Plate I. Davis' Obstetrics. The Abdomen at Term. (Martin.) A MANUAL OF PRACTICAL OBSTETRICS. BY EDWARD P. DAVIS, A. M., M. D., CLINICAL LECTURER ON OBSTETRICS IN THE JEFFERSON MEDICAL COLLEGE, PROFESSOR OF OBSTETRICS AND DISEASES OF CHILDREN IN THE PHILADELPHIA POLYCLINIC, VISITING OBSTETRICIAN TO THE PHILADELPHIA HOSPITAL, PHYSICIAN TO THE CHILDREN'S DEPARTMENT OF THE HOWARD HOSPITAL, MEMBER OF THE AMERICAN GYNECOLOGICAL SOCIETY. WITH ONE HUNDRED AND FORTY ILLUSTRATIONS, TWO OF WHICH ARE COLORED. PHILADELPHIA: P. BLAKISTON, SON & CO. 1012 WALNUT STREET. l8qi. COPYRIGHT, 1891, BY P. BLAKISTON, SON & CO. PREFACE. THE preparation of this book has been suggested to me by the needs experienced in teaching students of medicine. The development of post-graduate instruction, and the estab- lishment of obstetrics as a Senior Study in medical colleges, have relieved obstetric study from the details of anatomy and physiology memorized by the student in his earlier years. Whether he be an undergraduate in a medical college, or a practitioner, he desires to know the reasons for scientific facts, and the practical deductions which their consideration suggests. As an aid in such study, I have endeavored to give a concise statement of modern practical obstetrics as taught by Parvin, Lusk, Schroder, Winckel, Carl Braun, Galabin and Diihrssen. Personal experience has guided my choice of methods of treatment commended. My best thanks are due to Professor Parvin for many acts of courtesy and kindness ; to Dr. Naudain Duer for assistance in preparing illustrations ; and to Dr. A. A. Eshner for the index. 250 S. 2ist Street, Philadelphia. TABLE OF CONTENTS. CHAPTER. PAGE. I. OVULATION; MENSTRUATION; CONCEPTION; THE OVUM . 9 II. THE EMBRYO 15 III. THE FCETUS AND ITS PHYSIOLOGY 24 IV. THE BIRTH CANAL 34 V. THE MOTHER IN PREGNANCY 43 VI. THE DIAGNOSIS OF PREGNANCY 45 VII. THE HYGIENE OF PREGNANCY 53 VIII. THE ATTITUDE AND LOCATION OF THE FCETUS .... 57 IX. LABOR, THE HEAD PRESENTING 61 X. ABNORMALITIES OF LABOR, THE HEAD PRESENTING . . 71 XI. THE TREATMENT OF NORMAL LABOR 77 XII. THE THIRD STAGE OF LABOR 83 XIII. THE TREATMENT OF ABNORMAL LABORS, THE HEAD PRESENTING 88 XIV. THE FORCEPS 91 XV. Axis TRACTION; THE RARER USES OF THE FORCEPS . 98 XVI. LABOR IN BREECH PRESENTATIONS 109 XVII. LABOR IN TRANSVERSE POSITIONS 120 XVIII. VERSION 123 XIX. LABOR WHEN THE CHILD AND BIRTH CANAL OF THE MOTHER ARE DISPROPORTIONATE IN SIZE 132 XX. LABOR COMPLICATED BY OBSTRUCTION IN THE BIRTH CANAL 135 3 4 TABLE OF CONTENTS. CHAPTER. PAGE. XXI. LABOR IN CONTRACTED PELVES 139 XXII. ABORTION; PREMATURE LABOR 149 XXIII. INDUCED LABOR 157 XXIV. MULTIPLE PREGNANCY 161 XXV. PATHOLOGY OF PREGNANCY: ECLAMPSIA 166 XXVI. THE ACUTE INFECTIONS OCCURRING DURING PREGNANCY 175 XXVII. AFFECTIONS OF THE GENITO URINARY ORGANS OCCUR- RING DURING PREGNANCY. THE BLOOD AND NERVOUS SYSTEM 179 XXVIII. THE SURGICAL TREATMENT OF COMPLICATED LABOR . 188 XXIX. EMBRYOTOMY 194 XXX. THE PUERPERAL STATE 206 XXXI. PUERPERAL STATE; LACTATION 212 XXXII. ARTIFICIAL FEEDING OF INFANTS 217 XXXIII. ABNORMAL INSERTION OF PLACENTA : PLACENTA PR.^EVIA 222 XXXIV. ECTOPIC PREGNANCY 228 XXXV. POST PARTUM HAEMORRHAGE 233 XXXVI. ACCIDENTS OF LABOR ENDANGERING THE MOTHER . . 238 XXXVII. LACERATION OF PERINEUM AND PELVIC FLOOR . . . 245 XXXVIII. PUERPERAL SEPSIS 251 XXXIX. THE TREATMENT OF PUERPERAL SEPSIS 258 XL. COMPLICATIONS OF THE PUERPERAL STATE 261 XLI. RETENTION OF THE PLACENTA 266 XLII. DISEASE OF FCETAL APPENDAGES 269 XLIII. DISORDERS OF THE FCETUS 273 XLIV. MONSTERS 277 XLV. DISEASES OF NEWBORN CHILD 279 APPENDIX 284 INDEX 291 LIST OF ILLUSTRATIONS. i. Two GRAAFIAN FOLLICLES. 2. HUMAN OVUM. 3. THE MURIFORM BODY. 4. THE DECIDUOUS MEMBRANES. 5. THE EMBRYONIC AREA AND AXIAL GROOVE. 6. EMBRYO, SEVEN OR EIGHT WEEKS OLD. 7. -OVUM Six WEEKS OLD. 8. -THE AMNION AND ALLANTOIS. 9 VILLI OF CHORION (low power). :o. VILLI (330 diameters), n.- PLACENTAL VILLI AND DECIDUA. 12. PLACENTA, MEMBRANES (stripped upward). 13. PLACENTAL AND UTERINE VESSELS. 14. THE PLACENTA AND UTERUS (injected while adherent). 15. -THE MEMBRANES. (Section through uterine wall.) 16. CROSS SECTION OF CORD. 17. DIAGRAM OF THE FCETAL CIRCULATION. 18. THE FCETAL HEAD. 19. THE FCETAL HEAD. 20. THE FCETAL HEAD. 21. THE BIRTH CANAL. 22. DIAMETERS OF PELVIC BRIM. 23. PELVIC OUTLET. 24. DIAMETER OF BRIM, AND Axis OF BIRTH CANAL. 25. Axis OF FCETAL BODY, FULCRUM, SHORT AND LONG ARM OF LEVER. 26. THE PELVIC MEASUREMENTS. 27. INTERNAL MEASUREMENTS OF THE ANTERO-POSTERIOR DIAMETER OF THE PELVIC BRIM. 28. THE PELVIMETER. 29. THE USUAL ATTITUDE AND LOCATION OF THE FCETUS. 30. LATERAL SURFACE OF THE PELVIS. 31. THE FCETUS IN A PRIMAGRAVIDA. 32. THE FCETUS IN A MULTIGRAVIDA. 33. THE DESCENT OF THE FCETUS IN LEFT OCCIPITO ANTERIOR LABOR. 34. THE HEAD ENGAGING IN THE PELVIC BRIM. S 6 LIST OF ILLUSTRATIONS. 35. DESCENT AND ROTATION. 36. THE HEAD UPON THE PELVIC FLOOR. 37. BEGINNING EXPULSION OF THE HEAD. 38. RETROCESSION OF COCCYX. 39. HEAD BORN IN RIGHT OCCIPITO-ANTERIOR LABOR. 40. THE OCCIPUT IN THE HOLLOW OF THE SACRUM. 41. FACE PRESENTATION; LEFT-FRONTO-ANTERIOR. 42. RIGHT- FRONTO-ANTERIOR. 43. MECHANISM OF FACE PRESENTATION. 44. EXPULSION OF THE HEAD IN FACE PRESENTATION. 45. HEAD BORN IN FACE PRESENTATION. 46 EPISIOTOMY. 47. EPISIOTOMY KNIFE DEVISED BY THE WRITER. 48. THE PLACENTA AND MEMBRANES, AFTER THE EXPULSION OF THE FCETUS. 49. THE ABDOMEN AFTER THE FCETUS is BORN, THE PLACENTA IN THE UTERUS. 50. THE EXPULSION OF THE PLACENTA, FCETAL SURFACE FIRST. 51. THE PLACENTA IN THE LOWER UTERINE SEGMENT. 52. DAVIS FORCEPS, PERFORATED FOR Axis TRACTION TAPES. 53. THE LEFT HAND GRASPING THE LEFT FORCEPS BLADE. 54. THE INTRODUCTION OF THE LEFT BLADE COMPLETED. 55. PROTECTION OF THE PERINEUM IN FORCEPS DELIVERY, THE PATIENT UPON THE LEFT SIDE. 56. Axis TRACTION. 57. LUSK'S TARNIER'S AXIS-TRACTION FORCEPS. 58. TARNIER'S LATEST AXIS-TRACTION FORCEPS. 59. SIMPSON'S AXIS-TRACTION FORCEPS. 60. SIMPSON'S FORCEPS, WITH POULLET TAPE ATTACHMENT FOR AXIS- TRACTION. 61. BREECH PRESENTATION, THE LEGS EXTENDED. (First position.) 62. DESCENT OF THE TRUNK, BREECH PRESENTATION. (Second position.) 63. THE SHOULDERS EMERGING, BREECH PRESENTATION. (Second position.) 64. EXPULSION OF THE HEAD IN BREECH CASES. 65. HEAD BORN IN BREECH LABOR. 66. BRINGING DOWN THE HIPS IN A DELAYED BREECH LABOR. 67. BRINGING DOWN THE TRUNK IN BREECH CASES. 68. THE ARMS BESIDE THE HEAD. 69. THE ARMS BESIDE THE HEAD. 70. DELIVERING THE ARMS. 71. THE DELIVERY OF THE AFTER-COMING HEAD. (A.) 71. ATTEMPTED SPONTANEOUS EVOLUTION IN TRANSVERSE POSITION. (B.) 72. RIGHT DORSO- ANTERIOR. 73. RIGHT DORSO -POSTERIOR. 74. COMBINED VERSION, (First stage). LIST OF ILLUSTRATIONS. 7 75. COMBINED VERSION, (Second stage). 76. COMBINED VERSION, (Third stage). 77. INTERNAL VERSION, (Grasping the lower foot). 78. INTERNAL VERSION, (Grasping the upper foot). 79. INTERNAL VERSION, (Grasping both feet). 80. THE NOOSE IN VERSION. 81. THE OBSTETRICIAN ANESTHETIZING THE PATIENT AND PERFORM- ING VERSION WITHOUT ASSISTANCE. 82. SYMMETRICALLY SMALL (Justo-Minor) PELVIS. 83. THE POSTURE AND ABDOMINAL PROTRUSION IN A WELL-FORMED PREGNANT WOMAN. 84. POSTERIOR SURFACE OF A WELL-FORMED FEMALE BODY. 85. HEAD ENTERING A FLAT PELVIS. 86. FLAT PELVIS, THE HEAD PASSING THROUGH AFTER VERSION. 87. FLAT RHACHITIC PELVIS. 88. FLAT RHACHITIC PELVIS. 89 ATTITUDE AND ABDOMINAL PROTRUSION (Pendulous Abdomen) OF WOMAN WITH RHACHITIC PELVIS. 90. SPONDYLOLISTHETIC PELVIS. 91. OBLIQUELY CONTRACTED PELVIS FOLLOWING FRACTURE. 92. OVUM OF Two MONTHS INTACT. 93. SAME OVUM, THE DECIDUOUS MEMBRANES OPENED SHOWING VILLI OF CHORION. 94. SMELLIE'S SCISSORS. 95. BLOT'S PERFORATOR. 96. LUSK'S CEPHALOTRIBE. 97. MARTIN'S STRAIGHT TREPHINE. 98. FCETAL HEAD TREPHINED AND DELIVERED BY CRANIOCLAST. 99. GRASPING THE HEAD WITH THE CRANIOCLAST. loo. BRAUN'S CRANIOCLAST. 101. CRANIOTOMY WITH THE SIMPLE PERFORATOR. 102. CRANIOTOMY WITH THE TREPHINE. 103. DECAPITATION ; TIGHTENING A CORD AROUND THE NECK. 104. BRAUN'S DECAPITATION HOOK. 105. DECAPITATION WITH BRAUN'S HOOK. 106. TARNIER'S BASIOTRIKE. 107. PLACENTA PREVIA CENTRALIS, INTRODUCING THE HAND TO BRING DOWN THE FEET. 108. COMBINED VERSION, (Pushing up the Head). 109. COMBINED VERSION, (Bringing down the Legs). no. TUBAL PREGNANCY. in. TAMPONING THE UTERUS FOR HEMORRHAGE. i la. THREATENED UTERINE RUPTURE. 113. VERSION IN THREATENED RUPTURE OF THE UTERUS. 114. INVERSION OF THE UTERUS. 8 LIST OF ILLUSTRATIONS. 115. METHODS OF CLOSING LACERATION OF THE PERINEUM. 116. METHODS OF CLOSING LACERATION OF THE PERINEUM. 117. METHODS OF CLOSING LACERATION OF THE PERINEUM. 118. METHODS OF CLOSING LACERATION OF THE PERINEUM. 119. METHODS OF CLOSING LACERATION OF THE PERINEUM. 120. METHODS OF CLOSING LACERATION OF THE PERINEUM. 121. METHODS OF CLOSING LACERATION OF THE PERINEUM. 122. METHODS OF CLOSING LACERATION OF THE PERINEUM. 123. HARD RUBBER INTRA-UTERINE DOUCHE TUBE. 124. REPLACING THE CORD WITH A CATHETER. 125. LABOR DELAYED BY HYDROCEPHALIC HEAD. 126. HYDROCEPHALUS AND BREECH PRESENTATION. 127. ANENCEPHALIC MONSTER. 128. FCETAL BONE, SYPHILIS, (Showing Syphilitic lines). LIST OF PLATES. PAGE I. THE ABDOMEN AT TERM (Martin} Frontispiece II. SUPPLEMENTARY DIAGNOSIS OF THE COURSE OF LABOR FROM THE SHAPE OF THE SKULL OF THE NEW BORN CHILD (Olsha'iseri) III. FLAT RHACHITIC PELVIS (Martin} IV. NORMAL AND CONTRACTED PELVES (Martin} V. RHACHITIC, ANCHYLOSED, OSTEOMALACIC AND CONTRACTED PELVES (Martin) VI. UTERUS WITH TWINS IN CRANIAL AND BREECH PRESENTATION (Smellie) VII. FLEXIONS AND RETROVERSIONS OF UTERUS i (Martin) .... VIII. FLEXIONS AND RETROVERSIONS OF UTERUS n (Martin) .... IX. NARROWING OF THE VAGINA BY AN OVARIAN TUMOR (Martin) Colored X. TRANSVERSE RUPTURE OF THE ANTERIOR CERVICAL WALL (Spiegelberg} Colored XI. SEAT OF PLACENTA OVER Os UTERI, FROM BODY OF A WOMAN WHO HAD DIED OF UTERINE H/EMORRHAGE IN THE NINTH MONTH OF PREGNANCY, PLACENTA PR.^VIA CENTRALIS (Mar- tin) MANUAL OF PRACTICAL OBSTETRICS. CHAPTER I. OVULATION; MENSTRUATION; CONCEPTION; THE OVUM. BY Ovulation is understood the formation in the ovaries and dis- charge from those organs of the ova or eggs, from which the human being, in common with other mammals, is produced. This pro- cess does not occur at regular intervals, but goes on almost con- stantly from the establishment of puberty to the menopause and even later. Menstruation is a discharge of blood and epithelial elements from the uterine decidua which occurs at intervals, usu- ally twenty-eight days each, but frequently is intermitted. The relation between ovulation and menstruation may be ex- pressed by the statement that a woman may ovulate without men- struation, but she will rarely menstruate without ovulation. The discharge of blood occurring after removal of the ovaries or operations upon the pelvic organs is not menstruation, but uterine hemorrhage, as it is not caused by the exfoliation of the endometrium, and does not contain the cellular elements of the menstrual fluid. Pregnancy causes menstruation to cease, as may also any cause which disturbs the general health, while ovulation may continue and a second conception occur prior to the formation of the decidual membrane in the first fecundated ovum ; conception also takes place during the temporary cessations of menstruation which follow change of climate or great alteration in a patient's environ- ment. Conception is the union of the male and female elements, 9 10 MANUAL OF PRACTICAL OBSTETRICS. the joining of the spermatozoid of the male semen with the fe- male ovum. When the woman's body contains this united ele- ment she is pregnant. To understand this condition known as pregnancy the anatomy of the ovum, the manner of its discharge from the ovary, and the site and mode of impregnation must be considered (Fig. i). FIG. i. Two GRAAFIAN FOLLICLES. tn. g. Membrana granulosa. j. t. Ovarian stroma. p. d. Proligerous disc. The ovaries contain the ova in ovisacs, called from their dis- coverer Graafian follicles. The capsule of a follicle is lined by round nucleated cells named the granular membrane (Membrana Granulosa). At some portion of the wall of the follicle these cells accumulate, forming the proligerous disc in which is found the ovum. This little body, TZTT of an inch in diameter, is com- posed of a yelk membrane (the vitelline membrane) , a yelk (the vitellus), a transparent vesicle (the germinal vesi- cle), in the centre of which is the germinal spot ; the germinal vesicle measures 7^ of an inch in diameter; the germinal spot raW, about the size of a red blood corpuscle (Fig. 2). The ova are discharged from the ovaries by rupture of the ovisacs, and pass thence through the oviducts to the uterus; or, meeting the spermatozoids, may remain and develop in some .portion of the duct of the ovary. These ducts, FIG. 2. HUMAN OVUM. 1. Germinal vesicle. 2. Yelk. OVULATION; MENSTRUATION; CONCEPTION; THE OVUM, n called the Fallopian tubes, are sufficiently large to permit the pas- sage of ova, spermatozoids and the secretion of the membrane lining the ducts. They terminate at the upper corners of the uterus, passing obliquely through the muscular wall to open upon the en- dometrium. At their ovarian extremities they expand into the pavilions, slightly concave dilatations lined with ciliated mucous membrane; the margins of the pavilions are fissured by irregular fringe-like projections called fimbriae ; one of these is attached to the ovary, forming the tubo-ovarian ligament, and anchoring the tube to the ovary. The oviducts or Fallopian tubes are four or five inches long; from ^ to ^ inch in diameter, and are com- posed of a peritoneal, muscular and mucous coat, the last having epithelium whose cilise move from the ovary toward the uterus. This mucous membrane is capable of nourishing by its secretion an impregnated ovum in its first days of life. The male element essential to reproduction is the spermatozoid , an albuminous cell from ^ to *fj of an inch in length, consist- ing of a head, tail and intermediate segment. Spermatozoids are endowed with motion sufficiently rapid to enable them to pass from the vagina to the oviducts in a few moments. Their vital- ity persists when in alkaline media for 24 or 30 hours; they are rendered motionless by cold and killed by acids. Impregnation, the joining of ovum and spermatozoid, may oc- cur in any portion of the genital tract from the uterus to the ovary. It probably happens most frequently at the pavilion of the oviduct ; when the impregnated ovum lodges in the uterus it is an entopic, intra-uterine, normal pregnancy; when the impreg- nated ovum is retained outside the cavity of the uterus, it is an extra-uterine or ectopic pregnancy, which is abnormal. It should be remembered that the genital tract, from the cervix uteri to the pavilion of the oviduct, is essentially one musculo-membranous tube whose epithelial lining membrane, in any portion of its extent, may receive and nourish the impregnated ovum in the early stages of its development, and whose muscular tissue finally expels the ovum at maturity. In normal pregnancy the fecundated ovum is soon passed onward into the uterus, whose muscular walls are es- 12 MANUAL OF PRACTICAL OBSTETRICS. pecially fitted to expel a body of considerable size, like a foetus at term, and overcome a marked resistance. It will be necessary next to consider the changes which occur in the ovum after fecundation, and also the accompanying modi- fications in the genital tract and in the general organism of the mother during the growth of the ovum to maturity. Before the contact of the spermatozoid, the germinal vesicle of the ovum moves towards the periphery and from the vesicle pro- jects one or more cells or globules, called polar globules, whose function in the production of the new being is unknown. The portion of the germinal vesicle remaining after the formation of the polar cells is known as the female pronucleus. The sperma- tozoid penetrating the yelk or vitellus, loses its tail and interme- diate portion, and the head forms the male pronucleus. After the entrance of one spermatozoid others are excluded by the formation of the vitelline or yelk membrane, thus rendering the production of monsters in normal cases impossible, by preventing the joining of more than one spermatozoid with the ovum. Both male and female pronuclei approach each other, joining in a nucleus, and segmentation or cleavage occurs. This begins in the nucleus which has been formed by the union of the ovum and spermatozoid ; the yelk, or vitelline mass which surrounds it, shares in the process, so that a portion of the yelk accompanies each of the first two nuclei formed by the division. This process is continued until the ovum has become a mass of minute spheres, the whole resembling a mulberry, and called the muriform, or mulberry-like body (Fig. 3). These spheres are of various sizes ; the larger and more transparent compose the epi- blast, or upper germs; the smaller the hypoblast, or under germs. The hypoblast remains in the centre of the ovum, while the epiblast surrounds it. The ovum, at this stage, is five or six days old, and usually passes from the oviduct to the uterus, where it lodges in an infolding of the endometrium, which undergoes vari- ous important modifications, fitting it to retain and nourish the embryo. The membranes which envelope the ovum are known as de- OVULATION; MENSTRUATION; CONCEPTION; THE OVUM. 13 FIG. 3. ciduous, and are, in the early stages of development, three in number. The first is the lining membrane of the uterus, on which the ovum rests, formerly called Decidua Serotina, now called Placental Decidua, be- cause it enters into the formation of the placen- ta. The lining decidua of the uterus gradually extends over the ovum, finally covering it ; this investing portion is call- ed the Decidua Reflexa or Ovular Decidua. The third deciduous mem- brane covers the interior of the uterus, and is the (Fig. 4). Returning to the ovum, we find that after the formation of the Fl( , mulberry, or muriform body, a fissure appears between the epiblast and hypo- blast, which separates them in such a manner as to form a vesicle inside the vitelline membrane, whose wall is form- ed by epiblast cells, with the hypoblast cells accumulated on a part of its inter- nal surface ; this vesicle is the blasto- dermic vesicle. It grows rapidly, the hypoblast flattening and extending with- in the epiblast. A third layer of cells is now formed, probably from the two others, called the mesoblast. From these layers are developed the various tissues and organs THE DECIDUOUS MEMBRANES, of the foetus, as follows : from the E. THE MURIFORM BODY. Decidua Vera, or Uterine Decidua 14 MANUAL OF PRACTICAL OBSTETRICS. epiblast are formed the nervous system and parts of the organs of the special senses : from the hypoblast are formed the epithelium of the digestive and respiratory tract, the cylindrical epithelium of the liver ducts, the pancreas, thyroid gland and glands of the alimentary canal, and the hepatic and pancreatic parenchyma. From the mesoblast are derived the muscles, bones, connective tissue, arteries, veins, lymphatics and capillaries with the urinary and generative organs (Fig. 5). FIG. 5. THE EMBRYONIC AREA AND AXIAL GROOVE. The epiblast, mesoblast and hypoblast unite in forming an em- bryonic area or Area Germinativa, which is oval in shape; in the centre of this body there appears a groove called the axial or me- dullary groove, which becomes enclosed by folds from either side forming a closed tube, the neural canal. CHAPTER II. THE EMBRYO. THE embryo now begins to take shape, and resembles rudely a boat with extremities of unequal size. The larger is the cephalic, the smaller the caudal extremity (Figs. 6 and 7). FIG. 6. EMBRYO, SEVEN OR EIGHT WEEKS OLD. The folding in of the blastodermic vesicle, which results in this boat shape, destroys its spherical form, and it becomes constricted into two parts, the smaller being embryonic, the larger forming the yelk membrane, or umbilical vesicle, which nourishes the em- bryo. The embryo has not only the membranes derived from the uterus, but others which surround it, formed in the process of its own development. These are two in number, the amnion .and chorion. The amnion begins in folds given off by the mesoblast and epiblast, finally joining to form a complete sac. As the embryo grows, the yelk sac or umbilical vesicle gradu- 15 i6 MANUAL OF PRACTICAL OBSTETRICS. FIG. 7. ally disappears, and another forms in its place, the Allantois, so called because it resembles a sausage. This in turn becomes con- stricted, and forms an outside and inside portion, that remaining within the body of the em- bryo forming the urinary bladder ; that projecting without forms an umbrella- like expansion which, with layers from the mesoblast and epiblast, constitute the second of the foetal mem- branes proper, the chorion. As growth proceeds, the blood vessels of the Allan- tois become so extensive as to form a part of the abund- ant circulation of the villi of the chorion. The allan- toid sac contains an albumi- nousfluid, but its chief func- tion is that of bringing blood vessels to the portion of the chorion forming the Placenta. As the embryo grows the Amnion forms two layers, the external of which joins the vitelline membrane, and the internal of which covers the foetal surface of the placenta and also the umbilical cord (Fig. 8). Through the medium of the amnion is formed the amniotic fluid or liquor Amnii. This is generally yellowish, opalescent in color, faintly alkaline, with a specific gravity from 1002 to 1015. It contains from i to 1.5 per cent, of solids, which are chlorides, phosphates, sulphates and lactates of sodium, potassium and cal- cium, creatin and creatinin, albumin and mucosin and urea. The weight of the amnial liquid is greater than that of the foetus dur- ing half of pregnancy, but after that period the foetus outweighs this fluid. Its color varies to a dark reddish brown in women who work in tobacco, and in cases where the contents of the foetal OVUM Six WEEKS OLD, In the ovular decidua showing three openings. THE EMBRYO. 17 intestine have been expressed into the amniotic sac. This fluid is derived from the fcetus and from the maternal blood vessels and those of the umbilical cord and placenta. The Amniotic fluid FIG. 8. THE AMNION AND ALLANTOIS. A, B, Transverse sections of the Embryo. C, D, E, f, Longitudinal sections, of, Amnial fluid. /, Alimentary canal, y, Yelk sac or umbilical vesicle, a, The Amnion. ac, Amnial cavity, a/, Allantois. The embryo is back downwards. serves as an elastic buffer to protect the foetus from violence, as a dilator during labor, protecting the cord from pressure, and also aiding in some degree in nourishing the foetus. It renders foetal i8 MANUAL OF PRACTICAL OBSTETRICS. FIG. 9. movements easy, and thus assists in the development of the foetus, as illustrated by deformities resulting in fostal limbs when the fluid is deficient. Between the amnion and decidua the chorion is developed ; it is derived from the vitelline membrane, or Zona Pellucida, which is at first a smooth membrane (Fig. 9). About the second week of pregnancy this smooth membrane becomes covered by tufts called villi ; they are at first solid. About the fourth week, blood vessels begin to penetrate the villi, and the chorion be- comes complete by the joining of the allantoid and an interme- diate layer of the epiblast. The general hypertrophy of the villi which follows causes the ovum to resemble a chestnut burr whose projections are delicate and vascular. At the third month, the villi over the larger free surface of the ovum atrophy and disappear, while the villi at the attachment of the ovum to the uterine wall, at the placental de- cidua, become larger and more branched ; the development of these villi and that of the placental decidua forms the placenta (Figs. loand n). This body is distinct first at the third month, being complete at the beginning of the fourth, or sixteen weeks of pregnancy. It is known as the "after-birth or mother-cake" and is a fleshy, flattened mass, usu- ally six to eight inches in diameter, VII.LI (330 diameters). and varying in thickness from over VILLI OF CHORION (low power). FIG. 10. THE EMBRYO. FIG. II. Villi. Placental rj decidua. Uterine muscle. FIG. 12. PLACENTAL VILLI AND DECIDUA. an inch to one-fifth, being thickest where the cord is inserted. Its usual weight is eighteen ounces, but it varies with the weight of the child. The average weight of the placenta to that of the child is one- third from the seventeenth to the thirty-second week. Between the thirty-second and thirty-third week the placenta attains its acme of weight, and remains from one-third to one-fifth the weight of the child, unless influenced by derangements of the foetal circulation, until birth at the fortieth week. After the fortieth week the placenta seems to . ,, ,.. PLACENTA, MEMHRANES (stripped upward., grow rapidly in multipart, 20 MANUAL OF PRACTICAL OBSTETRICS. or with women having large children, thus raising the average from one-fifth to one-fourth. The external or uterine surface is dark red, divided into many areas by fissures, and covered by a delicate greyish membrane, the placental decidua. The internal, foetal surface is smooth, a little depressed, yellowish in color, and formed of the chorion and amnion ^Fig. 12). The placenta is usually surrounded by a large vein, the circular FIG. 13. PLACENTAL AND UTERINE VESSELS. ^ a, Umbilical cord. f,f, Section of uterus, c, c, c, Umbilical vessels. d, d, Curling arteries of uterus. sinus at its margin. It maybe divided into many lobes of irregu- lar shapes. The point of attachment of the placenta is usually in the upper portion of the uterus, either anteriorly or posteriorly. Examination of the circulation of the placenta shows that the enlarged blood vessels of the decidua gradually lose their walls until only the endothelial cells of the lining membrane remain, THE EMBRYO. 21 forming large sinuses which empty themselves partly through sepa- rate veins, and partly through the large vein or sinus at the border of the placenta, which communicates with the sinuses in the mus- cular tissue of the uterus ; this may be termed the uterine portion of the placental blood system (Fig. 13). The foetal blood system consists of the villi and their vessels. The longer villi fit loosely into the decidual sinuses as a finger may be inserted into a glove too large for it. The shorter villi terminate in the superficial cellular strata of the decidua. It is quite pos- sible to prove by the injection of different colored fluids into the uterus and placenta, that the blood vessels of each do not directly communicate, as is illustrated by the accompanying (Fig. 14). FIG. 14. Amnion. THK PLACENTA AND UTI.KIS (injected while adherent). It is very common to find lime salts deposited in normal placentae of children born at term, forming greyish masses which can be readily felt by the finger, imbedded in the placental tissue. The areas into which the uterine surface of the placenta is divided are called cotyledons; a placenta which has several supernumerary cotyledons connected with the principal mass is 22 MANUAL OF PRACTICAL OBSTETRICS. called placenta succenturiata. The relation between the mem- branes and the wall of the uterus at term may be well shown by the accompanying (Fig. 15). It must be remembered that the FIG. 15. Amnion. Chorion Placental dec Uterine decidua muscle. Point of separation. THE MEMBRANES. (Section through uterine wall). chorion itself has neither vessels nor nerves ; the villi grow only at those points where the vessels of the allantois pass into them to protrude, within the villi, into the endothelial sinuses of the de- cidua. The villi bud and subdivide luxuriantly in the decidua, often containing a capillary loop of allantoid vessels. The placenta and foetus are connected by the umbilical cord, which consists of blood vessels enclosed in a sheath of embryonal connective tissue known as Wharton's jelly. In ligating the cord after the birth of the child, this jelly may be pressed out from the stump of cord left upon the foetus by grasping the stump with the thumb and index finger of one hand close to the umbilicus, pressure being made against the child's abdomen to prevent traction upon the umbilicus. With the thumb and fingers of the other hand the cord may be grasped and the jelly pressed out by traction away from the THE EMBRYO. 2 3 FIG. child's body. The blood vessels are three in number, two arteries and one vein which is one sixth longer than the arteries. The arteries have especially strong walls, and although they twist in a spiral they very rarely become dilated into varicosities; the vein is large, with a thin wall and without valves. It comes from the placenta, and winding about the arteries passes to the foetal liver. Pressure in the vein is greater than that in the arteries ; the result is a twist usually from right to left in the cord. These spirals vary greatly in number, from none to forty or more, and form gradually early in pregnan- cy when the foetus is freely mov- able and can follow the twisting of the cord. Later, the foetus is too large and heavy to rotate evenly, and the cord may then coil about some portion of the foetus or open loops remain (Fig. 16). Lumps of Wharton's jelly which form along the cord are called nodes. In two-thirds of all cas^s the cord is inserted in the placenta between the centre and the margin : in one-fifth of the cases it is inserted in the centre, less often in the margin. When the umbilical vessels pass between the membranes to be inserted in the placenta it is called a velamentous insertion. The cord is derived from the allantois with the umbilical ves- sels and the vitelline vessels. With Wharton's jelly as a padding or mould, its covering is the amnion. It is, at term, usually a little longer than the foetus, over twenty inches : it is as thick as a man's little finger. CROSS SECTION OF CORD. v, u. Umbilical vein. a. u. Umbilical arteries. CHAPTER III. THE FCETUS AND ITS PHYSIOLOGY. THE term embryo is usually applied to the young being before the perfect formation of the placenta at the fourth month ; after this period it is known as the foetus. While the subject of embryology requires separate consideration, the practical interest of the obstetrician is concerned so far as the recognition of the probable stage of development reached by an embryo prematurely expelled, and the mode of production of the most frequent deformities. During the first month the dorsal plates enclose the central neural canal in which are found the rudiments of the nervous system. The heart begins to beat at the third week, and the cavities of the body are formed at the end of the fourth week, the ovum being as large as a pigeon's egg, the embryo half an inch long. During the second month the face, head and ear develop, and hare lip and cleft palate may result from failure ot union in the bones of the face and head. The eyes appear like black spots, the kidneys are formed, the fingers and toes are webbed, the ovum is as large as a hen's egg, the embryo an inch long, weighing one drachm ; the cord is over an inch long. At three months ossification begins, spina bifida resulting from failure of ossification in the lumbar vertebrae. At the fourth month the foetus is six or seven inches long, the genital organs are distinctly developed, down (lanugo) forms on the skin, meconium is in the intestine, the limbs move. Such a foe- tus may show heart-beats for some hours after birth ; but no respiratory movements occur. When five months advanced, the foetus is ten inches long, the cord being twelve inches in length; hair is fully formed, and vernix caseosa is present. The foetal heart can generally be 24 THE FCETUS AND ITS PHYSIOLOGY. 