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PRACTICAL OBSTETRICS.
conrauuto
tegnancy, Labor, and the Puerperal State, and Obstetric Surgery.
EGBERT H. GRANDIN, M.D.,
GEORGE W. JARMAN, M.D.,
TTIT-O VOr-UMES I3SI OISTE.
iBustnted with FIfty-SU Pull-Page Pfaotagraplilc Pbtes and Eighty- Five llliutratlaiu In the Text.
THE F. A. DAVIS COMPANY, PUBLISHERS. 16B1.
GOFTBIOST, 1W4 AND 1895.
BT
THE F. ▲. DAVIS GOlfPANY.
[Bifistortd at Suuonera' HsU. London, Eng.]
FUladelphU, Flu. U. 8. A.
TIm M«di«a BolltliB Printing-Honat,
1916 CtMR7 StrMi.
. PREFACE-VOLUME I.
(Pbbonakct, Labob, and thb Pubbpbbal State.)
The last decade has witnessed not alone progress in the practice of obstetrics, but also change in methods of instruc- tion. The clinical teacher is no longer satisfied with grounding his students in the theory of the art, but he aims, as far as his opportunities will allow, to give his classes that practical instruc- tion which alone enables them to follow understandingly the normal course of pregnancy and of labor, as also to recognize and to cope with the emergencies. The teaching of obstetrics, therefore, has very properly become more practical and less theoretical. This is the inevitable outcome of that higher medical education which aims at thorough grounding in every science before the student is deemed competent to undertake practice. Above all are such methods requisite in case of the science we are dealing with, since familiarity with the phenomena of pregnancy, and of labor, and of the puerj^eral state, as wit- nessed in the living and at the bedside, best fits the student for the great responsibilities of his chosen calling. Rarely, now- adays, is the student — filled wdth theory, and this alone — licensed to care for woman in labor. Practice on the manikin and studv in the lying-in room have taught him that, however sound theory be, it cannot be made to uniformly fit the individual case, but that the course of action must alter with the concurrent circumstances.
Before undertaking the study of obstetrics, the student should be well grounded in anatomy, physiology, embryology, and pathology, and therefore there is no longer call for the text- book of the present being filled with abstract of knowledge which can, to better advantage, be secured in works dealing specifically with such subjects. When the student has been
(iii)
IV PREFACE.
drilled in the preparatory branches, he wishes to find in ti^ treatise on obstetrics only such data of an anatomical and ex:=^' bryological nature as are essential to the amplification of obstet^^^ teaching. He seeks for facts in regard to pregnancy and lab^--^ and the puerperal state, and looks to his clinical teacher for su statement of theory as in the opinion of the latter may see judicious. Similar remarks are applicable to statistical Too frequently the student rises from his study confused by wealth of statistics which, it has been well said, can be made t^-^ prove anything.
The student, then, grounded in the facts and after practical- exemplification of these facts, is surely better qualified for actuaKl practice than he who is constantly endeavoring to make fact^ accord with theory.
To-day the major part of obstetric practice is founded on fact. Where divergent views obtain, the weight of authority is on the one or the other side ; at least, it is safe to teach that which commends itself to the majority of teachers, even though in a very short time further experience may cause modification in the teaching. The general practitioner, amidst the activities of his calling, when in search of information, wishes to secure it without the loss of time entailed in searching through a mass of theory and of statistics. His personal experience will teach him if the statement he reads in the work he consults is valid, or, in case he lacks such experience, knowing that the given statement commends itself to the majority of clinical teachers, he will not hesitate to test it.
On such grounds the present work has been prepared. It aims at being a guide to practice. It is clinical in its teach- ing. It is direct in its statement wherever fojcis warrant such directness. Such should be the aim of all clinical teaching. Anatomical and embryological and pathological data are alone inserted when essential. Whenever there appears ground for difference of opinion as to fact, that which preponderates ig given even though liable to change.
In the matter of illustration, fidelity to nature has been the ftim rather than attempt at artistic effect. It has not been deemed advisable to insert the numerous wood-cuts which from time immemorial have been copied from one work to another, since tlie majority teacli nothing which cannot be learned to better advantage at the bedside, — indeed, which can only be properly learned there.
In this connection the authors desire to record the deep obligation they are under to Dr. Simon Marx, the Assistant Obstetrician to the Maternity Hospital, for time expended and the care taken in the securing of the photographic plates.
In the hope that this volume may prove helpful to the student in the acquisition of knowledge and to the practitioner as a reliable guide, the authors offer it to their professional bretitren.
CONTENTS-VOLUME I.
Part L— Pregnancy.
chapter i.
DtAONOEIB, DlFFKR£NTIAI. DuONOSIS, DCBATIOR, AND HlOIKNE Or
Peeqnamcy, 1
CHAPTER II. Patbolooy op Pregnanct, SS
CHAPTER III.
DiAQHOSIS OF THE PkES£NTAT1UN AND OF TBS POSITION OF THE F<ETU8, 76
Part II. — Labor.
CHAPTER I. Mechanism of Labor, ....
CHAPTER 11. Tec Clihioal Coubsi or Labob, ' . . 126
CHAPTER III. Manaoxhent of NoRiUL AND Abnobmal Labob, .... 189
CHAPTER IT. Cabi of tbb Nbwbobm Intaht, 18T
Part III.— The Puerperal State.
CHAPTER 1. Thi Nobjul PnxBl>EBniit, 208
CHAPTER XL
Tbi Patholoqioal PuXBFBRimi, 205
Index, 265
(vii)
LIST OP FULL-PAGE PLATES-VOLUME L
PA6X
Px^TX I.~Tbe Primary Areola (Primipara). The Secondary Areola (Plaripara) 4
Platb IL^The Mammary Signs of Pregnancy (Colored) 6
PuLTX in.— Oatlines of the Abdomen at the Fifth Month of Pregnancy 19
Platk IV.— OnUlnee of the Abdomen at the Seventh Month of Pregnancy 19
Platx v.— Outlines of the Abdomen at the Ninth Mouth of Pregnancy 19
Pi«ATX VL— Ventral Hernia Complicating Pregnancy Q
Plats VII.— Cystocele Complicating Pregnancy 5i
Plats VUL— Fig. L Melancholia Complicating Pregnancy. Fig. 2. Chloasma of
Pregnancy ; . . . . 64
Plats DL— Palpation of the Presenting Part at the Pelyic Brim 77
Plats X.— Palpation of the Dorsum of the Foetus 79
Plats XI.— Palpation of the Pelvic Pole of the Foetus, the Vertex Presenting 79
Plats XIL— Front View of the Festal SknU 81
Plats XUL— Top View of the Festal Skull 81
Plats XIV.— Posterior View of the Festal Skull 81
Plats XV.— Site of Maximum Intensity of the Foetal Heart-sounds in Presentation of
the Vertex. Position, Left Occipnt Anterior 88
Plats XVI.— Site of Maximum Intensity of the Foetal Heart-sounds in Presentation of
the Vertex. Position, Right Occiput Anterior 88
Plats XVIL— Site of Maximum Intensity of the Foetal Heart-sounds in Presentation
of the Vertex. Position, Right Occiput Posterior 89
Plats XVUL— Site of Maximum Intensity of the Foetal Heart-sounds in Presentation
of the Breech. Position, Left Sacro-anterior 89
Plats XIX— The Plane and the Axis of the Superior Strait, or Pelvic Inlet. The Plane
and the Axis of the Inferior Strait, or Pelvic Outlet 96
Plats XX.— Presentation of the Vertex. Left and Right Occiput Anterior 106
Plats XXL— Presentation of the Vertex. Left and Right Occiput Posterior 109
Plats XXII.— Presentation of the Face. Right Mento-anterior. Left Mento-posterior . 114 Plats XXIIL— Presentation of the Breech. Left Sacro-anterior Position. Right Sacro- posterior Position 116
Plats XXIV.— Presentation of the Trunk. Dorso-anterior Position. Dorso-posterior
Position 121
Plats XXV.— The Placenta 12S
Plats XXVI.— The Lying-in Bed 141
Plats XXVH.- Method of Catbeterizing the Puerpera 15S
Plats XXVTII.- Maintaining Flexion ... 164
Plats XXIX.— First Stage of Extension 164
Plats XXX.— The Head is Gradually Extending ; the Perineum is Retracting and
Relaxing 165
Plats XXXL— External Rotation, or Restitution 155
Plats XXXIL— Delivery of the Trunk 166
Plats XXXIIL— Clamping the Cord and Cutting Between the Clamps 156
Plats XXXIV.— Manual Expression of the Placenta IfiB
Plats XXXV.— Delivery of the Placenta by Manual Expression 16B
Plats XXXVL— The Puerperal Breast and Abdominal Binder and the Vulvar Pad ... 197
Plats XXXVH^Pygopagus (Tynberg) 188
Plats XXX VIIL— Washing the Eyes of the Foetus Immediately After Delivery .... 187
Plats XXXDL— The Dressing of the Umbilical Cord 191
Plats XL.— Scbultse's Method of Artificial Respiration 198
Pl^TB XU.— The Byrd-Dew Method of Artificial Respiration 196
(viii)
PREFACE-VOLUME II.
(Obstbtbic Sosobei.}
The key-note of this volume is election in obstetric ■»Urgery.
The results which are daily secured in general surgery "through resort to timely operation are obtainable in obstetrics if the same principle be held in view.
This volume, further, being written from a teaching basis, is necessarily imbued witli tlie personality of the authors, and is, therefore, not burdened with literature references and sta^ tistical data. The latter have atone been introduced, when necessary, in order to assist in the elucidation of some disputed point
The illustrations have been prepared and selected with the apeci&l end in view of teaching graphically. The works of Barnes, Charpentier, Lusk, Cazeaux, and Oscar Schaeffer, in particular, have furnished many of the wood-cuts, and the aathora hereby express their obligation. The photographic plates have been prepared from nature under the personal supervision of the authors.
On the basis of honest desire to promote progress in obstetrics, this volume is offered to the medical profession.
(K)
|
CONTENTS-VOLUME U. ^M |
■ |
|
INTRODUCTION. |
v |
|
OBBTiTKioAeiTBiSASi) Antisepsis, |
] |
|
CHAPTER I. |
|
|
Obstktrio Dystocia akb its Dkisbmination, .... |
i |
|
CHAPTER II. |
|
|
Abtificial Abortion and thb Inddction of Prematore LABoa, |
3< |
|
CHAPTER III. |
|
|
The Fobckpb, |
n |
|
CHAPTER IV. |
|
|
Veesion, |
93 |
|
CHAPTER V. |
|
|
StMPaTSIOTOSrtT, |
. ISO |
|
CHAPTER VI. |
|
|
The C.SSAHEAM Sectiok, .... S^h^^^^h |
^^L |
|
CHAPTER VII. ^^^^^1 |
^^^1 |
GUBBTOTOMT, . • • 1^8
CHAPTKR Till.
Thx Subok&t 01 TKi PurapuicH 163
CHAPTER IX.
ECTOFIO QlSIATION, 193
Isim, 903
U8T OF ILLUSTRATIONS-VOLUME II.
io. rtMt
1- Normftl female pelTli, 0
S- Beandelocquc'i pelvlmetar, , .... 10
a. Uirtln'spflvlioeter 10
4, Bthulue'B pelrimeter >■••,••■ 11
5. Collf «r'* poeket pelvlmeler 11
(, Joslo- major pelTls, 18
7. Generally eqnallf contracted p«lTl« (J"*'^'^''''''') ^^
8. Flat uDQ-racblUc pelvii SO
9. Flat rachitic pelvis (mild gradt) SI
). Flat rarhitic peWli (higb gratle) Sit
I. Oenetallf coDtracted Hat rachitic pelila, 33
!. Roberts's pelvla. The traneveracly contracted pelTlit, 9*
I. The kyphotic peWlB, showing narrowtag In the trBoavanB diameter and ten^h-
enlDR In the eonjuggte, 25
\. Non-rachitic scoliotic ikelctoo 2fl
i. Ru^l]ltlc scoliotic skeleton, 2«
I. SpoDdrlolIalbetlo pdTli B7
r. The Dstsomaliuio pelvl> SO
I. Obliquely dlilorted pulvls of Naegele, 30
t. Osteoaarcoma of the pelria, 83
1. Steel- branched dilator, 41
1. UteHoe cnretlc, «
). Ovum Turcepe .....49
I. Glasf irHgatlog tube A%
I. FrltAih-BiHWinan caUleter, ii
i. EdcbohrBBpcculuni, 4S
1. Cenlcal tenaculnm, .....,,.,.,.. IS
r. lutra-atcKne drrulug forccpa. ........... Vi
i. Bsrues's bags, -■-••... ......M
>. McLeaD'sbag, «
). Man'a Ineobator (vloeed) TO
I. Mara's lucabaMr (opeu), 71
i. Elliott forcepa, 72
1. Hunter forcepe 73
I. Lnsk-Tamier Torcepa , . 73
5. Jewell's HUls-traclIon forcops, 7*
I. Showing RejDolds'a traction rods in position, 7S
r. iDtroduction of the left blade of the forceps 79
). The left blade Introduced ; the right blade (In outline) read; to be totrodaced, . SO
). The forcep* adjusted and readj to be locked, 81
>. BboiTlng the direction of tbe line of traction, 8-S
1. Showing direction of tractioo In face praaentatlon, 84
L Tamler forcepa applied to tbe thighs, 88
I. iDcision of the cervix, 89
I. Appllcatinn of medtam tbrcept,
(xiii)
xiv LIST OF ILLUSTBAnOHS.
45. nm •tec* of Mpolw Tenloo, lOS
46. GntfADg tht kiMS, 1<B
47. BepraMottngfintaetoreilnetloo, 104
48. Venion tn bead pwenUtton, IM
40. OompletlBS: tlie TOBloii, 107
50. Imprtwl ihoolder, 106
51. IntrodnetloD of the left hand to biiof dowii tlie posterior (lefl) k|g, . . 109
tt Showing dlrectloo of tnetioD, HO
Sa. Method of releeaing the cord^ Ill
54. DfeengageoieDt of the posterior (right) snn, 11^
55. Showing directloD of tnctioD, US
55. The child is lifted oTer the perineiim and the occiput passes from under the sym- physis, 11*
87. Chin arrested at symphysis, 115
58. Forceps applied to after-coming head, 11^
50. The bulging of peritoneum and of bladder into the opening at the Joint, . 12S 00, Galbiati-Harris Knife. (Harris's modification), 1^
61. Showing deep suture passed, the loops not cut, 138
62. The same, the loops cut, 138
6S. Suture of uterine wound, 139
6ft. Brann's trephine, 1^
65. Blot's perforator, 148
66. Martin's trephine, 148
67. Scissors-perlbrator, 149
68. Braun's cranioclast, 149
60. Effect of the cranioclast on the foetal skull, 151
70. Lnsk's cephalotribe, IM
71. Tamier's basiotribe, IW
72. Bone-forceps, 157
73. Crochet and blunt hook, 157
74. Braun's hook or decollator 158
75. DeliTcry of trunk after section of head, 150
78. Locked twins, 160
77. Sutures inserted on one ride of a lacerated cerrix, 186
78. Insertion of sutures. (After Hegar.), 171
70. Laceration through the sphincter. Sphincter sutures in place, .... 172
80. Bepair of a Tnico-Taginal fistula, 174
81. Simon's specula, 175
89. Transrerse rupture of the uterus, 179
83. CleTeland's licrature-carrier, 197
84. Emergency Trendelenburg posture, 108
LIST OF FULL-P
FI.4T* I.— MeUDremCDt of ftlataiice betwceo tbe aplnes, .... Platb II.— Fig. 1. MBMsrement of Be»udelodque dlnmetpr. Fig. 3.
Heuurement of Beindelocque dlsmctcr lu case of peDdulotu
tbdomen,
PUTB III.— Fig. 1. DetermlnatloQ of tbe dlagooal conjugate. Fig, 3.
DepreaaloD of tbe utcnu ao as to determine odaptsbliltj of pre-
aeatlDg part to the pelTlc brim,
pLiTB IV,— lotrodoctlon of tbe lea blade of the forceps,
Plitk v.— Fig. 1. Towel applied to handle of HaoWr'n foroepa. Fig, a.
Bilateral inclsloo of tbe periaeum (epUlotooif)
PLiTB VI.— Showing metliod of graaping the foot,
PLAT! VII.— Extracting tbe poiterlor leg,
PtiTK VIII,— Eltractiiig tbe poaterlor alrn,
Platb IX,— Head Imiacted at the outlet. AdmiWlug air that tba child
ma; breatbe 1
Tui-Ti X.— Tbe child ii lifted over tbe perinenai and tbe occiput paaaes
from under tbe aympbysls. An aaaiatant maliea auprapnblc
Pi^TB XI.— Traction while the bead la In the tranaverse diameter of Uie
pelvis 1
Pi.i,T> XH,— Application of tbe forcepa to tbe ■fler-comiiig head, . . 1
Ti^rr XIII,— Method of graaping tba chlld'i body In performing In-
tertial rotation 1
Pi^Ti XIV.— Fig. 1. Trephining the before^coming head. Fig. S. Per- foration of tbe after-coming head, 1
Pi^TB XV, — Inaertion of Braun'* decollator, 1
I
(XV)
VOLUME I.
PART I. Pregnancy.
Seventeen Photogpsphle Pistes.
I0SI8, DIFFERENTIAL D HTQIENE OF PREQNA
PATHOLOGY OF PREGNANCY.
CHAPTER I.
DIAGNOSIS, DIFFERENTIAL DIAGNOSIS, DURATION, AND HYGIENE OF PREGNANCY.
The signs or symptoms which lead to the diagnosis of |>r^Tiancy may be grouped under the headings of general and local, subjective and objective. Impregnation of the ovum affects the body in general as well as the reproductive organs in particular. The resulting train of general and of local symp- loms must be separately studied and tlie weight of each must be properly appreciated in order to reach a diagnosis which zeits on a basis of scientific exactitude.
The syBtemic and the local alterations will be separately «tadied, as far as is possible in the order in which they may be 'fint appreciable.
r. Tlie Ninisea and Yomiting of Pregnancy. — This sign of pregnancy often precedes the second sign, — araenonhcpa. It is A feirly constant accompaniment of pregnancy, although some women never suffer from it to any degree, whilst in others it is •exaggerated to such an extent as tn become an actual disease imperiling life. No satisfactory ox[ilauation for its occurrence has ever been offered, and we are obliged to rest content with the TagtiP term " neurosis " as descriptive. Very frequently clironic constipation, the result of torpor of the intestinal tract, is at the bottom of the symptom; but then, again, it is a prominent symptom, although the intestinal canal is functionating after a normal fashion. In some women it is excited only by the sight of food or the smell ; in others it occurs only in the morning on awakening and disappears on the ingestion of food ; in rare instances, by a curious coincidence, the sign fails to appear at all in the woman, but is present in a marked degree in the hosband. It is at once apparent that this sign can carry no
(1)
2 PREGNANCY.
weight in the estimation of the probable existence of pregnancy, being purely suggestive when associated with other sytnptoms. //. Amenorrhoea, — As a rule, the function of reproduction in woman is associated with that of menstruation. Therefore, in general, cessation of menstruation is one of the earliest signs of pregnancy. This rule, however, is subject to a number of exceptions. There are some women who never menstruate at all, and yet they conceive with considerable regularity. Wit- ness the case of a woman who conceives during lactation, when usually menstruation is absent ; witness, also, the exceedingly rare instances where there has never been present a red dis* charge, although there occur each month the general symptoms of menstruation, — the so-called molimina. Absence of menstrua- tion, therefore, in women of this type may or may not mean the occurrence of conception. Whilst, also, the cessation of men- struation is a usual accompaniment of conception, other causes may arrest the function. Change of climate, mental impressions, exposure to cold, certain diatheses, — such as chlorosis, anaemia, or disease of the kidneys or lungs, — are affections which often are associated with absence of or irregular menstruation. Further still, in some women, notwithstanding the occurrence of pregnancy, there exists a periodical red dischai^e which simu- lates menstruation. This discharge may be due to the presence of a small cervical polyp or may be a transudation from the surface of an eroded cervix ; whatever the cause, this introduces an element of uncertainty in the diagnosis. Suppression of menstruation is, therefore, a sign of little value except in case of women who have been previously regular and in whom the factors mentioned above are absent. Taken alone, this sign carries simply strong presumption. Too great care cannot be exercised not to allow this sign to swerve the judgment of the physician into the expression of a positive opinion ; and, at the same time, the presence of this sign should always lead him into being exceedingly circumspect in making any intra-uterine treatment, particularly since, absence of menstruation being
DIAGNOSIS, DURATION, AND HTGIENE OF PREGNANCT. 3
associated in the lay mind with the presence of pregnancy, a woman who does not desire to bear children will unquestionably endeavor to deceive her physician by giving a false history of regular menstruation.
In connection with this subject of suppression of menstru- ation it must ever be remembered that the most dangerous affection to which woman is subject, if it be not recognized early,— ectopic gestation, — is associated with irregular haemor- rhages at the stage when, above all others, it is necessary that a correct diagnosis should be made in order that the proper surgical treatment may be instituted.
///. Quickening, — Quickening, or the sensation of fcetal motion, is a sign of considerable value when taken in conjunc- tion with others. It is, however, of greater value in assisting us to predict the probable period of gestation than as assisting us in reaching a diagnosis of pregnancy. Many women hardly are conscious of the motion of the fcetus until other very positive signs of pregnancy exist; other women, in their anxiety for children, feel this sign when they are not pregnant, or deceive themselves into the belief that they feel motion long before it is likely they could. The time of the appearance of the first sensation of fcetal movement is rather variable. As a rule, the sixteenth week is the date, although some women are affected earlier and others much later. Tlie sign is described as a "flutter" in tlie abdomen, and is believed to be due to the first contact of the enlarged uterus with the abdominal wall. The fact that the sign is felt so much earlier by some women and so much later by others would seem to disprove this idea. Tlie preferable explanation is that which looks to the transference by nerve-impulse of the motion of the foetus. As gestation advances these motions become more and more active, although varying in character in different w^omen. This sign is likely to be simulated by the motion of gas in the intestinal canal, and in women of a highly nervous organization the belief in the exist- ence of pregnancy, although absent, may become firmly estab-
PREGNANCY.
lislicd, especially if other supjiosed symptoms concur, giving risel to the occurrence of that pecuHar neurotic condition to which j the term " pseudocyesis " has been applied. Sudden cessation of fcetal movements is often coincident with death of the foetus, although there are scores of cases recorded where healthy cliU- dren have been born even after motion lias not been appreciated for months or even never felt. The sensation of motion, there- fore, by the woman carries only relative value as a sign of preg- nancy. When felt by the physician the case, as will be noted, is different. There is nothing which is likely to simulate the motion of the fcetns to the hand of an expert. Neither con- J traction of the abdominal muscles, nor the movement of gasiaJ the intestines, nor a wandering kidney, — whicli, by the wayj frequently imposes on the woman, — can yield to the hand of thi unprejudiced observer the sensation of the moving fcetus, must be remembered, however, that there are conditions — si as excess of liquor amuii — which will interfere with the percep4 tion of these movements by the physician, and, in excesain cases, by the woman.
IV. Mammary Signs. — Changes in the breasts are amoi the earliest signs of pregnancy. In many women the bw become painful and enlarge within a fortnight of the occurretia of conception. As a rule, however, the characteristic changi do not occur until a much later date. About tlie end of the eighd week the nipples swell, become erectile, deepen in color, : their sensibility is increased. Frequently even as early as I twelfth week a drop or so of colostrum may be expressed fro the breasts. The sebaceous glands of the nipples increase : size, appearing as papnles above the level of the skin. ThJ areola of the nipples takes on a deeper hue, this phenomenon being especially marked in brunettes. About the twentieth' week a secondary areola is formed outside of the margin of the primary, this again being especially miuked in brunettes. (Plate I.) As gestation advances these changes in the breasts become intensified, the surface of the glands being traced with bluish
ThB SectHiddF, A'Bola tPlunpara).
DIAGNOSIS, DURATION, AND HYGIENE OF FRE6NAN0T. 5
vessels and the glands becoming not only larger, but also more painfol. These changes may be traced to the intimate sympathy viiich exists between the genitalia and the mammary glands. Therefore, the breast signs described are, early in pregnancy, oolj of relative value as a means of diagnosis. In women of AD erotic temperament these same signs are not of uncommon occurrence aside from pregnancy, particularly at the menstrual period, and, again, disease of the uterus or of the ovaries is often associated with the same signs. The mammary ^igns are, perhaps, of greater value in primiparae than in multiparee, cer- tainly at an early stage of pregnancy. The negative value of the signs is, at this date, of greater value than the positive. Absence of the signs entirely is strong presumptive evidence of absence of pregnancy. (Plate II.)
F. Vaginal Signs. — Of considerable presumptive value of pregnancy is the bluish discoloration of the vagina or, rather, of the urethral bulb. This sign is an early one, being appreci- able at about the sixth week. It is due not alone to venous congestion, but also to the actual increase in size of the venous radicles which exist in this locality. As pregnancy advances this discoloration increases, in certain instances the color being almost black, when, however, marked varices are present. This discoloration of the urethral bulb may also be noted in con- nection with other causes of vaginal congestion, such as marked prolapse of the uterus or impacted fibroid growth, but then other symptoms characteristic of pregnancy will be absent. The sign altogether is of considerable presumptive value in connec- tion with other signs, particularly in the nullipara.
VI. Cervical Signs, — At a very early date of pregnancy the cervix, on inspection, has a similar bluish tint to that just dwelt upon as present at the urethral bulb. The characteristic change in the cervix, however, which should always suggest the existence of pregnancy, is the so-called softening, which is the natural result of the congestion of the cervical tissues asso- ciated with the presence of pregnancy. This softening, it should
6 PBEGNANGT.
be noted, i8 in the substance of the tissues, and not alone at the tip of the organ. Sensation of softening at the tip may be due solely to an erosion of the epithelium ; softening in substance is very diflFerent and not alone yields a diflFerent sensation to the examining finger, but on inspection the cervix is found intact as regards its epithelial layer. This change in the cervix is necessarily most marked in nulliparse. In the multipara the cicatricial tissue left by lesion sustained at a previous delivery obscures, to a greater or a less degree, the softening. As a rule, it may be stated that this softening in substance of the cervix is a very valuable sign of the existence of pregnancy. Patho- logical changes in the cervix due to the presence of cancer will alone, in a primipara, prevent the softening. In conjunction with other signs dwelt upon, — the nausea, the suppression of the menses, and the mammary changes, — this softening may be taken as strong presumptive evidence of impregnation.
VIL Uterine Signs. — ^Within four weeks after conception the uterus begins to assume the shape which is characteristic of pregnancy. This is especially true of the organ which has never been impregnated. The organ loses its pyriform shape and assumes that of a flattened sphere. The implantation of the fecundated ovum in the uterus is associated with an increase in the blood-supply; the uterus, becoming heavier, sinks in the pelvis ; the organ develops more in its transverse diameters than in the longitudinal. Even before the changes in the cervix become at all marked, even before the subjective symptoms — ^tbe nausea and vomiting — and the mammary signs become pro- nounced, the uterus of the nullipara presents the following characteristic alterations as regards the body : The shape is that of a flattened spliere ; the lower uterine segment — that is to say, the portion of the body of the uterus just above the vaginal reflexion— juts over the cervix. On combined abdomino-vaginal examination the body of the uterus, whilst spherical in outline, seems to be compressible. This compressibUity is especially marked if the internal finger, either m the vagina or in the
mAGNOSIS, DURATION, AND HYGIENE OF PEEGMANCY. 7
rectum, is applied just above the reflexion of the vagina from the cervix. Obviously the determination of this early change in the body of the uterus will depend on the ease with which it is possible to make the conjoined examination. It is piirticii- larly in women who are not especially stout that the sign will be determined with the greatest ease. As pregnancy advances — that is to say, from the sixth week on — the characteristics which have been noted become intensified, until, at the eighth to the tenth week, tliese changes in the body of the uterus are suf- ficient, in women of lax abdominal walls and in nnlliparee, to render the diagnosis of pregnancy strongly presumptive. Tlie evidence, it must be remembered, is not sufficient to justify the physician in giving an opinion at all positive ; but in his own mind there will remain Htlle doubt as to the correctness of the diagnosis, which, if the woman be examined after the lapse of a week, will be certified in the event of the changes having be- come intensified, for, if the woman be pregnant, these changes become more marked as gestation progresses, until other signs of pregnancy of a more positive nature appear.
The conditions likely to simulate these changes are so- called chronic metritis and uterine fibroid. In neither of these conditions, however, is the uterus spherical in shape or com- pressible, nor does the lower uterine segment jut over the cervix ■with that doughy consistency which is associated with early gestation. Indeed, at the period when this sign is most marked — about the tenth week — the co-existence of the other early signs we have dwelt upon form a very strong justification of the diagnosis of pregnancy ; certainly, the weight of evidence will be in favor of such assumption.
VIII. Abdominal Signs. — At an early period of gestation, beginning with about the twelfth week, the linea alba becomes darkened, the color deepening as gestation advances, and the change being most marked in brunettes. About the twelfth week the abdomen itseif begins to enlarge, for it is about this time, in women with normal pelves, that the uterine tumor
i
y
8 PREGNANCY.
reaches the level of the pelvic brim. From this time on, ab- dominal palpation and conjoined abdomino-vaginal examination reveal si^s of considerable value hi reaching a diagnosis of pregnancy. From tlie eiglith week on the gravid uterus con- tracts rhythmically, giving us the sign known after Braxton Hicks, who first called attention to it. These intermittent uterine contractions may be obtained, in women with las ab- dominal walls, by elevating the uterus on the finger inserted into the vagina, and by grasping and gently rubbing the body of the uterus through the abdominal walls. The uterine tumor will be found to harden and to relax at intervals. Of course, as gestation progresses these intermittent uterine contractions become more marked, but tiieir especial diagnostic value is between the eighth and the twelfth weeks of pregnancy. About the fourth month, when the uterus has risen above the pelvic brim, conjoined manipulation through the abdominal walls will elicit contmctions. The only conditions which are likely to simulate these contractions are myomata of the uterus, hjemato- metra, and a distended bladder. The history and the shape of the uterus should suffice to differentiate the former conditions, and the catheter will eliminate the last. J
Whilst intermittent uterine contractions are not aloOM sufficient to justify a diagnosis of pregnancy, the sign must be considered a very valuable corroborative one. It is never absent when the uterus contains a product of conception, and if it be absent there will not he present other presumptive signs of pregnancy. Another sign to be secured through the abdomen is bnllotlement, — the term given to the motion imparted to the foetus when one or the other of its extremities are strurk, the other portion impacting at the opposite side of the abdominal wall. Ballottement may be either direct abdominal or combined abdomino-vaginal. Vaginal ballottement is secured to best advantage when tlie woman is in the erect position ; but ordi- narily this sign, when needed for diagnosis, can be obtained with the woman in the recumbent posture, which should always
DIAGNOSIS, DURATION, AND HTGIENE OF PRE6NANCT. 9
be chosen when feasible, since the innate modesty of the woman is thus better protected.
To obtain vaginal ballottement the woman stands in front of the physician, her legs separated slightly, and the physician inserts one finger into the vagina, depressing, or rather pushing, the perineum backward as much as possible, in order to reach as high up as is necessary. This intra-vaginal finger is placed in the anterior or the posterior fornix of the vagina and a sharp upward impulse is given, the result of which is, in case the uterus contains a foetus floating in the liquor amnii, that this fcetus is displaced upward and falls back on the finger.
To obtain abdominal ballottement the woman lies on her bed or couch, the abdomen being covered by a sheet. The bladder should be empty. The t)hysician determines by palpa- tion a point of resistance in the uterine tumor, and gives a sharp impulse here, his other hand lying flat on the abdomen at the opposite pole. The foetus is thus dislodged in the liquor amnii and the impulse is received on the flat hand. A necessary pre- caution prior to this manipulation is that the hands should be warmed and that tlie uterus should not be manipulated over- much, otherwise the organ will contract on its contents and ballottement can only be obtained during uterine relaxation.
Ballottement is hardly available before the fourtli month, because, prior to this date, tlie foetus is too small and tlie amount of liquor amnii present too slight to allow of motion to a suf- ficient extent. From the fourth montli on to the eighth the sign may be obtained, but allor the eiglith month, or earlier in case of very large foetus or of deficiency in liquor amnii, the sign is not obtainable, because the foetus is too large to be made to float. As a diagnostic factor this sign, however, is chiefly of value be- tween the fourth and the sixth months of pregnancy, for after this latter date the foetal heart may be heard, which of itself alone certifies to the presence of pregnancy.
It must never be forgotten that the presence of ballottement sim[)ly certifies to the fact that there is sometlung which floats
10 PREGNANCY.
in thc» uterus. This is no proof that a live foetus exists, and the abm*nce of ballottement is no proof that the woman is not preg- nant, since, as aheady stated, there are conditions under which the Hign cannot be obtained, although the woman is pregnant. There arc, further, certain sources of error which must be borne in mind. A movable stone in the bladder may give the impulse to th(j vaj;inul finger which the foetus does ; a pediculated sub- p(»riton(»al fibroid, or an ovarian cystoma, or a wandering kidney may (»ach simulate ballottement. Care in securing the history of tlin patitMit, however, which will reveal symptoms suggestive of lh(» prownu^e of one or another of these conditions and the abw»n(^o of cxntain of the symptoms peculiar to the stage of gesta- tion whioli the woman has supposedly attained, ought to prevent <nTor. Fortunately, at the period when ballottement may be Noouvod to best advantage other symptoms of pregnancy of far };:nn\tor w(M)jht are present,
Talimtion of tlie abdomen affords information of consider- nblo vuluo toward tlie diagnosis of pregnancy. The outline of tho utorus n\ay tlnis Ih^ mapiHHl out ; its height above the pelvic bv\n\ nu\y Ih> estimated ; the presence of one or more points of gmUov iV5asU\nct> may Ih^ determhied, leading at times, perhaps, to tht^ suspicion of multiple pregnancy; the presence of a com- \4ioutiui;: Uuuov in addition to the uterine. Such are certain of tho la\to\>i which oar^tul \)aI\^tion may reveal. We would Hjjaiu U> st\\^s.s on tho taot that manipulation should be delicate, eU\ al\x r tho txt^h month of j^>$tation. the uterus, if gra\nd, >mU u\o>\tuW\ Kvnti^ur and doft^t the aim of the manipulation.
I .^U V ^M\. u\uU r tho iH^d i>t^ ^^ AUtoiuinal Rilpation," will W vUvxx viK\l tho iiUvMuuiUou to be ^tecuml in leference to the \HVMUvvu s^f i^H- i\x>^us in tin- u^^ru$.
ri^ msvv^ iu\jsn^5^u: m&>nu^ux>e obc^naUe thnmgh the ab- sU^w w<*l »^IU .>. :{h^ t^^^t^t K^rt^vutNK whWh roostitute alone a vlu^^^vvvuc ^^n s^^ {>*x>^u^tvx ; unI.^ :hb fe$ the sole sign which NX it: ^hmM%^ iKvv ^^x^.v^.. V ,v«tl\ ^> :he exfe^tmce of gestation ^H .A v^^^^^ v^ t^,, V\N^^ ;«^:t^ ic^fw Amuih Strang piesump-
DIAGNOSIS, DURATION, AND HTGIENB OF PREGNANCY. 11
tive evidence amounting practically to a certainty, but they are one and all liable to erroneous interpretation with the exception of the sounds of the heart.
Whilst it has been claimed that the fcetal heart-sounds may be heard as early as the sixteenth week, and whilst certain ob- servers have noted them even as early as the twelfth week, as a rule they are not discernible until the twentieth week, and then only under exceptionally favorable circumstances, such as very thin abdominal walls and close apposition of the uterine parietes to the abdomen. From the twenty-fourth week on these sounds should always be obtained in case the foetus is alive, although their absence will not certify to foetal death, since, in instances of liydramnios or in cases of thick abdominal parietes, the sounds may not be able to penetrate to the ear.
The quality of the heart-sounds has been likened to the ticking of a watch under a pillow, but the student may best familiarize himself with this quality by listening frequently to the heart-beats of a newborn child, remembering that the sounds when heard through the abdominal walls are necessarily some- wliat fainter.
In listening for the heart-sounds the maternal pulse should always be noted coincidently, for tlius a possible source of error — that of mistaking tlie communicated sound of the maternal pulse — will be avoided. The rapidity of the foetal heart varies exceedingly, the average being about 130. This rate differs, however, within physiological limits, being dependent in a measure on the condition of the woman, and, possibly, also on the active or passive state of the child.
Whilst it has been asserted that there is a difference in the foetal heart-beats in the male and the female, the latter being more rapid than the former, and whilst repeated attempts have been made to predict the sex of the fcetus according to tlie rapidity of the beats, the result of sucli attempts lias been failure as well as success in about the same ratio. It is probable that a large female fcetus has a slower pulse than a small male, and
12 PREGNANCY.
vice versdy although any prediction as to the sex of the foetus must be considered as guess-work. This is as would be expectec/ when it is borne in mind that the pulsations of the foetal hearf are intimately dependent on the maternal condition, and that, therefore, the rapidity of the beats may vary not alone from day to day, but also from hour to hour.
Auscultation tor the determination of the fcetal heart-sounds may be mediate or immediate through the abdominal walls. The attempts which have been made to popularize auscultation through the vagina have very properly failed, not only because the desired information can be secured to better advantage through the abdomen, but also because vaginal auscultation is bound to be repugnant to the woman ; and, in the absence of decided advantages, it should therefore not be resorted to.
According to individual taste, auscultation may be practiced through the stethoscope or by direct application of the ear to the abdominal wall. In either event the woman should lie on the bed or couch, the abdomen covered by a thin sheet. Abso- lute quiet of the woman and her surroundings is requisite, since, whilst often the sounds are very loud, again they may be ex- ceedingly faint. At an early stage of gestation the sounds ate necessarily to be sought over the fundus of the uterus in the mid-line ; later, as the uterus rises high above the pelvic brim, the entire anterior wall of the organ may be explored. After the sixth month, as a rule, the outline of the foetus may be mapped out, and then the area within which the sounds should be heard to best advantage is circumscribed according to the presentation of the fcetus. It has been established that th^ foetal heart occupies a position about equidistant between it* cephalic and pelvic poles, and, therefore, where the pelvic e^* tremity of the foetus occupies the lower portion of the uterus tb^ sounds will be heard higher up than when the head of the foetiv ' is the lowest part of the foetal ovoid. Thus, in breech presenta ^ tions the foetal heart-sounds are heard above the umbilicus, anC^ in vertex presentations they are heard below. Tliis statemenC^
DIAGNOSIS, DtTEATION, AND HTGIENE OF PBEGNANCT. 18
presupposes a normal pelvis, however; for, otherwise, neitlier presenting pole can engage as deeply ; and, tlierefore, the point where the sounds are best obtainable will vary.
As will be noted in the proper place, tiie site of maximum intensity of the heart-sounds is of considerable value in the diagnosis of position of the foetus. The hearing of two sounds varying in rhythm and at different points of t)ie abdomen, especially if repeated examinations give tiie same result, is strong presumptive evidence of twin gestation.
As we Jiave noted, the only condition which will simulate the fcetal heart-sounds is the maternal arterial beat transmitted through the abdominal walls. Counting of the pulsations will, as a rule, clear the diagnosis unless the woman be suffering from some affection associated with rise of temperature, in whicli case the increased rapidity of lier heart-sounds will, of necessity, render it difficult to differentiate.
Distinct recognition of the fcetal heart-sounds is positive evi- dence of the presence of pregnancy. Absence of the fcetal heart- sounds does not negative pregnancy, since the fcetus may be dead. When, on rejwated examination, the fcetal heart-sounds are found to be growing weaker and altering in frequency, the assumption is strong that fcetal death is imminent, in which case, if gestation has advanced far enough to be compatible with extra-uterine existence, the induction of premature labor, in the interests of the child, might seem desirable.
Aside from the foetal heart-sounds auscultation reveals other sounds which, while not diagnostic of pregnancy, are associates of the condition. These sounds are known as the funic souffle and the uterine bruit. The funic souf&e is so termed because it is considered to emanate from the umbilical cord. It is synchronous with the heart-sounds, and occasionally is so loud as to obscure these. This sign is not constant; indeed, according to some investigators it is heard in only 20 per cent, of the examined cases. Its value, therefore, from a diagnostic stand-point, of the existence of gestation is very
14 PREGNANCY.
slight. The uterine bruit was formerly termed the placental murmur, being supposed to originate in the vessels of the placenta. Modern investigation, however, has disproved this view, since this sound persists in many instances for days after the delivery of the placenta. The sound is a blowing one, syn- chronous with the maternal heart, and varies markedly both in quality and in intensity. The sound is apt to be intermittent, disappearing at the height of a uterine contraction. The gen- erally-accepted view to-day is that the sound is produced in the uterine vessels, and proof of this would seem to be the fiict that a similar souffle may often be detected in connection with uterine myomata of a very vascular character. This sound is hardly appreciated through the abdominal walls until the fourth month, but it may be detected through the vagina at an earlier period. Its value as diagnostic of pregnancy is only relative, since, as we have noted, it accompanies other conditions.
Determination of the Period op Gestation.
Whilst variable within limits, in appearance these signs of pregnancy may be conveniently grouped together as character- istic of stages of gestation. The evidence on which a diagnosis of pregnancy should be based is rarely positive up to the time when the foetal heart may be heard, and yet Uie concurrence of certain symptoms at a given period will furnish strong presump- tive proof of pregnancy.
During the first three months of pregnancy its existence may be reasonably predicated by the presence of the following symptoms : Suppression of the menstrual discharge in a woman previously regular, associated with nausea or vomiting in the morning, should always awaken suspicion. On examination during this period we shall find, after the first menstrual period has been skipped, bluish discoloration of the urethral bulb, and a uterus lower in the pelvis than under normal conditions we should expect to find it. The cervix usually will present a s^i- sation of softness to the touch, and the circular arteries will
DIAGNOSIS, DURATION, AND HT6IENE OF PRE6NANCT. 15
pulsate markedly. At about the sixth week, the body of the uterus will have assumed a spherical shape and the lower uterine segment will project over the cervix. On inspection of the breasts, if the woman be a brunette, the primary areola will be noticed and a few sebaceous follicles will be prominent. About the eighth week the changes in the body of the uterus become more marked and the entire tip of the cervix yields, to the touch, that softening in structure which is characteristic. At the tenth week the outline of the uterus is distinctly spherical, the boggi- ness of the lower uterine segment and its projection over the cervix are very pronounced, the nausea and vomiting are ordi- narily not so marked, the mammary signs are intensified, and the violet hue of the vagina is deeper.
These characteristics are not sufficient to justify the phy- sician in making a diagnosis of pregnancy, although the pre- sumption in a woman who has never borne children is a very strong one. All the signs noted may be present as the result of other conditions, except, possibly, the peculiar configuration of the lower uterine segment, although it would be unusual for this group of symptoms to co-exist in a pronounced degree if the woman were not pregnant. From the twelfth to the sixteenth week the nausea and vomiting usually disappear, although in some women it remains throughout gestation ; the mammary signs become more pronounced ; the cervical signs and those of the lower uterine segment are very characteristic ; the uterus rises to the pelvic brim ; and tlie abdomen begins to round out. About the sixteenth week, a trifle earlier in some women and later in others, the first foetal motion is appreciated by tlie woman ; at times, on conjoined abdomino-vaginal examination, the intermittent contractions of the uterus may be evoked. At the twentieth week, where the pelvic brim is not contracted, the uterus may be palpated through the abdominal walls midway between the symphysis and the umbilicus ; in case the pelvic brim is contracted the uterus will be found at a higher level. When thus palpated the uterus will have the distinctively
16 FBB6KAKCT.
spherical shape of pri^:nancy ; it will contract rhythmically on manipulation ; in excessively rare instances the beating of the icBtal heart may be heard. Usually, vaginal ballottement may be secured. At this date, the twentieth week, the physician, as a rule, possesses sufficient evidence on which to base a diagnosis of pregnancy, but his opinion must be guarded, for even yet there are sources of error.
From the twenty-fourth to the thirty-second week the di- agnostic signs become rapidly more pronounced. The uterus reaches the level of the umbilicus about the twenty-eighth week, its spherical outline being very marked ; the cervix is softened throughout one-half its extent ; the passive motions of the foetus are intensified and may be evoked by the physidan ; abdominal ballottement may readily be obtained ; the uterine souffle is dis- tinct and the fcetal heart may ordinarily be heard.
We have attained, then, the period when the diagnosis of pregnancy may be certified. Even without the positive evidence afforded by the fcetal heart, the signs are distinct enough, if weighed in connection with the past history, to justify a diag- nosis of pregnancy. Of course, the data are not perfect without the foetal heart, but it must be borne in mind that the woman may be pregnant without the heart-sounds being appreciable, and, furtlier^ that tlie foetus mav be dead.
m
The evidence in our possession simply becomes stronger from Uie thirty-second week on to term. — tlie fortieth week. In women with thin abdominal parietes the parts of the foetus may be pal|>ated. and, if the foetus be alive, the movements are such as can be simulated by nothing else. The motion of gas in the intestines may lead tlie woman astray, but the sensation of motion communicated to the palpating hand is unmistakable. On ^Tiginal examination tlie cervix will be found to be grad- ually becoming merged in tlie lower uterine segment, and the presenting part of the fcetus may be felt in the anterior fornix of the vagina, except where tlie i^acenta is implanted below.
During this ixmod— die thirty-second to the fwtieth week
DIAGNOSIS, DDRATION, AND HVGIENE OF PKEGNANOT. 17
— the changes in tlie cervix are very characteristic. The vaginal portion sotleus very rapidly, until, in primiparse, at the end of gestation the cervix lias become merged tntirely in the lower uterine segment.
About the thirty-eighth week the utenis begins to sink gradually in the pelvis, attaining, in normal pelves, the height it sliould occupy about the eighth mouth of pregnancy. This sinking is due to the attempt at engagement of the presenting part in the pelvic inlet, and normal sinking may be taken as a sign that the inlet is not contracted. The respiration of tlie woman is easier on account of the lessened pressure on the diaphragm associated with the sinking, but the tedema of the lower extremities and of the external genitals is proportion- ately increa.sed. These various symptoms are chiefly of value as indicating that labor is about to set in, although they are all corroborative of the ascertained diagnosis of pregnancy.
DoBATioN OF Pregnancy and the Prediction of the
Probable Date of Labor. The average duration of pregnancy in tlie human female is ten lunar months, or forty weeks, or 280 days from the be- ginning of the last menstrual period. This duration, however, varies within wide limits, since it is impossible to determine the exact date of conception, and since ova are shed not alone after and before a menstrual period, but also in the interval between two periods. In certain cases gestation seems to be prolonged less than this approximate period, and in others far beyond. Under the old French law the legitimacy of a child could he disputed which was bom 300 days after the deatli of the father ; in Austria 240 and 307 days are recognized as the early and the late limits of legitimacy ; in England and in the United States we rightly find no dogmatic statement as to legitimacy, the fact of protracted gestation being admitted by the law. There are many imdoubted instances of protraction of pregnancy beyond the 32Uth day after the supposed conception.
i
18
L
In predicting the date of probable delivery we are met, at I the outset, by the difficulty that it is not possible to determine the time when fruitful coition occurred. The data which have been obtained from a large number of cases where it was ascer- tained with a sufficient degree of certainty that tliere had been but one coitus, at wliicli time conception had necessarily occurred, has enabled us to fix the average period of gestation as being about two hundred and eighty days. Even in such instances, however, there is a margin of error of a fortnight, because the spermatozoa are capable of life to this extent, and even beyond this in the normal secretions; and, furtliermore, at tlie time of coitus there I may be present no ovum ready to be fertilized, even though the woman has but just menstruated, or none of the ova shed at j this period may be fertilized, the spermatozoa awaiting the shed- ding of later ova. AVe have, hence, ground for error varj'ing J between a fortnight and a lunar month. These facts go far I toward explaining instances of protracted gestation. For similar f reasons tiie date of the last menstrual period is open to erro- 1 neous interpretation. The woman may conceive either just J before the period which failed to appear, or just after that wliich. I did appear, or iu the intermenstrual interval. Here, again, there | is ground for error within from two weeks to a lunar month. J Quickening does not furnish a reliable guide, for the reason that I the period when this is first felt varies within the limits of e month, and then again many women are not conscious of the | first movements of the fcctus or are deceived by tlie motion of j gas, for instance, in the intestines, into the belief that life is | present, or rather is felt, far earlier than it is at all likely it could 1 be. The height of the uterus above the pelvic brim, although ' fairly constant under normal conditions at different periods of pregnancy, is not reliable as a means of predicting the probable J date of labor, because this height is subject to considerable varia-l tion according to the capacity of tlie pelvic brim, the condition of [ the neighboring viscera, and according to the size of the fcetus and' I the amount of liquor amnii present. Still, it offers an apprcxU J
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Outlines cf the Abdomen |
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DIAGNOSIS, DURATION, AND HYGIENE OF PREGNANCY. 19H
I mate guide for the estimation of the period which pregnancy has attained. This statement holds true only for the jjclvis in which tlie pelvic inlet is of the normal type. In case of tlie contracted brim the uterus as it enlarges cannot sink to the same degree ; so tliat it will be always higher above the brim than under normal conditions. At the third montli the uterus approaclies the brim ; at the fourth month it is about on a level with the brim ; at tlie fifth month it is situated midway between the pubic symphysis and the umbilicus; at the sixth montli it attains the level of the umbilicus; at the seventh montli it rests about two fingers' breadth above the umbilicus; at the eighth month it reaches midway above the umbilicus; at the ninth month it reaches the ensifurm cartilage and gmdvially sinks until at term it occupies the position wliich it did at the end of the eighth month.
When viewed in outline the abdomen has the shapes which are shown in tlie plates at given periods of pregnancy. (Plates III, IV, and V.) Of course, extreme laxity of the ab- dominal parietes or the deposit of a large amount of adipose in the walls of the abdomen interferes witli the usual outline appearance.
Certain observers — the late Karl Braun, for instance — laid considerable stress on the estimated lengtli and weiglit of the fcetus, the methods for determining which are given in the por- tion of this work devoted to obstetric surgery ; but at best, even here, there are elements of error aside from the problematical nature of evidence as to weight and length of a body which can be measured only after an exceedingly indirect manner.
Our argument goes to show how much open to error is the statement of the probable date of deliver)-, and, as is noted in "Obstetric Surgery," this is very unfortunate when it is desired, for one or another reason, to induce premature labor without imperiling unduly tlie chances of ftetal viability. A generally accepted rule, and one which enables us to approximate the date of delivery within from one to two weeks, is the following: Having determined the date of the last menstrual period, add
J
L
20 PREGNANCY.
seven to fourteen days, according to the usual protraction of the menstrual period in the given individual, and count forward nine calendar months, or, what amounts to the same thing and is more convenient, count hack three montlis. We shall thus, in the average case, come witliiu a week of the correct time, which will be found to vary between 275 and 280 days from the last menstrual period. Even under this rule tliere is an element of great uncertainty, for many women have an apparent menstrual flow for one or more periods after they have conceived. In such cases the height of the uterus and the ascertained date of quickening will be found not to correspond with the date of apparent conception.
A further element of error on which we must dwell, although the theory on which it is based is as yet not proven witliiu the limits of scientific exactitude, is the contention tliat during the fruitful life of woman she is constantly engaged in preparing her sexual organs for insemination. The menstrual period is looked upon as an act which cleanses the system of the prod- ucts which liave been laid up during the intermenstrual period for the nourishment of the ovum in the event of its becoming inseminated. Now, in some women tlie duration of this cycle is less tlian in others. For instance, in certain women in every respect healthy the menstrual |)eriod anticipates the lunar cycle, — that is to say, recurs every 21 instead of every 28 days, whilst in other women the cycle is uniformly prolonged beyond 28 days. If then labor should occur, as lias been claimed, at or near what would have been a menstrual epoch had the woman not conceived, in many women tiie duration of gestation will he about 270 days, and in others nearer 300 days instead of about 280. It is apparent, therefore, tliat the physician, in order to avoid an exceedingly wide marpn of error, should not rest content with the determination of the menstrual date, as regards the last beginning or cessation, but should also question his patient as to' the ordinary recurrence of the flow, and make due allowance for this before giving an opinion.
I
DIAGNOSIS, DDRATIOK, AKD HYGIENE OF PBEGNANCT. 21
A fairly reliable point in regard to impending labor may be secured by the determination of the date of sinking of the uterus. As we have stated, the uterus sinks into the pelvic brim, under normal conditions, about two weeks before labor. At a late date of pregnancy, also, the changes in the vaginal portion of the cervix give a fairly reliable guide. So long, in primiparie, as this portion of the cervix remains unmerged in the lower uterine segment, labor is not likely to occur unless it should do so prematurely.
Differential Diagnosis of Pregnanct. Whilst tlie diagnosis of pregnancy, under normal con- ditions, may frequently be reasonably predicated even before the absolute sign, the (cetal heart-sound, is discernible, often it is an exceedingly difficult matter to attain a positive diag- nosis. In neurotic women, especially at the time of the meno- pause, all the rational signs of pregnancy may be present, asso- ciated with increasing abdominal enlargement. These women are either exceedingly anxious to bear a child or else they have subjected themselves to the risk of conception apart from the married state, Sucli women give a clear history of the early signs of pregnancy. — the amenorrhoea, the nausea and vomit- ing, the enlargement of the breasts and of the abdomen, the sensation of Icetal motion ; they are not trying to deceive tlie physician, but are deceiving themselves. Numerous instances are on record where they liave made every preparation for tlie impending labor, and many cases are also on record where the physician has been himself a party to the deceit. To this con- dition the term " pseudocyesis" has been applied, meaning false pregnancy. A careful estimation of the symptoms and an equally careful local and combined examination should serve to convince the physician of the true state of affairs. If the uterus can be grasped bimanually, it will always be found much smaller than the supposed date of pregnancy, and it will always lack the pecuUar shape to which allusion has been made. The
23 FBEGNANCT.
cervical alterations will never be present, and on auscultation the cliaracteristic sounds will never be beard. If the woman is too atout to allow of bimanual exaraiuation, or if the accumula- tion of gas iu the intestinal tract is too great to enable the ex- ternal hand to properly depress the abdominal wall, then at times the symptomatology is marked enough to call for anses- thesia to determine the true state of affairs.
The persistence of an apparent periodical menstrual dis- charge during the early months of pregnancy, and at times throughout gestation, is by no means uncommon, and this will tend to render the diagnosis of pregnancy difficult. The ques- tion for differential diagnosis here may usually be settled by careful local examination. A submucous cervical polyp may be at the bottom of the discharge, and on its removal the anomalous symptom ceases, Heemorrhage, however, during pregnancy is not so important as casting doubt on the exist- ence of the condition as it is a signal of a pathological con- dition associated with the pregnancy. Local examination should alwaj's be resorted to, since early malignant disease of the cervix may be the causal factor, or tlie placenta may be im- planted in tlie lower uterine segment, botli of which condltiouB the welfare of the woman requires should be detected early. It should be remembered, also, that liEemorrhoids or polyp or malignant disease of the rectum may give rise to haemorrhages, and tliat in an obscure case the lower bowel should be exam- ined. The mistakes made by eminent men should serve as a waniing never to rest satisfied v^ith a superficial examination.
Long-standing congestion of the pelvic organs may lead to the presence of many of the early symptoms of pregnancy. The nausea and vomiting, the bluish discoloration of the vagina, the enlargement of the uterus, the apparent softening of the cer- vix, the enlargement of the abdomen, the mammary signs, — all these symptoms may exist and yet pregnancy be absent. Here, again, careful examination and a proper appreciation of the signs should serve to guard against error in diagnosis. The
I
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DIAGNOSIS, DUHATION, AND HYGIENE OF PREGNANCY. 23
uterus will never be found to have the spherical outline wliich may be determined even at a very early stage of gestation in the nullipara, and with less exactitude in the pluripara. The apparent softening of the cervix wilt, on inspection, be found dependent on an erosion of tlie epithelial layer of tlie cervix, the result of acrid discharge from the uterus ; tlie enlargement of the abdomen may be determined as due to the constipation which is such a frequent associate of pelvic congestion ; the sensation of ftEtal motion will be determined as due to the presence of flatus in tlie intestines.
Fibroid tumors of the uterus may at times render the diag- nosis of pregnancy difficult. This will especially be the case in women with a large amount of adipose in the abdominal walls. Whenever careful bimanual examination is possible, however, the differential diagnosis ought not to present difficulties. The cervical signs of pregnancy are absent ; the uterine outline is not apt to be spherical unless the fibroid is symmetrical, and then the consistency of the uterus is harder tlian iu pregnancy, and, instead of amenorrhcca, the menstrual flow is either natuml and regular or else there is a history of liromorrhages. The rational signs of pregnancy will rarely be present; after a sug- gestive manner, if at all. If tlie fibroid be subperitoneal, on careful palpation the tumor will be found independent of the uterus or projecting in a nodular fashion from it. Of course, the two conditions, fibroid and pregnancy, may co-exist, and then the differential diagnosis maybe difficult; but the after- course of events will, very shortly, on renewed examination, clear the diagnosis. It is, in particular, fibroids inserted in the lower uterine segment which are likely to obscure diagnosis, and this for the reason that their presence interferes with care- ful bimanual examination. In tliese cases the combined ab- domino-rectal examination will be found serviceable, as ena"bling us to map out the outline of the uterus, and perhaps to obtain ballottement. Wlien the fibroid is large, occupying perhaps the entire abdominal cavity, it will frequently be no simple matter
24
to exclude a complicating pregnancy. The inability to hear the fcetal heart-sounds offers the strongest corroborative evidence, however, although it must be remembered that, owing to the position of the Ibetus or of the complicating tumor, this sound might not be transmitted to the ear. Very seldom, however, will the grouping of symptoms give us preponderating evidence of the existence of gestation in its absence, when the symptoms of fibroids are marked.
Large ovarian cysts, filling tlie abdominal cavity, are hardly likely to simulate gestation. The early history of pregnancy will be lacking; the enlargement of the abdomen, usually, will have been slower ; the percussion outline of the tumor will not yield the spherical sliape of the gravid uterus; the intermittent uterine contractions will be absent, and it will not be possible to obtain tlie fcetal heart-sounds. The facies of the woman, again, is utterly different, that wliich is associated with an ovarian cyst of large size being almost pathognomonic of tlie condition. Of course, pregnancy may co-exist with the ovarian cyst, and then tlie diagnosis may he most difficult. As a rule, the question to decide will not be as to the existence of pregnancy, but rather the co-existence of a complicating factor, since the major signs of pregnancy — the fo3tal heart-sounds and the cervical signs — ■ are apt to predominate. A condition which is likely, on the other hand, to simulate ovarian cyst, is hydmmnion, where the large amount of water present is apt to obscure tlie major signs of pregnancy, such as the fcetal heart-sounds. But then the cervical signs are present to influence our conclusion. Small ovarian cysts, impacted in the pelvis, are much more likely to obscure the diagnosis. Not uncommonly the rational signs of pregnancy will be present, — the nausea and vomiting, the amenorrhoea, the enlargement of the breasts, with possibly prom- inence of Montgomery's follicles, — and the close apposition of the cyst to the lower uterine segment will simulate the signs in this locality which are characteristic of gestation. In such instances, if the symptoms are of a nature urgent enough to requir*
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DIAGNOSIS, DURATION, AND HYGIENE OF PREGNANCY. 25
speedy diagnosis, it is advisable to anaesthetize the woman in order to make the careful bimanual examination which ought to clear the diagnosis. If a waiting policy is allowable, then, in the course of a few weeks, the diagnosis may be reached through the development of signs more characteristic of preg- nancy. In any event, remembering that to-day the surgical rule is to remove an ovarian cyst before it has attained great size, it will not be wise to temporize overlong, but, in view of the safety of ansBsthesia, to resort to this method of certifying the diagnosis.
Ascites should not lead to difficulty in differential diagnosis except where pregnancy co-exists, and then many of the cliarac- teristic signs of gestation may be masked by the enlargement of the abdomen due to the presence of fluid. Particularly is this apt to be the case where the fluid is encysted, for then we shall not obtain the evidence of free fluid in the peritoneal cavity yielded by change in position of the woman, but we may have a tumor similar in outline to that of the gravid uterus. The rational history here, however, will not be that of pregnancy, and local examination will reveal the absence of the cervical and uterine changes of gestation. In a very obscure case, how- ever, it may be necessary to resort to anaesthesia in order to reach a diagnosis.
The condition above all most difficult to differentiate, and yet calling for early and accurate diagnosis, is the distinction between uterine and extra-uterine gestation. On the diffenni- tiation the life of the woman may depend, and, fortunately, tlie information obtained in modern times usually enables us to avoid making the misUikes in diagnosis of the past. The symp- toms of early ectopic gestation arc exactly similar to those of normal pregnancy. There is the same rational history of amen- orrhoea, and of nausea and vomiting, coincident with the mam- mary and the local signs. Generally, however, on close ques- tioning, certain points of value from the differential stand-point will be evoked. Thus, usually a history of precedent disease
26 PRE6NAKC7.
of the genital system may be obtained, associated with a period of relative or of absolute sterility. At the eighth week of gestation or thereabouts the woman has irregular haemorrhages, at times associated with such sharp, colicky, abdominal pains as to cause fainting or actual collapse. These symptoms should always call for a local examination, when, in addition to the enlargement of the uterus which accompanies ectopic gestation, a tumor will be found in the region of the broad ligament, which is, to a greater or a less degree, tense and giving evidence of congestion. Such symptomatology should always awaken the keen anxiety of the physician. It will not follow that uterine pregnancy is absent, but the chances are that ectopic pregnancy complicates. The woman should be watched and examined daily to determine if the tumor to the side or behind the uterus is enlarging. When the haemorrhages recur the discharge should be examined for the presence of the decidual membrane which is shed in these cases, but which is rarely seen. If the symptoms recur, then the time has come for examination under anaesthesia to reach a more exact diagnosis, when, if the inference is strong that ectopic and not uterine pr^;nancy exists, the course of treatment outlined in the section dealing with obstetric surgery should be followed. If the case be not seen until after rupture into the layers of the broad ligament with development of the fcetus, instead of its death, then the diagnosis is often imiK>ssible, notwithstanding all our methods. Fortu* nately« the woman does not run the same immediate risk that she does prior to the twelfth week, and expectant treatment is allowable until term. Usually, in these instances of so-called abitominal gt^tation ad^nnced beyond the fourth month, ex* aminatiou under anae^sthesia wiU enaUe the physician to differen- tiate the uU^rus from the ectopic-gestation sac with sufficient degree of certitude to warrant him in examining the interior of the uteras for the purix>se of proving it empty. Whilst the foptal he<urt-sounds will be heard, it is questionable if the intermitt»t uterine contractions are ever pcesent in the ectopic
DIAGNOSIS, DURATION, AND HrGIENE OF PKEGNANCT. 27
sac, and then the foetus can be palpated much more readily through the abdominal walls than is possible in normal preg- nancy, except in very exceptional instances when the uterine walls are excessively thin.
Management of Gestation.
Whilst gestation is a physiological process and, in a normal woman under normal conditions, ought to progress without en- taihng greater strain than the system is prepared to stand, the great alterations in tlie sexual organs and the concomitant strain to which every other organ in the body is subjected call for watchfulness on the part of the physician and mdical change in many respects in the habits of the woman.
Since tlie system is subject to extra strain, it follows, at the outset, tliat extra food is requisite in order that the system may bear this strain after a physiological manner. As a rule, the woman should be allowed to eat wliatever slie finds agrees with her, partaking as i'reely as is possible of fresh meats, vegetables, milk, fruits, and water. Highly-spiced articles of diet are objec- tionable not on the ground that they are apt to affect the foetus unfavorably, which is the popular idea, but because such articles do not, as a rule, contain the elements best qualified to nourish the system. Where the nausea and the vomiting of early preg- nancy are pronounced, it will often be a very difficult matter to persuade the woman to ingest sufficient food to nourish her, and yet this is a period of gestation when it is, above all, essential that the system should be well nourished in order to prepare it for the great strain it will be subject to as gestation progresses. Fortunately, we are able now to utilize a large number of pre- digested articles of diet, which contain the essentials for proper systemic nourishment. In aggravated cases of nausea we can nourish efficiently for the time by utilizing the rectum. Ordi- narily the appetite of the woman will depend largely on the state of the intestinal canal. The nausea and vomiting of early pregnancy should not be considered a pure neurosis, but the
28
PBEGNANCY.
fact should be recognized that torpor of the liver aud the con- secutive constipation are responsible for a large share of the dis- turbance. AVomeii are by nature and by force of habit of a constipated type, and, when the interference by tlie growing uterus with tlie lower bowel is superadded, this habit simply becomes intensified. Further, it is surprising what a mass of feecal matter the average woman unconsciously carries in her colon, and this, too, althougli she will state that her intestinal tract is emptied each morning. So it is, but rarely thoroughly. As a rule it will be found advisable to instruct the woman to take a laxative each iiiglit or every other night on retiring. Enemata, as a routine measure, should he avoided, since their constant use can but result in aggravating the hsemorrhoids wliich are an associate in many instances of late gestation, and because, furthermore, injections into the rectum are very apt to irritate the uterus and may induce premature labor.
Tlie hygiene of tlie skin should receive careful attention. Daily baths are not only allowable, but are indicated as one of the means for relieving the great strain to whicli the kidneys are subject during gestation. These batlis may be taken, con- trary to lay opinion, up to terra. Vaginal injections, if the water be lukewarm and not in excessive amount, are not likely to do any damage; indeed, are valuable as a means of keeping this canal reasonably clean, Wliere the normal secretions of the vagina are intensified during pregnancy, or where there is present a profuse secretion from the cervical canal leading to irritation of the external genitals, these injections should be ordered, associated with some astringent, such as powdered alum 1 teaspoonful to tlie quart of water, and, in aggravated cases, the physician should apply astringents to the vagina, such as nitrate of silver, in the strength of 1 drachm to tlie ounce of water. Such a measure will be forced on the pliysician in the presence of a leucorrlioea of a very acrid nature, otherwise the nervous system of the woman will suffer from tlie constant pruritus. Sexual intercourse during gestation must be left to
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DIAGNOSIS, DURATION^ AND HT6IENE OF PREGNANCY. 29
the desire of the woman. The only advice the physician can give is in regard to moderation. Of course, in instances where abortion or premature labor is feared it should be absolutely interdicted.
The urine of the gravid woman should be examined care- fully throughout gestation, at intervals of every two weeks at least during the later months, and oftener in the event of albu- min being detected. This is one of the means of forestalling eclampsia, or of determining when to interfere in order to save the integrity of the Iddneys.
The clothing of the woman should, be warm, and yet not so heavy as to tire her. The abdomen and the breast should not be subject to compression. The average corset should be discarded and one or another of the modern waists, devised to support these regions and yet not to compress, should be worn instead. It is essential that the abdominal walls should have ample space in which to expand, that the respiratory functions should not be impeded through interference with the action of the diaphragm, and that the nipples should not be compressed by inelastic pressure. During the later months of gestation, particularly if there be a tendency to pendulous abdomen, the woman will find comfort in the application of an abdominal binder pinned from below upward so as to support the weight of the uterus. This binder, also, will relieve the dysuria from which many women suffer. Daily exercise, of the gentler type, should be taken, the guide as to the amount being dependent on the sensation of fatigue which the woman suffers. It stands to reason that overfati<i:ue should be avoided, and vet it will be found very difficult to persuade many women to take exercise at all. This should be insisted upon, and at a time of the day when the sun is shining, and not after dark, as many women, if not expostulated with, will prefer. In the absence of a special symptom contra-indicating, railroad travel may be safely under- taken from the third to the seventh and one-half or even eighth month, and sea-voyaging is not to be forbidden except in the
30
PBEGNANCT.
case of women who suffer from nausea. Indeed, many women are improved in liealtli during gestation by such means of travel.
It may be laid down as a rule to be rigidly insisted upon, that the pelvic capacity of every woman should be gauged at as early a date as is possible, not alone to determine whether the woman is so built as to be able to bear a cliild in safety at term, but also to find out if there are present in the pelvic canal tumors not appreciable externally and yet of a nature to render delivery at term impossible. This subject of pelvimetry is amply exemplified in tlie portion of this work wliich deals with obstetric surgery, and we insist upon it here because it is, above all, necessary to impress upon the student that, without the data obtainable through pelvimetry and examination of the abdomen, he knows nothing about liis patient except that slie may be gravid. It is as safe to make a diagnosis of cardiac disease without listening over the area of the heart as it is to pretend to care properly for a woman during gestation and at term with*i out having made a thorough examination at as early a dat of pregnancy as is possible.
The mental condition of the pregnant woman will fro- quently require anxious oversight. Women of an emotional temperament are apt to become moody and despondent, brood- ing over their condition and fearing all sorts of untoward con- sequences. Fresh air and exercise and the effect of moral suasion suggest themselves as the best remedy for this condition. The physician may do much to dispel the woman's anxiety, and it will often be his duty to relieve the mind of the woman in regard to the possible effect of the so-called maternal impressions on the fcetus. However strong the apparent evidence may be in favor of the view that such impressions may affect the fcetuB unfavorably, there is just ground and stronger ground for the belief that such impressions do not affect the foetus.
The care of the mammary glands during gestation is of the first importance. The nipples should be kept free from
I
DIAGNOSIS, DtlEATION, AND HYGIENE OF PREGNANCY. 31
pressure, aod the breasts, if pendulous, should have due support, The wearing of a tight compressive corset should be discounte- nanced. The circulation throughout the breasts should be free, and the proper kind of support is that which aims at the pre- vention of local congestion without the exercise of pressure. Nowadays the so-called shirt-waists are the proper articles to wear for the giving of support. The nipples should be batlied frequently for purposes of cleanlinesB, but alum, tannin, and the like should not be used, since their only effect is to injure the delicate protecting epithelial layer. Traction on the nipples should not be allowed, since this is apt to set up uterine con- tractions, and it is very questionable if such traction will cause nipples to project which are lacking in erectile tissue. If the nipples are in a normal condition, after the birth of the child they will soon adapt themselves to the demands of lactation. It is, above all, necessary to avoid in-itating the nipples by local applications and by traction, since it is recognized to-day that tih» nmt «(wulon eanae of pumpenl martitu u the pteseaoe of cawka in tha aipplM thiov^ which elenento of infection gain access to the glands. In case the nipples are depressed and altogether lacking in erectile tissue an attempt may be made at frequent intervals to cause them to project, but these attempts should be of a gentle nature and are only allowable because, if they should foil, the woman will not be able to nurse her child.
The pathology of pregnancy includes all morbid conditions of the woman or the child which lead to deviations from the normal. Certain of these conditions must be looked upon as physiological, since, to a greater or a less degree, they are con- stant accompaniments of pregnancy. Therefore, the morbid conditions from the side of the woman must include: The pathological exacerbations of physiological processes and the accidental complications of pregnancy.
It is difficult and occasionally impossible to determine where physiological action ends and morbid condition begins. This ia rendered doubly so from the fact, as is dwelt upon else* where, that we are not dealing with an individual in a condition of nature, so to speak, but with one whose physical being has been altered by the demands, rational and irrational, of civil tion. Much which, in a state of nature, was physiological has been altered by civilization into a process which, in many.' respects, verges on the pathological.
We will consider at the outset the exaggeration of physii logical processes which accompany gestation, and next dwell upon the accidental complications in pregnancy.
The Pehnicioos Vomiting of Pregnancy. Wliilst the nausea and the vomiting of pregnancy is a physiological accompaniment, when the condition is exaggerated it is termed " pernicious " and is an exceedingly grave complica- tion. Fortunately it is rarely met with in the aggravated type, and certain German observers have gone so far as to deny its occurrence. A sufficient number of authenticated instances, however, have been reported, both here and abroad, to prove the grave nature of the complication. (32)
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1
TATHOLOGY OF PHEGNANCY.
33
Pernicious vomiting has been observed more frequently amongst primiparte than multipaite. The etiological factor cannot always be determined. Frequently reflex nervous action is at the bottom of the condition. Again, the cause may de- pend on morbid condition of the cervix, such as cervical metritis, erosions, and hypertrophic elongation of the cervix. On tlie other hand, instances are on record where none of these factors were at work.
In geiieml, it may be stated that the pernicious vomiting is but an exaggeration of the morning nausea, and vomiting which is the rule rather than the exception in pregnancy. At the outset, at least a portion of the ingested food is retained at the midday and evening meals. The nausea is often associated with violent straining; so that the woman eventually complains of considerable abdominal tenderness. If tlie condition become aggravated, then the nausea persists, even thougli there is noth- ing in the stomacli. Occasionally the condition is complicated by profuse salivation. Constipation is usually of an obstinate type.
As the affection progresses the woman becomes wasted, feeble, and feverish. The pulse becomes accelerated, — an index of weakness. The vomited matter consists of watery material tinged with bile. When the retching is severe the material may be tinged with blood. The tongue becomes brown and dry and fissured. Emaciation becomes extreme, and tlie woman passes into a typhoid condition. At times there occurs a reverse peristaltic action of the intestinal tract, and fascal vomiting ensues. Even when the woman has reached this extreme con- dition it is not often that the fcetus is expelled prematurely, and, strange to relate, in certain cases where the woman has been tided over to term the child has presented very little evidence of lack of nutrition. It has seemed to thrive even at the expense of the exiiausted mother.
Prognosis. — Hyperemesia of gestation should always occa- sion anxiety, and the prognosis should always be guarded.
34
Especially is this the case where the woman reaches an extreme I degree of emaciation and has had hectic fever.
TVeiitment. — The woman should be placed in bed and kept I prone, since this position alone frequently ameliorates the nausea I and the vomiting. Careful alimentation is to be insisted upon. A cup of black coffee taken the first tiling in the morning allays in a measure, at times, the condition. Solid food must be inter- dicted, although the woman will not ask for it and could not retain it if administered. Milk and lime-water, one-third of the latter to one of the former, should be tested in small quantities at intervals of two hours. It should be borne in mind that at times the most readily digested foods ave not retained and the craving of tlie woman should liave respectful attention.
If all food be rejected it will be necessary to resort to rectslJ alimentation. Inasmuch as it may become necessary to feed byj tlie rectum for a protracted interval, great care is necessary froufl the start that the rectum does not become irritated. This ma]f J in a measure be prevented by washing out the lower bowel fre«J quently with cold water.
Beef-juice, peptonized milk, defibnnated blood, or egg-albu* J men, 4 ounces every three or four hours, may be utQized. TheJ rectum is apt to retain its tolerance longer if a few drops of the! tincture of opium be added to alternate enemata, and absorption of the food is more rapid if it be acidulated with dilute hydro- chloric acid. It is to be borne in mind that all raucous surfaces absorb saline solutions very freely. Hot black coffee makes an excellent stimulant enema, and this may be added to advantage to the peptonized milk.
The rectum and the stomach should not be both utilized ati the same time. Either one or the other should be given abso-' lute rest. Lavage of the stomach should always be tested. The stomach-tube is inserted and about every six hours the organ is thoroughly flushed with a 2-iJer-cent. boric-acid solution.
It is needless to dwell upon the many drugs which haTi
PATHOLOGY OT PBEGNANCT.
Ivocates. There ^1
been recommended. Scores have had their advocates, exists absolutely no specific. The drug which apparently assists one woman proves a lamentable failure iu another. Oxalate of cerium has a very wide reputation. It may be tested in 5-grain doses frequently repeated, on the ground that if it does no good it will not do harm. Cocaine, in 4-per-cent. solution, admin- istered 10 drops every three hours, may be tested for a few doses ; but its effect will be found to be but transitory and it may pos- sibly intensify the nervous condition in wliich, of necessity, the woman is. Ingluvin, administered in 20-grain doses every six hours, at times affords relief Small doses of creosote, a few drops of tincture of iodine well diluted. Fowler's solution iu J-drop doses every hour for six doses, drop doses of ipecac fre- quently repeated, — such are certain of the remedial agents which have been tested and which result in failure only too frequently. To quiet the restlessness of the woman in extreme cases it may be requisite to administer hypodermatic injections of morphia; but this should be avoided as long as possible, since we mi aim at keej^g tbe inteatinat tract m order.
The best results are probably yielded by washing out the stomach and by rectal feeding. It must be remembered that local conditions may be at the bottom of the hyperemesis. Any abnormality of the pelvic organs should be looked for and rectified if possible.
Bemembering that normally the uteras is anteflexed and slightly anteverted, and that a degree of retroversion is not in- compatible with the normal prt^ress of gestation, the physician should simply look for exaggerations of these positions. In case retroflexion exists an attempt should be made to lift the uterus forward. In mild cases the woman should be placed in the left semiprone position, the fingers are inserted behind the organ, and pressure, directed forward and upward, may succeed in rectifying the displacement. If the organ is impacted behind the hollow of the sacrum, then a Sims speculum is inserted, a tenaculum is hooked into the anterior cervical lip, the uterus is
36 PREGNANCT.
drawn downward and then may possibly be pushed forward as the cervix is carried backward. Fortunately women with marked retroflexion mrely conceive. The manipulations should be gentle, of course, else the woman may be caused to miscarry. After reposition, a pessary of the Albert Smith type, with large posterior bar, should be inserted to maintain the uterus in position.
In case of marked anterior displacement posture is suffi- cient. In case the cervix is eroded it should be painted with a solution of nitrate of silver, 30 grains to the ounce, and next dusted with boric acid.
Dilatation of the cervical canal has frequently proved of benefit. Anjesthesia is not requisite; indeed, the administra- tion of eitlier ether or chloroform will simply intensify the vomiting. Painting the cervix with a 10-per-cent. solution of cocaine may, in a measure, allay the pain, which at best ia sligiit. The steel-branched dilators, figured in " Obstetric Sur- gery," should be selected for dilatation. The vaginal canal should first be irrigated witli bichloride solution 1 to 5000, and the hands and the instruments should be sterile. The dilator is inserted to the level of the internal os, the organ being steadied by a tenaculum inserted into the anterior lip. The process of dilatation is slow and gradual. In aggravated cases the internal os must be dilated as well. This procedure may induce abortion, but we are only anticipating what may be forced upon us. Very exceptionally, however, if the dila- tation be carefully performed, will the uterus throw out the ovum.
It 13 never justifiable to allow the woman to reach an extreme degree of emaciation. As a rule.active interference has been deferred too long. After tlie measures we have stated have been tested and yet the woman's condition becomes progressively worse, the time for active interference has arrived. It has been proven that, even in the face of the most despemte exhaustion, emptying of the uterus has averted a fatal termination.
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PATHOLOGY OF PREGNANCY. 37
Counsel should always be obtained before resorting to the induction of abortion. The operative measures are described in " Obstetric Surgery."
Aside from this pernicious vomiting of pregnancy there are certain disturbances of function associated with pregnancy which call for consideration. Salivation to an extreme degree is a rarity ; still, instances have been recorded wliere the woman has, in consequence, been reduced to an extreme condition and where it has been necessary to interrupt gestation. This saliva- tion is simply a reflex sympathetic phenomenon of pregnancy, and within limits need give rise to no anxiety. The best remedy for the milder instances is belladonna or its alkaloid, atropia, pushed to the physiological extent.
The serous diarrhtea from which certain women suffer may be the result of pressure of the growing uterus on the intestines, and it will often be cured by tlie thorough evacuation of the intestinal caual by a lnxative and higli enema. The latter should* be administered with care, lest the uterus be irritated and throw off the ovum.
Many women suffer from neuralgias, especially facial and sciatic. Oflen full doses of arsenic will grant relief, or the an ti period ics,^-quinine and Warburg's tincture. Toothache will usually be dependent on caries of one or more teeth, when the physician need not fear to counsel extraction. The risk of abortion being induced is to be dreaded less than the nervous strain the woman will be otherwise subject to.
In the latter months of pregnancy the woman will fre- quently suffer from cramps in the thighs and tlie legs. Massage of the extremities, by equalizing the circulation, will relieve these temporarily.
Caediac Disease Complicating Pregnancy. When a woman with organic disease of the heart becomes pregnant she should always give her pliysician great concern. ^Vllen we remember that, normally, the heart bears additional
strain during pregnancy, it is easy to understand why the organ, aheady crippled, may be unable to perfonn its functions. For- tunately, as a rule, hypertrophy of the organ compensates lesion. This certainly holds true in instances where the can lesion is not of an aggravated type.
Acute endocarditis not infrequently proves fatal throi its tendency to become ulcerative. Women suffering from clironic endocarditis are rarely able to withstand the strain of gestation, since, as a rule, compensatory hypertrophy has already taken place, the woman being fairly comfortable until the greater hypertrophy is demanded by the occurrence of preg- nancy. The heart is unable to stand the increased arterial tension which is associated with pregnancy, and not infrequently, although the woman passes tlirough gesUition, a fatal issue occurs during or immediately after labor. There exists inability on the part of the heart to accommodate itself to the sudden variations in the vascular tension during labor.
Tlie reason why acute endocarditis complicating pregnancy is so prone to assume the ulcerative type cannot be stated. The impaired nutrition which is so frequently associated with preg- nancy, together with the extra work the heart is called upon to perform, may co-operate to produce this result.
In case of chronic endocarditis the symptoms will depend on the site of the lesion and upon the extent of the injury to the valves. In case of aortic stenosis and insufficiency the symptoms often become marked during the early months. The woman wiU suffer from dyspncea, a hard dry cough, and occa- sionally she will have haemorrhages from the lungs, stomach, gums, and nose. Where the cardiac lesion is not of an aggra- vated type the woman may go to term, and during labor these symptoms will manifest themselves or become greatly exagger- ated. Syncope and cardiac paralysis may ensue.
Where the mitml valve is injured, if the lesion is slight and compensatory hypertrophy is complete, the woman may not manifest any cardiac symptoms unless an acute exacerbation
For-
tha^ diacM
from^H
PATHOLOGY OF PREGNANCY. 39
occurs. Pregnant women suffering from cardiac disease are peculiarly liable to fresh attacks of endocarditis, on exposure to cold, for instance, or on unusual exertion. Compensatory hypertrophy may be sufficient to enable the woman to bear tlie extra strain of prcfjiiancy during tlie early months; but often, without special warning, the woman may develop pulmonary cedema of a type rapidly fatal.
The effect on the foetus in these aggravated instances is that it often dies in utero^ or, if delivered alive, it is weak and succumbs at an early day.
Whilst not a contra- indication to marriage, cardiac disease is certainly badly affected in each succeeding pregnancy. In an early stage of the disease the woman may pass tlirough her pregnancy and her labor witliout any untoward symptom. Each recurring pregnancy, however, aggravates the lesion ; so that as soon as hypertrophy seems to fail or secondary dilatation takes place it is dangerous for the woman to conceive again.
In any event the physician will do well to give a guarded prognosis. Of course, where tliere exists disease of the heart secondary to disease of the kidneys his prognosis must be all the more guarded. Aside from pulmonary oedema, the comjilicatiou to be feared in advanced cases of cardiac disease is embolism, and this possibility obviously always renders the prognosis more grave.
Treatment. — Since, where the cardiac lesion is aggravated, the infant rarely survives even though the woman be carried to term, we are not justified in jeopardizing the maternal life in order to give the child a very problematical chance of living. The broad rule may therefore be laid down that, where com- pensation does not exist or where secondary hypertrophy has set in, nothing will be gained by endeavoring to tide the woman to term. Medicinal treatment of the cardiac lesion will not vary from that which holds irrespective of gestation, except that earlier resort to the cardiac strengtlieners will be needed, When, notwithstanding, the symptoms become iiiteustfied, — in partic-
40
PBEGNANCT.
ular the dyspnoea, — then, no matter what the period of gestation, I the safe rule, atler due consultation, is to empty the uterus, and J this after as rapid a fasliion as is consistent with the integrity of J the maternal soft parts, absolutely no account being taken of I the cliild.
If the woman reach term and is taken in labor the t rule liolds, — which is to empty the uterus just as soon as this is feasible without inflicting unnecessary lesion on the maternal soft parts. The woman must be counseled against making any unnecessary effort. As soon as the cervix is dilatable or dilated, if the conditions for version (see "Obstetric Surgery") amfl present, this operation should be elected ; if not, then the forcep* ■ sltould be applied.
Anseathesia is requisite, and the physician should not hesitate, on account of the presence of the cardiac lesion, to resort to it. There is a choice in the anEcsthetic. Ether should be avoided where kidney disease complicates, and also since it tends to provoke palmonary oedema. In general, chlorofonaj slioutd be selected and be administered most carefully, siooj danger of cardiac syncope is imminent.
After delivery the physician should remain by his patieni for a number of hours, since, frequently, everything has pass* smoothly and of a sudden the woman dies. The attendance o{M the physician may not avail raucli, but he will receive the en for having been in watchful attendance.
Strychnia hypodermatically, ■^\ grain repeated every two honrs, will assist the heart in withstanding strain. Inhalations of oxygen will reheve the dyspnoea. Hypodermatic stimulants — camphor, musk, digitalis, and tlie like — should always be in readiness to be used pro re nata^ but spurring a weakened organ by drugs must be avoided.
If the woman die before delivery has become effected, thi physician's duty is to perform the Ctesarean section, althoud this will rarely avail to save the child. Since relief from th< strain of labor often adds to tlie life-limit of the woman, :
^^^^ PATHOLOGY OF PREGNANCY. 41
cases wlieie the woman reaches term and the cervical canal is soU and dilatable we question if, at times, it be not justifiable to anaesthetize the woman, perform manual dilatation, and deliver by version. This procedure commends itself in par- ticular because, under the given conditions, it spares the woman miiny hours of strain which her weakened heart cannot stand as well as it may the necessary anaesthesia. The actual con- dition being critical, it must be met by emergency measures. In the event of the cardiac being secondary to a kidney lesion it may be necessary to elect the rapid delivery in order to avoid impending eclampsia.
There is probably no complication of pregnancy where it is less possible to lay down fixed rules for guidance. Each case constitutes an entity which must be treated according to the emergency nature of the symptoms. It must never bo forgotten, however, that frequently tlie storm does not break until after delivery, and that therefore it is wisdom not to allow the labor to be protracted, wliich simply means extra exhaustion. Since it is of the utmost importance to conserve the vital forces as far as is possible, the physician should be prepared to tampon the uterus with sterile gauze in case of inertia after the completion of the third stage of labor, in order to spare the woman the loss of blood, which she cannot stand.
Diseases of the Kidney Complicating Pregnancy.
Although the literature relating to disease of the kidney complicating pregnancy is enormous, it must be admitted that a satisfactory explanation of the clinical facts has not been offered. It is not the purpose of tlie authors to attempt a risiimi of tlie many theories advanced. The aim is to ofter the student the data which justify a line of treatment wliich is in accord with the preponderating modern belief, frankly admitting that re- searches in the future may lead to modification of the statements in many respects.
At least two etiological factors appear to offer the best
"*«2
explanation of the renal complications of pregnancy: (1) tlie alteration of the blood associated with gestation ; (3) the me- chanical interfeieuce with tlie venous circulation through the abdominal and the pelvic viscera.
Tlie blood of the pregnant woman is usually more watery than under normal conditions. It contains a greater proportion of the white corpuscles and a proportionate diminution in the red. This being the case, it seems plausible to assume that, as in other conditions associated with impoverishment of the blood, renal lesion may occur witli the excretion of albumin. We thus find a possible explanation for the occurreace of the albuminuria of gestation.
The other factor noted — the mechanical interference with the venous circulation — has many warm advocates, and yet a number of valid objections offer. Ovarian tumors much larger than the full-term uterus or fibroid tumors may cause as much pressure and consequent interference with the venous circula- tion ; and yet tliese tumors do not, as a rule, lead to the renal lesion. When, however, we remember the intimate relationship between the circulation of the pelvic organs and that of the kidney, and also that tiiis blood from the pelvis is all returned into the general circulation through the renal veins, then It appears allowable to lay considerable stress on the pressure theory as a cause of the renal lesion. It is a well-known fact that no tumor, be it ovarian or fibroid, malignant or benign, causes such development of the pelvic vessels as is associated with pregnancy. Hence it cannot be the mere pressure of the gravid uterus ; but we must look farther for a cause of the renal lesions, and we may find it in the mechanical obstruction offered to the return of the blood through the renal veins. Furtlier, the position of the renal veins protects them from direct pressure exerted by the gravid uterus. The lower part of the uterus being within the pelvic cavity and the promontory of the sacrum preventing backward pressure, the renal veins cannot be compressed, lying, as they do, in front of the second lumbar
PATHOLOGT OF PKEGNANCT.
43
vertebra. Further still, after the gravid uterus has riBen above the brim it presses forward against the anterior abdominal wall.
The renal complications of pregnancy may originate with this latter condition or tliey may be dependent upon previous attacks of nephiitis, which are exacerbated on the snpervention of gestation. The acute nepliritis of pregnancy frequently attacks women who have never suffered from renal lesion. It ordinarily manifests itself without any marked disturbance of the general health and without any febrile reaction. Often the first symptom noted is cedema, and this is not limited to the feet, which frequently is associated with normal pregnancy, but extends not alone to the lower extremities, but also to the eyes and the hands. On examination of the urine albumin may be detected, sometimes only a trace, and, on microscopical ex- amination, casts may or may not he found.
Again, cedema may not be present, and, unless it is the routine practice of the physician to examine the urine of his patients at regular intervals, the renal condition may not be recognized at all. The woman may then be delivered without complication, or during labor or afterward eclampsia may ensue.
Frequently it is a difficult matter to diagnosticate tliis nephritis complicating pregnancy from a chronic parenchyma- tous nephritis. In the latter the specific gravity of the urine is not apt to be so high nor is the amount of albumin apt to be so great. Again, the number of casts is apt to be greater in parenchymatous nephritis.
In chronic interstitial nephritis albumin may never be found in the urine unless very frequent examinations are made, and even then the amount may be very slight. Indeed, high tension of the pulse, lessened amount of urine, cedema, head- ache, and visual disturbance are more important from a diag- nostic stand-point than the presence of albumin.
A further class of cases is furnished by women who are the victims of nephritis and become pregnant. Here all the former symptoms become exacerbated. The albumin increases in
44 PREGNANCY.
amount and the casts in number. Such women rarely yrogi-d to full term, the fcetua often dyiug in itiero, the result 1 dependent, according to many, on changes in the placental structure.
It has been noted that eclampsia is far less frequent among women affected with chronic Bright's disease tliaii among those who develop acute nephritis during pregnancy. This may, in part, be due to tlie fact that the former class of women are very apt to abort at an early stage of gestation.
Clinical History. — We have noted that renal complications may exist during pregnancy without the supervention of any special symptoms. Such, however, is the exception. At any rate, that physician is less likely to be taken by surprise who systematically examines the urine of his patients at stated intervals during pregnancy and who is watchful for the symp- toms wliich are self-suggestive of kidney- lesion.
The urine of women suffering from chronic nephritis is usually markedly lessened in amount through concentration, and is high-colored. This applies, in particular, to instances of chronic parenchymatous nephritis. Headache and visual dis- turbances are frequent. CEdema may be very extensive. On exertion the woman is apt to complain of sliortness of breath. High tension of tlie pulse is a fairly constant symptom. In case these symptoms increase as pregnancy advances, then, before labor, or during or afterward, eclampsia may develop.
Eclampsia occurs once in from five to six hundred pregnan- cies, unless the woman develops an acute nephritis during \ncg- nancy, when the proportion rises to about 25 per cent. In this latter class of cases the matenial mortality ranges about 30 per cent, and the fcetal about 50 per cent.
In the vast majority of cases there are certain premonitory symptoms of eclampsia. Exceptionally, however, — and this point is to be remembered, — eclampsia occurs without previous evidence of kidney-lesion or premonitory symptom. The marked premonitory symptoms are: Headache; cedema of the feet.
PATHOLOGY OF PBEGNANCT.
4»
extremities, face, and external genitals; imperfect vision (spots before the eyes, at times transient inability to see at all) ; dyspnoea; liigh-teiision pulse.
The characteristic symptoms of eclampsia can scarcely be mistaken for any otlier condition. During the tiist few attacks tlie woman may simply pronate and supinate the forearms, closing the fingers upon the thumbs. Soon, however, the wide- open eyes become fixed in a vacant stare, the pupils being con- tracted, and this is followed by the rapid opening and closing of the lids and the rolling of the eyeballs from side to side. Tlie muscles of the face partake in the convulsive action, the mouth being drawn to one side, perhaps, the head being tossed from one side to the otlier with great rapidity. The lower extremities are also in motion, the legs being rapidly flexed and extended.
