnancy. It contains many sebaceous glands, and in addition twelve to twenty papular or tubercle-like projections called the tubercles of Montgomery. The central zone is occupied by the nipple, which is nearly | inch high and ^ inch in diameter. Its surface is slightly roughened from the presence of papillae. The nipple may be retracted ; this is seen especially in mahgnant disease of the breast. The gland itself is racemose, there being from fifteen to twenty lobes, each composed of lobules, which are again divided into acini or cul-de-sacs. The ducts of the lobules drain the acini and unite to form the excretory ducts of the lobes — galactophorous or milk ducts. These end in the lactiferous sinuses in the nipple. In ad- dition to the glandular substance each contains transverse and longitudinal muscles and some connective tissue. Beneath the peripheral portion there is considerable fat. The skin covering the gland has developed in it sebaceous glands and hair follicles. CHAPTER II PHYSIOLOGY Ovulation. — The chief functions of the ovary are to supply the ovum and to expel it, when ready for impregnation, into the Fallo- pian tubes. In the human female this expulsion is closely related to menstruation, occurring usually before the commencement of the period and immediately following the rupture of the follicle. Graafian follicles develop very early, but only begin to mature at puberty, and continue to mature throughout the entire child-bear- ing period. Ovulation, however, ceases during the periods of ges- tation and lactation. When ovulation is about to occur one of the follicles becomes especially developed, grows and becomes congested and distended with fluid. The coverings of the ovary over the follicle are thinned by pressure and rupture occurs. The ovule, surrounded by some cells of the membrana granulosa escapes into the fimbriated extremity of the Fallopian tube, which grasps the ovary over the site of rupture and is propelled along the tube by the cilia and the muscular contraction of the tube walls. The follicle, after its rupture, and the escape of the ovum, is called the corpus luteum. Of these there are two kinds, the true and so-called false corpus luteum. The true corpus luteum is the corpus luteum of pregnancy. The follicle continues to grow until the third or fourth month and projects on the surface of the ovary, the size being 1 inch by h inch (2.5 by 1 cm.). After this it com- mences gradually to decrease and disappears about the end of gestation. The false corpus luteum is formed when impregnation of the ovum does not occur. After the escape of the ovum the edges of the rent in the follicle adhere and the folHcle shrinks. The inner layer becomes wrinkled and begins to show yellow folds, which enlarge and adhere, filling the cavity. The yellow color gradually changes to white. There is progressive diminution in size, and in about forty days disappearance occurs, leaving a slight depression on the surface of the ovary. 3 15 16 PHYSIOLOGY Menstruation. — This is known by various names, catamenia, periods, monthly sickness, courses, etc. It becomes estabhshed at puberty, in temperate chmates at about fourteen to sixteen years, but it may come on earher in hot chmates and later in cold. It occurs regularly every twenty-eight days in the majority of women, although in some it may be every twenty-one. Its average dura- tion is four to five days. The quantity of blood lost varies from 2 to 4 ounces (64—124 gm.) ; but this is more or less affected by climate and modes of living; more is lost by women living in hot climates or those living an easy, luxurious life. The blood is pure, but does not coagulate except w^hen there are large amounts, on account of the mucus contained in it. At first it is dark, but becomes lighter in color. The menses usually have a slight odor: The blood is derived from the mucous lining of the uterus, the mucous membrane being intensely congested at the time of men- struation. The time of the cessation of menstruation is uncertain, but generally occurs at the age of forty-five to fifty, frequently earlier, sometimes later. After this time Graafian follicles no longer mature, and the ovaries become shriveled and wrinkled on the surface. The Fallopian tubes become atrophied and some- times obHterated. The uterus decreases in size. This is es- pecially marked in the cervical portion. Its projection into the vagina disappears, and the orifice of the os uteri in old women is often found to be flush with the roof of the vagina. Theory of Menstruation. — Some say that menstruation depends on ovulation. There is certainly a close connection between ovula- tion and menstruation. Others say that ovulation does not de- termine menstruation, which is probably correct. It is likely that both ovulation and menstruation depend on a common cause, the periodic nervous excitation and congestion due to an impulse from the sympathetic system (Hirst). They generally occur together, but there are many exceptions and either may occur without the other. Conception and Generation. — Conception means the union of two living elements — one male, the other female — and is effected by union of the spermatozoon with the ovum. This union is called fecundation or impregnation. It is simple or single if one ovum has been impregnated, multiple if two or more ova have been impregnated. The spermatozoa are ejaculated in the semen, a viscid, opales- CONCEPTION AND GENEEATION 17 cent fluid. Each has a head, body, and tail and possesses a power of movement similar to that of an eel in water. This movement is very important in conception. They may live for many days in the female genital tract. Impregnation takes place probably in the Fallopian tubes near the pavihon. The spermatozoa move up through the uterus and tubes to meet the ovum. Even when deposited at the vulva they may pass up through the vagina, cervical canal, and uterus, into the Fallopian tubes. This is brought about partly by their own vibratory motion, and partly by their being sucked up by the uterus. CHAPTER III THE EMBRYO AND FCETUS Early Changes in Ovum. — After impregnation segmentation of the yolk begins. The yolk-mass becomes divided up into first two, then four, eight, sixteen, and so on, parts, each of which is a nucleated cell. When segmentation is completed some of the cells arrange themselves in a layer around the periphery of the ovum, thus forming a membrane enclosing the rest of the cells. The enclosed cells adhere in a mass to one spot on the inner surface of the enclosing layer and thus form the embryonic area. At this spot the embryo commences to be formed. The outer layer is called the epiblast; the inner layer of adherent cells the hypo- blast. A middle layer grows from the angle of their union and is called the mesoblast. At the central part of the ovum a quantity of fluid appears. The ovum now has four layers surrounding the cavity contain- ing the fluid, which are from without inward — the zona pellu- cida; the epiblast; the mesoblast; the hypoblast. The three in- ner layers are fused together in the embryonic area. The meso- blast splits into two layers, one of which is united to the epiblast, forming the somatopleure ; the other is united to the hypoblast, forming the splanchnopleure. The embryo now commences to be formed and sinks toward the center of the ovum and develop- ment into the foetus is commenced. During this development from embryo into foetus several very important structures are formed. Decidua. — After impregnation the uterine mucous membrane becomes congested, convoluted, and hypertrophied ; it is called the decidua vera. When the ovum enters the uterus it lodges be- tween two folds of the decidua vera. The decidua grows around the ovum, forming the decidua reflexa. For a time there is a space between the decidua reflexa and decidua vera which con- tains a mucous fluid. At the end of three months this space it 18 DECIDUA 19 obliterated by the union of the two layers. That portion of de- cidua vera on whirh tho ovum rests is called the decidua serotina. Fig. 16. — Uterus lined by Decidua, containing Seven- to Eight-Days' Ovum (Leopold), x 1. There are three membranes surrounding the embryo from within outward : the amnion ; the chorion ; the decidua refiexa ; and serotina. The amnion is essentially a foetal membrane, formed from a fold of the somatopleure, principally from the head to the tail ends, but also from the sides. Two layers are formed: (1) the internal layer of amnion, or true amnion, which surrounds the foetus, but becomes grad- ually distended with amniotic fluid ; (2) the external layer of amnion, or false amnion, or prechorion, which unites with the allantoic structures, forming the cho- rion. The chorion is made up of two layers, the prechorion or false amnion and the allantois. The allantois is a continuation of the intestinal mucous membrane, mostly solid, although there is a small hollow in the stalk. It spreads inside the O^ Fig. 17. Fig. is. Figs. 17, 18. — Diagrams SHOWING Formation OF Decidua Reflex.^ (Coste). 20 THE EMBEYO AND FCETUS hollow amniotic pouch and finally surrounds the foetus. The por- tion of the allantois within the abdominal walls becomes the apical part of the bladder and the urachus. The portion out- side the abdominal plates forms the vasculosa or inner layer of the chorion and part of the umbilical cord. The vitelline mem- brane is so greatly thinned by enlargement of the ovum that it practically disappears. The chorion shortly becomes covered with projecting villi. Each villus receives a capillary vascular loop from the vessels of the allantois. These grow especially in that Fig. 19. — Diagram showing Transverse Section through Mammalian Embryo, showing Formation of Amnion (Williams). part which is concerned in the formation of the placenta. The villi after a time disappear from the remaining portion of the chorion. There is therefore from within outward the inner layer of. the amnion containing the liquor amnii, in which the foetus floats. Outside this there is the allantois united with the outer layer of the amnion forming the chorion. After a time the chorion blends with the decidua reflexa and the reflexa with the vera ; so that at birth this outer layer is formed of three, the chorion, the decidua reflexa, and decidua vera; the inner layer is formed of the true amnion alone. Placenta. — This in the human female is a circular mass attached to the internal surface of the uterus, generally at or near the fundus. PLACENTA 21 E. "RT \ Fig. 20. — Seventeen-Days' Pregnant Uterus. x 1. (Anatomical MuseTim, Johns Hopkins University.) Embryo drawn relatively too large (Williams). D.R., deeidua reflexa; D.S., decidua serotina; D.V., decidua vera; E., embryo; O.L., ovarian ligament; R.L., round ligament. It is developed in the decidua vera. Its average diameter is from 6 to 9 inches; it weighs from 1 to 1^ pounds. Its functions are: (1) respiration, (2) nutrition, and (3) ex- cretion. 1. Respiration. It acts as the lung, or rather the gill, in oxy- genating the foetal blood by the interchange of gases which takes 22 THE EMBKYO AND FCETUS place between the foetal and maternal blood. The blood from the foetus, darkened with carbon-diox de, passes through the umbil- ical arteries to the placenta, and the oxygenated blood returns through the umbilical vein of the ^oetus. 2. Nutrition. The epithelial cells of the chorionic villi absorb nutriment from the foetal blood and in doing so show a selective power. 3. Excretion. The epithelial cells of the chorionic villi also excrete waste products from the foetus. The foetal membranes cover the foetal surface of the placenta and pass from its edges to Hne the portion of the internal surface of the uterus not including the decidua serotina, but do not form a sheath to the cord, as formerly s u p - posed. The cord is generally attached at or near the center of the placenta. The maternal surface is rough and divided by numerous sulci. After expulsion of the placenta, this surface is covered by the superficial or cel- FiG. 21.— Diagram of Placenta. lular layer of the decidua serotina, while its deeper layer remains attached to the wall of the uterus. Numerous small openings are found on it which are the apertures of veins torn off from the uterus. Structure and Formation of the Placenta. It is made up of two portions : a foetal portion containing the hypertrophied villi of the chorion with their contained vessels, and a maternal portion containing the decidua serotina with its contained vessels. These two portions are intimately blended, forming the placenta which is expelled after the birth of the child. It is formed in the following manner : The villi of the chorion penetrate the decidua serotina, forming large sinuses into which the villi enter. The intervening structures between the two sets pf vessels are, to a large extent, but not altogether, absorbed. APPEARANCE OF THE F(ETUS 23 There is never any direct communication between these two sets of vessels — i. c., the maternal and foetal blood never mix. Be- tween the maternal blood, coming directly from the lungs and fully oxygenated, and that of the foetus which is carbonized, there is only a thin layer of tissue, composed of (a) the epithelium cover- ing the surface of the villus, (b) the tissue of the villus itself, (c) the wall of the small branch of artery in the villus. The epithelium covering the surface of the villi is partially, if not wholly, absorbed. Through this thin layer, or diaphragm, the two currents of blood interchange their gases and soluble substances by diffusion and osmosis. The carbon-di- oxide gas from the foetus passes into the maternal blood, while oxygen passes from the maternal blood into the foetus. Umbilical Cord. — This is the channel of communication between the foetus and the placenta, passing from the umbilicus to the center of the placenta (generally). It is generally 18 to 24 inches (46 to 61 cm.) long, but may be in exceptional cases 5 to 60 inches (13 to 152 cm.). At birth it is formed of an external layer derived from the skin of the embryo, two umbilical arteries, an umbilical vein, and the remains of the allantois embed- ded in a gelatinous substance called ' 'Wharton's jelly." Early in foetal Hfe the vessels are straight, but soon become much twisted. The arteries are external to the vein and have no branches; the vein has no valves. The pedicle of the umbilical vesicle, which is present early in pregnancy, disap- pears. Sometimes a funnel-shaped diverticulum of the coelome (a diverticulum of the abdominal peritonaeum) persists into which coils of the intestine may pass and be strangulated during the ligature of the cord. Appearance of the Foetus at Different Months. — The following short description will indicate the development of the foetus. At the end of the first month the ovum is about | inch (2 cm.) long, being about the size of a pigeon's egg. The embryo is about 4- inch (1 cm.) long. The umbilical vesicle is smaller th^D Fig. 22. — Section through Young Umbilical, Cord (Minot). A., artery; AIL, allantois; U.S., stalk of umbilical vesicle; V., vein. 24 THE EMBEYO AND FCETUS the embryo. The amnion is separated by a small interval from the chorion. At the end of the second month the ovum is 2 inches (5 cm.) long, being about the size of a hen's egg. The amnion is distended Fig. 23. Fig. 24. Fig. 25. Fig. 26. Figs. 23-26. — Embryos from Fourth and Fifth Weeks (His), x 2. and is in contact with the chorion. The villi of the chorion are more developed. The cord is straight. At the end of the third month the ovum is 4 inches (10 cm.) long. The placenta is formed. The villi in the other portions of Fig. 27. Fig. 28. Fig. 29. Figs. 27-29. — Embryos from Second Month (His). x2. APPEARANCE OF THE FCETUS 25 the chorion have nearly disappeared. The cord is longer and slightly twisted. The limbs anfl head have developed. At the end of the fourth month the foetus is 6 inches (15 cm.) long and weighs 3 ounces (93 gm.); the sex is distinguishable. Fig. 30. Fig. 31. Fig. 32. Fig. 33. Fig. 34 Figs. 30-34. — Composite of Fcetuses at Ages of Two, Three, Five, Seven AND Nine Months respectively. At the end of the fifth month the foetus is 9 inches (23 cm.) long and weighs 11 ounces (342 gm.) There is hair on the head and lanugo or down covers the body. The foetus when born may move, and such movements continue for some hours. 26 THE EMBKYO AND FCETUS At the end of the sixth month the foetus is 12 inches (30 cm.) long and weighs 24 ounces (746 gm.) The eyebrows and lashes are beginning to form. The foetus born at this time may breathe feebly, but soon dies. A little meconium exists in large intestine. At the end of the seventh month the foetus is 15 inches (38 cm.) long and weighs 45 ounces (1,400 gm.). The eyelids are open. The child is viable. The face is wrinkled. One testicle generally is in the scrotum. The nails do not reach the tips of the fingers. The membrana pupillaris is absent. At the end of the eighth month the foetus is 17 inches (43 cm.) long and weighs 4^ pounds (2,200 gm.). The face is less wrinkled, owing to a greater deposit of subcutaneous fat. The foetus may live. At the end of the ninth month (full term), the foetus is 21 inches (53 cm.) long and weighs 7 pounds (3,470 gm.). The finger nails project beyond the tips of the fingers. It is covered with the Fig. 35. — Child's Head at Term. (American Text-Book.) vernix caseosa, a greasy material formed of epithelial scales and the secretion of the sebaceous glands. The foetus at full term presents some very important charac- teristics, differing in some respects from the adult. THE FCETAL HEAD 27 The Foetal Head. — The bones of the skull, particularly at the vertex, are but loosely joined together by membrane allowing the head to be molded, to a certain extent, in passing through the mother's pelvis. The su- tures are merely mem- Ucciput branous septa between the separate bones. They are as follows : the sagit- tal suture unites the two parietal bones; the fron- tal unites the two por- tions of the frontal bone and is continuous with the sagittal suture; the coronal unites the frontal and the parietal bones and extends from the squamous portion of the temporal bone across the head ; the lambdoidal unites the occipital and the parietal bones. Fontanelles. In two places there are membra- nous interspaces where the sutures join each other; these are called fonta- nelles. One, the anterior fontanelle, is larger and lozenge-shaped ; it is formed at the junction of the frontal, sagittal, and coronal sutures. The other, the posterior fontanelle, is smaller and tri- angular; it is formed at the junction of the sagittal suture with the two arms of the lambdoidal suture. Diameters. A knowledge of the diameters of the foetal skull is of great importance. They are as follows : The occipito-mental, from the occipital protuberance to the point of the chin, 5^ to 5j inches (13 cm.); the occipito-frontal, from the occipital protuber- ance to the center of the forehead, 4 J inches to 5 inches (12 cm.) ; the suhoccipito-bregmatic, from a point midway betw^een the oc- cipital protuberance and the margin of the foramen magnum to the center of the anterior fontanelle, 4 inches (10 cm.) ; the cervico- FiG. 36. — Child's Head at Term, x f . (American Text-Book.) 28 THE EMBEYO AND FCETUS hregmatic, from the anterior margin of the foramen magnum to the center of the anterior fontanelle, 4 inches (10 cm.); the hi- parietal or transverse, between the parietal protuberances, 4 inches (10 cm.) ; the fronto-mental, between the apex of the forehead and chin, 3 J inches (9 cm.). These diameters may be altered by compression and molding during labor. Foetal Circulation. — The chief difference between the course of the blood in the foetus and that in the adult is that in the former there is no pulmonary circulation. The umbilical vein, bringing blood from the placenta to the foetus, after entering the umbilicus sends two branches to the liver joining the divisions of the portal vein, while the main trunk, called the ductus venosus, empties into the inferior vena cava. The blood from the liver also empties through the hepatic vein into the inferior vena cava. The pure blood from the placenta is thus mixed with the blood coming through the inferior vena caVa from the lower extremities. The inferior vena cava empties the blood into the right auricle. From the right auricle the blood is directed by the Eustachian valve through the foramen ovale into the left auricle; — from the left auricle into the left ventricle; from the left ventricle into the aorta. The greater portion of the blood passes through the branches of the aortic arch to the head and upper extremities. From these the blood returns by the descending vena cava to the right auricle; from the right auricle to the beginning of the pulmonary arteries ; thence into the ductus arteriosus; thence into the descending aorta; thence a portion into the lower extremity which returns by the ascending vena cava; and a larger portion passes along the umbilical arteries to the placenta. Changes after Birth. — The current through the umbilical ves- sels ceases, the portion of cord retained drying up and falling off; the umbilical arteries inside the abdomen, that is, the foetal hypo- gastric arteries, become permanent in a part of their course, constituting the superior vesical arteries; the ductus venosus and the ductus arteriosus shrivel into fibrous cords ; the foramen ovale closes ; the lungs expand ; the blood which formerly went through the ductus arteriosus now passes through the pulmonary arteries to the lungs; the blood from the lungs returns by the pulmonary veins to the left auricle; from the left auricle it passes into the left ventricle; from the left ventricle it passes into the aorta and is distributed to the head, trunk, and extremities. NERVOUS SYSTEM 29 Foetal Liver and its Functions. — It is large proportionately, and assumes its characteristic structure and secretes bile about the fifth month; it helps to form sugar, which is abundant in the foetus. The bile is partly collected in the gall-bladder and sub- sequently passes into the intestinal canal. Here it mixes with the intestinal mucous secretions, forming the meconium — a thick tenacious greenish substance which is voided in considerable quan- tities soon after birth. Urine. — A certain amount is formed during intrauterine life, some of which may be voided into the amniotic cavity. (This is denied by some.) Nervous System. — The nervous system is developed to some extent, perhaps sufficiently to allow reflex action. The gray mat- ter of the brain is quite rudimentary in new-born babes. CHAPTER IV PREGNANCY FCETUS IN UTERO Relations. — The following terms are used in connection with the relations of the foetus in the uterus: attitude, position, lie, presentation. Attitude refers to the relations of different parts of the foetus to each other. Position refers to the relation of a given surface of the foetus to the anterior, lateral, or posterior aspects of the mother. Lie refers to the relation of the long axis of the child to that of the mother. Presentation refers to the part of the child felt most prominently in vaginal examination. There is a certain confusion about the two terms, lie and pre- sentation. For instance, when the head is downward we are said by many to have a head presentation. This ought, in the opinion of some, to be called a head lie. The term head presentation is, however, more commonly used. Presentation, strictly speaking, means the part of the child which is first touched by the examin- ing finger while it is passing through the parturient canal. As expressed by Matthews Duncan, the term presentation means that point on the surface of the child's head through which the axis of the fully developed pelvic canal passes, or, as it is expressed more simply by Tyler Smith, the part which is felt most prominently within the circle of the os uteri, the vagina, and the ostium vaginae in the successive stages of labor. CHANGES IN THE MATERNAL ORGANISM Size of Uterus. — The uterus is greatly increased in size. It increases from 1 ounce (31 gm.) in weight and 2^ inches (6 cm.) in length to 24 ounces (746 gm.) in weight and 12 inches (30 cm.) in length. Before the third month the enlargement is chiefly in 30 CHANGES IN THE MATERNAL ORGANISM 31 the lateral direction. After the third month it is more in a vertical direction. At the end of the third month the fundus uteri is on a level with the pelvic brim. At the end of the fourth month it is 2 inches (5 cm.) above the symphysis pul:)is. At the end of the fifth month it is half-way between the pubis and the umbilicus. At the end of the sixth month it is on a level with the umbilicus. At the end of the seventh month it is half-way be- tween the umbilicus and the ensiform cartilage. At the end of the eighth month it is near the ensiform cartilage. At the end of the ninth month it sinks a little in the abdomen (about the last three weeks in primipara and the last week in multiparae). (Fig. 48.) The uterine w^alls become hypertro- phied, but, at the same time, somewhat softened. The enlargement takes place chiefly in the body of the uterus, while the cervix is very httle, if at all, enlarged. The increase in the size of the uterus corresponds to some extent to that of the foetus, but such increase is really a growth and not due to distention. In fact, the uterine cavity in early preg- nancy increases in size faster than the ovum, while, at the same time, the walls become thicker. At a later stage of pregnancy the ovum completely fills the cavity of the uterus, although there is but little or no pressure produced upon it as long as the uterine walls remain relaxed. One of the most remarkable things in this connection is the fact that in an ectopic gestation the uterus goes on increasing in size up to the fourth month or longer while the fructified egg is grow- ing in the tube. Lower Uterine Segment. — This portion of the uterine body, which is situated immediately above the internal os, deserves care- ful consideration. It is thinner and less vascular than the rest of the body. There is a well-marked ring between the lower and upper segment of the uterus which has received many names, as follows : ring of Bandl, contraction ring, retraction ring, and re- traction ring of Schroeder. 4 Fig. 39. — Pregnancy (Five Weeks). (Tor. Univ. Mu- seum.) 32 PEEG^ANCY Cervix. — The cervical canal remains intact until about the end of pregnancy. It was formerly supposed that during the latter part of pregnancy the internal os was drawn up to a level above the symphysis and that the part of the cervix thus drawn up was dilated in such a way that it became, practically, a part of the uterine cavity which con- tained the ovum. We now believe that there is no enlargement of the internal OS until labor has com- menced or is about to com- mence. A certain amount of confusion has arisen be- cause there is an apparent shortening of the cervix. The cervix is really not shortened in the ordinary sense of the word. The erroneous impression that such shortening exists is probably due to the fact (as explained by Dakin) that the uterus passes down in the pelvis until some of the weight rests on the pel- vic floor at a spot on the posterior vaginal wall and that the cervix is thus compressed. It is usually bent so that the external os looks forward in the axis of the vagina. The second reason is that there is a downward bulge of the anterior uterine wall just above the cervix. The softening of the cervix, which occurs early in pregnancy, is due to oedema from congestion on account of the pressure of the uterus on the veins. It generally begins about the end of the first or early in the second month and can be readily detected in most cases, but especially in primiparse. It should be remembered in this connection that a similar condition, that of softening of the Fig. 40. — Pregnancy Two Months Ad- vanced, SHOWING Embryo, Membranes AND Villi op Chorion. (Tor. Univ. Mu- seum.) CHANGES IX THE MATEEXAL ORGAXISM 33 cervix, may be ])r()(luc(Ml by the jjrcsence of fibroid or otiicr tumors. The late Dr. Goodcll, of Philadelphia, attached a good deal of importance to this sign, and said that in the unimpregnated uterus the cervix on being touched by the finger felt about as hard as the end, of the nose, while in the impregnated uterus it felt about as soft as the surface of the lips. The cervical canal contains a plug wliich has been called by some the operculum. Considerable interest is attached to this plug, inasmuch as it forms a barrier which, under ordinary circumstances, prevents path- ogenic germs from passing into the uterine cavity during preg- nancy. Reference is also made to the operculum in the chapter on Puerperal Infection. Broad Ligaments and Peri- tonaeum. — As the fundus uteri rises in the abdominal cavity the broad ligaments are carried with it so that the edge, instead of being nearly horizontal, after a time becomes almost vertical ; at the same time the fundus of the uterus becomes much ele- vated above the level of the two cornua. About the end of preg- nancy the tubes appear to join the uterus about midway be- tween the fundus and the inter- nal OS (see Fig. 84). The peritonaeum is probably to some extent stripped from the bladder. The central part of the lower portion of Doug- las's cul-de-sac does not appear to be raised during pregnancy. There is some hypertrophy of the round ligaments and also of the muscle-fiber in the broad ligaments. The increase in the round ligaments is so great that they can often be felt through the ab- FiG. 41. — Pregnancy Three Months, SHOWING FCETUS BeLOW, CoRD, AND Placenta forming on Right Side Above. (Tor. Univ. Museum.) 34 PEEG^^ANCY dominal walls at the latter part of pregnancy, the left being more readily felt on account of dextrorotation of the uterus, which brings the left side forward. The ovaries are lifted slightly above the pelvic brim and are brought closer to the side of the uterus on account of the growth of the lat- ter between the layers of the broad ligament. Decidua. — The mucosa dur- ing labor consists of three layers : compact, spongy, and deep. The compact layer is superficial and has decidual cells lying between the glands, which are much di- lated with epithelium flattened and degenerated. The spongy or middle layer has glands widely dilated with spindle cells and fibers of connective tissue be- tween them. The deep layer is thin and dense and consists of connective tissue containing blind ends of glands whose epithelium is unchanged. It is closely at- tached to the muscular wall. The separation of the decidua at abortion or full-time parturi- tion occurs through the spongy layer, the dilated glands acting like the row of perforations be- tween two postage stamps and allowing separation to occur eas- ily. After the separation of the decidua the mucosa is renewed, and covered by the epithelium of the blind ends of the glands which remain attached to the muscular wall (Fothergill). This is again referred to in the chapter on Abortion. Circulatory System. — It was formerly supposed that the blood in pregnancy was increased in quantity and also changed in char- acter. It was thought that it became more watery and contained Fig. 42. — Five Months Peegnancy. Placenta with Sac containing FcETUs attached. (Tor. Univ. Mu- seum.) CHANGES m THE MATERNAL ORGANISM 35 more fibrin and white corpuscles, and at the same time fewer red corpuscles and less albumin. It has been clearly demonstrated, however, in recent years that no important changes occur in the blood during pregnancy. The slight increase in the number of the white blood corpuscles, or leucocytosis, which occurs during the last few days of pregnancy, but especially during the first week of the puerperium, is referred to in another chapter. It is also thought by many recent observ- FiG. 43. — Full Term Pregnancy; Fcetus in Sac, Membranes partially Detached from Edge of Placenta. (Tor. Univ. Museum.) ers that the amount of haemoglobin and red corpuscles is actually increased in the latter part of pregnancy. Nervous System. — The irritability of the nerve centers becomes increased. It is likely that the changes which take place in the 36 PEEGNANCY nervous system are entirely functional. This is the general rule, to which, however, there are some exceptions. In certain cases changes appear which are serious in character and can scarcely be called functional, as, for instance, mental disorders, chorea, and other affections showing more or less loss of regulating power. Respiratory System. — The breathing becomes more thoracic and sometimes embarrassed. This is due to the fact that the uterus, as it rises in the abdominal cavity, presses against the diaphragm Fig. 44. — Pendulous Abdomen of a Multiparous Woman with Normal Pelvis, showing also Old and New Stri^ (Williams). and thus diminishes the thoracic space. Some say, however, that this space is not much diminished, because as the diaphragm presses upward the thorax widens to a slight extent at its base. Some contend that the vital capacity of the chest is only slightly, if at all, diminished. I am not sure whether this statement is correct, but we know from clinical experience that in certain pa- tients, especially in those who have a tendency toward bronchitis or asthma, or both, there is a certain amount of embarrassment of the breathing apparatus, which is caused by the changed condi- tions which prevail in pregnancy. CHANGES IN THE MATERNAL ORGANISM 37 Osseous System. — OstcMjphytcs or irregular bony deposits are frequently found between the skull and dura mater. These, how- ever, are not peculiar to pregnancy and are not important. Urinary System. — The urine is greater in quantity, possibly from increased arterial pressure, and is more watery. The spe- cific gravity is about 1.014. Albumin and sugar arc found in a certain proportion of cases without giving rise to serious symptoms. Cutaneous System. — Many changes take place in the skin dur- ing pregnancy. Pigmentation occurs in certain parts of the body, especially in the breasts, where the areola becomes much darker in color, and in the abdomen, where a similar change takes place in the linea alba. This deposit of pigment is more marked in bru- nettes than in blondes. Sometimes the skin of the face shows deposits of pigment as irregular patches on the forehead and the neck (chloasma). There is also increased activity of the glands of the skin, especially the sebaceous and sweat-glands. Some- times the enlargement of the glands may cause lumps, particularly in the skin of the axilla; such lumps should not be confounded with supernumerary breasts which sometimes appear in the same position. Where the skin is much stretched, as, for instance, on the sur- face of the abdomen, certain markings are found. These are due to cracks in the skin, which are called striae, linese albicantes, or linese gravidarum. They are due to changes in the corium caused by stretching, and they lie at right angles to the direction of the stretching. The epidermis covering the cracks does not show any change in structure. The striae are mostly oblique in direction, running downward and inward. The color of these cracks is at first gray or pinkish and sometimes a bluish purple. These lines sometimes grow whiter and more opaque after labor. If small striae are formed in subsequent pregnancy, the difference between the old and the new is quite easily recognized (Fig. 44). Alimentary System. — -Although disturbances of the digestive organs are apt to arise, it is not likely that in healthy women assimilation is often seriously affected. However, it happens in a certain proportion of cases that evil effects arise on account of defective assimilation, such as osteomalacia, acute atrophy of the liver, general toxaemia, etc., which will be considered in connec- tion with the diseases of pregnancy. 38 PEEGNANCY Bladder. — The bladder is affected, to some extent, on account of the pressure of the ante verted gravid uterus. Under ordinary- circumstances the position of the uterus early in pregnancy is largely affected by the condition of the bladder (full or empty). As pregnancy advances, however, the uterus ceases to be affected by the bladder and the conditions are reversed ; that is, the blad- der has to adapt itself to the space available for it. The bladder is especially pressed upon during the first three months of preg- nancy. After the uterus rises above the brim there is for some months more room for the bladder in the pelvis. In the last couple of months, however, the lower part of the uterus again occupies a good deal of space within the pelvis and the bladder is then much pressed upon. Under such circumstances the bladder frequently rises above the pubes in such a way that it lies between the anterior abdominal wall and the uterus. It happens that there is no fixed rule about the position of the bladder in the latter part of pregnancy, and on this account it is often quite difficult to pass a catheter at this time. Howard Kelly says the female blad- der expands physiologically like saddle-bags, most from side to side and least in an antero-posterior direction, and this method of distention becomes more marked in pregnancy. Intestines. — Intestinal peristalsis is generally impaired during pregnancy. It is especially important to consider the condition of the rectum. The pressure on the rectum is apt to produce con- stipation, sometimes of an obstinate form. Another very common and serious condition is that of piles, which is produced by pressure on the pelvic veins. In a fairly large proportion of cases haemorrhoids appear during the first pregnancy for the first time, and sometimes require careful and judicious treatment. DIAGNOSIS OF PREGNANCY In a great majority of cases pregnant women make their own diagnosis, and engage the accoucheur to attend them during labor. The physician when called on to decide as to the condition will get little credit for making a correct diagnosis, while, on the other hand, he will be seriously blamed for a mistaken diagnosis. It is very important in certain instances that no mistake be made, especially where the reputation of the patient is at stake. DIAGNOSIS OF PREGNANCY 39 It is sometimes exceedingly difTirult, if not impossible, to make a correct diagnosis. Under such circumstances it is better to wait for a time and perhaps make repeated examinations before giving a definite opinion. Mistakes in the diagnosis of pregnancy happen to be somewhat frequent and occur even in the hands of very care- ful practitioners. A few years ago a man of large experience examined a patient and made a diagnosis of ovarian tumor. He decided to operate and made all the necessary arrangements. It was discovered, however, when the woman was placed on the table for operation, that she was pregnant, nearly at full term. In other cases which might be narrated the mistake was not detected until the ab- domen had been opened. About a year ago a patient was sent to a surgeon of this city to be operated upon for a supposed ovarian tumor. As there was considerable obscurity about the condition present I was called in consultation. We examined the patient very carefully under chloroform and formed the opinion that there was a pregnancy advanced about six months and that the foetus was dead. The patient denied the possibility of such a condition and her relatives were seriously offended. We were allowed shortly afterward, however, to empty the uterus, and found a dead foetus six months advanced. In such a case one assumes a serious responsibility in giving a decided opinion, especially when, as in this instance, the patient is an unmarried girl. It is important in such a case to get one or more consultants to share the responsibility. A patient herself will sometimes make the error of considering that she is pregnant when no such condition exists, and this not unfrequently happens even with women who have previously borne children. Further references to such mistakes are made in connection with the Differential Diagnosis of Pregnancy. SIGNS AND SYMPTOMS The ordinary signs of pregnancy have been classified in various ways. By some they are divided into the probable, or symp- tomatic signs depending upon changes taking place in the mater- nal organism, and the physical or direct signs produced by the growth of the uterus and the ovum. The simplest plan is to considei the signs pretty much in the order in which they occur. 40 PEEGNANCY Cessation of Menstruation. — The suppression of menstruation, or the amenorrhoea of pregnancy, is in many respects the most im- portant sign, because it is the first which leads a woman to suspect that she is pregnant. It is not a certain sign. Irregular haemor- rhages taking place during pregnancy from various causes are frequently mistaken for menstruation. In other instances it is possible for genuine menstruation to occur during early preg- nancy, that is, during the first three months, while there is still a space between the decidua vera and the decidua reflexa. We hear of cases in which menstruation has been supposed to occur during the whole of pregnancy. There may be haemorrhages at any time during pregnancy, and they may occur with a certain amount of regularity, but they are not menstrual discharges when they occur during the fourth and later months. Suppression of menstruation, even in the healthy, may occur from various emotional and other causes. Such temporary cessa- tions of menstruation without pregnancy are especially apt to occur shortly after marriage or after illicit intercourse. The occurrence of pregnancy during the amenorrhoea of lacta- tion is not at all uncommon. Many women while nursing their children become pregnant and have no suspicion of any such con- dition until they feel the motion of the child within the uterus — that is, quickening. Morning Sickness. Nausea and vomiting are common in preg- nant women, and as the sickness occurs more frequently in the morning it has received the name of morning sickness. There may be simple nausea with no other disturbance, or there may be nausea accompanied by retching, or there may be nausea accom- panied by more or less vomiting. These symptoms commonly occur about the end of the first month, and are generally relieved or mitigated at the end of the fourth or fifth month. They may, however, occur almost imme- diately after conception and continue through the whole of preg- nancy; on the other hand, they may be absent altogether. It happens in a certain proportion of cases that the nausea and vomit- ing become so serious as to require careful treatment. Changes in the Breast and Nipples. — The mammary changes are especially important in those pregnant for the first time. They sometimes occur very early, in which case there may be from the very onset of pregnancy a sense of fulness and tenderness in the DIAGNOSIS OF PREGNAXCY 41 breasts. In the second month a distinct enlargement of the breasts may be apparent, and such enlargement is more mani- fest as pregnancy advances. As the enlargement takes place chiefly in the glandular tissue the breast has a knotty feeling ; in the latter months the large blue veins may be distinctly visible under the skin. Changes in the nipples and the areolse are still more pronounced. The nipples generally become more prom- inent and are often covered with minute branny scales due to the drying of the secre- tion which oozes from them. A sec- ondary areola may be visible during and after the fifth month and its presence af- fords a strong pre- sumption of preg- nancy. In the latter part of pregnancy the breasts droop to a certain" extent, causing the nipples to become directed downward, and thus better adapted for the infant to seize. Secretion in the breasts begins early, and a clear liquid may be squeezed from the nipple as early as the third month. The fluid, however, which is formed in the gland early in pregnancy is not milk, but a mucoid fluid which is quite clear and transparent. After a time microscopical examination re- veals colostrum corpuscles which are similar to those found in the breast secretion immediately after delivery. Changes in the breast similar to those described may occur with various uterine and ovarian disorders and in those cases of imaginary pregnancy called pseudocyesis. Changes in Size, Shape, and Consistency of the Uterus. — The uterus commences to enlarge shortly after fecundation of the egg. The increase in the size of the body is chiefly in the antero-posterior diameter during the first few weeks, changing the pear shape of Fig. 45. — Bimanual Exam- ination SHOWING NO Enlargement of the Uterus. 42 PEEGNA^TCY the uterus into that of an "old-fashioned fat-belHed jug" (Par- vin). This "behying" of the uterine body can generally be de- tected in front of and above the cervix by one or two fingers in the vagina, while the uterus is pushed downward by the other hand. The body of the uterus also becomes soft, doughy, and elastic. This change in consistency can generally be detected on bimanual exami- nation. Hagar's sign appears early in pregnancy, about the sixth week, and depends on the softening of the lower uterine segment, which gives the im- pression to one making a com- bined examination that the body and the cervix of the uterus are disconnected. One or two fingers are passed into the vagina, or the thumb is passed into the vagina and a finger into the rectum, while the fundus is pressed down by the other hand from above. A great deal of importance is attached to this sign by many, but it does not always point to pregnancy. This softened condition of the lower uterine segment may sometimes be found in the non- pregnant uterus, being caused by congestion or inflammation pro- duced by tumors, etc. Softening of the Cervix and Enlargement of the Os. — The cervix begins to soften in its texture during the first month of pregnancy, owing to the congestion and the effusion of serum into its sub- stance. In the latter part of pregnancy the softening is sometimes so extreme that a beginner may find it difficult to distinguish the cervix from the vagina. The softening is superficial in the first month, is more marked by the fourth month, and reaches its ex- treme extent in the seventh or eighth month. The cervical glands secrete a larger amount of mucus during pregnancy than under ordinary circumstances. It is this tena- FiG. 46. — Bimanual Examination show iNG " Bellying " of Uterus. DIAGNOSIS OF PPtEGNANCY 43 cious mucus which forms the cervical jjlug or operculum. The external os becomes niore patulous than it was before impregna- tion. In most cases the finger may be easily introduced within the OS during tlie last three months of pregnancy in multipara?, but not iu pi'imipar;e. Changes in the Vaginja. — The changes in the color of the vaginal mucous membrane from normal to a dark purplish appear early in pregnancy and arc due to venous congestion. The vaginal walls become thickened and are thrown into folds which sometimes pro- trude slightly from the vaginal orifice. The laxity of the mucous Fig. 47. — Method of detecting Hegar's Sign (Williams). membrane is well marked after the sixth month and there is also a secretion of mucus. Hypertrophy of the Ureters. — Palpate back of the S3'mphysis with finger in the vagina and then starting above at one side of the 44 PREGNANCY joint draw the finger downward and slightly outward along the back of the pubes. Jellett says that the ureter, which here lies back of the pubes between the anterior vaginal and the posterior bladder wall, is displaced forward against the pubes and is felt to slip from under the finger. It is not easy to distinguish whether it is enlarged or not, but Jellett adds that if it is felt at all by the student it is prob- ably hypertrophied, because it is difficult to feel a non-hyper- trophied ureter. Ballottement. — This word is derived from halloter, to toss up like a ball. It means the sensation imparted to the fingers when they are placed beneath the foetus as it lies in the body of the uterus and is tossed up in the liquor amnii. The Avoman is placed on her back, or in a position mid- way between sitting and lying. As Gala- bin describes it, the finger in the vagina with its tip resting just in front of the cervix should give a sudden but gentle push or jerk upward. The foetus is then felt to recede from the finger and after a moment's interval to return with a gentle tap. The physician may not be able to feel the return tap, but if he feels the hard body (the foetus) recede and finds after a moment or two that it has Fig. 48. — Height of Fundus Uteri. Five months, between symphysis pubis and umbilicus ; six months, at umbiUcus; seven months, half-way between umbilicus and ensif orm cartilage ; eight and nine months, near ensiform cartilage, sinking in latter part of ninth month. DIAOXOSTS OF PT^EGXAXCY 45 returned to its former position he may consider that he has obtained the characteristic evidence furnished by this sign. Foetal Movements. — The movements of the foetus are usually felt by the mother when pregnancy is about four and one-half months advanced, but the time of such occurrence is very variable. This sensation of movement which the mother notices is called quickening, and is first hoticed when the uterus rises sufficiently into the abdomen to come in contact with the abdominal walls. The foetal movements become more evident and much stronger as pregnancy advances and may often be seen as well as felt during the later months. Quickening is of much importance in certain cases where it furnishes to the woman the first sign of pregnancy. Recognition of foetal movements by abdominal palpation proves to us not only that pregnancy exists, but also that the foetus is living. This is often of great importance when the foetal heart sounds can not be heard. The subjective sign of quickening — that is, the feeling of foetal movements by the mother, should not be considered in any case a positive sign of pregnancy. Even women who have before borne children may be deceived and may mistake intestinal move- ments for those of the foetus, as, for instance, in cases of pseudocye- sis. It is sometimes difficult even for the physician to be certain of foetal movements which may be simulated by movements of the intestines or of the abdominal muscles. Foetal Heart Sounds. — By auscultation over the abdomen of a pregnant woman several different sounds can be heard. The fol- lowing are mentioned by Smyly: foetal heart sounds, uterine souffie, funic or umbilical souffle, maternal heart sounds, respira- tory murmur of the mother, movements of the child, friction be- tween the uterus and the abdominal wall, crepitating noises due to air in the uterus or abdominal walls, the muscular susurrus — that is, the note given out by contracting muscle-fiber. The foetal heart sounds are said to resemble the ticking of a watch beneath a pillow, but it is better for one to learn them by listening to the heart of a young infant soon after birth. The sound is really double, but in a large proportion of cases only the first can be heard. The rate varies between 120 and 160 in the minute. It is much affected by accidental circumstances. Active foetal movements sometimes increase the rapidity to the extent of twenty beats in the minute. The condition of the mother often affects 46 PEEGNANCY the rate. When the rate of the mother's pulse is increased by- fever or other causes the foetal pulse may also be increased, al- though not in a proportionate degree. During a labor pain the foetal heart becomes slower and resumes its ordinary rate during the interval between the pains. In a tedious labor, if the vitality of the foetus is lowered by long continued pressure, the foetal heart rate becomes slower. In such a case the foetal heart often be- comes slower while the mother's pulse is becoming more rapid. Diminished rapidity of the foetal pulse is often an indication of danger to the child's life. The foetal heart sounds are acknowledged by all to furnish the most valuable sign of pregnancy. A recognition of such sounds proves beyond a doubt that a living foetus exists. After we have discovered the evidence of a living foetus the only doubt that can arise is due to the possibility of an extra-uterine instead of a uter- ine pregnancy. The foetal heart is most frequently heard at a point half-way between the umbilicus and the center of Poupart's ligament on the left side. This is because the sounds are best transmitted, as a rule, through the back of the foetus and when the foetus is in the first or most common position, with its back directed toward the left front of the mother's abdomen. In the second position, when the back of the child is directed toward the right front of the mother's abdomen, the sound is of course best heard on the right side. In face presentation the heart sounds are heard better through the thorax than through the back. In other cases when the back of the foetus is lying posteriorly the foetal heart is heard with difficulty or not at all. The only mistake which is likely to arise is that due to hearing the mother's pulse instead of the foetal heart. Generally speak- ing, one can easily distinguish between them by comparing the rate of the pulse of the mother with that of the foetus. Some- times when the woman's pulse is rapid there may be some diffi- culty. However, even in that case, if one listens with the stetho- scope and feels the radial artery at the same time, it will be found that the two pulses will not continue simultaneous for any length of time, one is sure to be slower than the other in time. It is thought by some that the pulse rate may be of some value m distinguishing the sex. If, for instance, the foetal pulse is 140 or more it is likely that there is a female child ; if it falls below DIAGNOSIS OF PREGNANCY 47 140 it is likely to be a male child. However, when we remember that the rapidity of the heart varies in the same children at differ- ent times and that it depends largely on the size of the child, we can easily see that the sign is not of much importance. Uterine Souffle. — The uterine souffle is a blowing sound syn- chronous with the mother's pulse, generally heard on one or both sides of the body of the uterus, but most frequently in the left flank. The sound has been compared to the puffing of an engine of a goods train going slowly and heard from a distance. It was at one time called the placental souffle, because it was thought that it had its origin in the placenta. That this is not the case is proved by the fact that it may be heard for some time after dehvery and also that a similar sound may be heard in some cases of uterine tumors. The sound is produced in the large arteries which come from the broad ligaments and enter the uterine walls. The sound is first heard about the end of the fourth month and continues until the time of labor and for a certain time into the puerperium. In the earlier months one may hear it by placing the stethoscope close above the pubes on either side. As a sign of pregnancy it is sometimes especially valuable, since it may be heard before the foetal heart sounds, and, although it may occasion- ally be heard when uterine tumors are present, we know that such tumors are rarely associated with amenorrhea. We also know that tumors no larger than a foetus five months old seldom pro- duce a souflfle. The souffle in the pregnant uterus varies more in quahty, pitch, and tone than that produced from the presence of tumors. In fact, the souffle in pregnancy is said to be more or less musical, and is sometimes composed of several notes which form a sort of chord in the rhythmic contractions which constantly take place during pregnancy. Intermittent Uterine Contractions. — Gentle, painless contrac- tions of the uterine wafls take place at regular intervals during the whole of pregnancy. Each contraction produces a tense condition lasting for a minute or two, or about as long as a regular labor pain. Each contraction is followed by a relaxation lasting about ten to fifteen minutes. These contractions and relaxations may be de- tected as soon as the uterus rises from the pelvic cavity and comes in contact with the abdominal wall, and become more distinct as pregnancy advances. During the intervals of relaxation the foetus 5 48 PEEGNANCY can generally be felt through the uterine walls, which are then quite flaccid. During the contraction the foetus can not be so dis- tinctly felt. The uterus becomes more pyriform in shape and more prominent in front. Although uterine contractions may be caused by the presence of certain tumors they are not so distinct in the latter case as when they are caused by pregnancy. Funic or Umbilical Souffle. — The umbihcal souffle is a mur- mur which is produced in the vessels of the cord, probably the umbilical vein, and is synchronous with the foetal pulse. The mur- mur is generally produced in the cord at some point where it is subjected to pressure or twisted. It may be heard toward the end of pregnancy in about 10 per cent, of cases. This murmur is of very little practical importance. Other Sounds, — Some other sounds of no great importance may sometimes be heard. Among these are the sounds produced by the movements of the child or by friction between the uterine and abdominal walls. Certain crepitating sounds, due to the presence of air in the uterus, may also occasionally be heard. DIFFERENTIAL DIAGNOSIS OF PREGNANCY The following conditions may be mistaken for pregnancy: (1) Those which increase the size of the uterus ; physometra, hydro- metra, haematometra, uterine fibroids. (2) Those which increase the size of the abdomen from growths, etc., outside the uterus ; ovarian tumors, enlarged organs and malignant tumors within the abdomen, ascites, accumulation of fat in abdominal walls or omen- tum, spurious or false pregnancy. Physometra. — This is a collection of gas in the uterus frequently due to the decomposition of fragments of the ovum. If large enough for percussion a tympanitic sound will show the nature of the enlargement, while at the same time palpation and ausculta- tion will not furnish the ordinary sign of pregnancy. The most common cause is atresia or some form of stenosis. Hydrometra. — This is a collection of watery fluid which is re- tained on account of occlusion of the os. As in the case of physo- metra the increase in the size of the uterus is slow. The uterus is seldom found to be larger than an orange. It generally appears in women who have passed the menopause. DIFFERENTIAL DIAGNOSIS OF PREGNANCY 49 Haematometra. — This is an accumulation of menstrual blood in the uterus which is due to cither C()n<^enital or accjuired atresia of some portion of the genital canal. Such atresia may be readily detected by physical examination. Errors of diagnosis due to such accunuilatious are unfortunately not very rare. In studying the history of the enlargement of the uterus in such cases we gen- erally find that it has lasted for a long period and that it has increased periodically rather than continuously. The rapid in- crease which occurs periodically is generally attended by severe pain and usually occurs once a month. The uterus is found on palpation to be tense and resisting, not elastic and yielding as it generally is in pregnancy. On palpation also no foetal parts are felt and auscultation furnishes none of the ordinary sounds caused by pregnancy. Uterine Fibroids. — These tumors, more properly termed my- omata, are not infrequently mistaken for pregnancy. When the uterus is enlarged on account of the presence of fibroids, it is gen- erally irregular in shape and hard and resisting instead of elastic and yielding. There is usually metrorrhagia (irregular and profuse hcemorrhage) instead of amenorrhcea. Ovarian Tumors. — Menstruation is generally present with ova- rian tumor, but amenorrhoea is occasionally produced. Under such circumstances the cessation of menstruation comes on grad- ually. In ovarian tumors there are no heart sounds and no foetal movements. The enlargement is generally observed on one side of the abdomen rather than in the median line and its develop- ment is slower than that of pregnancy. When a patient has an ovarian tumor there is generally marked deterioration of health with emaciation, the latter being especially noticeable in the face. Enlarged Organs and Malignant Omental and Mesenteric Growths. — Certain organs within the abdominal cavity which become enlarged from any cause may be mistaken for a pregnant uterus. Such enlarged organs, however, develop from above down- ward, and can generally be mapped out by percussion. We get the dulness above the Une of the lower edge and a resonant strip below. Misplaced organs, like the kidney and spleen, may gener- ally be pushed upward. Malignant tumors of the omentum and mesenteric glands are lumpy and fixed, and nearly always grow more slowly than a pregnant uterus. 50 PEEGNANCY Ascites. — Enlargement of the abdomen, caused by a collection of fluid within the abdominal cavity, has sometimes been mistaken for a pregnant uterus. A differential diagnosis, however, of the two conditions is a comparatively easy matter. In addition to the ordinary signs of ascites the uterus is unchanged in form, size, and position, while menstruation is generally uninterrupted and the ordinary reflex disturbances of pregnancy are absent. There is also, generally, an obvious cause for the ascites, usually disease of the liver, kidneys, or heart. Accumulation of Fat in the Abdominal Wall or Omentum. — There is very frequently a marked and rapid increase in the size of the abdomen, especially in women forty to fifty years of age, which is due to the accumulation of fat in the abdominal wall or in the omentum. In such cases the abdominal wall becomes not only prominent but pendant, and the woman has, as Dr. Bailey ex- pressed it, "a double chin in the belly." There is an entire absence of the ordinary signs of pregnancy as discovered by aus- cultation and abdominal palpation. It is generally easy when the patient is lying down for one who places a hand on each side of the abdomen to include between the hands the mass of fat and partially lift it up, thus showing its true character. Pseudocyesis or False Pregnancy. — This singular condition is said by some to occur in women who have married late in life, especially when they are very anxious to have children. We, however, find it in women who have borne children, especially in those who have had a number of children in early married life with a considerable interval before the menopause. In some of these cases abdominal enlargement may exist, menstruation may cease, the breasts may become large and painful and contain milk, the ordinary signs of stomach derangement may be present, and generally the patient is positive that she can feel the movements of the fcEtus. It may go on so far as to be followed by what is called spurious labor. In such cases the patient feels certain that she has ordinary labor pains. We know that these supposed symptoms are due to some perversity of the nervous system, and yet the aetiology is to a certain extent obscure. In most cases the women are perfectly honest in their belief and have no desire to deceive others. In such cases the physician who makes no special inquiries or examination, but trusts entirely to the statements of his patient, DURATION OF PREGNANCY 51 may easily be deceived. In attempting to make a diagnosis he should attach little or no weight to the subjective signs of preg- nancy. A careful examination will generally enable him to find the true condition of affairs. If, after making an examination in the ordinary way, there is still some doubt as to the condition, it is well to have an ana3sthetic administered. Anaesthesia makes the diagnosis a very simple matter. I have, however, seen two pa- tients in whom for certain reasons there was some difficulty in arriving at a correct diagnosis. In one instance the patient was so positive that pregnancy existed that she would scarcely submit to anything like a proper examination. It is sometimes an exceed- ingly difficult matter, as well as a very thankless task, to convince a woman under such circumstances that she is mistaken. I know another case where the doctor made a very casual examination, asked a few questions, and predicted that labor would come on a certain date. A nurse was brought from a neighboring town and kept for a month in the house waiting for the labor which never came. In this case both the doctor and patient were greatly humiliated. Pregnancy combined with Fibroid or other Tumors. — Myomata, ovarian tumors, malignant tumors, ascites, and enlarged abdom- inal organs may coexist with pregnancy. This is especially the case in reference to uterine fibroids and ovarian tumors. When one or more of these conditions coexist with pregnancy ther6 is sometimes great difficulty in making an accurate diagnosis and in deciding as to the best form of treatment. DURATION OF PREGNANCY There are certain reasons which prevent us from determining the exact date of conception. The only date that we can be cer- tain about which we have to reckon from is that of the last men- struation. Those who have studied carefully the statistics of the subject tell us that the average duration of pregnancy is from 271 to 276 days. The question of the duration of pregnancy derives its chief interest in certain cases from medico-legal considerations. Sometimes the courts have to decide as to the legitimacy of a child that has been born at an interval longer than usual after the last possible date of coitus with the husband. In England and 52 PEEGXAN^CY America there is no absolute limit laid down, and each case has to be judged on its own merits. In America the legitimacy has been allowed after intervals of 313 to 317 days. The laws of Scotland, Austria, and France allow a possible limit of 300 days, while those of Prussia allow one of 302 days. As intimated before, we can arrive at a more definite conclu- sion as to when pregnancy will terminate, or when labor will com- mence, by considering the date of the commencement of the last menstrual period. In the great majority of cases the ovum which escaped at the last menstruation is the one impregnated, and labor is most apt to occur at the time when the patient ought to men- struate. If, then, we add to the date of the first day of the last occurring menstruation ten lunar months, or 280 days, we should get the probable date of the commencement of labor. A common method is to add nine calendar months to (or what amounts to the same, subtract three calendar months from) the date of the first day of the last menstruation and add seven days to the date thus found. For instance, if the last menstruation commenced on May 10th, the day nine calendar months from that would be February 10th. The addition of seven will give the probable date of deliv- ery, February 17th. Or we may take the date of the commence- ment of the last menstruation and count from that 280 days. Such calculation should indicate the date of expected labor. Most tables are founded on this method of calculation. In certain cases we can not rely on the date of menstruation at all, for instance, when conception takes place during a period of amenorrhoea or when irregular haemorrhages take place during the early part of pregnancy. In some cases we have to rely to some extent on the time of quickening. As quickening generally takes place about the middle of pregnancy, we may form some idea of the time of expected labor by adding four and one-half months to the date when quickening was first felt. There are two other methods by which we may get some idea and perhaps a pretty definite one as to how far pregnancy has advanced. 1. By Determining the Size of the Uterus. We can get a fair idea of the size of the uterus by a bimanual examination during the early part of pregnancy, before the fundus has reached the level of the brim of the pelvis. Such an examination will enable us to decide approximately how far pregnancy has advanced. DIAGNOSIS OF PliEVIOUS riiEGNANCY 53 After the fundus passes above the level of the brim we can ascer- tain the height of the uterus by external examination. (Fig. 48.) 2. Length of Faial Ovoid. Tliis is said by some to give the most reliable data. In trying to discover the length of the ffjctal ovoid one should first make out that the foetus is in its normal attitude of flexion. One arm of a i)air of calipers is then intro- duced into the vagina, antl the end is placed on the lowest point of the child's head felt through the anterior vaginal wall ; the other is then introduced over the highest point of the breech on the abdominal wall. According to Dakin the following numbers will then be a guide as to measurements thus obtained : Weeks 26 28 30 32 34 36 38 40 Length in inches. 7.2 7.6 7.9 8.3 8.8 9.2 9.5 9.7 DIAGNOSIS OF PREVIOUS PREGNANCY In some cases it may be important from a medico-legal point of view to know whether a woman is pregnant for the first time, or whether there has been a previous pregnancy which has gone on to full term. In the woman pregnant for the first time the abdominal wall is generally smooth, tense, and resisting, so that it can not be easily depressed ; while in succeeding pregnancies the skin of the abdominal wall is not smooth but relaxed. In first pregnancies the uterus is more apt to be confined to the vicinity of the median line and does not incline to the front so much as it does in succeeding pregnancies. In first pregnancies the mammary glands are generally round and firm instead of being relaxed, flabby, and pendant. The vulvar orifice is small and closed and the posterior commissure is complete. The vagina is comparatively small and the neck of the uterus is conical, its closed orifice show- ing a uniform rim or border. As mentioned, however, by Parvin, it has been observed by Kleinwatcher that all these signs have only a relative value. The striae upon the abdomen and breasts and the tears of the cervix may be wanting, the perinseum may be entire, and yet the patient may have been pregnant. The signs of a previous pregnancy are chiefly the results of mechanical force produced by carrying and giving birth to a large fcBtus. They may, therefore, be in part or entirely absent, provided the flrst labor was premature and the foetus too small to produce any 54 PEEGNANCY injury from distention or tears. It should also be remembered that abdominal striae may be due to great abdominal distention from ascites or the presence of an ovarian tumor. If several years elapse between two labors the soft parts may be so nearly restored to their original condition that it will be impossible to decide whether the person is a multipara or a primipara. PELVIMETRY This means the process of measuring the pelvis. We have passed through various phases of thought in connection with deformities of the pelvis and a proper estimate of them by correct pelvimetry. Many were inclined years ago to think that pelvic deformity, while comparatively common in the older countries, was very rare in America. It was, of course, always understood that we occasionally met with a generally contracted or a flat pelvis through which it was impossible to extract an ordinary child, but it was somewhat easy to recognize such a pelvis in the dwarf, the humpback, etc. We tried to do our duty by making use of pelvimetry to a certain extent. Unfortunately, the subject was greatly obscured by the multiplicity of methods described. We found that "complete" pelvimetry was a very tedious procedure involving great exposure of the patient and much ma- nipulation, all of which were very distasteful to her. It was not the custom in private practice in England to carry out such meas- urements. It was not often attempted even in hospital practice. In recent years pelvimetry has become common in most of the British lying-in hospitals, but not in private practice. On the Continent, and especially in France and Germany, routine pel- vimetry has been carried out in hospitals and to a certain extent in private practice for some time. A few years ago such men as Parvin and Lusk in the United States described the French and German methods of pelvimetry, but expressed the opinion that pelvic deformity was very rare among native-born women. So far as I know, Whitridge WiUiams was the first in that country to properly carry out routine pelvimetry. He was thus enabled to demonstrate the fact that the proportion of women with con- tracted pelves in the United States was much greater than had PELVIMETEY 55 previously been supposed by Parvin, Lusk, and others. Williams and Robbins found in 1,000 consecutive cases of labor 130 con- tracted pelves, that is to say, about 13 per cent. Methods. — Since we have carried out routine pelvimetry in the public wards of the Burnside Lying-in Hospital, we have discov- ered a fairly large proportion of pelvic deformities. We have endeavored to simplify oiir methods as much as possible, and, as a result, have been able to carry out pelvimetry in a satisfactory way. We always take three external measurements, using a mod- ified pair of cahpers, as Bandelocque's or Schultze's pelvimeter, as follows : 1. The inter s'pinous — between the anterior superior spines of the ilia — normal 25 cm. (10 in.). 2. The intercristal — between most widely separated points of crests of the ilia — normal 28 cm. (11 in.). 3. The external conjugate — between the anterior surface of the symphysis pubis and the depression below the spinous process of the last lumbar vertebra — normal 20 cm. (8 in.). If these measurements are abnormal the following are taken : 4. The interischial — between the tuberosities of the ischia — normal 10 cm. (4 in.). 5. Pubo-sacral — between the pubes and the sacro-coccygeal articulation — normal 12 cm. (5 in.). 