25 heard, and the mother usually appreciates foetal movements. At six months the foetus weighs a little over a pound, and presents many of the appearances characteristic of a full-term foetus. It may live several days, but dies chiefly because the lungs are too imperfectly developed to admit of respiration. A few cases are recorded where a foetus nearly seven months old has survived. At seven months the foetus weighs three or four pounds, the eye-lids are open, the testicles begin to descend, and the nails are almost formed. The child may live, is, in other words, viable ; but its vitality is feeble. The eighth month is marked more by increase in weight than by any new developments. At the ninth month, or at term, the foetus is from nineteen to twenty inches long, weighing between six and seven pounds. Males exceed females slightly in weight. There is no one positive sign that the foetus is at term. By observing the presence of a number of characteristics, the age of a fcetus may be approximately estimated. Twenty inches may be taken as an average length. The body should be plump, covered by the cheesy substance called vernix caseosa, which is a secretion from the sebaceous glands of the foetal skin; the nails should be firm, the cartilages of the nose and ear resisting, hair from one to two inches long ; the child moves and cries lustily. The cord is inserted a little below the middle of the trunk. Children weighing twenty and twenty-two pounds have been born, whose parents were not monstrosities. The following convenient table, constructed by Diihrssen, will assist in forming an idea of the rate of foetal development : At the end of I month I x I = I cm - = f inch. At the end of 2 months 2X2= 4 cm. = i| inches. At the end of 3 " 3X3=9 cm. = 4 inches. At the end of 4 " 4 X 4= 16 cm. 7^ inches. At the end of 5 " 5 X 5 = 25 cm. = n^ inches. At the end of 6 " 6X5 = 3 cm - = 1 3& inches. At the end of 7 " 7 x 5 = 35 cm. = 15^ inches. At the end of 8 " 8 X 5 =40 cm. = 17^ inches. At the end of 9 " 9 X 5 = 45 cm. = 20 inches. At the end of i o " 10 X 5 =5 cm. = 22| inches. 2 26 MANUAL OF PRACTICAL OBSTETRICS. To obtain the length of the foetus, multiply the month of pregnancy (ist, 2d, etc.) by a co-efficient, i for the first month, 2 for the second, etc., up to 5. After the fifth month the co-efficient remains 5. Thus at the seventh month the foetus is 7 x 5 centimetres long, 35 cm., or 15^ inches. The nourishment of the foetus is effected at first by the granu- lar matter of the yelk or vitellus. It also acquires an albuminous coating in passing through the oviduct, which contributes to its nutrition ; so soon as they are formed, the first chorial villi absorb nourishment from the decidua ; the umbilical vesicle as- sists for a short time. The amniotic liquid probably contributes slightly to nourish the foetus, although its functions in this re- spect are not positively known. The great source of foetal nourishment is the placenta; a direct interchange of gases and fluids takes place when the villi project into the mother's blood by the process known as osmo- sis, and this transfer of gases and solids in solution has been demonstrated by various substances which, when given to the mother, affect the foetus. There are two foetal circulations, the first during the existence of the umbilical vesicle, the vitelline circulation ; the second, the placental circulation. In the former, the heart is a tube giving off two vessels at its superior, and two at its inferior extremities. The heart's contraction forces blood through the two superior vessels, the aortic arches, into the embryo, thence into the vitel- line arteries, through which it passes into the vitellus ; it is re- turned by a sinus which surrounds the umbilical vesicle, and passes through the omphalo-mesenteric veins to the heart again. At the beginning of the third month, the placental circulation commences. The foetal heart is fitted for this circulation by two important modifications ; one is an oval opening between the auricles called the oval foramen or Foramen Ovale, also Botall's foramen. In addition, the Eustachian valve, at the entrance of the inferior vena cava, is so formed as to turn the larger portion of blood into the left auricle, through the oval foramen and into the left ventricle. Two additional ducts or blood vessels are THE FCETUS AND ITS PHYSIOLOGY. 27 needed for the circulation, a venous and arterial duct. The former, the ductus venosus, connects the umbilical vein with the inferior vena cava ; the latter, the ductus arteriosus, joins the pulmonary artery and aorta just below the orifices of the arteries of the head and upper limbs. The fcetal circulation will be best understood if we remember that' the lungs are inactive during intra-uterine life; there is need for sufficient blood in the lungs to provide for their growth, but not for pulmonary respiration, as the foetus respires through its absorption of oxygen from the maternal blood. Starting at the placenta, we find the purified and oxygenated blood passing through the umbilical vein at the umbilicus. It will be noticed that an exception is formed to the general law that oxygenated blood is carried by arteries only. From the umbilical vein it passes through the venous duct to the inferior vena cava, where it is joined by the blood from the lower portion of the fcetal body; a little of this blood goes to the liver, and blood from the liver is emptied into the vena cava. From the vena cava the blood passes into the right auricle, where the Eustachian valve turns the stream out of its usual course through the oval foramen into the left auricle ; thence it goes, as usual, into the left ventricle. When the heart contracts, the blood is sent from the left ventricle into the aorta, from the right ventricle into the pul- monary artery. The blood from the left ventricle goes to nourish the head and arms; blood from the right ventricle, being needed in the lungs in small quantity only, the greater portion passes through the arterial duct into the aorta. It will be ob- served that venous blood is carried by the arterial duct and ar- terial by the venous duct, a reversal of what is usually the rule, resulting from the inactivity of the fcetal lungs. The aorta finally contains mixed blood, which passes partly to the lower limbs and partly through the umbilical arteries to the placenta (Fig. 17). The fcetal organ which receives the purest blood is the liver, because important nutritive functions are carried on in that organ. The head, arms and trunk receive purer blood than the legs, hence their better development. As the foetus has little 28 MANUAL OF PRACTICAL OBSTETRICS. FIG. 17. Diagram of the foetal circulation. I, the umbilical cord, consisting of the umbilical vein and two umbilical arteries, pro- ceeding from the placenta (2) ; 3, the umbilical vein dividing into three branch- es two (4, 4) to be dis- tributed to the liver, and one (5) the ductus venosus, which enters the inferior vena cava (6) ; 7, the portal vein, returning the blood from the intestines, and uniting with the right hepatic branch ; 8, the right auricle the course of the blood is denoted by the arrow proceeding from 8 to 9 ; 9, the left auricle ; 10, the left ventricle the blood following the arrow to the arch of the aorta (il), to be distributed through the branches given off by the arch to the head and upper extremities; the arrows (12) represent the return of the o'.ood from the head and upper ex- tremities, through the jug- ular and subclavian veins, to the superior vena cava (14), to the right auricle (8), and in the course of the arrow through the right ventricle (15) to the pul- monary artery (16) ; 17, the ductus arteriosus, which appears to be a proper continuation of the pul- monary artery the offsets at each side are the right and left pulmonary arteries cut off; the ductus arteri- osus joins the descending aorta (18, 18), which divides into the common iliacs, and these into the in- ternal iliacs, which become the umbilical arteries (19), and return the blood along the umbilical cord to the placenta, and the external iliacs (20), which are continued into the lower extremities. The arrows at the termination of these vessels mark the return of the venous blood by the veins to the inferior cava. (After Carpenter.) THE FCETUS AND ITS PHYSIOLOGY. 29 need for powers of locomotion, the growth of these organs comes after the development of more vital parts. Foetal respiration is accomplished by the passage of oxygen from the mother's blood to the red blood corpuscle of the fcetal blood. This results from osmosis, a physical property of gases which enables them to pass through animal membranes under certain conditions which are present in the placenta. There is abundant need for oxygen in the foetus, and its blood often contains more haemoglobin than its mother's. Whatever stops circulation in the umbilical cord kills the foetus by asphyxia. The temperature of the foetus is about one degree higher than the mother's. The metabolic changes in the fcetal body while in the uterus are much slower than those in the mother's, and as it stores up oxygen it often survives for some time after its connection with the mother is cut off by separation of the placenta. The various secreting glands of the fcetal body are formed and active at term. The great size and activity of the foetal liver is caused, not by ex- cessive formation of bile, but by important processes in the form- ation of blood corpuscles which go on in that organ. Bile is formed as early as the third month, and the intestines contain meconium, a tarry substance resembling burnt molasses, composed of bile and intestinal juices, with substances swallowed from the amniotic liquid. While reflex motions have been observed on ir- ritating a fcetal limb through the uterine wall, conscious move- ment does not exist for some time after birth. The gustatory nerve responds to bitter substances in children born at seven and eight months. THE FCETUS AT BIRTH. At two hundred and seventy days the human foetus measures on an average twenty inches in length, weighs from six and one-half to seven and one-half pounds, and is marked by the characteristics already mentioned. The diameter 8 of its head will be considered in relation with those of the birth canal of the mother. The diameter of its trunk, which is of the greatest practical importance to the obstetrician, is the bis-acromial. This is measured from one acromian process to the other, and is on the average twelve centimetres or four and three-fourths inches 30 MANUAL OF PRACTICAL OBSTETRICS. in extent ; it is capable, however, of considerable reduction by pressure during labor, from the fact that the foetal bones possess considerable elasticity. The foetal lungs at this time are capable of inflation, while the other organs of the fostal body have already established their various functions. THE FOZTAL HEAD. The foetal head is of especial interest and importance to the obstetrician, because it is the largest portion of the foetus and therefore is most likely to occasion difficulty in its passage through the birth canal of the mother. It is composed at birth of two parietal, two temporal and frontal and an occipi- tal bone, which are not yet solidly united. The facial bones of the foetus are more nearly united at birth than are the bones of the skull, nature seeming to leave the latter imperfectly joined to favor the moulding of the head. The spaces between these bones are known as sutures ; they are the sagittal or arrow suture, extend- ing antero-posteriorly in the middle of the cranial vault ; the fronto-parietal, extending at right angles to the sagittal between the frontal and the parietal bones, and the lambdoid, separating the two parietal bones from the occipital. Two spaces between the bones of the skull are found at the junction of the frontal and the two parietal bones, and at the junction of the two parietal with the occipital. The former, the larger, is called the anterior fon- tanelle and also the bregma ; the latter is known as the smaller or posterior fontanelle (Fig. 18). Other fontanelles are sometimes found between other bones of the skull. These two fontanelles are of special interest to the obstetrician because their recognition assists greatly in diagnosticating the position of the foetal head during labor. The anterior or greater remains unaltered by the pressure exercised upon the head and always admits the tip of the examining finger during labor. It is to be recognized by the fact that four bony lines or sutures extend from this fontanelle. The posterior or smaller fontanelle, on the contrary, is often ob- literated by the pressure upon the foetal head during labor, and its site is distinguishable only from the fact that three bony lines can be identified as extending from this fontanelle (Fig. 19). The recognition of the anterior and posterior fontanelle enables THE KKTUS AND ITS PHYSIOLOGY. 31 the obstetrician to locate the frontal and occipital regions of the head. The diameters of the foetal head are measurements taken between certain bones by which its size is estimated. These di- ameters are those of length, width and depth; there are four di- ameters of length, the maximum or greatest extending from the FIG. 1 8. The anterior, greater fbntanelle. The posterior, smaller fontanelle. chin to a point in the sagittal suture midway between the fontan- elles. It measures thirteen and a half centimetres, or five and one-third inches. The next diameter of length is the occipi to- mental, measured between the point of the chin and the occipital protuberance. It is thirteen centimetres, or five and one-eighth inches. The most important diameter of length, when the me- chanism of labor is concerned, is the occipito-frontal, from the root of the nose to the occipital protuberance. It measures twelve centimetres, or four and three-fourths inches ; a diameter of length which is frequently substituted for the preceding in the mechanism of labor is the sub-occipito-bregmatic; it is measured MANUAL OF PRACTICAL OBSTETRICS. FIG. ig. i. The parietal eminences. 2. The lateral fontanelles. from the middle of the anterior fontanelle to the under surface of the occipital protuberance, nine and a half centimetres, or three and three-fourths inches (Fig. 20). Measures in width are two in number the bi-parietal between the protuberances of the parietal bones, nine and five-tenths centimetres, or three and three-fourths inches, and the bi-temporal, eight centimetres, or three and one-eighth inches. The measures of depth are t.vo in number the fronto- mental, between the forehead and the chin, measures eight centimetres, or three and one-eighth inches, and the trachelo- bregmatic, between the middle of the greater fontanelle and the of. Occipito-frontal diameter. o m. Occipito-mental diameter. JT m. Maximum diameter. 6 s. Sub-occipito-bregmatic diameter. t b. Trachelo-bregmatic diameter. y m. Fronto-mental diameter. THE FOETUS AND ITS PHYSIOLOGY. 33 neck in front of the larynx, nine and a half centimetres, or three and three-fourths inches ; the greatest circumference coincides with the maximum diameter, measuring thirty-seven centimetres, or fourteen and one-half inches. CHAPTER IV. THE BIRTH CANAL. IT will now be necessary to consider the birth canal of the mother, and to compare these measurements with those of the foetus just stated. At labor the uterus, sinking at first into the pelvis, forms an irregularly cylindrical cavity, the axis of which is the line of direction followed by a body in passing through this cavity; the lower elastic portion of the uterus is retained in the bony pelvis during the last weeks of pregnancy and the first hours of labor, and its dimensions are practically thosa of the bony canal. The uterus in pregnancy may be divided into three portions. The first is the expulsive, consisting of the strong interlacing muscular fibres at the fundus, which end in a border or ring. The second is the tissues between this border or ring and the internal os, known as the lower uterine segment ; while the third extends from the internal through the external os, forming the cervix. The lower uterine segment is the elastic portion of the uterus, and is composed of fibrous and muscular tissue capable of considerable distension (Fig. 21). Before pregnancy, it is impossible to recognize this lower seg- ment of the uterus, and its length increases during this period till at term, when it may be demonstrated between the lower border of the upper or expulsive uterine segment, and the internal os ; the cervix retains its former length during pregnancy and labor. In the early stages of labor, the cervix and lower uterine seg- ment are contained in the bony pelvis, but as labor proceeds, the upper expulsive segment of the uterus contracts and retracts, thus drawing the elastic or lower uterine segment just above the brim of the pelvis. The diameters of the bony pelvis are the measurements most important in studying the mechanism of labor, and determining whether or not the normal foetus can pass through the pelvis. 34 THE BIRTH CANAL. 35 The most important region of the bony pelvis is the entrance or FIG. 21. Upper expulsive uterine C, K. Contraction ring. o. i. Internal os. o. *. External os. THE BIRTH CANAL. superior strait ; this is also known as the pelvic brim, its measure- 36 MANUAL OF PRACTICAL OBSTETRICS. ment from the posterior surface of the pubic joint to the projec- tion or promontory of the sacrum being eleven and one-half cen- timetres, or four and one-half inches. This is the most important measurement in the birth canal, and is known as the true conju- gate, or antero-posterior diameter of the brim (Fig. 22). FIG. 22. DIAMETERS OF PELVIC BRIM. The diagonal or oblique measurements at the brim of the pelvis extend from one sacro-iliac joint to the ilio-pectineal eminence of the opposite side ; they measure twelve and one-half centimetres, or four and three-fourths inches. Transversely, from side to side, the brim of the pelvis measures thirteen and one-half centimetres, or five and one-third inches ; this last measurement is that in the bony pelvis; in the pelvic canal of the living patient the muscu- lar and other tissues reduce the transverse diameter, making it less than the oblique. This reduction is largely effected by the ilio- psoas muscles of each side, which may be relaxed by flexing the thighs upon the body; hence during the first stage of labor, when delay occurs in the descent of the head into the pelvic brim, it is often advantageous to flex the patient's thighs, thus rendering these muscles relaxed and facilitating the descent of the present- ing part below the brim. THE BIRTH CANAL. 37 The cavity of the pelvis is found to measure, on an average, twelve and one-half centimetres in diameter, or four and seven- tenths inches. This measurement is of interest because it is suf- ficiently great to allow the head, when perfectly flexed or perfectly- extended, or the breech of the child, to rotate freely during labor. The pelvic brim having been passed, there is evidently no reason why the mechanism of labor should be impeded, so far as the di- mensions of the pelvic cavity are concerned. Passing to the outlet of the pelvis the average diameter is eleven centimetres, or little over four inches. The most important measurement of this region is the anterior-posterior diameter, from beneath the pubic joint to the tip of the coccyx. This is FIG. 23. PELVIC OUTLET. increased during labor to measure from thirteen to fifteen centi- metres, or from five to five and one-fourth inches. The transverse diameters of the pelvic outlet measure four and one-third inches, or eleven centimetres (Fig. 23). The birth-canal of the mother, however, is but partially de- scribed in a description of the pelvis ; but a portion of the uterus is contained in the pelvis at labor, and this important organ and also the floor of the pelvis must be considered in any study of the birth canal. It has been shown by means of frozen sections and MANUAL OF PRACTICAL OBSTETRICS. FIG. 24. post-mortem examinations, as well as by observations upon the living patient, that during labor the fundus of the uterus extends forward above the line of the pubic joint. The axis of the birth canal is that line which would be taken by a globular or cylindrical body moving through this canal. Such a line would extend from the fundus of the uterus downward and back- ward until it should meet the posterior por- tion of the pelvic floor; it would then be de- 1 fleeted at nearly a right angle upwards and for- wards, to emerge be- neath the pubic joint (Fig. 24). It is to be remembered that the pelvic cylinder is so formed by a com- bination of bony and membranous tissues, that resistance and elas- ticity are counterbal- anced, thus favoring ro- tation of the presenting body. During preg- nancy the pelvic joints share in the general hypertrophy of this re- gion. The pubic joint becomes specially enlarged and its mobility is greatly increased. This may become, in some cases, a source of great annoyance to the patient and may necessitate rest in bed X Y. Antero-posttrior (sacro-pubic) diameter of brim. ABC. Composite line representing axis of birth canal. THE BIRTH CANAL. 39 FIG. 25. or the application of a strong bandage. Ordinarily, however, the other joints of the pelvis, although enlarged, do not show in- creased mobility. A comparison of the diameters of the foetus with those of the birth canal will serve to explain the phenomena of labor. It will be remembered that the maximum diameter of the foetal head is greater than any diameter at the brim of the pelvis in the living patient. The same is true of the occipito-mental. It is evident then, that the head must enter the pelvis in its descent in such a position that neither the maximum or the occipito-mental diam- eter shall be brought to present to either of the diameters of the pelvic brim. The avoidance of this occur- rence results from the fact that the foetal head is placed upon the trunk as a lever upon its fulcrum. If a foetus be held per- pendicularly and the head be allowed to drop freely, it falls towards the front, the chin resting upon the breast. This then is the longer arm of the cranial lever ; the shorter arm being the distance from the centre of the head to the occipital protub- erance (Fig. 25). The result of this move- ment of the head is to substitute for either of the two long diameters mentioned a shorter one, thus in place of the maximum diameter of 13^4 cm. or 5^ inches or the occipito-mental 13 cm. or 5^ inches, there is presented the occipito-frontal 12 cm. or 4^ inches or the sub-occipito-bregmatic 9^ cm. or 3^ inches. A comparison of these last two diameters with those of the pelvic brim will show that when the compression which the mother's soft parts undergo is taken into account, there is no reason why the head when flexed, with the chin upon the breast, should not pass through the pelvis. If the motion opposite to flexion, extension, occurs, one of the vertical diameters of the head is substituted for one of the two A, C. Axis of foetal body. C. Fulcrum. O, C. Short arm of lever. C, F. Long arm of lever. 40 MANUAL OF PRACTICAL OBSTETRICS. greatest and thus descent is possible ; it will be noticed, however, that either flexion or extension must be present, otherwise a large diameter will be presented which cannot pass. THE PELVIC FLOOR. The study of the pelvic floor is of special interest to the obstetrician. It is that portion of the birth canal most frequently injured in labor and most often demanding re- pair. From the standpoint of practical obstetrics it may be regarded as composed of two segments: the anterior, upper, shorter segment and the lower, posterior, longer segment. The former embraces the anterior wall of the vagina and the tissues beneath the pubic joint, while the latter comprises the strong muscles and fascia attached to the sacrum and coccyx. At the moment of labor the second or sacral segment is stretched strongly downward and backward by the advancing foetus, while the first or pubic segment is pushed upwards beneath the pubes. From the standpoint of obstetric anatomy, the levator ani muscle and the fascia and muscular slips attached to the perineal body are the most important tissues in the pelvic floor. These tissues may be divided into three portions: the pubo-coccygeus, embracing the muscles arising beneath the pubic joint and pro- longed to the sides of the pubes, with the anterior wall of the vagina and the urethra; the obturato-coccygeus muscle, which arises from the obturator fascia and sides of the pelvis, and the ischio- coccygeus, which includes the muscular slips having origin from the sides of the ischium. The first of these three divisions is known as the pubic, the remaining two as the sacral segment of the pelvic floor. The importance of the perineal body consists in the fact that it is the point of blending and membranous attachment for the interlacing muscular fibres of the superficial tissues of the pelvic floor. While, from the standpoint of the anatomist, the pelvic floor requires minute analysis and descrip- tion, the obstetrician will gain little by any but a practical study of this region and its functions. During labor the presenting part descends in the axis of the pelvis downward and backward until the sacral segment of the pelvic floor is reached. The resistance afforded by the muscles THE BIRTH CANAL. 41 already mentioned as comprising this segment, with the strong coccygeal fascia, exerts a considerable obstacle to the progress of the head, and forces it upward and forward beneath the pubic joint. The anterior or pubic segment of the pelvic floor is lifted upward and greatly compressed beneath the pubic joint by the presenting part. The movement of the coccyx upon the sacrum at the sacro-coccygeal joint and the elasticity of the tissues ena- ble the sacral segment to move downward and backward. The movements of the two segments of the pelvic floor may be likened to those of folding doors swinging in opposite direc- tions. In the space left between these segments, room is af- forded for the escape of the presenting part. Regarding the question of injury to the pelvic floor, it is a familiar fact that it is not a simple linear tear which results in serious disability, but the separation from their points of attach- ment to the sides of the pelvis and .their insertions into the peri- neal body of the muscles, which have been collectively described under the heads of the segments of the pelvic floor; and it is also evident that in the repair of recent injuries it is not suf- ficient to simply bring the superficial parts in accurate apposi- tion. Beginning from above, the laceration in the vagina should be brought together until the perinaeum is reached. It is well then to begin a second line of sutures extending from the lower end of the tear in the perinaeum upward to meet the first. Ine- qualities in the tissues can then be adjusted and an accurate clo- sure be made. The suture should be carried beneath the entire surface of the tear, emerging and re-entering, if desired, in the centre of the tear.