Daring the seizure the heart's action becomes irregular, the vessels of the neck are prominent, and the face has a cyanotic hue. Respiration is impeded and becomes stertorous. As the seizure passes off the face resumes its natural color, the heart's action becomes regular, and the breathing quiet. As a rule, the seizures do not last more than about thirty seconds, and in the intervals the woman may be aroused, except tlie attacks recur with great frequency.
When the convulsions are tonic in character the head and the mouth are drawn to one side, the eyes are fixed, and opisthotonos may occur. The heart's action is very irregular and respiration may be suspended. This tetanic spasm is also of short duration, — about thirty seconds ; but such violent inter- ference with the heart's action, if repeated, must eventually result in cessation and death. As regards the number of seiz- ures, they are variable, as many as seventy-five to one hundred in twenty-four hours having been noted. After the delivery, in favorable cases, the convulsive seizures become less frequent, or cease at once. Occasionally, however, the attack does not manifest itself until some time an;er the birth of the foetus.
46 PREGNANCY.
From this analysis of the synnitomatology of eclampsia we feel justified in accepting the view tliat, whatever the prime etiological factor, a secondary factor is urc^mia. Either the excretion of urea is interfered with or else there is increased production over ehraination. This fact would seem to be certi- fied by the results secured through resort to treatment the aim of which is to favor the climinatiuu of the urine in full amount. Whether the urea acts as a poison after decomposition in the blood or not is uncertain and, as yet, theoretical. Sufficient the recognition of the fact tliat, in a large proportion of cases, if not in all, we are dealing, in part, with the effects of a poison on the higher cerebral centres and on tlie spinal centres.
Prognosis. — The prognosis of eclampsia is always grave, although of late years this has been very much modified through resort to measures of a less temporizing nature in ths^ presence of the preliminary renal evidence wliich usually fore bodes the occurrence of the seizure.
Treatment. — Seeing that renal lesions may and very fre- quently do affect pregnancy in an unfavorable manner, it is es- pecially incumbent on the physician to examine the urine of his patients at intervals in order to detect ttie supervention or t presence of nephritis. When only traces of albumin are detecte or when symptoms suggestive of impending uremia have not " manifested themselves, much may be accomplished by dietetic measures. The woman should be restricted to a non-nitrogenous diet. Milk is by far the best food for the woman sufferi; from the acquired or existing lesion of the kidney, whether $ be only functional or organic. The consensus of opinion is th) meat should be absolutely forbidden as well as alcoholic betj erages. Articles of diet containing much starch, such as bree and potatoes, should be partaken of in moderation. SiaoC aniemia is an accompaniment of lesion of the kidney, and sina wlien absent, the tendency is toward it, iron in an easily" assimilated form, such as the peptonate, should be given in full doses. This is a precaution which should never be neglected
fre- s es- fhis - tbJ K:teJ|
PATHOLOGY OF PBEGNANCT. 47
ia instances T?here it is necessary to keep the womau for a pro- longed period on an absolute milk diet.
The woman must be protected from the possibihty of taking cold as far as may be. She should be told to wear flannel, and this will also tend to keep the skin moist, sucli diaphoresis assisting and relieving the kidneys. The sweat-glands eliminate the mea, or, rather, the carbonate of ammonia into which it is altered. An abundance of water should be drunk in order to flush the kidneys, so to speak. Frequent hot baths are valuable adjuvants as exciting the sudoriferous glands to action, and, in case symptoms of impending uremia manifest themselves, then the hot pack should be administered.
Another channel tinougli which the urea and its product may be eliminated is the intestinal canal. Therefore the bowels should be kept free by the administration of laxatives.
Ia initaauM wheie there ia high tennon - of the pain ^ODOB ifaoiild be ordeted in fiill dosct,— that is to mj, ^f^ gndn ahottld be adnnnutered vnrj three boniB until the tensicm abates, and then the drag should be given at greater intervals pro re nata. By attention to these measures it may frequently be possible to carry the woman to term and to deliver without the supervention of eclampsia. It must be remembered, how- ever, that this untoward complication may set in even when the " sky is most serene," and therefore the greatest watchfulness is called for until the woman has been delivered.
In instances where, notwithstanding these dietetic and hygienic measures, the albumin increases in amount and the other symptoms — ^headache and cedema — become intensified in- stead of lessening, the time for dallying has ceased and it becomes the duty of the physician, after due consultation, to take steps for the emptying of the uterus after the manner de- scribed in " Obstetric Surgery." As stated in that portion of this work, we should not wait until the symptomatology has become extreme. If we do, even though we save the patient's life, — and this will rarely be possible, — it will be with greatly
48 PREGNANCY.
aggravated disease of the kidneys aud possibly with impairment of vision or hemi- or para- plegia.
When eclampsia develops suddenly, with or veithout the premonitory history we have dwelt upon, then time is not to be lost. The uterus must be emptied by as rapid a measure as is consistent with the integrity of the woman *s genital tract. We cannot hope by delay to save the child, and each recurring con- vulsion simply makes matters worse for the woman.
Whilst awaiting the action of the method selected for emptying the uterus much may be accomplished by resort to measures which tend to lessen arterial tension. Venesection, in particular, is indicated where the pulse is full and bounding. As much as ten to sixteen ounces should be allowed to flow, according to the effect on the pulse. The tension may further be relieved by the hypodermatic injection of glonoin, using ^ grain at a dose and repeating hourly if required. This drug may be used more freely tlian is generally recognized, and with positive good effect without danger. Inhalations of chloroform to the extent of surgical narcosis form the most reliable of all methods for controlling the eclamptic seizures. Where vene- section and glonoin are contra-indicated by the absence of the full pulse of tension, morphia hypodermatically in full dose will tend to quiet the woman. Chloral hydrate, in doses of 40 grains by the rectum, will have the same effect, and bromide of soda in the like dose may be added to tlie enema.
These measures are of value in keeping the woman quiet and in sparing her nerve-force whilst the measures are being taken for the emptying of the uterus. As is noted under the subject of "The Induction of Premature Labor" ("Ob- stetric Surgery "), the ordinary measures for the emptying of the uterus in the face of a complication which cannot be termed one of emergency are too slow in the presence of eclampsia. The elective accouchement, the so-called accouchement forcS^ here finds its sphere. If need be, multiple incision of the infra- vaginal portion of the cervix must be resorted to.
PATHOLOGT OF PBEGNANCT.
49
Diabetes Complicating Pkegnanct.
In studying this subject we must carefully differentiate glycosuria occurring as a functional derangement and that which is characterized by the constant and,' it may be, hicieasing presence of sugar in the urine. During pregnancy, even as it holds aside from the condition, sugar is frequently found in the urine, especially after eating, but this is of a transitory nature and need occasion no anxiety, even as it gives rise to no symp- tom. It is diabetes proper with wliich we are concerned, and this may exist before the supervention of pregnancy or may develop during its course. As a rule, unless the condition has existed before tlie occurrence of pregnancy the glycosuria will larely be diagnosticated until the later months, for, if the characteristic symptoms are not prominent, the physician will not examine tiie urine for sugar;
The complication must be considered a rare one, unless we assume, as is plausible, that it is often overlooked, lor very few cases have been recorded.
The occmrence of glycosuria aiter delivery and during lac- tation, however, is quite common, and this fact has led to the impression that there exists a causal relationship between tlie function of the mammary glands and the development of dia- betes. Certainly, what is termed physiolotrical, or functional, glycosuria is quite common during liictation.
Diabetes proper, when associated with pregnancy, is apt to be of a malignant type, so much so that certain observers claim that the diabetic woman should be counseled against marriage, — a view which we share. The symptomatology of diabetes does not differ from that aside from pregnancy except tliat tlie proper symptoms of tlie latter condition are intensified. The gastric symptoms are increased and the urinary excretion is of greater amount than is the case in diabetes unassociated with preg- nancy. Salivation to an exaggerated degree is apt to be present.
Where a fatal issue has occurred in the few recorded cases, this has been due to coma. The question, therefore, arises:
50 PREGNANCY.
Are we justified in allowing a diabetic woman to go to tcrmT The answer to this question must as yet remain an open one. Much will de[)end on the condition of the woman. If by means of the recognized dietetic measures the amount of sugar in the urine can be held in check, and if the woman do not offer other untoward symptoms of constitutional failing, such as increasing emaciation, cephalalgia, tendency to sleep, then under the most careful oversight she may he allowed to go to term. But if the reverse hold true, then notliing is to be gained by temporizing. The woman may at any time during the progress of gestation pass into coma ; even if she reach term the disease has simply been aggravated, and it is questionable if her child will survive; during lactation, if this be attempted, the disease will simply become aggravated. It is wise conservatism, therefore, in any case where the progress of the affection is toward the worse, to induce abortion after due consultation,
Sucli statistical data as are at our disposal prove the wis- dom of this advice. Of the twenty-four cases of which we can find record there were six maternal deaths from coma. These deaths occurred in all but one case before term.
If the emptying of tlie uterus be determined upon, then a rapid method should he selected, since the woman will not bear protracted strain. J
Displacements of the Pregnant Uterus. ^
In the early months of pregnancy the customary antever- Bion and flexion of the uterus become somewhat exaggerated, but this never produces any symptom aside from the dysuria or the frequent micturition, which is dependent on the sinking of tlie heavy organ and on consequent traction on the neck of the bladder. In women of lax muscular development and in those on whom abdominal section has been performed ttie uterus may meet with insufficient support from the anterior abdominal wall and fall forward, constituting what is known as pendulous al*- doraen. Tliis falling forward of the uterus is found in particalar
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PATHOLOGr or PREGNANCY. 51
in multiparee, especially those who have borne children in rapid succession. Tlie symptoms associated with pendulous abdomen may become very marked and labor may be interfered with. The application of a suitable abdominal binder is indicated for the rectification of the malposition.
The condition is especially aggravated when there exists also a ventral hernia. In this complication, as a rule, the de- veloping uterus pushes the intestines upward, and risk of incar- ceration hardly exists. Wliere, however, the hernia is ad- herent, then, at any time, symptoms of strangulation may offer. If we have reason to fear this occurrence, then, after due con- sultation, it will be wise to interrupt the course of gestation. Should the strangulation occur suddenly, then operation on the hernia is indicated, and this may or may not interfere with the progress of the pregnancy. Since, however, the development of the uterus will cause the site of the abdominal union, after operation, to yield and result in recurrence of the hernia, the welfare of the woman demands here, as well, evacuation of the uterus. (Plate VI.)
Owing to the fact that endometritis is an associate of retro- version, pregnancy rarely occurs, or, if it does, gestation is in- terrupted spontaneously, since the diseased endometrium offers an unsuitable soil for the development of the ovum. If preg- nancy should occur, however, and early abortion not ensue, then, if there be no posterior adhesions, either the uterus rises above the pelvic brim or else retroflexion occurs, and the fundus may become incarcerated below tlie promontorj' of the sacrum.
If the uterus does not spontaneously rise above the brim, then symptoms of incarceration ensue. Tlie symptoms will at the outset be more marked from the side of the bladder, because the peritoneum of the anterior cnl-de-sac is drawn more tense, and distension of the bladder after tlie normal fashion is inter- fered with, and also because the cervix is forced forward and may press so firmly against the vesical neck as to prevent the
52 PREGNANCY.
escape of the urine. These symptoms develop gradually. Painful defecation or obstipation may exist from the start, the result of the pressure of the fundus on the rectum. Frequently pelvic peritonitis ensues. Not infrequently spontaneous abor- tion occurs before tlie symptoms become aggravated to this de- gree. In very rare cases rupture of the bladder has resulted. Pressure gangrene may follow the incarceration. The diag- nosis, as a rule, may be made with ease. The vesical and rectal symptoms being out of proportion to those which may accom- pany early pregnancy, a vaginal examination is made and a soft body is found, occupying the posterior ciil-de^ac^ which may be readily traced laterally to the cervix, which lies tucked under the symphysis. Examination by the rectum will clear the diagnosis. Error is only likely in case the woman is very stout, when we may be unable to determine the absence of the body of the uterus in front, and the condition may simulate a soft fibroid or an exudate in the posterior cul-^e'Sac. In such ob- scure instances anaesthesia should be resorted to, since, if the correct diagnosis be not reached, symptoms of a grave nature will ensue.
A large cystic ovary and an extra-uterine gestation-sac are other conditions which it will be necessary to differentiate. In both of these instances, however, the fundus of the uterus can be made out anteriorly except the woman be very stout, in which event anaesthesia is called for.
The treatment of retropositions of the gravid uterus con- sists in reposition. This may prove an easy or be a very dif- ficult aftair. The bladder should be emptied. It wDl rarely be necessary to puncture the bladder, since ordinarily the soft cath- eter may be inserted. In case of difficulty, however, then, under strict asepsis, the puncture may be made in the anterior fornix, selecting the mid-line, or else suprapubic puncture is necessary. The rectum is next emptied by enema, and then the vagina is rendered sterile according to the methods outlined in "Ob- stetric Surgery." The woman is next placed in the Sims
{H)sition, a tenaculum is inserted into the antciior cervical lip, and traction is made in the axis of the pelvic outlet. Two fingers of the left hand are next inserted into the vagina, after tlie speculum has been removed, and the attempt is made to push the fundus forward. Should this fail the like manipulatioa through the rectum may succeed, since the pressure can thus he diieeted h^het agmhut the fandm. As the ptessore is verted it mnat be to ane or the other side of the ndd-Une, in order to dislodge the organ from beneath Hie promontory of the sacmm.
These mauipulations, if ousfVilly perlimned, will raielj cause abortion ; but even if. they do the reralt is simply tiiat which would have occurred hod we fiuled in leotiffing the mal- position, to say nothing of the nujor risks, the woman would have run.
In the event of there existiBg posterior adhesions, then attempts at reposition will, of oonxse, fiul. In many cases these adhesions stretch and the utertu rectifies itselC But it is nefei wise to await this result, since incarceration is more likdy to ooenx tiian spontaneons rectification. In any erent, as soon as symptoms of incarceration set in, if it be impossible to cor- rect the malposition, abortion should at once be induced, always, except in strict emergency, after the support of a con- sultant has been secured.
Prolapse of the uferas to the first and the second degrees frequently complicates pregnancy, but it usually rectifies itself as the uterus rises out of the pelvis. Prolapse to the third degree is rare, and if the organ cannot be replaced and main- tained in position abortion will ensue. Hypertrophy of the cervix may simulate prolapse, but vaginal and rectal examina- tion will difierentiate, since the body of the uterus will be found in fairly normal position.
The recumbent posture and reposition will correct the symptoms associated with prolapse of the milder grade. After the uterus has risen above the brim the prolapse cannot recur to much degree, although the pressure symptoms will be aggra-
vated. In the event of it being impossible to replace the uterus or to maintain it in position, then, after consultation, the organ should be emptied, thus anticipating that whicli will otherwise occur spontaneously.
Abnormalities of the Vagina.
Certain diseases of the vagina are intensified by pregnancy. Catarrhal vaginitis will frequently be a source of great discom- fort during pregnancy. The discharge becomes aggravated, and it may be very irritating, leading to pruritus. If there be a history of gonorrhoea the infection must be exterminated, not alone in the interests of tlie woman, hut also of the child, since infection of this nature is the source of ophthalmia neonatorum. The vagina should be carefully painted, through a cylindrical speculum in order to expose the rugse, with a solution of nitrate of silver 30 grains to the ounce, and frequent douches of I chloride of mercury should be ordered, in the strength of 1 to 5001 In case of simple vaginitis douches containing 10 grains of powdered alum to the pint of water will suffice. Applications of a saturated solution of bicarbonate of soda will allay the pruritus, or else an ointment containing 10 grains of caJomel % the ounce will assist.
Gonorrlioeal condylomata will grow rapidly under the'" stimulus of the normal congestion of pregnancy- These con- dylomata as they grow have a great tendency to bleed, and this might lead to serious complications during labor. Equal parts of powdered alum and calomel, freely dusted on a number of times daily, will often cause tliem to shrivel. The knife should not be used, owing to their great vascularity, but in case of the need the actual cautery is called for.
Piidapse of the anterior vaginal wall during pregnancy is usually due to loss of support from lesion of the pelvic floor. Irritability of the bladder is about the only concurrent symptom. The woman is unable to empty her bladder thoroughly and the alteration in llie residual urine may result in a cystitis. Cathe-
trate
.oooM
- of" ons the 1^
1 /
will tend to make the woman comfortable. The patient may, to advantage, be instructed to void her urine in the knee-chest position.
Fbeghahct Complicated by Certain Acdte and Chronic Diseases.
The pregnant woman is not alone liable to accidental dis- ease, but she is less able to resist the inroads of disease than when non-gravid. The acute infectious diseases are peculiarly dangerous, when they complicate pregnancy, by reason of their tendency to destroy the life of the foetus. The life of the fcetus is imperiled by the high temperature, by the lack of nutrition, — owing to the effect of disease on the woman, — or it may be- come infected by the disease from which the woman is suf- fering.
Small-pox, measles, and scarlet fever are chiefly deserving of mention among the eruptive fevers. The gravid woman ia peculiarly susceptible to small-pox, possibly because she has passed through the other eruptive fevers in childhood. The mortality-rate is very high, and statistics would show that it is especially apt to assume the hwmorrhagic type. Should the affection not terminate in the death of the woman the child is likely to die. The child, however, may be bom with the characteristic markings showing that it suffered from the dis- ease in tUero, or it may develop the disease shortly after birth. In tare instance it has escaped unscathed.
Measles rarely complicates pregnancy, since the vast major- ity of women have it during childhood. In the event of its occurrence the htemorrhagic type is likely to ensue, and pneu- monia is a frequent sequela. Death of the fcetus not infre- quently occurs during the progress of the disease, and abortion is a complication to be feared. The fcetus may contract the disease in utero.
Scarlet fever occurring during pregnancy is especially
56
PREGNANCY.
serious by reason of its tendency to cause lesions of the kid- neys. The fact of pregnancy causes hyperemia of the kidneys, and to this is superadded the congestion which is the associate of scarlet fever.
The treatment of the eruptive fevers will not vary over- much from tliat called for aside from pregnancy. Means must be taken to control the temperature, otJierwise the exaggerated rise will affect the fcetus.
Malarial fever is particularly apt to complicate seriously, the puerperal state. During pregnancy there is no reason why quinine should not be administered. This drug has not been proven to induce abortion, although it is a decided accelerator of contractions when once they have set in. On the contrary, the administration of quinine in full doses, by raodilying tlie disease, in so far spares the woman as well as the fcetus. Latent malarial infection will frequently not manifest itselC until after delivery. It may then complicate the puerperal state, leading to a question, at the outset, of puerperal sepsis.
It was formerly tlie belief that pregnancy exercised a favorable modifying action on tuberculosis. Clinical experience does not bear out this view. Latent tuberculosis often does not. manifest itself until the woman has become enfeebled by preg- nancy. It seems valid to state that, on this gioinid, women with tubercular tendencies should be dissuaded from marriage, aside from the probability of the effect on the possible off- spring.
Women who become infected with syphilis at the begin* ning of or during pregnancy manifest unusually severe initial symptoms and have proportionately mild secondary lesions. When the initial lesion is on tlie vulva it develops rapidly, owing to the normal exaggerated bypersemia of the part. The ulcer rapidly spreads to the vagina and may even extend upward. Extension to the glands is slow, and the rash is apt to be light or does not appear at all. Syphihtic fever is rarely present.
I
PATHOLOGY OF PREGNANCY. 6T
The prognosis as regards the fcetus is unfavorable. • TUi is especially so if the woman has become affected before im-. pregnation. Again, tlie foetal prognosis is less favoraUle if infection occur during the early months of pregnancy. Tha Icetus will be affected if citlier i)arent is syphihtic at the time of conception ; that is to say, the semen, or its active elements* may be the carrier of the infection. Still, if tlie woman were. not affected until after conception the fcetus may escape. In- case the infection was active in either parent at the time of con- ception, tlien tlie fcetus will likely enough die in utero, owing to the changes undergone by the placenta.
Women who are known to be affected with syphihs at the time of conception should be subjected to rigorous antisyphilitic treatment. Local lesions should be carefully attended to, so that, in case the child escai)es the infection whilst in uiero, it maj not receive it during delivery.
If tlic foBtus be born without eridence of the disease it .sliould not be nursed by its mother, otherwise it may become infected. If the child be born with evidence of infection received from its father, the mother having escaped, it should not be nnrsed lest the woman become infected through the nipple.
Chorea is not a very frequent complication of pregnancy, and attacks by preference those who have an hereditary predis- pontion. It is far more common in primiparee.
Etiologically, the lowered nutrition of the nervous system due to the hydisemia which is associated with pregnancy, together with the hereditary predisposition, must be considered as the cause.
The symptomatology does not differ markedly from that which is the associate of the disease occurring apart from preg- nancy. The manifestations ordinarily set in during the early months and continue after delivery. Abortion and premature labor are frequent.
The prognosis is grave and must alvrays be guarded.
58
PBEGNANCT.
When death ensues it is the result of the constant musculwi exertion whicli entails exhaustion.
The treatment does not materially differ from that whi is proper in case of the disease aside from pregnancy. Ferni| nous tonics of the easily assimilated type are indicated, am Fowler's solution should be administered in full doses. Tha^ constant administration of the potassium salts is contra-indicatedj on account of their tendency to interfere with the digest) process. The woman should be placed amidst the best poi sible hygienic surroundings.
Should palliative measures prove of no avail and the womai show signs of exhaustion, then the artificial induction of tion or of premature labor should be elected, after due consulta- tion. Statistical data prove the folly of temporizing in extreme cases in the hope of securing a viable child. Of the 131 cases of which we find record there were 29 deaths. As a rule, Rggmvated cases the child stands but little chance, since abortioi or premature tabor is very apt to set in spontaneously. Under the subject of "The Induction of Premature Labor," in the iwrtion of this work devoted to obstetric surgery, we have given our reasons for recommending this procedure as one of election in all instances where the maternal condition is becoming aggravaUHl.
Pregnancy is rarely complicated by icterus, but the disei assumes sj>orial imjuirtance from its tendency to become of mnlignnnt type. The reasons for this are manifest. During pregnancy tlie venous congpstion of the kidneys interferes with ihc pmjwr eliminntion of tlie biliarj' salts and there results les- seninl oanliar energy, owing to the accumulation of these waste- ptwlucls in the blood, and therefore diminished excretion and
{K>iM>l)iug.
The diSHun mux manifest itself at any period of pregnancy. The ptflgiitwi* for lh« rfiiUl is gloomy, since the course of tion is almost nlwavs interrupted. The cause of forial death tmisoning by the bite-snits circulating in its blood.
les
PATHOLOGY OF PREGNAW
The causes of simple icterus occurring during pregnancy are the same as those which produce the disease apart from the gravid state. Acute duodenitis, with the consequent obstruction of the common duct, is tlie most frequent etiological factor. Orten, however, the causal factor is not evident.
The diagnosis is readily established. The yellow discolor- ation of the skin and of tlie conjunctivEe, together with the urmary signs, will make the diagnosis.
Since simple jaundice is apt to assume the malignant type, the prognosis must always be guarded. Further, the great tendency of the affection to cause abortion adds to the danger which the woman runs.
The indications for treatment are the same as in case of the affection irrespective of pregnancy. In case of simple icterus the indication for the induction of abortion rarely will exist, since, as far as the woman is concerned, she is apt to recover if the affection does not assume the malignant type. As regards the child, if born during an attack of jaundice at all severe, it will rarely survive.
The transition of a simple icterus into the malignant form is gradual and usually manifests itself by rise of temperature, this being absent in case of simple icterus. Cerebral symptoms rapidly develop, such as headache, difficulty in speech, delirium. The course of the disease is rapid toward a fatal termination in a few days. The treatment can be simply symptomatic. It avails nothing to empty the uterus either in the interests of the woman or the child.
The intercurrence of pneumonia or typhoid fever during pregnancy affects the course simply in that the usual symptoms of these diseases are superadded to the normal symptoms of pregnancy. Pneumonia, of course, interferes decidedly with the life of the fcetus, owing to the high-temperature rise and the interference with the oxygenation of the blood, — the result of the lung affection. Nevertheless, the position of the phy- sician as regards the pregnancy must be passive. It will avail
60 PREGNANCY.
nothing, either for the woman or the fcetus, to mduce abortion or premature labor. The probability is that one or the other will ensue spontaneously, when, of course, the woman's chances of recovery are lessened, inasmuch as, in addition to the strain of the disease, she must withstand the strain of labor. The duty of the physician in such an event is to terminate the labor as rapidly as possible in order to spare the woman protracted strain.
Typhoid fever will rarely call for active interference with the progress of gestation. The chances are, if the attack be at all severe, that the woman will miscarry ; if she do not, nothing is gained by attempts to save the woman the added strain of pregnancy by emptying the uterus.
Pernicious aneemia is an afifection which, fortunately, is rarely associated with pregnancy. Such women rarely conceive, and, if they do, in the event of the symptomatology becoming aggravated, the physician is called upon to empty the uterus in order to spare the woman the additional strain which she cannot bear.
Uterine Tumors Complicating Pregnancy.
Fibroid tumors do not often complicate pregnancy, since, as a rule, they are associated with sterility. They may either be submucous, interstitial, or subperitoneal.
Submucous tumors rarely permit conception to occur. If it does, the uterine mucous membrane is kept in such a state of congestion that the ovum does not find a suitable soil for development. Early abortion is therefore the rule. Where the fibroid is attached to the lower uterine segment or to the cer- vical endometrium pregnancy may occur and may proceed to full term.
Mural or interstitial fibroids are less likely to interfere with conception or the progress of gestation. Their presence, how- ever, may seriously complicate labor. This is especially so when they are situated in the lower uterine segment
PATHOLOGY OF PREGNANOY.
Subperitoneal fibroids are not likely to interfere with preg- nancy except when they are situated where they can sink into the pelvis, when they cause pressure symptoms, and at the time of labor may interfere with delivery. Fibroid tumors partici- pate in the hypertropliy incidental to pregnancy.
The diagnosis is oftentimes difficult, and wlien the tumor is small it may be impossible. Their presence may be entirely masked by the usual symptoms of pregnancy, and, again, the tumor may so obscure the major sigiis of pregnancy as to lead to error in diagnosis. In the majority of cases careful palpation will clear the diagnosis. If there be any doubt and the symji- toms are at all urgent, auEesthesia should be resorted to. Vaginal and rectal examination will often enable the physician to differ- entiate the bard fibroid frora the gravid iitcrus. The presence of the ordinary signs of pregnancy should render the pliysician very circumspect in inserting the sound into the uterus in order to reach a differential diagnosis. If the fibroid tumor be small it will not cause any symptoms during pregnancy, neither will it often complicate delivery. It becomes a matter, however, of concern if the pelvis is contracted by the presence of a fibroid which cannot be replaced above the brim. In this event the uterus must be emptied early if the cervical canal is accessible. If the uterine cavity is not accessible, tlien, the pregnancy being well advanced, suprapubic hysterectomy is called for. The mere destruction of the fcetus without removal of the parts will almost necessarily entail septicEemia, wliich jeopardizes the woman's life fully as much as an hysterectomy. In the event of the woman having reached term tlie simple Cesarean section will not suffice, but the Porro must be superadded. Post-partum hasmorrhage and necrotic changes in the tumor are likely to ensue if the uterus be not removed. Even in tlie early months of pregnancy, where the tumor is of such a size and in such location as to interfere with delivery at term by tlie natural passages, hysterectomy should be advocated early instead of waiting until term in the hope of saving the foetus. The extra
62 PREGNANCY.
development of the pelvic blood-vessels will subject the woman to too much risk at term in order to save a fcBtus whose life ia, at best, exceedingly problematical.
Submucous tumors which appear in the vagina should be removed at any stage of pregnancy, either by torsion or by cut- ting, arter splitting the capsule \vhere necessary.
Cancer of the uterus, if primary in the body, necessarily precludes the occurrence of conception. Carcinoma of the cervix does not interfere with conception. Even when the di»» ease is well advanced and necrotic clianges liave taken place, certain women have conceived. The disease rapidly spreads on the supervention of pregnancy, as would be expected when we ri-'mcmber the increased liyperEemia wliich ibllows pregnancy. In case the disease is in its early stage gestation may not be interfered witii. Where the disease lias invaded the deeper fltructuros of the cervix early abortion is the rule. IIsemorrhag9 Ih of frequent occurrence not only because of the necrotic process, ill the diseased area, but also as the result of the normal uterii growth and expansion. The biemorrhage may be profui enough to j<'0[)ardize the woman's life.
In tlio early months of pregnancy, if the disease is limited to the cervix, liyateroctomy should be performed, since early opurutiuii oti'ei's a chance of prolonging the woman's life, and the sliglit ctmnce of saving the foetus by temporizing deprives the woman of this chance of cure through early operation. The diMoaso rai)idly progresses during pregnancy, and, even though the woman should go to term and be delivered of a live child, her (ThanccH from operative interference have simply been lessened tliroiigii temporizing in the interest of the foetus. In case the (lUenNe has extendi-d beyond the cervix, then, the woman's life being doomed, only the interests of the foetus should be con- nldrred and the attempt sliould be made to conduct the woman to term. In cane the cervix and the vagina are so involved to render dilatation impossible, or if it be probable that the dilatation will result in such hsemorrhage as to imperil thi
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PATHOLOGY OF PREGNAKCY. 63
chances of the child, then the CBesareaii section should be elected.
Ovarian tumors are not uncommon complications of preg- nancy. Abortion is not frequent unless tlie tumor, by reason of its location and the presence of adhesions, prevents the normal development of the uterus.
The ovarian cyst is usually excited to increased growth by the supervention of pregnancy. As the tumor increases in size a low-grade peritonitis may ensue, or else the pressure symp- toms of pregnancy are greatly aggravated. Necrotic changes may occur in the cyst, from twisting of its pedicle or from direct pressure from tlie gravid uterus. The position of the tumor in the pelvis may preclude delivery unless operation be resorted to.
Unless tlie tumor be of a fair size its presence may he unrecognized. Wliere pregnancy has advanced to about the sixth month it may prove an exceedingly difficult matter to reach the differential diagnosis. If the cyst cannot he differ- entiated and yet the case is evidently complicated by sometliing beyond pregnancy, or if the question of pregnancy has not been settled, then it is wise to resort to anscsthesia.
As soon as an ovarian cyst is diagnosticated it should be removed, irres]>ective of the presence of pregnancy. If tlie ad- hesions be slight it is perfectly feasible to perform ovariotomy without interrupting the course of gestation ; but, aside from this, if the cyst be not removed, the woman is subject to tlie risk of twisting of the pedicle, with consequent necrosis and sepsis, as, also, to that of the occurrence of peritonitis, In case the woman is too debilitated, when the diagnosis is reached, to permit of removal, then, as a temporary expedient, it may be punctured, which will relieve certain of the pressure symptoms. Whenever possible, the vagina should be selected as the site for puncture, under, of course, absolute asepsis.
Small tumors presenting in the vagina and impacted should be punctured if not recognized until about term, since thi procedure is preferable to spontaneous rupture during delivery.
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64 PBEGNANCT.
It is very exceptional that in women of good health and antecedents there occur psycliical disturbances during pregnancy. Melancholia to a greater or a less degree is not infrequent. Much may be done by firm conduct on the part of the physician to lessen the anxious fears of the woman, and yet. in a propor- tion of tlie cases, the melaiu-liolia deepens and it will become a question of tlie induction of abortion or of premature labor, in order to prevent the development of insanity of, possibly, a per- manent type. (Fig. 1, Plate VIII.) Young women illegiti- mately pregnant are peculiarly prone to deep melancholia, particularly in the better walks of life. In the event of the melancholia deepening, then, always after consultation, it may J seem advisable to empty tlie (iterus. It goes without saying! that t!ie greatest care is requisite not to be deceived by a simu lated melancholia. The cunning of woman illegitimatcljij pregnant should always be rememl>eved. She will attempt f persuade her physician by every possible means into eraptyin] tlie uterus.
The peculiar pigmentation of the skin, which is associati with pregnancy in many women, calls for reference. The t "chloasma of pregnancy" lias been applied to it. and, in aggi vated cases, it alters the woman greatly. (Fig. 2, Plate VTI] Ttie pigmentation may assume the appearance of a raasl whence the popular term. Chloasma is apt to complicate lactation rather than pregnancy, but when it is an associate of this latter condition it will probably simply be intensified by lactation. As a rule, the woman may be assured that it will disapiwar spontaneously when the sexual system has recovered^* from the demands of pi-eguancy.
Diseases of the Membranes and Placenta.
We pass now to the consideration of affections of the 1
membranes and the placenta, the occurrence of wliich alters I
pregnancy from the normal to the pathological. At the outset |
it is to be remembered that, primarily, the majority of suchJ
PATHOLOGY OF PREGNANCT.
65
affi?ctir>i)8 are intimately linked with diseased states of the wutnan. SyphiHs, for example, i3 an etiological factor of moment, as also disease of the interior of the uterus. Even an endometritis of liglit grade, antedating conception, renders the soil unfit for the projier development of the ovum, and, if the result be not abortion or premature labor, the effect is inter- ference with certain of the phenomena of labor, as is amply dwelt upon later.
Disease of tliedecidua is apt to follow on an existing endo- metritis, or it may develop as the sequence of an acute inter- current disease of tlie woman during tlie course of pregnancy. Thus, in the course of cholera, or scarlet fever, and tlie like, inflammatory changes may set in in the decidual lining of tlie uterus and thence spread to the placenta and the membranes. As regards the membranes, we tlius may witness the develop- ment of a diffused inflammatory form of endometritis or else a degeneration resulting in what is termed "hydrorrhcea of preg- nancy." As a rule, where inflammation of the decidua is not followed by miscarriage, no especial alteration in the phenomena of pregnancy is noticed, but difficulty occurs after the birth of the foetus when the membranes are not shed under the natural efforts, owing to the morbid adhesions whicii have formed. In case of so-called hydrorrlioea of pregnancy the water may collect either between the decidua vera and reflexa, or between decidua and chorion, or between chorion and amnion. What- ever the case, the diagnosis is difficult, being made by tlie appearance at intervals of a discliarge of water in greater or less amount from the uterus. In the few recorded cases the ejection of the water was associated with painful uterine con- tractions. The affection has but little import, seeing that it does not interfere with the progress of pregnancy or with the development of the foetus. Of far greater import are the diseases of the placenta, since these lead to alterations in the progress of pregnancy and affect often the vitaHty of the fcetus.
Inflammation of the placenta is of chief import owing to
66 PREGNANCY.
the changes wliich take place in the fcctal portion, leading to alterations in the chorion which affect pregnancy nnfavombly. It will be veraembered that tlie maternal surface of the placenta is formed from the decidua serotiua and that tlie fcetal surface is fonned by the villi of tlie chorion. The net result of changes in the maternal surface of the placenta may be bseraorrhage, the so-called apoplexy of the placenta, or calcareous degeneration at one part or in whole, or fatty degeneration. The phenomena are exaggerated according to the extent of the lesion. Wtien extensive, the result is abortion or premature labor, or, if the pregnancy nevertheless progress to term, the shedding of the placenta and of the membranes is interfered with, owing to the morbid adhesions whicti have formed.
We may note, also, either atrophy or hypertrophy of the placenta, the effect of which on the course of gestation and on the life of the fcetus varies according as the processes are local ' or general. The prime etiological factor in most instances of | affection of the placenta is syphilis, although alterations in the i vascular system, the accompaniment of renal lesion, also are followed by the same result.
Diagnosis of these changes In the placenta is hardly po»- sible until after delivery, when, frequently, careful microscopical examination will be requisite. Tlie effect of the changes on I the course of pregnancy is simply to interrupt it at one ot J another stage, wliere the changes are extensive.
A concomitant result is tlie formation of what are termed | "moles." These moles are known as fleshy or else they result in the formation of hydatids, leading to what is known as hy- datid degeneration of the chorion. The latter would seem to j be dependent on a dropsy of the chorionic villi, although the i matter is in dispute. The prime etiological factor is probably an endometritis antedating conception.
Cystic degeneration of the chorion is rather unusual i occurrence. Its presence is based on the following symptom^'
PATOOLOGT OP PBEGNANCTrf
Rapid development oT the abdotnen not correfipoiiding witli the period of gestation which the woman tliinks she has attained. Recurring hfemorrhages. At times, if the blood lost be examined, it will be found to contain a number of hydatids. Frequently, the sole symptom up to the later months of preg- nancy will be the exaggerated size of tlie abdomen. This will render the woman exceedingly uncomfortable, owing to the pressure symptoms, but the abdominal increase may lead only to the assumption that tiiere exists multiple pregnancy. As a rule, however, it is the occurrence of repeated htemorrhages which excite the concern of the woman and of lier attendant, but this may mean, as will shortly be noted, vicious insertion of the placenta. Whether the occurrence of cystic degeneration of the chorion has led to early fcetal death or not, the usual signs of pregnancy are present except that, in the latter event, fcetal movements will not be appreciated; but this is not a diag- nostic factor of value, seeing that not infrequently in normal pregnancy these motions are not appreciated.
The prognosis both for tlie woman and the child is grave. Not infrequently the woman succumbs to profuse hsBmorrhage before the diagnosis is established with sufficient exactitude to enable the physician to feel justified in actively interfering. The cardinal rule for treatment, therefore, ia not to temporize with hsemorrhage associated with pregnancy, for, even though this be dependent on vicious insertion of the placenta, and not on the development of a mole, the indication is the .same, — to empty the uterus by as speedy a method as is consistent with the integrity of the maternal parts. Temporizing will avail the foetus nothing, and the next hsemorrhage may be profuse enough to cast the woman into a condition of acute aneemia, if it does not kill her.
The method of procedure for emptying the uterus is described in " Obstetric Surgery." The uterus having been dilated, the entire hand should be inserted into the vagina and the fingers should clean out the interior of the organ. This
68 PBEGNASCT.
mauipulatioii is always preferable to the endeavor to curette the uterus. Tliis instrument is liable to clean the organ only in part, and, tlien again, in advanced cases the uterine walls may ■ be thin and perforation is likely to occur. The finger or fingers I may, as a rule, explore the entire interior of the uterus, pro- J vided the organ be depressed by tlie external hand. Ilfenior- , rhage during these manipulations is apt to be profuse, and J therefore tliere is need of haste, and, when need be, tlie organ I should be thorougiily tampouaded with gauze in order to check | loss of blood which the woman, in probably a reduced state, cannot stand. It goes without saying that tlie most scrupulouti asepsis should be associated with these m«nipulations.
The most important affection of the amnion is dropsy, or J hydramnion.
Hydramuion consists in the accumulation of the liquor ^ amnii in exaggerated amount in the amniotic sac. Within limits tlie amount of liquor amnii is very variable; so that it is difficult to differentiate the normal from the pathological. Enormous accumulations are exceedingly rare. As a rule the accumulation is gradual, and it is only in instances where the liquor re-accumulates rapidly that the symptomatology of preg* ■ nancy is markedly affected. I
As the source of the liquor amnii is unsettled, even so is the etiological factor or factors at the bottom of hydram- nion a matter of theory. Whether it be of fcetal origin or of maternal is in dispute, and probably the safe opinion to hold to- day is that both foetus and woman are factors. The frequency with which hydramnion occurs in syphilitic women lias been j noted, and yet the affection not uncommonly develops in I instances wliere there can be found no trace of Byphtlitiol infection.
Dropsy of the amnion is a frequent complication of twial pregnancy, and in instances where the affection exists to anl exaggerated degree the foetuses are apt to be malformed. Thel occurrence of dropsy of the amnion, again, is not infrequent IilI
PATHOLOGY OF PKEGNANCT. 69
repeated conceptions and is a common cause relatively of re- (>eated abortion. As a rule the affection does not sliow itself until about the sixth month of gestation. The nausea and the vomiting of eaily pregnancy is apt to persist and the woman is feeble and with a tendency to emaciation. Abdominal pain is a marked factor, the associate of the rapid stretching of the abdominal walls, in part, and also of uterine origin, the result of undue distension of the organ before its muscular structure has reached that stage of development which admits of such distension. Shortly, the abdomen rapidly develops m size, associated with a marked thinning of the uterine walls and great fluctuation. In consequence of this rapid development of the abdomen, pressure symptoms become exaggerated and cedema of the abdominal wall and of the extremities sets in. In extreme cases, fortunately rare, the woman becomes ema- ciated to an extreme degree; she cannot retain food, and hectic fever appears. The pains in the abdomen are almost constant, shooting down the thighs and interfering with rest. If nature do not interfere by the occurrence of spontaneous labor the pliysirian must, in order to give the woman a chance for life. The uterus, however, in these extreme cases has lost contractile power, and it is exceptional that nature is able alone to empty the uterus. This accomplished, uterine retractility is absent, and the physician must be prepared to tampon against profuse hfemorrhsge.
The prognosis for the child is gloomy. It may be expelled from the uterus dead or else it lives for only a lew days.
Such is the course of aggravated cases. Fortunately, as a rule, the condition does not take on au aggravated type, and passes unrecognized until labor sets in, when the enormous amount of water discharged makes the diagnosis. Even here the prognosis for the child is gloomy. The sudden discharge of the liquor amnii is apt to he associated with prolapse of the cord, and this should be borne in mind in order that the phy- sician may resort to means for replacing the cord or for termi-
70 PREGNANCY.
nating delivery rapidly in the interests of the child whenever the condition of the maternal parts will permit.
In acute or in exaggerated cases it will not be a question of measures for saving the child, since ordinarily the child is dead if it be not shed prematurely; the question will be purely that of the woman's life. If the membranes do not rupture spontaneously it will be wise to rupture them arti- ficially, high up in order to avoid the rapid emptying of the uterus, which might lead to syncope. The further course of action should depend on the condition of the woman. If it be not unfavorable, then it is wise to await the natural efforts, remaining in attendance in order to interfere actively should nature show lierself unable to complete the task. The lack of contractile power in the uterus may perhaps be re-enforced by the administration of quinine by the mouth or the rectum in large doses, such as 20 grains by the mouth or 40 grains by the rectum. Often tliis and other measures will, however, be of no avail, and, instead of allowing the woman to pass into a state of exhaus- tion from the ineffectual, nagging pains, the physician should resort to such measures for emptying the uterus as are consistent with tlie least damage to the maternal parts. Where the cervical canal is soft and dilatable the elective accouchement described in "Obstetric Surgery" will answer admirably. In any event, it should be remembered that there is danger of uterine atony, and therefore the physician should be prepared to tampon the uterus with sterile gauze in case of hsemor- rhage, after delivery.
Death of the fcetus prior to the occurrence of term — indeed, at any stage of gestation — may be the associate of any of the lesions of the phuvnta or the membranes on which we have laid stress. It by no means follows, however, that the uterus will attempt to ex|H^l the dead foetus. For months it may be n^tained, aiuU so long as the membranes are unruptured and souiTes of infiH^tion do not gain access to it, it may remain in utenK At times the liquor amnii is absorbed and the foetus
PATHOLOGY OF PBEGNANCT. 71
becomes iniimmified before it is shed. Again, the fcetus may I slowly become macerated.
The alteration in the signs of pregnancy due to fcetoi I death are slow. For a time the abdomen may increase in size*! and the other subjective and objective symptoms may continue. This will account for instances wliere the dead ftetus has been shed not developed to the degree called for by the stage of ges- tation. As a rule, however, the abdomen gradually decreases i in size, the breasts diminish, and the other signs of pregnancy | either disappear or do not offer iit all.
The health of the woman is only apt to be affected if she become infected and the fcetus decompose, in whieli event, on the recognition of the fact, the duty of the physician is to empty the uterus as soon as is feasible without inflicting unnecessiiry injury on the maternal parts.
Ynnous Insibtiow or thi Plaobnta.
We have parpoielj left fiir fUial consideration vidoos inser- tion of &e i^aoenta. This is not a disease, properly, so called, complicating pregnancy, and yet its occurrence impresses ges- tation after a fashion which renders it markedly pathological. On prompt recognition the life of the woman will ofcen depend, to say nothing of the fact that vicious insertion of the placenta very frequently entails fcetal death.
Under normal conditions the placenta is implanted at the fundus of the uterus or to one or the other side, and may there develop without altering the physiological course of gestation. Further, when the placenta is implanted after the normal fashion the development of the uterus, in particular the changes in its lower segment, may progress without there being any interference with the growth of the placenta. The uterine mucous membrane when in a normal condition offers proper soil for the development of the ovum at any point. In case the ovum engrafts itself at the lower zone of the uterus, or in case during the early weeks of gestation it becomes dislodged and
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PREGNANCT.
obtains a second attachment in the lower zone of the uterus, | then we have present a vicious attachment of the placenta.
Two varieties of attachment of the placenta out of the | normal may occur. It may become attached and develop just I above tlie level of the internal os or else it may become im- planted over the internal os. The former is known as a mar- ginal attachment and the latter as a central attacJiment The ] symptomatology and the prognosis and the course of action will I vary according as one or the other of these vicious insertion* | occur.
Marginal attachment of the placenta is not likely to give I rise to symptoms until the gestation has advanced to about ' seven and one-half months, since, until tliis date of gestatiou has been attained, changes do not occur in tlie lower uterine zone which infringe on the site of placental growth. In case of central attaclinient, on tlie other liand, symptoms occur at J an earlier date, since the development of tlie lower uterine seg-1 ment of the uterus of necessity puts on the stretch the entire 1 circumference above the level of tlie internal os. As tlie mus- J cular fibres of the uterus increase in size, and as the uterus I spreads in every direction in tlie coiu'se of development, it stands 1 to reason that if tlie placenta does not concomitantly develop J certain of its attachments are bound to yield, and tlius we have! the prime and tlie initial symptom of the vicious attachment, I namely, haemorrhage. Obviously, also, this htemorrliago willl be profuse or not, according to the degree of separation, and I such separation must always be greater when the insertion i»'l central than when it is marginal, and also earlier in occurrence. I Tills is the reason wliy we have repeatedly laid stress on the4 fact that luemorriiage occurring during the course of pregnancy! should always be a matter of grave concern. It should always! suggest tlie possibility of vicious insertion of the placenta, and,! as will be noted, as soon as the diagnosis is establislied with al fair show of reason, tlierc is but one possible course of treatment, i whether we consider the woman alone, as is the case in earlvi
PATBOLOGT OF PREGNANCY. 13
gestation, or both the woman and the child, as will hold in advanced gestation.
The diagnosis is not always easy, particularly in early gestation, before it is possible for the examining linger to pene- trate the cervix and to reach higli enough up to feel tlic pre- senting placenta. Ili're the diagnosis will often remain in doubt until after the uterus lias been emptied and tlie placenta is examined. In early pregnancy — that is to say, prior to the sixth month — we shall have to proceed by a process of exclusion. Thu3, we must rule out cervical polyp as a cause of liffimor- rhage, and also partial sei)aration of the placenta. Cervical polyp will be detected by touch in case it he large enougli to cause sufficient haemorrhage to justify the name. Partial sep- aration of the placenta is apt to be associated with but slight oozing, and, if tins should recur in any amount, the indication for treatment is the same as if tlie diagnosis of vicious implan- tation of the placenta had been reached. In the event of the haemorrhage recurring prior to the seventh month of gestation, then, even though it is not possible to feel the vicious insertion, the nile will be to take steps to empty the uterus. Oflen, before it is possible to insert the finger into the cerrical canal, the increased development of the lower uterine segment to one or the other side and the additional pulsation in this neigh- borhood over that which is normal will excite the suspicion of the physician. As soon as it is possible for the examining finger to penetrate through the cervix the diagnosis will be made in case of central implantation, since the finger will reach the soft, bc^gy, placental tissue instead of the presenting part of the fcetus. In the event of marginal attachment, the diagnosis obviously still can only be certified in case it is possible to pass the finger above the internal os and to reach the lateral wall of the uterus. In case of lateral attachment, however, it is excep- tional that the first hsemorrliage occiirs before the seventh month of gestation, and then it is apt to be slight. The next hamor- rhage, however, may shortly follow and be more profuse ; so
74 PRE6NANCT.
that even in case of lateral attachment it behooves the physician to be on his guard in order to resort to the proper method of treatment before the woman has the chance to become exhausted or exsanguinated.
Ilcemorrhage, then, recurring at greater or- less interval, is the cardinal sign of placenta prsevia. Locally, the suspicion of tlie physician may or may not be aroused by the abnormal enlargement and the vascularity of the lower uterine segment. The first haemorrhage may not amount to much, but, since haem- orrhage to any degree in the course of pregnancy is abnormal, the physician should watch carefully. He may to advantage instruct his patient, after a manner which will not .alarm her, that it is advisable that she should notify him in the event of there being a second flow, and that on its occurrence she should at once go to bed and remain quiet. Thus, in cases of lateral implantation, it may prove possible to tide the woman over to term, or, at any rate, to tlie term of foetal viability, — about seven or seven and one-half months, — ^when, of course, we give the foetus a chance of life, slender though it be. In the event of the haemorrhage being at all profuse or where the physician is able to feel the placenta presenting, then it is unwist^ to tomixirize. A consultation should be called and stoj^ should W taken to empty the uterus according to the motliod and in aix\>rdance witli the line of argument which will l>o found in ** Obstetric Sura:erv.**
I'ndor tlio mothoil of treatment advocated in "Obstetric Surgi^ry ** tlio projrnosis of placenta pnevia has greatly bettered over that which older methods of treatment gave. The elective omptyinjj of the uterus enables us to save nearly 90 per cent, of the iuiaut$ insti>ad of losing tins number* as was the record of the \^st* and the ohamvs of tlie woman's life being saved mav b<^ i^laitxi at aKnit 9S }vr wnt These statements apply strictly to instaui^^s whon^ thoiv is no lemporixing with the tam- \vn. or* wors^^ than alK with el5^>l, The uterus is emptied, at\T dilatation by the hand, prcceded. where need be, by
PATHOLOGr OF PKEGNANOT.
15
incision of the ceivix, and the uterine tamponade is at once utilized in cases where the organ does not contract, the woman being thus spared loss of blood as far as is possible. The risk associated with tliese manipulations is simply septic iufectioD, and therefore the con^lary to proceed asepticfJly.
CHAPTER III.
DIAGNOSIS OP THE PRESENTATION AND OP THE
POSITION OP THE PCETUS.
A PREREQUISITE to the conduct of labor is the diagnosis of the presentation and of the position of tlie fcetus. This infor- mation is secured through resort to abdominal palpation associ- ated with vaginal examination. By presentation of the foetus is understood that portion of the foetus which endeavors to enter the pelvic inlet. By position of the foetus is understood the relation which certain portions of the presenting part bear to certain fixed points of the pelvis.
The longitudinal axis of the foetus may be coincident with that of the uterus, or it may occupy the transverse diameter of the organ, or it may assume a position intermediate between. The first is normal ; the latter are abnormal. By means of abdominal palpation, conjoined with vaginal examination, the different presentations and positions may be differentiated, ex- cept in instances where the abdominal walls are so fat as to interfere with palpation, when vaginal examination alone must suffice. As a general rule it may be stated that, prior to labor, only the presentation may be determined, and this through palpation. In order to differentiate position it is requisite that the cervical canal shall have opened sufficiently to enable the finger in the vagina to recognize certain landmarks on the pre- senting part.
To properly perform abdominal palpation the woman should lie on a bed or couch, the legs flexed on the abdomen, and the abdominal w^lls covered by a thin sheet. Tlie bladder should be empty. There need be no exposure of the woman, and if the reason for examination be explained it will be exceptional 1* 9aij objection ; indeed, she will have a higher
o^ion of her attendant, who is evidently taking every pi-e- autiou necessary tor her welfare.
By means of percussion the outline of the uterus is cle- tomined and its height above tlie pelvic brim, — an approximate IS, as has been noted, of determining the probable period gestation. The flattened hands, are then made to traverse uterine tumor with the end in view of determining the !tion in which the uterus is enlarged. Marked increase in 'fte transverse diameter of the uterus will suggest tliat the fcetus wcupies this diameter chiefly, iu which event the foetal poles, ffli deep palpation, will be found above the iliac crests, one tbove and the other below the line drawn through the centre of llie uterine tumor transversely. The woman should be counseled to breatlie quietly and to resist the effort to contract llu; abdominal muscles. Tl ? tips of tlie examining fingers may tius be insinuated deeply and a greater sense of resistance will be met with at one or tlie other side of tiie uterine tumor. To tbe touch the sensatiou may be one of greater hardness and the oatliiie may be rather spherical. The inference is that the foetal Wad is being paljmted. If this portion be struck sharply it will ordinarily be felt to rebound from the fingers, giving the ab- dotainal ballottement. In case the abdominal walls be thin and tiie gestation has advanced to about the seventh month, the (laljiating fingers may trace out the outline of the Icctus from tliis harder surface along the dorsum to the breecli and may teach the ftetal small parts, usually the feet. The dorsum of the fetus, being harder than tiie anterior aspect and being applied closer to the uterine walls, always yields the sensation of greater lurdness. The evidence thus obtained of transverse or oblique position of the ftetus as regards the uterine axis may now be Wrobomted by iJal])ation of the pelvic brim. (Plate IX.) The fingers of one or of both hands are applied just above the pubes ^ pleased downward as far as is possibJe. If the poles of tht; fetaj occupy the tranaveTse diameter of the uterus they will not ^ Ibtmd at the pelvic inlet unless there be multiple pregnancy.
78 PREGNANCY.
in which event corroborative evidence must be sought. In case of doubt as to whether the pelvic inlet or the space just over it be occupied or not, resort to vaginal examination will clear the diagnosis. Where the foetus is presenting by its longitudinal axis coincident with that of tlie uterus, examination by the vagina will reveal the I'tetal pole resting on the lower uterine segment. If tliis segment be not occupied and the extermi palpation has revealed the transverse axis of the uterus occu- pied by the poles of the fcetus, the inference is clear that we are dealing with a transverse presentation of the foetus. This pres- entation may be directly transverse or oblique. In the former event the poles of the fcetus will be coincident with the trans- verse axis of the uterus ; in the latter event the poles will be found just above one or the other iliac crest. Auscultation wQl assist in reaching a correct estimation of the position of the foetus. Wliere the position is transverse, tlie beat of the foetal heart will be heard above or below the umbilicus in tlie mid- line, according to the position of the dorsum of tlie fcetus.
The information of the transverse or the oblique presenta- tion of the foetus thus acquired is especially valuable, since, if detected before rupture of the membranes and in the presence of sufficient liquor amnli to allow of the procedure, external manipulation will enable us to convert it into the more favor- able one of presentation of tlie vertex, according to tlie method described under "Version " in the portion of this work dealing with obstetric surgery.
The transverse or oblique presentation of the fcetus is an unfavorable one for the occurrence of normal labor, and, whenever detected, the proper efforts should be made toward converting it into the favorable one of presentation of the ceph- alic pole or even of the i>elvic pole; tliat is to say, where the long axis of the foetus corresponds to the longitudinal axis of the utenis. Under these conditions the shape of the uterine tumor is more that of a flattened sphere, the transverse diameter of the uterus not being enlarged out of proportion to the longi-
PKESESTATION AND POSITION OP FCETCS.
79
tndinal. On palpating there will be a distinct sense of greater resistance along one side of the uterus than on tlie otlier, cor- responding to the dorsum of the foetus. (Plate X.) This sense of greater resistance is noticeable mainly when the doi'sum of the fcetus is applied to the anterior parietes of the uterus. When the dorsum of the fa?tu8 is posterior the resistance will not be felt except on deep palpation, but instead the small parts of the fcetus, usually the feet, may be palpated with greater or less ease, according to the amount of adipose in the abdominal walls and the quantity of liquor amnii. Tlie dorsum of the fcetus having been determined, by following the outline upward a hard, roundish body or a denser body not so regular in outline will be detected, — in the first instance the head and in the second the breech of the foetus. (Plate XI.) If tlie liquor amnii be present in normal amount and the presenting part be not fixed in the pelvic brim, impulse on this part will result in the determination of abdominal ballottement. The fingers next proceed to palpate above the pubes. The bladder having been emptied, the fingers are inserted deeply above the pubes, and either a hard, spherical body is determined or else a rounder, softer mass, — in the first case the head of the foetus, in the second the breech. If the head of the fcetus be felt just above the pel- vic brim, then, by following the outline of the dorsum, the position of the breech may be readily determined ; if the breech be detected above the brim, then the head will be recognized at the opposite pole. The breech can never engage prior to labor, and will, therefore, always he found above the pelvic excavation. The head of the fcetus, on tlie other hand, may enter the pelvic brim just prior to or at the time of labor, unless tliere be dis- proportion between the head and tlie pelvic inlet. By means of vaginal examination the data secured by abdominal palpation may be certified. In case the long axis of the fcetus corresponds with the longitudinal axis of the uterus on vaginal examination, either the hard head will be found in the lower uterine segment or the softer breech. In the event of the membranes not
I
I I
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80 PREGNANCY.
having ruptured and there being a sufficiency of liquor amnii, the presentation may be further certified by the obtaining of vaginal ballottement.
The attitude of tlie foetus may be neither transverse nor I longitudinal, hut oblique. In this event conjoined abdomino- vaginal examination will aid in diagnosis of presentation. The I finger being in the vagina, the fingers of the other hand palpate the space above the pubes, when to one or the other side a i round body, hard to the toucli, will be detected, — the head, — | or a softer body less determinate in outline, — the breech. If I there be a sufficiency of liquor amnii, these parts of the fcetus, by conjomed manipulation, may he brought over the pelvic inlet.
The following presentations of the foetus may be recog- nized, and it is important to diflerentiate them as accurately as possible: Presentation of the vertex; presentation of the brow ] or face ; presentation of the breech, complete or incomplete ; presentation of the trunk. '
Under the subject of "Normal Labor" we will note in detail the manner after which these various presentations may be rec- ognized through vaginal touch. In this place the endeavor is I simply to determine what information may be secured through j abdominal palpation at the stage of pregnancy when the fcetal I presenting part is not accumtely palpable through the vagina, I owing to the closure of the cervical canal. 1
It is essential to recall here what may he termed the J obstetrical landmarks of the foetus, since on the knowledge of j these will depend the ability of tlie physician to differentiate j presentation and variety of position. I
The foetus lies in the uterus inclosed in its membranes in I an attitude of flexion. In such attitude it best accommodates J itself to the dimensions of the uterine cavity so as to occupy J the least possible space. The trunk is flexed ; the chin is ap-l plied to the sternum ; the legs are flexed on the abdomen anda the arms on the thorax. This leaves a free space between tbftl upper and the lower extremities, and here the umbilical cor^
. ...*
II
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41
1
I'l.ATR XIV.
PRESENTATION AND POSITION OF FfETUS.
81
lies, — where it is the least subject to pressure. The shape thus assumed by the fetus is that ol' an ovoid, the pelvic extremity forming the larger and tlie cephalic extremity the smaller end. . Various theories have been advanced to explain the assumption of lliis attitude by the fcetus, but the most rational is tliat which looks upon it as simply the exaggeration of the primal curva- ture which exists in earliest embryonal life. In the vast pro- portion of instances the cephalic extremity of the fcetus is the fewest in the uterus, and such presentation is looked upon aS' the normal. It must I)e remembered, however, that, owing to the natural motility of the fcetus, it may assume any position prior to engagement of the presenting part in the pelvis. The advantage derived from early abdominal palpation, therefore, is the possibility of recognizing what are regarded as unfavorable presentations and of rectifying them into the favorable.
The foetal head at term is ovoid in shape, its larger extrem- ity being posterior. The bones which enter into the structure' of the skull are separated by the sutures and the fontanelles. These dividing portions are of especial interest to the obste- trician, since it is througli the recognition of them by vaginal touch that he is in a position to accurately picture the portion of the cephalic extremity which is presenting, — a matter which will be fully elucidated later. The fontanelles, of value from an obstetrical stand-point, are the anteiior and posterior, (Plates XII, XIII, and XIV.) The anterior fontanelle is larger thau the posterior, is quadrangular in shape, and is formed by the separation of the parietal from the frontal bones. This separa- tion is affected by meaus of the frontal, the coronal, and the" sagittal sutures. The anterior angle of this fontanelle is formed by the sepamtlou of the two halves of the frontal bone; the posterior angle is formed by the union of the pariotals. Tlie borders of tlie fontanelle are formed by the frontal and parietal bones. The quadrangular shai>e of the greater fontanelle and the fact that each angle may be traced into a suture enable the physician to differentiate this fontanelle, and, in consequence,
82
PREGNANCY.
he is in a position to determine which povtion of the vertex is presenting or has engaged.
The posterior fontanelle is pkced where tlie sagittal and lambdoid sutures unite. It is always much smaller than the anterior fontanelle, and in shape it is triangular. These angles are formed by t!ie occipital and parietal bones.
The recognition of these fontanelles is facilitated by re- membering the course of the sutures which separate the bones of the fa3tal head. The sutures are four in number. The frontal suture runs between tlie two halves of the frontal bone. The coronal suture separates the parietals from the frontal bone. The sagittal suture extends from the frontal suture to the point where the lambdoid suture forms its apex, and crosses the coronal suture. The lambdoid suture lies between the occipital bone and the posterior borders of the parietals. These are the sutures which enter into the composition of the foetal head and which are of importance to the physician in his capacity of accoucheur. Like the fontanelles, tliese sutures are of utility in determining the position of tlie fcetal head only after the pregnancy has advanced to that stage when the examining linger can reach tlie head directly through the open cervix. The sutures and the fontanelles constitute the essential ob- stetrical landmarks, so to speak, of the fcetal skull, hut their presence in the head must be remembered in endeavoring to cliange position by external examination, since it is by adapting certain portions of the liead to the pelvic inlet by external manipulation that we are frequently enabled to convert an unfavorable position into a favorable.
On external manipulation, the bladder having been emp- tied, and the abdomen of the woman being covered by a thin sheet, the palpating fingers inserted above the pubes as deeply as possible may be able — under circumstances when deep palpa- tion is not impossible, owing to great adipose in the abdominal wall or excessive amount of liquor amnii — to differentiate the hard, oval occiput from the flatter brow of the foetus. Having
I
I
*XD nomnr or vaam. 88
detendned the pceMntetkm of the oedpat, juit sboTa or joat bdow the pabei, it k a compufttiTely pimple matter to follow oat dw oatUne of the dontim of the fiBtos aloi^ one or the other ntaxme wall to the upper extremity of the ftetns or the bieech. Farther, the preeenoe of a lense of greater or leae nwtance to one or the other aide of the mid-^bic line will onahle the phynoiaa to detennine whether the ocdput points tomud the right or the left ndeof the woman, — a matter of im- fnr*mnm, 08 wiU be noted later on in the discussion of the sab- jeot of ** Labor.** Absence of marked resistance abore the pnbes and ooincideat absmce of a sense of greater resistance on one ■de of die aterns over the other also give \u valuable informa- tim, in thiU the ioferenoe is sound that the dorsum of the fcstus lies in the posterior segmmt of the uterus and that either the brow or the &ce of the ftetus is presenting, — un&Torable prea* entations, as will be seen. /
When, on palpation above the pubes, we do not find /the fislal head, bat instead the larger, softer, more irregular ouiine of the breeeh, we are enabled through deep palpation to determine - whether the dorsum of the fcetus is anterior or is posterior. In the one case the breech may be readily palpated in outline ; in the other, the anterior face of the fcetus being applied to the uterine walls in front, we shall only on palpation be able to de- tect an indistinct sense of resistance above the pubes, and, fol- lowing along laterally to one side or the other, we shall feel the fcetal feet or knees, except where the abdominal walls are very &t or there is an excessive amount of liquor amnii.
We have noticed that the foetus presents either by the cephalic pole, or by the pelvic, or transversely. Under the sub- ject of " The Mechanism of Labor " these presentations will be considered in detail. Seeing that it is important to recognize as accurately as possible the variety of presentation during preg- nancy in order to alter a disadvantageous into an advantageous, it is proper to study here in outline the main facts bearing on the subject. When the head of the foetus presents, flexed, at the
84 PRE6NAKGT.
pelvic brim, we have what is known as presentation of the'vertex. When the head of the fcetus presents, extended, at the brim of the pelvis, we have a presentation of the face.
The pelvic extremity may appear at the brim completely flexed, the thighs being closely applied to the abdomen and the heels resting on the nates, in which case we have a complete presentation of the pelvic extremity. The thighs and the legs may be completely extended along the ventral surface of the foetus, in which case we have a presentation of the breech. When the thighs are flexed on the pelvis and the legs on the thiglis we have a presentation of the knees. When both thighs and legs are extended we have a presentation of the feet. In case of transverse presentation, — presentation of the trunk, — cither one or the other shoulder presents at tlie pelvic brim.
Wlien these varieties of presentation descend vertically into the pelvis the presentation is known as regular. When, how- ever, the descent is inclined we have varieties of each presenta- tion. Thus, of the cephalic extremity, we have an occipital, a frontal, and a parietal presentation, according as the occiput or the frontal or tlie parietal bone is over the centre of the pelvic inlet. Similarly, in case of the pelvic extremity, we may have pubic, iliac, or sacral varieties of presentation. Of the trunk, we may have costal, abdominal, cervical, or dorsal.
During the course of labor, as will be noted, these irregular presentations are apt to become regular, or, if not, it is the duty of the pliysician in attendance to recognize and to rectify them.
The position of the presenting part of the foetus is again, for purposes of study, — and, indeed, of practical import,— divided acconling as certain points of the foetal presenting part are re- lated to certain fixed points in the maternal pelvis.
In practice the obstetrical landmark for presentation of the vertex is the occiput ; and, for presentation of the face, the fore- head or, prefenibly, the chin. In case of the pelvic extremity, whether the presentation be complete or incomplete, the sacrum is selected as the landmark ; for the knees the anterior surface
PRESENTATION AND POSITION OF FCETUS. 85
of the tibia; and, for the feet, the heel or calcaoeum. In case of trunk presentation, since the shoulder presents at the brim, the acromion has been selected as the landmark.
By bearing these specific landmarks in mind the ph)'6ician, when he makes his local examination during labor, can tell which portion of the presenting part is offering, and can thence deduce the course of labor or of action. These are points which will be amply considered under the proper heading.
As regards the pelvis, practically it must be remembered that the presenting part of the foetus may be turned toward any portion, but in the vast proportion of cases cither the presenting part at the brim of the pelvis occupies one oblique diameter or the otlier. The pelvis, therefore, has been divided into two syraraetiical halves, — a right iliac region and a left iliac region. The presenting part of the foetus must occupy one or tlie other of tliese halves, and, according to the case, one or another given term is applied. Tims, in case of presentation of the vertex, the occiput is either in the left oblique diameter of the pelvic brim or in the right oblique. It may occupy a position intermediate between, but then we have simply the presenting landmark in the transverse diameter, either to the right or the left, however.
The diameters of the pelvis are the an tero- posterior, the oblique, and the transverse. The presenting part of the foetus always occupies at the brim either the oblique or the transverse diameter of the pelvis. The pelvic obstetrical landmarks are therefore selected in these diameters; and in the oblique diam- eter the ilio-pectineal eminence and the sacro-iiiac synchon- drosis, left or right, are taken as the extremities, and the centres of the ilium are taken as the extremities of the transverse diameters. Now, according as the prominent fcetal landmark in a given case points toward one or another of the extremities of these diameters, the position is denominated after one or another manner.
Where the vertex of the foetus presents, the occiput lies in the left or in the right iliac region and points either toward
86 PREGNANCY.
the right or the left pectineal eminence or toward the right or the left sacro-iliac synchondrosis. Therefore we recognize the following varieties of presentation of the vertex : —
Occiput to the left, pointing toward the left ilio-pectineal line ; occiput to the left, pointing to the left sacro-iliac synchon- drosis ; occiput to the right, pointing to the right ilio-pectineal line ; occiput to the right, pointing to the right sacro-iliac syn- chondrosis.
In case of the face, the anatomical landmark heing the chin, we recognize varieties of presentation according to whether the chin points to one or the other of these pelvic landmarks : —
Chin to the left or to the right, anterior or posterior, according to the half of the pelvis, right or left, which it occu- pies, and according to wliether it points to the right or the left pectineal eminence or to the right or the left sacro-iliac syn- chondrosis.
In case of the pelvic extremity, the sacrum behind taken as the landmark, we speak of left or of right sacro-iliac anterior or posterior position, according to whether the breech presents in the right or the left lialf of the pelvis and points toward tne left or the right pectineal line or sacro-iliac synchondrosis. In case of the trunk, the shoulder being taken as the landmark, we speak of the left or riglit anterior or posterior position of the shoulder, according as it presents in the right or the left half of the pelvis and points toward the left or the right ilio- pectineal line or the right or tlie left sacro-iliac synchondrosis.
In practice these varieties of presentation are denominated thus : —
Vertex.
L. O. A., Left occiput anterior.
R. O. P., Riglit occiput posterior.
L. O. P., Left occiput posterior.
R. O. A., Right occiput anterior.
The intermediate positions are known as O. T. L. or O. T. R., according as the occiput points toward the centre of the left or the right ilium.
FR^SKTATIOH AMD FOBmOIT Of nETUS. 87
H. L. A. Hento-Ieft KotaOai,
ILR. P Hento-riglit p<Mt«rior.
H. L. P. Hento-left porterkv.
' M. R. A. Hflnto-right anterior.
The intermediate podtions are known as M. L. T. and M. B. T., according as the chin points toward the centre of the right or the left ilium.
8. L. A.. BKCram Ml anterloT.
S. B. P. SMrum right pcMteilor.
B. Ii. P., Bacnun left poeterior.
8. R. A. Sacnun right mnterior.
Only in case of exceptionally large pelvis or very small child can the sacrum poiat toward the middle of one or another ' ilium ; so that practicall]r such portions need not be taken into accouut.
txua*.
Presentations of the trunk are differentiated according as the right or the left shoulder points toward the right or the left sacro-iliac synchondrosis, the dorsum being anterior or posterior. In practice it makes no difference, since we are dealing with a presentation which cannot be delivered by nature short of the occurrence of what is termed spontaneous evolution, but always requires otherwise the * interference of the physician. These presentations and the method of dealing with them will be fidly discussed under the subject of "The Management of Abnormal Labor."
The presentations and the positions which we have consid- ered not uncommonly alter during pregnancy and frequently during labor. During pregnancy, where the liquor amnii is present in normal amount, the foetus is capable of considerable motion prior to engagement of the presenting part ; and during labor, under the influence of the uterine contractions and in obedience to the configuration of the pelvis, the presenting part changes in position, usually, fortunately, after a fashion which
PREGNANCY.
best favors deliver)'. After an understanding of the meclmu- isra of labor tlie stndent will be in a position to appreciate the reasons for these changes and the effect they liave on the course of labor.
A further aid, and a very valuable one where the conditions are favorable for diagnosticating the presentation and the po- sition of the fcetus, is yielded us by auscultation. The fcetal heart is situated nearer the cephalic extremity than the pelvic. As we liave noted, the posture of tlie ftetus in the xiterus is one of anterior flexion, and therefore the sounds of the feetal heart are best transmitted througli the back of the ftetus. Where the fcetus is presenting by tlie cephalic extremity, the foetal lieart-sounds must necessarily be heard with greatest intensity below a line which divides the uterus about its middle portion. In case the pelvic extremity is presenting, the heart-sounds will be heard above this line. In pmctice, therefore, when the fcetal heart is heard below the umbilicus the inference is safe that the presentation is one of the cephalic extremity, and the reverse holds true for the pelvic extremity.
A convenient way of remembering where to listen for the fcetal heart under different presentations and positions is the fol- lowing : Imagine tlie uterus divided by a line drawn vertically through it and passing through the umbilicus. Bisect this line by a second at the umbilicus. Tliis divides the abdomeu into four equal quarters. In one or another of these divisions the foetal heart will be heard with maximum intensity, according as the presentation is of one or another variety. Thus, as will be further elucidated under the subject of the " Mechanism of Labor " ; In case of presentations of tlie vertex the lieart-sounds will be heard in the left or in tlie right lower segments, accord- ing as the back of the fcetus occupies the left or the right seg- ment of the uterus. (Plates XV and XVI.) In case of breech presentations the heart will be heard in the left, or right superior segments, according as the back of the foetus lies in the left or the right segment of the uterus.
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PRESENTATION AND POSITION OF FCETUS. 89
For. the vertex we seek the heart-sounds along a hne connectmg the umbilicus and the left or the right anterior superior spine, according as the position is leil or right anterior. In case of posterior positions of the vertex the maximum inten- sity is posterior to these lines. (Plate XVII.)
In case of the breech the heart-sounds are heard where the positions are anterior, to the lefl or the right of a line extending through the centre of the umbilicus to the centre of tlie last rib. The sounds are discernible behind these lines to the left or the right, according as the position is left or right posterior. (Plate XVIII.)
In case of presentations of the face the heart-sounds are lieard with maximum intensity in the same localities as in case of presentation of the vertex.
In case of transverse presentations, where the dorsum of the foetus is anterior, the point of maximum intensity is apt to be below the umbilicus, near a line drawn transversely through it to the left or the right, according as the head of the foetus is to the left or the right.
Of subsidiary importance in the diagnosis of position is the point where the woman usually fools the movements of the foetus in the given case. These movements are often due to motion of the small parts, in particular the feet, at times direct impact being felt. When the occiput is to the woman's loft side motion will often be felt to the f>;r(^atest extant in the right upper uterine segment, where tlie foot aro, and vice versa. In case of presentation of tlie pelvic oxtromity, motion due to movement of the feet will be api)rociatcd by the woman bolow tlie umbilicus to the left or to the right, according as the breech is to the woman's left or right.
Information thus acquired carries by itself but very little weight, but may be utilized as corroborative of information in regard to presentation acquired througli palpation and ausculta- tion.
In case of multiple pregnancy, the hearing of two or more
90 PREGNANCT.
foetal hearts differing in rhythm and of different intensity at different parts of the abdomen, particularly if these sounds are heard by independent observers, will lead to the strong presumption that there exists more than one fcetus.
PART II.
Labor.
or
THE CLINICAL CODRBB OF LABOR.
HANAGEHENT OF NORMAL AND ABNORMAL LABOR.
CARE OF THE NEWBORN INFANT.
(91)
CHAPTER I.
KEOHANISM OF LABOR.
A THOROUGH understanding of the mechanical phenomraa of labor must precede the study of its course and its manage ment Labor may be defined as the effort of certain expelling forces to overcome certain resisting forces. The chief eXpelHog force is furnished by the uterus. The resisting forces which constitute the obstacle to be overcome are offered by tlie pelvis and its floor and by the fcetiis, — the body which it is tlits aim of the uterus to drive into the world. In great part labor is the result of muscular contraction and of muscular relaxation. One set of muscles contract and relax (the uterine) and another set yield or relax (tliose of the pelvis and of the pelvic floor). Fnitbermore, the shape of the fcDtiis and the amount of com- pressibility it is ameuuble to mast be coasidered, for were it not for certain movements which it executes the fcetal body could not be made to adapt itself to the mechanical forces by which it is gradually propelled along the pelvic canal and thence out of the pelvic outlet.
As we have noted, tlie foetus at term Ues in the uterus, under normal conditions, in a state of flexion, surrounded by its membranous envelopes and floating in a greater or less amount of water, which subserves the double purpose of acting, through the membranes, as a dilating wedge and also of protecting the fintus from injury from the application of direct muscular power to its surface. During the course of pregnancy coincident with the growth of the fcetus the uterus not only enlarges in bulk, bat also in each individual muscular flbre, so that, at term, we have a body which, properly re-enforced by the action of the abdominal muscles, is, under normal conditions, competent to
(93)
94 LABOR.
drive iti coutenti down through the pelvic canal and out into the world. We have seen that during the whole course of pregnancy the uterine muscle alternately contracts and relaxes. Ah pregnancy approaches nearer to term these intermittent con- tractions become more appreciable and recur at more frequent intorvals until, finally, they merge, as it were, and, under their iiifliujuce, the lower uterine segment opens at the cervix and thcj fcntus is allowed to descend toward the pelvic outlet. These contractions of the uterus are strictly involuntary, and they con* Htitnto the efficient cause of labor. When the uterus has ex- p(Mul(Hl its forego and luis succeeded in opening the way through itH (un'vix, thou the abdominal muscles are called into play and aNHiHt in completing delivery. The effect of the contractions on tho \itt»niM is to harden it, wliereby it alters both in shape and in position. The tvansvei-se diameter of the organ becomes ahtu'ttn* and its antoro-posterior longer ; it approaches nearer the antorior abdominal wall. During the period of relaxation the \ittn*\is rt^turns to its previous shape and consistency. These periods of relaxation are necessary in order that the circulatory piHHvss may not bi> interfered with, and in order to enable the iuusc\dar tilnvs to regain tone. Were the contractions con- tinuous the rt^sult would be spasm of the muscular fibre instead of ^'luxation* During tmch contraction the contents of the utorUs>i are driven downward, the result being that the water in whieh the tWtus floats forms a wedge at the lowest portion of the nuMubmue^ and this wedge assists in forcing the muscle of the lower uterine segment to relax* As the uterine contractions iuer^>as<^ in tVtH^uenoy and in duration^ the total result is the gravhial ojvnitig of tlie cervix* whereby the feetus is enabled » enter the vajfiwa. It is then that the abdominal muscles are \*«lle\l into j>la\. The wmtractions cease to be inTolurrtarr. "Pie wv>mau must Mp ht^rself through expolsorr eSotL The in- vv^luutarv wtttractious of tht> uterus haTing opened up tfie certix. the r\Nji5^tau<v to be ovecwme now b that offined by the walls v^f the (vlvb auU the pelvic floor, in additioa to diat oi&red bf
^
PLATE XIX.
HECHANISM OF LABOR. 95
Ibe fcetus itself, which must be made to adapt itself to the shape and the dimeusions of the canal through which it must pass.
The canal through which the fcetus must pass consists of the pelvis and of the pelvic floor. The pelvis is divided, from an obstetrical stand-point, into a suj^rior and an inferior por- tion. The superior portion of the pelvis constitutes what is termed the pelvic inlet, and, except where it is deformed to a considerable degree, it does not interfere with the passage of tlie child. Tlie dividing line between the superior and the inferior pelvis is the linea iUo-pectinea.
In order to appreciate the mechanism of labor we must study the characteristics of these portions of the obstetric pelvis, chiefly what are known as its straits and its planes: —
STEAITS OP THE OBSTETRICAL PELVIS.
There are two straits, — the superior, or that of the inlet, and the inferior, or that of the outlet.
The superior strait is oval in sliape, and when the woman is in the erect posture its plane is an oblique one, tlie direction being from behind forward and from above downward. It follows that the axis of the pelvic inlet is not in a line with the abdominal cavity, the inclination of the plane of this strait being about sixty degrees. The axis of the superior strait being a line perpendicular to tlie centre of its plane, if prolonged upward and forward it will emerge in tlie abdominal wall at a point a trifle below the umbilicus, and, if prolonged downward and backward it meets tiie anterior face of the coccyx about midway from the tip of the organ. The importance of remem- bering the direction of tliis axis is obvious, since, in order to enter the pelvis, ttie fcetus must accommodate itself to this line of the pelvic inlet. (Plate XIX.)
The circumference of the superior strait varies, within normal limits, between thirteen and sixteen inches. There are three diameters of obstetrical import: The an tero- posterior, or sacrorpubic, extending from the upper edge of the pubic sym-
96 LABOR.
physis to the centre of the sacro- vertebral angle, and measuring, in the average, four and one-half inches. The transverse diameter, extending from the centre of the innominate line of the one side to that of the other, and measuring about five inches. The right and the left oblique diameters, extending from the pectineal eminence of each side to the sacro-iliac syn- chondroses, and measuring from four and one-half to four and three-fourths inches.
The inferior strait is formed by two triangles, the common base of which is the line uniting the ischiatic tuberosities. The apex of the anterior triangle is at the pubic symphysis, and the apex of the posterior is at the tip of the coccyx.. The circum- ference of the inferior strait is uneven, owing to tlie projection of the coccyx and the tuberosities of the ischium and the depressions formed by the pubic arch and the edges of the greater sacro-sciatic ligaments.
The plane of the inferior strait extends from the tip of the coccyx to the subpubic point. It is only in labor that this plane assumes importance, and then it alters owing to the reces- sion of the coccyx under the pressure of the foetal head. When the woman is in the recumbent posture, as she is apt to be in labor, the inclination of this plane is from above downward and from in front backward. The axis of the inferior strait, when prolonged upward and forward, meets the axis of the superior strait at the centre of the pelvic cavity, and, if it be prolonged beyond, will end at the sacro-vertebral junction or a trifle above this pohit. When prolonged backward and downward the axis of the inferior strait meets the pelvic floor just anterior to the anus. When a woman is in the dorso-recumbent po- sition the axis points almost directly forward. (Plate XIX.)
In the normal pelvis the diameters of the inferior strait measure about four inches, but during labor, owing to the recession of the coccyx and the yielding of the sacro-sciatic ligaments, there is a gain of about one-half inch.
Intermediate between the superior and the inferior straits
MECHANISM OF LABOR.
97
lies the cavity. The foetus, having entered the superior strait, must undergo certain changes in position and in shape in the cavity before it can engage normally at the inferior strait. The shape of the cavity of the pelvis varies greatly witliin normal Umits, since it is dependent on the curve of the sacrum and the coccyx, and this ia different in each woman. It follows, there- fore, that we cannot properly speak of an axis of the pelvic cavity, for we are not dealing with a straight line, but with a curvilinear. The direction which the foetus must follow in order to reach the pelvic outlet is a curved one. We may define tlie axis of the cavity as being a curved line passing through the centre of the true pelvis, at all parts being equidistant from the sacrum and the pubes. Along tliis line, from inlet to outlet, the fcetus passes in order to enter the world.
The diameters of the cavity, with their average measure- ments, are ; Tlie antero-posterior, which extends from the middle of the posterior surface of the symphysis to the junction of the second and third sacral bones and which measures, on the average, about four and one-half inches; the transverse diameter, which extends from about the middle of each side of the cavity, crossing the antero-posterior at a right angle and measuring about four and one-half inches; the two oblique diameters, which extend from the centres of the great sciatic foramina to the posterior face of the subpubic grooves on each side and measure about four and one-half inches.
The foetus, having entered the superior strait and engaged in the cavity, meets with resistance at the pelvic floor, which it must overcome in order to emerge at the pelvic outlet.
It will be remembered that the pelvic floor is richly sup- plied with fascia which interlaces the muscular structure, giving this floor great resistance as well as great distensible power. The muscles, which are of importance from an obstetrical stand- point, are few in number and are conjoined in a central raphe, so that the pelvic floor can yield to applied pressure not alone laterally, but also from before backward, as is essential in order
k
98 LABOR.
to allow the fcetal presenting part to emerge at the outlet of the pelvis. These muscles are, in brief, the following: The levator ani, the constrictor vaginaB, the ischio-coccygeus, and the ischio- cavernosus. Througli the relaxation of certain of the muscular fibres of these muscles and tlirough the contraction of others, the lower pelvic diaphragm is enabled to open in order to give exit to the fcetal presenting part.
These muscles and the fascia are pierced by three open- ings,— the anal, the vulvar, and the urethral. The muscles we have noted not only clothe the pelvic floor, as it were, but they also surround, in a measure, each of these openings, acting both as constrictors and relaxors. It is important to remember the points of attachment and of origin of these muscles, and they are as follow : The levator ani and the ischio-coccygeus is a double symmetrical muscle, attached in front, on the intenial surface of the body of the pubes, close to the symphysis, to the posterior surface of the horizontal rami of tlie pubes, to the ischiatic spine, and to the anterior surface of the lesser sciatic ligament. From these attJichments the fibres radiate to a cen- tral fibrous raplie which extends from the coccyx to the rectum, being attached to the lateral walls of the rectum, to the lateral walls of the vagina, and to those of the bladder. The fibres passing from the sciatic spine and the sciatic ligament to the ooccyx constitute the ischio-coccygeus muscle, and form the posterior fasciculus of llie levator ani.
The sphincter ani is a muscle surrounding the lower ex- tremity of the anus, and extending from the tip of the coccyx to the posterior portion of the rectum. It encircles the rectum, the anterior fibres decussating — those from the right passing to the left, and vice versd — and uniting to form the constrictor vaginee. This muscle, the constrictor vaginie, surrounds the urethra anteriorly and extends to the clitoris, joining the fibres of the ischio-cavernosus. The constrictor vaginie and the sphincter ani, therefoi-e, form a figure-of-8.
The transversus periuei consist of a pair of symmetrical
MECHANISM OF tABOB. 99
muscles. They originate fiom tlie anterior surface of the jschi- atic tuberosities and, passing into the space between the vulva and the anus, blend there with the sphincter ani and tlie con- strictor vaginie. Tiie ischio-caveniosa are symmetrical muscles extending from the iscluatic tuberosities and the ischio-pubic rami, surrounding the root of the clitoris and merging witli the upper attachment of the constrictor vagina;.
Such, in brief, are the constituent parts of the pelvic floor. The force essential to overcome the resistance of tlie pelvic floor is furnished chiefly by the contractions of the abdominal muscles aided by the hearing-down eff'ort of the woman, wliereby, of course, the intm-abdoniinal pressure is increased. Tliese forces are largely dependent on the volition of the woman and are intermittent in action, — a very necessary factor, it will be noted, in order to prevent undue pressure on the pelvic floor of a con- tinuous nature, which could but residt in injury.
The pelvic floor measures, on the average, from the tip of the coccyx to the anus one inch and three-fourths, and from the anus to the vulva one-fourth of an inch. As the presenting part emerges at the pelvic outlet the relaxation and retraction of the muscles and the fascia are such as to give a measurement of about five inches from the coccyx to the posterior margin of the outlet. Having considered the nature of the expellent forces and the resistance to be overcome which is oft'ered by the pelvis and the pelvic floor, it remains to note the configura- tion, from an obstetrical point of view, of tlie foetus, whicli must pass from the uterine cavity out at the outlet.
The foetal head is the portion of the foetus which presents the greatest mechanical obstacles in its passage through the pelvis, and therefore it is important to understand its configura- tion thoroughly. The fcetal head, in shape, is oval, being com- posed of the face and cranium, its larger extremity being pos- terior. Eight bones enter into the composition of the cranium, — the occipital, frontal, ethmoid, sphenoid, two temporals, and two parietals. The frontal bone in front, the parietal and
100 LABOR.
the squaraous plate of tlie tempoml laterally, and the occipital bone posteriorly form the vault of tlie cranium. Its base is composed of the sphenoid, the etlimoid, the petrous portion of the temporal, and the basilar portion of the occipital bone. The bones which enter into the composition of the vault of the cranium are separated from each other by tlie sutures and the fontanelles. The result is that there exists not alone consider- able motion between these bones, but there is room for consider- able compressibility.
The sutures of obstetricaLinterest are the sagittal, coronal, and the kmbdoidal. The sagittal extends from the middle of the coronal suture to the apex of the lambdoidal. It separates the parietal bones. Tlie coronal suture divides the parietals from the frontal, and is intersected at its middle by the sagittiil suture. The lambdoidal suture lies between The occipital bone and the posterior borders of the parietals. The extremities of this suture lie at the squamous plate of the temporal bone, and its apex is at the posterior end of the sagittal suture. As will be noted, since the head of the fcetus is subject to compression as it passes through the pelvis, these sutures project, from the sliding of the bones on one another. In this way the dimensions of the fcetal head are diminished in certain of the diameters and are in- creased proportionately in others. The determination of the direction of these sutures enables the examining finger to become cognizant of the portion of the fcetal head which lies in one or another part of the pelvis.
The presence of the fontanelles enables the head of the foetus to be further compressed as it passes through the pelvis, and the recognition of one or the other fontanelle of obstetrical significance teaches that one or another portion of the head occupies one or another part of the pelvis. We distinguish the greater and the lesser fontanelle, as has been stated, and it is important to bear in mind the characteristics of each. To re- capitulate; The greater fontanelle is quadrangular in shape, and is bounded by the borders of the frontal and the parietal bones. J
11ECUAI4ISM OF LABOR. 101
The anterior angle is formed by the separation of the halves of the frontal bone; the posterior angle is formed by the juiu^UHi of the parietals ; the lateral angles are formed by the divergence of the frontal from the parietal on each side. At each angle ft suture terminates, and this characteristic, together witli the quad- rangular shape, enables the finger to readily recognize this Rnitft* nelle. The smaller and posterior fontanelle occupies the point wliere the sagittal and the lambdoidal sutures unite. In shape this fontanelle is triangular, the angles being formed by the parietals and the occipital bone.
The circumference and the diameters of the foetal head an of prime importance, since on their adaptability to the pelvis depends the emergence of the ftetal head at the outlet. The importance of the diameters mcreases with the degree in which t!ie configuration of the pelvis differs from the normal, as is amply excm]>lified in the portion of this work dealing with the snidery of obsletrics. The chief diameters of the fcrtal head, with their measurements, are: —
The occi pi to-frontal, extending from the occipital protnbeiv ance to the root of the nose, measures about four and three- fourths inches.
The occipito-mental, extending from the occipital protuber- ance to the chin, measures about five and one-fourth inches.
The cervico-bregmatic, extending from the posterior border of the anterior fontanelle to a point midway between the oc- cipital protuberance and the occipital foramen, measures three and three-fourths inches.
The fronto-mental, extending from the top of the forehead to the chin, measures three and one-fourth inches.
The Buboccipito-bregmatic, extending from the occipital protuberance to the centre of the anterior fontaneUe, measures three and one-fourth inches.
The biparietal, extending from one parietal protuberance to the other, measures three and three-fourths inches.
The bitemporal, extending from the centre of the temporal bone on one side to the other, measures about three inches.
102 LABOR.
The bimastoid, extending from the mastoid process of one side to that of the other, measures about three inches.
A further point about the fcetus, of interest in connection with the mechanism of labor, is the manner after which the head of the fcetus is articulated to the spinal column. This articulation is of such a character that when, under the influ- ence of the uterine and abdominal contractions, the head enters the pelvis, it is in a position of flexion, — the position so neces- sary, as will be noted, in order that the favorable diameters of the fcetal head may become applied in the favorable diameters of the pelvis. The articulation, further, to the spinal column is sucli that the portion of the head anterior to the foramen magnum represents the long arm of a lever, and, in consequence, when, under normal conditions, the head enters the pelvis, the forces being equally distributed anteriorly and posteriorly, the head must flex on the sternum.
Tlie mechanism of labor differs in detail according to the presentation, although, in general, the foetus performs a series of evolutions each of which tends to facilitate its passage from the uterus through the pelvis. These movements are : flexion, descent, internal rotation, extension, external rotation or resti- tution, and complete delivery.
AVe have already noted that the attitude of the fcetus in the uterus is one of flexion, this attitude being the one under whioli tlio firtus Ix^st accommodates itself to the capacity of the ftjmoo in wluch it lies. Under the influence of uterine and nbdomiuul action this flexion becomes intensified until the pre- nt^uting jmrt nniohes the i>elvic floor, when, in order to facilitate doUvtn*Y» the firtus undoi^oes the movements of rotation and of oxtousion* Flexion and descent assist in the engagement of the pivst^nting [Uirt in the sui>erior strait ; when the presenting part i^^^ohoii the floor of the jn^lvis rotation occurs in order to bring tht^ n\ost tHY\>mWe diameters of the foetus into the most favorable diiuuotew of the oavitv and of the outlet of the pelvis. In order tt) eiut^i^> at the outlet the presenting part must extend to a
gjeatcr or a less degree in order to bring into the i diameter of the outlet — the widest diameter — tl f
the presenting part which can best be there 8 imt External rotation is essential in order that the iion oi fcetus yet in the pelvis may, in turn, present its most favoraoie diameters to tliose of the cavity and of the outlet of the pelvis.
Whilst, normally, tlie general mechanical scheme is tl same for all varieties of presentations, the mechanism varies ii certain respects with each position, and, therefore, it is esse to consider tersely tiie mechanical phenomena of each.
Because of their greater frequency, we first study the mechanism of presentations of the vertex.