6. Diagonal conjugate — between the lower edge of the symphy- sis and the promontory of the sacrum — normal 12 cm. (5 in.). Pelvimetry pertains especially to pregnancy, and should always be practised as a matter of routine by every physician during pregnancy. Herman tells us that the pelvis can be measured more easily and more exactly after delivery than at any other time, and says that on that account the pelvis should be meas- ured after a difficult labor, in order that the patient might be rightly advised and treated in subsequent pregnancies and labors. This is quite right, but it is infinitely more important to have the measurements made before than after the difficult labor. DESCRIPTION OF PELVIMETRY In taking external measurements Bandelocque's pelvimeter or some modification of it is used. I have for some years used Schultze's instrument and think there is none better. It has firm 56 PEEGKANCY arms and is more portable than most pelvimeters. When closed it occupies very little space in the satchel. The patient lies on her back, preferably on a hard table covered with a folded blanket, with her hips as near the edge as possible. Fig. 49. — Pelvimetry; Inter-Spinous Measurement. If she is especially sensitive as to exposure she may be covered with a thin sheet. One can, however, examine more satisfactorily without the sheet, and the exposure required for the first three ex- ternal measurements is so slight that few will object to it. The head and shoulders are slightly elevated and the knees partially flexed. The physician stands beside the patient (preferably the right side) with his face toward her head. It is better to have an assistant, not necessarily a skilled one, to hold one or both points of the instrument when required. Interspinous Measurement. — In taking the interspinous meas- urement the points of the two arms of the pelvimeter are placed on the spines external to the insertion of the sartorius muscle. It is sometimes difficult to get these points. According to the TELVIMETRY 57 German method the points of the two arms should first be placed outside the iliac crests and then moved forward until it is consid- ered they have reached the anterior end of the crests — that is, the external surface of the spines. Another method adopted by Herman and others in England is to press the thumbs against the inner surface of each spine so that the points of the caliper shall not move inward beyond the spine. It is easier for beginners to place the thumbs in these positions and allow the assistant to place the points on the bone just outside the thumbs. These two methods give slightly different results, the measurement according Fig. 50. — Pelvi.metry; Inter-Cristal Measurement. to the German method being, on an average, from 1 to 2 cm. more than that by the other. The average by the German method is about 26 cm. Intercristal Measurement. — In taking the intercristal meas- urement the points of the arms are placed on those portions of the iliac crests which lie farthest apart. Generally it is quite easy to find the portions of the crest farthest distant from each other. The 58 PEEGNANCY average is 28 cm. In certain kinds of deformed pelves, however, which are probably always rhachitic in character, the measurements between the spines are equal to, or greater than, those in any por- tion of the crests. In such cases measurement is made from the two spots on the crests which are situated 6 cm. posterior to the spinous processes. External-Conjugate Measurement. — In taking the external con- jugate the patient is turned on her side, one extremity of the pelvimeter is placed upon the fossa just beneath the spinous proc- ess of the last lumbar vertebra and an assistant holds it in posi- FiG. 51. — Pelvimetry; Antero-Posterior Measurement. tion ; the other extremity is placed upon the anterior surface of the symphysis pubis about 1 cm. from the upper border. It is not always easy to find this depression beneath the last lumbar verte- bra. Generally, however, with care it can be found by follow- ing down the spines of the lumbar vertebra and feeling a little hole below which no spinous process can be found. If there is doubt a horizontal line is taken between the highest points of the iliac crests ; the last lumbar spine lies about 4 cm. below this. Or, another horizontal line is taken between the posterior superior iliac spines; the last lumbar spine lies about 2.5 cm. above this. The average measurement is 20 cm. From this measurement is de- ducted 9 cm.; the difference, 11 cm., will be, approximately, the measurement of the true conjugate diameter. If the external conjugate is less than 17 cm. it is certain that the true conjugate PELVIMETRY 59 diameter is abnormally short ; but the external measurement does not necessarily indicate the amount of shortening of the true con- jugate. When the external conjugate is more than 17 cm. we can not be certain that there is not shortening of the true conjugate. However, a great majority of deformities included under the term of flat pelvis may be discovered by this measurement, and the great majority of universally contracted pelves may be discovered by the three measurements combined. These are the three measurements that are taken as a matter of routine in all patients in the Burnside as before mentioned, and they are the three measurements which should be taken in private practise. If there is no special deviation from the normal nothing further is done ; if, however, there is reason to believe from these measurements that there is shortening of the transverse, or the antero-posterior diameter, or both, further measurements are taken. These cause more exposure of the patient, the most impor- tant requiring a vaginal examination. If, for instance, there is reason to suspect the existence of a short conjugate diameter a vaginal examination should be considered absolutely necessary. For internal measurements the best pelvimeter is the hand of the accoucheur. In taking these measurements the patient is placed in a lithotomy position with the nates slightly beyond the edge of the table. The index and middle fingers of the left hand are intro- duced into the vagina, the posterior vaginal wall is pushed well backward, the elbow is sunk, and the fingers are pushed almost directly upward. If there is any shortening of the true conjugate it is generally quite easy to reach the promontory of the sacrum. It is sometimes possible to reach the promontory by this method even in normal pelves. If one is not able to reach the promontory with the tips of the fingers he may decide that there is no shorten- ing — that is, that he has not a flat or generally contracted pelvis to deal with. The measurement is taken by pressing the middle finger firmly against the most easily reached portion of the promontory, while the radial edge of the hand, or index finger, is raised to the sub- pubic ligament. The point of contact with the latter is then marked with the nail of the index finger of the right hand. The distance from the mark of the nail to the tip of the finger is meas- ured with a small rule or a pelvimeter. A certain amount is deducted from this to obtain the length of the conjugata vera. 60 PEEGNANCY One can not tell exactly how much, as the amount will depend on the height and inclination of the symphysis pubis and on the degree of elevation of the promontory above the symphysis. A safe rule, however, is to deduct from 1.5 cm. to 2 cm. This will leave 10 to 10.5 cm. as the true conjugate diameter. Additional Measurements. — The three external measurements already described, together with the internal measurement here referred to, are practically all one requires to take even in doubtful cases. Sometimes, however, it is desirable to get some informa- tion as to the outlet. For such a purpose it will be well to take the following measurements : Inter-ischial or Transverse Diameter at the Outlet. With the patient still in the lithotomy position the thumbs are placed upon the skin over the ischial tuberosities ; the palmar surfaces of the thumb are pressed against the inner aspect of the tuberosities at the level of the line running through the anterior margin of the anus. An assistant then measures the distance between the two points. The beginner is very apt to make this measurement about 2 or 3 cm. too short, on account of the thickness of soft tissue cov- ering the tuberosities. Pubo-sacral Measurement. The end of the second finger is placed against the sacro-iliac articulation and the radial edge of the hand is brought in contact with the subpubic ligament, the point at which the latter rests against the hand is marked by a finger of the other hand. On withdrawing the hand the distance between this point and the finger-end is measured. This measure- ment should be about 12 cm. The consideration of other measure- ments, such as those between the trochanters, the external oblique measurements, those between the posterior superior spines, and others, is omitted, because of their relatively small importance. Much information can be obtained by introducing the whole hand into the vagina, with the patient thoroughly anaesthetized, especially after difficult labors. For instance, we may get a pretty exact knowledge as to the true conjugate diameter by ascertaining whether the forefingers or the palm of the hand, or the closed fist with thumb flexed across the hand, or flattened against the fore- finger, or to some extent extended, will pass between the promon- tory of the sacrum and the pubic bones. The part of the hand which is used in taking the measurements is across the narrowest part of the brim and not lying obliquely to it. HYGIENE AND MANAGEMENT OF PREGNANCY 61 HYGIENE AND MANAGEMENT OF PREGNANCY Pure air is especially necessary, because the patient "breathes for two." Her chamber sliould he well ventilated and should contain as few extras in the way of heavy window curtains and bed curtains as possible. Clothing. — Woolen garments should be worn next to the skin. Combination suits (shirt and drawers in one) are the most suit- able. Corsets, belts, and tight garters should be discarded. Skirts should be suspended from the shoulders. For house wear wrappers are most suitable. Diet. — No great change from the ordinary diet is required. The patient should take plain food and omit all rich foods, pas- tries, hashes, stews, and fancy dishes, and should also take plenty of fluids, especially water. Constipation should always receive treatment sufficient to over- come it. If regulation of diet with plenty of water be not sufficient to relieve the constipation, cathartics, such as Hunyadi water, aloes, salines, or cascara sagrada should be taken. Cascara sagrada with maltine is a good mild cathartic and is useful in many cases. Mammary Glands. — These should, as a rule, be left alone. Re- tracted nipples are apt to cause much trouble, but endeavors to pull them out during pregnancy probably do more harm than good. Efforts to harden nipples by bathing wath alcoholic solutions and the like are bad, because after such treatment they are more apt to crack than if they are left alone. If some application seems advisable it is safe to use something which will soften them or keep them soft, such as lanolin, or castor oil and bismuth com- bined, equal parts. Efforts to draw out depressed or inverted nipples are dangerous, because they usually cause irritation. Exercise. — A fair amount of exercise should be encouraged, but such exercise should as a rule be somewhat less than the ordinary. The patient should avoid fatigue, jars, strains, overreaching, and lifting heavy weights. Sexual indulgence is more or less dangerous. Abdominal Bandage. — In a large proportion of cases pregnant women should wear a belly-band or supporting corsets after the middle of pregnancy. (Diihrssen says every woman should do so.) Importance of Examination. — The importance of pelvimetry during pregnancy has been mentioned and its methods have been 62 PREGNANCY described. Too much credit can not be given to Dr. Whitridge Williams, not only for what he has done in pointing out the amount of pelvic deformity which exists in the New as well as the Old World, but also for the practical turn he has given to the subject. It is now generally recognized, mainly through his teachings, that an examination of the patient before labor should be a matter of routine on the part of the accoucheur. In considering present opinions as to the management of preg- nancy it is interesting to note three distinct features in what may be called progressive evolution during the last thirty years : First. Great importance was attached to the condition of the kidneys, and especially albuminuria. Second. A broader view of the subject was taken, and more importance was attached to general toxaemia, of which albuminu- ria is only one of many symptoms. Third. Great importance was attached to the dimensions of the pelvis and to many conditions of pregnancy which may be discovered by inspection, pelvimetry, and palpation. Although these matters are discussed in various succeeding chapters, a few brief rules are here given as to certain points in connection with the management of pregnancy. Physicians should carefully watch for and treat any abnormal conditions which may arise, such as disorders of digestion, head- aches, disorders of vision, swelling of the feet and legs, albuminuria, etc., with a view of preventing general toxaemia. They should also frequently examine the urine, to discover especially the amount of urea excreted and albuminuria and glycosuria when present. It is better to adopt some system with reference to the urinary examinations. One should, of course, be guided to a considerable extent by circumstances as they arise, but it is well to carry out some rules, such as the following: The urine should be examined once a month from the end of the fifth to the end of the eighth month, and once a week or once a fortnight during the ninth month. A preliminary examination should be made in the eighth month of pregnancy, about six weeks before the expected date of labor. As suggested by Williams, and, as I have found preferable, such examination should be made with the patient in bed in her own home. The first part of the examination is an inspection, so far as one can make it, to detect gross deformities of pelvis, hips, and HYGIENE AND MANAGEMENT OF PREGNANCY 63 back, and abnormal lios of the fci'tus. The next part is external pelvimetry, and then internal pelvimetry in the small proportion of cases in which it is re([uired. After pelvimetry the abdomen should be carefully examined by external palpation. The Patient's Outfit. — The physician should make careful in- quiries and give definite directions as to articles required before labor. The patient usually has her outfit at least partially pre- pared at this time. I have found it advisable to give a definite Fig 52. On right side, above, the "guard," made of a piece of butter-cloth eight inches square folded twice, placed over vulva; below, piece of butter-cloth twenty-one by eighteen inches; seven inches from end (one-third whole length). Cut inward on each side five inches. In center, below, absorbent cotton placed on cloth and edges folded over it; above, part containing absorbent cotton folded twice. On left side, portion containing absorbent turned over twice ; pad com- plete, to be placed over guard. list of things needed, and have lately used a modification of that recommended by Cooke, as follows : Four abdominal binders, Ij yards long by | yard wide, made of the cheapest grade of unbleached muslin. This muslin comes in a width of one yard, and Sf yards are required to make the necessary number of binders. They should be torn the proper size and the selvage torn off, but it is not desirable to have them hemmed or finished in any other way. They should be washed and ironed to make them soft and comfortable. The cheapest grade of muslin is recommended, because the more expensive and 6 64 PEEGNANCY consequently the heavier quality does not take the pins well and is stiff and uncomfortable when in use. Two obstetrical pads, each twenty inches square, made of cheese- cloth stuffed with cotton batting (not absorbent cotton) until they are three or four inches thick. They should then be tacked or tufted sufficiently to keep the cotton from slipping, and are to be placed under the patient's buttocks during the first stage of labor. When practicable it is well to have them sterilized before use, but this is not absolutely necessary if the pads are made with clean hands from new material, as should always be the case. Two and one-half dozen sanitary or vulvar pads (Snively pat- tern). The vulvar pad is made from a piece of butter-cloth 21 inches square. This is doubled, and a cut made extending inward 6 inches, which will leave 7 inches of cloth at one end and 14 inches at the other. Before folding, a layer of absorbent cotton, 14 inches long and 7 inches wide, is placed in the center, and over this the butter-cloth is folded from either side. The next step is to double the part containing the absorbent cotton, then double again, and over this fold one-half of the piece at the top, which will be 3^ inches in width, and completely envelops the pad, leav- ing a stub at each end, which can be slipped under the binder and pinned to keep it in position. The patient should know how to make these pads. As soon as they are made they are to be done up in packages of six, and each package wrapped separately in a clean towel or in clean white muslin and laid away in a conven- ient place, free from dust, until wanted. One dozen clean towels, preferably old soft ones without fringe. These are to be pinned up in another clean towel, and laid away with the other things. They are for use only about the patient, and are not for the hands of the physician or nurse. If a sterilizer is available they should be sterilized, but this is not indispensable. Safety pins. Two papers of large and one of small in addition to those required for preparing the bed. Absorbent cotton. One-half pound. Lysol, four ounces, and bichloride tablets. Two pieces of mackintosh or rubber sheeting. One slop jar or pail made perfectly clean to be used during labor for receiving soiled sponges, towels, and the like, as well as any solutions or discharges that can be directed into it. A good supply of clean towels (in addition to the dozen already mentioned) , sheets, pillow cases, and nightgowns for the patient CHAPTER V PHYSIOLOGY OF LABOR Labor is the process by which the foetus and its appendages are expelled from the body of the mother. It is generally rec- ognized that there are three factors in this process: 1, the ex- pelling powers; 2, the body to be expelled, the passenger ; 3, the canal through which it passes, the passage. Cause of Labor. — Many discussions have taken place and many theories have been advanced as to the determining cause of labor with results so barren as to be practically worthless. The cause is unknown. THE EXPELLING POWERS Uterine Contractions. — The uterine contractions are the most important of the expelling powers. The painless contractions of the uterus which are present during the whole of pregnancy, gradually gain in force during the later weeks until labor com- mences, when the patient becomes conscious of them. These contractions are then accompanied by pains which become the prominent symptoms. These true pains (as they are sometimes called) generally begin in the back and pass around the body to the neighborhood of the pubes or down the thighs. They are in- termittent and come on at regular intervals. We may say, ap- proximately, that the intervals are about thirty minutes at the beginning and lessen in length as labor advances. Near the end of the expulsive efforts the intervals do not usually exceed one, two or three minutes, and sometimes they disappear, causing the pain or the uterine contraction to be practically continuous. The last strong contractions are called "bearing down pains " by the laity. The duration of a pain is about a minute. This is nearly the average time, but it varies from about half a minute to one or two minutes until the final pain, wdiich may last four or five min- 65 66 PHYSIOLOGY OF LABOE utes. It not infrequently happens that for hours the labor pro- gresses very slowly, when suddenly, without any apparent cause? the pains or contractions become strong and long-continued and the child is expelled in a few minutes, instead of one or more hours as one might have expected. Such vagaries in connection with uterine contractions and their results add much to the per- plexities of midwifery practise. The Value of the Intermittent Character of the Pains. — When the contractions cease to be intermittent, there is a condition called tetanic contraction of the uterus. This tetanic contraction stops the circulation in the uterine sinuses and in the placenta, and shuts oJEf the oxygen supply from the blood of the foetus. As a result the foetus sometimes dies in a comparatively short time. The tetanic spasm also causes in the mother extreme pain, great exhaustion, sometimes rupture of the uterus, sometimes death. While the pains or uterine contractions are intermittent the temporary impediments to the circulation during the pains disap- pear during the intervals between the pains, and no harm comes to the foetus or mother. The Action of the Abdominal Muscles. — The uterine contrac- tions cause the dilatation of the lower segment of the uterus. When this dilatation has been completed, or nearly so, the action of the uterus is reenforced by certain auxiliary muscles. There are two sets of such muscles, namely, the abdominal muscles and the muscles of the pelvis. At the height of the uterine contraction the woman generally holds her breath, the diaphragm becomes fixed and the contracting abdominal muscles press upon the ute- rus. In consequence of these various forces the child is impelled in the direction of least resistance — that is, downward through the dilated cervix. Generally, the contractions of the abdominal muscles are under control of the will, but toward the close of the second stage they become more or less involuntary on account of the reflex factor of painful distention of the passage. The uterus may, however, expel its contents without any assistance from the abdominal muscles. The pelvic floor is at first, to a certain extent, an obstacle to the progress of labor, but on the eve of expulsion it helps to push the head forward in the direction of the outlet; the muscles of the vaginal wall will take some part in such expulsion. These forces THE EXrELLTNG POWERS 67 also form an important (>l(MiK'nt in tho expulsion of the after-com- ing heiitl in l)reech eases, and in the expulsion of the placenta. Influence of the Nervous System. — There are certain motor cen- ters which have more or less influence in regulating the uterine contractions. There are probably three such centers, one in the medulla, one in the lumbar spinal cord, and a third lying on the posterior vaginal fornix and intimately connected with the uterus. We are not sure that parturition is altogether a reflex act, but it is chiefly so ; the ordinary labor pains are probably reflex acts. We do not know what the stimulus is early in the first stage of labor. At a certain time the contractions which were previously painless become painful; at the same time there is probably some relaxa- tion of the sphincter fibers at the lower end of the body of the ute- rus which permits the amnion, with its inclosed fluid, to pass slightly within the internal os. This causes some irritation of the nerve endings in consequence of which certain stimuli are carried to the nerve center which is supposed to be in the lumbar portion of the spinal cord. From this center the stimuli are reflected to the mus- cular fibers of the uterus, causing those of the fundus and upper segment to contract, while those of the lower segment and cervix slightly relax. We make use of our knowledge of such reflex acts when we wish to induce- labor. Definition of Terms used in Connection with Uterine Contrac- tions. — It is a matter of great importance to have a clear concep- tion of certain facts in connection with Bandl's ring. It divides the body of the uterus into two portions, which are not only differ- ent from an anatomical and physiological point of view, but are affected differently by the various forces in action during labor. The ring gradually ascends during labor. At the same time the two segments are changed; the one becomes thicker and shorter, and the other becomes thinner and longer. These are the main prominent facts which one can easily understand. Frequent ref- erences are made to these facts especially in connection with tedious labor, dry labor, prolapse of the cord, placenta praevia, rupture of the uterus, expulsion of the placenta, etc. The following possible result furnishes an example of the im- portance of these different forces. The upper segment of the wall pulling on the lower is getting stronger, thicker, and shorter. The lower segment was the weaker at the commencement of labor, and when stretched in this way is likely to get still weaker. Such a 68 PHYSIOLOGY OF LABOE process as that can not go on indefinitely with safety. The portion that is being stretched, thinned, and weakened may give way. This sometimes happens, causing rupture of the uterus. There is a certain amount of confusion respecting some terms used in this connection. Daldn says : "Contraction means a shortening of the muscular fiber which, when relaxation follows, returns to its original condi- tion and shape." A large number, if not most physiologists, give a similar definition of contraction. Horrocks says : ''When a muscle contracts it is unable of itself to return to its former condition. Some other muscle or force is Fig. 53. — Section of Pregnant Uterus before Retraction. required to pull it out or extend it." When a muscle contracts and then relaxes it is in a condition called "retraction." Galabin says : " Retraction means the contraction and shorten- ing of the uterine muscle not followed by relaxation." THE EXPELLING POWERS 69 These quotations are from the writings of three eminent ob- stetricians of Lontlon. It may make things a httlc more clear in considering the three terms, contraction, relaxation, and retraction, to state that in con- nection with various processes of labor there is, normally, no such Fig. 54. — Section of Pregnant Uterus after Retraction. thing as complete relaxation at any time. A muscle may contract slightly or completely (so far as strength or nerve energy will per- mit), but in a living, healthy body it probably can never com- pletely relax. If the muscular fibers become completely relaxed after labor there could be no such thing as tone or retraction. There would be nothing to prevent a woman from rapidly bleeding to death. It may be considered, therefore, that relaxation, when re- ferred to by physiologists or obstetricians, always means partial relaxation. Contraction of a muscular fiber is the power to alter its condi- tion so as to actively pull on its attachments and thus bring them, 70 PHYSIOLOGY OF LABOR or tend to bring them, nearer together. A muscle may contract, however, without shortening. Retraction is the condition of the muscle which is produced by partial relaxation after active contraction (see Figs. 53, 54). Partial relaxation means that the contraction of the muscular fiber has become less active and complete. The Law of Polarity. — When a muscle contracts its opponent relaxes. When the flexors of the forearm contract the extensors relax; when the extensors contract the flexors relax. When the circular fibers of the iris contract the radiating fibers relax, and the result is that the pupil gets smaller ; when the radiating fibers con- tract the circular fibers relax and the pupil dilates. In the case of the hollow organs, such as the bladder, heart, uterus, etc., the pressure of the contents of these cavities acts as an opponent to the contracting fibers. As the bladder becomes filled the detrusor fibers tend to drive the contents out through the urethra. At a certain time, during the act of contraction of these fibers, the sphincter relaxes, allowing the urine to be voided. Similarly the upper and lower portion of the uterus are opposed to each other. The muscular fibers of the lower segment and the cervix uteri form, practically, a kind of sphincter muscle. While the upper fibers contract these sphincter fibers relax, and the result is that they are stretched by the pressure brought to bear on the amnion with its liquor amnii. I am, to a large extent, using Horrock's explanation of polarity. He goes on to say that one of the commonest mistakes made by students, when asked to state the law of polarity, is to say that when the body and fundus of the uterus actively contract the lower zone and cervix actively dilate. It is true they are often dilated, "but not unless there is something to dilate them. The law is that when the body and fundus contract the lower zone and cervix uteri partially relax, and hence while in this state of partial relaxation they are capable of easy extension, that is, dilatation by an ex- tending force, such as that exerted by the pressure of the bag of membranes; in other words, they do not actively dilate, but are passively dilated. Elasticity.— This is a property which, according to Matthews Duncan, is chiefly possessed by the peritoneal coat. It means the power of a body to shrink into its original dimensions after a force expanding it is withdrawn. The peritongeum has no contractility STAGES OF LABOR 71 and yet it shrinks from its size, as it covers the uterus at term, down to the comparatively small area of the outer wall of the empty organ, the pcritonoDum over the upper segment usually being without a wrinkle. The bag of membranes commences to assist in dilatation as soon as the OS is slightly opened by the contraction of the upper and the stretching of the lower uterine segment. It forms a fluid and uniform wedge, which becomes progressively more effective as dilatation increases. As a dilator this smooth bag is more effect- ive and much safer than any solid or irregular wedge, such as the head or breech of the foetus. STAGES OF LABOR The three stages in labor are: (1) From commencement of labor till complete dilatation of the cervical canal. (2) From com- plete dilatation of the cervical canal to the expulsion of the child. (3) Expulsion of the placenta. The division of labor into three stages is convenient and almost universally recognized by obstetricians. The first stage is that of dilatation of the cervix, during which little or no propulsion of the ovum is taking place. While this is the usual definition, it is not correct. It is really the stage of softening and dilatation of the cervix, vagina, pelvic floor, and perinseum. Normally, rupture of the membranes takes place at or about the end of this stage. Exceptions to this, however, are not infrequent. There is no well- defined boundary between the first stage and the second during which the foetus is expelled. The third stage is more definite. During it we have separation and expulsion of the placenta and membranes. The average duration of labor is eighteen hours for primiparae and twelve hours for multiparae. The Changes in the Cervix. — During the first stage we have the "taking up of the cervix," by which process the cervical canal becomes continuous with the lower uterine segment. At the same time the os uteri becomes fully dilated, thus making the vaginal canal continuous with the utero-cervical cavity. The Taking-up Process in Primiparae and Multiparae. — In pri- miparae the cervix is fairly long at the commencement of the first stage, the external and internal os being almost, if not entirely, in 72 PHYSIOLOGY OF LABOK their normal condition. First the internal os is dilated, then the extravaginal portion of the cervical canal, then the intravaginal portion, and last the external os. In multiparse the external os is usually dilated and the cervix is somewhat patulous at the commencement of the first stage. During a vaginal examination the finger frequently passes easily into the cervical canal until it reaches the internal os. As uterine contractions continue this internal os dilates. As the internal os is being stretched the whole canal becomes dilated at the same time. This is quite different from the condition in the primiparae when the dilatation travels from above downward. The result is that as soon as the ' ' taking up " of the cervix has ceased the uterine orifice is encircled by blunt, comparatively thick edges instead of extremely thinned edges, as in a primipara. METHODS OF EXAMINATION Abdominal Palpation. — We can ascertain by palpation of the abdomen ( Jellett) seven important facts : 1. The presence or absence of pregnancy, at any rate from the seventh month onward, by feeling a tumor shaped like the uterus, and by feeling foetal parts within it. 2. The period of pregnancy, by mapping out the height of the uterus. 3. The presentation and position of the foetus. 4. The presence of pelvic contraction, which is by far the com- monest cause of non-fixation of the head. If we find that the head ballottes freely above the brim at a time when it should be fixed, pelvic contraction is the first thing to be thought of. 5. If the patient is in labor the important points are, the pres- ence of pains or of painless contractions ; and in the multiparse, the fixity or non-fixity of the presenting part. 6. The course and progress of labor, by noting the descent of the presenting part. In the early stages the height of the chin above the symphysis can be measured in finger-breadths. As labor advances the chin approaches the level of the symphysis and then sinks below it. The rate of advance can now be determined by the fourth grip (as described hereafter). 7. The indications of threatened rupture of the uterus, by the rising of Bandl's ring upward in the abdomen. METHODS OF EXAMINATION 73 DESCRIPTION OF ABDOMINAL PALPATION Grips in Palpation. — Four distinct grips or methods of apply- ing the hand arc used. One should avoid uufkio pressure, as it causes pain and contraction of the abdominal muscles and renders further jxilpation impossil)l(\ One should avoid, also, lifting the finger-tips off the abdomen — " playing the piano on the abdomen " — as this also causes contraction of the recti. The fingers and hands should be moved gently from place to place without hfting them off. 1. Funded Grip. The patient is placed flat on her back with her pelvis and her legs extended. The physician then sits down Fig. 55. — Abdominal Palpation. Examination of the Upper Pole of the FCETUS. FUNDAL GrIP. at her right side, about the level of the pelvis and facing her head. He next lays both hands, gently, flat upon the fundus of the uterus and feels what is lying there. He notices the shape and mobility of the part of the foetus lying beneath the hands. 2. Umbilical Grip. Having palpated the fundus, the hands are moved gently downward until the level of the umbilicus is reached. By moving the hands about the nature of the foetal parts at that level can be ascertained. To determine upon which side of the uterus the back of the child lies, the hands are laid flat on either side of the uterus and moved synchronously first to one side, then to the other, making the uterine contents move with them. By this means one notices that there is a greater resistance 74 PHYSIOLOGY OF LABOR offered to one hand than to the other. This greater resistance is usually on the side at which the back is. Mcllwraith says that in examining the middle zone of the uterus one can more readily Fig. 56. — Examination of the Middle Zone. Umbilical, Grip. detect the back of the child by the following manipulation : One hand is placed on the fundus and feels that part of the uterus ; Fig. 57. The same as in Fig. 56, except that the position of the foetus is determined by a greater resistance being felt by the lower hand over the back than over the front of the foetus. the other hand presses first on one side of the middle zone, and then on the other. Pressure on the back of the foetus makes METHODS OF EXAMINATION 75 the part undor the fuiulal hand move. Pressure on the other side of the middle zone does not. 1 il;. .j8. — McIlwraith's Maneuver. The hand at the fundus presses the fcetus downward against the symphysis. Then pressure on the back of the foetus with the other hand makes the upper pole of the foetus move under the hand at the fundus; pressure over the front of the fcetus does not do so. 3. Pelvic or Pawlic's Grip. This is made with the right hand only. The fingers are sunk into the false pelvis over the center of Fig. 59. — Examixatki.v ov tiik Lowkk I'uli: hv iih; I'u.ri-s. Pawlic's Grip. Poupart's ligament on the left side and the thumb into the corre- sponding point on the right, and then they are approximated. By 76 PHYSIOLOGY OF LABOR this means one discovers what is lying in the pelvic brim and whether it is movable or fixed. Fig. 60. — Deep Pelvic Grip. 4. Fourth Grip. This is only necessary when the presenting part has sunk deeply into the brim. Instead of facing the patient's Fig. 61. — Head Presentation, Heart + below Umbilicus. head one should turn so as to face her feet. Both hands are used. The tips of the fingers of the right hand are sunk into the true pel- vis on one side, and the tips of the fingers of the left hand similarly MECHANISM OF LABOR 77 on the other side. By this means the extent that the presenting part has dcseendecl can 1)(> estimated. Examination per Vaginam. — By it can be determined the nature of the presenting part, the fixity of the presenting part, the con- dition of the membranes, the size of the os uteri, and the presence of a prolapsed limb or card. Auscultation of Foetal Heart. — The heart sounds vary with the position of the foetus. If the head is in the lower segment the heart sounds wdll be heard below the horizontal umbilical line. If the head is in the upper segment the heart sounds will be heard above this line. Generally the sounds are best heard at that side Fig. 62. — Breech Presentation, Heart + above Umbilicus. of the abdomen toward which the back of the foetus lies, excepting in a case of face presentation, in which they are generally heard on the side of the abdomen where the limbs are. MECHANISM OF LABOR Vertex Presentations. — The vertex is the space between the anterior fontanelle and the posterior, and is the lowest portion of the head in vertex presentation. Vertex presentations occur in about 96 per cent, of all labors. The following classification of vertex presentations is the one most commonly used and most easily understood. It is presumed that the occiput is the most important part to be considered, and four positions of the occiput are recognized: 78 PHYSIOLOGY OF LABOR 1. Left occipito-anterior — L. O. A. The occiput points to the left foramen ovale. The forehead points to the right sacro- iUac synchondrosis. The long diameter of the head is in the right oblique diameter. 2. Right occipito-anterior — R. 0. A. The occiput points to the right foramen ovale. The forehead points to the left iliac synchondrosis. The long diameter of the head is in the left oblique diameter. 3. Right occipito-posterior — R. 0. P. The occiput points to the right sacro-iliac synchondrosis. The forehead points to the left foramen ovale. The long diameter of the head is in the right oblique diameter. 4. Left occipito-posterior — L. O. P. The occiput points to the left sacro-iliac synchondrosis. The forehead points to the right foramen ovale. The long diameter of the head is in the left oblique diameter. Some prefer to add the word iliac in accord- ance with French nomenclature. For example, the first position would be called the left occipito-iliac-anterior position or L. O. I. A. We are told that there is no doubt as to what this means, whereas the term left occipito-anterior might be applied to either breech or vertex presentation. In the great majority of cases the long diameter of the head is in the right oblique diameter of the pelvis — i. e., the most frequent positions of the occiput are the left front and the right rear, or the first and third vertex presentations, respectively. The first position, L. O. A., is by far the most frequent, and probably occurs in about 70 per cent, of vertex presentations. FIRST POSITION OR LEFT OCCIPITO-ANTERIOR On vaginal examination a hard round tumor, with sutures and fontanelles, can be felt. The posterior fontanelle is near the front of the pelvis ; the anterior fontanelle is nearer the back of the pel- vis. The posterior fontanelle is small and triangular and is the point where three sutures meet. Feeling these three different sutures may be our chief guide to diagnosis. Fothergill gives the following practical point: Pressing on the posterior fontanelle, the angle of bone which dips below the other two is the tip of the occipital bone whose position is thus known. This is, I believe, generally correct and has frequently helped me to make a rapid diagnosis of occipito-anterior position. The anterior fontanelle is MECHANISM OF LABOR 79 high up toward the mother's back and can be felt in a certain proportion of cases. It may be recognized by its lozenge-Uke shape, its large size as compared with the posterior fontanclle, and the fact that four sutures meet there. The sagittal suture runs between these two fontanelles. If the finger-tip, after it touches the suture, is directed toward the mother's pubes, it should reach the small fontanelle. If it is directed backward and if it is pushed far enough, it will roach the anterior fontanelle. If it can reach the anterior fontanelle very easily, there is something abnormal. The most favorable time for examination is immediately after rupture of the membranes. As labor goes on the presenting part becomes oedematous and the bones lap over each other more or less, owing to the molding. It may thus become difficult or im- possible to recognize either the sutures or fontanelles. Some- times, when one has been unable, after both external and internal examination, to decide as to presentation, the accoucheur may obtain valuable information by placing his finger or fingers on the ear of the child. This can generally be reached 'per vaginam; and its lobule, pointing to the occiput, will give positive evidence as to whether the occiput points to the front or the rear. Flexion with Descent. — It is true that descent goes on with all the movements that are concerned in the mechanism of labor, but it is well to give this process some prominence in connection with the early movement of flexion. While the head descends, it at the same time becomes flexed. The result is to substitute the sub-occipito-bregmatic diameter for the occipito-frontal — that is, the shorter for the longer diam- eter. This allows the head to slip easily into the pelvis when it could not do so before. This is illustrated by Fothergill, as fol- lows : ' ' Just as a man can get a hat on the back of his head which is too smaU to fit on the top of it, so a foetal head can pass through a pelvis when the occiput is leading which it could not traverse with the vertex leading." During this flexion or dipping of the occiput, the posterior fontanelle becomes more perceptible to the touch, the anterior fontanelle passes backward and upward out of reach, and the presentation is changed from vertex to occiput. Internal Rotation. — After flexion the head advances, with the presenting part, the occiput, lying lowest until it reaches the pelvic floor. The posterior part of this floor forces the occiput to turn 7 80 PHYSIOLOGY OF LABOE in the direction of the least resistance — that is, to the front or under the pubic arch. Berry Hart thinks that the great factor in pro- ducing rotation is the recoil of one lateral half of the sacral segment on the part first touching it. Extension. After internal rotation has been completed and the occiput is turned to the front the head is forced in a downward direction. Up to this time the head has passed downward and backward ; it now takes what may be called a sharp curve forward ; the difference in direction, which takes place almost suddenly, in- volves nearly a right angle. Before delivery is accomplished there must be a certain amount of extension of the head, although the chin does not leave the sternum until the greater part of the head has emerged from the vulvar outlet. It is exceedingly important to remember that this movement of extension is not nearly so great as was formerly supposed. I think, however, that the cor- rect description of the mechanism of delivery varies little from that which was given about eighty years ago. Opinions of the Edinburgh School. The Edinburgh school ap- pears to think differently, and as it has taught us so much with reference to the physiology and pathology of pregnancy and labor, its views are worthy of careful consideration. Berry Hart speaks highly of Naegele's epitome, which was translated by Rigby in 1822, and, while he believes the account of the relations be- tween the fontanelles and bony pelvic canal are correctly de- scribed, he thinks that Naegele's description is inaccurate in other respects. He speaks especially of flexion and extension, which, as descriptive of certain movements, are in his opinion most mislead- ing terms, while he does not profess to know how to abandon them. He thinks one can only define them anew. He considers that when a new definition is a contradiction of the accepted use of the term the student's mystification may be only imagined. He refers to certain measurements between the pubes and fundus as ascertained by Shroeder and Stratz (which I shall consider presently), and to the study of frozen sections, as furnishing a new theory of the mechanism of labor which is now too little taught, but will become a basis for accurate teaching in the future. He states that the present teaching, as to its nature and nomenclature, is in the melting-pot, and how it would emerge would be difficult to predict ; the hard-worked student will cer- tainly suffer most in this process. It seems somewhat strange MECHANISM OF LABOR 81 and very discouraging that a school so brilKant in teaching capacity as that of lOdiuburgh, should bo unable, after study- ing the question carefully for fifteen years or longer, to do anything more than mystify its students. Opinions of Sdwoeder and Stratz. The following are some of the clinical facts ascertained by Schroeder and Stratz. These clini- cians found, by actual measurement during labor, that the fundus of the uterus is quite as high after the head has descended to the pelvic floor as at any previous time. Men in London and in Edin- burgh have reached similar results. It seems that after the liquor amnii escapes uterine contractions act on the foetus in a different manner. The circular fibers contract more strongly than the longi- tudinal, causing the uterus to become narrower and longer, the foetus at the same time becoming straightened and lengthened. We are told by the Edinburgh school that there is no flexion as the head becomes engaged in the brim, although it is true that dur- ing this time the posterior fontanelle becomes more palpable. They say this is due, however, to the fact that the occiput dips below the sinciput. They also say the lever theory of flexion is incorrect, for two reasons : first, it gives a cause for a movement which does not occur; second, it is doubtful if any pressure is transmitted to the head through the spine. Referring to the measurements before spoken of, they say that the fundus does not sink during the second stage, the foetus is elon- gated and the curved spine of intra-uterine life is straightened. Fothergill tells us that to understand this subject it is necessary to remember that the term flexion was applied to this movement, when the movement was supposed to be a flexion of the child's head relative to the child's body. Now that the movement is understood to be only a movement of the head relatively to the pelvis of the mother, the term flexion is retained, with a meaning which does not belong to it. This use of an old name with a new meaning is misleading, and it remains to be seen how long the term will be retained in the nomenclature of the mechanism of labor. It is stated that sectional anatomy shows that the chin is touching the sternum before the so-called flexion takes place, and, therefore, the flexion of the head can not be possible. I shall say nothing about the different theories, whether they be called lever, wedge, or inclined plane; but I think that flexion and extension do take place pretty much in the way which has been 82 PHYSIOLOGY OF LABOE described during so many years. I do not see that proof has been brought forward to show anything to the contrary. Flexion and Extension. — First, as to flexion, I understand that it is not considered possible that flexion of the head can take place while the chin is touching the sternum. Let a person who is sitting keep his back in contact with the back of his chair and bend his head until the chin touches the sternum. Let him then keep the lower portion of his back against the back of the chair, and at the same time flex the upper part of the spine. He will be able to bend the head forward 40 to 60 degrees without much difficulty. On account of the great flexibility of the spine of the foetus the head in the undelivered child may be bent still more. I am at a loss to know, in connection with the movement which takes place and which brings down the occiput, the difference between ''dip- ping " and flexion. It seems still more evident that there must be extension of the head before its delivery and also before it reaches the vulva. It is stated correctly that the posterior fontanelle is the presenting part after internal rotation has occurred, and that it is still the center of that part of the head which becomes visible when it has descend- ed as far as the vulvar aperture. In the first instance the posterior fontanelle is pointing backward toward the coccyx, the body of the child is held within the tightly constricting uterine walls, the fundus and body of the uterus can not be tilted backward to any material extent, if at all. Under such circumstances, it does not seem possible for this presenting part to change its direction to the extent of nearly a right angle without extension of the head. It may be that straightening of a spine which was before curved or flexed causes the occiput to be forced forward. If such movement of the head is not extension, what is it? Fothergill says it is only slight undoing of flexion. What is the difference between exten- sion and undoing of flexion? It is true that the fundus uteri, just before the escape of the head, is higher than it was at the commencement of labor. Such lengthening of the uterus is partly due to the action of the circular muscular fibers, but also to the straightening of the foetal spine which probably causes the extension of the head. I should not spend so much time over this subject were it not for its vast importance from a clinical standpoint. Without giving any further reasons now, I shall consider that the head can be MECHANISM OF LABOR 83 flexed at the brim either by Nature's effort or by our own. In other words, I shall consider that it is always possible for Nature, in her own way, or for us, by pushing on the occiput, to change a vertex into an occiput presentation. External Rotation. — As soon as the head is born and free to move as it pleases it recovers its usual relation to the shoulders. It does this as soon as the head clears the vulva, generally rather quickly. The right shoulder now rotates to the front, and as the head turns with it the face is brought exactly to the mother's right. External rotation occurs in all mechanisms in which the head is born first. At the end of the rotation the back of the foetus always looks to the same side of the mother as it did when the head entered the pelvis at the beginning of labor. Molding the Head. — In all labors the head is more or less changed in shape while it is being driven through the pelvis. This is an important fact in connection with the mechanism of labor because it assists in the adaptation of the head to the pelvis. In vertex presentations the occipito-frontal, sub-occipito-bregmatic, bi-temporal, and bi-parietal diameters are diminished, while the longest diameter of the head — that is, the diameter between the chin and a point in the sagittal suture in front of the occiput — is increased. The caput succedaneum — that is. the oedematous lump formed at the presenting part — forms at first near the coronal suture over the right or left parietal bone as the foetal head hes in the first or second position. As the head descends this swelling or caput moves backward along the sagittal suture until it lies close to or slightly over the posterior fontanelle. In other than cephalic presentations a similar swelling develops on the present- ing part. THE OTHER VERTEX POSITIONS The mechanism of delivery in the three other vertex positions differs slightly from that of the left occipito-anterior position. In the second position, or R. 0. A., the left parietal bone is the presenting part ; the sagittal suture is in the left oblique diameter ; the occiput is forced to the front after it reaches the pelvic floor — i. e., the occiput turns from right to left ; after the occiput comes to the front the head is expelled ; after the expulsion of the head the face turns toward the mother's left thigh. In the third position, or R. O. P., the left parietal bone is the 84 PHYSIOLOGY OF LABOR presenting part ; the sagittal suture is in the right obhque diam- eter; the occiput generally rotates from right to left, and thus comes into the second position, or O. R. A., during its progress; the occiput continues to rotate until it comes to the front; after the occiput comes to the front the head is expelled; after the expulsion of the head the face turns toward the mother's left thigh; exceptionally the occiput turns to the rear, causing the difficult occipito-posterior position. In the fourth position, or L. 0. P., the right parietal bone is the presenting part ; the sagittal suture is in the left oblique diameter ; the occiput generally rotates from left to right and thus comes into the first position, or L. O. A., during its progress; the occiput con- tinues to rotate until it comes to the front; after the occiput comes to the front the head is expelled; after the expulsion of the head the face turns toward the mother's right thigh; exceptionally the occiput turns to the rear, causing the difficult occipito-posterior position. The following table assists one to recollect the normal diameters of the pelvis: Antero-posterior. Oblique. Transverse. Brim 4 in. ^ in. 5 in. 4* in. 5 in. 4i in. 5 in. Cavity Outlet 4i in. 4 in. The figures are approximately correct and easily remembered: 4, 4^ and 5. The most important diameter, as will be found when considering contracted pelves, is the antero-posterior diam- eter at the brim — the true conjugate. CHAPTER VI MANAGEMENT OF NORMAL LABOR In some countries it is considered possible for any ordinary woman or man to learn how to conduct a case of normal labor in a few weeks or a few months. The prevailing opinion in America is that it takes an educated woman or man not less than four years to learn how to properly conduct a normal case of labor. We think that no one can intelligently understand all about normal labor until he has a good knowledge of anatomy, physiology, and pathol- ogy, and, in addition, has gained a knowledge which will enable him to detect the first sign or symptom of abnormality in any form. GENERAL DIRECTIONS The accoucheur will generally have seen the patient before labor. It is certainly very desirable that he should have done so for many reasons. It is quite an ordeal for a young practitioner to visit a patient in labor whom he has never seen before, and conduct himself in such a manner as to win the confidence and respect of his patient and her friends. A great deal might be said about that rather use- ful commodity which is ordinarily called tact. If Nature has not given the tact it is not a very simple matter to acquire it. Above all things the most important consideration is to show kindly feel- ing toward the patient under any and all circumstances. She is apt, in her semi-delirium, to say some rather uncomphmentary things. The absolute rule in this connection should be never to give way to anger ; always to be patient and kind. This is the time when we should throw aside all hospitalism and show the most perfect consideration for the suffering of our patient. Kindly actions will certainly bring their reward. The gratitude of obstetrical patients forms the best sort of capital for medical practitioners. 85 86 MANAGEMENT OF NOKMAL LABOE Students and physicians should ever cultivate their powers of observation. When one first sees his patient it is not advisable to ask abruptly about her symptoms. It is better to converse for a time on some ordinary topic. While thus talking, the physician should watch the patient carefully (without, if possible, appearing to do so). He should see and hear as much as possible and thus get a fair idea as to her general condition and also as to the par- ticular symptoms present at the time. One can thus generally ob- tain an almost exact knowledge as to the frequency and severity of her pains. But comparatively insignificant circumstances, such as the entrance of the physician, often cause emotional disturb- ances, which have their effects on tl^e pains. Questions asked in a brusque, abrupt manner may cause the pains to be suspended for some time. It is not easy to explain the difference between the false pains which occur so frequently during the latter part of pregnancy (especially during the last two weeks) and the regular or true pains of labor. They are, in fact, in many respects similar in character. The true pains, however, are more rhythmical and grow in strength and frequency. The early pains are frequently described as grinding or nagging. They are often very severe and cause suffering which may be more intense than that produced by the later and stronger expulsive pains, even though the latter are more powerful and prolonged than the early pains. The pa- tient instinctively aids them by using the expiratory muscles as in defecation. These bearing-down efforts are partially under the control of the will, as before mentioned in connection with the physiology of labor. A method popular with the laity is to have the patient push with her feet against some fixed object and pull on a sheet tied to the foot of the bed. She takes a deep breath, closes the glottis and puts all the expiratory muscles into action, thus helping the ordinary uterine contractions. The pains are probably caused by the stretching of soft parts, especially the cervix, and by compression of nerve filaments through contraction of the uterine muscles. Questions. — One naturally soon asks his patient something about her pains. Has she pains ? What is their character ? Where are they and where were they first felt (in the back or abdomen) ? How long do they last? How frequent? Is there any discharge (show)? Without appearing to have any doubt on the subject. GENERAL DIRECTIONS 87 one should try to satisfy himsolf that she is pregnant and try to ascertain whether she is in labor. If the patient is sitting up and having only slight pains at long intervals one may ask her general questions as to her pregnancy. If a multipara, one should find out as much as possible about former pregnancies. Has she now reached full term? She may think that she has or has not and will probably give her reasons for such opinions. Inquiries are made on many points, and especially as to last menstrual period, and a calculation is made as to the prob- able date of labor. Examination. — This is more or less distasteful to the patient. Fortunately it is considered now that the external examination is the more important and the first which should be conducted. It is better, as a rule, not to mention the word examination. One should not halt or hesitate in an awkward sort of a way, but simply ask her as a matter of course to lie down (unless she is already in the recumbent position) . If necessary to say anything tell her that you would hke to find how the child is lying in the abdomen. Abdominal Palpation. — The Dublin method of examination has been described and indorsed. Let us now consider the subject from the clinical side. While palpating we use our eyes in accord- ance with rules already given as to inspection. The enlargement of the abdomen is not generally symmetrical; there is usually more prominence on the right side of the median line on account of the torsion of the uterus. The umbilicus is generally protruded. We notice the pigmentation and striae, some at least of which are recent, while others may be old. In former times the chief method of examination was per vaginam. Many practitioners still employ this as their chief method. Most of us now believe that the best method of exam- ination is the external by abdominal palpation. In many cases, with little practise, one is able in a very short time to make a cor- rect diagnosis of position and presentation. Let us go over a few points to demonstrate this. We shall suppose that in placing our hand, or hands, over the top of the uterus we find the breech at the fundus. This is generally easily detected. We shall also suppose that on placing the hands on the sides of the abdomen we find the back of the child toward the mother's left side, but slightly toward the front. We may have ascertained this much in less than a minute. Does it tell us any- 88 MANAGEMENT OF NOEMAL LABOR thing? Yes, it practically tells us everything. The child is lying - in the first vertex position. In another case we find the breech at the fundus and the back of the child toward the right side of the mother ; at the same time we feel small parts (legs and arms) moving on the left side, rather toward the front. What is the position? The back of the child is toward the mother's right side and inclined to the rear ; the occi- put must be in the same position — that is, the occiput is toward the right posterior. We probably have third vertex position. In another case the woman is large and has thick abdominal walls. On placing the hands over the fundus we are not quite sure whether we feel breech or head. On examining the sides of the uterus we think the back of the child is toward the left side but are not certain. Suddenly, however, we feel small parts on the right side of abdomen. We know now the back of the child is on the mother's left, but still we do not know where head and breech are. We examine per vaginam, but are unable to reach the pre- senting part. Pains continue in the mean time. After an interval of an hour we make another vaginal examination. We reach something hard and globular, think it is the head. After moving the finger a little we feel a suture, but are not sure about fonta- nelle ; there is considerable oedema. However, we are fairly certain that we have a first position — that is, left occiput anterior. It is certain that the occiput is toward the left side, because the back is in that position. We must, therefore, have a first or fourth vertex presentation. It is likely to be first, because the fourth is very rare. We feel almost certain that the back of the child is slightly toward the front. However, we shall suppose there is a little doubt. We examine again in another half-hour. We again reach the globular body and find a suture. Running the finger along the suture toward the front, we feel a f ontanelle ; it is small and formed by the junction of three sutures; that indicates that it is the posterior fontanelle. Perhaps we have found that one of the bones dips as we press on the fontanelle. The bone that dips is the occiput, at least in the great majority of cases. We have now verified our diagnosis, both by external and internal exam- ination. The back of the child is toward the mother's left. The head is presenting with posterior fontanelle toward the front. There can now be no doubt. The child is lying in the first vertex position. GENERAL DIRECTIONS 89 Auscultation. — The foetal heart sounds are generally double; the pulse-rate is between 120 and 150. The sound is heard most commonly between the navel and the anterior-superior iliac spine on the left side, because the back of the child is located there in a great majority of head presentations. The area over which the sound may be heard has a diameter of from 5 to 10 cm. (2 to 4 in.). Vaginal Examination. — When a vaginal examination is con- sidered necessary, one should simply ask for some hot water and make the hands aseptic or antiseptic, and make the internal exam- ination as a matter of course. As a rule, it is better to make such an examination after the bladder and rectum are thoroughly emptied. If a competent nurse is present she is asked to prepare the patient. The accoucheur then leaves the room. The nurse should then thoroughly cleanse the vulva and adjacent parts. The physician is probably washing his hands in the next room. When called into the lying-in room he again cleanses the hands in a lysol solution or something of that sort. According to our modern ideas as to cleanliness the correct method is to pass in the finger by sight. In doing this the left hand draws the labia wide apart, so that the first contact of the examining finger will be with the hymen or the vagina inside the hymen. This involves an exposure so marked tha;t the sensitive woman naturally shrinks from it, especially at this early stage in labor. My custom in private practise is, in a large proportion of cases, to examine the patient lying on her back with her side close to the edge of the bed. She raises the knee by flexing the thigh. I am thus able to put one hand under the thigh and the other over the pubes (right under and left over, we shall say) ; while doing this the woman is covered with a sheet. I then endeavor with the thumb and finger of the left hand to separate the labia and intro- duce the finger or fingers of the right hand without any risk of picking up septic matter during the process. It is better to get into the habit of using either the right or left hand in examining, according to the position of the patient. It happens, however, in a large majority of cases, that the patient and her nurse make their preparations with a view to using the right side of the bed. Our first aim should be to reach the os and note its form, con- sistence, and degree of dilatation. Sometimes the external hand may depress the fundus in such a way as to bring the head within 90 MANAGEMENT OF NOKMAL LABOE more easy reach.- If partial dilatation has taken place the pre- senting part is examined. The examination is made between the pains, so as to avoid the risk of too early rupture of the membranes. Feeling a parietal bone, then a suture, and then one or both fon- tanelles will probably give sufficient information as to the presen- tation. Then the finger is passed around the pelvis to discover any abnormality of shape. An effort is made to find the prom- ontory of the sacrum with the tip of the middle finger. If this can be reached easily one may be practically certain that there is some abnormal condition — that is, a short conjugate diameter with probably a flat pelvis. One should notice whether the vagina is normal, whether its walls are relaxed, whether there is a proper secretion of mucus, or a dry and hot condition ; also the condition of the perinsBum as to rigidity. If the perinaeum is rigid, the vagina constricted, the os closed, with no secretion of mucus (show), the patient is not in labor. If the perinaeum is soft and dilatable, the vagina soft and dilatable, the cervix fully dilated, perhaps to such an extent that one can not detect it at all, the patient has completed the first stage of labor — that is to say, the parts are prepared for the passage of the child. Preparation of the Patient. — The patient, when near term, should wash carefully with soap and water the vulvar region at the time of her daily bath. When labor is expected the nurse should clip the ha,ir about the vulva as closely as possible with a pair of scissors. This assists in the prevention of sepsis and the discomfort which is caused by the clotting of lochia upon the hair. Before the first examination is made in labor the vulva and neigh- boring parts should be thoroughly scrubbed with soap and water for not less than five minutes. The majority of obstetricians recommend the use of a nail-brush. I do not insist on this always, but I do insist that a nail-brush when used should always be new. An antiseptic pad soaked in lysol, or other antiseptic solution, should then be placed over the vulva. A pad of this sort should be changed somewhat frequently, and the vulva should be thus protected as far as possible until the labor is completed. . Some obstetricians insist that the vagina should then be douched with an antiseptic solution. This is quite unnecessary, unless there is some special indication for it, such as the presence of gonorrhoea or some condition which causes an offensive dis- charge. In administering a douche before labor one should never GENERAL DIRECTIONS 91 use a bichloride solution, because it corrugates the tissues, hinders to some extent the descent of the presenting part, and renders the tissues more liable to be lacerated ; and to formalin these objec- tions apply even more strongly. I think the best solution for antepartal douching is a 1 or 2 per cent, of lysol. Preparations during Labor by Nurse and Doctor. — The nurse should make arrangements to have water boiling continuously during labor. For such purpose the water may be heated in an ordinary clothes-boiler or preserving-kettle or a teakettle. The advantage in using a boiler or large preserving-kettle is that one may introduce any instruments, such as forceps, etc., for steri- lizing purposes. The nurse should also empty some of the water, after it has been boiling for a certain time, say fifteen minutes, into some receptacle, such as an ordinary pitcher, and allow it to cool, at the same time covering the mouth of the pitcher with a sterilized towel. One or two such pitchers, filled with sterilized water, should be placed in the lying-in room to be used for cooling certain solutions, as, for instance, normal saline solutions for sub- cutaneous injection. The nurse should also have a sufficient supply of receptacles for her solutions. Ordinary wash-basins, soup-plates, or platters, will suffice. The following will be sufficient for any ordinary case : Wash-basin for general purposes and especially preliminary hand washing. Wash-basin for lysol solution, 2 per cent. Wash-basin for bichloride solution, 1-1000. Soup-plate for catheter, artery or tongue forceps, and rub- ber tubing with bulb attached, in lysol solution. 2 per cent. Soup-plate for twenty small cotton swabs, in lysol solution, 2 per cent. Soup-plates for cotton, silk, or bobbin, to tie the cord, and cord scissors, in lysol solution, 2 per cent. Large soup-plate, or small platter, for receiving the placenta. This should be covered by a towel taken from a lysol solu- tion, 2 per cent. Teacup for boric-acid solution for babe's eyes. Most of these may be placed on a table at one side of the room. The lysol solution in the wash-basin should be placed close at 92 MANAGEMENT OF NOEMAL LABOE hand for the use of the operator, especially during the birth of the child and the expulsion of the placenta. The doctor should, in good time, put his instruments, including the forceps, in a towel and have them sterilized with boiling water. As before intimated, this may be easily done by placing them in a closed boiler or preserving-kettle containing the boiling water. Fig. 63. — Room Prepared for Labor. After they are sterihzed the different smaller instruments should be placed in the plates as indicated. The forceps should be wrapped in a sterilized towel. THE ONSET OF LABOR Diagnosis. — It is difhcult to lay down rules as to the diagnosis of the onset of labor, as it is impossible with our present knowl- edge to name any definite set of symptoms which will indicate with certainty the exact time of the commencement of labor. While making an examination one may be able to determine that the presenting part is low down. Although under such cir- cumstances the OS is but slightly or not at all dilated, one might consider that labor had either commenced or was about to do so. This, however, would not always be correct, because under ordi- GENEEAL DIRECTIONS 93 nary circumstances the presenting part is almost invariably low down in primipara3 one to two or three weeks before the onset of labor, whereas in multipara) the presenting part may remain higher up until the labor is well advanced. Excessive cervical secretion (the so-called "show"), together with pains, furnishes the most certain sign of the onset of labor. Unfortunately, however, even the combination of pains and show does not furnish a positive indication. Sometimes such excessive cervical secretion is not immediately followed by labor, and occasionally labor sets in without it. Regular, rhythmical contractions gradually increasing in fre- quency and severity, progressive dilatation of the os, together with the copious blood-stained discharge, indicate with certainty that the patient is in labor. We have been told that even these three concurrent signs are not necessarily followed by progressive labor. For instance, " in a patient suffering from contracted pelvis, where labor was induced by the introduction of De Ribes's bag, contain- ing 16 ounces of water, through the cervix without rupture of the membranes, regular pains ensued until full dilatation of the os. The bag was then expelled, the pains gradually ceased and twelve hours afterward the os had contracted down to the size of a two- shilling piece. Twenty-four hours afterward the os just admitted two fingers with difficulty. The bag was again introduced and the membranes artificially ruptured, when the bag was expelled. Labor terminated naturally " (Mathew, Queen Charlotte Hospital). It is quite true that when dilatation of the os has been produced by artificial stretching it may be followed by more or less contrac- tion after the stretching process is stopped and thus prevent the progress of labor for a more or less indefinite time. This does not contravene the clinical fact that regular pains, show, and natural dilatation of the os indicate positively the condition of labor. We are often asked by the patient or nurse to name the sign which will indicate the necessity or advisability of summoning the doctor. It is easy and correct to say that as soon as the patient has regular pains similar to those which have been already de- scribed as true pains, together with a show, the patient should be considered in labor. The physician should try to explain the differ- ence between the so-called true pains, which generally radiate from the back, and the false pains, which are more apt to appear in the front, and are generally due to colic. It is safer, however, to have 94 MANAGEMENT OF NOEMAL LABOE the patient or nurse consider that the doctor should be summoned when the patient has anything hke severe pains, whether com- mencing in the back or front and whether accompanied or not by excessive cervical secretion and dilatation of the os. The follow- ing rules are useful for the nurse and young accoucheur : I. Rules for the Nurse. Send for the Doctor — a. When there are pains with excessive cervical secretion — ''show" (almost certain). b. When there is ''show " even with doubt as to character of the pains. c. When there are fairly severe and regular pains, especially when they radiate from the back. n. Rules for the Doctor. a. When there are rhythmical contractions (pains) gradu- ally increasing in frequency, show, and dilatation of the OS, with or without protrusion of the bag of mem- branes, the patient is in labor. b. When the contractions are not strong nor frequent and the OS is only dilated to the size of a twenty-five cent piece the patient is in labor but not far advanced. One may probably leave her for an hour or two, especially if a primipara. c. When the contractions are strong or fairly strong and fre- quent and the os dilated to the size of a fifty-cent piece, the patient is probably well advanced in labor. It is not safe to leave her. The Obstetrical Satchel. — No one has been able as yet to fur- nish an obstetrical satchel which is satisfactory in all respects. The ordinary leather bag can not be kept aseptic and for this reason some have used metallic cases. These, however, are heavy and clumsy. The so-called aseptic midwifery bag with removable linings ceases to be aseptic, as a rule, when it is handled. Most surgeons and obstetricians continue to carry their instruments in leather satchels or bags. For obstetrical purposes I prefer the leather cabin bag, 16 or 18 inches long. The articles placed in the bag should be protected by proper coverings ; the best material for such being metal, glass, or washable linen or cotton. GENERAL DIRECTIONS 95 The following articles are rcconuiu'iHlcd fcjr the satchel: Axis-traction forceps. Pelvimeter. Hypodermic syringe with morphine and stryclniine tablets in a case. Artery forceps which may be used as a needle-holder. Needles in metal case. Scissors. Double tenaculum. Uterine dressing foi'ceps. Posterior, or Sims's si)e('ulum. Hollow needle for hypodermoclysis. Nail-brush. A soft rubber tube with bulb attached. Catgut, silkworm gut, and silk in hermetically sealed bottles or tubes. Ergot. Lysol or carbolic acid. Tablets of corrosive sublimate. Antiseptic powder. Tablets of chloral. Chloroform. Mixture of chloroform and ether (equal parts by bulk). Sealed packet of iodoform gauze (5 per cent.). Gravity, or Davidson's syringe. Glass or metal douche tube. Soft rubber or glass catheter. Buckmaster's shng or Robb's leg-holder. White hnen coat or operating gown. Rubber gloves. The Accoucheur's Dress. — Very few modern surgeons think of operating either in hospital or private practise without wearing a fresh gown or apron of some sort. Obstetricians do not so com- monly prepare themselves in this way ; many of them simply take off their coats and roll up their sleeves within sight of the patient, and look sometimes as if preparing for a fight. The sight of a big, muscular doctor thus preparing to treat a poor, delicate, little woman, generally causes fear and trembling. On the other hand, I can not say that I admire a butcher's apron, nor the nightgown such as old Smellie used to wear a hundred and fifty years ago, but prefer a plain white coat with short sleeves, buttoned either in front or behind. Let the physician choose what he likes, how- ever, so long as it is clean, but he should prepare himself in an adjoining room, not in the patient's bed-room. This is especially 96 MANAGEMENT OF NOKMAL LABOR necessary if he uses overalls as well as a gown. If he has nothing better let the nurse fasten over his waistcoat, shirt or suspenders, a large towel to take the place of an apron, and also a smaller towel around one or both forearms. The Lying-in Chamber. — One should choose, if possible, the most suitable room in the house. It should be large, airy, and re- moved as far as possible from the noise of the house and the streets. There is always a certain amount of danger when the room is close to a water-closet, or when there is in it a sink or basin with waste pipe passing through it. All unnecessary furniture and heavy cur- tains should be removed. The Bed. — It is better to have a bed which is narrow and fairly high, but in the majority of cases one will have to take the bed as he finds it. A soft feather-bed, however, is decidedly objection- able. We scarcely see such a thing in our larger cities, but in many country districts a feather bed is highly prized. When it is present on the obstetrical bed it should be removed. Sometimes a poor mattress on weak springs is almost as objectionable as the feather- bed, especially where interference is required, as, for instance, in the management of breech cases and forceps delivery. Under such circumstances the placing of one or two boards immediately under the mattress — that is, over the springs — improves the con- dition of the bed very materially. Two pieces of mackintosh or rubber sheeting — one full size of bed, the other half size — are required. The rubber sheeting is more expensive, but if it is thoroughly cleaned after labor it may be used for two or three years on the infant's bed (Cooke). It is a good plan to use a large mackintosh and a small piece of rubber sheeting. The large mackintosh is used chiefly to protect the mattress. The under blanket, bolster and sheet are used to make the bed comfortable. The smaller mackintosh or piece of rubber sheeting with the draw sheet is used to protect the bed from the copious dis- charges which take place during the second and third stages of labor and is so arranged that it can be easily removed from the bed after the completion of labor. Some of our obstetricians use the Kelly's pad or something similar to it, but I do not recommend its use in ordinary private practise, because, in the first place, it is too bulky for a satchel such as I have described, and in the second place, it is difficult to keep it aseptic. It is also very liable to become displaced and interfere with labor, more especially if forceps are GENERAL DIRECTIONS 97 being applied, with the patient on her side. There are, however, specially made pads of other material, such as wood wool, cotton- batting, etc., which are very convenient. Antisepsis and Asepsis. — ^Every physician should carry out cer- tain definite rules as to antisepsis and asepsis. His constant aim should be to have his patient, her surroundings, and himself per- fectly clean. He may do that perhaps with soap and hot water, and may call his methods aseptic. If so, I shall not object, al- though I may say that both soap and hot water are to some extent antiseptic or germicidal. I prefer, however, the use of stronger antiseptics for certain purposes. If called upon to recommend only one antiseptic for midwifery practice I should certainly choose lysol. A few years ago I should have said carbolic acid. Either of these is, in a sense, unobjectionable if not used in poisonous doses, while corrosive sublimate, as already stated, is sometimes injurious, especially when used immediately before or during labor. After using carbolic acid for years I tried lysol, but, finding its odor somewhat unpleasant, I went back to carbolic acid. After using this for a time and carefully comparing results, I have again chosen lysol as the best all-round antiseptic for obstetrical purposes. As compared with carbolic acid it is less corrosive, less poisonous, more readily miscible with water, less likely to injure the hands, and above all other comparative considerations, is decidedly soapy in character ; at the same time lysol is probably quite as destructive of microbes as carbolic acid. I, however, always carry bichloride tablets and use them especially for cleansing the external parts after labor. While I advise and use both antiseptic and aseptic methods, I quite agree with Di.ihrssen that "the introduction of asepsis with- out antisepsis into midwifery is a mistake, since the field of opera- tion in midwifery is a germ-containing one." For ordinary obstetrical purposes make the antiseptic solutions in the following proportions : Lysol solution, 1 or 2 in 100, or, roughly speaking, one or two teaspoonfuls to the pint, supposing the ordinary teaspoon to contain about 80 minims ; bichloride solu- tion, 1 to 1000 — that is, one 7^ grain tablet to a pint. Lubricants. — One should not use, as a lubricant for the finger, any vaseline, oil, etc, that may be in the house. One should also avoid the so-called medicated lubricants, because many of them are absolutely worthless and frequently harmful. The physician. 