* By reference to the movements of the segments of the pelvic floor, we appreciate the advantages of that method of delivery in head presentations which consists in pushing the pubic segment upward and backward by pressing the head up beneath the pubic joint with the left hand, passed between the mother's thighs, while the right, spread out upon the sacral segment of the pelvic floor, * For more explicit directions for closing such lacerations, the reader is referred to the treatment of the accidents of labor. ->* 42 MANUAL OF PRACTICAL OBSTETRICS. regulates the stretching of these parts by the head as it advances, estimates the elasticity of this segment, and finally allows it to retract, between the pains, over the head of the child. As the orifice of the birth canal at the vulva becomes an oval, with tense edges, during delivery, it will be seen that lateral in- cisions at the centre of each side of the oval will enable both pubic and sacral segments to retract to better advantage. Such a procedure is termed episiotomy. CHAPTER V. THE MOTHER IN PREGNANCY. CHANGES IN THE MOTHER OCCASIONED BY PREGNANCY. These may be described as of two kinds : functional and organic. Under the first may be considered disturbances of digestion, and of the functions of the nervous system, while under the latter may be included the various hypertrophies in the tissues of the body, in- cluding the uterus, variations in the composition of the blood, and structural changes in the skin and in the excretory organs. The first and most common functional change consists in the variations in appetite and digestion commonly observed. There is no anatomical reason for these abnormalities, and they must be classed as reflex, temporary and functional. They consist of nau- sea, repugnance to food, appetite for unusual articles of diet, ex- cessive or diminished appetite. The result of these functional disturbances is usually a temporary condition of anaemia, which often disappears as pregnancy advances. In many patients, a full and even ravenous appetite after the third month of pregnan- cy, produces a condition of plethora. In some, assimilation, which is ordinarily defective, is greatly stimulated by pregnancy. Disturbances of the nervous system consist in an increased sen- sibility to reflexes; heightened excitability of the central and peripheral nervous system, manifested by melancholia or exalta- tion, apprehension, increased imagination and, very commonly, forebodings of evil. The sympathetic nervous system is espe- cially liable to functional variations, and the balance ordinarily maintained in the organism seems to disappear on a slight cause which occasions general perturbation, the action of the heart and respiration being especially affected. The most important structural changes occur in the genital organs. The uterus becomes twenty times heavier than before 43 44 MANUAL OF PRACTICAL OBSTETRICS. pregnancy; its surface about seventy times larger; its capacity sev- eral hundred times as great. Its muscle hypertrophies by the de- velopment of embryonic muscle nuclei. Its walls are thinner than in the non-pregnant uterus, but elastic and resisting. The en- dometrium undergoes corresponding hypertrophy in its glandular elements. The entire genital tract shares in the hypertrophy of the uterus, in its muscular, elastic and epithelial structures. The neck of the womb softens, the difference being very noticeable on touch. In first pregnancies the external os is usually closed during pregnancy; in women who have borne many children it can be readily entered by the finger. The hypertrophies otherwise observed are found in certain por- tions of the mother's skeleton, as the inner table of the skull and about the joints. The vascular system is marked by hypertrophy of the left ventricle and of the muscular coat of the arteries. The skin is altered by the deposit of pigment in various portions of the body, forming the areola around the nipple, for example, and the excretory organs undergo a general glandular hypertrophy, which consists in a multiplication of the cells of the various organs. The same change is observed in the secretory organs of the body. The changes in the blood are at first a diminution in the red corpuscles and haemoglobin, followed by a decided increase as pregnancy advances. The loss of blood usually occurring at labor results in temporary diminution of the amount of corpuscles and coloring matter, followed during the healthy puerperal state by an increase to an amount equal to or greater than that found during pregnancy. As the red corpuscles and haemoglobin diminish, the white cor- puscles and water increase ; albumin diminishes at first, as does fibrin, but toward the latter months of pregnancy fibrin increases very considerably. Marked anaemia occurring during pregnancy cannot be regarded as physiological, but is usually caused by improper hygienic sur- roundings. Anaemia after labor is usually the result of hemorrhage, and occasionally follows the establishment of the function of lacta- tion; as a rule, however, when the secretion of milk is well estab- lished, anaemia should give place to a normal condition of the blood, and very often to slight plethora. CHAPTER VI. THE DIAGNOSIS OF PREGNANCY. WHILE many conditions exist which may justify a presumptive diagnosis of pregnancy, yet a certain diagnosis of this condition cannot be made before the existence of the foetus is appreciable by sight, hearing, or the tactile sense. The conditions upon which presumption may be based are the cessation of menstrua- tion, nausea, occurring in the early morning, abnormal sensibi- lity with sensations of prickling, stinging, or sharp pains through the mammary glands, with discoloration about the nipples: a sensation of weight or fullness of the lower portion of the abdo- men, and those ill-defined sensations which cause the woman to believe that pregnancy exists. These conditions, however, may all be present, and yet the patient not be pregnant. Again, from the standpoint of the physician, presumptive evi- dence may be found of pregnancy, and yet the condition be absent. Any cause which produces an enlargement of the uterus and softening of the neck and mouth of the womb may give rise to a presumption of pregnancy, especially if menstruation is absent ; but it must be insisted upon that it is not until the phy- sician can feel the movements of the foetus, or see those move- ments through the abdominal wall of the mother, or hear the beating of the foetal heart, that a positive diagnosis of pregnancy can be made. A strong presumption that ectopic or extra uterine pregnancy exists may be based upon absence of menstruation ; a tumor found by examination near the uterus, but distinct from it: changes of the mammary glands ; the fact that the uterus itself can be de- monstrated to be but slightly enlarged, and the occurrence of ir- regular attacks of hemorrhage. While there is no one symptom on 45 46 MANUAL OF PRACTICAL OBSTETRICS. which a positive diagnosis of ectopic pregnancy can be made, yet if decidual membrane can be demonstrated as discharged coincidently with hemorrhages, a very strong presumption exists, especially if the other symptoms be present. If the physician be consulted by a patient who has reason to suppose herself in the early months of pregnancy, a careful ex- amination should be made, and if a strong presumption exists, this fact should be stated to the patient. She should be in- structed regarding the hygiene necessary for this period, and informed that a positive diagnosis cannot be made for several weeks or months. As early in pregnancy as possible, the physi- cian should examine his patient thoroughly to make a positive diagnosis of pregnancy, and also to determine the presence or absence of any abnormalities of the pelvis or birth-canal of the mother. A second examination at seven or eight months should be made to diagnosticate the position of the foetus, and to determine the necessity for version or some procedure to alter an abnormal position at the occurrence of labor. When the first examination takes place, it is well to make an appointment with the patient to come to the physician's office, or that he may call upon her at her home. The assistance of a friend or nurse is often advantageous and agreeable. The patient should be instructed to lie upon a bed or couch, clad so that but one thickness of linen will be found covering the abdomen and pelvis. The physician should palpate the abdomen carefully, mapping out the enlarged uterus, and auscultate for fetal heart- sounds, being careful to take sufficient time to recognize them, and then measure the patient's pelvis. All of this can be done through one thickness of linen, if that linen be not new and stiff. The pelvic measurements which should be invariably made are but three in number : they are, between the anterior superior spines of the ilia, twenty-six and one-half centimetres, or, in round numbers, ten inches ; between the crests of the ilia, twenty-eight centimetres, or eleven inches ; from beneath the spine of the last lumbar vertebra to the middle of the pubes, eight inches, or twenty THE DIAGNOSIS OF PREGNANCY. 47 and one-half centimetres. This measurement is known as the external or Baudelocque's conjugate diameter. Three and one- half inches or nine centimetres should be subtracted for the thick- ness of the sacrum and pubes. Four and one-half inches, eleven centimetres, the remainder, is known as the internal conjugate, or conjugata vera. To make the last measurement, the patient should turn upon her side, her thighs flexed, and lying conveniently with her face turned away from the physician. Should doubt exist as to the location of the last lumbar spine, visual inspection of the back may be made without offending the patient. If the three measurements given are found to be normal, the probability that any deformity in the bony birth-canal exists sufficiently great to complicate labor, is very slight. The distance between the tro- chanters may also be conveniently measured ; it is thirty-two cen- timetres, or thirteen inches (Fig. 26). At the second examination the position of the foetus should be carefully outlined by palpation, and auscultation be repeated. Palpation is best performed by standing with the face towards the patient's feet, the extended hands resting lightly upon the patient's abdomen. By gentle pressure simultaneously with both hands, a sense of resistance can usually be readily appreciated, which will indicate the location of the child's back. The fin- ger tips of each hand should then be placed in line parallel with Poupart's ligament on each side; by gentle, but deep pressure downwards and inward, the presenting part is felt. If now both hands be moved together either to the right or left, the head or breech will be felt to move with the hands. In women whose tissues are relaxed, the position of the head, in extension or flexion, can often be determined. The site of the placenta can occasionally be found by palpation, when it is situated upon the anterior wall of the uterus. In multiple pregnancies, the ob- server must outline three large foetal parts or extremities before a diagnosis can be made by palpation. Two distinct foetal hearts must be heard by auscultation to make a diagnosis positive. Information of value may also be gained by the obstetrician if, during palpation, he will notice the muscular development 4 8 MANUAL OF PRACTICAL OBSTETRICS. and consistence of the abdominal walls, as their contraction fur- nishes an important accessory force in labor. The bladder should be invariably emptied before palpation, as a full bladder FIG. 26. A A'. Distance between crests of ilia. B B'. Distance between anterior superior spinous processes of ilia. C C'. Distance between trochanters of femora. renders an accurate examination impossible. During palpation foetal movements are appreciated by the fingers, and often seen THE DIAGNOSIS OF PREGNANCY. 49 in cases where the foetus moves vigorously. In hysterical or maniacal patients a slight degree of anaesthesia may be required for a satisfactory examination. On auscultation, in head present- ations the heart sounds are heard below the umbilicus, on the left or right side ; in breech presentations above the umbilicus ; in transverse positions near the pubes. A loud, rushing sound, syn- chronous with the mother's pulse, is the uterine souffle, caused by the blood in the enlarged uterine sinuses. A faint, rapid hissing sound is the umbilical souffle, a murmur in the cord which is twisted about the foetus. Gas may be heard to crackle in the mother's intestines. In doubtful cases, percussion must be resorted to in distin- guishing the pregnant uterus from ovarian tumors or ascites. It will be remembered that the pregnant uterus forms a solid or semi-solid tumor occupying the centre of the abdomen, sur- rounded on three sides by intestines which usually give a reso- nant note on percussion. If the patient be turned upon either side, the relative position of the dull and resonant note changes but slightly, while in ascites the gravitation of fluid to the sides alters the location of dullness. An ovarian cyst can be distin- guished in its early growth as located more upon one side of the pelvis. A uterus enlarged by fibroids which are undergoing a cystic and often malignant degeneration may give the same phy- cal signs as the pregnant uterus. Percussion of the pregnant abdomen should also give informa- tion regarding the size of the uterus, and hence the period qf pregnancy. In general, we may say that the uterus can first be felt above the pubes at the fourth month. In the sixth month it is at the umbilicus ; at the end of pregnancy, a hand's breadth above the umbilicus. We add a table, constructed by Duhrssen, showing the size of the uterus at the different months of pregnancy : In the 1st month the uterus is slightly enlarged. In the ad month the uterus is as large as a goose egg. In the 3d month the uterus is as large as a child's head. In the 4th month the uterus is as large as a man's head, and can be felt by external examination above the symphysis pubis. 3 50 MANUAL OF PRACTICAL OBSTETRICS. In the 5th month the uterus is half-way between the umbilicus and the symphysis. In the 6th month it is at the umbilicus. In the 7 th month it is two fingers' breadth above the umbilicus. In the 8th month it is the width of the hand above the umbilicus. In the Qth month it is at the xyphoid process. In the loth month it is again the width of the hand above the umbilicus. If anything abnormal be detected in the position of the foetus indicating disproportion between the child and the mother's pelvis, an internal examination should be made (Fig. 27). To measure FIG. 27. INTERNAL MEASUREMENT OF THE ANTERO-POSTERIOR DIAMETER OF PELVIC BRIM. the antero -posterior diameter of the pelvic brim (conjugata vera, true conjugate) the patient is placed on her back at the edge of a bed or table, her thighs flexed. The bladder and rectum being empty, the physician introduces the index and second fingers of THE DIAGNOSIS OF PREGNANCY. 51 one hand, pushing the cervix aside, and touching the promontory of the sacrum with the second finger. The edge of the hand is raised against the sub-pubic ligament, and with the nail of a finger of the other hand the point where the edge of the pubes presses is marked upon the examining hand, which is then withdrawn, and the distance from the tip of the second finger to the point marked is measured by tape line or pelvimeter. Two centimetres, or three-fourths of an inch, is deducted for the thickness of the pubes. The measurement first obtained is thirteen centimetres, less two, is eleven centimetres, or four and a half inches. It is well to follow the sacral curve upwards with the examining finger, to avoid mistaking the projection of other sacral vertebrae for the promontory. If the maternal parts be relaxed and labor be approaching, it is well to attempt to estimate the proportionate size of the foetus and the pelvis by pressing the presenting part gently downward FIG. 28. into the pelvis while its progress is recognized by an internal ex- amination. It cannot be too strongly urged that it is the duty of the physician to make preliminary examinations in every case, as experience has shown us that they can be so conducted as to give the patient no inconvenience, while affording valuable data for the conduct of labor. The pelvimeter which we commonly employ is indexed in centimetres and inches, and can be conveniently taken apart and carried in the pocket (Fig. 28). 52 MANUAL OF PRACTICAL OBSTETRICS. In making a vaginal examination to determine the existence of early pregnancy, in addition to the softened condition of the os and cervix, the lower uterine segment may be distinguished in many cases. The finger may detect softened, elastic tissue just above the cervix, the body of the uterus swelling out above it as the body of a jug bulges sharply above its neck. It is often ne- cessary to examine with one finger in the vagina and another in the rectum, to obtain this sign distinctly. This is Hegar's sign and can be found at the third or fourth month. Cases will come to the notice of practitioners of experience where the reputation and happiness of the patient may depend upon the physician's diagnosis. In such cases the greatest cau- tion must be exercised ; the physician must give no statement which can be misconstrued. He will do well to satisfy himself with a statement of what he actually finds after a careful examina- tion. He may then state that such symptoms and conditions sometimes accompany pregnancy, but that an absolute diagnosis at the moment of speaking is impossible. CHAPTER VII. THE HYGIENE OF PREGNANCY. THE care of the pregnant woman should begin from the time when her condition is first suspected. Fortunately for her, that which is best for her, if pregnant, is also proper care if she be not pregnant, but suffering from any condition which may give rise to a supposition of pregnancy. A subject of perhaps the first importance at this time is the patient's dress. It is best to lay aside corsets, or if the patient will not do this, to wear such as have been carefully made to fit the body loosely. Better than corsets are waists of various sorts, to which skirts can be buttoned, and which are so devised as to avoid injurious pressure. The important point is to remove from the abdomen the pressure of the patient's clothing, and the benefit to be derived from this will not be realized until a radical change in the patient's dress is made. If skirts are not attached to a properly constructed waist, they should be supported from the shoulders by suspenders. Next to the patient's skin should be worn woolen of fine qual- ity and light weight. The so called combination suits, in which shirt and drawers are virtually one piece, are excellent in this con- dition. Woolen or silk stockings should be worn, and, if possible, supported without encircling garters. Shoes and slippers should be sufficiently easy to avoid pressure, and if warm clothing is necessary, dresses and wraps may be altered or made so as to keep the patient thoroughly warm while distributing the weight of the garments as evenly as possible, and suspending them from the shoulders. Many of the pressure symptoms from which patients suffer during the early months of pregnancy are more relieved by the adoption of suitable dress than by any other measure. The first symptom for which the physician will commonly be asked to prescribe is nausea and vomiting. The patient should 53 54 MANUAL OF PRACTICAL OBSTETRICS. be informed that these symptoms are almost the invariable accom- paniments of her condition, and that they will grow better as time goes on. Drugs should be used as sparingly as possible, and the case can often be palliated by simple precautions regarding the taking of food. Many patients get on comfortably by taking a breakfast in bed. Others are helped by a cup of soup, or tea, or coffee, hot water, an effervescing drink, champagne, brandy- and-soda, while severe cases require confinement in bed and the most careful feeding, nutritive enemata being especially useful. Slight dilatation of the cervix relieves a considerable number of cases of the vomiting of pregnancy. The finger is the best di- lator, or a hard rubber dilator of about the same size. Where endocervicitis is present alterative applications are indicated. A strong solution of silver nitrate, gr. 20 to the ^, has been often advantageous. Creolin or iodine is also useful. Such applications should be followed by a glycerine tampon. In general, it may be stated that every cause of irritation about the womb should be removed, and this, in many cases, will greatly diminish the nausea and vomiting. It is especially necessary to see that 'the patient does not suffer from constipation, and her un- pleasant sensations will often disappear when this is remedied. Should these measures, however, not be sufficient, and the patient become anaemic, the aid of drugs should be sought. Oxalate of cerium, or valerianate of cerium, sub-nitrate -of bismuth, pan- creatin, pepsin, and ingluvin may also be tried. Two and a half, or five grains, of one of the compounds of cerium, frequently repeated, often gives good results. Bismuth may be used in these, and larger doses. The digestive ferments may be given with food, or pre-digested food may be employed. Should this not be sufficient, one drop of tincture of iodine may be given, or creo- sote, or carbolic acid. Cocaine, or wine of cocoa, will often be successful when all else has failed. Fowler's Solution and tincture of nux vomica may be given in doses of one drop of each. Num- berless other remedies have been employed, and each case must be studied and treated upon its own merits. It must be remem- bered, however, that the local treatment of the uterus, and the THE HYGIENE OF PREGNANCY. 55 patient and skilful use of small quantities of suitable nourishment, with the digestive ferments, furnishes the most rational- method of treating these complications. If the trouble persists, the physi- cian should assure himself that the uterus is not dislocated, espe- cially by some backward displacement. It will often be possible, by using finely carded wool or jute in the form of antisepticized tampons, to restore the uterus to its proper position, and relieve the patient's symptoms. In cases of obstinate vomiting in preg- nancy, every remedy should be tried which offers the slightest prospect of success. Among those recently employed is menthol, which may be given in doses of from one to five grains. The question of the interruption of pregnancy will depend upon the presence or absence of dangerous anaemia in the mother. As our study of the blood progresses, we shall undoubtedly be able to recognize conditions dangerous to mother and child alike, by microscopic examination of the maternal blood ; at present, however, the general rule may be stated that whenever the mother is threatened with dangerous anaemia, pregnancy should be in- terrupted at once. It may be possible, after the uterus has been emptied, to cure an endometritis, or remedy some other condition which has caused the patient's suffering. A repeated pregnancy would then result successfully. In replacing a retroverted preg- nant uterus, it will be well to hold it in position by some device other than a stiff pessary. Tampons such as have been already mentioned may be covered with ointment of equal parts of lanolin and cosmoline, to which is added powdered boracic acid, ten grains to the ounce. In hospital practice, an ointment of balsam of Peru, cosmoline, and iodoform may be used to advantage. Warm douches may be very cautiously taken if there be extensive irritation about the uterus, and if the douches can be administered by a thoroughly competent and careful person. Regarding the further hygiene of pregnancy, it may be stated that moderation is the golden rule. The patient's usual tastes in the matter of food and drink should be consulted and continued. She will do well to avoid fatigue, especially standing and walking for long periods. There should be an abundance of sleep, and 56 MANUAL OF PRACTICAL OBSTETRICS. an abundance of fresh air. Lukewarm baths should be taken daily, or if preferred, a sponge-bath of moderately cold water. She should avoid long drives over rough roads, but should fre- quently take drives of moderate length and over smooth roads. Seasickness should be avoided, and any excitement or over-strain. Very hot churches and theatres, and crowds of any sort should be shunned. At the same time, every care must be taken to make the patient's life during this period one of interest and pleasure. Her natural forebodings should be met by kind encouragement, and books and surroundings which furnish healthful diversion may be amply supplied. There is sufficient evidence that the mother's emotions influence the child powerfully to make it necessary for her to avoid fright, or an outburst of any violent emotion. It should be remembered that the teeth are especially liable to de- teriorate during this period, and the services of a dentist may be sought early in pregnancy. The patient should be urged to take moderate exercise in the open air. Her diet should be of the most easily digested and nutritious articles of food. If the patient be found to be lapsing into a condition of mal-nutrition, arsenic, iron, cod-liver oil with hypophosphites, malt and meat extracts may be persistently given. Koumyss, Matzoon, and Mellin's Food will be found useful in such cases. CHAPTER VIII. THE ATTITUDE AND LOCATION OF THE FCETUS ; THE DURATION OF PREGNANCY. AT five or six months of pregnancy the foetus begins to as- sume a definite position in the uterus, and can be recognized as having a definite relation in situation to the mother. By a natural law of accommodation, an ovoidal body contained in a cylinder naturally turns its long axis parallel to that of the cylinder. This is exemplified in the fact that as the foetus grows, it assumes a position which, in a majority of cases, brings the head to present at the brim of the pelvis, the breech and feet occupying the fundus of the uterus. The ovoidal shape of the foetus is the result of a condition of flexion which approxi- mates the limbs and head to the trunk. During the early months of pregnancy the specific gravity of the amnial liquid is so great that the foetus floats readily about, assuming no definite position ; but as it increases in size, its specific gravity exceeds that of the amnial liquid, and hence the heaviest portion of the foetus tends to sink lowest in the uterus, and this fact, together with the law of accommodation already mentioned, results in the attitude and lo- cation of the foetus. In obstetric phraseology these facts are de- scribed under the head of (Fig. 29) POSITION AND PRESENTATION. By position is meant the rela- tion which a definite portion of the foetal body bears to a defi- nite portion of the birth-canal of the mother. By presentation is meant that portion of the foetus which descends lowest in the birth-canal, and which comes first to the notice of the obstetri- cian on examination. As we have said, ordinarily the head of the foetus sinks lowest, and hence presents most frequently. The majority of presentations, then, are head presentations. From the fact that the attitude of the foetus is that of flexion, it results 57 58 MANUAL OF PRACTICAL OBSTETRICS. that the top of the head or vertex is the portion of the cranium which is most frequently lowest, and hence presents. Thus it happens that the majority of head presentations are vertex pre- sentations. Should the attitude of flexion of the head not exist, but should the head have become extended, the face of the foetus will be lovvest, and hence, while the head will continue to pre- FIG. 29. THE USUAL ATTITUDE AND LOCATION OF THE FCETUS. sent, the face instead of the vertex will be the portion of the head sinking lowest into the pelvis. On the other hand, the child may present by the lower ex- tremity of the trunk or breech, and thus the long axis of the fcetal ovoid be brought to correspond with that of the cylindrical birth-canal of the mother. Occasionally, through some failure in the law of accommodation, the foetus at the moment of labor becomes turned transversely across the birth-canal, and then a THE ATTITUDE AND LOCATION OF THE FCETUS. 59 transverse position results. The efforts of the uterus to expel the child thus turned across the birth-canal result in bending the head upon the trunk with a lateral flexion, the shoulder of the child sinking downward, and finally presenting in the birth-canal. If we enumerate the presentations which may occur, we shall find five : the vertex, the face, the breech, the right and the left shoulder. If we consider the situation which any of these pre- senting portions may occupy in the mother's pelvis, we shall have the positions and presentations grouped together. It is of the utmost importance that, in studying obstetric cases, the obstetrician remembers the simple fact that the mother's pelvis has two sides, the right and the left. If the bony pelvis be examined, it will be seen that the points projecting furthest toward the centre of the pelvis from each side are the spines of the ischia; extending obliquely upward and outward from these points there will be seen a slight elevation or ridge on the bony surface of the wall of the pelvis. This slight ridge, like a water- shed, divides each side of the pelvis into an anterior and poste- rior half. The pelvis may then be said to have a left anterior compartment and a right anterior compartment, a left posterior compartment and a right posterior compartment. It only remains to locate the foetus in one of these four compartments to com- plete what is technically described as a presentation and posi- tion (Fig. 30). It must be remembered, however, that more important than the especial compartment in the pelvis occupied by the present- ing part is the question as to which side of the abdomen the back of the foetus occupies. In fact, the more rational and modern view makes but two positions : If the back of the child be toward the left side of the mother's pelvis, it is the first posi- tion ; if the back of the child be toward the right side of the mother's pelvis, it is the second position. When the mechanism of labor is considered, it will readily be seen how this simple division of positions accounts for the phenomena of labor. In the majority of cases the back of the child lies upon the left side of the mother's abdomen, the vertex presenting at the entrance 6o MANUAL OF PRACTICAL OBSTETRICS. FIG. 30. to the pelvis, and turned in its left anterior compartment. The resulting position and presentation is a left occipito-anterior, and this will be found in more than three-fourths of all cases. THE DURATION OF PREGNANCY is usually two hundred and eighty days. Instances where pregnancy is prolonged for ten months and more are not rare. The cause for the termination of pregnancy has not been clearly demonstrated ; but it is most probably the fact that the foetus can no longer be adequately nourished by the mother. The accumulation in the mother's blood of irritat- ing compounds derived from the processes of foetal nourish- ment causes an increased ex- citability to reflex stimuli. As the foetus grows, its move- ments become more vigorous, until the uterus is roused to contraction, and labor results. Rhythmic contractions of the uterus continue during preg- nancy, and furnish a sign of pregnancy. They assist in bringing the long axis of the foetus to coincide with that of the uterus. In estimating the duration of pregnancy it is best to avoid fix- ing an especial date, especially with primiparse. From ten days to two weeks' variation from a calculated date is not unusual. It is customary to reckon from the last day of menstruation, and a simple rule of calculation may be stated as follows : Count backward three months from the last day of menstrua- tion, and add one year and seven days to the date thus reached. In questioning patients to ascertain the date of last menstrua- tion, the answer elicited will usually refer to the date of the beginning of menstruation, instead of the end, the day desired. LATERAL SURFACE OF THE PELVIS. CHAPTER IX. NORMAL LABOR; THE HEAD PRESENTING. BY labor is understood that process of contraction of the uterus and abdominal muscles which results in the extrusion of the foetus. It may be commonly divided into three stages ; the first, the stage extending from the beginning of expulsive uterine contraction until the birth-canal is fully dilated ; the second, the interval oc- cupied by the extrusion of the foetus ; the third, the time required for the delivery of the membranes and placenta. The characteristics of the first period of labor vary in different individuals in first and subsequent labors. Intermittent uterine contractions occur frequently during pregnancy, and have much to do with accommodating the foetus to the birth-canal. The beginning of a first labor is usually characterized by an intensifi- cation of these wave-like uterine contractions, occupying a vary- ing number of hours. Thus a patient may be in this stage of labor for one or two days before active pains begin. As the name indicates, uterine contractions or labor pains are attended by suffering. Nerve fibres in the walls of the uterus are com- pressed by the contractions of the uterine muscle, and nerve trunks lying along the brim of the pelvis are also subject to con- tusion. The stage of intermittent uterine contraction is marked by the dilatation of the os uteri and the gradual obliteration of the cervix. When this process is completed, the membranes commonly rupture, and the actual expulsion of the child begins. The diagnosis of labor often requires perception and judgment on the part of the physician. He will frequently be called to primagravidae who imagine themselves in labor because abdomi- nal pain is experienced. Acute indigestion, muscular rheuma- tism of the walls of the abdomen, intercostal neuralgia, and an ex- 61 62 MANUAL OF PRACTICAL OBSTETRICS. aggerated nervous condition may all give rise to the sensation of abdominal pain. The practitioner can best satisfy himself as to the presence or absence of genuine labor pains by placing his patient in a comfortable position upon a bed or couch, and hav- ing her clothing so arranged that his hand can rest upon the ab- domen. He will then appreciate the frequency and vigor of uterine contractions, and after a short time of observation can generally determine whether labor has actually commenced or not. The arrival of the physician, especially if he be a stranger, will not infrequently cause the pains of the first stages of labor to cease for a short time. Tact should be used in approaching a parturient patient for the first time, and the physician will do well not to enter her room until his coming has been announced and a few moments have elapsed. During the second stage of labor uterine contraction will usually go on without interruption. As labor proceeds, the sensations of pain which at first are diffused through the abdomen will commence in the back, exten- ding along the sides of the abdomen to the supra-pubic region. Although intermittent, they will increase in frequency and sever- ity until, the membranes having ruptured, they become later in labor almost continuous. Positive information regarding the ex- act stage of a labor can be obtained by internal examination only. In multigravidae, experience enables a patient to estimate with greater accuracy the exact stage at which the practitioner is summoned. A vaginal discharge of blood-stained mucus is usu- ally a symptom of the dilatation of the cervix, and the beginning of actual labor. The mechanism of labor in head-presentations consists of the adaptation of the head to the brim of the mother's pelvis, the de- scent of the head and body of the child into the cavity of the pelvis, the rotation of the child as a whole toward the anterior surface of the mother's body, and, finally, its expulsion. During the later weeks of pregnancy, the intermittent uterine contractions to which reference has (Fig. 31) been made, aided by the elasticity of tissues previously distended will generally result in the descent of NORMAL LABOR; THE HEAD PRESENTING. 