The vertex may present at the superior strait in one of four positions denominated as follows: Left occiput anterior (L. O. A.), right occiput anterior (R. O. A.), left occiput posterior (L. O. P.), and right occiput posterior (R. O. P.). Prior to descent inter- mediate positions are possible, such as transverse, pubic, and sacral; but since, in order to descend, the vertex must assume one of the four positions noted, except where we are dealing with an abnormally large pelvis or an unusually small fcetus in relation to the given pelvis, it is only necessary to remember these positions and to study their mechanism.
h. 0. A. Position {Occiput to the Left and Anterio}-). — The diagnosis of the position is established by palpation, auscul- tation, and vaginal touch.
On palpation, when the attempt, is made to grasp the head at the superior strait, a greater sense of resistance is determined to the right of the mid-line. This is due to the fact that the forehead lies here, flexion of the chin on the sternum of neces- sity making the forehead more prominent here when the occiput lies to the lell of the pelvis and anterior. The palpating hands will hence be able to map out a greater sense of resistance along the left anterior surface of the uterus, where the back of the fcetus lies. The small parts of the foetus will be found occupying the right upper uterine segment.
104
On auscultation, since the back of the foetus is applied to the left anterior uterine segment, and since the fcetal heait occupies a position nearer the cephalic pole of the fetus than the pelvic pole, the fcetal heart-sounds will be heard below the umbilicus in a Hue extending from the left anterior superior spine to the umbilicus,
Vaginal touch only yields information of value after the cervical canal has dilated sufficiently to enable the finger to reacli the presenting part, and often not until the membranes have ruptured. The finger reaches the head and determines the sagittal suture. This suture is recognized by remembering tliat at its extremities are the fontanelles, the anterior fontanelle in the position we are now considering being found behind and to the riglit, and the lesser fontanelle being found in front and to the left. The sagittal suture, therefore, lies in the left oblique diameter of the jK^lvis, which is the diameter extending from the left ilio-pectineal eminence to the right . sacro-iliac synchondrosis.
Under normal conditions the head does not become per- fectly flexed until the membranes have ruptured; that is to say, descent does not begin. Under the influence of the uterine contmctions the cervix opens and tlie fcetus is forced down into the sui>erior strait. Flexion and descent are practically coin- cident, and the vertex enters the superior strait with its plane nearly coincident with that of the strait. Tlie chin being flexed on the sternum, the sagittal suture may be traced in the left oblique diameter of tlie strait. The vertex thus descends to the pelvic floor. Normally, during descent, the vertex is nearly perpendicular ; that is to say, tlie parietal eminences are in the same plane. "When, liowever. the head enters the cavity and approaches tlie pelvic flour, the anterior parietal eminence — in this position the riglit — sinks lower than the posterior; so that tliis eminence, instead of tlie sagittal suture, will be determined in the left oblique diameter of the jielvis. When the head reaches the pelvic floor rotation occurs, The result of rotation
MECHANISM OF LABOR,
105
is that the occiput is brought to the front; that is to say, tlie chin remaining flexed on the sternum, tlie round occiput glides along the left antero-Iateral plane of the cavity of the pelvis until it looks toward the pubes, the forehead and the cliin looking toward the sacral concavity. The cervico-hrcgmatic diameter of the head is tlms brought into apposition with the antero-posterior diameter of tlie outlet ; that is to say, a measure- ment of about three and one-half inches is applied to one of about four and one-half. The Inparietal diameter occupies the transverse of the jielvis, or a measurement of about three and one-half inches is opposed to one of about lour and one-fourth inches. It will be noticed that the head rotates into this favor- able position for the reason that further descent is impossible otherwise, and, since the occiput has all along pointed to the left and anteriorly, the natural motion for it to make is from the left toward the ftont. In acquiring this position the foetal neck is twisted to a degree, for the body of the foetus, being still in the uterus and grasped by its contracting walls, does not rotate, the shoulders remaining in the oblique diameter of the superior strait.
As the contractions of the uterus, aided now by those of the abdominal muscles, in great part, increase, the occiput, or short lever of the head, descends — flexion of the chin on the sternum becoming exaggerated — until the neck of the foetus gets under the pubic arch. Further descent of the occiput is now impeded, and, since the expelling force is still in action, the effect is applied to the anterior lever, and the chin leaves the sternum or the head extends. The floor of the pelvis bulges greatly, its muscles relaxing latcmlly and retracting backward, and gradu- ally the forehead and the face and the chin sweep over the perineum into the world.
"We have seen that in the movement of rotation the neck of the foetus necessarily becomes twisted. As soon as the head is bom the neck untwists and the occiput turns toward the left of the woman, — the position it originally occupied. This
^ movement is termed "external rotation, or restitution." The!
I shoulder's, still in the oblique diameters, now descend until thej I
I reach the pehic floor, wlieu ttiey rotate autero-posteriotly. I
I The right, or anterior, shoulder, in the position we are consid* I
ing, descends under the pubic arch and there becomes the fixed
point. The left, or posterior, shoulder swttjpa down the pelvic
floor, and, as a rule, emerges over the margin of the floor
first, when it drops down and allows the pubic shoulder to
emerge. Tlie emergence of the remainder of the fcetal body
is now usually rapid, the nates being expelled after the same
manner as the shoulders; that is to say, in the position we are
considering, tiie anterior, or riglit, natis appearing under the
symphysis and there becoming fixed, whilst the posterior, or left,
natis sweeps over the pelvic floor and out at the outlet. {Plate
XX.)
R. 0. A. Position (^Occiput to the Right and Anterior). — On palpation at the superior strait the hands meet with a sense of greater resistance in front and toward the left, corresponding to the fcetal foreliead. Along the right antero-lateral segment of the uterus greater resistance is determined by the palpating hands tlian along tlie left segment, corresponding to the back of the fcetus. At the right upper segment of the uterus the outline of the foetal breech may be determined, and opposite this the small parts may usually be made out.
On auscultation the maximum intensity of the fcetal licart- sounds is determined in the line extending from the umbilicus to the right anterior superior spine, because the dorsum of the foetus is applied to the right antero-lateral wall of the uterus. On vaginal touch, during labor, the posterior fontanelle is found forward and to tlie riglit and the anterior fontanelle behind and to tlie left. The sagittal suture may be traced along the right oblique diameter of tlie pelvis, extending from the anterior fontanelle, which is on a level with the left sacro-iliac synchon- drosis, to the posterior fontanelle, which is on a level with th< right ilio-pectineal eminence.
PrB^M.t.on o( the V.rtB. Right Occiput ,
MECHANISM OF LABOR.
[Flexion and descent are similar in mechanism to that just noted for the position L. O. A. Rotation differs only in that in order to bring the occiput under the pubes tlie ht;ad must turn forward along the right lateral plane of ttie pelvis. Extension occure as in case of the position L. O. A. External rotation, or restitution, brings the occiput pointing toward the right thigh of the woman. Tlie left, or anterior, slioulder becomes fixed under the pubic arch, whilst tlie right, or posterior, shoulder sweeps over the pelvic floor. The left, or anterior, natis passes under the pubic arch and the right, or posterior, natis sweeps over the pelvic floor.
L. 0. P. Poailion {Occiput to the Left and Posterior). — On palpation the hands at the pelvic brim must sink in deeply before meeting with resistance, and this is determined to the left and behind. Along the left lateral segment of the uterus greater resistance is determined than along the right, but the hands must palpate more deeply tlian in case of the position -L*. O. A., since the back of tlie fcetus is deeper and posterior "Wstead of being applied close to the antero-lateml wall of the **teruson the left. In the right upper segment of the uterus *"e foetal small parts are, as a rule, easily determined, more to *he front, however, than in case of L. O. A. position. On ^Uscultation the maximum intensity of the fcetal heart-sounds *® in a line extending from the umbilicus to the left anterior ^^^X^Prior spine, but posterior to this line instead of about its •^Ontre, as in case of the left anterior position. By vaginal ^vich, during labor, the posterior lljntanelle is determined hz- "*Ud and to the left, and the anterior fontanelie is found on ^ level with the right ilio-pectineal eminence. The sagittal future lies in the right oblique diameter of the jwlvis, the 'Occiput pointing toward the left sacro-iliuc synchondrosis.
The mechanism of this position throughout depends on whether flexion of the chin on the sternum is complete or not. This is an extremely important point to remember, for, as will W noted later, during tlie progress of labor in this position
108 LABOR.
everything depends on the attendant realizing the importance of maintaining this flexion by means of such measures as will be described. Where flexion is complete the head enters the pelvic superior strait and descends to the pelvic floor without special difficulty ; but in case of incomplete flexion the longest diameter of the fcetal head — the occipito-frontal— cannot engage with ease at the superior pelvic strait, and there results altcF ation in the clinical course of labor, which will be dulv dwelt upon. '
The head, being well flexed, descends to the pelvic floor in the right oblique diameter of the pelvis. On reaching the pel- vic floor, under normal conditions of pelvis and of fcetal head, anterior rotation occurs. Since the occiput still points toward the left sacro-iliac synchondrosis, it is apparent that, in order to bring the occiput under the arch of the pubes, it must traverse the posterior lateral pelvic plane and then the anterior left lateral plane. In order to accomplish this, since the posterior lateral plane is deeper than the anterior, the occiput is able, as a rule, to sink deeper before beginning the rotation, flexion be- coming exaggerated. The route the occiput has to travel is much longer than in case of the left anterior position, and often rotation does not occur until the pelvic outlet is reached. This is a point to be remembered, because, under normal relations as regards size, this position is apt to give rise to anxiety unless it be borne in mind that rotation is apt to occur even though delayed. The occiput once under the pubic arch, expulsion is similar to the mechanism in case of L. O. A. External resti- tution throws the occiput farther backward as regards the woman's thigh than in case of L. O. A., but the shoulders and the nates emerge aft;er the same mechanism.
When the fcetal head reaches the pelvic floor in this po- sition and flexion is incomplete, then, instead of rotation occur^ ring anteriorly, the occiput glides into the hollow of the sacrum, giving us a position which may constitute one of the most dif-
MECHANISM OF LABOR.
109
ficult of all to deal with. This will be fully discussed in speak- ing of the clinical course of abnormal labor. (Plate XXI.)
M. 0. P. Jhsi(io7i (Occiput to the Right and Posterior'). — On palpation, the back of the foetus being posterior, the hands must penetrate deeply, in order to determine the greatest resist- ance, whicli is along tlie right lateral segment of the uterus and posterior. The breech is found in the upper right segment of the uterus, but again at a deeper level tlian in case of E. O. A. The small parts of the fcetus are determined in tlie left upper segment of the uterus, nearer the mid-line than in case of R. O. A, On auscultation the maximum intensity of tlie heart- sounds is posterior to the line extending from the umbilicus to the right anterior superior spine. On vaginal touch, during labor, the posterior fontanelle is determined behind, to the right, ' near the right sacro-iliac synchondrosis, and the anterior fonta- nelle is found to the left and in front, on a level witli the left ilio-pectineal eminence. The sagittal suture lies in the left oblique diameter of the pelvis.
The mechanism of this position, aa in case of L. O. P., de- pends, for its normal course, as to ivhetlier flexion is comi)Iete or not, and similar remarks are applicable. Flexion being com- plete, when the head reaches the pelvic floor the occiput, in order to get under the pubic arch, must traverse tlie right postero-Iateral plane, and next the right antero-Iateral plane. After expulsion the occiput points a trifle posterior to the position it assumes in case of the jx)sition R. O. A. ; the shoulders and the nates are delivered after a similar mechanism, the left en- gaging under the symphysis and the right sweeping over the pelvic floor. Where flexion is defective, either the head does not rotate until the outlet is practically attained or else the occiput turns into the sacral hollow, giving rise, as will be noted, to an exceedingly unfavorable position as regards the termination of the labor and the integrity of the structures of the pelvic floor.
110
iRREGnLARlTlES IN THE MECHANISM OF PRESENTATIONS
OF THE Vertex.
Under normal conditions the mechanism of labor occors after the manner described. There are deviations from this mechanism, however, which we must consider.
At the superior strait obliquity of the uterus or dispropor- tion between the pelvic inlet and the presenting part leads to irregularities in the presentation whereby the necessary mech- anism of flexion and of descent does not occur or occurs, at best, after an imperfect fashion. Where there exists imperfect flexion of the head, instead of the occipito-bregmatic circumfer* ence presenting the occipi to- frontal presents. Such a position is not at all uncommon before tlie onset of labor; but, when once this has set in, perfect engagement necessitates perfect flexion. Again, not uncommonly we note what are termed inclined pres- entations of the vertex, where a parietal protuberance or an ear.i offers at tlie centre of the superior strait instead of t)ie vertex.1 The most common cause of this is obliquity of the uterus, and tlie result of this presentation is that the long occipi to-mental diameter off'ers at the superior strait. As a rule, the position alters on rectification of tlie uteiine obliquity, the head becomes properly flexed, and lalior progresses normally. Should this not occur, obviously, tlie iiead becomes impacted at the brim and the woman cannot deliver herself. I
In the cavity, as we have noted, deficiency in flexion is a common cause of posterior rotation of the occiput. The in- dication, therefore, is to promote flexion as soon as its absence is determined. In general, the effect of deficiency in flexion ia.,. to retard the progress of labor.
Rotation may fail altogether, particularly in multiparro wil large pelves or disproportionately small foetus. The occiput then escapes obliquely along the ischio-pubic rami instead of from under the pubic arch. Again, whilst the head may rotate prop- erly, the shoulders or the trunk may not, in which case thefi emerge obliquely.
1
MECHANISM OF LABOR. Ill
Rotation may become exaggerated; that is to say, the occiput may pass under the symphysis, when, instead of be- coming fixed to permit of extension, it turns to the other side of the anterior lateral pelvic plane, a right position becoming a left, or vice versd. Ordinarily this excessive rotation is not per- manent, but the occiput shortly reverses its path and again becomes fixed under the pubic arch.
Rotation of the occiput toward the sacrum instead of under the pubic arch is the deviation from the normal mechanism which is most to be feared. In such an event, if the deviation remain permanent, it is exceptional if interference be not called for in order to effect delivery, — especially in the primipara with rigid pelvic floor. In case the head be small in proportion to the pelvic outlet, or in multiparae with relaxed pelvic floor, the occipito-sacral position may be bom spontaneously, but the process is a tedious one and always at the expense of the in- tegrity of the muscles and fascia of the pelvic floor. The occi- put must pass along the entire posterior pelvic wall, which is much longer than the anterior. The chin becomes forcibly flexed on the sternum, the forehead becomes the fixed point under the symphysis, and the occiput emerges first, followed by the face and next by the chin. Usually this mechanism occurs obliquely, but often in the mid-line, when the chances of lacera- tion are greatly increased. Very rarely, as will be noted, flexion fails altogether and the face presents. In such a case, if the chin rotate backward, delivery by the natural eff*orts is impos- sible. If the chin rotate under the symphysis, then delivery occurs as will be noted under *' The Mechanism of Face Pres- entations."
External rotation, being in a measure dependent on the shoulders, will fail if the shoulders descend obliquely, or super- rotation will occur if the shoulders rotate in a direction contrary to that which is customary. As a rule, however, where this superrotation occurs it is only apparent, being dependent on an erroneous diagnosis of the original position.
112 LABOR.
CHANGES IN THE FCETAL HEAD UNDER THE INFLUENCE OF THE
MECHANISM OF LABOR.
The fcetal head, in order to undergo the mechanism we have described, alters somewhat in shape or molds, as it is termed. This molding is most marked where there exists dis- proportion between the pelvis and the fcetus, but, under normal conditions, what is termed the " caput 8iux:edaneum** forms, which varies in size according to the length of the labor and as to whether the membranes rupture early or late. The caput stiC' cedaneum is the result of a sero-sanguinolent infiltration of the soft parts of the fcetal head, and it forms on that portion which is not subjected to pressure ; in other words, on that portion of the head which offers in the centre of the pelvic planes. It is of no importance and disappears at the end of a few days after labor. Its chief value is that it enables us to confirm, after the birth of the child, the diagnosis we had reached as to the po- sition, for its situation varies according to the position of the occiput. Thus, in right positions it forms on the left lateral surface of the head, usually at the left parietal bone, whilst in left positions it will be found on the right surface of the head at tlie right parietal bone.
THE MECHANISM OF FACE PRESENTATIONS.
Presentations of the face occur about once in two hundred and fifty labors, and are, therefore, relatively uncommon. They result from lack of flexion, giving us the chin as the landmark instead of the occiput. According as the chin points to the left or the right antero-lateral or postero-lateral plane of the jHjlvis we recognize four cardinal positions (using the Latin word mento for chin): M, L. A. (mento-left anterior), M. R. A. (mento-right anterior), M. L. P. (mento-left posterior), and M. R. P. (mento-right posterior).
Originally all face presentations are either right or left transverse, but eventually the position assumed is one or the other above noted. Intermediate positions, chin to pubes and
UECHANISU OF LABOR. 113
chin to sacrum, are described, but, under the influence of the mechanism of labor, ttiese alter to an anterior or a posterior oblique.
Tlie most frequent variety of presentation of the face is W. R. P. ; that is to say, the forehead points to the left iHo-pectin- eal eminence and the chin to the right sacro-iliac syncliondrosis. In fact, tliis position of the face is the direct extension of the most frequent presentation of tlie vertex, — L. O. A. Before rupture of the membranes the position is really one of the brow, but as soon as rupture occurs, the uterine forces acting through the vertebral column in a direction toward tlie chin, the head necessarily extends, giving us a presentation of the face. The iace occupies the left oblique diameter of the superior strait, the mento-bregmatic diameter of the face lying in this diameter of the pelvis, the bimalar diameter of tlie face occupying the right oblique diameter of the pelvis. The ventral surface of the fetus looks backward and to the right, the dorsal surface for- ward and to the left. The uterine contractions increase the ex- tension until the occiput rests on the dorsum of the foetus. The head thus extended descends, but never as far as in vertex pres- entations, since the amount to which it can descend is limited by the length of the neck of the foetus. When farther descent is impossible the chin rotates along the right antero-latenil plane of the pelvis, the effect being that the chin is brought under the symphysis. This process is a slow one, and when tlie chin reaches under the arch it becomes the fixed point. The expellent forces are now applied to the forehead, and this gradually sinks lower, flexing and emerging first over the posterior commissure of the vulva. Thus, in succession, the mento- frontal, the mento-bregmatic, the men to-occipital, and finally the meuto-suboccipital diameters emerge. When the face has been delivered the shoulders undergo the movement of rotation, the chin turns toward the woman's right thigh, and the remaining evolutions are exactly as in case of presentations of the vertex.
This general description of the mechanism applies to all positions, tlie variations simply depending on lotation from left to right or from right to left, according as one or the other ua requisite to bring the chin under the pubes. I
As we noted that rotation of the occiput, in case of vertex presentations into tlie hollow of the sacrum, or, at any rate, posteriorly instead of anteriorly, constituted an abnormal mech- anism, and one which rendered labor difficult or impossih' without assistance, similarly in case of the face posterior rotatioi is unfavorable and to a greater degree, since we may at onG4 state that, when the face has descended with the chin to tlu sacrnra, delivery constitutes a mechanical impossibility withotlj resort to art.
The diagnosis of face presentations prior to labor must I considered impracticable so far as tlie differentiation of tlw varieties are concerned. (Plate XXII.) By palpation we may ordinarily, in case the abdominal walls are tliin, make out the occiput as more prominent to the riglit or the left on the sid< corresponding to the dorsum of the fcetus, and occasionally, evenj we may be able to feel the furrow formed between the back and the head by the process of extension of the head ; but, beyoiu this, little information will be secured. On auscultation oia suspicions are further aroused, since the maximum intensity of the heart-sounds, owing to the higher position of the head in face cases, will be about on the level of a line running through the umbilicus instead of in the line extending from the umbil- icus to one or the other anterior suiierior spine, as is the case in flexed presentations of the vertex. As a rule, it is by vaginal touch that we may reach a diagnosis, and tliis is only possible after rupture of the membranes and with sufficient dilatation of the cervix to enable the finger to come in contact with the pr« senting part. On one side or the other, according to the j sition, we reach the sagittal suture ending at the anterior fonta nelle. When the finger follows this suture as far as possible i reaches the superciliary ridges and the root of the nose. Eeloij
I'l.ATE XXU.
|
■ |
^wl |
■ |
|
H| |
PP |
|
|
Kp^'i |
- |
V
Right SlC'D'potTBnDr Poiitl^
^^" MECHANISM OF LABOR. 115 '
this we find the nostrils and the mouth. We may not be able to reach the chin, but a Uttle care in recognizing the land- marks we have just noted will save from error in diagnosis. The direction of the nostrils will teach where the chin lies, and sometimes we may be able to reach one or the other ear, when, bearing in mind the shape of this organ, the diagnosis is again further certified to.
The above landmarks are easy of recognition early in labor, but, in cases where the labor has been prolonged before a proper examination is made, the formation of the caput on the face practically obliterates them, rendering the diagnosis exceedingly difficult unless we are able to reach the chin. In case of pro- longed labor (and face cases are usually very tedious) the caput distorts the face to a great degree. The cheeks and the lips are greatly swollen and the lids of the eyes are enormously cedema- tous ; oHen the head of the fcetus remains extended for days after deUvery.
PRESENTATIONS OF TQE PELVIC EXTREMITY.
The pelvic extremity of the fcetus may offer at the superior pelvic strait either after a complete or an incomplete iiishion. A complete presentation is where tlie breech of the fcetus and the lower extremities offer ; that is to say, wliere the thighs are flexed on the pelvis, the legs on the thighs, and the heels are applied to the nates. (Plate XXIII.)
There are varieties of incomplete presentation ; thus, the legs may be extended on the ventral surface of the foetus, or the feet may offer, or the knees, or either one foot or one knee.
Whatever the variety of presentation, the mechanism of labor is the same.
Presentations of the pelvic extremity are next in frequency to those of the vertex, occurring about once in fifty cases. The positions are denominated according to whether the sacrum of the foetus points toward the left or the right anterior or pos- terior lateral plane of the pelvis.
Thus we determine : S. L. A. (sacro-left anterior), S. R. A. (sacro-right anterior), S. L. P. (sacro-left posterior), and S. R. P. (sacro-right posterior).
The left positions are more frequent than the right, ei-en as held in cases of presentations of the vertex.
From a study in extenao of the left anterior sacral position the mechanism of the otlier positions can be readily understood.
MECHANISM OF SACRO-LEFT ANTERIOR POSITION.
On palpation the pelvic extremity is determined in the left iliac fossa. Tlie outline of the dorsum of the fa;tus may be traced along the anterior left lateral wall of the uterus. In the rigtit upper uterine segment the hard, roundish head may he felt, and where the liquor amnii is present in sufficient amount baliottement of tiie head may be elicited. On auscultation the maximum intensity of the heart-sounds is determined above the level of the umbilicus and to the left. Prior to rupture of the membranes vaginal touch reveals simply the absence of an accessible presenting part, tlie lower uterine segment being filled to a greater extent than is the case where tlie cephalic pole of tlie fcetus presents. After rupture of the membranes, the cervix being patulous to the examining finger, we reach the anterior, or left, natis ; below this the cleft between the nates is determined. When tlie finger is passed upward to the left the anus is detected, and beyond this the coccyx. The deter- mination of the coccyx not alone certifies to the presentation, but also to the position, since it always points toward the ventral surface of the foetus. In case of the position we are considering, the coccyx points posteriorly and to the right. In case tlie sacrum can be felt it will be found to point forward and to the left. The fossa between the nates occupies nearly the left oblique diameter of the pelvis, the bi-iliac diameter being in the right oblique of the pelvis.
In case of presentation of the pelvic extremity, when the membranes rupture, since the breech does not fit the superior
I
I
I
MECHANISM OF LABOH.
117
strait as accurately as the vertex, the liquor amnii drains away rapidly and the uterine walls close down on tlie fcetus. The result is that complete flexion of the fcetal parts occurs, the fcetus thus being made as small as possible to adapt itself to the superior strait. The first mechanism, therefore, is termed '■adaptation." Next occurs descent. Tlie sacrum sinks down the left anterior plane in an oblique manner to the floor of the pelvis. Here it meets with resistance. In accordance with the same law of physics wliich held in case of the other presen- tations we have considered, — that is to say, when a body is subject to the action of two opposing forces it moves in tlie direction intermediate between the two, viz., in tlie direction of least resistance, — tlie sacrum rotates until the anterior, or left, liip passes under the pubic arch and tlie posterior, or right, hip glides backward into the sacral concavity. This rotation is necessarily a slow procedure, especially in case of primiparte, because the soft, yielding breech of the fcetus offers but slight resistance, comparatively, to the opposing forces. The anterior hip having passed under the pubic arch, tills hip becomes the fixed point, and around this the posterior hip gradually revolves along the ]>elvic floor till it emerges at the posterior vulvar com- missure. It then drops down toward the woman's anus and the anterior hip emerges from under the symphysis. Whilst the hips have rotated an tero- posteriorly, the shoulders and the head have remained transverse. The shotdders now rotate obliquely and thus descend to the pelvic floor, where they meet with resistance and rotate in turn antero-posteriorly, the left shoulder becoming fixed under the pubic arch and the right gliding into the concavity of the sacrum. The left shoulder becoming the fixed point, the right traverses the pelvic floor and is delivered over the posterior vulvar commissure. The left then passes from under the symphysis. The head of the fcetus next rotates into the oblique diameter and descends to the pelvic floor, when it in turn rotates antero-posteriorly, the occiput becoming fixed under the pubic arch, and delivery
118 LABOR.
occurs even as in original presentations of the vertex, — ^left anterior variety,
MECHANISM OF SAGR0-RI6HT ANTERIOR POSITION.
On palpation the pelvic extremity is found chiefly in the right iliac fossa. The back of the foetus lies forward and in the right anterior lateral segment of the uterus. The head occu- pies the left upper uterine segment, and where the liquor amnii is not deficient it may be ballotted there. The maximum inten- sity of the foetal heart-sounds is above the umbilicus and to the right. On vaginal touch, after rupture of the membranes, the intergluteal fossa may be traced in the right oblique diameter of the pelvis, the coccyx pointing to the left and backward. The bi-iliac diameter of the foetus occupies the left oblique diameter of the pelvis.
The mechanism of labor is the same as in case of position S. L. A., except that rotation occurs in the direction from left to right for the hips and from right to left for the occiput.
MECHANISM OF SACRO-RIGHT POSTERIOR POSITION.
On palpation it is necessary to press in deeply in order to meet with the sense of greater resistance, for the reason that the dorsal plane of tlie foetus lies posterior. By turning the woman on her left side the right lateral posterior plane of the uterus is brouglit more to the front and the back of the foetus may be indistinctly mapped out, the head occupying the left upper uterine segment, although determinable with greater difficulty, since the occiput is more to the rear. On ausculta- tion the maximum intensity of the heart-sounds is to the right of the umbilicus and above, although more posterior than in case of S. R. A. On vaginal examination, after rupture of the membranes, the intergluteal fossa is found in the left oblique diameter of the pelvis, the coccyx pointing forward and to the left and the sacrum being posterior and to the right. The bi-iliac diameter of the foetus lies in the right oblique
I J ;;h '*
UGHANiaif OP LABCXR, 119
ftliepdlTis. The mechanism of labor 18 ideiitical with thai deaenbed for anterior podtions, except that the anterior hip has to tmv^rse a portion of the posterior right lateral plane and fte antrakxr right lateral plane in oider to ragage unda the pobie vgIl This rotation oocnrs from right to left. Rotation ]s» oi conrse, more prolonged than in case of anterior positions.
MIGHANISIC OP SACSO-LBR FOSnEBIOR FOBIflQir.
The dorsal plane of the foetns is directed to the left posts- i|or wall of the uterus; the inteigluteal fossa is in the right obl^ue diameter of the pelvis, and the bi-iliac in the left eUique. The ooccyx points forward and to the right, the left hip being finrward and to the left. Again, the steps in mechanism an die same as for anterior positions except that rotetion is BKire prolonged smce the anterior left hip has to trayel a greater distance in order to impinge under the symphysis.
Ibbioulabities nr thb Mechanism of Prbsbntatioks
OF THB FkLTIG -EXTREMITT.
Even as in the case of presentations of the vertex and of the face, the pelvic extremity may present obliquely at the superior strait, and this gives rise to abnormality in the mech- anism of engagement. The phenomena of flexion and of descent will occur more readily, furthermore, the more complete the presentation, since the foetus will thus best adapt itself to the plane of the pelvic inlet. Where the foetus lies obliquely the uterine contractions never act as favorably as when the foetus approaches the plane of the superior strait perpendicularly. Again, the less complete the presentation, the less readily does the pelvic extremity act properly in causing dilatation.
Rotetion may be incomplete or may fail altogether. The fiu5t, however, that the pelvic extremity is very compressible renders oblique delivery possible, and such an occurrence is by no means rare.
A frequent irregularity in delivery which greatly compli-
120 LABOR.
cates is extension of the arms above the head. This complicap tion may be traced to irregularity in the contractions of the uterus, whereby the arms are not kept closely applied to the body of the foetus ; but often the arms extend because, after delivery of the trunk, the attendant makes injudicious traction on the breech, especially in the absence of uterine contractions.
After delivery of the trunk the life of the foetus is neces- sarily greatly imperiled, since the umbilical cord is likely to become compressed. It is requisite, therefore, that the foetal head should rotate after a normal manner. The irregularities in mechanism here are dependent on the manner after which rotation of the head occurs. There are two important devia- tions from the regular mechanism: either the head does not rotate at all or else it rotates posteriorly. Again, the head may rotate, but, instead of remaining flexed, it extends. In the latter event the chin is arrested behind, above, or below the sacro-vertebral angle. Each one of these irregularities in mech- anism requires interference on the part of the attendant, as will be noted when the subject of " The Management of Abnormal Labor " is considered.
During descent of the pelvic extremity that portion which is subjected to the least pressure swells according to the duration of the labor after rupture of the membranes. As a rule, the caput forms on the anterior buttock, but not exceptionally the swelling extends to the genitals, the scrotum being greatly enlarged.
Presentations op the Trunk.
Presentations of the trunk are denominated according as the right or the left shoulder presents, with the foetus offering its dorsal or its ventral surface anterior or posterior. The head of the foetus is, therefore, either to the left or to the right. The simplest classification, therefore, is that which takes account InUh of which shoulder presents and in what direction the head of the fa>tus Ue& Thus, we recognize the following positions : —
MECHANISM OF LABOR. 121
Head to the right with the right shoulder presenting, in which case the ventral surface of the fcetus is in front.
Head to the left with the left shoulder presenting, in which case the ventral surface of the foetus is in front.
Head to the right with the left shoulder presenting, in which case the dorsal surface of the fcetus is in front.
Head to the left with the riglit shoulder presenting, in which case the dorsal surface of the fcetus is in front.
The diagnosis of position, in case of presentation of the trunk, depends, therefore, obviously, on the determination of which shoulder offers and on whether the head lies to the right or to the left. (Plate XXIV.) Only very exceptionally are these positions exact ones. As a rule, either the elbow offers instead of the shoulder or else the hand or tlie hand and the arm prolapse, in which event the diagnosis is greatly simplified, since the recognition of tlmt hand which is prolapsed at once tells us the necessary position. These points will be appro- priately dwelt upon in the chapter which treats of " The Man- agement of Labor." At the present we will simply study the mechanism of deliverj' in this untoward presentation.
At the outset the statement holds that almost invariably presentation of the trunk calls for intervention, and, therefore, the mechanism is that which is imparted by the attendant. The classical steps which apply to other presentations are fol- lowed here, however, according to the method selected for inter- vention.
Nature's mechanism of dealing with presentations of the tnink is twofold: Either spontaneous version occurs or else 9po7itaneo7i8 evolution.
By spontaneous version we mean that, under the influence of the expulsory forces, the trunk is converted into either a pres- entation of the cephalic or of the pelvic pole of the foetus. Before the onset of labor spontaneous version occurs with great frequency. Indeed, before engagement of tlic foetal presenting part, unless the liquor amnii is markedly deficient, there is
129
nothing to prevent the foetus from executmg any motion. After engagement, iiowever, or after the rupture of the memhranes, spontaneous version is of ^'ery rare occurrence, although it may and does occur.
The mechanism of spontaneous version is the following: Where spontaneous version occurs, if the case has been caie- fully examined beforehand, it will be noted that one or another pole of the fcetus lies lower, although it is still the shoulder which offers. The force of the uterine contractions is thus not directed against or in favor of the engagement of the pre- senting part, but it acts unevenly, and the fcetal pole which lies lowest is forced down. Tlie shoulder thus necessarily recedes and the head or the breech takea its place. Obviously, such mechanism is hardly likely to occur aft^r engagement, and the attendant slioutd. in any event, never expect it; but there are many cases recorded where, even after engagement and descent, version has occurred, although always in cases where the foetus has been very small or tlie pelvis very large.
Spontaneous version having occurred, delivery takes place in accordance with the meclianism peculiar to either vertex oi pelvic presentation, according as the conversion has been into one or the other type.
By spontaneous evolution is understood the delivery of the trunk, although tlie shoulder remains the presenting part. These instances are exceedingly rare, but they are authentic. The mechanism is as follows : —
The membranes having ruptured and the presenting shoulder having engaged, the uterus applies itself closely to the foetus, compressing the component parts together. The result is that the cephalic pole tends to approach as closely as it can the pelvic pole. The shoulder impelled by the expellent forces descends as far as it can, and the extent of descent that is pos- sible depends on the length of the fcetal neck. After a variable interval, usually a protracted one, rotation occurs. The shoulder is thus brought under the symphysis. Coincident with rotation
PLATE XXV.
|
1 |
|
|
The Place nil. A Th« Milsrnd Surface B. The Fatal Surface afid the Membtjne ^1 |
_, |
MECHANISM OF LABOB.
123
of the shoulder the head moves above the symphysis and there becomes fixed. The anterior shoulder and the head of the fcEtus are situated in front, and the posterior shoulder, with the rest of the foetus, lies behind. As the uterine contractions continue to act, the posterior shoulder is forced downward along the posterior portion of the pelvis and emerges over the posterior vulvar commissure, followed in turn by the thorax, the hips, and tlie pelvic extremity. The anterior shoulder, during these evolutions, has remained fixed under the symphysis and is now expelled, tlie liead remaining behind to be born according to the mechanism of delivery of the after-coming head.
Caput Siiccedaneum. — The caput auccedanetim forms on that portion of the foetus wliich is subjected to the least press- ure, and therefore is found on the anterior shoulder, as a rule. This siioulder and the corresponding arm and hand are greatly enlarged and ecchyniosed, as would be expected when we remember that the described mechanism is exceedingly tedious.
The Mechanism or Placental Delivert.
Since labor does not terminate with the expulsion of the foetus, but remains incomplete until tlie placenta has been delivered, it remains for us to consider the mechanism of placental expulsion, a proper understanding of which is requi- site in order to enable the attendant to deteiinine, in actual practice, the boundary-line between the normal and the ab- normal in this stage of labor.
The foetus having been expelled from the uterus, there remains behind the placenta with the membmnes. The pla- centa, at term, consists of a spongy tissue, rich in blood-vessels, measuring, on an average, about seven and one-half inches in diameter, irregularly round in shape. One surface is covered by the amnion and is smooth ; the other surface is applied to the uterus and is rough. (Plate XXV.) This uterine surface is grooved and is divided into spaces eacii of which forms a placental tutl, or cotyledon. At its edges the placenta thins out
124
and merges into the membranes. The rough uterine surface of the placenta is covered by that part of the decidual membrane which separates from tlie uterus when the placenta is expelled. It will be remembered that the uterus, at the site of implanta- tion of the placenta, is thickened tlirough the formation of the serotina, and tlie mechanism of placental expulsion is completed througli the separation of a portion of this, — a spUttiug, as it were ; so that, after placental delivery, part of the serotina re»j| mains on the uterus and the balance covers the maternal part 1 of the placenta.
Tlie placenta in position follows the curvature of the J uterine walls, the amniotic or fcetal surface being concave and I tlie maternal surface being convex. After the uterus has ex- pelled the foetus there occurs a pause, a period of rest, as will '] be dwelt upon later on. During this pause what is termed the j retro placental lijematoma is formed, varying in size and con- ,j sisting simply of an effusion of blood under the placenta, ' Wlien, after a variable interval, the uterus again contracts, the major part of its contents having been expelled, the uterine walls can retract to a greater degree, and the result is not alone that the placenta is pressed upon firmly, but also that the walls i of the uterus retract greatly at the site of placental attachment. The result of these three causes — formation of retroplacental clot, compression of the placenta, and retraction of the uterine walls — is that the decidual surface is split and the placenta becomes separated from the uterus. This may be taken as the . usual method of placental separation. Occasionally no retro I placental clot forms or, at any rate, it is so slight as not to be effective in the mechanism ; or else a large retroplacental clot forms at the centre of placental attachment, the result being that this central portion bulges downward, the periphery re» maining attached. Then the separation of the placenta occurs J more gradually, one area after another becoming detached.
Separation of the placenta having taken place, the next ] step is expulsion. Either immediately after separation or after J
I I
XECHANISM OF LABOR. 125
an interval, the nterine contractions drive the placenta from the uterus into the vagina or out of the vulva. ' There are two ways after which the placenta is expelled from the uterus: it passes out edgewise or else its surface is inverted, the foetal portion appearing first. The consensus of opinion favors the ▼iew that the edgewise expulsion is the most frequent, the placenta sliding down along the uterine wall and presenting its edge at the cervix and thus entering the vagina. It is highly probable that expulsion of the placenta through inversion — ^that is to say, the fcetal surface appearing first — ^is due, as a rule, to injudicious interference with the normal mechanism, such as by traction on the cord to expedite delivery.
CHAPTER II.
THE CLINICAL COURSE OP LABOR.
The clinical phenomena of labor are conveniently studied under the following headings : The Precursory Phenomena, or the Stage of Onset ; The Phenomena of Dilatation, or the so-called First Stage; The Phenomena of Expulsion, or the so-called Second Stage ; The Phenomena of Retraction, or the so-called Third Stage.
PREGURSORT STAGE OF LABOR.
The active phenomena of labor rarely set in suddenly. As a rule, there are certain precursory signs which point to im- pending labor. The first is the subsidence of the uterus, — the so-called lightening. This is due to the sinking of the uterus toward the pelvic brim, which is associated with a greater or less degree of engagement of the foetal presenting part. The abdomen becomes less prominent at the ensiform cartilage, the woman suflFering less in consequence from interference with respiration, and the abdomen bulging more between the um- bilicus and the pubes. A result of this sinking of the uterus is that the pressure symptoms on the bladder and on the rectum are intensified, micturition being more frequent and occasionally an artificial diarrhoea being provoked. (Edema of the lower extremities and of the genitals is increased, and often there is an hypersecretion from the vagina, the result of increased venous congestion.
These precursory signs set in usually about two weeks before the appearance of active labor, and they furnish a fairly reliable guide for the prediction of the time of labor. For a few days preceding the appearance of active contractions the woman complains of abdominal pain which is associated with a hardening of the uterine tumor. We have noted that, through- (126)
THE CLINICAL COUBSE OF LABOB. 137
oat pregnancy, the utenu nonnally contracts and relaxes, giving US the intermittent uterine contractions which, we have seen, axe Talnable as assisting us in reaching a diagnosis of pregnancy. These .precarsory pains are simply the intensification of the normal nterine contractions^ but, since they have very little actoal eSect in causing dilatation, they are known as " &Ise " pains.
On vaginal examination at this period we note marked changes in the cervix. It gradually ceases to exist as such, be- coming merged in the lower uterine segment. This change in the cervix was fonnerly considered as only an apparent one due to the so-called normal softening ; but to-day we know that the change is the direct consequence of the merging of the f»Tvix into the lower uterine segment So long as the vaginal portion of the cervix remains it may be definitely concluded that normal labor is not impending. Just so soon as the efiace- ment of the vaginal portion of the cervix occurs, this may be tdun as a sign that labor is imminent. These cervical cliaoges di&r according as the woman is a primipara or a multipara. In the primipara the - foetal part becomes engaged early and the cervical changes are rapid, so that, just before active labor sets in, the internal os and the external os have practically merged, the cervix being represented simply by a dimple in the vaginal vault.
In case of the multipara, engagement of tlie fcetal pre- senting part is less pronounced and effacement of the cervix is less marked. The cervical canal, however, is apt to be open, the finger readily reaching the internal os and the membranes. Even here, however, so long as there remains space between the external and the internal os it may be safely predicted that normal labor is not impending.
These changes which we have noted set in about the thirty- eighth week of pregnancy; that is to say, in the neighborhood of two weeks before terra. About the fortieth week true labor sets in and we pass to the consideration of dilatation.
128 LABOR.
STAGE OP DILATATION.
This stage is known as the first stage of labor. During this stage the cervix opens widely, so as to allow the presenting part to enter the vagina. We have seen that, for a number of days prior to the onset of labor, the woman suffers from pains to which the term " false " has been applied, for the reason that they are not effective, to an appreciable degree, in causing dila- tation of the cervix. These false pains are short and nagging, being located chiefly in the lower part of the abdomen. True labor-pains, on the other hand, differ in site and in character. These pains are simply the intensification of the intermittent contractions of the uterus which prevail throughout pregnancy. They are still intermittent, but they possess a true rhythm. They start from the back and extend around the abdomen. At first of short duration, as uterine action becomes intensified they last for fully one minute. The contractions are purely involuntary. During their continuance the woman suffers greatly, the face becoming flushed and the pulse accelerated. Following the subsidence of the contraction there occurs a pause of variable interval, this being succeeded b)' renewed contrac- tion. The intermittent nature of these uterine contractions subserves the double purpose of enabling the woman to recover strength to bear another, and also to enable the uterine circula- tion to become re-established, which, in turn, enables the blood of the foetus to become oxygenated. Further still, the intermit- tence of the contractions results in gradual yielding of the mus- cular fibres of the cervix, whereas continuous contraction would result in spasm and defeat the object aimed at, which is the opening of the cervix.
As the uterus contracts it changes in shape and in its axis. The organ hardens and, in the interval, again becomes soft. Its shape becomes cylindrical, the transverse diameter becoming shortened and the antero-posterior diameter lengthened. The position of the uterus changes, the fundus approaching the anterior abdominal wall, its longitudinal axis, therefore, tending
THE CONICAL COURSE OF LABOR. 129
to become more coincident with that of the axis of the superior strait.
The effect of these contractions is twofold: The cervix is caused to open and the membranes are driven down toward and into the opening cervix, which fact also, as we shall note, assists in dilatation.
The manner after which the cervix is caused to open is the following: The body of the uterus is composed mainly of longitudinal muscular fibres and, beneath these, of a layer of transverse fibres. When these fibres are in action the effect is that the organ becomes shortened antero-posteriorly and trans- versely. The cervix, on the other hand, is composed of circular fibres, which are attached to the longitudinal fibres of the body of the organ. It is at once apparent that the necessary effect of the contraction of the muscular fibres of the body of the organ is the exercise of traction on the cervical fibres. As the uterine contractions increase in force, the fibres of the body of the organ being stronger than the circular fibres of the cervix, the latter must needs yield or relax, and thus the cervix opens.
A further effect of the uterine contractions is to drive its contents downward toward the cervix. Under normal con- ditions, since the expelling force acts in the direction of the axis of the inlet of the pelvis, the contents of the uterus exert direct pressure on the cervix. The foetus floats in its membranes, and when tlie uterus contracts the water in these membranes is driven down, forming an hydrostatic wedge of great dilating power. It is likely, further, that the pressure of this wedge on the cervix acts as a direct irritant which, of course, leads to an intensification of the uterine contraction. After the membranes rupture, if this should occur prior to complete dilatation of the cervix, the foetus itself, descending against the cervix, acts as the wedge. Premature rupture of the membranes, however, is undesirable, as will be noted, because the foetal presenting part can never as effectually assist in dilatation, since it cannot pro- ject into the cervix as can the bag of waters.
130 LABOR.
This process of dilatation of the cervix is slow and pro- gressive under normal conditions. As a rule, ten to fifteen hours are requisite in the priraipara and six to eight in the woman who has borne children. During dilatation the shape of the cervix varies according as the woman is a primipara or not. In the primipara tbe opening of the cervix retains its circular shape, its edges becoming thinner and the presenting part, owing to its deeper engagement from the start, being more accessible to the examining finger. In the multipara the shape assumed will depend on the lesions which the cervix has 8ufi"ered at previous deliveries and the amount of the cicatricial tissue which has in consequence formed.
As the cervix dilates certsiin of its muscular fibres tear superficially, giving rise to a bloody oozing known as the " sliow," because its appearance is distinct evidence that dilata- tion is progressing.
Whilst, as a rule, under normal conditions, when once uterine contractions set in they are apt to continue after a rhythmical fashion, not infrequently these contractions will cease for hours or, instead of retaining the normal rhythm, tiiey will become short in duration and nagging, being absolutely lacking in dilating force. If tbe membranes have not ruptured the cessation of the contractions need cause no anxiety, because the foetus cannot possibly sutfer so long as it remains uncompressed hi its natuml uterine habitat, but tbe occurrence of the nagging contractions of short duration tires out the woman and usually means that the uterine force is not acting in the proper axis or at a disadvantage owing, possibly, to faulty position or to dis- proportion between tlie pelvis and the fcetns.
As the cervix approaches complete dilatation its circular fibres are drawn upward until they tend to retract over the Icetal presenting part. The membranes then rupture with a gush ; the uterine walls become closely applied to the foetus ; flexion of the fcetiis is intensified, and the presenting part passes through the open cervix into the upper part of the
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THE CLINICAL COURSE OF LABOR. 131
yagina. There is, however, no established rule as regards the time when rupture of the membranes occurs. At times rupture sets in even before labor, although then, often, it will be found that there existed a double amniotic sac, the second remaining intact. Again, the membranes may not rupture until the foetus is on the point of being born, or even until after birth, the child coming into the world surrounded by its "caul." Fre- quently, where the membranes are tliin or careless vaginal examination is made during a uterine contraction, they rupture before the cervix has dilated to an appreciable degree. This occurrence, as will be noted, is unfavorable, since the process of dilatation is thus impeded and much prolonged.
As the membranes bulge through the cervix they assume various shapes, according to the amount of water they contain and the nature of the presenting part. They are tense and resisting during a contraction and soft and flaccid during the interval. The degree of bulging depends not alone on the amount of liquor amnii present, but also on the presenting foetal part. Thus, in case of a normal presentation of the vertex, the membranes will never bulge to the same degree as in case of presentation of the pelvic extremity, for the reason that the vertex can apply itself more closely to the lower uter- ine segment than can the breech, and therefore less water can emerge in front of the vertex. This is a wise provision, as will be noted, since, in case of presentation of the pelvic extremity, dilatation must necessarily be accomplished by the membranes, the breech, from its shape, not forming a dilating wedge as may the vertex.
Dilatation of the cervix having been completed and the membranes having ruptured, the presenting part engages and escapes from the cervix, and we pass to the
STAGE OF EXPULSION.
During this stage the contractions of the uterus are re- enforced by the action of the abdominal muscles. The same
132
rhythmical character is present, — first the contraction, then the relaxation, then the pinise. During tlie period of coutraction the fcetal presenting part descends in tlie vagina, and dnring the pause it recedes a trifle, thns avoiding the consequences of con- tinuous pressure on the soft parts of the pelvis. The duration of this, the second stage of labor, is exceedingly variable. In the multipara with relaxed pelvic floor, as soon as the cervix has dilated, the presenting part may descend, rotate, and be delivered by a very few pains and in only a few minutes. In the primipara, however, the condition of the soft parts is dif- ferent. Whilst during the latter part of pregnancy tlie vagina has undergone changes which prepare it for the process of dila- tation, to which it must become subjected, the muscles and the fascia of the pelvic floor require time to stretch; so that ordi- narily the second stage in the primipara lasts two or three hours. The greatest resistance is offered at the outlet, and it is througli the intermittence of the pressure that the vulvar deft is caused to yield without resulting lesion. During tliis expul- sory stage of labor the actions and the appearance of the woman alter. Slie assists herself during the contractions ; that is to say, through forcible bearing-down eff'ort she is able to drive the presenting part downward. As the presenting part reaches the outlet the urethra is pushed upward, the perineum bulges out- ward, the anus dilates, and the suffering of the woman becomes of the most acute type. It is here, as will be noted, that auies- thesia should be resorted to, not only to spare the woman suf- fering, but also to protect the integrity of the maternal soft parts, which are greatly endangered if the bearing-down efforts are not paitially suspended. The contractions continuing, the fcetus is shortly expelled and there follows the
STAGE OF tTTERINE RETRACTION, OR OP PLACENTAL EXPULSION. The birth of the child is followed by a gush of bloody 1 fluid consisting of the residual liquor amnii and of blood, A ] pause in the phenomena then ensues. Tliis pause is conserva- I
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THE CLINICAL COURSE OF LABOR. 133
tive in that the woman is granted a few minutes' rest from her labors, and the uterus is enabled to regain tone for the final act of delivery. This period of rest varies in duration from a few minutes to fifteen or twenty. During the interval the umbiUcal cord is tied off and the child is separated from its mother. In rare instances the cessation of contraction is continuous, because in the final act of delivery of the child the placenta has also been expelled from the uterus into the vagina, rarer still into the world. As we have noted, the detachment of the placenta takes place through retraction of the uterus, consequent com- pression of the placenta, and separation of a layer of the decidua at the site of insertion. This detachment does not take place after a uniform manner. At times the centre becomes detached, a retroplacental hsematoma of considerable size forming, or else the primary detachment is marginal. Whatever the case, uterine retraction is followed by uterine contraction, and the placenta, as a rule, slides down the uterine wall, the foetal sur- face rolled together, and thus it passes into the vagina and through the vulvar cleft. The expulsion of the placenta after this normal fashion is practically painless, and is followed by the passage of clots and a variable quantity of blood. For a time thereafter there is a tendency to uterine relaxation, especially in instances where the act of labor has been protracted and the uterus has in consequence lost tone, but, eventually, firm uterine contraction sets in, which is so desirable as a safeguard against hsemorrhage. After expulsion of the placenta the maternal and the foetal surface should be carefully examined to determine if all has been shed, since, as will be noted, complete expulsion is essential to a smooth puerperal state.
The completion of the stage of placental expulsion marks the beginning of the puerperium.
Anomalies in the Clinical Phenomena.
The physiological course of normal labor is as we have stated it. Anomalies in the phenomena vary in degree.
134
and when they are mtensified the course of the labor becomes abnormal,
The contractions of the uterus may, from one or another cause, l>e inefficient as regards provokinf>; dilatation of <be cer- , vix. The woman may be of the highly nervous, Iiyperffisthetic type, in whom reflex nerve irritability is, at best, abnormal, and then the contractions lack the requisite rhythm or are short in duration and in so far ineffective. So long as the membranes ■ remain unruptured tlie consequent prolongation of the labor I lias no effect on the foetus, but the woman becomes exhausted J and, if means are not taken to secure regular and effective con- tractions, the fcetus suffers indirectly, since it necessarily sym- pathizes with the maternal organism. Another consequence of I ineffective, irregular contraction is the provoking of sjmsm of I the uterus, in wliich event, the uterine circulation being impeded, ] the fffitus necessarily suffers. After the rupture of the mem- bmnes tetanic spasm of the uterus, if not relieved, will kill tlie I foetus. The contractions of the uterus, on the other hand, may be excessive; that is to say, but little pause occurs between the contractions. The effect of tliis, aside from tiring out the ^ woman, may be the occurrence of precipitate labor, with tha| consequent risks to the woman and the child. The fcctns, I placenta, and the membranes being suddenly expelled, haemor- rhage from the organ may be profuse enough to exsanguinate the woman before the uterus lias a chance to regain tone and contract efficiently. Should the woman be in the erect position when this precipitate delivery occurs the fcetus might strike the floor with sufficient force to kill it, and inversion of the uterus may occur. After the rupture of the membranes the uterine I contractions may affect chiefly the lower uterine segment; that | is to say, the portion just above the internal os where the body | of the uterus is differentiated from the cervix. In such an event tliis area may be thrown into a spasm and a contraction J ring may form, which impedes further descent of the foetus J unless the attendant interferes. Irregular spasm and con-.
THE CLINICAL COURSE OF LABOR. 135
traction of this nature may, further, lead to rupture of the uterus.
After the rupture of the membranes the abdominal walls may not respond and do their share toward effecting the ex- pulsion of the fcetus. These walls may be weakened from one or another cause, such as hernia or laxity from excessive dis- tension long continued, and then the vis a tergo will not suffice to overcome the resistance of the pelvic floor.
Obliquity of the uterus, whereby the uterine force is unable to act in the centre of the pelvic planes, pendulous abdomen, disproportion between the pelvis and the foetus, abnormal presentation, intercurrent disease, — Bright*s or cardiac lesion, — such are further causes of inefficiency in the uterine contmc- tions, the result of which is delayed labor, possibly calling for active interference.
Even though the uterine contractions follow the normal course, dilatability of the cervix may be excessively slow or im- possible unless the attendant interferes. Premature rupture of the membranes, especially in case of an abnormal presentation, and even in case of the normal presentation of the pelvic ex- tremity, uniformly retards labor, for the reason that the dilating hydrostatic wedge is absent. Rigidity of the muscles of the cervix, the result of cicatrices from previous labors, or of actual disease of the cervix, such as beginning cancer, or the result of the application of caustics, — all these factors act as impediments to normal dilatation. Whilst the uterine and abdominal contrac- tions are strong and regular, in certain of these instances the attendant must interfere in order to avoid maternal exhaustion with the concomitant fcetal risk.
After rupture of the membranes and complete dilatation, notwithstanding strong and regular expulsory efforts, descent of the foetal part may be impeded. Very frequently this will be found to be the case with primiparaj who have passed the age of 25, the cause of arrest being an unyielding coccyx or an actual ankylosis at an acute angle. Instances of this nature
136 LABOR.
will asually call for interference on the part of the attendant not alone in order to release the impacted presenting part, but also in order to avoid protracted pressure on the maternal soil parts. During the second, or the expulsory, stage of labor we have noted that the normal clinical course is for the presenting part to descend during a contraction and to recede during the interval. This is a wise provision, since the result is that con- tinuous pressure is not exerted on the muscles of the pelvic floor. Just as soon as this recession of the presenting part fails to occur the time has arrived for interference, else sloughing and, perhaps, fistula into the bladder or into the rectum may occur.
When, under the influence of the expulsory contractions, the presenting part reaches the pelvic floor, excessive rigidity may lead to protraction of the stage of final expulsion. The vulvar cleft may be actually too small to allow of the expulsion of the presenting part, even though there be no impediment from the side of the pelvis ; or else the muscles and the fascia may be excessively rigid, in which case, in order to avoid deep laceration, it may be necessary for the attendant to interfere by the performance of episiotomy. ( Vide " Obstetric Surgeiy.")
During the first and the second stages of labor haemor- rhage may occur from premature separation of the placenta in part or in whole. Such haemorrhage constitutes one of the most alarming of obstetrical complications. It stands to reason that the life of the foetus is directly placed in jeopardy and, as we shall see, the woman may become exsanguinated before the attendant can render her any service. Haemorrhage of this character is called concealed haemorrhage for the reason that the blood may be eff'iised above the uterine contents, but little appearing externally, often not enough to attract the attention of the attendant. The general clinical phenomena, however, alter. The pulse becomes rapid ; the woman complains of feel- ing faint ; the uterine tumor distends abnormally ; the contrac- tions alter in character, becoming weal: luid ineffective or ceas-
THE CLINICAL COURSE OF LABOR. 137
ing altogether, as a result of the weakened condition of the woman and, further, as a result of the distension of the uterus. All this time, as we have stated, there may be no appreciable flow of blood externally, and yet the woman is surely drifting into a condition of acute anaemia. The watchful observer will note the alteration in the clinical phenomena. On auscultation he will determine that the foetal heart is becoming rapid and faint, and the change in the maternal pulse will awaken his suspicions. Perhaps, on pushing up the presenting part, a gush of blood will ensue or clots will pass ; but usually the diagnosis of concealed haemorrhage must be based on the alteration in the clinical phenomena, and the course of action should be simply according to the surgical rule of getting at the source of the haemorrhage and checking it. The chances are that when the diagnosis is strongly suggestive the child has already suc- cumbed. Whatever is done is in the interests of the woman alone. Since the haemorrhage is going on in the uterus, dissect- ing oflf the placenta and distending the uterus, the sole way to check it is to empty the organ in the quickest possible manner consistent with its integrity, and tlien resorting to compression of the bleeding-point, so to speak, according to the metliod which will be described under the subject of "The Treatment of Post-partum Haemorrhage." It should be remembered that, prior to rupture of the membranes, the amount of blood Avhich may be effused is simply limited by the distensibility of the uterus. As an actual fact, the woman, in certain reported cases, has practically bled to death before the complication has been recog- nized. The emptying of the uterus has been followed by tlie placenta and quarts of blood and of clots.
• After the completion of the second sta{2:e of labor certain anomalies of the third stage may demand interference. As a rule, very little haemorrhage accompanies the expulsion of the placenta. Exceptionally the uterus has lost tone, in which event it does not contract, and the attendant may have to face one of the most alarming complications of delivery. If the uterus does
138
not contract tlie uterine sinuses do not close, and in this eveni the amount of blood which the woman may lose in a relatively short time may be sufficient to exsanguinate iier. The methods for meeting this emergency will be treated of in the proper place, the aim being the promotion of uterine retractility and contractility, or else the compression of tlie bleeding-point, so to speak, in accordance with the surgical rule applicable to hsemorrhage.
The third stage may further be anomalous in that, notwith- standing efficient retractility of the uterus, the placenta does not separate, owing to the fact that pre-existing disease of tlie end(^ metrium or disease of the decidua has led to the Ibrmation of ad- hesions at the placental site. These instances are exceptional, since disease of either type is apt to cause the woman to shed the foetus before term. Apparent adherence of the placenta is not uncommon. In such an event either the placenta has been shed and is lodged in the upper vagina or else the internal os or the lower uterine segment has closed down and the placenta has not passed through, although lying free in the cavity of tlie uterus, The formation of a contraction ring above the level of what would constitute the internal os were the parts not dilated is a common cause of retention of the placenta.
Ordinarily the conrse of labor is not associated with lesion of the soft parts. Lacerations of the cervix and of the pelvic floor, however, are of not infrequent occurrence, and this, too, without the attendant being necessarily to blarae. The course of labor should never be deemed completed until these lesions are looked for by digital touch of the cervix and direct inspec- tion of the pelvic floor, since the attendant will be blamed, and rightly so, who, when repair is feasible, does not resort to it in accordance with the methods exemplified in the portion of this work dealing with surgery of the puerperal state. (^Vlde " Obstetric Surgery.")
I I
CHAPTER III.
MANAGEMENT OP NORMAL AND ABNORMAL LABOR.
Normal Labor.
Under the term " normal labor " are understood instances where the foetus enters the pelvic inlet and emerges at the pelvic outlet after a fashion in accordance with the normal mechanism of labor. Engagement, descent, rotation, extension, and delivery occur after that fashion which is essential for the welfare of the woman and of the child, under the natural efforts and within that time-limit which, according to the individual case, is consistent with the conservation of the strength of the woman and the vitality of the foetus. Under this definition any yariety of presentation may be normal, since, as we have noted, presentations of the pelvic extremity and of the face may be terminated within the stated limits and Avith the stated result.
Before entering into the consideration of the management of normal labor it is necessary to consider certain factors atten- tion to which is essential in order tliat the labor, and in particular the period following, may proceed after a normal fashion. These factors are the preparation of the surroundings of the woman and the Avoman herself Whilst under unfavor- able surroundings and in an unfavorable condition the phe- nomena of labor may progress after a normal manner, it stands to reason that that woman Avill best stand the ordeal of actual labor and best Avithstand the possible comi)lications of the puerperal state who has been confined under the best possible conditions of personal health and of personal surroundings. The ideal conditions requisite for smooth delivery and smooth puerperal state are not always attainable, but, the nearer these are approximated, the better the ultimate result.
Our prelude to the study of normal labor — and this also
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140 LABOR.
applies to the deviations from the normal — must consider the condition of the lying-in room and the necessary precedent care of the woman about to be confined. Labor being essentially a physiological process, complications which ensue should only be those which cannot be forestalled.
THE LYING-IN ROOM.
Cleanliness, fresh air, and sunlight are characteristics which the lying-in room should possess as far as possible. Whilst it is doubtful if puerperal infection can be traced to impure surroundings, — that is to say, can occur through atmospheric influence, — ^it nevertheless holds that in the performance of a physiological process such as labor, even as during the passage through a disease, the human body can best withstand agen- cies which may work harm if the conditions which hold sway over health are present. The best room in the dwelling should be selected for the lying-in room, and where possible this room should have no direct contact with the water-closet. It should contain as few articles of furniture as possible, heavy rugs and hangings being removed. The room should be thoroughly cleansed, the Avails wiped down and the bare floor scrubbed. Even though the carpets and hangings may do no harm, they are at least liable to damage, and the air is the purer and the sweeter for their absence. In case at any previous time an acute infectious disease has run its course in the room, greater precautions are necessary. It is accepted to-day that the lying- in woman is exceedingly susceptible to the absorption of conta- gion, and, therefore, a room which has been occupied by a per- son sick of scarlet fever, measles, or the like, should be prepared even as would the ward of a well-appointed hospital. The walls should be wiped down with a solution of bichloride of mercury 1 to 1000, the floor should be scrubbed with the same solution, and then, notwithstanding the skepticism prevalent, the room should be fumigated carefully by the burning of sulphur. This pro- cedure may eventually Ik" i Aitile or mmeoessary ; but, just
FLATF, XXVI,
MANAGEMENT OF NORMAL AND ABNORMAL LABOR.
141
SO long as many believe the process necessary in order to guard against contagion, it can do no harm to resort to it.
The simpler the appointments of the lying-in bed, the better. (Plate XXVI.) Tlie mattress should be covered with a large piece of ruhber sheeting ; over this the sheet is spread; a second piece of rubber slieeting covers this ; and over tliis is placed the draw-siieet, — that is to say, a sheet folded a number of times on itself, on which the woman is confined. After tlie completion of the act of delivery the nurse or attendant simply pulls this folded sheet and the uppermost piece of ruhber sheet- ing from underneath the woman, and at once, without specific- ally adding to her exhaustion, she lies in a clean hed.
We have already laid stress on the necessity, whenever possible, of the woman being watched with care during the ' process of gestation. If the urine has been examined at stated intervals, if the pelvis has been measured in order to determine the possibility of delivery at term, if the hygiene of tlie skin and of the intestinal canal has been attended to, the woman reaches term in a good condition to undergo, without undue strain, tlie physiological phenomena of labor. Immediately preceding the onset of labor tlie intestinal canal should be thoroughly cleansed by laxative and enema, because the normal mechanism of labor proceeds to best advantage when the rectal cul-de-sac is not loaded with fgeees and, again, because, during the expulsory stage, the crowding out of fsecal matter is annoy- ing to the attendant as well as interferes with the requisite cleanliness. As soon as true labor-pains set in the external genitals should be washed with bichloride-of-mercury solution (1 to 5000) or with creolin solution (1 per cent.), and a vulvar pad should he applied. A similar pad should he worn during the progress of labor, being changed as often as it becomes sat- urated. Ordinary absorbent cotton, sewed in cheese-cloth bags, will answer admirably for pads at this time and during the puerperal state. Tlie cheese-cloth should be boiled to remove the sizing, and after the pads are made they should be baked
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in an oven before use. The physician should not countenance the wearing of the old-fashioned napkin. Nowadays, a material should be used wliicli may be burnt after use, and the pads described are so inexpensive that their cost is hardly to be counted when compared with the additional cleanliness secured through their use. In the houseliolds of the very poor, where, of necessity, cloths of whatever nature attainable must be used, the attendant should be directed to boil them carefully before use. These precautions are absolutely necessary, in order to avoid infection, which, according to modern views, comes from contact.
The attendants should he scrupulously clean. Asepsis and cleanliness are synonymous terms. Both may be secured without resort to antiseptics, but, in order to leave no loophole for infection, wliich can but alter a normal, pliysiological act into a pathological, the latter must be used. Especially is this requisite if the physician has been or is in attendance on an in- fectious disease. Tlie exigencies of a large general practice will not allow the piiysician to refuse to attend cases of labor, but, in view of the truth of the assertion that the lying-in woman becomes septic, with rare exceptions, owing to the carelessness of some one of her immediate attendants, extra precautions are not alone requisite, but become the bonnden duty of evei7 con- scientious man. These precautions take but little time, and the man who is not willing to give this time in order to safeguard a human life had better decline obstetrical work altogether. Com- plete change of clothing, washing of the hair and the beard, washing of the hands, and a full bath, before going from an infectious case to the lying-in woman, are the requisites. It matters not so much the kind of antiseptic used. The aim to be attained is cleanliness.
The careless nurse is even more dangerous than the care- less physician. From force of training he will always aim at a degree of cleanliness, while she, in her supreme ignorance, wliich in her opinion is often of greater worth than the knowl-
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MANAGEMENT OF NORMAL AND ABNORMAL LABOR. 143
edge of the physician, may go so far as to disobey his instruo* J tioiis. Fortunately, the puerpera who has been contined after an aseptic manner, and wlio has been left clean, requires but little attention, tiie lack of precaution in regard to which might lead to infection. This is one of tlie advantages gained by the giving up of the systematic douching wiiich characterized the puerperiuni of the past. These points will be dwelt upon in the chapter dealing with the puerperal state.
Evei7 preparation should be made to meet tlie possible emergencies of labor. The well-appointed lying-in room should contitiu a bed-pan and douche-pan, a fountain-syringe, absorbent cotton, at least five yards of gauze, fluid extract of ergot or the preparation known as ergotole, auiesthetics (chlo- rofoini and ether), a glass, and a soft-rubber catlieter. Of course, the amount of material present will de^iend, of necessity, on the means of tiie individual case. For the poorer class of patients tlie plijsician will probably have to furnish the cottpn and gauze, and possibly tlie ergot and auiesthetic, and often he will be obliged to dispense with the bed-pan and douche-pan. We are noting here the articles whicli ouglit to be obtained or furnished in order that the physician may be fully prepared to meet every possible complication. These articles must be care- fidly sterilized by heat and thereafter kept sterile. Wlien sum- moned to a case, however normal it promises to be, the phy- sician should at least carry his forceps with him, since he may frequenlly feel called upon to use this instrument to avoid , maternal exhaustion or death of the foetus. It goes without saying that the forceps will be rendered aseptic before use,
"Whilst we have noted that it is desirable to have anses- thetics at hand, it by no means follows that they need always be used. Much depends on tlie exigencies of the individual case. It ia definitely settled now that auBesthesia during labor, administered as it will ordinarily be — short of the surgical extent, carries no risk to either the woman or to the child. On tlie contrary, we are enabled not only to si>are tlie woman need-
suffering, but also often to forestall impending maternal exhaustion and at the proper time to protect the integrity of fixe maternal soft parts. The questions to consider are the kind €»f anaesthetic which it is preferable to use and the lime when we ought to resort to it. Tlie belief, long prevalent, that anies- thesia tended to favor the occuiTence of post-partum htemor- .riiage. may to-dav be disposed of by the statement that, unless it be giTeii fur a prolonged interval to the surgical degree, it does not Interfere with the firm retractiUtj' and contractility of the uterus, which are desirable after the stage of placental delivery.
As a rule, chloroform is the best obstetrical ansesthetic ex- cept, possibly, where the administration is to be prolonged. In •ach a case ether should be selected, for the reason that acci- dents following its administration have been less frequent than [after chloroform. These accidents, in all fairness it should be ; stated, are very exceptional during labor. The tendency to , heart-failuie and to respiratory failure is lessened during the 'parturient act, owing to the fact that the uterine contractions are [constantly driving the blood to the brain through the heart, and, iiagain, the efforts of the (jartiirient necessarily entail free oxygen- F'tttion of the blood. Such statements hold true, at any rate, for ■ ordinary obstetrical anaesthesia, which is never pushed to the sur- l^cal degree. The woman always remains conscious of her I lurroundings ; we are able, at a moment's notice, to relieve her jrf the influence of the anaesthetic; consciousness is never com- ■jJetely abolished, as ia the case in surgical anaesthesia. And ^yet we accomplish a number of desiderata : We take the edge [off the suffering, so to s|>eak ; we aboUsIi, in a measure, reflex Excitability, — which often nullifies the bearing-down efforts; we nuBist in the relaxation of the muscles of tlic pelvic floor and, ueren without resorting to surgical anesthesia, we raav relieve [«pasm of the uterine muscle; we are enabled often to save the itegrity of the pelvic floor, which otherwise would ineritably [liave to yield to the applied pressure of the presenting part.
.\n£esthesia given to the non-surgical degree does notabol-
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145
ish uterine or abdominal contractions, but, on the contrary, ether, in particular, at times, would seem to re-enforce them, — at the moment wlien tlie presenting part is clearing tlie perineum, when the suffering is of the acutest type; this is pmctically abolished by simply, for the time, pushing the ansesthetic to the surgical degree.
In case of operative interference we prefer ether. Under such conditions it is requisite to obtain anoestliesia of the sur- gical ty[je, and it is unquestionable that then the safest ana^stlietic is etiier.
The more profound the anaesthesia, the greater the abolition of the contractions of the uterus and of the abdominal muscles and the longer it requires for the uterus to regain tone on emergence from the auEesthetic. Therefore, after the adminis- tration of an anaesthetic to the surgical degree, the greater the danger of post-iiartum hEeraorrhage. It is wise, therefore, for the physician to have everything in readiness for the control of hsemorrhage, sliould this occur.
As a rule, obstetric anaesth^la ia called for only when the presenting part reaches the pelvic outlet. Then is the time wlien abolition of the contractions is desirable for the double purpose of savnig the woman the intense agony of the final expulsory act and the integrity of the muscles and the fascia which form the diaphragm of the outlet.
The rules for administering an anfesthetic to the surgical degree are identical with those wliich hold for anesthesia in general. The presence of anotlier physician is requisite in order tliat the respiration and the pulse may be noted lege ariis. Ordinary obstetrical anesthesia, being intermittent and never prolonged to the surgical degree, may be safely administered by the attendant himself or by the nurse. In emergencies, the woman herself may be allowed to antesthetize, and a convenient method is the following: An ordinary goblet is packed with a handkercli icl", the edges of the goblet are greased with oil or with vaselin to prevent the chloroform from trickling down
and burning the face of the woman. The goblet is handed to the woman and slie is instructed to hold it over her mouth and her nose during the acme of the contraction. This takes the edge off her pain, and, In case she takes enough of the anes- thetic to abolisli reflex action, the goblet at once drops from her hand and any risk of over-antestliesia is avoided. It is dan- gerous to hand the woman a handkerchief on which the cldo- roform has been poured, for, in the event of the anesthesia sud- denly becoming deep, the handkerchief will drop on her face, and, if the attention of the physician is required for tlie con- duct of the delivery, the woman may take too much of tlie anEBsthetic. As a general rule it may be stated tliat, whenever possible, a physician should be present to give the antesthetic.
The minor ansesthetics or, rather, analgesics of utility during labor are chloral and opium or its alkaloids.
Chloral has a ])lace of great value in obstetrics. Whilst it is not an analgesic in tlie true sense, it certainly gives decided relief. During the first stage of labor, wlien the pains are nagging and in so far ineffective, the administration of chloral in 15-giain doses, rejicated half-liourly for three doses, regulates the contractions of the uterus and tlius gives the woman a period of rest during the pains. The interval between the con- tractions is lengthened and the pains are intensified, the uterus regaining tone during the longer intermissions. It has been claimed that this drug has a direct effect in causing a rigid cervix to soften and, in so far, to dilate witli greater readiness. This is questionable, but it is certainly tnie that rigidity of the cervix will often yield under the effect of the drug, although the true explanation probably is that, owing to the regulation of the conti-actions, the intensity is greater and tlierefore the dilating effect is increased.
Chloral is also of value for tlic control of the false pains which typify the precursory stage of labor, and acts admirably in allaying the suffering caused by ttio after-pains of the puer- peral period. Opium and its salts should rarely be used in
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MANAGEMENT OF NORMAL AND ABNORMAL LABOR. 147
labor or the puei'peral state. The aim is to secure physiological action of the intestinal canal after labor and during tlie puer- peral period, and, if opium is administered there is likelihood of intestinal i^ristalsis being checked. The chief value of opium is to allay reflex nervous excitability, and if other means fail, and the woman is becoming exliausted from the inefi'ective character of the contractions, tliis drug holds out a means of relief by giving the woman a period of sleep, during which the irritability of tlie uterus may be checked, with tlie result that the contractions become rliytlimical and natural, Codeine is the form in which opium had better be used. It lias not the same inliibitory effect on the peristalsis of the intestine that opium and morphia have, and yet, if administered in sufficient dosage it is as speedy in effect. The dose of codeine is larger than is generally recognized. Thus, it is safe to administer IJ grains by mouth and 3 grains by rectum.
In obstetrics, as elsewhere, opium is the best remedy of all for the relief of deep sliock. After the completion of tedious labor where the pulse is rapid and tlie woman is iu shock — to a degree — reaction may best be secured through tlie adminis- tration of an hypodermatic injection of morphia. Barring this exception, it is wise to remember that that puerperal state will be the smoother in which the administration of opium has been avoided, and that certain possible complications of this state are most amenable to treatment where the woman has not been saturated with opinm for the relief of symptoms which will ordinarily yield to chloral.
The first duty of the physician when called to a case of labor is to satisfy himself that the presentation is a normal one. If he has been engaged befoi-ehand he has familiarized himself with the configuration of the jKilvis according to the rules laid down under the subject of " Pelvimetry," and therefore knows that, so far as the pelvis is concerned, there is no obstacle to the progress of labor after the normal mechanism : or, in case he has determined pelvic contraction or abnormity, he is in a position
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' to take advantage of those measures which the character of the deviation from the normal demands. If he has not been engaged beforehand, his duty is to study the pelvis and to make up his mind if it is of sufficient capacity to enable tlie woman to deliver herself unaided. On the acquiring of this knowledge will depend the regulation of his own movements as well as the safety of the woman and child. In the case of a primipara, where the pelvis and the presentation are normal, it is not desirable that the physician should remain in immediate attend- ance, but, having assured liimself and his patient that all is right, he may safely attend to liis other duties in the kno^vledge that a certain length of time mnst elapse before his immediate services will be required. He may, therefore, leave his patient with the nnrse, and tluis avoid causing unnecessary anxiety in the mind of the patient, as well as be spared the constant ques- tioning to which he will be subjected if he remain in the house. The lying-in room should be left to the patient and her nurse. The presence of anxious relatives has a demoralizing effect on the woman, and also uses up the oxygen in the room which she needs in order to go through her ordeal in the best possible con- dition. A few quiet re-assuring words from the physician, especially if his manner be calm and his appearance free from anxiety, will do much to give the patient confidence in her ability to pass through her ordeal in safety.
The physician, having scrupulously disinfected his hands, proceeds to determine the presentation. The woman lies on her back, the abdomen being covered by a thhi sheet, and pal- jmtion determines the attitude of the fcetus. Above the brim in multiparse, and a trifle below it in primipara, the palpating hand will detect the head or the breech unless the shape of the uterus — transverse — certifies that tlie presentation is transverse, in which case no pi-esenting part will be determined at the superior strait. The hands next palpate the lateral walls of the uterus to determine on which side there is the greatest resistance, due to the dorsum of the fcetus. Next the listening ear makea
MANAGEMENT OF NORMAL AND ABNORMAL LABOR.
out the point of maximum intensity of the heart-sounds, as also their rhythm. The presentation liaving been determined, the next step is to make the vaginal examination, which enables the pliysician to satisfy himself in regard to the progress of dila- tation and the position of tlie presenting part.
The hands having been again carefully rendered aseptic, and the external genitals of the woman having been similarly disinfected, the physician separates the vulvar cleft with the thumb and the index of one hand and introduces the index or the index and the middle fingers of the other hand into the vagina, depressing the jierineum as much as is possible in order to be able to reach the cervix, which, during the first stage of labor, owing to the approach of the body of the uterus to the anterior abdominal wall, is apt to be in the sacral excavation. This method of inserting the finger is preferable to that gen- erally followed, where the finger finds its way into the vagina by being swept from the anus into the posterior vulvar commissure, since it is, above all things, necessary to carry no infectious material into the vagina, as is likely if the woman has involuu- tarily defecated between the cleanshig of the genitals and the insertion of the finger. The examining finger takes note of the degree of engagement of the presenting part and of the con- dition of the cervix. If active labor-pains have been present the cervix will be found somewhat dilated, and if the finger be left in the vagina during a contraction the membranes will be found to bulge during a pain. During a contraction care must be taken not to rupture the membranes, since on their integrity during the first stage of labor rapidity of dilatation depends, particularly in case of presentation of the pelvic extremity.
If the membranes be tliiti and dilatation has progressed sufficiently to enable the finger to reach the presenting part, then, in the interval of a contraction, an attempt may be made to determine the landmarks of the presenting part which lead to the difi'erentiation of the position, such as the fontanelle and the direction of the sagittal suture in case of presentation of the
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cephalic pole, the coccyx aud the intei^Iuteal cleft in case of the pelvic extremity, etc. As a rule, however, until dilatation has progressed one-half, — that is to say, until the cervix has dilated sufEciently to permit of exploration without much risk of rupt- ure of the membranes, if the jielvis is normal, and if the presentation is of the type which ordinarily causes no anxiety — vertex or breech, — the pliysician at this stage may rest satisfied with the information secured. He may then inform the woman and the relatives that everytliing is progressing satisfactorily and that he will return in a variable interval of time, according to the determined degree of dilatation. When asked, as he will be, how long labor will last, iie must never commit himself to a definite time, since, in the most normal case, the contractions may suffer arrest and the labor be protracted. The best answer to give is that everything depends on the frequency of tlie con- tractions and that it is simply impossible to state a time. Before leaving he should inform the nurse of his movements, so that he may be notified in case a complication arises.
During the stage of dilatation the position of the woman may vary according to her inclination. It is better that she should not assume the recumbent position, since the contractions of the uterus act to better advantage if she be erect or sitting; and then, again, she bears tlie (mins to better advantage. She may eat aud drink what she pleases, chloral being ordered, in case of nagging pains or nervous excitability, in ttie dose of 15 grains every hour or lialf-hour for three or four doses.
It will be remembered that during the first stage of labor the contractions are purely involuntary, the abdominal muscles being ineffective prior to rupture of the membranes and full engagement of the presenting part. The woman sliould, there- fore, be directed not to waste her strength in fntile bearing- down efforts. In the event of the contractions being regular, rhythmical, and yet the cervix remnins rigid, a valuable means of assisting dilatation is the hot douche. This should be ad- ministered under perfect aseptic precautious. Sterilized water
MANAGEMENT OF NORMAL AND ABNORMAL LABOR.
at a temperature of 110*" F. may be used, to which creolin may be added to make a 1-per-cent. solution. Bichloride of mercury- iiad better be avoided, since a large quantity of water will be necessary and tlie risk of poisoning sliould be borne in mind. At least four quarts of water should be used and the douche should be repeated at half-hourly intervals. This hot douching, aside from favoring dilatation by directly assisting in the softening of the rigid cervical muscles, also intensifies tlie uterine contractions.
Whei-e, notwithstanding these measures, the pains remain ineffective and become nagging in cliaracter, tlie physician, having satisfied himself that the pelvis is normal, should think of the possibility of the position being an unfavorable one. It will be remembered that obliquity of the uterus will interfere with proper dilatation, since the contractions cannot act in the axis of tlie plane of the superior strait. Such obliquity may be corrected by the application of a bandage, underneath wliich is placed a pad at the side toward which the uterus inclines; or the woman may be directed to lie down on the side opposed to the inclination of the uterus. Should this anomaly be rectified and still dilatation does not progress, or the contractions assume the nagging type, the time has arrived for determining the exact cause, for it is, above all, necessarj- that the woman does not become exhausted in fruitless efforts. A very common cause of faulty dilatation and of nagging, ineffectual pains is the lack of engagement of the head, owing, possibly, to a tendency to extension at the brim or to a posterior position of the occiput.
Exact diagnosis is now requisite, and, if on digital ex- amination the physician is unable to make out the position, the insertion of the entire hand into the vagina is necessary, under aneesthesia. This procedure enables the diagnosis to be certi- fied, and at one and the same time the measures for remedying the faulty position may be resorted to. These deviations from the normal course of labor will be considered in the section
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devoted to the consideration of the course and the managementl of abnormal labor.
The physician repeats his visits, and, each time under care-1 ful asepsis, makes his examination, until the stage of dilatationJ is completed or the membranes have ruptured. Just so long asl there is no evidence of maternal or of fcetal exhaustion, andl just so long as the clinical course of labor is proceeding aflerfl the normal fashion, the physician's policy is a waiting one, andl his immediate attendance is not requisite; on the contrary, hisi presence in the lying-in room simply excites the anxiety of the I woman, As a rule, the diagnosis of position and of the I capacity of the pelvis having been determined as normal, the I fewer the examinations, the better. No matter how careful we I are in our asepsis, each examination carries the risk of infection. ]
When dilatation has become complete or when the mem-, branes have ruptured, the physician should remain in the I house, especially if the woman be a multipam. The second I stage of labor not infrequently is very rapid, and the services of I the physician may be needed at any time. Interferenre will! rarely be called for, unless the woman or the fcetus gives evidence 1 of exhaustion, just so long as the presenting part is undergoing I the normal mechanism of descent and engagement. Tlie po- | sition of the woman during tlie second stage of labor, espe- ] cially when the presenting part has reached the pelvic floor, should be recumbent on the side or on the back, according I to the preference of the accoucheur. The dorsal position, in | the vast proportion of cases, is the preferable one for delivery, — the woman lying across the bed, her nates at the edge. The i abdominal muscles now coming into play, the woman may assist 1 herself by bearing down, and such effort is more effective if she [ can make traction on the hands of the nurse or on a fixed object, such as a sheet tied to the bed, and if also slie can press her heels against the edge of the bed or against two chairs. In ' case of great rigidity of the pelvic floor and a tendency of the I presenting part not to recede during the interval in the con-
TLATE XXVII.
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tractions, it is advisable to place the woman in the lateral position, when the presenting part is less likely to exert undue pressure on the pelvic floor.
During tliis second stage of labor the bladder should be emptied at intervals, whenever possible through the voluntary efforts of the woman, or, if she cannot, slie sliould be catheter- ized, always by sight after precedent cleansing of the introitus of the vagina. (Plate XXVII.) A distended bladder will interfere with descent of tlie presenting part, aside from the risk of rupture of tlie bladder under the forcible expulsory efforts.
A frequent cause of delay in this stage, when otiierwise everything is normal, is non-retraction of the anterior lip of the cervix. This Up becomes excessively oedematous and bulges down in front of the presenting part, thus interfering with descent. The remedy is to pusli this lip over the presenting part in the interval of a contraction and to maintain it there during a contraction.
At times, after rupture of the membranes, the tone of the uterus apijarently gives out and the inertia is complete. Ob- viously, tlie child is apt to suffer if such inertia be allowed to continue, and the effect on the woman of such delay in the progress of the labor is bad. There are a number of things which may be resorted to for recalling the contractions. Mass- age of the uterus will at times prove successful. The adminis- tration of quinine in large doses, such as 20 grains by the mouth or 30 by the rectum, occasionally appears to evoke contractions. Should these measures fail and tiie woman show evidence of exhaustion or the ftetal heart point to a similar condition im- pending, delay is no longer advisable, but the physician must apply the forceps as is indicated in the chapter dealing with this instrument.
Descent and rotation having occurred, we pass to tlie con- sideration of the management of the final stages of the expul- sory phenomena. When the presenting part reaches the pelvic floor, undergoing the normal mechanism, the resistance to be
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overcome is that which is oft'eved by the muscles and the fascia of the introitus of the vagina. This resistance must yield after a gradual manner, else the structures will be damaged. Re- laxation and retraction must occur and the accoucheur may materially assist by retarding progress of the presenting part and by maintaining the proper relation of this part to tlie diameters of the outlet. Whenever there does not exist dispro- portion between the object which aims to emerge and the parts through which this object must pass, the line of action is as follows: Let us take, for example, the most frequent position of the vertex ; Rotation occurs so as to bring the occiput imder tlie pubes. Vi'e have noted tliat the shortest diameter of the fcetal head is the suboccipito-bregmatic and that this engages in the autero-posterior diameter of the outlet. The head must remain well flexed in order that its favorable diameter may offer in this diameter of the pelvic outlet. Furtiier, in order that the head may emerge without damaging the maternal structures, slow exfx;usion must take place. The cardinal points to remember, therefore, are that extension must be delayed until the suboccipital point has become fixed under the pubes, and that then, and only then, extension after a gradual fashion should be allowed. (Plates XXVIII and XXIX.) The teaching of "support of tlie perineum" has been of great harm as regards the maintenance of the integrity of the maternal soft parts. It is not the perineum which needs support. It is the head which must be delayed in its progress until the muscular structures have relaxed, as they inevitably must unless diseased, and extension must be prevented until the proper diameter of the head lias engaged at tlie outlet under the pubic arch. If anything is to be " supported " it is the foetal head, and the support given is in the line indicated. In the normal case the perineum need ]iot be touched. Reference to the plate shows how tlie thumb of the attendant is delaying advance and, at tiie same time, promoting flexion until the structures have yielded and until the suboccipital point is
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engaged under the pubes. This accomplished, the piitient is ausesthetized momentarily to the surgical degree, and, in the intervals between the pains, tlie liead is shelled out over the perineum. In case, for one or another reason, it is inadvisable to administer an anesthetic to the surgical extent, the woman is counseled to avoid all expulsory effort. She is told to open lier mouth and to call out during a contraction, thus nullifying the effect of the abdominal contractions, and then tlie liead may be gradually [>eeled out over the pelvic floor. (Plate XXX.)
The methods still figured of the "support of the perineum" should serve as warnings wliat not to do. The thumb applied to tlie head and, if need be, the index finger inserted into ttie rectum, in order to enable tlie extension to be of the most gradual type, is the proper way to deliver the head, under normal circumstances.
Stretching of the muscles of the pelvic floor should be avoided, since such action leads to increase in the action of the uterus and to spasm of the muscular structures of tlie floor.
The head having been shelled out over the perineum, it is supported in tlie band until external rotation, or restitution, takes place. (Plate XXXI, ) Next the shoulders must be delivered without lesion of the maternal soft parts. Under the normal mechanism, with which, at the present, we are alone concerned, the shoulders rotate antero-posteriorly, the anterior becoming fixed under the pubic arch and tlie posterior sweeping over the pelvic floor and out at the posterior commissure, ^yhen the head has been delivered the nurse follows down the fundus of the uterus or the physician does so with his disengaged hand. The object of this is to cause the uterine walls to leraain in close apposition to the fcetus, — a point of exceeding importance in case of presentation of the pelvic extremity, since thus ex- tension of the arms above tlie liead is prevented. In case of inefiicient contraetions alter the birth of the presenting part it is nece.ssary to re-enforee them, since, the presenting part being in the world, the life of the foetus may become imperiled through
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pressure exerted on the umbilical cord. Whilst, therefore, it is wise to await the recurrence of normal contractions, in the event of these being delayed, the attendant, by pressure oyer the fundus of the uterus, may assist in the expulsion of the remainder of the ftEtus, this pressure being aided by traction on the portion of the fcetus which is in the world, such traction being made in the axis of the pelvic outlet, — that is to say, directly downward. (Plate XXXII.) In case of further delay, the finger inserted under the pubic arch or over the posterior commissure, according as one or the other arm is accessible, hooks this arm down and delivers it by a procedure of flexion and extension over the ventral surface of the fcetus. During extraction of the arms the woman should be still counseled not to bear down excessively, for sudden emergence of the arms is .apt to damage the pelvic floor.
The arms having been extracted, the trunk follows rapidly, in case of presentation of the vertex; and in case of presenta- tion of the pelvic extremity, if the normal mechanism is fol- lowed,— that is to say, if the occiput rotate anteriorly in a position of thorough flexion, a position whicli may always be maintained by suprapubic pressure, — the after-coming head emerges, by its shortest diameters, in turn.
As the child is born it is supported by the nurse until the umbilical cord is tied.
Where the child is strong and cries lustily the cord may be tied without special delay ; but, if the reverse is the case, it is desirable to wait a few minutes in order that the fcetus may receive as large an amount of blood as possible. In case the child is born asphyxiated it is necessary to tie the cord as rap- idly as possible, or to clamp it and to cut between the clamps, in order that tlie measures requisite for resuscitation may be resorted to. (Plate XXXIII.)
The cord should be tied at two places, — the first about one inch and a half from the umbilicus and the second three to four inches nearer the mother. Boiled silk-worm gut forms an
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MANAGEJIENT OF NORMAL AND ABNORMAL LABOR, 157
excellent material for ligature, since thus we minimize the risk of infection of the fcetus at the umbilicus. Whatever the material used, it should be thoroughly sterile. Ligation is ac- complished by making a single knot and then carrying the ends around the cord and tying in tlie surgical knot. Thus we avoid risk of slipping, which might entail lisemorrhage and foetal death. The object of the second, or the ligature on the matenial side, is twofold. In the first place, a second fostus may lie in the uterus with common placenta and amniotic sac, and if the cord be not ligated toward the motlier the life of the twin would be imperiled. Secondly it would seem as though the expulsion of the placenta were facilitated if the retraction of the uterus take place on a firmei' placenta, as the organ necessarily la when filled witli blood. In case the umbilical cord is very ' tliick, before applying the ligature it is advisable to strip the cord of its gelatinous covering, since then the vessels may be the better secured and there is less risk of hffimorrhage.
The cord having been tied, it is cut between the ligatures and the child is handed to the nurse. The carewliicli it should have, as well as the measures for resuscitation, should it be as- phyxiated, will receive attention in the chapter treating of the "Care of the Newborn Infant."
With tlie expulsion of tlie body of the foetus there follows a gush of fluid consisting of the residual liquor amnii and of blood. The uterus, it has been noted, should be followed down as the child is exjielled, and the hand should keep control of it during the next, or the third, stage of labor.
After the expulsion of the child the uterus, as a rule, rests for a variable interval, regaining tone, as it were, in order to retract and expel the placenta. Occasionally, wlieu the con- tractions are very energetic, there is no appreciable pause, but as soon as the child is born the placenta follows. This, how- ever, is the exception. It is important to remember that, as a rule, there is a decided interval between the end of the second and the beginning of the third stage of labor; otherwise inju-
158 LABOR.
dicious and premature attempts may be made to accelerate tlie tliird stage, with results of an untoward nature. It has been noted tliat separation of the placenta occurs through tlie splitting of the serotinal layer, and that coiicomitiintly tlie titerine walls retract, squeeze down upon the placenta, and drive it into the vagina. The course for the attendant to pursue is to keep his hand on the uterus for a few minutes to guard against undue relaxation, and then, when the uterine globe is felt to harden under tlie hand, to assist in the expulsion by the method of manual compression, which is knowu after Crede, who first systematically described it, (Plate XXXIV.) TI procedure is as follows : Tlie radial surfaces of the hands i applied at the fiuidns of the uterus, the palms of the hani resting over the body of the organ, the thumbs meeting in ti mid-Une. When the uterus is felt to harden, pressure is mm by both hands in the direction of the plane of the pelvic inlt Thus tlie muscular force of the hands of the physician Is addi to the contractions of the uterus and often, at the first attemp the placenta is not only expelled from the uterus into vagina, but out of the vagina into the bed. Rarely, howeve is the first attempt successful. Where it fails, the attendai keeps his hands in position and awaits a second uterine contra tion. Should this not tend to recur, or should it be feeble, gei tie massage of the uterus, will often evoke stronger contraction Patience is requisite and the uterus should not be spurrw into action before it is ready to act, — that is to say, before has regained tone. Usually from fifteen to thirty minutes elaps from the termination of the second stage of labor until the i of the third stage. This is entirely within physiological limita and if no complication offer, such as hasmorrhage, delay to thi extent need give rise to no anxiety.