98 MANAGEMENT OF NOEMAL LABOR after anointing the finger or fingers with one of these lubricants, may carry pathogenic germs into the parturient canal and leave them there so protected that they can not be washed away by the liquor amnii. The most common of these antiseptic lubricants is probably carbolized vaseline, which has been proved to be, in certain cases, a good culture medium for the bacteria, the vase- line protecting the germs from the action of the carbolic acid. It has been pointed out by some obstetricians that the application of a lubricant to the finger adds an element of safety when there are sores on the vulva or vaginal wall. That is true to a certain extent, but when such sores are present one should always wear rubber gloves. FIRST STAGE OF LABOR Importance of Enemas. — The patient is now in her lying-in room; she has been properly prepared for labor. For weeks or months we have been trying to get her into good condition. We have especially looked after the liver and kidneys and have kept the bowels open. What next? Let the nurse administer an en- ema. "There is no necessity for that, Doctor," the nurse may say, "because the patient has already had two evacuations this morning, in fact she almost has diarrhoea." Make no difference on that account. In all cases one should insist on the adminis- tration of an enema. A short time ago I had a somewhat tedious labor. I had looked after my patient carefully during pregnancy and had one of my best nurses. She had looked after everything required for the labor, as I supposed. I found it necessary to apply the forceps, and, on using traction, some soft faeces emerged from the anus. "Didn't you administer an enema, Miss S.?" I asked. "No, Doctor, it was not necessary; her bowels were well moved this morning. ' ' The extraction was somewhat slow and a plentiful supply of the softened faeces came constantly during the process. The nurse was kept busy using towels in the necessary cleansing process, and, while doing so, I hope learned the lesson which I supposed she had been taught some years ago in our Training School for Nurses. The following morning, on going to the Burnside, I asked Miss McKellar when she considered an enema should be administered before labor. She said, in all cases. " But," I asked, "what will you do if the patient already has diarrhoea ? " "In any case we FIEST STAGE OF LABOR 99 administer the enema. Is that not what you teach, Doctor?" "Yes," I said, "but, notwithstanding what you and I teach, some of your nurses do not understand what they should do under such circumstances." It happens that the escape of fsccal matter in these so-called diarrhoea cases is frequently the worst sort one meets with. Such an accident is not simply unpleasant, it is also dangerous, because it interferes sadly with asepticism and it is often exceedingly hu- miliating to a patient. This is one of the small points in connec- tion with the conduct of labor which should be considered impor- tant. When an enema has been administered early in a prolonged first stage it is well to have a second enema administered after an interval of twelve to fifteen hours. Some women object strongly to the administration of an enema, but if one explains to such how the enema is likely to prevent unpleasant accidents she will, as a rule, readily withdraw her objections. Directions for the Nurse after Labor. — Definite directions are given to the nurse with reference to the after-treatment of the patient, especially for four days. If not certain as to her methods the directions should be put in writing. Why specify four days? Certainly not because I wish the nurse to become careless at the end of four days. But the rents and tears in the parturient tract are covered with healthy granulations in three or four days. Such a granulating surface is practically non-absorbent. Cases of Emergency. — At an examination a few years ago I asked a graduating class: What should the obstetrician do when he came into the room while the child was being born? Some in their answers gave full directions as to the preparation of the hands before touching the mother or babe. I need scarcely point out the absurdity of such a course of action. In such a case one must help the patient and child at once. Receive the babe in one hand and place the other over the uterus, then clean the hands thoroughly before touching the vulva or vagina. One may be called upon to conduct a case of labor without any of the ordinary instruments or antiseptics recommended for the satchel; in such a case he should aim at doing aseptic work. This is not difficult to do in any house, especially if soap, hot water, and clean towels can be obtained. Introduction of Hand into Uterus. — The accoucheur should wash well the hand, wrist, and arm before introducing the hand 100 MAIsTAGEMENT OF NORMAL LABOR into the uterus. I presume that the hands have been washed before this and also that the vulva and adjacent parts have been carefully cleansed. Such directions, of course, are common as to midwifery practise. A great many add, however, that an intra- uterine douche should always be administered after the hand has been introduced into the uterus. I have never given any such recommendation nor adopted any such rule for myself. In the first place, certain dangers are always associated with intra-uterine douching. In the second place, there is no necessity for such procedure after introducing a clean hand into the uterine cavity. Prognosis. — The physician, after having made his examination in the ways already indicated, will have reached certain conclu- sions. He will have found the condition favorable or unfavorable, as the case may be, and will have formed some idea as to the progress of labor. He will be asked certain questions of which the following is probably the most common : ' ' Is everything right ? ' ' The patient or her friends, in asking such a question, mean, "Is there any danger to the mother or child." If he finds the head presenting in a favorable position and the condition otherwise quite normal he may answer with confidence, that there is no sign of danger to either the mother or child. The answer should always be as favor- able as possible. The physician may sometimes be in doubt or find something absolutely unfavorable. It is better to explain his misgivings to the relatives of the patient rather than to the patient herself. Another question very commonly asked is : " How long will labor last? " or "When will it be over? " The physician should be very careful as to how he answers this, because, as a matter of fact, he does not know, nor will any number of years of experience enable him to give a definite answer to such a question. It is not necessary to say in an abrupt way, " I do not know." It may be well to say that if everything goes on well it is likely that labor will be completed within a few hours or possibly within one hour or less, but the little clause commencing with " if " should never be forgotten. Diet During Labor. — It is not necessary to give any very definite rules as to diet during labor. In a large proportion of cases the patient wants but little and may generally have what she desires. Simple, light diet, however, is best for her, because the process of labor interferes to some extent with that of diges- FIRST STAGE OF LABOR 101 tion. In considering the evil offocts of overfeeding during labor it is always well to have in view the atlministration of chloroform. Occasional Absence from the Room, — The pressure upon the bladder and rectum generally causes frequent desire to pass water and evacuate the bowels. On this account the physician should make it a point to retire occasionally into another room. In fact, if he has a good nurse it is better for him to be out of the room as much as possible during the early part of the first stage. It sometimes happens in practise among the poorer classes that there is no second room to which one can retire. In such a case there is no necessity for worry, as the patient will be forced to adapt her- self to the circumstances in which she is placed. Position During the First Stage. — The patient should, as a rule, do pretty much as she pleases during the first stage. It is not necessary nor desirable to keep her in bed during the early hours of the first stage. It often happens that the pains are more effec- tual when she is sitting, standing, or walking. For these reasons the question of position may be left to the patient. If the pains become feeble when she lies down on a lounge or a bed one may encourage her to get up occasionally and walk about. It is not well, however, to make her take too much exercise during a tedious labor. While it is well to allow a woman to assume any position she pleases early in labor, it is advisable to adopt the rule that a woman shall always go to bed when the pains have become very strong. Progress. — One can generally have a fair idea of the progress of labor by carefully observing various symptoms. As labor ad- vances the pains should become more frequent, stronger, and longer in duration. It is difficult to have any definite idea with- out occasional vaginal examinations. These should, however, be infrequent, chiefly because we wish to avoid all possible chances of causing septicsemia. When the os uteri and soft parts below it are becoming dilatable and dilated labor is advancing. While we attach much importance to dilatation of the os, we should attach similar importance to the dilatation of other parts which must occur before the child can be safely born. We find the following conditions in practise: Early in the first stage, on making a vaginal examination, one can barely insert one or two fingers sufficiently far to reach the os uteri. The perinseum, pel- vic floor, vulva, vagina, are aU more or less rigid and contracted. 102 MANAGEMENT OF NORMAL LABOE After labor has gone on satisfactorily for a number of hours a great change has taken place. These parts have become first oedematous, then softened, then dilatable, then actually dilated or stretched. One may now introduce within the vagina the whole hand without causing any more pain or discomfort than was pre- viously produced by the introduction of one or two fingers. When all these structures have become softened and dilated, the parts are properly prepared for the expulsion of the child. When may a Patient be Left ? — The doctor is not required dur- ing the whole or even a large part of the first stage of labor. He is generally summoned during that stage, makes his examination and probably reaches certain conclusions. If he finds that very little progress has been made, that the first stage is likely to con- tinue for many hours, he may leave the house, pay other visits, and return at a certain time. When is it safe for a doctor to leave his patient, and how long may he stay away? In a large propor- tion of cases there is no special difficulty in deciding early in labor that he is not likely to be wanted for some hours. In the following case a doctor of my acquaintance was absurdly cautious, if not extremely ignorant. During his first year in prac- tise he was called to see a patient supposed to be in labor. Three or four of the wise women of the neighborhood surrounded her bed. The patient was pulling hard on a sheet attached to the lower end of the bed and was encouraged in her efforts by her good friends who told her to "hold her breath and bear down." The doctor thought things looked serious, but on making vaginal exam- ination could discover little or nothing. He thought this was due to want of skill, and was correct in so thinking. He deemed it safer, however, to stay a portion of the night. After some three or four hours the pains diminished to such an extent that the patient fell asleep. He then thought he could with safety leave the house and told the friends to summon him when he was re- quired. After ten weeks he was again summoned to the house when he found the patient actually in labor, and then conducted the case in a way that was satisfactory both to the friends and himself. One may be guided largely by the advice of Swain and Gooch, which was pretty much as follows : The physician may leave the patient in the first stage of labor under the following circumstances (Swain) : FIRST STAGE OF LABOR 103 1. In the case of a priniipara if tlie presentation is natural and the OS uteri not yet dilated to the size of a fifty-cent piece. 2. In the case of a multipara if pains are few and weak, the presentation natural, and the os uteri not yet dilated to the size of a twenty-five cent piece. 3. In any case if there have been very few pains before the physician's arrival, and none for at least one hour afterward. If the pains have ceased in consequence of the patient's nervousness at his sudden appearance he will, by waiting an hour, have allowed ample time for the effects of this feeling to wear off. Gooch gave excellent advice pretty much as follows : The propriety of leaving a patient in labor will depend upon many circumstances, but principally upon whether or not it is a first labor. If a first labor and one can be within call, he may visit other patients, return, ascertain the condition, and perhaps go out again. This he may do until the os uteri is dilated to the size of a fifty-cent piece, a process which will occupy about two-thirds of the time of labor. Afterward no prudent man should leave his patient until labor is completed. But, if it is not a first labor, the progress is very different. The patient has slow pains occurring about every ten or fifteen minutes, just sufficient to remind her that she is in labor. The accoucheur is informed so that he may be easily reached. On being sent for after a notice of this kind, he will find that these trifling pains have been sufficient perhaps to completely dilate the os uteri, ''the pains now become stronger and the membranes more distended — presently they are ruptured — gush goes the liquor amnii, and if his arrival has not been pretty expeditious he may be greeted, on entering the room, with the squall of the child under the bedclothes. If I am called to a labor which is not the first and find the pains regular, though slight, how- ever trifling may be the dilatation of the os uteri, I am exceedingly shy of leaving my patient." Assistance, Bearing-Down, etc. — It unfortunately happens that we are not able to render much assistance during the first stage of labor even though the woman may suffer seriously from the pecul- iar "grinding " pains. It may be laid down as a rule that one can do very little before the end of the first stage in a normal case. When this stage continues longer than it should, it becomes to some extent abnormal and tedious and may require definite treatment. It sometimes happens that one or two warm baths help to alleviate 104 MANAGEMENT OF NORMAL LABOR the pains. These are, of course, always safe. The nurse and doc- tor should do all that they can to encourage the patient. While it is not easy to tell definitely how the patient may be assisted, it is less difficult to tell what should not be done. The patient should not be allowed to tire herself out by pulling on a sheet and by the so-called bearing-down. It is well to guard continuously against anything of this sort, because nurses and friends of the patients are so apt to give bad advice in this regard. There may be and is fre- quently a time for ''holding the breath and bearing-down," as hereafter mentioned, but that is not during the first stage. Preparation of Patient Toward the End of the First Stage. — During the early part of the first stage the patient should be lightly clad with undergarments covered with an ordinary wrapper. When the pains become strong toward the end of this stage and the patient has to lie on her bed, which has been prepared in accord- ance with directions already given, she should wear her night-dress and a pair of long stockings, or the Snively combined drawers and stockings. The night-dress should be pulled up under the arms and properly fastened there to prevent its being soiled by the dis- charges ; at the same time a sheet, folded once, should be neatly pinned around the patient's waist. This should be arranged in such a way that it can be easily removed along with the Kelly pad or ordinary obstetrical pad after the completion of labor. Then the patient should be covered with an ordinary sheet and as many bedclothes as are required. Presence of Husband. — It occasionally happens that a husband desires to be present during labor, although why he should do so I could never understand. My custom is generally to allow him to be present if he wishes during the first stage, although I much pre- fer his absence. He can do no good and is apt to be intensely alarmed on account of his wife's sufferings. Under such circum- stances he becomes sometimes almost an intolerable nuisance, and it will keep one pretty busy assuring him that this is not the first time in the history of the world that a woman has suffered so severely. During the progress of the second stage I generally say, quietly, " You had better leave the room now, we are getting near the end," without giving any reasons why. He almost invari- ably leaves when so instructed without making any trouble. If by any chance he should insist upon remaining, I have nothing more to say. MANAGEMENT OF THE SECOXD STAGE 105 Rupture of Membranes, — Rupture of ilic membranes may occur at any time during the labor or before labor has commenced, but under ordinary circumstances should take place about the end of the first stage or at the commencement of the second stage. Very often such rupture may be said to be the dividing line between the first and second stages. In a large proportion of normal cases the history is somewhat as follows : labor advances steadily until the child is in proper position for expulsion and the mother's soft parts are sufficiently softened and dilated to allow the passage of the child, the membranes suddenly rupture, pains become more fre- quent and more vigorous and the child is soon expelled. Some- times it happens that such rupture does not take place without artificial interference. Under such circumstances the doctor may cause the rupture by pressing with the finger end. Years ago he was advised to do so with his finger-nail, sometimes sharpened specially for the purpose. As we now prefer to have short finger- nails we must use the finger-tip or some hard instrument. An or- dinary surgical probe answers well. If no probe is procurable a coarse hairpin may be used ; first straighten it and then hold it for a long time in a flame ; after it is thus steriUzed it should be passed along the finger-tip as a guide and pressed against the bag of mem- branes during a pain. In rupturing the membranes in this way it is well to hold a soft bichloride towel closely against the vulva to receive the gush of waters and prevent soiling the bed. MANAGEMENT OF THE SECOND STAGE During the first stage the patient has been allowed, during the greater part of it at least, to sit, stand or walk pretty much as she pleased; in the second stage she should not be allowed any such liberties. She should not be allowed to leave her bed even for evacuation of the bladder or the bowels, because of the danger then existing of sudden expulsion of the child. The pains in the second stage are changed in character. The ordinary uterine expulsive efforts are assisted by certain of the voluntary muscles. The patients are very apt during these pains to brace their feet and pull on something near them, frequently on the hands of some bystander. These voluntary efforts assist to some extent in the expulsion of the child, but in the so-called pre- cipitate labors may do a certain amount of harm. It is well, as a 106 MANAGEMENT OF NOEMAL LABOE rule, to make an effort to regulate these voluntary efforts. When it is desirable to hasten labor she is directed to press her feet against something and at the same time pull on a sheet attached to the foot of the bed. She is told to hold her breath and make full use of the accessory powers during each uterine contraction. When, on the other hand, the uterine contractions are already too strong, she is directed to cry out during pains instead of holding her breath. In addition to the ordinary pains accompanying the uterine contractions the patient may have cramps in the lower limbs which add much to her suffering. Such cramps may be overcome by powerfully contracting the antagonistic muscles. For example, in case of cramps in the calf of the leg the patient should forcibly flex the foot and hold it so until the muscular spasm subsides, at the same time the cramped muscle should be well rubbed by the doctor or nurse. Sometimes the ordinary pains are extremely acute in the sacral region. These may be relieved to some extent by firm pressure of the palms of the hands against the sacrum during the uterine con- tractions. To apply such pressure is generally supposed to be one of the duties of the nurse, and is sometimes onerous in character in a prolonged second stage. When the patient finds that such pressure furnishes a certain amount of relief she will insist upon having it during every pain. It not infrequently happens that an abdominal binder firmly applied may slightly relieve these pains. Such binder may also assist expulsion, especially in multiparas with pendulous bellies. When the head begins to distend the perinseum, the patient should be watched with great care. Some recommend that at this time a pillow should be placed between the knees to support the thighs or that somebody should lift up the right knee. I do nothing of this sort as a rule, but occasionally, when the patient appears to feel instinctively that expulsion may take place more readily with the thighs separated, I use the pillow or the hands of an assistant as recommended. At this time we have to keep several things in view. We should watch the patient's voluntary efforts, make her hold her breath when necessary and bear down, or ask her at critical moments to cry out and stop bearing down. We should watch the perinseum and vulva as they are being distended. We should keep the parts as clean as possible. MANAGEMENT OF THE SECOND STAGE 107 During the whole of the second stage the vulva should be cov- ered with a diaper, pad, or towel which has been soaked in an anti- septic solution, preferably a lysol or bichloride solution. Before each examination the vulva should be again washed, and after an Fig. 64. — Bladder Empty before Labor. examination a fresh pad if possible, or at least a pad freshly soaked in the antiseptic, should be reappHed. In spite of all precautions the descending head may press some faeces from the rectum. These should be carefully wiped away with a piece of cotton or a pledget of wool soaked in the lysol solu- tion. In using any such pledget be careful to pass it from before backward so as to wipe from and not toward the vulva. Each pledget, after being used, should be thrown into the slop-pail or basin. Hot fomentations or oily preparations have sometimes been used to help relaxation of a perinaeum when very rigid. I am very doubtful, however, as to the efficacy of any such applications. Before making any special reference to the management of the perinaeum and pelvic floor it should be noted that this is a very Fig. 65. — Bladder Full during or before Labor. critical time in the process of labor. One should be keenly on the alert to do all in his power to assist his patient without doing her any harm. There is no time in our professional career when it is more important for us to be what the world calls "calm, cool and collected." A careful study of all the steps in this stage, all the details in management and nursing, and all the precautions to be 108 MANAGEMENT OF NOEMAL LABOR taken from an aseptic or antiseptic standpoint should give us a knowledge which will enable us to conduct properly any normal case without serious difficulty. Management of the Perinaeum. — Many procedures which have been recommended by various so-called authorities instead of effecting any good do a positive injury. One of the most harm- ful of such procedures is what is called "supporting the peri- naeum." I believe it is a great deal easier to do too much than too little at this time. Fig. 66. — Controlling Passage of Head through Vulva, One Hand passed BETWEEN THE ThIGHS. It was stated in connection with the mechanism of labor that after the head passes downward and backward in the pelvic cavity for a certain distance it turns rather sharply forward and continues in this new direction until it emerges from the vulva. During this part of its descent it presses against the floor of the pelvis and the perinaeum and may do more or less injury to these structures. Such injuries are more likely to occur in first labors. It is estimated by some that lacerations of the pelvic floor and perinaeum occur in 40 per cent, of first and 15 per cent, of subse- MAN"AGEME?TT OF THE SECOND STAGE 109 quent labors. Such injuries have frequently very serious effects. A strong, healthy young woman may give birth to a healthy child and may make a fairly good recovery. She and her friends are perfectly satisfied with her condition for a time after labor, but even under such apparently favorable circumstances the pelvic floor may be so severely injured as to cripple her for the rest of her life. It is probable that at least half of such injuries might be avoided by careful and judicious methods of management. Many lacerations of the pelvic floor, which ought to be readily apparent to any one who looks for them, are not recognized because they are not properly looked for. In first labors the fourchette is gen- erally torn, a slight rupture of the peringeum is also c[uite common and is generally observed. A complete rupture of the perineum Fig. 67. -C'oxiKuLLixu Passage of Head through Vulva, Both Hands BEHIND Thighs. passing through to the rectum occasionally occurs, and is, of course, generally observed, but in a large proportion of cases seri- ous injuries take place in the pelvic floor which are not recognized. A certain amount of time must elapse before the pelvic floor 110 MAI^AGEMEXT OF NORMAL LABOR and perinseum are in a condition to allow the child to pass with safety. After the uterine contractions have continued for a cer- tain time the pelvic floor begins to bulge. It may look to a begin- FiG. 68. — The Pelvic Floor seen from Above (Kelly). ner at this time as if labor ought to be concluded very quickly. It is undesirable, however, to have the head expelled for at least half an hour after such bulging commences in primiparse, and probably about twenty minutes in multiparae. Position of the Patient. — The patient may lie either on her side or on her back during the first and part of the second stage. As soon as the head is found to distend the pelvic floor and perinseum the patient should be placed on her left side, with her buttocks near the edge of the bed and her thighs and legs flexed. The pelvic floor and perinseum are now in plain view and should be kept so MANAGEMENT OF THE SECOND STAOE 111 until the head and shoulders are expelled. The physician stands at the side of the bed with his face toward the; foot, having the right hand ready to use pr(>ssure from behind and the l(;ft ready to manipulate the vertex, tiic left forearm resting on her right or uppermost thigh. As a rule, especially when the thighs are flexed, both hands can be kept posterior to the thighs and buttocks ; but when the patient is restless or the thighs are extended so as to be in a line with the body, it is better to have the nurse hold up the right leg and pass the left arm over the mons veneris and between the thighs to the vulva. This position is sometimes awk- FiG. 69. — The Pelvic Floor seen from Below (Kelly). ward, but it affords a good opportunity to completely control the patient. In doing this the hand should be wrapped in an anti- septic or aseptic towel while it is passing over the mons veneris to prevent it from becoming infected. The bladder should be empty at this time, because fulness of this organ may considerably prolong the second stage. During the strong pains of this stage chloroform may be administered to the obstetrical degree. When the head presses with some force, as shown by the bulging of the pelvic floor and perinaeum, an effort is made to prevent lacer- 9 112 MANAGEMENT OP NOEMAL LABOE ation in the following way. The accoucheur puts a clean towel over the anus and presses with the heel of the right hand between the anus and the tip of the coccyx in such a way as to push the head forward toward the symphysis pubis; and places the thumb and fingers of the left hand over the vertex, seizing the latter if he can. One thus gets good control over the head. It is very much as if a person had one hand over the vertex and the other over the chin and mouth without the intervention of the perinseum and pelvic floor. One gets still better control over the head as it is passing Urethra Clitoris Vagina y\ \ M. Constrictor cunni M. Ischio-cavernosus M. transversus perinei Levator ani Centrum tendineum Sphincter ani Fig. 70. — Pelvic Floor distended by presenting Part, showing Superficial Muscles of Perineum (Bumm). through the vulva by seizing it with the left hand over the occiput and the right hand over the forehead in front of the fourchette. In this way one can prevent undue extension and too rapid advance of the head, while he keeps part of the heavy strain off the pelvic floor and the perinseum. If, at this time, the perinseum seems in danger, as shown by undue tightening of the skin around the vulva, the patient is directed to extend the legs and thighs so as to bring them in a straight line with the body, such procedure having a tendency to considerably slacken the tension around the vulva. A backward arching of the patient's back also assists in relieving such tension. MANAGEMENT OF THE SECOND STAGE 113 When the pelvic floor, perinaeum, and vulva seem sufficiently softened and dilated, and the head sufficiently far advanced, one may hold it steadily with two hands, and gently slip it out during an interval between the pains. When this can be done there is sometimes less danger of laceration than when the head is expelled during the acme of the- muscular contractions. Some prefer to put the thumb or fingers of the right hand in the rectum instead of Fig. 71. — Birth of Head, Scalp appearing at Vulva (Williams). behind the anus. This method, while no more efficient than the other, perhaps not so much so, is obviously objectionable. As soon as the head is expelled or extracted the right hand is moved forward to support it and the left is placed over the fundus uteri. Emergence of the Head and Neck. — When the head is born the neck is examined to see if there is a loop of cord around it. When one or more are found the loop or loops are slipped over the head. 114 MANAGEMENT OF NOEMAL LABOE If the cord is too tight to allow this the loop is passed over the shoulders as they emerge. If neither one of these can be done the cord is cut with a pair of scissors, and a clip is put on each divided end, or, if there are no clips at hand, the proximal end, which is Fig. 72. — Birth of Head, Vulva partially distended (Williams). recognized by the spouting of two umbilical arteries, is held between the thumb and index finger until it can be tied. While the physi- cian is thus manipulating the cord the nurse should press with some force (not too much) over the fundus uteri. The child's face, after expulsion of the head, is at first white or somewhat pale, but soon becomes purple. This may cause alarm in the beginner, but it generally involves no special danger to the child. The head is now the only part of the foetal body free from pressure and, consequently, the blood rushes into it and is pre- vented from returning freely to the body by the pressure about the neck. There is danger, however, sometimes. If the child's face MANAGEMENT OF TTIE SECOND STAGE 115 remains purple during the interval between the pains there is cer- tainly danger of asphyxiation. If a ligature has l^een put on the cord there is also danger of asphyxiation. When such danger exists one should extract quickly. If there is no prolonged con- gestion of the child's face, and no cord complication, one should generally wait until the child is expelled by Nature's efforts. The inexperienced physician or midwife is apt to get flurried at this time and make injudicious efforts to extract the child. Rapid extraction of the shoulders, under such circumstances, frequently causes serious lacerations, and sometimes inflicts serious injuries to the child's spine. It is quite right for the physician to assist ex- FiG. 73. — Birth of Head, Vulva completely distended (Williams). pulsion by rubbing or kneading the uterus or by pressure with the hand over the fundus. Generally with such slight assistance the shoulders descend, rotate, and emerge quickly. After the expul- sion of the shoulders the remaining portion of the body follows 116 MANAGEMENT OF NORMAL LABOR rapidly. As soon as the shoulders are expelled the patient should be turned on her back. Quick Extraction of Shoulders. — When interference becomes necessary for the extraction of the shoulders one of two methods may be employed. 1. Hook the finger in the posterior axilla from behind and lift the shoulder over the edge of the perinseum, while the anterior Fig. 74. — Birth of Head, showing Delivery by Extension (Williams). shoulder still rests behind the symphysis. Gently extract the pos- terior arm. The anterior shoulder will now pass easily under the pubic arch. At the same time the assistant should press over the fundus. 2. Push the neck backward against the perinaeum and pull slightly so as to bring down the anterior shoulder; then push the neck forward, pass the finger under the posterior axilla and extract. There is generally or always danger of asphyxiation when two pains have occurred after the expulsion of the head. MANAGEMENT OF THE SECOND STAGE 117 Sometimes the ovum is exj^clkHl intact — that is, with the child completely enveloped in the membranes. In such cases the mem- branes should be ruptured at once to prevent the child from being smothered. The membranes over the head, under such circum- stances, are known as the "caul." In former days a caul used to be considered very lucky, and was not uncommonly sold for a large sum of money. I think the expulsion of an intact ovum is more common in twin lal^ors, the first child being delivered after rupture of the membranes in the ordinary way, and the second being de- livered surrounded by its unruptured membranes. Tying the Cord. — In former days, when it was the fashion to keep the patient on her side until after the expulsion of the placenta Fig. 75. — Birth of Head, Face falling backward toward Anus (Williams). the child was simply placed on the bed, below or behind the pa- tient's buttocks, and remained there until after the ligaturing and division of the cord. If, however, the patient is placed on her back, as I strongly recommend, before the complete expulsion of 118 MANAGEMENT OF NOEMAL LABOE the child, it is not quite so convenient to care for the latter. If the cord is fairly long the mother may flex the right thigh and leg while the child remains mider the right knee or close to the outer side of the thigh; or, the patient may separate the thighs and the child be left between the knees. The position of the mother on her back after the completion of the second stage involves a certain amount of exposure, but this is a small matter when compared with the Fig. 76. — Birth of Head, External Rotation (Williams). benefits to be derived. While waiting to ligature the cord still keep the left hand on the fundus uteri. I repeat this direction somewhat frequently on account of its importance; at the same time I wish again to insist upon it that there should not be any rough kneading or strong pressure used. It is now generally recognized that we should wait for some time after the birth of the child before tying the cord. During this time the foetal circulation is well aspirated, especially after the child has cried. It is probable that during this process of aspira- MANAGEMENT OF THE SECOND STAGE 119 tion the chikl gains two or throe ounces of blood. It is thought by some that the diminution in the size of the placenta through the abstraction of this blood is one ol the causes of the separation of the placenta from the uterine wall. Some say that we should wait until the cord ceases to pulsate. I do not know how long this might take in certain instances, but I make it a practise not to wait any longer than five minutes, especially if the child has cried. The physi- cian should see that there is no protrusion of the bowel in the cord. When the cord is thick one may squeeze some of the gelatinous matter toward the placenta. This is called stripping the cord and is to some extent dangerous Fig. 77. — Soudan Labor Chair. (Photograph by James F. W. Ross.) Fig. 78. — Demonstration of the Method of conducting Labor in Soudan, Africa. Patient in labor chair in the grounds of the Civil Hospital in Obdurman, opposite Khartoum. Hospital behind with part of the surrounding wall visible on the right. Woman behind "helping" patient. Native midwife "waiting." (From photograph taken by Dr. James F. W. Ross, with the permission of Dr. Christopherson, Superintendent, February, 1904. 120 MANAGEMENT OF NOEMAL LABOE because it is liable to do violence to the navel. The safer plan is to simply squeeze the cord at the spot where the ligature is applied. After the cord has been tied and cut, the nurse may take the babe, or it is sometimes more convenient for the physician to do so, and hand it to the nurse. This should not be done in a clumsy and awkward manner. A child covered with the vernix caseosa is Fig. 79. — Native Midwife holding out heh Hands to receive the Babe. (From photograph by Dr. Ross.) sometimes rather slippery and therefore difficult to hold. It will not inspire confidence on the part of the onlookers if the child is allowed to fall to the floor. I always pick up the child in a definite way as described by Uzziel Ogden. Place the left hand under neck and shoulders so that the thumb and index finger support the head, and let the thumb, index, and middle fingers of the right hand seize the thighs immediately above the knees, the index finger being between them. Or the hands may be reversed. . CHAPTER VII NORMAL LABOR {Continued) THIRD STAGE OF LABOR Crede's Method. — About fifty years ago Crede introduced into Germany a certain method of expressing the placenta without any suspicion apparently (according to Robert Barnes) that the same method had long been practised in Great Britain. It was prac- tised especially in Dublin and the procedure was minutely de- scribed by McChntock and Hardy in 1848. About the time that obstetricians of Great Britain w^ere learning the dangers of rapid expulsion, physicians of the continent, United States, and Canada were, as a general rule, practising the Crede method. The impor- tant difference between methods in vogue in the middle of the last century may be best understood by the use of two words — ex- traction and expression. The older method of extraction in the course of years gave way to that of expression. The Rotunda school of Dublin was the first in the world to adopt expulsion or expression. In a few years many of the disciples of Crede on the continent, and those of the Rotunda in Great Britain, discovered that rapid expulsion was frequently followed by evil results. One of the first in Canada, and perhaps in North America, to recognize the evils of rapid expulsion was George A. Tye, of Chatham, Ontario. After carrying out for some years the original Crede method he relin- quished it in 1887, and adopted almost in its entirety the expectant method. There was, during all these years between 1850 and 1887, some doubt and uncertainty as to the exact nature of the methods of expression. Fortunately we are able now to lay down definite rules as to the conduct of the third stage of labor which are gen- erally considered correct by obstetricians in all countries. What was Creole's method? Some confusion has arisen as to this term from the fact that Crede himself, after some years, made an important change in his method. His practise, in the earlier 121 122 NOEMAL LABOR years of his work especially, was to apply friction to the uterus as soon as the child was expelled. When the first uterine contraction occurred he grasped the fundus in his hand with the thumb on the anterior wall and the four fingers on the posterior wall and thus squeezed out the placenta — ''as the seed from a ripe cherry com- pressed between the thumb and fingers." His aim was to com- plete the operation as soon as possible, and according to some of his earlier statistics the average duration of the expression was four and one-half minutes. This method was popular for years, although many opposed it. After a time the opposition grew stronger and a complete reaction set in. It was then condemned as harsh and unscientific. The adverse criticisms, which became so common at this time, were essentially correct. In the hands of many, if not the majority, the method of expression was extremely harsh and caused much unnecessary pain. Too much attention was given to the rapid expulsion of the placenta and too little to the expulsion or extraction of the membranes; as a consequence large portions of the latter were frequently left in the uterus. The rapid expression of the placenta emp- tied the uterus before retraction and contraction were properly established. Under such circumstances accou- cheurs were likely to meet with two conditions, inertia of the uterus and retention of membranes, which together favored post-partum haemorrhage, and yet Crede's chief aim was to prevent such hsemorrhage. It is somewhat remarkable that re- sults so varied should follow any one plan of treatment. It is probable that in the hands of Crede and his assistants the results were fairly satisfactory, but the bad results were very serious in the practise of many who were either unskilled or im- properly taught. Crede himself, after practising his methods some years, recog- nized certain defects and accepted the rule that no one should endeavor to squeeze out the placenta until at least fifteen minutes Fig. 80. — Placenta in Utb Rus AFTER Birth of Child. THIRD STAGE OF LABOR 123 had expired after the expulsion of the child. This extremely important modification of Crede's original method is a great improvement, and while it makes the plan almost perfect in the opinion of the great majority, will account for some of the mis- conceptions which have appeared in the numerous discussions • which have taken place on this subject. Elements in the Third Stage. — We have received some very valuable lessons from Dohrn and Ahlfeld in Germany, and also from the Edinburgh and Dublin schools in Great Britain. We now know that there are two separate and distinct elements in the third stage of normal labor. 1. The spontaneous separation of the placenta and membranes. 2. The delivery of the placenta and membranes. The Dublin and Crede schools taught us that the old method of removing the pla- centa by pulling on the cord was wrong. Careful observers during the last twenty years have discovered that we should allow Nature to complete the separation of the placenta and membranes without any of that violent rubbing and kneading which used to be done immediately after the expulsion of the child. This process of separation is generally completed in from fifteen to thirty minutes, probably in the majority of cases in less than twenty minutes. As soon as the separation takes place the pla- centa is pushed by the ordinary uterine contractions wholly or partially into the vagina, and in a certain indefinite time thereafter is generally expelled from the vulva. I think it was Ahlfeld who first pointed out that this separation and expulsion of the placenta into the canal of delivery are shown by the advance of the cord and by the firm continuous contraction and retraction of the uterus, which, while becoming more narrow, generally rises somewhat higher in the abdominal cavity and at the same time becomes more mobile. This apparent lengthening of the cord is clearly shown if one follows the Rotunda plan of putting a second ligature on the Fig. 81. — Placenta Sep- arated AND PUSHED PARTIALLY INTO Va- GINA. 124 NORMAL LABOR cord close to the vulva. When the placenta passes wholly or partially into the vagina this vulvar ligature passes about two inches downward. Although violent rubbing and kneading of the uterus imme- diately after expulsion of the child is harmful we should not go to the other extreme of leaving the uterus to look after itself. One should keep the left hand on the uterus, pressing gently or rubbing gently with the tip of the finger between the recti mus- cles. If, however, serious haemorrhage should occur at this time we shall generally find feeble contractions. In such a case the uterus should be grasped firmly so as to induce a contraction and Fig. 82. — Placenta being Expelled. Nurse holding plate to receive it. arrest the haemorrhage. As soon as separation and slight down- ward movement of the placenta have occurred, pressure should be made over the fundus in the way described by Crede or with the palmar surface of the two hands, the fingers interlocking each other. The placenta can generally be pushed out during the first firm contraction; if not, pressure should be continued during each subsequent contraction. Slight traction on the cord in con- junction with pressure on fundus is sometimes allowable when the placenta is partially or wholly in the vagina. Caution is, however, always required. If pressure during three or four con- tractions does not expel the placenta there is probably some ab- normal condition. THIRD STAGE OF LABOR 125 Extraction of the Membranes. — After the oxpnlsioti of the pla- centa, we have to consider tin extraction of the membranes. The term extraction, as distinguished from expulsion, is used advisedly. It is a very common practise to continue pressing on the uterus and at once commence turning the placenta so as to twist the mem- branes into a cord. I believe the result of this method is frequently Fig. 83. — Placental Site near Fundus, Rough and Prominent, often Mistaken for Portion of Retained Placenta. (Tor. Univ. Museum.) to tear through the membranes while a considerable portion of the same is retained in the uterus. We are so thoroughly imbued with the vis a tergo idea in connection with the delivery of the child and placenta that we are apt to forget that the extraction of the membranes should be effected by an entirely different process. 126 KOEMAL LABOR Plenty of time should be taken in this procedure, not less than five to ten minutes. The accoucheur should not drag away the mem- branes rapidly. On the other hand, he should support the placenta Fig. 84. — Pregnant Uterus at Seven Months. Note the height of the fundus above the Fallopian tubes. in such a way that it will not pull forcibly on them. He should watch for slight relaxation or dilatation of the uterus and during such coax them away. If one detects a slight tear on one side he should pull gently on the other. A httle judicious twisting may assist sometimes, but one should remember the dangers connected therewith and beware. During the delivery of the placenta and the extraction of the membranes the nurse should hold the soup- plate or platter, which has been set aside for this purpose, between the thighs pressed against the perinseum to receive the placenta, the gush of blood which generally follows it, and the membranes. If no abnormal condition is present it is quite unnecessary to in- troduce the fingers or hand into the vagina or uterus during the third stage of labor. The objections to such procedures are not based on mere inutility, but on the fact that this is the period when THIED STAGE OF LABOR 127 there is the greatest danger of introducing septic matter into the system. The passage of the child has produced tears of greater or lesser extent in the cervix, vagina, and perinseum, or perhaps in all three combined, and the open-mouthed blood-vessels and lym- phatics are ever ready to absorb and distribute through the body any poison which comes within their reach. Without discussing at length the physiology of placental separa- tion and expulsion, we may presume that the detachment of the placenta is caused by contraction in the area of its insertion, in which contraction the placenta itself can not share. Separation occurs probably in different ways, varying according to the posi- tions of the placental insertion. When inserted at the fundus it begins to separate at the center, forming a cavity in which a certain Fig. 85. — Pregnant Uterus with Front Wall removed showing Section of THE Uterine Wall, Large Surface of Placenta with Uterine Surface of Membranes below and to the Left. amount of blood accumulates. When separation is completed the foetal surface of the placenta falls toward the cervical canal and the membranes follow, being turned inside out and containing a 10 128 NOEMAL LABOE certain amount of blood. The placenta and membranes emerge in the same order from the vulva. When the placenta is inserted in the anterior or posterior wall the separation begins either at the Fig. 86. — Placenta and Membranes turned to the Left showing Section OP Placenta, Fcetal Surface of the Placenta, Cord, and Fcetus. upper or lower edge and as it descends it may appear at the vulva by its foetal or maternal surface. The lower the insertion the more apt is the maternal surface to present at the vulva. These views do not coincide with those of Matthews Duncan and others, who thought that when there was no interference the common method of separation was such that the edge of the placenta presented at the cervix. The practical point to bear in mind in this connection is that when traction on the cord is employed before the pla- centa is dislodged from its place of insertion the initial separation is central, a partial vacuum is thereby produced which sucks the blood from the larger uterine vessels or tends to invert the weak and flaccid uterine walls. This generally admitted fact furnishes the strongest and most convincing argument against the pernicious practise of early traction on the cord. THIRD STx\GE OF LABOR 129 There are three objects gained by the iiKKleru or modified Crede's method. 1. By maintaining retraction anrl contraction of the uterus it prevents hicmorrhage. 2. By causing comparatively rapid expulsion it tends to prevent the dangers arising from retention. 3. By thoroughly emptying the uterus without introducing the fingers into the genital canal it tends to prevent septicaemia. The Membranes. — As already stated, the membranes do not, as generally supposed, form the sheath of the cord. The external Fig. 87. — A Pregnant Uterus with Po.sterior Wall removed showing Section of the Uterine Wall and Fcetus in Position, with Cord around Neck .\nd Thigh. layer of the cord is really the skin of the embryo, as pointed out first, I think, by Minot. On examining the membranes one finds the two layers, which can generally be easily separated. When the 130 NOEMAL LABOR membranes are not inverted, that is when they are right side out, the chorion is the external or outermost layer and is continuous with the edge of the placenta. The amnion is internal or inner- most. One may strip the amnion from the surface of the placenta as far as the root of the cord and no further. This clinical fact has been noticed by such men as Galabin and others, although Berry Hart speaks of it as if it has been entirely overlooked until very recently. Its full significance, however, has been only lately understood. One should be able in almost all cases to distinguish the chorion from the amnion. The chorion has a rough outer surface which is due to the portion of the decidua which remains attached to it, the amnion, on the other hand, is smooth on both sides and is thinner but stronger than the chorion. In further examination one should endeavor to decide whether all the membranes have been expelled or not. There should be enough present to have enclosed the foetus, making some allow- ance for a certain amount of shrinking due to their elasticity. In looking for the layers it may be noted that the chorion wholly or in part is more likely to be left in the uterus than the amnion. When the chorion has come away the amnion is not likely to be left behind. In a certain number of cases, however, the amnion may be torn away from the edge of the placenta and separated from the chorion when it has been carried down as a bag descend- ing far in advance of the head. There is considerable difference of opinion among eminent obstetricians as to the proper procedure when there is simply a suspicion of the retention of a portion of membranes or placenta. For instance, Galabin, who is careful and conservative, tells us that if any portion of the placenta or membranes appears to be absent it must be sought for within the uterus and removed. Jewett, on the other hand, who represents the views of a large number of American obstetricians, expresses the opinion that frag- ments of membranes remaining wholly in the uterine cavity are, as a rule, better left to be expelled with the lochial discharges unless they give rise to haemorrhage. We should, of course, in all cases prefer to be certain that the placenta and membranes have been expelled entire. In cases of doubt the introduction of the hand within the uterus, the exploration of the cavity, and the removal of its contents, whether they be bits of placenta, mem- THIRD STAGE OF LABOR 131 brancs, or clots, would seem to be the correct and thorough method. Unfortunately, however, such introduction of the hand adds very materially to the danger of septicieniia. If the labor has been properly conducted no saphrophytic or parasitic (pathogenic) microbes will have been introduced into the uterus, and consequently small fragments of membranes and pla- centa are not likely to cause septicaemia. One is not justified, however, in leaving large portions of the placenta or membranes within the uterine cavity. The following rules are recommended : 1. When one suspects that small portions of placenta or mem- branes are retained in the uterine cavity the introduction of the hand is not necessary. 2. When one suspects or is certain that considerable portions of placenta and membranes are retained the hand should be intro- duced and the uterine contents removed. In carrying out such procedure it is necessary to use both antiseptic and aseptic meth- ods as to the hand introduced, the vulva, adjacent parts, and the vaginal canal. In certain cases, when the membranes are only par- tially retained within the uterine cavity and a certain portion projects into the vagina, the safest procedure is to seize it with a dressing forceps and extract, using torsion carefully — as recom- mended by Durhssen. 3. If on the second, third, or fourth day, or even at any sub- sequent time, there is reason to suspect that the retained debris is causing mischief, and especially if the discharges are offensive, the interior of the uterus should be thoroughly explored and properly treated. The Administration of Ergot. — Ergot was at one time very commonly administered during labor, and was supposed to be fairly safe and efficacious in the latter part of the first stage when the child was in good position, the presenting part low down, and the soft parts well dilated. I remember one case which happened during my first year of practise in Toronto. The patient was a healthy primipara. The head had been on the perinseum for something like two hours ; the parts were well dilated. My proper course was clear. I should have used the forceps, but I was somewhat timid, and the patient and her husband both objected to the use of "instruments." I gave one dose of ergot, and a second in fifteen minutes after. In 132 NOEMAL LABOR due time I noticed a strong pain coming on. This rapidly became more severe. I soon found, to my dismay, that the patient was simply having one extremely severe and continuous pain (tonic contraction), without the slightest expulsive action on the part of the uterus. Fortunately I had sense enough to apply the forceps at once and deliver the child without any difficulty. A certain proportion of obstetricians, even at the present time, administer ergot before the expulsion of the placenta. In a fairly large proportion of cases it is probable that such administration does little harm or good, but in certain cases it does positive harm. If the placenta can not be expelled in an hour it is either adherent or simply retained. For adherent placenta ergot is absolutely useless; for simple retained placenta ergot is likely to do more harm than good, because it may produce a tightening of the mus- cular fibers near the cervix which will cause an incarceration which is difficult to overcome. The contractions caused by ergot are tonic, not intermittent, in character. Ergot by mouth usually acts in fifteen minutes ; hypodermically in four or five minutes. It is better to watch the uterus for one hour after the expulsion of the placenta. It is not necessary during this time to use any violence, which is not only useless but harmful, on account of the extreme discomfort or pain which is produced. CARE OF THE MOTHER AND BABE IMMEDIATELY AFTER LABOR TREATMENT OF THE MOTHER As external tears are especially dangerous from a surgical standpoint, it is important that the vulva and adjacent parts be washed or bathed with great care, as mentioned in the Rules for Antiseptic Midwifery. A warm antiseptic solution is the safest and should be applied as gently as possible, because the parts are more or less tender. These dressings should be sufficiently fre- quent. Some physicians direct the nurse to change the pads and wash the parts every four hours. Such a rule is faulty because it is frequently misleading. I once found a foul smell coming from a bed three days after labor. On examination we discovered that the discharges had passed through the vulvar pads into the bed. I was surprised, as I had great confidence in the nurse, and remarked CAEE OF THE MOTITEK AND BABE 133 that the pads had not been changed sufficiently often. She told me she had carried out the routine rule prevailing in that hospital and had changed the pads every four hours. Each vulvar pad should be removed if possible before it becomes saturated. If even a slight cjuantity of the lochia has passed into the bed the sheet should be replaced and the mackintosh or rubber sheeting washed. The frequency of the dressings should depend largely on the amount of the lochial discharges. Numerous changes may be required during the first twelve or twenty-four hours. In cleansing the hands when there is blood on them it is better first to wash in cold water; soapy water does not dissolve blood readily. Clear water and perhaps a nail-brush should be used first, and water with soap next. Injuries to the Perinseum and Pelvic Floor. — It is generally under- stood, as already explained, that laceration of the perinseum is apt to occur. It is not so generally understood that laceration of the pelvic floor or of the posterior wall of the vagina is also apt to occur. These injuries are discussed more fully in the chapter on Operative Midwifery. It should, however, be a rule in every case to make a careful examination with a view of discovering any such injuries and also their extent when they exist. When in doubt as to the extent of injuries to the pelvic floor the examination can be best carried out after placing the woman in the dorsal position across the bed with the thighs flexed upon the abdomen. It is better to have a nurse or other assistant hold the labia apart. One can then cleanse the posterior wall of the vagina with pledgets of cotton soaked in lysol solution, and leave a plug in the vagina to prevent the blood from running over this region during the inspection. In this way the tear of the perineal body, and also of the posterior vaginal wall or pelvic floor, can easily be detected and examined. Abdominal Bandage. — An abdominal bandage is applied after the removal of soiled clothing. There has been considerable differ- ence of opinion in the past as to the advisability of applying a binder. Something like forty years ago certain obstetricians in Paris dispensed with its use. Shortly after this Gaillard Thomas advised obstetricians not to use an abdominal bandage. It is now generally, but not universally, admitted that a binder should be applied in all cases immediately after labor. It adds much to a woman's comfort and allows her to turn upon her side with greater safety. It should be worn not merely while she is confined to bed, 134 NOEMAL LABOR but for some time after she begins to sit up. A bandage is gener- ally ready at hand, but if not, one may choose unbleached muslin or ordinary factory cotton. It should be long enough to surround the body with a few inches to spare and wide enough to extend from the ensiform process to a point slightly below the trochanters. In adjusting the bandage seize the near end between the thumb and two fingers of the left hand and draw the further portion smoothly over it with the right hand, then hold the two ends with the left hand and insert the safety-pins with the right. Insert the pins from below upward, taking care to draw the bandages as tightly as possible before inserting the lower two or three pins. The intervals between the pins should be about two inches. After inserting the lower two or three pins, I sometimes introduce the next pin immediately above the fundus uteri and afterward put one, two, or three pins in the interval which has been left. About six to eight pins should be used altogether. It is better, especially in country practise, where one has not, as a rule, many skilled nurses, to make it a point to apply the binder the first time himself, otherwise many women think they are neglected. Such being the case it is very important that skill be shown in the application of the binder. In carrying the bandage under the patient's back it is well to roll one-half and then pass the roll under the patient's back to the opposite side, then unroll. One should take care that there are no wrinkles in the binder under the patient's back. Some are in the habit of placing a pad made of folded diapers, or something of that sort, over the abdomen before fastening the bandage with the idea of producing compression of the uterus. This is likely to do more harm than good, because the pad thus applied is apt to slip and then press the uterus out of place. In some cases, however, when there is considerable haemorrhage following the relaxed condition of the uterus, especially in a thin woman, it may be well to use something in the form of a pad, which is likely to assist in keeping the uterus contracted. The best method of doing this is the one which used to be adopted by James Ross, of Toronto. Make three rolls of three towels about as thick as the wrist, place one of them transversely just above the fundus uteri and the other two at the sides of the uterus and then fasten the bandage firmly over them. In this way the uterus, as Parvin expresses it, is enclosed in a box, the Hd of the box being the portion of the bandage in front of the abdomen. CAEE OF THE MOTHER AND BABE 135 After the application of th(> Imndago and tlic adjnstniont of the night-dress the patient should be; dry and comfortable. One should make it a point to carry out all these details in as thorough and kindly a manner as possible. If a physician is careless and in- different and inclined to leave all the details to the nurse, he will certainly not have pleased his patient, and I think will not have done his duty. It is a good rule to remain an hour in the house after the delivery of the placenta. One should always keep in mind the danger of haemorrhage. Post-partum haemorrhage is generally due to relaxa- tion of the uterus, but also occasionally to laceration of the cervix. Whatever be the cause one should always stay with his patient until such haemorrhage is checked. There is an old rule that one should not leave the house if the pulse is 100 or over. It is right to consider a rapid pulse as a danger signal, especially if it becomes rapid somewhat suddenly within a short time after the completion of labor. Sometimes, however, the pulse, for some reason or other, is 100 or thereabouts during the latter part of labor and remains rapid for some time after without any serious accompanying symptoms. MANAGEMENT OF THE BABE Dressing the Cord, — It is better to apply some antiseptic solu- tion, such as one of lysol, wipe dry and then surround the cord with absorbent cotton. This will be kept in position by the ab- dominal bandage, which should be applied until the cord has come away. The stump or wound of the cord may be covered by uniting the edges of the skin of the cord (formerly called the amniotic sheath) with a running kangaroo or catgut suture. The nurse generally looks after the babe from the time that it is lifted from the bed. Before giving the babe in charge of the nurse, however, for its first washing one should examine it very carefully with the following points in view : Examine the cord for bleeding. Examine the whole body for birthmarks, etc. Examine the head for meningocele, etc. Examine the back for spina bifida, etc. Examine the Hmbs for talipes and other deformities. Examine for imperforate anus. 136 NORMAL LABOR Apparent Death of Babe. — 1. When the face is dark in color and swollen, with perceptible action of the heart {asphyxia livida), the case is favorable. 2. When the face is pale {asphyxia pallida), limbs flaccid and no apparent action of heart, the case is unfavorable. Fig. 88. — Cutting the Cord. Treatment for Asphyxia. — The physician should adopt a definite line of treatment for the purpose of resuscitating a child partially asphyxiated or apparently dead. First, slap the front and back of the chest and then invert the child, holding it by the feet for two or three seconds. If these procedures fail, employ artificial res- piration, of which the best methods are those of Sylvester, Byrd, and Laborde. Atelectasis, a persistence of the foetal condition of the lungs, is frequently associated with and may be the main cause of the asphyxia. This condition does not necessitate any change in our methods of resuscitation. Fatal death. Chapin distinguishes between the dead-born and the still-born babe. In the former the respirations and reflexes are absent, the pupils are widely dilated and the rectal temperature rapidly falls to 10° or 15° below normal. DESCRIPTION OF METHODS OF ARTIFICIAL RESPIRATION Sylvester's Method. Place child on its back, with a small cushion under its shoulders, so as to incline head slightly back- ward. Stand behind the child and seize an arm above the elbow CARE OF THE :M0THER AX I) P.A?,E 137 with each hand. Raise arms slowly above the head, at the same time rotating each humerus slightly outward. Keep them raised two or three seconds. Next bring down the arms and press gently against side of chest two or three seconds. Repeat these movements. ByrcVs Method. Lay the child on its back upon the palmar surfaces of your outstretched hands. Elevate the radial edges of your hands so as to double the child's trunk upon itself — to cause expiration. Then lower the radial edges well below the level of the ulnar borders of the hands so as to extend the child's body — to cause inspiration. Repeat these movements. Laborde's Method of Rhythmic Tongue Traction. Seize tongue with catch forceps or by finger and thumb wrapped in a piece of Fig. 89. — Artificial Respiration. Sylvester's Method. (First Part.j cloth, and strongly draw it out of the mouth, then allow it to fail back into its normal position. Repeat fifteen times in a minute. In using; these methods the different movements should not be 138 NOEMAL LABOE made too rapidly. Once in three seconds is sufficiently often for the methods of Sylvester and Byrd, and once in four seconds for that of Laborde. The methods of Sylvester and Laborde may be used in conjunction, one person drawing out the tongue while the other Fig. 90. — Artificial, Respiration. Sylvester's Method. (Second Part.) is raising the arms over the head. Laborde 's method may be used while the babe is held in a warm bath. These methods are useful, especially for full-term babes. Great care should be used in em- ploying them for premature infants, for whom we often have to rely chiefly on the effects of heat. It is often necessary to clear the mucus out of the throat. This may be done with the simple rubber bulb and tube. Direct Insufflation. — Mouth to mouth method. Place the child on its back, with head slightly extended. Cover its face with a handkerchief or towel, draw a full breath and blow gently the first portion of the expired air into the mouth, one hand at the same time pressing over the epigastrium to prevei;it the air from passing into the stomach. Do not keep the nostrils closed, as sometimes recommended, but leave them open to act as safety valves. Too CARE OF THE MOTHEE AND BABE 139 much force in blowing air into the lungs injures the air cells. Catheterization of the trachea is dangerous because it, too, inj ures the air cells. While carrying out these various procedures the nurse may be directed to bring two large basins or foot-baths — one containing hot and the other cold water. Put the child alternately into the two basins, taking care that the water is not too hot and do not leave it too long in the cold water. If the face is very livid it is well to cut the cord and let some blood escape before tying. Some advise hypodermic injections of whisky — 10 to 20 drops — and strychnine y^y gr. Their utility is doubtful, but a saline enema — 2 to 4 ounces, at a tem- perature of 110°, some- ~ times has a good effect. Washing the Babe. — The nurse should use warm water and bland "baby" soap and may use olive oil to assist in removing the vernix caseosa. If the babe is prema- ture and very weak it is better to anoint it with oil and wrap in cotton wool without dressing for days (see page 167). Dressing the Babe. — The Gertrude baby suit is a reform method of cloth- ing for infants, designed by Dr. Grosvenor, of Chicago, and introduced into To- ronto by Miss Snively. The Gertrude baby suit consists of three garments and diapers for the day, viz., dress, middle garment, undergar- ment, and diaper; a nightgown and diaper for the night. The undergarment — i.e., the garment next the skin — is made of canton flannel or fine flannel or flannelette, cut in princess style, and reaching from the neck to ten inches below the feet, being Fig. 91.- -Aetificial Respiration. Method. (First Part.) Byrd's 140 NOEMAL LABOE altogether 25 inches long; sleeves to the wrists; a tie and one button behind. The middle garment is made of baby flannel, same pattern as the undergarment, but without sleeves, with neck and armholes scalloped, not bound, and with two buttons behind at the neck. It may be embroidered in any way desired. The dress or outer gar- ment is made after the same pattern as the other garments, but about an inch longer. Any style of dress, however, may be used. The diapers are of two sizes, 18 X 18 and 10 X 10 inches, the larger to be folded diagonally. The addition of the smaller where most needed saves unnecessary thickness over the hips and kidneys. Can- ton flannel is the material recommended. The night- gown is similar to the un- dergarment in pattern and made of baby flannel, but may be a httle longer. All seams should be smooth and the hems at the neck, wrist, and bottom on the outside. This method of dressing the baby commends itself because of its simplicity. It does not interfere with the ordinary outside dress, which may be made in such styles as taste may dictate. The advantages claimed are : First. — All the clothing hangs from the shoulders. Second. — There are no bands or bandages to interfere with the freedom of the thoracic, abdominal, and pelvic organs. Third. — There is no pinning blanket or barrowcoat, and no shoulder blanket. Fig. 92. -Artificial Respiration. Byrd's Method. (Second Part.) CAEE OF THE MOTHEK AXD BABE 141 Fourth. — There is evenness of the covering of the horly and no difference between that of the shoulders and other parts. In dressing the infant the three garments are placed together — sleeve within sleeve — the baby, face downward, the combined garments are slipped over the head, the arms placed in the sleeves, and the garments fastened behind. At night the three combined garments are removed together and the flannel night-dress replaces them. No stockings or socks are worn night or day. There should be no fixed rules as to fabrics used. A fine all-wool stockinet of soft texture answers admirably for the undergarment. The designer proposes to use no abdominal binder on the babe. I consider it almost a necessity, until the cord has become sepa- rated. I also prefer some sort of belly-band to be worn during the greater part of the time for one or two years. It affords great protection especially during the late summer and autumn months Fig. 93. — Gertrude B.\by Stht. The undergarment in the center, the middle garment on the left, the outer garment on the right. when young children are subject to bad forms of diarrhoea and dysentery. The tight band is, however, objectionable in some re- spects, because it "interferes with the freedom " of internal organs. My preference is to replace the band after the separation of the cord with a cylindrical knitted or woven band, which furnishes the protection without causing undue compression. The flannel skirts afford sufficient protection to the feet. The woolen socks com- monly used can only be retained by the use of a band around the ankle, which may interfere with circulation in the feet. 142 NORMAL LABOE ANESTHETICS IN LABOR Importance of Chloroform. — Chloroform easily takes prece- dence over all other anaesthetics in labor. Sir James Y. Simpson proved, early in 1847, that sulphm^c ether could be safely inhaled for the rehef of pain in labor, and, later in. the same year, that chloroform might be inhaled in a similar way and with similar results. For some years he strongly advised the use of this anaes- thetic as a routine practise in the treatment of all cases of labor. This new treatment was stubbornly opposed, espe- cially in Great Britain and the United States. The ob- stetricians of London were ^^gf probably the most stren- uous in their opposition for a short time. This perhaps , • should cause no special •^ I " surprise, because we often * find that the Edinburgh '^'*'%f- leaven leaveneth the Lon- *-' ' don lump somewhat slowly. However, we are told that Her Majesty, Queen Vic- toria, had faith in Simpson and insisted upon her phy- sicians adopting his meth- FiG. 94.— Sir James y. Simpson. ^jg ^^ her subsequent con- finements. This helped to popularize the administration of anaesthetics during labor even in conservative London. Chloroform was first administered to Queen Victoria by Snow in her seventh labor in April, 1853, when Prince Leopold was born. The medical attendants in charge were Locock, Grant, and Ferguson. Chloroform • properly administered is comparatively safe in labor. Clinical experience teaches that it is safer in obstetrical practise than in any other branch of medicine or surgery. And yet I do not wish to convey the impression that it is perfectly safe and may be administered to any extent in a case of labor. It some- ANAESTHETICS IN LABOR 143 times stops the uterine contractions and thus prolongs the labor. It sometimes predisposes to post-i)artum hicmorrhage. The administration of chloroform too early in labor, as, for in- stance, in the first stage, and in too large a quantity, is always dangerous. It fortunately happens that a death from chloroform during labor is almost .unknown, excepting when the anesthetic has been administered in an exceedingly careless and negligent way. It is also an interesting fact that chloroform in labor almost never causes vomiting, whether administered to the obstetrical degree only or to the surgical degree. Administration of Chloroform. — In considering the proper method of administering this amesthetic it is well to observe cer- tain rules. 1. Never administer it during the first stage. Some exceptions may arise, as, for instance, when there is extreme rigidity of the cervix due to spasm. In other words, in a normal labor never administer the chloroform until after the completion or about the time of the completion of the first stage. In an abnormal labor, however, there are exceptional conditions which require special treatment. 2. Administer the chloroform only during the pain, and only to Avhat is called the obstetrical degree. By the obstetrical degree we mean that a patient is never completely anaesthetized — that is, she never becomes totally unconscious. The most common way of administering it now is by an Esmarch mask or something of that sort. This should be placed over the nose and mouth. The chloroform should be in a proper "dropper" bottle. This may be improvised by simply cutting a canal in the side of a cork (or two canals — one on either side) with a penknife, and then putting the cork in the bottle sufficiently tightly to let the chloroform come through drop by drop. It is better to put a little vaseline or cold cream over the nose and chin at the base of the mask to prevent burning from the chloroform. At the commencement of a pain and during the pain pour on the mask three to eight drops of chloroform. As soon as the pain has ceased remove the mask from the face. The patient, during such administration, is very apt to move her head, sometimes quite suddenly. Be careful, under such cir- cumstances, not to pour the chloroform into the patient's eye instead of on the mask. 11 144 NORMAL LABOE 3. Administer the chloroform a httle more freely toward the end of the second stage, especially while the head is passing the rima pudendi. 4. Administer no chloroform after the head is expelled. Chloroform will require to be administered to the surgical degree in most obstetrical operations, whether performed during or after labor. It should be remembered, at the same time, that the relative safety of chloroform in parturition ceases with the birth of the child. It may be considered advisable, under certain con- ditions, to administer ether instead of chloroform, but of that more hereafter. Forceps delivery is so common in uncomplicated labors that a brief reference may be made to the operation at the present time. During this operation the patient should be completely anaesthe- tized, or she should get no anaesthetic at all. If ''under " only to the obstetrical degree the patient may plunge about to such an extent that the forceps, when partly or completely applied, become a source of danger. After the administration of chloroform in the slighter degree for a certain time the contractions may become weaker and less fre- quent and progress may stop. Under such circumstances it is better to stop the administration of the anaesthetic for a time. This is not always easy to do, because the patient, after obtaining some relief from the anaesthetic, always clamors for more and cer- tainly objects strongly to suffering any pain without getting a ' ' few whiffs" at least. Under such circumstances, one may say that he is compelled to stop the chloroform because it is interfering with the progress of labor. The other alternative is to have the patient thoroughly anaesthetized and deliver with forceps. It should be a positive, rule when the patient is completely anaesthetized to get an expert anaesthetist, or at least a licensed practitioner, to administer the anaesthetic. Ether. — It is generally understood that chloroform is more suit- able for obstetrical purposes than ether, especially when one only wishes to anaesthetize the patient to the obstetrical degree. The ether is less pleasant (or more unpleasant) to inhale and is not apt to cause bronchial irritation. Most obstetricians will also agree that chloroform is preferable for forceps dehvery. Many, how- ever, prefer ether for protracted operations during labor or after labor, such, for instance, as caesarean section, symphysiotomy, and ANiESTHETICS IN" LABOR 145 post-partum operations for lacerations of the perinseum and pelvic floor, if there be no bronchial or kidney disease. Chloroform and Ether Combined. — During the last few years I frequently coiubinc chlorofonu and ether, using 1 ounce of chloro- form to 2 ounces of ether, or equal parts by bulk (as recom- mended to me by Stevenson). I carry in my satchel one 2 oz. bottle of plain chloroform and another 2 oz. bottle containing a mixtun; of chloroform and ether. I frequently administer the plain chloroform for a while and toward the end of the second stage put aside the plain chloroform and use the combined mixture. Spinal anaesthesia by means of medullary cocainization, which was recommended two or three years ago, is now generally re- garded as dangerous. Chloral. — Although discovered by Liebig in 1832 chloral was not used in medicine until 1869. Early in 1870 Simpson com- menced to administer it to women in labor and thought that it relieved pain without interfering with uterine contractions. One of the most enthusiastic advocates of the use of chloral in normal labor was Playfair, who first recommended it something like thirty years ago. He considered it peculiarly adapted to the first stage of labor when the patient is suffering greatly and the os is rigid and dilating very slowly or not at all. He advised 15 grain doses of chloral every twenty minutes until three doses are given. The effect of this is that the patient becomes quite drowsy and dozes between the pains and wakens as each contraction be- gins. It may be necessary to give a fourth dose at a longer inter- val, say an hour after the third, but rarely more than a dram is required in the whole labor. About four or five years ago Play- fair, at a medical meeting in London, reported his views as to the administration of chloral and stated that after more than twenty- five years of experience in its use he still thought as favorably of it as ever. After using this remedy in the way described by Playfair for about twenty- five years, I can say that it answers admirably in a certain proportion of cases, and I have often wondered why it was not more generally used by the profession. CHAPTER VIII THE PUERPERAL STATE GENERAL CONDITIONS As before stated, it is often difficult to distinguish between the physiological and pathological in obstetrics. Especially is this the case in connection with puerperality, or the puerperal state. During the puerperium we find a variety of physiological condi- tions which might, under other circumstances, be considered patho- logical. This has been well pointed out by Schroeder and Lusk, the latter of whom uses the following words : ' ' Thus the exfolia- tion of the decidua and the copious serous exudation with the abundant formation of young cells, which accompanies the develop- ment of the new mucous membrane, would elsewhere be regarded as characteristic features of catarrhal inflammation. The acute degeneration of the uterus presents a phenomenon which, when re- peated in any other organ of the body, would prove speedily fatal. The thrombus formation in the open placental vessels possesses no corresponding physiological analogue. Again, the torn vessels may lead to haemorrhage, while the traumata, which, even in nor- mal labor, result from parturition, the ease with which deleterious materials are absorbed by the wide lymphatic interspaces, the serous infiltration of the pelvic tissues, the exaggerated size of the lymphatics and veins, create a predisposition to innumerable forms of disease. The nicety of the balance between normal and morbid conditions renders it peculiarly necessary for the practitioner to make himself familiar with the physiological limits of the phenom- ena of childbed." And yet, if we do not interfere with Nature's methods, the won- derful changes included under the term involution take place as a matter of course after normal labors in the great majority of cases ; and the healthy young woman becomes, at the termination of her puerperium, as vigorous and strong as she was previous to her 146 GENERAL CONDITIONS 147 pregnancy. It is not strictly true that all the organs and tissues are restored to their ori^itial condition. The uterus, after preg- nancy and labor, is n(>ver ((uitc the same as the nulliparous uterus. The hymen and fourchette arc almost invariably torn during labor and Nature does not restore them. However, the difference be- tween the healthy uterus after labor and that before pregnancy is of no account practically, and tears of the hymen and fourchette do not as a rule produce serious consequences under aseptic or antiseptic methods. It is generally considered that the puerperium lasts about six weeks. While this is not strictly true it is generally accepted as a E 107° 106° 105" 104° 103° 103° 101° 100° 99° 98° 97" In. C.m. 7 17.5 6 15 5 12.5 4 10 3 7 2 5 1 2.5 5 P n ^ \ ^X^ N \ ~"*^. ^ ^ ,A -.