63 the presenting part into the cavity of the pelvis in multigravidse. In primagravidte, however, at the commencement of labor the head will probably be found at the brim of the pelvis, resting FIG. 31. THE FCETUS IN A PRIMAGRAVIDA. against its upper edge (Fig. 32). The movement of accommodation by which the head enters the pelvis will consist in adapting the di- ameters of the foetal head to those of the pelvis. The head en- 04 MANUAL OF PRACTICAL OBSTETRICS. tering obliquely in the majority of cases, the vertex being at the left anterior half of the pelvis, the chin and face of the child will point toward the right posterior portion. It will be remembered FIG. 32. THE FCETUS IN A MULTIGRAVIDA. that the oblique diameters of the pelvic brim in the living patient measure four and three-quarters inches, twelve centimetres. The occipito-frontal diameter of the head measures also four and three- NORMAL LABOR; THE HEAD PRESENTING. 65 quarters inches, or twelve centimetres. By relaxing the iliopsoas muscles the oblique diameters of the pelvis are capable of slight increase, sufficient to enable them to accommodate the occipito- frontal diameter of the head. These muscles may be relaxed by flexing the patient's thighs upon the abdomen, and this simple manoeuvre will often assist in the descent of the head in a linger- ing labor. Should, however, the head be large for the pelvis, it may become necessary to substitute for the occipito-frontal a smaller diameter. The foetal head is placed upon the trunk, like a lever across its fulcrum, the long end of the lever being the distance from the chin to the foramen magnum. The tendency shown by the human head to drop forward upon the breast, as exemplified in adults as well as in infants, illustrates the fact that the preponder- ance of weight is in front of the centre of gravity. This move- ment of complete flexion substitutes for the occipito-frontal diameter the sub-occipito-bregmatic, which averages nine and five- tenths centimetres, or three and three-fourths inches. In the oppo- site oblique diameter, the left, will be found one of the transverse diameters of the foetal head. Thus, when the occipito-frontal diameter occupies the right oblique diameter of the pelvic brim, the bi parietal will be in the left oblique diameter. When perfect flexion has occurred with some descent, the bi-temporal will be found in the left oblique diameter. Both of the transverse diameters of the head are sufficiently small to be easily accom- modated in the oblique diameters of the pelvic brim. The head having been perfectly flexed, descends gradually through the pelvic brim into the cavity of the pelvis (Fig. 33). The back of the child remaining directed toward the left side of the mother, the trunk descends as the head precedes it, the bis-acromial diameter of the trunk, which measures four and three-quarter inches, or twelve centimetres engaging in the left oblique diameter of the pelvic brim. When the foetus has descended sufficiently to fairly enter the pelvic cavity, the membranes have commonly ruptured, the amniotic liquid escapes, and the exact position of the head can 3* 66 MANUAL OF PRACTICAL OBSTETRICS. readily be determined upon examination. In the first position, a left occipito-anterior, the sagittal suture will be found occupy- ing the right oblique FIG. 33. diameter of the pelvis (Fig. 34) Toward the mother's right side, and a little posterior to the centre of the pelvic cavity, can be felt the anterior fontanelle. This landmark is not obliterated by the pres- sure which the foetal head undergoes, and it may be readily dis- tinguished by its size, and by the fact that out from it run four bony lines. These are the sagittal, the fronto- parietal of each side, and the suture between the two frontal bones. On the contrary, the posterior fontanelle is ordinarily obliterated by the pressure FlG ... exercised by the walls of the pelvis upon the foetal head, the bones sliding under each other in such a manner as to fill up the interval and leave simply a point of convergence of three sutures, namely, the sagittal and the two branches of the lambdoid. In head presentations a swelling forms on that portion of the head which is not pressed upon during labor. It results from infiltration of the scalp with bloody serum. In ver- THE HEAD ENGAGING IN THE tex presentations with normal rotation, PELVIC BRIM. it is found on the upper angle of the THE DESCENT OF THE FCETUS IN LEFT OCCIPITO-ANTERIOR LABOR. x. The caput succedaneum. NORMAL LABOR; THE HEAD PRESENTING. 6 7 FIG. 35. parietal bone, opposite the presenting point ; in left occipito-an- terior, on the upper angle of the right parietal bone. It is called the caput succedaneum. The physician, in his examination at this stage of labor, will find this point of convergence (the smaller, posterior fontanelle) upon the left side of the mother's pelvis, and toward its anterior surface. He will be able to distinguish the sagittal suture extending toward the right and posteriorly, and unless the tissues are firm and resisting, he will also be able to find the anterior fontanelle. Labor proceeding, a phe- nomenon of rotation occurs as the head descends. By rotation, we understand the turning of the head upon the pelvic floor so that its antero-posterior diameter is parallel with that of the pel- vic outlet (Fig. 35). It will be remembered that the only pelvic diameter at the outlet large enough to per- mit the expulsion of the head is the antero-posterior, which may be reinforced by the bending backward of the coccyx at its articulation upon the sacrum. Thus, a diam- eter of from twelve to fifteen centimetres, or four and three-fourths to over five inches may be obtained. The anterior turning or rotation of the head brings the vertex beneath the pubic joint, the occipito-frontal diameter resting upon the antero-posterior diameter of the pelvic outlet. The vertex being forced strongly DESCENT AND ROTATION. 68 MANUAL OF PRACTICAL OBSTETRICS. FIG. 36. beneath the pubes, the neck pivots upon the sub-pubic ligament (Figs. 36 and 37). Under the force of uterine contractions the coccyx is bent back- ward, and the forehead and face of the child are forced over the pelvic floor and peri- neum by a movement of extension. The trunk meantime follows the head with a correspond- ing rotation. The bis- acromial diameter hav- ing entered the pelvis in the left oblique diame- ter, the trunk descends, and the right shoulder of the child turning to- ward the pubic joint is first forced downward, emerging beneath the THE HEAD UPON THE PELVIC FLOOR. joint with a mechanism similar to that which the occiput has already executed. The lower shoulder is then extruded by a process similar to the extension of the face and chin, and the trunk and limbs of the child follow. The fact that the head rotates and emerges before the shoulders causes the vertex to turn toward the left thigh of the mother as soon as the head is born. There is no diameter of the trunk of the foetal body, except the bis-acromial, suffi- ciently large to occasion delay in the mechanism of labor, FIG. 37. BEGINNING EXPULSION OF THE HEAD. NORMAL LABOR; THE HEAD PRESENTING. 6 9 FIG. 38. and the head and shoulders born, only a mal-formation in mother or child will occasion delay (Fig. 38). The characteristics of the second or expulsive stage of labor are stTong contractions of the uterus, supplemented by those of the ab- dominal muscles, with fixation of the diaphragm and contraction of such of the muscles of the trunk as are necessary for this phe- nomenon. At the moment when the membranes rupture, there oc- curs a discharge of the amniotic liquid, although more or less dis- charge of blood-streaked mu- cus has been going on during the first stage. At the inter- vals between the uterine contractions, a slight pause occurs, during which the patient, if fatigued, often lapses into a condition of partial stupor or sleep. The surface of the body is fre- quently covered with slight perspiration, the face is flushed, and the entire or- ganism gives evidence of the great muscular activity which is going on. The complaint of pain increases as contractions become more violent, until the pain seems unendur- able. Occasionally a condition of temporary delirium or mania supervenes, which is of short duration. The pulse of the patient, although quicker than usual, is firm and strong, and shares in the vigor of the muscular system. During the early stages of labor the patient will naturally assume such a posture as is calculated to bring the head well into the pelvis, thus facilitating birth. She will frequently walk about the room, assume a semi-recumbent position, and often kneel at the side of the bed, her head resting upon her arms which are folded on the body. After the rupture of the membranes she RETROCESSION OF COCCYX. a, b, pubes. c, d, curve of sacrum and coccyx be fore retrocession, c, tf after retrocession. MANUAL OF PRACTICAL OBSTETRICS. FIG. 39. instinctively assumes a recumbent position, often turning from side to side if her sufferings be severe. The mechanism of labor when the vertex is directed toward the right side of the mother's pelvis and anteriorly, corresponds to that already described, with the simple reversal of direction in rota- tion. Thus the head and trunk, in the first instance rotating from left to right toward the middle line of the body, in the second instance, turn from right to left toward the cen- tre. While the former is much more frequent, the latter is not to be con- sidered as an abnormal labor. Prac- tically, the distinction between a nor- mal and an abnormal labor, the head presenting, will depend upon two factors: presence or absence of flexion, and the anterior or posterior rotation of the occiput (Fig. 39). HEAD BORN IN RIGHT OCCIP- ITO-ANTERIOR LABOR. CHAPTER X. ABNORMALITIES OF LABOR, THE HEAD PRESENTING. A NOT infrequent abnormality of labor, the head presenting, is the failure of the vertex or occiput to rotate anteriorly as the head descends. Many writers describe this phenomenon under the head of occipito-posterior positions, but the simpler and more rational explanation is to view them as cases of defective rotation, and not as separate positions and mechanisms. The physician will find FIG. 40. early in labor the vertex presenting, but not turned so plainly in front as is usually the case. The course of labor is more prolonged, and greater suffering is sometimes ex- perienced. As the head descends, the vertex, in- stead of turning to the front, remains directed pos- teriorly, and finally the head reaches the pelvic floor with the occiput near one or other of the sacro- iliac joints. If the expul- sive force of the uterus and the abdominal muscles be normally great, and the resistance of the pelvic floor be considerable, the head being flexed, the occiput will turn, in nearly nine-tenths of all cases, toward the front, and the expulsion of the child will be completed as usual. Should, however, the resistance of the pelvic floor be deficient, THE OCCIPUT IN THE HOLLOW OF THE SACRUM. 72 MANUAL OF PRACTICAL OBSTETRICS. and the expulsive forces be lacking, flexion being incomplete, the head may turn into the hollow of the sacrum and remain lodged in this position. The conditions necessary for anterior rotation of the occiput are, sufficient expulsive force, the resist- ance of the pelvic floor and the maintenance of a condition of flexion on the part of the head. When any of these factors is deficient, the impaction of the head may result (Fig. 40). Another abnormality of labor in head presentations occurs when, from any cause, the antero-posterior diameter of the pelvic brim is so much lessened as to encroach upon the oblique diame- ters, and prevent the head from entering in one of them as is usual. The head, in attempting to enter, will then turn trans- versely to the entrance of the pelvis, the occiput upon one side, the forehead upon the other, and if expulsive efforts continue, the head will be flexed laterally upon the spinal column, and one or other of the parietal bones will slip downward and forward, pre- senting at the entrance to the pelvis. This is known as a Parie- tal-bone presentation. A most important abnormality in head presentations is that by which the head becomes extended instead of flexed. Should partial extension occur, what is known as a Brow presentation may result, the lower portion of the forehead and the superciliary ridges becoming the presenting part. Should, however, com- plete extension be present, a Face presentation will result. FACE PRESENTATION. This abnormality of the presentation of the head is definitely named in accordance with the portion of the head which is considered as the presenting part. Thus the forehead may be taken, and the presentation be spoken of as a Fronto anterior presentation. Others select the chin, and speak of Mento- anterior presentations. The occurrence of either will be best understood by following a case of Left occipito anterior, or first occipital presentation, in which the head, instead of becoming flexed, is completely exten- ded. As the occiput rises upon the left side of the mother's pel- vis, the forehead descends, and, sweeping through an arc of a circle in the right oblique diameter of the pelvis, it lodges in the ABNORMALITIES OF LABOR, THE HEAD PRESENTING. 73 left anterior compartment of the pelvis, formerly occupied by the occiput. The chin sinks deeply into the pelvis pointing toward FIG. 41. FACE PRESENTATION ; LEFT-FRONTO-ANTERIOR. the mother's right side and posteriorly, the back of the child re- 4 74 MANUAL OF PRACTICAL OBSTETRICS. FlG. 42. maining as usual toward the left side of the mother, and turned slightly in front (Fig. 41). The forehead may be taken as the presenting part, and the presentation and position will then be called Left-fronto-anterior. This may also be styled the first position in a Face presentation. Should a similar mechanism be executed upon the right side of the pelvis, a Face presentation in the second position would re- sult. Others, however, prefer to take the chin as the cardinal point presenting in these cases, and to name the position, Men- to-anterior or posterior. Thus, the position just described as Left-fronto-anterior might be considered a Right-mento-posterior, and similarly, the chin may occupy any one of the four compart- ments of the pelvis (Fig. 42). The mechanism of a face presentation will depend upon the degree of extension which is present. In a case of Left-fronto-an- terior, if extension be completed, the trachelo- bregmatic diameter of the foetal head will en- gage in the right ob- lique of the pelvis. In the left oblique diame- ter will be found the bi- temporal diameter of the head. Each of these diameters will be re- membered as less than four inches, or ten cen- timetres in extent, and hence, is not sufficient- ly great to cause delay in rotation. The head descending with perfect extension, the chin should rotate anteriorly, and engage beneath RIGHT-FRONTO-ANTERIOR. ABNORMALITIES OF LABOR, THE HEAD PRESENTING. 75 the pubic joint. In this way, first the thickness of the head from foramen magnum to the anterior fontanelle, and then the thick- ness of the child's trunk above the shoulders are received in the antero-posterior diameter of the pelvic brim, the chin piv- oting beneath the pubes : by a motion of flexion the occiput is brought down over the concave surface of the sacrum, the coccyx and the distended pelvic floor, finally emerging by the retroces- sion of the coccyx at the sacro-coccygeal joint. If perfect exten- sion does not exist as the head descends, its maximum diameter, FIG. 43. MECHANISM OF FACE PRESENTATION. a. Anus. f. Fourchette. ur. Urethra. B. The bladder. 2 S. Second Sacral Vertebra. R. Rectum. or the occipito-mental, will be brought in relation with the di- ameters of the pelvic brim, and impaction will result and labor cease (Fig. 43). A most dangerous complication in face presentation is the turn- ing of the chin posteriorly into the hollow of the sacrum. The antero-posterior diameter of the pelvis must then receive not only the thickness of the head from the occipital region to the anterior 7 6 MANUAL OF PRACTICAL OBSTETRICS. fontanelle, but also the thickness of the chest of the child ; the combined mass cannot enter the pelvis, and hence impaction of FIG. 44. EXPULSION OF THE HEAD IN FACE PRESENTATION. FIG. 45. the foetus results. The factors necessary for the production of a normal . mechanism in face pre- sentations are sufficient expulsive force in the uterus and muscles of the abdomen ; adequate resistance of the pelvic floor, and the main- tenance of extension. A position of the head between extension and flexion in these cases must result in impaction (Figs. 44 and 45). Cases occur not infrequently in which the head is born last, but this will be considered under HEAD BoRN IN FACE PRESENTA . breech presentation. TION. Plate II. Davis' Obstetrics. CHAPTER XI. THE TREATMENT OF NORMAL LABOR. THE treatment of the first stage of labor requires the exercise of judgment regarding the administration of drugs which might seem naturally indicated in this condition. When the physician finds the patient actually in the first stage of labor, if she be under the charge of a competent nurse, he will do well to disturb her as little as possible. He should first scrub his hands tho- roughly with soap and water ; then rinse them ; then scrub them in bichloride solution, i to 1000. A thorough vagi- nal examination will then assure him that the time for active in- terference has not arrived. There are no active means by which the dilatation of the birth-canal can be hastened, which are not fraught with danger, and which should not be reserved for urgent cases. The complaint of pain, which will so strongly tempt a physician to prescribe narcotics, is the most distressing feature he has to encounter. The patient, however, should be diverted as much as possible from a consideration of her sufferings, while caution should be exercised that her strength does not become exhausted. She should be encouraged in first labors to remain up and about as long as possible, assuming any position most comfortable to herself. The nurse should see to it that the bladder and rectum are completely empty, and if any suspicion of a pre- vious inflammation about the birth-canal exists, the patient should receive a vaginal douche of bichloride of mercury, one to five thousand. Among the many drugs which have been given to mitigate the suffering of the first stage of labor, chloral and anti- pyrine are most deserving of confidence. The first may be given in doses of fifteen grains, repeated hourly, until three or four doses have been taken. It may be conveniently administered by rectal injection, as the stomach of the patient is often sensitive at 77 78 MANUAL OF PRACTICAL OBSTETRICS. this time. Antipyrine may be given in doses of two and a halt grains each, either dissolved in water, or in wafer or capsule. The writer's experience has shown him that larger doses than these of antipyrine result in delaying labor, while small doses fre- quently give the patient considerable comfort. The drug may be repeated three or four times at intervals of one or two hours. In abnormal cases of labor where it is feared that exhaustion may result from delay in the first stage, it is well to give the patient frequent hot douches. These should be rendered anti- septic by some substance which does not destroy the natural smoothness and slipperiness of the mucous membrane. A one per cent, solution of creolin will be found best adapted for this purpose. Carbolic acid, one per cent., or a very dilute solution of bichloride of mercury, one to ten thousand, may also be employed. In hospital practice, where the antecedents of patients are not known, it is well to give a preliminary douche of green soap and creolin, sufficiently strong to contain two per cent, of the anti- septic, before labor. The writer's experience in the Philadelphia Hospital has convinced him of the decided advantage to be gained by such an injection, either before or during the first stage of labor. With hospital patients a full bath, either in a tub, or if the patient's sufferings will not permit, by a sponge, should be invariably given ; the external genital organs should be washed in bichloride solution, one to two thousand, and if the membranes have ruptured, an antiseptic napkin should be worn until the physician's arrival. Should this stage be prolonged, care must be taken that the patient receives some easily digested nourish- ment. Stimulants should be avoided unless exhaustion is actually threatened. The physician should discriminate regarding the existence of delay in the first stage of labor from the inhibitory action of the sensation of pain. Thus, labor may begin, and after a short time the pains die away, the patient complaining of severe suffering which has gone to the point of nervous exhaustion. It will be well then to give the patient a full dose of some anodyne, putting THE TREATMENT OF NORMAL LABOR. 79 her perfectly to sleep for a few hours, when labor may go on successfully. An injection of morphia, one-eighth of a grain, with atropia one two-hundredth, will usually be found best for this purpose. When, however, the membranes rupture and the actual expul- sion of the foetus begins, the part which the physician is to play becomes a more active one. The patient should then lie upon her left side upon a bed suitably prepared by the nurse, a pillow or blanket roll between her knees, and her clothing should be so arranged that it may readily be changed after the birth of the child without great disturbance or fatigue. The physician should then examine the patient thoroughly to sat- isfy himself of the position and presentation. He should have at hand a basin containing a solution of bi-chloride of mercury one to two thousand, in which pieces of absorbent cotton, or old linen, are immersed ; he needs also to have available, Squibb's Fluid Extract of Ergot, brandy or whiskey, a hypodermic syringe in good order, tincture of strophanthus, tincture of digi- talis, and aromatic spirits of ammonia. The ligature for the cord should have been previously prepared from silk or stout thread thoroughly antisepticized. The physi- cian should have within easy reach a stethoscope, a pair of scis- sors suitable for cutting the cord, a small blunt-pointed bistoury, and a pair of haemostatic forceps. Beneath the edge of the bed should be a receptacle into which soiled pieces of cotton or linen may be thrown, and also a suitable vessel for receiving the placenta. The question of anaesthesia during normal labor is one admit- ting of difference of opinion and discussion, but the writer is convinced of the value of an anaesthetic given to a mild grade of anaesthesia, in expediting labor, facilitating delivery, and reduc- ing the tendency to laceration of the perineum. It is his custom to use chloroform, and a mask composed of canton flannel stretched upon a wire frame. This flannel may be readily re- moved and washed, and hence cleanliness in this respect can be easily observed. As labor proceeds, the patient's requests for relief from suffer- 80 MANUAL OF PRACTICAL OBSTETRICS. ing may be met by allowing a few drops of chloroform to fall upon the mask, and having her inhale sufficient to appreciate the odor without being affected by it. Should, however, it become evident that the patient's pains are so severe as to threaten exhaus- tion, it will be well to encourage her to inhale sufficient of the anaesthetic to give her brief periods of repose between the pains. A sleep for three or four minutes thus obtained will often change a lingering to a speedily successful labor, and prevent the application of forceps. When the head descends upon the pelvic floor, the physician must choose that form of support to the perineum which, in his judgment, best reduces the risks of laceration. The writer has no hesitation in stating his belief that by far the most efficient method of delivery is that taught so long in the Vienna Obstet- ric Clinics, and sometimes denominated " The Vienna Meth- od." It consists in placing the right hand broadly extended upon the perineum, the curve of the posterior commissure being received in the space between the thumb and index finger ; the left hand is placed between the patient's thighs, and as the head emerges, the fingers of the left hand in a semi-flexed condition grasp the vertex, holding it strongly upward beneath the pubic joint. Should the patient threaten to expel the child suddenly, either hand may be placed over the vulva, the other pressing upon it, and the strength of both arms is instantly available to check the too rapid progress of labor. As the head descends, the phy- sician cleanses the perineum by means of the cotton or linen im- mersed in the antiseptic solution, dropping these pieces into the waste receptacle beneath the edge of the bed. At the moment of delivery, he requests that the patient inhale the anaesthetic deeply to complete the transient anaesthesia. Directing or main- taining the flexion of the head by the left hand, with the right he presses the head backward until a pain has ceased, and then at a favorable opportunity, having tested the elasticity of the peri- neum by allowing it to move back and forth under the right hand as the head descends, he slips it back over the head, allowing the head to be born between the pains. THE TREATMENT OF NORMAL LABOR. 8l FIG. 46. The nurse should have ready a solution of boracic acid and glycerine, with small bits of old linen, and as soon as the head is born, the eyes and mouth of the child should be cleansed with this material. During the brief pause which occurs between the expulsion of the head and the shoulders, the patient should be allowed to rouse partially from the anaesthesia, although the vigil- ance of the physician should be in no way relaxed. His left hand should grasp the neck of the child, bending the child's trunk by a lateral flexion so that the presenting shoulder, usually the lower, is prevented from ploughing downward into the perineum. The right hand should still support the pelvic floor, and thus the delivery of the shoulders be managed upon the same prin- ciples applied to the birth of the head. The shoulders born, the anaesthetic should be entirely sus- pended, and upon the expulsion of the child the nurse or physi- cian should place a hand upon the fundus of the uterus, while the child is allowed to lie upon its right side until the pulsation EPISIOTOMY. of the cord has ceased. A tem- The dotted line on the patient's right shows ligature may then be the line of incision. The dark oval shows f*"""*.J t the amount of dilatation gained by thrown about the COrd three fing- episiotomy on both sides. ers" breadth from the umbilicus. If the child is asphyxiated, and haste is imperative, the cord may be clamped by the haemostatic forceps, and cut without ligation. The child, when separated from the mother, is wrapped by the nurse, pre- ferably in a woolen FIG. 47. EPISIOTOMY KNIFE DEVISED BY THE WRITER. blanket, and when its respiration has been observed to be normal, 82 MANUAL OF PRACTICAL OBSTETRICS. it is placed aside until the time for its first bath (Figs. 46 and 47). In cases of excessive distention of the perineum, serious rup- ture may often be prevented by the simple procedure of episiot- omy. This is effected by introducing a blunt-pointed bistoury, or a blade of a pair of blunt-pointed scissors, between the head and the edge of the vulva at the junction of the upper two-thirds with the lower third. The extent of such an incision will de- pend upon the degree of distention; but, ordinarily speaking, from an inch to an inch and a half may be incised without dan- ger. The blade of the knife should be turned up against the edge of the vulva at the occurrence of a pain, when the tissues will separate, and the perineum can often be observed to retract to a remarkable extent over the presenting part. After delivery, these incisions should be stitched with fine catgut, plentifully powdered with boracic acid, aristol or iodoform, when, as a rule, they heal promptly. The serre-fine has been used in place of the suture with success. CHAPTER XII. FIG. 48. THE THIRD STAGE OF LABOR. WITHOUT narrating the many theories which have been formed regarding the separation and expulsion of the placenta, it seems in the present state of our knowledge to be the fact that the placenta separates from the wall of the uterus by the intervention of a clot (Fig. 48). It is expelled from the uterus by the contractions of that organ, and especially by those of the abdominal muscles. The time normally occupied for the accom- plishment of this is sufficient, first, to allow partial separation and the formation of a clot to occur ; and, second, to give the patient sufficient interval in which to recover con- sciousness, if she has been anaesthet- ized, and to regain control of the diaphragm and abdominal muscles. When labor is accomplished with- out putting the patient entirely to sleep at the moment of birth, the placenta may follow within ten or fifteen minutes after the expulsion of the child. When, however, the THE PLACENTA AND MEMBRANES, patient is exhausted or has been After the expuUion of the foetus, anaesthetized, from half an hour to an hour may elapse before uterine contractions bring about the expulsion of the placenta (Fig. 48). The question as to whether active interference is demanded must be determined by the presence or absence of hemorrhage 83 8 4 MANUAL OF PRACTICAL OBSTETRICS. FIG. 49. and the consistence of the uterus as felt through the abdominal wall. If the uterus remains moderately firm, and there be no hemorrhage, the practitioner should wait, if the labor has been normal, until the patient has had from twenty minutes to half an hour's rest, and is able to make voluntary expulsive efforts. The left hand should then be placed upon the fundus of the uterus, and that organ roused to contract by gentle friction with accom- panying pressure in the axis of the pelvis. The right hand of the physician, having been freshly cleansed and antisepticized, should examine to ascertain the descent of the placenta. Usually a few vigorous contractions of the uterus and abdominal muscles will bring the edge of the pla- centa at the vulva within easy grasp by the physician. He should then fold it together with the thumb and fingers, and by a gentle rotary motion it will be felt to slip easily away, the mem- branes following it in a twisted cord. The nurse should hold a suitable receptacle between the patient's thighs, and thus the placenta may be transferred with- out exposure and with but little soiling of the bed, and reserved THE ABDOMEN AFTER THE FCETUS is f future examination (Figs. 50 BORN. The placenta in the uterus. and 51). The attention of the physician should next be directed to the firmness or laxity of the uterus. In healthy, young primiparae, the mechanism of the closure of the uterine sinuses is amply sufficient to guard against hemorrhage ; but where repeated labors have weakened the uterus, or where it has been relaxed by protracted or abnormal labors, it is the part of caution to administer a teaspoonful of the Fluid Extract of Er- THE THIRD STAGE OF LABOR. 