As the placenta emerges at the vulva it is received in the ban and held tliere until the membranes are shed. (Plate XXXV. In normal cases the membranes follow the placenta at once, bill frequently, after the uterus has expelled the placenta, the lowt
h^
MANAGEMENT OP NORMAL AND ABNORMAL LABOR. 159
uterine segment contracts and the membranes are nipped. This is particularly apt to occur where attempts have been made to hurry the third stage or where the uterus lias been irritated by over-zealous massage. In the event of the membranes becoming caught as described, the policy to pursue is to allow the uterus to reUix a trifle, when, witliout difficulty, the membranes emerge. The teaching, tliat wlieu tlie placenta has been delivered the membranes should be rolled into a cord in order to enable their extraction intact, is a common cause of so-called retention and "morbid adliesions " of tlie membranes. The fact is that, when the membranes are twisted, if tlie internal os should close down a portion of tlie membranes are inevitably torn off. Adherent placenta and retention of the membranes become very rare as the physician familiarizes himself with tlie proper conduct of the tliird stage of labor. Such occurrences are due either to pathological cliunges at tlie placental site or else the adhesion and the retention is only apparent, tlie placenta liaving become detached or the membranes being torn off' by the method of delivery and remaining incarcerated in the uterus through the shutting down of the lower uterine segment.
It will be noted that we have avoided referring to a prev- alent metliod of placental delivery, — traction on tlie cord. This metiiod is to be rejected on the ground that resort to it is unnecessary, and that it may prove dangerous. Wlien we re- call the normal mechanism of placental expulsion it is apparent how futile traction will be before separation of the placenta at the serotina has occurred. If tiie attachment be a firm one, what is needed is patience in order to await the natural separa- tion which is an associate of the natuml retraction of the uterus. Traction will simply irritate the organ, and, should it he forcible enough to cause detachment in advance of the normal mechan- ism, the venous sinuses of the uterus will not have a chance to close after the requisite normal fashion, and the woman becomes subject to the risk of liieraovrhage. Alter normal separation of the placenta traction on the cord may certainly be effective in
160
the delivery of the placenta, but resort to 3uch a method is um necessary, since the normal mechanism is sufficient. Further^ in a given case we are never aware that the placenta is not ad herent, and, if we make traction under such circumstances, thi effect is simply to pull off a portion, or else, if the uteru atonic, to pull down the site of placental implantation, and thu to favor inversion of the uterus. It maybe laid down as a cai dinal rule that, if tlic placenta cannot be expelled within i reasonable interval by the natural powers, assisted by manualj compression, it is adherent, or else that it is incarcerated aboyi the lower uterine segment, in which event traction on the cord i also bound to fail in effecting delivery, and manual extractionJ will be necessary. Just so far as the normal mechanism of th^ shedding of the placenta is borne in mind, and just so far i tlie physician is familiar with the manner of application ofl Crede's method, just so infrequently will he resort to extraction! of the placentfi through traction on the cord. When uterine globe is felt to harden effectually, becoming smaller and remaining so, then, if the placenta has not api>eared at the o\iU let, the inference is allowable that it has simply been expelle< into the vagina. In such an event the examining finger wili detect it in the vagina, and then traction on the cord is allow-^ able to remove it from this passage.
When the uterus has been emptied it ordinarily will conJ tract into a hard mass like a cricket-ball; but for some time it i^ very apt to undergo relaxation, and therefore the golden rule keep the hand on it for at least one-half hour after delivery, la order to guard against relaxation and post-partum haemorrhage,!
After the delivery of the placenta and membranes the]P should be carefully examined in order to determine if they area entire. Not alone should the fcetal surface be looked at in! order to be assured that the two layers of the amnion are prea-l ent as well as the chorion, hut the maternal surface should t most carefully scrutinized in order to detect absence of a coty*l ledon or deficiency in a large part of the placenta. This pte-J
MANAGEMENT OF NORMAL AND ABNORMAL LABOR. 161
caution should never be neglected, since the nonnal course of the puerperal state depends on the absolute emptying of the uterus. In the event of there bemg auy doubt as to the in- tegrity of the placenta or the membranes, then the interior of the uterus should be at once explored. Under strict aseptic pre- cautions the hand is inserted into the uterus, the organ being depressed as much as possible by the other hand. The cavity is carefully explored and wliatever remnant is found is removed. It is far easier to explore the interior of the uterus after this fashion immediately after labor, when the vagina and the uterus are wide open, than a number of days afterward, as will be- come necessary if the retained remnants are not detected until symptoms of septic infection set in. All that the physician need remember is the necessity of absolute cleanliness and of gentle manipulation.
Wlien satisfied that the uterus is empty, ergot should be administered, in the dose of 1 drachm, by the mouth. The necessity for the administration of ergot is disputed. Unques- tionably, under physiological conditions, the uterus will contract after delivery and remain in that state of contraction which is so essential to tlie smooth course of the puei-peral state. But women rarely approach labor or pass tlirough it in a strictly physiological manner. As a rule, under the pressure of our high civilization, nervous strain is exaggerated during pregnancy and intensified during labor. Tlie result is that the contractility and retractility of the uterus stands in need of re-enforcement, as it were, and this may be secured through the administration of ergot. The drug cannot do harm, and extended experience would seem to prove that its administration, after the completion of the third stage of labor and during the first few days of the puerperal period, assists in maintaining due contraction and, thereby, hastening involution. This, however, is the only time when ergot should be given. During labor it has no place. We possess far safer means of accelerating deficient contrac- tions, and, if an indication offer for the speedy termination of
162 LABOB.
the labor, the minor operative measures, being under the contnf of the physician, are far safer for the woman than the action irf a drug the property of which is to set up and to maintain con*- tmctions in a manner often beyond our control. The distinctive property of the drug should ever be borne in mind. If adm istered during labor it may at once lead to the speedy expulsiffl of the child, but it may also lead to tetanic spasm of the uterui whereby the life of the fcBtus is imperiled and whereby, alsfl should operative interference become necessary, this is nullifie or rendered dangerous, owing to the spasm which has I evoked. Further, ergot administered during labor may affa cliiefly the lower uterine segment, and the fcetus becomes iocai cerated or, the upjier segment remaining relaxed, haemorrha| may ensue, which will kill the child and excessively endau| tlie woman.
After the expulsion of the placenta there occurs a loss of variable amount of blood, the overflow, as it were, from l' uterine sinuses. This is pliysiological, and, as a rule, the uten contracts and remains so, the further loss being the lochl which is a discharge consequent on tlie involution of the nten "Wliere the labor has been protmcted or where it has bet necessary to resort to surgical aneesthesia, the loss of blood mi be considerable, leading to wliat is termed post-partum hcemCI rhage and constituting one of tlie most alarming of ohst^trio complications. This post-partura h^morriiage may set in irara diatoly after the completion of the third stage of labor or a number of hours afterward. Even at a still later date hiemor* rhage may occur, — called secondary post-partum hfemorrhage; but such an occuiTence is due, usually, to tlie presence of a for- eign body in the organ, such as a portion of tlie placenta, and is not dependent on atony of the organ, as is the type of bleed- i ing we are now considering.
Post-partum hemorrhage is caused by deiiciency in the ' contractility and retractility of the uterus. Long-continued labor; exhaustion of the woman; sudden termination of the '
MAKAGEMENT OF NORMAL AND ABNORMAL LABOR, 163
labor, especially of the placental stage ; the presence of a tumor, such as a fibroid, in a segment of the uterus leading to unequal contraction, — such are the causes of post-partum heemorrhage. Where nerve-tone is at par, and the woman has passed tlirough her labor after a physiological manner, and the uterus has been absolutely emptied of all remnant of placenta and of membrane, the occurrence of htemorrhage is excessively rare ; still, after every case, the possibihty should be borne in mind and the physician should be prepared to meet the complication.
The minor bleeding may be met by the administration of ei^ot by the mouth or hyiiodermatically, and by gentle massage of the uterus. The source of the hfemorrhage should be care- fully differentiated. It should be borne in mind that profuse hemorrhage may come from a lacerated cervix tlirough involve- ment of the circular artery or from extension of the rent higher up into the broad ligament. Of course, the treatment of such a lesion will be vastly different from tiiat of oozing from the uterine sinuses. Under aseptic precautions, therefore, the first step in every case is to investigate the cervix. After labor the marghis of the cervix are flabby and in contact with the vag- inal walls, and, therefore, the simple vaginal toucli is uncertain in making the diagnosis. The woman being on her back, the cervix should be seized between the thumb and fingers and brought down to the introitus of the vagina, when, under in- spection, the extent of the lesion, if any exist, may be deter- mined. It can tlien be repaired after the method described in the chapter dealing witli " The Surgery of tlie Puerperium." ("Obstetric Surgery.") If this source of hiemorrliage lias been excluded, then, unless the bleeding be profuse, the milder methods may be tested for controlling it. Such methods are ; massage of the uterus and the hypodermatic injection of ergot; the injec- tion into the uterus of water at a temperature of 115° F.; the insertion of ice. These are the only measures we can approve of In a strict emergency, where the physician is not prepared with all that is requisite, the injection of vinegar into the organ
ia allowable, but we unqualifiedly condemn the use of iroi Iron injected into the uterus, in the form of the subsulpliate, i without question a powerful styptic, but the clots which are " formed are very liable to decompose and septicaamia is a likely result of its use. Besides, to-day there is no excuse for the use of iron or iodine or other styptic. We have seen that among; the tilings which should be in the well-prepared lying-in room is sterilized gauze, and it is a good rule for the physician carry such gauze with him whenever he is summoned to a ( of labor.
If the milder means of checking post-partum hasraorrhage through evoking uterine contractility and retractility fail, — such as the hot intra-uterine douche, massage of tlie uterus, and the injection of ergot, — then the time lias come for a resort to the one certain means of controlling the hsemorrliage, and this is the intra-uterine tamponade. But little time should bej tost in resorting to this measure, for the woman, exhausted hjm the efforts at delivery, cannot stand tlie loss of much blood, andl if we dally overlong she may sink into collapse or lose enough to pass into a condition of acute anaemia often of a rapidly fatal type.
It has been proved that the intra-uterine tamponade is nol alone effective, but safe. It was feared that tlie hyiwrdistensiott of tlie uterus caused by the firm tamponade would interfere with.! retraction after the removal of tlie tampon. This, however, hatf.a been proved a groundless fear. The uterus, as a rule, contracts firmly when the tampon is removed and remains contracted.1 Should there be any tendency to permanent relaxation it is a simple matter to tampon again.
The gauze for purposes of the tamponade should be tw^ inches in width, and fully five linear yards will be needed, Ifl must be emphasized that this gauze must be sterile, and,! further, that every step of its insertion must be sterile. Aflerl labor at term, where the uterus is wide open, as it is customaryl to find it in case of hiemorrhage due to want of tone, it is sJ
MANAGEMENT OF NORMAL AND ABNORMAL LABOR. 165
simple matter to pack this gauze in the uterua by the hand, the other hand controlling the organ through the abdominal wall. What we are aiming at is control of the blecdmg tliiough com- pression of the bleeding-point, so to speak, and, therefore, the uterine cavity must be packed full and the uijjjer vagina as well. This packing may be left in for at least thirty-six hours, when, under careful asepsis, it is removed, and, if the uterus is still atonic, the cavity is washed out with hot sterilized water and a new packing is inserted. Whilst the gauze is in place the chances are that the woman will have to be catlieterized, and this should be done by sight after careful precedent cleans- ing of the vestibule.
In order to counteract the anasmia caused by loss of blood the usual methods of stimulation sliould be resorted to, such as whisky or brandy, hypodermatically ; stryclniia, ^\ grain, hypo- dermatically, repeated hourly for three or four doses ; but the best means of all for restoring the quality and the quantity of the blood is resort to hot saline infusion. In conditions of acute anaemia it is a very difficult matter to resort to venous infusion, since it is hard to find the calibre of the collapsed vessel and the apparatus is never at hand. It has been found that injec- tion of 1-per-cent. hot saline solution into the cellular tissue of the back or abdominal wall is very effective, and a number of pints may thus be given. Alt that is necessary is a clean syringe and a large hypodermatic needle. It is questionable, however, if, in the average case, injection of the same solution into the rectum be not as effective. The rectum rapidly absorbs hot salt water, and we avoid the risk of abscess in the cellular tissue, which we are liable to get if the instruments used and the solu- tion and the surface of the skin be not aseptic, and in our liurry to meet the emergency there is ample loophole for error in tech- nique. Tiie hot (115" F.) saline (1 per cent.) solution is injected into the rectum, about 2 quarts being used, and this proced- ure is repeated to advantage hourly until tlie quality of the pulse improves. All of this solution is, of course, not absorbed.
166 LABOR.
but sufficient is to stimulate the beart-action and to improTC I the quality of the blood.
The placenta and the membranes having been delivered, and the uterus remaining thoroughly contracted, the next step is to cleanse the woman's genitals and to apply the puerperal binder. If the delivery has been conducted alter that aseptic fashion which should alone be tolerated to-day, there is no call for the administration of a vaginal or the intra-nterine douche. In case, however, there is any reason to question the strict asepsis of the different steps necessary for delivery, then it is wise to administer one douche, and this should be the last during the puerperium unless certain symptoms develop, stress upon whicli will be laid in the cliapter dealing witli the puer- peral state. According to individual custom, this douclie may consist of a l^per-cent, solution of creoHn or a 1 to 2000 solu- tion of bichloride of mercury. It goes without saying that the syringe should be sterile as well as the hands of the attendant who administers tlie douclie. For both intra-uterine and vaginal douching immediately after the completion of labor, the ordinary glass tube attached to a bulb or a gravity syringe is the best. In case the douche is intra-uterine, the physician alone is comp tent to give it. Such a procedure should never be intrusted ( the nurse.
The external genitals of the woman are carefully washn with a 1 to 2000 bichloride solution, and then the sterilizt gauze pad is applied to the genitals and this is pinned, back andj front, to the abdominal binder.
Whilst the application of the abdominal binder can haT< no effect, as is the popular belief, on tlie restoration of the forna of the woman, it nevertlieless holds true that she is more com^ fortable if it be used. For a considerable time the abdomeaf has been subject to the strain of distension, and the suddeoj relief of tlua strain seems to call for some support. The bindeijl is applied mainly for the above reason, except in those instanra where there is reason to anticipate relaxation of the uterus, and!
_k J
L
MANAGEMENT OF NORMAL ASB ABNORMAL LABOR. 167
then the binder serves the purpose of holding in position the pad which it is customary to place above tlie fundus of ttie uterus to guard against relaxation. (Plate XXXVI.) Tlie preferable binder is made of unbleached muslin, gured at tlie sides to fit over the hips. It is pinned firmly so as to give sup- port, never to sucli a degree as to press the uterus out of its natural relations to tlie abdominal cavity.
The binder and tlie pad having been applied and the soiled draw-sheet having been removed, the woman lies in the clean bed and the puerperal state begins, the management of wliich is considered in a separate chapter.
Abnormal Labor.
Tlius far we have traced the course of normal labor. Ab- normal labor may depend on deviation from the course of the customary phenomena, either through abnormity in the mech- anism or in the position of the presentation. We would lay renewed stress on the fact that any variety of presentation may terminate normally, provided the necessary mechanism be fol- lowed. Thus, even as we may have deviations from the normal in case of presentation of the cephalic or pelvic pole of the ftBtus, even so may the face and the shoulder presentations ter- minate normally, provided only that the mechanism requisite for delivery be followed. It serves no useful purpose, therefore, to describe the course of labor under the various presentations. If the requisite mechanism in each case be fully understood there is need for descriptions only of the complications the result of such position of the presenting part as necessarily entails defect in the mechanism.
Under this definition we pass to the description of
ABNORMAL VERTEX PRESENTATION.
It will be remembered that, in order that presentation of the vertex may start the normal mechanism from the pelvic brim under the best possible conditions, the head should present
168
in a position of flexion, which becomes intensified as, under the uterine contractions, engagement and descent take place. Occasionally the vertex presents semi-flexed, or, practically, tlie brow of the foetus offers instead of tlie occiput. Under such circumstances, as the uterine contractions tend to cause engage- ment, one of two things happens: Either the brow becomes con- verted into a presentation of face or else flexion occurs and we obtain the more favorable presentation of the occiput. The cause of this semi-flexed position at the superior strait will usually be found to be an obhquity of the uterus, the result of wliich is that contmctions of tlie uterus do not act on the short arm of the lever, but on the long arm, and consequently the head offers semi-ffexed instead of flexed. The rectification of such an anomaly, in case it be recognized before engagement, suggests itself It consists simply in applying a bandage with an underlying pad over the side toward which the uterus in- clines, with the result that the obliquity is rectified; or, the woman may be made to He on the side opposed to the obliquity, when, under the force of gravity, the obHquity is rectified. In the event of the position being determined, as will ordinarily be the case, after engagement and before the rupture of the mem- branes, then, by means of suprapubic pressure on the occiput and applied pressure on the forehead by the finger in the vagina, there may result proper flexion of the head, which is what should be aimed at. Ordinarily, however, if the head enter the pelvic inlet in this semi-flexed manner the result of the con- tractions will be to convert the position into one of the face, when, as we have seen, if anterior rotation of the chin take place delivery is perfectly possible through a normal pelvis, only the stages of labor — the dilating and the expulsory — are pro- tracted. We will speak of this further under the subject of " Face Presentations."
Under the subject of " Mechanism of Labor " stress was laid on the untoward nature of posterior positions of the vertex wliere anterior rotation failed. It was further stated that, in the
J
MANAGEMENT OF NORMAL AND ABNOEMAL LABOR. 169
majority of instances, anterior rotation probably occurred, even though delayed until the occiput reached tlie pelvic outlet. Still, we are never in a position to predict the case where this anterior rotation may not fail, posterior rotation into the hollow of the sacrum being substituted. In view of the untoward effect of sucli rotation on the woman and the child, it seems wise to advocate the conversion of the posterior occiput into the anterior as soon as it is detected, and so long as the conditions essential to success without damaging the woman or the child are present. When recognized at the brim, before rupture of ■ the membranes and before deep engagement, two courses are open to us, — the one is version and the other is the manual rec- tification. Where the pelvis is normal and the child is not too large for the pelvis, version does not seem to us called for. If the cervix is wide-enough open to permit of version or if it be dilatable enough, then the insertion of the entire hand into the vagina and the grasping of the child at the neck and rotation of the foetus and, therefore, of the occiput into the anterior plane, as specifically described in "Obstetric Surgery," suggests itself as preferable. This entails ansestliesia, but so also does version. The advantage gained, provided the foetus can be made to occupy tlie position into which it is altered, is that the chances of the delivery of a living child are greater than when the fcetus is made to engage by tlie afler-coming head, as is necessarily the case after version. Where disproportion between tbe foetus and the pelvis exists, on the other hand, it is preferable to elect version, since, in dystocia due to this cause, the after-com- ing head molds better than the before-coming. Where the head has engaged by its greater segment before the posterior position of the occiput is detei-mined, tlien, should the mem- branes have ruptured, botli manual rectification and version are contra-indicated, and the duty of the attendant is simply to watch both the mother and the foetus in the hope that anterior rotation may occur. Of course, the labor will be tedious, but in- terference will not be allowable unless either the woman or the
170
foetus shows signs of exhaustion. In such an event the best tha the attendant can do is to apply the forceps and deliver, witl the consequent necessary damage to the pelvic floor, unless, evei during cxtmction by the forceps, anterior rotation should occui
Rarely, in connection with presentation of the vertex, pro lapse of a hand or of the cord occurs. Prolapse of the han( by the side of the liead delays the labor, because it interfere with the requisite mechanism of labor. The treatment consist in the endeavor to push up the hand, and, this accompUslied. il the membranes have not ruptured, then it is wise to break then in order that, the vertex descending into the cervical ring, thi hand cannot prolapse again. Rarely will it be necessaiy ti resort to version to meet this abnormity. If the presenting par has engaged with ttie hand prolapsed, then it probably will no be possible to replace the hand, and the delay in tlie labor ma; be sucVi as to threaten exhaustion, and tlien the forceps will b indicated to terminate the delivery.
Prolapse of the cord in case of vertex presentation is un common, compared with the occurrence in connection with pres entations of the pelvic extremity. If it be determined befon rupture of the membranes and engagement, then postural treat ment will often answer for the correction of the prolapse, or, a any rate, the cord may he saved from pressure during the con tractions until sufficient dilatation lias occurred to enable ua tc either rupture tlie membranes and push up tlie cord before thi head has a chance to engage or else to resort to version.
Very exceptionally we note what is termed an "inclined' presentation of the vertex. In such cases t!ie ear or the pari etal protuberance presents at the centre of the superior strait Such presentations are the result of obliquity of ttie uterus. Ii case this presentation does not become rectified, then, since th( long occi pi to-mental diameter of tlie head offers at the superioi strait, arrest of the head necessarily occurs and termination oi the labor under the natural efforts is impossible. As soon therefore, as this presentation is recognized, interference li
MANAGEMENT OF NORMAL AND ABNORMAL LABOR. 171
called for at a time when assistance is comparatively easy, since, if the head become impacted, destruction of the foetus through diminution in its bulk is the only method of delivery. "When the head is still movable, if the membranes are unruptured, as soon as there is sufficient dilatation of the cervix, version is the ojieration of choice. In case the membranes have ruptured, the whole hand should be introduced into the vagina, the occi- put is to be seized, and, during the absence of a contraction, the head is to be puslied up and flexion is to be secured. This, however, is not sufficient, but the head must be maintained flexed until the recurring uterine contractions have caused it to engage in the favorable position. If this mauipniation is im- possible, then, under deep surgical autesthesia, whereby the uterus is relaxed as mucli as possible, the manipulation may succeed. This failing, the only resort, short of craniotomy, is a tentative application of tlie forceps. We lay stress on the word tentative, for, the forceps being applied above the pelvic brim and necessarily grasping the fcetal head so tliat the long occipito- mental diameter offers at the su]>erior strait, it is questionable, unless the head be small in relation to the given pelvis, if traction will suffice to promote flexion and to cause engagement without the infliction of considemble traumatism on the mater- nal parts. The good rule, wliere version and restitution by the hand fail or are contra-indicated from tlie start, is to resort to craniotomy, unless, in full view of the increased ri.sk, the woman or her representative elect sympliysiotomy or the Ciesarean .sec- tion. These operations will always be contra-indicated when the woman or the fcetus sliows signs of exhaustion, since a major operation resorted to in the presence of exhaustion of either can but result in the delivery of a dead foetus at the greatly-increased risk to the woman's life.
FACE PRESENTATIONS.
Our study of tlie mechanism of labor has taught us that presentations of the face may terminate under the natural
172
I postei
i tence
effoits, provided that rotation occurs with the chin to the pubes It is a fact, however, that, under the most favorable conditions face presentations prolong labor unduly, and that there is alwayi imminent risk of maternal and of fcetal exhaustion. Further even thougli the face enters tlie superior strait with the chit pointing to the antero-lateral plane, in a given case we car never feel snre that, on reaching the pelvic floor, posterior rota- tion may not occur, Tlie evident corollary is that a presenta tion of the face, when recognized before engagement, should always, where feasible, be treated either through conversior into a presentation of the vertex by a mechanism of flexion oi else that version sliould be the operation of election. Where the memhranes are unruptured, the cervix is dilated or dilatable. The woman being anfesthetized, the hand sliould be introduced into the vagina and, during the interval in a contraction, the occiput should be seized and the head flexed. This manipula- tion is not alone sufficient, but the head must be maintained flexed until, under the influence of the uterine contractions, the flexed liead has engaged. Manipulation of this nature will rarely be successful without the membranes becoming ruptured, and then, if the manipulation should fail, one of the necessarj conditions for version is absent. Unless, therefore, the pelvif be roomy or the child small, we favor the conversion of a face presentation into one of the pelvic extremity by version, when it is recognized at a time when this operation is not contra- indicated. That is to say, the membranes being unruptured or. if they have just ruptured and the presenting part has nof engaged, the cervix in each case being dilated or dilatable, version should be the operation of election.
Wiiere the face has entered the cavity witli the chin point- ing to one or tlie other antero-lateral plane, tlien the duty of the attendant is to stay by his patient and to watch the mech- anism carefully. In case there appears to be a tendency to posterior rotation he must interfere, in order to avoid the occur- rence of a position which can alone be dehvered with safety to
MANAGEMENT OF NORMAL AND ABNORMAL LABOR.
173
the woman through craniotomy. The assistance which may be rendered by the physician consists simply in an attempt to favor anterior rotation of the cliin. The most feasible way to do this is to apply the hand to the posterior cheek and to keep it there during contractions of the uterus, in order to prevent the rota- tion of the chin toward the sacrum. This manffiuvre certainly favors anterior rotation, and often after a rapid fashion, thus avoiding a very tedious labor and consequent deleterious press- ure on the maternal soft parts and injurious prolonged extension of the fcetal neck.
A partial presentation of the face is simply a presentation of the brow. Such a presentation, if not converted into one of the occiput or even of the face, cannot be delivered by the natural efforts, since the occi pi to-mental diameter of five inches ' offers at the superior strait. The indication for treatment, as Boon as the presentation is recognized, is to insert the whole hand into the vagina, grasp the occiput, and flex the head. This flexion must be maintained until engagement, otherwise the brow presentation will recur. This manipulation applies, in particular, to instances where the brow presents, the occiput being in front. It is obvious that, in such a case, this is the only method, for, if we convert the impossible brow into a face, we have the equally impossible chin-to-the-sacrum position. Where tlie brow offers, with the occiput pointing posteriorly, then, if we flex the head, we convert the position into an occipito-posterior, which, we have seen, is an unfavorable position of the vertex. T)ie aim of treatment, in such an event, is to extend the head and to convert the brow presentation into a face, with the chin anterior, or — and this we much prefer — to resort to podalic version if the necessai7 conditions for version are present, — that is to say, the membranes unruptured or just ruptured, the cervix dUated or dilatable. In case of a presenta- tion of the brow, one or another of these manipulations are called for before tlie attendant sliould even think of the applica- tion of the forceps. It is simply a mechanical impossibility to
174
deliver a presentation of the brow, before rectification, by th application of the forceps.
PRESENTATIONS OF THE PELVIO EXTEEMITT.
The characteristics of a presentation of the pelvic extreif are slow engagement, slow descent, slow rotation, and slow delivery. The pelvic extremity cannot assist in dilatation a: can the rounded vertex, and, after engagement, the hips unde^ rotation in a more protracted manner than the occiput. A corollary is that the membranes should be maintained intact at long as feasible in order to secure the advantage of the dilating hydrostatic wedge. The normal breech having engaged, the physician need only have patience in the vast majority of cases, simply watching the woman and the fcetal heart-beat in ordei to interfere if there occur sign of impending exhaustion. Where the pelvis and the foetus are not disproportionate, and the complete breech presents, it will rarely be necessary to decompose tlie wedge, — that is to say, to extract tlie legs in order to favor tlie emergence of the nates, — the sole precaution here being to Ibllow down the uterus closely as the breech emerges, otherwise the arms may become extended above the head and delivery become very complicated. Not alone must the arms be kept from extending, but the head of the fcetus must be maintained well flexed by suprapubic pressure, for, if extension of the chin take place, tlie delivery of the after- coming head is exceedingly complicated and usually at the expense of the foetal life. Indeed, looking at presentations of the pelvic extremity from a broad stand-point, it is the manage- ment of the stage of delivery which may offer difficulties and in which the fcetus is exposed to the greatest risk. Under usual conditions, if maternal exhaustion seem imminent, the labor may be always terminated through extraction even aa would be the case had a primary cephalic extremity been con- verted into a presentation of the pelvic pole. The cardinal rule to bear in mind, therefore, is that, on the emergence of the
MANAGESCENT OF NORMAL AND ABNORMAL LABOR.
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i
breecb, the uterus mast be kept firmly applied to the fcetus, in order to avoid extension of the arms above the head, and that the head in turn must be raaintaiiicd in a position of flexion except, of course, wliere the occiput has rotated posteriorly, when, under the necessary mechanism, extension is requisite, in order that the cliin may engage under the pubic arch to enable the occiput to make its long sweep over the pelvic floor. The shoulders having been delivered spontaneously, or artificially by flexion and extension over the ventral suiface of the foetus, the sooner tlie after-coming head is extracted, the better. Tlie child is apt to suffer greatly now throwgli delay. Pressure on the umbilical cord cannot always be avoided and deep asphyxia always threatens. Downward traction on the shoulders, assisted by firm suprapubic pressure, will, in the vast proportion of cases, suffice to deliver tlie after-coming head, occiput to the pubes. We cannot lay sufficient stress on this downward trac- tion. It is necessary that the suboccipital point should be engaged under the pubic arch before the mechanism of extension of the face over the posterior commissure can take place normally. Karely, if this point be borne in mind, will it be necessary to resort to the application of forceps to tlie after- coming head. Further essential details in reference to the management of the after-coming head will be found in the portion of this work dealing with the surgery of obstetrics.
The management of presentations of tlic incom])lete breech — that is to say, of presentation of the feet or foot or of the knee — does not differ from that of the normal pelvic extremity. The same essential points should be borne in mind. The mem- branes must be maintained intact as long as is possible, and, after delivery of the nates, the uterus must be closely followed down, in order to guard against extension of the arms above the head and in order to avoid extension of the chin in case of the normal anterior rotation taking place. There is one com- plication of these presentations which mnst be borne in mind a8 very likely to occur, and tliis is prolapse of the cord, — an acci-
176
k
I dent which, if not remediable, certainly entails foetal death. So long as the membranes remain unruptured tlie fcetus cannot suffer, since direct pressure on the cord is not possible. Tlie attendant, therefore, need only wait and watch, directing the woman to lie, by preference, on the side opposed to that on which the cord tends to fall. This waiting policy is called for, since, until the cervix has dilated or is dilatable, interference of an active nature is unlikely to save tlie cliild, for delivery can- not be effected quickly enough with regard to the integrity of the maternal parts. By watching, tlie physician may take advantage of the period when rupture occurs in order to push up the cord and enable the presenting part to engage and to fill the upper pelvic strait so that there is no space for the cord I slip down.
Such conditions, however, are rather ideal ones. In tht fir-st place, prolapse of the cord will only exceptionally be recw nized prior to rupture of the membranes. The physician, how ever, should always remember the possibility of this in iucom plete pelvic presentations and accordingly be prepared to acd If the prolapse occur and the cord cannot be replaced befonj engagement, then the course of action is to place the cord ia that part of the pelvis which is least exposed to pressure, whicj varies, of course, according to the position of the presentir breech. During the fnrtlier progress of the mechanism, should the pulsations of the cord become weak or cease altogether, i| stands to reason tiiat the sole hope for the child lies in delivei after as speedy a fasliion as ia consistent with the safety of tia woman. Tlie foot or the knee presenting, this is seized and e traction is accomplished according to the rules which goverj version, the details of which are found in the portion of thi work dealing with the surgery of obstetrics.
Other methods tf reposition of tlie cord, such as the sewiql of the gelatinous coating to a soft catheter and the carrying i of the catheter with the attached cord toward the fundus • of the reach of pressure, are not apt to be successful, aside frod
MANAGEMENT OF NORMAL AND ABNORMAL LABOR.
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the fact that the extra manipulations entailed may infect the woman, no matter how careful our teclmique.
Presentation of the pelvic extremity, with the legs extended along the ventral surface of the foetus, offers special difficulties, particularly in the final stage of expulsion. The same manage- ment of the stage of dilatation and of descent and rotation is indicated, but, when the presenting part has undergone thia mechanism, unless the fcetus be relatively small in comparison with the capacity of the pelvic outlet, it will be necessary to decompose the wedge; that is to say, to bring down one or both feet before delivery can be effected. It is at once apparent how difficult this is where the pelvic extremity is wedged in the pelvis and the walls of the uterus are closely applied to the body of the fcetus. In order to reach the feet or even the knee it is necessary to secure uterine relaxation so that the hand may reach the fundus of the uterus in order to grasp a foot or the knee. Even if this can be accomplished, the task of flexing the leg on the thigh and then of bringing the leg down into the vagina is difficult. Surgical anjestliesia will he necessary in order to secure the requisite relaxation of the uterus, and, if the manipulation is successful, delivery should be terminated whilst the woman is anEesthetized.
Where this manipulation fails, and it ordinarily will if the breech is deeply engaged, there are a number of manoeuvres at our disposal.
Where the groin of the fcetus is accessible we may be able to pass a sterilized gura-elastic catheter around, thread the eye with a stout sterilized cord, and make downward traction in the axis of the pelvic outlet. This manipulation will, of neces- sity, be around the anterior groin, since the posterior will be in- accessible, and the anterior must descend first and become fixed under the pubic arch in order to allow the posterior to sweep over the posterior wall of the pelvis. The string, or so-called fillet, is always to be preferred to the blunt hook which is still described in works on obstetrics, since this hook is very apt to
L
178 LABOR. ^^^^^^^B
injure the fcetus and, if it should slip, will damage seriously the maternal parts. If the groin is accessible and the foetus and the pelvis are normally proportionate, then, frequently, the breech may be brought down by inserting the finger of one or the other hand into tlic groin, and, grasping tlie wrist of thia hand by the other, downward traction in the axis of the pelvic outlet may suffice to bring the breech down. Should these manipulations fail, then the only resource is tlie forceps to the breech, applied as is indicated in " OV)stetric Surgery."
During traction incidental to all these manipulations it is necessary tliat tlie uterus should be followed down well, other- wise the arms will extend over the head or the chm will extend, thus romplicating the delivery of the after-coming head.
Of course, if extension of the legs along tlie ventral surface of the foetus is diagnosticated before engagement, the proper course to pursue is to insert the hand and to bring down a foot whilst the manipulation is comparatively easy. This sub- jects the fcetus to risk, however, since then the cord may pro- lapse, but it is a question simply of choice between two evils, • and the lesser consists in the manipulation just described.
In case of presentation of the pelvic extremity, when the trunk of the fcetus has been delivered, if the arms have been allowed to extend above the head, these must be delivered before the head can be extracted. The difficulties are great, and the life of the foetus is very much compromised. It is necessary to insert the hand practically to the fundus and, by a mechanism of flexion, bring down first one arm and then the ottier. The umbilical cord, if not already subject to pressure, will certainly be during these manipulations, and there is, further, considerable risk of uterine rupture should the lower uterine segment be thinned out. Where the foetid pulse-heat in the cord has ceased it is useless to subject the woman to the accompanying risks of extraction of the Icetus, but perforation of the after-coming head had better be at once resorted to. Occasionally, after delivery of the trunk, the lower uterine segment closes down on
MAKAGGUENT OF HOl
tlie neck of the fcetus and then delivery of a living cliild is im- practicable, unless the attendant at once incises the cervix in order to release the neck. This procedure is one of great risk to the woman. It is difficult to make the requisite incisions, since the trunk of the fcetus is in the way of tiie necessary manipulations, and, again, owing to the fact that the muscular fibres are closely applied to the fcetal neck, it is a difficult mat- ter to insert the scissors. The incisions, furtlier, cannot be limited as we would desire. In case they extend into the lower uterine segment they may involve the broad ligament and give rise to extensive hsemorrliage into the subperitoneal tissue. In view of these facts, in case, under deep surgical ausesthesia, the spasra does not yield, it is wise to elect perforation of the after* coming head.
As was noted to be the case in presentations of the vertex, we may meet with what are termed deviated presentations of the breech. In such cases the sacrum or the hip offers at the superior strait, when, unless the position be rectified manually, the foetus cannot engage and descend. As a nde, the necessary rectification will entail the insertion of the hand and the bringing down of a foot, when labor is completed as is the case in a primary presentation of the foot.
PRESENTATIONS OF THE TRUNK.
"We have seen that, through spontaneous evolution, transverse presentation may be delivered under the natural mechanism. Such an event, however, should never be antici- pated. As soon as recognized, a transverse presentation should be converted into a presentation of the pelvic or of the ceplialJc pole. Before labor external version will accomplish this, although the vicious presentation is very likely to recur. If the transformation into a vertex presentation is accomplished before the onset of labor, a firm bandage should be applied with pads at opposed sides of the abdomen above and below, the object being to prevent the breech from descending and the '
180 LABOR.
■ from rising. Notwithstanding these precautionary measures, tlie transverse presentation may recur, and tlien, in addition to the pads, it may be necessary to keep the woman in bed, lying as much as possible on the side opposed to the breech.
If the presentation of tlie trunk be not recognized until labor has set in, then precautions should be taken to keep the membranes intact until the cervix is dilated or is dilatable, when, under ansesthesia, podalic version should be resorted to. Where the presentation is not recognized until after rupture of the membranes, then, if the shoulder lias not engaged deeply, it may still be possible, under the relaxation secured through the administration of ether, to push up the shoulder and to bring down the foot ; but, if the uterus is firmly contracted around the body of the foetus and the engagement is deep, then, instead of endeavoring to perform a forced version witli the accompany- ing risk of rupture of the uterus, decapitation should be elected, unless the woman, in full view of the greater risk to herself, should elect the Cesarean section. Tliis major operation will be always contra-indicated, however, if the mother's condition be not good or if there is evidence of exhaustion of the fcetus. In the rare instances where spontaneous evolution occurs the duty of the physician is purely passive, watching tlie woman for evidences of exhaustion. Exceptionally, even after impac- tion of the shoulder, it may be possible to cause spontaneous version to occur. This will only be the case, however, where the foetus is small in comparison with the pelvis, or the reverse. Then, by replacing the prolapsed arm and by pressing on the shoulder, sometimes the one or the other pole of the foetus will present instead, and the labor is terminated by nature or by art, according to the condition of the maternal vital forces.
MULTIPLE PREGNANCIES.
Although a woman may deliver herself of two or more foetuses without the intervention of the physician, still, since the course of labor is apt to be complicated at one or another
MANAGEMENT OF NORMAL AND ABNOKMAL LABOK.
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stage, it seems wise to discuss the subject of multiple pregnancy in this chapter.
Three reasons are offered for the occurrence of multiple pregnancy : either two Graafian follicles are fecundated at the same time and develop concomitantly, with the result that two fcetuses are delivered ; or a single follicle contains two ova which are fecundated at the same time ; or a single follicle contains two nuclei.
An outcome of these possibilities is the fact that two ova shed at the same time may be fecundated at difft-rent periods by the same or by different persons, giving rise to what is termed superfecundation ; or, again, two ova shed at different times are fecundated at intervals move or less prolonged. This latter occurrence is termed superfcetation . Suj^rfecundation has been proved possible by the delivery of women at term of foetuses of different color, tlie result of the women having sexual commerce with a white man and a negro at periods not far removed. Superfcetation, on the other hand, is not so easy of explanation. This occurrence necessitates that, after the first foetus has attained a certain degree of development a second ovum becomes fecundated and finds lodgment in the uterus. It is very diffi- cult to believe that the male sexual elements can gain access to an ovum when the cavity of the uterus is occupied by another impregnated a number of weeks previously. It must be re- membered, however, that up to the third month of gestation the two deciduje are not opposed so as to forbid access of the spermatozoa to the uterine cavity ; and it must be still further home in mind that ovulation possibly continues throughout gestation, even as it does tliroughout lactation, when, similarly, what is considered the outward manifestation of the process — menstniation — is absent. Therefore, the possibility of super- fcetation cannot be denied, although we are justified in being very skeptical in reference thereto. The result of the manner in which the ova are shed gives a different arrangement of the twins in the uterus, and with this we are chiefly coucemed.
182 LABOR.
Where the two ova which are shed come from separate Graafian follicles, each has its own membranes, and, therefore, there are two separate amnions and two chorions. There are also two placentae, although the separation between the two may only be determined on careful examination, the partitiou between them Ijeing membranous and the apposition of the twO' being close.
Where the fcetuses are formed from the fecundation of two ova in a single Graafian follicle, we still find two amnions, bat only a single chorion. The placentte are separate, but tliere is close union between the two and free anastomosis of the vessels.
If the twins result from the fecundation of one ovum con- taining two centres of development, then we find a single amnion and chorion and placenta, the twins floating in the same sac and having a similar blood-circulation.
On the arrangement of tlie fcetuses, according to the fashion after which they have developed, depends many of the diffi- culties wliich are offered in tlie delivery of twin gestations. Thus, it is at once apparent that where the fcetuses occupy separate sacs the birth of one is not as apt to be interfered with by the other as where they occupy the same sac.
Usually the combined weiglit of the fcetuses exceeds that of a single fcetus, hut not uncommonly one fcetus seems to he developed at the expense of the other, leading to the suggestion of immaturity. At times, one ftetns dies dnring gestation, either from lack of proper blood-supply or, what really amounts to the same thing, through compression exercised by one ftetus on the other. Where the fcetuses occupy a common sac the cord of one may become entangled around the neck of the other, the result being that through tightening of tlie cord this fcetus ia killed. At times, in twin pregnancy, one fcetus is born perfect in development whilst the other is imperfect, possibly to such a degree as to constitute a monstrosity. Again, where the fcetuses occupy a single sac fusion may occur at one or another part, giving rise to a species of monstrosity known as joined twins.
PLATE XXXVII.
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i |
Iffk |
y |
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r .^: |
1 i- \ |
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M |
I
MANAGEMENT OF NOKMAL AND ABNORMAL LABOK.
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The junction may be at the head, or sternum, or back, or at the pelvis, an interesting example of the latter which we liave seen being tiguved in Plate XXXVII, Again, one fcetus may be in- cluded in tlie other, — so-called cases oi'lbetal inclusion. Details in reference to these cases of monstrosity will be found in works devoted to the subject.
The diagnosis of multiple pregnancy is by no means a simple matter; indeed, in the average case only a presumptive diagnosis may be reached. The excessive size of the abdomen, where this is a factor, may be present in cases where there is simply an excess of liquor amnii. In case hydramnion compli- cates twin gestation, the diagnosis is concomitantly more diffi- cult, owing to the greater difficulty of making abdominal palpa- tion. Where, on auscultation, two fcetal hearts are heard beating with separate rhythm and with maximum intensity at different parts of the abdomen, particularly when such data are estab- lished by separate observers, then there is a reasonably strong presumption of multiple gestation. If, In addition, on palpation two heads are felt or two pelvic extremities, then this presump- tion is strengthened.
As a rule, in cases of twin gestation, the tension of the abdominal walls is greater, owing to the greater distension of the uterus. Tliis, however, is purely a relative phenomenon, since the same condition accompanies cases of hydramnion. Late in pregnancy we are apt to find suprapubic oedema and also a transvei-se depression just above the pubes. The same signs, however, may, again, accompany instances of excessive amount of liquor amnii. Wliere, on vaginal examination, the head is found presenting and yet at the upper uterine segment a head is felt, or if a second head is determined in one or the other lateral uterine walls, then the diagnosis of twin gestation is certified. As a rule, however, the only positive sign of value is the hearing of two fcetal hearts differing in rhythm and in location of maximum intensity.
Labor in case of multiple gestation is apt to be prolonged,
184
since the woman has to undergo the process twice, as it wen The third stage is apt to be complicated by haBmorrhage, since, owing to the excessive uterine distension, uterine atony is a common sequence. The labor itself will rarely offer dithculties unless one fcetus interferes with the execution, by tlie other, of the requisite mechauisra. The fcetuses may present in any po». j sible way. Thus, tliey may both offer by tlie heads or the pelvic, extremities, or one may present by the breech and the other fc the head, or one may offer by the head or the pelvic extremitj and the other be transverse. Where the fcetuses occupy sepa^a rate sacs interference is less likely ttian when they lie in a singlal sac. Afler one fcetus has been delivered there occurs a pauael and then the uterine contmctions start in agaiu, the second'l amniotic sac ruptures and the second fcetus is born. It must j never be forgotten that even though there exist two placcntsoJI tiie anastomosis between the two may be partial or complete, ' and that, therefore, if on the delivery of one fcetus the cord be I not tied toward the maternal as well as toward the fcetal surface I hsemorrhage will kill the second fcetus. Where after the d^ | livery of one foetns there is sign of impending maternal ex-J haustion we sliould not await the onset of tlie second labor, but^l dilatation having been effected, the twin should be delivered by forceps or by version, according to the degree of engagement,] and aller the manner laid down in the portion of this workj dealing with the surgery of obstetrics. We should always bew in mind the danger of uterine atony and consequent hsemofi rhage and be prepared to tampon the uterine cavity in case thd milder means for causing uterine contraction do not speedilys suffice.
Where the fcetuses occupy a common sac one twin mafi descend by the head or the breech and occupy the pelvic inlet! with the first fcetus. This is alone possible, of course, where th^ pelvic inlet is excessively large compared with the bulk of th« fcetuses, or tlie reverse. In such an event we have an impactionJ aud, in order to effect delivery, it may be necessary to sacrifici
MANAGEMENT OF NORMAL AND ABNOBMAL LABOR.
185
one or the other fcetus in order to give the other an opportunity to be born alive. Wliere the head of tiie second fcetus engages in advance of that of the first we have a complication known as locked twins, and here, in order to deUver at all, it becomes necessary to decapitate one before the otlier can be delivered.
Transverse presentations are not uncommonly met with in case of multiple gestation, a point to be remembeied, because, on the birth of the first foetus, if the other occupy the trans- verse diameter immediate delivery by version is called for before we obtain an impacted shoulder. The occurrence of spontane- ous version or evolution should never be awaited.
The statements we have made in reference to twin ges- tation apply with equal force to instances of triplets, or quad- ruplets, etc. Triplets occur about once in eight thousand deliveries ; quadruplets and quintuplets are of excessive rarity, although a number of authentic cases have been recorded. Obviously, the difficulties which delivery may offer are intensified by the number of fcctuaes present. If the physician will only bear in mind the fact that it may become necessary to interfere in the interest of the foetuses or of the woman, and tliat the danger of haemorrhage from atony of the uterus is greater than in case of single gestation, he will be ready to meet the exigencies of tlie individual case as they offer.
INVERSION OF THE UTERUS.
An occun-ence which renders labor abnormal, and which remains to be referred to, is inversion of the uterus, and this constitutes a most serious complication. The causes, in general, are atony of the organ associated with irregular contraction at the fundus, or a possible cause is attempt to deliver the placenta by traction on the cord. This factor will liardly be efficient unless there is associated atony, with tlie tendency to contraction of the upper uterine segment. As a rule, traction on the cord, if the placenta does not appear, will result in rupture of the cord.
186
Inversion of the uterus may be partial or complete. On or another hoin may appear or the entire organ may tun inside out and emerge at the vulva. The uterus being atonic^ the blood is pouring out of tlie uterine sinuses and the i ditiou of the woman may become most critical. Reposition may be most easy and again most difficult. Where diificultjf'l arises it is due to tlie fact that the inverted lower uterine se( ment, which now hes above, contracts down and oflFera a barriel to reposition. If tiie inversion can he promptly rectified by f ing up one horn and then the otlier, and finally the centre of tl uterus, it must he remembered that the tendency to recurrence i very great, and, therefore, the physician should remain by I patient until, through the administration of ergot and of strychnia, he is satisfied that the organ has regained tone and will remain contracted. In case spasm of the lower uterinej segment occurs, preventing reposition, then, under ether anre thesia, tlie spasm may yield and reposition be possible. If th fail we would advise a waiting policy unless the woman losing much blood, since the spasm may yield after an interva In case the hsemorrhage is free the attempt may be made I clieck it by tlie firm tamponade with sterile gauze held in plao by a bandage, bringing to bear compression, as it were, although, under the given conditions this will prove very difficult. Shouldl this attempt fail, before the woman becomes exsanguinated the! sole resource — desperate as it is — is to open the abdomei and stretch the contraction ring. It has become a choia between two evils, — allowing the woman to bleed to death a subjecting her to the risk of sloughing of the imprisoned port! of the uterus, or resorting to the major operation for the relet of the spasm. The manipulation which this complication i quires must be characterized by the most absolute asepsis, elat the woman will be infected.
CHAPTER IV.
CARE OF THE NEWBORN INFANT.
The foetus having been separated from its mother througli ligation of tht; umbilical cord, the first care requisite is attention to tlie eyes. Even before the cord is tied, where the exigencies of the individual case do not call for immediate ligation, the eyes should be washed. The average fcetus comes into the world with its eyes coated with the vernix caseosa, and, although in a case where the woman is free from infectious taint this can- not affect the eyes injuriously, seeing that in no given case are we in a position to certify that our technique has been absolutely aseptic, care in the early cleansing of the eyes is called for. (Plate XXXV^III.) The vast proportion of cases of ophtlinlmia may be traced to infection wliilst the child is emerging from the genital canal, or even whilst it is in the canal, since, once the membranes vuptuied, the eyes may readily come in contact with infectious material. The method of caring for the eyes will vary according as we are satisfied or not that the woman is free from specific taint. If she give no history of precedent vaginal dis- charge or if she is in that walk of life where gonorrhoeal virus is not so apt to exist, — although such inference is never safe, since, whilst we may feel quite sure of the woman we can never have the same degree of confidence in thepurity of themale. — then the fol- lowing procedure is ample. AVith aseptic hands the physician or the nurse wipes off the eyelids with a piece of sterile gauze or cotton saturated with a solntion of boric acid of 50-per-cent. or full strength, and, this arcomplished, the eyelids are opened by the thumb and index of one hand, wliilst the conjunctival sin-face is carefully cleansed by irrigation with tlie same soln- tion. If the pal|>ebral surface of the lids is covered with the vernix caseosa, then the physician should evert the lids and wash this surface off. We lay stress on the careful asepsis
(1R1)
188
which should be associated with this manipulation because eyes otherwise not infected may become so if our technique is at fault, and this may mean irrepamble damage. The same care should be associated with the washing of the eyes thereafter, although, unless symptoms develop, it is not necessary after- ward to do more than wash carefully the external surface of the eyelids. Since these principles have been introduced into obstetrics it has become exceptional to meet with cases of even mild ophthalmia.
In the event of there being a suspicion of gonorrhceal in- fection, it is not sufficient to use the boric acid. Opposed, as we are, to the routine adoption of Crede's method of instillation of silver-nitrate solution, we are firmly convinced that its adoption in every suspicious case has been the cause of the infrequent occurrence of aggravated ophthalmia with its awful sequelte. We look upon it as little short of barbarous to instill the silver solution unnecessarily into the eyes, whilst we realize to the full the great value of tlie method in aborting a possible virulent ophthalmia or in modifying its course.
Where there is a suspicion of possible infection, the eyes are first carefully washed with boric-acid solution, and then tlie eyelids are everted by the physician, — for tiie nurse, unless spe- cifically trained, is not competent, — and 2 drops of a 2-per-cent. solution of nitrate of silver is instilled, care being taken that the solution comes in contact with the conjunctival surface of the eyelids as well as of the eyeball. Too much stress cannot be kid on tliis point. If tliis precaution be neglected, then our technique is imiierfect and ophthalmia may develop. The rationale of tlie method depends on the determined ability of silver nitrate of killing the hifectious elements, — the gonococci of Neisser. After a minute or two the excess of nitrate of silver is washed off and neutralized by instilling a solution of sterile 2-per-cent. salt. As a result of this instillation of the nitrate of silver a traumatic inflammation is induced, wliich leads to congestion of the conjunctiva and more or less swelling of the
A
CARE OF THE NEWBORN INFANT. 189
eyelids, but these symptoms should abate in the course of twenty- four hours, and it is unnecessary to repeat the process. Where the eyes have not been carefully washed or where they become infected notwithstanding the care taken, then we have to face an ophthalmia which will run a mild or a severe course, accord- ing to the degree of infection and also according to the meas- ures resorted to for treatment. In case of the development of an ophthalmia, the severest oversiglit is necessary to avoid the complications, — ulceration, perforation, and permanent blind- ness.
If, in the course of twenty-four to thirty-six hours after delivery, the eyes, or one alone, begin to secrete a muco-puru- lent matter, tlien the instillation of nitrate of silver should be repeated, and, as soon as there appears chemosis or swelling, ice- pads should be kept over the eyes constantly, A convenient method of doing this is to place a number of tliin pledgets of absorbent cotton on a block of ice and to instruct the nurse to apply them over the eyes frequently. In case only one eye is affected, great care is requisite to avoid infection of the other. The nurse should never touch the other eye without first care- fully sterilizing her hands, and all cloths or cotton used for the infected eye should at once be destroyed to avoid the possibility of their being used for tlie non-infected eye. When the phy- sician lives in a city where he can obtain the services of an ophthalmologist, it will be wise to turn the infant over to his care. In remote country-districts, however, this will not be possible, and the points to be borne in mind are tliose on which we have laid stress, and, further, that, as soon as the swelling of the eyes begins to disappear, the time has come to discontinue the use of the ice. It is not possible to lay down definite rnlea for the frequency with which silver nitrate sliould bo instilled, since there is difference of opinion among the expert. Our impression is that, after thirty-six hours, repetition of the silvet solution is inicalled for, except where microscopical examination of the secretions shows that the gonococci are still present. As
190
long as they exist the silrer solution is indicated, and no longi As soon as it is possible to dispense with the silver solution^f eitliei a saturated solution of boric acid sliould be used or elsttf a sterilized 2-per-cent. solution of common salt.
During the few days following the birth of tlie child the most rigid precautious as to tlie cleanliness of the eyes sliould be enforced, since, at this time, they are unable to resist infection as they are, to a better degree, later, and on these precautions the sight of the infant depends.
The eyes having been attended to, tlie next step is to bathe the child. From the start the infant should be accus- tomed to its altered surroundings, and the greatest of all mis- takes is to coddle it. As it is started so it is apt to progress through life. It can beat resist the effect of changes in temper- ature if it become accustomed to such changes. Tlie infant who is looked upon even as a fragile china doll would be will not grow up with the sturdy constitution and the resisting power which is so essential to healthy manhood and woman- hood. Tlie bath of tlie infant, therefore, should approximate in temperature that of its external surroundings. What should be aimed at is the avoidance of chill. The temperature of the bath, therefore, should be only slightly in excess of that of the room in which it is bathed. As a rule, a temperature of 80° to 90° F. should be selected, except in the case of immature iiifiints, when, since we are not dealing with an individual of normal capacity, we must make tlie circumstances meet the case. Tlie first step is to remove the coating of vernix caseosa and of blood with which the infant is covered to a greater or less degree. This is accomplished by greasing its surface with some unctuous material, such as sweet-oil or vaselin, the precau- tion being taken not to allow any of the material to get into the eyes or the stump of the cord, since it is not sterile. This greasing accomplished, the infant is supported on the hands of the nurse and placed in the bath so that the entire surface is covered with the exception of the head. It is then soaped and
n
11
ll
CABE OF THE NEWBORN INFANT.
191
washed until the surface of the body lias been cleansed, when it is removed from the bath and thoroughly dried. Tlie flexures of the body are then covered with vaselin or a pure rice- or bismuth- powder, to avoid chafing of tlie delicate integument, and next the body is examined for defects. The natural open- ings are investigated in turn and the toes and the fingers are counted, since one of the first questions of the anxious relatives will be as to whether the child is perfect or not. If any imper- fections are determined it is wise not to tell tlie mother, since the nervous anxiety she would be subject to would complicate her convalescence ; but the father or some relative should he told, and, in case of such a complication as imperforate anus or urethra, steps requisite for giving speedy surgical aid should be taken.
The cord should now be dressed. (Plate XXXIX.) This matter is usually left to the nurse, but it falls within the province of the physician, since infection at the site of the umbilicus is a frequent cause of sepsis of the newborn. We are dealing with a wounded surface and the attention requisite is similar to tliat which any wounded surface demands; that is to say, asepsis is a sine qtui non. A pledget of sterile absorbent cotton or of gauze is wound around the cord, and this is left in place until the cord drops, varying from the seventh to the tenth day. During this interval the child should not receive a full bath, since our aim is to have the cord undergo dry gangrene after an aseptic fashion, and this is interfered with if the dressed cord is wetted, aside from the danger of infection with each manipu- lation.
If the cord has been properly tied there is little danger of secondary hfiemorrhage except in case of haemophilia; still it is a wise precaution for the physician to investigate tlie dressing at his first visit after delivery, in order to satisfy himself that there has been no bleeding. In the event of liBemorrbage if the first ligature has been applied as it should be, at a sufficient distance from the body of tlie child to admit of the application
193
of a second ligature, it may prove an easy matter to arrest the hfemorrliage ; otherwise, without trusting to the possible action of astringents, transfixion of the base of the umbilicus should be resorted to. lu this connection we would note that a most valuable liiemostatic for oozing from the cord is offered by autipyrin appHed in powdered form. Possibly any of the coal-tar derivatives will answer as well.
After the cord has separated it should still be treated as a wounded surface would be; tliat is to say, according to aseptic principles. It should be kept dusted with bismuth-powder and a film pad applied over it until cicatrization has become firm, in order to avoid the possibility of umbiUcal hernia.
The child should now be dressed. All that we, as phy- sicians, can do is to suggest forcibly the desimbility of the infant not being clothed too warmly. Excessive weight should be avoided, and yet the infant should be sufficiently clothed to avoid chill. The nurse should be instructed never to cover the head of the infant, all that is really needed being to see that the infant does not He in a current of air.
After the woman has rested for an interval after delivery, it is advisable to apply the child to the breasts for the triple purpose of accustoming the nipples to lactation ; of giving the child the colostrum in the breast, which is nature's castor-oil, 60 to speak; and, finally, for the purpose of obtaining the reflex effect of irritation of the mammary glands on the uterus, which conserves the desired firm contractions of that organ.
Before applying tlie child to the breast, and tliis rule holds for every nursing, the mouth should be washed out with a saturated boric-acid solution, and the nipples should be similarly treated before and after nursing. These precautions are essential in order to avoid infection of the nipple, which is the cause of abscess of the mammary gland.
During the first few days of the infant's life it requires, be- sides the colostrum which it obtains from the mother's breast, only an abundant supply of water. This infant has come from
J
CABE OF THE NEWBORN INFANT. 193
the uterus, where it knew nothing about catnip-tea and sugar and milk and water ; it enters the world with its intestinal canal filled with the liquor amnii and possibly meconium, and before its stomach is ready to assimilate food these waste products must be eliminated. The colostrum does tliis, and on or about the third day, when, as a rule, the milk appears in the breasts, the infant is prepared to receive it and to assimilate it. At intervals of about four to five hours prior to the advent of the mQk the child should be applied to the breasts, the nipples thus becoming accustomed to traction and the child receiving its supply of colostmm. On the appearance of the milk the average infant should be put to the breasts at intervals of two to two and one- half hours, and this routine should be the rule up to the third month, when the intervals between the nursings should be length- ened to three hours. It is impossible to rear every baby ac- cording to a fixed routine, since the gastric capacity and the func- tional activity of one necessarily differs from that of another. It has been proven that the rules we have laid down as to fre- quency of nursing are applicable to the average infant, and, according as they are followed or not, so will the child start in life with good or bad digestive tract. Overfeeding is as bad as underfeeding. Each child must be judged by itself, and it will require a week or two to find out just wliat the individual infant needs and can digest. During the intervals between the nursings the child shoidd be given boiled, cooled water to drink, and then, if it be healthy and not chafed and the mother affords it a sufficiency of milk, both in quantity and in quality, the early days of the infant are spent in sleeping and in feeding.
An infant can be tmined from the start even as can a puppy. If it be accustomed to being rocked and walked the floor with and overfed, so must the parents continue or else have a struggle for the mastery. If from the start regularity of habit be followed, then the nursing mother will secure needed rest at night and the healthy infant will remain so. For the first few months of its existence it will be nursed about seven to nine ,
194
times in the twenty-four hours, at intervals of two to two and one-half hours during the day and at from four- to five- hour intervals during the night. The child should be weighed every ten days to a fortnight, and so long as it is gaining in weight it is thriving, even though it occasionally suffers from colic or has, at times, stools of a gi^een or slimy cliaracter. Frequent feed- ing or, rather, overfeeding will be found to be at the bottom of green stools or colic, where the maternal milk is of proper quality, and tlic administration of a teaspoonful of lime-water, for a few doses, before the application of the child to the breast will correct the hypemcidity of the stools and the fermentation, or else an enema of soap-suds and warm water will do so by clearing the undigested milk from the intestinal canal. These milder measures shoidd always be tested before resort to the administration of drugs. Tlie more common sense is utilized in the rearing of the infant, the less will it be requisite to resort to drugs.
Regularity in nursing, sleep, bathing, and a sufficiency of fresh air and water are the keystones which lead to the development of the healthy child.
Thus far we have traced the care which should be given to the infant born at term and in sound condition.
Premature infants demand special attention. The child ' born at the thirty-fourtli to the thirty-sixth week does not aa readily accommodate itself to its new surroundings. Its organs are not developed to tlie requisite degree, and we must lend it j artificial aid. Thus, it must be clothed more warmly, and this is accomplished by wrapping it in cotton and surrounding it J with hot-water bottles, or, in case of prematurity to the extent of six weeks before term, it should be placed in an incubator such as is described in the surgical portion of this work. If such an apparatus be not obtjiinable one may readily be irapro- , vised. Often the premature infant has not the power to exert sufficient suction to empty its mother's breast, and if we do not come to its aid it drifts rapidly into a condition of inanition.
CABE OF THE KEWBORN INFANT.
Obviously, as the maternal milk is the best food for the infant at term, it becomes all the more so where the child is immature. The woman's breasts should, therefore, be milked out by hand and the child fed with it by means of an ordinary medicine- dropper. Absolute cleanliness should characterize this process, in order that the milk should reach the infant in as sterile a condition as it exudes from tlie breasts. The immature infant, further, requires feeding at more frequent intervals than does the mature, since, its gastric capacity and function being less, it cannot obtain the requisite amount of nourishment in the same interval of time as can the mature child. Possibly, we can supplement the food of such an infant by having its body anointed a number of times a day with sweets or codliver- oil.
As far as the infant is concerned, the great emergency which offers is asphyxia. We distinguish two types, — the anaemic form of asphyxia and the congestive or apoplectic form.
The causes of asphyxia, in general, are dependent on con- ditions of tlie woman and on the placenta or the cord. The anosmic form results from insufficient nourishment dependent on disease of the placenta or on compression or twist in the cord. Thus, the anaemic type results from the fact that the infant either receives a deficient supply of oxygenated blood or else the condition of the woman is such that she is unable to give the infant the oxgen whicli it needs. Ante-partum liEemorrhage, for instance, associated usually with placenta prEevia, is one cause of the anaemic type of asphyxia, for the reason that the woman loses so much blood tliat what she furnishes the fcetus is of poor quality. Disease of the placenta interferes with the infant receiving the oxygen which it needs, seeing that the cir- culation through this organ is impeded. Obviously, where the cord is twisted or compressed the fcetus suffers from lack of blood.
The apoplectic form of asphyxia, on the other hand, usually follows protracted labor or conditions which have re- sulted in spasm, to a greater or less degree, of the utenis during
196 LABOR.
the second stage. In this form the fetus receives a sufficient supply of blood", but it is again improperly oxygenated, becomes venous in quality, and there results congestion.
In the anjEmic form the infant is born pale and limp, the surface being cold and the muscular system flaccid. The sphincters are relaxed; the heart-beats are faint and rapid or imperceptible. The pulsation in the cord is similarly faint or imperceptible. Respiration is absent altogether or gasping at long intervals. The picture is one of acute shock from loss of blood. In the apoplectic form, on the other hand, the surface i» congested; the muscular system approaches rigidity ; the pulsa- tions of the heart are slow and labored ; it may be possible to excite reflex movements in the fcetus ; respiration is slow and labored.
Either of these types of asphyxia may be so profound as to simulate death, and yet, in every case, the methods of resuscita- tion should be faithfully tested, since there are many cases on record where, through perseverance, even a forlorn hope has resulted in a victoiy. Where the diagnosis of the form of asphyxia is made prior to the cutting of the cord, it is advisable not to tie in the anaemic form so long as it is possible for the woman to furnish the infant with blood ; that is to say, tying should be delayed for a number of minutes. lu the apoplectic form, on the other hand, it ia wise to allow the cord to bleed, thus in a measure relieving local congestion. During these procedures the mouth and nose and pharyngeal vault should be cleared of mucus and liquor aranii by inserting the finger, covered by a piece of muslin, into the mouth and a cotton- wmpped probe into the nostrils. If there is valid ground for thinking that much liquor amnii and vaginal mucus has entered the trachea, then a catheter should be passed into the trachea and suction be exerted. As a rule, however, tliis will not be requisite, since either of the methods of artificial respiration we shall shortly describe causes the expulsion of detritus from the trachea and upper bronchi.
CARE OF TBE NEWBORN INFANT.
197
The mouth and the nostrils having been cleansed, a piece of miisUn should be applied over the infant's mouth and, whilst its nostrils are being compressed, the physician should apply his mouth over the child's and slowly breathe into it, tlien depress the infant's thorax and again breathe in. This raouth- to-niouth insufflation we much prefer to attempts at insufflation by means of tiie catheter, and often, if persisted in, we shall be able to resuscitate the infant in this way alone, esi)ecially if we are dealing with the apoplectic type. If the type is anfemic, then we question if over-anxiety and resort to active measures do not kill many an infant. As we have stated, the anffimic infant is suffering from shock, and the measures which suggest themselves are similar to those we would resort to were we dealing with an adult. Heat to the suriace, the injection into the rectum of a pint of hot (115° F.) saline (2 per cent.) solution, the instillation into the mouth of 10 drops or so of brandy, — such are the primary measures of utility. If we seize such an infant and plunge it into hot water and then apply ice to its surface and then spank it or hold its head down, exposed to the chill of the room, the chances are that we shall not be able to resuscitate it. Calm demeanor and absence of overhaste will do the child more good if the simple measures we have outlined are resorted to.
In case of an apoplectic infant we need not worry so much over attention to bodily warmth or stimulation. What this child needs is resort to measures which are going to cause it to breathe deeply, the result being relief of congestion through proper oxygenation of the blood and, in consequence, vigorous heart-action, since, concomitantly, the venous engorge- ment of this organ is relieved. Here then, alter cleansing the mouth and the nostrils, it is well to resort to one or another of the methods of artificial respiration.
The two methods of artificial respiration with which the student should familiarize himself are the Scliultze and the Byrd, the latter haring been of late yeara resuscitated andj
198
advocated by Dew ; and we therefore prefer to give it the name of the Byrd-Dew method, since Dew unquestionably indepen- dently systematized the method which Harvey Byrd, of Balti- more, described a quarter of a century ago.
Schultze's metliod is well represented in the accompanying plate (Plate XL). It aims at producing alternate expansion and compression of the thoracic walls, thus imitating nature's respiratory acts. Further, the descent of the diaphragm ia favored and tlie necessary associated compression of the abdom- inal walls drives the diaplnagm upward in the expiratory act, and thus the lungs are alternately expanded and compressed. The child is grasped just below the neck, the fingers resting on the dorsum and the thumbs on the thorax. Tlie first motion is to hold tlie child downward and tlien the second motion is to swing the child upward and backward over the head, thus flexing the lower extremities on the abdomen. These alternat- ing movements are repeated at intervals, and may be followed by the restoration of the function of respiration.
Practically, the Byrd-Dew method accomplishes the same effect as the Schultze, but it lias the decided advantage that the \ steps of the metliod may be followed whilst the surface of the! child is kept beneath !iot water, — a necessary accompaniment ia I cases wliere we are dealing witli the anaemic type of asphyxia i or where the stimulus of heat to the body is otherwise desirable.
Tlie steps of the Byrd-Dew method (Plate XLl) are the I following : The neck of the child is held between tlie thumb and the index finger of one hand, whilst the other hand holds the child at its nates. The first step ia to flex the body of the ] infant along its dorsal surface as much as possible, and then to [ gradually flex the ventral surface. As the body of the child is j flexed dorsally, the diaphragm is pulled down mechanically and as a result of the descent of the abdominal viscera. Thus we imitate inspiration. As the body of the child is flexed on its \ ventral surface the diaphragm is necessarily pressed upward and 1 the thoracic walls are compressed. Tliis is the imitation of the \
Sc)iull2e'; Method 0< Artificial Rsipira
CAKE OF THE NEWBORN INFANT. 199
expiratory act. During these manipulations, which should be repeated about three times to the minute, the air may often be heard entering the trachea during the inspiratory act, and on resorting to the expiratory act not alone is air driven out, but also any mucus or liquor amnii which may have entered the
One or the other of these methods, associated with mouth- to-mouth insufflation, will result in the resuscitation of the majority of infants who are suffering from the effects of the venous form of asphyxia. The metliods are tedious, but they should be kept up so long as there is the slightest audible heart- beat. Of the two methods, the Byrd-Dew has answered best in our hands, for the reason that other restorative measures can be resorted to at one and the same time. The ordinary Mar- shal-Hall or the Sylvester method presents no advantage over those we have described; indeed, in infants, we question if they possess the same advantages that they do in adults.
A further metliod worthy of trial, although we are not as yet prepared to vouch for it, is the recently resuscitated one of promoting respiration by traction on the tongue. The tongue b grasped by a vulsellum forceps and, at intervals of three to six times to the minute, it is drawn outward and then allowed to return to its natural position in tlie mouth. This traction is supposed to set up reflex respiratory action, but in the instances where we have tested it we have been very doubtful of its value ; certainly the effects have never been as marked as from recourse to the Byrd-Dew method.
In case of the antemic type of asphyxia, when the progno- sis is always worse, the Sylvester method, with the infant's body held in a tub of warm water on the hands of the nurse, or else the Byrd-Dew method similarly applied, should be preferred. It must be remembered that, in tiiis form of asphyxia, the sur- face of the body of the child must be kept warm, in order to enable it to emerge from the condition of acute shock, so to speak, in which it is.
I
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PART III,
The Puerperal State.
THE NORMAL PUEBFEBIUU.
THE FATHOLOOICAL FnEBPBKinK.
(201)
CHAPTER I.
THE NORMAL PUEBPEBIUM.
Thb puerperal state can only be physiological wheie the woman is uninfluenced by other than natural environments. The Indian squaw, in the early history of this country, gave birth to her child without delaying her companions when on the march, and was able at once to join them in their journey. To-day we have to deal with an entirely different being. Woman has inherited from her ancestors a physical organism so fitr removed from that belonging to the savage that what was once a physiological act, pure and simple, now verges on the pathological. Indeed, it requires the astuteness of the careful physician to recognize deviations from what should be normal and yet what is too frequently pathological.
The puerperium comprises the period beginning with the end of the third stage of labor and terminating when the woman returns to her normal state of health. It is impossible to accurately define the length of time the puerperal state covers, since so many conditions influence this interval. The process of labor involves an enormous amount of muscular energy, loss of blood and strength, and therefore it is followed by exhaustion to a greater or a less degree. The frequently necessary exposure of a portion of the body, together with the rapid evaporation of heat from portions which are wetted, results in loss of tone, which is manifested, often, by a sense of chilliness or even by a decided chill. This chill is, how- ever, of no special significance, being unaccompanied by rise of temperature. The pulse, which during the act of labor has become accelerated, slows down and becomes regular, falling as low, frequently, as fifty beats to the minute. This is of good
(203)
204
THE PUERPEBAL STATE.
prognostic omen, and the careful physician will always watch his patient when the reverse holds true. Undue acceleration of pulse is an indication of impending hcemorrhage or of exhaustion.
In case the labor has been tedious we may witness, during the twelve hours following delivery, a rise of temperature to 100° F. After this period the temperature should not rise above 99" to 99.5* F. unless there be some complication impending or existing. Before the days of asepsis during labor and the puerperal state the physician rather expected a rise of tempera- ture about the third or the fourth day. Indeed, this occurrence was so constant that it was ascribed to the filling of the breasts, and it received the name of "milk fever." To-day, however, where asepsis is carefully maintained this rise of temperature is not noticed except in instances where the intestinal tract b clogged, and then it is due to absorption of waste products, A laxative reduces the temperature to the normal.
Inability to empty the bladder is a frequent and annoying complication of the early puerperal state. This is often due to the fact that the woman is unable to empty her bladder in the recumbent position. Again, the cedema of the vestibule may partially occlude the calibre of the urethra and offer such an amount of obstruction that the somewhat paralyzed bladder cannot empty itself. The bladder should receive attention at least every eight hours, and where it is necessary to catheterize the nurse should be instructed to do so by sight after precedent asepsis of the vestibule.
Involution of the uterus begins coincidently with the process of labor. The firm contractions of the muscular fibres necessi- tate waste and at the same time the lessened blood-supply causes fatty degeneration to set in. Conicidcntly with this fatty de- generation new cells are being formed ; that is to say, the degenerative and the regenerative processes go hand in hand. The uterus thus diminishes jn size and its walls increase in density. It requires about two months for this process of re-
THE NORMAL FDKRFlBnTlL 205
generation to be accomplished, and yet the utenu never returns to the sixe it had before conception. It always remains larger and heavier except in those rare instances where excess of involution occurs.
Immediately following delivery the cervix is soft and its canal is patulous. It is difficult to define the margin of the cervix, it being apparently merged in the vaginal walls. Twenty- four hours after delivery the cervix becomes well defined, although the canal is still patulous. At the end of two weeks the cervix has regained much of its normal shape, the external os stiU admitting the tip of the finger, although the internal os should be dosed. The original size and appearance of the cervix is never regained. The external os, instead of being round, pre- sents a transverse sHt^ except in instances where it has been ' lacerated to a greater or a less degree and has not healed, in which case the appearance may be most varied according to the d^;ree of laceration.
During the eighth month of pregnancy certain of the uterine sinuses become obliterated through the coagulation of the blood. After delivery the blood coagulates in the remaining sinuses. Their walls become thickened through the develop- ment of new connective tissue. This tissue contracts until the sinuses are completely obliterated. This process is necessarily gradual and the obUteration is not completed for some months after delivery.
After delivery the vagina is relaxed and the site of abrasions varying in depth and in distribution. In case laceration has not occurred, or where this has been immediately repaired, in- volution proceeds rapidly. The vagina, however, never returns to its original size. About six weeks are requisite for involu- tion to be completed.
The repair of the uterine mucous membrane is coincident with involution. The superficial layer of the decidua is in great part detached with the membranes and the placenta. During the few days following delivery the attached fragments
208
THE POERPEHAL STATE.
canal for each lobe, and this is termed the "lactiferous duct." Tlie lactiferous ducts terminate in the nipple by small openings, about one-fortieth of an inch in diameter. As the duct passes downward from the nipple it enlarges into what is- termed the sinus of the duct. The space between the lobes is filled in witli adipose tissue and the whole structure is firmly held together by connective tissue.
Tlie breasts enlarge and grow more firm during pregnancy, from the accumulation of fat between the lobules and the devel- opment of new acini. The fluid which is secreted before and during the first few days of the pueri)erium is known as colos- trum. It contains fat, albumin, salts, sugar, water, and large bodies known as colostrum-corpuscles. Tliese latter are derived from the disintegration of the epithehum which lines the acini. This colostrum has a laxative action, and cleanses the intestinal canal of the infant in order to prepare it for the milk, which is secreted about the third day. The early milk does not contain as large an amount of solids as the later, the fluid altering in density as the gastric capacity of the infant becomes better able 1 to assimilate it.
The care which the newborn infant should receive has I: dwelt upon in the chapter devoted to that subject. During th* first four to six days of its existence the infant will decrease intfl weight, owing to the small amount of nourishment which ia receives. Tliis loss should be gradually recovered, the original weight being regained about the seventh to the ninth day afb delivery. The infant's head gradually regains its shape, and the swelling of the presenting part subsides in a few days, the end of two or three days exfoliation of the epithelium begin aud continues for seven or eight days. During this perioi icterus not uncommonly sets in aud, as a rule, passes off withouH remedy being indicated. In tlie event of its becoming deeperj then a mUd laxative will assist in its disappearance when organic cause does not exist.
the normal pderperium. 209
Management of Convalescence.
Before leaving the woman, after delivery, the physician should carefully examine her. H,e should satisfy himself that the uterus has remahied firmly contracted. He should look at the vulvar pad to see that the flow of blood ia no more than what is natural. This is especially requisite, because, even though the uterus may be firmly contracted, haemorrhage may be occurring from a lacerated cervix or from some portion of the vagina. He should note the condition of the pulse and respira- tion. A slow and regular pulse is what he should expect to find unless the woman is greatly exhausted or is losing an undue amount of blood.
The physician should remain by his patient for at least one hour after delivery. Before leaving, written directions should be given the nurse or attendant in regard to the method of controlling hsemorrhage should it occur. The woman should be allowed to rest quietly for a number of hours alter delivery, and ordinarily she will sleep. After about four hours the infant should be applied to the breast. This causes contraction of the uterus and assists in maintaining the organ firm.
The diet of the lying-in woman should be bland for the first few days. Milk and hght soups are preferable. After the bowels have been thoroughly cleansed and the milk is begin- ning to be secreted ttiere is nothing gained by tlie starving process of the past; indeed, much is lost. Tho woman needs food not only for recuperative purposes, but also to enable her to stand the strain of lactation. Where the course of the puerperium is smooth solid food may be administered carefully after the second or the third day. Tlie amount will vary accoid- ing to the desire of the woman, and never to the exclusion of milk.
A laxative should be administered the evening of the second day, at least, since the puerperal state will progress to better advantage in case the intestines are kept unclogged. In case the woman is of the constipated type, tliis laxative should
210
THE POEBPEBAL STATE.
be given twenty-four hours after delivery. Whilst normal evao uations should be secured daily, hypercathar&is should be avoided except it be desired to diminish the flow of milk.
In case the woman finds it difficult to empty her bladder or her rectum in the recumbent posture she may be allowed to sit upon the bed-pan wlienever tliere is no coiitra-indication from the side of the heart. The popular idea that the woman sliould maintain the recumbent posture for days after delivery is erroneous. It has been experimentally proven that, where the pulse is slow and regular, it does tlie woman no harm to begin to assume the semi- recumbent posture witliin twenty-four hours after delivery. Invohition progresses as normally and drainage is better. After the fourth day the woman will be able to assume this posture for the greater part of the day, and the result will be that, when the time arrives for her to leave her bed, she will be in better physical condition.
The consensus of opinion would seem to be that ergot should be administered as a routine measure for the week fol- lowing delivery. The drug seems to favor involution and the uterus is certainly prevented tliereby from relaxing. Thirty drops of the fluid extract may be ordered three times daily. A sixtieth of strychnia three times daily would appear to favor involution.
The physician should see his patient at least eight hours after delivery and should then note the state of the uterus, the amount of lochial discharge, and inquire as to whetlier the bladder has been emptied or not. For the three days after delivery it will be wise to see the woman, when possible, twice daily, since this is the period when untoward ciiange is apt to occur. The temperature and the pulse sliould be taken morning and evening for the first week. The nurse or attendant should be instructed to exercise the most absolute cleanliness before touching the woman. Slie should be instmcted to wash her hands and to dip them in a solution of bichloride of mercury 1 to 5000 before chaagiug the vulvar pad and before washing
I
THE NORMAL PDERPEBIDM.
^11
the genitals. Tlie old-fasliioned napkins should not be allowed in the lying-in room. Absorbent cotton baked in the oven or, in the households of the indigent, cloths boiled before use should take their place. In the households of the well-to-do the sani- tary napkins, which may now be obtained everywhere, should be used. Tliey should also be baked in an oven before use. These pads should be changed as frequently as they become saturated. The external genitals should be bathed frequently, a solution of bichloride, 1 to 5000, being used, or a 1-per-cent. solution of creolin. Vaginal douclies are never indicated in the normal puerperium; indeed, their routine administration adds to the danger of infecting the woman. The indication for the vaginal douche is odor to the lochia, whicli is possibly due to the decomposition of a clot in the vagina. In case the odor persists, then the indication becomes stringent to examine the woman carefully for the early detection of a beginning sapreemia. In case a vaginal douche seems indicated it should be admin- istered with absolute asepsis, as is fully exemplified in the chapter dealing with obstetric asepsis (vide " Obstetric Surgery "). An intra-nterine douche should never be administered by the nurse or the attendant, but always by t!ie pliysician, who alone is competent. The indication for such douche wUI, as a rule, be odor to the locliia which persists after vaginal douching.
The pliysician who is careful to persuade every healthy woman to nurse her child will do much toward lowering the mortality-rate of children under five years of age. The woman who is not willing to sacrifice social pleasures and personal com- fort for the benefit of her child is unwortliy to become a mother. Mothers' milk constitutes the natural food of tlie infant and nothing has been found which will in every respect take its place. Of course, where the maternal condition will not allow of lactation, either because of imperfect development of the mammifi or because of organic disease, the woman cannot prop- erly nourish her offspring, in which case artificial means must be resorted to. When the woman sufi'ers from the distension
212 THE PUERPERAL STATE.
' associated witli an excess of milk the application to the breasts of hot cloths for ten minutes, and repeated at intervals, may reheve her ; or, what is preferable, the nipples should be covered mth a pledget of sterile gauze and a firm compression binder should be applied. The breasts will often thus empty them- selves under this pressure. At the same time the amount of fluid tiken by the woman should be diminished. In the event of there being an insufficient supply of milk or a diminution in the amount, a strong infusion of the milk-plant — tlie Galega officinalis — may be ordered in tablespoonful doses three to four times daily. At times there will result an increased supply.
The period when the woman should be allowed to leave her bed is very variable. As a rule, the uterus has involuted below the pelvic brim by the tenth day, and the woman may be allowed to leave the bed and to spend a portion of the day on a lounge. She should not be allowed to walk until the fourteenth day, and then after a gradual fashion. As long as the uterus lias not involuted below the pelvic brim, in particular if the red lochia tend to recur on much exertion, it is wise to limit the ex- ercise whicli the patient will take, and often it may be necessary to keep her in bed. It is the after-care which the woman receives which tends to allow the uterus to return to a fairly normal condition aft:er labor, and which will do much toward the prevention of uterine diseases, in particular uterine displace- ments.
The resumption of sexual intercourse should not be per- mitted imtil after the second month, since the pelvic congestion which the act entails interferes with proper involution of the pelvic organs.
There remains to be considered the method of rearing the infant artificially in cases where, for one or another reason, the woman is unable to nurse. Unquestionably the milk of another woman is the ideal substitute, but in practice great difficulties are met. It has been truly said that the "model wet-nurse should be a woman of suitable age who has lost her own child
I
THE NOBMAL PUEBPEBIUM. 213
at about the same age as the foster-child. She should have a breast of good and abundant milk ; be free from actual or he- reditary predisposition to disease ; possess a Itindly disposition and an even temperament; have no vicious, gluttonous, lazy, or uncleanly habits ; be animated by a love of children rather tlian the money- value of her services." If such a woman could be found, then unquestionably the best substitute for the woman herself would be the wet-nurse. But, unfortunately, the aver- age woman to be secured is the very reverse. She enters the household and at once assumes that all should bow to her and be subservient to her wishes. She thinks that the parents of the infant will put up witli all her wliims and demands lest the infant suffer. She eitlier drinks or develops a taste for liquor. As a rule, she is fonder of a lie tlian the truth, and if she does not neglect the baby she may drug it. Again, notwithstanding the most careful examination, hereditary or acquired disease, such as syphilis, may be the legacy she will leave the babe.
On the above and other grounds it will resolve itself into the physician prescribing some artificial food for the ini'ant. There is no food which can take the place of milk, and that of an animal must be utilized. Cows' milk is universally obtainable. The milk of a cow, however, unmodified, is not fit for the new- bom babe. It contains a greater proportion of casein than does woman's milk, and it coagulates in the stomach into dense curds which the infant's gastric juice cannot digest. It also contains a greater proportion of butter than human milk and therefore fat-acids are almost certain to form, and tliis upsets the infant's digestion. Proper dilution with water, in a measure, renders cows' milk suitable for the average infant.
It is immaterial whether the milk is obtained from one or more cows, provided the animals are healthy. By obtaining the milk from a number of cows the average quality is more readily secured. The milk should be as fresh as possible and it should be sterilized at once by means of boiling, a sufficient quantity being prepared to suffice for twenty-four hours' feeding. The
214 THE PDERPEBAL STATE.
following formula for preparing milk for the infant will be found reliable : Dissolve 20 grains of French gelatin (this is about two inches, as it is found in the shops) in half a pint of hot water. Add 1 teaspoonful of pulverized arrowroot and 5 grains of sugar of milk. Strain a half-pint of milk so as to distribute the cream evenly and add this to the mixture. Add one tablespoonful of cream in order to bring the amount of fat to the proper standard. The entire amount is well stirred and poured into a sufficient number of nursing-bottles to answer for the twenty-four liours' feeding. Place the bottles in a steam- flterilizer and heat to a temperature of 212° F. The bottles having been sealed with rubber stoppers, the milk will remain perfectly sweet. The child should be given a bottle every two hours, up to the age of three months, during the day-time. It will soon become accustomed to sleep from four to six hours during the night. In case the infant is constipated the amount of cream added is increased, and the reverse holds where the child has watery movements. A small pinch of salt should be added to each bottle. In case of acid fermentation a little bicarbonate of soda may be added.
Those who have the care of the infant must be impresse with the fact that, unless the bottles and the rubber nipples arel kept perfectly clean, intestinal disturbance is sure to result..! The bottles must be well scalded before filling with milk ; the- nipples should be inverted and scrubbed with a brush, WheRiJ the nipples are not in use they should be kept in a solution of 4 boric acid or of salt. The nurse should never he permitted to I use anything except the plain nipple which fits directly over thOi bottle. No tube extending into the bottle should be allowed*]! since it is practically impossible to keep it clean. As soon ) possible, tlie child should be trained to take its milk from a cupi, ]
THE PATHOLOGICAL PUERPERIUM.
The boundary-line between the physiological and the patho- logical puerperiums is rarely sharply defined. It has been seen that, under normal conditions, the retrograde plienooiena of the puei-peral state are not constant in their course, largely because the woman never can approach labor in the ideal condition. We can hope, therefore, only to lay down approximate rules for the determination of the minor deviations from the physiological puerperium, laying stress on the fact that watcliful care will rarely overlook excess in these boundary-line phenomena, since on early recognition and on prompt treatment will depend the aborting of major complications.
Propliylaxis, armed expectancy, — such should be the role and the attitude of tlie physician during the puerperal state.
The student wlio has been grounded, as he should be, in the young science of bacteriology will appreciate the fact that the study of the patliological puerperium may be much simpli- fied. Even though as yet the foundation of our modern belief may be in minor details a trifle insecure, the keystone is well laid, and on this is inscribed the words "wound infection" as the definition of alteration of the physiological into the patho- logical. A possible exception is termed saprtemia, although it eventually results in septicsemia, and, when traced to its source, this is found to be dependent on the development or on the result of the activity of pathogenic organisms. Tliat is to say, sapreemia following decomposition through infection becomes in import the same septiciEmia which follows wound infection.
The term " puerperal fever" may still suffice for the laity. It can have but one meaning for the physician, and tliis is sep- ticaemia, blood-poisoning, wound infection, the absorption of
(215)
216 THE PUERPERAL STATE.
products of decomposition altered through infection into a yiru- lent poison.
Whence the infection t
Three possible sources have been described and each, in turn, has carried weight in the past in the nosology of so-called childbed fever. These sources are ; the atmosphere ; the body of the puerpera ; material of an infectious nature, or capable of causing infection, brought in contact with the genital system of the puerpera (including under this term the mammary glands).
Reference to the lirst two possible sources may well be brief, since modem knowledge and belief have relegated them well nigli to the shelf of oblivion, where they rest as evidence of past erroneous teaching. J
Atmospheric infection of the puerpera as a cause of septlfl CEemia, whilst a comforting belief, since it casts the responsibility* on nature, is not a tenable one. Given a puerpera delivered after an aseptic iashion and caved for similarly afterward, and she may lie in an infected room — whetlier the infection be erysipe- las, measles, scarlet fever, etc. — and the puerperium may be un- affected so far as septicaemia is concerned. She may develop either of these acute infectious diseases, but tiiey run their proper course, only modifying the puerperal state in so far as arrest of retrograde metamorphosis is concerned. If she die, th* lesions peculiar to the intercun'ent disease will be found. Asid from arrest of involution of the sexual organs, we may i nothing suggestive of septicemia. On the other hand, as wilt J be noted shortly, let the erysipelas or the scarlet-fever infection J material be brought into direct contact with the wounded gert itals of the puerpera and septicfemia may follow, modified or r by the development of the infectious disease from which t contact-virus emanated. If she die, the lesions due to infection 1 — the lesions of septicfemia — will be found in addition to those J peculiar to the intercurrent disease ; for instance, scarlet fever, 1 or erysipelas phis septicemia.
For years the doctrine of auto-infection played a prominenb]
THE PATHOLOGICAL PUKKPERIUM. 217
rSle in the nosology of so-called puerperal fever. It was con- tended that the poison developed within the body of the puerpera and led to those pathological changes which resulted clinically in septicaemia. Such theory is untenable to-day, in view of tlie proven fact that spontaneous generation of disease is not pos- sible, and, again, in view of the fact that the recognized caus- ative agents of disease are never found in the healthy body.
Given a woman in good health, delivered aseptically and treated thereafter in the same manner, tlien, unless infectious material be brought to her, she will remain in tlie same state of health, the transient modifications being only such as are normally associated with the processes of normal retrograde metamorphosis in the puerperal state. Apparent exceptions are offered by those cases where, during labor or tlie puerperal state, an abscess of tlie ovary or of the tube ruptures, partly or in entirety, giving rise to a clinical symptomatology like that of puerperal sepsis. Unquestionably here the sepsis emanates from the body of the puerpera, but this is a pure epiphenomenon of the puerperium. Before labor, before pregnancy, the source of infection lay quiescent in the ovary or the tube, which had precedently been infected through the reception, perhaps, of gonorrhceic virus or as tbe result of a badly-managed abortion.
A further exception is apparently offered by instances of what has been termed saprEeraia. A woman in good health is confined aseptically. By oversight a portion of placenta or of membrane is left in the uterus. Tliis decomposes, and, if not removed, the woman becomes infected. But why does it de- compose ? Because, notwitlistanding all our care, it has become infected. Scores of cases prove that such remnants are carried for days and finally shed without the woman suffering liarm. Where they do affect her we will find that the reason is that infectious material has been brought to the woman's body and that these remnants have become infected. To go further, it has been proven that tlie organisms which produce putrefaction cause the development of ptomaines which may theraselves be
218
THE PtJEBPEEAL STATE.
toxic. The modem consensus of opinion in reference to this matter may be summarized as follows : —
In putrefactive tissues micro-organisms are at the bottom of the process. Infectious material is thus produced, and, if the excretion of these substances is interfered with, septic infection results. Now, the very entrance of these micro-organisms inter- feres or, rather, may interfere with excretion, and, therefore, we possess in the body, under the given conditions of putrefaction, material which not alone may poison, but which may interfere with excretion, from which necessarily infection will result.
Thus far, then, our argument has shown that the source of puerpeml sepsis must be looked for outside of the body of the puerpera, and we have determined that the infectious material must be brought to the body of tlie woman.
Let us recall the condition of the recently delivered puer- pera. We assume that the act of labor has been conducted aseptically and that the accessible lesions of the genital tract have been repaired after established rules, in order to close every pos- sible avenue for tlie entrance of infectious material. Still there remains a wounded surface which offers a site for infection, and this is at the placental insertion. Micro-organisms enter the geni- tal tiuct and reach this site notwithstanding every possible pre- caution taken by the physician. Now, if the body of the puer- pera lack the requisite resisting power, if, in other words, she is in a condition below the normal, then, her resisting power to the onset of disease being lessened, these micro-organisms flourish, the soil they engraft themselves upon being suitable for their growth. A living ferment is at work in the tissues. Destruction of tissue may take place, or else ptomaines and leucomaines are formed. The final result is the same : The production of infectious material which poisons the body of the puerpera and leads to the symptoms of septiccemia. As will be noted later on, these symptoms vary, lu a measure, according to the point of entrance of the pathogenic bacteria, the effects being purely local at the start and being kept local through the
THE PATHOLOGICAL PUERPERIUM. 219
proper treatment, or else the effects being general and most rapidly fatal in character.
Puerperal septicBemia, tlierefore, is never endogenous in origin. It is always exogenous; tliat is to say, emanates from without. Whence tlie corollary dwelt upon so frequently, that the most absolute asepsis should be associated with the conduct of labor and the care of the puerperal state ; and wlience the further corollary that, when puerperal sepsis develops, one or more of the attendants on the woman are culpable, even though the source or the manner of infection cannot be determined.