-*> / s/ VA LJI^ ^^ >-*i .^ Y^ A ^ ^^ .,* ^^u M Pulse E 70 6i 65 66 68 66 68 66 66 68 66 68 66 68 66 66 66 70 70 69 69 70 71 70 70 72 70 70 Fig. 95. — Chart showing Normal Involution Line, Temperature, and Pulse-rate. Column on right shows scale in inches and centimeters. S'. P. is symphysis pubis. fact by obstetricians. What is the full meaning of involution after six weeks? As expressed by Robb, it means that after six weeks the normal functions of the non-impregnated genitalia, namely, menstruation and conception, can begin again. While menstrua- tion is rare in nursing women so early after labor, it is a fact that it is possible for them, from this time forward, to conceive again, the possibility becoming greater every month. Involution of the Uterus. — This may be briefly defined as the process by which the uterus resumes its ordinary condition after labor. The rapidity of the diminution in the size of the uterus during the first two weeks 9,fter labor is remarkable, After the 148 THE PUERPERAL STATE expulsion of the placenta the uterus is strongly anteflexed, the fundus lying against the abdominal wall. The anteflexion increases somewhat during the first three weeks of the puerperium and is probably a part and an important part of Nature's provision for drainage of the lochia. After four weeks the uterus gradually re- turns to its normal shape. The superficial layer of the mucosa 107° 106° 105° 104° 103° 102° 101° 100° 99°/ / i 1- 5\ y \ \ \ \ 1 \ \ •».^_^ "^X^ "~ ^., J N, -^ ,A A >A \ ,A I^ f \ / V v\ uA / ^^ ^ { \ y K V V V V M Pulse E 81 86 78 74 80 70 82 78 68 72 100 78 72 70 88 90 92 76 88 78 81 80 76 120 98 98 76 74 Fig. 96. — Chart showing Abnormal Involution Line. Rise of temperature from emotional cause. (the cellular layer), which is in contact with the decidua, is gener- ally thrown off with the membranes, forming a part of what we call the chorion. The deeper layer (the glandular layer) remains behind, and from it is developed the new endometrium in about four to six weeks. The Involution Line. Daily measurements of the distance of the fundus uteri above the symphysis pubis should be taken. By marking the position of the fundus from day to day we obtain what is called in Queen Charlotte's Hospital the involution line. We have had this line traced on all our charts at the Burnside during the last three years. The fundus descends more rapidly in the primipara than in the multipara, the difference being on an average one or two days in favor of the former. . It reaches the top of the sym- physis before or on the eighth day in 70 per cent, of primiparse, and only about 40 per cent, of multiparse. It reaches the symphysis GENEKAL CONDITIONS 149 before or on the tenth day in the majority of multipara. In both primiparse and multipane the time may vary from five to twelve days without any apparent abnormality. We attach much im- portance to the involution line in the Jiurnside and also in private practise. The involution of the vagina, the process by which the vagina resumes its ordinary condition of after labor, is probably slower than that of the uterus and is complete in about eight weeks. Chill or Rigor. — The patient is very apt to have a rigor or chill toward the end of labor or after the completion of labor. It gen- erally lasts from a few minutes to a quarter of an hour and is not accompanied by any change in the pulse or temperature. When a patient is seized with a chill the nurse should put on a little F. 107" 106° 105° 104° 103° 102° 101' 100° 93° 98° 87° , 6 TJi '?i k' \^y ^'^- ""*•- >-^ o 1 ^N— H -N^ X \ V ^ K t\ A V V^ V^ •7' 4 V\^ v^ j^ 'sA ^ /^ V V V s/1 U-. M Pulse E 72 70 71 72 72 74 70 72 68 70 72 68 70 Si 78 80 76 78 88 84 78 78 78 84 8U 72 72 Fig. 97. — Abnormal Involution Line. Slight subinvolution caused at first apparently by distended bladder, administration of ergot appeared to assist involution. The extra covering and the doctor should encourage her by telling her that it means nothing serious, but is quite a common occurrence after labor. After-pains are so common that they may generally be consid- ered as physiological. They are not so apt to occur after first labors and frequently grow steadily worse after succeeding labors. As they are due to contractions of the uterus, which tend to empty 150 THE PUERPEKAL STATE that organ and also to bring about involution, they are really bene- ficial. On this account we should avoid interference for a time. After three or four hours, however, it is well to give some simple opiate if the pains are severe. Pulse. — The pulse usually increases in frequency during labor, reaching 90 or 100, but shortly after delivery it becomes less Fig. 98. — Bladder after Labor, Empty, Uterus in Normal Position. rapid, sinking frequently, if not generally, below the normal in from eight to twenty-four hours. It frequently falls to 50 and sometimes to 40. This slowing of the pulse is a favorable indi- cation and generally lasts about five or six days. Temperature. — There is generally some increase of temperature during labor, which may continue for about twelve hours after. Mcllwraith believes that a rise of temperature during labor ought not to be considered physiological, but pathological, inasmuch as it indicates that the patient is growing weak, and probably re- quires artificial assistance. Generally, however, the temperature declines again within twenty-four hours and remains stationary during seven or eight days with only the usual morning and even- ing variations. There are no special changes in respiration. Modifications of Secretions. — The secretions, especially from the skin and kidneys, are greatly increased for a time after labor. Soon after delivery the body is generally covered with perspiration, especially during sleep. This hypersecretion continues for about a week. The quantity of urine is also greatly increased. This frequently helps to cause a condition which may be considered GENERAL CONDITIONS 151 to a certain extent patholof^ical, or, at least, abnormal; that is, retention of urine. This retention may exist with a certain amount of overflow. An inexperienced practitioner does not always appreciate the fact that the Ijladder may become enormously distended within a very short time after labor, especially if it has not been thoroughly emptied chn-ing labor. It is well to have in one's mind the fact that an abdominal enlargement appearing after labor is generally due to a distended bladder. A friend of mine has frequently told me that he felt extremely mortified on one occasion something like thirty years ago, when he called in Dr. W. T. Aikins to make a diagnosis of an abdominal enlargement about twenty-four hours after the termination of labor. The enlargement in that case was found to be due to retention of urine. This condition is discussed in another part of this chapter under ''Micturition." The Condition of the Digestive Organs. — One can easily under- stand that, on account of the great increase of the secretions of per- spiration and urine, considerable thirst is apt to occur during such Fig. 99. — Bladder after Labor, Distended, Uterus pushed upward. hypersecretion. The appetite for the first two or three days is generally lessened and the bowels are apt to be slightly constipated. Lochia. — On account of some doubt as to the derivation of the term lochia, the word may be used either in the singular or in the plural, although I think it is more commonly considered a plural word. The lochial discharge is composed of red blood cells, por- tions of clots, and shreds of decidua at first, and is called lochia 152 THE PUERPERAL STATE rubra. It gradually becomes pale in color and in about a week after labor, contains colored serum, epithelial and cylindrical cells, leucocytes, albumin, chlorides, etc., and is called lochia serosa. Finally it becomes muco-purulent and is then called lochia alba. The character of the lochia varies greatly in different women. After becoming colorless, or nearly so, it frequently becomes red again without any apparent cause. The discharge generally lasts from two to five weeks. The lochia within the uterus should always be sterile. Gener- ally the discharge is sterile even in the vagina for a day or two, but after two or three days numerous microbes are found in it, such as streptococci, staphylococci, and colon bacilli. These probably originate mostly from those existing in an inert condition in the vagina before delivery, while some probably enter from without. Changes in the Cervix Uteri. — Immediately after birth the cer- vix is lying relaxed and soft and the os more or less torn. The internal os is not well marked and the lower uterine segment and the cervix appear like a long tube with thin walls. The contraction ring very quickly approaches the internal os and the two become blended in a week, or perhaps less. The internal cervical ring remains relaxed and soft so that one or two fingers may be passed through it up to about the end of the second week. It is possible, therefore, to explore the uterus with the fingers during the first two weeks after labor. The Breasts. — A fluid called colostrum is found in the breast during the latter part of pregnancy and immediately after labor. This colostrum is not really a secretion from the gland cells, but rather a transudation from the blood. It differs in many respects from milk. It is yellowish- white in color, richer in fat and sugar than milk, and contains albumin instead of caseinogen. Microscop- ically it contains fat globules, pavement epithelium, occasional milk corpuscles, and large round glandular cells. The Establishment of the Secretion of Milk. — The breasts soon become congested and at the same time hard and tense. The swollen condition thus produced causes some discomfort or pain. There is sometimes slight general disturbance of the system, which, in the old days, v/as called milk fever. The secretion of milk gen- erally commences on the second or third day after labor and is fully established by the third or fourth day, generally the third in multiparge and the fourth day in primiparse. THE CARE OF THE MOTHER 153 The mother's milk is not pure, as formerly supposed, but gen- erally contains many stai)hylococci and sometimes a few strep- tococci. It is supposed tliat these microbes have found their way into the breast through the channel of the nipples, but it is under- stood that they do not, under ordinary circumstances, injure either the mother or -child. THE CARE OF THE MOTHER The Visits of the Physician. — The physician should remain in the house one hour at least after the expulsion of the placenta. He should make arrangements to have the patient kept as comfortable as possible and should leave some rules respect- ing the treatment of the after-pains. He should also leave instructions to keep the patient as quiet as possible for a number of hours. He should make his first visit within twelve hours after labor. He should at this time get full information as to temperature, pulse, respiration, time occupied in sleep, character of the discharges, presence of pain or aches, and particularly as to the passage of urine. It is very important to get full information as to every symptom, no matter how slight it may seem. If the patient has had a comfortable time — if, for instance, she has slept a good por- tion of the night, has no headache or any other unpleasant symp- tom — one has great reason to feel encouraged. If she says that she feels very well excepting that she has a slight headache and did not sleep very well, there is reason to fear that something is wrong. The first visit after labor should never he a hurried one. While asking certain questions the physician should watch the patient carefully without appearing to do so. He should note the expression of her face, the condition of her eyes, forehead, lips, etc., the character of her respirations, the position in which she is lying, the position of the legs, arms, etc. After the first day the physician should see his patient at least once a day for a week or ten days, then every second or third day until the end of the third or fourth week. Such directions apply especially to attendance on patients in cities or towns. It happens in many country districts, that the physician in certain cases makes no subsequent visits after attending his patient in confine- ment- I do not think, however, that any physician should take 154 THE PUEKPERAL STATE the responsibility of conducting a case of labor without seeing his patient at least once or twice after the birth of the child. The Duties of the Nurse. — The nurse should be scrupulously clean in her methods and should be careful to keep the patient and everything around her as clean as possible. The vulvar pads should be changed frequently and the parts washed with a warm aseptic or antiseptic solution, as mentioned in connection with the management of labor. The antiseptic solutions are preferred, not so much on account of any inherent virtue existing in them, but chiefly because their systematic use for external washings is apt to make the nurse more thorough in her methods. The first vulvar pad should be removed in less than an hour after its application. After the second pad is applied the nurse should generally expect the patient to have some rest. With that object in view she should disturb the mother as little as possible. A sleep of an hour or two at this time is worth much. When she wakens the nurse should then again change the pad. There was at one time a belief that combing or brushing the hair was apt to induce post-partum haemorrhage during the first week of the puerperium. There is, of course, no reason for such belief excepting in so far as the dressing of the hair might cause fatigue. The nurse in the Burnside, in preparing the patient for labor, always thoroughly combs and braids her hair after she has had her bath. When this has been done it is quite a simple matter to look after the dressing of the hair. The nurse should wash the hands and face at least twice daily and should also sponge the whole body with tepid water once a day. It is well also, especially in warm weather, to dust with baby powder such regions as the groins and axillae. The nurse should loosen the bandage once every day and search for the fundus uteri so that she may properly mark the involution line. The bandage should then be reapplied as carefully as it was immediately after labor. Post-Partum Vaginal Douching. — Routine vaginal douching during the puerperium was very commonly carried out some years ago. I have for a long time opposed the practise for the following reasons : 1. Douching disturbs that perfect rest and quiet which are so desirable for a patient after labor. No reference is here made to surgical rest of wounded tissues^ but to rest in a general way, which THE CAKE OF THE MOTHER 155 is so delicious to a weary and more or less exhausted woman. I have often thou<2;ht and sometimes stated that meddlesome mid- wifery reached the acme of absurdity when, in 1883, T. (laillard Thomas, one of the most distinguished oyna^eologists in the world, recommended one of the most extraordinary methods of aggressive obstetrical meddling- that had ever been conceived by the brain of man. He advised, among other things, the administration of a douche every eight hours and the introduction of an iodoform suppository every two or three hours for at least ten days after delivery; that is to say — the bruised and lacerated vagina was invaded from eleven to fifteen times every twenty-four hours for at least ten days, if the unfortunate victim should live so long. Little wonder was it that Fordyce Barker entered a vigorous protest. 2. Douching is unscientific on surgical grounds. After labor the utero-vaginal canal is bruised and wounded. On surgical principles the most important points in the treatment are rest, pressure, position, and drainage.- By rest, I refer to that physiolog- ical rest to which so much importance has been attached by Hilton and many others. The wounds of the cervix and vagina are, as a rule, kept closed by the elastic and even pressure of the surrounding tissues. The introduction of suppositories and douching seriously interfere with the rest and pressure as described, and, in my opinion, materially delay healing of these wounds. The recumbent posture with the slight changes in position required in voiding urine and faeces is well adapted for drainage. 3. Douching is actually dangerous. It is apt to disturb clots and thus open avenues for infection, to open lacerations of the cer- vix and vagina and thus prevent them from healing, to wash bac- teria into the uterine cavity and thus cause septic endometritis. Among other dangers which are generally clue to accident or care- lessness are the introduction of septic matter by fingers and instru- ments. In a certain minority of cases the douching becomes advisable, as explained in the chapter on Septicaemia. Care of Breasts. — Thirty years ago obstetricians were taught to be careful about massage of the breasts, but they thought a certain amount of massage and pumping was necessary in some cases. In 1882 Garrigues commenced the systematic use of his breast bandage, which made the rubbing and pumping unnecessary as a rule. 156 THE PUEEPEKAL STATE Unfortunately, a serious massage epidemic seems to be spread- ing again over the North American continent. The rubbing and squeezing evil is back again among us. I think that four artistic plates, which are found in a certain Textbook of Obstetrics, to- gether with an elaborate description of the technique of breast Fig. 100. — On left, piece of factory cotton 36 x 16 in. folded twice with lines indi- cating portions to be cut out. In center, piece of cotton with portions cut out On right, piece of cotton unfolded showing the bandage ready for application. massage, is, to a large extent, responsible for the present popularity of this dangerous procedure. According to Bacon, of Chicago, the directions seem to have become common property and are copied from one textbook to another in the United States. The following are the main objects of the breast-binder: 1. To support the swollen and tender breasts when congested and distended with milk. 2. To prevent pain by evenly applied pressure, which prevents, to some extent, the congestion and distention. 3. To ''dry up" the breasts when the child is still-born, or when the patient, through disease or other cause, is prevented from nursing her babe. 4. To prevent mastitis. I have used for the last fifteen years a breast-binder devised for me by Miss Snively, of Toronto. It is similar in shape to that of Miss Murphy or Dr. Garrigues, of New York. With a piece of cotton and a pair of scissors one can quickly cut out an excellent bandage. The following directions furnished by Miss Snively, explain very clearly how it is made. Material, 16 to 18 inches of strong factory or bleached cotton, one yard wide. TTTE OAUK OF THE ^[O^rTTET? 157 1. Fold the selvage edges together, then fold in the same direc- tion again. The cloth is now four thicknesses and must remain so until all cutting is finished. 2. Tiie first cut will he on the side opposite the selvage edges. Place scissors 2 implies from tlu^ edg{> and cut downward 8 inches, taking a circular direction outward after cutting 7 inches. This forms the armhole. The straight edge, 36 inches long, is now the ])ottom and the opposite side the top. 3. Now fold the four thicknesses over about 4 inches. This will bring the selvage edge even with the first 7 inches of the _ wM Fig. 101.— Snively Breast-Binder applied. opening first made for the arm. Press this firmly with the hand so as to leave the mark of the fold, then unfold. 4. Place the scissors three inches from the top on the selvage side and cut in a circular direction toward the top of the mark of the fold ; this forms the neck. 5. In applying binder the shoulder pieces can be joined with small safety-pins, while the front is joined with ordinary pins or larger safety-pins. The front is turned in to fit the patient, no sewing being required. Sometimes the bust measures more than 36 inches; in such 158 THE PUEEPEEAL STATE cases take a piece of cotton and cut it lengthwise, making it 38 or 40 inches long and 16 to 18 inches wide. Then cut as directed in rules 1, 2, and 3. In private practise I use the Snively bandage in all cases where the breasts become in the slightest degree uncomfortable from distention. It affords a wondrous degree of comfort in a large proportion of cases, especially in "drying up" the breasts. No application of atropine or belladonna is required when the bandage is used. The bandage has one drawback which should ever be kept in view in the nursing woman. It diminishes the secretion of milk when tightly applied. In consequence of this we do not use it in Fig. 102. — Murphy Binder, " Ready-made." all cases as Garrigues and others do in New York, but only when the breasts become tender. We only make it sufficiently tight to re- lieve pain and remove it as soon as we can. Further reference is made to this bandage in speaking of the prevention and treatment of mastitis. Nipples. — In speaking of the hygiene of pregnancy, it was stated that it is dangerous to handle the nipples to any great extent. The condition of the nipples, however, should be ascertained soon after labor, if not known before. It is sometimes advisable, especially in primiparse, to make certain attempts to increase the prominence of the nipples before the secretion of milk. A common way of doing this is to have the patient herself or the nurse pull the nipples forward with the fingers in imitation of the action of the babe's mouth. Sometimes they may be drawn out by gentle suction of a breast pump. A very simple and common method of suction is by means of a hot bottle. Take a six or eight ounce bottle and fill it with hot water, pour out the hot water rapidly and apply the THE CARE OF THE MOTHER 159 bottle quickly over the nipple. The condensation of the air which occurs during the cooling of the bottle creates a partial vacuum and thus a certain amount of suction upon the nipple, which is drawn into the neck of the bottle. Any or all of these procedures may, however, seriously irritate and injure the nipples. Food. — The patient is not generally hungry during labor, nor for two or three days after, as before mentioned. It is not neces- sary to make any hard and fast rule as to diet, but to be largely guided by the appetite of the patient. On the first day a very simple and plain diet seems most suitable ; for instance, hot drinks, such as tea, milk, gruel and some simple solids, such as bread and butter, bread or rice puddings, and the like. On the second day the patient may take any sort of plain sul^stantial food that she chooses — that is, she may be placed on what we call mixed diet. It is well, however, to watch the effects of vegetables, fruits, and sweets until the patient has left her bed and is having a certain amount of exercise. Micturition. — As before mentioned, there is likely to be an un- usually large secretion of urine for sonle days after labor. For certain reasons, already alluded to, retention of urine is not unusual. The nurse should look after the patient in this respect and encour- age her to void urine before the bladder becomes distended. It is frequently difficult for the patient to do this while lying on her back. If not too much exhausted after the labor it is well sometimes to raise her nearly, if not quite, to the sitting position or allow her to turn on her hands and knees. Catheterization should be avoided if possible. It exposes the patient to the risk of septic infection of the bladder, which is a very serious condition. Again, when catheterization has been once performed it must generally be con- tinued for many days. One should remember, however, that retention of urine, even when there is some intermittent or con- tinuous flow, not infrequently causes enlarged bladder and dis- placement of the uterus. In such a case catheterization is neces- sary. Since we adopted the involution line w^e have discovered that partial retention of urine is more common than we formerly supposed, and is the cause of pain in the region of the uterus, which may last for days and is frequently misunderstood. One of the most common expedients for encouraging the flow of urine is to place a hot compress, such as a hot sponge, over the suprapubic region. Miss McKellar. in the Burnside, has frequently 13 160 THE PUERPERAL STATE found a good result from the administration of an enema. The enema of soap suds is retained for some time, the patient put in a partial or completely sitting position, and the urine is voided while the soap suds or fsecal matter is coming away from the bowel. Bowels. — It was formerly understood that the bowels should be moved on the third day. I think that only one day should inter- vene before the bowels have been moved. For instance, when a patient in labor one day passes the following day without a motion of the bowels an aperient should be given that same evening. It is well to ascertain what cathartic the patient is in the habit of taking. Any of the simple cathartics, such as rhubarb pills, cas- cara, compound licorice powder, phosphate of soda, sulphate of soda, etc., will answer very well. After taking the cathartic in the evening an enema may be administered the following day before noon, if necessary. The patient should be kept in bed nine to fourteen days after labor. She may be allowed to walk in three weeks. She should be well in four weeks, but should not do much work for six weeks. THE CONDITION AND CARE OF THE BABE The following are a few of the practical points in connection with the anatomy and physiology of the babe : Breathing. — The breathing is superficial, and rapid up to 50 a minute; the pulse can not be counted at the wrist immediately after birth, but can be over the heart. The rate is 130 to 140 during the first two months, 120 to 130 from the third to the sixth month, 115 to 120 from the seventh to the twentieth month. Evacuations from the Bowels. — Some meconium may be ex- pelled during the birth of the child and more is expelled shortly after birth. It is a dark, green, tarry substance. This is followed by brown fsecal matter, which becomes lighter in color until the end of the first week, when it has a light yellow color. Urine. — There is very little urine in the bladder at birth and very little is secreted during the first twenty-four to thirty-six hours. When urination takes place very soon after birth the fluid is light in color, but when delayed for twenty-four to thirty-six hours it is apt to have a deep yellow color and to be turbid. Some- CONDITIOX AXl) CARE OF THE BABE IGl times it contains considerable uric acid and urates causing yellow- ish or red deposits on the napkin, which are sometimes mistaken for l)l()od. No alarm need be caused if the urine is not voided inside of thirty hours. If no urine is passed within thirty-six to forty hours it is better to pass a small catheter or a silver probe ; but this is very rarely necessary. Bladder. — The bladder, when distended, is egg-shaped and lies chiefly in the abdomen. The muscular wall is relatively thick, causing the bladder in female infants sometimes to be mistaken for the uterus on post-mortem examination. The urethra is situated along the anterior wall of the vagina and its meatus appears almost as large as the orifice of the vagina. This causes a little confusion sometimes in passing a catheter. Growth. — The average weight at birth is 7 pounds (3,200 gm.), the average length, 20 inches (50 cm.). The babe loses weight for two or three days after birth, but after the fourth or fifth day it should commence to grow and such growth should continue steadily. The Cord. — After the first dressing the cord requires no special care. If the dressing is disturbed by the daily bath it may be re- placed in a clean way. The cord generally separates in from four to eight days, a small superficial ulcer being left. This should be kept clean and dry and dusted with boric acid. The diapers should be changed frequently. When soiled the buttocks and genitals should be washed with lukewarm water, but after washing the parts should not be wiped with an ordinary towel. Soft linen, cotton or muslin should be gently pressed against the skin so as to soak up the moisture, the parts should then be dusted with some fine powder, such as talcum. The Stomach. — The stomach of a new-born babe is very small, being little more than a simple dilatation of the intestinal tube, and will hold, without distention, little more than an ounce of fluid. When more than an ounce is taken vomiting is apt to occur from simple contraction of the stomach walls. This occurs very fre- quently and should cause no alarm, as it is not ordinary vomiting but a simple regurgitation without nausea. Feeding. — During the first three days before the secretion of milk in the mother's breast the babe requires very little or no food. A little plain warm water slightly sweetened may be given to it occasionally during these early days. Generally speaking, during 162 THE PUERPERAL STATE the first month the child takes about 20 ounces daily, during the second about 24 ounces, during the third about 28 ounces, from the fourth to the ninth month 30 to 35 ounces. It is generally recognized that in the interests of the child the mother, providing there be no contraindication, should always nurse her babe. In some respects this is also in the interests of the mother, because involution of the pelvic structures takes place more slowly when the mother does not nurse her babe. Contraindications to Maternal Nursing. — It is not easy to lay down definite rules as to such contraindications. On the one hand the healthy woman should always nurse her babe, unless her nipples are extremely deformed ; on the other hand, a woman suf- fering from advanced tuberculosis, severe puerperal septicaemia, or any disease which greatly enfeebles the system, should not attempt to nurse her child. Generally speaking it would be neither in the interests of her child nor herself. In cases of doubt, however, it is well for the mother to make the effort to nurse her babe in part at least. Frequently she may be able to nurse the babe wholly or partly for three or four months, but if it becomes evident at any time that such efforts are injuring the mother, and perhaps the babe as well, the suckling must be stopped entirely. The mother may not have sufficient milk for her child even at any one time of nursing. When in doubt on this point it is always well to offer the babe a little sweetened warm water after suckling. Always take care that the babe has sufficient liquid. Never let a day pass without the mother or nurse offering the child three or more times in the day a certain amount of sweetened water. Wet Nurse. — Next to the mother, probably all will agree that a suitable wet nurse is best for the child. It is a very simple thing thus to state what may be considered an actual truism, but, unfor- tunately, it is an exceedingly difficult thing to get a suitable wet nurse. A wet nurse should be perfectly healthy in all respects, but, especially, free from tuberculosis or syphilis. Her mammary glands should be well developed and the nipples should be well formed. The milk should contain not less than 10 per cent, of cream. It is better, if possible, to have a married woman. In the majority of instances a wet nurse is more or less unsatisfactory, and frequently intolerably so. Artificial feeding is, of course, not satis- factory, but on an average it is probably better than wet nursing. CONDITION AND CAllE OF THE BABE 163 ARTIFICIAL FEEDING Milk. — All things considered, cow's milk, when properly modi- fied, makes the best food we can get for infants. It contains, how- ever, more caseinogen and less sugar than woman's milk. It should, therefore, be diluted so as to diminish the proportion of casein and should be sweetened with cane sugar or sugar of milk. Some think that it should be completely or partially sterilized. Sterilization. To sterilize milk thoroughly so as to destroy the bacteria and spores of bacteria it is necessary to boil the milk not less than thirty minutes. This decomposes the sugar, melts the fat, and toughens the casein in a way that renders it much less digestible than the unsterilized milk. Pasteurization. This means a partial sterilization of the milk at a temperature not exceeding 158° F. for fifteen minutes. This is said to destroy the typhoid, diphtheria, and tubercle bacilli and also a large proportion of bacteria. The process probably injures the digestibility somewhat, but not nearly so much as the complete sterilization. The following are simple rules as to the methods of modifying cow's milk for infants. During the first month mix the cow's milk with twice the quan- tity of plain water and add one-half teaspoonful of milk sugar for each feeding. During the second month mix the milk and water in equal parts and add milk sugar as before. During the third and fourth months mix two-thirds to three-fourths of milk with one- third to one-fourth of water. During fifth and sixth months give the milk undiluted. Some prefer to dilute the milk by mixing it with barley water instead of plain water. It is probably not well, however, to use the barley water before the third month on account of the starch which it contains. Cream Mixtures. — The cream mixtures, of which there are many varieties, are probably the best for infant feeding. Skim the cream from milk after it has been standing six or eight hours, or, say, over- night. Some prefer to leave the milk standing in a jar for some hours and then siphon off the lower half, two-thirds, or three- quarters of the milk thus leaving the portion which contains the cream. One can not lay down any fixed rules as to the proportion 164 THE PUEEPEEAL STATE of a cream mixture which will suit all infants, but the following table, by Louis Starr, may be taken as an excellent guide : Table of Ingredients, Hours and Intervals of Feeding, and Total Quantity of Food for a Healthy Artificially- fed Infant from Birth to the End of the Seventh Month. Age. During 1st week .... From 2d to 6th week . fsij f3ij From 6th week torr- end of 2d ^ "> ^^ month . . . From 3d to 6th month During 6th and 7th months . . flss f I ss f3iij f?ss f3x f!ij f 1 iijss gr.xx gr.xx a pinch 3 ss 3j a pinch a pinch 3 j a pinch I 3 iij n] fSx ffife 5 A.M. to 11 P.M. 5 A.M. to 11 P.M. 5 A.M. to 11 P.M. flisS 5 A.M. to f!ij 7 A.M. to 10 P.M. 2 hours 2 hours 2 hours 24 hours. 3 hours O 3 HO" f!xij f !xvij f ? XXX f § xxxij f I xxxvj It is more convenient to vary the ingredients of the cream mix- ture according to the age of the child. Some prefer, however, to determine the composition and amount of food according to the weight instead of the age. It is perhaps better to consider both the weight and age. For instance, one babe at six months may not be larger than another at three months. In such a case it is better to give the food suitable for the earher age. It is generally better in all cases to dilute the food rather than change it when the child is not thriving. The mothers can not always understand the philosophy of such treatment, but it is better to teach them if possible. One of the most important columns of the Starr table is that which gives the intervals of feeding. The infant should be fed with absolute regularity whether it gets mother's milk or artificial food. The young babe should have one long sleep of six hours during the night, and should be wakened at the proper hours during the day — i. e., every two hours if necessary. Many mothers and nurses dis- like to disturb peaceful sleep, but there is no harm in doing so. CONDITION" AiYD CAEE OF THE BABE 165 The babe will take its meal after being thus disturbed and go back to the "peaceful sleep" in good time, often immediately. It should sleep eighteen to twenty hours out of twenty-four, but if allowed to sleep four or five hours at one time during the day it is more apt to become wakeful at night. Good or bad training in such regard will produce in young infants good or bad habits in a very short time. It is better in some cases to use the whey for a longer time than one week as recommended by Starr. Whey and cream form an admirable mixture. Vigier's method of preparing cream and whey mixture : Divide one quart of milk into equal portions, let both stand three or four hours in a cool place. Then skim the cream from one portion and add it to the other. Add one teaspoonful of liquid rennet to the skimmed portion and warm to 95° to 104° F. with frequent stirring for twenty minutes, or until it forms a tough curd. Then heat to a temperature of 155°, after which strain through muslin and cool. For infants under five months mix equal volumes of this whey with the enriched milk. I prefer for infants under two months mixing two-thirds of whey with one- third of rich milk. With infants over six months mix two parts of rich milk with one of whey. Monti prefers a mixture of whey with ordinary milk in equal volumes for the first three months, and after that two parts of milk with one of whey. When a child appears to be suffering from in- digestion, as shown by the presence of undigested casein in the stools, it is well to feed the babe for one, two, or three days on whey alone. Even when depending on whey alone or any mixture of whey with cream or milk, it is still desirable to offer the babe fre- quently plain water or plain sweetened water to drink. One should be very careful to see that the bottles and nipples are properly cared for. Each bottle should, if possible, be only sufficiently large to contain about one meal for the babe. The nip- ples should be made of plain black rubber, with three holes of size not to allow too much nor too little milk to pass. When too much passes it chokes the child, and when too little can be drawn through the child grows tired of sucking. While the infant is being fed it should lie on its back with the head a little raised. The bottle should be held or placed so that the bottom points upward, with the nipple placed against the 166 THE PUERPEEAL STATE tongue. Garrigues points out that if these rules are observed the child is not apt to get its stomach filled with air. Condensed Milk. — Condensed milk is used by many for infants up to the ages of nine to twelve months. The canned milk, which contains a large amount of sugar, is more commonly used. This milk, in addition to containing too much sugar, has also some of the disadvantages of sterile milk, and should not be used for any length of time. I believe, however, that it does very well for a limited time, up to three months, if not more. Such being the case, it may be used by people who are not in a position to devote the time to the proper preparation of other food, such as cream mixtures. It is often more convenient and safer for young chil- dren when traveling. Manufactured Artificial Foods. — Some of the artificial foods now found in the market are very good. I think it better to choose those which may be mixed with warm water. Such foods are also convenient and safe for children when traveling. When the mother is able to nurse her child she should do so for nine months. The period of lactation may perhaps be prolonged to twelve months, or it may require to be curtailed. Very fre- quently it happens that the child may get its nourishment par- tially from the breast and require supplementary feeding with artificial foods. CARE OF PREMATURE INFANTS We can not say exactly at what period of time in pregnancy a child becomes viable. It is generally supposed that the child is viable at the end of the seventh month of gestation. This is recog- nized by law in certain countries. It is probably a fact that a child may be viable at the end of the sixth month. From a medical standpoint it is probably better to consider any child viable when it breathes at birth. It is well at the same time to have a clear idea of the general appearance of a seventh-month foetus. A singular case occurred a few years ago, in which Dr. Temple and myself were called to report as to the probable viability of an infant. A premature infant expelled at 2 a.m. Supposed, from the history, to be five months advanced. Poor light, poor surround- ings, in a small house. Foetus, when examined with the dim light of the candle, showed no sign of life and was left on the bed for CONDITION AND CARE OF THE BABE 167 some time while the mother was cared for. Fcetus again examined carefully, covered with cotton-batting and placed in a rough box, which was covered, and carried, between 9 and 10 a. m., to what would correspond to a vault in a large cemetery, the intention being to bury it in an hour or so. Some one passing thought he heard a cry. The box was opened and the infant was found to be living. It was exceedingly feeble, however, and died in a few hours. In our report we expressed the opinion that the child was born in the seventh month of pregnancy and perhaps early in that month. While the child was born alive, we doubted whether it could be con- sidered viable in the proper sense of the word — that is, we doubted whether it was born with sufficient vigor to enable it under the best of circumstances to live to manhood or even to boyhood. Two things are of great importance in the care of a premature infant : 1. The maintenance of the body temperature. 2. The proper administration of nourishment. The Maintenance of the Temperature of the Body. — Heat is the all-important thing for the premature babe. Artificial respiration, which is so important in certain cases for the full-term babe, is not of much use for the premature infant. The old-fashioned way of treating the premature babe was to wrap it up warmly and put it behind the kitchen stove. Such procedure seems sometimes to be quite as effective as the use of the most modern and expensive incubator. Incubator. An incubator is something that one can very easily manufacture in any house, even in the backwoods. A large market- basket, a small clothes-basket, or a candle-box is used. One-half the basket or box is filled with cotton-wool or something of that sort. The child is anointed thoroughly with warm sweet-oil or cod-liver oil (which I prefer), and placed undressed in the basket or wooden box on the cotton-wool, having, however, an absorbent pad under the buttocks for the collection of faeces and urine. Cot- ton-wool is then added to the sides and over the front of the child, leaving only the face and part of the head uncovered. Two hot- water bottles are placed on either side and one below the feet. The hot-water bottles are so arranged that they can be filled with- out disturbing the child. The temperature in the box is kept at or about 85° to 95° F. and the temperature in the room from 72° to 75°, or perhaps even up to 80°, for the first half day. The box 168 THE PUEKPERAL STATE may be covered by a quilt or shawl, leaving the face still uncovered. The only difficulty that one need experience in a house in the backwoods will perhaps be the want of a thermometer. In such a case put in the bottles water as hot as the hand may be immersed in without discomfort, change occasionally, and leave the box in a portion of some warm room where you are satisfied the tempera- ture is not below 70°. If something more pretentious in the way of an incubator is required the Tarnier or Crede or Auvard or ' ' Ideal ' ' incubator may be chosen. The Proper Administration of Nourishment. — The premature infant, like any other infant, should receive definite amounts of nourishment at regular intervals, the quantity and frequency of administration depending upon its age, vigor, etc. The mother's milk, of course, is the best food. The milk from a healthy wet- nurse will answer if milk from the mother is not available. If artificial feeding becomes necessary some of the foods which have been recommended should be used, a mixture of very little cream with whey and a little lime-water being one of the best. During the first day probably plain warm water, a quarter to one-half tea- spoonful every hour or two, will be sufficient, or occasionally the same quantity of milk from the mother's breast, or artificial food. It is generally better to give it to the babe with a tea- spoon, or a few drops may be introduced into the back part of the mouth or the pharnyx through an ordinary medicine dropper or small syringe. Gavage. — Another method of administering food is known as gavage. The infant hes with the head slightly raised, a 14 or 16 (French) soft rubber urethral catheter, thoroughly sterilized, is first anointed with a little of the food to be given. It is then in- troduced into the pharynx and gently passed on to the stomach as the child swallows. A little artificial food is passed through the catheter from a small glass funnel or syringe inserted into the outer extremity of the tube. CHAPTER IX FACE PRESENTATIONS, BREECH PRESENTATIONS, MULTIPLE PREGNANCIES FACE PRESENTATION This condition is found in 1 out of 250 cases and is probably produced by extension of the occiput in vertex presentations. It is thought by some that such extension is occasionally found be- fore labor, but in the great majority of cases it is developed after the onset of labor. The causes are briefly these : Obliquity of the uterus, through which the head, instead of being driven downward into the pelvis is forced against the side of the brim. In this way the descent of the occiput is arrested and the descent of the chin is favored. Dolichocephalic head — that is, with occiput projecting, causing lengthening of the posterior arm of the cephalic lever (doubted by some). Round and small head, causing equality of the two arms of the cephalic lever. Flat pelvis, pre- venting the broad occipital portion from engaging in contracted conjugate diameter and causing it to be pushed to the side of the pelvis. Congenital swellings of the neck — tumors of the thyroid or thymus glands. Small foetus. Anencephalic foetus. Hydramnios, especially with sudden escape of liquor amnii. Coiling of cord round the neck. Occipito-posterior positions in which there is a "tight fit" at the brim (Cameron and Webster). Among these causes the most common are obliquity of the uterus, especially when the back of the child is toward the mother's right side, flat pelvis, and hydramnios. It is especially important to keep these causes in view, because they can generally be dis- covered during pregnancy. Diagnosis. — Abdominal palpation. Sometimes diagnosis by pal- pation alone is exceedingly difficult or impossible; sometimes the projecting occiput can be readily detected above the pubes and at one side, while the breech is felt at the fundus on the same side (Pinard). The heart sounds can generally be heard on the opposite 169 170 FACE AND BREECH PEESENTATIONS side because in face presentation the chest of the foetus usually presses directly against the uterine wall, while the back does not. We therefore hear the heart sounds from the front of the chest instead of from the back. The furrow between the back and occi- put may sometimes be felt, and there is a lack of adaptation of the foetus to the uterus and abdomen. Digital Examination. As the presenting part is high up early in labor it is difficult to make out much by a vaginal examination. The examining finger may touch the forehead and this may be mistaken for the vertex. After a time we are able to feel the fore- head, the edges of the orbits, eyes, nose, nostrils, mouth with its hard alveolar ridges, and the chin. Sometimes, however, the face is swollen and distorted to such an extent that it may be mistaken for the breech. The simplest way to be sure of the diagnosis is to press on the alveolar ridges inside the mouth. These correspond to nothing found in the rectum, where, instead of hard ridges, we find shght action of the sphincter, which caused Parvin to make use of the expression, ' ' The anus bites instead of the mouth. ' ' In making the examination it is always important to note the direc- tion of the chin ; the best guide to that is the nostrils, which point in the direction of the chin. Mechanism of Face Presentations. — The mechanism of vertex presentations being known, it is a simple matter to get a clear con- ception of the mechanism of face presentations. In the latter the chin plays the same part that the occiput does in vertex presenta- tions. As the head descends rotation must occur in the one case as well as in the other. In vertex cases, under normal circumstances, the vertex is the lowest part of the head in the pelvis ; this is pro- duced by flexion of the head. In face presentations the chin is the lowest part of the head in the pelvis and this is due not to flexion but to extension. Extension of the head turns the occipito-left- anterior into the right mento-posterior and so on, thus (Fothergill) : 1. O. L. A. = M. R. P. Mentum right posterior. 2. O. R. A. = M. L. P. Mentum left posterior. 3. O. R. P. = M. L. A. Mentum left anterior. 4. O. L. P. = M. R. A. Mentum right anterior. The order of frequency is : 1, 3, 2, 4. There is some doubt as to whether the first or third face position, that is, the mentum right posterior or the mentum FACE PRESEXTATIOX 171 left anterior, is tlie more common, but all are agreed that these two positions arc fur more common than the others — that is, in these presentations the face nearly always lies in the right oblique diameter the chin being to the left front or toward the right rear. The mechanism is the converse of that in vertex cases. There are four movements, (mentum right posterior) : 1. Extension and descent. 2. Internal rotation — long rotation of chin to front through three-eighths of a circle, 3. Flexion. 4. External rotation. Very rarely we have a malrotation with the mechanism as follows : 1. Imperfect extension or slight flexion with descent. 2. Internal rotation — short rotation of forehead instead of chin to front through one-eighth of a circle. 3. Extension. 4. External rotation. This malrotation — i. e., the rotation of the forehead, brings the chin into the hollow of the sacrum, making it a persistent mento- posterior position, in which natural expulsion is nearly always impossible. The three important movements in the delivery of normal face presentations are descent and extension, rotation of the chin to the arch, and delivery of the head by flexion. The fourth move- ment of external rotation which is generally described is less important. The mechanism of the first position may be more minutely de- scribed as follows : When labor begins the forehead is lower down than the chin, during descent extension takes place which causes the chin to come lower down; next, a rotation takes place which turns the chin toward the pubic arch. The rotation of the chin is brought about in the same way as that of the occiput in normal labors — that is, by pressure against the posterior part of the pelvic floor, especially the strong sciatic ligaments. The right cheek, which is anterior, descends a little lower than the other, the mouth and chin appear at the vulva. As soon as the chin gets clear of the pubic arch flexion occurs by which the chin is pushed up in front of the symphysis pubis, while the nose, eyes, forehead and 172 FACE AFD BEEECH PEESENTATIONS vertex successively roll over the perinseum. After delivery of the head external rotation takes place. Mechanism of the left mentum anterior 'presentation. As before, extension makes the chin descend lower than the forehead. As soon as the chin reaches the pelvic floor it is rotated forward to the right and toward the middle line, the chin is then delivered and Fig. 103. — Diagram showing Delivery of Head in Face Presentation (Williams). flexion follows as before, causing the mouth, nose, eyes, and fore- head to appear successively, after which the occiput glides over the perinseum. MANAGEMENT When hydramnios is present abnormal presentations are fre- quent. When it is a face presentation it is desirable to change to a vertex before the liquor amnii has all come away. (See Treatment of Hydramnios.) When there is a flat pelvis it is always better to turn. When there is a generally contracted pelvis it is better to change to a vertex presentation or to turn; probably version is the safer procedure. In the great majority of cases Nature can complete the delivery without great difficulty. Such being the case, it is not necessary for the accoucheur to risk much in efforts to change the presen- tation according to the methods described by some obstetricians. FACE PRESENTATION 173 Active interference is therefore unnecessary, excepting in the cases above referred to. Among the methods recommended the following are probably the best, although 1 should not advise physicians to place much reliance on them. Herman's Method by Pressing on the Face and the Occiput. — Put tu'o fingers in the vagina and the other hand on the alxlomen, press the face up by pressure, first on the jaws and then on the fore- head, and at the same time press the occiput down with the exter- nal hand. If you have succeeded in pressing the forehead above the pelvic brim, then use both hands outside, pressing the occiput downward into the pelvis with the one hand and pressing the face upward and tow^ard the middle line with the other. Schatz's Method. — Raise the shoulders and press them down toward the dorsal aspect of the child so as to undo the extension of the spine, at the same time steadying or raising the breech with the other hand applied near the fundus, so as to make the long axis of the child conform to that of the uterus: and finally, press the breech directly downward. As the child is raised the occiput is allowed to descend, and then as the body is bent forward head flexion is produced by the resistance of the side walls of the pelvis. The proper time for this manipulation is previous to rupture of the membranes. When the head is in the pelvic cavity, with the chin toward the front, and the os, vagina, and vulva are fully dilated, apply the forceps if, after waiting one or two hours, satisfactory progress is not being made. When the head is low in the pelvis with the chin posterior, and the OS, vagina, and vulva are fully dilated, one should wait for a cer- tain time, one or two hours, with the hope that the chin will rotate to the front. If this does not happen, the patient should be fully anaesthetized, the whole hand is introduced into the vagina, the face is grasped with the thumb on one side and fingers on the other and the head is turned so as to bring the chin to the front by the shortest route ; at the same time, with the other hand on the abdo- men, an effort is made to press the anterior shoulder in the same direction. I shall again refer to this procedure in speaking of difficult occipito-posterior positions. Herman, who has given the most definite instructions as to this form of procedure, tells us that when the chin points directly back- 174 FACE AND BEEECH PEESBNTATIONS ward we should observe in which obHque diameter the shoulders lie, and move the chin in the same direction as that in which we press the anterior shoulder to get it to the front. When the chin is brought to the front we should apply forceps immediately and deliver. If we are unable to dehver by any of the methods described nothing remains but a serious operation such as Csesarean section, symphysiotomy, or embryotomy. As the chances of delivering a living child at this time are very poor the operation of embryotomy is the one most commonly performed. Prognosis. The foetal mortahty is from 10 to 15 per cent., and the maternal mortality is a Httle above the normal. Labor is usually slow. Treatment. — The treatment may be summed up as follows : Keep the patient in bed and preserve the membranes intact as long as possible. No interference is required, as a rule. When there is a flat pelvis or prolapse of the umbilical cord employ podahc version (Diihrssen). Schatz's method, producing "universal flex- ion " of foetus by external manipulations, or Herman's method is occasionally practicable. After the os is dilated the mem- branes may be ruptured and the hand introduced into the uterus may flex the head. Forward rotation of chin may be assisted by pressing the forehead upward and somewhat backward, and occasionally by drawing the chin downward and somewhat for- ward by two fingers hooked over it during an interval between pains. It may be necessary to apply the forceps, or perform Csesa- rean section, or symphysiotomy if child is ahve, or embryotomy if child is dead. Head Molding and Caput Succedaneum. — The vault of the head becomes flattened and pushed backward, while the frontal and occipital bones are bulged and curved. The diameters short- ened are the suboccipito-bregmatic and the cervico-bregmatic. The diameters lengthened are the occipito-frontal (considerably) and the occipito-mental (shghtly). The caput succedaneum will be found to extend from the an- terior angle of the mouth over the cheek to the level of the eyes and perhaps to the other half of the face. The disfigurement is so great that the friends should be warned before dehvery, and the mother should not be allowed to see the child until the swelhng has to some extent subsided. BREECH PRESENTATION" 175 BROW PRESENTATION At one stage during the change from vertex to face presenta- tion we have what is known as brow presentation, the prominence of the forehead being the presenting part. This is due to the fact that the two arms of the head lever balance each other. Generally in such a presentation we can feel the bridge of the nose or the supra-orbital ridges on one side of the pelvis and the anterior fon- tanelle on the other, at the same time the frontal suture occupies the same position in the center of the pelvis that the sagittal holds in vertex presentations. This is a very difficult presentation, although it is barely possible that without interference dehvery may take place. During labor the forehead generally turns to the front and the occiput to the rear, the following parts appear suc- cessively at the vulva, forehead, eyes, and nose, after which the vertex and occiput ghde over the perinaeum, then the mouth and chin emerge under the pubic arch. The prognosis in such cases is bad for both mother and child. Treatment. — Early in labor we should endeavor by manipula- tion to change the presentation into a vertex or face. If we are unable to do this try to perform podalic version. Sometimes the head may be delivered with the forceps. If all such efforts fail, caesarean section, symphysiotomy, or embryotomy becomes neces- sary. BREECH PRESENTATION In a certain proportion of cases the breech presents instead of the head. The dangers to the child in breech labors are fairly well known but not always fully appreciated. In the most skilled hands probably 7 to 10 per cent, of the children are still-born. In some Charities, we are told by Herman that 30 per cent, or more perish during dehvery. In other words, the excess in the mor- tality rate depending on want of skill in management sometimes amounts to 20 per cent, or more. The mortaUty among children in breech deliveries conducted by midwives in Great Britain is simply appalUng. A country, however, which by act of Parhament converts the ordinary midwife into a legalized obstetrician, must inevitably suffer seriously from such extraordinary legislation. Carelessness and ignorance as to proper methods of conducting breech cases are not, however, confined to midwives. My own experience and observation lead me to believe that many physi- 13 176 FACE AI^D BREECH PRESENTATIONS cians neglect to use proper and systematic methods in the manage- ment of these cases. Version before labor in breech presentation has become some- what popular in London, England, during the last few years, but is not often performed in the United States or Canada. The pro- cedure is sometimes easy of performance and fairly safe in skilled hands. One can not, however, in any case be certain of getting a good vertex position after the version. It is, I think, better for the general practitioner to make no attempt at version, but to em- ploy proper methods of extracting the child as quickly and safely as possible. The main points as to classification, prognosis, causes, diag- nosis, mechanism, and preparation may be summarized as follows, before speaking in detail as to the management of breech delivery. Pelvic presentations are subdivided into: 1, Breech; 2, knee; 3, footling. The mechanism is nearly the same in all; the fre- quency is 2 to 3 per cent. ; the prognosis is good for mother, bad for child. The child is still-born 1 in 10 cases, some say 1 in 5 cases. The dangers to child are : 1, Suffocation from respiratory efforts before delivery of- the head; 2, asphyxia from compression of cord after umbilicus has emerged from vulva ; 3, stoppage of the foetL A V^ >•- — -•-^ i \ -»-— ■*""• ^s. / \ A A n A "/ ^- A- -•». / \/ V r \^ \h A ^./N / V ^A V Y \ V V \A a V \ / V % M Pulse E 98 90 92 91 96 90 88 90 1 81 130 121 96 80 81 96 98 100 108 112 91 96 100 120 136 116 100 81 88 Fig. 151. — Chart showing Rise of Temperature from Sore Nipples. looking like a small strawberry, and very painful when touched. 3. Fissure of the summit is a linear ulcer running generally from the circumference to the center. 4. Fissure of the base is a linear ulcer running transversely, and is generally the worst form of sore nipple. In all cases wash the nipple after nursing. For ordinary ex- coriation apply first a mixture of castor-oil and bismuth (equal 424 ABNOEMAL CONDITIONS OF THE UTEEUS parts), as recommended by Hirst. This mixture may also be applied to a slight fissure of the summit. If this does not effect any improvement, apply orthoform — either in the form of a powder or an ointment having 10 per cent, orthoform and 90 per cent, lanolin. The orthoform is a mild antiseptic, and also produces local anaesthesia, which lasts for some hours after its application. Another plan of treatment in the Burnside is to carefully wash the nipple after nursing with a solution of boric acid; then apply a solution of carbolic acid, 1-40 ; then soak some absorbent cotton in a solution of boric acid, place it over the nipple and have it retained in position by the breast-binder. In other words, wash nipples, apply carbolic solution, and then apply a boracic poultice and re- tain it until the next time of nursing, A piece of oil silk or gutta- percha tissue may be placed over the poultice. In case of fissure of either the summit or the base, nothing is more satisfactory than the application of the solid stick of nitrate of silver, as our fathers used it long ago. The parts should be thoroughly dry. Separate the opposed surfaces, apply the stick lightly to bottom and sides of the fissure, and if the fissure is deep apply absorbent cotton between the two surfaces. After opposing surfaces have become healthy in appearance apply the compound tincture of benzoin, two or three layers, with a camePs- hair brush. When nursing causes extreme pain after treatment as described, use a nipple-shield. This is at first refused by the baby, as a rule, but a good nurse can generally get the baby to take the shield after a few trials. Apply the flat surface tightly to the breast, and if the child will not seize the rubber nipple, or will not retain it, press a little milk into the shield with the fingers placed on the surface of the breast outside the base. Miss MacKellar finds in the Burnside that the best form of nipple-shield is one made of glass with an india-rubber teat attached. I also use this kind in my private practice. After using a shield, always wash it carefully and then place it in a saturated solution of boric acid until again wanted. While the nipple shield generally answers a good purpose, it hap- pens occasionally that it can not be used. This is true especially in the bad form of fissure of the base, when the drawing of the nip- ple into the shield opens the opposed surfaces at each nursing. It is sometimes necessary to stop nursing for a time — two, three, or four days, or sometimes altogether — i. e., to " dry the breast." MASTITIS 425 When the breast is given a rest as to nursing it becomes distended with milk. If such distention is present notwithstanding the use of the breast-binder, it should be relieved by the process of milking the nipples with the fingers, much as a milkmaid milks her cow, or by the use of the breast-pump. The Use of the Breast-Binder. — In speaking of the puerperal state I referred especially to the use of the breast-binder for disten- tion of the breasts a few days after labor. The judicious use of such a binder prevents much discomfort as well as actual pain, and also tends to prevent mastitis. Massage. — I desire to return to this subject and refer to the pro- cedure in connection with pathological conditions of the nipples or breasts. The use of the breast-binder fortunately makes massage absolutely unnecessary for what may be called physiological ful- ness or distention of the breasts. In certain cases, however, which appear to be, or are actually becoming, pathological, in spite of the use of the binder or careful treatment of the nipples, a modified form of massage sometimes has a good effect. I do not refer in this connection to rubbing from the circumference toward the nipples, but to an altogether different sort of massage which I have used lately, and which, as far as I know, was first described by Bacon of Chicago. The fulness of the breasts after labor is not primarily due to an accumulation of secreted milk, but rather to a distention of the blood and lymph vessels. The object of the modified mas- sage is to relieve the painful engorgement by emptying the congested vessels. Bacon does this by beginning outside of and above the breast and rubbing in the direction of the venous and lymph flow toward the axillary and subclavian trunks. After the surrounding area is massaged, the breast itself, or a portion of it near the per- iphery, may be gently rubbed, but always in a direction away from the nipple. No pain should be caused by this manipulation. Abnormalities of Milk Secretion. — ^Agalactia means a marked diminution of mammary secretion. Galactorrhoea means excessive mammary secretion. The sup- ply of milk may be so abundant that it is constantly escaping from the nipples. The milk is generally thin and watery, and the health of the patient is impaired. Treatment. — Apply a breast-binder; administer tonics, espe- cially strychnia, belladonna, and arsenic; and saline laxatives. Potassium iodide, so often recommended, is, I think, worse than 426 ABNORMAL CONDITIONS OF THE UTERUS useless. In the majority of cases lactation should be discontinued in the interest of both mother and babe. Galactocele means the condition in which a lactiferous duct is completely blocked. It may be single or multiple, and affect one or both breasts. Sometimes the fluid part becomes absorbed, and the casein and fat become inspissated; or a cyst containing both fluids and solids may be formed. Diagnosis is sometimes difficult. Treatment. — Make a free incision (not a puncture), clear out the contents, wash out, and apply pressure. Treatment of Mammary Abscess. — As soon as the existence of a mammary abscess is suspected one should act promptly as fol- lows: Clean the skin over the breast, get an assistant to give an anaesthetic, make a deep incision in the most dependent portion of the suspected abscess cavity, cutting in a line toward the nipple, make the incision long enough to admit the index finger, allow the pus to run out of the opening, pass the finger in and break down all the diseased tissues so as to destroy the walls of the various loculi of the honeycombed mass and form one cavity, scrape the wall of this cavity thoroughly with the tip of the finger or with a dull metallic curette, douche out the cavity and plug it fairly tight with iodoform gauze. Apply a breast-binder, not too tightly lest it prevent the secretion of milk in the sound breast. Remove the gauze daily, wash out, and reintroduce the gauze, as long as pus is found — generally from two to eight days. After this do not pack the cavity, but introduce a piece of gauze to keep the skin wound open, put a pad of absorbent or sheep's wool over this portion of the breast, and a breast-binder over all. Or the breast may be strapped and the strapping may be left on three or four days. This is not so comfortable as the bandage, and the removal of the strapping causes much pain. The breast may be supported by a figure-of-eight bandage. The pressure obliterates the cavity after you stop the plugging, and the wound is healed in from ten to twenty days after incising the abscess. If, when you make your incision, you find no pus, no harm will be done. In fact the result- ing haemorrhage will probably relieve tension and thus lessen the pain. Plugging in such a case will not be necessary, and suturing the wound is not advisable. The child should not nurse from the diseased breast so long as there is pus in it. CHAPTER XX THE EMOTIONAL ELEMENT IN THE PUERPERAL PERIOD, AND PUERPERAL INSANITY EFFECTS OF EMOTIONAL DISTURBANCE In the literature of thirty years ago we find many references to serious effects, puerperal fever, eclampsia, mania, etc., produced by emotional causes, such as worry, fright, anger, and the like. More recent developments showed conclusively that many of the results referred to were due to septicaemia. The innumerable discussions on sepsis and the various means adopted for its prevention have to a certain extent overshadowed the emotional element in the puerperium. Many go so far as to deny that simple emotions can cause serious rise of temperature. I believe, however, that very serious results may follow causes which are purely nervous in their origin. Cases. — The following brief notes of a few among many cases which have come under my notice will illustrate some phases of the subject. I. Mrs. A., aged twenty-three. Unusually healthy and free from hysteria. Second labor : normal until fifth day, when I found her condition quite serious. She was weeping, had a severe rigor, temperature 104°, pulse 125, milk secretion and lochia normal. On inquiry, found she had had a dispute with her nurse, who was acting badly in various ways, but especially in her treatment of the babe. The husband was sent for and the nurse at once discharged. In the evening, temperature and pulse were nearly normal, and on the following morning patient felt perfectly well. II. January 22, 1889. M. H., unmarried. Labor normal. Temper- ature normal until tenth day, when she was visited by her mother, who had an interview with her alone. After the mother left, the matron found patient much excited and crying. Temperature 105°, pulse 120. Next morning temperature and pulse were normal, and remained so until she went out on the fifteenth day after labor. 427 428 ELEMENT IN THE PUERPERAL PERIOD III. Mrs. A., aged twenty-seven. IV para, healthy. Labor normal. Symptoms of slight septicaemia appeared on fourth day. On four dif- ferent occasions during four weeks the temperature rose suddenly from emotional causes. There happened to be an entire absence of that sym- pathy which should exist between patient and nurse, and the two were continually at "cross purposes." The nurse was honest and conscien- tious, but singularly injudicious, and acted in such a way as to be a con- tinuous source of irritation to her patient. On the twelfth day an accident happened to the babe, which much alarmed the mother. She became greatly excited, and I was sent for but did not arrive until two hours had expired. In the meantime the nurse was much distressed and went re- peatedly to the window to look for me, and finally became as much excited as her patient, and wondered if the "doctor would never come." On my arrival I found the patient in a serious condition. She had a rigor, tem- perature 104.5°, pulse 120. There appeared to be in this patient a com- bination of septicsemia and emotional fever. She was confined to bed six weeks, but made a perfect recovery. Conclusions. — It is, of course, difficult to arrive at definite con- clusions with mathematical exactness, but I think there can be no doubt in Cases I and II that the rise of temperature and accom- panying symptoms were caused entirely by emotional reactions. I think that an emotional explosion may cause a rise of temperature to the extent of seven degrees or more within a short time — cer- tainly less than an hour, perhaps a few minutes. Case III suggests the question, May emotional disturbance during the puerperal period produce serious effects and even en- danger life? I believe that it may. In this case I thought the dangers to the patient were vastly increased by purely emotional causes, due principally to the want of tact of the nurse. It seems to me that any one who believes that a nervous cause may produce an elevation of temperature to the extent of six or eight degrees, can scarcely refuse to assent to the opinion that in many a serious case, when life is in danger, such nervous disturbance may turn the balance in the wrong direction. It is generally admitted that mental emotions play an important part in the causation of eclamp- sia and puerperal mania. I sometimes fear that certain evils have arisen out of our mod- ern methods of laboratory and hospital teaching as compared with the old-fashioned apprentice system. It appears to me that there is at the present time considerable danger that we are cultivating science at the expense of art in our profession. I have noticed in EFFECTS OF EMOTIONAL DISTURBANCE 429 medical students, trained nurses, and resident physicians and sur- geons in hospitals, a tendency to look upon the sick and wounded as mere machines, and not as fellow creatures made of flesh and blood, and endowed with nervous organizations which are capable of unlimited suffering. ' I have seen many acts of positive cruelty on the part of those who appear to aim at treating the diseases and injuries, and not the patients. If it is granted that the emotional element in the puerperal state is a powerful factor for good or evil, we must of necessity agree that it is important that we should ever endeavor to treat the pecu- liarities and idiosyncrasies of our patients, as well as the serious ailments and emergencies which may arise. We should always strive to guard against undue excitement from any cause. Much depends upon the manner and methods of the obstetrician. He should avoid what may be called " fussiness," but at the same time be ever on the alert. He should be quiet and kind without being weak and irresolute. In the lying-in chamber he is watching what should be a physiological process in one who is fulfilling the noblest function with which God has endowed her. He should, so far as possible, sink self into oblivion and think only of the inter- ests of her whom he is called to serve. He should have his obstet- rical satchel well equipped; he should be armed with a supreme knowledge of the best definite method of treating all emergencies ; but he should keep his satchel and his knowledge in the background until they are actually required. He should use all the tact with which he is endowed, and at the same time exhibit unlimited firm- ness concealed under a kind and gentle manner. He should make all the surroundings for his patient as cheerful as possible, while enjoining perfect rest and quiet. He should strive to imbue nurses and immediate friends with the ideas herein expressed, and if possible keep all curious visitors and gossiping neighbors out of the house. Possibly I may attach too much importance to what may be considered small matters; but it has appeared to me that in the practice of our art nothing can be deemed small. The success of the physician or surgeon depends on the strictest observance of things great and small, down to the most minute details. The most successful in our noble sphere of alleviating the ailments of our suffering fellow creatures have at all times been acutely observant, exceedingly watchful, and ever kind and gentle. In the practice 430 ELEMENT IN THE PUERPEEAL PERIOD of obstetrics we should be second to none in the rigid and careful observance of all the rules, whether manifestly great or seemingly insignificant, which are likely to conduce to the welfare of our patients. PUERPERAL INSANITY Insanity of pregnancy, or of the puerperal period, or of lac- tation, does not differ in symptoms from ordinary insanity. The symptoms most commonly appear within six or seven weeks after labor, but frequently near the end of lactation and occa- sionally during pregnancy. The prodromal stage is generally short and hallucinations soon appear. Constipation is frequently very marked. Melancholia is the most serious form and is frequently incurable. One may hope, however, for a cure in the majority of cases in about nine or ten months. One may look for recovery from mania in about six or seven months, but sometimes the mania is incurable. In monomania, or hysterical insanity or transitory frenzy, rapid recovery generally takes place. Treatment. — When septic infection is present it should receive appropriate treatment; otherwise, the most important considera- tions are quiet, rest, watchful care, and nourishing diet. Much depends on the tact and judgment of the nurses or the friends in charge. The patient should never be left alone. A "transitory frenzy " in the shape of aversion to her babe may suddenly appear. In such a case the child's life is endangered. A suicidal tendency often develops. The patient often takes a strong dislike to all those she loved best during her sane moments. She sometimes takes a sudden dislike to a nurse she formerly liked. Under such circumstances one whom she now dislikes should keep out of her sight, though it be her husband, mother, or sister. When she refuses to take food force must be used. One of the most com- mon symptoms is sleeplessness. For the treatment of this the most suitable hypnotics are hydrobromate of hyoscine, chloral hydrate, trional, sulphonal, and chloralamide. The most important question for consideration comes up in connection with the advisability of sending the patient to an asylum for the insane. The relatives generally object to this. Many physicians also object on account of the after-effect on the patient. Most of our asylum physicians tell us that it is greatly PUERPERAL INSANITY 431 in the interest of all such patients to send them at once to asylums. When the patient refuses to take food, or when she turns against her nurse or nurses, or when she shows any homi- cidal or suicidal tendency, she should certainly be sent to an asylum as soon as possible. In mild cases most physicians will probably prefer to keep the patients at their own homes. This always means some risk, which should be fully explained to the friends. 