85 got. In some cases five grains of quinine will act more efficiently than ergot. In severe cases where the effect of the drug must be obtained at once, it may be injected into the walls of the abdo- men in doses of thirty minims. The patient should now be left in charge of the nurse to be properly cleansed. FIG. 50. FIG. 51. THE EXPULSION OF THE PLACENTA, THE PLACENTA IN THE LOWER FCETAL SURFACE FIRST. UTERINE SEGMENT. The physician will have had opportunities during the progress of labor to be aware of the presence or absence of lacerations of the pelvic floor; if he is not satisfied as to their existence and their extent, he will do well, before leaving his patient, to exam- ine thoroughly, and should sufficient laceration be found, and 86 MANUAL OF PRACTICAL OBSTETRICS. the condition of the patient permit, it should be closed at once. The question as to just what extent of median laceration of the perineum demands suture is a difficult one to answer. The sani- tary regulations of some of the countries where midwives prac- tice extensively under license require them to summon a physi- cian to close a laceration of more than one-half or three-fourths of an inch. In hospital practice it is safe to say that all lacera- tions except those of the posterior commissure should be closed by sutures. Abrasions of the mucous membrane or stellate tears in the mucous membrane of the vagina should be heavily pow- dered with a suitable antiseptic substance. In hospital practice, iodoform is best; in private practice where the odor of iodoform is so objectionable, powdered boracic acid or aristol may be employed to advantage. It will not infrequently be found that instead of a laceration of the perineum, the mucous membrane of the vagina may have been dissected up from the sub-mucous tissue for two or three inches at one side. If it can be done without too much suffering and inconvenience, it is well to close such a laceration. The immediate closure of perineal injuries of slight extent is com- paratively a simple matter. Curved needles, needle-holder and a pair of dissecting forceps, and a good quality of antisepticized silk will usually be sufficient. Silver wire is preferred by some, and the over and over stitch with catgut by others, but, as a rule, the average practitioner will do better with silk than with any other material. The principle of closure consists in simply bringing together lacerated surfaces, remembering that the stitch should go sufficiently deep to bring the wound together from the bottom. As to the time for the performance of this slight operation, if the patient and the physician be exhausted, if the light be poor, and the conditions unfavorable for closing a lacerated perineum, where labor has occurred during the night, it is well to wait four or eight or even twelve hours until the patient has become some- what rested, and the physician can perform his duty under favor- able circumstances. A great advantage in immediate closure is found in the fact that the tissues are less sensitive to pain than THE THIRD STAGE OF LABOR. 87 usual, but a mild degree of anaesthesia will relieve the patient of suffering if the operation be deferred. It is almost needless to say that the strictest antiseptic precau- tions should be observed in all cases of labor. After a normal labor the patient should be given one vaginal douche of bi-chloride of mercury, one to five thousand. Further douches are superfluous and often injurious, unless complications arise. If, however, the patient has been lacerated and stitches have been inserted, she should have two and possibly three vaginal douches, in twenty-four hours, of bi-chloride of mercury one to five or eight thousand, creolin one per cent., carbolic acid two per cent., thymol one to two thousand, or a saturated solution of boracic acid. After the douche, the parts should be powdered well with iodoform or boracic acid. After attending to the mother, the physician should examine the placenta and the membranes to assure himself that no part of them has been left within the uterus. He may also note any peculiarity about the placenta in form, size, weight, or the pres- ence or absence of calcareous or fatty degeneration which may be present. The child should also claim his attention, and he may, at his leisure, grasping the cord at the umbilicus with the thumb and finger of the right hand and cutting it freshly at the ligature, strip or squeeze the cord from the umbilicus outward. A cord which is not rich in Wharton's jelly may not need stripping, but in all cases where the cord is large this procedure should be attempted. A convenient and useful method of dressing the cord is to powder it with salicylic acid one part, and starch five. It is then enveloped in absorbent cotton and placed upon the child's body, pressing gently against the trunk on one side of the um- bilicus. A knit or flannel binder is then applied after the bath of the child, and the cord is thus protected from violence. CHAPTER XIII. THE TREATMENT OF ABNORMAL LABORS, THE HEAD PRESENTING. THE treatment of abnormal labors in head presentations must be directed to secure the conditions requisite for a normal mech- anism of labor. These conditions are sufficient expulsive force on the side of the mother, the resistance of the pelvic floor, and the flexed position of the head. As regards failure of the mother's expulsive forces the most com- mon example is lingering labor from weak pains. Delay from this cause is most often seen in poorly developed, neurotic primiparse, in old primiparae where the birth canal is not easily dilated, and in multipart where the uterine and abdominal muscles have been so often distended that they have lost their elasticity and contractile power. The cessation of expulsive efforts, before the membranes rupture, is attended with little danger to the mother and none to the child. After the membranes rupture, both are in danger from protracted labor. The complete cessation of expulsive efforts after rupture of the membranes should give rise to the suspicion that the foetus and the birth canal, in a head presentation, are dispro- portionate. It cannot be too strongly urged that only a prelim- inary examination by pelvimetry, palpation and auscultation can enable an obstetrician to rationally conduct a case of even nor- mal labor. When by such examination the pelvis has been found normal, the position and presentation are occipito-anterior, either left or right, and the head has engaged favorably, thus showing a normal proportion in the size of the foetus and birth canal, failure of the expulsive forces before the membranes rup- ture is to be treated by anodynes and sedatives to secure rest ; by emptying bladder and rectum; by small quantities of easily di- gested food, and by allowing the patient to assume such postures as conduce most to her comfort. Occasionally toughness of the 88 THE TREATMENT OF ABNORMAL LABORS. 89 membranes delays labor, when the obstetrician must rupture them ; but as a rule the membranes should be left to rupture spontaneously. During the second stage of labor in these cases, failure of ex- pulsive efforts is to be treated first by posture By turning the patient on that side to which the presenting part is pointing, and flexing her thighs, descent and rotation will be facilitated. In addition, the uterine and abdominal muscles may be stimulated by friction. This is best done by commencing to rub the abdo- men and gently knead the uterus when a pain begins, increasing the rate and vigor of manipulation as the pain advances. As the pain reaches its acme, pressure may be made in the axis of the pelvis and continued until uterine contraction abates. Drugs which experience has shown may be safely employed to stimu- late expulsive efforts are the diffusible stimulants, as alcohol, tea and coffee, and quinine. The last is advantageously given in capsules containing three grains of quinine and one or two grains of scale pepsin, a combination which does not usually excite the nausea so often seen at this time. The mother's expulsive efforts may be stimulated and encouraged by her cooperation, in fixing the diaphragm and bringing the necessary expulsive muscles into play, by pulling upon a sheet tied at the foot of the bed, or grasping the hand of an attendant. Whenever the sensation of pain is so acute as to inhibit expulsive muscular action, an anaesthetic in small doses will allow the reflex mechanism of labor to proceed success- fully. At the beginning of a pain the patient should be allowed to smell of the anaesthetic; at the height of the pain she may ex- perience its effects sufficiently to enable her to sleep for a few minutes when the pain has passed. In this way action and re- pose alternate, and progress continues. An abnormal position of the head will be usually discovered when the membranes rupture, as the obstetrician should then thoroughly examine the patient. It can best be remedied by the insertion of the antisepticized hand, aided by the administra- tion of an anaesthetic. In face presentation extension is to be sought. If the physician detects, early in labor, that the occiput 4* 90 MANUAL OF PRACTICAL OBSTETRICS. is turned posteriorly, he will do well, before the membranes rup- ture, to place the patient upon the side toward which the occiput is pointing. By so doing, the fundus of the uterus is allowed to incline toward that side, and the rotation of the presenting part is favored by bringing the foetus more perfectly into the axis of the birth-canal. As the head descends the hand may be used to push up the forehead and favor flexion. The expulsive forces of the mother should be conserved by the administration of tonics or stimulants, and should these forces fail the forceps is indi- cated. It must be remembered that labor, when the head turns posteriorly, is usually longer and more painful than normally, but it should also be borne in mind that nearly nine tenths of these cases terminate spontaneously with an anterior rotation of the occiput. When the occiput turns into the hollow of the sacrum, great caution is needed in attempting to complete delivery. A choice lies between the forceps and craniotomy, and should the child have perished, the latter, in skilful hands, is the better of the two procedures. The method of applying the forceps in these cases will be described under the general consideration of the use of this instrument. The treatment of brow presentations consists in the endeavor with the antisepticized hand to convert a brow into an occipital presentation, with craniotomy should impaction and foetal death occur. Version in the early stages of labor, when dilatation is complete, is also indicated in brow presentation, when the pelvis is normal and the foetus proportionate in size. Face presentations must be treated by securing as complete ex- tension as possible, by retaining the membranes unruptured to the latest moment, and occasionally, by the use of the forceps. When the head is turned transversely at the brim of the pelvis, causing the presentation of a parietal bone, the case demands most cautious treatment, and will be considered under the head of The Treatment of Labor in Contracted Pelves. CHAPTER XIV. THE FORCEPS. A FREQUENT complication in labor, when the head is presenting, is failure of the mother's expulsive power, necessitating instru- mental delivery. In the early days of obstetric science, such cases invariably terminated by the death of the child, and its mutilation and extraction by sharp hooks. When, however, the idea of blunting these hooks and converting them into a harm- less tractor arose, the forceps was invented. Its model was doubtless suggested by the shape of the hand about to grasp a round object like the head. It consists of two blades, named in accordance with the sides of the pelvis nearest which they lie, the left and the right. Each blade is composed of an expanded portion for grasping the head, an intermediate portion bearing some device for fastening the two blades together, and two handles, one at the extremity of each blade. The ex- panded portion for grasping the head resembles the hand ren- dered concave by flexion. This concavity gives to this portion of the forceps blade a curve called the Cephalic Curve, because it is intended to favor the approximation of the instrument to the head. From the tip of the expanded or head portion of the for- ceps blade to the handle the entire blade describes a curve some- what resembling the axis of the pelvis. This is called the Pelvic Curve of the forceps. In the centre of the cephalic portion of the forceps blade is an ovoid aperture called the Fenestra of the blade. The device for fastening the forceps blades together, called the lock, consists in some instruments of a large screw with thumb-piece by which the upper can be fastened firmly to the lower blade ; in others of a button-like knob placed upon the lower blade, while a niche in the upper blade receives the stem of the button when the blades 92 MANUAL OF PRACTICAL OBSTETRICS. are brought together ; the lock may also consist of a loosely fit- ting joint formed by a niche in the lotver blade receiving a loose- ly fitting ledge upon the upper. The lock most frequently in use is the last, which is exemplified in the Simpson forceps. The material of which the forceps is made is tempered steel, plated with nickle ; the handles are often of hard rubber, darkly stained wood, and, occasionally, of metal entirely, the purpose of the last being to avoid a corrugation which in wooden handles may give lodgment to septic material. Forceps are divided commonly into long and short, the long being, as the name implies, several inches greater in length than the short forceps. The various modifications of this instrument FIG. 52. DAVIS FORCEPS, PERFORATED FOR Axis TRACTION TAPES. are so many that only those most in use will be mentioned, and especially those whose merits have been proven by personal ex- perience. Forceps may be divided into two classes as construct- ed with direct reference to the manner of application. For ex- ample, the Simpson forceps, one of the most commonly used, is constructed to be applied to the sides of the pelvis without re- gard to the rotated or unrotated condition of the head. On the other hand, the Davis forceps was shaped to be applied to the sides of the child's head. Various other instruments are inter- mediate in construction, but each is made with some reference to this manner of application (Fig. 52). The indications for the use of the forceps are, danger to the life of the mother or child, or both, arising through delay in labor. Occasionally, in precipitate labor, the head may be so THE FORCEPS. 93 grasped and its progress controlled by the forceps as to render the birth a normal one so far as the rate at which the child is ex- pelled is concerned. While the forceps has powers as a lever, compressor and rotator, yet these are secondary and accidental, and its chief and important function is that of a tractor. The conditions under which the forceps may be safely applied are a vertex presentation, very rarely a presentation of the breech or face. The size of the child should be proportionate to that of the birth-canal of the mother, the folly of attempting to drag a large head through a small pelvis being self-evident. The birth-canal must be dilated, and the foetal membranes must have ruptured. The dangers attending the use of forceps are laceration of the maternal tissues, laceration of the child's scalp, compression and injury of the child's brain, and the increased risk of septic infection accompanying the use of instruments. Although this instrument, improperly used, is one of the most dangerous to mother and child, yet its proper employment, under antiseptic precautions, does not increase the mortality and morbidity of labor beyond a very slight extent. The first and simplest complication of labor for which the forceps may be employed occurs when the vertex presents ; rota- tion has occurred ; the head has descended to the pelvic floor, but the mother's expulsive forces failing, the life of the child is threatened through asphyxia, and the mother's tissues are in danger through pressure, while her strength is well-nigh exhausted. The application of the forceps under such circumstances is known as the Low-application or Low-forceps-operation, because the head is resting upon the pelvic floor when the instrument is applied. Danger to the foetus in such a case is recognized by weakness of the foetal heart, with rapid beating, and sometimes a much dimin- ished frequency in cardiac action. Danger to the mother in such a case can be diagnosticated by her exhausted condition, rise in her temperature, rapidity of her pulse-rate, and a dry and swollen condition of the birth-canal. A careful physician, however, will not wait until the conditions mentioned are present in the birth- canal, but will interfere when the other indications exist. 94 MANUAL OF PRACTICAL OBSTETRICS. To apply the forceps, the patient is placed upon her back across a bed, her hips brought to the edge of the bed, and her feet in chairs. An antiseptic douche should be given before the appli- cation of the instrument, and the physician should be sure that the bladder and rectum are empty. In primiparae an anaesthetic should always be administered ; in multiparae it is sometimes possible to avoid anaesthetizing the patient. The physician should prepare his instrument by dipping it in hot water, washing it carefully in soap and hot water, rinsing it thoroughly ; the forceps should then be placed conveniently in a pitcher of a hot anti- septic solution, creolin two per cent., carbolic acid two and a half per cent., being convenient. The instrument may be lubricated by slightly smearing the outer surface with some antiseptic oint- ment, or with carbolized oil. The physician should then place himself directly opposite his patient, so that he can appreciate any deviation from the central line of her body. The left blade of the forceps, or lower blade is to be inserted first ; the hands having been thoroughly cleansed and antisepticized, the fingers of the right hand should be introduced into the vagina between the head and the wall of the birth canal ; grasping the left blade of the instrument at its centre with the left hand, the physician gently inserts the left blade guided by the fingers of the right hand. (Fig. 53). To facilitate introduction, the left blade should be held with its handle parallel with Poupart's ligament of the right side ; the thumb of the right hand gently pushes against the posterior surface of the cephalic portion of the blade, the instrument gliding gently between the head and the fingers of the right hand (Fig. 54). When properly applied, the forceps blade slips in almost imper- ceptibly ; the handle of the blade will tend naturally to drop toward the floor, and should be held by an assistant. The fingers of the left hand having next been introduced as a guard, the right blade should be grasped in the right hand of the physician, and inserted toward the right side of the mother's pelvis. If it fits easily over the head, an effort may then be made to lock the blades by allowing the right or upper blade to fit down upon the left, and the parts of whatever lock may be present to adapt THE FORCEPS. 95 FIG. 53. themselves to each other. If the forceps will not lock easily, the blades should be slightly shifted with great gentleness until they lock easily. Locking having been accomplished, the physician may then by gentle traction try to move the head. A very moderate force, such as that exercised by the fore- arms of the operator only, is all that it is safe to use. Traction should imitate so far as possible uterine contractions and the normal expulsive efforts of the mother. If the mother be conscious, she should be urged to "bear down," and traction by the forceps should be simultaneous with her effort. If she be anaesthetized, traction may be made every five or ten minutes as the case demands. In simple cases such as that under consider- ation, the force should be directed first slightly downward, then di- rectly outward, and last, upward. By this means the occiput will be brought out from beneath the pubic joint ; traction directly outward should then follow until the head begins to distend the perineum. By this means the occiput will have emerged from beneath the pubic joint, and will be distend- ing the vulva. Traction should then be almost directly upwards, w hen the head will be delivered over the perineum. In this way the natural mechanism of labor is imitated, and laceration of the perineum through downward pressure of the head may often be prevented. The simple procedure of Episiotomy, THE LEFT HAND GRASPING THE LEFT FORCEPS BLADE. 9 6 MANUAL OF PRACTICAL OBSTETRICS. to which reference has already been made, is especially well adapted to such cases. After the delivery of the head, the shoulders will usually follow if the uterus be roused to con- traction by friction. After delivery, the patient should receive a thorough douche of bi-chloride of mercury one to five thousand, FIG. 54. THE INTRODUCTIOX OF THE LEFT BLADE COMPLETED. and any slight lacerations should be thoroughly dusted with an antiseptic powder. Although lacerations very frequently occur when the forceps is used, yet in many cases a laceration is pre- vented through the better control afforded the practitioner by his instrument (Fig. 55). THE FORCEPS. 97 In other countries, the patient is frequently placed upon the side during forceps delivery, although the position upon the back is the favorite one in America. The low-forceps-operation, or use of the instrument when the head is upon the pelvic floor, is a FIG. 55. PROTECTION OF THE PERINEUM IN FORCEPS DELIVERY. Patient upon the left side. comparatively simple and safe procedure. When, however, the head has not rotated, and especially if the head be situated at the brim of the pelvis, the application of the forceps is a difficult and dangerous manipulation. 5 CHAPTER XV. THE APPLICATION OF THE FORCEPS AT THE BRIM OF THE PELVIS : AXIS TRACTION. ANY one who has ever introduced the instrument, both blades being in position and locked, into the pelvis of a skeleton so high that he could grasp a head situated at the brim of the pelvis, must have observed that when traction was begun with the forceps so applied, the result was either failure to cause the head to descend, or its extraction with great difficulty. If the cause for such difficulty was sought, it was found that when the forceps was turned strongly forward, the tips of the cephalic portions of the blades impinged against the walls of the pelvis, and progress be- came impossible. In a living patient, the lining membrane of the birth-canal would have been badly lacerated by such an effort. If, however, a piece of tape be passed through the fenestrae of the forceps, and when introduced to the brim of the pelvis, traction be made downward and backward by pulling upon the tape, this difficulty is avoided, and a comparatively easy traction will result. Remembering that the direction of the axis of the birth- canal is downward and backward until the pelvic floor is reached, when it is deflected upward and forward, it will be seen that trac- tion in this direction may be appropriately termed axis traction (Fig. 56). Any forceps fitted with a device for performing this manoeuvre, namely, pulling downward and backward when the forceps is ap- plied at the brim of the pelvis, is an axis-traction-forceps. The more elaborate of these instruments possess metal tractors hinged upon the cephalic portion of the blade, which are not detachable. The simpler axis-traction-forceps have some convenient device for the accomplishment of this purpose by which traction is gen- 98 APPLICATION OF FORCEPS AT BRIM OF PELVIS. 99 erallymade with tape or bandage, the whole being easily attached or disconnected. Of the first class are the elaborate instruments of Tarnier, Simpson and Breus, and their modifications. The latter form of instrument is well represented by the tape attach- ment devised for the forceps by Poullet, which may be applied to any ordinary pair. If we consider the best means of promoting flexion in cases in which rotation is deficient, we shall see that traction in the axis FIG. 56. Axis TRACTION. a. b. Traction with the ordinary forceps. c d. Traction with the axis traction forceps. of the pelvis is among the most valued of resources. The axis- traction-forceps then is especially valuable in this complication, and hence it is that posterior rotations of the occiput and defec- tive rotations are often best treated by axis-traction. An equal advantage in face presentations is often gained by the use of such an instrument in the ability to secure perfect extension. Before proceeding to consider the application of the forceps at 100 MANUAL OF PRACTICAL OBSTETRICS. the brim of the pelvis, we may be allowed to repeat that the case already described is the simplest condition calling for the use of this instrument, namely, failure in expulsive force, the occiput presenting and having rotated anteriorly, the head resting upon the pelvic floor, the child being proportionate in size to the pel- vis; the function of the forceps is simply to imitate the mechan- ism of the last portion of the second stage of labor. The dan- gers attending its use in such a case are undue compression of the foetal head and laceration of the perineum and pelvic floor. We next proceed to the more serious conditions requiring the use of the instrument, namely, the expulsive forces of the mother failing before the head has descended to the pelvic floor while FIG. 57. LUSK'S TARNIER'S AXIS-TRACTION FORCEPS. rotation is as yet incomplete, and in cases in which, often-times, the child is not proportionate in size to the mother's pelvis. The use of forceps in face presentation and when the child pre- sents by the breech, is comparatively rare. It not infrequently happens that the mother's strength becomes exhausted when the head has engaged at the brim of the pelvis and before descent and rotation have occurred. In such cases the dangers of exhaustion and foetal death are greater than in the cases just described, as are the risks of injury to the mother by the instrument itself. The two classes of instruments already described were designed APPLICATION OF FORCEPS AT BRIM OF PELVIS. 101 with a special reference to these cases. Thus the Tarnier axis-trac- tion-forceps and the Simpson long-axis-traction forceps represent two theories of application (Fig. 57). In the first, the operator endeavors to apply the forceps accurately to the sides of the head ; the instrument is firmly secured in its grasp of the foetal head, traction is made in the axis of the pelvis, and the instrument and the head are allowed to rotate together (Fig. 58). In the use of the sec- ond instrument mentioned, the forceps is applied to the sides of the pelvis and in the pelvic axis, grasping the head as it conveniently FIG. 58. TARMER'S LATEST AXIS-TRACTION FORCEPS. can. Intermittent traction is then made in imitation of labor pains and between the tractions the blades are slightly separated, and the head is allowed to rotate by degrees until, by the time the pelvic floor is reached, it has fitted itself gradually to the in- strument (Fig. 59). The first method of application is the more difficult ; the second is comparatively easy, but requires discrimination and skill in fa- voring the rotation of the head. We have employed for some 102 MANUAL OF PRACTICAL OBSTETRICS. time in axis traction the ordinary Simpson forceps to which we have adapted the tape attachment of Poullet. A brief descrip- tion of the method of adapting these tapes is as follows : The blade of the forceps is made in its cephalic extremity a little heavier than ordinary, the fenestra of the blade measures four and one-half inches in length ; two and one-half inches from the cephalic end an aperture is made in each limb of the blade surrounding the fenestra one-quarter of an inch in length, one-eighth of an inch in width ; this aperture is so bevelled as to present no sharp surface ; through it is passed a piece of strong linen tape one-half inch in width, inserted from within outward through one aper- FIG. 59. SIMPSON'S AXIS-TRACTION FORCEPS. ture, and then from without inward through the other ; each piece of tape is one yard long, or eighteen inches after it has been doubled by passing through the forceps blade ; the tapes are received in a traction bar consisting of a straight portion eight inches long curving downward a distance of four inches, and terminating in a rotary traction handle ; just before the traction bar curves downward, it has upon the upper surface a cross piece, two and one-quarter inches long, which has at each end an aper- APPLICATION OF FORCEPS AT BRIM OF PELVIS. 