The careful student of bacteriology will remember that B number of pathogenic bacteria have been isolated, and that, through experimentation, we are in a position to-day to ex()ect the development of certain specific symptoms if one or another kind of bacterium gain entrance to the system. In tlie neighbor- hood of forty have been isolated as being the source of sep- ticEemic or pysemic processes. The student is necessarily re- ferred to works on bacteriology for a description of the bacteria, all that we aim at accomplishing here being to impress the fact that the clinical symptoms vary witli the kind or the kinds of micro-organism.s which have gained entrance into the system, with the nature of the soil where they have lodged, — wlietlier rich in lymphatic supply, for instance, or not ; and, finally, that the sum-total of the clinical symptomntolngy must neces- sarily depend on the resisting power of the individual in wliose body they have obtained foothold. A pucrpera weakened by precedent disease obviously will resist the onset of these in- fectious elements to a far less degree than the woman wlio has reached her terra and has passed throngli her labor with undiminished or, rather, unweakened vital forres. All this ex- plains the degree of virulency which the same disease — septi- ciemia — offers in different women infected at the same time, and afler the same fashion, and at a similar site. How far this resist- ing power depends on the action of the leucocytes of the body is yet to be proved through careful study and research. So much
'£6U TBE PUERPERAL STATE.
may be taken for granted now, and tliis is that these leucocytes appear to oifer a barrier to the entrance of bacteria into tlie system and to oppose their progress when once they have gained a foothold.
Tlie teachings of modem pathology only render stronger the data established from clinical study of the disease known to-day as septicaemia.
Tlie changes found after death are of the most varied type, and yet they are only similar to those which follow death from septic infection aside from the puerperal state. The accentua- tion of the lesions may be more marked around the genital tract, but the systemic findings are exactly alike in sepsis follow- ing an infected wound of tlie arm, leg, or face as after an infec- tion of the puerperal tract One great fact stands prominent, and this is that the lesious vary and are widely spread, accord- ing to the lymphatic supply of the part first affected. Remem- bering tliat, first, we need a wound or abrasion where the infection may enter, it is evident that any part of the genital tract may be the site of primary infection. The lacerated perineum or cervix, the wounded endometrium at the site of placental separation, — such are the obvious points of infection. Later on in the puer\)eral state the abraded nipple may become infected, giving rise to a mastitis with consecutive systemic infection.
When we remember tlie vascular supply of the sexual system, increased manifold during pregnancy, and when we recall the rich lymphatic supply of the same system, it is not suqjrising that infection, starting In this locaUty, should very readily spread to the various serous cavities of the body and be deposited by the veins in every organ.
According to the site of the primary infection the lesions at the start are diffuse or not. Systemic Infection, we repeat, supervenes, with greater or less rapidity, according as the point of primary infection is rich or not in lymphatics. Thus, infec- tion at a perineal laceration, even though It takes on tlie
THE PATHOLOGICAL PDERPERIUM. 221
socalled diphtheritic type, through energetic and timely local treatment, may be checked prior to tlie occurrence of much systemic infection, and much more speedily tlian can infection emanating from a lacerated cervix or the body of the uterus. Here the lymphatic supply is so rich, leading to the tubes and ovaries and the peritoneum, direct extension through the tubes being further possible, that general systemic intection may be most rapid in character.
Even in the most rapidly fatal forms of puerperal infection, where the local and the systemic lesions do not have time to become sharply marked, we shall find the lympliatics and the veins affected.
From his studies in pathology the student has familiarized himself with the essential changes associated with septicaemia, ' Before passing in review the clinical features of puerperal sepsis we would again emphasize the fact that, pathologically, the affection entails simply the same changes as those which follow infection of a wound in any part of the body aside from the puerperal state.
Clinically, puerperal septiccemia offers a varying symptom- atology, according as the infection affects cliiefly one or another of the pelvic organs and according as the infection is detected early and treated promptly. It seems to us wise to study the disease as an entity, and not to confuse the student by endeav- oring to sharply differentiate a symptomatology of one infected organ from another. Very rarely, indeed, will one organ be affected, or the part of one organ, without there being consecu- tive affection of another. Again, it is the exception that the symptoms of infection of the system at large do not predomi- nate over the signs offered by the local lesion. Under tlie sub- jects of ti'eatraent and of prognosis we will dwell at length on the characteristics of the individual lesions. By following this course we best impress the fact that we are dealing really with a systemic affection, even though the starting-point be a local lesion.
322 THE PDEBPERAL STATE.
"We proceed to note the alterations in tlie customary pbe« nomena of the puerperal state known as the normal phenomena,! laying stress on the meaning of certain groups of symptoms (objective and subjective). The point to remember ia that we may meet with septic vulvitis, vaginitis, endometritis, metritis, salpingitis, oophoritis, peritonitis, cystitis, etc., and each may offer cardinal evidence of its presence; but the systemic disease is the same, the constitutional disturbance only varying according toJ the degree and the extent of the primal lesion.
Infection of the woman may occur before labor, during labor, or during the puerperal state.
Ante-partum infection is uncommon, but when it occuW* tlie course is ordinarily very rapid and fatal; so that on autopsy but little evidence of systemic infection is found except that the lymphatics and the veins are affected. The woman never reaches the normal puei-peral state. She is confined either inW the midst of systemic septic disturbance, characterized by chilli^ high temperature, and rapid pulse, or else these symptoms fol- low closely on delivery. Instances of this nature are rare, except in times of epidemic, when one woman after another is rapidly infected and as rapidly dies. Nowadays such experi- j ences are unheard of, and such an occurrence would reflect thfrl most lamentable ignorance and the most culpable neglect.
As a rule, it is about thirty-six hours after delivery that the first symptoms of septic infection manifest themselves. Chill is by no means a marked precursory symptom except in the so- called fulminating types of sepsis, where the woman seems to pass from health into death. Very frequently, even though the woman has a chill, it passes unnoticed. The average puerpera reacts very readily to emotional disturbances, and, therefore, a chill, should it be noted, may have no significance of evil im- pending. Its occurrence should, however, awaken our anxiety, even as it would aside from the puerperal state. Its significance carries the same weight as it does when it ushers in any acute affection. It may mean a developing pneumonia or, indeed, in
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It
i
THE PATBOLOGICAL PUERPERIUM. 223
paludal districts, it may be only something wliich the woman lias for years suffered from at iiTegular intervals. If, however, it be followed by fever of a non-intermittent type, then, iii the puerperal state, our first thought should be of septic infection.
The pulse-rate affords, as a rule, most valuable evidence of alteration in the smooth course of the puerperium. A slow pulse ia incompatible with sepsis in its early stage, A rapid pulse is a danger-signal. Either hBemorrhage is impending or else it may be septic infection. Danger from hremonhage ia practically at an end thirty-six hours after delivery, particularly if on palpation the uterus is ibund to remain hard. Where the pulse increases in frequency and the temperature rises above 99" to 100° F. about the tliird day, impending mischief of a septic nature may usually be suspected. Formerly, this consti- tutional disturbance was laid to the incoming of the milk, — the 80-called milk fever. To-day such a fever is not recognized. The establishment of the function of lactation in a woman in good health is not accompanied by constitutional disturbance. A frequent cause of disturbance about the third day, however, is the fact tliat the intestinal tract has not been properly cared for. There is an absorption of intestinal products resulting from retained fiecal matter, and thence the rise in temperature and in pulse-rate. A laxative should clear the scene. If it does not, then, in case no intercurrent disease is developing, sepsis is.
At once the most careful examination of the woman is called for. If the pelvic floor has been lacerated, sloughing in this locality may be found, or, possibly, the developmental stage of the so-called puerperal diphtheria. Should the pelvic floor be found unaffected, and if, on examination, the urine present none of the characteristics of a cystitis, then the cervix sljould be examined by speculum for sloughing process or similar pseudodiphtheritic appearance. Tliis failing, the uterus must be carefully questioned. We are proceeding, in other words, by a process of exclusion, to establish at an early date tlie source of the infection whilst it is amenable, possibly, to local treatment,
tt
224 THE PUERPERAL STATE.
at any rate, before general systemic infection has progressed to a great degree.
Probably, in the vast majority of cases, septicuemia emanates from the uterus. Either its lympliatics have absorbed the septic virus directly or els§ a decomposing mass lies in its cavitj' and becomes infected. In the first instance we may have a rapidly supervening salpingitis and peritonitis ; in the second instance we have, first, a sapr^mia (a poisoning from the absorption of the products of decomposition), and, secondarily, a septicsemia with local lesion in the endometrium at the outset. If the process be not checked here, then, in succession, a metritis, a salpingitis, an oophoritis, and a [jeritonitis may develop.
As a general rule, it may be stated that the relation be- tween the pulse and the temperature in the puerperal state is of exceeding value from a prognostic as well as a diagnostic stand-point. Acute septic conditions, where the system is sur- charged, as it were, with the poison, are associated with great rapidity of the pulse and very low temperature. The system is deeply shocked by the poison ; we have a condition of collapse, as it were, the temperature ranging about 99° to 100° F. and j the pulse-rate averaging 120 to 140. A scene of this characM carries the most gloomy diagnosis and prognosis. On the oth) hand, where the lesion is more of the acute inflammatory tyjn and the systemic infection is slight, we are apt to have a 1 thermometric range, wliilst the pulse remains relatively slow Thus, in an endometritis, where the infectious lesion does no^ extend beyond to tlie tubes and the ovaries and the pe cellular tissue, we may note for days, until resolution, temperature ranging from 103° to 104° F. whilst the pulse-rat< remains at 115 to 120. The most virulent of all types i puerperal septicffimia — general purulent peritonitis — is usualljl associated with low temperature and high pulse-rate, and oftenJ also, with flat instead of tympanitic abdomen. In short, in that puerperal state the pulse furnishes a more reliable prognostii guide than does the temperature.
THE PATHOLOGICAL PUERPERIUM. 225
Associated with rapid pulse and elevation of temperature the lochial dischai^e becomes altered. The lochia may be par- tially or altogether arrested ; it may become foul, giving rise to what has been termed foetor.
Arrest of the lochia may be the result of diminished ex- cretion, the associate of the systemic infection, or the arrest may be only an apparent one, due to stenosis at the internal os with consequent retention and stagnation. In either event careful aseptic local examination will diflferentiate. If there be reten- tion from flexion the examining finger will find the body of the uterus bent on the cervix at the level of the vaginal reflexion, and, if means be taken to straighten out the flexion, the lochia will again appear, whilst if there be arrest of secretion it will not. In the event of there being stagnation without septic infection, the constitutional disturbance will abate on the resto- ration of the flow. Diminished or impeded excretion of the waste products certainly causes systemic disturbance, — as is shown by the rapid pulse and the rise in the temperature, even aside from infection ; but, in such a case, the temperature is apt to be high and out of proportion to the pulse-rate, whilst in deep systemic infection, as we have noted, the pulse is apt to be high relatively to the temperature. Should infection of the stagnant lochia ensue, then we may have consecutive infection of the tubes, ovaries, and peritoneal cavity.
Foetor of the lochia is simply a sign of decomposition and is an accompaniment of saprsemia. A uterus may be infected and yet there may be no odor to the diminished lochial discharge. A sloughing pelvic floor or cervix may give rise to fcetor, and such a source should always be differentiated before we conclude that the uterine cavity is at fault. The most common source of foetor is a portion of placenta or of membrane or a decomposing clot in the cavity of the uterus.
In this connection, then, it is to be remembered that the most acute type of sepsis may be absolutely unassociated with foetor, whilst on the early recognition of foetor and on its prompt
226
THE PUERPERAL STATE.
treatment saprBemia may be aborted before it merges into a septicemia. J
In early sepsis pain is usually absent. As a rule, it becomes | marked as the peritoneum becomes affected. Of course, pressure J over the septic uterus will evoke pain, but we are now speaking 1 of spontaneous pain. As systemic infection deepens and the I various organs become affected this pain emanates from each in I turn or is present in all. Thus we may have a complicating ] septic pleurisy with as sharp a pain over the affected lung as ia | case of pleurisy unassociated with septic infection. When the 1 veins of the lower legs become thrombosed, giving rise to a 1 phlebitis, the pain is of an acute type. Similarly, the paia I associated with exudate in the pelvis is sliarp and radiating. ] When the systemic infection is deep and associated with peri- tonitis of the purulent type, pain may be absent altogether, or, I in case of rupture of an accumulation of pus into the peritoneal I cavity, the pain may for a time disappear, j
The intestinal tract sympathizes markedly with the sys- | temic septic phenomena. Further, these phenomena are aggra- J vated if tiie intestinal canal be not kept functionating. Such I constipation may be the result of the septiceemia, particularly I where the peritoneum is affected, when absolute paresis of the 1 intestine frequently ensues. As a result, we have tympanites j witli the consequent pain in the abdomen and interference with ] respiration from pressure on the diaphragm. As the lesion of the peritoneum becomes more intense the intestinal coils cannot move, since they are firmly held by the bands of lymph or adhesions which are thrown out.
The upper digestive tract sympathizes, of course, as ia I shown by the coated tongue and the nausea and the vomiting. 1 As the infection deepens the skin assumes the cliaracteristic sallow hue and tlie exhaled breath has a sweetish odor. The woman lies in a species of typhoid condition from which it may ■ be very difficult to rally her. Possibly, now, septic emboli area thrown off and metastases into the various organs of the body J
THE PATHOLOGICAL PUEEPEBIUM.
227
occur, giving rise to a pyiemia. Each embolus is apt to give rise to fresh constitutional disturbance, as evidenced by the repeated chills and alteration in the temperature- rate. In short, we are now dealing with nothing else than the pyemia which occurs, independently of the puerperal condition, as the result of tlie infection of a wounded surface on any part of the body. It is the same story, only modified in so (ar as we are dealing with a puerperal woman.
As the systemic septic infection deepens the cerebral centres become affected, as is certified by the delirium, active or low in type. Concomitantly with the embolic deposits the various para- and herai- plegias may develop. These affections of the brain and of the spinal cord may be temporary or remain per- manent. Puerperal mania and puerperal insanity may develop and in course of time disappear or tlie intellect may remain affected.
In short, there is no organ and no system of the body which may not become affected by tlie septic process, even as holds for septicaemia occurring aside from the puerperal state. If the woman ultimately recover it is rarely that sIig regains the normal in function. Some trace of an organic nature is apt to remain, be it in tlie nervous system, the kidneys, the heart, etc.
Such may be the clinical course of puerperal septicsemia, looked at from tlie broad stand-point of general systemic infec- tion. We will now consider more in detail the separate local lesions, tracing as far as feasible the clinical picture offered by affection of one or another of the sexual organs and noting the treatment applicable in each case.
Clinically, we may differentiate tlie following septic dis-
I
Septic vulvitis HncI vaginitis. Septic metritis and cutlomelritia (in-
cludlngsapriEmift). Septic salpingitiB and udpliorilis. Septic peritonitis : (1) local ; (2) gen- Septic IhromboBJB.
Pelvic ceUuIilia (including pelvic
nbscesB), Septic pyteiuia. Lftte puerperal infection. Puerperal mania and inBanUf . Puerperal I eta dub. Mnstitia.
228
THE PUERPERAL STATE.
Septic Vulvitis and Vaginitis. — The vulva and the vagina, in particular the pelvic floor, are peculiarly liable to iniectiou^ since they are very accessible to contact. Rarely, further, is I a labor terminated witliout the vulva being subject to a greater I or less degree of contusion, and the ])elvic floor, as a rule, suffers a certain amount of lesion, even though this be limited entirely to rupture of the fourchette. If the act of delivery has not been conducted aseptically, or if, during the puerperal state, | care be not taken as regards asepsis, infection is likely to set in, J and, in case of the development of local or general symptoms interfering with what we expect during tiie normal puerperal state, the vulva and tlie vagina should be tlie first locality to investigate.
Infection of the vulva, aside from sloughing and throtn-; bosis, is very likely to spread to the glands of BarthoUn. Thel infectious element gains access to the glands through the ducts, and this is followed by abscess. Possibly these glands may | have been infected through a precedent gononhoea which lia.s I apparently been cured, but the latent virus has remained there, and the septic infection is cliaracterized by a gonorrhoea! com- plication.
Infection of the vagina may be direct at the wounded or I abraded surface or it may be traced to the material used to suture ] a laceration. Improperly-sterihzed catgut or silk will often be the starting-point of infection, and for this reason we prefer, for suture material in the emergency-surgery which lesion of the pelvic floor demands, a material, such as silk-worm gut, which may be readily rendered sterile through boiling for ten minutes. ,
Septic vaginitis may show itself by an increased secretion | from the vagina, purulent in character and associated with a greater or a less degree of sloughing, or else we may find char- acteristics which, from their similarity in ap^jearance, have been described as a diphtheria of the vagina. It is very questionable , if we are dealing with a process similar to that which occurs in J tlie throat, although clinically it makes no diflerence, since waJ
THE PATHOLOGICAL FUERPERIUM. 229
have the same infiltration of the submucous tissues and the same constitutional infection.
The appearance of the vagina in these cases of so-called diphtheria is, at the outset, that of a surface covered with grayish dots which cannot be removed readily from the surface ; that is to say, we are dealing with an infiltration, and not with the mere formation of a membrane on the surface of the vagina. Later these small points coalesce, giving us the appearance of a dirty- grayish deposit on the vagina. On bacteriological examination it will be exceptional that the bacillus of Loeffler, which is pathognomonic of diphtheria in the fauces, will be determined, and thus we may differentiate the condition firom a true diph- theria. In principle it matters not, since the treatment will be identical.
As complications of septic infection of the vulva and of the vagina we often find extension to the urethra and the bladder or to the rectum, giving us a cystitis and a proctitis. A more common cause of this cystitis, however, is careless catheterization by touch instead of by sight and without precedent disinfection of the introitus. The characters of these complications are simply like cystitis and proctitis occurring aside from the puerperal state as the result of infection. We have painful defecation and micturition followed by the passage of pus from the bladder or the rectum. On inspection of the rectum or the bladder we will find the mucous membrane denuded and the site of an active inflammatory process.
Septic vulvitis is likely to be followed by infection of the inguinal glands, leading to suppuration and to abscess formation, or the veins of the thighs may become affected and puerperal venous thrombosis may occur in one or another thigh, giving us the so-called milk-leg.
If not checked in an early stage the infection from the vagina may extend to the cervix and thence to the endometrium.
Whilst a certain amount of constitutional disturbance is associated from the start with septic infection of the vulva or of
230 THE PUERPERAL STATE.
the vagina, the chief symptoms are local. Thus, there is swelling of the vulva, with possibly induration of one or both of the glands of Bartholin, and the woman complains of a sense burning and of heat in the vagina. The temperature may ri one or two degrees above the normal and tlie pulse-rate will' always be accelerated, as is common to all affections which affect the general system. The woman furtlier complains of pain on micturition, not necessarUy because the bladder is affected, but since the urine flows over the posterior commissure, which is inflamed.
These symptoms simply become intensified as the inflai matory process progresses. In case of sloughing or the formi tion of the pseudodiphtheritic membrane the temperature ma] range over 103° F. and the pulse be accelerated in proportioa,^ rising to 130.
It is obvious that early recognition and prompt treatmei is requisite to prevent extension and sloughing, which latl might speedily lead to the formation' of fistulce into the bladder or into the rectum.
According to the intensity of the local lesion and the. amount of lymphatic absorption, the constitutional disturbani will vary. Usually the secretion of milk will be arrested become diminished. The lochial discharge will also sympathize with tlie constitutional disturbance, becoming arrested or dimin- ished as the temperature rises high or not. The lochia further will become fetid, but the source of the odor will be the sloughinj and not decomposition in the uterine cavity unless, indeed, two processes are combined.
Since these lesions are the result of infection of woum abrasions of the vulva or pelvic floor, the symptoms will ap] early or late according to whether the infection enters durini labor or at any time during tlie puerperal state, for as long the wounds remain unhealed infection is possible.
The treatment of vulvitis is aseptic and expectant until evidence of suppuration offers. Aseptic cold compresses to the
the —
4
i
THE PATHOLOGICAL PUERPERIUM. 231
swollen labia will add much to the comfort of tlie woman, as well as in a measure modify the temperature rise. Abraded surfaces should be washed with a solution of bichloride 1 to 5000 a number of times daily, and dusted with iodoform, aris- tol, or bismuth. As soon as there is evidence of suppuration, under aseptic precautions incisions should be made, the various pockets being opened up, in order to avoid extension. In case one or both of the glands of Bartholin suppurate the incisions should be made into the gland along the inner surface of the labia; the abscess-wall should be curetted and cauterized with carbolic acid; tincture of iodine and carbolic acid, equal parts; or even the actual cautery may be used. Tlie sac is then packed with aseptic gauze and thereafter treated as any abscess-cavity would be.
If the site of infection is a perineal wound which has been sutured, the stitches should at once be removed, the infected sur- face washed off with bichloride solution 1 to 5000, and then cauterized with nitrate-of-silver solution 60 grains to the ounce. We thus destroy whatever germs are active on the surface, and we form a wall of tlie albuminate of silver through which new infection will find it difficult to enter. After cauterization the surface may be dusted with iodoform or bismuth. A number of times daily the affected pelvic floor should be irrigated with bichloride solution 1 to 5000, or witli 1-per-cent. creolin solu- tion, and afterward dusted again witli one or the other powder. Vaginal douching should be avoided so long as the lesion is localized at the introitus. The only effect of douching would be a possible infection of tlie upper vagina or tlie cervix.
Cystitis is to be treated according to tlie recognized methods apart from the puerperal state. The bladder should be irrigated every four hours with a 50-pcr-cent. solution of boric acid, and diluents should be administered ^>j-o re natn.
Proctitis is beat treated by the local application of a solu- tion of nitrate of silver 60 grains to the ounce. This applica- tion is, of course, to be made tlirough a speculum.
232 THE PUERPERAL STATE.
So-called diphtheritic vaginitis calls for the same treatment, except that tlie nu'asiires at the outset should be more radical. The application of subsulphate of iron, which is strongly recom- mended, we do not favor, since the caustic effect is hut sliglit and superficial and the resulting slough is very prone to decompo- sition. Cauterization witli the chloride of zinc in oO-per-cent. solution is highly recommended, but we question if it be neces- sary to cauterize so deeply aside from the difficulty of limiting the action of the zinc. Where the process is just beginning the whitisli patclies may be touched to advantage with the actual cautery, or they may be scraped off with the curette and a solu- tion of nitrate of silver 60 grains to the ounce may be applied. In case the infiltration has extended widely before it is discov- ered we believe that the best measure is tliorough cauterization of the surface n-ith the actual cautery. The surface is then kept powdered with iodoform or bismuth and carefully watched for the detection of evidence of spreading, when the same cautery should be used.
Tlie treatment of local lympliatic extension will be referred to under the heading of " Septic Thrombosis," since the affection of the lymphatics is usually associated with tliat of the veins.
The constitutional treatment is self-suggestive. An abun- dance of liquid food — in particular, milk — should be given, and stimulants according to the condition of the pulse. It will do no harm to give 5 grains of tlie carbonate of ammonia every four hours as a routine measure, since tlie tendency of septic poisoning is to weaken the heart. In case the stomach is not tolerant the drug may be given in double the dose by tlie rectum. Tlie bowels should be kept regular by laxatives and enemata, and opium should be avoided except when stringently called for, when codeine should be tested in large dose — 1 grain bv the mouth and 3 by the rectum — before other alkaloid of opium is administered. The tem^ieratnre rise need not be a source of anxiety. It is simply an evidence of the systemic infectioit, and it may be kept within limits by the application of an ice-bag.
THE PATHOLOGICAL PUERPERIUM. 233
Antipyretics should be avoided, — ^in particular the coal-tar derivatives, which have such a weakening eflfect on the heart.
Metritis and Endometritis. — Whilst endometritis may exist and run its course without the concurrence of metritis, the presence of the latter necessitates the former. The etiological factors are extension infection from the lower genital tract, direct infection at the site of placental separation, contact infection by unclean hand or instrument introduced into the uterus, infection from a saprsemia the result of the decomposition of clot or rem- nant of placenta or of membrane left in the uterine cavity.
It is essential to differentiate sharply the infection following on saprsemia from that which results apart from the latter, since the clinical signs are different, as also the demanded treatment.
Infection following sapraemia, or putrid infection, may be an early or a late phenomenon of the puerperal state. Ordi- narily the symptoms manifest themselves about the third day, but in many instances nothing abnormal may be noted until a much later date, in certain cases not until the woman has been practically discharged from observation. Remnants of placenta and of membrane or clot (partially organized and partially attached) may remain in the uterine cavity for days without giving rise to local or constitutional symptoms, so long as these retained particles do not become infected. For this reason the symptomatology is of the most varied nature.
Ordinarily the course of events is as follows : About the third day we note increasing rapidity in the pulse-rate without elevation of temperature above 99^ F. Chill may occur, but usually it is slight or absent altogether. It is more likely to be marked in instances where the lesion is of a sharp inflammatory nature from the start, instead of being characterized by a process of slow systemic poisoning, so to speak. The lochial discharge very shortly becomes altered. There is apt to be diminution in quantity and the color becomes darker and the consistency thicker. Gradual diminution or suppression of the lochia is only likely to set in at an early date, where there exists, as a compli-
h
234 THE PUERPERAL STATE.
cation, stenosis of the cervix witli defective drainage. The odor of the lochia sliortly altera ; it becomes stale or of a most pro- nounced necrotic quality. On local examination the uterus is found to be larger than it should be at the stage of the puerperal period, and it is also softer on bimanual palpation. As the case progresses the endometritis merges into a metritis, and then we find a soft, boggy uterus, tender on pressure. Pain is apt to be absent until the tubes and the ovaries or the uterine covering of the peritoneum become affected, wlien, in addition, there is present a variable amount of tymjianites, the evidence of paresis of tlie intestines the result of tlie systemic infection. If the condition be overlooked or if the proper therapeutic measures are not resorted to, the general systemic infection progresses through lymphatic absorption and direct extension through the Fallopian tubes, and we note the development of peritonitis, local and general, with, at a still later period, thrombosis and embolism and pysemia.
Should the endometritis be the consequence of contact infection without sapveemia the symptomatology is different, and the physician, unless especially observant, is apt to be led astray. In these instances fcetor of the lochia is a late and not an early symptom. When it occurs it is dne to tlie necrosis and the separation of tlie infected endometrium, and this process does not set in until the infective element has been at work for many days. In aggravated cases not only does the endometrium necrose, but the process extends to the muscularis, and a cast of the uterine cavity may ultimately be shed, giving us the very rare condition of a puerperal dissecting metritis. As a rule, in the condition of the endometrium we are considering, there" is apt to be a cliill at the start, the result of the rapid development of tlie inflammatory process in the endometrium and the conse- quent rapid systemic infection. The temperature vises more rapidly, although, as in the case of all acute iiiflamniatory proc- esses, the pulse-rate sympatliizes, — the reverse of that which occurs at the outset of a saprsemia, where tlie pulse-rate is rapid,
THE PATHOLOGICAL PUERPERIDK.
235
out of proportion to the temperature rise. The locliial discharge is diminished or suppressed at the start, becoming, as a rule, free and even profuse later on, as the necrotic endometrium separates. Extension to the tubes and the ovaries and to the pelvic peritoneum very frequently occurs early, by both lym- phatic extension and by direct route through the tubes. Pain, again, is not a marked factor until tlie peritoneal coating of the uterus is approached. Tympanites develops early, because the intestinal tract necessarily sympathizes with the systemic infec- tion. Ultimately, if tlie process is not recognized early and treated after the recognized fasliioii, we note the development of all tlie characteristics of general systemic infection, — multiple tliromboses and embolism. Unfortunately, an endometritis de- veloping apart from a saprmmia is not as amenable to treatment. It may be stated that sapra^mia is one of the most frequent of puerperal deviations from the normal, and that, when recognized eaiiy and treated properly, it is most readily cured.
The clinical course portrayed above is by no means con- stant. Frequently, particularly in case of saprEemia, we shall note marked remission or even intermission in the symptoms. This occurrence is due to fresh systemic infection, either because the treatment applied has not been thorough or else because, during certain of the requisite manipulations, asepsis lias not been complete. Thus, apparently, the woman is convalescing, the alarming symptoms having abated, when, of a sudden, there is renewed chill, rapid pulse-rate, and elevation of temperature. If this recurrence cannot be traced to recrudescence in the original local affection, then it is evidence of the extension of the process to the tubes or the peritoneum.
The treatment of these forms of endometritis differs markedly. It is very essential to differentiate them from the start. We are convinced that a great deal of harm has been done by resort to tiie curette in one of the forms, even as a great deal of harm has resulted from adlierence to tlie douche in the cases where much more radical measures are demanded.
THE PDERPERAL STATE.
The first step is accurate diagnosis. The lower genital tract 19 carefully investigated by sight and by touch to exclude infection here. The interior of tlie uterus should then be investigated by the finger, for this is the only way to difieren* tiate a beginning saprseniia from contact infection of the endo- metrium. In order to examine the interior of the uterus it may be requisite to administer an aniesthetic, but this should always be done wliere need be, since on careful difierential diagnosia will depend the limiting of the infectious element or process at a time when extreme radical measures are not requisite, Ane^s- thesia by nitrous oxide is eminently feasible for this careful exploration of the interior of the uterus, and it is to be hoped that, before long, a fairly portable apparatus for administering this gas will be devised. Chloroform, as a rule, however, will answer, since tlie ansssthcsia need rarely be prolonged. If the examining finger find the cervix wide open it is evidence that there is a foreign body in tlie organ, for such is the case, unless there exists stenosis at the level of the internal os. The body of the uterus is depressed by the external hand, and thus the examining finger may reach the fundus of the organ and examine the entire interior. In case clot or remnant of placenta or membrane be present the finger will recognize it, and it will also be able to form some idea of the extension of the infectious process beyond the point of attachment of the necrosing particles.
Frequently the finger may remove the putrid mass, and then, if the endometrium feel normal — that is to say, if it does not yield, to the touch, the sensation of a soft tissue on the point of breaking down — a douche of bichloride 1 to 5000 or of creohn 1 per cent, may be sufficient to cause the symptoms of putrid infection to abate. Rarely, however, will tins be the case. As a rule, the infection has spread to tlie entire endo- metrium, and then a careful curetting, as is described in " Obstetric Surgerj'," is called for.
In the event of the examining finger determining a steno*
THE PATHOLOGICAL PUERPERIUM. 237
sis, with consequent retention of the infected lochia, thorough irrigation of the uterine cavity should be resorted to before the use of the curette is indicated.
In case the examining finger does not find anything in the uterus, then curetting is not called for until a later stage, when the necrosing endometrium begins to separate. Indeed, curet- ting in this condition will result in harm. The process may be as yet purely local on the surface of the endometrium, so to speak, and, if we curette, we simply open channels for fresh systemic absorption. It is in these instances that the repeated intra-uterine douche is indicated. This should always be ad- ministered by the physician, and creolin should be used instead of the bichloride, since a large quantity of the solution will be requisite at frequent intervals, and there is considerable danger ' of poisoning. It goes without saying that the manipulations should be characterized by the most absolute asepsis, otherwise the net result will be new infection. At the outset it is wise to wash out the uterus at least every three hours, unless the lochia become fetid, the index of necrosis, when the curette is called for.
In putrid infection, after careful curetting, we believe it good practice to pack the uterus with gauze, not for the pur- pose of drainage, but in order to keep the abraded uterine walls apart. This gauze should not be left in longer than twenty-four to thirty-six hours, since at the end of this period there has inevitably collected a certain amount of detritus, the portion of the endometrium which has escaped the action of the curette, and this is simply retained by the gauze, which only allows the serum to escape. The gauze is therefore removed, the uterus is irrigated aseptically, and a fresh packing is inserted. Iodoform gauze is ordinarily recommended for this purpose, but we have become rather circumspect in its use, since we have often noted poisoning. The first packing may be of iodoform gauze, 5 per cent. ; but for the second and third we much prefer ordinary sterilized gauze.
In all septic conditions it is requisite to keep up the bodily
23S THE PUERPERAL STATE.
strength, therefore the administration of the carbonate of am- monia in 5-grain doses every three hours is indicated at the start. Other stimulants, such as whisky and brandy, we prefer to reserve for later stages of t!ie process should we be unable to abort it early.
The prime reason for mdical treatment of septic endo- metritis from the start is to prevent the extension of the in- fectious process to the tubes, ovaries, and peritoneum, when the remedial measures are necessarily of a much more radical type. This constitutes a further reason for supporting the system, as far as possible, by the admuiistration of plenty of readily- assimilated food, so that, should the process extend further, the woman may be in as good a condition as possible to stand the operative measures which may be forced upon us.
Attention to the intestinal tmct is, above all, called for, else the concurrence of absorption of ftecal products will obscure the diagnosis of the progress of the local affection. It is not sufficient to empty the bowel by enema, but every night, where requisite, a laxative should be given. A calomel purge is an excellent thing to start with, giving a half-dozen triturates, 1 grain each, one every hour, and then a saline should follow. Thereafter one or two compound-cathartic pills at night will keep the intestines in order, particularly as the woman will be receiving liquid food, which is in most part absorbed.
Pain not being marked, it will rarely be necessary to ad- minister an opiate, and tins is fortunate, since we are exceedingly desirous of not paralyzing the intestines. An ice-bag applied over the abdomen, and kept on as long as the temperature ranges over 101° F., will quiet tlie slight amount of abdominal pain present as long as the infectious process remains local, and this will also spare tissue waste, which is associated with con- tinuous high temperature.
An endometritis and a metritis may remain localized for weeks without extension to the tubes or the peritoneum. This iact is firmly established by clinical observers, and therefore it
THE PATHOLOGICAL FUERPERIUM. 239
is well to sound a note of warning against accepting too readily a growing teaching, which is, that if the local process does not yield within short order, then, if we desire to avoid infection of the peritoneal cavity, with its concomitant great risk as regards the woman's life, the time has come when dallying with local measures should cease, and extirpation of the septic organ is indicated. We freely grant that this procedure is preferable to the gloomy outcome of attempts at curing general septic perito- nitis, but the difficulty, as yet, is to decide what case is going to be cured by local treatment after the manner outlined and what case is going to pass into infection of the tubes and perito- neum. The physician who has been in a position to follow clinically such cases from an obstetrical stand-point, as well as the gynaecological, is less likely to err on the side of ultra- operative enthusiasm than he who has only witnessed septic endo- metritis and metritis and their sequelae as a gynaecologist. We are satisfied that the vast majority of cases of septic endo- metritis will resolve under the modern treatment applied early, even though the course of the affection be a most protracted one, and therefore we counsel against the rash assumption that early hysterectomy is demanded. Where the infection is cer- tainly progressing toward infection of the peritoneum, as be- comes evident, usually, by the diminishing temperature rise and the increasing pulse-rate and the increasing tympanites unrelieved by the administration of laxatives and of enemata, where the symptom of abdominal pain becomes marked, then the time has come for hysterectomy, although, unfortunately, since this is an operation which calls for an expert, it will rarely be performed outside of large medical centres. And yet, when properly indicated, it is the operation which promises hope of saving a percentage of cases which will otherwise be lost. When performed, the vagina should be selected as the route, for reasons noted later on.
The technique consists in opening the anterior and the posterior cul-de-sacs^ entering the peritoneal cavity, ligating or
16
240 THE PDERPERAL STATE.
clamping the broad ligaments, removing the uterus and then the appendages. The details of the technique must be studied in treatises on gynEecoIogy, although tlie operation should never be undertaken unless tlie physician is familiar with these details either from practice or from observation.
When, notwithstanding all our care, the infection extends beyond the uterus, we note the development of septic infection of the tubes, the ovaries, and the peritoneum and cellular tissue. The symptomatology of these affections is often blended, and therefore we describe them clinically togethei".
Periionidit, Local arid General ; Pelvic Cellulitis ; Salpin- gitis^ and Odjjkoritie. — Although pelvic cellulitis unquestion- ably complicates the puerperal state indeiiendently of peritonitis, it is preferable to consider it as a subheading of the latter, in order to impress on the student the fact that, as a rule, it is an associate. This is what should be expected when we remember that the cellular tissue of the pelvis is either surrounded by the peritoneum or else is in intimate contact. It is established, however, tliat, whilst it is exceptional to see peritonitis without implication of the tubes or the ovaries, cellulitis may occur and suppurate, and the woman recover with intact appendages.
The infection of the cellular tissue of tlie pelvis is through the lymphatics. Whilst, aside from infection, an exudate may be witnessed and may run tlie familiar course, — the so-called traumatic cellulitis, — cases of tlie kind must be looked upon with exceeding skepticism. The most common cause etiologicAlly of puerperal cellulitis is infection from a laceration of the cer* vix. In such a case, about the third or the fourth day after delivery the woman may have a chill, although this may be so slight as to pass unnoticed. On local examination a bogginess of one or both lateral vaginal cal-de-sacs will be determined ; that is to say, a sensation of fullness associated with evidence of congestion. The temperature rises often to 103° F. and the pulse is proportionately accelerated. These subjective symptoms continue from a few days to a week, ^vhen on local examination
THE PATHOLOGICAL PUERPERIUM. 241
the vaginal cul-de-sacs will be found tense. Whilst the malaise of the patient has been exaggerated, in case there is no impli- cation of the peritoneum or of the appendages there will not be present tympanites. In the event of the affection being traumatic the chances are that the high-grade symptoms will continue, gradually abating as the exudate is absorbed. On the other hand, if infection has occurred, after an interval varying from a week to two the cul-de-sac on the affected side will be found to soften and concomitantly the temperature is apt to drop, whilst the pulse-rate remains high. Such are the evi- dences of pus formation and of beginning systemic infection. We will find in such cases the development of what is termed pelvic abscess. The localization of the exudate which has broken down is extra-peritoneal, and the indication is to incise the abscess-cavity per vaginam and to treat it aseptically. As a rule, the above symptomatology is much more obscure. It may be that there are signs of peritoneal infection, such as tym- panites and pain extending over the abdomen instead of being localized over the side where the exudate is determined. In such an event it requires often the most expert touch and knowl- edge to determine whether peritoneal infection has occurred or not. Examination by the rectum will tell us, frequently, that the appendages are affected, there being evidence of marked congestion and, at times, enlargement. Again, we may note nothing especial by the rectum except the exudate under or within the broad ligament. In this case it is advisable to order hot douches frequently repeated, and to meet the temperature rise by the ice-bag or, in case the rise is not over 102° F., and the abdominal pain is not especially marked, poultices. If, at the expiration of twenty-four to thirty-six hours, the tympanites increases and the local signs do not abate or offer evidence of local pus formation, the time has come for exploratorj^ abdominal section. Temporizing with a slowly-developing infectious peri; tonitis is out of the question. In every case where the evidence is strong that the tubes or the ovaries are affected by the septic
242
THE PUERPERAL STATE.
process, early removal of the source of peritoneal infection offers the woman a chance of recovery. Otherwise, as will be noted, the chances are against her, no matter what the line of treatment resorted to.
Salpingitis and oophoritis complicating the puerperium are the result of infection extending, as a rule, from the uterine cavity. Remembering the lymphatic distribution of the pelvic organs, infection of the tubes or the ovaries by these channels is perfectly possible, but such an occurrence is exceptional with- out coincident infection of the peritoneum. The tubes and ovaries may become affected, and, if the infection be not of a virulent type, then complicating peritonitis may not ensue, and, after a variable interval, the symptoms may abate, leaving the woman with diseased appendages. In these cases the symp- toms are not apt to be marked. Pain over the affected region is present, but rarely of an acute type. The febrile disturbance is slight, as also the constitutional disturbance. On local ex- amination congestion, varying in degree, will be noted at the ontset in the broad ligaments, and, afler subsidence of the acute stage, there will be determined more or less exudate around the appendages, with fixation, according to the amount of peritoneal and cellular implication. The treatment will consist in poul- tices in case the temperature rise does not exceed 102° F.. or the ice-bag if the reverse hold true. Opiates should be with- held so as to be in a position to properly meet the peritonitis which may complicate. The bowels sliould be kept unloaded for a similar reason and also to obtain the derivative effect on the pelvic circulation.
In instances where the tubal and ovarian affection is of a higher grade, within a few days we shall obtain evidence of peritoneal infection, such as tympanites and diffuse abdominal pain. Even then the peritonitis may remain local, in which case the termination may be resolution of the acute process, with remaining disease of the appendages, or local abscess. In the latter event, — that is to say, if the symptoms instead of
THE PATHOLOGICAL PUERPERIUM. 2i3
abating increase in severity, as shown by the increasing tympan- ites and abdominal pain, and locally by the boggineas in the re- gion of one or both broad ligaments, — the course of action must depend on whetiier the pus points toward the vagina or above Poupart's ligament. As soon as pus formation is determined, or where there is strong ground for suspecting it, in case it is possible to evacuate it by incision in the vagina this site should be selected. If it be not possible to reach it here, then, after certifying the presence oi" pus by conjoined examination under aneesthesia, the wise course to pursue is to open the ab- domen and to remove the appendages. Tliis will hold unless the exi)eriments which are now in active progress should prove the entire feasibility of removing these accumulations of pus in the tubes by vaginal section. Certainly, so far, it has been established that incision in the vagina posterior to the uterus enables us to palpate the diseased tubes with ease, and, in case they are accessible by this channel, it should be selected, since it subjects the woman to less immediate risk than does abdom- inal section, to say nothing of the ultimate risk of hernia at the site of abdominal incision. The general treatment is to avoid opium as far as feasible in order not to intensify the intestinal paresis, to administer laxatives so as to favor peristalsis and elimination as far as is possible by the intestinal canal, and, further, in order to limit, in a measure, the formation of intes- tinal adhesions. Nourishing food and stimulants i>ro re nata are obviously indicated.
Peritonitis may be the result of extension from the tubes through the fimbriated extremities or by direct rupture of accu- mulations of pus, or else it may result from infection through the lymphatics. Clinically, it is hardly feasible to differentiate the source of infection except in cases where the disease of the tubes has been watched for a variable period and there is super- added peritonitis.
Pre-existing pyosalpinx, or ovarian abscess, may rupture during the course of labor or at any time during the puerperal
244
THE PDERPEHAL STATE.
state and set up a peritonitis. In this event the peritonitis 1 comes simply an epiphenomenon ol' the puerperal state i cannot be traced to puerperal infection. These cases are excet ively rare, since women suffering from pyosalpinx or ova abscess, if bilateral, are not able to conceive. When the" rupture occurs, however, the peritonitis is of tlie most virulent type, especially if the infection emanate from an abscess of the ovary. Speedy development of a peritonitis after dehvery, i shown by tlie chill and tympanites, sliould always awaken thi suspicion of tlie attendant. The subjective symptoms may uol be marked. Tiie cliill is likely to occur, but there may be qJ marked elevation of temperature or much tympanites. Thi nerve-centres are, as it were, paralyzed by the infection ; facies may look pinclied within a few hours, tlie pulse-rate ma4 be high although the temperature is low, and the belly may t flat. In these cases there will usually be present a liistory c precedent pelvic disease to guide us in our diagnosis; bii whether tliere is or not, the treatment resorted to must 1 prompt, otherwise the woman is inevitably lost. Indeed, olleii she dies, notwitlistanding tlie promptest treatment, Thij^ treatment is abdominal section, the removal of the ruptured appendages, the flushing and cleansing of the peritoneal cavity as far as possible, and multiple drainage.
Similar remarks are pertinent to instances where a compU> eating appendicitis leads to peritonitis in the puerperal state.
Aside from these factors, peritonitis complicating the | peral state must be traced to infection extending eitlier by dir route from the uterus to the tubes or by the lymphatic i
Where the infection is slight and the lesion partakes more of the inflammatory type and less of the infectious, it woul^ seem as though the clinical symptoms were diff'erent, althou; at the present, this statement is made with reservation, flammatory excess is shown by the high-grade subjective ] nomena. High temperature and gradually increasing tympanite unaccompanied by absolute paresis of tlie intestinal tract, evca
THE PATHOLOQIOAL FUBBFBBIUIL 245
though the initial chill may he very seveie and the gastric dis- turbance very marked, may lead the physidau to suspect that he is dealing with an attack which is more benign as regards life. The treatment justifiable here is expectant. The ice-bag on the abdomen, maintained as long as the temperature remains above 102^ F., will control excessive rise of temperature and, in a measure, quiet abdominal pain. The woman should be fed by enema if the stomach is intolerant, and this may be con- tinued for days if the rectum be frequently flushed with cold water. Attempts should be made to keep the bowel unloaded by enemata of ox-gall and saturated solution of Epsom salts, but it is useless to endeavor to administer laxatives by the mouth, owing to the intolerance of the stomach. Opium, if absolutely called for, should be given by suppository, codeine being used in 2-grain doses, since it has less tendency to upset digestion or to limit peristalsis. In the event of the attack being mainly of an inflammatory type, the symptoms should abate at the end of a week. Locally, unless there be a complicating cellulitis, nothing may be determined. At the end of about a week possibly, on examination by the vagina, fluctuation may be detected, in which case the peritonitis has been locaUzed, and vaginal incision and drainage of the pus collection is called for. In case the symptoms subside in inten- sity as regards the temperature rise and the tympanites, and yet the pulse remains relatively high and the facies become pinched, then the chances are that the peritonitis is of an infectious type, and, in order to give the woman a slim chance of life, abdominal section is called for.
Where the symptoms are not high-grade at the outset, or where they measurably increase as regards the evidence of gen- eral septic infection, as shown by the rapid pulse, out of pro- portion to the temperature rise, then surgical treatment is called for, although it must be confessed that, where the peritonitis is generalized, the woman's chance of life is very slender. The result obtained in the past through the administration of large
246
THE PCERPEBAL STATE.
doses of opium must have been in instances where the peril nitis partook of the inflammatory type with a minimum of infectious element. The same statement holds for cases recovery under the free administration of salines. Those i have opened women with general septic peritonitis and have seen the wide distribution of the pus, encapsulated under all the abdominal organs, will be loath to believe that either the free^ administration of opium or of saline can save tliese womt The fact is that general puerperal peritonitis, occurring froi lymphatic infection, is simply an epiphenomenon of genei systemic infection. On autopsy the veins and the lymphatics throughout the system will be found gorged with pus and in- fectious elements, and where the case lias been protracted similar deposits will be found in every organ of the body. The women die from general septic infection and not from the peritonitis. Hence the urgency of either preventing the development of general septic peritonitis or of removing the source of infection early, where it can be traced to the tubes and the uterus.
Local peritonitis may run as high-grade a course as maj general, often more so, and this obscures differentiation, the symptoms of i>eritonitis tend to run a long course we mi rest assured that we are dealing with a local process, and wil a process where operative interference for the removal of tl source of infection, usually the tubes or ovaries, will often residl in the saving of the woman.
In instances of local peritonitis we may or we may not able to palpate at an early stage the exudate wiiich forms aroum the focus of infection and shuts off" the general peritoneal cavity. The tympanitic distension of the abdomen may be as aggravated as in case of geneml peritonitis, and this will interfere with pal- pation. On vaginal examination, however, as a rule, it will possible to determine tlie lower boundary of the exudate in oi or the other broad ligament. In this event, if the exuda! approach the vault of the vagina, the proper course of pro- cedure is to open the posterior cu!-de-sac, enter the subperitoneal
iraT
al-
THE PATHOLOGICAL PUERPERIUM. 247
space, and evacuate the pus by the vaginal route and drain. This is not curative in that the probable source of infection is the tube, but the evaluation of the pus will enable the woman to emerge from the puerperal state and later, if need be, an operation may be undertaken for the removal of the diseased appendage or appendages. Not infrequently the pus attempts to point in the abdominal wall, above Poupart's ligament. In such an event the incision should be made parallel with this ligament, and when the abscess-cavity has been opened counter- drainage should, whenever feasible, be established into the vagina. Drainage is thus more perfect and convalescence is shortened. The systemic treatment applicable to these cases of local purulent peritonitis is to support the woman's vital powers through the administration of an abundance of easily-digested * food associated with stimulants according to the demands of the heart. Febrile rise may be controlled by the application of an ice-bag over the abdomen, and here, as elsewhere when dealing with septic complications, the intestinal canal should be kept functionating.
General purulent peritonitis emanating from infection of the uterine cavity must receive the most speedy surgical treat- ment if we would hope to save the woman. In the event of a septic endometritis not yielding markedly within twenty-four to thirty-six hours of the application of the radical treatment we have elsewhere dwelt upon, the symptoms of peritoneal infection becoming marked, — that is to say, tlie tympanites becoming aggravated and the pulse-rate being elevated out of proportion to the temperature rise, which latter, we would again emphasize, may be only a degree above normal, — then recently-reported cases seem to prove that the time has come for operative interference of the most radical nature, in order to give the woman a slim chance of hfe. It has been certainly established that if the peritonitis become generalized the woman will die, no matter what the treatment. We must forestall this generalization by removing at onfce the source of the systemic and the peritoneal
248
THE PUERPERAL STATE.
the deatj
infection, — comprising the uterus, the tubes, and the ovai According to the skill of the operator, total extirpation may resorted to by tlie vagina or by the abdomen. The former is the route which is associated with tlie least systemic sliock, but it is also the route which offers to tlie inexperienced the greatest difficulties. Wiiatever the route selected, we must remember that after total ablation we have only succeeded in ridding the system of the source of fresli infection. We still have to di with tlie infection which had entered the system before ative measures were resorted to, and this demands food and stimulants, attention to the function of the intestinal canal and of the kidneys. In cases of systemic sepsis tlie latter organs require an abundance of water in order tliat they may be kept flushed and the system be thereby relieved of tlie waste product, which otherwise simply adds to the sepsis. The role played by urea and its derivatives in intensifying septic phenomena is of as great importance as that of the ptomaines absorbed from the intestinal canal.
Septic infection which takes on the chronic type is ated with thrombosis or offers the manifestations of pysmisi' Tlivombosis is a late manifestation of the septic puerperium, and ordinarily shows itself in the veins of the lower extremities. We thus witness the development of what is popularly known as "milk-leg," — a phlebitis and lymphangitis of one or both the lower extremities. Phlebitis and lymphangitis of this nature may either develop as a late manifestation of general sepsis the puerperal state may have been on the surface uncomplical when, from the tenth day to the tlnrd week after delivery, woman complains of dull pain in one or the other thigh, creasing in intensity and gradually associated with swelling ai oedema. There may or may not occur a precedent chill temperature rise, however, is apt from the start to be hi except in those instances where the complication sets in late manifestation of a protmcted attack of systemic s when the phenomena are more apt to be low-grade. Tl
THE PATHOLOGICAL PUERPERIUM. 249
phlebitis runs a protracted course and subjects the woman to the risk of embolism of a fatal nature. The treatment consists in bandaging the affected extremity and administering an abundance of easily-digested food. Stimulants, such as the carbonate of ammonia, 20 to 30 grains in the twenty-four hours, should be given from the start. Counter-irritation by iodine over the course of the affected vessels is useful, in particular where the lymphatics markedly participate in the affection. Absolute rest in bed must be insisted upon.
Nowadays it is not often that we observe septic pyaemia. The reason doubtless is that the modem methods of treating sepsis in the puerperal state are more radical from the start, and such deep systemic infection as was formerly the custom rarely develops. The course of a septic pyaemia is exactly similar to that which is associated with wound infection apart from the puerperal state. Abscesses develop in remote parts of the body and in all the organs, and, whilst the course of the disease may be most protracted, the result is almost always death. The treatment at our disposal is purely nutrient and stimulant, meet- ing the complications as they develop ; that is to say, opening the abscesses which become apparent on the surface.
Late Puerperal Infection. — Under this term are understood instances of infection which manifest themselves from the sixth day to even as late as the third week after delivery. The course of events is somewhat as follows: The woman passes through the early days of the puerperal state without any ap- preciable deviation from the normal. Of a sudden she has a chill or chilly sensations or else — and this is the most common course — the temperature shows an evening rise to 100° or 101° F. If the physician does not make the evening visit or if the nurse does not take the evening temperature this devi- ation from the normal may pass unnoticed. The woman loses her appetite and sense of well-being. If these symptoms occur at a period when there is still a lochial discharge this is arrested for an interval and then returns either profusely or else in
250
THE PUERPERAL STATE.
P
diminished amount and with necrotic odor. There evidently has occurred arrest of involution, for on careful examination it will ordinarily be noticed that the uterus occupies a higher position than it is customary to find at the given date after delivery.
This symptomatology, although, as has been noticed, it is not exact or especinfly pathognomonic of any lesion, should awaken at once tlie anxiety of the attendant. Careful exploration of the pelvic organ is called for, shice, to emphasize a point frequently dwelt upon, it is, above all, requisite in the puerperal state to meet local septic complications early, before they have an opportunity to become generalized. Tlie chances are — and this may be stated as the rule — that the source of the infection is in the uterine cavity if the systemic symptoms cannot be tmced to the mammary glands. It is exceptional for infection of the tubes or the ovaries to develop tlius suddenly at a late period of the puer])eral state. Examination of the interior of the uterus, if need be under aniesthetics, will usually reveal a portion of the placenta or a piece of membrane which is necrosing. In the event of there being present in the uterus a foreign body such as the above, the organ is not only larger than it should be, but the cervical canal is open, and it is a com- paratively simple matter to remove the necrosing remnant by the finger, whicli is prefei'able to the curette, since thus we may not alone be certain that we are removing the entire portion, but we may also satisfy ourselves of the condition of the endo- metrium. If this be necrosed through extension from the in- fectious remnant, then it will be necessary to curette the dis- eased endometrium ; otherwise it suffices to remove the remnant, to wash out the cavity of the uterus with bichloride 1 to 5000, and then, for a period of twenty-four hours, to pack with sterile gauze. At the end of this period the gauze should be removed under absolute aseptic precautions, and if the systemic signs of infection have abated we need do nothing more. In case, how- ever, there is still a necrotic odor or if the uteruis does not show
THE PATHOLOGICAL PUERPERIUM. 251
a tendency to contract, — that is to say, to involute, — then it is wise to repack, watching for symptoms suggestive of spreading of the infection, wlijch is not unlikely to occur. Extension to the tubes and ovaries or the peritoneal cavity, wMlst uncommon at a late |>eriod of the puerperium, where the symptoms of be- ginning infection of the uterine cavity are recognized early and properly treated, may yet occur, and in this event the treatment dwelt upon is called for.
Puerperal Mania and Insanity. — In women not predis- posed to these comphcations their occurrence must be looked upon as evidence of septic infection. In this latter class of cases the manifestations occur late in the puerperal state, either concurrently with other evidence of infection or else suddenly. Women who have passed through pregnancy in a melancholy state are apt to develop acute mania during the early puerperium or, at any rate, at some time during early lactation. Women whose constitutions are undermined by an intercurrent attack of an acute affection during pregnancy, or women who are the sufferers from one or another chronic disease, are also apt to develop mania during the puerperal state. Especially is this bo if such women are allowed to endeavor to nurse the infant. The system cannot stand tlie extra strain of lactation, as it were, and the evident corollary is tliat such women should not he allowed to attempt to nurse the infant.
Mania of an acute typo runs tlie course customary aside from the puer^ieral state. The temperature is elevated, often to an exaggerated degree, and delirium or hallucinations are com- mon accompaniments, varying in grade according to the systemic disturbance. Careful local examination should be resorted to in order to exclude local sepsis in the pelvic organs as the source of the abnormal symptoms. Tlie temperature rise may be, in a measure, controlled by the application of an ice-bag and ice-cap; absolute quietude of surroundings is advisable; the bromides may quiet the mental disturbance, although hyoscyamine in large dose, frequently repeated, answers better. Where the
252 THE POERPERAL STATE.
woman refuses food, as she often will, rectal feeding is neces- sary. Stimulants should be avoided, since they intensify the cerebral congestion which is likely to be present. The course of the mania is apt to be very protracted, even in cases where the tendency is toward cure and not toward permanent insanity. Such patients do far better if tliey can be removed from home, apart from the anxious solicitude of relatives and friends, for frequently a marked hysterical type associates the mania, and this is fed by oversolicitude.
Mania of a less acute type requires the most careful watch- ing. The woman is very apt to take a sudden dislike to her child, and may destroy it. She is likely, also, to injure herself. Chronic mania passes insensibly oflen into permanent insanity. It is well from the start to place the woman in an asylum where she may have the care and the oversight so difficult to obtain at home. Aside from this, the woman's condition will frequently alter for the better when she has been removed from her home surroundings, to which, often, she has taken an intense dislike. The treatment of the chronic tj-pe of mania is through hyoscya- mine in large doses, the administration of an abundance of readily-assimilated food, and the securing of quiet. Obviously, lactation should not be countenanced.
Piterperal Tetan m. — This excessively rare complication of the puerperal state finds its etiological cause in wound infection, even as do all the manifestations of sepsis in the puerperal state. Hardly one hundred instances have been recorded, and mortality -rate in these approximates 90 per cent. It is seen al abortion as well as after labor at full term, and, whatever the treatment employed, the course is apt to be toward fatal result. Superadded to manifestations of septic infection we see stiffness of groups of muscles develop, associated with tonic spasmi Aside from the treatment demanded by the septic manifestationi of wliich it is a complication, we can do little. The chang< have been rung on the antispasmodics and opiates, but withoT result from a curative stand-point. Chloral and the bromii
ate.
th^ lleM
THE PATHOLOGICAL PUERPERHTM. 253
in large doses by the mouth and by the rectum will palliate the chief symptoms.
Maatiiia. — Again, we note that wound infection is the source of mastitis. The infection occurs at the nipple and thence is carried by tlie lacteal ducts into the gland, to be drunk up by the lymphatics and disseminated throughout the system. Hence the reason uliy, during pregnancy and the puerperal state, the greatest cleanliness of the nipple is requisite, as well as the avoidance of applications the tendency of which is toward the destruction of the protecting layer of epithelium. Further, cleanliness of the child's mouth is requisite as well as of the hands of the nurse before she touches the breasts. A not uncommon cause of infection is the woman herself, wlio touches an abraded nipple with unclean hands.
Cracks in the nipple should be kept aseptic by washing with boric acid in saturated solution, and the cracks should be touched with lunar caustic, thus forming the albuminate of silver and erecting, as it were, a barrier against the entrance of infec- tious elements. Tiie infant should not be applied directly to a breast the nipples of which are cracked, but a rubber nipple- shield, rendered aseptic by boiling and soaking in a saturated solution of boric acid, should be the intermediary.
The development of a mastitis shows itself frequently by slight chill or only by (ebrile disturbance, which cannot be ex- plained from the side of the pelvic organs. As a rule, a mastitis develops within the ten days following delivery, although infec- tion of the nipple may occur at any time during lactation. "We distinguish a glandular and a subglandiilar form of the affection. As is noted in " Obstetric Surgery," it is essential to differentiate these forms as early as is possible, since the snbglandnlar form may do extensive damage befoie the local evidence of inflamma- tion offers. The cardinal signs of inflammation characterize the glandular form ; that is to say, heat, redness, and swelling of the affected gland. As soon as induration is detected in the gland nursing should be interdicted, although engorgement of
254
THE PUERPERAL STATE.
the mamma must be prevented by emptying the breast at reg- ular intervals by the hand. Of course, the child may be nursed on the unaffected side, even though this tends to congest the affected side. The application of the child to the unaffected breast at ratlier infrequent intervals, however, does less harm to the woman than absolute interdiction of nursing may do the child. An ice-bag applied over the site of tlie uiduration may abort it before pus formation, and in this septic complication, as in all others, the derivative effect of purging should be resorted to. Diminution in the amount of liquid ingesta allowed the woman will do much toward preventing the accumulation of milk in the gland, although it must be remembered that we thus also dimhiish the total secretion of milk. Just as soon as there is evidence of pus formation this should be evacuated as is stated iu "Obstetric Sur«rery."
The submammary form of mastitis in the vast majority of cases will make rapid strides before diagnosis is sufficiently cer- tified to warrant incision. The pus travels everywhere under the mamma, dissecting it off the pectoral muscle, and in un- recognized cases the pus may perforate into tlie pleura. Usually the local symptom of pain in the affected breast will justify ex- ploration in the absence of evidence of possible source of the symptoms elsewhere. Aspiration under aseptic precautions with a large needle — for the pus is frequently thick — may reveal the presence of pus, in which case free incision, with multiple drainage where necessary, is the treatment. This treatment i8 exemplified in " Obstetric Surgery."
INDEX TO VOLUME I.
Abdomen, appearance of, at stages of pregnancy, 19 palpation of, in the diagnosis of pregnancy, 10 Abdominal palpation, 76 signs of pregnancy, 7 Accouchement, elective, in eclamp- sia, 46 in placenta praevia, 74 Amenorrhoea of pregnane}-, 2 Anaemia, pernicious, in pregnancy,
60 Anaesthetics, use of, daring labor,
143 Ascites co-existing with pregnancy,
25 Asphyxia of infant, 185 Auscultation, as a means of deter- mining presentation of foe- tus, 88 for the determination of foBtal
heart-sounds, 12 for the funic souffle, 13 for the uterine bruit, 13
Ballottement, 8
abdominal, 9
vaginal, 9 Binder, abdominal, 166 Bladder, catheterization of, 204
inability to empty, after labor, 204
inflammation of, 229 Breasts, areola of, 4
care of, during pregnancy, 30
first appearance of milk in, 207
inflammation of, 253
structure of, 207 Breech, management of the incom- plete breech presentation, 175
prolapse of the cord in case of, 176 Brow presentation, 168, 173 Byrd-Dew method of artificial respi- ration, 198
17
Caput succedaneum, in case of pres- entation of the pelvic ex- tremity, 120 in case of trunk presentation,
128 on head, 112 Cellulitis, septic, 240
abscess following, 241 symptomatology of, 240 treatment of, 241 Cervix, anomalies in dilatability of, 135 condition of, after delivery, 205 contraction ring above, 138 dilatation of, 128
in case of pernicious vomiting, 36 laceration of, 163 mechanism of dilatation of, 129 softening of, 5 Chloasma of pregnancy, 64 Chloral, use of, in labor, 146 Chloroform, use of, in labor, 144 Chorea in pregnane}^ 57 Chorion, cystic degeneration of, 66
treatment of, 67 Colostrum, 192, 207 Condylomata complicating preg- nancy, 54 Cord,' dressing of, 191 hemorrhage from, 191 prolapse of, in case of breech pres- entation, 176 in case of vertex presentation, 170 umbilical, tying or clamping of, 156 Cysts, ovarian, and pregnane}', 63 obscuring the diagnosis of preg- nanc}*, 24
Decidiia, disease of, 65 Diabetes complicating pregnancy, 49 treatment, 50
(255)
Douche, intra-uterine, 16(>
vaginal, 166 DuiicliCB during the piici-pei
Eiitopic gestatiou, (Itll'tii'entiation
froi
■, 23
EclampBia, 41
treatment of, 48 Endometritis, septic, 233 (liagiiofile of, 236 exteuBiuu to tubes aud peritoneum,
238 symptomatology of, 233 treatment of, 235
gauze packing in case of, 237 tbe curette in case of, 337 tbe douciie in cash of, 237 Erj^ot, ndininistrution of, 161 Ether, use of, in labor, 145 Evolution, spontaneous, in case of
trunk presentiition, 122 Eyes, attention to, al'ler labor, 187
Face presentation, 168
abnormal meclianiam of, 171
caput Bnceeiliineuin on, 115
diagnoais of, 114
mechanism of, 112
varieties of, 113 Fever, puerpeml ( inde Septicemia) Fibroid tumors and pregnancy, CO Fillet, use of, 177
Fcetat head, articulation of, to spinal column, 102
description of sutures of, 81, 100
diametei-B of, 101
extension of, 105
external rotation of. 111
flexion of, 104
lack of flexion of, 110
lack of rotation of, 110
rotation, exteruul, 106
sacral rotatiou of. Ill
shape and composition of, 90
sutures of. 100 FcBtul heart-son ndfi, sites of max- imum intensity according to jiresentation. 88 Fcetal movements as an aid to diag- nosis of presentation, 89
FceLus, attitude of, 80
dehnitiou of position of, 76
of preseiitiitiot) of, 76 obstetrical hmdmarks of, 80 position of, in uterus, 93 presentation of face, 65 of pelvic extremity, 84 of vertex, 83 varieties of presentations of, 8 Fontiitielle, anterior, 81 posteritii', 82
Qestatioii, determination of Ijeriod of, 1* management of, 27
Hsemorrliftge, conceided, 136 treatment of, 137 post-partum, 162 Head, flfter-eoinin-:, 175
f(Btal deficiency in flexion of, 168 Heart disease complicating preg- nancy, 37 prognosis, 39 treatment, 39 Heart, foetal, sites of oiaximuin in- tensity, 88 Hydramnion, 68
treatment, 70 H
Icterus, in pregnancy, 58 ^|
of the newborn infant. 208 "
Inertia of tiie uterus, 153 Infant, application to the breasts, 192
artificial rearing of, 212
artificial respiration methods, 197
asphyxia of, 195
bath of. 190
Byrd-Dew method of artificial tea- pirntion, 198
care of eyes of, 188
care of the newborn, 187
clothing of, 192
premature, 194
Seliultze's method of artificial res- piration, 198
the ncwlHirn, loss of weiglit of. 208
traction on the tongue to promote respiration. 109
INDEX.
257
Infection, ante-partum , 222
auto-, 216
exogenous, 219
late puerperal, 249
treatment of, 250 Insanity, puerperal, 251
Kidney disease complicating preg- nancy, 41 clinical history, 44 eclampsia in case of, 44 etiology, 42 prognosis, 46 significance of albumin in urine, 43
Labor, abnormal, 167
mechanism in face presentation,
171 presentation of the vertex, 167 administration of ergot, 161 anaesthesia during, 143 anomalies in clinical course of, 133 application of abdominal binder
after, 166 asepsis of the external genitals
after, 166 care of infant after, 190 causes of delay in second stage,
153 changes in the cervix during, 127 clinical course of, 126 delivery of the placenta, 157 of the shoulders, 155 of the trunk, 156 dressing of the umbilical cord, 191 expulsory stage of, 131 haemorrhage after, 162 inversion of the uterus after, 185 management of the incomplete breech presentation, 175 of, in case of multiple gestation,
183 of normal, 139 of stage of delivery, 154 of the after-coming head, 175 necessity of asepsis during, 142 phenomena of precursory stage,
126 position of woman during de- livery, 152 during first stage, 150
Labor, posterior presentation of the occiput, 168 precipitate, 14, 134 presentation of the brow, 168, 173 of the face, 168 of the pelvic extremity, 174 prolapse of the cord, 170 pulse-rate at the end of, 203 stages of, 126 dilatation, 128 placental expulsion, 132 tying or clamping the umbilical cord, 156 Lochia, alterations in, due to sepsis, 225 amount of, 207 significance of foetor of, 225 Lyi"g-in room, preparation of, 140 Lymphangitis, septic, 248
Malaria during pregnancy, 56 Mammary glands (vide Breasts) Mammary signs of pregnancy, 4 Mania, puerperal, 251 Mastitis, 253
etiology of, 253
symptomatology of, 253
treatment of, 254
varieties of, 253 Measles during pregnancy, 55 Melancholia during pregnancy, 64 Membranes, diseases of, 64
effect of, in causing dilatation of the cervix, 129
extraction of, 159
rupture of, 130 Menstruation, cycle of, 21
persistence of, during pregnancy, 22 Metritis, septic, 233 Milk, diminution in, 211
excess of, 212
fever, 204, 223
first appearance of, in the breasts, 207 Moles, 66
Nausea and vomiting of pregnancy,
1 Nipples, care of, during pregnancy,
31
|
^^^0sss ^^^^^H |
|
|
Ophtlialniia of the newborn, 187 |
Peritonitis, local, 246 |
|
Opium, use of, in labor, UT |
vaginal section in case of, 21' |
|
Ovarian cjstB and pregnancy, 63 |
opium treatment of, 246 |
|
0\-iirj,abBues8 of, 343 |
saline treatment of, 246 |
|
vaginal incision in case of, 243 |
|
|
Palpation, abdominal, 76 |
Phlebitis, septic. 248 |
|
[ determiDfttion of presentation by |
Placenta, adhesion of, 138 |
|
means ol', 79 |
atrophy of, 66 |
|
Pelvic brim, palpnlion of, 77 |
diseases of. 64 |
|
V Pelvic extremity, deviated preeenta- |
expulsion of. 132 |
|
j^^H tions of, 179 |
hypertrophy of, 66 |
|
^^H extension of the legs in case of, |
inflammation of, 65 |
|
^H 177 |
mechanism of delivery of, 123 |
|
^^H irregularities in the mechanism of, |
method of delivery of, 158 |
|
^H 119 |
necessity of examination of, a< |
|
^^^H mechanism of, 116 |
delivery, 160 |
|
^^B presentation uf. 174 |
Placenta prcevia. central, 72 |
|
^^" use of fillet, 177 |
marginal, 72 |
|
P varieties of, 115 |
diagnosis, 73 |
|
1 Pelvic floor, 97 |
prognosis, 74 |
|
1 measurement of, 99 |
treatment, 74 |
|
muscles of, 98 |
Pneumonia in pregnancy, 69 |
|
rigidity of, 136 |
Position, breech, varieties of, 8T |
|
Pelvic presentation, extension of the |
face, varieties of, 87 |
|
arms in case of. 174 |
transverse, varieties of, 87 |
|
extension of the head in case of. |
vertex, varieties of, 86 |
|
174 |
Post-partum hiemorrbage, causes |
|
Pelvimetry, 30, 149 |
and treatment of, 163 |
|
Pelvis, axis of inferior strait, 9S |
Pregnancy, acute and chronic tlij^ |
|
superior strait, 95 |
eases complicating, 55 ^| |
|
diameters of, 85 |
chorea, 57 ■ |
|
measurements of, 96 |
icterus, 58 ■ |
|
inferior strait of, 96 |
malarial fever, 56 ■ |
|
plane of inferior stiait, 96 |
measles, 55 ■ |
|
superior strait, 95 |
pernicious iiii)emiii, 60 ^M |
|
straits of, 95 |
pneumonia. 59 ^M |
|
Perineum, care of, during delivery, |
scariet fever. 55 ^M |
|
154 |
smatl-pox. 55 ^H |
|
Peritoneum, methods of infection |
flypbilis,56 ^M |
|
1 of, 244 |
typhoid fever, 60 ^H |
|
Peritonitis, abdominal section in |
baths during, 28 ^H |
|
1 case of, 244 |
ectopic, 24 ^1 |
|
following rupture of abscess of |
cardiac disease complicating, 3t^H |
|
the ovary, 243 |
care of breasts during, 30 J^^ |
|
from extension from the endo- |
clothing of the woman during, S^| |
|
metrium, 239 |
complicated by diabetes, 49 ^1 |
|
general purulent. 224, 247 |
disease of the kidney, 41 ^1 |
|
^^_ abdominal section in case of, 247 |
flhroids, 60 H |
|
^^K vaginal hysterectomy in case of, |
ovarian cysts, 63 ^M |
|
^H 348 |
cramps in the legs during. 3? ^M |
|
^^H infections, 241 |
diet during, S7 ^M |
INDEX.
259
Pregnancy, differential diagnosis of, 21 duration of, 17
method of determining, 18 examination of the urine during, 29 bydrorrhoea of, 65 hygiene of the skin during, 28 management of, 27 mental condition of woman during,
30 multiple, 180
neuralgia complicating, 37 pathology of, 32 pelvimetry during, 30 pernicious vomiting of, 32 psychical disturbances during, 64 railroad travel during, 29 salivation during, 37 serous diarrhoea during, 37 sexual intercourse during, 28 signs of, 1 abdominal, 7 amenorrhoea of, 2 ballottement, 9 cervical, 5
changes in the uterus, 15 color of the vagina, 14 determination of the period of,
14 diagnosis of, 14 foetal death, 71 foetal heart-sounds, 10 intermittent uterine contractions
in, 8 mammary, 4
nausea and vomiting of, 1 quickening as a sign of, 3 softening of the cervix, 15 uterine, 6 vaginal, 5 superfecundation, 181 superfoetation, 181 use of laxatives during, 28 Pregnancy and uterine displace- ments, 50 Pseud ocyesis, 21 Pubes, palpation above, 79 Puerpera, infection of the, 216 Puerperal state, length of, 203 management of, 209 the pathological, 215
Puerperium, after-pains during, 206 asepsis during, 210 changes in infant during, 208 mucous membrane of the uterus
during, 205 uterus during, 205 condition of the cervix during, 205 diet of the woman during, 209 diminution in the amount of milk
during, 212 size of the uterus during, 207 douches during, 211 first appearance of the milk during,
207 involution of the uterus during,
204 lactation during, 211 laxatives during, 209 management of, 209 normal, 203
normal chill at beginning of, 203 pathological, 215 period when woman may leave the
bed, 212 posture of the woman during, 210 pulse at beginning of, 203 pulse-rate during, 223 significance of chill during, 222 state of vagina during, 205 the lochia, 206
visits of the physician during, 210 vulvar pads for use during, 211 wet-nurse during, 213 Pyaemia, septic, 249
Quickening, 3
Quinine, use of, in labor, 153
Rectum, infiammation of, 229 Respiration, artificial, methods of,
197 Restitution, movement of, 106
Sapraemia, course of, 233 definition of, 215 treatment of, 236 Scarlet fever during pregnancy, 55 Schultze's method of artificial res- piration, 198 Septicaemia, action of leucocytes in, 219
|
INDEX. ^^^^^^^^H |
|
|
Sepliceemia, affection of tUe cerebral |
Tumors, fibroid, and pregnancy, 60 |
|
centres d wring, 227 |
obscuring diagnosis of preg- |
|
alteration in the lochia, 225 |
nancy, 23 |
|
ante-partum infection, 222 |
Typhoid fever in pregnancy, 60 |
|
appearance of first aymptomB, 222 |
|
|
cellulitiB resulting from, 240 |
Umbilical cord, tying or clamping |
|
changes found after death from. |
of, 156 |
|
220 |
Urine, examination of, during preg- |
|
chill as a symptom of, 222 |
nancy, 29, 141 |
|
condition of the intestinal tract |
Uterus, changes in, after delivery, |
|
during, 226 |
205 |
|
definition of, 215 |
associatetl with pregnancy, 93 |
|
emanating from the uterus, 224 |
shape of, G |
|
endometritis as a result of, 233 |
contractions of, after delivery, 206 |
|
fnetor of the lochia during, 225 |
during labor, 128 |
|
general symptomatology of, 221 |
diminution in size of, after de- |
|
hysterectomy during, 239 |
livery, 207 |
|
insanity resulting from, 251 |
displacements complicating preg- |
|
mania resulting from, 251 |
nancy. 50 |
|
metritis as a result of, 233 |
treatment of, 51 |
|
micioorganisms as the cause of. |
height of, at stages of pregnancy. |
|
218 |
18 |
|
necessity of early local examina- |
hysterectomy for septic infection. |
|
' tion, 223 |
239 |
|
oophoritis following, 242 |
inefficient contractions of, 151 |
|
pain during, 226 |
inertia of, 137, 153 |
|
peritonitis resulting from, 241 |
|
|
phlebitis as a consequence of, 248 |
184 |
|
pytemia complicating. 249 |
intermittent contractions of, 8. 94 |
|
salpingitis folloning, 242 |
irregular spasm of, during labor. |
|
sources of infection, 216 |
134 |
|
symptoms of acute, 224 |
inversion of, 185 |
|
tetanus resnlting from. 252 |
involution of, after delivery, 204 |
|
vaginitis as an accompaniment of. |
obliquity of. 135, 168 |
|
228 |
outline of, in case of transrerse |
|
varieties of, 227 |
presentation of the foBtus, |
|
vulvitis as a result of, 228 |
78 |
|
SmalUpox during pregnancy, 55 |
prolapse of, in pregnancy, 53 |
|
Strait, inferior, of pelvis, 96 |
repair of raucous membrane of, |
|
superior, of pelvis. 95 |
after delivery, 205 |
|
Super fecundation, 181 |
septicicmia emanating from, 224 |
|
Superfcetation, 181 |
sinking of, before labor, 17, 21 |
|
Syphilis in pregnancy, 56 |
tamponade of. in case of btemor- |
|
rhage, 164 |
|
|
Tetanus, puerperal, 252 |
|
|
Thrombosis, septic. 218 |
Tsirinft. bluish discoloration o^ S |
|
Tongue, traction on. to promote res- |
diphtheria of, 229 |
|
piration in case of asphyxia, |
disease of, in pregnancy, 54 |
|
199 |
inflammation of, during pregnancv, |
|
Trunk of fstus, presenUtion of, 120 |
28 |
|
^^^ pieseuutions of, 179 |
sUte of, after delivery, 205 |
INDEX.
261
Vaginal injections daring pregnancy,
28 Vaginitis, septic, 228
treatment of, 231 Version, in case of brow presentation, 173 face presentation, 172 occiput posterior, 169 spontaneous, in pelvic presenta- tion, 121 Vertex, inclined presentation of, 170 irregularities in presentation of,
110 occiput posterior, version in case of, 169
Vertex, posterior position of, 168 presentation, abnormal, 167
prolapse of the cord in, 170 varieties of presentation of, 103 Vomiting, pernicious, of pregnancy, 32 prognosis, 33 symptomatology, 32 treatment, 34 Vulvar pad after delivery, 167 Vulvitis, septic, 228 treatment of, 230
Woman, duty as regards nursing, 211 the lying-in, diet of, 209
VOLUME II.
Obstetric Surgery.
With Bigbty-Plve Illuatratloiu in the Toart and PiftMa
Ptaotographk Plates.
Obstetric Surgery.
INTRODUCTION.
OBSTETRIC ASEPSIS AND ANTISEPSIS.
It is only within the last decade that obstetric surgery has progressed toward the scientific eminence to which it may justly lay claim to-day. Before the advent of the era of antisepsis and asepsis, before the fear of handling the uterus had been swept away, the forceps and version were the only operations which came within the ken of the average practitioner, and the results from resort to these were anything than matters to be proud of So-called childbed fever was virulent not alone after spontaneous labor at term, but also after resort to any and all obstetric operations.
To-day the scene has radically changed. Septicaemia after labor is justly considered as due, in almost every instance, to faulty asppsis ; gradually bettering attempts are being made to educate the student with a practical knowledge of the entire range of obstetric surgery, and extra stress is being laid, as it should be, on the absolute necessity of studying the pelvis of the pregnant woman before the advent of labor, so as to be in a position to take advantage of that operative procedure, where any is indicated, which is best not alone for the woman, but which also takes into account the welfare of the child. Whilst, then, more accurate educational methods enter as factors in the science of obstetrics as practiced to-day, the fundamental reason why mortality rate has been lowered is the recognition of the culpability of the man who neglects the laws of cleanliness
(1)
OBSTETBIC SURGERT.
to, thfl^l orting^H
ssible
abso-
A'hilstfl
(asepsis and antisepsis) throughout the conduct of labor am during the puei"peral state. Lack of cleanliness (asepsis i antisepsis) will ruin the most expert technique, and, therefore, t thorough grounding in the fundamental laws of cleanliness t applied to obstetric work is essential to the undertaking of i of tlie surgery of the art.
Antisepsis is simply the means of certifying to asep (cleanliness). The whole question has been needlessly compli- cated by the introduction of scores of chemical agents which possess, to a greater or less degree, the power of rendering inert— the micro-organisms which exist in, or may be conveyed to, human body. It is possible to secure asepsis without resort to antisepsis, but, in order to surround surgery with every possible safeguard, these chemical agents must be looked upon as abso- lutely essential. The point to be remembered in obstetric surgery is that too free indulgence in antisepsis may do liarra even wh. it aims at good. The nature of many of the antiseptic agents on which we must needs rely is poisonous to the human body. Therefore the corollary must be borne in mind that overzealous- ness in matters of antisepsis may injure and kill, even as lack of asepsis may be followed by similar effects. Obstetric asepsis i secured through attention to (a) the person of the accoucheiK the nurse, and assistants ; (&) the lying-in woman ; (c) instruments and accessories.
(a) Asepsis of the AccoucHEnR and Attendants. It being absolutely proven that septicajmia is heterogeneti — that is to say, does not originate within the body, — it is th< bounden duty of all who come in direct contact with the Ijing-ifl woman to keep themselves not alone clean, but also fi-ee from those acute infectious elements which, through inoculation, breed sepsis. The ideal obstetrician, like the ideal surgeon, should avoid seeing patients suffering from certain of the acute infec-, tious diseases, such as scarlet fever and diphtheria ; and, exce] in absolute emergency, should have nothing to do with ]
OBSTETRIC ASEPSIS AND ANTISEPSIS. 3
mortem examinations. These rules of conduct should be abso- lute with the expert obstetrician, who, from recognized standing, is liable at any time to he called upon to give advice in tlie minor emergencies of labor or to act as chief in major operative obstetrics. Barring spontaneous or operative traumatic lesions, the risk the lying-in woman runs is septic infection at the hands of lier immediate attendants. Tlic geneml practitioner of necessity must perform obstetric work even whilst his routine duty calls for attendance on scarlet fever, for instance. The greater, therefore, the precautions he should take to bathe thoroughly, to change his garments, to wash his hair and beard, to asepticize his hands before going from such diseased states to a woman who is about to perform a pliysiological act. In the event of liis time being occupied to a great degree with attention to patients sick from any of the acute infectious dis- eases, so that he finds it difficult to take tlie simple and yet most essential precautions mentioned above, tlien it is wise, to say no more, for the time being to refuse to attend labor cases, else, as has too frequently hapi)ened, one pueri)era after another will be diseased, if not killed. Tlie man who makes post-mortems frequently is a deatli-deahng obstetrician, and the careless gen- eral practitioner may become such. It has been well said, and cannot be emphasized too strongly, that puerperal sepsis means faulty technique, — that is to say, one or more of the attendants are to blame. There is no sliifling the responsibility on nature. Such general measures as have been noted apply with even greater force to the nurse. She will come more frequently in contact with the woman, and, if careless, is even more likely to septicize. If ignorant, as outside of large centres she is apt to be, she may even now, in this aseptic age, fill grave-yards as she did in the past. It becomes, therefore, the duty of the physician to investigate the previous occupation and where- abouts of the nurse his patient has engaged, and to insist on her practicing the most rigorous antisepsis as regards her clothing and person. Asepsis is not sufficient for the average nurse ; she j
OBSTETRIC SURGERY.
must be provided with antiseptics in order t« cause her I approximate cleanUness. It goes without saying that she shou never be allowed to attend the l)iiig-in woman if she has beenJ witliin at least a week, in attendance on one of the acute infeo^ tious diseases. The rigid rules about to be noted as applicable to the care of the obstetric hands are to be enforced with her even as they must be with tlie physician.
In the lying-in room the physician should remove his coat and roll up his shirt-sleeves above the elbow. Since, aside from instruments, the hands are most Hkely to septicize the woman from direct contact, great care must be exercised to render tliero aseptic. If the pbysician has recently been in contact with any infectious material, thorough washing in soap and water andJ scrubbing in bichloride solution will not suffice to render thesOn hands aseptic. Under such conditions the following method must be resorted to : Tlie hands and arms are scrubbed for at least ten minutes in hot soap and water, the latter being fre- quently changed. Especial attention must be paid to the hngerJ nails, under whicli the infectious elements are most prone bM lodge. The hands and the arms are next covered with a bon saturated solution of permanganate of potash, and are theid immersed in a hot satiirated solution of oxalic acid until thflH stain of the permanganate has entirely disappeared. ThM oxalic acid is next removed by soaking tlie hands in hotH sterilized water. ■
If the physician be at all suspicious about the nurse, shu should be compelled to resort to the same process under hiM direct supervision. It has been proven by culture experimental that this method of treating the hands renders them absoluteljV free from micro-organisms. fl
Under ordinary conditions, where tlie physician is sure oifl his freedom from infectious mateiial, this elaborate process is nofl necessary. It will suffice to scrub the hands in hot soap ao^fl water, and next to immerse them in a 1 to 1000 solution o» bichloride of mercury. They are then washed in alcohol. Alldfl
OBSTETRIC ASEPSIS AND ANTISEPSIS. 5
this sterilization of tli6 hands tlie physician must avoid touching anything which has not been similarly sterilized.
Before proceeding to the performance of any obstetric manipulation, the physician should cover liis clothing with a clean sheet, which may be found in even the households of the most indigent.
(i) Asepsis of the Lying-in Woman.
Thorough asepsis of the genital tnict of tlie woman is most essential, and, at the same time, most difficult to secure. Tliese organs must be rendered surgically clean, and yet the means resorted to must be such as will not injure the protecting coat of epithelium. It is very questionable if douching of the geni- tals is sufficient for asepsis. The antiseptic agents thus em- ployed at best only come in contact with the suj>ertlcies. The vagina, in particular, is rendered aseptic with difficulty. It is in the depths of the rugosities that the micro-organisms lodge. Before undertaking any surgical manipulation tlie following means should be resorted to : The external genitals are to be scrubbed witli liot soap and water, and next washed with a solution of bichloride (1 to 1000). If the required manipu- lations are in the vagina, a new tooth-brush sliould be inserted into the canal, and this should also be scrubbed with soap and water. It is next to he scrubbed witli a solution of bichloride of mercury (1 to 1000).
In the event of the proposed operation being a symphysi- otomy or a Ciesarean section, the pubcs must be shaved, the skin thoroughly washed with soap and water, then washed with bichloride solution (1 to 1000), and finally with alcohol or with ether. After any manipulation in the uterus, in order to certify to perfect post-operative teclinique, the entire genital tract should be douched with bichloride solution (1 to 5000). There is risk of poisoning if stronger solutions than this are used in the uterus.
6
OBSTETRIC SURGERY.
(c) Asepsis of Instrdments and Accessories.
The eialiorate processes which are in use in hospitals ously cannot be resorted to in private practice. Just as thorough asepsis, however, as regards instruments, may be secured if these instruments have been carefully cleansed by the physician before they are taken to the woman's house. Instruments which have been scrubbed with soap and water, and next boiled for ten minutes in a 1-per-ceut, solution of carbonate of soda (the com- mon washing-soda), may be deemed aseptic. This asepticism, however, is destroyed if they are then placed in the average] obstetric bag, whicli contains bottles and cotton, and, from old age, micro-organisms of every possible genus. I
The sterilized instruments must be wrapped in a sterilized napkin or towel before they are placed in the bag, and imme- diately before use must be again washed in hot soap-suds and next boiled in the 1-per-ccnt. soda solution. In every household the washing-soda wUl be found, as well as the pot in which to boil tliem. The instruments may be used directly from soda solution or else may be tirst transfeiTed, with aseptic handsel into a 5-per-cent. solution of creolin, — a solution which is an efficient antiseptic and yet will not injure the instruments as does bichloride. This creolin further answers the purpose of emollient. If there is one thing more dangerous to the patient tlian another, it is the vaselin which it is customary to use as an emollient. The vaselin-pot should, once and for all, be banished from the lying-ui chamber. If newly opened it may not contain micro-organisms, but when it has been repeatedly exposed to tiie air, and possibly has been used scores of times, it will he found a veritable culture-medium for bacteria. Creolin will answer as a lubricant for the finger and for the instruments, and this should be the only lubricant allowed in the lying- room, unless the physician prefers to use sterilized oil.
As far as is possible the physician should avoid using ru her instruments. It is difficult to render them sterile. The stronger antiseptics will ruin them, the weaker will not asepti-^
I
OBSTETRIC ASEPSIS AND ANTISEPSIS. 7
cize them. Prolonged boiling may sterilize them, but often at the expense of their integrity and, therefore, of their utility. Glass catheters and glass irrigating-tubes should be selected. These may be boiled, and thus be rendered safe to use. The metal catheter, which the average nurse will produce with pride, should be taken from her and returned only when she leaves the case, and then with the injunction to either throw it away or to lock it up and to forget it. Many a case of puerperal cystitis has been traced to the use of this relic of pre-aseptic days.
During the performance of an obstetric operation sponges should not be used. This is another article which should have no foothold in the modern lying-in room. Sterilized towels and sterilized gauze or absorbent cotton should take the place of the sponge. In every household, no matter how humble, there is an oven, and in this towels and gauze may be baked. If the oven is lacking, there always exists a means for boiling them.
For purposes of irrigation boiled water should be used. To this creolin may be added to make a 2-per-cent. solution, except where it is essential to see the irrigated portion, and then, since the milk-white creolin solution will obscure vision, bichloride solution (1 to 5000) must be substituted.
Ligature and suture material must be absolutely sterile. In view of the difficulty of obtaining sterile catgut it is wise never to use it. The ideal suture is silk-worm gut. If this be boiled for ten minutes in creolin — 5-per-cent. solution — ^it is rendered aseptic, and is further rendered pliable. Obstetric sur- gery being often emergency surgery, the operator has not the time to prepare beforehand his catgut and silk so as to feel certain about them. Further, since the major portion of ob- stetric work falls to the lot of the busy general practitioner, his precedent preparations must be as simple as is consistent with absolute asepticism.
If these simple rules for securing asepsis of the lying-in woman and her surroundings are followed, the morbidity rate
8 OBSTETRIC SUBGERT.
and mortality rate in private practice will approximate those which are secured to-day in maternity hospitals, where the mortality rate has been reduced to a fractional percentage, and where morbidity from sepsis is practically abohshed. We have endeavored to emphasize our belief, and this is the current be- lief, that the lying-in woman is septicized solely through personal contact. By this we mean that the atmosphere is not a factor, and that the infectious material does not originate in the body of the woman. The sole exception to this latter statement is where, during the progress of labor or during obstetric manipu- lation, a pyosalpiux, for instance, ruptures. Such an event may lead to septic infection of the woman, but then the sepsis cannot be properly considered an obstetric epi-phenomenon.
Aseptic and elective obstetrics rob labor of its terrors and the puerperal state of well-nigh its sole risk.
CHAPTER I.
OBSTETRIC DYSTOCIA AND ITS DETERMINATION.
A SCIENTIFIC knowledge of the configuration of the female pelvis and of the methods of estimating its capacity is an essen- tial prelude to the practice of midwifery. The surgical side of the art, in particular, rests its results on accurate pelvimetry. The fate of the woman and of the ioetus is intimately linked with the expertness of the physician in determining, before or at the time of labor, the probable capacity of the pelvis in its
il FflUiKle PelTli.
relation to the estimated size of the fcetus, A consideration, therefore, of the surgical means at our disposal for assisting labor or for facing its emergencies, must be preceded by a care- ful study of the pelvis, normal and abnormal.
Furthermore, the pelvis is not the only element in the problem which is to be solved. An approximate idea of the size of the fcetus which is to pass through the birth-canal is also to be secured. It is essential, therefore, to precede the surgery of parturition by a description in brief of the anatomy of the obstetric pelvis and of the geneml physical features of the foetus.
(9).
10
OBSTETRIC SURGERY.
The pelvis is formed by tlie union of the ossa innominata with the sacrum. The sacrum is connected with the vertebral column above and with the coccyx below. The resulting canal is larger abo^e than below, and is flattened to a degree from in front backward. The superior, wider portion constitutes the greater pelvis, the inferior and narrower portion the lesser pelvis. The pelvis is further subdivided into a number of_
straits, tlie entrance into tlie canal receiving the name of si> perior strait, tlie median portion constituting tlie middle strait, the exit from the canal tlie inferior strait. It is the determi- nation of the measurements in various directions of these three portions which is termed pelvimetry, and the resultants consti- tute the diameters of the pelvis. The diameters of the pelvis are to be obtained both externally and internally, and the former stand in a certain relation to the latter.
OBSTETRIG DTSTOGIA AND ITS DETERIONATION.
11
Instruments fob the Determination of the Pelyig
Diameters.
The best-known pelvimeter is that devised by Beaude- icqne. In view of the fact, however, that the instrument iKrald be portable, the Martin pelvimeter will be found prefer- He, It should ever be remembered that the pelvimeter is as
Fig. 1— Schultze*8 PelYimeter.
Fig. 5.— CoUyer's Pocket Pelvimeter.
indispensable to the obstetrician as is the microscope to the
physiologist, and, therefore, that it should be associated with
pregnancy in his mind as the forceps is with labor. (Figs. 2, 3,
t, and 5.)
External Diameters of Pelvis.
The following external diameters are of chief obstetric gnificance : The distance between the anterior superior spines * the ilium, that between the crests of the ilium, that between
12 OBSTETRIC SURGERY.
the trochanters, that between the spinous process of the last lumbar vertebra and the centre of the anterior surface of the pubic bones (the diameter of Beaudelocque). These are the essential measurements wliich are to be obtained by means of the pelvimeter. The objection which has, over and over again, been made to this instrument, that the patient will object to the exposure which it entails, will not hold, for the reason that there need be none, as flie patient is covered by a sheet; and, instead of there being objection made, the patient will have a higher opinion of the physician who evidently is taking every requisite precaution for her future safety. It cannot be emphasized too strongly that the physician is to-day not guiltless who, whenever it may be, does not practice pelvimetry. (See Plates I and II.) In using this or any similar instrument the utmost care must be exercised to adapt the points of the blades accurately to the soft parts (as is purposely shown in the plates), and, in in- stances where it is of considerable importance to determine with great accuracy the exact measurements, it is advisable that these should be taken by two persons independently. These external measurements, of course, give us purely a relative idea of the internal, but, occasionally, a slight diminution beyond the nor- mal in one or another diameter, may turn the scale in favor of one over another obstetric operation.