29 CHAPTER XXI LISTERISM AND OBSTETRICS Without discussing in detail the exact meaning of the word Listerism, we shall suppose that it includes the principles and prac- tice of modern aseptic and antiseptic medicine in all its depart- ments, although the term antiseptic surgery is probably the one most commonly used. Frederick Treves, in his paper on The Progress of Surgery (The Practitioner), speaks as follows about Lister and his work : "The great feature in Victorian surgery has, it is needless to say, been the introduction of the antiseptic method, and the great name which stands out above all , '' others in the array of Victorian surgeons is the name of Lister. ' ' Lister created anew the an- cient art of healing; he made a reality of the hope which had for all time sustained the sur- geon's endeavors; he removed the impenetrable cloud which had stood for centuries between great principles and successful practice, and he rendered pos- sible a treatment which had hitherto been but the- vision of the dreamer. The nature of his discovery — like that of most great movements — was splendid in its simplicity and magnifi- cent in its littleness. To the surgeon's craft it was but 'the one thing needful.' With it came the promise of a wonderful future, without it was the hopelessness of an impotent past. It might well have been in Browning's mind when he wrote — "Oh! the little more and how much it is ! And the little less and what worlds away ! " 432 Fig. 152. — Lord Lister. LISTERISM AND OBSTETRICS 433 Semmelweiss, Fordyce Barker, and Lister are three men whose names are inseparably connected with the great advances in mid- wifery during the hist fifty years. Semmelweiss made a great discovery which the world did not properly appreciate during his lifetime. Barker made many improvements in the art of midwifery, which obstetricians recognized ; but during his later years hugged a mistaken theory as to the nature of puerperal fever long after it had been exploded. Lister made the greatest discovery of last century, which, fortu- nately, the world fully appre- ciates. Semmelweiss, in 184 7, clearly and positively enun- ciated the view that puerperal fever was caused by the in- troduction of putrescent sub- stances deposited in or about the genital tract of the par- turient woman. He thought that such noxious substances were in reality decomposed ani- mal matter, and also considered it possible that such offending material might be developed in the body of the patient (auto- genetic). These views were adopted by a limited number, and from the year 1848 antiseptics have been used to a greater or lesser extent. Fordyce Barker commenced the use of antiseptics, including antiseptic vaginal douches, about the year 1854. In addition to the use of antiseptics he practised the strictest clean- liness, and in his teaching urged the importance of the same. Lister, for years before he discovered the relationship between microbes and bad results in wound-infection, recognized the evil of putrefaction in surgery and endeavored to counteract it by cleanliness and the use of deodorant lotions. L^p to this time he had advanced as far as Semmelweiss and Barker, but no farther. Fortunately, however, he did not stop here, but went on with his good work, and applied his knowledge of Pasteurism to surgery. His grand discovery stimulated surgeons and obstetricians in all Fig. 153. — Semmelweiss. 434 LISTEEISM AND OBSTETEICS parts of the world, and caused them to make special efforts to avoid septicaemia. Listerism has completely revolutionized our views and our methods in obstetrics. The idea that puerperal fever is a specific disease, like scarlet fever, is replaced by the opinion that it is a pre- ventable disease produced by microbes which come from without. Auto-genetic puerperal fever, as it was formerly understood, is not now recognized. Our former theories as to varied forms of in- flammation occurring during the puerperal period are changed and simplified, because we have ac- cepted Lister's views as to the causes of surgical diseases. About the year 1872 obstet- ricians commenced to use Lis- terian methods, especially in large maternity hospitals. The new ideas and the new methods spread rapidly from hospital to hospital in Germany, France, Great Britain, America, and other countries. Rigid antiseptic methods were adopted, with marvelous changes in the mortality rates. The wonderful reduction in mortality rates does not, however, tell the whole story. It tells us that many thousands of lives have been saved during the last thirty years through the application of Listerian methods ; but it does not tell us how many other thou- sands have been relieved from the ill effects of septic infection which kills not, but cripples sadly. It is very unsatisfactory, in this connection, to find that the general results in private practice have not kept pace with those in lying-in hospitals. The annual reports of the Registrar- General of Great Britain show that the death-rates from childbirth have not appreciably diminished in England and Wales. In the United States and Canada the mor- tality from puerperal septicemia has probably diminished during the last twenty years, but it is still very high. Fig. 154. — Fordyce Barker. PUERrERAL SEPTIC INFECTION" 435 PUERPERAL FEVER OR PUERPERAL SEPTIC INFECTION Puerperal fever is a disease resulting from infection during labor, or the puerperium, by certain micro-organisms. It is an ordinary surgical toxaemia (as the term is now generally known), caused by the absorption of septic matters in the wounds of the utero-genital canal produced during parturition. It may be called puerperal infection, puerperal septic infection, puerperal scpti- ctemia, puerperal sepsis, or childbed fever, a term so commonly used by the laity thirty years ago. No one of these terms, how- ever, is correct in every sense. The term puerperal fever, or febris puerperarium, was first used by Willis in 1676, and was in general use in Great Britain and America during the first three-quarters of the nineteenth century. When through the work of Semmelweiss, Pasteur, Lister, and others we began to acquire the new ideas as to its origin, the fitness of the term, puerperal fever, was called in question. The late Fordyce Barker, of New York, believed that puerperal fever was a specific disease, as definite in its nature as erysipelas, scarlet fever, or typhoid fever. Listerism, however, soon demonstrated the incor- rectness of this contention, and the new term, puerperal septi- caemia, was largely used. Algernon Temple was one of the first in Canada to deny the specific entity of puerperal fever, and agreed with Garrigues that the term puerperal fever should be dropped and puerperal infection should be substituted. Septicsemia is not a fortunate term, because etymologically it means a condition in which septic matter circulates in the blood throughout the whole body, and can not therefore properly include those numerous manifestations of sepsis which are distinctly local in character. This is rather unfortunate, because, as has been pointed out by Garrigues, it is an improvement in so far as it reminds us of the identity of puerperal infection with wound infection. While speaking on this subject I shall not frequently use the term puerperal fever, but, instead, puerperal infection. The word infection is not exactly suitable, inasmuch as it is the cause of the condition we are considering, not the condition itself. Nor is it exactly correct, because, with the meaning generally attached to it in connection with this subject, it does not include all puerperal infections. 436 LISTEEISM AND OBSTETEICS NATURE OF PUERPERAL INFECTION It is an infection caused by the absorption of septic matter in- troduced from without. The doctor may introduce the poisonous germs at any step of labor on his finger-tips or on his instruments. The nurse may do the mischief while assisting the doctor during labor or, more frequently, after labor. Twenty-five or thirty years ago childbed fever was said to be caused by a cold. I have often heard this story. The patient was doing well until the third or fourth day, when an open window caused a draught which struck her and produced a chill. After that she went on from bad to worse until death ensued in a few days. We know now what that chill meant. It was a well-pronounced symptom of a dreadful but preventable disease — acute septicaemia — which has in the past, in a relentless way, claimed so many victims. One meets nothing in his professional experience more inexpressibly sad than a death from septicaemia. The bright and happy girl of yesterday becomes a bride to-day. In due course there are indications that she will soon become a mother. Her friends take an unusual interest in her welfare. Many years ago Oliver Wendell Holmes wrote as follows : ' ' The woman about to become a mother, or with her new-born infant upon her bosom, should be the object of trembling care and sympathy wherever she bears her tender burden or stretches her aching limbs. The very outcast of the streets has pity upon her sister in degradation when the seal of promised maternity is im- pressed upon her. The remorseless vengeance of the law brought down upon its victim by a machinery as sure as destiny is arrested in its fall at a word which reveals her transient claim for mercy. The solemn prayer of the liturgy singles out her sorrows from the multiplied trials of life, to plead for her in the hour of peril. God forbid that any member of the profession to which she trusts her life, doubly precious at that eventful period, should hazard it negligently, unadvisedly, or selfishly. ' ' The bride to whom I have referred, with the help of loving friends, makes preparation for the babe that is to come. With her maternal instincts developed to the highest point she looks at the little shirts, the little petticoats, the little dresses ; she thinks and dreams of her unborn child ; she wonders if it will be marked, and hopes it will be "all right." At the proper time the nurse and doctor are summoned. She goes through the terrible ordeal of PUEEPERAL SEPTIC INFECTION 437 labor. She hears with joy the first cry of her baby. In a short time she clasps him to her breast — thankful and happy. Anxious friends ask many questions. The accoucheur replies with much satisfaction, mother and child both doing well. All goes well, or apparejitlij well, for three or four days. Then a cloud arises, the dread chill comes, a terrible poison fills the blood, and notwith- standing the efforts of the physician that happy young mother becomes cold in death. Loving friends are stunned and agonized, and an innocent motherless babe has lost its best friend. The tragedy is sad enough in all respects; but, from a professional point of view, the worst feature is that death should not have occurred — it should have been prevented. Infection may occur, however, in spite of precautions of doctor and nurse. The dangers are so many, and so little (apparently) may sometimes produce serious results, that the most careful among us can never feel sure about the safety of the patient until a certain time has elapsed. Neither the man nor the institution has yet been discovered that sees not puerperal infection. Let us be rigid in our examination of ourselves when we have a patient sufTering from any form of puerperal infection, and at the same time chari- table in judging of others under similar circumstances. HOW DOES THE INFECTION TAKE PLACE ? Certain poisonous matters are introduced from without and are absorbed by the open-mouthed blood-vessels and lymphatics which exist in the wounds of the perinseum, vulva, vagina, cervix, or the interior of the uterus (especially at the placental site) . The result may be simply a putrefactive decomposition, or a mild septic in- fection with perhaps local purulent collections, or severe general systemic infection (acute septicaemia which causes death in from two to five days) . In mentioning the sites of absorption the perinseum is named first, because I think that in a majority of cases of puerperal fever the infection occurs through the tears of the perinseum or pelvic floor. John Caven had this point in view for some years, and in three consecutive cases found evidence post mortem to convince him that the torn perinseum was the site of absorption. It is hard, of course, to form a very definite opinion, but I think that in most cases of severe or acute septicsemia the poison is 438 LISTEEISM AND OBSTETEICS absorbed in the tears of the perinseum or vulva ; in those of mild septicsemia or mixed infection the poison is absorbed in the tears of the vagina or cervix ; in cases of saprsemia the poison is absorbed within the uterine cavity. It may be asserted, however, that all sorts of germs may be, and are actually, absorbed in wounds in any or all of these structures. BACTERIOLOGY We have learned much about bacteriology in recent years and we hope to learn more in the near future. We know that puerperal infection is produced by micro-organ- isms generally, if not always, introduced from without. We know which are the most common and which are the most virulent of these organisms. We know that certain organisms are very viru- lent at times and comparatively innocent in other cases. We know that we have sometimes two or more kinds of organisms in con- nection with certain forms of sepsis — i. e., mixed infection. We know that we can, in a large proportion of cases, if not in all, by certain aseptic and antiseptic methods, prevent the ingress of such organisms and thereby avoid septic conditions. We know that we have certain vital protecting forces in our body which fight these pathogenic germs that come in from without. We know that these vital forces within our body are frequently victorious, and we know they are sometimes vanquished. We do not know whether these pyogenic organisms are them- selves the septic matter, or whether they carry it, or whether in certain cases they are simply " accidental concomitants." We do not know why certain organisms are more virulent than others. We do not know why in some cases the vital forces in our body are victorious, while under similar circumstances at other times they are vanquished. We do not know why certain organisms are ex- tremely virulent in some instances and comparatively innocent in others. We do not know what portion of the evil work accom- plished is done by the different organisms which we find in mixed infections. Some tell us that there are, under ordinary circumstances, pyogenic organisms in both the uterine cavity and the vagina; others say there are none in either ; others say there are cocci, in- cluding the streptococci, which we fear most, in the vagina, but they are not pyogenic but rather saprophytic in character. PUERPERAL SEPTIC INFECTION" 439 The subject will here be simplified as far as possible, and reference will be made only to facts related by bacteriologists which coincide with those acquired by clinical observation. The specific microbes which produce puerperal infection are streptococci, staphylococci, colon bacilli, gonococci, and sapro- phytic bacteria. Other microbes occasionally found are bacillus diphthcrise, diplococcus pneumoniae, the gas bacillus of Welch, and the bacillus sepsis. In the first place, it may be well to say a few words about the ordinary condition of the utero-vaginal canal during pregnancy and the natural barriers which prevent the ingress of the outside organ- isms. No special reference will be made in this connection to the gonococcus, which is different from all other organisms in various ways. I think it never produces acute septicaemia, but as it gen- erally produces some serious effect, especially after labor, it will be considered in another chapter. Uterus. — Normally there are no pathogenic organisms present in the uterine cavity during pregnancy. This is positively stated by such a large number of careful observers, and at the same time is in such thorough accord with clinical observations, that it may be accepted as a fact. Cervix. — The plug of mucus found in the cervix uteri of the pregnant woman is a peculiar and important structure and is called by some the operculum. The plug is practically sterile. There has been a little confusion as to this subject through differences of detail in the methods of examination, but it is generally admitted that the upper part of the plug is absolutely sterile and fills the cavity so completely that it prevents the passage of germs. Vagina. — The vagina is practically sterile, and not only is it sterile, but the vaginal secretion itself will destroy certain germs, especially the staphylococci. That is to say, if these germs are introduced within the vagina they will be destroyed within a limited time. This quality of the secretion is due to the pres- ence of what is called the vaginal bacillus, which keeps the secre- tion acid. Vulva. — There is a different condition in the neighborhood of the vulva. In a large proportion of cases pyogenic bacteria exist at the vulvar orifice, and these organisms, situated thus superfi- cially, are dangerous during labor and the puerperium. A very 440 LISTEEISM AND OBSTETRICS important difference in the condition is found after labor. Within a short time the acid secretion of the vagina becomes alkaline from the destruction of the bacilH vaginse by the lochia. Any- septic organisms may, under the changed conditions, cause much mischief, especially during the first three days after labor. If everything has gone on favorably for three or four days the wounds will be healthy and as a consequence will be covered with granulations. These granulations, as before mentioned, are a great barrier to absorption, and therefore if there is no infection before the formation of the granulations the danger of serious or acute septicsemia thereafter is almost nil. VARIETIES OF PUERPERAL INFECTION It is difficult to name specifically the different varieties of puer- peral infection. It seems convenient to speak first of two varieties — that is, saprsemia, or putrid intoxication, and septicaemia, or in- fection by pyogenic germs. Unfortunately the term saprsemia, which was first used by Matthews Duncan, has been applied to so many forms of infection that much confusion has arisen. Smyly, JeUett and Lyle, of the Rotunda, beheve that organ- isms which were at first saprophjrtic and thus able to five upon dead matter only, may under certain conditions become parasitic and thus able to exist on living tissues. According to their views, therefore, saprsemia may be both saprophytic and parasitic (or septic). This is, I think, going beyond what Duncan intended. In sepsis we may have only one form or one kind of pyogenic germ, or we may have two or more kinds of such germs. In cer- tain cases the germs are less virulent and cause results less serious ; in other cases the germs are very virulent and cause death rapidly ; in other cases there is severe poisoning, the symptoms of which may become, to a certain extent, chronic ; and under such circum- stances metastatic abscesses may occur. In considering the various forms of septic infection that may arise it is advisable to use a classification which is simple in char- acter from a clinical standpoint; but while the clinical aspects should be kept in view, it should be founded on a bacteriological basis. Puerperal infection includes the following: (1) saprsemia, (2) mild septicsemia, (3) mixed infection, (4) acute septicaemia, and (5) pysemia. PUEKPEUAL SEPTIC INFECTJON 441 Sapraemia. — Saprconiia is a condition caused by the absorption of the products of decomposition. The bacteria concerned in the process are called saprophytic organisms, which live on dead matter, such as blood clots, portions of placenta, or membranes. Mild Septicaemia. — Septicaemia of any sort or degree is a dis- eased condition produced by the absorption of the products of F. 107' 106^ 105° 104" 103° 102° 101° 100/ 99° 98° 97° 11 o-^ ■^^^ ,/ /• -•— -•-- ^ \ \ n i ' \ A A A J\ V V \ V ^__ A f^ / V V \l \ V 1 \^ \A . A V Y V y ^ f V ^ y^ V M Pulse E 100 102 108 106 98 104 98 98 90 88 90 84 80 80 108 111 112 114 112 108 120 100 96 96 98 96 88 90 Fig. 155. — Abnormal, Involution, Temperature and Pulse Rate, Mild Septicemia, with Subinvolution. Temperature rose to 105.4 after curettement on seventh day. The curettement was probably unnecessary and harmful. pathogenic bacteria. It is convenient for clinical purposes to speak of a mild septicaemia as opposed to a severe or acute sep- ticemia. The clinical differences between the two are well marked ; the bacteriological differences between the two are not so well marked so far as we understand the subject at present. Mixed Infection. — Mixed infection is produced by the ingress of two or more varieties of pathogenic germs. We might, for in- stance, find in the system streptococci with a few staphylococci and colon bacilli. This would be, in a sense, mixed infection, but it might be that the streptococci did all the damage, while the staphy- lococci and colon bacilli had little or no effect. From a clinical standpoint this should not be considered a mixed infection. 442 LISTEKISM AND OBSTETEICS In another case a patient might be ill for some time with per- haps peritonitis, produced chiefly or altogether by streptococci, metastatic abscesses in various organs produced by staphylococci, and perhaps the colon bacilh might have a certain effect on each of these separate processes or conditions. This would be from a clinical point of view a case of mixed infection. Acute Septicaemia. — Acute septicaemia (or acutest septicaemia of Garrigues) is that virulent form of septic poisoning which causes death in from two to five days. In this variety of sepsis the germs are so powerful for evil that they produce their fatal effects in a short time. The nerve centers are completely overpowered, and death comes so rapidly that there is not sufficient time for the development of the ordinary gross pathological conditions which are found after death from the milder infections. Pyaemia. — Pyaemia is a form of toxaemia in which living bac- teria are carried in the blood currents to distant tissues, where they grow, multiply, and produce abscesses. It is probable that these bacteria are first lodged in clots and gain entrance to the general circulation as the clots break down. Pyaemia has never been con- sidered a scientific term, and is not at all, as its etymology imphes,. a condition of pus in the blood. It has been retained chiefly on account of its clinical value as referring to a disease with formation of abscesses in various parts of the body. (In other words, it may be considered a subacute or chronic septicaemia with the forma- tion of the abscesses before referred to.) The germs which pro- duce the infection are, in the majority of instances, those which produce acute or severe septicaemia. There is another classification of less importance: (1) Hetero- genetic infection, when the poison is introduced from without. (2) Autogenetic infection, when the poison is generated within the body. There has been a great deal of discussion on this subject in the past. The importance of the autogenetic infection was at one time greatly exaggerated. Many authors spoke very strongly on the subject. Chalmers Cameron considered that the doctrine of auto-infection, as commonly expounded, could do nothing but harm and therefore should be absolutely condemned. Obstetricians should in practice consider that in all cases the poison comes from without,, although it may be admitted that auto- infection does occasionally occur. rUERPEEAL SEPTIC INFEC'IHOX 443 PATHOLOGY After a consideration of the bacteriology of septic infection one can understand, to a certain extent at least, the reasons for the great variety of lesions which are produced in the body by the microbes or their products. The following are the principal types of pathological conditions which are found : Poisoning.— TAe 'profound poisoning which overpowers the nerve centers causes death so quickly that there are no gross lesions. There are, however, as pointed out by Garrigues, traces of lym- phangitis or phlebitis, swelhng of the connective tissue, and a little bloody fluid in the different cavities. The abdominal organs are large, soft, and friable, the microscope showing their cells to be in the condition called cloudy swelling; the blood is thin, dark, and only slightlj^ coagulable. Vulvitis and Vaginitis. — In connection with inflammation of the vulva and vagina, one of the most important conditions is the so- called diphtheritic ulcer, which may be found on the surface of the tears about the vulva and in the vagina. In almost all cases, if not in all, such an ulcer has nothing in common with diphtheria except its external appearance. Puerperal vaginitis may there- fore occur in two forms : either inflammation where a certain por- tion of the vagina is covered by this pseudo-diphtheritic mem- brane, or a general inflammation when the mucosa becomes thick, soft, red, and covered with pus (Williams). Endometritis. — The endometrium is, in a large proportion of cases (some say in the majority), an important seat of the puer- peral infection. The septic endometritis thus induced varies greatly according to the character of the organisms and the vary- ing virulence of such organisms. When produced by virulent streptococci or staphylococci the changes are comparatively slight, as before indicated. On the other hand, when produced by putrefactive organisms, and perhaps by the colon bacilli, the local lesions are much more apparent. The infection may be limited to the placental site or it may be spread over the entire mucosa. When confined to the placental site the organisms usuall}^ pass into the thrombi ; when extending over the whole inner surface of the uterus the local effects are much more marked. A great deal of necrotic material is produced, dirty and yellowish green in color. Ulcerated surfaces coated with fibrin ("diphtheritic 444 LISTEEISM AND OBSTETEICS patches ") are sometimes found. In cases of infection due to the invasion of virulent streptococci, or staphylococci, there is usually little or no odor from the lochia; but in cases of invasion by saprophytic organisms or the colon bacilli there is a very offen- sive odor from the discharges. Metritis. — Various forms of metritis are hkely to exist in con- nection with the different forms of infection. There may be a simple inflammatory condition, in which the walls are thickened, soft and friable, or a more serious form called putrescent metritis. In the latter form the uterus is large, although the walls may be thin. There is considerable destruction of tissue, and irregular cavities are found filled with a dark-colored pulp or with puru- lent fluid. Parametritis is inflammation of tissues in the vicinity of the uterus. It is usually caused by the passage of the organisms from the uterus, especially from a lacerated cervix, through the lymphatics to the peri-uterine connective tissue. According to Whitridge Wilhams, the first effect is a marked inflammatory oedema with very little or no suppuration. In mild cases the process is stopped here ; in more severe cases the infection spreads to the surrounding connective tissue and causes the formation of abscesses. Salpingitis. — Inflammation of the Fallopian tubes is quite common, and is generally due to an extension of the process from the uterine cavity, but sometimes is probably due to infection through the lymphatics. Oophoritis. — Less commonly we have septic inflammation of the ovaries, probably due in most cases to infection through the lym- phatics. We are told, however, that in a certain number of cases it may be due to direct infection of a ruptured folHcle by means of the peritonitic exudation. Peritonitis. — Peritonitis is such a common affection in puer- peral fever that at one time the two terms, puerperal fever and puerperal peritonitis, were thought to be synonymous. The in- flammation may be local — that is, confined to the pelvis ; or gen- eral — that is, extending over the whole abdomen. It is generally due to infection by the organisms that pass from the interior of the uterus through the lymphatics to its peritoneal surface. It may rarely be due to infection by pus from the Fallopian tubes or by rupture of parametric or ovarian abscesses. The inflammation PUEEPERAL SEPTIC INFECTION 445 may be plastic or purulent. Fluid is found in the peritoneal cavity which may be serous or purulent, which often resembles milk. Pyaemia. — This is probably due in most cases to the infection of the thrombi at the placental site, followed by inflammatory changes in the veins. When the thrombi break down small par- ticles are carried to various parts of the body, giving rise to the abscesses before referred to. Such abscesses may be found in all the internal organs and in synovial cavities. Phlegmasia Alba Dolens. — This is a peculiar form of infection, in which there is an extension of the infective process to the tissues surrounding large blood-vessels, generally of the lower extremi- ties, but sometimes those of the upper extremities, through the lymphatics. Thromboses then occur in these large vessels due to the lymphatic involvement. SYMPTOMS OF PUERPERAL INFECTION One can easily understand the vast importance of the ques- tion of diagnosis of puerperal infection. An early recognition of the symptoms will enable the accoucheur to treat promptly, and in a large proportion of cases successfully, this dread disease. The descriptions of the symptoms of septic infection given in the majority of our text-books are unsatisfactory and to some extent misleading. The following paragraph from one of the best treatises on obstetrics may be taken as an illustration : " In the cases of septic endometritis everything goes smoothly for the first three or four days of the puerperium, when our patient, who thus far has done perfectly well, suddenly experiences more or less malaise, possibly has a headache, and toward the end of the third or fourth day a chill, after which the temperature rises to 103° or more. Generally the chill occurs but once, while the tem- perature remains constantly elevated.'' This is wrong ; things never go " smoothly for the first three or four days of the puerperium" in a case of infection. On the other hand, we have had correct descriptions from authors on the Continent. Ferre some years ago described very clearly what he called the premonitory symptoms. Shght elevation of temperature once or twice daily, and usually in the evening ; pulse SO or more, especially in the morning, when 446 LISTERISM AND OBSTETEICS the temperature is not yet raised ; relative or absolute insomnia ; headache, at first intermittent and slight; vague impressions of cold, not usually a distinct rigor. The following quotation from a very able but modest little pamphlet entitled ''Chnical Observations on Two Thousand Ob- stetric Cases," published in 1898 by Porter Mathew, of London, formerly Resident Obstetric Officer at St. Mary's Hospital and Queen Charlotte Hospital, is, I think, in all respects correct. ''Any one who reads or hears of fatal cases of septicae- mia must be very much struck with the fact that the account of the case is invariably that progress was perfectly satisfac- tory until the third or fourth day, or later, as the case may be, when the patient developed a rigor or high temperature, and then treatment was started but too often without avail. This would lead the unwary to imagine that the onset, like many of the specific fevers, was of a very sudden, almost fulminat- ing, character. It is a curious fact, however, that though I have looked through twelve thousand puerperal temperature charts I can not find a single instance of perfectly satisfactory progress fol- lowed by septicffimia. There are always present premonitory signs and symptoms of mischief brewing before the rigor, which by so many is looked upon as the beginning of the illness. These symptoms are loss of appetite, insomnia, a feeling of fatigue or lassitude, low spirits with tendency to tears, perspiration, and frontal headache. The signs are a progressive, step-like, or irreg- ular rise of temperature, with marked morning remission and evening exacerbation, a gradual rise in pulse rate with marked remission at night, with or without tenderness, especially local tenderness of the uterus, and decomposition of the lochia in the uterus. Some of these signs or symptoms, usually both, were Fig. 156. — Louis Pasteur. PUERPEEAL SEPTIC INFECTIOK 447 invariably present, but in a few cases the only apparent abnormal condition was the temperature, especially the gradual increasing rise at night. Evidently, then, if the development of septicaemia is preventable it is to these early symptoms we must look for warn- ing, and if any treatment be of avail its success will be the more enhanced the earher the recognition of these premonitory signs." We have, then, two sets of symptoms : the early or premonitory, on the one hand, and the ordinary symptoms on the other. The directions as to watchful care of the patient during the early days of the normal puerperium may be repeated to some extent. On the second day study the appearance of the patient care- fully. Has she a happy, restful aspect of countenance, or has she a worried expression? Does she appear to be quiet and comfort- able, or restless and uncomfort- able? You make your inquiries from the patient. Has she felt well since you last saw her? She may say, ''Yes, quite well." That will be satisfactory. She may say, "Yes, doctor, I feel pretty well, but I have a slight headache. I think it arises from the fact that I did not sleep very well. I think I couldn't sleep because the baby was trou- blesome and cried a good deal." This answer is very unsatisfac- tory. In it there are two of the most constant premonitory symptoms of infection: insomnia and headache. Continue inqui- ries with reference to both these features, and also as to whether she feels tired. Find out if she has any perspiration. With reference to the headache, find out where it is — that is to say, is it frontal? What is the pulse rate ? Is it under or over 80? What is the temperature? This may be increased to a slight degree, of course, without evil results. A temperature of 100 would in the majority of cases not be so serious a symptom as insomnia with headache. 30 Fig. 157. — Oliver Wendell Holmes. 448 LISTEEISM AND OBSTETEICS Then get all the information possible from the nurse as to all these points which you have already inquired about, and especially as to the quantity and quality of the lochia. Pursue 107° 106° 105° 104° 103° 102° 101° 100° 99° 98° 97° Midi ight ■ ^. n \ \ It h f\ \ V \ i \ 1 V V \ \ \ 3 A.M. M Pulse E 9U 88 96 100 102 110 120 114 98 96 108 100 112 140 160 ? Resp. ■ E 23 24 32 26 34 66 58 68 as 24 28 32 34 44 54 54 Fig. 158. — Patient Attended by a Midwife; seen by Dr. William Britton, Five Days after Labor; Septicaemia, Pneumonia. Highest and lowest during each twenty-four hours. On the day before death tem- perature rose 10° between 3 a. m. and midnight. Died at 4 a. m. next day. a similar method of investigation during the third, fourth, and fifth days. In speaking of ordinary symptoms there is considerable diffi- culty in giving anything like a definite classification. In speaking of the pathological anatomy reference was made to the various conditions found in the different parts of the body. The symp- toms will naturally vary according to the parts of the body infected. Lesions which are localized will naturally give rise to symptoms very different from those where the whole system is in- fected. Differences in the character or in the virulence or in the number of the infective organisms will also cause great variations in the symptoms. PUERPEEAL SEPTIC INFECTION" 449 ORDINARY SYMPTOMS Smyly's admirable aphorisms are interesting and useful. If a patient with a high temperature looks well, sleeps well, and says she is well, she is, at any rate, not septic. If a patient with a high temperature looks very ill, sleeps ver}' badly, and says she feels ill, she generally is very ill. If a patient with a high temperature looks very ill, sleeps very badly, but says she is very well, she will probably die. Rapid Pulse. — The pulse rate is the one symptom which is im- portant above all others. It is, in a large proportion of cases, the most certain indicator of the condition of the system. For ex- ample, the pulse rate on the second day is 90, and steadily advances F. 107" 106° 105" 104° 103' 102" 101° 100° 7 97° n §3,5 •^ -^1 ,A^ \ / > ^- "^H V" \ A K A A f ^/ V ^ •*.^ / /^ y \i V s \A K v V^ .A uA A > / V y'- \ V M Pulse E 104 116 96 91 90 92 90 8i 88 90 88 82 80 78 108 120 112 118 108 104 96 90 90 92 92 88 86 96 Fig. 159. — Abnormal Involution Line. Case went " queer " for a few days from unknown causes. Good recovery followed eliminative treatment. until the fifth day, when it is 140. Without having any regard to other symptoms it may be stated that this patient will surely die. Increased Temperature. — An abnormal temperature is also an important symptom, especially as it is likely to be one of the first to be observed. A very high temperature or a very low tempera- ture is a serious sign ; irregular fluctuations in the temperature in- dicate a serious condition, but it may happen that the temperature 450 LISTERISM AND OBSTETRICS at a very critical period is normal, as, for instance, when it is pass- ing from an abnormally high to an abnormally low degree — that is, one may happen to take the temperature while it is crossing the normal line. As before indicated, there may be a slight rise of F. 107° 106" 105" 104° 103° 103° lOl' 100° 99° r\ ^■^ > » \ V. h i\ ■^f ~*N^ / \ V^ / V L y"^ s,-. i A V v-^ -•■''^ !=•=»- r*~*~- .^ .»— • 97° M Pulse E 70 C2 7i 78 70 68 68 68 66 68 61 62 61 m. 61 70 90 78 70 72 70 68 66 61 66 68 68 Fig. 160. — Slight Influenza; no Complications; Good Recovery. temperature, the so-called reactionary temperature, which may be considered physiological, at least not pathological. There may be also a rapid pulse, increased temperature from other causes some of which have been discussed, such as influenza, indigestion, gen- eral malaise, etc. It is hard to give a definite rule, but it may be stated in a general way that when the temperature rises to 101° or more and remains there for some time the patient is in a serious condition. Rigor. — A rigor, or chill (so called), when due to sepsis, is a very serious symptom. The chill which the patient has very com- monly immediately after delivery is not at all serious. There may be a very pronounced rigor in certain cases from very slight causes, especially emotional causes. However, any rigor occurring one or more days after delivery should be considered serious. It is well to take the more serious view, although one may at the same time have the slighter causes in his mind. In any case careful inves- tigation should be made. PUERPERAL SEPTIC INFECTION 451 Pain and Tenderness. — Pain in and about the parturient canal is a conunon symptom. I'ain and tenderness over the abdomen are also common symptoms. We are apt to find such pain and tenderness especially when there is general peritonitis. However, one may have general septic peritonitis with very little or abso- lutely no pain ; and, unfortvmatcly, under such circumstances the absence of the pain and tenderness is a very bad sign, and prob- ably points to that terrible condition known as acutest septicasmia. Low Delirium. — There is nothing special about the character of the low delirium, which is similar to that which we find in many, or all, diseases accompanied by high temperature and great debility. Expression and Color of Face. — There is generally, or always, some change in the expression of the face and also in its color. 107° 106° 105° 1M° 103° 102° 101° 100° 99° 98/ 97° 1 i 5 V^ o ^". X 6 \ \ h "--. Va A \ A A A V.A 1 A . .^ u/^ n/ VN ■i V V \^ ^> A V V V V -^ ^' M Pulse E 84 78 76 70 84 74 80 112 96 80 78 70 70 68 88 80 84 76 88 78 96 108 100 84 80 72 7d 78 Fig. 161. — After Delivery of Placenta, Fundus Ascended. Clots Expelled, Fundus Immediately Descended. Temperature rose on eighth day from acute indigestion, caused fall of temperature. A dose of castor oil The countenance is anxious and sometimes the color is sallow. There is, in many cases of acute septicaemia, a peculiar expression which I can not describe, but which when once seen is generally remembered. The face is pinched and ghastly, with frequently a 452 LISTEEISM AND OBSTETRICS bright red spot on each cheek and an unnaturally bright expression in the eyes. After a time the face is covered with cold drops of perspiration and the hps become blue. Disorders of the Stomach and Intestinal Canal. — There is gen- erally derangement of the stomach, as shown by loss of appetite and vomiting; also of the intestinal canal, as shown by diarrhoea. Vomiting of coffee-ground substances is an especially serious symptom. Changes in the Lochia. — Sometimes the lochia become offen- sive. This indicates sapra^mia, although the lochia may become slightly offensive simply by retention in the vagina. In other cases the lochia may be suppressed. This is generally an indica- tion of sepsis. There is, however, a very serious septic condition without suppression of the lochia, and sometimes in such cases the lochia may not be in the least offensive. Reference "mil now be made briefly to some of the varieties of infection which have special characteristics. Saprsemia.^ — Rapid pulse and rise of temperature occur in from the second to fifth day after labor. The symptoms appear some- what gradually, at the same time the lochia become offensive. With these signs we have the ordinary symptoms, before described, of headache, insomnia, and weaHness. We do not consider this a very serious condition because we believe that we can cure it. One should, however, never forget that sapraemia may be followed by the more serious condition of septic infection. Mild Sepsis. — The symptoms of mild sepsis include all those which were described as premonitory; and in addition many of those termed ordinary. Pain and tenderness are generally prom- inent symptoms and depend on the parts infected. In many cases the system is able to throw off the poison, in other cases localized inflammations occur, which may end in resolution or in suppuration. In such cases we have the ordinary symptoms associated with such inflammatory processes. The most common varieties of localized inflammation caused by mild sepsis are pelvic celluUtis and pelvic peritonitis. Parametritis or Pelvic Cellulitis. — The physical signs of in- flammation of the pelvic connective tissue generally appear about the fourth or fifth day, or two or three days after the commence- ment of the ordinary premonitory signs of sepsis, or about one day after the onset of the more serious symptoms. There is an effusion PUEEPERAL SEPTIC INFECTION 453 of lymph nearly always confined to one side of the pelvis (gener- ally the left side) ; this causes a swelling, which can easily be felt by vaginal examination, and which is frequently so large that it pushes the uterus toward the opposite side. When the swelhng reaches the pelvic wall it follows the latter closely, while in peri- tonitis the fingers may be inserted between the swelling and the bones (Garrigues). When suppuration takes place we get what is commonly known as pelvic abscess. The lymph effusion may extend from the broad Ugaments to the connective tissue about the psoas muscle, or beneath the parietal peritonsBum, or along the round ligaments to the inguinal canal, or from the utero-sacral ligaments to the connective tissue about the rectum. Dakin says the effect of such spreading is sometimes confusing, especially when the cellulitis has disappeared from the pelvis, leaving masses of inflamed tissue in remote parts of the abdomen. During the process of absorption of an ordinary inflammatory effusion in the broad ligament, the contraction, which usually occurs in resolving inflammatory deposits, causes the uterus to be drawn toward the side originally affected. Thus we are likely to find during the progress of the case the uterus at first pushed toward the right side of the pelvis, and after a time drawn close to the left side, or occasionally vice versa. Pelvic Peritonitis. — The physical signs of localized inflammation of the pelvic peritonaeum generally appear about one or two days later than those of pelvic celluhtis. This can be detected in those cases where the patient had both parametritis and peritonitis. The premonitory and actual symptoms of sepsis are generally well pronounced some days before the inflammatory products can be detected. These symptoms are to some extent similar to those due to parametritis, but in peritonitis, even when fairly well locaUzed, the initial chill is more common and more protracted. This is followed by great pain and tenderness in the lower abdo- men, with rapid pulse and high temperature. It is frequently hard to draw the line between general and local peritonitis, and for some days it may be impossible to decide in a particular case. After a time (generally seven to twelve days after labor) the inflammatory exudate in the pelvis and lower abdomen may be detected by internal and external examination. The mass is not usually unilateral as in parametritis, and is situated behind in Douglas's pouch and not on one side of the uterus. The exudate 454 LISTEEISM AND OBSTETEICS gradually appears to surround the uterus, causing a fixation of that organ similar to that which would be produced by "pouring plaster of Paris into the pelvic peritoneal cavity. ' ' The outer wall of the exudation is composed of agglutinated omentum, intestines, uterus, and appendages. The abdominal surface of the mass is uneven, and sometimes shows different degrees of resistance in different parts. As in pelvic cellulitis, so also in pelvic peritonitis, the inflammation may end in resolution, the hard exudation melting away, and it, together with the contained fluids, being absorbed. In other cases suppuration takes place, forming one or more ab- scesses. Such abscess, or abscesses, may open into hollow organs, or externally, as in the case of the abscesses due to cellulitis. After weeks or months of suffering with chills and fever, recovery may take place. Unfortunately, however, it too frequently happens that the woman becomes a chronic invalid, with more or less per- manent lesions in the pelvis and lower abdomen. Diffuse Peritonitis is generally associated with general systemic infection, although the symptoms of the former may largely pre- dominate. The symptoms of diffuse peritonitis are similar to those of local peritonitis, but appear sooner and are more pro- nounced. The chills last longer and are more severe. The pains are extreme and extend over the whole abdomen. These pains may cease before death, or, as before mentioned, they may be ab- sent altogether in very bad types of infection. The abdomen is distended, the breathing shallow, rapid, and diaphragmatic. The other symptoms are those which have been described in connection with general infection, and will again be referred to under the heading of Acute Sepsis. Acute Sepsis. — In giving the symptoms of acute sepsis I shall closely follow Jellett. The symptoms appear from twenty-four to fifty hours, or even less, after infection. Frequently a severe rigor occurs early, during which the temperature rises to 104° or 106°. The pulse is exceedingly frequent, and is even out of pro- portion to the temperature. Rigors recur frequently, and during the intervals the patient is bathed in a profuse cold perspiration. The lochia and milk secretion are either not established or cease completely. The patient is sleepless and looks extremely ill; her face is pinched and often jaundiced. The angles of the mouth and face are drawn down and the eyes appear sunken into the head. Sometimes in the worst cases the patient may say that she feels PUERPERAL SEPTIC IXFECTIOX 455 extremely wvU. This condition is calhMl euphoria, and is duo to the fact that the higiicr nerve centers are dulled by the poison which is circulating in the system. Frequently there is a diffuse septic peritonitis. The duration is from two to five days, or some- times a week. Pyaemia. — It is fi-('(|U(iitly stated, in connection with pyaemia, that the symptoms do not appear until the seventh to the twelfth day after delivery. I desire to repeat that I consider this wrong. The premonitory symptoms always appear within two or three days after deli\'ery. The symptoms are really very much like those of acute sepsis, but the serious ones come on later and last much longer. In a few days after the onset of the serious symp- toms metastatic abscesses form. These may occur in any part of the body, but they generally follow one of two definite courses. They are found in one class of cases in the superficial parts of the body, generally either in the joints or subcutaneously ; they are found in the other class in the deeper organs, as the liver, lungs, spleen, brain, etc. As each new abscess is developed there is a recurrence of the rigors. The patient may gradually recover, but quite as frequently dies. Death from pyaemia may occur in several ways : from exhaustion due to long-continued suppuration, from septic pneumonia, peritonitis, endocarditis, or from abscesses form- ing in vital organs, such as the liver and brain. TREATMENT OF PUERPERAL INFECTION As soon as symptoms of septicaemia appear, two therapeutic procedures should be at once considered : catharsis and local treat- ment. Reference is here made especially to the early or premoni- tory symptoms. If, on the second, third, or fourth day, there are headache, sleeplessness, rapid pulse, shght elevation of tem- perature, and chilly feelings, or any one or more of these, the accoucheur should at once carry out the first mentioned thera- peutic procedure. Catharsis. — Give calomel, one-half to one grain every fifteen to thirty minutes, for four to six doses ; follow with, magnesium sul- phate, saturated solution, two to six drams, every hour or two until the bowels are moved. If the bowels are not moved after three or four doses, administer an enema of soap suds, a pint to a quart, with a tablespoonful of turpentine. Aim at having four to 456 LISTERISM AND OBSTETEICS six watery evacuations in the twenty-four hours for several days if necessary, even twelve evacuations in the twenty-four hours will do no harm. Some people fear the danger of such active treatment. There may be some danger of causing extreme prostration, and one should, of course, guard against that. However, the danger in that respect is only slight. We find, from cHnical experience, that the elimination of any poison from the body is not hkely to produce weakness ; it rather tends to keep up the strength of the resisting forces in the body. If the symptoms are only slight, such as headache, insomnia, and are relieved by the calomel and sahne, stop the medication. We may carry out this cathartic treatment with confidence, because, with the exception of certain cases of acute local or gen- eral peritonitis (in the early stages), benefit will always accrue. When we come to consider further the advisability of local treat- ment we cannot act with so much certainty. If the symptoms are due, for instance, to an ordinary influenza or a slight attack of indigestion, local treatment would be not simply useless but might do actual damage. We want always to avoid the " meddlesome" feature in our work. We cannot give an intra-uterine douche, or even a vaginal douche, without causing some constitutional effect, as shown by increased temperature and pulse rate. Therefore we should look upon such procedures as evils, to be avoided unless we adopt them to remove still greater evils which exist. Mann advises us to first make our diagnosis by bacteriological examina- tions according to the methods of Doderlein and Whitridge Will- iams. Mcllwraith has done work on these lines in our General Hospital, and has shown that such examinations aid us to a lim- ited extent in diagnosis, prognosis, and treatment. Three difficulties in this connection present themselves. First, a great many have not the facilities for carrying out such investi- gations in private practice ; second, streptococci and staphylococci are sometimes found in the puerperal uterus in normal cases; third, a certain amount of very valuable time may be lost while waiting for the results of such investigations. Virulent strepto- cocci within the uterus generally travel somewhat rapidly along the lymphatics toward the peri-uterine tissues. Under such cir- cumstances it would be unfortunate to lose twelve to twenty-four hours, during which time they might get beyond our reach, while, if we acted promptly, we might counteract their evil effects. PUERPERAL SEPTIC INFECTION" 457 The following simple rules may be accepted : 1. In all cases when the lochia become offensive, treat locally. 2. When it is suspected that portions of placenta or membranes are retained and symptoms of sepsis appear, explore the interior of the uterus, remove debris if present, and wash out. 3. When in doubt as to the condition of the uterus when symp- toms of sepsis appear, explore and wash out. If return flow is clear do not repeat. Local Treatment. — I fear that, in a large proportion of cases, local treatment even during the last few years has been very imperfectly or improperly carried out. Take, for instance, the administration of intra-uterine douches. In the first place, a large number of practitioners do not know how to administer an intra-uterine douche ; in the second place, the intra-uterine douche, no matter how well it may be administered, frequently if not gen- erally does little or no good. In saprsemia it only washes away some shreds and clots, while it leaves putrid debris and adherent clots behind. It may be, however, that in a very sm.all proportion of cases it cures mild saprsemia. Proper Method of Local Treatment for Uterine Infection. — Let an assistant administer a general anaesthetic. Adopt all the antiseptic precautions that should be employed for an abdominal section or any other surgical operation. After having made your- self thoroughly clean, wash the vulva and vagina as before described, then introduce the hand or half hand into the vagina and one or two fingers thence into the uterus. If portions of the placenta or membranes or debris of any sort are found, scrape thoroughly and remove. There is no instrument so good for this purpose as the intelligent finger-tip. After removing the debris, wash out v/ith hot water (110°-118° F.) that has been boiled, or with a weak antiseptic solution, pack the uterine cavity somewhat tightly with iodoform gauze and the vagina loosely with the same ; leave the gauze in position twenty to thirty hours. The weak antiseptic solution which has been mentioned is really of small consequence. The sterilized water will wash out all the debris which has been loosened with the fingers. If anti- septic solutions which are strong enough to kill pathogenic germs are used, they will produce a certain amount of necrosed tissue which wiU simply form a culture medium for the growth of 458 LISTEEISM AND OBSTETEICS microbes, while if they are not strong enough to kill germs they are no better than sterilized water. Some use the blunt curette. This is not so safe nor effective as the finger-tip. Others use the sharp curette. This is not safe, because it is likely to open vessels which may absorb more poison, or it may destroy that so-called reaction zone which is said to be formed in the uterine tissue during the inflammatory process, which tends to resist the invasion of germs. If nothing has been found in the uterus and the discharges are not offensive, but still the patient becomes worse, the system is profoundly infected, and any further local treatment of the uterine cavity will do more harm than good. Local treatment is especially useful in ordinary saprsemia, which it generally cures at once. It also produces very satisfactory results in a certain proportion of cases of mild infection. Other forms of local treatment are suitable for pelvic cellulitis and pelvic peritonitis, especially after the exudations can be detected. Vaginal douching, according to the directions given by Emmet about twenty-five years ago, is generally soothing and promotes the absorption of the inflammatory product. It fell into disrepute a few years ago, but now seems to be returning again to popularity. Douching to be effective should be admin- istered in a thorough and careful manner by the physician or a skilled nurse. The patient should not be made uncomfortable, the pelvis should be on a higher level than the shoulders, a good douche pan should be used, the temperature of the water should be 115°-118° F. One or two gallons of water should be used for a douche, which should be given twice a day, if it does not cause fatigue. As to that, much will depend on the skill of the nurse. It is well in most cases to paint the groin occasionally with tincture of iodine. Garrigues does this once a day, and then cov- ers it with a piece of lint soaked in this lotion, I^ Acidi carboHci 3 j (4 gm.), T"\ ^ liijOOgm.), with the expectation that it will prevent the skin from cracking, and allow one to continue the use of the iodine and favor its absorp- PUEEPEEAL SEPTIC INFECTION 459 tion. When the tenderness has subsided sufficiently to allow a speculum to be introduced, he also paints the vault of the vagina every three days. One should be careful not to use too much tincture of iodine, and it should l)e applied with a very small pledget. I prefer to use, instead of the tincture, equal parts of the compound solution of iodine and glycerine every day or two, taking care not to use too much. Reference will be made to the treatment of abscesses in connection with operative treat- ment. Operative Treatment. — When the streptococci have passed beyond the reach of the curette, Henrotin advises certain operative procedures with a view of stopping the ravages of the organisms before the entire system is poisoned. When the germs pass through the uterine walls they set up a peritonitis, or parametritis, or both. A fibrinous and serous exudate is thrown out which accumulates in the pelvis or in the general peritoneal cavity. Henrotin opens the posterior fornix of the vagina and passes the finger through this opening into the peritoneal cavity, with a view of draining away as much of this fluid as possible. After a thor- ough exploration with the finger he packs the cul-de-sac with iodoform gauze. Pry or approves of this plan. He thinks it is especially useful when there is a mixed infection, as, for instance, saprophytes and streptococci together. Mann also goes somewhat farther with this operation, and opens recent accumulations of pus within the tubes or broad ligaments. He tells us the opening of the cid-cle-sac is a very simple operation, attended with little or no risk, and when nothing is found the wound heals in a very short time. Our results from this operation in Toronto have been somewhat disappointing. In a certain proportion of cases we have a pelvic abscess. The proper treatment for such an abscess is to open it and give free vent to the pus. If the abscess is not interfered with it generally opens in time through the wall of the bowel. It may, however, open into the bladder, uterus, vagina, or externally, above or below Poupart's ligament. After discharging for a time the hard wall surrounding the abscess may become absorbed and a com- plete cure may be the result. The following rules as to active interference will, I think, fairly represent the views of the majority of conservati"\'e obstet- ricians : 460 LISTEEISM AND OBSTETRICS Active curettage, especially with a sharp curette, or even with a large dull wire curette, is dangerous. Garrigues's opinion in this regard is worth much. He says he does not remember to have seen a patient recover when the curette was used after sepsis had set in after childbirth. Henrotin's operative methods are not always followed by satisfactory results. A pelvic abscess, whether cellular or peritoneal, should always be opened and freely drained. Puerperal Ulcers. — Ulcers are frequently found and vary to a considerable extent in size. They generally have a gray, slough- ing base, with an inflamed margin, situated on lacerations of the genital tract. Local treatment is all that is necessary for such ulcers. Do not use a vaginal douche, for fear of carrying some of the discharge from an ulcer into the uterus. It is well to have the head of the bed raised in order to favor free drainage. Intro- duce a speculum, get a good view of the ulcer, and apply pure carbolic acid and then iodoform powder ; or nitrate of silver, 40 grains to the ounce. Medicinal Treatment in Addition to the Administration of Cathartics. — Probably the best drug at our disposal is alcohol. The patient should take as much as possible. Jellett says that she should have as much as she can be urged to take without any qualification, and he considers that the amount should be about from 16 to 24 ounces in twenty-four hours. Reynolds recommends us to give whisky in sufficient quantities to preserve a normal fulness of the pulse without producing any loquacity or dizziness — that is, we should stimulate as much as possible without pro- ducing intoxication. Jewett recommends the administration of a quart of brandy or its equivalent daily, and recommends that whisky, brandy, and the wines be used in alternation. Certain tonics are useful, and are said to hinder waste and to promote oxidation of the toxines and the products of tissue dis- integration. The best of these is probably strychnine, gV of a grain every three to six hours. Quinine, 1 grain with 10 minims of hydrochloric acid every four to eight hours, appears to answer in some cases better than strychnine. It was the custom, especially a few years ago, to give quinine in large doses to reduce the tem- perature. I seldom use quinine for this purpose, never unless the temperature is over 104°. Jewett says that large doses are PUEEPERAL SEPTIC INFECTION" 461 injurious by hindering oxidation. Tincture of digitalis or tinc- ture of strophanthus in 10 to 15 minim doses, given every four to eight hours, are useful for weak heart. Some, however, prefer to use sparteine or caffeine for heart depression. Coal-tar anti- pyretics, such as antipyrine, antifebrine, have been used to bring down the temperature, but they are dangerous from the fact that they act as depressants. Robbin tells us that they also hinder elimination of microbic poisons and the products of tissue dis- integration by preventing their oxidation. Feeding. — The most important matter in connection with feed- ing is probably the administration of fluids in as large quantity as possible, and especially water, either plain or mild alkaline mineral waters. It has been found by experiments on animals that the quantity of septic poison required to intoxicate is doubled or trebled when the animal drinks abundantl}- of mildly alkaline waters. Alkalies are believed to facilitate the combustion of or- ganic substances in the blood. Diuretic drugs are used by many, acting on the view that it is well to endeavor to eliminate the poison by all the emunctories, but especially the skin, kidneys, and bowels. Plain water is the best diuretic. Give opium and morphine in full doses for severe pain, but it is advisable to have the bowels freely moved before and during the administration of opiates. Some take a rather extreme view of the effects of opium and say that opiates should not be used at all. During the last few years there has been a reaction against this view. Garrigues uses opium or morphine in very large doses for puerperal peritonitis. He endeavors to give prompt relief by injecting hypodermically at the beginning ^ of a grain of morphine, and giving thereafter by the mouth |- or ^ grain every half hour until the patient is fully under the influence of the drug — i.e., free from pain, but not too deeply narcotized to prevent her from being aroused. When the heart is weak a little atropine may be com- bined with the morphine. If the patient has general peritonitis with severe pain when first seen it is probably better to follow Garrigues 's advice. First narcotize sufficiently to relieve pain ; then give enemata : glycer- ine ( 3 ij- 3 iv), or a quart of flaxseed-meal tea containing one or two tablespoonfuls of castor oil and a dessertspoonful of glycer- ine. A teaspoonful of inspissated ox-gall ( fel hovis) may be added. For vomiting give cocaine hypodermically, gr. ^ (8 gm.) every 462 LISTEEISM AND OBSTETRICS two to four hours, or hydrocyanic acid by the mouth according to this formula (Garrigues) : IJ Acidi hydrocyanic diluti 3 ss. (2 gm.) ; Acidi citrici j -- ,•• /o 3 ij (8 gm.. Sodii bicarbonatis Syrupi rubi idsei 3 ss. (15 gm.) ; Aquae destillatse ad 3 vj (180 gm.). M. Sig. : A tablespoonful every one, two, or three hours. Unguentum Crede has been used for some years on the Con- tinent and in some parts of the United States. It contains silver in a soluble form called collargolum, which, after absorption, enters the lymphatics and circulates in the blood. The collargol may also be injected under the skin or into a vein, or it may be taken by the mouth, or be placed in certain cavities, such as the uterine and peritoneal cavities. In inunction (the method generally employed) thirty to forty grains (2-3 gm.) of the ointment are rubbed once a day into the skin, where it is soft and free from hair, as, for in- stance, the inner sides of the arms or thighs. This procedure is said by some to yield good results in general systemic infections. Mannorek's Antistreptococcic Serum. — Among the various antitoxic sertims which have been used during the last ten years, none created more interest for a time than the antistreptococcic serum. Much was expected of it, but the results in the majority of cases were quite disappointing. A committee appointed by the American Gynaecological Society condemned it in a report which was presented in May, 1899. Their investigations indicated, how- ever, that the serum was practically harmless, but many observers have concluded that it is quite injurious. It should be remem- bered that in many cases the serum was only used after curette- ment — an operation with a very bad record. In August, 1899, the subject was fully discussed at the meeting of the British Medical Association. Herbert Spencer's conclusions (generally endorsed) were : 1. Serum therapy, as usually applied, has not a scientific basis. 2. It has not lowered the mortality of puerperal sepsis. 3. It usually lowers the temperature and sometimes improves the general condition. 4. Its use is not free from danger. PUERPERAL SEPTIC INFECTION 463 It is iinfortunato that tlio sul)jcct of .soruin therapeutics re- mains so long indefinite. This is partly due to the fact that the standards of strength of most of the antitoxic serums are, to a cer- tain extent, uncertain. Probably the only exceptions at present arc the antidiphtheritic and the antitetanic serums. The doses and the effects of dosage in the case of these two serums are fairly definite, and the results in the treatment of diphtheria and tetanus, in the opinion of the great majority of clinicians, have been emi- nently satisfactory. Let us hope that in the near future we may get equally satisfactory results from the use of antistreptococcic serum in suitable cases. After having passed through various phases of hope, doubt, and actual unbelief, I now hold opinions which are not in accordance with the report of the Committee of the American Gynaecological Society. These may be briefly expressed as follows : 1. The injection of Marmorek's serum does occasionally cure antistreptococcic infection. 2. The serum is not always harmless ; it is frequently injurious. Unfortunately, those who believe in the occasional efficacy of the remedy cannot give any definite rules for guidance. During my own attack of septicaemia in the fall of 1900, Drs. Caven and Bruce determined to try the serum. It was injected at a time when I was suffering from intense pain, which was but little influenced by morphine. The pain appeared to be deeply seated in or near the left hip joint. After the injection I gradually got a sensation as if something were warming the stagnant congealed blood within my heart. This warm blood soon commenced to flow in all directions, and as it did so my pain scattered and finally disappeared, causing a dehcious feeling of rest and peace, followed shortly by an inchnation to take some interest in my surroundings and a desire to live. How much hysteria there was in me at the time I know not, but it appeared to me that the serum brought me back to life. I know very little as to particulars, as I have never consulted the history or the charts ; but I understand that my medical attendants. Osier, Caven and Bruce, thought that it accomplished much good. McUwraith has pubHshed some histories of cases coming under our observation. In one instance I watched the patient very care- fully and thought that she showed marked improvement after each injection (as shown by effect on .temperature, pulse, and in other 81 464 LISTEEISM AND OBSTETEICS ways), and finally made a good recovery. I have seen some patients on whom the serum treatment appeared to have a bad effect ; other patients on whom it appeared to have no effect whatever. I should recommend the following rules : Use the serum in cases of acute septic infection where the patient is steadily growing worse under ordinary treatment — i.e., practically as a last resort. Do not use it in cases of mild septicaemia, chronic septicaemia, pyaemia, or in localized infections. Directions as to Injections. — Make the initial dose 20 c.c, never less. Watch the effect of this, and if patient shows any signs of improvement, inject 10 c.c. every twelve to twenty-four hours for three or four days. In the Toronto General Hospital we have generally injected between the shoulder-blades. Nuclein, a substance obtained from yeast, has been used to produce an artificial leucocytosis with a hope that the leucocytes, with large reinforcements, may be able to destroy the pathogenic microbes. Hofbauer reported favorable results from its admin- istration in 1896. Hirst has used it for some years and speaks favorably of it. The nuclein solution is given hypodermically, or by the mouth, according to directions issued by the manufacturer. The initial dose is usually 10 minims (60 centigrammes) hypo- dermically twice a day, or 3 ss. (2 gm.) by the mouth. The dose is generally increased slightly from day to day. Enemata and Subcutaneous Injections of Normal Saline Solu- tions, as recommended for toxaemia and eclampsia, should always be given. Intravenous injections are used by some; but they are probably no more efficacious than the subcutaneous injections, require great care and considerable skill in technique, and are more or less dangerous. • Atmokausis — i. e., the intra-uterine use of steam — has been employed, but has been followed in many cases by results so dis- astrous that it is worthy of no favorable consideration. Hysterectomy. — This operation has been performed by a few with the aim of removing the infected uterus before the microbes have invaded the general system; but it is hard to conceive of a case where the uterus is so affected as to require removal without general infection. The following brief notes of some cases in practice will iUus- PUERPEEAL SEPTIC INFECTION 465 trate certain points as to the nature and treatment of puerperal infections. Mrs. A., aged thirty. Labor normal. Felt ill on second day, grew worse until I saw her on the fifth day after delivery. Pulse 125, temper- ature 104°. Lochia offensive, with ordinary symptoms of sepsis. Chloro- form administered ; vulva and vagina washed ; hand introduced into the vagina, two fingers into the uterus; scraped the interior of the uterus, bringing away considerable debris. Intra-uterine injection of hot water; uterine cavity packed with iodoform gauze; also vagina packed loosely, gauze left in twenty-four hours. When the gauze was removed patient's temperature was 99°, pulse 100. Patient was then practically well; there were no other serious symptoms. This was probably an ordinary case of uncomplicated saprsemia. I have frequently asked members of my classes the following cjues- tion : If you see a patient on the fifth day after delivery and find high temperature, rapid pulse, headache, sleeplessness, etc., with offensive lochial discharge; if you see another patient Avith similar symptoms but no offensive lochial discharge, which of the patients is probably in the worse condition? The answer has frequently been, the patient having offensive lochial discharge. Such answer is generally, at least, wrong, because in many very serious cases of streptococcic infection the lochia are not at all offensive at any time. When there are bad symptoms with no change in the lochia there are probably serious constitutional conditions with general systemic infection. But when the lochia are offensive there is reason to suspect that the condition is due to the decomposition in consequence of the presence of saprophytic bacteria. Nothing can be more satisfactory than the results of treatment in simple saprsemia. Mrs. D., aged thirty-five. Ill para. Labor normal. Suffered from headache, sleeplessness, and chilly feelings during the second week. Pulse slightly rapid, temperature occasionally increased a little. Symp- toms supposed to be due to nerve disturbances. I first saw the patient on the fifteenth day after deUvery. Temperature 103°, pulse 120, every eA^idence of serious illness. Pain and tenderness in left iliac region. In- ternal examination showed swelling and tenderness on the left side of the uterus. In a few days — that is, in about three or four weeks after labor — a well-defined mass could be felt between the left of the cervix uteri and the left iliac fossa. This mass remained without much change for some weeks, when there was a free discharge of pus from the rectiun. Tliis discharge continued, more or less, for four weeks. After the dis- 466 LISTEEISM AND OBSTETRICS charge ceased the hard wall of the abscess appeared to melt away slowly and patient made a fair recovery. Eight months after labor the uterus was apparently normal in size, and freely movable. There was no local manifestation of any pelvic lesions. An important question might come up in connection with this case. Would it not have been better to open the abscess in such a way as to have free drainage? The proper answer is, Yes. In a large proportion of cases of pelvic abscess it is a very simple matter to make an opening and evacuate the pus. The abscess has been formed in the cellular tissues, generally, if not always, between the layers of the broad ligament, and has separated these layers and pushed the peritonaeum upward as it increased in size. Under such circumstances, after it has reached a point some inches above the pubes, the abscess may be opened without exposing the peritoneal cavity. In this case the patient and her friends abso- lutely refused to allow any operative interference. Mrs. S., aged thirty. Had two children and three abortions. Septem- ber 22d advanced three months in pregnancy, abortion. Attended by Dr. K. September 24th and 25th, temperature 100-101°, pulse 110. Sep- tember 26th, temperature 102°, pulse 120. Chloroform administered by Dr. L. Dr. K. introduced hand into vagina and finger into the uterus; removed uterine contents and packed with iodoform gauze. September 27th, patient better in the morning. At one o'clock seemed not quite so well, temperature 101°, pulse 110. Dr. K. removed gauze, washed out the uterus, and curetted. Little or nothing found in the uterus. At 4 P.M., temperature 104°, pulse 120. At 11 p.m. I saw the patient in consultation with Dr. K. Temperature 102.5°, pulse 140. On vaginal examination found os contracted, could not introduce finger. Uterus not tender. After I was in the room twenty minutes, pulse 120. I ad- vised no further interference. September 28th, patient much better, temperature 100°, pulse 100. September 30th, patient completely re- covered. Temperature and pulse normal. When I was called in to see the patient on the night of Septem- ber 27th I was considerably puzzled. It will be noticed that at four o'clock in the afternoon temperature was 104° and pulse 120. When I saw her at eleven o'clock the temperature was 102.5°, pulse 140. I thought it a favorable sign to find the temperature reduced, and I thought at the same time that the rapidity of the pulse (140) might be due to nervous causes produced by my entrance into the room. I was pleased but not greatly surprised PUERPEKAL SEPTIC INFECTION 467 to find in twenty minutes that the pulse was only 120. I consid- ered carefully what Dr. K., a very competent and careful prac- titioner, had done. He had, in my opinion, done exactly the right thing in having his patient anaesthetized, and thoroughly exploring antl clearing out the uterine cavity and packing with iodoform gauze. I do not know why the temperature and pulse were aljnormal the next day at one o'clock, but I think I can tell the cause of the condition at fcnu* o'clock, with temperature 104°, pulse 120. This was almost certainly due to the intra-uterine douche and curettement. As before stated, the intra-uterine douche always produces some, and sometimes very considerable, constitutional disturbance. I also feel certain that curettement in this case was worse than useless. This case has been described somewhat in detail to illustrate the fact that an honest and con- scientious physician may do too much rather than too httle. In this connection I wish to give a report of another case with a very sad ending: Mrs. C, aged twenty-eight. Two children. Four months advanced in pregnancy. Abortion. First attended by Dr. X. Two days after came under the care of Dr. Y. Nothing known about Dr. X.'s treatment. Dr. Y. gave intra-uterine douches every four hours for about a day and a half. I was called in on the morning of the fifth day. Temperature 99°, pulse 150, extremities cold. Patient felt comfortable, faculties clear, but she was evidently dying. Dr. Y. washed out the uterus again in my presence, the return flow being perfectly clear. We were simply douching a dying woman without any possibility of doing any good, because the poison was not situated in the uterine mucosa, but had traveled far be- yond that into every part of the system. In this instance I had no idea that the douching did any particular harm, but I am certain it was doing no good, and I am greatly opposed, as I have before intimated, to the use of intra-uterine douche when I am sure that it is at least unnecessary. The patient died in about half an hour after the last douche — that is, probably about four days after infection. This is a typical example of death from very acute sepsis with the condition called euphoria. The following is a typical example of that condition produced by septic infection which has long been known to clinicians as pyaemia : M. M., aged seventeen. Single. A strong, healthy girl, delivered of a well-developed male child March 28, 1893, at the Burnside. Three stitches introduced in a torn perinseum, sterilized silkworm-gut being used. On the evening of March 30th (60 hours after delivery) pulse 92. 468 LISTERISM AND OBSTETRICS Next morning pulse 95, temperature 100.6°. Magnesium sulphate ad- ministered until bowels moved freely. Condition improved for three or four days. Stitches removed seven days after labor. A little pus found in one stitch hole. No union. Patient complained of pain in her right leg and arm April 6th (nine days after labor), arm swollen. April 9th (twelve days after labor) patient was anaemic, breathing very rapidly, right forearm red and swollen on dorsal aspect, the affected part being exquisitely tender. Left arm also swollen and tender. Calf of right leg slightly swoUen and very tender. No pain or distention of abdomen, no headache; took nourishment well ; pulse 120, temperature 102.2°, respiration 40. Free incisions were made in right forearm and left arm, the knife being carried to the bone. The subcutaneous tissues of the right forearm presented a very peculiar appearance, gray in color, looking something like clear transparent jelly, no pus nor fluid of any kind. Only the subcutaneous tissues affected. Discharge from wounds became purulent three days after incision, contained streptococci in abundance. In addition to these local measures patient was treated by free stimulation, taking about twelve ounces of whisky in twenty-four hours. For a time quinine was administered, but without effect. Salol was substituted, but it disturbed her digestion and was discontinued. The patient's condition gradually became worse, persistent high temperature 101° to 105.6°, remarkably rapid respirations, ranging during the last week from 36 to 74 per minute, more rapid during sleep. Patient restless, very ner- vous. Lips quivered but never had an actual rigor. Amount of pus discharged from wounds never very great. Died April 21st, twenty-four days after confinement. Post mortem by Professor Caven. No abscesses in internal organs. Peritonaeum normal in appearance, uterus enlarged and soft, vagina nor- mal. Careful dissection of the vagina and broad ligament, after removal, showed the veins running from the neighborhood of the perineal lacera- tions to be partly filled with puriform clot and to present the appearance of acute phlebitis. Microscopic examination demonstrated the presence of streptococci in great numbers in the clot. Posterior a,spects of both forearms and of the left arm presented an extensive subcutaneous suppuration spreading widely beneath the skin, but to a very slight degree along the intermus- cular septa. On the left side there was also subcutaneous suppuration over the back of the hand, extending to the roots of the fingers. The calf of the right leg, on incision, was found in the same condition as the arms, the suppuration being extensive but strictly limited to the subcutaneous tissues; about twelve ounces of pus found here. Phlebitis was found extending up into the thigh. Dr. Primrose assisted me in taking care of this patient, making the incisions and looking after the dressings. There were many PUEEPERAL SEPTIC INFECTION 469 interesting points connocterl with the same, some of which I could never clearly understand. While I call it a case of pyaemia, I consider it a form of septicaemia which frequently ends in recov- ery. The nerve centers were not suddenly overpowered by the intensity and virulence of the poison, as is the case in the most malignant form, which kills so rapidly and leaves little in the way of gross lesions to be found post mortem, and yet the blood-vessels appear to have been the principal carriers of the poison; conse- FiG. 162. — Letjccpcenia. 