103 ture for making fast the tapes ; the end of the traction bar which is nearest the mother has a rim of metal through which the tapes pass to be tied into the apertures ; the forceps is applied to the sides of the pelvis in the usual manner, the tape being held along the blade by the obstetrician and the instrument being first in- troduced on the left side of the mother as is customary ; care is taken that the tape rests between the forceps blade and the head of the child ; the tapes are then passed through the ring of the traction bar, passing below the locked forceps, and are made se- cure at the cross piece ; to prevent cutting the perineum and pos- terior wall of the vagina, Sim's speculum or any suitable depres- sor or guard may be used. It has been found by experience that a special screw for hold- ing the forceps firmly locked is not necessary; extraction is made with one hand, while with the other the forceps is grasped as usual and easily held and applied to the head ; the pull upon the tapes is such as to tend to keep the forceps tightly applied to the head instead of drawing the blades apart. We are accustomed to carry the tape and traction bar with us, using the forceps with- out them when axis traction is not necessary. The fact that this attachment can be fitted to any forceps with which the practi- tioner is familiar, its little cost compared with expensive axis- traction instruments, the ease with which it is cleaned and car- ried in the regular obstetric bag, have made the instrument a very convenient one in our hands (Fig. 60). The high forceps operation, or the application of the instru- ment at the brim of the pelvis, is admissible only when the child is proportionate in size to the birth-canal of the mother ; when the head has at least partially engaged at the brim of the pelvis ; when there exists no obstacle to delivery in the centre of the bony pelvis and at the pelvic floor ; when the membranes have ruptured, and, as is the rule in these cases, when mother or child, or both, are in danger from delay. While it is sometimes possible in the simple or low forceps operation to perform delivery without changing materially the patient's position, in the application of forceps to the head at 104 MANUAL OF PRACTICAL OBSTETRICS. the brim of the pelvis, the patient must be brought to the edge of the bed or table, her hips projecting over the edge sufficiently far t6 enable traction to be made in the axis of the pelvis. An anaesthetic is nearly always indispensable. As in all obstetric operations, the bladder and rectum should be thoroughly emp- tied, and means should be at hand for promptly resuscitating the child. In selecting an instrument, the average practitioner will do better with one to which he is accustomed than with a strange, FIG. 60. SIMPSON'S FORCEPS, With Poullet Tape Attachment for Axis-Traction. although possibly superior instrument. The patient being anaes- thetized, a thorough examination should be made to determine as far as possible the exact position of the head. If the operator purposes to apply the forceps to the sides of the pelvis, the blades may then be introduced as usual in the pelvic axis, and passed in sufficiently far to grasp the head. If the instrument is selected to fit upon the sides of the head, especial care should be taken to apply and secure it in the proper manner. APPLICATION OF FORCEPS AT BRIM OF PELVIS. 105 With the former, traction should be made downward and backward at intervals resembling as far as possible the contrac- tions of the uterus during labor. Between the tractions the grasp of the forceps should be slightly relaxed to afford the head an opportunity to rotate. As the head descends, especial care should be taken when the pelvic floor is reached to relax the forceps more than in the earlier traction. It will be remem- bered that it is not until the pelvic floor is reached that rotation occurs,, and hence the necessity for allowing the head greater freedom at this time. If the Poullet tapes are used, they can be disconnected from the traction bar after the pelvic floor is reached, and the head delivered as in an ordinary application at the pelvic floor. If the axis-traction-forceps with non-detachable traction bars are used, these bars may be folded up upon the shank of the forceps when no longer in use. In applying axis-traction forceps to the sides of the head, care should be taken to clamp them sufficiently to secure a firm hold. Traction, however, should be made as in the former case, in the axis of the pelvis toward the median line. The use of the for- ceps as a rotator is a secondary, and not a primary employment of the instrument. The forceps and head must rotate together when the instrument is applied to the sides of the head ; but the rotation must be effected by traction in the axis of the pelvis, and not by forcible rotary movements. Compression and lever- age are also secondary functions of the forceps ; but the operator should not purposely compress the head to any great extent, nor pry it loose from an impacted position. Only such compression and leverage as are incidental to the securing of a firm grasp and making traction in the axis of the pelvis are admissible. Research has shown that the diameters of the fcetal head are lessened in some directions, and enlarged in others, by pressure with forceps. If the forceps is so applied that either a trans- verse or antero-posterior diameter be lessened, the vertical diam- eter may be slightly increased without serious damage. In nor- mal labor such increase takes place through the projecting of the parietal bones at the sagittal suture, and this may be imitated 106 MANUAL OF PRACTICAL OBSTETRICS. during forceps delivery. A physiological pressure upon the foetal head may be said to be such as would force cerebro-spinal fluid from the ventricular spaces of the brain into those of the cord, and vice versa, thus temporarily lessening the volume of one portion of the cerebro-spinal nervous axis at the temporary ex- pense of the other. The writer has observed, after several cases of forceps delivery where the death of the child resulted within a week or ten days, patches of cerebral softening not resembling those occasioned by embolism, but apparently resulting from pressure. When the head does not engage at the brim of the pelvis, as a rule the forceps should not be applied. Version, or some other obstetric operation, is then indicated. A method of obtaining axis-traction, sometimes useful, consists in passing a piece of tape through the fenestrae of the blades sufficiently long to reach nearly to the floor. The tapes are then tied together while the operator makes traction by the handles; the loop of tape is passed about his feet, and downward pressure in this way rein- forces the usual methods of traction. THE USE OF THE FORCEPS IN POSTERIOR ROTATION OF THE OCCIPUT. In occipi to -posterior positions, it will be remembered that, as a rule, rotation occurs when the head reaches the pelvic floor. To secure this end, however, the expulsive forces of the mother must be good, and the resistance of the pelvic floor be also considerable. Flexion of the head must be present to secure this result. The use of the forceps in these cases is to promote flexion, and aid the descent of the head. For this purpose, axis- traction is desirable. The instrument most appropriate is that of Simpson, or some modification, which leaves the head free to ro- tate as labor progresses. When, however, the occiput is turned directly backward into the hollow of the sacrum, axis-traction is not necessary, and de- livery can usually be secured by applying the instrument to the sides of the head, and making traction directly outward and slightly downward until the forehead of the child begins to ap- pear beneath the pubic joint. The grasp of the instrument should APPLICATION OF FORCEPS AT BRIM OF PELVIS. 107 then be relaxed, the handles should be slightly lowered, and a fresh grasp obtained. A movement of flexion should then be performed by the forceps, the handles being slowly raised to allow the occiput to pass over the perineum. In such cases, laceration of the perineum usually occurs, is generally considerable in extent, and sometimes complete. THE FORCEPS IN FACE PRESENTATIONS. The best authorities agree that the application of the forceps in face presentations is not to be commended. It is true that a narrow-bladed straight instrument has been employed on several occasions successfully, securing perfect extension, and favoring the rotation of the chin anteriorly. As a rule, however, the use of the instrument results in such injury to the child and the mother as to render version a far more desirable expedient. THE FORCEPS APPLIED TO THE BREECH. In cases of breech presentation where the progress of labor is slow, it has been found possible to favor descent by applying the forceps in such a way that the trochanter of each side should fit into the fenestra of each blade. If the instrument is applied in any other man- ner, serious injury may be done through pressure of the tips of the blades upon the abdomen of the child. Traction in the pel- vic axis should be made. MORBIDITY AND MORTALITY CAUSED BY THE FORCEPS. When the indications for the use of the forceps are intelli- gently comprehended, and the instrument is rationally employed with strict antiseptic precautions, its use does not increase the maternal morbidity and mortality of labor, but under other con- ditions a very considerable increase in both occurs. The injuries most common to the foetus from the forceps are bruising and laceration of the scalp, fractures of the cranium and face, and in- juries to the brain through pressure. It occasionally happens that very extensive laceration of the scalp occurs, followed by sloughing after birth. Fractures of the cranium and bones of the face are rarely fatal of themselves, and are serious in proportion as they are accompanied by injuries to the brain through pressure. Frac- ture of the jaw rarely occurs and will often recover perfectly 108 MANUAL OF PRACTICAL OBSTETRICS. without the application of a splint. Paralysis of the facial nerve by pressure upon the trunk soon after it emerges from its foramen is not uncommon, but is usually temporary in character. Pres- sure upon the brain may produce limited areas of softening as already described, and even death from extensive injury to the vital centres. Although it has been believed that idiocy is often the result of pressure by forceps, yet proof of this is wanting in the majority of cases, while a causal relation between forceps delivery and epilepsy is also not proven. Plate III. Davis' Obstetrics. Uterus with Twins in cranial and breech presentation (two ova). (Smellie.) CHAPTER XVI. LABOR IN BREECH PRESENTATIONS. A BREECH presentation may be diagnosticated before labor by feeling the foetal head in the upper portion of the abdomen, by hearing the foetal heart sounds at or above the umbilicus, by detecting at the brim of the pelvis a body less round and hard than the head, and by mapping out the foetal limbs. At labor, such a presentation will be suspected when the head cannot be recognized as the presenting part by its hardness and globular outline ; a diagnosis can be made with certainty when the thighs of the child can be felt, and their relative position to the trunk be recognized. The natural course of labor in breech presentation is more prolonged than when the head presents, because the breech is inferior, as a dilator of the birth-canal, to the head, and also because delay is apt to occur in the descent and delivery of the after-coming head. Nature endeavors in these cases to retain the membranes unbroken as long as possible, thus securing thor- ough dilatation (Fig. 61). The positions of breech presentation are designated by select- ing the posterior surface of the sacrum as the cardinal point upon the foetus. In the first breech presentation, the back of the .oetus is toward the left side of the mother, the posterior surface of the sacrum being opposite the left ilio-pectineal eminence. The diameter of the foetal body principally concerned in the mechanism of the engagement and descent of the breech is the bis-trochanteric, extending from one trochanter to the other, measuring three and three quarter inches, or nine and five-tenths centimetres. When labor occurs in the first position, this bis- trochanteric diameter engages in the right oblique of the pelvis. 109 I 10 MANUAL OF PRACTICAL OBSTETRICS. The body of the child descends into the pelvic cavity, and the anterior hip, in this case the left, rotates forward under the pubes. If the child be small and the birth-canal capacious, the hips may emerge diagonally across the outlet of the pelvis. The body is bent slightly upon itself by lateral flexion as it emerges. In normal cases the arms of the child remain folded across its breast. The left shoulder of the child engages first under the pubic joint, and pivots beneath the articulation while the right FIG. 61. BREECH PRESENTATION, THE LEGS EXTENDED. First Position. shoulder sweeps over the perineum. The back of the child then turning anteriorly, if flexion be complete, the chin emerges closely approximated to the breast, and the occiput pivots be- neath the pubic joint. Flexion continuing, the head passes over the perineum from the chin to the occiput successively by a mo- tion of perfect flexion. When the back of the child rotates pos- teriorly toward the back of the mother, the chin often pivots LABOR IN BREECH PRESENTATIONS. Ill behind the pubic joint, and delivery may take place by expulsion with strong extension (Figs. 62 and 63). When the back of the child is toward the right side of the mother in the second position of breech presentation, the mech- anism is the same, with a reversal in the direction of the rotation. The treatment of breech presentations requires, so far as possible, very early recognition of the presentation. It is of espe- FIG. 62. DESCENT OF THE TRUNK, BREECH PRESENTATION. Second Position. cial importance whenever the obstetrician detects an abnormal presentation that the membranes be not ruptured until the very last moment. One of the dangers to which the child is exposed in abnormal presentations arises from the defective dilatation of the os and cervix, which contract about the head and neck of the foetus at the moment of delivery, often causing death by asphyxia. This is especially true in labor with breech presentations, in which MANUAL OF PRACTICAL OBSTETRICS. the head, coming last, is exposed to pressure and resistance from an imperfectly dilated birth-canal. The membranes, then, should FIG. 63. FIG. 64. THE SHOULDERS EMERGING, BREECH PRESENTATION. Second Position. EXPULSION OF THE HEAD IN BREECH CASES. FIG. 65. be retained until the breech has de- scended, and oftentimes until the membranes begin to protrude at the vulva (Figs. 64 and 65). In a simple case of labor with breech presentation, the obstetrician should avoid hastening the descent of the trunk. Traction carelessly made upon the hips and limbs will often cause the ascent of the arms to the sides of the head, seriously com- HEAD BORN IN BREECH LABOR. LABOR IN BREECH PRESENTATIONS. 113 plicating its delivery. As the breech emerges, the wedge formed by the breech and flexed thighs will be gradually decomposed, and the limbs will become gradually extended. It occasionally happens that descent of the limbs is present from the beginning of labor, constituting what is often known as a ''footling case." As the FIG. 66. BRINGING DOWN THE HIPS IN A DELAYED BREECH LABOR. body of the child descends the physician should support it with his hand, or with a warm towel, standing ready to raise the body of the child toward the mother's abdomen with one hand, while making prompt and energetic pressure over the uterus behind the pubic joint with the other, at the moment when the head emerges. 5* MANUAL OF PRACTICAL OBSTETRICS. FIG. 67. These two simple manoeuvres will result in the prompt expulsion of the head in uncomplicated cases. If an anaesthetic has been used, itsadministration should be discontinued before the head reaches the pelvic floor, so that the mother's conscious efforts may be solicited at the critical moment when the head is pass- ing (Figs. 66 and 67). It is well in all breech cases to have at hand the forceps ready for instant use, and also appliances for resusci- tating an asphyxiated child. Of the latter, the warm bath accom- panied by a fine stream of cold water directed upon the chest, is the best. It is well to have a small English cathe- ter which may be in- troduced into the tra- chea, should direct in- flation of the lungs be necessary. In the ma- jority of cases an as- phyxiated child in whom circulation per- sists can be resuscitated by placing it in a hot bath, directing a fine BRINGING DOWN THE TRUNK IN BREECH CASES, stream of cold water LABOR IN BREECH PRESENTATIONS. 115 upon its chest and making passive respiratory movements. The application of cold water should be brief, and the stream should be so fine as to resemble a jet of spray. The entrance of air into the foetal chest can be secured by Schultze's method of inflation. The foetus is grasped by both hands, the palmar surfaces on the scapulas, the thumbs on the sternum, the head between the hands. The body is then raised until the legs drop over the physician's head; it is swung gently outwards and forward, in the arc of a FIG. 68. THE ARMS BESIDE THE HEAD. circle, until it almost touches the floor. Expiration occurs during ascent; inspiration during descent. Should the heart's action fail, digitalis or strophanthus given by hypodermic injections, and the application of heat are often useful. The precaution should always be taken to remove mucus from the child's mouth and fauces with a bit of soft, old linen dipped in a solution of boracic acid. When the arms of the foetus have become extended beside the head, the physician must liberate them and bring them down. To accomplish this, the thighs of the child are grasped, we will u6 MANUAL OF PRACTICAL OBSTETRICS. say, by the left hand ; downward traction is first made upon the body, and then the trunk is bent strongly toward the mother's right side and obliquely upward and outward. The index and middle finger of the right hand are then passed over the child's right scapula, and along the upper surface of the humerus, until the bend of the elbow is reached. The foetal arm is then flexed at the elbow and carried downward and across the child's chest, when FIG. 69. THE ARMS BESIDE THE HEAD. it easily drops into the vagina. Grasping the thighs with the right hand, the body is then carried obliquely upward toward the mother's left side, and the left arm of the foetus is liberated by the left hand of the physician. The arms having been delivered, an effort should be made to deliver the head by the simple procedure already described. Should flexion not be well marked, the head may delay and the LABOR IN BREECH PRESENTATIONS. 117 life of the child be lost through the pressure of the pelvic floor upon the blood-vessels and nerves of the foetal neck. It is necessary then to act with promptness. The physician should FIG. 70. DELIVERING THE ARMS. stand squarely in front of the patient, who has been brought to the edge of the bed and placed across it, her hips projecting over the edge. The left arm should be uncovered to the elbow, thor- oughly cleansed, and should be turned with the palmar surface of n8 MANUAL OF PRACTICAL OBSTETRICS. the hand upward. The body of the foetus should then be placed astride the fore-arm of the physician, and the index and middle finger of the left hand should be passed upon the face of the child, making strong pressure upward and forward upon the malar prominences. Raising the body of the child upon his left arm, the physician should press strongly downward with his right hand FIG. 71. THE DELIVERY OF THE AFTER-COMING HEAD. placed behind the pubic joint. Should he not succeed in promptly effecting delivery, he may place the middle finger of the left hand in the child's mouth, the index and other fingers resting upon the child's shoulders. He may thus make strong flexion, com- LABOR IN BREECH PRESENTATIONS. 119 bining it with external pressure, and urging the voluntary efforts of the mother. If great resistance is to be overcome, the pressure behind the pubic joint may be made by an assistant, while the right hand of the physician is placed upon the child's back, the fingers of the hand grasping the shoulders to aid in traction. When the back of the child is directed posteriorly toward the mother's back, the same method of manual extraction is indicated, delivery occurring with the occiput behind ; the forceps can often be used success- fully to better advantage than when the back is anterior (Figs. 68, 69, 70 and 71). The morbidity and mortality of breech presentations is not increased especially with the mother, but is considerably greater than usual with the child. Asphyxia and exhaustion through pressure upon the after coming head, the inspiration of matter from the birth-canal, and injury done to the mouth by efforts at delivery, are the principal dangers. It is not uncommon, after the delivery of the child in breech presentation, to have the development of broncho-pneumonia caused by inspiration. The use of antiseptic douches during the early stages of labor dimin- ishes the risk of such pneumonia, and the delivery of the head without the introduction of the finger into the mouth also lessens risk. The causes of breech presentation are sometimes found in a relaxed condition of the uterus, which allows the foetus to assume various positions during pregnancy. In twin pregnancy, it is common to find one of the children presenting by the breech. Labor is longer in breech than in'head presentations as a rule, and the case demands patience and careful attention. CHAPTER XVII. LABOR IN TRANSVERSE POSITIONS. IN contracted pelves and in large pelves where the membranes rupture suddenly and the amniotic liquid escapes rapidly, the foetus may become turned transversely across the birth-canal, giv- ing rise to a transverse position. The part which usually pre- sents in these positions is the shoulder. This may best be under- stood if we suppose a case in which, during the latter months of pregnancy, the foetus occupied the usual position in the uterus, that is, the back towards the mother's left side, the head at the brim of the pelvis, the occiput slightly in front. If now, for any reason, as contraction at the brim of the pelvis, the foetus cannot descend through the brim, or if, by the sudden rush outward of the amniotic liquid the foetus be suddenly moved downward, it may happen that the head will delay in the left iliac fossa, the breech will be near the right iliac fossa, the back of the child to- ward the abdomen of the mother, the feet in the upper portion of the right side of the mother, while opposite the left ilio-pec- tineal eminence will be found the posterior surface of the right scapula. As a rule, should labor pains continue, the right arm of the foetus will descend and may even protrude. When the child is of average size, its descent and expulsion spontaneously may be said to be impossible. It is true that a small foetus or a foetus in an abnormally large pelvis may be so folded upon itself by forcible uterine contractions that expulsion may take place. This occurrence, however, is so rare that the practitioner should never count upon its occurrence, but when the transverse position is detected he should at once rectify it and terminate the labor (Fig. 71). The nomenclature of transverse presentations commonly ac- LABOR IN TRANSVERSE POSITIONS. 121 cepted designates the posterior surface of the scapula as the car- dinal point upon the foetus. The word dorso is used to express the fact that the back of the child presents in these cases. The word right or left is added to the word dorso to designate the shoulder which is presenting. Thus the most frequent transverse position is that in which the right shoulder is at the brim of the pelvis, the back of the child directed in front as has been already explained. It rarely happens that the back of the child is turned posteriorly (Fig. 72). FIG. 71. ATTEMPTED SPONTANEOUS EVOLUTION IN TRANSVERSE POSITION. The diagnosis of such positions and presentations may be made, first, by palpation, and then by internal examination. On pal- pating the abdomen, the head can usually be distinguished upon one side above the brim of the pelvis. The breech can generally be recognized upon the opposite side, and if the transverse posi- tion has existed for some time, a hand and arm will have pro- lapsed, and can readily be found upon examination. It is of practical importance to recognize promptly which shoulder is presenting, and this can be done by determining which hand is prolapsed. If the hand and fore-arm of the foetus is turned with 6 MANUAL OF PRACTICAL OBSTETRICS. the radial side or thumb uppermost, and the practitioner grasps the hand as if to shake hands with it, if the foetal hand fits into his right hand, palm FlG - ? 2 - to palm, the foetal arm is the right, and the right shoulder is presenting. If, how- ever, the prolapsed hand fits the left hand of the practitioner, it is then the left shoul- der which is present- ing (Fig. 73). A further diagnosis FIG. 73. RIGHT DORSO-ANTERIOR. may be made by reaching the axilla with the finger, when the ribs of the child are easily distinguish- ed. Passing the finger over the shoulder, the clavicle and the child's neck can sometimes be felt ly- ing in a direction op- posite to that in which the ribs were felt. RIGHT DORSO-POSTERIOR. CHAPTER XVIII. THE TREATMENT OF TRANSVERSE POSITIONS ; VERSION. IN transverse positions, the treatment of such conditions con- sists in turning the child about so that its long axis shall co- incide with the axis of the birth-canal. This may be accom- FIG. 74. COMBINED VERSION (First Stage). plished, first, by external manipulation only ; second, by external and internal manipulation combined ; and third, by turning the child within the womb. To accomplish the first of these procedures, the membranes should not have ruptured, and the patient should not be in active labor. If she is sensitive and the abdominal muscles irritable, 123 124 MANUAL OF PRACTICAL OBSTETRICS. she may be partially anaesthetized with ether or chloroform. The practitioner can usually outline the two extremities of the foetus, and by pressing upward upon one of them and downward upon the other by a series of gentle sliding movements, either the head or the breech can usually be brought to the brim of the pelvis. This procedure is known as " External Version." FIG. 75. COMBINED VERSION (Second Stage). By "Combined Version," we understand a method by which one hand of the physician is placed upon the abdomen, while two fingers of the other inserted within the vagina and cervix endeavor to lift up the presenting shoulder, thus dislodging it and favoring the turning. The external hand, by pressing upward upon the breech, favors the descent of the head. This method is often known as that of Braxton-Hicks. It is appropriate for cases in which the membranes have not ruptured ; when the os and cer- vix are partly dilated, and uterine contractions are not strong. To perform this successfully, anaesthesia may be, but often-times is not, required (Figs. 74, 75 and 76). " Internal Version," or turning the child within the womb, is the procedure necessary in cases in which the membranes have THE TREATMENT OF TRANSVERSE POSITIONS; VERSION. 125 raptured, or are ruptured by the operator, 'and in which there is not sufficient time to perform either of the other manipulations. Internal Version consists in introducing a hand within the uterus, grasping the feet of the child and bringing them down, thus con- verting a transverse into a breech presentation. Although a seri- ous procedure, it is one of the most valuable expedients in the FIG. 76. COMBINED VERSION (Third Stage). obstetric art, and when skillfully performed, is very safe for mother and child. The patient should always be anaesthetized and placed across a bed, with her hips projecting over the edge. A preliminary antiseptic douche should be given, and, as in all obstetric operations, the bladder and rectum should be empty. Before proceeding to turn, the operator should carefully palpate the abdomen to determine the presence or absence of excessive 126 MANUAL OF PRACTICAL OBSTETRICS. distension of the lower uterine segment. A clear diagnosis of the position and presentation should be made, and from such diag- nosis the situation of the feet of the foetus can be readily deter- mined. The operator will then select for introduction the hand which will pass most readily to grasp the feet (Figs. 77 and 78). FIG. 77. INTERNAL VERSION (Grasping the Lower Foot). Referring to our original example, in a right-dorso anterior posi- tion and presentation, the head of the child is in the left iliac-fossa of the mother, the feet and legs of the foetus lying at the brim of the pelvis and posteriorly upon her right side. As the obstetrician sits before her, his left hand can be introduced most readily to grasp THE TREATMENT OF TRANSVERSE POSITIONS; VERSION. 127 the feet. His arm should be uncovered to the elbow, rings upon the fingers should be removed, and the nails cut short and carefully cleaned. The hand and arm should then be thoroughly antisepti- cized ; the back of the hand may be slightly smeared with some antiseptic . ointment. To introduce the hand, the patient being anaesthetized, the thumb and little finger may be folded toward FIG. 78. INTERNAL VERSION (Grasping the Upper Foot). each other, thus reducing the width of the hand very considerably. The hand should be brought in such relation with the vulva that its greatest diameter of width will be parallel to the greatest di- ameter of the vulva. The right hand should palpate the abdo- men externally, endeavoring to push up the foetal head while the 128 MANUAL OF PRACTICAL OBSTETRICS. other hand brings down the breech. The internal hand the left, in the case which we are considering should be gently FIG. 79. INTERNAL VERSION (Grasping both Feet). pushed on until the feet of the foetus can be grasped. This sim- ple manoeuvre of grasping the child's feet should be so done that the finger nails of the operator are turned away from the THE TREATMENT OF TRANSVERSE POSITIONS; VERSION. 