The following external measurements may be taken as nor- mal in the average case, althongli it should ever be remembered that the estimated capacity of a given pelvis depends on the estimated size of tlie foetus which must pass through it: —
Distance between tlie spines, . . 10 to 10^ inches.
Distance between the crests, , . lOjtoll inches.
Distance between the trochanters, , 12 to 12^ inches.
Diameter of Eeandelocque, .... 8 inches.
The most important of those external diameters is that of Beaudelocque. By means of this external conjugate we are enabled to approximate the true conjugate, — that is to say, the diameter of tlie pelvic inlet, — the distance from the
4
I
T
OBSTETRIC DTSTOCU AND ITS DETERMINATION. 13
upper margin of the pubic symphysis to the promontory of the sacrum. In general it may be stated tliat a mean deduction of three inches from the measurement of the external conjugate will give us that of the true conjugate. As regards the other external diameters, suffice it to say that diminution below the foregoing measurements, whicli represent a mean I'rom a large number of pelves examined, should always be a source of tliought and solicitude to the physician. This matter will be amply considered under the heading of the various operations.
Internal Diameters of Pelvis. Many instruments have been devised for determining the internal diameters. The finger and, if need be, the hand of the physician best subserve the purpose. Obviously, the liand can only be used under anaesthesia ; but in every instance where the determination of the internal diameters is of moment in tlie selection of one operative procedure over another, in view of the almost absolute safety of anaesthesia, this should ho resorted to. In the vast majority of cases, however, digital pelvimetry yields us sufficiently exact information in regard to the capacity of the pelvis. This should be practiced as a routine measure in every case. We may thus determine the diagonal conjugate, and, this having been obtained, the true conjugate is readily ascer- tained by deducting the estimated depth of tlie pubic symphysis. The transverse and oblique diameters may also be thus approx- imately measured. To perform digital ]x;lvimetry the patient should occupy tlie dorsal position, witli the nates on the very edge of the bed or couch. Tlie index and tlie middle finger of the right hand are introduced into the vagina, the perineum bemg de- pressed as much as possible. Tlie aim of the fingers is to reach the junction of the sacrum with the last lumbar vertebra, for it is the distance from this point to the lower margin of the sym- physis pubis wbicli yields the diagonal conjugate. If the sacral promontory cannot be reached, the inference is safe that the
14
OBSTETRIC SDRGEHY.
This ijunfifl
pelvis is normal as regards its antero-posterior diameter. If the promontory can be reached, then the wrist is carried upward until the edge of the index finger rests against the pubic sym- physis. The index of the other hand notes this subpubic point, the fingers are withdrawn, and, by means of a tape-measure or the pelvimeter, the distance from the end of the middle finger to the noted point on the edge of the index is measured. This measurement is tlie sacro-subpiibic or the diagonal conju diameter. (Plate III, Fig. 1.)
According to the estimated depth and obliquity of the s physis in a given case, it is necessary to deduct from one-fourtli to one-lialf an inch from this measurement, in order to obtain the dimension of the sacro-suprapubic or true conjugate of the pelvis.
In taking the above measurement it should be remembered that occasionally the first sacral vertebra projects over the second, forming a false promontory. To avoid mistaking this for the true sacral promontory, it is only necessary to depress the perineum or to carry the fingers as high upward as possible. Then, in the event of the existence of a false promontory, the true will be found above it.
The transverse and the oblique diameters of the pelvis cannot be measured with the same exactitude as the conjugate. As a general rule, it may be stated that, wheu the promontory cannot be reached in a symmetrical pelvis, labor at term is pos- sible with a fcetus of average size. If there be a suspicion, how- ever, of a deviation from the normal in the pelvis, then the welfare of the woman and the fcetus calls for ansestliesia, in order that the entire hand may be inserted into the vagina, so that the capacitj- of the pelvis may be determined. This point cannot be emphasized too strongly. The scientific determina- tion of the opemtive procedure to be elected in the presence of an abnormal pelvis depends on pelvimetry as accurate as pos- sible. The instruments which from time to time have been devised for the purpose of internal pelvimetry cannot take the
|
IK |
m |
1: |
H |
|
B |
1^^ |
s |
VbH |
|
^^^^^r^'^ |
^ |
m |
■ |
OBSTETKIC DYSTOCIA AND ITS DETERMINATION.
15
place of tile finger and hand ; further, outside of maternity hos- pitals these instruments will rarely be at the disposal of the practitioner. Usually, fortunately, the careful measurement of the external diameters of the pelvis and the accurate estimation of the true conjugate will give a sufficient estimate of the capacity of the pelvis. Where the estimate tlius obtained falls below the normal, we repeat, manual pelvimetry under antes- thesia is called for. Further, in the presence of a contracted pelvis, we thus not alone note the capacity of and shape of the pelvis, but we also — and this is of equal importance — may form an approximate idea of the size of the fcetal presenting part. (Plate III, Fig. 2.) Whilst the liaud is in the pelvis the uterus may be depressed, and the facility with wiiicli tlie presenting part is likely to engage within the pelvic inlet may be noted, ' Far too little stress is laid on the relation which the fcEtus bears to the canal through which it must pass Into the world. A given pelvis may be large enough, altliough diminished in all its diametei-s, for a fcetus below the average size, and the reverse is equally true. Could we solve as approximately the size of the fcEtus as we can tlie capacity of the pelvis, the surgical side of obstetrics would be much simplified. As yet, liowever, we may only form an imperfect and relative idea of the ease with which the fcetal presenting part will enter the pelvic canal. In general, however, if a fcetus can engage at tlie pelvic inlet the chances are that it can engage at the outlet, unless, indeed, the alteration in shape of tliis outlet is marked enough to be deter- mined even by digital pelvimetry.
Aside from the conjugate, the internal diameters of the pelvis which the practitioner should estimate in the average case are as follow, with the dimensions necessary for the birth of the average fcetus : —
|
Diunetcrs. |
Brim. |
Cavity. |
Outlet |
|
Transverse, |
5 in. |
5 to 5i in. |
4|in. |
|
OUiqiie, . |
. 4i^to5 in. |
5 to 5i in. |
4$ in. |
|
Conjugate, |
. HtoHlu. |
i} in. |
5 Id. |
16 OBSTETRIC SCTRGERT.
It will be noted from these figures that in the normal pelvis the transverse diameter is widest at the brira and nar- rowest at the outlet ; the oblique is widest in the cavity and narrowest at tlie outlet ; the antero-posterior is widest at the outlet and narrowest at the brim. Therefore, a fcetus of average size, engaging normally at the brim, can pass without assistance through the cavitj' and emerge at the outlet, if the estimate of the pelvic capacity do not fall below these figures. Where the obtained measuiements are below these figures, we are in face of an abnormal pelvis, and the degree of abnormality in relation to the estimated size of the foetus must be carefully weighed before we are in a position to determine the measures, if any, which are requisite for the safe conduct of the labor.
A further measurement to he taken is the circumference. This is chicfiy of importance in determining asymmetry of the pelvis. The circumference may be secured by means of a tape- measure. Failing this the pelvimeter may be utilized by meas- uring each lateral half separately. This latter method will best enable us to secure knowledge in reference to pelvic asymmetry.
Before entering into a consideration of deviation of the pelvis from the normal, it is essential to recall briefly the aver- age dimensions of the foetus at term, for, as already stated, the practitioner must take into account in his estimate not alone tlie probable capacity of the given pelvis, but also the probable size of the body which must pass through this pelvis.
The weight of the average fcetus at term varies from 6i to 7i pounds, and the length is about 20 inches. The chief diam- eters of the foetal head, with tlielr measurements, are : —
Occipito-f rental, 4| inches.
Occi pi to-mental, 5J inches.
Cervico-bregmatic, 3| inches.
Fronto-mental, ....... 3J inches.
Suboccipito-bregmatic, ..... 3j inchee.
Biparietal, 3J inches.
It should ever be remembered that during the course o
OBSTETBIC DTSTOCIA AND ITS DETERMINATION.
17
labor some of these diameters, owing chiefly to the presence of the fontanelles, are capable of diminution, always, however, at the expense of others. In the course of a normal labor the molding; of the foetal head as it descends flexes and rotates in the pelvis, results in diminution of those diameters which adapt themselves to the most favorable diameters of the pelvis, and the corollary is that in case of abnormal pelvis the aim of the attendant slionid be to guide the longest diameters of the foetal head into the longest diameters of the pelvic canal. Such an aim presupposes accurate knowledge of pelvic configura- tion, and hence a fuither reason for accurate pelvimetry in every case. The problem before the physician is rarely a simple one, and as we pass from a consideration of the normal pelvis to that of the abnormal pelvis this problem becomes all the more complex.
General Considerations op Abnormal Pelves.
On the accurate determination, as far as possible, of the degree of pelvic abnormality in relation to the estimated size of the fcetus depends the scientific selection of the operative pro- cedure which off'crs the fairest chance both to the woman and to the fcetus. Only through the deliberate election, in a given case, of a determinate operative procedure can the physician plead that he has done his whole duty by the two beings whose welfare depends ou his skill. The midwifery of the present differs in many respects from that of the past. In no respect is the difl'erence more striking than in the growing tendency to elect the proper operation before, in the face of maternal and of fcetal exhaustion, it is forced upon us.
Careful inquiry into the antecedents of the patient; inspec- tion, where need be, of the general configuration of the body, — data of this kind arc essential aids in the determination of the nature of pelvic abnormality. Diseases of early life, such as rachitis and marasmus, almost inevitably leave their impress on the pelvis,- — an impress which superficial pelvic examination
18 OBSTETRIC SURGERY.
may not reveal, — but the knowledge of which will urge the physician to bring all his skill to bear on a more careful aud thorough examination of the pelvis.
The abnormalities of the female pelvis may be conveniently divided into minor and major, rommon and uncommon. In the United States the major deformities are rarely met with, but their determination is a far simpler matter than that of the minor deviations from the normal. It is in the latter class of cases that extreme accuracy is requisite, since at times shades of dif- erence may turn the scale in favor of one or another operatLvta
Fis. a,-JuBto.M!i]or PelrU
procedure. In instances of major deformity the choice of oper- ation will ordinarily be limited, in the presence of a foetus of average size, within a very narrow range.
The varieties of pelvic deformity and the salient character- istics of each are as follow : —
/. Jiisto-Major Pehm. — The equally enlarged pelvis is of obstetric significance only in so far as it may lead to precipitate labor or to prolapse of the funis. It is not a variety of pelvic abnormality which is at aU likely to call for operative inter- ference. External pelvimetry will readily diagnosticate the con-
OBSTETRIC DYSTOCIA AND ITS DETERMINATION.
19
ditioD, seeing that the diameters obtained exceed the measure- ments which have been stated as normal. The diagnosis, therefore, is chiefly of value as warning the attendant of the possible complications just mentioned, in order that he may be prepared to meet thera. Precipitate labor may mean, for the woman, post-partum hemorrhage, inversion of the uterus, lacer- ation of the genital tract, and prolapse of the cord may entail fcetal death.
//. The Justo-Mitior Pelvis. — This form of pelvic deformity is of infrequent occurrence. The external configuration of the patient and her antecedent history may give us no clue to its presence. It is only through careful pelvimetry, extern^ and
i
Fig. T.— Qenerklly Rqiiall; ContrMted Pelrls (Jaito-Mlnor] .
Internal, that the diagnosis, ordinarily, may be reached. All the diameters of the pelvis are diminished to a greater or less degree, and it is apparent how essential it is to determine the amount of diminution in order to elect the proper operative procedure in any instance wlicre the estimated size of the foetus suggests that assistance will be needed. In general, it may be stated, that in the presence of this variety of pelvic deformity, certainly in all but the lesser grades, it is advisable to explore the pelvis manually (under anrestliesia), in order to determine, as approximately as possible, the length of the transverse and oblique diameters from the brim to the outlet. In reported instances the diminution in the diameters has amounted to an
OBSTETRIC SURGERY.
Ivis, thera^l
inch and over. Early recognition of this type of pelvis, fore, might suggest the induction of premature labor : if the time for this operation had elapsed the question of choice between forceps and version might arise; in the extreme degrees of contraction the delibemte election of symphysi- otomy, the Csesarean section, or of embryotomy would offer as alternatives. J
///. The Flattened Pelvis.— 1)\vs, abnormality of the pelvSl may be met with, like the preceding, in women of normal ex- ' temal configuration and of healthy antecedents. It is a tj-pe of pelvis very frequently found, so much so, indeed, that many authorities rank it as the most frequent variety of deformity.
Fig. 8.— Flat Non-IUoblCio Polrli.
The etiological cause can rarely be definitely stated, pelvis is found amongst all classes, the wealtliy as well as the poor, amongst those subjected to privations in infancy and to toil before maturity, and those who are reared with tenderest care from the start. Pelvimetry alone, in the vast proportion of cases, will reveal the abnormahty, and that its recognition is important is apparent when we recall the well-known fact that this deformity is a frequent source of the most deplorable results in childbirth.
The diagnosis of this form of pelvic deformity rests on the fact that there is narrowing in the external conjugate whilst, as a rule, the other diameters are normal. The transverse diam-J
OBSTETRIC DYSTOCIA AND ITS DETERMINATION.
21
eter may be increased ; there is no pelvic asymmetry. The true conjugate measures, generally, about three inches.
From a surgical stand-point, bearing these characteristicB in mind, the recognition of this form of pelvic deformity tells the physician that his aim, in case of difficulty in extraction, should be to guide the largest diameter of the foetal presenting part into the largest diameter of the pelvis. In other words, labor through this type of pelvis requires constant watchfulness on the part of the accoucheur. It is only by not trusting to nature overmuch that deplorable results, chiefly from the fcetal side, may be avoided. Here, again, the question of the election of version or forceps will often be forced on the physician.
-Flat BKhicio FelTl* (Mild Grade).
/y. The Eachitic Pelvic. — In certain sections of Europe the rachitic type of pelvis is very commonly met with. In the United States, except among our foreign-bom population, this pelvis is infrequent compared with the simple flat pelvis. The external configuration of the woman may or -may not suggest the presence of rachitic deformity. Inquiry into the early history of the patient will, however, generally give the requisite clue. Often, in marked instances, the aj)pearance of the patient is characteristic; the size is dwarfed; the abdomen prominent; the gait clumsy ; the sacrum is flattened externally In outline ; a variable amount of spinal deviation may be present. External
22
OBSTETEIC SURGERY.
pelvimetry will reveal, as a rule, diminution (slight in the minor degrees of deformity) in the measurements between the crests and the spines. The external conjugate is always diminished. These results call for internal pelvimetry under anassthesia, for the liand alone, exploring the pelvis, can give us sufficiently accurate data as to the degree of deformity. The pelvic capacity will be found to be generally limited. The pelvis is often asym- metrical.
The most marked internal change is due to the downwa] sinking of the sacrum, the residt being approximation of the promontory to the symphysis. This antero-posterior shortening
4
Fig. 10.— Flat RublUo Pelvi« (High Orade).
may be compensated by a slight increase in the transverse di- ameter, but this is not the rule in the typical rachitic pelvis. The pubic arch is generally widened. The total result of these alterations is a pelvis with contraction at the brim, whilst the outlet may be normal or slightly widened.
In the extreme degree of this defoimity the approximation of the sacral promontory to the symphysis may be such as to practically divide the brim of the jjelvis into two portions.
The importance of the recognition of this pelvis before labor is at once obvious. The contraction at the brim neces- sarily interferes with the normal engagement of the fcetal pre- senting part. The safety of the fcetus, certainly, depends
OBSTETRIC DYSTOCIA AND ITS DETERMINATION.
23
therefore on the diagnosis of the deformity before long-contiuued efforts — leading to maternal and foetal exhaustion — at engage- ment have been made. Here, again, it is evident how accnrate pehic exploration before labor may teach the physician that his patient has a pelvis where the judicious election of one or another obstetric operation wQl redound to tiie safety of the child if not always, in tliis deformity, of tlio mother. In minor degrees of the deformity, even, the fcetal head cannot enter the pelvic brim obliquely (as is normal). The physician, for instance, if he recognize this, may conclude that the chances
rally UonttBCUd FIM Rachitic Pelvis,
for the fcetus are better if he perfonn version and guide the largest diameters of the head through the largest of the pelvis. The brim once passed, tliere will be rarely difficulty in the further progress of labor in the pure rachitic type (mild) of pelvis.
The pelves, the characteristics of which have been tersely passed in review, constitute tlie varieties with wliich the prac- titioner will ordinarily come in contact. As a rule, these pelves, except the higher grades of rachitic deformity, rarely suggest themselves from inspection of the general configuration of the patient. The varieties which are next to be considered are of
24 OBSTETRIC SURGERY.
rare occurrence, certainly in English-speaking countries, and, as a rule, the appearance of the woman at once suggests the ex- istence of i>eh'ic deformity- Accurate pelvimetry, however, is none the less requisite, seeing that due recognition of the exact deformity may, the time being opportune, point infallibly to the necessity of the induction of premature labor or even to arti- ficial abortion, in order to avoid at term embryotomy of the living foetus in instances where the indication for the Caesareau section is not absolute, and yet, where this operation cannot, for one or another reason, be deliberately elected.
(a) TXe Transversely Contracted Pelvis. — This tj'pe is also known as Roberts's pelvis from the fact that he first described it.
Fig. tZ.— Rolwrta'a FelTla. The Tranarcnicly Contracted
It is an uncommon variety of pelvic deformity, only thirteen instances being on record. The chief internal char- acteristic of this pelvis is its division into two halves antero- posteriorly. This is due to progressive narrowing of the transverse diameter from the brim to the outlet. Tlie conjugate diameter, on the other liand, differs but little, if any, from the normal. The sinking of the sacrum into the pelvis is marked, the posterior superior spines are close together, and the iliac bones pny'ect greatly posteriorly.
(b) The Kypholic Pelvis. — Inspection of the patient i the antecedent history will at oncesviggest this deformity. Th etiological cause is Pott's disease, and, according as this dist has affected one or another portion of the spinal column,
OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 25
anterior deviation of the column is in the dorsal, lumbar, or sacral region.
The effect of the spinal deviation on the pelvis is variable. In general, however, the pelvis offers the following characteris- tics: The true conjugate is increased, the transverse diameter is lessened at the brim, diminished in the cavity, and still more so at the outlet. The sacrum is carried upward and backward ; the pubic arch, as a rule, is narrowed. Where Pott's disease has developed in infancy, the total result, as regards the pelvis, Is
that its growth is arrested. This pelvis, in general, will call for the induction of premature labor, for at term the choice will almost necessarily lie between the Ctesarean section and embry- otomy, except in an instance of veiy small foetus.
(c) Tlie Scoliotic Pelvis. — It is essential to differentiate two types of scoliotic pelvis, — the rachitic and the non-rachitic, — for the characteristics are markedly difierent.
In case of the non-rachitic scoliotic pelvis the diminution in the diameters is only exceptionally great enough to prevent delivery at term. The chief characteristics of the pelvia are:
26
OBSTETRIC SUEGERT.
!The side of the pelvis toward which the spinal column deviates is flattened to a greater or less degree. As a result one of oblique diameters is shortened, but the other may not be altei i. The pelvic inlet is chiefly the seat of contraction,
i The rachitic scoliotic pelvis, on the other hand, presents
Fig, W.-N.>ii-Haoli
Kiff. IS.— Hai^hitio 9
changes have supervened in early infancy or later. Leopold states the following as the striking characteristics of this pelvis: There is considerable shortening of the true conjugate owing to the projection forward of the sacral promontory. There is greater or less asymmetry of the pelvis according to the degi of lateral curvature of the spinal column. Tlie symphysis « the pubes is deviated toward the side opposite the scoliosis.
OBSTETRIC DYSTOCIA AND ITS DETERMINATION.
27
At the pelvic inlet there is contraction on the side of the scoliosis and widening on the other, whilst at the outlet the reverse holds true. The an tero- posterior diameter is here dimin- ished, but more to the same degree than the true conjugate.
In the usual variety of scoliosis the dorsal vertebral column is curved toward the right, and the comi>ensatory lumbar curve is toward the left ; the pelvic capacity, therefore, is ordinarily diminished on the right. If the fcetus can be borne spontane- ously, it must be through the wider (left) half of the pelvis.
^
Fig. llf.— Spondylollathetic Pelvla,
and in a given case, where the scoliosis is right-sided, the phy- sician in his manipulations should remember that it is within the left; half of the pelvis that he can alone work.
(d) SpmidyloUsthedc Pelvis. — Tliis pelvis results from the sliding downward of one or more of the lumbar vertebrse on the first sacral vertebra, forming a false promontory anterior to and below the true. Tlie result is marked narrowing in the conjugate, — to such a degree, in extreme cases, that the fcetus cannot enter the pelvic cavity. The deformity was first ^d
38 OBSTETRIC SURGERY.
by Kilian. Neugebauer has most elaborately studied it, and, as a result of his analysis of forty-three cases, he reaches the conclusion that the deformity is not the result of a dyscrasia, but of the physiological weight of the trunk. This explana- tion, however, hardly accords with the data furnished by the museum specimens, seeing that in the majority there is evidence of the destruction of one or more of the lumbar or sacral verte- brsB, suggesting Pott's disease as a causative factor.
The recognition of the deformity offers no difficulty. The contour of the lumbar spine at once suggests deformity, and digital internal i>elvimetry reveals the nature of the obstruction. This form of pelvis, if defected early enough, calls for the induction of premature labor. At term the indication for the Ceesarean section may be absolute.
(e) Funnel- Shi iped Pelvis. — This variety is so exceedingly rare as to call for but passing notice. The name accurately describes the appearance of the pelvis. There is slight contrac- tion in all the diameters at the pelvic inlet, and this narrowing increases progressively to the outlet, llecognition is easy if intei-nal pelvimetry be not neglected, and, again, we have a pelvis where wise conservatism will counsel the induction of premature labor, for at term the choice will almost inevitably lie between the Ciesarean section and embryotomy.
(/) The Osteomalacic Pelvis. — The disease causing this deformity usually develops after puberty, appearing, as a rule, during the gravid state. The early stages of the disease are characterized by the presence of acute pain in tbe hmbs and pehis, and this symptom during pregnancy should suggest the development of the disease, and sliould call for careful pelvic mensuration by means of the entire hand. The disease is verv rare in the United States. In Italy and in certain portions of lower Germany it is frequently met with. The etiological causes are the same as those of rickets ; but, except in advanced case the external configuration of the woman will not suggest i pelvic deformity.
OBSTETRIC DYSTOCIA AND ITS DETERMINATION.
29
The characteristics of the osteomalacic pelvis are : The bones, in general, are softened ; the sacrum is small, the promon- tory sinking into the pelvis and approximating the symphysis. The lumbar vertebrte, in consequence, approach the jielvic brim. The rami of the pubes bend inward, tlie pubic angle being sharply acute and shaped like a beak. The external measurement between the iliac spines is less than normal, and that between the crests exceeds that between the spines. As a rule, the outlet of the pelvis is narrower than the inlet, ^^'lulst the conjugate diameter may be only slightly narrowed, the
ng. 17.— The ObWi
transverse is considerably so at the biim and more so in the cavity and at the outlet.
In the slighter degrees of deformity due to osteomalacia, internal pelvimetry by the entire hand is absolutely essential not alone for accurate diagnosis, but also for determining the extent to which the softened jielvic bones can be made to yield to pressure. It is very essential to determine this latter point, for on this depends the determination of delivery per vkte naturaJee with safety to the woman. In many of the reported instances of osteomalacia the indications for Cesarean section
OBSTETRIC SURGERY.
have been absolute. Of 72 cases collected by Litzmann, 38 could not be delivered naturally. It is also to be remembered that the disease is aggravated in successive pregnancies.
If recognized in time, the osteomalacic pelvis calls for the induction of premature labor; in aggravated instances, for arti- ficial aboi-tion. If determined only at term, whilst the pelvis may yield sufficiently to allow of the delivery of the fcetus, in the vast proportion of cases the physician will be called upon to elect either embryotomy or the Ciesai-ean section, — here, as
always prior to maternal exhaustion, the result of ineffectual efforts at delivery.
(3) The OhUqiie Ovate Pelvis. — This form of pelvic de- formity was first described by Naegele. As a rule, the woman offers no external signs. The broad characteristics of the pelvis are the diminution of one oblique diameter associated with ankylosis of one of the sacro-iliac synchondroses. The pelvis is asymmetrical, one side of the sacrum is lacking in development, and the bone is pushed toward the affected side. The pubic eymphyeia is obliquely opposite the sacrum. The arch of the
OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 31
pubes is narrowed. The true conjugate is, as a rule, longer than normal; the transverse is narrowed at the brim, and this narrowing increases progressively toward the outlet. Pelvic mensuration of the lateral halves will reveal the asymmetry.
In aggravated instances the rule as regards the external configuration will not hold. The woman limps, one hip is higher than the other, and deviation of the pubes is marked. In such an instance the following measurements, which are the same in a normal pelvis and shorter on the affected side in the oblique ovate pelvis, should be taken as assisting in diagnosis : From the tuberosities of the ischium to the opposed posterior superior spines of the ilium ; from the anterior superior to the opposite posterior superior spines ; from the spinous process of the last lumbar vertebra to the anterior superior spines. These measurements may readily be taken with the pelvimeter. The oblique ovate pelvis is of not infrequent occurrence. The neces- sity of recognition is apparent from the statement that in a series of instances collected by Litzmann, 22 out of 28 women died and out of 41 children 31 were lost. Such results are ex- plainable alone on the assumption that the variety of deformity was not recognized before term. This pelvis calls strictly for the induction of premature labor in order to avoid the choice at term between the Csesarean section and embryotomy. Only ex- ceptionally, and then in the lesser degree of the deformity, can spontaneous labor at term occur, or will, at this time, version or the forceps be safe for the woman. Symphysiotomy is contra- indicated.
(h) Pelves Deformed hy Tumors. — The presence of tumors within the pelvic cavity obviously interferes with the progress of labor and may even render delivery by the natural passages impossible. These tumors may be bony projections (exostoses), osteosarcomata, carcinomata, fibroids of the uterus, ovarian cysts ; such, at least, are the common varieties. According to the size of tnese tumors will varj^ the obstetric operation requi- site for delivery. Ordinarily their presence may be detected
32
OBSTETRIC SmtGEBY.
only by exploration of the pelvis ; hence a further reason for the rule already dwelt upon, — the necessity for examining the pelvis of every gravid woman at an early date of gestation. Such a rule, if ordinarily followed, and if its necessity be recognized by every woman, will, time and again, result in the choice of a minor operative procedure, — sucii as artificial abor- tion or the induction of premature labor, in instances where, if the woman be only examined at term, the indication for the Csesarean section may be absolute. Further, in case of pedicu- lated fibroids, for instance, the risk resulting from impaction within the brim may be avoided where the woman is seen in the early stage of gestation, seeing that, at times, manipulatioa
in the proper position — the knee-chest — may enable the phy- sician to push the growth above the brim ; and in case of an ovarian cyst, for instance, the advisability of abdominal section for its removal miglit well be forced on the phj-sician.
The osseous, cancerous, sarcomatous tumors which spring from the walls of the pelvic cavity will, as a rule, if not de- tected till term, call for embryotomy or for the Cgesarean sec- tion, possibly for the Porro operation. It must be recognized as unscientific, to say the least, to attempt delivery by either forceps or version where the fcetus is estimated at average size and the tumor narrows the pelvis sufficiently fo warrant the assumption that delivery without mutilation is problematical.
OBSTETRIC DYSTOCIA AND ITS DETERMINATION. 33
Aside from the death of or injurtes inflicted upon the child by attempts at forceps extraction, the trauma the woman would necessarily be subjected to is a distinct contra-indication.
From this analysis of the salient characteristics of deformed pelves it is apparent how helpless the practitioner may be, at the term of gestation or when labor is advanced, if, for one or another reason, he has neglected or it has been impracticable to estimate the capacity of the pelvis either at an early stage of gestation or before the onset of labor.
Without the data obtainable through pelvimetry and ex- ploration of the pelvis, it is impossible to elect the obstetric operation, where one is demanded, which best subserves in a given case the interest of the two beings whose safety depends on the acquired knowledge and expertness of the accoucheur. In practical obstetrics, the forceps, for example, is too often used in instances where accurate pelvimetry will teach that it is contra-indicated. The major obstetric procedures are too fre- quently delayed until maternal and foetal exhaustion is immi- nent or present. The facts on which stress has been laid teach the necessity of deliberate election of every obstetric operation, and it is from this stand-point that these operations will be considered.
3
CHAPTEK II.
ARTIFICIAL ABORTION AND THE INDUCTION OP PREMATURE LABOR.
The term "abortion" is applied to Instances where the ute- rus is emptied of tlie product oi' conception either spontaneously or artificially before this product has reached that stage of devel- opment when it is fitted for extra-uterine life. Artificial abor- tion, thereibre, is performed purely in the interests of the woman. Premature labor, on the other hand, wlien induced, carries with it the assumption that the fcetus is capable of surviving apart from the motlier, — that is to say, that this foetus has reached what is termed the viable age. This operation, then, is resorted to both in the interests of mother and child, altliougli ordinarQy those ol' the former cliiefly urge the physician to resort to it. I The induction of premature labor is, in general, an elective operation ; artificial abortion is usually forced on the physician. The factors calling for the one operation are usually different from those calling for the other, and the method of procedure also differs. It is useful, therefore, to consider the subjects apart.
(a) Ahtipicial Abortion.
The diseases and anomalies wliicli justify artificial abortion are: 1. Advanced pulmonary and cardiac disease. 2. The pernicious vomiting of pregnancy. 3. Renal disease. 4. Per- nicious anasmia. 5. Chorea. 6. Absolute pehic contraction or occlusion of the genital tract by tumors, etc. 7. Irreducible displacements of the uterus. 8. Hgemorrhage from placenta prsevia, hydatid mole, etc.
Bearing in mind strictly the fact that artificial abortion is performed purely in the interests of the woman, we will con- sider these indications seriatim.
1 . Advimced Palmmiary and Ca rdlac Disease. — At a
glance it is apparent what an untoward effect gestation, if
(34) —
AHTIFICUL ABORTION.
36
allowed to advance, must have ou the life-Hmit of a woman in an advanced stage of phthisis or with serious cardiac lesion.
The vital force of the womnn is being actively expended in figliting the disease which shortly will kill her when, in addition, the extra burden of supporting foetal growth for nine months is thrown upon her. If such a woman be allowed to go to term, even if she can withstand the strain of pregnancy and of labor, the duration of her remnant of life has unques- tionably been shortened, and she will rarely have the satisfac- tion of leaving behind her a healthy babe. Wise and justi- fiable conservatism, therefore, counsels the artificial arrest of pregnancy as soon as detected, in case of advanced phthisis and of a cardiac lesion which has progressed to the stage of dilatation.
The indication may be said to be absolute in tlie former instance ; in the latter only when the heart has begun to dilate, since otherwise the physiological cardiac hyjwrtrophy of preg- nancy will enter as a compensator)- factor, and enable the woman to reach term with safety, and, likely enough, not deteriorated in general health.
2. The PismidovJi Vomilhig of Pregnane!/. — Tliis indica- tion may be called absolute only after the recognized general and local remedies have been tried. Rectification of a uterine displacement, applications of solutions of nitrate of silver to the cervix, digital or instrumental dilatation of the cervix, regula- tion of the diet and of the function of the intestinal canal, the internal administration of drugs (oxalate of cerium in large doses, ingluvin, minim doses of ipecac or of phenic acid), — such, briefly stated, are the chief measures on which depend- ence may be placed for the relief of pernicious vomiting. Only after such means have been tested does artificial abortion sug- gest itself as justifiable. It should then be deliberately elected. The physician should not wait until the emaciation is extreme, the pulse is rapid, and the fever of exhaustion sets in. On the occurrence of phenomena of exhaustion, the operation may fail
36
OBSTETRIC SURGERY.
in its object, — the saving of maternal life, — and generally emptying of the uterus is postponed too late, The fact that tlie vomiting, even when of the so-called jwrnicious type, in many instances ceases spontaneously at the third month, whilst a cause for Iio|}e, should never blind the physician to such a degree as to lead him to expectancy overlong. Whilst, as a rule, artificial abortion, under tliis indication, is rarely called for, it is safer not to wait until the vital forces of thej woman are at too low an ebb,
3. Renal Disease. — The co-existence of renal disease and of pregnancy is most unfortunate. Aside from the strong prob- ability of the development of eclampsia if the pregnancy be allowed to continue, the extra wear on the kidneys associated with gestation inevitably tends to shorten tlie woman's life if she be allowed to go to term. Tliis in particular holds true of the parenchymatous form of nepliritis. In a given case, if under absolute milk diet and the administration of iron and diuretics the amount of albumin in the urine do not decrease, artificial abortion should be resorted to. In the event of better- ment from tlie side of the kidneys, then, under constant watch- fulness, tlie woman might be tided over until the child is viable, and often to term.
4. Pernicious Ancemia. — Tliis indication will i-arely offer for the reason tiiat the affection is only exceptionally met with, and then conception is a rarity owing to the lack of function of the ovaries. In the event, iiowevcr, of pregnancy supervening on this depraved condition of the blood, artificial abortion is justifiable as soon as it becomes apparent that the anaemia, not- withstanding the recognized remedies, is becoming deeper. To wait longer is to aggravate the disease, only to obtain a foetus incapable of extra-uterine life.
0. Chorea. — Pregnancy has a deleterious influence on chorea. In all the reported instances the choreic movementa have become aggravated often to an extreme degree. Nature sometimes asserts herself and abortion is spontaneous. On the
I
I I
ARTIFICIAL ABORTION.
37
i
other hand, it cannot be positively predicated that emptying the uterus will modify the chorea favorably. The indication, there- fore, for artificial abortion is not an absolute one. The opera- tion shoidd be resorted to only in extreme instances, and then only in the hope that it may prove a remedial measure. Barnes's statistics prove that gravid choreic women often die of the dis- ease, and that the foetus rarely survives. It should further be remembered that in a few recorded instances chorea associated with pregnancy has merged into one or another variety of insanity.
6. Absolute Pelvic Contraction or Occlusion of the Genital D-act hy Titmoi-a, etc. — By absolute pelvic contraction is under- stood that degree of pelvic deformity which will not even permit of the induction of premature labor with viable child. This will be amply considered when the subject of premature labor is discussed. As soon as determined, artificial abortion is indi- cated in order to save the Avoman the risks of the alternative operations at term, — the Csesarean section or the Porro.
Until the results from these oiierations are of such a nature as to prove no greater mortahty rates than that after abortion, the duty of the physician, unless the woman deliberately elects the major operations, is to empty the uterus. The same view may be taken of instances of cicatricial contraction of the vagina of such high degree as to preclude tlie successful induction of premature labor. The tumors which come under consideration, aside from exostoses, are fibroids in the lower uterine segment, epithelioma of the cervix, impacted ovarian cysts. Exostoses, if sufficiently prominent to occlude the pelvis to a degree incon- sistent with tlie successful induction of premature labor, will always call for artificial abortion unless, again, tlie woman elects the Csesarean section at term ; fibroids in the lower segment of the uterus do not, as a rule, interfere with the development of the uterus to the term of foetal viability, at any rate ; but at this date, and later, tlie choice will necessarily lie between enuclea- tion of the fibroid per vaginam before delivery can be eiFected
J
38 OBSTETEIC SURGEET.
or else the Cjesaiean section or the Forro. Enucleatioii i fibroid by tlie vagina ia at best a formidable operation, and comes all the more so in the presence of tlie vascularity asso- ciated with pregnancy. To say nothing of the risk of septi- csBniia during the puerperium, the safety of the woman is best subserved by emptying the uterus at an early stage, unless, again, in full view of its risks, she elects the alternative operations at term. It is understood, of course, that an ovarian cyst impacted in the pelvis cannot be removed through abdominal section without fii-st emptying the uterus ; therefore, the proper course to pursue is to induce abortion, and at one and tlic same time to remove the cyst by one or another of the recognized methods. Epithelioma of the uterus, whenever discovered, should be r^ moved either by high amputation or by vaginal hysterectomy. In either event the gestation will be interrupted ; so that artificial abortion is forced on the physician, and not elected. Advanced carcinoma of the lower uterine segment, when compUcated by pregnancy, becomes all the more serious the longer the gestation is allowed to continue. The chief risk the woman runs is that from sudden profuse haemorrhage ; but, seeing that the woman may be made more comfortable by a partial operation, this should be resorted to even though it interrupt gestation. At term delivery per viaa natnraJes might be possible without iatal result to the woman ; but this being problematical, active inter- ference is justifiable before the child is viable. Fortunately women with advanced carcinoma rarely conceive.
It is a recognized siirgical rule, to-day, to remoTC an ovarian cyst as soon as it is discovered. If pregnancy co-exist, ovariotomy may be performed and the gestation not interrupted. This is exceptional in the favorable case, when the tumor is not impacted in the pelvis. In the latter instance the maternal chances are better if the uterus be first emptied lege artis, and the ovariotomy be performed afterward. Obviously the phy- sician should be on his guard lest, during the process of abor- tion, the cyst rupture. Puncture of the cyst by the vagina as
I
I
ARTIFICIAL ABORTION.
an elective measure cannot too strongly be condemued. Wliilst such a measure will diminish the size of the tumor, and thus, perhaps, enable the gestation to advance nearly or to term, with resulting viable foetus, puncture, however aseptically performed, carries with it the risk of suppuration of the cyst, in which event neither abortion nor ovariotomy might avail to save the woman. Obviously, where the obstructing tumors are so large as to interlere with access to the uterine cavity, it ceases to be a question of even artificial abortion, and the physician is called upon to decide upon the relative risks of interference surgically with the tumor befoi-e or at term. Where the risk is equal the latter period should, of course, be selected, since the cliild is then given a chance.
7. Irreducible DlsplacementB of the Utertis. — No displace- ment of the uterus uncomplicated by adhesions must be con- sidered iiTeducible so as to require artificial abortion until replacement under ancesthesia, with the woman in the knee- chest position, has failed. Simpler methods are, of course, first to be tested. Impaction of the gravid uterus below the promon- tory of the sacrum may simulate an adherent uterus ; but if the woman assume the knee-chest position and the cervix be drawn downward by means of a tenaculum inserted into the anterior lip, reposition may, as a rule, he effected if the displacement be uncomplicated. In an instance of this nature, if seen before the third month, emptying of the uterus will rarely be called for. It is the adherent fundus which generally will give rise to trouble. Unquestionablj-, in many of these instances, the adhe- sions stretch and enable the uterus to rise above the brim ; but where this does not occur, gentle attempts at manual stretching of the adhesions having failed, artificial abortion should he resorted to before the uterus, developing asymmetrically, — in case spontaneous abortion do not occur. — causes grave symp- toms from the side of the bladder, possibly leading to rupture of the organ.
8. Hifviorrlmge. — The slight discharge of blood which not
40 OBSTETRIC SURGERY.
uncommonly complicates the eaiiy months of pregnancy will never call for artificial abortion. Rest in bed with appropriate remedies — such as the viburnum prunifolium and, perhaps, opiate ; removal of the cause, such as a small submucoi poly]) — will, as a rule, suffice to check what at times is simply an attempt at periodical menstruation. It is the hsemorrliage met with between the third and sixth months of gestation which may warrant abortion. Hsemorrhage at this period should always suggest a low attachment of the placenta, and, when profuse enough to threaten matenia! exhaustion, it is conserva- tive to empty the uterus rather than to endeavor to tide ov< the patient until the fcctus has attained viability.
Such, briefly outlined, are the complications of early preg- nancy which chiefly will call for artificial abortion. This oper- ation should never be determined upon without the advice of a consultant. The risk to the woman where the operation is' carefully performed is shght, presumably always slighter thaa that she is subject to if the gestation be not interrupted; but] no physician, except in strict emergency, should induce abortion without the support of one or more consultants. H*] will thus be amply protected agaiust scandal and legal process,, should either arise.
In view of the fact that artificial abortion is an operation which is forced upon tiie physician, when the indication presents, the object is to empty the uterus as rapidly as is consistent with the welfare of the woman. The method of procedure about to be described is peculiarly applicable to gestation which has not advanced beyond the third month. After this period, the fcetus and its adnexa being larger, and fuller dilatation of th( cervical canal being therefore requisite, the method to be scribed under the subject of the induction of premature laboc is to be selected.
The administration of so-called abortifacients and resort electricity are proposed methods for the induction of ab( tion which are so problematical in their results aa not to
ate
'a- ^g
1
ARTIFICIAL ABORTION. 41
worthy of trial. Tamponing the vagina, associated with the administration of ergot, was a method formerly greatly in vogue. It should be rejected, however, because it is slow in action, un- certain in its results, and difficult to maintain aseptically. The sponge t«nt for dilating the cervix cannot be too strongly con- demned, on the ground that the chances of sepsis following its use are very great. It should ever be borne in mind that the operation is performed in tlie interest of the woman, and that the one risk the physician subjects her to is sepsis.
OPERATION FOR THE INDUCTION OF ABORTION.
The instruments strictly requisite are: A steel-branched uterine dilator, a uterine dull curette, an ovum forceps, an intra-
uterine irrigating tube, the finger. These instruments should be carefully sterilized.
The intestinal canal should be thoroughly emptied by enema, and the bladder by catheter. The external genitals and
Vie. 21.— Uterini
the vagina must be thoroughly asepticized. Douching will not accomplish this. Both the genitals and the vagina should be scrubbed with soap and water, and then washed with a 2-per-cent. solution of creolin or a 1 to 5000 solution of
42
OBSTETRIC SORGERT.
bichloride of mercury. Thus alone may the rugosities of thff vagina be rendered aseptic. If the operator prefer continuou irrigation diuing his manipulations the creolin solution answei
Fig. aa.— Orum Fori
admirably, since it will not injure tbe instruments and will notfl poison the patient. Tlie liands of the operator and of his assist-f ant should be scrupulously scrubbed with soap and water, and!
at,— ai»j>9 Irrlgatine Tube.
then carefully washed in a solution of bichloride of mercury., These details are called for in order to avoid septic infection ol the patient, — the risk, we would repeat, which the woman ii)
g. 2*.— Frilsch-Bni
subjected to. As a rule, it is desirable to aneesthetize patient. Tlie operation, when resorted to at all, mast btf thorough, and it is difficult to secure this if the patient be struggling and complaining. The patient is placed upon the
I
ARTIFICIAL ABORTIOK. 43
table in the lelt lateral or dorsal position, according to the preference of the operator. We prefer the dorsal position because all the necessary steps are best followed in this position, and because, furtliermore, the uterus is under better control.
A speculum is inserted into the vagina, and, the cervix having been exposed, a tenaculum is inserted into the anterior cervical lip to stead}' the uterus.
The steel dilator is passed into the cervix beyond the in-
ternal OS, and the canal is slowly stretched to the extent of an inch and a half to two inches. The cervical muscle is made to yield to the applied pre-ssure; the aim is not to rupture the cervix. Owing to the hyperBemia and softening of the cervix,
44
OBSTETRIC SUItGERT.
which, as a rule, is present even in the early months of preg- nancy, dilatation to this extent will ordinarily be possible. The instruments are then to be removed, and the next step is tl extraction of tlie ovum.
The best of all instruments for the loosening of the ovum, the breaking up of the fcetns, and for the removal of the dibrie is the aseptic finger. It is sentient, and therefore it is less likely to do harm than any instrument. We are operating to protect the interests of tlie woman, and, therefore, must take every pre- caution to see that these interests are not endangered. In the average case of abortion under the third montli it is possible to empty the uterus by the finger alone, provided the physician proceeds as follows : The woman should be aneesthetized. Thb fundus of the uterus is grasped through the abdominal wall,j and the organ is depressed deeply into the pelvic cavity in the axis of the inferior strait. The other hand is introduced into the vagina, and the index finger is inserted to the fundus of the uterus, slowly, in ordei' to obtain greater dilatation than has fol- lowed the use of the dilator. The ovum is then carefully pealed from its connection with the uterus. Up to the second month of gestation it may ordinarily be removed in its entirety* Beyond tliis jwriod it is usually necessary to break up the ovui by the intra-utenne finger, and this may be accomi»lislicd witl out great difficulty, provided the external hand firmly control and steadies the uterus.
In instances where it is not possible to depress the utei sufficiently to enable the finger (the hand being in the vagina] to reach the site of the o%-nm, the long uterine curette takes thi place of the finger. Tlie instrument, however, should be uf simply to loosen the connection of the ovum with the utei tlie after-extraction being accomplished either by means of thi ovum-forceps or by the finger. The manipulation is as fol lows: The curette seeks to penetrate between the ovum an« the uterine wall, the external hand being conscious of and thi indirectly controlling the action of the instrument. When
ARTrFIClAL ABORTION. 45
lodged in this manner, if the finger cannot complete removal, the ovum-forceps slionid be used to grasp and to extract it.
The hsemorrhage from these manipulations is, as a rule, considerable, but the external hand grasping the uterus may soon cause efficient contraction. Wlien satisfied that the uterus has been thoroughly emptied, a J-drachm of ergot or 10 minims of ergotole should be injected into the nates, the intra-uterine tube should be inserted into the cavity of the uterus and the organ washed out either with a 1 to 5000 solution of bicliloride of mercury or with a 3-per-cent. solution of creolin. The last step, and we believe a most important step, is the insertion to the fundus of a sterilized-gauze drain.
The object of tliis drain is twofold : At times, owing to
"O
FlK- 27.— iDtra-uterliic Dreaaing Foti
flexion at the level of the intenial os, drainage from the uterine cavity is imperfect and the retained secretions might give rise to septic symptoms ; furthermore, no matter how exact our asepsis, an error in technique may creep in, and, if local sepsis should develop, we want above all things free external drainage, in order to avoid, as far as is possible, extension to the Fallopian tubes. This drain, therefore, is prophylactic in its aim. It can do no harm, and it may be the means of preventing serious damage.
The steps detailed will answer for the induction of abortion and for its completion in the average case under the fourth month. Occasionally, however, the cervi.x is rigid, and then the steel-branched dilator and the finger cannot secure ample- enough dilatation. In such an event many practitioners resort
46 OBSTETRIC SURGERY.
to tents; but for the reason already stated aud again empliasized, that the sponge tent cannot be rendered aseptic, we emphatically condemn this agent (including as well all other forms of tent), and we commend the following procedure : The external gei tals and the vagina iiavlng been rendered aseptic in the manner we have dwelt upon, the cervix is exposed through a speculum and steadied by a tenaculum. As mucli dilatation as possible is secured by the steel-branched dilator, and tlieu the cervical canal and the lower uterine segment is packed by means of the intra-uterlne dressing forceps witli sterilized gauze. At the end of from six to eight hours the gauze may be removed, when, as a rule, the cervical canal will be found sufficiently patulous for the finger or else tlie cervical tissues have been sufficiently softened by the gauze to enable tlie steel-branched dilator to act efficiently. The further steps are similar to tliose already detailed. i
There remain for consideration those instances where thn cervical canal is not accessible to the dilator, owing, as a rule, to the marked retroversion of the uterus with or without ad- hesions. It has been recommended, in such instances, to punct- ure the uterus through the rectum, the object being to tap t] amniotic sac, which procedure will result in spontaneous tion. This method should never be resorted to, owing to tl absolute certainty of carrying products of infection into uterus. The rectum cannot be asepticized as may the vag The aim of the method will be as well subserved by tappi tlirougli the vagina, care being taken to avoid any large and also the ureteral triangle. Very rarely will such a step necessary, however, and if resorted to the method must be calli an uncertain one. In the face of an emergency suggesting it is wise to weigh the alternative step, — abdominal section, breaking up of the adliesions, and reposition, ^e>' abdomh of the uterus.
Artificial abortion, if performed aseptically, and if elecl before the woman is at too low an ebb from the affection ini
LUy it)J
IKDUCnON OF PREMATURE LABOR. 47
eating the operation, ought not to have a mortality rate. Haemorrhage we may control ; sepsis is avoidable by the steps of the operation we have advocated ; shock need be feared only when the physician sees the patient too late or trusts to expect- ancy overlong. The ailer-treatment of cases where the phy- sician has been called upon to induce abortion is similar to that which is applicable to the puerperium after delivery at term. The woman should remain in bed for about a week, not neces- sarily in the recumbent position, however. If there be no contra-indication from the side of the heart, and if the disease which called for the induction of abortion will permit, it is de- cidedly advantageous for the patient to sit up in bed according to her fancy, for thus the vagina drains to better advantage.
If the operation has been performed aseptically, there will be no call for either vaginal or intra-uterine douching. Where a gauze drain has been inserted into the uterine cavity, it may be removed at the end of sixty hours ; and if there be no evi- dence of local sepsis, it need not be re-inserted. If, notwith- standing all our aseptic precautions, sepsis develop, its surgical treatment will be in accordance with the rules to be emphasized in the chapter dealing with the surgery of the pathological puerperium.
(h) The Induction of Premature Labor.
Obviously, the indications for the induction of abortion hold with equal, if not greater, stringency in case of the induc- tion of premature labor. The object to be attained, however, is twofold. Both the interests of the fcetus and of the woman are to be considered. Exceptionally, as will be noted, those of the former alone call for the operation. From the side of both the woman and of the child, the chief indications for the induction of premature labor are: 1. Contracted pelves. 2. Haemorrhage. 3. Eclampsia.
From the stand-point of the child alone the indication offers where, in a previous labor, the foetus has died a short
48 OBSTETRIC SURGERY.
time before term as a result, frequently, of disease of the php centa, such as fatty degeneration. Here, by electing prematun labor in a succeeding pregnancy a few weeks before term, at a period when, from the decrease in foetal movements, it may be inferred that death is imminent, the physician may succeed in obtaining a living child.
1. Induction of Premature Labor in Case of DeformUj of the Pelvis. — Deformity of the pelvis of varying grade is bjf far the most frequent indication for the induction of premataie labor. The aim is a most beneficent one, seeing that the maj(M obstetrical operations — the Csesarean section, symphysiotomy, and embryotomy — are thus often avoided. As Robert Bamea with a certain amount of truth, puts it, spontaneous labor ma] supersede the forceps, the forceps may supersede version, version craniotomy, and the Caesarean section may be eliminated Whether it is desirable or not that craniotomy should supersede the Caesarean section will be considered later, as also the effecl of the resuscitation of symphysiotomy.
In the instances under consideration, the problem for the physician to solve is most complex. He must determine a! accurately as possible the term of gestation, in order to speak with any degree of authority in regard to the chances of viability of the child. He must estimate the probable size of the foetus in relation to the degree of pelvic contraction in a given case. He must bear in mind the degree of molding to which the diameters of the foetal head are susceptible within safe limits. He must, lastly, ever be conscious of the fact that in deferring the operation overlong in the interest of the child he may be increasing the risks which the woman runs. It is thus apparent how difficult it is to select just the right time for the induction of premature labor from an elective stand-point.
The determination of the stage of gestation so as to insure foetal viability is not a simple matter. In almost every instance there is likely to be a margin in error of at least a fortnight Where the exact date of the cessation of menstruation can be
INDUCTION OF PREMATURE LABOR. 49
loertamed, the rule of adding seven days and counting back iiee months, in order to approximate the term of gestation, is Lact enough only in the lesser grades of pelvic deformity ; for ire, if the error of a fortnight creep in, at best the child has ii passed the seven and a half months of gestation. Where le interests of the child, on the other hand, demand the indue- on of premature labor at the seventh month, at least, the ifficulty in determining this date might lead us to resort to the peration before the term of viability or else beyond it, when, I either event, the operation, so far as the child were concerned, rould be a failure. The two hundred and twentieth day of estation may be taken as the lowest limit when, with the nproved means at our disposal (the couvetise^ or incubator), a hance of the child being reared exists. Error in our data dew this period may be taken as being fatal to the child. Not nly, therefore, is it essential to obtain as accurately as possible lie date of the cessation of the last menstruation, but also that f quickening. The first sensation of fcetal motion occurs from bee to three and a half months after conception, in some cases lot till the fourth month. Here, again, is a chance of error of k fortnight But, by weighing the probable date of conception igwnst the date of perception of foetal motion and comparing his with the height of the uterus above the pelvic brim, the )liysician is, at any rate, unlikely to err against the term of riability. It will be remembered, of course, that tlie general statement of the height of the uterus at various stages of gesta- ion is subject to modification in the presence of a contracted )elvis. Whilst, normally, the fundus of the uterus is on a evel with the umbilicus at the sixth month of gestation, and ibout two fingers' breadth above this at the seventh month, a case of contraction chiefly at the pelvic brim these relative itoations will be a trifle higher. Thus, at the sixth month the Indus may occupy the position which normally it would at the jventh.
Having determined as accurately as possible the date of
do
OBSTETRIC SURGEBT.
conception, the next factor is the estimation of the size of the ftetus which must pasa through the given contracted pelvis. The size of tlie fcetus can, of course, only be relatively estimated. The best guide at our disposal is that furnished by Ahlfeld, and the value of this guide at best is very limited, Fiora extended study, Ahlfeld concluded that the long axis of the foetus lying flexed in the uterus is nearly half the entire length of the ftetus when extended. To determine the axis in lUero of the foetus, one arm of a pelvimeter is placed in the vagina in contact with the fcetal presenting part, and the other arm is placed on the abdomen at the site of the fundus over the otlier end of the foetus. Multiplying the obtained measurement by two, the total length of the fcetus is obUiined. According to Ahlfeld, the length of tlie extended ftetus bears a certain definite relation to the period of gestation. Thus; From the 38th to the 40th week of gestation the length of the intra-uteriue foetal axis varies from 9f inches to 10. The total length of the ftetus, therefore, is about 20 inches. From the 35th to the 38th week the intra-uterine axis varies between 8f and 9| inches. The length of the foetus is 18i to 19J inches. From the 30th to the 35th week the intra-uterine length varies from 81 to 8} inches, and the total length of the foetus is 16 to 18 inches. From the 25th to tlie 30th week the intra-uterine length varies from 7 to 8i inches, and the mean total length of the fcetus is about 15 inches.
Ahlfeld further determined that this length of the fceti stood in the following relation to the weight : —
|
Weight. |
LeoEtti. |
|
|
At tbe 40tb week, . |
. expounds. |
191 inches. |
|
At tbe 38tb week, . |
. 6 J pounds. |
19^ incbes. |
|
At tbe 36t1i week, . |
6J pounds. |
I8| inches. |
|
At tbe 35tb week, . |
. 6 pounds. |
17i inches. |
|
At tbe 34th week, . |
. 5^ pounds. |
\l\ inches. |
|
At tbe 33d week, . |
. 4^ pounds. |
16| inches. |
|
At tbe 30tb week, . |
. 4^ pounds. |
1 6^ inches. |
|
At tbe 28tU week, . |
3^ pounds. |
15 1 inches |
L
INDUCTION OF PREMATDRE LABOR. 51
The data furnished by these researches of Ahlfeld, whilst only of approximate value in estimating the size of the foetus, are still of great assistance in determining tlie period at which labor should be induced. An important factor lacking, liow- ever, is the average size of the fcetal head at various stages of gestation. The diameter of the foetal head of the greatest im- portance is the biparietal. As the restilt of many measure- ments made by Budin, Tarnier, Stolz, and others, the average length of this diameter at various stages of gestation is: at term, about 3| inches ; at 8* months, about 3.4 inches ; at 8 months, about 3.2 inches; at 7 J months, about 2.96 inches; at 7 montlis, about 2.75 inches.
The foetal head, further, may be safely compressed to tlie extent of about ,0.4 inch. Remembering this degree of safe compressibility, having estimated the size of the foetus and the stage of gestation, the next important element in tlie problem is the determination of the degree of pelvic deformity present. Before passing, however, to renewed reference to tliis, we will state the method of estimating the adaptability of the fcetal presenting part to the pelvic canal wliich answers every pur- pose for private practice, and which commends itself, also, on account of its simplicity.
As long as the fcetal presenting part can enter the pelvic brim, obviously the time for the induction of premature labor may be deferred ; but just as soon as the presenting part engages witli difficulty, the time is ri[>e for interference.
Everj- week, therefore, the physician should examine his patient for the purpose of determining the above fact. Intro- ducing one or more fingers into the vagina, he presses the fundus of tlie uterus downward in the axis of the pelvic inlet and the fingers in the vagina are able to appreciate the ease with which the presenting part adapts itself to the pelvic brim. If need be, the patient should be examined under anaesthesia. (See Fig. 2, Plate in.)
By reference to Chapter I "f determining the_
53
OBSTETRIC SUHGERT.
pelvic diameters and the characteristics of the chief varieties of 1 pelvic contraction will be recalled. Taking the length of the conjugate of tlie brim as our guide, seeing that it is the in- ternal diameter of the pelvis which alone can be determined with any degree of accuracy, and remembering that in a given case tlie capacity of tlie pelvis may be approximately estimated best by examination by the entire hand under anaesthesia, %ve j may, with Charpentier, formulate the following general rules, which are the result of an extended study of the reports of j numerous maternities and clinics : —
If the conjugate is at least 3i inches, the biparietal diametei of the fcetal head at term being Sf iuches (compressible to the4 extent of about 0.4 inch), then, in raultiparEe, labor should induced between 8i to 8* months, according to tlie estimated'^ size of tile foetus and the difficulty in delivery offered by former labors. In primiparEe, since, in general, tlie child is smaller, it is safe to wait till a week before term. Where the conjugate is 3.35 inches premature labor, both in the multipara and in ths^ primipara, slionld be induced at 8 to 8J months. Where the'fl conjugate is 3.12 inches, labor is to be induced between 8 and 8i months at least. AVhere tlie conjugate is 2.95 inches, labor* is to be induced between li and 8 months. Where the con-ij jugate is 2.75 inches, labor is to be induced between 7 monthsfl and 7 months and 3 weeks. Wliere the conjugate is 2i to 2.361 niches, labor must be induced as near the seventh month asl practicable, and certainly no later than 7t months. Below 2.361 inches tlie indication for the induction of premature labor doesj not exist. To resort to it would necessarily entail an embry»fl^ otomy, and this carries risk to the mother and subserves noK the child. At this point, then, the indication for artificial aboiv tion in contracted pelves begins.
It is to be remembered that the figures just given hold goojl only for tlie fcetus estimated to be of tlie average size, and for a pelvis which ranks under the flat type or, possibly, the generally contracted type. The prognosis for the cliild is better, under
INDDCTION OF PREMATURE LABOR.
53
the measurements given, if the pelvis be of the former variety than if it be of the latter. In general, of course, the special type of pelvis will alter the indication. All that we aim to do here is to state the general indications which serve as guides in tlie election of the period at which premature labor should be induced in the face of peh"ic deformity. It is impossible to lay down sj)ecial rules, since each case must be studied from its special stand-point.
2. Hemorrhage as an Indication for the Inditcilon of Pre- mature Labor. — Hffimorrhage occurring after the fourth month of gestation should always awaken the suspicion of placenta prsevia. There is little agreement amongst obstetrical wTiters as to the advisability of inducing premature labor on the apjyear- ance of the first haemorrhage due to faulty implantation of the placenta. A careful study of this question, in the light chiefly of the mo e modem statistical data, warrants the following state- ments, which assist in reaching a conclusion sound in practice, seeing that it takes account of the interests both of the woman and the child. As has been noted under the subject of artificial abortion, in rare instances tlie hiEmorrhage due to faulty insertion of the placenta occurs as early as the fifth month of gestation. As a rule, however, it is within the six weeks preceding term that hffimorrhage appeare. Usually the first hi^morrhage is not profuse enough to endanger either the womiui or the child. It may be taken, however, as nature's danger signal, warning the alert physician that a second hgemorrhage may at any time occur, and in such amount that not alone will the child probably die before delivery, but that the woman as well will be seriously en- dangered. Instances of this nature are extreme ones, but in no given case can it be predicted that such will not be the issue of the second hreniorrhage. Unquestionably, through enforced rest in bed. the woman may often be tided to term and deliver)' be safely accomplished for the child as well as for the woman ; but even during rest in bed profuse hiemonhage may occur, and this too at a time when the ph}'sician may not be in ready reacb J
54
OBSTETRIC SURGERY.
of the woman. All authorities are agreed that the excessive m»* I temal mortality of tiie past was due, in part, to faulty methods I of treatment, in part to delay in resort to active measures. Tbov maternal mortality has varied from 32 to 9 per cent, and the;! infantile from 50 to 85 per cent. The modern method of treat*! ment has given a maternal mortality, in the hands of Tarioua-fl observers, of from I to 4 per cent., whilst even the infantilel mortality has heen lowered. The facts, then, at our disposal I prove clearly that by any and all methods the child sufFera \ excessively, whilst for the woman there is a choice in method.
The question may be summed up as follows : The risk taj the woman increases progressively to term ailer the first hfemor-1 rhage. On the occurrence of this hsemorrhage the child : viable. Renewed hfemorrhage simply risks viability. Th interests of the child, therefore, are not subserved by expect^ ancy. Those of the woman are actually imperiled. The'] teaching is sound, therefore, whicJi says : On the occurrence of 1 the first haemorrhage, whether profuse or not, elect the induc- tion of premature labor. The earlier the haemorrhage, the greater the chance of the placenta being implanted centrally. It is central implantation which at term subjects the woman to^ the greatest risks and holds out but very slim chance for the f chUd.
3. Eclampsia as an Indication for the Inductifni of Prema- \ ttire Labor. — Absolute statement in regard to this indication is I not wise owing to the very just diversity of opinion amongst 1 experienced obstetricians. To reach an approximately accu- rate conclusion it \vill be necessary to sharply differentiate the j instances where eclampsia seems imminent and those whererfl convulsions have developed.
Albuminuria is an almost constant forerunner and accom- paniment of eclampsia. Such, at least, is the rule with but rare exceptions. The albuminuria may or may not be dependent on organic renal disease, and in the latter instance it may or may | not lead to organic disease. The question, therefore, wliich thej
INDUCTION OF PREMATDRE LABOR. 65
physician has chiefly to face is the immediate risk to mother and child if pregnancy be allowed to progress to term, remembering that in no given case can it be predicated that the emptying of the uterus will ward off the convulsions, and also that the inter- ference with gestation may excite convulsions, Tlie problem, it is evident, is most complex, Still, the following considera- tions help toward its solution.
In the vast majority of instances, tlie development of eclampsia leads to premature labor. If we do not shut our eyes, then, to nature's teachings, it seems wise, in the presence of eclampsia, to resort to such measures as will hasten the empty- ing of the uterus instead of to such as will tend to protract the gestation. The latter course, certainly, will avail naught to the child, for its life is directly imperiled by the first eclampsic attack, and, should it survive this and labor not occur spontane- ously, its chances of living through further attacks are all the less. As regards the woman, if spontaneous premature labor do not occur during the first attack, experience teaches that the liability to further attacks is greater if the uterus has not been emptied tlian where it has. The first attack exhausts the woman, if it do no more. The second attack adds to her ex- haustion and may kill. Therefore, in the presence of eclampsia it may be stated that, in general, nothing is gained by endeav- oring to protract gestation and everything may be lost. One of the recognized methods of treatment of eclampsia is deep anses- thesia protracted, if need !«, for hours. During this anaesthesia resort to the measures we shall shortly consider will empty the uterus possibly of a live child, for at the period of gestation under consideration the child is viable; otherwise it becomes a question of artificial abortion, — a subject already considered.
Where convulsions are imminent, there is even greater diversity of opinion as to the advisability of inducing labor. Whilst apparently imminent, they may never occur ; the induc- tion of premature labor may not ward them off; indeed, the measures necessary for hiduction may provoke convulsions, Iq j
66
OBSTETRIC SURGERY.
the face of this fair statement of fact, what ground is there for advocating the operation 1
Supposing that, in spite of resort to the recognized methods of treatment of albuminuria, in particular absolute milk diet combined with iron, the albumin increases in amount, headache and visual disturbances appear, dropsy to a greater or less de- gree sets in. The woman has reached the seventh month ; the child is viable, and the fcetal heart certifies that it is alive. It may be safely predicated that the chances are that this woman will have eclampsia before or at term, during labor or afterward. If she do before the onset or the completion of labor, the child's chances of survival are very slight. Meantime the woman risks aggravation in the renal symptoms and condition, disturbances of vision more or less permanent, puerpeml mania, and puer-; peral paralysis. Now, if the operation of inducing premature labor be elected at t!ie period under consideration, the child's chances are better even if, as the result of the manipulations, eclampsia is induced ; for, as already stated, in the presence of eclampsia rapid emptying of the utenis is advisable. As for the woman, medical and dietetic treatment having failed to arrest the progress of albuminuria (the usual forerunner of eclampsia), the induction of premature labor may save her the complications just enumerated, to any and all of which she is liable if the pregnancy is allowed to go to term. Should eclampsia develop as the result of the necessary manipulations, labor having been started it may be more quickly ended than if emptying of the uterus is forced upon the physician by the spontaneous occur- rence of convulsions.
As the case has been stated, therefore, the immediate and the remote welfare of the woman calls for the induction of premature labor in instances where the development of eclamp- sia is feared ; and this fiict should outweigh the ai^iment, from the side of the child, that its chances of survival are less the earlier before term it is bom, whether spontaneously or arti- ficially. To be bom in the midst or at the expiiation of an
I
I
INDUCTION OF PREMATURE LABOR. 57
eclampsic seizure at the eighth month or at term imperils its existence fully as much as, with our modem methods of rearing premature infants, its chances of survival are relatively great.
Modem opinion is tending toward the acceptance of this view. Lusk protests against postponing resort to the induction of premature labor until the grave symptoms (chiefly cerebral) which precede eclampsia develop. Tamier, of the French school, holds practically the same opinion. The opponents of this view are certainly many, and their names carry weight; but a careful estimate of the question, both from the stand-point of the woman and of the child, forces on us the conclusion that, dietetic and medicinal measures having failed to ameliorate the symptoms which precede eclampsia, the best interests of both are subserved by the election of premature labor.
Such, briefly outlined, are the indications for the induction of premature labor. In determining the best method for per- forming the operation, the fact must never be lost sight of that the intent of the operation will ordinarily be to save the woman the greater risk she suffers if allowed to go to term, and also to obtain a living child. To amply satisfy this intent in the indi- vidual case, the operation, where election is possible, should be postponed to as near term as is absolutely consistent with the interest of the mother, for thus the chances of the infant's life are increased. Further, the method selected should be one which, while the safest for the woman, takes into full account the phenomena of normal labor, since thus alone are the inter- ests of the child fully subserved. Again, in view of the fact that the child has not attained full maturity, ample preparation should be made beforehand for the rearing of the immature child. Finally, the physician should be prepared to meet every emergency which labor at term might involve; for premature labor may call, before it is completed, for any of the obstetric operations (the forceps, version), and its completion may be followed by the same complications as labor at term (haemor- rhage, adherent placenta).
58 OBSTETRIC SURGERY.
METHODS FOR THE INDUCTION OF PREMATURE LABOK.
Many of the methods which have been proposed for the induction of premature labor are purely of interest from an his- torical stand*})oiut Such, for instance, is the administration of medicinal agents,— ei^t, rue, quinine, cinnamon, and the like. These drugs will not provoke contractions, although some of them will intensifv action when contractions are in force. AgHin^ it has been suggested to start the expulsive action of tlie uterus by injecting water or air between the membranes and tlio uterine u^L Such a procedure would doubtless be effect- iw> but should not be countenanced, since it is likely to rupture the membranes^ tlius imperiling the child, and since it may |m>\^ filial to the woman from the entrance of air into the uteriuo xxnu^^v. Vaginal irrigation witli hot water is slow and uncertain in action, and, if prolonged, may give rise to local ctMXg^^on, un&vorsible alike to woman and ioetiis. As will be nol^i, Uiis method, wiihin limits is useful as pieparatoiy to otln^r m^'^thod^ in that bv messms of ii soAenins^ <^ the cervix may be a:ssi:«4>e\l. Electricdn* is of >:alue only as an adjutant for Kt^nxi^xg laK^r thiv^iigh re^Kifoririv-g contractions wben these Kaxx" o:hv Kvn si^u^ovi. Used alroe^ this agent is very prob- WvatXTjtl in etRiva. and hicr/:v uncv^rrri&in as welL
Thtsn^ a3t^ Id* for oon>ooej:aiiix: tbe f L>Dowxng fiie methods : I. l\u>o:>iiv of the lat-^sn^caue^ 5 Tamponing ibe vrngina. ^ The ;n>eo:i>n v>f c^^vvdn. 4, The inf^TDon of an elastic K^^^ Vj^ftYv-r, :i?e r>«::'SraDes aiii ibe i2:fcame wmIL 5.
I . ?\ w,^^ -V <r rW Xf mh^n.%cf^. — T^i? mav b? ^
Y3\NWi>CJir>^ >^ici xr >T Ttr^wcrnc tiif cnil rvRr :2>e *vfcL
r>i^ MK)e»^i >mi fanMc> iiciu^ it fiivw ^ria :2ie Tksuia
* ■<" *
INDUCTION OF PREMATURE LABOR. 59
Puncture of the membranes will certainly induce labor, and, where aseptically performed, the method may be ranked as safe for the woman. The method, however, is open to the objection tliat it does not imitate natural methods, and there- fore may imperil the child. In the course of normal labor premature rupture of the membranes Invariably leads to tedious labor, and this may entail botli maternal and foetal exhaustion. Our aim should be to maintain the dilating water-wedge intact. This is the sound rule of practice in the course of spontaneous labor at terra. Similarly, in case of the induction of premature labor, an operation resorted to in the interests of the child as well as in those of the woman, the object should be to maintain the membranes intact, in order to avoid a protracted first stage of labor, with its concoraitant risks. Therefore, puncture of the membranes should be dismissed from consideration as a means of inducing premature labor.
2. Tamixmimj the Vagina. — Thorough tamponing of the vagina by means of aseptic tampons will unquestionably, in course of time, provoke uterine contractions, and the more speedily the nearer the woman is to term. The method, if aseptic throughout, carries with it no risk either to the woman or the child, but it is slow in action. Days may elapse before effects on the uterus are noted. Now, when speaking of the indications under which the induction of premature labor was justifiable, we have noted that in pelvic contraction, for in- stance, it was highly important not to err in the date assigned for the operation, and that under the best possible conditions there existed a chance of error of at least a fortnight. Obvi- ously, no method siiould l>e selected for the induction of prema^ ture labor which carries with it the strong probability of greatly magnifying this chance of error. The selection of such a method is not fair to the child. Neither under other indications is it fair to the woman. If eclampsia threaten, for instance, and the physician determines that labor should be induced, he cannot afford to place dependence on a method which may not
60 OBSTETRIC SURGERY.
prove effective for days. There exists, indeed, but one indica- tion under which the tampon might fill a place, and this is in tlie event of premature labor being indicated by hsemorrhage, due, likely enough, to faulty placental insertion. Here the tampon prevents further haemorrhage whilst the cervix is di- lating sufficiently to warrant resort to the next step in treat- ment. The colpeurynter of the late Karl Biaun is an excellent agent for tamponing the vagina in such an instance, but it can ne\Tr fill the jilace of the aseptic gauze, in private practioe cer- tainly, for the reason that it is made of rubber, — an agent which deteriorates witli certainty in course of time, and can therefore not be dejxnided u{>on as to quality. Further, it is not as rttictly ase|>lic as steriliied gauze.
Wlien the tamjx^n is indicated it should be inserted under the strictest a$epeas« and with the patient in the knee-chest or in the left lateml {x^tion^ for thus alone can the vaginal fomices be etSciently )^ckt\L An iodofi>nn or boraled gauxe inserted iu a continuous strip fv^rms the best tampon. If uterine con- twcti\>us be r,ot es:a^bi:$hed wi:h:n thirty hours the strip should K'^ tvniox^xis the x::^^.::^ Ox^ischTxi w::h 'J-i^r-oect. creolin solution \>r x^i:h I ro hXH> :5o>a:;v^n c^* rk:-I.^rIoe. amd a new strip in- ser^xU ur,V^ :he oer>ix :s :V.:::i sufSiiec:2T dieted for resort
J,^X. — V^;s r,^;^:-Vxi \.Jts r^xvcilT S?er: hiz^tilT cocn mended in
l5v^:*^,\i^ Xs a:xI ,x: :i!c^ ixr ccc:fc56,^cs wt:«f?r :: bis be«t tested in
:^.^s >vur:r\ : v >^:?,\>f^>^ >->i>i >:vc ft:^TVT :rr JrrrL. Tbe cases on ^\\v;\x s^rt." r.x" i'« r." i,lr.^ : :c^ ^x^^::-*^ >cxri^?r!>fcr In oar own ^i^^VxN >;x\\>5^ "^^ls vcc xvt: Tr»iri.f*£. re: w^if!r w^ :esced it the t;v\ c.v \i:.l ^x^c Xx*?:: ^.xrN-rc-^i i< :: iits j.: rie mr^sent. ^*N\\^' \ >fc\s^: \xxx\xi :'*",^ tijc :i:?-r:^ >frv«^!i iae membranes
N^^^i ^x^c\x^»r/;:^^ N "i v • »* ^ . rrtcr.ccn^ ts^c :n:. Tin? nnecbod of V«VvN\^*S^ J5S ^V ix v** ^^ —
INDUCTION OF PREMATURE LABOR. 61
The external genitals and the vagina having been rendered thoroughly aseptic, a sterilized gum-elastic catheter is insinuated to the fundus, between the membranes and the uterine wall. The woman is then placed in the knee-chest or in the left lateral position ; the catheter is connected by means of a sterilized rub- ber tube with a glass funnel, and into the funnel is poured sterilized glycerin. Under the influence of gravity this flows into the uterus. The catheter is carefullv withdrawn, and the vagina is tamponed with sterilized gauze. The woman should maintain the lateral position for a number of hours, otherwise the glycerin will flow from the uterus and the effects of the in- jection will be nullified. Uterine contractions should be evoked in the course of a few hours, otherwise the procedure will have to be repeated. Instead of the glass funnel a syringe may be used for injecting the glycerin. It goes without saying that every precaution should be taken against the injection of air into tlie uterus. The objections to this method which suggest themselves at the present are that it is uncertain in its action, and therefore, where the indication calling for the induc- tion of premature labor is an urgent one, the physician is scarcely justified in taking tlie chances of failure. A further objection is tlie risk of rupturing the membranes during the in- troduction of tlie catheter, — an accident which, should it occur, places the welfare of the child in an unfavorable light. Further, recent data would seem to prove that nephritis may result. The future, however, may speak with more favor for tliis method than, at the present, we are inclined to grant it.
4. The Lisertion of an Elastic Bougie between the Merri" hranes and the Uterine Wall (Krause^s Method). — The method of inducing labor by the introduction of an elastic bougie be- tween the membranes and the uterine wall is probably resorted to with greater frequency than any other. The bougie acts as a foreign body, and at a variable interval provokes uterine action with certainty. The method is safe for the woman, provided proper asepsis accompany the insertion of the instrument. There
63
OBSTETRIC SURGERY.
are weighty objections against it, however. In the first place the presence of the bougie in the uterus may not induce labor for some days, and exceptionally not at all, unless it be rotated in the uterus with the aim of separating to a degree the attach- ment of the membranes. Wlien the induction of premature labor has been duly elected by the piiysician, nothing is gained by awaiting what in any case may prove the slow action of the bougie; and, for reasons already amply considered, delay may mean the loss of the child. Further, in introducing the bougie (a step not always easy of performance) tlie membranes may be ruptured, and this accident it is very desirable to avoid in the interest chiefly of tlie child and partly also of the Homan. Ro- tation of the bougie witliin the uterus is objectionable: first, on account of the possibility of injuring the placenta, mtli resulting lifemorrhage (perhaps of the concealed type, — so fatal both to the woman and to the child), and, secondly, on accomit of the risk, again, of rupture of the membranes. Lastly, it is not a very easy matter to asepticize the bougie. Soaking in weak antiseptic solutions will not suffice, and soaking in strong will injure the bougie. The material of which the bougie ia constructed forbids its subjection to the most reliable method of obtaining asepsis, — exposure to dry heat. It is evident, there- fore, that this method is not an ideal one ; still, it is tlie best at our disposal, and, where the emergency calling for the induction of premature labor was not a very urgent one, this method has answered well. In case of urgency, however, it must be supplemented by a further step, which we will shortly describe. Technique of ICraiise's Method. — The instruments requisite are a speculum (preferably the Sims), a steel-branched dila- tor, and a tenaculum. The external genitals and the vagina having been tlioroughly asepticized, the woman is placed in the left lateral position, and the cervix is exposed through the speculum. The tenaculum is inserted into the anterior lip of the cervix to steady the uterus, and the cervical ranal is dilated to the extent of a half-inch by the steel-branched
INDUCTION OF PREMATUBE LABOR. 63
dilator. This step is requisite in order to enable the passage of the bougie with least risk of injuring the integrity of the membranes. The asepticized bougie is tlien carefully in- sinuated to t!ie fundus, between the membranes and tlie uterine wall. A tampon of sterilized gauze is inserted into the vagina to keep the bougie from slipphig from the uterus. The woman is put to bed and remains there until uterine contractions are evoked. In the event of these contractions not supervening within twenty-four hours, the bougie must he removed, the vagina douched with creolin solution, and, if the emergency is still not pressing, a second sterilized bougie is inserted. If uterine contractions have been evoked, then, if the emergency be not pressing, the progress of labor is left to nature. In the event of a complication arising calling for speedy delivery, the' physician may resort to the method shortly to be described.
5. DihiUitioii of the Cervix as a Means of Iiidac'mg Pre- mature Labor. — "With this method as a working basis, labor may be induced and completed within fairly normal limits, with less risk to the woman and the child than by any other method. Under this heading, then, tlie operation for the induction of premature labor will be described.
The ojwration having been elected, ever — except in strict emergency — under tlie support of a consultant, the physician will ordinarily have ample time to thoroughly cleanse the intes- tinal canal by the administration of one or another laxative, or, failing sufficient time for this, the lower bowel, at any rate, should he emptied by a copious enema. Convalescence from any obstetrical operation is favored when the great emunctory of the system is neither clogged nor torpid. The bladder is emptied and the field of operation is carefully asepticized as fol- lows: The labia and vestibule are thoroughly washed with soap and water, and then with a 2-per-cent. creolin or with a 1 to 5000 sublimate solution. By means of a small tooth-brush the vagina is similarly prepared. Simple douching of the vagina is not sufficient, since the folds of the canal cannot thus be ran-
64
OBSTETRIC SURGEBT.
dered aseptic. The pliysician, and wlioever assists him, should scnib his hands witli soap and water, and next immerse them in a 2-per-cent. creolin or in a 1 to 2000 sublimate solution.
The instruments necessary are the following : A Sims speculum, an intra-uterine forceps, a tenaculum, a steel- branched dilator. Tliese are to be carefully disinfected beforehand, and at the time of use may be placed in sterilized water or in an antiseptic solution, according to the preference of the individual operator. About two yards of sterilized gauze, two inches in width, are also needed.
Such are flic precautions which are strictly essential in order to guard tlie woman against her main risk, — septic infec- tion. The bladder having been emptied, the woman is placed in the lell lateral position, the speculum inserted, and the ten- aculum fixed in the anterior cervical lip. In rare instances it may be necessary to dilate the cervical canal to the extent of half an inch before proceeding to the next step ; this, however, will prove the exception beyond the seven and one-half months of gestation, owing to the softened condition of the cervical tissues at this period. The sterilized gauze is grasped by the packing forceps and carried into tlie cervix up to and not beyond the internal os. The cervical canal is thus progressively packed full, and the remainder of the gauze is utilized to tamjKjn the upper vagina. The object of the gauze is twofold ; it will in all probability excite uterine contractions, but, if it do not, it mechanically dilates the cervix to a sufficient degree to enable the next step to be resorted to. The patient is placed in bed, and, in the event of the presence of the gauze being painful, a suppository of two grains of codeine may be inserted into the rectum. Within ten to twenty-four hours the gauze will prob- ably excite con tactions, with the greater certainty the nearer the woman is to term. The physician's duty now becomes ex- pectant or active, according to the emergency which has de- manded the induction of premature labor. In the event of the indication for rapidly terminating labor not being urgent, the
INDUCTION OF PREMATURE LABOR. 65
gauze is removed, under aseptic precautions, and the labor may be allowed to progress toward its natural termination. The physician's duty is purely passive, even as it is during the prog- ress of normal labor. This applies particularly to instances where labor is induced in the presence of a contracted pelvis, where the lapse of even twenty-four hours has no untoward eflfect on either the woman or the child. Here, until full dila^ tation of the cervix, artificial aid is only called for under stringent indication from the side of the woman or the child, such as haemorrhage or evidence of foetal heart-failure. It is absolutely essential to maintain the integrity of the membranes, since, the cervix once dilated, the safety of the woman or of the child, or the degree of pelvic contraction may call for the deliberate election of version.
In the event of contmctions not having been induced, if no emergency requiring specially active measures be present, the physician, under strict asepsis, may insert another strip of gauze ; but if the indications be pressing, the cervical tissues have been dilated to a degree by the gauze, and have been softened so that it is possible to resort to the next step in the operation, which, in the vast majority of cases, will give the physician full control of the case.
The aim of the step to which we now pass is to secure full dilatation of the cervix or, in any event, sufficient dilatation to enable the physician to resort to version, the conditions under the premises being still favorable for this operation. According to whether the indication for interference be urgent or not, the physician may elect one of two procedures, — the first, in case delay of a few hours seems allowable ; the second, if delivery is necessary within as brief a space of time as is consistent with inflicting no damage on the cervix and lower uterine segment. Both measures entail mechanical dilatation of the cervix.
The first method consists in the use of Barnes's hydrostatic bags or their essential modification, McLean's bags ; the second depends on the use of the hand, a method not highly favored
OBSTETRIC SURGERr.
because of the objectionable and erroneous term applied to it,-« accouchement ford.
The difference between Barnes's and McLean's bags is that the former has but one compartment, removal being necessitated for the insertion of progressively larger sizes. McLean's bag, on the other hand, has two compartments, so that wlien the ceivieal canal has been dilated to the full extent of one com-
Flg. 28.— Bunei'i Bhgh.
partment the other may be brought into action without removi of the bag.
The method of using these hydrostatic dilators is the fol- lowing: The vagina and the external genitals having been asepticized, and the bag and the forceps having been similarly treated, the bag is seized in tlie grasp of the forceps, and, under the guidance of one or two lingers in the vagina, it is inserted into the cervical canal just beyond tlie internal os. If uterine contractions are present the attempt at insertion should be
INDUCTION OP PREMATURE LABOR. 67
made in the interval of the contractions, in order to avoid pos- sible rupture of the membranes. The bag being in place, the forceps is withdrawn, the rubber tube of the bag is connected with a Davidson syringe, and the bag is distended with sterilized water. The object in using sterilized water is to avoid septi- cizing the uterus, in case the bag should rupture. The rubber tube is then clamped and the patient is put to bed. Ordinarily, after the lapse of two hours, the cervical canal has been dilated to the full extent of the single compartment of the McLean bag, and the tube of the second compartment is connected with the syringe and similarly distended with sterilized water. In about an hour more the cervix lias been sufficiently dilated to enable the physician to resort to delivery of the foetus, prefer- ably by version, if the integrity of the membranes has been maintained.
It is at once obvious that this method will not answer where the emergency requiring interference is urgent, as, for instance, in case of placenta prsevia or eclampsia. Here time is an important factor, and a more rapid method is called for. Of late years a method of rapid dilatation, called by the French the accouchement forci^ has been resuscitated from unmerited oblivion, and in the presence of the emergencies just noted it oiFers the best aid to the woman, and also about the only hope for the child. The reason why the method fell into disuse and has been reprobated by obstetricians generally up to a compara- tively recent date is because of the name which was applied to it. Tlie fact is that absolutely no force need be used or is used in securing dilatation. The method depends for its success on the well-recognized fact that any muscle in the body will yield to continuously applied pressure. The procedure is, of course, tiresome to the operator, but the clinical results which may be secured through timely resort to it will amply compensate. The technique is the following: The woman being deeply anaes- thetized, and the genital tract having been thoroughly asep- ticized, the hand is introduced into the vagina and the index
68
OBSTETRIC SURGERY.
finger is inserted into the cervical canal. Steady pressure li maintained, and shortly it will be found possible to insert the middle finger. Progressively thus finger after finger is inserted, until the entire hand has been introduced. The fist is then doubled and in a few minutes the remaining obstacle to dilata- tion will be found to yield and the physician can at once take the subsequent steps requisite for delivery,
We would again impress the fact that this method should be reserved for strict emergency. The risk the method subjects the woman to is laceration of the cervix, the rent from which might even extend into the lower uterine segment. This major accident should not, however, occur unless the cardinal rule is neglected, which is to use absolutely no force, but to cause the cervix to yield to the applied pressure. In the event of a minor laceration of the cervix occurring, the immediate operation on the cervix should be performed. This will be described in its proper place.
Both these methods — the use of the hydrostatic dilators as well as manual dilatation — evoke uterine contractions as well as dilate the cervical canal. Tiiese metliods constitute at the pres- ent the ideal ones of inducing labor. They fulfill every requisite indication. They are aseptic. They start labor by the natural method, by evoking uterine contractions witliout the possible sacrifice of the child through premature rupture of the mem- branes ; as a rule, they enable dcHvery to be effected within fairly normal limits. They necessitate, of course, the constant attention of the physician after tlie completion of the first step, the provoking of uterine contractions, but, as noted under indi- cations, such attendance is requisite in order to fulfill strictly the aim of the operation, which is the safety both of the woman and the child. At any time it may become necessary to interfere actively in the interests of eitlier. Tlie first stage once com- pleted, labor is ended spontaneously or by forceps or version, according to the individual case.
Prognom. — The prognosis of tlie ojieration for the indi
I
INDUCTION OF PHEMATUHE LABOR.
69
tion of premature labor obviously will vary according to the indication which reqmres it. If resorted to in the presence of eclampsia or placenta prsevia, the result both for woman and child is necessarily more unfavorable than when, tlie emergency not being an extreme one, tlie physician has time at his disposal for the due election of each and every step. Everytliing, further, it should be re-iterated, depends on the careful observ- ance of strict asepsis. Whilst the prognosis should be guarded, in general it may be stated that the operation should not have a mortality rate. Election of the operation and asepsis are the key-notes of success.
As regards the child, its chances of survival are the less the earlier the stage of gestation at which the operation is resorted to. Under the thirty-sixth week the infant can only be reared through the exercise of every possible care. In liospital prac- tice, with modem appliances, it ought to be possible to save, at the thirty-sixth week (the ninth lunar month), fully 80 per cent, of the children. This has been accomplished by means of the incubator and forced feeding. At the Paris Maternity, 30 per cent, of children at the sixtli month have been thus reared, 63.6 per cent, at seven months, and 85.7 per cent, at eight months. These figures refer to calendar months. In private practice, and jmrticularly in country districts, it is not possible to always obtain an incubator, and the physician must do the best possible by means of an improvised incubator, such as an oven, the temperature being maintained at about 90° F. Re- cently, an inexpensive and portable incubator, so simple in construction that trained intellect is not necessary for its man- agement, has been devised by Marx, of New York, and the hope is that before long every physician who contemplates the induction of premature labor will take steps to secure one in advance.
This incubator consists of a box made of well-seasoned hard wood, 21 inches long, 20 inches wide, and 14.4 inches high, lined throughout with sheet zinc, between which and the
I
70
OBSTETRIC SURGERY.
wood is a layer of sheet asbestos. It is divided by a partitiffl into two unequal portions, one of wliich, slightly wider than thi other, is the incubator proper, the other containing the '. generating apparatus. This latter is a copper boiler of the^ capacity of one quart, resting on a tripod, underneatli which is " a Bunsen burner or an alcohol- lamp, which supplies heat to the water. Passing from the boiler througli the partition and wind- ing about the coils over the V-bottom of the incubator portiott
is a -J-inch pipe about 10 feet in length, terminating in afl free vent outside the box. The steam thus received in a suita-l ble vessel, condenses and gives us an index of the condition of J the boiler. The top of tlic boiler projects through the box and! is closed by a metal cap, whicli unscrews so that the V-boUerl may be readily replenished witli water. In the incubator f proper there is a well-padded basket suspended so tliat :
INDUCTION OF PREMATDKE LABOR. 71
bottom is about 5 inches above the coil of the steam-pipe, A glass plate sliding in grooves acts as a cover, which may be par- tially or entirely withdrawn to aid in the ventilation, which is supplied by numerous holes drilled in the walls of the box. A thermometer is fastened horizontally to the top of the basket, immediately beneath the glass slide.
This simple apparatus commends itself on account of its
relative cheapness, thus bringing it within the reach of even people of moderate means in whose families the operation of the induction of premature labor becomes an operation of election. Even so, we question whether, outside of maternity hospitals and the homes of the well-to-do, it will orten be practicable to rear infants under the thirty-second week of gestation, in view of the necessity of having an attendant to watch the inci night and day.
^
J
It is not intended here to enter into the history of the subject at all, nor to describe the various instruments and their modi ti cations which are in general use. The special modifi- cation of the instrument is of very much less service than an accurate knowledge of the use of the instrument. Kecogniziug the fact that traction is the essential power of forceps, it will appear that any instrument which is easily kept clean, easily adjusted to the child's liead, and which is rigid enough to pre-
vent slipping, will be the instrument which will meet thi greatest number of requirements,
Numbei-s of instruments have been devised, which, though not perfect, will so nearly meet tliese requirements as to leavl little to be desired. A forceps wliich is in very general use, an^ which is capable of being adapted to a large number of case is Elliott's (Fig. 32). This is a long, well-curved, and somewhat* heavy instrument, which has an adjustable screw in the handle, by means of which the amount of pressure on tlie head can be regulated. While this is a convenience, it is no easy matter 1 keep the screw aseptic, and the same end may be gained 1 placing a folded towel between the handles of instruments nol furnished with this attachment.
An instrument which is not in veiy general use, but wliid (12) ,
78
undoubtedly possesses merit, is known as Hunter's (Fig, 33). This instrument, having almost no handle, is grasped by means of a bar formed by tlie locking of the two blades. A firm pur- chase is attained in this way, and the hand is so near the head
Fig. Sa.— Hnntor Forceps.
of the child that but little leverage force is possible. The short- ness of the handles renders tliis forceps easy of application.
In addition to possessing some instrument which will meet the requirements mentioned, the operator who wishes to be prepared to meet emergencies must, of necessity, supply liim- sclf with some instrument wliich will permit him to make use of the principle of axis-traction. This can be found best perhaps
in the instrument as devised by Tai-nier and modified by Lusk (Fig. 34). The disadvantages of this instrument are that it is heavy and adds an amount of weiglit to the obstetric bag which is objectionable. It is somewhat expensive, thus deterring some from supplying themselves with It. The axis-tractiou rods
74 OBSTETEIC SUKGEBT.
which have been devised by Reynolds (Fig. 36) possess the advantages of being light, taking up but little room, and are comparatively inexpensive. They may be attached to any pair of fenestrated forceps. This contrivance consists of a pair of steel rods, which terminate at their upper ends in flat buttons in- tended to engage in the lower extremity of the fenestra ; and at their loner ends in hooks, which are received by rings connected witli a transverse traction handle. The appliance is perfectly
degi
simple, and any operator can easily apply it to his ordinary for- ceps. They may be fastened to the forceps-blades either befoie or after the blades have been adjusted to the child's head.
Traction is not the only force of which the forceps is capable, for compression and leverage are coincident to a greater or la degree.
In order that the forceps may not slip, a certain amouat C
FORCEPS.
75
compression is necessary when traction is being made. It is wise to remember this specially in those cases where the opera- tion is prolonged, in order that injury may not result to the child. From time to time the instrument should be unlocked and the handles slightly separated, thus liberating the foetal head. The forceps is not used for this compression force ; it is simply an unfortunate condition, without which traction cannot be made. It is better that traction should be of an intermittent character, if for no other reason than that the head may be re- lieved of this necessary compression at least every two minutes. Most authors hold that any form of leverage to be obtained
*••*"««•
»' J
^
Fig. 36.— Showing: Reynolds's Traction Rods in Position.
by forceps is not only objectionable, but absolutely harmful. The use of the swinging or pendulum motion during traction may easily result in dangerous consequences to the mother, and should not be attempted. Without any doubt, a very slight up-and-down motion will facilitate the extraction ; but it must be borne in mind that, at the same time, the free ends of the forceps may be plowing into the maternal soft parts.