144 squares Thoma Zeiss diluted 1-10 0.3 per cent, acetic acid, methyl green. P, polymorphnuclear; LM, large mononuclear; SM, small mononuclear (W. N. Meldrum). quently I should suppose there was no let or hindrance to a rapid infection of the whole system. The serous and mucous mem- branes were remarkably free from any signs of serious infection. It belongs to that class of cases in which the superficial parts of the body are especially affected. While the force of the poison appears to have been expended in the subcutaneous tissues, there must have been a serious infection of certain nerve centers which produced the extreme rapidity of respiration which was out of proportion to the accompanying symptoms. Why this rapidity 470 LISTEEISM AND OBSTETEICS of respiration was most marked, as a general rule, during sleep, I do not know. It will be noticed in the synopsis of Dr. Caven's post-mortem report that there was a collection of pus strictly limited to the sub- cutaneous tissues in the calf of the right leg. It caused me great surprise to find that there were twelve ounces of pus in this region. We made incisions in other parts. Why did we make none here? We at one time suspected the presence of pus and intended to incise. Another careful examination shortly after gave us the im- pression that our previous opinion was wrong and consequently no incision was made. The lesson to be learned is that in all such Cases the rule should be, when in doubt as to the presence of pus, to incise without waiting for positive evidence. Another case of pysemia. Mrs. D., IV para, admitted to Gen- eral Hospital ten days after labor. Symptoms of septic infection. After a couple of weeks some doubt as to diagnosis. Typhoid fever Fig. 163. — Normal Blood. P, polymorphnuclear LM, large mononuclear; SM, small mononuclear (W. N. Meldrum). suspected. Blood examination by Dr. McLaurin. Widal test, nega- tive. Leucocyte count, 30,000. After a few days several abscesses developed, the first being in the vulva, and were opened. Patient recovered after a long illness. PUEKPEEAL SEPTIC INFECTION 471 Brief reference is made to this case on account of the leucocy- tosis. Much was expected a few years ago from the leucocyte count as an aid to diagnosis in suspected pus formations. The Fig. 164. — Leucocytosis. P, polymorphnuclear ; LM, large mononuclear ; SM, small mononuclear (W. N. Meldrum). results of investigations were in many respects unsatisfactory, and it is the habit of many now to belittle the significance of such count. I think, however, we may obtain much assistance from the leucocyte count in certain cases. The following facts as to leu- cocytosis are generally admitted. There is a slight leucocytosis in pregnancy, which increases for two or three days after labor and then decreases up to the end of the first week, when it ceases. There is no leucocytosis in a large proportion of cases of acute sep- ticemia, especially the rapidly fatal forms. There is generally leucocytosis in puerperal infection with the formation of abscesses. There is little or no leucocytosis with some forms of chronic ab- scess, especially those due to tubercle bacilli and gonococci. A leucocytosis of 20,000 to 30,000, continuing three days, generally indicates pus formation. 472 LISTEEISM AND OBSTETEICS This case may be compared with that reported on page 233, a case of supposed septic infection which was probably typhoid fever. It seems probable in certain cases that a marked leucocytosis, with negative Widal results, furnish strong evidence of pus formation, while a marked leucopoenia, with a positive Widal reaction, will furnish strong evidence of typhoid fever. CHAPTER XXII PUERPERAL INFECTION (Continued) Phlegmasia A Iba Dolens ; Femoral or Crural Phlebitis ; Milk Leg ; White Leg. This is a peculiar swelling of the lower extremity (very rarely the upper extremity), white in appearance, accompanied with great pain and general constitutional symptoms. Occasionally both legs may be affected, but seldom does the affection begin in both at the same time. The symptoms nearly always appear in second or third week, although before this time there have been some of the premonitory signs of septicaemia, such as headaches, insomnia, etc. There is very severe pain during the acute stage, which abates after the hard, brawny condition gives place to soft oedema. There is swell- ing, which is at first hard and brawny, with a glistening white sur- face. It commences sometimes in the thigh, sometimes in the leg, occasionally in the neck or arm. There are also general malaise, rapid pulse, increased temperature, and usually constipation. Coagula are generally felt along the course of the veins. The other limb may become similarly affected. The acute painful stage lasts a week to a fortnight. The whole duration is from four to six weeks — sometimes longer. Phlegmasia alba dolens is probably always due to mild septic infection. It received the name milk-leg because it was once thought to be caused by a metastasis of milk. There is generally present a phlebitis and occasionally a celluHtis, or both phlebitis and cellulitis. The simple thrombosis of the veins of the leg — some- times called a marantic thrombosis — should not be included. It is so seldom found in the upper extremity that many authors do not mention the possibility of puerperal phlegmasia dolens in the arm and neck. Two cases have come under my observation, and Spence of Toronto has reported one case. My first case caused me much 473 474 PUEEPEEAL INFECTION anxiety for a couple of days. The patient was doing fairly well for about ten days, when a brawny swelling suddenly appeared in the neck, accompanied with very severe pain. The swelling grad- ually extended down the arm, forearm, hand, and fingers. After Fig. 165. — Many-tailed Bandage on the Right. T-bandage on the Left, a few days the brawny induration changed into a soft oedema, and the pain disappeared. The swelling gradually subsided and the arm was fairly well in five weeks, although it remained weak for several months. In the other case (Dr. McPhedran's patient) phlebitis appeared in left leg and thigh one week after labor, in the right leg fifteen days later, and left side of neck three days later. The swelling soon extended down the arm to fingers. The pain in neck and arm was much more severe than that in the legs. Recovery took place in reverse order: arm first, right leg second, left leg third. The illness lasted altogether about four and a half months. The most important feature from a therapeutic standpoint is the extreme pain which the patient suffers during the time of the hard brawny swelling. The patient should get large doses of opium during this time. If the pain is thus kept in check, I think as a rule the length of the illness will be diminished. Lotions are not of much service, but the dry poultice should always be applied. In PULMON^ARY EMBOLISM 475 doing this surround the Hmb with cotton wool, cover with oil silk, and keep the dressing in position with a many-tailed bandage, and not by an ordinary roller bandage such as is too often used. Keep the limb, as far as possible, absolutely at rest and slightly elevated. Do not use friction at any stage, for fear of separating a portion of the clot. Keep the bowels fairly open and give good food and strychnine. Pulmonary embolism is one of the possible accidents of the puerperal period. Generally, if not always, there has been a pre- vious thrombosis in some of the veins of the pelvis or lower limb. The embolus, after it is broken off, travels toward the heart, and when large may be arrested in the heart, causing sudden death, or it may pass through it into the pulmonary artery. When it com- pletely blocks the main trunk of this artery- it causes death, as a rule, in a few minutes. When a smaller plug blocks merely a branch of the pulmonary artery it may cause severe symptoms. Fig. 166. — Many-tailed Bandage Partially Applied. but the patient will probably recover. When the embolus is arrested a secondary thrombosis is hkely to occur. Symptoms. — The symptoms generally appear suddenly and are so well marked that one can hardly fail to recognize them. The patient is seized with the most intense and distressing dyspna-a. She gasps and struggles for breath. Although air does actually enter the lungs, she still has the feeling of suffocation. The face generally becomes purple, although occasionally it is pale. The 476 PUERPEEAL INFECTION action of the heart is at first violent, but it soon becomes weak and irregular, and the pulse becomes small, rapid, and irregular. Death may occur in a very short time. A patient of the late Dr. Burns, who was apparently doing well, had a sudden seizure fif- teen days after labor and died in about five minutes. Dr. John L. Bray had three similar cases, in which the patients died in nine, ten, and eleven days respectively, after labor. Sometimes after the serious symptoms have lasted a few minutes the patient gradu- ally improves and recovery takes place. It is, of course, very important to keep her absolutely quiet. Stimulants, such as Fig. 167. — Many-tailed Bandage Applied for Phlegmasia Dolens. whisky, ether, and ammonia, may be administered. Oxygen may be inhaled. Opium should be given after the urgent symptoms have subsided. Venesection may be performed if there is marked cyanosis. GONORRHCEAL INFECTION Whatever doubt there may have been about the matter in years past, it is now generally conceded that gonorrhoea is caused by the gonococcus. Some say that this peculiar germ is septic, while others deny that it alone can produce sepsis. Galabin says the gonococcus appears to be capable of acting on certain organ- isms under certain circumstances. Mann says that the gonococci are much milder and slower in their action than are the septic germs, meaning, I presume, that the former are not alone capable of producing sepsis. GONORRHCEAL INFECTION 477 Without attempting to discuss the different views, I shall con- sider the gonococcus an ordinary septic microbe. We know, from clinical observation, that gonorrhoea produces serious results in the female, and therefore we are inclined to look upon the gonococ- cus as the direct, or indirect, agent in the production of such results. The parts attacked in the early stages are the vulva, urethra, Bartholinian glands, cervical canal, and perhaps to a cer- tain extent the vagina. In the majority of cases of acute gonorrhoea the disease is set up in the cervix and vulva at the same time, but there is no cer- tain rule as to this, and it not infrequently happens that the cervix is at first attacked and the external parts afterward, and in a few cases it appears that only the vulvar region is infected. When all the acute symptoms have disappeared the germs may still be pres- ent in the region of the urethral orifice, in the ducts of the Bartho- linian glands, and in the cervix. The disease is apt to extend slowly along the genital tract, ex- tending upward from the cervix, along the uterine mucosa, along the Fallopian tubes, and perhaps into a small portion of the peritoneal cavity. It fortunately happens that it does not spread to this extent in the majority of cases. It is also a fortunate circumstance that its progress is very slow, as the disease in any case is not likely to reach the tubes in less than six weeks to two months. It is said that it has been known to reach the tubes in ten days after infection. While I do not deny the possibility of this, I think such cases must be very rare. According to Schmitt, as quoted by Herman, gonorrhoea extends to the uterus in about one case in five, and to the tubes in about one case in twenty. The most important site of infection, from an obstetrical point of view, is the cervical canal. The germs may lie in this canal for months or even years. They often lie here during the whole of pregnancy without any attempt to spread. After labor the con- ditions are entirely changed, and the germs, which were before ap- parently asleep, become actively wide awake. This is probably due to the fact that the lochia afford a good culture medium for the germs, which, under the new conditions, thrive, multiply, and spread until they have traversed the entire genital tract. Nature steps in here in a very remarkable way to prevent these germs from going far beyond the tubes. We have the salpingitis and fre- quently ovaritis, but, generally speaking, the pavilion of the tube 478 PUERPEEAL INFECTION is sealed up by adhesive inflammation. Pryor says that we have a gluing together of the fimbriae, or else an attachment of the tube to some adjacent structure, usually the ovary, which causes the occlusion of the tube. But he adds that generally the uterine end of the tube is also occluded. We thus have the tube entirely shut off not only from the peritoneal, but also from the uterine cavity. One of the effects of such occlusion of both tubes is sterility. In many cases a woman becomes infected during her first pregnancy ; such infection more frequently occurs probably early in pregnancy, although it may happen at any time. If early, the acute symp- toms will have passed away probably in a few weeks and the germs will be situated in the lower part of the cervical canal. After labor double salpingitis sometimes occurs, producing a condition called by Sanger "one-child sterility." Some obstetricians justly dread the presence of gonorrhoea, especially at or near the time of labor, and if puerperal infection takes place during the first week after labor they are apt to think that it is caused by the gonorrhoea. The gonococcus cannot, however, cause the infection in so short a time. Nor does it do so even when the patients have a copious gonorrhoeal discharge dur- ing labor. Sanger found in the Leipzig Clinic that 26 per cent, of pregnant women had gonorrhoea ; Oppenheimer, in the Heidelberg Clinic, found 27 per cent. ; Lohmer, in Berlin, found 28 per cent. These observers all agree that, notwithstanding the large propor- tion of women infected with gonorrhoea, the mortality in all the hospitals was small, showing that gonorrhoea has but little effect in the early weeks after labor, and seldom or never causes the ordinary puerperal infection. In fact, Sanger says that a gonor- rhoeal woman runs, in the first few weeks after labor, little more risk of septic infection than any other puerperal woman. Pryor, after quoting Sanger as above, says that when she has ceased to be puerperal she becomes liable to complications incident to gonor- rhoea. He points out, as was before shown by Baumm and Fenger, that the squamous epithelium of the adult vagina, the endometrium of the puerperium, and also the endometrium of the nulliparous uterus, have great resistant power against the spread of gono- cocci. He adds that gonorrhoea runs a shorter course in the female than in the male and with less risk of complications. Fenger, in referring to the fact that a general peritonitis rarely or never occurs from gonorrhoea, says that Mercier reports a typical case of GONOERHCEAL INFECTION 479 a strumpet who died while suffering from gonorrhoea. The autopsy- showed the uterus deeply infected, tubes distended by muco-pus, the fimbrisB closely adherent, and the peritoneum healthy. Therefore, if we care for our patient during labor in a cleanly way, we shall not find any evil results from the gonorrhoeal infec- tion for some weeks ; but if we introduce, or allow to be introduced, any streptococci or any staphylococci, we have reason to believe that we shall then have a mixed infection, in which the two forms of germs will materially aid each other in their destructive ravages. As pointed out by Mann, the pure gonorrhoeal infection usually shows itself in the third or fourth week, whereas the mixed infec- tion develops soon after labor. We must not conclude from these facts that the gonorrhoea does not produce serious and lasting results. Salpingitis, ovaritis, and the other inflammations in the neighborhood of the uterus, produce at least two very serious results, the first being the con- dition of sterility, the second being the more serious condition of permanent loss of health. Pus Tubes. — We hear much about pus tubes, and I fear that many of our physicians and surgeons have only hazy or incor- rect ideas as to their cause and results. Some have talked of pus tubes as if they were always produced by gonorrhoea. Gonorrhoea, in a certain proportion of cases, does certainly cause pus tubes ; and I have studied statistics pretty carefully in order to find its prob- able frequency as a cause. So far as I have learned, I can find no careful observer who considers that gonorrhoea is the cause of pus tubes in more than 20 to 30 per cent, of all cases. The most com- mon cause is septic infection after abortion or labor. It may be added in connection with this subject, that pus tubes due to gonorrhoeal infection never cause puerperal fever. There has been a great deal of confusion in the past about the germs found in these purulent collections in the tubes. In a fairly large proportion of cases no organisms of any sort can be found. This is due to the fact that bacteria confined and encapsulated in closed pus cavities soon lose their virulence; they die from their own products, the toxines. The average time in which the pus thus becomes sterile is about nine months. 32 CHAPTER XXIII DEFORMITIES OF THE BONY PELVIS AND INJURIES TO THE CHILD DURING DELIVERY Deformities of the pelvis include all variations from the size and shape of the normal pelvis. These variations are nearly always contractions. No others need be considered. The contractions which affect labor are chiefly those at the brim. The most important of these is contraction of the antero- posterior or conjugate diameter. CAUSES AND FORMS OF DEFORMITY The causes and varieties generally recognized are as follows : Causes. — 1. Rickets — producing changes in the shape of the pelvis in early life before the bones are properly ossified. 2. Osteomalacia — producing changes in adult life through soft- ening of bones that have been properly ossified. Much less com- mon than rickets. 3. Displacement of bones in or near the pelvis, such as forward and downward displacement of lower lumbar vertebrae (spondylo- listhesis), and displacements of sacrum from curvature of spine. 4. Diseases of the pelvic bones from tumors, etc. 5. Interference with normal development of the pelvis pro- ducing the infantile pelvis. The more common forms are : 1. Flattened pelvis. 2. Generally contracted pelvis, including the dwarf pelvis. 3. Obliquely distorted pelvis. 4. Spondylolisthetic pelvis. 5. Transversely contracted pelvis (Roberts's pelvis). 480 CAUSES AND FORMS OF DEFORMITY 481 6. Funnel-shaped pelvis (masculine pelvis). 7. Rhachitic pelvis. 8. Osteomalacic pelvis. 9. Deformity from- tumors, exostosis, etc. Flattened pelvis is the most common form of pelvic deformity in Canada. In the majority of cases the patients do not show any traces of rickets, which is so commonly the cause in some coun- tries. It is probably acquired during early life in some cases, while it seems to be the result of a congenital condition in others. The important feature is the shortening of the conjugate diameter — i. e., the antero-posterior diameter at the brim. It sometimes happens that a flat pelvis is also " generally contracted." Generally contracted pelvis comes second in frequency as a form of pelvic deformity in Canada. Under this term are included the pelvis, which is equally and slightly contracted in all parts, and also what is called the dwarf pelvis. The difference between the two is chiefly one of degree, but in most of the dwarf pelves the word sequabiliter cannot be used in describing the contraction. Obliquely distorted pelvis is by no means uncommon in this or any other country. There is in this deformity a deviation of a part or the whole of the pelvis toward one side, causing a marked difference in the length of the oblique diameters in all the planes of the pelvis. One form is called Naegele's pelvis, in which the dis- tortion is caused by unilateral disease, fracture, or failure of devel- opment in the region of one sacro-iliac joint. Among other causes of the obliquely distorted pelvis are the various forms of spinal curvature, coxalgia, and unequal lengths of legs. Spondylolisthetic pelvis is due to the forward and downward displacement of the fifth lumbar vertebra. Transversely contracted pelvis or Roberts's pelvis consists in symmetrical narrowing and antero-posterior elongation of the pel- vis. It is considered by some to be a sort of double Naegele. Funnel-shaped pelvis is one whose internal diameters diminish from the inlet to the outlet. Rhachitic Pelvis. The most common form of this is the rha- chitic flat pelvis, which usually results from early rickets before the child walks. The patient is generally below medium height, with a pendulous abdomen and clumsy gait. The iliac crests are everted in front so that the interspinous diameter is relatively lengthened and is equal to or greater than the intercristal. 482 DEFOEMITIES OF THE BONY PELVIS Osteomalacic pelvis or malacosteon is caused by a disease called osteomalacia, which does not occur in Canada, so far as I know, but is endemic in certain parts of Europe and other countries with hot climates. The disease causes extreme softening of the bones in adults, and frequently extreme deformity of the pelvis. Deformity from Tumors, Exostoses, etc. Various bony tumors, both simple and malignant, in the pelvis cause serious obstruction to labor. Simple bony tumors include exostoses, ossifications of insertions of ligaments and tendons, masses of callus, results of rheumatoid arthritis, etc. Malignant tumors of the bone are gen- erally sarcomata, but occasionally carcinomata. They are most likely to cause serious obstruction, because they grow very rapidly during pregnancy. CONTRACTED PELVIS The following conditions indicate the probability, or at least the possibility, of contracted pelvis : Extreme smallness of figure. Kyphosis (curvature of spine with convexity posterior). Scoliosis (lateral curvature of the spine). Lordosis (curvature of spine with convexity anterior). Unequal length of legs. Pendulous abdomen. Difficult previous labor. Variations from normal labor, such as : Premature rupture of the membranes. Prolapse of the cord. Non-engagement of the head in the pelvis. Descent of the large fontanelle with sagittal suture in trans- verse diameter of the brim. Striking descent of the small fontanelle, as in generally con- tracted pelvis. An extremely small woman generally has a small pelvis; a woman with marked curvature of the spine, with one leg shorter than the other or with pendulous belly, generally has a distorted or contracted pelvis. A patient showing any such conditions should be examined very carefully. If there is a dwarf pelvis or an extreme contraction of any sort, one can quickly come to a decision. The greatest difficulties as to passing judgment will arise in the minor degrees of contraction, when one has to con- CONTRACTED PELVIS 483 sider such alternatives as induction of premature labor, version, forceps delivery — or, to go a little farther, symphysiotomy, ab- dominal section, and embryotomy — and make a proper choice. Variations from Normal Labor. — The variations of special importance are noii-cngagcnient of the head in the pelvis and abnormality as to either fontanelle. When one can easily feel the large or anterior fontanelle there is always something abnor- mal. It is generally satisfactory to be able to feel the small or posterior fontanelle after labor has advanced to a certain extent, but it is not satisfactory to be able to reach it early in labor while the head is at the brim. Some obstetricians attach considerable importance to this and designate it posterior fontanelle presenta- tion, as distinguished from vertex presentation. It means undue or extreme flexion before the head has entered or when it is enter- ing the brim. This abnormal position is commonly produced by a generally contracted pelvis causing sufficient obstruction to produce the early flexion, but it is also produced in the case of a very large foetal head coming into a normal pelvis. Mechanism of Head Presentation in a Flattened Pelvis. — This may be briefly described as follows : The long occipito-frontal diameter of the head is in the trans- verse diameter of the brim. As the head descends the posterior parietal bone is partially stopped by the promontory, causing the head to rotate on its antero-posterior axis, inclining a side of the head toward the cor- responding shoulder. As a result the sagittal suture approaches the promontory and the anterior parietal bone lies lowest. This is sometimes called Naegele's obliquity or anterior parietal 'presentation. The head is caught between the sacrum and symphysis in front of the parietal eminence. Flexion is thus prevented and some extension takes place. The posterior parietal bone generally rounds the promontory, is grooved vertically, and occasionally fractured. In a small proportion of cases the posterior parietal bone lies lowest and the sagittal suture approaches the pubes. The anterior parietal then rounds the symphysis, the posterior parietal being grooved as in the other case. The posterior parietal presentation is much less favorable than the anterior. As soon as the head passes through the brim the occiput 484 DEFOEMITIES OF THE BONY PELVIS rotates to the front and delivery is completed as in the ordinary- vertex presentations in the normal pelvis. Mechanism of Head Presentation in a Generally Contracted Pelvis. — The extreme flexion of the head making the posterior fontanelle the presenting part at the brim is the chief feature of the mechanism, as before mentioned. Apart from this there is nothing special to note. If the contraction is not too great in proportion to the size of the head, the mechanism is similar to that of vertex presentation. TREATMENT Minor Degrees of Contraction. — Opinions vary greatly as to the proper treatment in cases of slight contraction of the pelvis — i. e., when the true conjugate measures 4 to 3^ inches. I had a patient a year ago pregnant for the third time and supposed to have marked contraction of the pelvis. Ten years ago symphysi- otomy at full term was performed by Drs. Atherton and Burns and a healthy child (still living) was extracted with the forceps. During her second pregnancy she was under the care of physicians in Charleston, S. C, who induced premature labor at the end of the seventh month. The child was born alive, but died in a short time. In her third pregnancy she came to Toronto (her home in girlhood) when six months advanced. After careful measurements, using Shultze's instrument for external pelvimetry, and fingers and Skutsch's instrument for internal, I concluded that there was slight general contraction without any flattening, and decided to watch her carefully and induce premature labor if at any time it seemed advisable. I thought that interference would not be necessary before the end of the eighth month and hoped she might go on to full term. As the head could always be pressed into the brim there was no interference until labor commenced about one week after the expected date. The vertex presented — O. L. A. — the head had entered the pelvis when I first examined her. At the proper time she was anesthetized, and a well-formed living child weighing six and a half pounds was extracted with forceps without any special difficulty. The child died shortly after birth, from what cause I do not know. It is not often that one patient in three successive pregnancies gets such varied methods of treatment. One can not give a pos- itive opinion without knowing particulars as to whether symphysi- CONTEACTED PELVIS 485 otomy was necessary or advisable ten years ago; but certainly it was justifiable, and the results were eminently satisfactory in all respects. Similarly one cannot say, without knowing partic- ulars, whether the induction of premature labor was necessary or advisable in the second pregnancy; but it is always a pity to have to deliver a foetus at the end of the seventh month. Each week thereafter during the eighth and ninth months, under ordi- nary circumstances, increases the vigor of the child. In the third pregnancy it was easy to discover that the induction of premature labor was not necessary at any time in the eighth or the first half of the ninth month. The following general directions as to treatment in minor degrees of contraction may be given. When it is known or even suspected that the patient has pelvic contraction, an examination should be made at the end of the seventh month, and, if necessary, every week or ten days there- after until it is found that the head can not be made to enter or engage in the brim. Use Miiller's method as follows: Place the patient in the cross-bed position ; introduce one or two fingers into the vagina and palpate the head. Then let an assistant grasp the head through the abdominal wall and try to push it down through the brim. If he succeeds, the induction of labor is not necessary. If in the next trial the head can not be pushed through the brim, labor should be induced at once. Miiller's method is the best, but one can sometimes push the head through the brim when the patient is lying in the ordinary semirecumbent position and be sure of doing so without an internal examination. The cervix frequently dilates slowly or imperfectly, rendering artificial assistance necessary or advisable. In the second stage allow the head to "mold" at the brim for one hour. If it engages in the brim, allow it to mold for two hours longer, during which time it will probably be pushed through the brim. If delivery has not been accomplished, apply the for- ceps in accordance with the rule that the second stage should not be allowed to last longer than one to three hours. If at the end of one hour the head shows no tendency to engage the brim, turn and treat as an ordinary pelvic presentation. Forceps versus Version in Slightly Contracted Pelvis. — It was formerly generally supposed that the disadvantage of forceps as 486 DEFORMITIES OF THE BONY PELVIS compared with version was the bulging of the parietals in the conjugate during traction. Milne Murray and Porter Mathew have shown clearly by certain experiments that such bulging does not take place because the child's head, instead of being a continu- ous elastic box, is made up of segments which, under pressure, glide under and over one another. It may be admitted that when it is possible to extract a living child version has no advan- tage over good axis-traction forceps properly applied, and in the interest of the child forceps delivery has some (not ''every") advantage. It has been demonstrated that much can now be done with the axis-traction which could not formerly be accom- plished with the ordinary long forceps. It unfortunately happens, however, that the application of the forceps to a head which has not engaged in the brim is exceed- ingly difficult as well as dangerous in the majority of cases to both mother and child, although such dangers are lessened in the hands of experts who have become skilled by considerable prac- tice. Turning is easier of performance and safer, as a rule, than the high forceps operation, and should be the operation of election when the head is above the brim. When the head has partially engaged, but the greatest diameter of the head is still above the brim, it is not easy to give a fixed rule. If one has waited three hours for the head to mold and finds the head has engaged well, even though not certain as to the position of its greatest diameter, he should apply the forceps and use traction with the patient in Walcher's position. If in any case the accoucheur has properly applied the for- ceps so that they hold and is unable to bring the head down, he should not on any account attempt version. Jardine, who has had a varied and extensive experience in difficult obstet- rical cases in the Glasgow Maternity Hospital, tells us that most of the cases of rupture of the uterus have been caused by such procedures. While the general rule should be to turn when the head has not engaged, there should be certain exceptions. One should not turn when rupture of the uterus is threatening, or when there is tetanic contraction of a uterus from which the waters have long escaped. Under complete anaesthesia, however, the tetanic con- traction may wholly or partially disappear. I have turned in a number of cases of shoulder presentation after I found the uterine CONTRACTED PELVIS 487 walls grip the foetus very tightly, and have often been surprised at the marked change produced by anaesthesia and the ease with which I accompUshed my task. Mechanical Advantages of Turning. — (1) After turning, the narrower bitemporal diameter is first engaged in the contracted conjugate. (2) The head of the child is shaped like a cone, the narrowest portion being the base of the cranium. After turning, the apex of the cone is brought first into the contracted brim, and can be more easily pulled through than the broader base of the cone can be pushed through by the uterine contractions or pulled through by the forceps. Some obstetricians do not attach much importance to these points. Dublin method. In flattened pelvis, the true conjugate measur- ing 4 to 3-2^ inches, or in generally contracted pelvis measuring 4 to 3f inches, the Rotunda obstetricians do not apply the forceps when the head is above the brim. Their choice is between pro- phylactic version and leaving the head to mold. I do not know their precise rules as to choice between the two. According to Jellett, when they decide to allow the head to mold through the brim of itself the only special assistance they can render is by plac- ing the patient on the correct side. In a generally contracted pelvis, she should lie upon the side at which the posterior fontanelle is, in order to favor its descent. In a flat pelvis, she should lie at first upon the side at which the forehead is, in order to favor the descent of the anterior fontanelle, and as soon as this takes place upon the opposite side to favor the descent of the occiput. With such exceptions they leave the case to Nature until signs of danger to the mother or child appear. In such cases they may apply the forceps. They do not as a rule apply the forceps until the head has passed the site of contraction. In case of failure with forceps, or if the child is dead, they perforate. There is one very unsatisfactory feature in this line of treat- ment. It occasionally means craniotomy on a living child. This is the most horrible operation in the whole range of obstetrical surgery, and probably most of us think it should never be per- formed. The Roman Catholic Church forbids its performance, for which I honor her. If, however, we have left our case to Nature for a considerable time, then applied forceps, but failed to deliver the living child, what are we to do? We may regret that we did not before decide on Csesarean section. We may now 488 DEFOEMITIES OF THE BONY PELVIS perform this operation, but the chances for our patient's recovery will have been much lessened on account of our delay. There seems to be a general consensus of opinion now that Caesarean section should be done before or in the beginning of labor, and not after we have tried other methods, such as version or traction with forceps. Under such circumstances symphysiotomy is con- sidered by some the most suitable operation. If we are unable to complete delivery after a reasonable trial of the ordinary methods, the child being aHve, and advise Caesa- rean section or symphysiotomy, and if the patient and her hus- band refuse consent, what shall we do? In the Rotunda, under such circumstances, they perform craniotomy. Treatment in the second degree of contraction when the true conjugate measures 3^ to 3 inches. This degree of contraction is, I think, very uncommon in Canada. Many believe that the induc- tion of premature labor is the best treatment if one sees the patient sufficiently early in pregnancy. If one does not see the patient before the advent of labor, the choice lies between version, use of forceps, symphysiotomy, Caesarean section, and craniotomy. The chances of delivering a child of average size alive either by version or by use of forceps are not good; but the chances of delivering a small child by either method are at least fair. Delivery by either method is possible with a conjugate of 2| inches if the child is small. Treatment in the third stage of contraction with a conjugate of 3 to 2 inches. A symphysiotomy is of doubtful utility with a conjugate under 3 inches, but it sometimes gives good results down to 2| inches. It is not, as a rule, justifiable with a conjugate less than 2| inches. After symphysiotomy the only alternatives are Caesarean section or embryotomy. Treatment in the fourth degree of contraction with a conju- gate of 2 inches or less. Caesarean section is the only justifiable or possible operation. Extraction of even a mutilated child is either impossible or accompanied with serious difficulty and great danger to the mother. Summary of Rules for Treatment. — Treatment in minor degrees of contraction with true conjugate 4 to 3^ inches (10 to 8 cm.). During Pregnancy. Examine patient every week or ten days during eighth and ninth months to ascertain when the head can- not be pushed into brim. Then induce labor. INJURIES TO CHILD DURING DELIVERY 489 During Labor. Perform version as soon as possil^le and treat as an ordinary breech case; or, allow the head to mold through the brim and let Nature complete the delivery ; or, allow head to mold two or three hours, and then use forceps. In second degree of contraction with true conjugate 3:^ to 3 inches (8 to 7 cm.) : Induce premature labor at end of seventh month; or, perform symphysiotomy; or, perform Csesarean sec- tion; or, perforate if child is dead. In third degree of contraction with true conjugate 3 to 2 inches (7 to 5 cm.) : Perform symphysiotomy ( ?) ; or, perform Csesarean section; or, perforate if child is dead. In fourth degree of contraction with true conjugate below 2 inches (5 cm.) : Perform Caesarean section. INJURIES TO CHILD DURING DELIVERY Caput Succedanaeum. — This is simply a serous infiltration of that portion of the presenting part which corresponds to the exter- nal OS. The lump is largest immediately after birth, and usually disappears in three or four days. It requires no treatment, CephaLhaematoma. — This is an effusion of blood between the pericranium and the bone in any part of the vault of the cranium. It occurs about once in two hundred labors. In rare cases the blood is effused under the occipito-frontalis tendon. When the blood is effused under the pericranium, it cannot extend beyond the bone over which the effusion occurs. The swelling is generally found in the situation of the caput succedanaeum and is occasion- ally double. After a time a bony ridge is found round the edge of the swelling. The whole lump sometimes becomes hard and bony. It is distinguished from the caput succedanaeum by the fact that it is not present immediately after birth, by its fluctua- tion, its long persistence, and its limitation to one bone ; and from a meningocele, because the latter is situated over a fontanelle or suture and swells when the child cries. Treatment. Do not interfere with it in any way. Spontaneous cure takes place in from fifteen days to two months in the great majority of cases. If, however, it becomes painful, or persists more than two months and still appears soft, Treeves advises aspiration of the mass and the application of firm pressure. I have never found such interference necessary or advisable. 490 DEFOKMITIES OF THE BONY PELVIS Depressions of the skull sometimes occur, especially during artificial delivery. They are most frequently produced by the promontory of the sacrum, some other bony prominence, or by the forceps. They are cup-shaped, spoon-shaped, or furrow-shaped, and are most frequently found on the anterior part of the parietal or on the frontal bone. Treatment. Apply pressure to the head obliquely. The de- pression will thus disappear quickly sometimes. In other cases the depression gradually disappears in a few days or a few weeks. When the depression does not disappear, but causes serious symp- toms, surgical interference becomes necessary. Fractures of bones are said to be caused sometimes by blows received by the mother before labor. Jardine reports a case of intra-uterine fracture of the skull. Fracture of the skull occasionally occurs during delivery. When the bone is also depressed, causing injury to the brain or haemorrhage, the condition becomes very serious and frequently results in death. When there are symptoms of pressure, elevate or trephine the depressed bone. Fracture of Long Bones. — The long bones which are most fre- quently fractured are the femur, clavicle, and humerus. Treat in the usual way by the application of plaster or splints. Injury to Muscles. — Haemorrhage sometimes occurs in the substance of muscles, especially the sterno-cleido-mastoid, caus- ing a hard lump or haematoma. It is apt to occur a few days after birth and usually disappears in a few weeks. Injury to the Eyes. — In high or mid-forceps delivery one blade usually presses over or near the eye. Generally no injury results, but occasionally the eye is more or less hurt or even destroyed. In a flat pelvis the injury to the eye is sometimes caused by the promontory. Sometimes subconjunctival haemorrhage or haem- orrhage into the back of the orbit occurs, but is generally soon absorbed. Corneal opacities have not infrequently occurred in the Glasgow Maternity Hospital. Jardine tells us that in most of the cases the opacity cleared up, but there was usually a linear scar left in the vertical axis. Injury to Nerves. — Pressure of the forceps blade frequently causes injury to the seventh nerve, resulting in facial paralysis. Usually improvement commences in a few hours and the paralysis disappears in a few days. Injury to the brachial plexus is a very DISEASES OF THE NEW-BORN CHILD 491 rare event, but cases of such injury throufi;h dislocation of the head of the humerus are reported. Another rare form of paralysis of the arm, affecting chiefly the deltoid, biceps, and supinator longus muscles, is known as Duchenne's paralysis. ABNORMALITIES AND DISEASES OF THE NEW-BORN CHILD Imperforate Anus. — As before stated, one should always con- sider the possibility of imperforate anus when examining the new-born child. Sometimes there is a condition akin to imper- forate anus, of complete obstruction of the bowel one-half inch above the anus. If the bowels do not move within a few hours after birth, examine the rectum by passing up the little finger. Treatment. Operate at once. Incise and carefully dissect upward until the blind end of the rectum is reached. Dilate the opening thus made, daily, with a bougie to prevent con- traction. Umbilical hernia in a minor degree is not unusual. It should be treated by the application of a simple pad made of a penny or a piece of sheet lead properly covered, or by a special rubber pad as made by the manufacturers, kept in position by a piece of ad- hesive plaster or an abdominal bandage. Umbilical Haemorrhage. — Apart from haemorrhage which may occur from insufficient ligation or slipping of the ligature, second- ary haemorrhage occasionally occurs between the fifth and fifteenth day. The supposed causes are syphilis and haemophilia. Treatment. In the majority of cases the patient dies because the haemorrhage cannot be controlled. Use a compress of lint saturated with a styptic tightly applied with adhesive strips; or transfix umbilicus with two needles placed at right angles and surround tightly with a figure-of-eight ligature. Umbilical vegetations from the floor of the umbilical fossa sometimes appear after the falling of the cord. Treatment. Cauterize with solid stick of nitrate of silver and apply a dry dressing of boric acid. Engorgement of the breasts is quite common in infants, and generally appears between the fourth and tenth days after birth. A milky fluid is secreted and can easily be squeezed out, but unfortunately the squeezing-out process is fraught with 492 DEFOEMITIES OF THE BONY PELVIS danger and not infrequently causes suppuration. Without such squeezing suppuration may occur from septic infection. Treatment. Be sure to warn the nurse not to squeeze the breasts. Avoid everything that is hkely to irritate. Do not allow even rubbing with warm oil, as frequently recommended. Put a pledget of cotton over the breast under the binder for pro- tection. When suppuration occurs incise freely at once. Jaundice or icterus is very common in early infant life. It generally requires no treatment, although it is perhaps well to give one dose of castor oil or a half grain of gray powder three times a day for six doses. Occasionally a severe form of icterus occurs, caused by or accompanied by occlusion of the bile ducts or syph- ilitic disease of the liver. It is usually fatal. Club feet should be carefully looked after by the physician and nurse. The nurse when instructed by the doctor can do much in the way of curing the deformity by straightening the foot and massage of the faulty muscles many times a day. A simple medicated oil, such as a weak menthol liniment, a dram each of chloroform and menthol in four ounces of olive oil, may be used. Spina bifida is really a spinal meningocele due to a gap in the spine. This is a very serious condition, and should be treated by a skilled surgeon. Ophthalmia neonatorum is a form of purulent conjunctivitis most frequently caused by gonorrhoea. The symptoms generally appear on the second or third day, but may be present at birth. When the symptoms appear five days or more after birth, they are generally due to infection by attendants. The inflammation is very virulent and frequently causes irreparable damage. Symptoms. The eyelids become red, and swollen with a copious secretion, at first serous but soon becoming purulent. If prompt treatment is not adopted the eyes are soon destroyed. Prophylatic Treatment. Employ antiseptic vaginal douches in all cases in which the patients have suspicious discharges. Drop two or three minims of a 2 per cent, solution of nitrate of silver into each eye of the babe after the head is born. Separate the lids before putting in the drops. This is done as a matter of rou- tine in all cases in the Burnside Hospital. We find the nitrate of silver (Crede) more satisfactory than a solution of bichloride 1 to 2,000, or a solution of protargol, 20 per cent. In private prac- tice it is generally sufficient to wash out the eyes with a solution DISEASES OF THE NEW-BORN CHILD 493 of boric acid. If, however, there is a vaginal discharge, one should always use one of the strong antiseptic solutions. Curative Treatment. Obtain the assistance of a skilled oculist at once if possible. Wash away the pus with a saturated solution of boric acid, and instil a couple of drops of a solution of silver nitrate every two hours. Cyanosis is generally caused by some malformation of the heart, such as non-closure of the foramen ovale, or deficiency in the interventricular septum or great vessels, such as the pulmo- nary artery. As a consequence the blood is deficient in oxygen and has an excess of carbon dioxide. The resulting blueness of the skin is most pronounced over the cheek-bones, nose, lips, and fingers. The action of the heart is rapid and tumultuous; various sorts of bruits are sometimes heard; the respiration is disturbed; evidences of failure of nutrition usually soon appear. Most babes thus affected die within a few months after birth. They may, however, live for years, but always show signs of impaired vitality. The main indication as to treatment is to keep the child as quiet as possible. Tetanus neonatorum is a rare disease beginning within ten days after birth. After some fretfulness and disinclination to nurse, rigidity of the muscles appears and reaches its maximum in twelve to twenty-four hours. The rigidity generally commences in the masseter muscles ; the head is soon thrown back with per- haps opisthotonus, while there is general flexion of the extremities. It is a specific disease due to the invasion of the tetanus bacillus, the seat of infection being most frequently the umbilical wound. Treatment. Preventive treatment by cleanly management of the cord is the most important consideration. The disease when established is nearly always fatal. The best medicines are chloral and sulphonal by the rectum, one to two grains of the former every hour; three or four grains of the latter every two hours; or the tetanus antitoxin as produced by our leading manufacturing chemists. Discharge of blood from the vagina occasionally occurs. As a rule, it is not at all serious and ceases in a day or two. Syphilis. — The infant may show symptoms of syphilis at birth or shortly after birth. The earlier the symptoms appear the worse the attack will be. The symptoms are the ordinary copper- colored eruption, bullae especially on palms of hands and soles of 494 DEFOEMITIES OF THE BONY PELVIS feet, coryza, fissures of anus and mouth, emaciation, and evidences of visceral and bone disease. Treatment. Administration of mercury by the mouth or preferably by inunction. Er3rthema intertrigo is a hypersemic disorder occurring between the thighs and over the buttocks. As a rule there is no infiltra- tion or thickening, and thus it is distinguished from eczema ; but sometimes it grows worse and becomes an actual eczema. It is generally due to want of care in changing the napkins and cleans- ing the parts, but it may occur under the most careful nursing. Treatment. It is of course important to change the napkins as soon as they become moist and cleanse the parts thoroughly. Use very bland soaps, and remember that too much water often increases the irritation. The best apphcations are : first, dusting powders ; second, lotions ; third, ointments. The best powders are boric acid, talcum, or the old-fashioned baked flour. The following mixture answers well: 5 Pulveris acidi borici 3 j ; Pulveris zinci oxidi 3 j ; Pulveris talci 3 v. One of the best lotions is a saturated solution of boric acid. One of the best ointments is cold cream. Tongue-tie is said to exist when the frenum is too short or comes too far forward. It occasionally prevents the child from sucking, but nothing hke so frequently as is supposed by the laity. Treatment. Place the babe with its head on the nurse's knees toward the surgeon. Raise the tip of the tongue, put the frenum on the stretch with two fingers of the left hand and cut through its thin edge with a sharp pair of scissors, pointing the scissors downward parallel to the ranine veins. Then tear the frenum with the tip of the nail of the forefinger of either hand to an extent sufficient to allow free movement of the tongue. If a free cut is made with the scissors parallel to the base of the tongue, dangerous haemorrhage may ensue. Thrush or sprue is the common name of a parasitic stomatitis, the parasite being the oidium albicans or saccharomyces albicans which is identical with the mold of wine. White patches appear in many parts of the mouth, including the tongue, cheeks, and DISEASES OF THE NEW-BORN CHILD 495 hard palate, and occasionally the soft palate, pharynx, and per- haps the stomach and intestines. Treatment. Strict cleanliness in all respects will prevent thrush. When the patches appear, apply the glycerinum acidi borici or a solution of salicylic acid 1 to 250 frequently. The solu- tion of borax and honey so commonly used is objectionable, be- cause the honey tends to increase the growth of the parasite. Indigestion is frequently a complication, and should be treated with half-grain doses of gray powder or teaspoonful doses of castor oil. Colic is one of the most frequent ailments of infancy. The most common cause is some error in feeding. The most common symptom is an intermittent and loud cry, the infant drawing up its knees during the paroxysm. The babe sometimes cries because of hunger, but such a cry is more constant, less loud, and more like fretting. Treatment. Observe great care as to food and regularity in feeding. Carminatives, such as peppermint, anise, fennel, gin, whisky, etc., should be avoided. Half a teaspoonful of glycerine to an ounce of warm water may be given, or as much of this mix- ture as the babe cares to take. A high enema of a pint of warm water through a double rubber cannula or an ordinary enema of a dessertspoonful of glycerine in three ounces of hot water will sometimes have a good effect. One grain of chloral hydrate with ten drops of glycerine and a teaspoonful of warm water will often afford prompt relief. Half-grain doses of gray powder three times a day for two days, or a single teaspoonful dose of castor oil, as recommended for thrush, will often produce good results. Adherent prepuce and phimosis. — Every male child should be carefully examined the first week after birth to ascertain the condition of the prepuce. There is commonly slight adhesion, and occasionally contraction or phimosis. Treatment of adhesion. " Strip " the glans and secure, if pos- sible, a prepuce freely movable. The mother or nurse should retract the prepuce and wash the parts daily. If an easily glid- ing prepuce cannot be obtained on account of phimosis, some cutting operation such as circumcision is necessary. Complete removal of the foreskin, however, leaves a tender, sensitive glans exposed — a condition not generally desirable. 33 . CHAPTER XXIV OBSTETRICAL OPERATIONS General Considerations. — The important consideration in all kinds of obstetrical procedures is cleanliness, involving as it does both asepsis and antisepsis. For reasons already given it will be considered that asepsis alone is not sufficient for obstetrical opera- tions, because the parts concerned cannot be made aseptic. During childbirth our aim is to have the patient clean in every part of her body. She gets her bath and lies on a clean bed. In addition, the vulva and adjacent parts are thoroughly scrubbed with soap and hot water. Nearly all soaps are more or less anti- septic, but green soap, which is the best for such purposes, is strongly so. We then wash with our antiseptic solutions. We consider for obstetrical purposes that the corrosive sublimate solution answers admirably for this external cleansing, and that lysol solutions and iodoform gauze are better suited for the utero- vaginal canal; or, if we are limited to one antiseptic, we choose lysol as the one that is suitable and efficacious in all sorts of obstetrical procedure. We endeavor to have our hands, instruments, and all the sur- roundings absolutely clean. Under such circumstances we dilate the cervix, apply the forceps, perform internal version, deliver the placenta manually, etc., without any further attempts at asepsis or antisepsis. At this point we differ to some extent. Many think that in most forceps deliveries, and in all cases where the hand has been introduced into the uterus, an intra-uterine douche is advisable. Others think that such an intra-uterine douche is generally harmful to some extent, and that it is unnec- essary if a clean hand has been used. The gynaecologist, as a rule, will not perform any operation on the vagina or uterus without endeavoring to make the whole field, including the vagina, abso- lutely free from organisms, so far as such can be accomplished. There is a certain class of obstetrical operations in which the rules of the gynaecologist are advisable. It may be well to refer to 496 GENERAL CONSIDERATIONS 497 some notes of warning given by the gyniecologists which are of equal importance to obstetricians under all circumstances. The nurse may inadvertently convey septic matter to the patient. One should neyer consider that a nurse is surgically clean until he has proved her to be so, no matter through what training school she has passed. I witnessed a very important operation not long since, when one of our best surgeons did his work in a very skilful and cleanly way. He was assisted by two surgeons and two nurses, I being simply an onlooker. One of the nurses happened to make three or four mistakes. She pushed up her left sleeve once with her right hand when it was not surgically clean; she allowed surgical dressings to touch the same sleeve twice; she touched a chair at another time after she had carefully washed her hands and had commenced to handle the dressings. Such mistakes are not small — they are wofully and terribly large. The patient died of septicaemia. I cannot say that the nurse referred to (a very worthy and conscientious woman) was respon- sible for the poisoning ; but I know the operation was not aseptic, while the surgeon-in-chief thought it was. It is to be feared that both general surgeons and obstetricians still make many mistakes about these supposed small matters. They know, perhaps, that it is not safe to take a needle and thread from the floor and use them, but they frequently do not know how to sterilize the same piece of thread. In some cases they think that, after soaking it for a few minutes in a 2 or 3 per cent, solution of lysol, or a couple of minutes in boiling water, it will be sterile. Certain germs, and especially certain spores, will not be thus destroyed. In all operations involving the invasion of the vagina during pregnancy, such as induction of abortion, removal of blighted ovum, curettement in inevitable abortion, induction of premature labor, etc., it is better to prepare the vagina as for a vaginal hys- terectomy. Such preparation is probably advisable, even though it be considered that in the great majority of cases the vagina is practically sterile. It may be considered sterile in a sense because it contains no pathogenic cocci, and therefore nothing which can produce septicaemia. It does, however, contain bacteria, which produce putrefaction under certain circumstances (see page 366). I fear these bacteria in operative work before and after labor, but I generally disregard them during labor. 498 OBSTETEICAL OPERATIONS Preparation of Patient. — For any operation on the genital organs during pregnancy, commence to prepare the patient one or two days before the operation. It is better to have the prep- aration made by or under the supervision of a nurse. On the day before operating give her a purgative before breakfast, and administer an enema about eight or nine o'clock in the evening. Give her a bath about one hour after, scrubbing her well, using soap and fairly hot water. Put her in bed and as soon as con- venient administer a vaginal douche, using a gallon or two of fairly hot lysol solution 1 per cent. On the morning of the oper- ation administer another enema of warm boric solution 3 per cent., three or four hours before the operation. As soon after this as convenient, shave or cut closely with scissors sufficient hair from the labia majora and mons veneris to give clear space for opera- tion. Wash the pubic, peritoneal, and anal regions and the inner surfaces of the thighs with soap (preferably green soap) and hot water, and finally a hot solution of lysol 1 or 2 per cent. The nurse may then apply a vulvar pad soaked in a 1 to 100 lysol solution or a 1 to 2,000 bichloride solution. When the operator arrives he should first prepare himself, arrange his instruments which have been sterilized, and see that the nurse has completed her preparations. Then see that the bladder is empty. After the bladder is emptied rinse the hands in the lysol solution which is in a basin close at hand. Then wash vulva and adjacent parts as was formerly done by the nurse. Then scrub the vagina with green soap and hot water, using a piece of absorbent cotton as a mop. Then douche thoroughly with lysol solution. The patient is now prepared for the operation. Sterilizing of Instruments. — Various forms of sterilizing cham- bers are in use, some of which are very good, while others are of doubtful utility and difficult to manage. Fortunately, they are not required, as we can thoroughly sterilize our instruments, appliances, ligatures, etc., by keeping them in boiling water for fifteen minutes. A small teaspoonful of common salt and half a teaspoonful of sodium carbonate should be added to each pint of water. After the instruments are sterilized they should be placed in a 1 per cent, solution of lysol or in plain sterilized water. As the boiling dulls the edges of sharp instruments and the points of needles, I prefer to sterilize knives, scissors, needles, etc., by first washing in soap and water or warm lysol solution, then im- GENERAL OPERATIONS 499 mcrsing in pure lysol for five minutes, and then placing them in lysol solution 1 per cent, or sterile water. GENERAL OPERATIONS Sutures. — Most of the wounds caused during parturition should be sutured. Asepsis and antisepsis have made the modern suture absolutely safe. In obstetrical surgery, silk, silkworm gut, cat- gut, kangaroo tendon, and silver wire are used. We can easily sterihze our silk, silkworm gut, kangaroo tendon, and silver wire, but it is more difficult to sterilize the catgut. It is better to have it absolutely sterile and at the same time sufficiently antiseptic to make it unfit as a culture medium for pathogenic microbes. The kangaroo tendon is suitable for cases in which the catgut is used, and some say safer, because the tendon can be easily sterilized and is less susceptible to infection than the catgut. The silk is tied in a reef knot or a surgeon's knot, silkworm gut in a surgeon's knot, kangaroo tendon in a reef knot, catgut in a triple reef knot, silver wire is twisted. Hypodermic Injection. — This small operation may seem insig- nificant, and yet it is sometimes followed by serious consequences. A few years ago one of our students had serious septicaemia from the use of a hypodermic syringe. Senn reports a very distressing case. The father of a young, promising physician suffered from a painful but not serious affection. The son made a hypodermic injection of morphine. The patient died in a few days from acute sepsis, which had its starting-point at the seat of puncture. The needle had not been sterilized. Hypodermic needles and trocars should always be sterilized by keeping them fifteen minutes in boiling soda solution. Do not pass them through a flame or dip them in lysol solution. The boiling process is the only safe pro- cedure. Thoroughly cleanse the seat of puncture before intro- ducing the needle. This can be done with soap and water ; but it is safer to also clean the skin with turpentine or lysol solution. Subcutaneous Injections of Salt Solutions. — Add a teaspoonful each of common salt and acetate of soda to a pint of sterilized water raised to a temperature of 100° F. Various forms of apparatus have been invented, but the simplest way is to use an aspirating needle attached to a rubber tube having a funnel or fountain of some sort at the upper end. Clean thoroughly the seat of puncture, 500 OBSTETEICAL OPEEATIONS as before described. Make a small incision in the skin with a scalpel and push in the needle while the water is running through it, to prevent the injection of air. The injections are most com- monly made behind the mammary gland. High Rectal Enemata. — Add a teaspoonful each of salt and acetate of soda to a pint of warm water. Use a fountain syringe with a large gum-elastic catheter as a nozzle. Pass the catheter about eight or nine inches up the bowel. This should be done very gently, as the sphincter ani is frequently very irritable and some patients object seriously to the procedure. Most people can retain 12 to 16 ounces. Absorption as a rule takes place quickly. Prolonged irrigation of the bowel with a hot salt solution (tem- perature 120° F.) is sometimes done, as already mentioned. For this a double-current cannula is employed and several gallons of solution are used. Intravenous Injection of Salt Solution. — In this procedure the saline infusion (common-salt-sodium-acetate solution) is injected directly into the vein. The apparatus employed may be the same as that for subcutaneous injection, a small cannula taking the place of the needle. Cleanse the skin over the median basilic vein. Put a snug bandage round the arm below the shoulder. Make an incision one inch long parallel with and close to the vein. Free the vein from its attachment for half an inch with the handle of the scalpel. Introduce beneath the vein an aneurism needle threaded with a double silk ligature. Cut the ligature, retain both strands in position, and remove the needle. Draw one of the ligatures into the lower angle of the wound and ligate the vein. Draw the other ligature into the upper angle of the wound and tie loosely one-half of a reef knot. Pick up the vein with a pair of dissecting forceps and make an oblique upward slit with scissors, taking care to cut through the entire caliber of the vein. Pass the cannula, with the solution running through it, quickly into the vein. Remove the bandage from the arm. Then draw tightly the half knot round the vein and cannula. Hold the funnel or fountain about three feet above the vein and introduce one or two pints of the solution. Then withdraw the cannula, tighten the ligature and complete the reef knot. Cut ends of both ligatures close to the knots. Divide the vein completely between the lig- atures, close the skin incision by two or three sutures, and apply a suitable dressing. GENERAL OPEKATIOXS 501 Catheterization is always dangerous, because it may cause a troublesome or incurable cystitis. It is sometimes a very difficult operation to perform during labor and after labor. During labor the difficulty is generally .produced by the pressure of the present- ing part on the urethra; after labor, by the distortion due to bruising and tearing. Choice of Catheter. A soft-rubber catheter (Nos. 10 to 12, English) is generally preferred. It is not easy to sterilize such an instrument. If it becomes septic, or if there is reason to suspect that it has, do not try. Have a clean new rubber catheter in the satchel. Before using it wash it with soap and warm water, and leave it for a time in 5 per cent, solution of lysol. After using it wash it again with soap and water, then use a soda solution, and finally leave it in a 2 per cent, solution of lysol or a 1 to 2,000 solu- tion of bichloride until wanted again for the same patient. When it is no longer required for this patient, destroy it. Never use a soft-rubber or a gum-elastic catheter on a second patient. As the parts are very sensitive, it is occasionally advisable to administer an anaesthetic. I saw not long ago, with Dr. Herbert Hamilton, a patient who had retention of urine after labor. Each of us endeav- ored to pass a soft-rubber catheter and failed. We could pass it in about an inch, but no farther. We then introduced a glass catheter without much trouble. It is well to carry both a rubber and a glass or metallic catheter in the satchel. The patient is placed in the lithotomy position with knees widely separated, as this puts the vestibule on a stretch and generally brings the meatus within easy reach. Never attempt to pass a catheter after labor by the sense of touch under the clothing, but always expose the parts thoroughly in the best possible light. The legs and thighs should at the same time be covered as well as possible. Operation. First wash external parts. Then separate the labia with two fingers of the left hand, so as to bring the meatus into view. Cleanse thoroughly with a pledget of cotton soaked in warm lysol solution, or use a douche with same solution. Take the clean catheter from the warm solution, pass it into the meatus and gently push it along the urethra into the bladder. When dur- ing labor the presenting part is wedged low down in the pelvis, place two fingers of one hand on this head or breech, as the case may be, and push it up out of the pelvis until the catheter is passed into the bladder with the other hand. If this fails, place 502 OBSTETEICAL OPEEATIONS the patient in the knee-chest position, which will cause the foetus to gravitate away or allow it to be pushed away from the pelvis, when the catheter can be pushed into the bladder. The Douche. — Three kinds of douche are recognized: vulvar, vaginal, and uterine. Vulvar Douche. The patient is placed on her back as described for catheterization. Bring nates to or slightly beyond the edge of bed. Place under the buttocks a Kelly pad or a piece of mack- intosh or oilcloth so arranged that the water as it runs away will be carried to a slop-pail under the edge of the bed. Use an ordi- nary vulcanite or glass nozzle on the end of a tube running from a fountain. Turn the stream first on external part of vulva and adjacent parts. Then separate the vulva with two fingers and direct the stream to parts between them. Vaginal Douche. In all cases the vulvar should precede the vaginal douche. The nozzle and its openings should be sufficiently large to allow a good flow. A double catheter — i. e., one with one tube for the in and the other for the outflow — is not necessary. Most of these found on the market are too small for good work. The best kind of nozzle is made of glass, but it is so easily broken that many prefer one made of vulcanite. The only objection to the latter is that boiling water soon spoils it. A metallic nozzle is suitable in many cases, but not for a very hot douche, because the metal, being a good conductor of heat, becomes hotter than the patient can bear. The openings in the nozzle, should be slits, not round holes, and situated at the sides, never at the end. A nozzle with a hole in the end is more convenient for douching the external part of the vulva and adjacent parts, but one prefers as a rule to complete the procedure without changing nozzles. For purely external douching the nozzle with the shts at the sides may require to be turned sidewise, or the solution may be poured over the vulva from an ordinary pitcher. After this, separate the labia as before described, place the end of the nozzle just within the vagina, and the flow from the side slits will accomplish what we want. The patient has been placed in proper position for the vulvar douche. Keep her in the same position and introduce the nozzle well into the vagina. While doing so also introduce two fingers into the vagina and separate so as to insure a good outflow. Or the two fingers may be first passed into the vagina, then separated, and nozzle passed between them. • GENERAL OPERATIONS 503 Uterine Douche. It has boon stated that an intra-uterinc douche, no matter how carefully administered, is frequently fol- lowed by serious results; and one can readily understand that when carelessly administered it is likely to be followed by still more serious results. Two points in connection with the intra- uterine douche should ever be kept in view: (1) unskilful, and even skilful, administration is frequently dangerous; (2) when skilful administration is not dangerous it is frequently useless. The dangers are supposed to arise from shock, forcing fluid or air through the Fallopian tubes into the peritoneal cavity, dis- lodgment of clots from the placental site causing haemorrhage, allowing the entrance of fluid or air into the sinuses, or poisoning from the absorption of the antiseptic, especially when corrosive sublimate is used. Shock was the apparent cause in most of the cases that I have observed. Why shock should be caused by the introduction of hot water into the uterine cavity, when a free outflow is allowed, I do not know. Intra-uterine injections of hot water soon after labor, as for post-partum haemorrhage, appear to cause less serious results than those administered some days after labor, as for septicaemia. I have had no experience of a case where death has been caused by air embolism induced by a douche. Such cases, however, have been reported. Operation. Both the vulvar and the vaginal should precede the intra-uterine douche. ' Introduce the large-sized nozzle such as has been described, and endeavor to pass it up to the fundus. In order to do this the nozzle should be long and have a pelvic curve. It is also especially important that the tube should be large enough to allow a full-sized stream to pass through. In order to pass the nozzle with certainty up to the fundus of the ante- flexed uterus it is necessary to employ some means to straighten the uterine canal and bring its axis more in line with the vagina, as pointed out by Chalmers Cameron. To accomplish it, seize the anterior lip of the cervix with a pair of blunt bullet forceps and draw it gently downward. Be sure that the water is passing through the tube before the nozzle is passed into the uterus. Let the assistant pull on the handle of the bullet forceps while the operator places one hand like a cap over the fundus and occasionally presses on the uterus through the abdominal wall so as to expel all fluids, clots, and debris of every kind. The slight traction on the anterior lip generally keeps the cervix 504 OBSTETEICAL OPERATIONS sufficiently open, and should be continued after the nozzle is withdrawn until all the fluids and debris are pressed out of the uterine cavity by the hand over the fundus. If corrosive subli- mate has been used, some plain hot water should always be injected to wash out or dilute any of the solution that may be retained in either the vagina or uterus after vaginal or uterine douches. One should keep in view the fact that some patients are very susceptible to its evil effects, and also keep in mind the ordinary symptoms of mercurial poisoning. They are diarrhoea with tenesmus, and occasionally blood and mucus in the stools, abdominal pains, sore gums, loosening of teeth, salivation, metallic taste, occasionally vomiting. Curettage. — The use of any metallic curette is seldom advis- able in obstetrical practice. In severe cases of septicaemia, espe- cially in streptococcic infection, it should never be used, for reasons which have already been given. It may be used occasionally with advantage for inevitable abortion during the first ten weeks of pregnancy. It may also be used occasionally for that form of haemorrhage which continues for a long time after labor, due to subinvolution or for secondary post-partum haemorrhage, as before mentioned. Curettage for Early Incomplete Abortion. Prepare the patient by cleansing vulva and vagina. If cervix is not sufficiently dilated, introduce if possible a cervical and vaginal tampon, or dilate with a suitable dilator. The ordinary tents are more or less dangerous. The best position for the patient is on the side (Sims), especially when vaginal tamponage is done, or on the back, especially when a dilator is used for the cervical canal. If the finger cannot be introduced into the uterine cavity, seize the anterior lip of the cervix with volsella or bullet forceps, draw it down gently. Let an assistant seize the handle of the forceps and make steady traction, while the dull curette is passed into the uterus with one hand and the other hand is placed over the fundus so as to ascertain when the instrument has reached the top of the uterine cavity. When this has been accomplished the forceps may be held in one hand, while the curette is used with the other. Scrape the interior of the uterus methodically; first, the anterior surface ; second, the left side ; third, the posterior surface ; fourth, the right side; fifth, the right cornu; sixth, the left cornu. In curetting, always push upward gently (Diihrssen), but scrape GENERAL OPERATIONS 505 downward with a certain amount of force. One is more apt to perforate the uterine wall in pushing upward than in scraping downward. Such perforation with a clean instrument does no great damage in the majority of instances, but its occurrence is a very serious matter when curetting for incomplete abortion with septicicmia or sapra3mia. It is certainly an unpleasant accident in any case. If the instrument suddenly passes into something like empty space, it may be a question whether the uterine wall has been perforated or the instrument has been pushed into one of the Fallopian tubes. Generally, however, the uterine wall has been perforated. After scraping, give an intra-uterine douche of hot salt solution, using a double cannula or some form of nozzle which will insure ample return flow. Anaesthesia is generally advisable but not always necessary for this operation. If a metallic instru- ment is considered necessary a dull curette with a somewhat flexible stem should be used. I know of none better than Thom- as's dull wire curette, which consists practically of a copper wire with a small loop at its extremity. Materials for vaginal, cervical, and uterine tampons are strips of iodoform gauze, iodoform cotton, iodoform linen (more correctly, iodoformed), or strips lysoled, borated, or carbonated — all being previously sterilized. Pledgets or balls of absorbent cotton or wool properly medicated may also be used. DUhrssen frequently uses a combination of iodoform gauze and salicylic wool for one tampon- ade. One long strip is better than a number of separate pledg- ets or balls, because the one strip can be removed more easily and the removal causes less pain. One has only to seize the end of the strip and pull it out slowly, while with a large number of pledgets one has to search for them and remove them separately. The latter objection may be removed, however, by attaching them to a single string about six inches apart, forming the so-called kite-tail. Tamponade. — The use of the tampon has been frequently referred to in other chapters. The chief varieties of tamponades are vulvar, vaginal, cervical, and uterine. The vulvar tampon or the vulvar pad is used to control haem- orrhage from the vulva, especially that due to ruptured labial thrombus or varix. When clots are present, remove them ; if there is a cavity, pack it with iodoform gauze ; if necessary, tamponade the vagina as well; put a pad over vulva, hold in position by a 506 OBSTETKICAL OPEEATIONS T-bandage tightly applied. This T-bandage is applied by passing a fairly broad bandage (about three inches) around the waist and fastening the ends in front. Another piece of bandage stitched to the center behind is brought forward between the thighs over the vulva pad and fastened to the waist bandage in front of the pubes. Vaginal Tamponade. Prepare the parts. See that the bladder and rectum are empty. Place patient in Sims's position. The upper half of the vagina should be ballooned as much as possible, in order to enable one to introduce enough material to properly control haemorrhage or cause dilatation of cervix, or both. The dorsal position is quite suitable for uterine curettage, or even for uterine tamponade, but never for efficient vaginal tamponade. Introduce a Sims's speculum, and let an assistant hold it in posi- tion in such a way as to pull back the perinseum and the posterior vaginal wall. A valvular speculum may be used, but nothing answers so well as a Sims's, especially when there is an assistant. One can manage by using one or two fingers to retract the peri- nseum, as recommended by Shauta; or an imitation of Sims's speculum may be improvised by bending the handle of a dessert- spoon to a right angle close to the spoon. Take the end of the strip in a dressing forceps and first pack the posterior vaginal vault, then left of cervix, then anterior vaginal vault, then right of cervix, then against os. Continue to pack as tightly as possible until about two-thirds of the vagina has been filled. A dilated or ballooned vagina is like an inverted funnel, and one should endeavor to fill the cone but not the pipe or mouth of the funnel. The entrance to the vagina is like the short pipe of the funnel and should not be tightly packed so as to put it on the stretch, because this causes great pain and frequently retention of urine. If the very dilatable vault is properly packed it is seldom, perhaps never, necessary to pack the entrance. It is better to have the material moistened by antiseptic solution, preferably lysol, especially the first half of the tampon. This is particularly important when using iodoform gauze, because it makes more cer- tain the antiseptic action of the iodoform, which is inert if perfectly dry. The wet strip or pledgets can also be packed more firmly than the dry material. The soapy lysol also tends to prevent irritation of the vagina and make the tampon more easy to remove. The simplest plan is to have the long strip or kite-tail in a bottle GENERAL OPERATIONS 507 with a proper cover. Let an assistant remove the cover and hold the bottle while the end of the strip or kite-tail is seized with the forceps and passed directly into the vagina. It is con- venient to moisten the strip by pulling a few feet out of the bottle and placing the portion removed in a basin containing a 1 per cent, warm lysol solution. Then remove from basin, squeeze well, and place on sterile towel close to patient's nates. Then introduce the strip thus moistened into the vagina. An iodoform tampon may be left in the vagina from one to two days, or more if necessary ; a lysol tampon twenty to twenty- four hours; an aseptic tampon eight to ten hours. An iodoform tampon which has been also lysoled will, as a rule, cause little or no irritation. After removal a second may be introduced at once if advisable. A third and a fourth may be introduced without causing much irritation or any septic infection. Intra-uterine Tavi'ponade. Place patient in the cross-bed posi- tion on her back. See that the bladder and rectum are empty, and remove all clots, membranes, etc., from cavity of the uterus. Seize anterior and posterior lips of the cervix with two volsellae and draw the os uteri down, to the vulva or as near it as possible. Let an assistant hold the handles of the volsellse. Introduce the strip of iodoform gauze directly from the bottle (as described for vaginal tampon) into the uterine cavity with a long dressing for- ceps or some form of gauze packer. Place one. hand over the uterus to ascertain when the fundus has been reached. Gradually fill the uterus tightly from fundus downward. Sometimes the volsella may be dispensed with if the uterus is carefully pressed into the pelvis by an assistant with hand over fundus. Or the whole hand may be passed into the uterus and the gauze pulled in and packed by it. After the cavity has been filled remove the volsella (if used) and loosely pack the vagina with the gauze while the patient is still on her back. When it is considered necessary to tampon the vagina tightly, turn the patient and place her in Sims's position; or the whole utero-vaginal tamponade may be done with the patient in the Sims's position. Remember the objection to the gauze on account of its penetrability, and for severe haemorrhages use the medicated cotton wool plugs, espe- cially in the vagina. If the bleeding still continues, notwithstand- ing combined gauze and wool tamponade, on account of atony of the uterine wall, compress the uterus from without against the 508 OBSTETRICAL OPERATIONS tampon. Sometimes the tampon stops the haemorrhage for a time, but after the occurrence of strong uterine contractions bleeding commences afresh. In such cases the blood is usually being squeezed through the plug, and the latter should be at once removed. Episiotomy. — It is thought that one or two clean incisions may prevent rupture of the perinaeum. Make each cut back- ward and outward from the side of the fourchette toward the tuber ischii. After delivery suture the cuts. I know of no prom- inent obstetrician in Great Britain or America who approves of episiotomy. Repair of Lacerations of the Genital Canal. — We have learned, chiefly from obstetricians of the United States, the vast importance of the pelvic floor from an obstetrical point of view. We now know that the perinaeum — i. e., the triangular body situated be- tween the vagina and the rectum — is a structure of but little im- portance when compared with the pelvic floor. The student learns in the dissecting-room that this pelvic floor is composed chiefly of muscle and fascia, so arranged as to give the structure consid- erable sphincteric and great supporting power. It is probable that the principal supporting power is furnished by the different layers of fascia. We should, however, consider that all structures, includ- ing both muscles and fascia, are of the greatest importance, and when torn should be restored as nearly as possible to their original relations and conditions. Commencing from above and going downward, the most serious injuries are lacerations of the body of the uterus (generally the lower segment), cervix, vagina, pelvic floor, perinaeum, and various parts of the vulva. It is the duty of the obstetrician to consider carefully and treat properly all such lacerations. There is another class of injuries which the obstetrician should ever bear in mind — necroses and sloughs of tissues, generally produced by long-con- tinued pressure of the presenting part of the child, resulting in various forms of fistulae. He should endeavor to prevent such accidents, and thus avoid the humiliation of giving his patient into the hands of the gynaecologists for after-treatment. Lacerations of the Cervix. — Obstetricians have differed much in the past as to the proper treatment of lacerations of the cervix. It is now, however, generally believed that in the great majority of cases such lacerations should be left alone. Nature can care GENERAL OPERATIONS 509 for the ordinary small lacerations better, as a rule, than the obstetrician. If there is considerable tearing of the vagina or copious haemorrhage with contracted uterus, one should suspect serious laceration of the cervix and ascertain the condition by vaginal examination, using a speculum if necessary. When a deep laceration is found the primary suture is advisable. Operation. Immediate operation should be performed when the indication is to stop haemorrhage. An anaesthetic is generally unnecessary, as the cervix is not sensitive. Place patient on back in the cross-bed position with nates well over edge of bed. Wash vulva and adjacent parts, but do not administer a vaginal douche. Retract perinaeum with a large Sims's speculum or a Garrigues's weight speculum. Keep the anterior wall of the vagina out of the way with a retractor if necessary. Pull down the cervix with a single volsella; hold the two lips of the wound in contact with the volsella, one point being in each lip near the lower end of the tear. Introduce the first suture on a level with or just above the upper angle of the tear and tie at once. This should control the bleeding. Then introduce one, two, or three more sutures if required. Kangaroo tendon or catgut is the best suture for this operation. It holds sufficiently long to allow union, and it pleases the patient much to be told that no stitches will require removal. The catgut should be taken with a clean pair of forceps from the bottle in which it is kept in alcohol and placed on a sterile towel or plate, because if placed in a lysol solution or in sterilized water it will swell to such an extent that it cannot be threaded in an ordi- nary needle. It is also convenient to place the kangaroo tendon on a sterile towel, but its retention for a limited time in a sterile or antiseptic solution will not cause swelling. Lacerations of the Vagina. — There may be lacerations of the vagina, especially in the upper part, which do not involve the pelvic floor. Such a laceration is frequently continuous with the tear of the cervix. This should be sutured immediately after the repair of the cervical laceration. Generally it is more convenient to use rather short needles well curved. A Hagedorn needle is suitable, but the ordinary curved needle held in a needle- holder is satisfactory. 