129 uterine wall and toward the centre of the uterine cavity. To accomplish this, the feet should be seized between the index and middle finger, and the thumb folded over upon them grasping them firmly in the palm of the folded hand, as shown in the ac- companying illustration (Fig. 79). Traction by the internal hand should be slow, gentle, but strong. When the limbs of the foetus FIG. 80. THE NOOSE m VERSION. have fully descended, the external hand should endeavor to push up the head, thus favoring version. When the feet have been brought down, if haste is not neces- sary, it is well to delay the extraction of the child, allowing time for the mother's uterine contractions to expel it. If there be a fear lest the foetal limbs should recede within the uterus, a loop of gauze or bandage should be slipped around a foot or hand. When version is accomplished, the subsequent course of the labor will be simply that of an ordinary breech presentation (Fig. 80). I 3 MANUAL OF PRACTICAL OBSTETRICS. It will be observed that version by external manipulation can be performed only before the membranes have ruptured, and no considerable degree of dilatation of the os and cervix exists. FIG. 81. THE OBSTETRICIAN ANESTHETIZING THE PATIENT AND PERFORMING VERSION WITHOUT ASSISTANCE. Version by combined manipulation requires sufficient dilatation to permit at least the introduction of one or two fingers. The membranes may or may not have ruptured. In combined version it is often advantageous to introduce the four fingers through the THE TREATMENT OF TRANSVERSE POSITIONS; VERSION. 13! os, thus grasping the head or breech, and bringing it at once to the desired position. To perform internal version, the membranes must have ruptured, or must be ruptured, and dilatation should be at least almost complete Fig. 81). Version is further divided into Cephalic and Podalic, accord- ing as the head is brought to the brim of the pelvis, or the feet are brought down, as in internal version. Version as an opera- tion will be further considered in treating of labor in contracted pelves, when we shall find that in transvere presentations in highly contracted pelves it may be necessary to lessen the size of the foetal body by emptying the trunk of a portion of its con- tents or, in rare cases, by cutting through or dividing the trunk. So far as nomenclature of these presentations goes, we have, first, and far most common, right-dorso-anterior ; second, and next in frequency, left-dorso-anterior, the dorso posterior positions being rare. CHAPTER XIX. LABOR WHEN THE CHILD AND THE BIRTH-CANAL OF THE MOTHER ARE DISPROPORTIONATE IN SIZE. A CONSIDERABLE number of cases of difficult labor arise from the fact that the child and the birth-canal of the mother are not of proportionate size. In successive pregnancies, it is common to find a slight increase in the size of children born after the first. Again, conditions affecting the mother's nutrition may also influence the growth and size of her child. Thus, children born during a period of famine are naturally smaller than chil- dren born amid plenty. The most potent influence in determin- ing the size and type of the foetus is found in the size and type of the father. For example, marriage between a large and finely proportioned man and a small and ill-developed woman may result in children larger proportionately and better developed than the mother, although rarely attaining the stature and perfec- tion of the father's form. On the other hand, a large and finely shaped woman, if married to a man inferior in size and develop- ment to herself, may give birth to children far inferior to her own excellences of form and feature. The influence of this law may be illustrated by reference to an actual case : an ill-developed, badly-nourished woman, married to a man as weak and poorly developed as she, gave birth to a small, ill-nourished child after a short and easy labor. The first husband dying, the mother married a large and well developed man, and became the second time pregnant. The size and proportions of the child were such that labor was so prolonged and difficult that the Caesarean Sec- tion was seriously contemplated by the obstetrician in attend- ance. Cases of disproportion between the size of the foetus and the 132 LABOR WHEN DISPROPORTION EXISTS. 133 birth canal may be conveniently divided into those in which the size and development of the child exceed comparatively those of the mother, and, second, those cases in which the birth-canal of the mother is contracted either by a deformity in the bony pelvis, or by a foreign growth, or previous pathological process in the mother's soft tissues. In cases where the disparity is that of size and development, pelvic measurements will reveal the fact that the pelvis is symmetrical in form, although often below the average in its diameters. Pelvimetry then gives us no informa- tion regarding the amount of disproportion in the size of the mother and child, but simply indicates that the mother is either of average size, or slightly below. There is no practical method available for measuring the child in the uterus, and any estimate as to the relation between its size and that of the mother's birth- canal must be reached by some method of practical comparison. In cases in which the head is presenting, an effort should be made to fit the head into the bony pelvis as a head is fitted into a hat. To accomplish this, the patient should lie upon her back, the thighs flexed, and should there be such sensitiveness or irri- tability of the abdominal muscles as to cause spasmodic contrac- tion upon pressure, an anaesthetic should be administered. The obstetrician then endeavors to press the head of the child gently into the pelvis of the mother. For this purpose, a hand should be placed transversely behind the pubes, while with the other, an internal examination is made, and the descent of the head is appreciated. If an assistant is available, he should place one hand upon the fundus of the uterus, the other above the pubes, and make pressure gently as already described. By engagement is understood the fitting of the head into the brim of the pelvis; if it is found that the head enters the pelvis, or engages, its size is such that a favorable termination of labor may be expected in the usual way. If, however, the head fails to engage, but remains above the entrance to the pelvis, some abnormality exists which should be investigated. In presentations other than those of the head, we have no practical method of estimating the relative size of the child and 134 MANUAL OF PRACTICAL OBSTETRICS. the birth-canal. Thus, if the breech presents, a head too large to pass easily through the pelvis may be found at the fundus of the uterus, and yet no accurate idea of its comparative size can be obtained by palpation. Excessive distension of the abdomen, the complaint of the mother of excessive weight, and projection of the fundus of the uterus anteriorly, may point to the presence of one very large child, or of twins. Auscultation may deter- mine that but one foetal heart is beating in the uterus, when a rational inference would be that one child of excessive size was present. Practical deductions from the effort to estimate the propor- tionate size of mother and child in symmetrical pelves bear directly upon the question of treatment. If the head can be brought to engage at the brim of the pelvis, and if the mother's muscular tissues, both of the uterus and of the abdomi- nal walls, are sufficiently strong and firm to promise good expul- sive efforts, the case should be left to proceed spontaneously, with the expectation that the patient will be able to bring the child through the brim of the pelvis and down upon the pelvic floor, where its delivery can usually be accomplished by the use of forceps, if necessary. When, however, the mother's uterus and abdominal muscles have been distended by previous labors, and their efficiency in contracting thus lessened, the obstetrician will not expect so much to be accomplished in delivery by the patient herself. When dilatation is well advanced, he must be ready, if the head engages but slightly, either to apply the for- ceps high up at the brim of the pelvis, or to perform version. In cases where the head is so large that it will not enter the brim of the pelvis at all under pressure from above, no attempt what- ever should be made to induce it to enter by the forceps; but a consultation should be held with a view of delivering the patient by version, craniotomy or a Caesarean section. The dangerous folly of attempting to drag a large head through a small pelvis is too painfully illustrated by actual occurrence in practice to need further demonstration. CHAPTER XX. LABOR COMPLICATED BY OBSTRUCTION IN THE BIRTH-CANAL. LABOR WHEN THE SOFT PARTS OF THE MOTHER PRESENT OB- STACLES TO DELIVERY. The birth-canal of the mother may be encroached upon by lesions of the soft tissues. The most fre- quent of these are fibroid tumors, cancer, ovarian tumors and contraction from stenosis resulting either from congenital malform- ation or from the presence of connective tissue produced by pre- vious inflammation and ulceration. In regard to the presence of fibroid tumors and their influence upon labor, it may be said that labor is not often impossible by reason of this complication. A sub-peritoneal fibroid may become pedunculated by the uter- ine contractions at labor, and such tumors are sometimes discov- ered after the patient's recovery when previously their existence had remained unsuspected. Such a tumor may be demonstrated to be freely movable and connected with the uterus by a pedicle. Interstitial fibroids may delay labor by their presence amid the muscular tissues of the uterine wall, and the child may suffer the effects of pressure from such a tumor at its birth. After labor an interstitial fibroid often undergoes partial involution with the uterus. Should septic infection occur, such a tumor will become gangrenous, occasioning a serious complication. Interstitial fibroids are of great importance in cases where Caesarean section is performed. When the incision passes through such a tumor, it will not subsequently unite. Necrosis of the fibroid with septic absorption has been the result in cases of Caesarean section where these growths have been incised. This furnishes a cogent reason for performing amputation of the uterus in such a case, instead of the usual Caesarean section. Submucous fibroids of the uterus frequently occasion delay in US 136 MANUAL OF PRACTICAL OBSTETRICS. labor, but rarely preclude the possibility of its termination. There generally occurs a movement of accommodation on the part of the presenting portion of the foetus and the tumor, which results in slipping the tumor upward and pressing the foetus downward, so that birth is often possible where at first the out- look seemed most doubtful. The practitioner will do well not to have recourse to a dangerous obstetric operation upon the mother when he first discovers the existence of such a tumor during labor. Should, however, the fibroid become prolapsed, it is sometimes possible to sever its pedicle and deliver it before the birth of the child. Should such a tumor remain after the birth of the child, it is well, if possible, to remove it. Inversion of the uterus has sometimes resulted from traction made by the pedicle of a submucous fibroid during labor. In cases of pregnancy complicated by cancer of the cervix, special precaution should be taken to keep the birth-canal, so far as possible, antisepticized. Douches of creolin or carbolic acid or permanganate of potassium, followed by the free use of iodoform in combination with bismuth or boric acid, may be employed to advantage for this end. If the cancer be discov- ered early when only the cervix uteri is involved, pregnancy is no contra-indication to the immediate removal of the growth. When, however, the cancer has penetrated above the cervix, the obstetrician should be prepared to further the continuance of the pregnancy, being ready to remove the child by Caesarean section when viability is well assured. The outlook for the mother after such Csesarean section is very grave from the danger of septic infection in the uterine incision from the cancer. By the free use of antiseptics and tamponing the vagina with iodoform gauze during the operation, it is possible to deliver a living child without materially shortening the life of the mother or increasing her suffering. When the cachexia caused by cancer is borne in mind, it will be seen that the free use of mercurial douches in these cases is unadvisable because of the added danger of mercu- rial intoxication. It is quite possible for labor to occur in a patient having cancer of the cervix and for the labor to termi- LABOR COMPLICATED BY OBSTRUCTION IN BIRTH-CANAL. 137 nate spontaneously. If dilatation is delayed by the infiltration of the cervical tissues with the growth, it is admissible to incise the cervix to a moderate extent, thus facilitating delivery. By the strictest antiseptic precautions it is possible in these cases to preserve the life of the child. Fibro-cystic tumor of the ovary or an ovarian cyst may com- plicate pregnancy and labor. It frequently happens that the pres- sure of the enlarged uterus upon such a tumor causes necrosis of its tissues, and may give rise to septicaemia. There can be no question of the duty of the obstetrician in such cases to at once remove the tumor. Pregnancy will generally go on to its normal limit, and should ovariotomy be necessary at the beginning of labor, it should not seriously endanger the mother's interests. Fibro-sarcomata of the pelvic tissues form a most serious com- plication of pregnancy and labor. If the patient is seen early in labor, amputation of the uterus is indicated. If the child is dead, however, embryotomy and its immediate removal are the duty of the obstetrician. In cases of stenosis of the birth-canal arising from congenital malformation, careful examination of the patient should be made with a view to determine the possibility of incising and dilating. The possibilities of nature are so great that cases seemingly hope- less have been delivered through the natural channel. This is especially true in cases where the stenosis is the result of congeni- tal malformation, and where the elasticity of the tissues has not been impaired by infiltration with pathological products. When it is decided, however, that birth cannot proceed normally, the Caesarean section should be performed so soon as labor pains begin. It should be remembered that the obstetrician is not justified in amputating the uterus, thus destroying a patient's power of reproduction. There are on record a sufficient number of cases of repeated Caesarean operation to justify simple uterine incision in these cases, and to discourage resort to amputation of the uterus. In cases where the tissues are infiltrated by patho- logical products, multiple incisions under antiseptic precautions have sometimes made it possible to deliver a viable child through 6* 138 MANUAL OF PRACTICAL OBSTETRICS. the natural passage. The most unfavorable of these cases are those of advanced syphilis, where the mother's danger of septic infection is very great. Here also the knowledge that the foetus is probably infected, should lead the practitioner to regard the interests of the mother more, and those of the foetus less, in deciding upon his treatment of the case. CHAPTER XXI. LABOR IN DEFORMED PELVES. LABOR IN SYMMETRICALLY LARGE PELVES. In women of large stature, and often without apparent cause in general development, the pelvis is found symmetrical, normally shaped, but larger than usually the case. These are called Symmetrically Enlarged (Justo- Major) Pelves. When the foetus is of average size, labor in such pelves is rapid and easy. Occasionally the child turns across the pelvis, or the cord slips down and prolapses, when version is re- quired. LABOR IN SYMMETRICALLY SMALL PELVES. Such pelves are symmetrical, normally shaped, but below the average in dimen- sions. They are named Symmetrically Small (Justo-Minor) Pelves. Labor and its treatment in these pelves have been con- sidered under the heading "Labor, when the Child and Birth- canal of the Mother are Disproportionate in Size." (Fig. 82). The bony tissues of the mother's birth-canal may be deformed and contracted from several causes. Rhachitis, osteo-malacia, fractures and abnormalities caused by abnormal forces acting upon the skeleton during the period of development, are the most fre- quent causes of bony deformities. It will be interesting to note some of the factors which give to the pelvis its usual contour and proportions. The most ap- parent force tending to push the sacrum downward and forward is the weight of the head and trunk transmitted through the spinal column. Acting at nearly right angles to these is the force exercised in walking and standing by pressure by the heads of the femora in the acetabular cavities. These two forces are modified by the elasticity of the pelvic bones, and by the strength of the ligaments at the pubic joint, the ischio-sacral 140 MANUAL OF PRACTICAL OBSTETRICS. and coccygeal ligaments, and by the inherent tendency through long evolution possessed by the bony tissues of the female organ- ism to develop after its type. The result of all these interacting forces is a pelvis of average proportions (Figs. 83 and 84). When, however, any one of these factors in development is deficient, there results a lack of symmetry or deformity in the pelvis. The most simple of these conditions is contraction in the antero-posterior di- FIG. 82. SYMMETRICALLY SMALL (JUSTO-MINOR) PELVIS. ameter only, giving rise to the simple, flat pelvis. This occurs in women who have been prevented by any reason from exercising the lower limbs during childhood, as in cases of infantile paralysis, where the lower extremities have been partially or wholly paralyzed, and life is still persistent. Such children remain principally in the sitting posture, thus transmitting weight downward upon the LABOR IN DEFORMED PELVES. 141 sacrum, while the counteracting forces of pressure by the femora are lacking. In many cases, no cause whatever can be ascertained for the occurrence of this deformity. There is usually no sign of FIG. 83. FIG. 84. THE POSTURE AND ABDOMINAL PROTRUSION IN A WELL-FORMED PREGNANT WOMAN. POSTERIOR SURFACE OF A \\ KLL-FORMED FEMALE BODY. its presence in the stature or development of the patient, and hence the great liability of the obstetrician to overlook such a 142 MANUAL OF PRACTICAL OBSTETRICS. FIG. 85. deformity unless it is his custom to universally measure th6 pelvis of his patient. When labor occurs in a simple, flat pelvis, the head will naturally turn in such a position as to bring one of its lesser diameters in relation with the smallest diameter of the pelvis. This results in a transverse position of the head at the brim, the bi-temporal or bi-parietal diameter being brought in relation with the antero-posterior diameter of the pelvic brim (Fig. 85). If the contraction be not excessive, and the patient's expulsive forces be good, the head will descend transversely through the brim of the pelvis. The centre of the pelvic cavity and the pelvic floor being reached, there will be found no obstacle to rotation, and labor may pro- ceed normally. When, however, the narrowing at the brim of the pelvis is considerable, the head will not descend, but will remain transversely at the brim. The pressure of the uterus continuing, one of the parietal bones will gradually descend lower than the other, and thus what is known as a parietal presentation will result. So far as the question of detection is concerned in such pelves, a diagnosis will be readily made by any one who practices pelvimetry as a rule. The narrowing of the antero-posterior diameter, while the other diameters of the pelvis remain unaltered, renders the diagnosis comparatively simple. If the obstetrician has the patient under his charge during the second half of her pregnancy, he may select a favorable opportunity for the induction of labor. It has been found that the greatest trans- verse diameter of the foetal head increases most from the thirtieth to the thirty-sixth week. Accordingly, when the antero-posterior diameter measures eight centimetres, or three and one-eighth inches and over, we may delay until the thirty-fifth week for the induction of labor. When it measures seven and a half to eight HEAD ENTERING A FLAT PELVIS. Plate IV. Davis' Obstetrics. 3 CD 0. ? I f LABOR IN DEFORMED PELVES. 143 centimetres, or two and nine-tenths to three and one-eighth inches, the thirty-first to the thirty-fourth week may be chosen, and when this diameter is smaller than two and nine-tenths inches, it is not well to delay beyond the thirtieth week. The obstetrician will hope that by the induction of labor the head may be enabled to descend through the brim of the pelvis, and the labor terminate spontaneously. When, however, he is called to a case at the end of gestation, in which he finds a simple, flat pelvis, he will do well to delay only until dilatation is com- plete, and opportunity has been afforded the head to descend by the natural forces of expulsion through the brim of the pelvis. Should such descent not occur promptly, podalic version should be performed, and the child delivered in that manner. The use of the forceps in simple, flat pelves is rarely to be chosen, as the instrument grasps the head at a disadvantage, and injury to the mother and child is likely to result (Fig. 86). A rhachitic pelvis presents not only contraction in the antero- posterior diameter of the brim, but also a diminution in the FIG. 86. FLAT PELVIS, THE HEAD PASSING THROUGH AFTER VERSION. transverse diameters of the pelvis. It will be remembered that in the normal pelvis the distance between the anterior-superior spines is always less than the distance between the outermost points of the crests. In the rhachitic pelvis this relation is either lost or reversed. The upper edges of the ilia, instead of curving downward from the anterior-superior spine, extend di- 144 MANUAL OF PRACTICAL OBSTETRICS. rectly backward, or even curve slightly inward. Upon pelvimetry, the obstetrician will find the antero-posterior diameter of the pelvis FIG. 87. FLAT RHACHITIC PELVIS. shortened, the transverse diameters contracted as indicated, and not infrequently some variation on closer examination in the ob- FIG. 88. FLAT RHACHITIC PELVIS. lique measurements of the pelvis (Figs. 87 and 88). In addition to these diagnostic points, close inspection of the patient's skeleton Plate V. Davis' Obstetrics. LABOR IN DEFORM F.D PELVES. FIG. 89. will reveal crooked limbs, enlargement of the epiphyses at the ex- tremities of the long bones, enlargement of the costal cartilages, producing the beaded appearance of the ribs and sternum, with the characteristic deformity of the cranium and face. Labor in such pelves will be difficult in proportion as the child is large, and the pelvis greatly de- formed. Here again the same indications for the induction of labor obtain which have just been stated in the simple, flat pelvis. As a rule, the head will enter in strong flexion, and should the child be small and the mother strong, the head may be forced down through the brim of the pelvis upon the pelvic floor. Labor may then be terminated by the careful use of the forceps. Should the head engage, the forceps may be applied at the brim of the pelvis, and axis- traction performed to deliver the child. If the head does not engage, but after labor- pains have become well estab- lished it continues to remain at the brim of the pelvis, or passes to one side into one of the iliac fossae, the question of craniotomy or the Caesarean operation must be raised (Fig. 89). In flat, rhachitic pelves, no advantage will be obtained by performing podalic version, as extension of the head would pro- bably result in impaction and subsequent death of the foetus. 7 ATTITUDE AND ABDOMINAL PROTRU- SION (PENDULOUS ABDOMEN) OF WOMAN WITH RHACHITIC PELVIS. 146 MANUAL OF PRACTICAL OBSTETRICS. Rhachitis may be found in combination with other deformities of the pelvis, resulting in irregularly shaped pelves, giving rise to vari- ous abnormalities in the course of labor. Thus, projection backward of the spinal column called kyphosis may be present, causing an enlargement of some diameters of the pelvis, with a contraction of others. Again, hip-joint disease in a rhachitic person would result in an oblique deformity of the pelvis, and hence a diminution in the oblique diameters. These mixed deformities of the pelvis can best be appreciated by internal palpation. The obstetrician, finding that the measurements obtained by external pelvimetry are abnor- mal, will then have recourse to an internal examination of the pelvis. Two or three fingers should be introduced, and the sides of the pelvis thoroughly examined. Thus a contraction at the brim can be estimated, and projection inward at the side of the pelvis will be detected, and by placing a finger upon each tuberosity of the ischium some idea may be gained as to the dimensions of the pelvic outlet. While elaborate instruments have been devised for such examination, none has been found so efficient as the hand of an intelligent observer. In estimating the existence of a deformity at the pelvic outlet during labor, the practitioner will find it of value to examine the lateral diameter of the pelvis at a line drawn from one spine of the ischia to the other. Should he find that the head with its greatest circumference has passed a line drawn between the spines of the ischia, he may conclude that no contraction sufficient to prevent the spontaneous termi- nation of labor exists at the pelvic outlet. Spinal deformities are not infrequently associated with rhachitis, and may delay the descent of the foetus into the pelvic cavity. A projection forward of the spinal column known as lordosis; lateral curvature of the spine known as scoliosis, kyphosis already men- tioned, and a peculiar deformity caused by a partial dislocation of the body of one vertebra upon that below, with a lateral twist of the vertebrae called spondylolisthesis, may prevent descent of the body of the foetus or cause an abnormality in its presentation or in the mechanism of labor (Fig. 90). Such spinal deformities, when detected during pregnancy, are additional indications of the Plate VI. Davis' Obstetrics. Flat Rhachitic Pelvis. (Martin.) LABOR IN DEFORMED PELVES. 147 probable existence of pelvic deformity, and should not escape the attention of the obstetrician. While the simple, flat pelvis and the rhachitis pelvis are most common, there exist comparatively rare forms of pelvic deformity known as the obliquely contracted pelvis of Naegele, the funnel- shaped pelvis, the infantile pelvis, and the osteo-malacic pelvis. FIG. 90. SrONDYLOLJSTHETIC PELVIS. The obliquely contracted pelvis can be examined by measuring between the posterior superior spines and the anterior superior of opposite sides (Fig. 91). The funnel-shaped pelvis retains somewhat the type of the male pelvis and, as its name implies, is longer and narrower than the normal. In the infantile pelvis, the widening and expansion character- istic of the normal female pelvis have not occurred, and the pelvis remains practically that of a young child. In the osteo-malacic pelvis, softening of the bones has resulted in the bending inward of the anterior half of the pelvis, bringing the two rami of the pubes almost in apposition in the form of an ir- regular beak or projection. Other indentations of the pelvis may 148 MANUAL OF PRACTICAL OBSTETRICS. result from osteo-malacia, giving rise to various deformities. It may be noted that the disease may occur during pregnancy. It is characterized by severe rheumatic-like pains in the pelvic bones, by great prostration, and by softening which becomes evi- dent upon careful examination. So severe may be these symp- toms that the in- FlG - 9I - terruption of pregnancy may be necessary to preserve the life of the mother. When recovery takes place from osteo-malacia, a process of thin- ning of the bones occurs known as osteo - p o r o s i s. OBLIQUELY CONTRACTED PELVIS FOLLOWING FRACTURE. comes thinner, lighter in weight, more fragile in consistence. On the other hand, when rhachitis advances but slightly, and recovery occurs during early life, a process of hardening and deposition of bony material takes place which is styled osteo-sclerosis. In summarizing the indications for treatment in deformed pel- ves, it may be repeated that the induction of labor should be kept in mind in cases coming under the care of the obstetrician before term. As pregnancy progresses, the simple manoeuvre already described of pressing the head into the pelvis may be employed at intervals of ten days or two weeks to give some idea as to the time when the induction of labor is necessary. When the head will not engage under gentle pressure, pregnancy should be in- terrupted. In simple, flat pelves, the obstetrician must be pre- pared to terminate labor by version. In flat, rhachitic pelves, a cautious use of the forceps, with craniotomy and Cresarean sec- tion to be kept in reserve, is indicated. CHAPTER XXII. PREMATURE LABOR. ABORTION : MISCARRIAGE. In a considerable proportion of cases pregnancy is terminated before its usual duration has ex- pired through some disease or accident. It has been customary to designate the termination of pregnancy before the formation of the placenta at the fourth month as abortion ; between the fourth month and the period of viability at the seventh month as miscarriage; and between the seventh month and ninth month as premature labor ; these distinctions, however, are with- out practical differences, and the simpler way is to consider the interruption of pregnancy before the period of viability as abor- tion, and between the period of viability and the usual termina- tion of pregnancy as premature labor. The word miscarriage is less objectionable to the minds of patients who commonly asso- ciate with the term abortion a possible criminal element. The causes of the premature termination of pregnancy are those which affect the mother or the ovum or both ; most common of all is syphilis. In regard to the conveyance of the syphilitic poison, it is possible for a syphilitic father to beget syphilitic children with- out infecting necessarily the mother ; it is probably impossible for a syphilitic woman to bear a child not tainted by syphilis ; when father and mother are both syphilitic the offspring present unmistakable evidences of syphilis. Diseases which affect the general health of the mother also interrupt pregnancy ; acute in- fections causing high temperature commonly interrupt pregnancy when the temperature remains above 104 F. for a considerable time. Chronic infections, such as, in addition to syphilis, mal- aria, lead poisoning, and alcoholism cause abortion. Diseases affecting the foetus and its envelopes also terminate its 149 150 MANUAL OF PRACTICAL OBSTETRICS. existence ; such are dropsy of the chorion, adhesion between the layers of the aninion and the abnormal secretion of amnial liquid. Violence may affect the mother and ovum by separating the latter from the wall of the uterus by rupturing the membranes, or by its influence upon the nervous system producing uterine contractions ; the effect of mechanical violence depends, however, largely upon the condition of the mother's tissues ; where the woman has never had endometritis and her tissues are in a healthy condition, she may sustain a very considerable degree of direct mechanical vio- lence without the occurrence of abortion ; persistent disturbance is often more dangerous than a considerable shock ; thus the jar of a railway train will sometimes produce disaster, when a fall of several feet will not. That which tends to increase irritability of the nervous system also results in the interruption of pregnancy, and when once this condition of exaggerated reflexes exists the slightest cause may produce an interruption of pregnancy. The symptoms of a threatened termination of pregnancy are ab- dominal pain and hemorrhage; the pain is caused by the contrac- tion of the uterus, and hence is to be distinguished from intestinal colic, neuralgia of the solar plexus, acute dyspepsia, or the suffer- ing caused by a distended bladder ; the hemorrhage is bright in color, and varying in quantity ; should the process go on, further symptoms are an increase in the hemorrhage, with the discharge of portions of the ovum or the ovum entire. The interruption of pregnancy is most common between the third and fourth month, and at any period of pregnancy when menstruation should have occurred if conception had not taken place. The treatment of abortion and premature labor consists, first, in prophylaxis ; if syphilis exists, the patient should be treated by the administration of the bin-iodide or bi-chloride of mercury, together with cod-liver oil, hypophosphites, iron and arsenic ; it is to be remembered that the treatment of syphilis demands not only the use of alteratives but also the employment of those agents which will most effectively favor the reproduction of the blood. During acute diseases but little can be done to prevent the interruption of pregnancy beyond that which is indicated in PREMATURE LABOR. 