Direct traction is fraught with so little danger to the mother, and will so certainly be successful in those cases where the forceps is indicated, that it would be better never to resort to this pendulum motion. Instrumental rotation should not be attempted, for maternal injury is almost certain to result.
76 OBSTETRIC SUBGERT.
However, it is necessary for the physician to bear in mind that if the forceps has been appUed before rotation has taken place he must be careful not to prevent it by rigidly holding his instrument.
Indications. — It would be almost impossible to mention all the indications for the application of tlie forceps. In a general way it may be said that inability of the mother's expulsive forces to overcome the obstacles to delivery is one of the most frequent indications.
Secondly, any cause wliich requires that the delivery should be accomplished vapidly, either in the interest of the mother or the child, provided, for other reasons, that the forceps is not contra-indicated, makes its application justifiable.
Forceps should not be appUed to the hydrocephahc head, a decomposing fcetus, nor upon a perforated head. If applied to the hydrocephalic head or one tliat is decomposing, it will almost certainly fail to hold, and, even if successful, tlie end gained is not commensumte with the risk of injurj' to the mother. The perforated head can be better liandled with a cephalotribe.
Forceps should not be applied until the os is three-quarters dilated or dilatable, nor until the membranes have ruptured and retracted. If the membranes have not rctmcted, there is the possibility that they may be grasped by the forceps and placental detachment occur.
The actual size of the os is of less importance than its dilatability. Forceps should not be applied until the elasticity of the cervix justifies the easy introduction of the blades.
There must be no mechanical obstruction on the part of the pelvic canal which will prevent the delivery of the child without unusual force. Carcinoma of the cervix, inasmuch as the cervix is rendered so pHable, is a contra-indicatiou to the application of forceps.
Forceps should not be applied where the fcetal head and the pelvic canal are so disproportionate that the probability of deUvering a live child seems small.
FORCEPS. 77
Finally, forceps should not be applied until the head has engaged.
In regard to the time which should be allowed to elapse before the obstetrician resorts to instrumental delivery, it must be remembered that it is a question of conditions, and not min- utes or hours. Undoubtedly many women would escape that condition of pelvic relaxation, which is so often seen, following tardy deliveries, if forceps were used before the muscles entering into the pelvic floor were paralyzed from overstretching. As soon as it is evident that the vis a tergo is not sufficient to over- come the resistance, then forceps should be applied. Another very safe rule to remember is : whenever the head fails to recede after a contraction of the uterus, forceps should be applied. The failure of the head to recede after a contraction shows that undue pressure is being made on the soft parts of the pelvic canal.
Ancesthesia. — Although it is probable that the extraction of the child with forceps is but slightly more painful than nor- mal delivery, yet it is rarely justifiable to apply forceps until the patient is thoroughly under the influence of the anaesthetic. The danger which may result from some sudden motion on the part of the woman is greater than the danger of the anaesthetic, to say nothing of the increased ease of extraction on the part of the obstetrician. Chloroform is so much more rapid in its effects, and leaves so little to be desired as an anaesthetic, that it is preferable to ether. The patient should be anaesthetized to the surgical degree before the instrument is applied.
Many authors hold that the application of forceps is only justiflable in head presentations. Undoubtedly it will seldom be necessary to apply it to the breech, but there are con- ditions which will render the application of forceps to the full breech very advantageous.
It is absolutely necessary to make a correct diagnosis of the position of the child and the causation of the tardy natural delivery before the application of forceps. Before the examina-
78 OBSTETRIC SUR6ERT.
tion is made which is to determine these points, it is better that the obstetrician have everything in readiness, so that no delay may occur. He should see that the usual heart stimulants are at hand. An hypodermatic syringe and fluid extract of ergot, together with other oxytocics, should be in readiness. The in- strument should be sterilized and placed in a basin containing 1 to 100 creolin solution.
Inasmuch as in forceps cases repeated digital examinations are made, it is wise to exercise unusual care in rendering the hands aseptic. They should be thoroughly scrubbed with soap and hot water, and afterward immersed in 1 to 1000 bichloride-of-mercury solution for five minutes. The patient should be anaesthetized and turned across the bed so that the hips will extend well over its edge ; the knees can be held by two assistants sitting on either side of the patient. The anaes- thetic sliould be given into tlie hands of a physician who will have no other duty to attend to.
The external genitals and vagina should be cleansed with soap and water and a soft scriibbing-brusli, and afterward douclied either with 1 to 3000 bicliloride-of-mercury solution or 1 to 100 creolin solution.
After palpating the abdomen, one hand should be passed into the vagina if the head is high, and with two fingers the operator should carefully palpate the fontanelles. If there be any doubt about their relation to the pelvic canal he should seek an ear, and finding it will enable the diagnosis to be made certainly. At the same time he can determine if any obstruc- tion on the part of the motlier exists. The foetal heart-sounds should be listened to, for their character will enable him to de- termine somewhat the effects of tardy delivery on the life of the child. The forceps is usually applied while the patient is on her back, though some prefer the left lateral posture. The bladder and rectum should be emptied before any operative procedure is undertaken.
The operator, having assured himself of the exact position
PLATE IV.
Inlioduclion o< the Left Sladi of the Forctpi.
FOBCEFS. 79
of the child's head, and that there are no co&tra-indicationa to delivery by the forceps, proceeds to apply it
The blades, for purposes of designation, are known as right and leit, correspondlDg to the right and left sides of the pelvic canal. The lell blade should be introduced first on account of the method of locking. The left blade, grasped near the handle with the left hand, is introduced into the vagina (Plate IV and Kg. 37). Two or more fingers of the right hand passed into the vagina until the head is felt will serve as a guide to its
Fig, 37.— iQtrodactlon of the Lett Blade of the Forceps.
introduction. The blade is made to gUde along the palmar surface of the right hand and pass between the fingers of that hand and the head. It is necessary to remember the two curves of the forceps in introducing it. As the blade passes the fingers the handle is to be depressed and carried slightly outward. At no time must force be used in its introduction. If the blade cannot be made to easily adjust itself, it is better to withdraw it entirely and make another attempt. Force is so certain to do injurj' to the soft parts that it is never justifiable. After the left blade has been introduced its handle should
OBSTETBIC SDRGERT.
right
be given into the hands of an assistant, and the right blade in- troduced. Here the left hand acts as the guide and the right hand manages the blade (Fig. 38). No attempt should be to introduce the blades during a contraction of the uterus. It is customary to apply the blades first to the sides ol pelvis, irrespective of the position of the child's head, and after- ward, if possible, have them grasp the child's head in its biparietal diameter. As soon as the blades are passed and adjusted, they should be locked (Fig. 39). This is usually ac- complished easily by slightly depressing both handles.
this not accomplish the desired end they may be advanced i slightly withdrawn, and another attempt made to lock them." Forced locking must not be attempted. The very fact that the blades will not easily lock indicates that there is either faiUty application or else the case is not one in which forceps should be used,
There is no operation which calls for more gentleness, judgment, and patience than the application of forceps. It is always necessary to bear in mind the possibility of including the
FORCEPS 81
mother's soft parts in the grasp of the forceps, and the injury which would result therefrom.
It is necessary to study the suhject of forceps operations In their various phases, inasmuch as they each present their own peculiarities.
The operations may be divided into low, medium, and high applications. Again, whether the occiput is anterior or pos- terior, and whether the head is proportionate to the pelvic canal or not.
The Application of Low Forces, Oocipito-<mterior PosUUm,
7<|!. 89,— The Forceps Adjiuted uid Rekdy ti
Head atid Birth-Canal Proportionate. — This operation is the most simple of all forceps deliveries. It is indicated when for any reason it is an advantage to mother or child that the labor be terminated. These are the cases where non-interference so often results in injury to the mother's pelvic floor, the head remaining on the pelvic floor for so long a time that the levator ani muscle and the triangular ligaments are not able to regain their tonicity after the labor and their diaphragmatic action is impaired.
82
OBSTETRIC SUBGEET.
are po^ ned, me
It must be borae in mind that the abdominal muscles \ by iar the greater part in the act of expelling the head from t vulva, and in women of poor muscular development or in those who liave become thoroughly exhausted from a prolonged first stage the muscular force necessary to expel the head may be wanting. Many of these women would undoubtedly dc-liver themselves if left alone ; but the question arises whether or not they will not suffer more injury, and of a more permanent char- acter, if unaided, than could possibly result from the application of low forceps. It is not intended by this to mean that every woman sliould be delivered with forceps as soon as the head is low down, but simply as an opinion that many women are ] manently injured by reason of an unnecessarily prolonged t stage.
Under strict aseptic precautions, as already mentioned, blades are applied over the biparictal diameter of the child's head. As soon as locking has been accomplished, it is well t make tentative traction to see that they have a firm grasp.
The instrument should be grasped with the right hai with palmar surlace downward. Should the instrument transverse shoulders, the index and middle fingers should | placed over one shoulder and the remaining fingers over t other. In using Hunter's forceps it is often a relief to pla towel over the cross-bar and with the right hand grasp { towel. (Plate V, Fig. 1.) The left hand should be plai against the patient's buttocks, with one finger over the four- chette. This will enable the operator to determine just how mncli force he is exerting on the (jcrineum. Traction should be made downward, or as nearly so as the perineum will permit, thus accentuating flexion (Fig. 40). Pendulum swinging force during traction is contra-indicated. Firm 1 tion exerted for not more than one minute will accomplish I extraction if i>ersisted in. It should be the operator's attera|? to imitate nature as nearly as possible in preparing the perineum for the deliver)' of the head. This can be done by
im a^_
allowing the head to recede ailer each traction. He should also release the grasp of the forceps slightly at each recession, that the child may not be injured.
In the majority of cases calling for instrumental extraction pains are so infrequent that it is not wise for the operator to wait for the help which uterine contractions may give him, but he should make traction irrespective of their presence. Well- directed abdominal pressure on the part of an assistant will be of undoubted value. If it is evident that perineal laceration is impending, it is better to at once perform episiotomy. This little operation is no doubt worthy of more consideration than it has ever received. The measure is a simple one, consisting
Fig. ».— Showing the Direction of the Line Ot Traction.
only in relieving the strain on tlie perineum by making a lateral incision on either side of the vulvar orifice. (Plate V, Fig. 2.) The incision need not be more than an eighth of an inch in depth and half an inch long, extending up into the vagina. It is not likely that hiemorrhage of any consequence will result from this procedure, but, even if it should, a con- tinuous catgut stitch will control it without difficulty.
As soon as tlie occiput is brought well down underneath the pubic arch, the forceps should be removed and tlie head delivered between pains, by introducing the finger into the rec- tum and, finding the chin, tilting it out over the perineum. * ' soon as the head is delivered it should be held so tha
84 OBSTETRIC SORGERT.
shoulders may not be driven through the vulvar outlet during pain; but as soon as the contraction, which is nearly always ex- cited by the delivery of the head, has subsided, they may be lifted out as was tlie head.
Low Forceps in Occipilo-posterior Position, with Partial Rotation. — It has been shown that firm uterine contractions, forcing the foetus to travel over the inclined planes of the pelvis and resisted by a firm perineum, will cause the occiput to rotate forward. Should any of these factors be absent rotation may not be complete, and the foetus will occupy an oblique position with occiput posterior. Usually, by giving the mother a rest, firm contractions will ensue and anterior rotation and normal delivery take place. It often happens, however, that in the interest of motlier or child instrumental delivery becomes necessary.
After a very careful examination, so that the exact position of the occiput is made out, forceps should be applied in one of two ways : either directly to the sides of tlie pelvis or else in an oblique position.
The latter is more difficult, but is preferable on account of the lessened risks to the child. The forceps should be applied in that oblique diameter whicli is not occupied by the head. This will cause the blades to grasp the biparietal diameter of the head. The rule tliat the left blade should be introduced first should be disregarded here, unless it be at the same time the anterior blade, for this is the difficult one and should be first introduced. Unusual care must be taken to guard the mother's soft parts from injury. The forceps should be unlocked after each traction, winch not only lessens the danger to the child, but also by releasing tlie head permits rotation to take place., At no time must instrumental rotation be attempted, nor, the other hand, must natural rotation be prevented. Oftentim< it is wise to remove the forceps altogether and re-adjust it over the biparietal diameter, which may have changed its po- sition. By patience and absence of any desii-e on the part
thy operator to hasten the rotation, the head will often gradu- ally mold itself, and under the tractions of the forceps, which acts as a re-inforcement to the expelknt forces, rotate anteriorly.
If. after patient and gentle efforts, it be irai)ossible to adjust the forceps over tlie bipavietal diameter, it should be applied directly to the sides of tlie pelvis. The same care must be exercised here that the mother's soft tissues are not injured. It is also imperative that tractions should not be prolonged longer than a minute, and that tlie grasp of the forceps be relaxed between tractions. The child is put to such a disadvantage, even under these circumstances, that its Ufe is olten seriously jeopardized and the operation is done primarily in the interest of the mother.
Low Forceps in Occiplto-poaferior /bsiVfoit. — It is the gen- eral opinion among obstetricians that few abnormaHties produce a more difficult condition to terminate successfully than those cases where the occiput has rotated posteriorly and is wedged in the hollow of the sacrum. Fortunately they are not very frequent, for the child's condition is most perilous and injury to the mother's soft parts almost certain.
It is far better to delay the application of forceps in these cases as long as possible, that, under continued uterine contrac- tions, anterior rotation may occur. If, however, the mother is showing signs of exhaustion, or if the fcetal heart become feeble, then there is no other resort but to apply forceps. Delay beyond this point is not admissible.
The patient should he auEcsthetized and the parts rendered aseptic, as before suggested. Carefully guarding the soft parts, the blades are applied to either side of the child's head, A moderate amount of pressure is necessary to prevent the blades slipping, but by relaxing the grasp frequently the injury to the child will be greatly lessened. As soon as the forehead is made to appear beneath the pubic arch it is well to remove the for- ceps, and, unless the reasons for immediate extraction are urgent, it is well to give nature a chance to rotate the occiput
86
OBSTETRIC SURGERY.
anteriorly. Otlierwise, in place of making traction horizontallv, as is necessary when bringing the forehead underneath the pubic arch, the handles should be lowered as far as the peri- neum will permit. This manoeuvre will cause marked extension of the head and the forehead will be brought underneath the pubic rami. Forced extension now will cause the forehead to clear the pubes. The forceps should now be removed and, pass- ing two fingers into the rectum, the head should be flexed until the occiput escapes over the perineum.
Laceration of the perineum will be almost certain to occii and it should be repaired at once.
As already stated, these cases are among the most diffi- cult ones found in obstetrics, and one of the hardest things to resist is the desire to attempt instrumental rotation. It will only be necessary to remember to what unusual risks this y subject the mother, to deter one from this procedure.
Low Forceps in Face Presentations. — The application i forceps in face present'! tions, when that condition has not 1 diagnosed until after the face is well down in the jjelvic canaljH should be delayed as long as is consistent with the safety of mother and child, in order that anterior rotation of the chin may occur. This rotation is nearly always tardy, and some- times does not take place at all. Manual rotation of the I if not too firmly wedged, is [iermissible and sometimes success
ful, but at no time should forceps be used to bring about this rotation. If the chin has rotated anteriorly, forceps should be applied directly to the sides of tlie child's iiead. A firm grasp must be taken and some compression used to prevent the blade3 slipping. Traction should be made horizontally until the chin is brought underneath the pubic arch, when the handles should be raised and the cranial vault and occiput lifted over the peri- neum. If the chin is turned posteriorly and the head la wedged in the pelvic outlet, there is so little probability that a living child can be extracted that it seems to be the part of conservative treatment to turn the attention entirely to the wel- fare of the mother and do craniotomy, or, iu favorable cases, symphysiotomy.
Forceps in Breech Pj-esentations. — Forceps should not be applied to the breech until after it has firmly engaged. When, however, the breech has entered the pelvic canal, and yet is too high to permit the finger passing over the groin or the application of the fillet, Tarnier's axis-traction forceps will be most advantageous. A dilated or dilatable os will render the opemtion so much more easy of success that this should be accomplished before the application of forceps. The majority of these cases are met in old primiparie, where the parts arc more than usually rigid, and the time spent in dilating the cervix will not be wasted. If rotation has occurred, tlic blades should be appUed over tlie sacrum and posterior aspect of the thigh.
It is here that caution will be necessary to prevent the blades impinging so firmly on the parts that the child will be injured, and at the same time firmly enough so that they will not slip and injure the mother's soft parts. Hence it is better to make tentative traction at first, to see that the grasp is firm. The application of the principle of axis-tractiou to forceps enables the operator to use very much less force in the extrac- tion, inasmuch as the resistance caused by the pressure of the presenting part against the anterior pelvic wall is very much lessened. Traction should be made only during a contraction
OBSTETKIG SDRGERY.
of the uterus, unless the pains be too infrequent. If this should be the case, it is better to imitate the methods of nature and permit the recession of the breech after each traction. The rigidity of the canal will rapidly lessen under the influence of the advance of the breech, and the integrity of the soil parts will more likely be preserved.
If this intermittent traction is used, a very small amount of force will accomplish the delivery of the breech. Should the hips be transverse, it is better to attempt manual rotation first. If this ia not possible, then the blades should be applied to 1
lateral surfaces of tlie thighs (Fig. 42). It is not espediel to allow the blades to embrace tlie crests of the ilia, inasmuch as the bones are too compressible and tlie forceps is almost cer- tain to slip. In all cases well-directed pressure over the fundu) will greatly facilitate the extraction.
The Application of Medium Forceps. — Most authors i to all forceps operations above the inferior strait as high forceps" and confuse in this way two very different operations. When the head has firmly engaged, indicating that its greatest diametc has entered the pelvic inlet, it seems better to consider it i being in a medium position, and, should it become arrested thei
J
nch
:er-
ndu^_
ref^
and necessitate extraction, to call the operation medium forceps. This condition depends either ou the disproportion of the head and the birth-canal or on lack of uterine force to overcome the resistance which is normally present
This operation is fraught with far more danger than low forceps, for the blades of the instrument must of necessity enter the lower uterine segment, when the most extreme caution will be necessary to prevent injury to the uterus. Hence it is ad- visable to delay the application of forceps until instrumental delivery seems imperative to the mother or child, or both. If the undilated cervix is preventing the advancement of the head,
Fig. 43.— InclBlon of the C«rrlz.
it is far better to mannally dilate it than to use the forceps as a dilating force, as is advised by many. Should cicatrization from any cause render the cervical tissue non-dilatable, the little pro- cedure of nicking the cervical ring, as will be described in the chapter on " Version," will greatly facilitate the dilatation. In a recent case, where there was a distinct history of diphtheritic vaginitis in early cliildhood, one of the authors encountered this condition very markedly pronounced. The head was firmly engaged and it was with difficulty that one finger could be in- troduced into the os, although the woman had been in labor twenty-four hours.
OBSTETRIC SDHGEBY.
After making five or six shullow cuts through Ihis hard- ened ring, manual dilatation was completed In eleven minutes. This procedure is fraught with no danger to the child and less to the mother than when dilatation is accomplished by alter- nately drawing the head down and allowing it to recede. If the delay in advancement is due to lack of uterine force, tliis organ will often resume its energy if the patieut is given a small dose of quinine, — 5 to 10 grains. Should it become necessary, however, to apply forceps, the most strict aseptic precautions will be necessary. The patient sliould be completely anes- thetized and prepared, as has already been stated. The opera- tor should be certain that the blades do not embrace any of the
cervical tissue in their grasp. This can be prevented by recog- nizing the exact relation of the cervix to the child's head, and permitting the blade to enter the lower uterine Begment tween the fingers and the ftetal head.
Medium forceps is usually applied directly to the sides the pelvis (Fig. 44). Axis-traction forceps in these cases certainly accomplisli more with less force than any other insi ment. Although, in tlic majority of cases, when the forceps is thus applied, it will be found that the blades have grasped the head in its oblique diameter, yet if the grasp of the forceps is frequently relaxed the injury to the child will not be great. As tlie head advances under the influence of axis-traction anterior
and
FORCEPS. 91
rotation will probably occur, and the free mobility, which is insured by the handle of the traction rod, will permit this rota- tion more certainly than if the ordinary long forceps is used.
As soon as the head has been brought down to the floor of the pelvis, it is better to remove the axis-traction instrument, and, if it is necessary to extract, complete the operation with the ordinary forceps. If the axis-traction forceps be not at hand, and the ordinary forceps be used, the operator must make traction as nearly downward as the perineum will permit, bear- ing in mind at the same time that the pelvic curve of the blades may be making undue pressure against the anterior aspect of the uterus. At the same time, if the handles are raised the presenting part will simply be forced against the symphysis and further advancement be prevented. Hence it will be necessary to exercise unusual patience, and at no time attempt to dislodge the head by the application of brute force.
High Forceps. — ^It has already been stated that while the head is movable above the brim forceps should not be applied.
In rare cases where the waters have drained away and the uterus has firmly contracted around the foetus, rendering ver- sion impossible, simply as a tentative measure forceps may be applied.
It is needless to say that the very greatest care must be taken, or else serious if not fatal injury to the mother will result. The patient should be thoroughly anaesthetized and the entire hand gently introduced into the vagina. It must be remembered that after uterine retraction has taken place the possibility of rupture is increased and no harsh measures must be adopted. It should be the aim of the obstetrician to deter- mine, if possible, the cause of the failure of the head to engage. If it is due to contraction of the pelvis to any marked extent, it will be useless to attempt to drag the head into and through the pelvic canal. If the true conjugate is less than three and three-fourths inches, with a normally-developed foetus at full term, forceps should not be used.
93
OBSTETRIC SUSGEHY.
If upon examination the pelvic canal be normal, and it is found that early loss of waters has taken place and that uterine contractions have not been of normal force, then the forceps may be applied while the head is still above the brim if version be contra-indicated. As in medium forceps, the cervix must be dilated before the forceps is applied. Carefully guarding the blade with the right hand, the left blade should be introduced. No force must be used, and if the blades cannot be adjusted to the sides of the pelvis without force tlie operation should be discontinued. If, however, they can be applied, only gentle force must be used to see if the head can be made to engage. Axis-traction forceps should be used. Should the head engage, the after-conduction of the case will be the same as in medium forceps.
Prognoets. — The application of low forceps should be at- tended with absolutely no mortality to either mother or child.
When the head has firmly engaged, j'et has not descended into the pelvis, forceps, when applied under the rules of asepsis already given, should not be attended by a mortality to the mother, and, where there is no malposition or disproportion, should be alike safe to the child.
In the high operation, where the head is yet above brim, the prognosis for both mother and child is very much 1) satisfactory. Extensive laceration of the soft parts and even rupture of the uterus may occur. Experienced operators hesi- tate before applying high forceps, realizing the great risk to the patient. The outlook for the child, on account of the prolonged compression of the head, is even more serious. Although the frequent unlocking of the blades will afford a greater degree of safety to the child, its life not only is often jeopardized, but injiuy to the cranium may result in fatal convulsions or epilepsi
ion^^
CHAPTER IV.
VERSION.
The term " version" applies to all operative methods for changing the relation between the long axis of the child and the long axis of the uterus.
Inasmuch as version is but another expression for turning, it also embraces the operation for converting an occipito-posterior position into an anterior one while the child is in utero^ even though the long axes of the child and the uterus remain un- changed. By means of this operative interference the cephalic or pelvic pole may be caused to present. The breech may be changed for the head, the head for the breech, or a transverse either to the breech or head.
Again, as is stated above, the back of the child may be turned toward the abdomen of the mother. Before any opera- tive procedure is performed it is absolutely necessary to deter- mine the exact relationship which the child bears to the uterus; also the mechanical obstruction which is to be overcome, and an estimate of the comparative size of the child's head and the pelvic outlet.
Ordinarily this can be determined by abdominal palpation and vaginal examination, both of which methods should be re- sorted to. External palpation is a procedure too seldom used, and those who will accustom themselves to study every obstetri- cal case in this way will be surprised to see how soon experience will yield happy results. It is so very important to know just what position the child is in, that if, as is sometimes the case, it is impossible to gain the proper information from these two methods of examination, it is better to introduce the hand into the vagina and one or two fingers through the os. In this way a positive diagnosis can be made. At the same time other valuable information can be gained, viz., the absence or character
(93)
94 OBSTETRIC SDRGEBY.
of the pulsation of the cord; the low implantation of the placenta, if such be the case; the normal or otherwise promi- nence of the sacral arch, and, in cases of slightly deformed pelves, whether or not one or both of the pnbic rami encroach on the pelvic outlet. It is necessary to determine as nearly as possible all these conditions, or else there will be far too manv cases of perforation of tlie after-coming head, with the too late realization that tlie case was not one on which version should have been performed.
The multiplication of terms is so proUfic a source of con- fusion in the study of any subject, that it seems wise to reduce the nomenclature of version to such simplicity as is compatible with clearness.
Cephalic version indicates that some other position been changed so that the head presents.
Pelvic version indicates that some other position has been changed so that the breech presents, Podalic version is a term which should be included under the head of pelvic Tei"si inasmuch as it is but a stop farther in tliat procedure.
Internal rotation of the child is tlie term which signified' that, while the long axis of the child bears the same relationship to the long axis of the uterus, the occiput has been made to undergo a half-rotation.
This changing of the foetal relationship to the uterine may he accomplished in three ways: External, internal, or com- bined external and internal manipulation. Hence, to sum up this simplification of the nomenclature as applied to version, it may be taken for granted that all versions are either cephalic, pelvic, or internal rotation of the child, and that the operation is performed either by external, intenial, or combined external and internal manipulation.
Cephalic version has found a few advocates and, theoretio ally, should be performed in all breech or transverse presenta- tions where no complications exist to contra-indicate such a procedure. Pinard, who perhaps has done more than any othet
lUDie
4
been term
rnifie3
VERSION. 96
to popularize cephalic version, intimates that any other than a head presentation is due to some abnormal accommodation be- tween the head and the pelvic inlet. Granting this to be true, it would seem that this very fact would contra-indicate the operation. So rarely will the patient be able to deliver herself, even after the cephalic version has been performed, that the operation is not to be regarded as practical except in a very limited number of cases.
Almost the only condition which renders cephalic version practicable is in transverse positions, where the waters have not escaped. The operation is contra-indicated in all cases where a rapid termination of the labor is indicated, when the child is not freely movable wi tUei-o^ and in prolapse of the cord. Should the operation be determined upon in cases of transverse position, as indicated above, the combined method of Braxton Hicks is far more likely to be successful than either the external or internal alone. Chloroform anaesthesia should be produced and the patient placed on a table which has been properly covered and protected. The operator and his assistant must exercise absolute care in cleansing their hands and arms. The patient's bladder should be emptied and a rectal enema given. The external genitals and vagina should be cleansed with soap and water by means of a brush and afterward douched with some antiseptic solution, such as bichloride-of-mercury solution 1 to 1000, or creolin solution 1 to 100. The prone lithotomy position will, perhaps, render the operation least difficult. The patient being in the condition of surgical anaesthesia, the operator proceeds to carefully palpate the abdomen and determine the position of the child. The operator now redisinfects his hand and, selecting the one which he most frequently uses in making vaginal examinations, introduces the hand into the vagina. If the OS is dilated sufficiently to admit the first and second fingers, they are carefully passed through the cervix, using as little force as is possible, so that the membranes may not be ruptured. If the OS is not dilated it will be necessary to gradually introduce
96 OBSTETRIC SUKGEUY.
one finger, and, as soon as possible, the second. By slowly Bep- aiating the fingers as much as possible enough room can soon be gained so tliat the fingers can be passed into the uterus. Should a contraction of the uterus take place the operator will desist from any manipulation in order tliat the integrity of the membranes may not be endangered. The fingers now seek the presenting part, and if it be a shoulder it is gradually raised and pushed toward the breech. The assistant at the same time pushes the head toward the pelvic inlet, while with the other hand the operator governs the movements of the breech, push- ing it up toward the fundus. As soon as t!ie head impinges on the vaginal fingers it may be made to settle into the brim of the pelvis. Carefully controlling the body of tlie child so that it may not again assume the transverse position, the membranes are ruptured and the water allowed to escape. This permits the uterus to contract more firmly on the body of the child, and thus retains the head in its proper position. The remainder of the delivery may now be left to nature unless some further indication presents itself
Pelvic version is, as already stated, the term applied to the operation of converting some other into a breech presentation. It is of no advantage unless the operator goes a step farther and brings down a foot, thus performing a podalic version. This operation, considered from an elective stand-point, and not as a measure of last resort, is capable of producing more favorable results than has ever been credited to it. It is not fair to charge this opemtion with fatal results to mother or child when the operation liiis been resorted to only after re- peated vain attempts to deliver the child with forceps, or after the mother has become exhausted with her long-continued efforts to overcome a resistance greater than the force at her disposal. In the hands of one who recognizes the difficulties to be overcome, either at the beginning of the labor or soon after- ward, it becomes a powerful measure in saving lives. Podahc version is indicated (1) in transverse presentations where t
VERSION, 97
child is not freely movable, or when cephalic version is not indicated ; (2) in head presentations where, from some compli- cation, the head fails to engage ; (3) in cases where it becomes necessary to expedite the delivery while the head is yet above the brim of the pelvis ; (4) in head presentations where the safety of the mother or the child is likely to be endangered should the head be allowed to enter the pelvic canal.
The indication for podalic rather than cephalic version in transverse presentations will be found far more frequent, inas- much as these cases are not always diagnosed in that stage of the labor which makes cephalic version possible. If the head is still above the brim of the pelvis and movable^ podalic version is so much less dangerous than delivery by forceps that it should be adopted. Even in the hands of the most expert the applica- tion of high forceps is fraught with no small danger to the integrity of the soft parts of the mother.
In that class of cases where it becomes necessary to expe- dite the delivery, such as eclampsia, placenta prsevia, accidental haemorrhage, or pressure on the prolapsed cord, podalic version is the operation which yields the very best results.
The danger of allowing certain malpositions of head pres- entations to enter the pelvic canal as such is so well known and admitted that they need but little more than be mentioned. In face presentations and in occipi to-posterior positions which cannot be corrected by internal rotation, podalic version should be performed.
Podalic version is contra-indicated (1) when the cervix is not dilated or dilatable ; (2) when the uterus is in tetanic spasm around the foetus ; (3) when the presenting part has become so firmly wedged into the pelvic inlet that undue force is neces- sary to push it upward; (4) in contracted pelves when the conjugate is less than three inches and three-quarters, and in oblique contractions when the brim of the pelvis is seriously encroached upon.
Operators who disregard the first contra-indication are the
98 OBSTETRIC SURGERr.
ones who will most frequently be compelled to perform crani- otomy on the after-coming head which has been grasped in a partially-dilated cervix. This, of course, applies when extraction follows version immediately. The combined method permits version with but slight dilatation of the cervix.
When the uterus is in tetanic spasm around the foetus the operation is fraught with so much danger that it is not ad- visable. Long-continued dry labors or the injudicious use of ergot is the most frequent cause of this condition, and rupture of the uterus is too possible an occurrence.
If the prL^senting part has become firmly impacted the force necessary to dislodge it will endanger the integrity of the soft parts so much that the operation is inadvisable, and some less dangerous method must be adopted.
Although it is easy to turn the ciiild in cases where the pelvis is contracted, yet the delivery of a living child is so un- certain if the conjugate is less than three inches and three- quarters that it becomes a contra-indication to podalie version. Perhaps one of the most frequent causes of failure in saving the life of the child in podalie version is the neglect on the part of the operator to take careful pelvic measurements.
It is not meant that tlie physician must leave his patient and seek a pelvimeter of some peculiar pattern, but it is meant that with his fingers he can form so nearly an exact idea of the true conjugate that he will be able to depend upon it. (The details for doing this have already been given under the head of pelvimetry.)
In this, as in all other obstetric operations, it is absolutely necessary that an exact diagnosis should be made.
The operator must have a true mental picture of the position of the fcetns in vtero. As stated under the head of <;ephalic version, external palpation and vaginal examination will, in most cases, render the diagnosis clear; but it is not in- frequent, even in the most skilled hands, to make a mistake if these two methods alone are resorted to. If there is any doubt
it is better to put the patient thoroughly under the influence of chloroform and introduce the hand into the vagina and two fingers into the uterus. In Iiead presentations the ear becomes a most valuable landmark. If it is felt, it is with perfect ease that even one of no great experience can determine the position of the head. Let it be remembered that in but very few cases is there necessity for haste in making a careful examination. It is only after extraction begins that work must be rapid.
Before o|jerating, the physician must have a j)er«o?io? knowl- edge that all the necessary preimrations for the various emerg- encies which may arise are at hand.
Fluid extract of ergot and the usual restoratives, — whisky, strychnia tablets, etc., — together with an hypodermatic syringe in good working-order, sboidd be in readiness. A perfectly clean, preferably new, gravity syringe, with an intra-uterine glass nozzle, should be filled with some mild antiseptic solution which is heated to 118° F. (Creolin solution 1 to 100 and hi- chloride-of-mercury solution 1 to 10,000 are as good as any.) Basins of hot and cold water and a number of freshly-laun dried towels should be in the room. Iodoform gauze 10 \wt cent., which is known to be fresh and clean, for intra-uterine tarn-* ponade, should be cut in strips several yards long and two inches wide. A basin of some antiseptic solution and a new nail-brush should be in easy reacli of the operator. A short- handled forceps, in case the after-comuig head becomes arrested at the brim, should be sterilized. Needles, needle-holder, silk, silk-worm-gut ligatures, sponge-holders, and artery-clamps should be boiled and placed in a tray of steriUzed water. The operator and his assistants must be conscientious in the details of antisepsis. If no operating-gown is at hand, a folded sheet can be made to take its place. The hands and nails are rendered clean with soap and brush and afterward by inimer' eion in bichloride-of-mercury solution I to 1000 for at least five minutes.
The patient should be thoroughly aneesthetized and
I
I
I
100
OBSTETRIC SURGERY.
ferred from the bed to any ordinary table, which has beenl covered with a blanket and a piece of rubber sheeting. The! patient should be placed on her back and the buttocks dra^vnl well over the edge of the table. The knees are to be separated 1 and drawn up over the abdomen. Confining the knees in this position by means of an improvised crutch made by tying one end of a sheet around one of the knees, passing the sheet back of the patient's head and tying the rtjmaining knee with tha otlier end of the sheet will leave more hands free and necessi-| tate a less number of assistants.
The vulva and adjacent parts should be thoroughly cleansed I with soap, water, and brush, and afterward with some antiseptic solution.
The catheter should be introduced, even though the pa^l tient may have recently passed her water. It is wise for the \ operator to inform his assistants exactly what duty is to be per- I formed by each. It is possible to perform this operation sinaply ' with the help of one physician and a nurse, or some one who will act in that capacity ; but it is far better to have the assist- ance of two physicians, — one whose sole duty it will be to admin- ister the antesthetic, and the other to assist directly in the operation. In regard to the hand which the operator should use in performing podalic version, it should be borne in mind that if an extremity is to be grasped the palmar surface of the liand must be turned toward the abdomen of the child. If the back of the child is to the lefl:, the left hand is to he used ; if to i the right, the riglit hand must be used. From the variableness I of the position of the child, the physiciun should attempt to I educate botli hands to an equal degree of tactile sensibility.
As has been stated previously, version may be performed j by three methods, — external, internal, and the combined exter nal and internal.
Pelvic version by the external method is so seldom applic- | able that little need be said of it. It is not often applicable, from the fact that a substitution of a breech for a head pres- A
VERSION. 101
entation is scarcely ever a desired condition. It is not often practical, inasmuch as the great majority of the indications for version presupposes the determination for rapid delivery by bringing down a foot. In transverse presentations when the waters have not ruptured, and when the breech is nearer the pelvic brim than the head, it may be indicated. While it may be in its performance absolutely without danger to the mother, it must be remembered that it may put the cord to such a dis- advantage that the child's life will be jeopardized.
If this method is decided upon, the patient should be placed upon her back with her knees drawn up so that the abdominal walls may be relaxed. The operator stands to the side of and facing the patient. The exact position of the child should be mapped out. The physician then places one hand over the buttocks and the other over the head of the child, and, by pulling the buttocks toward him and pushing the head up, he attempts to convert the position first into a transverse and then into a breech presentation. If the presentation is already a transverse, and the breech is nearer the brim, the head may be raised as the breech is forced into the pelvis. It is necessary that manipulations be made only during the interim between pains, and during the contractions of the uterus an attempt should be made only to retain the amount of advantage gained. This method presupposes relaxed abdominal walls, unruptured membranes, and free mobility of the child.
The combined method made so famous by the name of Braxton Hicks, who perfected and popularized it, is likewise limited in its application, inasmuch as it is not often successful, unless the liquor aranii is still present or has only recently escaped, and where considerable mobility of the child is still present. It is seldom performed, since version is nearly always followed by immediate extraction, and this presupposes suffi- cient dilatation to admit of the entire hand being introduced into the uterus.
In certain cases of placenta praevia where haemorrhage is
102 OBSTETRIC SURGERY.
taking place before the cervix is very much dilated, the com- bined method is of great advantage. In such cases the prime object is to control the haemorrhage, and if the operator can succeed in introducing even tviro fingers into the uterus he may be able to draw down a foot and thus plug the cervix with the buttocks. The operation is not easy or advisable if the head is wedged in the pelvis, nor when the uterus is contracted around
Fig. 45.— First Stage of Bipolar Version.
the child. The patient should be thoroughly under the influ- ence of the anaesthetic and the buttocks drawn over the edge of the table, as has been described.
After thorough asepsis on the part of the operator and his assistants and the external genitals and vagina of the patient, the entire hand, which has previously been dipped into 1 to 100 creolin solution, and corresponding to the position of the occi- put, folded upon itself cone-shape, should be introduced into the vagina. All force imparted to the hand should be gentle
VERSION. 103
and at first directed downward and backward, then forward and upward, till the cervix is felt
Counter-presBure with the unemployed hand can be made over the fundus of the uterus by the operator better than any skilled assistant can do for him. This counter-pressure answers two purposes: the vaginal attachment to the uterus is not put on an undue amount of strain and the cervix is forced nearer tlie examining finger.
If one finger only can be introduced, proceed to dilate with
Fig. 16.— GtwpLde
the index finger, if previous dilatation has not taken place (Fig. 45)
As soon as two fingers can be introduced the head is sought and pushed up toward the side to which the occiput is directed, wliile with the other hand the buttocks are brought down in the opposite direction. If extension of the head has taken place the chest of the child will be felt, which should be pushed upward in the same way as in case tlie head is felt. As soon ns the head is raised beyond the reach of the fingers the knees are sought, which should now be within reach. The
104
OBSTETRIC SURGERY.
knee must be carefully distinguished from the elbow before traction is made upon it. There will be no difficulty in doing this if the operator remembers that the flexed elbow points toward the buttocks and the flexed knee points toward the head. It is not necessary to waste time looking for the patella ; it is difficult to recognize, and the above rule is accurate. If the knee is felt, it should be grasped (Fig. 46) between the two
Fig. 47.— Representing First Act of Extraction.
fingers and brought still lower toward the brim ; at the same time the other hand can now be used to push the head toward the fundus. As the knee is brought down the fingers can be made to slip down the leg until the foot is grasped and ex- tracted (Fig. 47).
It sometimes happens that the foot is felt before the knee ; if so, the position of the great toe and the malleoli will enable the physician to distinguish the foot from the hand. If the
VERSION. 106
foot is felt and recognized it should be brought down, thus completing the version.
It has already been said that the external method and the combined method of Braxton Hicks are limited in their appli- cations for the reasons stated.
It is the internal method which has the broadest field of application, and which is of incalculable value in certain cases.
The indications and contra-indications have alreadv been given. The position of the patient and the previous prepara- tions are the same as in the external method. This operation should not be performed until the cervix is fully dilated or dilatable. Under thorough aseptic precautions the hand is introduced into the vagina very gently, until the cervix is reached. If the cervix is not dilated, its dilatation should be at once begun. By introducing one finger into the cervix it is easy to determine whether any constricting ring exists around the OS. If such is found to be the case, and it does not soon yield to the finger, it is wise, in case of urgency, to expedite the dilatation by using the knife. Any blunt-pointed bistoury, which has been protected by wrapping a piece of gauze around the blade so that only one-half inch at the point is left free, may be used.
Using the fingers as a guide, the knife protected in this way may be passed into the os and six or eight slight nicks made into the hardened ring of the cervix, distributed through- out its circumference. It is not necessary that the cuts be more than an eighth of an inch in depth. It will astonish one who has not tried this little procedure how much this will facilitate the dilatation. Under gentle pressure two, and sometimes three, fingers can be introduced and the dilatation completed. If the liquor amnii has not previously escaped, care should be exercised during the dilatation that the fingers do not make undue pressure on the membranes ; for it is better, if possible, to have the membranes intact until the cervix is fully dilated. This procedure of manually dilating the cervix, while simple, is
106
WSTETKIC SCBGEBT.
W t I ^ - i t I m m'**
oftentimes most trring on the operator's powers cif endmaDoe,
and irequCTitlT he will be forced to delegate m pftzt df its po^
foimance to his assistanL The hand dioald be
with creolin sedation 1 to 100, wfaidi at die oubbi
the place of other lufaiicants, whenever thexe is oocBskm to
introduce it into die ragina.
When die OS is follT dilated the opcxalor slMmld mss thit
?lC ^ ^ •' irrvuii ft
'i^MS
r»:c: :c ^t? .rcvrrnr::! ziAt
4NiNWll^ .^^t: jctc V^c x civci^ ^
l4 fe yift:»)t^ ^^^ ,*£jv 5i\i!t.- XJC. J
I:" a
107
it is recognized it should be grasped (Fig. 48). Before traction is made on the foot it is wise to note whether the cord is looped over the leg ; if so, it must be released. While the cord is be- tween the fingers its pulsations should be noted as regards their freqaency and character, for this may give the operator addi- tional reason for hastening the delivery.
As the foot is drawn down the other hand is placed over the fundus and makes counter-pressure. It should be the duty of the assistant to govern the movements of the head, and as
Fig. «.— Coinpl«tliiK tbe Venlon.
soon as the operator makes traction on the foot he should attempt to carry the head in the opposite direction.
As the operator draws the foot down into the vagina, the head ascends to the fundus and the version is completed (Fig. 49).
In transverse presentations, if there is no prolapse of the arm, the same method is to be adopted for performing version as has been described above, except, as the head is already above the brim, a foot is sought at once.
In cases where the arm has prolapsed, but has not become
lOS
OBSTETRIC SURGERY.
impacted, it can be pushed up with but little difficulty. It| well, however, while the arm is still in reach, to fasten a I of tape around the wrist before it is pushed up. This will | of assistance during the extraction, for, by drawing gently i the tape, at least that arm will be prevented from becom extended.
In those cases where the arm has become prolapsed i long-continued uterine contractions have taken place, the thra may have become wedged into the pelvic outlet. It must |
Fig. so.— Impacted Shoulder.
borne in mind that here it will be necessary to replace that j which last came down before the arm and shoulder can be l placed (Fig. 50). The thorax must be carried up above the brim before any attempt is made to replace the arm. This pro- cedure requires the greatest care on the part of the physician, or else a ruptured uterus is almost certain to result. If, after making well-directed pressure from below with firm counter- pressure over tlie fundus, the impactiou cannot be relieved, it is better to discontinue the efforts to perform version, and either do embryotomy iji the interest of the mother or, if the mother
109
be in good condition and the outlook for saving the child not too pool, resort to symphysiotomy.
The indications for versioa almost always presuppose immediate delivery.
Much has been written on the subject, " Which foot should be drawn down V* If there is no immediate leason for haste and the operator has time to make his selection, it would seem that it is best to draw down that foot wliich is nearest the anterior surface of uterus. In actual work, however, it does not make much difference which foot is brought down. That
tfae Fotterior (Left) Lag.
one is usually best which can be soonest recognized and most firmly grasped (Plate VI).
It is better, in primipane certainly, and often in multiparse, that one foot only be brought down, for the cervix which has permitted a half-breech to escape will be less likely to grasp the after-coming head than if it has been dilated by the pelvis alone. If, however, traction on one leg does not prove success- ful, it will be necessary to draw down the other (Fig. 61 and Plate VII). As the foot emerges from the vulva it is to be wrapped in a warm towel, which not only offers a better grasp
110
OBSTETRIC SURGERY.
on the part, but also tends to prevent the cool air of the room from causing enough reflex irritation to establish respirator)- efforts on the part of tlie child. Soon the leg can be grasped in the same way, and at this time traction is to be made in the axis of the brim downward (Fig. 52).
It is very necessary that during the entire process of ex- traction the assistant should make well-directed pressure on the child's head. This tends to prevent extension of the head and
also furnishes the vis a (ergo wliich the patient, by i the deep antesthesia, cannot give.
As the buttocks emerge from the Tulva, one finger of t hand corresponding to the flexed thigh should be hooked into the groin; this will enable the operator to lessen the traction on the extended leg, and at the same time permit him to exert greater tractile force. By raising the buttocks and making traction upward the flexed thigh can be made to clear the vulva. The peliis should now he grasped with both hands and dmwn downward again in the axis of the brim.
Ill
As the cord comes down it is to be drawn upon from the placental side, and if it is over one of the legs it must be re- leased (Fig. o3) and placed in the most favorable position as regards pressure. In rare instances it will be impossible to draw the cord down without making undue traction. If such should prove to be tlie case, it should be secured by means of two arterj'-clamps and cut. Of course, if this is done, it will be necessary to hasten the delivery as much as possible.
When the scapulae appear the arms must be liberated before extraction is continued. Under favorable circumstauces, — that is, if the assistant has kept up intelligent pressure on the fundus, or if the cervix was fully dilated previous to the
b
version, or if the operator has not made traction in too rapid a manner, — the arms will be folded on the chest and their ex- traction will be easy.
Even in the hands of the best operators and with the best assistants tlie arras sometimes become unavoidably extended. Although their extraction must be accomplished in as rapid a manner as possible, there is no need of breaking the arm if care is taken.
The arm which is to the rear is usually more easily liber- ated. To do this the ojwrator seizes the legs with one hand and carries the child's body well upward. This will cause the posterior shoulder to be more readily reached, and will permit more room for the manipulations necessaiy. Two fingers of
112
OBSTETRIC SUBGEEY.
the disengaged baud are passed over the back and posted shoulder (Fig. 54). The shoulder can now be pulled ■ gently so that the arm may be more easily felt. As soon i the humerus is felt it is to be pushed forward and toward l opposite shoulder. Now, by drawing the humerus downwa] the arm becomes flexed at the elbow and the forearm rests on the chest of the child. Its extraction after this is simple, and the same as in unextended cases. If it is impossible to extract the arm in this wiiy, tlie operator should pass the palmar surface of his liaiid over the abdomen of the child and attempt to hook one finger over the elbow of the posterior arm, and by gentle traction flex it over the chest (Plate VIII).
Fig. M.— Diicni
PoBterlor (Right) Aim
After the posterior arm has been liberated, the child's I should be carried downward, and the anterior arm is difficult of extraction. Should, however, there be any troii in releasing it, the anterior slioulder is to be rotated to the i where, with more room, its extraction is simple.
"With the arms released the operator hastens to extract t
If firm pressure has been maintained on the fundus the head should be found in the pelvis, either straight or somewhat flexed.
Extraction of the head may be accomplished either man- ually or instrumentally. Inasmuch as less danger to both child
PLATE VIII.
E>l'icllne the Pollen
TEBSION. 113
and mother results from manual extraction, forcepa on the after-coming head should be left as a last resort.
If there is no great disproportion between the head and the pelvic outlet, extraction will not be difficult
The child's body should be wrapped in a warm towel. Grasping the pelvis, with his left hand placed underneath the child and allowing the legs to straddle over his arm, the operator seizes the child's neck with his right hand, the palmar surlace of the hand being over the shoulders of the child aud the neck
Fig. SS.~^hawtTig: Direction ol Traction.
between the middle and third fingers (Fig. 55). Firm traction is now made almost directly downward. When the occiput has engaged immediately behind the pubic arch, the child's body is to be carried directly upward (Fig. 56). In favorable cases, the face, brow, and head will sweep over the perineum and extraction will be complete. So easy an extraction as this is the exception, however, from the very fact that those cases which demand version usually presuppose a disproportion between the size of the head and of the pelvic canal. When such is the case, othex
114
OBSTETBIC SUBGERT.
manipulations are Decessaty. The operator, as in the preceding method, lets the child's body rest on bis left arm. The middle and index fingers of the lefl hand are passed into the rag^a until the fingers can be applied on either side of the child's nose, the tips of the fingers resting over the malar prominences. Traction is made witli this hand downward, while with the right hand the occiput is pushed upward and forward. This manipulation has the tendency to flex the head. As soon as flexion is accomplished, the operator grasps the child's neck with his right hand in the manner described above, and now
d the Occipot PaaBBi from
with both hands makes firm and continued traction. The left hand should remain over the malar prominences, and not be introduced into the child's mouth, if firm traction is to be made wit]i that hand. Traction with the finger in the month does not produce flexion to the same degree, and if much force is nsed fracture of the jaw will probably be produced. If, how- ever, the delivery is very difficult and prolonged, if any con- vulsive movements of the child indicate an attempt at respira- tion, or if the pulsations of the cord are becoming imperceptible, a most valuable procedure is to introduce two fingers into the
TERSION. lis
child's mouth, and by slightly separating them permit air to enter the child's mouth, so that respiration may be established. The right hand must now be depended upon to make the necessary traction to complete the delivery (Plate IX).
If the head become arrested at the brim, extraction is far more difficult. Here the feet must be grasped with the left hand and the right fingers placed so as to straddle the nape of the neck, and traction is to be made directly downward. At the same time the assistant makes firm pressure from above, forcing the head downward (Plate X). Should the head fail to descend, it will often do so if it is made to enter the brim in a
Fig. GT.— Chin Arreated M Sympb^U.
transverse position. To do this, the operator, in place of making traction while the back of child is directed upward, turns the entire body of the child so that the back is directed to the side which corresponds with the shoulder that was posterior. (If the left shoulder was posterior, the back of the cliild should be turned toward the left side of the pelvis.) Now, by making traction directly downward, the head will enter the brim through its greatest diameter and descend into the lesser pelvis. Trac- tion now will usually result in the occiput turning forward, when extraction may be completed as described before.
Should the occiput not rotate forward, then the perineum, instead of the symphysis, becomes the fulcrum, and downward
116
OBSTETRIC SUKGERT.
traction will cause the face and brow to sweep under the synj- pliysis and delivery is completed (Plate XI).
In case, however, extension has taken place and the chin becomes arrested behind the symphysis (Fig. 57), traction should be made upward and two fingers of one hand should be passed into the rectum and the occiput " shelled" out over tlie perineum.
Wlien all these means have been tried and failed, forceps should be applied. The authors have obtained better results
I
Fig. 68.— Forceps AppbeU
with the short-liandle Hunter forceps than any other used. Usually the forceps can be adjusted posteriorly (Fig. 58 and Plate XII) better and more quickly than anteriorly, but it should be applied to that aspect of the child which can be most rapidly reached. It should be applied to the sides of the pelvis regardless of the position of the child's head.
It must be remembered that after extraction of the : the head must be delivered witliin three to five minutes if i living child is to he obtained. It is true that in exceptional cases a living child may be extracted witliin fifteen minute:
ii
OBSTETRIC SURGERY.
tlie same as for podalic version. The operator iutroduces that hand into the vagina which he is in the habit of using when making a vaginal examination. If the cervix is dilated so that two fingers can be passed into the uterus, no furtlier dilatation will be necessary at this time. Tlie head should be carefully raised between pains, and no undue pressure made upon the membranes. The fontanelles are sought and examined. If any doubt of the real position remain after this, the ear should be felt ; this will be an unfailing guide.
If the occiput is posterior the cervix should be dilated, pre- paratory to performing the internal rotation, in the same way has been described for podalic version. With the cervix fully' dilated the hand is introduced into tlie uterus. If the head has slightly engaged, it should be gently pushed up. The ftetus is now grasped and slowly rotated in its long axis until the occiput is anterior. The hand should now be slowly with- drawn until the head can be grasped, and in this position the operator waits for uterine contraction. When this has occurred the head is driven down and engagement ensues. It is wise to retain the hand until two or three contractions have taken place, so that the head may be firmly engaged. The case may now be left to nature, or, if necessity demands, the forceps may be applied and extraction completed (Plate XIII).
The course of action herein advocated is not novel, nor is it as radical as at first sight it may appear. The management of occipito-posterior positions has for a long time been a matter of strife among obstetricians. The lever, the forceps applied inversely, podalic version, the conversion into a face presenta- tion,— such means from time to time have been advocated. When the occiput, in faulty position, has become impacted, certain of these measures are forced upon us, with conse- quent damage to the woman and with as yet not sufficiently recognized injury to the fcctal brain.
For the purpose of rotation nothing can take the place of the aseplic hand, aside from the fact that at one and the same
J
.'41
f
I
II
VERSION. 119
time the hand may detect any additional anomaly hitherto un- suspected, such as pelvic deformity, which, aside from being a further cause of slow or impossible engagement, may alter the field of election at the very best time (from the stand-point of both the woman and the foetus), — that is to say, when the con- ditions are still favorable for version or some other procedure.
When the occiput rotates backward into the hollow of the sacrum, we are face to face with what — there is uniform agree- ment— constitutes one of the most difficult cases in obstetrics. The clean, educated obstetric hand at the pelvic brim is a source of positive safety to both the mother and child, compared with waiting until exhaustion calls for, for instance, the forceps within the pelvic brim.
A tedious first stage, characterized by short, nagging pains, is a fairly-uniform accompaniment of the instances which should cause anxiety. It seems clear that manual examination at this time will often lead to the adoption of a procedure which will alter the prognosis of, and lessen the difficulties attendant upon, the persistent oblique and sacro-rotated occipital position.
Prognosis. — Naturally the prognosis will vary greatly ac- cording to the conditions demanding the operation. In those cases where retraction of the uterus has not taken place, and where there exists no disproportion between the head and pelvis, the prognosis for the mother should be absolutely good if the operation is performed under aseptic precautions and in a skillful manner. The same may be said of the child if the oper- ation is undertaken before the foetal heart shows signs of failure. In the proportion, however, that these favorable conditions de- crease will the mortality rate to the child increase. There should be no mortality at any time for the mother unless uterine retraction has taken place, the operation being done only as a last resort, or where the pelvic outlet is markedly dispropor- tionate to the foetal head.
CHAPTER V.
SYMPHYSIOTOMY.
Tbe operation of symphysiotomy was first performed the year 1777 by Jean Rene Sigault. After a protracted con-' valescence the ultimate result was successful, and this led other operators to test the procedure. The results, however, were not sufficiently favorable to lead to its general adoption, as shown by the fact that up to the year 1858 the operation was per- formed only 86 times, with tlie loss of 29 women and the ex- traction alive of 29 children. Tlie operation thence fell into ■] disuse until the year 1866, when it was revived in Naples by i MoiTisani and Novi. Outside of Italy, however, the operation attracted scarcely any attention, receiving but scant, if any, ret erence in works on obstetrics until the year 1890, wlien, largely- through the publications of Pinard, of Paris, and Harris, of Philadelphia, the attention of obstetricians was attracted to the really beneficent results which were being secured through timely resort to it. The unfavorable results from the operation during its early years were unquestionably due to the lack of appreciation of the necessity of both asepsis and of election, and therefore our study of the operation need be based purely on the results which are yielded in modern times, when both of these factors play the chief rfile in obstetric surgery.
In 1892 Harris collated tlie operations which had been performed from January, 1886, up to July, 1892, as follows: 44 operations, with one maternal dciith and the loss of 4 chil- dren. Up to this time the operation had never been performed in the United States, although practical obstetricians liad been giving much attention to another alternate operation having in view the avoidance of embryotomy, — tiie Ctesarean section. From tiiis date on, however, as if by magic, operations were reported from various sections of tlie country until we are now (120) J
I
SyMPHYSIOTOMT. 121
in the position of being able to judge the operation from the stand-point of home results. Meanwhile, Pinard, in Paris, has been equally active, and the number of recorded operations has reached a sufficiently large basis to admit even of a degree of dogmatism in the estimation of the proper sphere of symphysi- otomy. The inevitable result of the rapid acceptance of the operation has been, as will be noted, a higher mortality rate, — in a measure doubtless due to the inexpertness of the majority of operators performing their first of the kind.
Indications and Limitations. — ^The aim of the operation of symphysiotomy is, through section of the pubic joint, to allow of separation of the symphysis, whereby the pelvic diameters are widened sufficiently to enable the delivery, pei* vias naturales^ of a foetus which otherwise would have to be sacrificed. The operation, then, is performed purely in the interests of the child, taking the place of embryotomy and displacing the Csesarean section from the stand-point of the relative indications. Before the resuscitation of symphysiotomy, indeed, the alterna- tive was either mutilation of the foetus or the subjection of the woman to the major operation of abdominal section. When, therefore, symphysiotomy becomes, as it should, an elective operation, with consequent lowering of the maternal mortality rate to m?, there will exist, other things equal, no further call for embryotomy, and the Cesarean section will be reserved strictly for cases which fall under the absolute indication. It is significant, indeed, that more than one obstetrician in Europe is already on record as claiming that the time has definitely arrived when the physician is not called upon to sacrifice the living foetus. In the United States, however, the time is not ripe for such an extreme statement outside of maternity hos- pitals. In private practice the woman herself or her representa- tive must continue to exercise the right of choice until the mortality rate from symphysiotomy has fallen to a figure at least as low as in expert hands is associated with embryotomy.
Til rough experiment on the cadaver we have learned that
122 OBSTETRIC SDRGEBT.
when the pubic symphysis is cut and the knees of the cadaver are separated the pubic bones diverge, without inflicting damage on the sacro-iliac joints, to the extent of two and three-fourths to tliree inclies. Into the oi)ening formed in front the present- ing part of the fcetus may enter and the following space is gained in the various diameters of the pelvis. The true conju- gate increases to the extent of from oue-fonrth to one-half an incli and the transverse and obUque diameters gain from three- fourths to one and a half inches. It is at once apparent how, with a fcetus of average size, this operation enables delivery to be accomplished without mutilation of the foetus, since the gain in the pelvic dimensions applies with equal force to the tj'pes of deformed pelves most frequently met with, — the flat and the generally contracted.
The indications for the operation are as follow ; The con- sent of the woman or lier representative. The fcetus viable and the woman and the fcetus not exhausted tlirough protracted labor. Careful precedent pelvimetry, instrumental and manual, proving that tliere exists dystocia which will not yield to either version or the forceps and testifying to the existence of a type of pelvis where, after pubic section, the sacro-iliac synchondroses will yield. In the generally contracted pelvis the conjugata vera must be at least three and three-fourtiiS inches in dimen- sions, and in the flat pelvis, where it will be borne in mind the transverse diameter is relatively wide, tlie conjugata vera may be reduced even to two and three-fourths inches if the child is below the average size. In impacted occi pi to-posterior j>ositions and in irreducible face presentations. The cervix must be dilated or dilatable. The presence of ankylosis of one or the other sacro-iliac joint must be ruled out.
Before passing to a consideration of the technique of the operation, it is well to recall briefly the structures involved in the operation and to point out the risks to which the maternal structures are subjected. In the vast majority of women at or near term there exists normally a certain amount of separatioa
STMPHYSIOTOMT. 123
at the symphysis, provided this be not ankylosed, when, of course, the operation iaper ae contra-Indicated. The operation is entirely extra-peritoneal, the bladder stripped of the perito- neum, and the urethra lying immediately under the symphysis. In certain instances, however, as Dickinson, of Brooklyn, re- minds us, the peritoneum pouches downward, and there may be danger of injuring this.
As a rule, however, the bladder and the urethra are the only organs which are likely to be injured, and these, we will show, need not be if the requisite care is taken during the per- formance of the operation and afterward when the parts are brought together. We are speaking now, of course, of the
it Blftditer into the
subcutaneous performance of the operation, the method which is favored by most practical accoucheurs. The open method of operating involves the structures and the vessels which cover the anterior face of the pubes, and the selection of this method of operating converts symphysiotomy into a much more serious operation and complicates greatly convalescence as well.
The two factors which control the result of this operation are election and aaeptidam. Where the operation is indicated it should be performed in a timely manner, and to-day there is no excuse for inattention to the stringent rules of cleanliness whereby the surgery of the present is so sharply differentiated from that of the past. If but one lesson has been taught by the results secured during the past three years, it is that sym-
124
OBSTETRIC SURGERY.
physiotomy need not have a mortality rate. As will be noted later, the fatal cases resulting since tlie rejuvenation of the operation have been due either to the fact that the operation lias been performed on an exhausted woman, or else because, through inattention to asepsis, the woman has succumbed to eepticEemia.
The instruments essential for the performance of the opera- tion are: a stout, blunt-pointed bistomy, a few artery-forceps, a needle-holder, needles, a melallic catlieter, or a metal sound. Silk-worm gut forms the preferable material for sutures. The Galbiati knife, which is highly favored by the Italians, has been found unnecessary. Indeed, in certain cases, the use of this in-_ strument is dangerous to the integrity of the maternal pai resort to it be at all possible.
HarrK Knire. (H>rrl»'i ModlflcstloD.)
In certain exceptional instances the symphysis of the pubes deviates from the mid-line, and in others the union of the halves is not cartilaginous, but bony. When this untoward complica- tion is present it will be impossible to separate the symphrsis with a knife, and a chain-saw is requisite. Fortunately, this occurrence is a rarity ; still, the physician should be prepared for every emergency, and, therefore, shoidd add a saw to his arma- mentarium.
Technique of (he Operation. — The method of operating which is favored by the vast majority of those who liave had practical experience is the subcutaneous one. There are weighty reasons why tlie open method should be rejected. If this is selected it will be very difficult to avoid infecting the
SYMPHYSioToirr. 126
wound with lochia during convalescence, and, further, the tissues near the clitoris are peculiarly vascular, — all the more so during pregnancy, — and section made in this neighborhood exposes the woman to the risk of considerable haemorrhage of a type very difficult to control. There are a sufficient number of modem instances of the operation on record now, where the subcutaneous method was followed, to prove its perfect feasi- bility, and in certain cases its wonderful simplicity. Although trained assistants are helpful, their presence is not strictly requisite.
The woman having been anaesthetized, the abdomen is pre- pared as for an abdominal section, — that is to say, the pubes are carefully shaved and thoroughly disinfected. The bladder is emptied. An incision is made in the mid-line down to the recti muscles, beginning at the suprapubic eminence, and ex- tending upward lor about three inches. The recti are separated by the finger and the handle of the scalpel, and this brings us to the retropubic space. A catheter is now inserted into the bladder and handed to an assistant to depress the urethra from under the pubes. This is a highly important step, since one of the accidents associated with the performance of symphysiotomy is injury to the neck of the bladder. The accident is entirely avoidable, and much depends, therefore, on the assistant who holds this catheter. The operator's index finger is next in- serted under the symphysis to further protect the bladder, and it must be held there until the section of the pubic symphysis is completed. If the fcetal presenting part has not as yet engaged, or, in case it has, if the part can be pressed upward, the inserting of the finger is easy, and there remains further space for the Galbiati knife if the operator prefer it ; but in case of engagement of the foetal part it will be found difficult to insert the finger, and, this accomplished, there is scant room, if any, for the sickle-shaped knife. Hence the reason why later opera- tors have discarded this knife and substituted the stout, blunt- pointed bistoury. The finger being in place below the sym-
126 OBSTETRIC SURGERY.
physis, the union of the pubic bones is incised in the directiou from above downward aud from without inward. The operator must not be satisfied until he has severed tlie inferior ligament of the pubes. If he fail to accomplish this the pubic bones simply separate at the top, and there is scant gain, if any, in the pelvic diameters. As soon as the subpubic ligament has been severed, the pubic bones separate and the pelvis becomes en- larged. As already noted, a separation of from two and one- half to three inches is possible witliout inflicting damage on the sacro-iliac synchondroses. In order to avoid separation beyond this, an assistant on either side of the woman should make firm inward pressure on the trochanters whilst delivery is being effected.
Any hsemorrhage occurring during the steps of the opera- tion should, if arterial, be checked by torsion or ligature. Venous oozing, which is apt to be considemble, is met by the tampon with sterilized gauze. This tampon is left in place until delivery has been effected.
It has been claimed tliat after division of the symphysis delivery sliould be left to nature, except in instances where the condition of the woman or the fcetus requires hasty action. There is, however, no advantage in this. The cervix being dilated or dilatable, since the woman is under anassthesia, there is nothing to be gained by delay. If the head is above the brim, the membranes unruptured, or if tlie presenting part has just engaged and the membmnes are intact, the conditions favorable for version are present and there is no valid reason why the physician should not proceed to deliver after tliis fashion. The chances are that the operation of symphysiotomy has been called for on account of maternal or of foetal dystocia, and under such condition, where version is possible, it should always be elected over the forceps. Where the presentin*' part has engaged, but cannot be delivered short of symphysiotomy, owing to contraction at the outlet, the forceps should be applied lege artis. If the operation of symphysiotomy has been elected
SYMPHYSIOTOICY. 127
to enable the delivery alive of a foetus presenting in a mento- posterior or in an occipito-posterior impacted position, then, after symphysiotomy, the malposition should be corrected as far as is feasible, and delivery be effected by the forceps.
After completion of the third stage of labor, the operator should turn his attention at once to the repair of the wound made necessary by the symphysiotomy. The aseptic catheter is again introduced into the bladder and handed to an assistant in order that the urethra and the bladder may be pressed down- ward carefully whilst the pubic bones are being brought into apposition. This step is a most important one. If neglected, or if carelessly performed, the bladder or urethra will be nipped in the symphysis, and in the course of a few days a fistula will be established. The thighs of the woman are ro- tated inward, and firm pressure is made on the trochanters by two assistants. The pubic bones are thus brought together, and are held there until the wound in the abdomen has been properly sutured and the bandage has been applied. If the subcutaneous operation has been performed, as we believe it should, it is useless to attempt to suture the symphysis. Nor is this necessary. Where the operation has been performed aseptically, and a proper bandage is applied, the pubic bones will remain in apposition and unite firmly. Unless the woman is specially fat, deep silk-worm-gut sutures will sufiice for bring- ing together the abdominal wall. If the woman is stout it is preferable to unite the divided recti muscle by a running catgut suture and to treat the skin and fat by the open method, which insures, in such cases, firmer union. After the sutures are in position and the usual dressing has been applied, a wide strip of adhesive plaster, extending from the trochanters nearly to the umbilicus, is carried around the woman, whilst the assistants are maintaining firm pressure on the trochanters. This immobil- izes the pelvis efficiently, and, barring indication of suppuration in the wound, this dressing need not be changed for from five to ten days. The after-treatment of the case is exactly similar
128 OBSTETRIC SURGERT.
to that which holds for the normal puerperium, except that very likely it will be necessary to catheterize the woman. The woman should be kept on her back for the first week, but after this period she may lie on )\er side. She should be kept in bed for at least three weeks, although cases have been allowed to rise sooner with apparently no bad effect. As a rule, in every woman, after symphysiotomy there will exist, for a variable in- terval, a gicater or less degree of motion at the joint, but we question if this is greater than tiiat which normally exists in young primiparffi after a difficult non-instrumental labor. The fact seems to have been overlooked that in probably the ma- jority of gravid women there exists motion at the symphysis for a variable interval. This motion, however, is not associated with disability, and before very long tiie fibrous tissue becomes organized and motion cannot be detected. Even if there should remain a degree of separation at the symphysis ailer symphysi- otomy, we should not look n[wn this as an evil, for in the event of a future pregnancy a second operation might not be demanded should the woman be allowed to go to term.
Complications. — In the reported modem cases, the only ones which need concern us, the most unfortunate coDaplication noted has been the formation of a fistula of the urinary tract, either vaginal or abdominal. The essential step for avoiding this we have already laid stress upon. If, notwithstanding', the accident should occur, often the lesion will heal spontaneously under cleanliness and catheterization. If spontaneous repair should not occur, then, some time after the pucrperium, a sec- ondary operation will be called for. It is a noteworthy fact that fistulcB have cliiefiy occurred in instances where the operation has been resorted to only after the foetal presenting part had be- come wedged in the pelvic brim, and where the Galbiati knife had been used. We believe that when it becomes the practice to elect the operation before engagement, or, at any rate, before futile attempts at engagement have uecessarily resulted in more or less pressure on the neck of the bladder, this complica- I
STMPHTSIOTOMY.
tion will become excessively infrequent. Further, we question if the use of the Galbiati knife, in cases where the presenting part has engaged, is not responsible for many of the fistulfe. As we have already stated, when the presenting part has en- gaged there is scant room for the insertion of botli the finger and the knife under the symphysis. Tlie insertion of the finger is absolutely necessary in order to insure the safety of the bladder; the Galbiati knife is not necessary for the performance of the operation. The majority of operations in this country have been performed without this knife, and we would, there- fore, limit its utility to instances where the fcetal presenting part has not engaged, and where, therefore, there is ample room both for tlie finger and the knile.
Htemorrhage as a complication of the operation need not be feared where the subcutaneous metliod is selected. At best this is only venous oozing, which is easily controlled by tlie gauze tampon. The open method of operating, which we do not indorse, entails, of course, wounding of tiie venous plexuses of the vestibule, as also the vessels which nourish the clitoris. Haemorrhage from this source may be very difficult to control, and the essential manipulations required carry extra chance of septicizing the woman. The oi>en method of operating, then, should be strictly reserved for instances where deviation of the symphysis from the mid-line, or where the bony ankylosis forbids the performance of the operation by means of the luiife, and calls for the chain-saw.
The further complication which is responsible for the loss of a fair percentage is septic infection, — a complication common to every surgical procedure, and an avoidable one.
When the operation was resuscitated it was feared that the ultimate result as regards locomotion would be bad. The record of the modern cases certifies, however, that this fear is unfounded. In many of the women there exists for a variable period a certain amount of motion at the joint, and in some cases the women complain of a sensation of motion there ; but
130 OBSTETRIC SURGEHT.
before long the fibrous tissue becomes organized, and these physical and rational symptoms disappear.
Prognosis. — For tlie pm-pose of determining statistically the prognosis of this operation, we shall consider alone the data which have accmed during the past few years. Prior to this period careless asepsis was responsible for a very high mortahty rate.
The following data will enable us to judge the prognosis fairly : In general the mortality rate has varied from 8 to 12 jjer cent. In the United States 31 o\)erations have been performed up to March, 1894, with 4 deaths. Analyzing these cases, we find that in not a single one of these fatal cases was the opera- tion elective. Thus: The first fatal case had been in labor twenty-five hours, and was exhausted, with a pulse of 150, when operated upon ; the second case died of septic peritonitis ; the third died of pneumonia ; the fourth had been in labor three days, and died on the eleventh day, of sepsis originating in the Bubosseous wound.
Of the last 15 operations in the United States there Iu^| been 1 death. .-^
In 1893, Pinard, of Paris, performed the operation 13 times. He has had 1 maternal death. She died of sepsis, having been operated upon after she liad been in labor three days. The sepsis might have originated before she entered the hos- pital. Of this last series all the children have been saved. In the last 31 operations in the United States there were 9 icetal deaths. Eight of these children would have been saved had the operation been elective.
From a critical examination of these recent data, it is ap- parent that the operation of symphysiotomy need not have a mortality rate when it is an elective operation. The sole risk the woman runs is from sep^s, — a risk which is associated with every operation, both major and minor. Here, again, the beneficent doctrine of election comes into tlie foreground in operative obstetrics.
SYMPHYSIOTOMT. 131
However bright the prospects of the operation are for the future, it still remains true that for the present it will find its chief field in maternity hospitals. We feel that as yet a suffi- cient number of cases are not on record to warrant the phy- sician in stating that there are no untoward results as regards locomotion. In private practice, therefore, it is essential, in order to guard against a possible suit for malpractice, to be very guarded in regard to the ultimate prognosis in this re- spect. Our own feeling in the matter is, that the future will estabUsh this operation on the firm ground of a scientific one, and when that day arrives there will exist no further warrant for the performance of embryotomy on the living in case of the lesser grades of pelvic deformity.
If the foetus is removed from the mother by means of an incisiou through the abdomhial and uterine walls, the operation is known as Ctesareau section. The reader is referred to the numerous monographs which have been written on this subject for its history and the various modifications through wliich it has passed.
Perhaps of no other operation can it be said that the appHcation of tlte rules ol" modern aseptic surgeiy lias accom- pUshed so much as in tiie one under consideration. It will require time yet, however, before the old prejudice among phy- sicians and laity, engendered by reason of the unneccssai-y large mortality which accompanied this operation, can be eradicated. Statistics which embrace operations performed ten or even five years ago are of but little value, inasmuch as the technique of the operation tias been so modified and perfected that results are entirely different.
The operation now is no longer postponed until t] mother's vital forces have been spent in unsuccessful attempi either on her part or on the part of the obstetrician, in dellvt ing the fcEtus per viaa naturales.
Indications. — Cesarean section may be performed either from absolute or relative indications. If tlie pelvic contraction is so marked that deliver)' of the cliild by the natural passages be impossible, or if tlie pelvic canal be obstructed by solid, be- nign, or malignant growths, the operation is absolutely indicated.
Caesareau section should be performed if the mother is moribund or has just died, if the child is still alive.
The relative indication has a much wider scope, and what
is advocated here in this regard would not have been admissihli
a few years ago, when the mortality rate was so high. Ho'
(132)
ted
C^SABEAN SECTION.
ever, in the light of recent caaes, and when it is remembered ' liow great a mortality exists as a result of embrjotomy, and how repulsive it is to every physician to deliberately destroy a life, it is certainly clear that Csesarean section of the future will be done more frequently for relative indications and as an elective operation.
Given an instance of pelvic contraction in which the chances are against the delivery of a living child per viae naturaleSi and the time for induction of premature labor with resulting viable child having elapsed, the obstetrician is justi- fied in performing the Cffisarean section, provided always the foetal heart-sounds are clear and regular. The operation is not only done here for relative indications, but is an elective one rather than as a last resort, as has too often been the case, Tlie patient is carefully prepared for it previous to or at the begin- ning of labor, and, before she has had a chance to become in the least exhausted either by nature or by art, the abdomen ia opened and the child delivered. When the operation is con- sidered from tliis point, embryotomy of the living fcetus will become a lost art.
Operation. — Perhaps there is no operation the success of which depends so largely on the many and various little details as in Ciesarean section. The operator must have a personal ob- servation of the preparation for the operation, if the best results are to be obtained. Formerly it was thought best to wait for the woman to go into labor before the operation was begun; but in those cases where it has been predetermined that the operation is necessary, it is far better to elect the time of its performance. The old idea that a certain amount of previous cervical dila- tation was necessary no longer holds good, in the light of the fact that a few moments only are neces.'^ary to sufficiently dilat« the cervix. The advantage which ia to be gained by the delib- erate preparation of the patient, to say nothing of being able to select tlie hour and light for the operation, more than compen- sates for the dilatation of the cervix which the normal labor-
134 OBSTETRIC SURGERY.
pains would induce. The statement that the uterus will coiiti more firmly if labor has already begun is purely theoretical, f in point of fact, experience with just such cases has proven that the uterus does contract firmly as soon as it is emptied.
The operation is much more easily j»erformed rf a sufficient number of well-trained assistants are at hand. It is wise, how- ever, that as few hands as possible be introduced into the peri- toneal cavity, for, in this way, the possibilities of infection are lessened. There should be an assistant whose sole duty is to administer the aniesthetic ; another to assist in lifting out the uterus; another to make compression around the cervix, and still another to assume the charge of the child. Two trained nurses will be necessary to wash sponges and manage the gating apparatus. Very few instruments are necessary for opemtion.
Two scalpels, one pair of laparotomy scissors, two disi ing forceps, twelve artery-clamps, four long compressive forcep one groove-director, one needle-holder, six large and six small curved needles, a Koeberlfi ecraseur, and a steel dilator should complete the list. A perfectly-new ibuntain-syringe with : glass tube will answer every purpose as au irrigator. Thei should be in readiness eighteen sterilized towels.
In place of sponges, pads made of absorbent gauze, lai^ and small, and sterilized, should be used. These should be counted before the operation and just before the abdominal cavity is closed. Five yards of 10-per-cent. iodoform gauze, cut in strips three inches wide and sterilized, should be at hand for intra-uterine tamponade if such prove necessary. A piece of rubber drainage-tubing, three-eighths of an inch in diameter and one yard long, should be boiled and held in readiness case manual compression should fail to control hsemorrhaj Two sizes of silk (Nos. 4 and 2), silk-worm gut, and some 1 catgut should be prepared.
All instruments and ligatures, except catgut, should be boiled immediately preceding the opeiation and placed in travs
le int-H or thi^H
lisseo^^l orcep^H
mall
ould
Lh a a
bev^
'ss in^^
1 be Jayg
i
C^SAREAK SECTION.
containing sterilized water. The operator, his assistants, and nurses must pay special attention to rendering their hands aseptic. Thorough scrubbing with soap and water, washing the hands in alcohol and tlien a five-minute immersion in 1 to 1000 solution of bichloride of mercury will accomplish this. The operator and his assistants should wear perfectly-clean opemting-gowns, or, if these are not at hand, freshly-laundried sheets can be used in their stead. It is the duty of tlie operator to see that his assistants do not touch anything which has not been rendered aseptic after they have disinfected their hands, without repeating the scrubbing process before they assist in the operation.
Where the operation is one of election and there is time for thorough preparation, the patient should be prepared in the same way as if laparotomy for any other purpose was to be performed. A mild laxative for two or three days previous to the operation should be administered. On the evening pre- vious to the operation the pubic region should be shaved and thoroughly washed. A compress which has been wmng from a solution composed of 1 part of the tincture of green soap and 3 parts of water is placed over the abdomen and held in place by means of an abdominal binder. The next morning the patient is given an enema of soap-suds and a vaginal douche of 1 to 3000 bicliloride-ot-mercury solution. The towel is removed and the entire surface of the abdomen is washed with 95-i>er-cent. alcohol and afterward with 1 to 1000 bichloride-of-mercury solution. A piece of damp bichloride gauze should be placed over the abdomen and confined by a few tunis of a roller bandage; tins the patient should wear to the operating-room. She should be catheterized immediately before the operation.
When the patient is brought to the operating-room she should be placed on a firm table, in the dorsal position with the knees slightly flexed. The upper and lower parts of the body should be covered over with pieces of new rubber cloth, and these in turn be covered with sterilized towels. The abdominal
136 OBSTETRIC SDRGEHY.
dressing is removed and tlie abdomen again washed with bichloride-of- mercury solution 1 to 1000. The operator, stand- ing on the patient's right, makes the ordinary laparotomy in- cision, extending tlirougli ail the layers of tlie abdominal wall. This incision can now be safely enlarged, to a point about four inches above the umbilicus, with the scissors, using the fingers of the left hand to protect the intestines. Five or six heavy silk sutures should be passed through the upper three-fourtlis of the abdominal incision and left untied. The uterus should now be turned out of the abdominal cavity. This is easily accomplished if It is drawn toward the operator so that its left border is made to appear in the wound and then depressing the abdominal wall underneath it. The temjiorory siik sutures are now to be tightened, care being taken that no loop of intestine is caught within their grasp. The uterus is enveloped in warm sterilized towels and held by the assistant. Sterilized absorbent gauze is placed around the lower segment of the uterus and over the abdominal incision, so that no blood or other fluid may enter the abdominal cavity. A second assistant grasps tlie lower segment of the uterus with both hands lightly, prepared to control haemorrhage by manual pressure if such become necessary. It is preferred by some to control the uterine blood- supply by means of a rubber ligature passed around the lower segment of the uterus ; but inasmuch as this nearly always causes serious injury to the peritoneum and does not control the hiemorrhage any better than can be done manually, it is n< advisable.
The uterus is to be opened by making a 4J-inch incision through the median Une of its anterior surface, embracing the middle third of its length. The assistant who is grasping the lower segment of the uterus should compress it fiimly at time, to control the hiemorrhage from the uteripe wall.
The incision should be made rapidly, and if the placenta is attached anteriorly it should be pushed to one side and the child oxtmcted. As soon as the child is withdrawn, the assist'
the
CfiSAREAN SECTION. 137
ant whose duty it is to take charge of it should clamp the cord with two compression forceps, cut the cord, and remove the child. The operator at once turns his attention to the pla^ centa, and, if it is adherent, rapidly peels it off. All portions of placental tissue should be carefully removed. It is frequently a wise plan for the assistant whose duty it is to steady the uterus, as soon as the child is extracted, to grasp the edges of the incision between his thumb and fingers, and in this way assist in controlling the haemorrhage from the cut uterine tissue. At this time an hypodermatic injection of the fluid extract of ergot should be made into the gluteal region.
If the cervical canal will easily admit the finger, no dila- tation is necessary ; otherwise, the steel dilator should be intro- duced through the incision and the canal gently dilated. The uterus should be packed temporarily with iodoform gauze, — 10 per cent, — and the sutures introduced. The uterine incision should be carefully closed by means of two sets of sutures, — a deep one of No. 2 silk, which passes through all layers of the uterine tissue except the mucous lining, and the sero-serous suture of No. 4 silk.
The deep sutures should enter the uterine tissue one-eighth of an inch from the line of the incision, and, passing diagonally outward into the uterine tissue, re-appear just above the mucous lining of the uterus. The needle used for this suture should be a half-curved, perfectly-round needle, possessing no cutting edge. These sutures should be placed about one-half an inch apart. Time is such an important element in this operation that any device which can safely be used to expedite its performance should be adopted. By threading the needle with a piece of silk sixty inches long, and passing the sutures in the same way as if they were to be continuous, except that the loops be left ijpur or five inches long and afterward cutting all the loops, the sutures can be more rapidly introduced than if each suture is on a separate needle. This is shown in Figs. 61 and 62.
138
OBSTETRIC SURGERY.
As soon as all the deep sutures are in position, the tempo* rary tamponade in the uterine cavity should be removed and
Fig. 61.— Showing Deep Suture Passed, the Loops Not Cat.
the endometrium sponged out with a weak creolin solution. A 10-per-cent. iodoform-gauze strip, three inches wide and one
Fig. 82.— The Same, the Loops Cut •
yard long, is packed into the uterine cavity. One end of the gauze should be carried through the cervical canal into the
CESAREAN SECTION.
139
vagina. This gauze not only provides for freer drainage, but is an additional safeguard against haemorrhage. During the dila* tation of the cervical canal and the passage of the gauze strip, the assistant who is controlling the haemorrhage by pressure around the lower uterine segment relaxes his grasp. He should keep up this pressure, except at these times, until the deep sutures are tied.
The sutures which embrace the muscular structure of the uterus are now secured by three knots, after which the ends are cut short.
The sero-serous sutures are of silk also, and interrupted.
ng. 68.— Suture of Uterine Wound.
a, d«ep mnscular ratare; h, deep mniealAr satan tied, with the ende ent ehort; e, MTO-Mroat ratart paued oTer deep ratare ; d, tero-aeroai ratare between the deep ratarae. ready to be tied.
The Lembert stitch is the ideal one for bringing the peritoneal edges together. The number is almost double that of the deep sutures, one drawing the peritoneum directly over the knot of the deep suture and an intermediate one between each deep suture. The arrangement of both deep and sero-serous sutures is shown in Fig. 63-
As soon as all the sutures have been secured the temporary abdominal sutures are removed and the peritoneal surface of the cuUde-aac of Douglas should be sponged out. If any liquor
140
OBSTETRIC SDRGERT.
amiiii has entered the peritoneal cavity it will be better to eponge it out with Thiersch's solution. When the cavity ii sponged dry the abdominal sutures should be introduced.
Silk-worm gut is, perhaps, tlie best material for this pur- pose. The abdominal walls are weakened to such an extent by reason of the pregnancy that unusual care must be taken to prfr vent the occnneiice of ventral liernia. Before the suture if passed the assistant should draw the fascia well forward with & pair of mouse-toothed forceps. This suture passes through all layers of the abdominal wall, including the peritoneum. Afla these sutures are passed the fascia on either side of the incision should be united by means of silk-worm-gut sutures, seemed by three knots, and the ends cut short. The deep sutures are now tied, and intermediate approximation sutures used if necessary.
An antiseptic dressing should be placed over the wound and secured by a closely-fitting abdominal binder. If at the con- clusion of the operation the patient's pulse is weak and rapid, an enema of whisky and hot salt water should be given before she is removed from the table. The patient should be put to bed and extenial heat applied to the extremities.
Nothing sliotdd be given the patient by mouth during the first twelve hours following the operation except small quan- tities of hot water to relieve the thirst. If she suffer much pain, she may be given a small dose of morphine hypodermat- ically. At the end of the first twelve hours, if she has ceased to experience nausea from the ether, small quantities of millt and lime-water can be given, which can gradually be increased according to circumstances.
An attempt should be made to mo%'e the patient's bowels as soon as any untoward symptoms, such as a rapid pulse, undue rise of temperature, vomiting, or abdominal distension develop. Otherwise the bowels should not be moved until the third day after the operation.
Calomel triturates, i grain each, can be given for this pu^
1 ^^uiume
1^
L
^^^^^^■^ CESAREAN SECTION. 141
pose every hour for six doses. This should be followed by a simple enema.
The patient should receive nothing but liquid nourishment during the first week after the opemtion. The ordinary anti- septic pad should be placed over the vulva and renewed as necessary. The intra-uterine drain should be removed on the second or third day. Should tlie flow at any time be excessive, hypodermatic injections of ergot should be used. Under no circumstances must the patient be allowed to assume the sitting posture during tlie first ten days.
The abdominal sutures, except those which unite the fascia, should be removed on the tenth day, and with the same care, as regards asepsis, as when they were introduced. The abdominal binder sliould be worn for one year after the section is performed. Unless some complication prolongs the convales- cence, the patient should be up and around her room at the end of three weeks.
This is the method of conducting the elective operation, and, if the patient be in good general condition and the various little details of aseptic surgery are appreciated and executed, tlie patient should, without any doubt, recover.
If, however, the operation is performed as a last resort, after perhaps thirty or more houi-s of labor, when the patient's vital forces are greatly lowered from her own and her phy- sician's unsuccessful attempts at delivery, the outlook is by no means so encouraging. On the other hand, the mortahty in just such cases is great, as is, in fact, any other operation which may be attempted.
Laparo-hysterectomt. Before the perfection of the method of performing Cesarean section as it is done to-day, the mortality rate was so high that an attempt was made to eliminate the uterine cavity as a pos- sible source of infection, by removing the uterus after the child had been extracted. Tliis was, without doubt, a great advan-
142 OBSTETRIC SDRGERT.
tage over the old method of either not closing the utsit incision at all or else very imperfectly so.
The operation should not be performed at the present not only on account of the greater and unnecessary mutilatia^ but also on account of the increased risk to the patient, there be some very well defined indication. If the CsesaiM section is performed on a uterus whose endometrinm is alm^ the site of sepsis, or if multiple interstitial fibroids complititt the case, or if suck marked uterine inertia persist that loa rf life from hEcmorrimge seems imminent, then the entire remonl of the uterus is indicated,
Ope.i-atio7i. — Exactly the same preparations as have hta suggested in Csesarean section should be made in case tolil ablation of the utenis is to be performed, except that a greate number of long compression clamps and a large piece of this rubber sheeting, such as is used by dentists, should be at banc The details of the operation are the same as in Cajsai-ean section until the uterus has been turned out of the peritoneal cavitj. At this time, instead of using manual compression, a piece nibber tubing should be passed around tlie lower uterine seg- ment and loosely tied with one knot. A small opening is now made in the rubber sheeting, wliich should be made to encircle the uterus just above the rubber tubing. The elasticity of the rubber slieeting will cause it to fit closely around the uterine tissue and prevent any fluid from the uterus entering the peri- toneal cavity. With every thing in readiness the assistant draws on the ends of the rubber tubing until the circulation is cut off. The operator at the same time hastily opens the uterus and extracts the child. The placenta is detached and tlie uterus amputated just above the rubber sheeting with the scalpel. If the endometrium has been the site of septic infec- tion great care must be taken that no fluids enter the perltooeal cavity. The stump above the rubber tubing should be c&iefollT disinfected and seared with the Paquelin cautery. If the patioit is in poor condition from either sepsis or other causes, it is betta
C>«SAREAN SECTION.
143
i
to treat the stump extra-peritoneally, inasmuch as this shortens the operation and lessens shock. If tlie stump is to be treated extra- peritoneal! y for the reasons already given, the wire loop of the Koeberle ecmseur should be passed around the stump just below the rubber tubing. It is necessary to see that no portion of the bladder is caught within the grasp of the loop. This acci- dent can be easily prevented if a sound is passed into the bladder to clearly define its attachment to the anterior wall of the cervix. The stump should be firmly compressed with the wire loop until the tissues are blanched. The stump should then be trimmed until it is three-fourths of an inch above the wire. The rubber tubing is removed as soon as the wire is tightened. The stump should again be cauterized and the two pins which accompany the ecraseur passed through the stump, just above the wire, at right angles to the abdominal wound. The peri- toneum should now be stitched with catgut around the stump. The cuJ-de-sac of Douglas should be carefully sponged out and the abdominal wall closed.
The operation is completed by powdering the stump with iodoform and applying the usual antiseptic dressings to the ab- dominal wound. The stump, which of necessity sloughs away, renders the convalescence tedious and the dressings frequent. The stump comes away in ten or twelve days and leaves a granulating surface. If tlie cervix is now dilated and in this way we permit drainage from below, the wound will heal much more rapidly. A piece of gauze can be passed from above through the cervical canal into the vagina. If, however, the patient's general condition be good, and if the operation is determined upon from an elective stand-point, so that ample preparations can be made, and if tlie uterine body is the site of multiple fibroids, then the entire uterus, together with the cervix, should be removed. In this case, as soon as the uterus is amputated and the field of operation disinfected, the assistant secures the rubber tubing by tying a double knot. The operator then proceeds to free the bladder from the anterior surface of
144 OBSTETRIC SURGERY.
the lower uterine segment. This can be easily and rapidly done by incising the peritoneum just above the bladder-fold and stripping the bladder-attachment off with the finger. The broad ligameut should now be secured on either side by means oi' vei7 strong silk ligatures. By palpation the uteriue artciy can be found and secured. The vaginal attachments to the cervix should be cut tlirough and the stump removed. Anj bleeding-points should be caught in the forceps and ligated. The ligatures should all be left long, and as soon as all hfemor- rhage is controllod the ends of the ligatures sliould be passed into the vaginal opening. Iodoform gauze should be packed in the supravaginal s])ace, and the peritoneum closed by sewing the anterior peritoneal layer of the cid-de'sac to the peritoneal covering of the bladder with a continuous catgut ligature. In this way tlie raw surface is placed entirely extra-peri to neally. The pelvis is carefully sponged and the abdominal wound closed. There is no necessity for drainage from above. The after-treatment should be the same as for Caesarean section,
Laparo-elttrotomt.
The operation for removing the foetus through an indsioD in tlie flank possessed advantages at the time when antisepsis and asepsis were unknown, inasmuch as it obviated the neces- sity of opening the peritoneal cavity. The improved Cmsarean section is so much easier of accomplishment, and is fmught with so much less danger, that the necessity for this method no longer exists.
Prognosis. — There is no obstetric operation in which elective surgery plays a greater role in determining the prog- nosis than the one under consideration. "Where the Csesareao section is only determined upon after forceps and version have failed, the woman being exhausted and tlie child as well, the mortality rate is necessarily high, Tlie elective Caesarean sec- tion, on the other hand, so simple and so accurate is its tech- nique, subjects the woman to hut one risk, and this is septic infection.
CESAREAN SECTION. 145
The Csesarean section should alone be judged by its modem fruits. The mortality rate in the past, ranging from 30 to 60 per cent, was due either to faulty technique or to sepsis. At the present, when the advantage of predetermining the opera- tion is recognized, the death-rate, as is noted, barring septic in- fection, has been lowered approximately to that which is asso- ciated with difficult embryotomy.