510 OBSTETRICAL OPEEATIONS LACERATIONS OF THE PELVIC FLOOR AND PERINEUM Either of these structures may be injured without the other, but in serious tears both are generally involved. As a matter of convenience we may consider four varieties: (1) Laceration of the pelvic floor and four- chette ; (2) laceration of the perineal body; (3) laceration of the pelvic floor and perineal body, but not including the sphincter ani; (4) laceration of the pelvic floor and the perineal body extending into the rectum. It is stated that lacerations of the pelvic floor occur in 35 per cent, of first and 10 per cent, of subsequent labors. I think those who use the axis-trac- tion forceps with care have a smaller propor- tion. When should the op- eration be performed ? When I first took charge of the Burnside Lying-in Hospital it was supposed that any- body could ''stitch a torn perinseum," and the members of the intern staff were in the habit of performing immediate opera- tion, suturing the perineal tear without any regard to lacerations of the pelvic floor, and at the same time being careless in some cases as to asepsis or antisepsis. One patient thus treated died from puerperal sepsis. Orders were then issued that no such operation was to be performed excepting by or under the direction of a member of the visiting staff. We found that the patient might be left a considerable time after the completion of labor before oper- ation was necessary, although we seldom waited more than twenty- four hours. In 1894 a patient had extensive laceration of the Fig. 168. — Lakgk Tjlak UN RioHT Side of Pelvic Floor. Showing triangular raw surface from slight tear involving only mucous membrane running to left, also slight tear of skin and body of peri- nseum. (Burnside Lying-in Hospital.) LACEEATIOXS OF THE TELVIC FLOOR 511 perineal body, which was sutured shortly after labor. We sus- pected non-union, and our suspicions were correct, as we found on removal of sutures in eight days. On the tenth day we found two clean granulating surfaces. Sutures were again introduced by Dr. Field, house surgeon, without freshening the wound sur- faces, and good union resulted. It is better, however, to vivify granulation surfaces by scraping gently with the sharp edge of a scalpel drawn sidewise, or, some say, by rubbing them with a fold of cheese cloth. I have found that after serious lacerations one is likely to do better work by waiting until he can get good light and make full preparations. Immediately after labor patients who h;n'e severe lacerations are usually exhausted and not in good condition to be anaesthetized. The obstetrician has many things Fig. 169. — Large Bilateral Tear of Pelvic Floor, Running up Each Side OF Median Raphe and Slight Tear of the Perineal Body. (Burnside Lying-in HospitaL) to think about in connection with the care of the babe and the mother, who has probably more or less inertia uteri. Under such circumstances even a competent and careful operator can scarcely do his best work. It is much better to wait one, two, or three days, when thorough and careful work can be done. I happened to be asked to give an opinion on a case interesting 3i 512 OBSTETEICAL OPEEATIONS from a medico-legal standpoint. Dr. A. attended Mrs. B. in a very difficult and prolonged labor. There was extensive lacera- tion of the perineal body extending to the rectum, and two tears running up the vagina as far as the Doctor could see. The patient was exhausted. On the following day Dr. C. was called in consultation and performed a very difficult and tedious operation, more than thirty sutures being re- quired. The result was good, the parts were re- stored and healing by first intention took place. Dr. C. rendered a separate account for the operation. Mr. B. objected, because he had been told that it was the duty of the obstet- rician to "stitch" such tears immediately after labor, and not to wait until the next day and have a separate operation with an additional fee. I of course expressed the opinion that Dr. A. was right in every respect, and I think Mrs. B. was extremely fortunate in passing into such good hands. I recently attended a slight, small woman in labor. The pel- vic measurements were nearly normal. Labor somewhat slow, but fairly satisfactory until the end of the first stage — first vertex position favorable in all respects. Axis-traction forceps easily applied. Slow, easy extraction. While the head was coming through the vulva I noticed shght laceration of the perineal body, just sufficient to require one or two sutures. I found one tear extending upward along left posterior wall of the vagina. I did not know how far, but I thought only a short distance. The Fig. 170. — Sutures Introduced into the Tears of the Pelvic Floor without Re- gard TO the Perineal Body. LACEEATIONS OF THE TELVIC FLOOIi 513 patient was exhausted, and there was a shght post-partum hajm- orrhage requiring careful attention. On examination next day I found considerable laceration of the pelvic floor and sent for Dr. Mcllwraith, who administered an anaesthetic while I intro- duced the necessary sutures. Without a careful examination I would have thought there was only a slight tear of the perineal body requiring two sutures, instead of a much more extensive laceration requiring ten sutures. The important lesson from these cases is this: Dr. A. and I, by simply introducing sutures through the skin at edges of the torn perinseum, as was formerly (if not now) frequently done, might have got a certain amount of union with an ap- parently restored perinseum. As a matter of fact, the best result we could obtain by such faulty operation would be a ribbon-like bit of skin be- tween the vulva and anus, with the pelvic floor de- stroyed and a woman crip- pled for all time. Repair of Laceration of Perineal Body. — Minor in- juries of the perineal body or fourchette should, how- ever, as a rule, be repaired at once without anaesthetic. If one uses a sharp needle and thrusts it through the skin quickly with a jab, the patient will not suffer much. Such sutures may be intro- duced, but not tied, before the expulsion of the pla- centa. After the expulsion of the placenta tie the su- tures sufficiently tight to coapt the surfaces without constricting the tissues. It has been well said (by I forget whom) that "a, ligature placed for the arrest of haemorrhage can hardly be drawn too tightly, but when its purpose is to approx- imate surfaces, and especially skin, we must remember that after Fig. 171. — Sutures in Pelvic Floor Tied and Two Buried Sutures In- troduced into Perine.\l Tear. 514 OBSTETRICAL OPERATIONS simple coaptation is effected we can do nothing but injury in using any greater degree of tension." Repair of Laceration of the Pelvic Floor and Perineal Body, but not including the Sphincter Ani. — Operation. Place the pa- tient on her back in a cross-bed position, with legs supported by a ^ftRr Fig. 172. — Suture Improperly Fig. 173. — Fault on Left Side Introduced, does not Include after Tying. Muscle on Left Side. leg-holder or by an assistant. Anaesthesia is generally necessary, chloroform or ether being used. The instruments and sutures required are needle-holder, needles, flat retractors, scissors curved on the flat, strands of silkworm gut in sterilized water, strands of catgut or kangaroo tendon. Some prefer a handled or perineal needle, while others use curved needles threaded with carriers. It is more convenient to use the needle with carrier for introducing the sutures within the vagina, if catgut or tendon is used. For sutures through skin, introduce straight or slightly curved needles threaded with the silkworm gut. Let the assistant separate the Fig. 174. — Suture Properly In- Fig. 175. — Correct Result. TRODucED, Including all Torn Tissues. vulva and hold upward the anterior wall of the vagina, if necessary, so as to give a good view of the posterior wall of the vagina. It is generally advisable to pack the vagina above the tear with iodoform or sterihzed gauze or absorbent cotton, to prevent the discharges from obscuring the view. There will probably be two LACERATIONS OF THE PELVIC FLOOK 515 tears within the vagina continuous with the single tear of the peri- neal body. These two vaginal tears run upward, one on each side of the median line, but one usually running higher than the other. The three tears form an irregular Y. Introduce the first suture on a level with the upper angle of the higher tear, about i to ^ inch from its margin. After pushing the needle through the mucous membrane, keep the point well outward so as to catch all the tis- sues (muscles and fascia3) which have been torn. While doing this make the needle go as deeply as possible without entering the rec- tum. Then turn the point inward and bring it out at the center of the tear. Re-enter it into the tissue and try to include all the torn structures, and push it through the mucous mem- brane on the opposite side at a point corresponding to that of entrance. Then let the assistant hold the ends of the sutures or include them in clip forceps. Some pass these sutures at right angles to the vaginal axis. I think, however, that the method re- commended by Kelly and Robb is better — i. e., pass the needle through the tissues rather deeply and then in a direction toward yourself or down- ward, so that the suture at the floor of the tear will be fully ^ inch (Robb says 1 inch) lower than the points of entrance and exit. To introduce the intra-vaginal sutures properly, and especially to avoid entering the rectum, I think it is better to introduce one forefinger into the rectum. One cannot be sure in any case that the rectum is aseptic, and should always consider that the finger after entrance in the rectum is septic. Introduce the remaining sutures in a similar manner in both tears at intervals of | to ^ inch until the lower end of the vagina is reached. The finger may be kept in the rectum until all the vaginal sutures are introduced. Then withdraw the finger from the rectum and wash it thoroughly. Tie the sutures in the order of their insertion (not too tightly, as before mentioned). The Fig. 176. — Two Sutures in Perineum Tied, and a Su- perficial Introduced be- tween them and Tied. 516 OBSTETEICAL OPEEATIONS difficult part of the operation is now completed. The tear of the perinseum is reduced to a small cavity, which can be closed by sutures introduced through the margins of the skin deep enough to go to the bottom of the cavity, carried transversely across and out at a corre- sponding point of the skin on the opposite side. Use either catgut, kangaroo tendon, or silkworm gut for vaginal su- tures. After using silkworm gut leave the sutures in for three weeks ; then have an assistant lift up the anterior wall of the vagina and retract the labia while removing them. Use silkworm gut for suturing the tear of the per- ineal body and leave the su- tures in ten days. Repair of Laceration of the Pelvic Floor and the Per- ineal Body extending into the Rectum. — This is one of the most difficult operations in the whole range of midwifery and surgery. There is not a clean cut through these struc- tures, but an irregular ragged tear with bruising of the tis- sues. The patient will almost certainly be in an exhausted X Fig. 177. — Tear of the Perineal Body, Extending into Rectum. Four catgut sutures introduced through the rectal mucous membrane on one side and ap- pearing on torn surface 3€ inch from edge, thence through opposite torn sur- face emerging from mucous membrane, the fourth suture including the torn ends of the sphincter. Additional silkworm- gut suture passed through skin some- what deeply behind the ends of the sphincter, across to the other side and emerging from point corresponding to the point of entrance. condition. It may be neces- sary to wait not simply one day, but several days, before operat- ing. It is often better to wait until there are clean granulating surfaces, with a certainty that there is no necrosed tissue in the wounds. There should be a skilled assistant in addition to a nurse and anaesthetist. If one has not acquired considerable skill in the performance of such operations, he should procure an expert. LACERATIONS OF THE PELVIC FLOOli 517 Description of Operation. Place the patient on her back across the bed and prepare as before described. First close the tear in the rectum by catgut or kangaroo tendon sutures. Introduce the first suture close to the apex of the tear on the rectal side, through the septum across to the other side of the tear, coming out on the rectal side at a point corresponding to point of entrance, and tie at once. Litroduce a set of interrupted sutures until the sphincter is reached. Approximate the two torn ends if possible. These ends are probably far apart, and not easily seen because retracted. Some recommend us to draw out these torn ends with a tenaculum so as to enable us to pass the catgut through the muscle. The suture connecting these torn ends may be buried. Before tying the last suture introduce one or two sutures of silkworm gut from the outside. The first of these is especially to assist in the restoration of the sphincter, and is really the old suture recommended by Emmett and Thomas many years ago. Introduce the needle (I prefer the straight needle for this purpose) behind the torn end of the sphinc- ter on one side, push it upward and inward until it emerges at a point near the united rectal edges about f inch above the anus, then reintroduce it, push it downward and outward until it comes out at a point behind torn end of sphincter on the other side and tie it. This suture is, I think, the most important one in the restoration of the functions of the sphincter ani. Introduce a second silkworm-gut suture about half an inch above this and pass in and out in a direction parallel to the former suture, but do not tie at once. These are sometimes called reenforcing sutures. Now inspect the bottom of the wound, and if there is any doubt about the sutures already Fig. 178. — Internal Catgut Su- tures Tied with Long Ends Pro- truding FROM Rectum. Exter- nal silkworm-gut suture also tied. Buried sutures introduced for per- ineal tear. 518 OBSTETEICAL OPEEATIONS introduced and tied on the rectal side, introduce two, three, or more buried catgut or kangaroo-tendon sutures or a continuous running suture. Then repair the pelvic floor as before described by introducing catgut sutures, commencing at the apex of the tear, tying and cutting short the sutures as they are introduced. Or if silkworm gut is used, leave for three weeks as in last operation. Then introduce your silkworm gut transversely through what remains of the torn perineal body. Probably only two or three sutures will be required to complete this part of the operation. Then tie these sutures, commencing with the lowest — i. e., the second reenforc- ing suture. These sutures are sometimes left about two inches long and fastened together at their ends or cut short near the knots. In the latter case the sharp ends often cause pain; in such cases the of- fending piece of gut should be readjusted. After-treatment. Separate the labia and cleanse the parts by a gentle stream of lysol or sublimate solution or squeeze the solution from a ball of soaked absorbent cotton. Make adjacent parts clean and dry, apply the antiseptic vulvar pad, place patient in bed on her back. After the slighter operations it is not necessary to bind the legs together ; sometimes, but not always, it is advisable to do so after the more serious ones. The patient may be allowed to turn slowly in bed and at the same time to flex both thighs together to a slight extent. Catheterization is only to be done when actually necessary. Give castor oil or a mild saline cathartic, such as sodium phosphate, Rochelle salt, or magnesium citrate, on the evening of or the next morning after the operation, or perhaps both. Endeavor to get the bowels moved before hard faeces are formed and before the sphincter has recov- ered its tone after the ordinary relaxation produced during labor. Fig. 179. -Perineal Tied. Sutures INDUCTION OF ABORTION 519 Some, however, prefer to wait two or three days and then give the cathartic, and follow some hours after with careful adminis- tration of half a pint of warm sweet oil, the enema to be repeated in four to six hours if. necessary. When the vulvar pads are changed, and after catheterization, voiding urine, or movements of the bowel, cleanse the parts after separating the labia as before described. In most cases a vaginal douche of half to a pint of ^-1 per cent, solution of lysol may be given in the gentlest possible way night and morning for cleansing purposes. Keep the patient in bed two weeks after the small and three weeks after the larger operations. Notwithstanding the unfavorable location and the usual bruis- ing of the tissues the results of these operations are generally good. If only partial union takes place, always perform a second opera- tion in ten days or two weeks. If some sloughing occurs, wait until the necrosed tissues separate. I'reshen the granulating surfaces as before described and suture. INDUCTION OF ABORTION The methods of inducing abortion are to a large extent those which have already been described under immediate active inter- vention in inevitable abortion. Vaginal Tamponade. — When successful, it has a great advantage in not destroying the ovum. The introduction of the uterine sound into the uterus, and turning it round to be sure of rupturing the egg-shell, is an old-fashioned and frequently unsatisfactory method of inducing abortion. Such a procedure frequently causes that dan- gerous condition which is known as incomplete abortion. I should never recommend the use of the sound alone, but rather in con- junction Vvdth the vaginal tamponade. This combined procedure with sound and tampon requires but little skill and involves very sUght danger. It may be repeated daily for a week if necessary. Rapid Dilatation of Cervix and Curettement is the most certain and satisfactory method in skilled hands. It is, however, an " operation " requiring as a rule an assistant to administer an ansesthetic and involving a certain amount of danger. In country practice the other methods are simpler and safer. Operation. Prepare the patient as before directed; anaesthe- tize; introduce a perineal retractor and pull backward; seize the 520 OBSTETEICAL OPEEATIONS anterior lip of the cervix with a volsella forceps and draw well downward. Dilate the cervix if necessary by artificial dilator or otherwise. Introduce the finger or a curette into the uterine cavity and remove completely the contents of the uterus. Then administer an intra-uterine douche of weak lysol solution and afterward pack with iodoform gauze. The cervical dilators most commonly used in Canada are Hegar's dilators or some modification of them, such as those of Leiter or Hanks, or MacNaughton-Jones, and the Goodell's metal- lic expanding dilator or some modification of it, such as that of Palmer. The metallic dilator is more rapid in action than the graduated vulcanite and aluminum bougies, but is considered by many to be more dangerous. Tents, so commonly used at one time, have been to a great extent discarded, because of the diffi- culty of making them aseptic. INDUCTION OF PREMATURE LABOR Premature labor is labor occurring between the twenty-eighth week of pregnancy and full term. Induction of premature labor is mechanical interference to excite uterine contractions and bring on labor at this period. The indications for the induction of pre- mature labor are : a contracted pelvis, causing defective propor- tion between the child and mother; a head found too large or prematurely ossified in previous labors ; a dangerous illness of the mother from excessive vomiting, albuminuria, ursemic convul- sions, chorea with mania, organic disease of heart, lungs, liver; irreducible displacements of uterus ; placenta praevia ; over-disten- tion of the uterus from dropsy of amnion; the death of children in utero in the latter part of former pregnancies. Method of Induction of Premature Labor. — The method most commonly adopted, the world over, when no special urgency is required, is that of Krause with perhaps the help of fingers or hydrostatic dilators, or both, after dilatation of the cervix has com- menced. The patient is prepared properly and placed in the cross- bed position, the bladder and rectum being emptied and the exter- nal parts and vagina thoroughly cleansed. A posterior speculum is introduced, and the anterior lip of the cervix is seized with a bullet or volsellum forceps and drawn down. One thus has a good view of the parts and can use the bougie without touching the vaginal INDUCTION OF PEEMATURE LABOR 521 wall, and therefore without danger of carrying vaginal germs (if any are left after the cleansing process) into the uterine cavity. A flexible gum-elastic bougie 12-14 English size (which has been previously .sterilized by boiling for ten minutes and then placed in a lysol solution 1-20 or a bichloride solution 1-1000 from which it may be taken for use) is passed into the cervical canal, and then pushed up gently between the membranes and the uterine wall as far as possible. The bougie should pass up into the uterus 7 or 8 inches, leaving about 1 or 2 inches in the vagina. In the first attempt it is pushed along the posterior uterine wall. One should try to avoid two things : puncture of the membranes and detachment of a portion of the placenta. If the bougie meets with any resistance, it is with- drawn a certain distance and again pushed upward, allowing it to take its own direction. If it again meets with resistance, it is with- drawn and pushed in another direction, say to the right or left or front, and when it is started on the new route it is allowed again to take its own direction as far as possible. The bougie may be used without a stylet, and probably the majority of physicians prefer this method. If the stylet is used there is greater danger of puncturing the membranes. To avoid this the bougie is pushed with stylet only to the internal os or 1 inch past it, keeping close to the posterior uterine wall. Then an assistant holds the stylet while the bougie is pushed off it into the upper uterine cavity. The greater part of the bougie is now in the uterine cavity, and it is hoped that the tip has reached the fundus. Sometimes, but not often, one can be certain of this from the sensation produced on the outside hand pressing on the fundus. An inch or two of the bougie is outside the cervix in the vagina. Introduce an iodoform vaginal tampon, first around the exposed part of the bougie, then over its end. The tampon should be sufficiently tight to prevent protrusion of the bougie from the uterus. Still greater distention of the vault of the vagina with a tightly packed plug can do no harm, and is likely to help the intra-uterine portion of the bougie in inducing uterine contractions. Although the method described is excellent in all respects, the speculum and volsellum forceps are not necessary, at least, in all cases. The index or index and middle finger are introduced up to the cervix to act as a guide. Then the bougie is passed as before directed into the uterine cavity. 522 OBSTETEICAL OPEKATIONS Never use a catheter instead of a bougie, because of the danger of admitting air into the uterine cavity. Otlier methods are mentioned in text-books. Some of these are worse than useless, and others which are useful under certain cir- cumstances will be described under Accouchement Force. Among former methods which have been generally discarded are puncture of the membranes (dangerous to both child and mother) ; vaginal douches (generally uncertain and inefficient); Cohen's method of passing catheter between the membranes and uterine walls, and injecting slowly seven or eight ounces of warm water (unsatis- factory and dangerous) ; administration of oxytocics, such as ergot (generally ineffective and dangerous) ; Pelzer's method by injection of three ounces of sterilized glycerine between the membranes and the uterine wall (dangerous). ACCOUCHEMENT FORCE This term is applied to an operation which includes two pro- cedures: (1) rapid dilatation of the cervix; (2) rapid delivery of foetus and placenta. In former times the operation was some- times performed with considerable violence. The hand was forced hurriedly through the cervical canal into the uterine cavity. The hand after its introduction quickly grasped a foot, turned, and extracted the child as rapidly as possible. The results were often bad and the operation for some time became unpopular. It appears to be coming again into favor. We are told that the improvements in the methods of dilatation and the introduc- tion of better surgical methods have greatly enlarged the scope of the procedure. While these statements are true to a certain extent, we have to recognize the fact that the operation is still extremely dangerous, especially in the hands of the modern stren- uous obstetrician who desires to accomplish as much in one hour as another can manage with safety only in three or four. When speaking of placenta praevia I referred to a case where a prominent and skilful practitioner of Toronto caused rupture of the uterus by a moderate traction on the child after version. Whitridge Williams recently published the following report: A patient in her sixth pregnancy had repeated haemorrhages due to placenta prsevia. During an examination after admission to the hospital such profuse haemorrhage occurred that immediate inter- ACCOUCHEMENT FORCE 523 ference was necessary. Dr. Williams intended merely to dilate the OS sufficiently to allow the introduction of two fingers for bipolar version, but the cervix yielded so readily that he com- pleted dilatation easily .and apparently without any injury by Harris's method. Subsequently, however, after death an exam- ination showed that in addition to a deep tear of the cervix, which had been discovered and sutured, there was a rupture of the uterus extending from the cervical tear up to the contraction ring. Such an accident in the practice of a careful and conscientious expert should impress upon all the dangers connected with such procedure. The essential element in accouchement force is rapid dilata- tion of the cervix uteri ; it is occasionally indicated in cases of eclampsia, haemorrhage from separation of placenta (ante-partum), prolonged, especially dry, labor, various conditions necessitating the induction of abortion or premature labor. Most of these conditions have already been discussed, but I desire to make certain repetitions. Where eclampsia occurs during pregnancy while the cervix is still intact, it is better promptly to treat the toxaemia and result- ing convulsions. When eclampsia occurs after effacement of the cervix or early in labor, do two things : treat the condition, hasten delivery. In haemorrhage from placenta praevia, artificial dilata- tion is very dangerous and should never be done. Rapid Dilatation of the Cervix Uteri. — Many of the pro- cedures and instruments recently used aid us materially, but all involve some danger. The following may be considered: fingers and hands, elastic and inelastic bags, metallic dilators, cervical incisions. Fingers and Hands. No instruments yet devised are equal to the fingers and hands intelligently used for rapid dilatation of the cervix. The best method of rapid dilatation of the cervix is that recommended by Harris. Push the index finger to its largest diameter through the os if necessary. Then insert the tijDS of the thumb and index fingers together within the os. This is the impor- tant thing in the procedure. Slide the thumb along the index finger in a direction away from its tip, and also finger along the thumb. One can put much force in this movement without turn- ing the hand and generally cause considerable dilatation. After this has been accomplished introduce the tip of the second finger 524 OBSTETEICAL OPERATIONS with those of the thumb and index finger. Then shde the thumb and two fingers over each other. Then introduce successively the third and fourth fingers, and flex all the fingers while you are sHding the thumb over the index and second fingers. This can be better understood after examining the accompanying dia- Fig. 180. — Diagrams Illustrating Manual Dilatation of Cervix (Harris). grams. Another method frequently adopted is to introduce suc- cessively one, two, three, and four fingers, forming all in the shape of a cone and always pressing upward, while with the other hand counter-pressure is made over the fundus uteri through the abdom- inal wall. Others prefer to use both hands and introduce the two index fingers back to back. Elastic and Inelastic Bags. About the middle of last century Carl Braun devised an elastic bag called a colpeurynter, which he placed in the vagina and then distended it with a view of stopping haemorrhages and dilating the cervix. Shortly after Barnes used elastic fiddle-shaped dilators for the cervix. These were used for many years, but have recently given place largely to Champetier de Ribes's bags, which are much used on the Continent, in Great Britain, the United States, and Canada. The de Ribes hydrostatic dilators are conical bags made of inelastic waterproofed silk. Instead of the set of bags our dealers in Canada generally have only the largest size. The base of the large bag measures 3^ inches, and the bag tapers 6 inches to the apex, which has a diameter of J inch. The dilator after being ACCOUCHEMENT FORCE 525 sterilized is folded along its long axis, caught in a specially designed forceps, and passed gently through the os and cervical canal, if not effaced, into the uterine cavity. It is generally better to use a speculum and get a full view of the cervix. The anterior lip is then seized with a volsella while the bag is introduced. The bag is sometimes introduced before the membranes are ruptured, but this is not safe because its distention generally causes intense pain by the sudden stretching of the uterine muscular fibers, as in acci- dental concealed haemorrhage. Previous dilatation if required may be effected by some arti- ficial dilator. A fountain douche is then attached to the nozzle of the dilator, and as the fountain is raised the lysol solution runs into the bag. As soon as the latter is sufficiently filled to insure its retention within the uterine cavity the forceps is withdrawn. About 22 ounces may be injected. If this cannot be accom- plished with the elevated fountain, and full distention is required, a Higginson syringe should be used. After distention the stop- cock is turned to retain the solution. Twenty-two ounces will cause a maximum circumference of about 13 inches; 18 ounces, 10 inches ; 15 ounces, 8 inches. As soon as the cervix is sufficiently dilated the bag is expelled by the uterine con- traction. In case of head presentation the bag should be fully distended. If rapid dilata- tion is desired steady or intermittent trac- tion may be made on the tube. The steady traction is sometimes made by the attachment to the tube of a slight weight running over a pulley at the foot of the bed. The ten- sion of the bag within the uterus may be alternately increased and diminished by raising and lowering the fountain of the douche syringe. While these different procedures may occasionally be useful, it is generally safer and quite sufficient to leave the bag quietly in position after introduction. This large foreign body will gen- erally excite uterine contractions, and then Nature can complete Fig. ISl. — Champetier de Ribes's Balloon (Williams). x ^. 526 OBSTETEICAL OPERATIONS the dilatation safely and efficiently. Traction may sometimes cause rupture of the lower segment of the uterus, just as it not infrequently does in the case of traction on the leg after version for placenta praevia. It is stated that the waterproofed silk of the de Ribes balloon is more durable than the rubber of the Barnes bag, but I have found both perishable. I fear that the silk, even when carefully prepared, Fig. 182. — Champetier de Ribes's Bal- loon READY FOR INTRODUCTION (Will- iams) . is poor, frail stuff, and when kept for a time becomes dry and hard. It then cracks and breaks up when manipulated. These bags, whether made of rubber or prepared silk, have proved most unsatisfactory in the hands of many country prac- titioners for the reasons mentioned. The de Ribes bags, however, have been largely used, especially in maternity hospitals. While visiting the Sloan Lying-in Hospital of New York last year, I was surprised to learn the frequency of the use of the de Ribes and the Voorhees cone bags. It appeared to be a matter of routine in certain classes of cases, without any consideration of other and simpler methods. The perishable nature of the silk bag is not its only drawback. When distended within the uterine cavity it is a large foreign body 13 inches in circumference, which frequently displaces the present- ing part and permits prolapse of the cord. I have endeavored to show both the advantages and the disadvantages of this much used bag. It occupies an important place in midwifery, but the place is somewhat limited for practice outside of maternity hospitals. Voorhees's Inelastic Rubber Cones. Voorhees, of New York, uses a cone-shaped bag somewhat similar to the de Ribes, but shorter and stronger. Dickinson tells us that this simple, strong, short cone, inelastic, thin enough to slip in when rolled wherever the finger-tip will pass, with no stop-cock to get out of order, is durable, efficient, and inexpensive. The set of four costs $1.50, ACCOUCHEMENT FORCE 527 while the de RiV)cs set costs $6.00. I now carry those bags in my satchel instead of the de Ribes balloon. The \V)r)rhees cone is used in a niaiuier siiiiihir to thai of the dr Ribes balloon, but it is intnxhieed witii the aid of any slender long-elainp for- ceps. When tlie bag is distended its tube is clamped by an ordinary forceps. Slight traction on the tube may be employed in some cas(vs. The hych'ostatic dilators may occasionally be used in cases of placenta prtevia (slight traction, if any, to be employed), separation of placenta, and for the induction of premature labor for various Fig. 183. — Voorhees's Dilating Bags. causes; or they may be used in conjunction with other methods of inducing or shortening labor. Metallic Dilators. Various dilators have been constructed for rapid dilatation of the cervix, but the one which now claims special attention is that designed by Bossi, of Genoa, in 1890. The Bossi dilator is a four-branched uterine dilator, with a strong screw on the handle and an indicator to show the amount of the dilatation. 35 528 OBSTETRICAL OPEEATIONS The four branches when closed form one body which is introduced within the os uteri. The blades are sometimes covered with rub- ber tubing before introduction. After insertion the blades are separated by a quarter turn of the screw every two minutes. It is used chiefly for cases of eclampsia when rapid delivery is indicated. It should never be used in cases of placenta prsevia. It is claimed that the cervix can be safely dilated with this instru- ment in from twenty to sixty min- utes. We have clear evidence, how- ever, from many operators, that this is not true in all cases. It frequently causes serious tears, especially when used before ef- facement of the cervix. Diihrssen, the great advocate for cervical incisions in labor, has published in con- siderable detail his views on the cases re- ported on the Conti- nent and has expressed a positive opinion that the Bossi dilator is both dangerous and in- efficient. On the other hand, several conserva- tive obstetricians strongly favor it as an efficient instrument in certain cases. Cervical Incisions. — Although incisions of the cervix in labor have been made by various obstetricians for at least a century, we are especially interested in the work of Carl Braun, Skutsch, and Diihrssen during the last twenty-five years. The latter has been the strongest and most persistent advocate of the procedure Fig. 184. — Bossi's Dilator. ACCOUCHEMENT FORCE 529 during the last fifteen years. The operation is incUcated in those rare cases of extreme rigidity due to preexisting disease or injury resulting in cicatrices where dilatation cannot be effected by ordi- nary methods. In addition, it is occasionally indicated in rigidity from unknown causes, but not nearly so often as recommended by Diihrssen, according to the opinions generally held in Canada. As this operation is always dangerous it is important to have a clear idea of the physiology of dilatation of the cervix, as has been explained in connection with normal labor. In primiparce, dilatation commences at the internal os and extends downward to the external os. The cervix is thus effaced before dilatation of the external os occurs. In multiparae, dilatation of the external OS generally takes place to some extent before it commences at the internal os. The cervix is thus not effaced until labor is considerably advanced. Cervical incisions should never be made until efTacement of the cervix is completed. Operation. The patient is properly prepared and placed on her back across the bed. An assistant administers an anaesthetic. The left hand is passed into the vagina, leaving the thumb outside. The index or middle finger is introduced within the os and another finger is placed outside the cervix. These two fingers will gen- erally fix the cervix and serve as a guide for the scissors. A pair of blunt-pointed scissors bent at the knee is taken in the right hand and introduced along the fingers within the vagina, one blade within and the other without the cervix, and an incision is made with one or two cuts up to the vaginal vault on each side. These two lateral incisions may be sufficient. If not, a posterior incision is made. There are now three incisions. Diihrssen thinks that two or three are generally sufficient, although in one case he found seven incisions necessary. When the cervix is yielding Diihrssen introduces specula which are held by an assist- ant, while he fixes the cervix with a volsellum on each side of the site of the incision and cuts between them. He also thinks that the incisions need not be sutured, because the unsutured wounds heal as well as the sutured. Immediate dehvery should follow the incisions, the forceps being applied if necessary. If haemorrhage occurs the wounds should be sutured if possible. If this cannot be done a utero- vaginal tampon should be used. Holmes, who recently read an 530 OBSTETRICAL OPERATIONS excellent paper on this subject before the Chicago Gynsecological Society, considers that in view of the post-partum repair which may be required there should be two assistants in addition to the anaesthetist for this operation. VERSION Version means turning the child in the uterus and altering the existing presentation to one more favorable. The indications for performing this operation are : a presentation of the shoulder, deformity of the pelvis, presentation of brow or other malpresenta- tion of the head, placenta prsevia, prolapse of the cord, prolapse of one or both arms or of an arm and a foot, and emergencies arising from eclampsia, detachment of the placenta, rupture of the uterus, etc. It is positively contra-indicated when there is ._.-. 1 Fig. 185. — External Ceph.alic VER.iioN (Pinard). retraction of Bandl's ring high above the symphysis, especially when the uterus above it is hard like a bullet. The conditions which should be present, or are most favorable for a successful issue, are as follows : when the pelvis is roomy and the child not VEKSION" 531 unduly large; whoii i]\v u1(>nis is (lislciidcil l)y rKiuor uiiuiii; when the os is dilated or dilatal)le; when the uterine walls are not tetanically constricted around tiie child. When the part of tlK> cliild that is brought down is considered, version is divided into two classes: (1) cephalic, when the head is brought down; (2) pelvic, including podalic, when the pelvis or foot is brought down. When the methods employed to turn the child are considered it is classified as (1) external, (2) combined external and internal or bipolar, and (3) internal. External Method. — In this method external manipula- tion — i. e., manipulation over the mother's abdomen alone — is used. The best example of this is seen in the con- version of a breech into a head presentation. The op- erator may stand at the side of the patient while she is lying close to the edge of the bed; or bet^veen her thighs when she is placed across the bed. Manipulations should be made between pains, not during pains, one hand being on the breech and the other on the head. Combined or Bipolar Method. — Braxton Hicks 's way of per- forming this is very common in England. He places the patient on her left side and introduces his left hand into the vagina. On the Continent and in America it is generally preferred to have the patient in the cross-bed position, the operator standing between her thighs. In all cases a previous knowledge of the position of the child, acquired by abdominal palpation, is of paramount impor- tance. If it is a head presentation this should be converted, first, Fig. 186. — Seizure of Foot in Inter- nal Podalic Version (Tarnier). 532 OBSTETEICAL OPEEATIONS into a transverse. It has now to be decided which hand the opera- tor should introduce into the vagina. The right hand is introduced when the child's feet are turned to the mother's right side, and the left when they are turned to her left. The whole hand is intro- duced into the vagina and two fingers into the uterus, rupturing the membranes, if this has not already occurred. The head should be pushed up with the internal hand and the breech down- ward with the external. The conversion into a breech is now completed. In this turn the child's back should be turned to the fundus of the uterus. A foot should now be seized and pulled downward into the va- gina, while the external hand is transferred to the other side and the head pushed upward. Sometimes when the os is not fully dilated it will be found impossible to bring the foot into the vagina. As Jellett expresses it, the os may be large enough to ad- mit the two fingers or the foot alone, but not large enough for the foot and fingers together. In such a case he ad- vises that the foot be brought down until the toes are through the os internum. Then the fin- gers should be drawn down into the vagina and an endeavor made to push the cervix over the foot. At the same time the external hand should press over the breech through the abdominal walls, so causing the foot to descend. The foot is then again seized and drawn downward, and at the same time the head is pushed upward with the external hand. Fig. 187. — Version: Transverse Presenta- tion, Back Posterior, Seizure of Upper Foot (Williams). VEKSION 533 Internal Method. --In this inothod the whole hand, not the two fingers alone, is introduced into the utcnnis. The same pro- cedure as in the bipolar method is adopted, but the greater part of the work is accomplished by the internal hand. Occasion- ally the external hand cannot push the head up while the foot is being brought down. In such a case bring down the second foot and pull both feet. If trac- tion then fails, take a strip of iodoform gauze and apply it to one or both ankles by a slip knot or clove hitch. Traction should be made on this strip with one hand outside the vagina, and at the same time the other hand in the vagina pushes the head upward out of the false pelvis (Jellett). In these operations deep anaesthesia is re- quired, not alone to render the abdominal walls lax, but to insure against prolapse of the cord brought on by the straining of a patient not sufficiently anaesthetized. In carrying out these methods of procedure care should be taken not to use too great force, for fear of rupturing the uterus. This accident is not apt to occur if version is undertaken soon after the rupture of the membranes, provided the operation is carefully performed. ^,,> Fig. 188. — Bipolar Podalic Version (Bumm). CHAPTER XXV OBSTETRICAL OPERATIONS {Continued) DELIVERY WITH THE FORCEPS Prof. Japp Sinclair, of Manchester, came to Canada in 1897, and told us that the obstetricians were the providers of material for the gynaecologists through unskilful use of the midwifery for- ceps. Baudeloque, on the other hand, has stated that the mid- wifery forceps is the most valuable instrument that has yet been invented. We believe the great mass of obstetricians in all civilized countries indorse this statement, and conscientiously and intelli- gently use the forceps to shorten the suffering and diminish the risks at childbirth. No one will deny that much injury is done in certain cases by the unskilful use of the forceps. According to Sin- clair and the few who agree with him, the common fault is the premature use of the forceps. Dr. Lapthorn Smith, of Montreal, makes the very serious accusation that the doctors use the in- strument early without any regard to the condition of the parts, simply to save time. This is, of course, not a new charge, and we may admit that some physicians apply the forceps prematurely to save their own time and suit their own convenience. The man, however, who does such a thing is guilty of a criminal act. Every physician should recognize the fact that premature use of the for- ceps is always dangerous, and should make it a positive rule in practice never to use the forceps through a partially dilated os. The forceps should never be used as dilators. Milne Murray refers to a form of spasmodic rigidity which is especially dangerous for forceps delivery. For instance, a woman has been in labor many hours. After a time an examination during an interval between the pains shows the os soft, flabby, fairly well dilated or at least dilatable. Some chloroform is admin- istered and the forceps are slipped over the head, of course within the OS. During the following pain the os becomes spasmodically 534 DELIVERY WITH TIIF. FOIJCKPS 535 contracted round the licad and forceps and not moi-e Hum half its apparent size. Dr. Murray considers such a condition an example of uterine incoordination, or uterine sUnnmer. Traction under such circumstances will tear the cervix into the vaginal roof with sometimes most disastrous results. Careful examina- tion, which should always be made during a pain as well as dur- ing the interval, will prevent one from making such a deplorable blunder. Reference has been made to secondary inertia. It is of course a condition which involves some danger as to the use of the for- ceps, but it should not be considered a positive contra-indication. Sometimes it is more dangerous not to interfere in a case of sec- ondary inertia than to deliver slowly and carefully with the for- ceps. It is somewhat confusing to a student to be told that the use of the forceps during uterine inertia is exceedingly dangerous, and afterward to learn that feebleness of pains is one of the indica- tions for the use of the forceps. While we should avoid the premature use of the forceps, we should not go to the opposite extreme and fail to use them when necessary. In former times when the forceps were used less fre- quently by the majority, and not at all by some, that horrible condition, vesico-vaginal fistula, was not uncommon. It is now comparatively rare. This is, however, telling a small part of the story. Dr. Murray says much in a few words when he tells us that by means of the forceps we have saved hundreds and thou- sands of weary hours and preserved countless children alive. The suitable conditions of the patient and the indications for the application of the forceps may be summarized as follows : Suitable Conditions. — The os dilated or dilatable; the vagina and internal genitals softened and dilatable ; the membranes rup- tured; the skull of child sufficiently large and firm; the head engaged (with rare exceptions) ; the pelvis sufficiently large ; the rectum and bladder empty. The Indications. — The indications for the use of the forceps are as follows : When the mother is in danger from exhaustion from prolonged second stage; where there is a slight pelvic contraction and the choice lies between the use of the forceps and version ; where there is a delayed face presentation, especially when the chin is rotating to the front ; when there is a hsemorrhage of any kind, or rupture of the uterus. It is also indicated in some cases 536 OBSTETEICAL OPEEATIOi^S of occipito-posterior positions, but it is better to wait as long as possible or correct the position if possible. It is indicated too when the child is in danger from prolapse of the cord, threatened asphyxia from any cause, or impaction of funis. This list of indications for forceps interference is practically that found in standard text-books, but it is neither scientific nor accurate. One should consider that each of the conditions named may render the use of the forceps advisable. These conditions have been discussed in former chapters. As before stated, the second stage of labor should be as short as possible. When all the soft parts, from cervix uteri to the vulva, inclusive, are softened and dilated or dilatable, quick delivery of the child is desired. To accomphsh this the forceps are used in certain cases. When shall we use them? This is not an easy question to answer definitely. Milne Murray lays down a rule to which he attaches much importance. ''A direct indication for the use of the forceps arises whenever, and only whenever, we are r I i t r I 1 1 V 1 ''■V, ^ T .^ Fig. 189. — Abdomen of Primipar^ at Term, showing Stri^. assured that the danger of interference has become less than that of leaving the patient alone." He claims that this is more than a mere truism, inasmuch as it implies that the use of the forceps is nearly always a matter of individual judgment. He considers that there is no accepted set of rules which can be applied to every emergency. DELIVERY WITH THE FOliCEI'S 537 At the Rotunda a definite time limit for the second stage has been recognized for several years. That limit, when I heard last, was four hours. The same limit was observed in St. Mary's and Queen Charlotte's Hospitals for some time, but in 1897 the max- imum duration was altered from four to two hours. Many express the opinion that the time ele- ment alone is not a proper basis for such interference. I quite concur, and yet I believe firmly in the time limit, al- though I do not depend upon that alone. I also doubt wheth- er any one at the Rotunda, St. Mary's, or Queen Charlotte de- pends on the time element a/one. I saw a patient recently in consultation with a very competent and careful young practitioner. The parts, I was informed, had been dilated about eight hours. The doctor was trying to reach a conclu- sion whether or not the time had arrived "when the danger of interference had become less than that of leaving the patient alone." The patient, although tired, was not suffering acute pain. The time limitation, if ob- served, would have prevented such prolonged delay with asso- ciated dangers. I think the maximum duration of the second stage should be three hours for primiparae and two hours for multiparas. This does not mean that in all cases one should wait for the three or two hours; but it does mean that in no ca.se should one wait any longer. In a large proportion of cases it is neither necessary nor advisable to defer the application of the forceps for more than one hour after full dilatation of the cervix, vagina, and vulva. "When the passages are in a fit state, and Nature fails to advance the head, apply the forceps " (Simpson). Position of the Patient. — The lithotomy position for the patient is generally used in Canada, the United States, and the Continent Fig. 190. — The Sxively Stockixg- Drawers. 538 OBSTETRICAL OPEEATIORS of Europe. We think it is much better than the left lateral, espe- cially in all cases of difficulty. We sympathize with those who object to undue exposure and cover the parts as well as possible. The Snively Stocking-Drawers. — The best available protect- ing garment, so far as I know, is the combination of stockings and drawers designed by Miss Snively. They are made of can- ton flannel, flannelette, or strong factory cotton. They are re- tained in position by means of tape which acts as a belt around the waist, preventing the possibility of slipping. They are adjustable to such an extent that they do not interfere with the operator, as they are open both back and front and also on either side. In ad- dition to these openings, the front is so arranged that it may be allowed to drop down away from the abdomen in cases where this may be necessary without in- terfering with the protection afforded by the combination elsewhere. It is generally advisable to fasten the thighs in the flexed position. I generally use for this purpose Robb's leg-holder. One end is fastened to a leg below the knee. The rest of the band is passed over one shoulder, across the back, under the other shoulder, and the other end of the band is fastened to the other leg below the knee. The old-fashioned sheet shng is quite satisfactory. It is made by two persons holding diagonally opposite cor- ners of a sheet and rolling the hanging portion around the part held taut until a sort of rope is formed. One end of this is tied to the leg below the knee, or sometimes to the thigh near the knee. The shng is passed (like Robb's strap) over one shoulder, under the other, and the end is tied to the other leg. If the band or sling is properly adjusted it tends to abduct or separate the knees ; while a shng passed under the knees, round the neck, with the ends then tied together (as sometimes recommended) would tend to draw the knees together and would be extremely uncom- fortable for the patient. Fig. 191. — Pattern of Snively Stocking- Drawers. ny.LIVKIlV WITTT THE FOKCKPS 539 Kinds of Forceps. — There are three kinds of forceps: (1) short, straight; (2) loiiu', two curves; (3) axis-traction. Each blade of Fig. 192. — Patient on table in lithotomy position, wearing the Snively stocking- drawers; vulva covered with small towel fastened with safet5^-pins, Robb's leg-holder applied. Upper part of patient hidden from view by curtain stretched across the room (Burnside Lying-in Hospital). the long forceps and the axis-traction forceps has two curves: a cephalic curve to adapt itself to child's head and a pelvic curve to adapt itself to shape of pelvis, especially when the head is high. Fig. 193. — Lower half ul' li.Awl IuiuulI up iurI pinncil. leaving sufficieut exposure to apply the forceps or operate on pelvic floor and perinseum. There is also a curve on each traction rod, and sometimes a third curve on the shank, as in Galabin's axis-traction forceps. There 540 OBSTETEICAL OPEEATIONS are three kinds of locks : English, Smellie, with shoulder projecting from each half of instrument, the two shoulders fitting into one Fig. 194. — Making Sheet Sling, First Stage. another by inclined planes : French, pivot having a projection or tenon on one arm which is inserted into a cavity or mortise on the Fig. 195. — Making Sheet Sling, Second Stage. DI'IJVKRY WITU THE FORCEPS 541 other, with a screw to hold them in position; German, one arm bitin<;- into the other, while a pin on one fits into a notch on the other. Choice of Forceps. — The varieties of forceps mentioned are the short, long, and the modified long — i. e., the long forceps with axis- traction appliances. The object of Tarnier in making his instru- ment was to have it so adjusted that the force in traction should Fig. 196. — Sheet Sling. lie in the true axis of the pelvis at all its planes, and that no part of that force should be either wasted or used in such a way as to cause injury. One can understand a part of this better by considering the action of the ordinary long forceps when applied at the superior strait. The axis of the superior strait points toward the lower part of the sacrum. The perinseum, the coccyx, and a small por- tion of the sacrum being in front of the axis of the brim prevent the handles from being pushed back to allow direct traction. Consequently, part of the force of traction is wasted in dragging the head against the symphysis pubis. This defect in the ordinary 542 OBSTETRICAL OPEEATIONS long forceps was clearly recognized more than one hundred years ago, and many devices were tried to overcome the difficulty, with Fig. 197. — Simpson's Forceps, Cephalic Curve. a certain amount of success. One of the most common devices is known as Pajot's maneuvers (Fig. 202). Tarnier solved the problem in 1877 by attaching one traction rod to each blade of the forceps and fastening both rods to a handle or crossbar. His original instrument was rather clumsy, and he Fig. 198. — Simpson's Forceps, Pelvic Curve. made many improvements on it before his death. Many slight modifications have been made in various parts of the world. As a rule, all that are constructed on the Tarnier axis-traction prin- ciple are good. But no such modification as the attachment of tapes by loops passed through the fenestrse of the blades or the perineal curve of Galabin is satisfactory. I fear that even Neville's forceps, so highly lauded by the Rotunda men, is not a true axis-tractor. I used the Milne Murray modifi- cation of Tarnier with much satis- faction for about ten years, but when in Paris three years ago I got the latest Tarnier forceps as recom- mended by Pinard. After using this instrument for a time I found it unsatisfactory. I then decided to either go back to the Milne Murray instrument or choose the Porter Mathew forceps, which Dr. Mcllwraith has used for some Fig. 199. — Lock of English Forceps. DELTVEKY WTTTT TTTE FORCEPS 543 years with excellent results. After careful comparison I have chosen for my own use the Mat hew axis-traction forceps. The choice in this part of Canada lies largely between Milne Murray and Porter Mat hew, many preferring the former. Description of the Mikie Murray Axis-Traction Forceps. — The application handles are smooth and light and 6 in. in length. The ordinary Smellie lock is u.sed, and the shanks are straight, strong, 2.5 in. in length and .75 in. between their inner sur- faces. The blades are 5.75 in. in length, measured along the cord of the pelvic curve (this arc has a radius of 7 in.). The termination of the arc joins the shanks, so that the axis of the in- struments and the cord form of the blade measures 1.75 in Fig. 200. — Lock of French Forceps. an angle of 120°. The solid part The fenestrum is 4 in. in length. The blades are kept in position by a fixation screw of the ordi- nary pattern, the butterfly-nut being prevented from coming ofT by a pin driven through the upper head of the screw. The trac- tion-rods are hinged to the blades. They lie on the outside of Fig. 201. — Robe's Leg-Holder. the solid part of the blade, against whidh they fit snugly. From their attachment the rods curve round the blades, and are bent at an angle so as to lie straight beside and a little to the outside of the shanks. One inch below the lock they are bent by an easy curve back- ward, and terminate in two flattened surfaces, in which are inserted the traction-handle studs. About half-way along the back curve is the traction-rod lock. It consists of a pin fixed to the lower 36 544 OBSTETEICAL OPEEATIONS traction-rod which enters a mortise on the upper, in which it is held by a simple bolt. Its object is to bind the two rods into one system and make sure that the force of traction is equally dis- tributed on the two blades. The inclination of the flattened surfaces terminating the rods and carrying the traction-bar studs is a matter of essential impor- tance. It must be such that the traction-bar plate when attached must be absolutely in the tangential line of the curve when the rods are touching the shanks. The distance of the studs from the center of the handles in these instruments is 3.5 in. The studs are square in section with large heads. The traction- bar plate is attached by a couple of key- holes, and when drawn down should fit firmly without to-and-fro motion of any sort. The traction-handle possesses a hinge- joint giving lateral motion, and the bar is attached by a swivel. The traction-rods are jointed to the blades, and run down close to the shanks and along the back of the handles, and at a point half-way down they then turn back at a right angle. The horizon- tal part of these rods is oval in section, and the upper one is divided into distances half an inch apart, which are numbered to 7. The handle is applied to these horizontal rods by a block pierced to allow them to pass through. This block can be fixed in any position by a pinching screw, which is secured in such a way that it cannot slip out. To this block is fixed the handle by a joint which permits motion in a plane parallel to the rods. This motion is necessary to allow the handle to fail into the proper line of traction for each position on the rods. To the pin of the hinge-joint is fixed a sector, whick moves Fig. 202. — Pajot's maneuver by which he endeav- ors to carry out the axis-traction principle with the ordinary long forceps (Elliott's). The right hand making traction on the handles. Two fingers of the left hand over the shanks drawing backward. DELIVERY WITH THE FORCEPS 545 with the handle. Th(> periphiM-y of Ihe sector lias iiiarke(l on it the position proper to it for each i)osilion of the block on the rods. Against one of these marks is placed the word " normal." When the handle is adjusted to this mark the iiislruincnt is, as regards construction and efficiency, an ordinary pair of axis- traction forceps. To adapt them to a pelvis whose inclination is less than normal, it is only necessary to shift the block one or more divisions nearer the handle; while to adapt them to one whose inclination is greater than normal, the block must be moved one or two divisions farther from the handle. If the index is kept at the figure on the section corresponding to the figure at which the block is set on the handle, the line of traction will always pass through the center Fig. 203. — Porter Mathew Forceps Disarticulated ; Front and Back View of Blades. of the fenestrum ; but, of course, its inclination to the vertical will vary with the position on the rods at which the handle is fixed. Dr. Murray has another forceps which is older and better known in this country than the one described and is constructed for the normally curved pelvis. In it the traction-rods are not 546 OBSTETRICAL OPEEATIONS rectangular, but slightly curved, and end in two flattened spaces to which the traction-handle is attached. Description of the Porter Mathew Axis-Traction Forceps. — The forceps are made entirely of metal and can be sterilized by boiling. The traction-rods are detachable and easily cleaned. The weight, especially where undesirable, has been di- minished as much as is con- sistent with perfect rigid- ity, the diminution being most marked in the appli- cation-handles, the latter thereby acting the more efficiently as true indicators of the change in the direc- tion of the descending head. There are no screws or fixed joints except to those parts outside the vulva, and such screws as are present, few in number, are not easily lost. When the head is de- livered, it is only necessary (without touching the trac- tion apparatus) to give a few turns to the large screw on the handles, when the blades slip off the head. The blades have a pelvic curve of a 7-inch radius; this enables a good grasp to be obtained on the cor- rect plane of the head. They are stout but narrower than ordi- nary blades, rendering them easy of introduction and manipula- tion, and of special service in those difficult cases of flattened pelvis when the head lies transversely at the brim. By being narrow they grasp only the occipital and frontal bones, avoiding the parietals, enabling the latter to mold without hindrance in the diameter of greatest obstruction. The lock is a close-fitting, ordinary English lock ; a model has Fig. 204. articulated g h Porter Mathew Forceps Dis- SiDE View of Blades. , traction-rod; 6, portion of traction-rod ho which traction-block is applied; c, han- dle of blade; d, blade; e, fixation screw; /, butterfly-nut of fixation screw; g, traction- block; h, catch of block with a screw and butterfl3^-nut ; i, traction-handle. DELIVERY WITH THE FORCEPS 547 also been made with reversed lock. The closo-fitting lock insures the blados when locked, being properly adapted to the head. The application handles have been nuich shortened and light- ened. Once the blades are applied the handles become merely "indicators" and are not designed for traction. Owing to their lightness they do not " fall downward," and the slightest move- ment of the head is communicated to them; being so delicate a guide, to insure proper axis-traction throughout the operator has merely to pull, keeping the traction-rods constantly par- allel and close to the applica- tion handles as the latter move forward with descent. Another great advantage of the short handle is, that on locking the forceps the second traction-rod falls into posi- tion without having to be carried far forward to clear a long application handle. An objection that the short han- dle would upset the balance of the blade and make it diffi- cult of introduction with the head high up, has been found to be purely theoretical even above the brim, for in intro- duction the traction-rod and handle are grasped together, and will be found to give a comfortable and convenient hold, the left blade being passed with its traction-rod behind the handle, the right blade with its rod just in front of the handle. On locking, the second traction-rod slips backward into position beside the first traction-rod. The traction-rods are the well-known rectangular ones of Dr. Milne Murray. The forceps are thus true for all pelves, instead of being true only for a normal pelvis. By an ingenious contri- FiG. 205. — Porter Matiiew Forceps Articulated. Catch of block underneath and closed in fourth notch of traction-rod, fixation screw fastened at end of handles. 548 OBSTETRICAL OPERATIONS vance, copied from Dr. Cullingworth's forceps, the rods are easily detachable by an aseptic joint, the old objectionable screws being done away with. The traction-block. Much time and care have been expended by Messrs. Down Bros, (who have made the forceps) in designing a new form of traction-block which should be mathematically and mechanically correct, and yet have the advantage of sim- plicity, lightness, ease, and rapidity of application and admit of being easily cleansed. The great difficulty has been to avoid screws, which might be lost and make the instrument temporarily useless. To in- sure asepsis it can be boiled. One movement fixes the block and rods securely. The line of traction has been calculated by "shadow projection," the ray of light being kept perpendicular to the blade ; very accurate results are obtained by this means. The two instruments are much alike. The Porter Math- ew is simply a modification of the Milne Murray, but it is smaller and lighter; its blades have a slightly different cephalic curve and are more easily applied, and its traction-rods are more easily got into position for the attachment of the traction-handle. Some of the advantages of the axis-traction forceps may be cited, quoting largely from Milne Murray. The great advantage of its use at the brim is generally understood and admitted. In many cases the axis-traction instrument will accomplish what the ordinary long forceps cannot do. " For once they have proved their efficacy at the brim, they have done so ten times in the cavity and twenty times at the outlet." The blades grasp the head securely without producing dangerous compression. Extraction is accomplished with comparative ease and without any waste of force. It is necessary only to preserve the proper relationship between the traction-rods and the shanks. By keeping the Fig. 206. — Porter Mathew Forceps. Blades and traction-rod held in hands before application. DELTVEin' WITH THE FOI^fEPS 549 instrument on the head until deli very there will generally be less injury to the pelvic floor and tiie perinoiUm. At no stage will the instrument prevent flexion and rotation of the child's head. Application of the Murray Forceps. — The blades are joined with concavity of j)el\-ic curve forward. The handle of the left blade is taken in the left hand. The handle is held in the full hand with the thumb lying on its inner surface while the other fingers are distributed over the outer surface near the lock. The fingers of the right hand are placed in the vagina with tips between cervix and the child's head. The blade is passed along palmar aspect of fingers toward the sacrum or slightly toward the left side of the pelvis, the handle being held well upward. As the tip of the blade enters the handle is brought downward along the internal surface of the mother's right thigh, and the blade is brought toward the side of the pelvis. While introducing the left blade the traction- rod is allowed to remain below (hanging down- ward). The shank of the blade wall now pass against the perinaeum. The handle is kept steady with the wrist, or an assistant holds it. The handle of the re- maining blade is taken in the right hand. The axis- traction is kept upward out of the way. The fin- gers of the left hand are placed in the vagina, and the right blade is intro- duced as in the case of the left blade. If a pain comes on during the application of a blade, manipulations cease until the pain has passed off. The handles are taken in the two hands, the blades adjusted and locked, and the screw is fastened. One traction-rod is now below and the other above. The latter is pulled down beside and below the locked blades. The two traction-rods are now below the application han- dles. The traction-handle is attached to the two traction-rods. Fig. 207. — Application of First Blade. Porter Mathew Forceps. 550 OBSTETEICAL OPERATIONS Application of Porter Mathew Forceps. — The traction-block and handle are laid aside at first, but the blades are applied with the traction-rods in place. The patient is in the dorsal position. The left blade is taken in the left hand, the thumb in the angle of the traction-rod, and the fingers encircling the trac- tion-rod and handle and keeping them close togeth- er. The fingers of the right hand are introduced into the vagina and the blade applied along their palmar surface as in the Murray forceps applica- tion. The handle of this blade being kept back out of the way by an assistant, the right blade is grasped in the right hand, as fol- lows : The traction-rod is carried far enough forward to bring it in front of its handle, the fingers encir- cling the handle ; the but- terfly-nut of the fixation-screw is run out to the end of its screw, and the screw itself turned out, away from the traction-rod, and allowed to project between the first and second fingers ; the traction- rod is kept in position by gentle pressure with the thumb on the outer side of its angle ; the rectangular part of the rod projects back- ward between the thumb and the fingers. Grasping the blade thus, it is applied like the second blade of the Murray forceps ; as the lock is closed the traction-rod falls easily back into position behind its handle. The fixation screw is then turned into its place and the nut screwed home, not tightly, but just enough to keep the handles as closely together as they can be brought by gentle pressure with the hands. Then take the traction-block, open its catch widely and run the butterfly-nut out to the end of its screw. Then slip the block on to the rods, taking care that the catch is on the side next to the notches in them. Slip it up the rods until three notches are passed and close the catch into the fourth notch, which is the Fig. 208. — Application of Second Blade. Porter Mathew Forceps. DELIVERY WITH THE FORCEPS 351 position for normal pelves, and screw the nut home. For flat pelves the block is fixed in the fifth, sixth, or seventh notch, accordino; to circumstances — i. e., traction is made in each notch until that notch is found in which the liead comes most readily. For "small round pelves " the block is fixed similarly at third or second. The handle is then hooked over the bar provided for that purpose, not over the catch. Traction is made keeping the traction-rods just parallel to the hantlles, not pushing against them nor widely separated from them. All traction must be made with the traction-handle, neither the traction-rods nor the handles of the blades being touched. As the head comes down the handles will be found to turn upward and forward. This indicates the direction in which traction is to be made, and each change in position must therefore be closely followed by the traction-rods. In removing the forceps the traction-block and handle are first removed. The fixation screw is then undone and turned outward. The right traction-rod is then carried in front of its handle and the right blade removed in the reverse direction of its application. The left blade is then similarly removed, except that its traction-rod does not need to be carried forward. When using the ordinary long or short forceps introduce the blades and lock as described for the ap- plication of the Murray forceps. This is illustrated by cuts show- ing what Williams calls low forceps introduction (Figs. 210 to 213). How shall the Blades be Applied?