The latest statistics, as collated by Robert P. Harris, are the following : Of 1 3 cases where the operation was performed before labor had begun, 10 women recovered and 13 children were saved ; of 6 cases where the operation was performed at the beginning of labor, 6 women recovered and 6 children were saved ; of 12 cases where the women had been in labor from two to six hours, 10 recovered and 11 children were saved; of 18 cases where the women had been in labor from seven to twelve hours, 8 recovered and 13 children were saved.
These figures speak most eloquently in favor of the elect- ive, predetermined, Csesarean section. Two of the three deaths in the category where the operation was performed before labor had begun were due to septic infection, and the third succumbed to secondary haemorrhage.
The record of individual operators in the United States and abroad surpasses the above statistical data, giving us, in general, a mortality rate varying from nil to 1 0 per cent.
The result of asepsis and of election, then, has been to place the modem Cesarean section on the same plane as other major surgical operations, with the addition of saving from 90 to 95 per cent, of infantile lives otherwise infallibly doomed.
As regards the Porro operation, the prognosis will probably always remain gloomier owing to the extra complications which necessitate resort to it. The mortality rate, however, has been in recent times lowered to about 25 per cent.
10
I
CHAPTER VII.
EMBRYOTOMY.
Under the term "embryotomy" are included a numbc of operative procedures which have received distinctive name but the uniform aim of which is to deliver the fcetns per vie naturales afler its mutilation to a greater or a less degree. I modem times the sphere of these operations has been greati narrowed, owing to the perfection in technique and in result of induced labor and of Caesarean section on the one hand, an( owing to the resuscitation and elevation to a scientific plane o; symphysiotomy on the other hand.
Embryotomy, generically considered, includes the foUowinj operative procedures: 1. Craniotomy. 2. Cephalotripsy. 3 Evisceration. 4. Decapitation.
In general the indications for these operations are: 1 Contracted pelvis, the foetus being dead or non-viable and thi conjugate diameter measuring above two and one-half inches
2. Obstructed labor, due to monstrosity or to hydrocephalus
3. Impacted shoulder presentation, impacted after-coming head or irreducible face presentation, the foetus being dead.
It will be noted that under these indications the proviso is ,T| made that the foetus be dead, except when dealing with moU'
strosities. Our reason for such proviso is the belief, stringentlj insisted upon throughout this treatise, that, the maternal con- dition not contra-indicating in the manner sufficiently dwell upon in the chapters on the Caesarean section and symphysi- otomy, recourse to these operations will usually be justifiable and embryotomy of the live foetus rarely be so. This, at am rate, has become the modern rule in maternity hospitals.
In private practice the question still remains open to thi choice of the patient, and will so remain until the Caesareai section becomes as safe an operation as, in the hands of an ex (146)
/
EMBRTOTOMT. 147
pert, embryotomy should be. In a given case, however, it is the bounden duty of the physician to set the relative stand- points of the two operations impartially before the woman. Neither sentimentality nor religious training or belief should «werve. To speak as definitely as possible, the woman's chances of recovery under embryotomy are fully nine out of ten, but then she loses her child; under the CaBsarean section the chances against her are two out of ten, whilst the child's •chances of survival are nine out of ten. This fair estimate is, of course, based on the assumption that the Csesarean section is an elective one, and, further, — a point to be well noted, — that the embryotomy of the living fcetus is not an elective one, for embryotomy under this condition will never become strictly elective. Where the Csesarean section is not going to be taken into consideration, the average physician, outside of a hospital, will attempt every other possible procedure before deliberately •electing an operation which entails the taking of life, even though it be to save life. This is an absolutely erroneous working basis. Where the cause of the pelvic dystocia is recognized, our science is well-nigh exact enough to enable the properly-trained physician to predicate the chance of delivery of the live fcetus of average size by means of the non-mutilating minor operations. Therefore, due election is as possible in the oase of embryotomy as it is in case of any other obstetric operation. There is no credit in delivering the woman by em- bryotomy when she is so exhausted as to have but slight chance of surviving the operation. In major dystocia, then, embry- otomy of the living foetus should be elected in order to avoid a single percentage of mortality rate ; else the maternal chances from the Caesarean section are far better than from non-elective •embryotomy. That is to say, where the choice between the two operations is based on an absolute indication, the one or the other must be deliberately elected. It is the border-line cases which will always call for the soundest judgment, and here, fortunately, symphysiotomy can stand between the Caesar-
148
OBSTETRIC SURGERT.
ean section and embryotomy of the living fcetus. As is amply emphasized under the subject of symphysiotomy, there is to-day left little ground for the choice of embryotomy. Under an absolute indication the Csesarean section is as safe for the woman as the difficult embryotomy, and under the relative indication pubic section narrows very strictly the indications of embryotomy. In the near future, then, the physician in prixaw
practice, as he is now in hospital practice, may be relieved of the duty of killing the foetus in cases where, through an alternate operation, both woman and foetus may be saved.
1. The Operation of Craniotomy. — This operation, as the name implies, aims at diminishing the bulk of the fcctal skull. It is performed either on the before-coming or on the after- coming head. In the latter event it will rarely become a ques- tion of killing the fcetus, since the child will usually be dead before craniotomy is demanded. At best, craniotomy must be
L
considered a difficult operation. The working room is slight owing to the contraction of the pelvis ; for the same reason the cervix is rarely fully dilated ; injury to the maternal parts is not an unlikely occurrence, and this traumatism increases greatly the risk from septic infection or, in any event, will complicate the convalescence.
The essential instruments requisite for the performance of
EKBEYOTOMT.
149
eraniotomy are : A trephine for perforation ; a cranioclast for extraction. There are a number of types of perforators, such aa Karl Braun's trephine, Blot's perforator, Martin's trephine, Naegele's scissors. Braun's and Blot's instruments are par-
mm
Fid. 68.— Martio-s Trephine.
ticukriy useful in case the operation is performed on the before- coming head; tlie scissors answers best for the after-coming head.
The head having been perforated, a sound (like the uterine or, better still, the metal urethral) is needed to break up the
Fig. S7.— Hcixnra-Parforator.
brain, and a syringe to wash out the contents of the cranium. This accomplished, the cranioclast or craniotractor — a better term, since it defines the purpose of the instrument — comes into play. The best instrument is that of Karl Braun.
The steps of tlie operation are the following: The external
genitals and the vagina having been tlioroughly asepticized, thu woman is placed on a table, the bed not sufficing for any of the major obstetric operations. The instruments are sterilized and the hands of the operator and of his assistant are cai-efuUy
150 OBSTETRIC SUHGERT.
cleansed. Too much care in this respect is not possible, sinoe the sole risk in expert hands to which the woman is subjected ia septic infection. If the woman be not excessively nervous, and the operative indication be not an extreme one, ansestfaesift is not absolutely essential. In view, however, of its safety, we always counsel it.
The bladder having been emptied by catheter, the woman is placed in the lithotomy position and we proceed as follows : —
(a) Craniotomy of the Before-coming Head. — The icelal head should be steadied at the brim through supra-pubic pressure made by an assistant. The operator determines the position of tlie head through vaginal examination and selects the preferable point for perforation. Either a parietal or the occipital bone will be accessible, and one or the other should be chosen, sutures and fontanelles being avoided. The fingers of the left hand are placed against the foetal head to steady the ti'ephine and to guard against injury to the maternal parts. The tre- phine is pressed firmly against the head, its handle is steadied by the operator's right hand, and the nurse or the second as* sistant turns the screw of the trephine until the head has been entered. The trephine is now removed and the metal sound is inserted into the cranium to break up the brain. The nozzle of the syringe or a glass iiTJgating tube, fitted to the syringe, next takes the place of the sound and the brain is wasJied out. (Plate XIV, Fig. 1.)
It has been contended that the preferable practice is now to leave the case to nature. AVe can see no advantage in this. The woman being aiiEesthrtized, it is better to follow perforation with extraction. We thus avoid what may prove futile efforts on nature's part, and we thus forestall possible maternal ex- haustion. The left or grooved blade of Braun's cranioclast ia inserted into the opening made by the trephine ; the other blade is applied to tjie outside of the skull, being guided into position by fingers of the right or left hand, according as the blade is applied to the lefl or the right of the pelvis. The blades i
les aittf
i
PT.ATE XIV.
EHBBTOTOMT.
161
locked ; the screw is tamed home, which results in firm hold of the head being secared. Traction is made, even as with the forceps, in the axis of the pelvic brim until the head reaches the pelvic floor, and then in the axis of the pelvic outlet The fcetus having been extracted and the placenta having been ex- pressed, an intra-uterine douche of 2-per«cent. creolin or of 1 to 8000 bichloride solution is given.
the FceUl Sknll.
Where extraction by the cranioclast proves difficult owing to non-yielding of the occiput, the cephalotribe, as will be noted, should be substituted. It is to be remembered that extraction by the cranioclast is possible because, the cranial contents having been evacuated, traction on the head causes it to be compressed, and thereby diminished by the pressure ex- erted by the pelvic walls. Undue pressure is to be avoided in order to prevent, in turn, traumatism of the maternal parts.
153
OBSTETRIC SDRGERY.
(i) Craniotomy of the After-coming Head. — The operation on the after-coming head presents greater difficulties than that on the before-coming head. The trunk of the fcctus having been extracted, it is in the way of the necessary manipula- tions. Only exceptionally, also, will it be possible to elect the desirable point for perforation, tliis point being the occipito- atloid ligament. Further still, after perforation and excere- bration, if the head he wedged tightly at the brim, the greatest possible care ia requisite, in inserting the blades of the ex- tractor, in order to a\oid inflicting considerable traumatism on the maternal parts.
When possible to reach the occipito-atloid ligament, the scissors-perforator of Naegele is the best instrument. When the necessities of tlie case require perforation through the dense mastoid or occipital bone, the |jerforator of Martin or of Blot, being smaller than the trephine of Braun, should be selected.
The steps of the ojrcration are as follow : After thorough asepsis of the genital tract and emptying of the bladder, one assistant steadies the head by suprapubic pressure, and a second pulls the trunk of the foetus laterally, downward or upward, according as the operator lias decided to perforate under the pubes, to one or the other side of the pelvis, or from below upward. If the occiput has been rotated under the pubes, as it ordinarily may, ttie operator determines with the finger the occipito-atloid articulation, and guides the scissors along this finger to the site. The finger must remain in po- sition during perforation, in order to protect tlie bladder in the event of the scissors slipping. The wedge of tlie scissors having been entered at tlie articulation, pressure on the handles enlarges the opening into the cranium laterally, and nest, by rotation of the scissors, similar pressure enlarges the opening antero-posteriorly. This liaving been effected, the scissors is removed and the metal sound is inserted for the purpose of breaking up the brain. The contents of the cranium are next waslied out with sterUized water tlirown in by the syringe. If
SMBRTOTOMT. 153
the pelvic contraction be not marked and uterine contractions are active, the excerebrated head may be bom spontaneously. As a rule, however, extraction by the cranioclast is essential. The left, grooved blade of Braun's cranioclast is inserted into the cranial cavity, the right blade is applied laterally, the instru- ment is locked, and the screw is turned home. Traction is made in the axis of the pelvic inlet or outlet, according to whether the head is in the cavity or on the pelvic floor. (Plate XIV, Fig. 2.)
If the position of the head is such that the occipito-atloid ligament cannot be reached, it becomes necessary to enter the skull through an opening made in one or another of the cranial bones, and then the scissors-perforator will not answer. Either Blot's or Martin's instrument is firmly applied to the point selected for perforation, and the skull is trephined. The other steps are similar to those just stated.
At times the fcetal head is extended at the outlet, so that practically we are dealing with an impacted face presentation. Under these circumstances the skull may be entered with the scissors-perforator through the roof of the mouth.
Exceptionally, owing to density of the cranium, it becomes impossible to extract with the cranioclast. Then, as will be noted, it becomes necessary to resort to cephalotripsy.
The operation of craniotomy having been completed and the placenta having been expressed, an intra-uterine douche of 2-per-cent. creolin or of 1 to 8000 bichloride solution should be administered. In the event of injury having been inflicted on the pelvic floor, the same should be repaired.
2. Tlie Operation of Gephalotnpsy. — The aim of this oper- ation is to crush the skull in order to allow of readier extraction than is possible in certain instances by means of the cranioclast. The latter instrument is a tractor, pure and simple ; the cephal- otribe is at the outset a crusher and afterward a tractor. Per- foration is as essential an initial step as in a case of craniotomy. The advantage, therefore, which the cephalotribe has over the
154
OBSTETRIC SnKGEKT.
cranioclast is that, being a more powerful Instrament, it enables the operator to overcome the difficulties in the way of delivery by the simple tractor offered by a dense and fully-ossified cra- nium. The cephalotribe, however, has the disadvantage of being a bulkier instrument than the cranioclast, and, further»J
Fig. TO.— Liisk's CeplwlotTtbc.
occupies more space in the pelvis, since neither of the blades laM applied within the cranial cavity. For this reason, therefore, ' the cranioclast is to be preferred whenever the emergencies of the given case will allow of its application.
Simpson, Hicks, Breisky, Lusk, and others have devised useful forms of the instrument, Lusk's cephalotribe, in most -j
respects, will answer best where the instrument is at all. Obviously, since the cephalotribe is applied ■ between the walls of the pelvis and the icetal head, and since, further, the instrument, whilst diminishing the diameter of the head in one direction, increases it in another, is applicable only
EMBRTOTOMT. 155
when the operation is indicated in the presence of the minor grades of pelvic contraction.
Exceptionally, even this instrument is not powerful enough to break up the base of the cranium to permit of delivery with-^ out subjecting the maternal parts to unnecessary damage. Then we must have recourse to the rather complicated, but most powerful, instrument devised by Taruier, — the basic tribe. This, instrument is a perforator and a cephalotribe in one. Tha screw-tip perforates the cranium and holds it firmly whilst the- action of the blades is crushing the base of the skull.
Notwithstanding its advantages in certain cases, the cepha-^- lotribe is a more dangerous instrument than the cranioclast. Injury to the maternal parts is more likely owing to the in-^ creased room in the pelvis its use entails ; and, further, owing ta the spicula of bone which are apt to project as the result of the crushing force applied. Still, the instrument is a most essential one in fortunately rare instances.
The initial steps of cephalotripsy are similar to those for craniotomy, — thorough asepsis of the genital tract, hands of operator and assistant and instruments, followed by perforation and excerebration. The blades of the cephalotribe are next applied accurately to the foetal head, under the guidance of the fingers in the vagina. The screw is then turned home and the cranium is crushed, being elongated in the diameter opposed ta to that in which the crushing force is exerted. This latter point is ever to be borne in mind, so that during the process of extraction the enlarged diameter of the foetal skull may be ro-^ tated, where choice exists, into the larger diameter of the pelvis. Extraction is made even as with the forceps, in the axis of the inlet, until the head reaches the pelvic floor, and then in the- axis of the outlet. After delivery of the I'oetus and the placenta, an intra-uterine douche of 2-per-cent. creolin or 1 to 8000 bi-^ chloride solution is to be administered, and any injury to the pelvic floor is to be repaired.
3 and 4. Evisceration and DecajOiitation. — These operar-
156 OBSTETRIC SURGERT.
tions are applicable to instances where the fcetua lies trans- versely in the uterus, and impacted to such a degree as to forbid version, for the purpose of bringing the foetal head in such relation to the pelvic brim as to permit of craniotomy.
Evisceration is called for where the neck of the foetus cannot be reached, whereas, when it can be reached, decapita- tion finds its spliere of action. Both these operative procedures must be considered as well-nigh the most dangerous of all ob- stetric operations. Aside from tlie increased risk of direct trau- matism to the uterus, in which organ, necessarily, the manipula- tions take place, the lower uterine segment is usually thinned, particularly in neglected cases, and, therefore, there exists considerable likelihood of rupture of the uterus, "^
Where the neck of the uterus is not accessible and eTi»^H ceration becomes the operation of necessity, the steps are as ■ follow : After tliorough asepsis of the genital tract, and similar precautions in regard to the hands of the ojierator, his assistants, and the requisite instruments, the scissors-perforator is guided ' along one or more lingers in the vagina to the most accessible! portion of tlie fcetal trunk, is inserted to its full depth, and the opening thus made is enlarged by pressure on the handles. The metallic sound is next inserted into this opening, and the contained organs are broken up. This process is tedious and calls for extreme caution lest the sound perforate the fcetus, and thus inflict damage on the uterus. Wlienever possible the flnger of the operator should take the place of the sound. The cavity having been emptied of its contents, any projecting spio- ulse of bone are removed by the bone-forceps, and then the fcetal trunk may possibly be bent on itself through traction applied by the blunt hook, and be thus delivered. ShoiUd this manipu- lation fail, the operator will be obliged to break the foetus up further, dismembering it, and resorting to the cranioclast or to the cephalotribe for the extraction of the foetal head. A num- ber of complicated instruments, such as chain-saws, have been devised for use in these extreme instances; but they are one
14
EMBRyOTOMT.
and all open to the objection that, being difficult to apply around the foetal trunk, they are liable to inflict great damage on the maternal structures. A simple device is the follow- ing: When possible a sterilized gum-elastic catheter, threaded through its eye with a stout sterilized cord, is carried around the trunk of the fcetus. The catheter is unthreaded and re- moved, leaving the cord around the fcetus. The ends of this
Fig, T2.— Bone-Foiceps.
cord are brought out of the vagina through a cylindrical specu- lum, and then, by traction on the ends of the cord, the fcetal trunk may usually be sawn through. This failing, the sole alternatiTe is to cut through the spinal column by the scissors. The name of spondylotomy has been applied to these proced- ures. Such an amount of traumatism is thus entailed that we question if, where the conjugate is diminished below two and three-fourths inches, it be not preferable to enlarge the pelvic diameters by symphysiotomy in order to obtain greater working space.
Where the neck of the foetus is accessible decapitation is
L
PlE. m— Crochet and Blunt Hook.
the operation of choice. A number of instruments, compli- cated to a greater or less degree, have been devised for the per- formance of decapitation. The simplest of all is the Braun hook or decollator. This hook can be used in every instance where the more complicated apparatus can ; it is serviceable where the latter is not, for the reason that if there is not space
e
J
158
OBSTETRIC STJRGERr.
enough to pass the decollator it is likewise impossible to ( the chaio-saw ; it Is readily rendered aseptic and is less 1 injure the maternal parts than any of the other de\'ices.
In an emergency, where the Braun instrument is not i hand, a stout sterilized cord may be carried around the fceta neck by means of a sterilized elastic catheter; the ends of tlie cord are carried through a cylindrical speculum out of vagina, and a see-saw motion associated with traction will sew the head from the trunk. Whenever possible, however, ' Braun hook is to be preferred, and the steps of the operation a^^ as follow : The bladder is to be emptied. Tlie genital tract, the liandsof the operator and of his assistants having been care> fully asepticized, the fcetal arm is brouglit down out of tfai
•^
' are act, are-
1
"7
Fig. 71.— Br»on-e Hook or DecolU
vagina and handed to an assistant, who, through the exei traction, steadies the foetal neck at the brim and makes it more accessible. It is desirable to exert traction on this arm by means of a tajx; or towel tied to it, otherwise the assistant wi be in the way of the operator.
Tlie aim of the operator is to pass the hook around the neck of the fcetus, and this is accomplished as follows: Inserting two fingers of the right or the left hand (according as the fcetal head occupies the left or the right half of the pelvis) into the vagina, the hook is passed flat along these fingers until the neck of the fcetus is reached. The point of the hook is then guidi around the neck by tliese fingers from above downward, order to lessen the risk of injuring the bladder. (Plate X
1
'1
M .1
^ i
EHBETOTOITT. i09
Firm traction is then made on the hook in order to assoie a thorough hold on the neck, the fingers remaining in place so as to certify that the point of the hook is not injuring the maternal parts. The hook is rotated, traction being maintained xmtil the neck is felt to yield through the breaking of the spinal column. As a rule, the soft parts iJso are thus severed, and the hook is removed along the fingers. If the hook has failed to sever completely the muscular attachments, the scissors, guided along the fingers, must be utilized.
Fig. 76.— DellTer; of Tranlc ttttn SwMoii of Head,
The neck of the fcetus having been severed, traction on the prolapsed foetal arm will ordinarily serve to deliver the trunk, the foetal head slipping upward. The next step is to remove the head.
If the indication for decapitation has been an impacted transverse position of the dead foetus, in a pelvis where there exists no special disproportion between the pelvis and the foetus, the forceps will answer for extraction. The head being steadied at the pelvic brim by an assistant, the forceps is
160
OBSTETBIC SUR6EBT.
applied in the usual manner, and delivery is effected under the rules applicable to the forceps operation.
Where, however, there exists dystocia due to contracted pelvis or to large foetus, the manipulations become more fUfficult according to the degree of dystocia. The method of inserting the blunt hook into the cranium through the foramen magnum and delivering by traction has been advocated, but should be rejected owing to the risk of the hook slipping and injuring the maternal parts. The preferable method is the following:
Fig. 7ft— Locked Twins.
If the head can be fixed at the brim with the foramen magnum presenting toward the vagina, then excerebration by the metal sound and extraction by the cranioclast or the cephalotribe is advisable. If the head cannot be so fixed, then perforation by the trephine or the scissors-perforator is demanded, followed by extraction by the cranioclast or the cephalotribe. The risk to the maternal parts is here great, owing to the fact that the point of impact of the trephine or scissors can rarely be at a right angle, and there is, therefore, great danger of the instru*
EMBRYOTOMY. 161
meiits slipping. If the pelvis be large enough to permit of its introduction, Tamier's basiotribe will answer admirably.
The uterus having been emptied, a 2-per-cent. creolin or a 1 to 8000 bichloride douche should be administered, and lesion of the genital tract be repaired us completely as is possible.
Aside from impacted transverse presentation, decapitation may be called for in case of locked twins.
The trunk of one foetus having been born, and it being found impossible by manual and postural treatment to decom- pose the wedge formed by the foetal heads, the only possible resource is the sacrificing of the first foetus — in case it be not already dead — ^in order to give the second foetus chance of life ; for it is the first foetus, the trunk of which is bom, whose life is most endangered. The steps of the operation do not diflFer from those just stated.
Prognosis of Embryotomy.
It is not possible to state specifically the death-rate from embryotomy. The statistical data at disposal are worthless, because of the fact that many of the records include operations performed before the stringency of asepsis was recognized, and, further, because the operation, except under absolute indication, has rarely been one of election. It is a significant fact that the mortality following embryotomy is higher in private than in hospital practice. The reason is that in the former practice the temptation is to test the methods of deliver)' by forceps and version before resorting to embryotomy ; often because accurate mensuration of the pelvis having been neglected, the prac- titioner is unaware of the cause of the dystocia till his eyes are opened by the fact that the methods of delivery with which he is most familiar are of no avail. Embryotomy is then resorted to on an exhausted woman with genital tract already damaged, to a greater or less degree, by the futile efforts at delivery by methods which the mechanical problem forbid. Deliberate
election of embryotomy, on the other hand, is more likely to be
11
162 OBSTETRIC SURGERT.
the rule in hospitals, and, therefore, the mortality is lower Farther still, the mortality depends on the indication for th( operation selected. Where the dystocia is not extreme and thi operation, therefore, not a difficult one, the sole risk entailed b^ embryotomy ia sepsis. In the higlier degrees of dystocia, par ticularly where evisceration is called for, the mortality mus always remain relatively liigh owing to the lesions which, ever in the hands of the most exiiert, tlie maternal parts are likel] to incnr.
Minor lesions, such as lacerations of the cer\-ix or of thi pelvic floor, if repaired at once and ascptically, are not likely U enter as complications of the pueriieral state. Neither an fistulfe, if tlie result of direct traumatism and not of sloughing following prolonged pressure. The major risk the woraan runt is rupture of the uterus, — a not unlikely accident wliere embry- otomy is demanded in a justo-minor pelvis of high grade through an imdilated cervix. Whilst, indeed, embryotomy may prove a very simple operation, it may also become the most difficult of all the obstetric operations. For this reason, when the child is alive, it has become the custom in hospitals to weigh carefully the chances in the boundary-line cases of Caisarean section and of embryotomy. It becomes a question not, as is often erroneously argued, of the greater value of one life over another; it becomes a question of the deliberate, scientific election of that operation which subjects the woman to the least risk. There is no doubt hut tliat difficult embry- otomy, in the hands of the non-expert, subjects the woman to greater risk than does the C'assarean section, provided always that he is familiar with the simple technique of the hitter opera- tion, as he should be, if competent to attend the lying-in woman at all.
CHAPTER VIII.
THE SURGERY OP THE PUERPERIUM.
The puerperal state begins with the expulsion of the pla* centa, which event terminates the third stage of labor. In case surgical interference has been required during the course of labor, the genital tract has likely enough suffered certain lesions which it becomes the duty of the physician to repair. As a rule, the surgery requisite may be denominated minor, with the exception of one complication, — rupture of the uterus.
In the event of the labor or the surgical interference not having been conducted aseptically, there will develop, during the course of the puerperal state, a number of complications, which may also require surgical intervention, and, as a rule, this sur- gery is of a major nature.
The operations, then, which we are called upon to consider depend either on traumatism, avoidable or unavoidable, or on sepsis, which, from the modem stand-point, must be looked upon as almost always avoidable.
The operations resulting from traumatism are the follow- ing : 1. Laceration of the cervix. 2. Laceration of the pelvic floor. 3. Fistulas. 4. Rupture of the uterus.
The affections depending on septic infection which may demand surgical interference are : 1. Endometritis and metritis. 2. Pelvic abscess. 3. Peritonitis. 4. Mastitis.
Immediate Repair of the Lacerated Cervix.
It is only of late years that it has been considered desirable to attempt the immediate repair of the lacerated cervix. The objections to the operation have been the problematical result as regards primary union and, further, the belief that it was impossible to resort to the operation without the presence of a number of assistants. There are now a sufficient number
(163)
164 OBSTETRIC SURGERY.
of cases recorded to warrant the assertion that primary unira may usually be expected, and if the technique we proceed to describe be followed skilled assistants are not necessary. On the other hand, the primary operation shuts off one of the avenues of sepsis, and removes at once one of the most frequent causes of subinvolution, as well as, in case of union, relieves the patient of the necessity of the secondary operation.
The immediate operation is either one of election or one of strict necessity. It becomes one of necessity when, either after spontaneous labor or after operative interference, profuse haemorrhage occurs and continues, which, on investigation, is found to be due to a cervical tear involving a circular artery. Here the only other resource is tamponing the vagina, which is unscientific as well as often nugatory. The operation becomes one of election in the lesser degrees of laceration. Un question* ably many such lacerations heal spontaneously, probablv the vast majority if the course of the puerperium is aseptic. Still we question if, where the laceration exceeds what may be termec the first degree, the patient has not the right to expect her phy- sician to leave her in the best possible condition, in order U save her from the grasp of the gynaecologist later.
In case the operation is called for on account of laceratior involving the circular artery, there exists no contra-indication The immediate safety of the woman demands it. There an contra-indications to the performance of the operation in th< presence of the lesser grades of laceration. If the woman i exhausted from prolonged labor, or if, owing to post-partun haemorrhage, it has become necessary to use the uterine tam ponade, then resort to the operation is either inadvisable o impracticable.
The instruments requisite for the performance of th< operation are the following: A strong vulsellum forceps, i needle-holder, and a few large curved needles, preferablv th< Hagedorn. The preferable suture material is silk-worm ""ut Catgut is unreliable, since it is apt to dissolve too soon and
THE SURGERY OP THE PUERPERIUM. 165
furthermore, because the knot is apt to slip. The silk-worm gut is readily sterilized by boiling for a few minutes, and may be left in situ for weeks, as may be requisite, if, at the same time, it is necessary to repair the pelvic floor. A speculum is not strictly requisite, since, according to the technique about to be de- scribed, the operation is performed without one. The main advantage in dispensing with a speculum is that thus an assist- ant to hold it is not required. If the operator happen to have an Edebohl speculum with him, however, the counter-weight may be obtained by means of a flat-iron, which is to be found in every household.
The steps of the operation are the following: The woman is brought to the edge of the bed ; the bladder is emptied ; anaesthesia is only requisite in case the woman is excessively nervous. If the requisite assistants — two in number — are pres- ent, each may support a leg ; but, in the event of these assist- ants not being present, the physician may use a sheet as a leg-holder by passing it around the knees and tying it to the patient's arms. The requisite instruments, having been steril- ized by boiling, are placed handy to the operator's right hand, a lighted candle or lamp, in case the gaslight is not sufficient, being held by the nurse or by some relative so as to illuminate the field of operation thoroughly.
The operator seizes the cervical lips firmly with the double tenaculum, and pulls the uterus downward until the cervix is at the ostium vaginae. The object of this traction is two- fold: In the first place, the laceration is thus made accessible for operation, being performed under the guidance of the eye, and, in the second place, when the uterus is thus pulled down- ward, it is a well-known fact that haemorrhage from the organ is, in a measure, checked. For this reason the technique de- scribed is preferable to that which entails operating through the Sims speculum, when the hsemorrhagic flow which always exists after the completion of labor renders the operation diffi- cult by interfering with the field of vision. The next step is to
166
OBSTETRIC SURGEKT.
pass the first and the most difficult of the stitches, which, once in place, gives tlie operator full control. A Hagedom needle threaded with silk-worm gut is passed deeply, at the angle through the posterior cervical lip. under the lacerated surface, emerging in the canal. It is re-inserted into the anterior lip at the canal, and emerges at tlie angle of the tear in the anterior lip. The remaining stitciies are inserted in a similar manner, first on the one side, and next on the other, until the raw sur- faces of each lip have been approximated. The sutures ate
next tied. It is important to remember that it is essential to tie tlie stitches tighter after the primary operation than after the secondarj', when the aim is simply to bring the denuded surfaces in apposition. After delivery, tlie cervix is always CEdematous to a greater or less degree, and, if tlie stitches be not tied tightly then, in the course of a few days, when the oedema disappears, the stitches will necessarily be slack and deep union by first intention is unliliely. It is to the neglect of this precaution, wc lielieve, that failure after the primary operation may often be traced.
THE SUR6ERT OF THE PUERPERIUM. 167
The sutures having been tied, the vulsellum forceps is removed and a hot 2-per-cent. creolin douche is administered. The average time requisite for this operation is ten minutes. In case of failure in obtaining union, the woman's condition is none the worse for the attempt made to leave her in the best possible condition, whilst, as already stated, if union do occur, the woman is spared many of the ills which a lacerated cervix sooner or later entails. There is a further phase of this question which it is well to dwell upon. If the immediate operation be not performed in case of deep cervical laceration, dense cica- tricial tissue inevitably forms, so that when the secondary opera- tion is called for there is not alone much more difficulty in performance, but it may even, in the opinion of many, become not a question of mere repair of a laceration, but one of ampu- tation,— a more radical operation. We believe that before long it will be recognized as desirable to perform immediate trache- lorrhaphy, as it is to-day considered a sign of incompetency if repair of the pelvic floor is not attended to immediately, in the absence of contra-indication.
The stitches in the cervix may be left in situ from ten days to a number of weeks, according to the necessities of the case. The longer interval is requisite where it has also been necessary to operate on the pelvic floor. If, the stitches are aseptic, as they should be, when introduced, they can give rise to no possi- ble trouble during the puerperal state. The assumption that they may interfere with drainage of the lochia is untenable, since the operation simply restores the cervix to the shape it has where laceration has not occurred. It goes without saying that we presuppose that requisite care has been taken not to sew up the cervical canal.
Immediate Perineorrhaphy.
The conscientious physician aims to leave his patient, after confinement, with the pelvic floor in as sound a condition as art can make it, in the event of its having been lacerated during
168 OBSTETRIC SDRGERY.
the process of delivery. There is little need at the present dav to dwell on the untoward sequelae which inevitably follow ilTl the train of unrepaired lesion of the pelvic floor. The laity, as well as physicians in general, recognize the necessity of the primary o[>e ration, —so much so, indeed, that the former con- sider their medical attendant hlameworthy who has failed to recognize a lesion, and thus neglected to rejmir it. The student need not have the fear that, if the lesion occur, it will be laid to his lack of skiU. The practitioner who claims that, in an extensive practice, he has never seen a lacerated perineum has become to-day a Tara avis iu the light of the recorded experi- ence from hospitals which certify to the necessarily frequent occurrence of lesion even in the hands of the most expert. The proper spirit to-day is to fear the blame which deservedly attaches itself to the attendant who neglects the performance of the primary operation whenever the conditions contra-indicati are absent.
The routine practice, after the completion of the third stage of labor, should be to investigate by sight, as well as by touch, the pelvic floor. There may he no apparent lesiou externally, and yet, on separation of the labia, the most da; gerous of all lesions, as regards its after-consequences, will detected. It is now firmly established tliat the mere external ^ tears are of no consequence beyond opening an avenue for the entrance of germs. It is the tears which involve the muscles and fascia of the peh-ic floor wliich entaQ idtimately rectocele and cystocele, with their sequelte. Too much stress, therefore, cannot be laid on the necessity of separating tlie labia and i examining the pelvic floor. m
Tlie sole contra-indication to the immediate operation is 1 exhaustion of the woman to such a degi'ee, from prolonged labor or from post-partum hsemonliage, as to call for absolute and immediate rest on her part. Of course, where, owing to post-partum htemorrhage, it has been necessary to resort to the gauze tamponade of the genital tract, the operation cannot be
ce of _
:hird 13 by -siou ^ danal 1 b^
THE SURGERY OF THE PUERPERIUM. 169
performed. Where the lesion, at best, requires but a few stitches, anaesthesia is not requisite, since the sensibility of the pelvic floor has been largely diminished from the pressure asso- ciated with delivery. But, if the tear be one of a major degree, ^ anaesthesia is desirable in order to enable the attendant to per- form the operation with the requisite care as well as in order to save the woman unnecessary pain.
The instruments requisite are the following: A pair of scissors, a needle-holder, a few curved needles (preferably the Hagedom). Material for suture will differ according to indi- vidual preference, but the silk-worm gut possesses all the advan- tages of silver wire or catgut, and has none of the disadvantages of the latter. Where the tear is chiefly internal, catgut, if its asepticism can be depended upon, answers admirably, since it is possible to use it as a running suture ; but even then it may dis- solve before deep union is secured, or, notwithstanding the pre- cautions taken, it may prove the source of local sepsis. As for silver wire, it possesses no advantages for the primary operation over silk-worm gut, and requires infinitely more time for adjust- ment as well as more instruments. Silk-worm gut is readily steriHzed by boiling, and, if aseptic, it may be left in situ for an indefinite time.
The method of operating will be modified according to the character of the laceration. The most complex operation, of course, is demanded where the laceration extends through the sphincter ani, to a greater or a less extent, up the rectal wall. In the lesser grades the suturing usually will be almost entirely within the vagina. Before proceeding to operate the physician should make a careful examination in order to determine the manner after which the pelvic floor has been injured, in order to secure deep union and proper approximation of the fascia and muscles. The ancient method of simply passing the sutures in at one side and out at the other will not stand the critical test of modem methods, for the day has gone by when securing a skin perineum is deemed sufficient. The parts operated upon
170
OBSTETRIC SURGERT.
must not alone look well, but must also subserve their intended purpose well.
Where the laceration has not extended through tlie ■sphincter of the anus the steps of the opemtion are as follow: Tbe woman is brought to the edge of the bed, the legs are flexed on the abdomen and are lield there by the nurse, or, if she is needed for other purposes, a sheet may be passed under the knees and each end tied to the patient's arms. As a rule, ex- cept in the minor degrees of laceration, anxsthesia is requisite. In order to avoid sponging, the field of operation nftay be irri- gated to advantage by a weak solution of bicliloride. Creolin is objectionable for irrigating puiposes, since, owing to its color, it interferes with a good view of the fiekl of operation. An assistant or tlie nurse, with aseptic hands, separates tlie labia so that the operator may determine tlie extent of the laceration. With the scissors jagged ends of tissue are cut off, thus securing' an even surface for union. If the laceration has extended chiefly into one xsnicns, as is not infrequently the case in the lesser degrees of lesion, a running catgut suture may be used to advantage. The needle is inserted at the apex of the tear, deeply, so as to secure as much of tlie divided fascia as possible, and the gut is tied. The over-and-over stitch is now rapidly taken, tlie needle on each occasion it is inserted being made to enter deeply, until the external end of the laceration has been reached, when it is tied. Occasionally the tear involves both sulci, in which event the process is repeated on tlie other side. In order to see well, the upper vagina is tamponed with steril- ized gauze, which prevents tlie trirkhng of the uterine discharges.
In general, however, Hcgar's method of operating (mod- ified) will give the most satisfactory result, even though its performance takes more time than that which we have just described.
The method is peculiarly applicable to the vast majoritv of lacerations, since these begin in the median line and extend laterally. The suturing is almost entirely internal, and appnix*
THE SURGERY OF THE PUERPERIUM. 171
imates accurately the divided ends of the muscles aud fascia, the aim which is essential in order to properly repair the lesion. The needle is inserted at the margin of the tear near its apex, and passed deeply around to the opposite side. Similar sutures are inserted at an interval of about a quarter of an inch apart, till the tear has been approximated down to the carun- culsB myrtiformes. The sutures are then tied and cut short. The superficial tear remaining is brought together by two or
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Fig. 78.— Insertion of Sutnres. (After Hegar.) A, A, iatrft-Tigiiial ratiirM ; b. b, aztenuU ratarM.
more sutures. Silk-worm gut answers admirably, and, if need be, a few interrupted sutures of catgut may be inserted. These sutures, if aseptic, may remain in place for a week or ten days. If there exist much oedema of the pelvic floor, the result of pro- tracted labor, the precaution must be taken to tie the sutures a trifle tighter than is the rale for plastic work ; otherwise, on the disappearance of the oedema, the sutures will be relaxed and deep union will not be secured.
172
OBSTETRIC SUKGERY.
Where the laceration has been so extensive as to involve not only the pelvic floor, but also the sphincter ani and the recto-vaginal septum, there is all the more call for tlie imme- diate operation, and tlie procedure is proportionately more com- plicated. It is above all tilings important to bring together the torn ends of the sphincter ani, for otherwise tlie woman will suff'cr from incontinence of f^cca to a greater or less degree, and will, in consequence, inentfvbly require the secondary operation, lu this operation we still prefer the silk-worm gut ibr sutuic
Fig. 79.-
pnrposes. It holds just as well as silver wire, and is a source of less discomfort to the woman. The first stitches to be inserted arc the rectal. The needle is inserted below the manjin of the tear and is carried deeply outward so as to grasp the torn ends of the sphincter. It circles around the recto-vaginal septum and emerges at the opposite side, grasping the other end of the sphincter. As a rule, two sutures are requisite to secure the sphincter muscle, and when inserted these may be tied. Tl laceration of the pelvic floor is then repaired according to method just described.
I
THE SURGERY OF THE PUERPERIUM. 173
Exceptionally, the laceration occurs directly through the perineum, giving rise to what is termed central laceration. In case of this accident, the method of procedure consists in converting the central laceration into a complete, by slitting through the bridge of tissue remaining between the laceration and the pelvic floor, and then repairing the lesion after the method described.
If the steps of the operations just described are aseptic, the management of the puerperal state does not differ materially from the normal. It is unnecessary to administer vaginal douches, since the non-septic lochia will not interfere with union. The old-time rule of keeping the bowels constipated is not deemed good practice to-day. The comfort of the puerpera demands that the intestinal canal should not be allowed to become clogged, and the perineal tear is more likely to heal from the depths if we take precautions to prevent hardened faecal matter from collecting in the rectal culrde-sac. It is a good rule, therefore, to order a saline laxative within twenty- four hours after delivery, and thereafter every day, so as to secure copious liquid evacuations. The coaptated surface may be kept powdered with iodoform, aristol, or boracic acid, and the nurse should be strictly enjoined to exercise scrupulous cleanli- ness of the external genitals. For the first few days the woman had better be catheterized, or else, and this we prefer, when she passes water it should be under the administration of a weak creolin or bichloride douche. It is very questionable if the normal urine will interfere at all with primary union.
In the event of the primary operation proving a failure, the woman should be advised to submit to the secondary opera- tion as early as may be, for the longer she waits the greater the cicatricial tissue, and the more aggravated the rectocele and possibly the cystocele which will form.
174
OBSTETRIC SURGERY.
FlSTUL-E.
Only exceptionally, nowadays, are fistulse of the genital tract encountered, for the reason that their chief causes are not allowed to act. Protracted labor was formerly responsible for the majority of fistulse. Traumatism, except in the presence of a major degree of pelvic contraction when surgical interference
FIE. bo.— Repair ot ■ Vealco-VaRlDal FIstnlk.
was demanded, was rarely a causative factor. It is only when a fistula forms as the result of surgical interference that the physician, in the capacity of accoucheur, will be called upon to perform immediate operation. The fistula which result from prolonged pressure of the foetal presenting jmrt on the pelvic floor rarely make themselves evident until a number of days
THE SURGERY OF TEE PUERPERIUM.
175
after labor. The process is purely one of sloughing in these latter instances. Of course, here, as well, it is eminently neces- sary to take measures for repair of the lesion as soon as the con- dition of tlie woman will allow, since the formation of extensive cicatrices will render the operation most difficult and the result problematical.
Fig. Bl.— Simon's Specula.
L
In view of the difficulty of the secondary operation for fistula, it may at first sight seem useless to attempt repair im- mediately after delivery. When we remember, however, the untoward sequelte of both urinary and fjEcal fistulae, and the repeated attempts which are often requisite before union ran be secured after the secondary operation, there is little need of dwelling further on the desirability of aiming at primary union.
176 OBSTETRIC SURGERY.
The main reason why the primary operation is difficult is the impossibility of placing the recently-delivered puerpera in the best position for performing the operation, particularly when the fistula aflfects the bladder. This, indeed, will prove a distinct contra-indication when the fistula is seated high up ; but when the lesion is low enough down to enable the physician to bring it into view without placing the woman in the genu-pectoral position, the attempt at primary repair should always be made. Rectal fistulsB may ordinarily be exposed with less difficulty than the vesical.
The steps of the operation either for rectal or vesical fistulse do not differ from those requisite for the performance of the sec- ondary operation. To prevent the lochia from trickling down and interfering with the field of vision, it suffices to pack the upper portion of the vagina with sterilized gauze. Since there is no cicatricial tissue and, consequently, no special tension to be overcome, silk-worm gut will answer for suture purposes.
If the fistula is at all accessible with the woman in the dorsal position, the edges are made tense by traction with a tenaculum, and the sutures are inserted one after another from one edge of the fistula out at the other. The same care is requisite, as in the secondary operation, not to pass the stitches through the vesical wall. Coaptation of the torn edges must be accurate and the stitches must be tied more tightly than in the secondary operation, because when any oedema present has disappeared the stitches will otherwise become relaxed.
The after-treatment will not differ from that of the normal puerperium. The bowels should be kept fluid, and where the lesion has involved the bladder the catheter should be passed at least every six liours for five to six days. As is the rule for the puerperal state, the catheter must be passed by sight, and this is preceded by careful disinfection of the external genitals and the vestibule. If the sutures be aseptic they will not suppurate, and they should be left in place for fully two weeks. Should the primary operation fail, the woman should be advised to have the secondary operation performed without overmuch delay.
the surgery op the puerperium. 177
Rupture op the Uterus.
Rupture of the parturient uterus constitutes one of the most fatal as well as most alarming of the obstetric complica- tions. There is scarcely an emergency which calls for more rapidity of judgment and of action ; for, as will be noted, on prompt differential diagnosis and equally prompt treatment the life of the woman depends. The accident, fortunately, is an infrequent one, and will become all the more so as the benefits of strictly elective obstetric surgery become uniformly recog- nized.
The etiological factor cannot be always positively deter- mined. In many instances rupture may be traced directly to the premature and injudicious administration of ergot ; again, the causal factor is the attempt to drag a foetus through a pelvis where attention to the ordinary rules of pelvic mensuration will teach that delivery by one or another method is alone possible ; further, a by no means infrequent factor has been protracted labor with consequent thinning of the lower uterine segment ; and, finally, the operation of embryotomy through a greatly- contracted pelvis may be associated with rupture of the uterus. In certain instances none of these factors can be held responsible when, in default of a better reason, we must consider that the uterus has become weakened at a certain point, and has simply given way at the point of least resistance.
There are two varieties of rupture of the uterus, and on their differentiation depend both the prognosis and the treat- ment. These varieties are complete rupture and incomplete rupture. *
The complete rupture is intra-T3eritoneal ; the incomplete rupture is extra-peritoneal. The clinical history will ordinarily enable the physician to differentiate the variety of rupture and the importance of accurate differentiation will shortly be apparent.
Incomplete rupture of the uterus may occur into either of the broad ligaments, or into the utero-vesical space, or into the
12
178 OBSTETRIC SURGERY.
cul-de'sac of Douglas. In any case the tear does not exteii( into the peritoneal cavity.
Complete rupture of the uterus necessarily invades the peri toneal cavity associated with, in general, the escape of the fcetui in part or in whole into this cavity.
In incomplete rupture the shock is not as great and the loss of Wood is Umited by the capacity of the cavity into whicli it is effused.
In complete rupture with extrusion of the entire foetus into the peritoneal cavity the shock is great, and the haemor- rhage which may take place is only limited by the amount of blood the patient has to lose. Where a portion only of the foetus is extruded, the amount of blood lost may be checked by the portion of the foetus which is not extruded acting as a tampon.
The signs which lead to diagnosis of rupture of the uterus are like those which are associated with hsemorrhage. These signs will vary in intensity according as the hsemorrhage is sud- den and great or slow, even though gradually progressive. Shock, rapid pulse, pallor, sighing, eventually syncope, — such are the symptoms which should awaken the keen anxiety of the phy- sician. The only positive way of making the differential diag- nosis between complete and incomplete rupture is to insert the hand into the uterus, excepting, of course, in those instances where the foetus escapes into the peritoneal cavity, when, so to speak, the diagnosis is made for us.
If the rupture is incomplete, surgical treatment is not demanded, certainly at the outset. The proper course to pursue is one of expectancy. Where the rent extends from the an^^le of a lacerated cervix into the base of the broad ligament, the haemorrhage, in great part, comes from the circular artery, and this may be checked by carrying a suture around the artery and tying it. Where the rent involves the broad ligament or the anterior or the posterior cul-de-sac^ the firm tamponade with sterilized gauze may check the haemorrhage and limit its
THE SUKGEBT OF THE PDERPERIDM.
179
extension. Often, however, the blood will continue to be effused until it has dissected the cellular tissue as far as its anatomical boundaries in the given region will allow. In other words, the condition becomes one of htematoma — ante-uterine, retro-uterine, or lateral — into the broad ligament. Later on, if the hsematoma do not become absorbed, or if, through some faulty technicLue, suppuration set in, surgical interference may
Kiome necessai-y. Where the rupture is intra-peritoneal the prognosis, in any event, is most gloomy. If the fcetus has escaped entirely or in greater part into tlie peritoneal cavity, the only possible operation is an abdominal section, not in the hope of saving the child, but in order to give the woman a single chance of life. There is no time in this emergency for special preparations. The physician must have the courage of his convictions; he must open the abdomen at once, extract
180 OBSTETRIC SUR6ERT.
the foetus, and treat the uterine rent by sewing it up after the manner pursued in the Csesarean section, or by remoTal of the entire uterus as is described under the Forro operation.
Where the rupture is complete, but the foetus has not escaped into the peritoneal cavity, there is scope for difference of opinion as to the proper treatment. The results from either of the methods which may be selected are the reverse of bril- liant, although possibly of late years one of them has seemed to modify the prognosis for the better. At first thought, immediate emptying of the uterus and abdominal section would seem to be the desideratum. The fact is, however, that the woman, being in deep shock, abdominal section is simply superadding shock, and the wonder is when any recover. The alternate method is to rapidly extract the foetus and then to tampon the uterus with sterilized gauze ; we thus compress the bleeding-point and per- haps check further loss of blood. Of late years a few cases treated after this fashion have recovered. If we are fortunate thus to check the hsemorrhage, the peritoneum will take care of the blood which has escaped within it ; and if the labor has been conducted aseptically and the gauze inserted is aseptic, then, if the woman do not die of shock, she will not die of sepsis. Resort to this method of tamponade is, however, only possible where the intestines have not protruded into the rent. If this has occurred, we cannot use the tamponade, because of the uncertainty as to whether or not the gut is strangulated at the uterine rent or through compression by the gauze. There can be no choice of procedure in case of intestinal prolapse ; the physician's only recourse is abdominal section.
In case of incomplete rupture, where the tampon has been applied, the gauze should be left in situ for from thirty-six to sixty hours. Adjuvant treatmant consists in raising the foot of the bed, bandaging the extremities, giving strychnia in large doses hypodermatically {^-^ grain every two hours, for its stimu- lating effect on the heart), and administering hot 2-per-cent. saline rectal injections.
THE SURGERY OF THE PUERPSRIUM. 181
A further and very rare form of uterine rupture is what is termed " annular rupture." This consists in separation of the cervix at the utero-vaginal junction, either in whole or in part. The treatment requisite is ligation of the circular arteries in the event of their being implicated in the rent.
We next pass to the consideration of the puerperal affec- tions due to septic infection, which may require surgical aid. A point to be noted is that elective surgery is peculiarly appli- cable to these affections, since early treatment of this nature very frequently spares the woman results of the most untoward nature.
Endometritis and Metritis.
These affections are considered together because the one is the direct consequence of the other. On the prompt recog- nition of a septic endometritis depends the safety of the tubes, ovaries, peritoneum, and not infrequently the Ufe of the woman. There has been, of late years, a radical change in the method of treatment of septic endometritis. The practice long in vogue, of repeatedly irrigating the uterus, has been found utterly inef- ficient as a means of guarding against infection of the Fallopian tubes, and thence of the peritoneal cavity. Whilst occasionally, when the local infection is slight and superficial, the repeated douche suffices to limit and to check extension of the process, we are never in a position to state definitely what cases will yield to this method, and, seeing that the aim is to check the septic process in ovo^ so to speak, treatment of a more radical nature is favored by the majority of obstetricians, particularly since it may be definitely stated that such treatment, whilst most efficient for good, carries with it absolutely no risk to the patient when properly and aseptically performed.
The objections to which the douche is open are the follow- ing : No matter how often the douche is administered, all that it can accompHsh is to wash the superficies of the endometrium. The germs at work on the surface are rendered inert, but those in the depths are not affected. To attempt to check a septic
182 OBSTETRIC SURGERY.
endometritis in this way is very much like trjing to quench a fire by sprinkling water on it at intervals. Further, since the douches are always administered vnth the addition of sorae anti- septic, usually the bichloride of mercury, there is imminent risk of poisoning the woman, as numerous cases on record prove. Again, each additional manipulation to which the woman is subjected carries with it tlie risk of additional septic infection. Lastly, the repeated douche entails disturbance of a sick and nervous woman, and this is bad for the morale so necessary for convalescence from any affection, in particidar where the dis- ease is septic infection, when the aim of all therapeusis is to support the heart. For these cogent reasons the i-epeated douche has been given up by practically all accoucheurs. The following method, varied in only insignificant detail, has been substituted. On the appearance of fcetor of the lochia, which, as a rule, is the precursor of developing septic endometritis, a vaginal douche is ordered, to certify to the fact that the fcetor is not due to a vaginal source. If the fcetor persist an intra- uterine douche is administered, to exclude the presence of clots or loose fragments of decidua in the uterus. If the fcetor then persist the time for action has come ; for it must be home in mind that, as yet, there m&y be no marked constitutional disturbance, such as chill or elevation of tcm|)erature, or even much eleva- tion of the pulse-rate. Whenever possible the manipulations about to be described should be preceded by digital examination of the interior of the uterus, since not infrequently the syinp- toms awakening our suspicion are due to the retention of a piece of placenta which is bcgintiiug to necrose, or to portions of the membranes left behind. As a nile, it is not necessary to ans&- thetize tlie woman ; but if she is hypcrtesthetic or peculiarly nervous, it is better to do so in order to lessen shock, as also in order to enable the procedure to be properly performed. The instruments necessary are a dull and a sharp curette with long handles, a vuUellum, a pair of intra-uterine packing-forceps, and a uterine irrigating-tube. A speculum is not strictly requisite
requiait^
THE SURGERY OF THE PUERPERIUIC. 183
since the manipulations may be performed along the finger,- practice necessary where the pelvic floor has been repaired. Thoroughness being requisite, however, the physician should never hesitate to sacrifice the restored pelvic floor, if necessary, in order to carefully explore the uterus.
Since it is desirable to avoid disturbing the woman as much as possible, we will describe the operation of curetting the puerperal uterus without the aid of the speculum. As a rule, also, we much prefer to use the sharp curette, since when the uterine mucosa is diseased it is absolutely essential to remove it in its entirety ; for thus alone can we certainly eradi- cate the disease process and avoid a' repetition of the operation. The risk we subject the woman to is slight compared with that she runs if the operation be not thorough. This risk is per- foration of the uterus. If requisite care be used this risk is slight ; still, it is desirable to have the friends of the woman distinctly understand that the procedure is not a minor one.
A fountain-syringe connected with a glass irrigating-tube or with a double-current intra-uterine catheter, and filled with a solution of 1 to 8000 bichloride of mercury, should be sus- pended within reach, and a pint bottle of peroxide of hydrogen should be opened. The hands of the operator, the instruments, and the external genitals of the woman should be thoroughly cleansed ; the woman is brought to the edge of the couch and her legs are flexed on the abdomen. At the period of the puerperal state, when the manipulations about to be described are indicated, the cervical canal is open so that precedent dila- tation will not be necessary. Again, whenever there is any- thing remaining in the puerperal uterus or whenever a septic process exists, the same state of the canal will be found. The index finger of the left hand is introduced into the vagina and placed at the external os. Along this finger the curette is guided into the uterus, absolutely no force being used, until the loop of the instrument reaches the fundus. If digital examina- tion has revealed the presence of a portion of retained secun-
I I
184 OBSTETRIC SURGERT.
dine or placenta undergoing degeneration, the instrument i guided to this and firm traction on the handle will remove it Whilst the left hand is manipulating the handle of the curette the right hand grasps the fundus of the uterus through the abdominal wall and not only controls it, but is ever conscious of the action of the curette. Herein lies a further value of the method of curetting without the speculum.
Where the entire endometrium is involved in the necrotic process, the curette, ever under the control of the external hand, should be made to traverse it, particular care being takeo to explore the openings of tlie Fallopian tubes into the organ. When satisfied that the process is thoroughly eradicated, the curette is withdrawn, the irrigating-tube or the catheter is in- serted and the uterine cavity is washed out, the antiseptic solu- tion being at a temperature of about 115° F. When the fountain-syringe is empty, the peroxide of hydrogen is poured in and the uterine cavity is washed out with this. The catheter is now withdrawn ; a strip of steriUzed gauze, about two inches wide and eighteen inches long, is grasped by the packing- forceps and carried into the uterus, the greater portion of the gauze being inserted. Tliis insures free drainage externally.
As a rule, considerable depression follows these manipula- tions where anaesthesia has not been resorted to, and, therefore, it is generally desirable to use it. The gauze is left in situ from thirty-six to forty-eight liours, when, after renewed asepsis of the genitals and with aseptic hands the gauze is removed. The uterus is irrigated with hot 1 to 8000 bichloride, or with 2-i>er- cent. creolin, and a second strip of gauze is inserted, on this occasion not being packed in, but being placed more as a drain. If the curetting has been thorough it will rarely be necessary to repeat it; the local septic process is either at an end or it has extended to the parenchyma of the uterus, givint^ rise to a metritis, or to the tubes and ovaries, giving rise to a salpingitis or to an oophoritis. It is to avoid these untoward complications that it is essential to recognize a septic endo-
THE SUR6ERT OF THE PUERPERIUM. 185
metritis early, and to treat it radically after the manner just described.
Whilst the method of curetting through the speculum is not favored by us, since it is indorsed by many, we deem it essential to describe it. The additional instruments requisite are a speculum and a vulsellum forceps. If the operator prefer the Sims speculum, the woman is placed, of course, in the left lateral position, otherwise the Edebohl or the Simon speculum wiU answer for the dorsal position.
Aft;er due asepsis the cervix is exposed through the specu- lum, the vulsellum is made to grasp the anterior lip of the cervix, and the curette is inserted by sight instead of by touch. The manner of curetting is exactly similar to the process just described.
Frequently, after the curetting, the woman has a chill ; but, as a rule, this has no significance, being entirely nervous in character. If, after the lapse of thirty-six hours, the tempera- ture fall and the pulse approximate nearer the normal (and this fall of the pulse is the chief good omen), the chances are that the operation has been timely and that the woman has been spared extension to the parenchyma of the uterus or to the tubes and ovaries. If, on the other hand, the septic phenomena become intensified, then the physician must suspect extension, and his position must become an exceedingly alert one. A sup- purative metritis or salpingo-oophoritis can be met in only one way, and this is through abdominal section. Even then the prognosis is most gloomy, since septic processes of this nature are ordinarily associated with deep systemic lymphatic absorp- tion,— an affection against which our therapeutic resources, both medical and surgical, as yet avail but little. If, however, there should be reasonable doubt as to the systemic infection, the physician must not hesitate, but proceed to the one operation which offers the woman a single chance of life, and this is abdominal section with extirpation not alone of the purulent appendages, but also of the septic uterus. This seems a forlorn
It ,»
186 OBSTETBIC SUBGERT.
hope, and so it is ; but the sole alternative in these aggravated types of sepsis is to allow the woman to die of septicaemia emap nating from the uterus or the appendages, and this course of action is reprehensible, seeing that sometimes, although very rarely, even such desperate cases recover under the bold use of the knife.
Unfortunately, septic metritis, salpingitis, and oophoritis, when developing during the puerperium, are of such a virulent type and the associated general systemic infection is so pro- found that we can expect but one result, no matter what the therapeusis, and this result is death. The women die not so much because of the local lesions as because of the deep sys- temic infection. Still, since there are now and then recorded cases where aggressive surgery has resulted in ultimate recovery, in a given case the physician is bound to take into consideration the advisability of resorting to abdominal section. The steps of the operation are similar to those which are called for when total hysterectomy is performed for other causes. The object of the operation being to remove from the body the source of the systemic infection, ablation of the involved organs must be thorough; that is to say, the abdominal cavity having been opened, the entire uterus with the appendages must be removed in accordance with the steps which are laid down in modem treatises on gynaecology.
As a rule, there is associated with metritis and septic appen- dages the next subject we are called upon to consider : —
Puerperal Peritonitis.
In considering this affection from a surgical stand-point, it is essential to note the change in practice which the last decade has witnessed, without, however, it must be confessed, any special change in secured results. It is a fact beyond dispute that, no matter what the form of treatment employed, the vast proportion of cases of puerperal peritonitis die. Large doses of opium, saline catharsis, abdominal section,— each of these
THE SURGERY OF THE PUERPERIXTM. 187
approved methods has an exceedingly high mortality percentage. It must be remembered that puerperal peritonitis, whether local or general, is due to infection by one or two routes, aside from instances when peritonitis complicates the puei-peral state, due •to, we will say, rupture of an ovarian or tubal abscess or to a purulent appendicitis. The two modes of infection are either by direct extension from the uterine cavity or by lymphatic absorption. In the former instance the peritonitis is likely to be and to remain local ; in the latter instance it is likely to become general. The systemic infection is by no means so exaggerated, as a rule, in local as in general purulent peritonitis. In general peritonitis the affection is secondary to general systemic infec- tiop. Not alone is the peritoneal cavity filled with multiple abscesses, but the lymphatics of the entire system are gorged with the infectious element and deposit it all over the body. The women die no matter what the form of treatment employed, not because of the peritonitis, but because of the deep general systemic infection. It is absolutely essential, therefore, to endeavor to differentiate local from general purulent peritonitis. Frequently this is possible ; then, again, the symptomatology of the one suggests the other. The physical signs may be as aggravated, frequently more so, in instances of local as in cases of general peritonitis. And yet, no matter how extremely unfavorable the case may appear, sometimes speedy surgical action reveals a local instead of a general peritonitis, and some* times the women recover.
So important is the factor of diagnosis that every means should be utilized toward reaching the desideratum, — a differ- ential diagnosis between local and general peritonitis. Examina- tion of the uterus with the finger to exclude septic focus there ; palpation of the appendages, particularly by rectum, and, in case of doubt, with the assistance of deep surgical anaesthesia, — these and every other means should be used to clear the scene.
Notwithstanding all these differential diagnostic means, there are a certain proportion of cases where the physician will
188 OAsnEnic
•till remain in donbt as to whetliCT he is dealing with a local with a general peritonitis. Thai, in lememlnance of die fiicft that, if the affection be local altliongfa simiiUting genetal pea— tonitis, tlie woman's dbanoe of life depends, in all pxohaliili^v on his speedy action, gloomy as is the prognosis, it is his dn^ toiesortto the single therapeutic measuie which affiitds a gfeasca ci hope. It must nevi^ be foigotten that smgery is fall of sof- prises, and that onr finite metliods of diagnosb most olfceat be supi^emented and aided throngh resort to most deqpentB measures.
Local peritonitis presents itself under two forms,— -as extia^ peritoneal and as incapsulated intnipperitoneaL The lattov however, iB really extra-peritoneal in the sense that it is diut oflT from the general peritoneal cavity by adhesions, being originalljr intra-peritoneaL Etiolc^cally tlie inxd extra-peritoneal exudate which may suppurate is not usually associated wi& tubal or ovarian infection, whilst the latter form is generally Ihe sequda. This is the main reason why a true cellular abscess carries a less graye prognosis than the intra- and yet extra- peritoneal yaiiety. The symptomatology of true pelvic abscess — that is to say, of abscess in tlie pelvic cellular tissue — may be as aggravated iii type as the intra-peritoneal form ; and yet the outcome of sur- gical treatment is much more favorable. Whenever the local and the general symptoms point to the existence of pus in the pelvic cellular tissue, the sooner it is evacuated the better. As a rule, the point of election for operating will be the vagina, since it is here that an abscess of this character usually points.
The operation is performed as follows : Thorough asepsis of the external genitals having been secured, under the guidance of tlie aseptic finger in the vagina an aspirator-needle is plunged into the softened exudate at a point close to the cervix, in order to avoid injuring the ureter. Along this aspirator-needle, as a guide, a narrow-bladed knife is passed and the opening into the cavity is enlarged. A steel-branched dilator is next inserted, and the opening is torn wider. The finger is then inserted into
THE SURGERY OF THE PUERPERIUM. 189
the cavity, and the dififerent chambers which frequently go to make up the cavity are broken down. The cavity is then irri- gated with bichloride or creolin solution, and next washed out with the full- volume peroxide of hydrogen. A T-shaped rubber drain-tube is then inserted, and through this the cavity is washed out daily until suppuration is at an end. If the cause of the symptoms has been the cellular abscess, in twenty-four to thirty-six hours the general condition of the woman will have altered materially for the better, and as soon as she has thrown oflf the general sepsis she will rapidly convalesce.
Such is the treatment and such the course of events in pure cellular abscess, which, we repeat, may present as aggra- vated symptoms as the intra-peritoneal variety. Rarely these cellular abscesses do not point in the vagina, but above Pou- part's ligament. Then the point of election for incision is at this site. The cavity is entered by an incision parallel to Pou- part's ligament, is washed out after the same fashion, and, where possible, a counter-opening is made into the vagina^ since thus we obtain better drainage, and, therefore, speedier convalescence.
It is the intra-extra-peritoneal variety of abscess which gives the most trouble, both from the diagnostic and the thera- peutic stand-point. General purulent peritonitis, being an epi- phenomenon of general septic infection, has as yet proven rebellious to every therapeutic measure. The woman dies not because she is sufifering from peritonitis, but because she is deeply poisoned. The post-mortem findings explain this. Not only does the peritoneal cavity contain multiple abscesses, but the venous and lymphatic systems are similarly gorged. What then, it may reasonably be asked, is the use of surgical pro- cedure? Because, as we have already stated, the symptoma- tology of local peritonitis sometimes is suggestive of general peritonitis, and, therefore, abdominal section, even though the case appear of the most desperate type, may reveal a local peri- tonitis amenable to treatment. It must further be remembered
190 OBSTETRIC SURGERY.
that peritonitis, associated with purulent appendicitis, may coi plicate the puerperal state, and here prompt sectdon may resi in the saving of life. In this desperate disease one must ha^ the courage of strong convictions, and operate, even thou^ the battle seem lost before action. We are absolutely assuR that nothing is to be gained from therapeutic nihilism, at ac rate.
The abdominal cavity is opened in the usual way, and, i we are fortunate enough to find a local peritonitis instead of general, the abscess-cavity is emptied, is washed out with pei oxide of hydrogen (full strength), and is packed with sterilize gauze. If, however, the peritonitis is general and purulent, the the most we can do is to break up the multiple abscess-cavitie as far as we can detect them, repeatedly flood the peritonei cavity with hot sterilized water, and pack the lower part of th pelvis with gauze. If the woman recover, the result is fairl miraculous. If she die, the physician has the satisfaction o knowing that he has done his full duty by his patient and thfi I the result was in no sense due to surgery.
Puerperal Mastitis.
In the light of our present knowledge, puerperal mastiti must be considered as due to infection. The germs or infectiou material gain entrance througli the lacteal ducts and cause th inflammatory process which may be aborted or which ma suppurate.
In the latter event, we have the affection which is terme • mammary abscess. Two varieties of mammary abscess are t be differentiated, — the glandular and the sub-glandular. Th former is not specially uncommon ; the latter is exceedinc^ly sc The one is readily recognized ; the other is not, running a; insidious course and undermining the gland often before it presence is made sufficiently known to call for the recognize treatment.
Whilst much may be accomplished in the way of abortinj
!;
THE SUR6ERT OF THE PUERPERIUM. 191
suppuration through the use of the ice-bag, or, if the individual prefer, by hot applications, as soon as the physician is sure of the presence of pus, the earlier it is evacuated the better for the welfare of the breast. Glandular abscess ought to be recog- nized early ; the reverse holds true in case of the sub-glandular variety. And yet this latter form is the one which always even- tually does the most damage to the glandular tissue, and, besides, subjects the woman to the serious risk of perforation into the pleural cavity before there exists at times sufficient evidence of pus to justify incision. In these obscure cases, when, under the use of ice or heat, the cardinal symptoms of inflammation do not abate, exploration with the aspirator- needle should be resorted to. Of course, this aspiration should be strictly aseptic, otherwise a non-suppurating exudation will be converted into a suppurating.
When the aspirator-needle reveals pus, or when there is evidence of pus without aspiration, the sooner the gland is incised the better. The line of incision should be radiating from the nipple outward, in order to avoid injuring more of the lacteal ducts than are already involved in the suppurative pro- cess. The affected breast should be scrubbed with soap and water, then with 1 to 8000 bichloride solution, and finally washed with sulphuric ether. With a clean knife an incision is made through the gland down to the abscess-cavity. When this has been opened, the finger is inserted in order to break up all the cavities into which the abscess is apt to be divided. After thorough irrigation with bichloride, the full-strength per- oxide of hydrogen is poured in and the cavity is packed with sterilized gauze. A firm compression-binder is applied. At the end of twenty-four hours the dressing is removed, the cavity is again irrigated, a gauze drain is inserted, and a large sterilized sponge is placed over the breast. A firm binder is applied over all. This method of compression secures close apposition of the abscess cavity-walls and prevents the further pocketing of pus. In the event of there being no evidence from the side
192 OBSTETRIC SURGEET.
of the pulse and the temperature of septic absorption, t second dressing need not be changed for a number of da when the cavity may be found entirely closed.
In more complicated cases, where, for instance, a subma mary abscess has not been recognized in its early stages, I pus may be found to have dissected the entire gland, and tli all attempts to save the lacteal ducts are futQe. As ma counter-openings as are necessary, in order to secure efficii drainage, must be made, and every possible effort ia requisite prevent the pocketing of pus under tlie pectoral muscle a toward the pleural cavity.
As tlie principles of asepsis as applied not alone to t maternal breast, but also to the infant's mouth before it applied to the breast, are understood by nurses and exacted physicians, mammary abscess will become one of the rar complications of the puerperal state. In laige maternity h< pitals, where the strictest care is required, the fact is tl mammary abscess is now rarely met with, and, when it is, 1 nurse has been at fault, unless the mother has handled ) bi'east with unclean hands.
CHAPTER IX.
ECTOPIC GESTATION.
The subject of ectopic gestation is of prime interest to the general practitioner, for the reason that on his ability to recog- nize the condition early depends usually the life of his patient. Seeing that the majority of obstetric work falls within the province of the general practitioner, it seems appropriate that ectopic gestation should be considered from its therapeutic side in a work dealing with obstetric surgery.
We shall not enter into a discussion of the value of elec- tricity in the treatment of ectopic gestation. Sufficient the statement that it seems proven that in its earlier stages the development of the ovum may be checked through the adminis- tration of galvanism or faradism. Our aim will be fulfilled when we have tersely noted the diagnostic points and have laid stress on the surgical treatment of ectopic gestation.
We shall consider this subject from the now generally accepted view that primarily all ectopic gestations are tubal. About the tenth week rupture of the tube occurs in one of two directions: (1) into the general peritoneal cavity; (2) into the broad ligament. In the latter event the gestation may or may not continue to term.
The surgery of ectopic gestation, therefore, envisages the subject from a number of stand-points : 1. Before tubal rupture. 2. After rupture (a) into the peritoneal cavity; (6) into the broad ligament. 3. During development to term. 4. At term and after term.
Essential to any treatment is accurate diagnosis. Before tubal rupture this will rarely be possible beyond strong hypoth- esis. At the time of rupture the symptomatology will ordi- narily establish the diagnosis. During development to term and at term the diagnosis is often in doubt, not as to whether
" (193)
194 OBSTETRIC SUR6ERT.
pregnancy exists, but as to whether it be uterine or extr uterine. After term, if the precedent history be clear, the diaj nosis is established ; but often it may be made only on abdomim section.
Before rupture — that is to say, before the tenth to twelft week of gestation — ^the diagnosis may be reasonably predicate on the following history: A period of amenorrhoea, associate especially with the reflex disturbances of pregnancy, foUowe j by irregular haemorrhages. Ordinarily there is a history su«
gestive of precedent disease of the uterus and appendages, anc I as a rule, the woman has never conceived before or there ha
^ been a period of protracted sterility. On local examinatio;
(vaginal and rectal) the uterus is found enlarged, and one o the other tube as well (either in situ or posterior to the uterus] The woman, furthermore, often complains of sharp attacks a abdominal pain, which are the associates of the distension of th tube, or are due to peritoneal irritation from tearing of th peritoneal covering of the tube. This eiuemble of symptom should at once awaken the suspicion of the existence of tuba gestation. It is at this period that galvanism may be resorte< to with safety, since it may do good and can only do harm ii that its use postpones resort to surgery, if it do not render thi unnecessaiy.
The symptoms of rupture vary according as the acciden occurs into the peritoneal cavity or into the broad ligament Accurate diflferentiation is essential, since there is but one pos sible line of action in the former event, and this is abdomina section as soon as feasible. The main symptom is coUaps of varying degree, with the formation of a tumor in case o rupture into the broad ligament. Where the rupture is intra peritoneal, the symptoms suggestive of haemorrhage (fainting sighing, rapid pulse, increasing pallor) are usually more grav than where tlie rupture is extra-peritoneal. The reverse ma hold, however, since the intra-peritoneal bleeding may b gradual and the extra-peritoneal profuse. The precedent liis
^^^^^^^^ ECTOPIC GESTATION. lOT^
toiy, however, and the immediate symptoms should certify to the diagnosis almost always so as to lead to the adoption of the proper therapcusls, whicli is immediate abdominal Eection in case of intra-peritoneal hsemorvhage, and expectancy in case of broad-ligament hsemorrhage.
The symptomatology of ectopic gestation after primary extra-peritoneal rupture may be self-suggestive as regards diag- nosis, and again may be very obscure. So long as the fcetus is alive, the hearing of the heart-sounds aud the perception of movements will certify as to pregnancy ; but, usually, short of exploration of the uterus, normal gestation cannot be excluded. After fcctal death, whilst tlie precedent history will suggest the likelihood of ectopic gestation, abdominal section alone, in the vast majority of cases, will clear the diagnosis.
The following conditions may simulate intra-peritoneal rupture of ectopic gestation : Abortion, dysmenorrhcea, rupture of some abdominal organ witli escape of its contents into tlie peritoneal cavity, and pelvic peritonitis.
The following conditions may be mistaken for extm-peri- toneal rupture of ectopic gestation : Intra-peritoneal rupture of the same condition, lisematoma of the broad ligament from other causes, exudate in the cellular tissue of the ligament, and cyst of the broad ligament or abscess within it.
In both series of instances, attention to the history and careful physical examination, if need be under an anses- thetic, will often clear the diagnosis. Peritonitis may be ex- cluded by the elevation of temi)erature, which exists, usually, from the outset. Exploration of the uterus, together with care- ful bimanual, rectal and vaginal, will exclude abortion, aside from the fact that shock rarely exists in the latter condition, except the woman he hypersesthetic and hysterical, when it is never deep and progressive, but transient. In case of rupture of some viscus. such as* the appendix vermiformis, with escape of its contents, where the depression is extreme, the therapeutic indication is the same as for rupture of a tubal pregnancy into
190 OBomBiu
file pentoneal oMitj. The feroMtiim or die proicuce of a tmiMnr in cme mr die oflMV bioed figament, no matter what the cooditioD, win lack the ingenej caning for immediate waxgaj. FlnaUy, then are instances wlusie comlrined nteme and mteiine gestation exist, and heie, no matter how refined our J=
diagnostic aids, die question can alone be settied by ezphxntbn
of the nterus, and, in the cTcnt of supposed infaBa»peritaieaL-J rupture, by abdonmial section.
The diagnosis (^ ectopic gestation having been made witkjfl sufficient exactitude to swer?e the judgment of tvro or mmt — physicians in its &Tor, the womaif must be regarded as sabjectrai to a greater or a less imminent risk, according to tibe period oi gestation. The ovum is a parasite of iU ommi to ite mother, and its destruction or rraioval is called for when, by so doing, the immediate or tiie ultimate safety of the woman so
Prior to tubal rupture, when the diagnosis is always oncer- tain, arrest of tiie growth of tiie ovum by means of galvanisn^M or of faradism is justifiable. Absorption of so sman a mass the ovum is prior to the eighth or tenth week is perfectiy sible, and, if this absorption should not occur, the woman best is carrjring a diseased tube, which at any time when il seems desirable may be removed by abdominal section. Wbsse^ however, the physician is a skilled opemtor, the immediate and future welfare of the woman is best secured through resort to abdominal section. The steps of the operation are the follow- ing : The abdomen and the pubes having been shaved and the integument having been cleansed by thorough scrubbing with soap and water, followed by 1 to 1000 bichloride solution, the woman is anaesthetized. The bladder is emptied. The instru- ments (scalpel, artery-forceps, ligature-carrier, Peaslee-Hagedom needle) should be thoroughly sterilized, and the hands of the operator and of his assistants should be scrupulously cleansed It must be remembered that septic infection is the sole risk the woman runs in the hands of an operator familiar with the technique.
ECTOPIC GESTATION.
The operation is likely to prove of shorter duration if the woman be placed in the Trendelenburg position. This position may be improvised by tying au ordinary kitchen-chair to the table 80 as to form the' inclined plane. (See next page.)
In addition to the instruments, the operator should have prepared at least four large, flat, gauze pads and one dozen small gauze sponges. A quart-bottle full of 1-per-cent. hot (120° F.) sterilized salt-solution should be ready to irrigate the peritoneal cavity, in the event of threatened collapse from im- avoidable haamorrbage. The peritoneum rapidly absorbs the salt-solution, and it forms our readiest restorative.
The usual incision is made down to the peritoneum, about three inches in length, extending upward from above the pubes. Any htemorrhage is cliecked by torsion of the small vessels.
Before opening the peritoneum the operator should emphasize his injunction that absolutely no antiseptics are to be used in the further progress of the operation.
The peritoneal cavity having been entered, one or more of the large gauze pads, wrung dry from the sterilized water, are inserted to keep the intestines from the abdominal opening. With one or two fingers the operator liberates the tube and ovary (if adherent) and brings them out of the abdominal incision. The ovarian artery being very vascular, it is desir- able, when feasible, to isolate it and tie it separately with medium-sized sterilized silk. The pedicle is transfixed by the ligature-carrier; a stout, sterilized, C'iiinese-silk ligature is brought through, tlie ends are crossed and firmly tied, after the usual manner. The appendages are then removed.
198
OBSTETRIC SURGERY.
The tube and ovary of the opposite side are next exam ined, and, if diseased, are similarly tied off.
The pads are now removed from the abdominal cavitj If tlie operation has not been associated with hasmorrlia^, iti not necessary to mop out or to irrigate the field of operatioii In case the pulse is flagging, however, irrigation with the sal solution should be resorted to.
The abdominal incision is closed by deep silk-worm^i
z3
sutures transfixing all the tissues and including carefully th( Ikscia of the recti.
In the event of the woman not being seen until tubal rupt urc lias occurred, tlie surgical treatment must be immediate if the Iitemorrhage be intra-peritoncal. The steps of the opera- tion are similar to thoi^e just stated, except that, on opening the peritoneal cavity, no time should be lost in grasping the rupt- ured tube and tying it off", for this is the source of the hfe^lo^ rhage. The peritoneal cavity sliould then be irrigated with hot, sterile salt-solution to act as a restorative and to wash, out
ECTOPIC GESTATION.
L
the major portion of the blood and clots. What must perforce be left behind the peritoneum will take care of, unless it be septic. Where this possibility is feared, drainage by gauze through Douglas's cul'de-eac is preferable to attempts at drain- age through the abdominal incision.
When the diagnosis of rupture into the broad ligament (extra-peritoneal rupture) has been reached the therapeusis should be strictly expectant ; operative treatment is rarely called for. If the woman be kept in tlie recumbent position until the hfematoma becomes smaller, but little other treatment will be necessary, beyond the self-suggestive means for meeting the greater or less acute ansemia from which the woman is suifering : such as frequent hot water (115° F.), saline (1 per cent.), rectal irrigation, strychnine hypodermatically {-^^ grain every three to four hours), etc. Rarely tlie blood-clot breaks down into pus from septic infection. An opening should then be made into the sac from the vagina. Tlie pus must be thoroughly evacu- ated, the sac washed out with the full-strength solution of per- oxide of hydrogen, and drainage resorted to.
In a small proportion of cases the ovum survives the extra- peritoneal rupture and continues to grow. The woman from now until term is in constant danger from the possibility of secondary rupture into the peritoneal cavity. Every day the increasing size of the child and of tlie placenta adds to the danger of this accident. The life of the woman alone is to be taken into considemtion. The chances that development will continue and the child reach fuU term are small, and even if it should, and be safely removed, it rarely survives the first few weeks, and is rarely, also, perfectly formed.
Inasmuch as the continuous growth of the child constantly increases the danger which the woman must encounter, it is the duty of the physician to destroy it as soon as it has been de- termined that development is taking place. If development has continued beyond the fourth month, the death of the child will not increase the woman's safety. The sac may have formed
900 oaganao
adhenims m&L loops of intestme, and tibxough tius aomoe wejgm may haye «iteied the system. In such cases it is necessary tm caiefully watch the woman, and, as soon as any sympfemns of sepsb are apparent, abdominal section is to be peifiMnned* These symptoms are chiUs, remittent tempemtoie, lapid pulse* The sac is to be opened, the decomposed fcetos is to be xemoTed^ and the opening of the sac is to be stitdbed to the abdominal, wall. Usnally the placenta will have become ficeed j&om i( attachments and may be lemoved at the same time. Should il be adherent, however, it is preferable to aUow it to come awai in fragments. Free drainage should be maintained. Usnall] this opemtion will be practically extm*pmtoneaL
If the child has reached fhll term and is alive, a rery teresting complication caUs for decision. The little notoriei which one gains from performing a brilliant op«»tion ahool^^ not influence the conscientious physician for a moment. ITdith^av must sentimental notions carry the least weight in reaching ^m conclusion. The question to be decided is the following ^ *^ Should I operate and possibly save the life of the duld, whkftz at best will stand but few chances of surviving, and by so doings greatly add to the dangers of the alieady-unfortunate mother; or j should I delay the operation and thereby permit the child to die and the placenta to lose very much of its vascularity, if, indeed, not all of it, and by this delay very much enhance the chance of recover)^ of the woman 1" To those who will look at this question purely from the stand-point of the woman, and who will consider, as they ought, the ectopic foetus as simply a para- site, the choice will unquestionably be in favor of delay. No one will deny the legitimacy or the imperative necessity of re- sorting to foeticide in the non-controllable vomiting of pregnancy, with the end in view of saving the woman. The belief of Tail, that those who advocate the killing of the child in developing extra-uterine pregnancy are simply "abortion-mongers,** is illogical, and must be looked upon as one of those statements which are made in haste and are not retracted owing, possibly, to false pride.
ECTOPIC GESTATION. 201
After the child is dead and the placental circulation has ceased, operation carries far less danger to the woman. It is contended by some that no operation should be performed until symptoms supervene, but nature's tedious methods of relief and the many obvious dangers to which the woman must be ex- posed do not seem to justify non-interference. The abdomen should be opened as soon as the placental circulation has ceased (and this is certified to by the absence of placental murmur), the foetus is removed, and the sac is stitched to the abdominal wound. If the placenta is detached and lying free it should be removed, and the sac is drained and allowed to close from the bottom. If the placenta is adherent, no attempt should be made to free it, for it will come away gradually through the abdominal opening. Convalescence is hastened if a vaginal opening can be made at the same time and through-and- through drainage thus established.
Under the modern method of treatment we have outlined, ectopic gestation has been practically robbed of its terrors, and the almost absolute mortality rate of the past has been con- verted into the almost certain recovery rate of the present. Once again is the value of election in obstetric surgery certified.
1
■
!. ,1
1.1
Pi
il
INDEX TO VOLUME II.
Aborti&cients, uselessnesB of, 58 Abortion, artificial, 34
in absolute pelvic contraction, 37 in case of haemorrhage, 39 in case of tumors, 38 in chorea, 36
in displacements of the uterus, 39 operation for the induction of, 41, 46 in pernicious anaemia, 36 in pernicious vomiting of preg- nancy, 35 in pulmonary and cardiac dis- ease, 34 in renal disease, 36 Abscess, mammary, 190 pelvic, 188 operation for, 188 Accouchement forc^, 67 Accoucheur, asepsis of, 2 Ansemia, pernicious, artificial abor- tion in, 36 Anatomy of pelvis, 9
of symphysis pubis, 121 Antisepsis, 1
definition of, 2 Arm, prolapse of, method of rectify- ing, 107 Arms, methods of delivery of. Ill Asepsis, 1
definition of, 2
of accoucheur and attendants, 2 of genital tract, 5 of hands and arms, 4 of instruments, 6 of ligatures and sutures, 7 of lying-in woman, 5 Axis-traction forceps, 73, 74 to the breech, 87
Basiotribe, Tamier's, 154 Beaudelocque, diameter of, 12 Bipolar version, 101 method of performing, 103
Bladder, danger of injury to, in sym- physiotomy, 123
Braxton-Hicks method of version, 101
Csesarean section, 133 abdominal suture after, 140 absolute indication, 132 dilatation of cervix after, 137 election in, 133 indications, 133 instruments for, 134 preparations for, 135 prognosis of, 144 relative indication, 132 statistical data, 145 suture of uterus after, 138 Catheter, Fritsch-Bozeman, 42 Cephalotribe, application of, 155 disadvantages of, 154 Lusk's, 154 Cepbalotripsy, operation of, 153 Cervix, dilatation of, after Csesarean section, 137 lacerated, immediate repair of, 163 after-treatment, 167 contra-indications, 164 instruments necessary, 164 steps of operation, 165 suture material for, 164 manual dilatation of, 89, 102 multiple incision of, 89, 105 Chin, arrested at symphysis, extrac- tion of, 116 Chorea, artificial abortion in, 36 Conjugate, diagonal, 13
true (conjugata vera)^ 14 Cranioclast, Braun's, 149
extraction by, 150 Craniotomy of the after-coming head, 152 of the before-coming head, 150 operation of, 148 Crotchet, 157 Curette, uterine, 41
(203)
204
INDEX.
> I
1'
It ii
•'•,
i
■' ;
Decapitation, 157 delivery of head after, 159 method of performance, 158
Decollator, Braun's, 158
Diameters of foetal head, 16 of pelvis, external, 11 internal measurements of, 15 pelvic, increase in, by symphysi- otomy, 122 transverse and oblique, 15
Dilator, steel-branched, 41
Dilators, hydrostatic, 66
Dystocia, obstetric, 9
Eclampsia, induction of labor in case of, 54
podalic version in, 97 Election, value of, in Csesarean sec- tion, 133
value of, in symphysiotomy, 121 Electricity as a means of inducing
labor, 58 Elytrotomy, laparo-, 144 Embryotomy, 146
prognosis of, 161 Endometritis, curetting in, 182
gauze tampon in, 184
objections to douche in, 181
operation for, 183
post-operative treatment of, 185
puerperal, 181 Episiotomy, 83 Evisceration, 155
indications for and dangers of, 156
Face presentations, low forceps in, 81 Fistiilae, 174
after-treatment of, 176
operation for repair of, 176 FcEtal head, diameters of, 16 FcBtus, determination of engagement of, 51
dimensions of, at term, 16
intra-uterine measurement of, 50
length of, 50
manual internal rotation of, 117 in case of occiput posterior, 118 Forceps, 72
anaesthesia for extraction by the, 77
application of low, 81 of medium, 88
Forceps, compression by the, 1 contra-indications to the use direction of traction in low, I EUiott's, 72 forces of the, 74 high, 91 Hunter's, 73
in breech presentations, 77 indications for the, 76 intra-uterine dressing, 45 introduction of left blade of, introduction of right blade o Jewett's axis-traction, 74 leverage of the, 76 locking of, 80
low, in face presentations, 86 in occipito-posterior, 84, 85 Lusk-Tarnier, 73
medium, dangers of, 89 ovum, 42
position for the application o prognosis of, 92 Reynolds's traction rods for, rotation by the, 75 to after-coming head, 116 to breech, 87 Funis, prolapse of, version in, S
Galbiati knife, objections to, 12 Gestation, ectopic, 193
broad ligament, rupture of, 1
treatment of, 196 development of, to term, 199
treatment, 200 diagnosis of, 193
at time of rupture, 194 before rupture, 194 intra-peritoneal rupture, ] 94
primary, 195 operation for primary rupture terminations of, 193 treatment after foetal death, 2 treatment of broad-ligament ture, 199 Glycerin, injections of, for indu labor, 60
Haemorrhage, artificial abortioi case of, 39 as a complication of symph^' omy, 129
INDEX.
205
Haemorrhage, induction of labor in
case of, 53 Hands, asepsis of, 4 Head, after-coming, forceps to, 116 arrested at brim, extraction in case
of, 115 delivery of, after decapitation, 159 fcetal, arrested at symphysis 116
compressibility of, 51 on perineum, method of delivery of, 83 Heart disease, artificial abortion in,
34 Hook, blunt, 157 Hunter's low forceps, 73 Hysterectomy, laparo-, 141 after-treatment, 144 indications, 142 technique, 142
Incision, multiple, of cervix, 89, 105 Incubator, 69 Instruments, asepsis of, 6
Jewett's axis-traction forceps, 74 Justo-major pelvis, 18 Justo-minor pelvis, 19
Kidney disease, artificial abortion in,
36 Knife, Galbiati, 124 Krause's method for inducing labor,
61 Kyphosis, 24
Labor, premature, induction of, 47 in case of eclampsia, 54 in case of deformed pelves, 48 in case of hsemorrhage, 53 method for, 58 •^ prognosis of, 68 Laparo-elytrotomy (vide Elytrot-
omy) Laparo-hysterectomy (vide Hyste- rectomy) Ligament, subpubic, necessity of cutting, in symphysiotomy, 126 Ligatures, asepsis of, 7 Lusk-Tamier forceps, 73
Mastitis, glandular, 191 puerpend, 1 90 Bubglandular, 192 Membranes, puncture of, for in- ducing^ labor, 58 Mento-posterior position, symphysi- otomy in, 127 Metritis, abdominal section in case of, 185 extension of sepsis causing, 184 puerperal, 181
Nurse, asepsis of, 2
Occipito-posterior position, forceps in, 84 manual rotation in, 118 symphysiotomy in, 127
Oophoritis, septic, 186
Osteomalacia, 28
Pelves, abnormal, 17
contracted, symphysiotomy in, 122
deformed, by tumors, 81 induction of labor in, 48 Pelvic version, elective, 96 Pelvimeters, 11 Pelvimetry, 11
digital, 13 Pelvis, anatomy of, 9
circumference of, 16
contraction of, artificial abortion in, 37
diameters of, increase in, by sym- physiotomy, 122
external diameters of, 11
flat, rachitic, 23
flattened, 20
funnel-shaped, 28
internal diameters of, 13
justo-major, 18
justo-minor, 19
kyphotic, 24
Naegele, 30
oblique-ovate, 30
osteomalacic, 28
rachitic, 21
rachitic-scoliotic, 26
scoliotic, 25
spondylolisthetic, 27
transversely conti*acted, 24
906
"nroiBf,
P«rlbnilor, Blot%, 148
Perineonliftphy, aftei4mliiiQiit| If 8 eonlm-liiaiemmis, 168 te oompltle niptibe. ITS for purtial raptiirei 170 H^iur's metbod of, ITO immediate, 16T instnunents requisite far, 169 SMtliod of pesformiiig, 169 •atare materiftl for, HI Perineum, oentrel laoemlioii of, 1T8 iMXuretimi of, d^ermlnafeion ot^ 168 Tuieties of laeemtion of, 168 Peritoneiim, melhode of in&otion of,
18T Peritonitie, differentiation of local firqm general, 18f intrsrperitcHMal, encapenlated, 189
operation for, 190 local, 188
operation for, 188 puerperal, 186 Phoente prsevia, 5$
bipolar version in, lOS Porro operati<m {vide Hyetereo-
tomy) Pregnanqr, extra-nterine (vide Gee- tatioii, ectopic) pernicious vomiting of, 35 Puerperium, eargery of, 163 Pulmonary disease, artificial abortion in, 34
Quinine to promote contractions, 90
Rachitis, 21
lleynolds's traction rods, 75
Roberts's pelvis, 24
Rotation, manual, of fcetus, 117
Salpingitis, septic, 186 Scoliosis, 25 Specula, Simon's, 175 Speculum, EdebohPs, 43 Spondylolisthesis, 27 Spondylotomy, 157 Sponges, dangers of using, 7 Suture, uterine, 138 Sutures, asepsis of, 7
Sympbysiotomy, ISO
amr-treatment of, IM
amount of gain in cUamiBtav Ikv 122
atiatemioal ocmrideiatioMi 121
eomplieatf<m8 of, 128
delivery after, 128
&oter8 controlling, 188
Gall^ati knife for, 124
indications, 122
instrumente eeeential Ibr, 124
prognosia of, 180
repair of wound after, 12Y
atetistical data, 180
structures involved in, 122
technique of, 124 subcutaneous method, 125
ultimate resnlte from, 129 Symphysis pubis, effect of operation at, 129
mobility at, 128
Tenaculum, cervical, 48 Trephine, Braun's 148
Martin's, 149 Tumors, deforming the pelvis, 81
pelvic, artificial abortum in, 87 Twins, locked, 161
Urethra, danger of injury to, in sym- physiotomy, 128 Uterus, displacements, artificial abor- tion in, 39 management of, after Cesarean
section, 136 rupture of, 177 abdominal section in, 179
annular, 181 prognosis of, 179 suture of, after Caesarean section,
138 tamponade in, 180 treatment of, 178 varieties of, 177
Vagina, asepsis of, 5
hand in, for purpose of examina- tion, 99
tamponing, for inducing labor, 69 Yaselin, dangers in using, 6
INDEX.
207
Yersion, 98
bipolar, in case of placenta prsevia, 102
Braxton-Hicks method, 101
bj external manipulations, 101
cephalic, 94
combined method of, 101
internal, 105
extraction after, 110 extraction of head, 112 insertion of hand in, 106 rotation of fcetus by, 94 seizure of foot in, 107
Version, liberation of arm after,
111 nomenclature of, 94 pelvic, 94
objections to, 100 performance of cephalic, 95 podalic, 96
contra-indications of, 97
indications for, 97
preparations for, 99 prognosis of, 119 varieties of, 94
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