— According to many author- ities in Great Britain and Germany, our aim should be to so apply the blades that they will be parallel to the sides of the mother's pelvis. Many obstetricians in France and America endeavor to apply the blades to the sides of the child's head without regard to the sides of the pelvis. The differences of opinion in certain Fig. 209. — Blades Locked and Traction-Handle APPLIED. Porter Mathew Forceps. 552 OBSTETEICAL OPEEATIONS communities are very decided. Take the University of Edin- burgh, for instance, where we find the extra-mural differing from the intra-mural teacher. The one tells us that it is largely the teaching and the practice of the British schools to apply the forceps as far as possible in relation to the pelvic transverse without reference to the position of the head. He at the same time expresses a positive opinion that this is wrong when the head is not prop- erly rotated. The result of this practice is to obtain an oblique grasp of the head, which causes difficulties in locking and certain dangers. Even though locking be ac- complished without injury, the head as it descends rotates, causing the edges of the blades, if there is no ^ „,„ ^ , „ removal and readiustment, riG. 210. — Introduction of Left Blade. Ordinary Long Forceps (Williams). to do mUch damage to the outlet. Or the head de- scends without rotating and engages the outlet in the oblique with results still more disastrous. An author representing the other side of Edinburgh tells us that the long forceps are always applied laterally as to the pelvis, no regard being paid to their grasp of the head. Clarence Webster, another Edinburgh man, considers the French method unscientific, ridiculous, and dangerous. Dr. Murray prefers the French method, and advises us to apply the blades to the biparietal diameter of the child's head wherever situated. As the head descends rotation brings the blades into the transverse diameter when the occiput comes to the front. The application of the blades to the sides of the head requires more care, but it is our duty to take what care is neces- sary for the benefit of the patient. There is nothing new in these allegations, nor have I any doubt that they are correct. Not- DELIA' FJJV Wrril T\\\'] FORCEPS 553 withstanding my admiration for the I^'reiich iiuMhod, however, I have for years hesitated about recommencUng it universally to my classes, nor am I prei)ared to do so now. Why not adopt the French method in all eases? l^ecause it requires more skill than the average obstetrician can acquire in a hfctime to accomplish it safely in a large proportion of cases. Strenuous efforts to apply the blades to the parietal diameter of the head in difhcult cases are dangerous to both mother and child. A large proportion of obstetricians are convinced that theoretically the French method is excellent, but practically it is often danger- ous and even impossible. At least such is my experience, and I have been endeavoring to carry out the French method for fifteen years. The following rules are recommended : One should try to ascertain the exact position of the child's head, and endeavor to apply the blades to the sides of the head without regard to the sides of the pelvis — i. e., make an effort to em- ploy the French method. If unable to accomplish this, apply the blades laterally as to the pelvis, but do not drag the head far before re- moving and readjusting the blades. It is comparatively easy in certain cases to apply the blades to the sides of the head. If, for instance, the head is in the cavity of the pelvis with the occiput to- ward the left front, one has only to introduce the blades so that the left blade will be slightly behind on the left side and the right blade slightly forward on the right side, times one can scarcely avoid doing this. Traction. — Seize the handle Avhich is attached to the traction- rods with the one hand, and while pulling see that the rods and shanks are kept just touching, or almost touching each other. r"iG. 211. — Left Blade in Place. Ordinary Long Forceps (Williams). Some- 554 OBSTETEICAL OPERATIONS While thus extracting the child one will find that the traction is exerted exactly in the right direction at all times as the head passes through the pelvis and emerges from the vulva ; flexion will be properly maintained, and when incomplete will frequently be pro- moted ; rotation will be allowed; the head will so far as possible be prevented from bearing too heavily on the pel- vic floor; the head will be lifted over the peri- naeum ; and as the head is brought through the vulva it will not be ex- tended so as to cause the chin to cut through the perinseum. In using traction do not attempt to extract rapidly. It was before stated that during nor- mal labor, after the vault of the head reach- es the pelvic floor, its expulsion from the vul- va should occupy at least "from twenty to thirty minutes. Extraction with the forceps should occupy no less time. Pull gently on the handle, as far as possible during pains, and desist during the intervals between them. If unable to detect uterine contractions, pull inteimittently. Endeavor to extract with the smallest amount of force. Use one hand at first ; this will generally be sufficient. In exceptional cases it will not, and then one will require more force and may use two hands. As soon as the head reaches the pelvic floor one should con- sider the danger of injury to that structure and the perinseum. It was stated in connection with normal labor that when the thighs are flexed on the body a tightening of the skin around the Fig. 212. — Introduction of Right Blade. Ordinary Long Forceps (Williams). DELIVERY WITH THE FORCEPS 555 vulva occurs. The patient is directed to extend the legs and thighs in order to slacken this tension. Tliis tightening is still more apt to occur when the thighs are fastened in the flexed posi- tion with sonic form of leg-holder. It is extremely important, therefore, to observe the following rule: As soon as the head commences to ])ress on the pelvic floor observe the time, remove the leg-holder, and allow extension of the thighs — i. c., allow the legs and thighs to hang over the edge of the bed or over the end of the operating table toward the floor. In an ordinary bed the patient's feet may rest on the floor while the nurse keeps the thighs separated by holding the knees out- ward. Do not employ less than twenty to thirty minutes in extracting the head after it has reached the pelvic floor. I attach a great deal of importance to this rule. It is very desirable that the operator take his time from a watch or clock and not trust to guess-work. Twenty to thirty minutes will appear a long time, especially if one has seen some strenuous and mus- cular operator drag the head over the pelvic floor and through the vulva in about a minute. In order to do so, however, he may require to use a force of one or two hundred pounds, while the safe operator by a slower and less brilliant method may only require to use a force of one to ten pounds. The former will probably pro- vide some material for the gynaecologist, while the latter will lift the head over the pelvic floor and through the vulva without in- flicting any injury. While pulling gently and intermittently for fifteen to twenty-five minutes, the anaesthetic may be withheld to some extent, but it should be freely administered while the head Fig. 218. — Fcjrceps Locked. Ordinary Long Forcepi (Williams). 556 OBSTETEICAL OPEEATIONS is emerging from the vulva. Occasionally the utenne contrac- tions assist expulsion while the head is pressing on the pelvic floor, and expedite delivery. If Nature's efforts should suddenly become violent, have the anaesthetic freely administered, leave the forceps in position, and guide the passage of the head so as to make it ghde over rather than cut into the pelvic floor. While exerting slight traction on the cross-bar with the one hand to Fig. 214. — Walcher's Position pull the head toward the pubic arch, it is sometimes advisable to push against the advancing head with the fingers of the other hand to prevent too rapid expulsion. While Milne Murray generally employs traction during the pains, he refers to one group of cases where a different plan should be adopted. It sometimes happens, especially in elderly primip- arae, that every uterine contraction when the head is low is ac- companied by spasmodic action of the muscles of the pelvic floor, which narrows or tightens the vulvar orifice and causes rigidity DELIVERY WITH TTTE FOKOEPS 557 of the pelvic floor and perinaeum. In such a case deepen the ana3sthesia and employ traction only during the intervals between th6 pains. As before intimated, in the majority of cases in the high and middle operations the blades will generally grasp the head oblique- ly. It is not safe to drag the head far before removing and re- adjusting the blades. The following rules are recommended : As soon as the position of the blades shows that rotation of the head has commenced, remove the blades, reintroduce and readjust them. Otherwise do not remove the forceps until after complete deliv- ery of the head. During the delivery of the head, even while it is passing over the perinseum, continue to pull on the cross-bar with- out regard to the application handles. Many, if not most, ob- stetrical authorities in the United States only use the traction in high and middle operations, and some only use them in the high operations. Some authorities, both in Great Britain and the United States, relax the fixation screw during the interval be- tween making traction. This is unnecessary when using either the Murray or Mathew forceps, because (as mentioned before) the blades grasp the head securely without producing dangerous com- pression, and the compression is not increased during traction as it is when using the ordinary short or long forceps. If the old forceps without the traction-rods and cross-bar are used, apply and lock as described for Milne Murray's instrument. If the head is high in the pelvis, pull first downward and back- ward. As the head descends bring the handles gradually toward the front — i. e., toward the mother's abdomen. Be careful, how- ever, not to bring the handles too far forward while the head is emerging — i. e., do not extend the head so much that the chin cuts through the perinseum. If the old long forceps is preferred, it is well to select the Simpson or ElHot instrument. Anaesthesia. — Operative interference adds a new element to labor. It was stated before that an anaesthetic might be admin- istered in two different ways: (1) to the obstetrical degree; (2) to the surgical degree — the obstetrical degree being generally suffi- cient in normal labor, the surgical degree being generally neces- sary for operative procedures. We may consider that the latter rule applies to forceps delivery, although not for the same reasons which prevail in other operations. The appHcation of the blades of the forceps and traction during uterine contractions causes 558 OBSTETRICAL OPEEATIONS little or no extra pain. We want profound anaesthesia, not espe- cially to prevent pain, but to keep the patient quiet during our manipulation. The violent movements of semi-intoxication may cause serious injuries. One should therefore do one of two things : (1) administer no anaesthetic. This may cause surprise to those who have seen anaesthetics administered as a matter of routine practice in maternity hospitals. Our custom generally in Toronto is to administer the anaesthetic. The country practitioner, how- ever, will often choose to use the forceps without anaesthesia, especially when miles away from a brother physician. (2) Get an assistant to completely anaesthetize the patient, especially during the application of the blades and the delivery of the head through the vulva, as already mentioned. Surgeons generally observe a good rule in making the administration of anaesthetics the work of one man who shall assume full responsibility. Obstetricians would do well to adopt the same rule, which is really the only safe one. Many practitioners, however, allow the nurse to give the anaesthetic. Although they direct the nurse and watch the patient as carefully as possible, such practice involves a certain amount of risk, which may occasionally be considerable. CHAPTER XXVI MAJOR OBSTETRICAL OPERATIONS Caesarean Section. — This is the removal of the child from the uterus by an incision through the abdominal and uterine walls. It is indicated when abdominal section is the only method by which the child can be delivered ; for example, when the con- jugate diameter in a generally contracted pelvis measures only 2h inches; when tumors or cicatrization in the pelvis prevent delivery; when, after the death of the mother, the child can be delivered more quickly by section than in any other way. It is also indicated in certain cases of rupture of the uterus, severe accidental haemorrhage, etc. Some operate about the end of pregnane}', but before labor begins, while others prefer to wait until labor has commenced. Operation. The instruments required are a sharp knife, scis- sors, needles and needle-holder, dissecting forceps, artery forceps (12 pairs), towels, gauze, ligatures, and sponges. Six assistants are reciuired: one to give the anaesthetic, one to assist in lifting out the uterus, one to compress the cervix, one to take charge of the child, and two to take care of sponges, irrigating apparatus, etc. The latter two may be nurses. The patient is prepared as for an ordinary laparotomy, the bowels and bladder are emptied, sub- umbilical region shaved, and all the parts, including the vagina, thoroughly cleansed with antiseptics, etc. The abdominal incision is made in the middle line one-third above and two-thirds below, or half above and half below the umbilicus. The assistant, after the uterus is exposed, presses the abdominal walls against it, and the uterine incision, 15-18 cm. long (6-7 inches), is made in the median line commencing at a point just below the fundus and running toward the cervix. Some make the abdominal incisions long enough to allow the uterus to be turned out before opening it. The amnion is rup- tured, the breech or one foot or both seized, and the child extracted as rapidly as possible. If the placenta lies in the line of incision, 37 559 560 MAJOE OBSTETEICAL OPERATIONS the fingers should be passed between it and the uterine wall to its margin, where the membranes should be ruptured and the feet grasped as before described. In delivering the child the head should be well flexed. The cord should be clamped by two artery forceps and then divided between them. The placenta and mem- branes should then be removed. If there is excessive haemorrhage at any stage, an assistant should grasp the neck of the uterus with both hands and make firm pressure until the deep sutures are introduced. The sutures should be placed in two layers, deep and superficial (Kelly). The deep sutures, two or three to the inch, pass through the entire thickness of the uterine wall down to the decidua. Twice as many sutures of fine silk are introduced through the peritonaeum on either side of the incision. Some use half deep sutures after the deep ones are tied, but before the super- ficial ones are introduced. The abdominal wound is closed in the ordinary way. (Some prefer a transverse incision through the fundus (Fritsch). The after-treatment is the same as that for any laparotomy. Vaginal Caesarean Section. — Dlihrssen advises vaginal Csesarean section where rapid delivery is indicated. A circular incision is made through the mucosa covering the cervix close to the fornix and extending into each lateral fornix half an inch. The mucosa flap is stripped upward with the bladder, and the cervix pulled down by means of a volsella. The bladder is held up out of danger by a retractor and the cervix divided anteriorly and posteriorly in the middle line. The anterior incision is extended four or five inches up the uterine wall, but not through the peritonaeum. The child is extracted through the incision and the placenta and mem- branes removed. The uterus is plugged with iodoform gauze and the incisions closed with catgut. Porro's Operation. — This is the supravaginal amputation of the uterus after a Caesarean section. It is indicated where the uterine tissues have been seriously injured by attempts at deliv- ery; where the child is putrid or where there is septicaemia; where there are extensive adhesions and cicatrices in the vault of the vagina ; where fibroids of the uterus exist ; where, after abdominal section for ruptured uterus, the tear is found to be very ragged and to involve other structures, or if the haemorrhage cannot be arrested; where, for- sufficient reason, there is a desire to avoid future pregnancies. SYMPIIYSTOTOMY 561 Operaiinn. The technique for this operation is the same as that for Ca^sarean section up to the point where the child is deliv- (>r('(l. Then the placenta and iiienibranes should be left in the uterus and an elastic; li segment. To prevent the abdominal cavity being contaminated by uterine fluids, a small opening in a large rubber sheet is passed over the fundus down to the elastic ligature. This ligature is then drawn tight by the assistant and the uterus ampu- tated f inch above it. The stump is disinfected and cauterized and may then be treated i,n one of two ways: (1) extraperi- toneal, or (2) intraperitoneal. In the extraperitoneal treatment the stump is encircled with a loop of a Koeberle's ecraseur just below the rubber tubing and the ecraseur drawn tight, care being taken not to include the wall of the bladder. The rubber tubing is then removed and two long needles passed through the stump above the wire loop. The abdominal wound is then sutured. The stump is brushed with a solution of the perchloride of iron ; if haemorrhage recurs the wire may be tightened. The needles are removed in from ten to twelve days. In the intraperitoneal treatment the mucous membrane is sutured first, then over this the muscular tissue, and over it the serous membrane. The rubber tubing is then removed, any haem- orrhage controlled by ligatures, and the pedicle dropped into the abdominal cavity. Or the stump may be treated as that in an ordinary myomectomy, a description of which will be found in any text-book on gyna?cology. * Total Abdominal Hysterectomy. — Occasionalh'^ in some cases it is advisable to remove the whole uterus, especially where there is malignant disease or a very bad rupture. This operation is described in text-books on gynaecology. S5miphysiotomy. — This is the operation of cutting through the symphysis pubis for the purpose of increasing all, but espe- cially the transverse, diameters of the pelvis. It is indicated where the pelvis is so small or deformed as to prevent delivery by version or forceps, but at the same time large enough with the increase in size attained by the operation to allow the delivery of a living child. It occupies, therefore, a position between ver- sion and forceps on the one hand, and embryotomy and abdominal section on the other. The range of operation lies between conju- gate diameters of 3;^ and 2f inches in a pelvis otherwise normal. 562 MAJOE OBSTETEICAL OPERi^TIONS Greater conjugate diameters are required in a pelvis otherwise generally contracted. Operation. The following instruments are required : a scalpel, a probe-pointed curved bistoury (or a Galbiani or Morrison knife), two or more haemostatic forceps, needles and needle-holder, a metallic catheter or vulcanite rod, strips of iodoform gauze, silk or wire sutures, strips of adhesive plaster, antiseptic cotton, a strong abdominal binder, obstetric forceps, and a Clover's crutch. Four assistants are required, one to give the anaesthetic, one to hold the catheter in the urethra, one to secure uterine contraction and to express the placenta, and one, a nurse, to take charge of the child. Italian or Subcutaneous Method. — The genitaha are carefully washed with an antiseptic solution, the mons veneris shaved, and the bowels and bladder emptied. The patient is placed in the lithotomy position with a Clover's crutch. The catheter or vulcan- ite rod is introduced into the urethra and depressed from the pubic arch and pushed over to the right side. A median incision 2 inches long is made, extending to or a little below the top of the symphysis, deep enough to reach the sheath of the rectus muscle and the joint. Any haemorrhage is arrested and small transverse incisions are made into the pyramidalis muscle on either side to make room for the finger. The left index finger is then introduced behind the symphysis down to its lower border, the urethra located where it has been depressed and pushed to the right by the catheter (or rod). This being out of the field of operation, the probe- pointed bistoury (or special knife) is introduced along the finger to the lower border of the symphysis. The subpubic ligament is then cut and also the symphysis from below upward and from behind forward. Haemorrhage may be controlled by plugging with iodoform gauze, and the catheter then removed. An assist- ant should watch and prevent too great a separation of the bones. Some now leave the case to Nature, waiting from one to twelve hours, interfering when they deem it advisable. Others proceed at once to hasten delivery, dilating the os if necessary and apply- ing forceps or delivering by version. An assistant should, after delivery of the child, express the placenta and keep the uterus contracted. The catheter may now be reintroduced to prevent the urethra from being caught between the bones. The abdom- inal wound is sutured, the lowest suture passing through the upper EMBRYOTOMY 563 cartilaginous surface of tho symphysis. Tho bones should not be wired. An antiseptic dressing is applied and retained in position by adhesive strapping; the vagina is loosely packed with iodo- form gauze. A firm abdominal binder is then applied and the limbs bound together, first placing a pad between the knees. The patient should be kept in bed for from three to five weeks ; and when the wound is completely healed an immovable apparatus should be put on to fix the pelvis. The Open, French, or German Method. — This method differs from the subcutaneous in that an open incision in the median line 3 or 4 inches long is made, beginning ^ inch or 1 inch above the upper border of the symphysis, extending to the root of the clitoris or a little to one side of it. In other respects the two operations are the same. The operation is dang3rous in the following respects : There may be considerable haemorrhage at the operation. The bladder, urethra, or vagina may be injured. Locomotion may be impaired from faulty union of the pelvic bones or injured sacro-iliac syn- chrondrosis. There may be septicaemia. Operation for Ectopic Pregnancy. — The preparation of the patient is the same as for an ordinary laparotomy. An incision about three inches long is made in the abdominal wall in the median line, extending downward from just below the umbilicus. Two fingers are introduced into the abdominal cavity and the uterus sought for, and then from it the Fallopian tubes are easily found. The enlarged one is held between two fingers and brought out through the wound. If rupture has occurred the perforation will generally be easily visible. The broad ligament is then transfixed and tied with interlocking ligatures and the tube cut away. It is generally advisable to wash out the abdominal cavity. The abdominal wound is closed in the usual manner. (The symptoms of ectopic gestation, before and after rupture, and the indications for operation, are given in Chapter XIV.) Embryotomy. — This is the mutilation of the foetal body, under- taken to render possible extraction of the child. It should very rarely, or better never, be performed on a living child. Where the patient and her friends absolutely refuse abdominal section it may be done in the following cases: where there is a great dis- proportion between the child's head and the mother's pelvis; where there is obstruction in the genital canal, due to tumors. 564 MAJOK OBSTETRICAL OPERATIONS cicatricial contractions, or inflammatory conditions of the soft parts; where malpositions and malpresentations have caused impactions; where there is hydrocephalus or other foetal deform- ities ; where the mother's life is in serious danger from eclampsia, etc. Some divide it into six varieties : (1) craniotomy, (2) eviscer- ation, (3) decapitation, (4) spondylotomy, (5) spondylolysis, and (6) amputation of extremities. Others divide it simply into two Fig. 215. — Simpson's Perforator varieties : craniotomy, denoting the mutilation of the foetal head, and embryotomy, mutilation of the foetal trunk. Craniotomy. — This is perforation and extraction of the foetal head. The following instruments are required : a perforator (Simpson's being the best), a cephalotribe or basiotribe (head crusher), a craniotractor or cranioclast (head seizer), a pair of volsella forceps, a catheter, and antiseptic solutions. Operation. The patient should be placed in the lithotomy position and the bladder and rectum emptied. The vulva and Fig. 216. — Scissors of Smellie. vagina should be made as nearly aseptic as possible. The head is fixed by an assistant exerting pressure on it from above, and the scalp seized by the volsella near the point of intended perfo- ration. The left index finger is used as a guide and a suture or fontanelle found, through which the head is perforated. If neither suture nor fontanelle can be found, perforation may be made through a bony plate, such as the parietal bone. Others think it CRANIOTOMY 565 better to perforate thr()Uf;h the presenting part, whether it be bone, suture, or foiitanelle. In cases of face presentation it is best to perforate throu.iih the more accessil)l(; orbit, or, faiUng that, Fig. 217. — Method of Perforating Head (Williams). through the roof of the mouth. Care should be taken lest the perforator slip ; it is least apt to do so if kept near the symphysis. When the perforator is inserted the points should be opened by pressure on the handles. The points are then closed again, the instrument turned on its ax's through a right angle and the pro- cess repeated. The brain substance, especially the medulla, is then destroyed, and may be washed out if necessary with a stream of Fig. 218. — Br.\un's Cranioclast. sterilized water through a Davidson's syringe. (In some cases after failure to deliver with forceps, it is well to perforate without removing them and then reapply traction.) 566 MAJOR OBSTETKICAL OPERATIONS Extraction. The child may in some cases be extracted with forceps ; in others a cephalotribe is used. The narrow blades are applied to the sides of the skull Uke ordinary forceps and are made to approach and to crush the skull by means of a screw at the ends of the handles. Others use a cranioclast, applying one blade within the skull and the other without, but underneath the scalp. It may be necessary in some cases to break up the base of the skull with a basylist or basiotribe before extraction. Jellett rec- FiG. 219. — Head Crushed by Braun's Cranioclast (Simpson). ommends for compression and extraction Winter's modification of Auvard's combined cranioclast and cephalotribe, which con- sists of three blades, a central or male blade resembling the male blade of an ordinary Barnes's cranioclast, and two outside blades which both lock into the central blade. One of these outside blades locks with the central blade so as to form a cranioclast, the other completing the cephalotribe. The Auvard instrument, how- ever, is much superior to this modification. PORRO'S OPERATION 567 Evisceration. — This is the operation of oix'iiiiig the thorax or abdomen of the child and removing some of the viscera. It is indicated in those cases where the size of the child's body prevents Fig. 220. — Tarnier's Cephalotribe. delivery. A perforator or a pair of scissors is introduced into whatever portion of the trunk is most accessible. Through this opening the hand is passed and some of the larger viscera — liver, lungs, or heart — are removed. The hand is then passed into the uterus, a foot seized and the child extracted. Decapitation. — This is the operation where the child's head is separated from the trunk at the neck. It is indicated in cases of neglected shoulder presentations when the neck can be reached. A Braun's blunt hook is passed over the neck and the soft parts and spinal column torn through. (Ramsbotham's hook is pre- ferred by most British obstetricians.) The arms are then drawn Fig. 221. — Simpson's Basylist, Disarticulated. down and the trunk extracted first, then the head. When it is difficult or impossible to extract the head, perforation of it may be necessary. Summary. — In all references to the major operations, includ- ing the brief summaries of the indications for the same, an endeavor has been made to give the views of the majority of obstetricians. But it should be remembered and fully appreciated that we are 568 MAJOR OBSTETEICAL OPERATIONS now passing through an evolution stage, and our views are chang- ing rapidly. Conservative Csesarean section is becoming very pop- ular. In skilled hands its mortality has been diminished to such Fig. 222. — Simpson's Basylist, Aetictjlated. an extent that it is now placed at 3 to 4 per cent, in cases where the women have not been infected before the operation. Porro's supravaginal amputation of the cervix after removal of the child was popular for many years after its introduction in 1876. Since, however, Sanger introduced his method of perform- ing Csesarean section in 1882 the Porro operation has rapidly lost ground. One of the supposed advantages of the Porro with the extraperitoneal treatment of the stump was that it could be more easily performed by a general practitioner who was not an expert abdominal surgeon. It was also thought it was a safer operation when there was infection, and that it could be performed more easily than the Csesarean section. The surgeon of to-day, how- ever, does not attach much importance to these considerations, and generally considers it a very unsatisfactory if not crude operation. Symphysiotomy is also fast losing its short-lived popularity. In a late report Tissier, of Paris, gave notes of the after-histories of c± Fig. 223. — Braun's Blunt Hook. twenty women who had been dehvered by symphysiotomy during the period 1898-1903. The patients were operated on at seven different hospitals. Four only out of the twenty escaped without POKRO'S OPERATION 569 some undesirable sequelse, the remaining sixteen all being more or loss damaged by the operation. One patient has })een a chronic invalid for five years. Eight suffered from phlebitis. Ten had urinary troubles during months or years, incontinence of urine being the most common affection. A number had difficulty in lifting or going up-stairs. A few years ago the operation was in a large proportion of cases con- sidered successful when it did not cause the death of the patient. Many of the operators were not frank, or at least prompt, in reporting the remote disastrous results such as those mentioned by Tissier. While it has many disadvantages, it is doubtful if it has one advantage over Caesarean section. From the present trend of obstetrical surgery it seems not unlikely that Porro's operation and symphysiotomy will soon be obsolete. It is to be hoped that all forms of embryotomy of the living child will be placed in the same category. It is not improbable that in the near future the following rules will prevail : When Nature fails to expel the child and we cannot safely complete deliv- ery by version or forceps, we must choose a major operation. Caesarean section will be the operation of election in the great majority of cases ; total hyster- ectoniy will be the operation of election in a few exceptional cases when infection is recognized or suspected ; embryotomy will be the operation of election when the child is dead and there is only slight pelvic deformity. Fig. 224. — Decapitation with Braun's Blunt Hook (Americaii Text-Book). INDEX Abdomen, discoloration of, in preg- nancy, 37. enlargement of, during pregnancy, 30. palpation of, 72, 87. pendulous, 36, 212. stritc of, in pregnancy, 37. Abdominal binder, 133. pregnane}^ 61. Abortion, 359. causes of, 360. cervical, 372. clinical history of, 363, 368. complete, 372. criminal, 359. curettage in, 368. incomplete, 372. induction of, 519. inevitable, 362. missed, 370. mole, formation of, in, 362. neglected, 372. prophylaxis of, 361. repeated (aborting habit), 361. threatened, 362. treatment of, 362, 368. tubal, 315, 319. vaginal tamponade in, 366. Abscess in puerperal fever, 466. of breast, 423. pelvic, 453. Acardiacus, 186. Accidental htemorrhage, 333. Accouchement force, 522. Acute infectious diseases in preg- nancy, 232. Adhesions, amniotic, 231. Adipocere, 330. After-coming head, 181. After-pains, 149. Agalactia, 398. Age of foetus, calculation of, 23. Albuminuria, 273, 285, 289. Albuminuric retinitis, 274. Alimentation, rectal, in hyperemesis, 195. Allantois, 19. Amaurosis during pregnancy, 274. Amenorrhoea, conception during, 40. Amnion, 19. diseases of, 228. Amniotic fluid, 228. Amputation, intra-uterine, 231. Anaemia in pregnancy, 200. Anaesthesia, 142. cocaine, 145. in heart disease, 262. Anencephalus, 407. Anteflexion of pregnant uterus, 211. of puerperal uterus, 148. Anteversion of pregnant uterus, 211. Antisepsis, 97. Antistreptococcic serum, 462. Anus, laceration of sphincter of, 516. imperforate, 491. Apoplexy in eclampsia, 298. Appendicitis during pregnancy, 242. Arbor vitae uterina, 9. Areola, glands of Montgomery, 40. of pregnancy, 40. Artificial feeding, 163. respiration, 136. Ascites, of foetus, 400, 406. of mother simulating pregnancy, 50. 571 572 INDEX Asepsis, 97. Asphyxia, neonatorum, 136. resuscitation from, 136-138. Atelectasis, 136. Atony of uterus, 375. Atresia of genital canal, 49. Attitude of foetus, 30. * Auscultation, obstetrical, 77, 89. Auto-infection, 442. Auto-intoxication of pregnancy, 284. Axis of pelvis, 4. Axis traction forceps, 543, 546. Babe, management of the, 135. dressing the, 139. Gertrude suit, 139. washing the, 139. Bacillus diphtherise in puerperal in- fection, 439. Bacteriology of lochia, 456. of puerperal infection, 438. of vaginal secretions, 366. Bag of waters, membranes, 71. Bags, Voorhees's dilating, 527. Balloon, Champetier de Ribes's, 525, 526. Ballottement, 44. Bandl's ring, 31, 67. Barker, Fordyce, 434. Barnes's fiddle-bags, 524. Bartholin's glands (vulvo-vaginal glands), 7, 270. Basilyst, Simpson's, 567, 568. Basiotribe, Simpson's, 567. Bath, during labor, 90. of new-born child, 139. sweat in eclampsia, 293. Battledore placenta, 403, 408. Bichloride poisoning from intra-uter- ine douche, 504. Bicornuate uterus, 11. Binder, use of, during puerperium, 133. Binovular twins, 188. Bipolar version, 345. Birthmarks, 135. Bladder, changes in, during preg- nancy, 280. Bladder, distended before labor, 108. distended after labor, 151. distended during labor, 395. empty after labor, 150. empty before labor, 108. Bleeding in eclampsia, 300. Blood, changes in, during pregnancy, 34. during puerperium, 471. Blunt hook, 568. Bossi's dilator, 528. Bougie, for induction of premature labor, 520. Bowels in pregnancy, 61. Braun's blunt hook, 568. cranioclast, 565. Braxton Hicks's method of version, 345, 531. Breasts, 14. anatomy of, 14. areola of, 14, 40. binder, 156, 245. care of, during nursing, 155. inflammation of, 420. in pregnancy, 40. massage, 156, 425. supernumerary (polymastia), 37. Breech presentations, 175, 179. Bright's disease, 273, 275. Brim of pelvis, 2. Broad ligament pregnancy, 321. Broad ligaments in normal pregnancy, 33. Bronchocele in pregnancy, 240. Brow presentations, 175. Byrd's method of resuscitation, 137. Cesarean section, 559. conservative, 568. technique of, 559. vaginal, 560. Calcification of foetus, 330. of placenta, 408. Callus formation, effect upon pelvis, 482. Canal, cervical, 32. Cancer, 346, 347. Caput succedaneum, 489. INDEX 573 Carcinoma of cervix with pregnancy, 346, 347. of rectum, case of dystocia, 395. Cardiac lesions in pregnancy, 257. Cams, circle of, 4. Catheterization, 501. Caul, 117. Causation of labor, 65. Cellulitis in puerperal infection, 452. Central placenta pra^via, 343. Cephalha^matoma, 489. Cephalic version, 401. Cephalopagus, 406. Cephalotribe, Tarnier's, 567. Cervix, 9. anatomy of, 10. apparent shortening of, in preg- nancy, 32. arbor vitff, 9. atresia, 392. carcinoma of, 346. changes in, after labor, 152. changes in, during labor, 32, 42. dilatation of, during labor, 101. manual, 524. with forceps, 534. during pregnancy, 32. glands of, 10. hypertrophy of, during pregnancy, 392. incision of, 528. rigidity of, 392. softening of, in pregnancy, 42. taking-up process in labor, 71. tears of, 508. Champetier de Ribes's balloon, 524. Child (see New-born Child), 160. Chill, during puerperium, 149, 445, 450. following normal labor, 140. in puerperal infection, 445. Chloral in labor, 145. Chloroform in labor, 142. Cholera complicating pregnancy, 237. Chorea during pregnancy, 204. Chorio-epithelioma, 372. Chorion, 19. cystic degeneration, 226. Chorion, Langhans's layer of, 372. pathology of, 226. syncytium of, 372. villi of, 19. Circulation of fcEtus, 28. in new-born child, 28. Clitoris, 7. Cloasma, 207. Clothing during pregnancy, 61. Club foot, 492. Cocaine ana?sthesia in labor, 145. Coccyx, 1. Coelome, 23. Cohen's method of inducing labor, 522. Coiling of cord, 409. Coitus during pregnancy, 61, 361. Colic, 495. Collapse from haemorrhage, 354. Colles's law, 266. Colon bacillus, 439. Colostrum, 152. Complete abortion, 372. Compound presentation, 401. Concealed hsemorrhage, 334, 340, 350. Conception, 16. Condensed milk, 166. Conduct of normal labor, 85. Confinement, estimation of date of, 52. Conglutinatio orificii externi, 392. Conjugata diagonalis, 55. externa, 55. vera, 84, 484. Conservative Caesarean section, 559, 568. Constipation during pregnancy, 197. dietetic treatment of, 197. hygienic treatment of, 198. medicinal treatment of, 198. Contracted pelves, 482. craniotomy in, 482. due to tumors, etc., 482. mechanism of labor in, 483. pelvimetry in, 54. treatment of labor complicated by, 484. 574 INDEX Contraction, 68,, 69. hour-glass of uterus, 348, 418. painless, 47. uterine, 68. ring, 31, 67. Convulsions (see Eclampsia), 294. Copeman's dilatation of the cervix, 196. Cord (see Umbilical Cord), 23, 117, 408. Coronal suture, 27. Corpulence simulating pregnancy, 50. Corpus luteum, 15. false, 15. true, 15. Correction of displacement of the uterus, 197. Corrosive sublimate, 504. Cramps, muscular, during pregnancy, 207. Cranioclast, 565. Craniotomy, 564. Cranium (see Head, Foetal), 27. Cream mixtures, 163. Crede's method of expressing pla- centa, 121. Criminal abortion. 359. Cul-de-sac of Douglas, 8. Curettage, 368, 504. Cyanosis, infantile, 493. Cystic degeneration of chorion, 226. Cystitis during pregnancy, 281. Cystocele complicating labor, 395. Death of foetus during pregnancy, 136, 409. Decapitation, 567. Decidua, 18, 34. changes in, in abortion, 34. compact layer of, 34. deep layer of, 34. development of, outside of uterus, 313. diseases of, 225. in extra-uterine pregnancy, 313. reflexa, 19. serotina, 19. spongy layer of, 34. Decidua vera, 19. Decidual cast in extra-uterine preg- nancy, 324. Deciduoma malignum, 372. Deformed pelves (see Contracted Pel- ves), 482. Delivery, normal, 85. Dental caries during pregnancy, 193. Diabetes during pregnancy, 283. Diagnosis, differential, of pregnancy, 48. of life or death of foetus, 409. of pregnancy, 38. of previous pregnancy, 53. of sex during pregnancy, 46. Diameters of head, 27. of pelvis, 55, 84. Diarrhoea during pregnancy, 199. Dicephalous monsters, 406. Diet during pregnancy, 61. during puerperium, 159. Differential diagnosis of pregnancy, 48. of foot and hand, 177- of knee and elbow, 177. Dilatation of cervix, 196, 519. in labor, 523. Dilator, Bossi's, 528. Diseases complicating pregnancy, 192. Displacements (see Uterus), 212. Dolichocephalic head, cause of face presentation, 169. Double Naegele pelvis, 481. uterus, 11. vagina, 11. Douche, uterine, 503. prophylactic, 154. vaginal, 502. vulvar, 502. Douglas's cul-de-sac, 33. Dropsy of amnion, 228. Dry labor, 377, 382. Duchenne's paralysis, 491. Duct of Gartner, 12. Ducts, lactiferous, 14. Ductus, arteriosus, 28. venosus, 28. INDEX 575 Duration of prepjiancy, 51. Dwarf pelvis, 481. Dyspna?a during pregnancy, 202. Dystocia due to abnormalities of the cervix, 392. to abnormalities of the expulsive forces, 386. to abnormalities of vagina and vulva, 392, 396. to contracted pelves, 482. to tumors of birth canal, 394. Dystocia following vagino-fixation or ventro-fixation, 393. Dysuria from incarcerated pregnant uterus, 213. Eclampsia, 294. blindness accompanying, 274. frequency of, 294. induction of abortion for, 306. pathology of, 297. prognosis of, 297. treatment of, 298. venesection in, 300. Ectopic pregnancy (see Extra-uterine Pregnancy), 310. Elderly primipara^, 377. Embolism, air, 503. pulmonary, 475. Embryo, 18. Embryotomy, 563. Emesis in pregnancy, 194. Emotional disturbances, 203, 427. Endometritis, catarrhal, decidual, 226. puerperal, 443. septic, 443. Enema, during labor, 98. high, 500. Enteroptosis during pregnancy, 199. Epiblast, 18. Epilepsy during pregnancy, 296. Episiotomy, 508. Ergot, use of, in labor, 131, 384. Er^'sipelas in pregnancy, 235. Erythema intertrigo, 494. Esmarch mask, 143. Estimation of date of confinement, 51. 38 Ether, 144, 145. Eustachian valve, 28. Evisceration, 567. Evolution, spontaneous, 400. Examination, 87. preliminary, during pregnancy, 62. vaginal, during labor, 89. during pregnancy, 77. Exostosis, producing pelvic deform- ities, 482. Expelling powers in labor, 65. Expression of placenta, 124. External conjugate measurement, 58. External version, 531. Extra-uterine pregnancy, 310. abdominal, 321, 329. abortion in, 315, 319. associated with intra-uterine, 327. Tittachment of ovum in, 313. broad ligament, 321, 326. classification of, 311, 312, 322. corpus luteum in, 314. decidua expelled entire in, 324. diagnosis of, 322, 323. etiology of, 312. fate of foetus in, 330. formation of decidua in, 313. formation of placenta in, 313. hematocele in, 318, 320. interstitial, 317, 324. lithopa?dion in, 330, 331. mole, 315. mummification in, 330. ovarian, 312. primary, 313. rupture of, 314, 316, 325. secondary, 321. suppuration in sac, 330. symptoms of, 318. terminations of, 330. treatment of, 330. tubal, 312. tubo-abdominal, 321. tubo-ligamentous, 321. uterine decidua in, 313. Face presentations, 168. conversion of, into vertex, 173. 576 INDEX Face presentations, diagnosis of, 169. management of, 172. mechanism of, 170. treatment of, 174. version in, 172. Facial paralysis during pregnancy, 206. Factory employment during preg- nancy, 241. Fseces of infant, 160. Fallopian tubes, 9, 11. False pregnancy, 50. Farre, white line of, 13. Fascia, pelvic, 5. Fat in abdominal walls simulating pregnancy, 50. Fatty degeneration of placenta, 408. Fecundation, 16. Fertilization of ovum, 16. Fibro-m.yomatum of uterus, compli- cating labor, 225. Fillet, 180. Fissure of nipple, 423. Flat pelvis, 481. Flexion in vertex presentations, 79. Foetal circulation, 28. diseases, 409. dropsy, 406. Foetal heart sounds, 45, 77, 89. Fojtal head, 27. nervous system, 29. Foetus, 18. ascites of, 400, 409. at full term, 26. attitude of, 30. calcification of, 330. circulation of, 28. congenital hydrocephalus, 409. cranium of, 27. death of, 136, 409. deformities of, 405. diameters of head of, 27. diseases of, 409. head of, 27. heart sounds of, in pregnancy, 45, 46. hydrocephalus of, 406. lanugo of, 25. Foetus, large, 407. lie of, 30. length of, 26. maceration of, 409. malformations of, 405. meconium of, 160. movements of, in pregnancy, 45. nutrition of, 22. over-development of, 407. papyraceus, 187. peritonitis of, 409. physiology of, IS. position of, 30. presentation of, 30. pressure marks on head of, 490. syphilis of, 409. urine of, 160. Footling presentation, 176. Foramen ovale, 28. Forceps, 534. application of, 549, 550. as dilator of cervix, 534. axis traction, 543, 546. choice of, 541. conditions necessary for application of, 535. description of, 543, 546. in after-coming head, 185. in contracted pelves, 485. indications for, 535. locks, 540, 542, 543. long, 541. Milne Murray's, 543. Pajot's manoeuvre, 544. Porter Mathew's, 546. Simpson's, 542. Tarnier's, 542. Forces concerned in labor, 65, Fossa navicularis, 7. Fourchette, 7. Fourth grip, 76. . Frontal suture, 27. Fundal grip, 74. Fundal incision in Csesarean section, 560. Funic souffle, 48. Funis (see Umbilical Cord), 23, 117. Funnel-shaped pelvis, 481. INDEX 577 Galactocele, 398. Galactorrhoea, 398. Gastroptosis, during pregnancy, 199. Gavage, 168. Generally contracted pelvis, 481. Generation, 16. Germinal epithelium, 13. spot, 13. Gertrude baby suit, 139. Glands, Bartholin's (vulvo-vaginal glands), 7, 270. cervical, 10. mammary, 14. uterine, 9. Glycerine, use of, in inducing labor, 522. Glycosuria during pregnancy, 283. Goitre in pregnancy, 240. Gonococcus, 477. Gonorrhoea in pregnancy, 269, 476. Graafian follicle, 13. Greater fontanelle, 27. Grips in abdominal palpation, 75. Guard, vulvar, 63. Hsematocele, diffuse, 318. pelvic, 319. Hematoma, 318, 320. of broad ligament, 318, 320. of sterno-cleido-mastoid muscle, 490. of vagina, 396. of vulva, 396. subperitoneal, 320. Hsematometra, 49. Hsemoptysis during pregnancy, 250. Haemorrhage, accidental, 333. ante-partum, 333. concealed accidental, 333, 334. curettage in, 363, 368. ergot in, 131. post-partum, 349. unavoidable, 341. Harris's method of dilating the cer- vix, 524. Head, foetal, 27. diameters of, 27. fontanelles of, 27. Head, of new-born child, 27. presentation, 77. sutures of, 27. Headache in eclampsia, 295. in pregnancy, 285. Heart, disease of, in pregnancy, 257. foetal, 45, 77. hypertrophy of, in pregnancy, 258. means of diagnosing sex, 46. Hegar's sign of pregnancy, 42. Hemiplegia in pregnancy, 206. Herman's method in face presenta- tions, 173. Hernia of pregnant uterus, 218. Herpes gestationis, 208. Hook, blunt, 568. Hour-glass contraction of uterus, 349, 418. Hydatidiform mole, 226. Hydrsemia of pregnancy, 34. Hydramnios, 228. Hydrocephalus, 408. Hydrometra, 48. Hydrorrhoea gravidarum, 226. Hygiene of pregnancy, 61. Hymen, 7. Hyperemesis gravidarum, 194. Hypertrophic elongation of cervix during pregnancy, 392. Hypoblast, 18. Hypodermic injection, 499. Hysterectomy, 561. Icterus of child, 492. Ilio-pectineal line, 2. Ilium, 1. Imaginary pregnancy, 50. Imperforate anus, 135, 491. Impetigo herpetiformis, 208. Impregnation, 16. Incarceration of retroflexed pregnant uterus, 213. Incisions of cervix, 528. Incomplete abortion, 372. Incubator, 167. Indigestion during pregnancy, 194. Induction of abortion, 519. of premature labor, 520. 578 INDEX Inertia uteri, 375. Inevitable abortion, 362. Infant, 135, 160. Infarcts of placenta, 408. Infection, puerperal, 435. Infectious diseases complicating preg- nancy, 232. Influenza during pregnancy, 238. Injuries to birth canal, 133. Innominate bone, 1. Insanity, puerperal, 430. Insertio velamentosa, 408. Insomnia during pregnancy, 203. Insufflation of lungs in asphyxia neo- natorum, 138. Intercristal measurement, 57. Intermittent contractions of the uterus, 47. Internal rotation, 79. Internal version, 533. Interspinous measurement, 56. Interstitial pregnancy, 312, 317, 324. Intra-uterine douche, 457, 503. dangers of, 457. Intravenous injection, 500. Inversion of uterus, 416. Involution of uterus, 147. Ischiopagus, 406. Ischium, 1. Jaundice of child, 492. Joints, mobility of, during preg- nancy, 3. relaxation of, during pregnancy, 3. Kidney, changes in, during preg- nancy, 272. acute nephritis, 273. chronic nephritis, 273. toxemic, 272. Knee presentation, 176. Krause's method of inducing labor, 520. Kyphosis, 482. Labium majus, 6. oedema of, 397. Labium minus, 7. Labor, abdominal contractions dur- ing, 66. action of expellent forces in, 65. anaesthesia during, 142. antisepsis in, 97. asepsis in, 97. bandage, abdominal, 133. bed, preparation of, for, 96. cause of, 65. cervix during, 71. chair, Soudan, 119. chill after, 149, 445, 450. collapse after, 354. conduct of, 85. first stage of, 71, 99. second stage of, 71, 105. third stage of, 71, 121. contraction of muscle fiber during, 69. cord, tying of, 117. course of, in contracted pelves, 483. delivery of head, 109. delivery of shoulders, 116. diet during, 100. dilatation of cervix, 524. dress of accoucheur, 95. dry, 377. duration of, 71. enemata during, 98. episiotomy, 508. ergot during, 131. examination in, 87. expelling powers in, 65. false, 330. first stage of, 98. forces concerned in, 65. in elderly primiparae, 377. introduction of hand into uterus during, 99. laceration of perinseum during, 107, 133, 510. lubricants in, 97. management of normal, 85. mechanism of, in breech presenta- tions, 177. in brow presentations, 175. in face presentations, 170. in vertex presentations, 77. IXDEX 579 Labor, missed, 330. molding; of head in, S3. nervous influences during, 67. normal, S5. obstructed, 392. onset of, 92. pains of, 65, 66. palpation, abdominal, 73, 87. perineal tears in, 108, 133. perineum, management of, 107. phenomena, clinical of, 8.5. physical changes during uterine contractions, 67. physiology of, 65, 378. position in first stage of, 101. position in second stage of, 109. precipitate, 374. prediction of date of, 52. premature, 360. preparations for, 90, 91. progress of, 101. prolonged, 374. retraction of muscle during, 70. room prepared for, 92. rules for doctor during, 94. rules for nurse during, 94. rupture of membranes in, 105. second stage, 105. shock during, 340. stages of, 71. taking up process of the cer\-ix during, 71. temperature in, 150. third stage of, 121. tying of cord in, 117. vaginal examination during, 89. value of intermittent character of the pains in, 66. Laborde's method of resuscitation, 137. Laceration during labor, 107, 133, 510. of cervix, 508. of cord, 398. of pelvic floor, 510. of perin^eum, 510, 513. of vagina, 509. Lactation, 152. Lactosuria during pregnancy, 283. Langham's layer of chorion, 373. Lanugo, 25. Laparotomy in extra-uterine preg- nancy, 330. Laxatives in puerperium, 61, 197. Lead poisoning during pregnancy, 240. Leg-holder, 95, .543. Lesser fontanelle, 27. Leucocytosis, 35, 471. Leucopenia, 469. Leucorrhoea of pregnancy, 218. Levator ani muscle, 6, 112. Lie of foetus, 30. Life, perception of, 45. Ligaments, 3, 11, 33. Lithopa^dion, 3.30, 331. Liver, changes in eclampsia, 297. Lochia, 151. bacteriological examination of, 456. Locked twins, 399, 403. Loops in umbilical cord, 408. Lord Lister, 152. Lower uterine segment, 31, 67. Lubricants in labor, 97. Lungs, changes in, during pregnancy, 36. Lying-in chamber, 96. Maceration of foetus, 409. Malaria during pregnancy, 239. Malpresentations, 399. Mammae (see Breasts), 14, 420. Mammarj' glands, management of, 14, 40, 1.55. Management of pregnancy, 61. Mania, 430. Manual removal of placenta, 419. Manufactured artificial foods, 166. Marginal insertion of cord, 407. Marginate placenta, 407. Masculine pelvis, 2. Massage of breasts, 156, 425. Mastitis, 420. Mathew's forceps, 546. Maturity of foetus, signs of, 26. Measles during pregnancy, 236. 580 INDEX Mechanism of labor, complicated by foetal monstrosities, 405. in breech presentations, 177. in brow presentations, 175. in contracted pelves, 483. in face presentations, 170. in occipito-posterior presentations, 385. in transverse presentations, 400. in vertex presentations, 77. Meconium, 160. Membranes, foetal, 129. extraction of, 125. Membranous placenta, 408. Menopause, 16. Menses, cessation of, in pregnancy, 40. persistence of, in pregnancy, 40. Menstruation, 16. causation of, 16. cessation of, in pregnancy, 40. relation of, to ovulation, 16. Mental and emotional changes during pregnancy, 203, 427. Mercurial poisoning in pregnancy, 240. Mesoblast, 18. Metritis, puerperal, 444. Micturition during the puerperium, 159. Milk, condensed, 166. corpuscles, 152. cow's, 163. fever, 152. human, 152, 163. leg (see Phlegmasia Alba Dolens), 445. modified, 164. pasteurization of, 163. sterilization of, 163. Milne Murray's forceps, 543. Miscarriage (see Abortion), 250, 359. Missed abortion, 317. labor, 330. Mixed infection, 441. Mole, 362. hydatidiform, 226. tubal, 315. Monsters, 405. Mons veneris, 6. Montgomery's glands, 14. Morning sickness, 40. Movements of foetus during pregnan- cy, 45. Miiller's method of impression of head, 485. Multiple pregnancy, 185. acardia in, 186. course of labor in, 191. diagnosis of, 191. foetus papyraceus in, 187. pathological conditions in, 190. presentation in, 190. relation of placenta and mem- branes in, 191. treatment of, 191. Muscle fibers of pregnant uterus, 68. Musculature of pregnant uterus, 68. Myoma of uterus, 222. complicating labor, 223. pregnancy, 222. Nabothian follicles, 10. Naegele's obliquity, 483. Naegele pelvis, 481. Nausea and vomiting in pregnancy, 194. Nephritis, chronic, during pregnancy, 272. morbid anatomy of, 277. Nervous system in pregnancy, 202. Neuralgia during pregnancy, 202. New-born child, artificial feeding of, 163. adherent prepuce of, 495. asphyxia of, 136. bladder of, 191. breasts, engorgement of, 491. cephalhsematoma of, 489. circulatory changes in, 28. club feet of. 492. colic of, 495. cyanosis of, 493. ductus arteriosus of, 28. erythema intertrigo of, 494. eyes of, injuries of, 490. feeding of, 161. INDEX 581 New-bom child, foramen ovale of, 28. head of, 27. icterus of, 492. jaundice of, 492. loss of weight of, 161. • nursing of, 162. ophthalmia of, 492. phimosis of, 495. spina bifida of, 492. stomach of, 161. syphilis of, 493. tetanus of, 493. tongue-tie in, 494. umbilical cord of, 161. umbilical haemorrhage of, 491. umbilical hernia of, 491. umbilical vegetations, 491. urine of, 160. weight of, 161. wet nurse, 162. Nipple shield, 424. Nipples, 61. care of, during pregnancy, 61. during puerperium, 1.58. excoriation of, 423. fissures of, 423. retracted, 61, 158. Nourishment, administration of, 168. Nuchal presentation, 402. Nuclein, use of, in puerperal infec- tion, 464. Nymphse, 3. Obliquely contracted pelvis, 481. Obliquity of the uterus, 169. Obstetrical outfit, 94. Obstructed labor (see Dystocia), 392. Occipito-anterior presentations, 78, 83. Occipito-posterior presentations, 385. CEdema in pregnancy, 287. ffidema of the vulva, 397. Oligo-hydramnios, 231. Oophoritis, puerperal, 444. Operations, obstetrical, 496. accouchement force, 522. Caesarean section, 559. craniotomy, 564. Operations, curettage, 368, 504. decapitation. .567. douche, 154, 503, 504. embryotomy, 563. evisceration in breech presenta- tions, 180. forceps, 534. induction of abortion, 519. induction of premature labor, 520. intra-uterine pack, .353, .507. manual removal of placenta, 419. preparations for, 498. repairing of lacerations, 513. symphyseotomy, 561. tampon, 353, 366, .507. Ophthalmia neonatorum, 492. Organ of Ro-senmiiller, 12. Os externum, 9. enlargement of, in pregnancy, 42. innominatum, 1. internum, 9, 32. Osteomalacia, 480. Osteomalacic pelvis, 482. Ovarian tumors, 49, 394. pregnancy, 312. Ovaries, 12. Graafian follicles, 15. Ovariotomy during pregnancy, 394. Ovula Nabothi, 10. Ovulation, 15. relation of, to menstruation, 15. Ovule, 13. Ovum, 13. development of, 18. diseases of, during pregnancy, 225. impregnation of, 16. Oxytocics, indications for use of, 131, 384, 385. Painful mammary glands during pregnancy, 221. Palpation, 72, 87. different grips in, 73. in anterior-occipito-iliac presenta- tions, 386. in face presentations, 169. of cephalic prominence, 176. of foetal heart-beat, 410 582 INDEX Palpation of lower uterine segment, 45. Paraglobulin in urine of pregnancy, 286. Paralysis, Duchenne's, 491. during pregnancy, 206. during puerperium, 206. facial, following forceps, 491. of nerves of special sense during pregnancy, 206. Parametritis, 444, 4.52. Paraplegia complicating labor, 206. during pregnancy, 206. Parovarium, 12. Partial placenta prsevia, 341. Parturition (see Labor), 65, 77, 85. Pathology of labor, 333, 374, 399, 410. of pregnancy, 192, 210, 232, 272, 310. of puerperium, 272. Pawlic's grip, 75. Pelvic abscess, 453. cavity, 2. cellulitis following puerperal in- fection, 452. fascia, 5. floor seen from above. 111. anatomy of, 5, 111. changes in, during labor, 66, 108. injuries to, 133, 508, 514. grip, 75. joints, relaxation of, during preg- nancy, 3. peritonitis following puerperal in- fection, 453. Pelvimetry, 54. Pelvis, 1. anatomy of, 1. articulations of, 3. axis of, 4. cavity of, 2. coccyx, 2. comparison of, 2. conjugata vera, 84, 484. contracted (see Contracted Pelvis), 482. diameters of, 84. Pelvis, double Naegele, 481. dwarf, 481. exostosis of, 482. female, 2. flat non-rhachitic, 481. flat rhachitic. 481. funnel-shaped, 481. generally contracted, 481. inferior strait, 3. inlet of, 3. justo-minor, 481. ligaments of, 3. male, 2. Naegele's pelvis, 481. normal conjugate, 59, 84. oblique conjugate of, 59. obliquely contracted, 481. obstetrical conjugate of, 59 of new-born child, 4. osteomalacic, 482. outlet of, 3. planes of, 3. pubis, 3. rhachitic, 481. Robert's, 481. sacro-iliac synchondrosis of, 3. sacrum, 2. sexual differences in, 2. simple flat, 401. spondylolisthetic, 481. symphysis pubis, 3. transversely contracted, 481. true conjugate, 84. tumors of, 482. Pelzer's method of inducing labor, 522. Pendulous abdomen, 36. Perforation of uterus, 505. Perforator, Simpson's, 564. Perinseum, anatomy of, 5. changes in, during labor, 107. lacerations of, 133, 513, 516. protection of, 107. rigid, 90. Peritonitis, puerperal, 444, 454. Pernicious anaemia in pregnancy, 200. Pessary in treatment of retroflexed pregnant uterus, 216. IXDEX 58S Phlebitis, femoral, 473. Phlebotomy in eclampsia, 300. Phlegmasia alba dolens, 445, 473. Physometra, 48. Pigmentation during pregnancy, 207. Placenta, 20. adherent, 418. anatomy of, 20. apoplexy of, 408. battledore, 403, 408. calcification of, 408. diseases of, 408. duplex, 13.5, 407. expression of, 121. fatty degeneration of, 408. functions of, 21. infarcts of, 408. inflammation of, 408. in multiple pregnancy, 188, 189. manual removal of, 419. marginata, 407. mechanism of separation of, 123. membranacea, 408. mode of delivery of, 123. mode of extrusion of, 123. multiple, in single pregnancy, 407. normal situation of, in utero, 20. retained for months, 370, 371. retention of, 418. separation of, 127. site, 125. site of post-partum, 125. situation of, in utero, 20. souffle in, 47. succenturiata, 407. syphilis of, 408. velamentous, 405, 408. weight of, 21. Placenta prsevia, 341. induction of premature labor for, 345. prognosis of, 343. symptoms of, 341. treatment of, 343. vaginal pack in, 345. version by Braxton Hicks's method, 345. Placentitis, 408. Planes of pelvis, 3. Pneumonia during pregnancy, 237. Podalic version, 401. Polarity, law of, 70. Polyhydromnios, 228. Polymastia (supernumerary breasts), 37. Porro's C;rsarean section, 560. Porter Mathew's forceps, 546. Position of foetus, 30. Post-partum haemorrhage, 349. primary, 349. secondary, 355. treatment, 351. Posture, in first stage of labor, 109. in second stage of labor, 109, 116. Prague manceuvre, 182. Precipitate labor, 374. Pregnancy, abdominal, 321. abdominal bandage in, 61. abnormalities of pigmentation in, 37. acardia in multiple, 186. acute infectious diseases in, 232. acute yellow atrophy of liver in, 37. albuminuria during, 273. alimentary system in, 37. amaurosis in, 274. amenorrhoea during, 40. amnion, diseases of, during, 228. anaemia in, 200. anteflexion of uterus during, 211. anteversion of uterus during, 211. appendicitis in, 242. areola in, 40. auto-intoxication in, 284. ballottement in, 44. bladder, changes in, 38. blood, changes in, 34, 200. bowels in, 38. breasts, care of, during, 61, 221. broad ligament, 321, 329. bronchocele in, 240. carcinoma of cervix during, 346, 347. cardiac lesions in, 257. cephalalgia in, 202. 584 INDEX Pregnancy, choasma in, 37. cholera in, 237. chorea in, 204. chronic nephritis in, 272. clothing during, 63. constipation during, 61, 197. cutaneous system in, 37. cystitis in, 281. death of foetus during, 136, 409. decidua polyposa during, 226. dental caries in, 193. depressed nipples in, 61, 158. derangement of stomach in, 194. diabetes in, 283. diagnosis, differential, 48 diagnosis of, 38. of death of foetus in, 409. of multiple, 191. of previous pregnancy, 53. diarrhoea during, 199. diastasis of recti muscles during, 218. diet during, 61. diffuse thickening of decidua dur- ing, 226. diseases of alimentary tract and liver in, 192, 194, 197. of blood in, 200. of circulatory and respiratory systems in, 200, 202. of decidua during, 225. of kidneys and urinary tract in, 272. of nervous system in, 202. of ovum during, 225. of skin in, 207. displacement of uterus during, 210, 211, 212. disturbances of vision in, 274. duration of, 51. dyspnoea in, 202, 257. eclampsia in, 294. ectopic (see Extra-uterine Preg- nancy), 310. emesis in, 194. enlargement during, 30. enteroptosis in. 199. Pregnancy, epilepsy in, 296. erysipelas in, 235. estimation of date of confinement in, 52. examination, preliminary, during, 62. exanthemata during, 232. exercise durinc, 61. extraperitoneal, 321, 326. extra-uterine, 310. facial paralysis in, 206. false, 50. foetal heart sounds in, 45. formation of lower uterine seg- ment, 31, 67. funic souffle in, 48. gastroptosis in, 199. glycosuria, 283. goitre in, 240. gonorrhoea in, 269. haemorrhages in, 240. haemoptysis during, 250. heart, hypertrophy of, in, 258. Hegar's sign of, 42. hernia of uterus during, 218 herpes gestationis in, 208. hydatidiform mole in, 226. hydrsemia in, 203. hydramnios in, 228. hydrorrhoea gravidarum during, 226. hyperemesis in, 194. hypertrophic elongation of cervix during, 392. hypertrophy of cervix in, 392. hypertrophy of the ureters in, 43. imaginary, 50. impetigo herpetiformis in, 208. incarceration of the uterus during, 313. incomplete retroflexion of uterus during, 217. incontinence of urine in, 283. indigestion in, 194. influenza in, 238. in rudimentary horn of double uterus, 329. INDEX 585 Pregnancy, insanity during, 204, 430." insomnia during, 203. intermittent contractions of uterus during, 47. interstitial, 324. intestines, changes in, 38. intestines, disorders of, in, 197. irritability of bladder in, 280. kidney of, 272. lactosuria in, 283. laparotomy during, 394. lead poisoning in, 240. leucorrhoea in, 218. malaria in, 239. mammie in, 61, 221. management of, 61. measles in, 236. menses, cessation of, during, 40. persistence of, during, 40. mental and emotional changes in, 203. mental derangements in, 203. mercurial poisoning in, 240. morning sickness in, 40. movement of foetus during, 45. multiple, 185. myofibromata with, 222. nausea and vomiting during, 194. nephritis in, 272, 273. nervous irritability in, 202. neuralgia in, 202. cedema in, 287. osseous system in, 37. ovarian cyst complicating, 394. palpation during, 73. paraglobulin in urine of, 286. paralysis in, 206. paraplegia in, 206. pathology of, 192. patient's outfit in, 63. pelvimetry during, .54. pendulous abdomen in, 36, 212. pernicious anaemia in, 200. vomiting of, 194. physiology of, 30. phthisis in, 249. pigmentation in, 37, 207. Pregnancy, placental souffle in, 47. placentitis in, 408. pneumonia in, 237. preliminary- examination during, 62. prolapse of uterus during, 210. prolonged, 52. pruritus in, 207. pruritus vulvae in, 220. psychoses during, 203. ptyalism in, 192. purpura ha>morrhagica in, 208. quickening in, 45. renal insufficiency during, 272, 286. respiration in, 36, 202. retention of urine in, 283. retroflexion of uterus during, 212. retroversion of uterus during, 212. sacculation of uterus in, 217. salivation in, 192. scarlet fever in, 234. serum-albumin in urine of, 286. signs of, .39. signs of previous, 53. size of uterus in, 44. smallpox in, 2,36. souffle, funic or umbilical, in, 48. souffle, uterine, in, 47. spurious, 50. striae of, 36, 37. suppression of menses in, 40. symptoms of, 39. syphilis in, 265. tetanus in, 238. tetany in, 238. thyreoid in, 240. tobacco poisoning in, 241. toothache in, 193. torsion of cord in, 408. toxsemia of, 283. toxsemic kidney, 272. tubal, 313. tuberculosis in, 249. tubo-abdominal, 321. tubo-uterine, 324. tumors complicating, 49, 51, 394. typhoid fever in, 232. umbilicus in, 87. 586 INDEX Pregnancy, urea, amount of, during^ 286. ureters, hypertrophy during, 43. urinary disturbances during, 37. urine, examination of, during, 62. urine in, 37. uterine intermittent contractions, 47. uterine displacements in, 212. souffle in, 47. uterus in, 41. vagina in, 43. vaginitis during, 218, 269. valvular lesions of heart in, 258. varicose veins in, 201. vesicular mole in, 226. Premature infant, care of, 166. Premature labor, induction of, 520. Preparation for labor, 90. Presentation, 30. anterior parietal, 483. breech, 175. brow, 175. cephaUc, 77. complex, 401. face, 169. footling, 176. head, 77. knee, 176. pelvic, 175. shoulder, 399. transverse, 399. vertex, 77. Presenting part, 30. Probable signs of pregnancy, 39. Prolapse of pregnant uterus, 210 of umbilical cord, 402. Prolonged labor, 374. pregnancy, 52. Prophylactic douche, 155. Pruritus during pregnancy, 207. vulvaj, 220. Pseudocyesis, 50. Pubes, 1 Pudendum, 1. Puerperal infection, 435. acute, 454. Puerperal infection, antistreptococcic serum in, 462. auto-infection, 442. bacteriological examination of lo- chia in, 456. bacteriology, 438. curettage in, 460. diagnosis of, 445. etiology, 436. hysterectomy for, 464. intra-uterine douche in, 457. operative treatment of, 459. pathological anatomy of, 443. phlegmasia alba dolens, 473. pysemia in, 442, 445, 467. saprsemia, 441, 452. septictemia, 441. symptoms of, 445, 449. treatment of, 474. ulcer, 460. Puerperium, 146. after-pains in, 149. anteflexion of uterus during, 148. binder in, 133, 425. bladder distended, 151. bladder empty, 150. breast binder, 156. breasts, 152, 425. care of patients during, 153. catheterization during, 159. cervix during, 152. chart, 147. chill, 149. diet during, 159. douching during, 155. embolism in, 475. establishment of the secretion of milk during, 152. hsematoma during, 396. incontinence of urine during (over- flow), 151. infection during, 435. insanity during, 430. involution, 147. laxatives in, 160. leucocytosis during, 35, 471. leucopenia during, 469. lochia during, 151. INDEX 587 Puerperium, management of, 153. mastitis during, 420. micturition during, 159. milk fever in, 152. nipples, care of, during, 158, 423. phlegmasia alba dolcns during, 445, 473. retention of urine during, 151. secretions during, 150. subinvolution of uterus during, 149. temperature during, 150. urination during, 159. urine in, 150. vaginal douching during, 154. vulvar toilet during, 132. Prolapse of uterus, 210. Pruritus, 207, 220. Pulmonary embolism, 475. Pulse during puerperium, 150. Purpura ha?morrhagica in pregnancy, 208. Pus tubes, 479. Pyemia, 442, 445, 467. Quadruplet pregnancy, 185. Quickening, 45. Quinine as an oxytocic, 385. Quintuplet pregnancy, 185. Rectal enemata, 98, 500. Rectocele complicating labor, 395. Rectum, carcinoma of, complicating pregnancy, .395. Reduction of retroflexed pregnant uterus, 215. Renal insufRciency, 272, 286. Repair of lacerations of perinajum, 513. Repositor for prolapsed umbilical cord, 403. Respiration, artificial, 136. Restitution (External rotation), 83. Retained placenta, 418. Retention of urine, 151. Retinitis, albuminuric, 274. Retraction ring (see Contraction Ring), 31, 67. Retroflexion of pregnant uterus, 212, 217. Retroversion of pregnant uterus, 212, 217. Rheumatism during pregnancy, 2.39. Rickets, 480. Rigor following labor, 445, 450. Ring of Bandl (see Contraction Ring), 31, 67. Robert's pelvis, 481. Room prepared for labor, 92. Rosenmiiller, organ of, 12. Rotation, external, 83. internal, 79. Round ligaments during labor, 33. Rubber gloves, use of, 95, 98. Rupture of uterus, 410. Sacculation (Sacciform dilatation) of uterus, 217. Sacrum, 1. Salivation in pregnancy, 192. Salpingitis, puerperal, 444. Salt solution in eclampsia, 302. in haemorrhage, 355. Sapr£emia, 441, 452. Satchel, obstetrical, contents of, 95. Scarlet fever in pregnancy, 232. relation of, to puerperal infection, 235. Schatz's method, 173. Schauta's method, 366. Secundines, retention of, 356. Semmelweiss, 433. Septica?mia, puerperal, 4.35. Serum-albumin in urine of pregnancy, 286. Sex, diagnosis by heart-beat, 46. Shock before and during labor, 337. Shortening of cervix, apparent, in pregnancy, 32. Shoulder, jaw traction, in after-com- ing head, 181. Shoulder presentation, 399. Shoulder, delivery of, 116. Show, 93. Signs of pregnancy, 39. 588 INDEX Simple flat pelvis, 481. Simpson, Sir James Y., 142. Simpson's basilyst, 567. forceps, 542. perforator, 215. Skull, depression of, 490. fracture of, 490. Slow pulse during puerperium, 150. Smallpox during pregnancy, 236. Smellie's method, 182. SmeUie's scissors, 564. Somatopleure, 18. Soudan labor chair, 119. Souffle, funic, 48. placental, 47. uterine, 47. Spermatozoa, 16. Spina biflda, 134, 492. Splanchnopleure, 18. Spondylolisthesis, 480. Spontaneous amputation by amniotic adhesions, 231. evolution, 400. version, 400. Spurious pregnancy, 50. Stages of labor, 71, 98, 105, 121. Staphylococcus in puerperal infec- tion, 439. Stenosis of umbilical vessels, 409. Sterilizing instruments, 498. Stocking-drawers, Snively, 538. Stomach, derangement of, 194. Straits of pelvis, 2. Streptococcus, 439. Strige of pregnancy, 37. Subcutaneous injection, 499. Subinvolution of uterus, 149. Succenturiate placenta, 407. Sugar in urine, 238. Superfecundation, 189. Superfcetation, 189. Sutures, 499. for perineal repair, 514. Sylvester's method of resuscitation, 136. Symphyseotomy, 561. Syncytial layer, 373. Syphilis, 265. Syphili , during pregnancy, 265. foetal, 409. infantfle, 493. Talipes, 135. Tampon, 505. in abortion, 366, 505. in accidental haemorrhage, 338. in placenta prsevia, 345. in post-partum haemorrhage, 353. in rupture of the uterus, 415. Tamponade, intra-uterine, 507. vaginal, 506, 519. Tarnier's cephalotribe, 567. forceps, 542. Temperature during labor, 150. during puerperium, 150. Tetanic construction of uterus, 66, 375, 378. Tetanus during pregnancy, 238. neonatorum, 492. Tetany in pregnancy, 238. Third stage of labor, 71, 121. Thoracophagus, 405. Threatened abortion, 362. Thrombosis of uterine vessels, 445. of vessels of lower extremities, 473. Thrush, 494. Thyreoid extract in toxaemia o. preg- nancy, 293. Tobacco poisoning in pregnancy, 241. Tongue-tie, 494. Toothache in pregnancy, 193. Torsion of cord, 408. of uterus, 87. Toxaemia of pregnancy, 283. symptoms of, 285. treatment of, 288. Transfusion of salt solution, 500, Transverse presentations, 399. cephalic version in, 401. podalic version in, 401. Triplet pregnancy, 188. Tubal abortion, 315, 319. mole, 315. pregnancy, 313. INDEX 589 Tuberculosis during pregnancy, 249. transmission of, to fa-tus, 251. Tubes, Fallopian, 9. Tumors, complicating pregnancy, 49, 51. fibroid, of ut°rus, 49, 222, 394. osseous, deforming pelvis, 482. ovarian, 49, 394. phantom, differentiation of, from pregnancy, 50. scalp, 489. vaginal, 394, 396. Turning (see Version), 345, 401, 530. Twins, 185. locked, 403. Tying the cord, 117. Tympanites uteri, 408. Typhoid fever during pregnancy, 232. Ulcer, puerperal, 460. Umbilical grip, 74. Umbilical cord, 23, 117, 402. abnormalities of, 408. care of, 135. coils of, about neck of child, 113. development of, 23. dressing the, 135. formation of, 23. hernia of, 409. infection of, 491. inflammation of, 409. knots of, 409. laceration of, 398. ligation of, 117. loops of, 409. prolapse of, 402. reposition of, 403. rupture of, 398. shortening of, 408. souffle, 48. stenosis of vessels of, 409. torsion of, 408. tying of, 117. variations in length of, 23. varices of, 409. Umbilical ha-morrhage, 491. Umbilical hernia, 491. Umbilical vegetations, 491. Umbilicus in pregnancy, 87. Unavoidable ha-morrhage, 341. Uniovular twins, 185. Urachus, 20. Uraemia, 272. Urea in pregnancy, 286. Ureter, hypertrophy of, 43. Urethra, 7. Urinary disturbances in pregnancy, 213, 283. Urine, before or during labor, 108, 110, 213. examination of, during pregnancy, 62. incontinence of, 213, 283. in toxaemia of pregnancy, 274. of foetus, 29. retention of, during pregnancy, 213, 283. during puerperium, 151. Uterus, 7. contractions of, 47, 65. fibroids of, 49, 222. inertia of, 375. souffle in, 47. Uterus, non-pregnant, 7. ligaments of, 11. lymphatics of, 11. mucosa of, 9. musculature of, 8. nerves of, 11. Uterus, parturient, action of, in la- bor, 65, 67. anteflexion of, 148, 211. atony, 375. faulty contraction of, 66, 375. hour-glass contraction of, 418. inertia of, 375. perforation of, 505. rupture of, 410. sacculation of, 217. Uterus, pregnant, abnormalities of, 210. anteflexion of, 211. anteversion of, 211. carcinoma of, 346, 347. changes in cer\ax, 32, 42. 590 INDEX Uterus, pregnant, changes in, during contractions, 67, 70. changes in size and shape of, 30. contractions of, 47. . developmental abnormalities of, 11. displacements of, 197. double, 11. incarceration of retrofiexed, 213. malformations of, 11. myoma of, 222. nerve supply of, 67. perforation of, 505. prolapse of, 210. retroflexion of, 212. retroversion of, 212. sacculation of, 217. shape of, 87. sinking of, 31. torsion of, 87. tumors of, complicating pregnancy, 49, 51. unicornis, 11. weight of, 30. Uterus, puerperal, anteflexion of, 211. hour-glass contraction of, 349, 418. inversion of, 416. involution of, 147. subinvolution of, 149. weight of, 30. Vagina, 7. atresia of, 49. changes of, in pregnancy, 43. double, 11. haematoma of, 396. injuries of, during labor, 375, 377, 379. lacerations of, during labor, 508, 509. neoplasms of, 394. prolapse of, in pregnancy, 211. rugse of, 439. secretion of, 366, 497. thrombus of, 396. tumors of, 394. ulcer of, 460. Vaginal Ceesarean section, 560. Vaginal douche, 154, 502. examination, 77, 89, 386. secretion in pregnancy, 366, 439, 497. in puerperium, 440. Vaginitis, puerperal, 443. Vagino-fixation, cause of dystocia, 393. Varicose veins in pregnancy, 201. Veit-Smellie manoeuvre, 181. Velamentous insertion of cord, 408. Venesection in eclampsia, 300. in heart disease, 263. Ventro-fixation, cause of dystocia, 393. Veratum viride in eclampsia, 301, 309. Vernix, caseosa, 26, 139. Version, 345, 530. bipolar, 345. cephalic, 401. combined, 345, 531. external, 531. internal, 533. in contracted pelves, 487. in transverse presentations, 401, 531, 532. podalic, 401. spontaneous, 400. Vertebrse, 1. Vertex presentations, 77. mechanism of, 78. Vesical calculus complicating labor, 395. Vesicular mole, 226. Vestibule, 7. Villi, chorionic, 19. degeneration of, 226. Vision, disturbances of, during preg- nancy, 274. in eclampsia, 274. Vitelline membrane, 13, 20. Vitellus, 13. Vomiting of pregnancy, 194. Vulva, 6. atresia of, 49. haematoma of, 396. injuries of, during labor, 375, 396. INDEX 591 Vulva, labia majora, 6. minora, 7. oedema of, 397. pruritus of, 220. Walcher's posture, 555, 556. Weight of foetus at various months, 23. of newly born child, 161. Wet-nurse, 162. Wharton's jelly, 23. White line of Farre, 13. Wigand-Martin method, 182. Wolffian ducts, 12. Yolk, 13. Zona pellucida, 13. (1) 39 A TEXT-BOOK OF GYNECOLOGY SECOND EDITION Edited by CHARLES A. L. REED, A.M., M.D. Professor of Clynical Gynecology in the Medical Department of the University of Cincinnati (Medical College of Ohio) ; President of the American Medical Association (1900-1901). With 400 Illustrations from Original Drawings by Roy J. Hopkins. 8vo, 900 pages. Sold only by Subscription. Cloth, $5.00. Nearly one-half of the work is from the pen of the editor, whose reputation is inter- national. The rest is based on contributions from distinguished British and American writers and teachers, not only of gynecology, but also of the cognate subjects of pathol- ogy, bacteriology, neurology, dermatology, general surgery, and internal medicine, unified and blended into a consecutive text. " Taken all in all, this book may be said to represent all that is accepted by conser- vative gynecologists, and is a book which can be followed with the most implicit faith by the practitioner." — Medical Progress, Louisville, Ky. " Students and practitioners will find this text-book a valuable guide in this im- portant field of special work. The book is judiciously illustrated, and the illustrations are especially well drawn and hdpfu] ." —J ourrial of Medical Science, Portland, Me. " The work of the editor in properly connecting the labors of the different contribu- tors so that the book would not have the appearance of a collection of monographs has been stupendous. The successful accomplishment of this reflects great credit upon his judgment, industry, and acumen." — IVestern Medical Review, Lincoln, Neb. " There are thirty-one contributors, the best talent to be found in the United States, with the result that we have one of the very best works upon gynecology extant. The editor is to be sincerely congratulated on the outcome of his labor, but those who know him best could not but feel that such a book only could be produced by him." — New England Medical Monthly, Danhury, Conn. " Dr. Reed has placed the profession under obligations to himself for a very valuable text-book of gynecology. For clearness of statement, exhaustiveness of treatment, and fulness of illustration, it is not excelled by any work of its size. The author has suc- ceeded in furnishing a text-book which will be a most valuable working manual for practitioners and students, embracing the best approved developments of gynecology. The work of his associates has been so woven into the text as to give it unity and completeness without repetition." — Columbus (Ohio) Medical Journal. " This volume is an original work of more than ordinary value, upon a subject which can boast of many distinguished authors. Its great value lies in the fact that it is of composite authorship, thirty-one contributors have lent their best efforts to the suc- cessful elaboration of this volume, and the list embraces the most widely known names of North America and Great Britain. The editor did his work thoroughly and well, and as a result we have a book whose contents are truly refreshing, it is up to date in every respect, and its preparation was done quickly but not hastily. The different articles are well considered, show much thought in their preparation, and give evidence of large experience and information on the part of their respective authors. The editor has not confined his labors merely to editorial supervision, but he has made many contributions as well, and they are by no means the least important." — St. Louis Medical and Surgica'l Journal. D. APPLETON AND COMPANY, NEW YORK. CANCER OF THE UTERUS: Its Pathology, Symptomatology, Diagnosis, and Treatment ; also the Pathology of the Diseases of the Endometrium. By THOMAS STEPHEN CULLEN, M. B. (Toronto), Associate Professor of Gynecology in the Johns Hopkins University. Illustrated by MAX BRODEL and HERMAN BECKER. Complete in One Royal Octavo Volume of about 700 pages, Twelve Colored Plates, and Three Hundred Illustrations in the Text. Cloth, $7.50; half morocco, I8.50. Sold only by subscription. "He presents in the book before us all of value that is known upon the subject. The book is of great value to the pathologist, to the family physician, and to the surgeon. The chapters on the early recognition of cancer are so distinct and clear that a wayfaring man, though a general practitioner, should not err in giving or di- recting prompt and efficient relief." — Medical News, New York. "A work of this class is an addition of real value to medical literature." — Boston Medical and Surgical Journal. "We know that the Baltimore school of medicine has carried the utilization of clinical and scientific material almost to perfection, and this volume is a fresh witness to this truth. Lastly, the clinical features of the different varieties of uterine cancer and of innocent disease which simulate it are described very clearly so that Dr. Cullen's volume will be as useful to the practitioner as to the special- ist and the teacher of pathology." — British Medical Journal. "It represents the latest exposition of all that is known about cancer of the uterus, and we may say at once that as a monograph on this subject it absolutely eclipses any previous work. No one who wishes to be well informed on the subject of cancer of the uterus can afford to be without it." — Medical Press and Circular, London. D. APPLETON AND COMPANY. NEW YORK. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of \3()3evp^inp^s proVidI'd by the library rules or by special arrangement mth the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE .] C28(S46)M25 1193 RG524 R&s'aH wia