151 the mother's interest only ; it is well to control if possible the patient's fever and lessen the irritability of her nervous system ; conditions of chronic infection are to be remedied by appropri- ate treatment which is most advantageously employed when the patient is not pregnant. By the habit of abortion is understood the recurrence of this accident ; when the cause is found and removed the habit is broken. In cases which present no easily found cause for abor- tion it is well first to see that the patient is not suffering from chronic endometritis ; should such be the case, dilatation of the uterus followed by the application of antiseptic and alterative substances to the endometrium, and often the removal of the diseased tissue by the curette may be followed by conception. When no cause other than excessive irritability be found, it is sometimes necessary to place the patient entirely at rest until her pregnancy be several months advanced ; actual confinement to her bed is the only successful treatment for such a condition : her health, in the meantime, should be maintained by massage and attention to her nutrition. When abortion has actually begun absolute rest is imperative ; usually opium will be found the best drug to allay the activity of the nervous system ; the patient should abstain from all kinds of stimulants, should remain lightly clad, and avoid heating and stimulating food (Fig. 92). Should the physician fail in his efforts to check the premature expulsion of the ovum, his treatment should be addressed to securing its expulsion entire; in cases occurring prior to the fourth month this can best be done by controlling the hemor- rhage with an antiseptic tampon and stimulating uterine contrac- tions; as material for the tampon, iodoform gauze, bi-chloride of mercury gauze, or masses of cotton impregnated with an antisep- tic may be employed. Where the odor of iodoform is not objec- tionable, iodoform gauze should be chosen; in the absence of gauze, cheese cloth soaked in a solution of bi-chloride of mercury, one to five thousand will answer ; failing to obtain cheese cloth, an ordinary roller bandage or a strip of old sheeting will serve every purpose ; if the assistance of a nurse is available it is well to MANUAL OF PRACTICAL OBSTETRICS. FIG. 92. have the patient given a hot antiseptic vaginal douche ; following this she is placed across a bed at the edge; introducing one or two fingers of one hand as a guide, the physician takes the end of the strip of tampon, and, with a pair of dressing forceps, passes it up, and with the finger packs it thoroughly into the os and cervix, and around these parts; the vagina may also be moderately dis- tended with the same material; the administration of ergot in medium doses, fifteen to thirty drops of the fluid extract every two or three hours, combined with the administration of quinine in debilitated patients, is also indi- cated. Under such treatment it is usual, after from six to twelve hours, for the physician to find the ovum in the upper portion of the vagina upon removing the tampon ; he may find it just within the os, whence he should remove it cautiously with the finger; after its expulsion a hot vaginal douche should be given, and if the fingers or any instrument have entered tot and nip- the uterus, an intra-uterine douche tured vessels. i t j r j . j should be administered. Should the ovum rupture, and a portion be retained, the uterus should be explored as soon as possible by the antisepticized fin- ger of the obstetrician and its contents removed ; if sufficient dila- tation is not present to permit of this manipulation, Barnes' dilators, or a solid uterine dilator, such as Simons', may be em- ployed; and if the cervix is found resisting, a tupelo, or slippery- elm tent should be used (Fig. 93). Next to the finger as an instrument for emptying the uterus after abortion, stands the intra-uterine curette ; of these our preference, from experience, OVUM OF TWO MONTHS, INTACT. PREMATURE LABOR. 153 is for that of Carl Braun, which has a long, hollow handle termi- nating in a blade whose edge is as sharp as that of a paper-knife; this handle is connected with a fountain syringe, and thus a con- stant stream of antiseptic fluid irrigates the uterine wall while the curette removes retained material ; after the uterus has been emptied and cleansed, it is well to leave within its cavity sixty FIG. 93. SAME OVUM, THE DECIDUOUS MEMBRANES OPENED, SHOWING VlLLI OF CHORION. grains of iodoform, aristol, or boracic acid in the form of a sup- pository. In view of the fact that portions of the ovum are often retained and spontaneously expelled without serious consequences to the patient, such thorough precautions may seem meddlesome and injudicious, but the number of cases of septicaemia which follow abortion is sufficiently great to warrant the obstetrician who desires to do his duty in not leaving his patient until he is satisfied that her genital tract has been thoroughly antisepticized. 154 MANUAL OF PRACTICAL OBSTETRICS. The treatment of abortion after the fifth month resembles that of normal labor, except that de.lay may occur in the dilatation of the os and cervix, and difficulty may be experienced in aiding the expulsion of the foetus; as the uterus is not fully prepared for labor, deficient expulsive pains are not uncommon. Although the foetus may present by the head, it will be better in such cases to perform version and extraction by the feet, as the forceps is not always successful in grasping securely the head of a premature foetus. It is in cases of this sort that adherent placenta is most often encountered, although fn the minds of patients and their friends the placenta is thought to be adherent when it is not promptly expelled. The obstetrician will recall the fact that adherent placenta is not a frequent complication, while tempo- rary retention of the placenta occurs quite frequently. In cases where the placenta is attached to the uterine wall so firmly that uterine contractions do not separate it, a cautious attempt should be made by the obstetrician to separate and remove it with his hand ; the greatest care should be exercised not to wound the uterine tissue any more than can possibly be avoided, and, rather than do violence, it is better to allow the placenta to remain, after antisepticizing the uterus, and keep the patient under observation until the placenta shall have become loosened, when it can be safely extracted. During this time, until the placenta can be re- moved, four vaginal douches of bi-chloride of mercury, one to five thousand, should be given in twenty-four hours ; the uterus should be irrigated twice in twenty- four hours with carbolic acid, creolin, thymol or boracic acid, as has been elsewhere described ; the local disinfection of the uterus should be maintained by iodoform, aristol or boracic acid, by uterine suppositories, and an antiseptic tampon can often be kept within the uterus to advantage. Under such precautions it is safe to wait for the loosening and expulsion of the placenta without radical interfer- ence ; but under less careful precautions it is hazardous to do so ; the curette is of advantage in such cases after the placenta has become loosened and small fragments still remain which do not admit of easy removal by the finger. PREMATURE LABOR. 155 Abortion is also divided into therapeutic and criminal ; by therapeutic abortion is understood the intentional interruption of pregnancy by the obstetrician in the interests of the mother ; pernicious vomiting, toxaemia, threatening eclampsia, and some obstruction in the mother's birth-canal are the most frequent indications ; the method best chosen in these cases consists in the dilatation of the uterus by tents, by solid dilators, or the Barnes' bag, with the removal of the ovum, as has just been described. In cases where pregnancy is further advanced, a bougie may be intro- duced into the uterus between the membranes and the wall of the uterus, and allowed to remain until expelled by uterine contrac- tion. In very early pregnancy the introduction of a sound into the uterus may rupture the ovum, when it may be absorbed with- out danger to the patient. Her safety, however, in all these pro- cedures depends very largely upon the careful antisepsis practiced by the physician, and in general it may be stated that that method of producing abortion is best which is most sure to do little violence to the mother's uterus, and leave it entirely empty. By criminal abortion is understood the interruption of preg- nancy without justification ; this is commonly practiced by the administration of drugs supposed to produce uterine contractions ; such are tansy, nutmeg, ginger, cantharides, and a number of patent medicines whose active principle is usually ergot or quinine. It is extremely doubtful in healthy women whether any of these drugs are capable of producing the desired effect ; they are certainly far from being reliable ; failing to produce abortion with these means, the patient usually seeks the assistance of an accomplice ; the injection of hot or cold water into the vagina, and the introduction into the uterus of a foreign body, are the most usual methods employed ; splinters of wood, hair-pins, pieces of whalebone, pieces of wire, and various articles have been used for this purpose. Those who practice abortion are usually ignorant of antiseptic precautions, and hence septic infection following criminal abortion, with death from septicaemia and peritonitis, are not uncommon; 156 MANUAL OF PRACTICAL OBSTETRICS. electricity has been tried to produce abortion, occasionally with success, often with failure. Diagnostic signs of criminal abortion, either attempted or successful, are signs of early pregnancy with some evidence that injury has been done to the genital tract; when such evidence is presented, the physician called to care for such a patient should remember the danger of septic infection and endeavor to counter- act it, while co-operating with the authorities to bring the offender to justice. CHAPTER XXIII. INDUCED LABOR. WHENEVER the interests of mother or child demand the termi- nation of labor after the child is viable, but without waiting for the forces of Nature to produce spontaneous labor, the artificial ending of gestation is known as induced labor. The indications for this procedure are diseases seriously threatening the life of the mother, a contracted condition of the birth-canal, making it dangerous for delivery to take place when the child is at term, and any condition of the foetus rendering its death probable if it be allowed to remain in the uterus. Among the maternal indications for induced labor are such diseases of the mother as result in pathological changes in the endometrium and placenta, rendering the life of the child impos- sible after a certain period of pregnancy. This may be well illustrated by chronic nephritis occurring during pregnancy. Whenever the obstetrician detects habitually in the urine of the pregnant woman various forms of tube-casts, with or without albumin, and this condition persists, he will know that the exist- ence of the foetus is jeopardized, and that labor should be induced when viability is assured. A distinction should be made between acute and chronic disease processes in the mother as regards the interruption of pregnancy. In acute infectious diseases, the course of the disease is usually influenced unfavorably by any effort to terminate the pregnancy, while in many chronic con- ditions the induction of labor greatly relieves the patient. The death of the foetus furnishes an indication for the induction of labor, and also any history of complications occurring during previous pregnancies, or at previous labors, threatening the lives of mother and child. In so far as contraction of the birth-canal is an indication for the induction of labor, this will evidently depend upon a com- '57 158 MANUAL OF PRACTICAL OBSTETRICS. parison instituted between the size of the child arid that of the birth-canal, as has been already described. In the section upon labor in contracted pelves, this point has been discussed, and also the precise periods of pregnancy at which interruption was justified. In general, it may be stated that when upon examina- tion of a pregnant woman the antero-posterior diameter at the brim of the pelvis is found to measure but eight centimetres, or three and one-eighth inches, the question of the induction of labor should be seriously considered. The methods of inducing labor consist in efforts by various means to cause uterine contraction. These efforts have been made by directly irritating the uterus, as with an electric cur- rent, with dilators or a bougie; also by the giving of some drug acting upon the uterine muscle and causing contraction, or by disturbing the relations of the foetus and the uterus by evacu- ating the amniotic liquid, thus allowing the child itself to make pressure against the wall of the uterus and excite contraction. To specify more clearly, the induction of labor has been at- tempted by the use of a strong faradic current, one pole being placed above the pubes, the other upon the lumbar spine. Ef- forts have been made to secure uterine contractions by rubbing or kneading the uterus, and also by hot douches. Barnes' dila- tors and tents of various sorts have also been introduced to dilate the cervix and promote uterine contractions. Water has been injected into the uterus between the membranes and the wall of the womb, to cause uterine contractions. Drugs whose proper- ties are to irritate and excite the uterine muscle have also been given, such as ergot, tansy, quinine, strychnine and some of the volatile oils. The membranes have also been ruptured, a portion of the amniotic liquid allowed to escape, and the head brought directly against the os and cervix, thus exciting uterine contrac- tions ; but the best and safest of all methods consists in intro- ducing within the uterus, between the membranes and the wall of the womb, a flexible rod or bougie. This acts as a foreign body whose irritation rarely fails to bring on labor. Second in effi- ciency and value to this is the use of Barnes' dilators. In intro- INDUCED LABOR. '59 ducing a bougie, one should be selected which is solid, and which has never been used before. A medium size should be chosen, and care should be taken that the bougie has not been corroded or roughened in any manner. It should be immersed for some time in a solution of bichloride of mercury one to five hundred, after which it may be kept in a mercurial solution one to two thousand, or in a carbolic solution five per cent., until it is used. If convenient, a vaginal douche should be given before the introduction of the bougie. The greatest care should be exercised by the obstetrician in cleansing his hands and in avoiding contact between the bougie and the bedding of the patient while introducing it. Two fingers of one hand are then inserted to the cervix, and the bougie passed along these fingers as a guide through the os. No force should be used in introduction; but it should be allowed to go where it will pass most easily, care being taken to avoid rupturing the membranes. The bougie should be inserted until but an inch of its length remains outside the cervix. If it shows a tendency to slip out easily, a moderate tampon of iodoform gauze should be inserted to retain it in position. A bougie may be conveniently inserted during the afternoon or evening. Intermittent uterine contractions causing dilatation will usually continue during the night. In the morning, it will be found upon examination that softening and dilatation of the os and cervix have resulted. The bougie should then be removed, an antiseptic douche be given, and the first bougie with a second in addition should be introduced. The number may be increased until several are employed at once. The length of time, required to bring on active uterine contractions by this method varies greatly. Forty-eight hours will usually suffice to cause active labor, but in a case in the experience of the writer, bougies remained in the uterus between five and six days before labor came on. If antiseptic precautions be faithfully observed, and the membranes be not ruptured, no harm will come to the patient from a prolonged use of this method. The employment of a Barnes' dilator to induce labor is indicated l6o MANUAL OF PRACTICAL OBSTETRICS. in cases where the os and cervix are already sufficiently large to admit of its introduction, and where it is desired to dilate the ute- rus and terminate labor as speedily as possible. The obstetrician should provide himself with several sizes of dilators whose capacity he ascertains before using them. A dilator should be slightly oiled, and introduced well into the cervix. An antiseptic solution is then forced into the dilator until considerable distension and the firm application of the dilator to the sides of the cervix have been se- cured. If the capacity of each Barnes' bag is known by the ob- stetrician, little danger will exist of rupturing the dilator and forcing fluid into the uterine cavity. The use of an antiseptic fluid reduces the risk from this accident to a minimum. It will usually be found in between one and two hours that the dilator has accomplished its mission, and that a second and larger is required. In from four to eight hours the uterus may be so dilated by this method that the application of forceps, or performance of version, will be possible. When induced labor has fairly begun, it should be remembered that the patient has greater difficulties than usual to overcome. The physiological softening and dilatation of the birth-canal which occur at normal labors are rarely present to the same de- gree. Induced labor may then be longer, more painful, and more exhausting. On the other hand, the fact that the child is smaller than in labor at term will prove an advantage at the time of delivery. Every precaution should be taken to maintain an aseptic condition of the patient because her liabilities to infection by reason of the interference practised are greater than in normal cases. When labor is induced by the use of the bougie or Barnes' dilators, morbidity and mortality rates of the mother should not be higher under antiseptic precautions than normal. The dangers to the child are greater than usual because of the possible failure in dilatation and also because of the necessity often arising of oper- ative interference in the delivery. If induced labor be delayed, the child will frequently perish from pressure of the uterus upon it, or from inspiration pneumonia coming on shortly after deliv- ery, and occasioned by the entrance of the secretions from the vagina into the respiratory passages as labor progresses. CHAPTER XXIV. MULTIPLE PREGNANCY. WHEN the genital tract of the woman contains more than one impregnated ovum the pregnancy is multiple or plural. Usually the ova find lodgement and develope in the uterus ; occasionally one developes in the uterus and one in the Fallopian tube ; rare- ly there is multiple ectopic pregnancy. When there are two ova the pregnancy is said to be with twins ; when three, triplets ; with four, quadruplets; with five, quintriplets ; with six, sextup- lets. One authentic case of miscarriage with six foetuses is re- corded as having occurred in Italian Switzerland, the greatest number on record. Twins occur on an average about once in too cases; triplets, once in 8,000; quadruplets, once in 400,000. These averages vary greatly in different races and countries. Two terms are used to express the impregnation of more than one ovum, Superfecundation and Superfoetation. Superfecunda- tion refers to the successive impregnation of several ova before an impregnated ovum has reached the uterus and before a second ovulation. This is observed in cases when twins are born of dif- ferent parentage, one black, the other a light mulatto. It has also been seen in cases where two ova of the same parentage have been found at different stages of development, one in the uterus, the other in some other portion of the genital tract. These cases are explicable by successive coitions by the same or different fathers. Superfcetation refers to the impregnation of a second ovum when the first has already advanced several weeks and has reached the uterine cavity. A second ovulation, after the first impregnation, would seem necessary to explain superfoetation. 7* 161 1 62 MANUAL OF PRACTICAL OBSTETRICS. Superfecundation occurs not infrequently; superfcetation cannot occur after the ovular and uterine decidua join, in the fourth month, and probably rarely takes place before. Twins are most often of similar sex, and more frequently boys. When of the same sex they often resemble each other very closely in physical and mental characteristics. They are rarely of precisely the same weight, although their combined weight exceeds that of a single foetus. The amnion and chorion of one ovum are not infrequently observed to take up considerable space on the foetal surface of the placenta of the other ovum. De- creased nutrition in the second ovum results. Five-sevenths of all cases of twins have but one placenta, this fact furnishing an argument against superfoetation. When the sex is the same there is one placenta, with one chorion and two amnions. When the sex is unlike it is not infrequent to find two chorions and two amaions with one placenta, both ova having been derived from a single follicle. There is then no vascular connection, each ovum having a separate blood supply. In twins and triplets which develope from one ovum, a circulation by means of villi has been found, forming a third blood system by which the same blood passes through both foetal hearts. Repeated pregnancies and hereditary tendency to multiple pregnancy are the chief causes of multiple pregnancy. The diag- nosis of more than one foetus is possible only by careful attention to the details of diagnosis by palpation and auscultation. Wo- men pregnant with more than one foetus have naturally larger abdomens, are more liable to suffer from varicose veins and oedema, and often experience greater discomfort than in single pregnancy. When the abdomen is examined and two fcetal heart- sounds in distinctly different areas can be heard, and three greater foetal parts, one head and two breeches, or two heads and one breech, can be plainly outlined, a diagnosis of multiple preg- nancy may be made. The patient's impressions, and any less positive data, are worthless in forming an opinion. At the time of labor, when the uterus remains large, after the birth of one child, and when a second can be felt on vaginal examination, MULTIPLE PREGNANCY. 163 twins may be diagnosticated. The possibility of twin pregnancy has led to the invariable custom, with careful obstetricians, of ligating the placental extremity of the umbilical cord, at labor, to prevent haemorrhage from the placenta. The diagnosis of multiple pregnancy is not often easily made, and a positive opin- ion should not be given without evidence afforded by thorough examination. Pregnancy rarely goes to full term when more than one foetus is present. The over-distended condition of the uterus renders it more than usually sensitive to reflex irritation, and labor pains are easily excited. Abnormalities in the membranes and pla- centae and polyhydramnios are often present in multiple preg- nancy. One foetus not rarely kills the other by pressing it against the uterine wall, the foetus which perishes becoming flattened, thinned and shriveled, hence called foetus papyraceus or parche- ment-like foetus. Monsters without heads, acephalous monsters, occur in multiple pregnancies. The position and attitude of the foetuses in twin pregnancies are usually one presenting by the head, the other by the breech. Less often both present by the breech or head. Labor in multi- ple pregnancies is slow in the first stage, because the cervix dilates slowly and the lower uterine segment is not readily formed. The second stage is often short, the small size of the children rendering their expulsion easy. In the third stage the over-distended uterus may contract imperfectly and placental retention and post-partum haemorrhage are not infrequent. If the position of both twins is not favorable for prompt expulsion, the imperfect dilatation of the cervix and lower uterine segment threaten the life of the second twin by pressure. In conducting twin labor the obstetrician should be prepared to deliver the second twin promptly if there is but one foetal sac ; where there are two and the second is unruptured after the birth of the first twin, there is less need of prompt delivery. Twins may become so intertwined that spontaneous delivery is impos- sible ; uterine contractions continuing and retraction of the upper uterine segment taking place, the twins become firmly fixed, and 164 MANUAL OF PRACTICAL OBSTETRICS. in their abnormal position are said to be "locked." When one twin presents by the head and the other by the breech, the body of the first (breech presenting) twin may be expelled ; both heads enter the pelvic cavity at once, the first head is in exten- sion, the second flexes, and the chin of the first and occiput of the second become wedged into the pelvic brim. A similar im- paction may result when both heads present. When the mother's pelvis is lar^e, the amniotic fluid abundant and the membranes rupture suddenly while the patient is erect, prolapse of foetal limbs and cords may result. Transverse position of one twin may also occur. The diagnosis of multiple pregnancy is often made for the first time after the birth of the first foetus. If the physician's suspi- cions are aroused he should at once make a thorough examina- tion, if necessary introducing the greater portion of the antisep- ticized hand. If the second foetal sac is unruptured, good uter- ine contractions should be secured by gentle friction and labor will proceed spontaneously. If the sac of the second foetus has ruptured and the second twin is not born promptly, the forceps may be applied if the vertex presents ; if the face presents or the shoulder, immediate version is indicated, with extraction by the breech. In complicated presentation and prolapse of the lirnbs and cords, the antisepticized hand, introduced under complete anaes- thesia by chloroform, is the most speedy and certain instrument. In locked twins, the first precaution must be to determine the condition of the uterine muscle. If the contraction be found high in the abdomen, uterine tetanus being present, the patient should be completely anaesthetized by chloroform, and a catheter having been passed and the bladder emptied, a cautious attempt should be made to dislodge impacted parts. Only the most gentle manipulation is permissible, as uterine rupture is easily produced. Failing in this, the physician must perform embry- otomy on the first twin in the interests of the second. The cir- cumstances of the case and the operator's judgment will deter- mine just what procedure is best. We have succeeded in a MULTIPLE PREGNANCY. 165 difficult case of locked twins, in which the body of one twin was born, its head being locked with that of the second, by decap- itating the first twin, pushing the severed head up into the uterus, delivering the second twin by forceps and then the severed head. Thorough antisepsis and precautions to prevent haemorrhage and secure good contraction of the uterus are imper- ative in these cases. CHAPTER XXV. THE PATHOLOGY OF PREGNANCY. ECLAMPSIA. By eclampsia is understood a convulsive state on the part of the mother, caused by the circulation in the blood of irritating and noxious materials which excite the nerve centres. These irritating substances result from failure or deficient action of the organs of elimination. In different cases, one or other organ seems most deficient. In some, the kidneys are greatly at fault, in others, the liver, and in others, the intestines and skin. It is usually impossible to ascribe to any one organ the entire causation of eclamptic convulsions, but probably all of the emunctories are in a measure at fault. The clinical proof that such is the origin of eclampsia is found in the fact that patients recover best under methods of treatment which tend, while nar- cotizing the nervous system, to procure speedy and thorough elimination. Eclampsia is most frequent in primagravidae, especially those be- yond thirty years old. Predisposing causes are such as produce progressive mal-assimilation with enfeeblement of the nervous sys- tem. Several causes render the pregnant woman especially liable to mal-assimilation and toxaemia from substances not thoroughly assimilated. Anatomically, the pressure of the enlarged uterus may occlude partially the ureters, thus damming up the urine, producing chronic congestion and impaired functions in the kidneys. Since attention has been drawn to a toxaemic condition as producing eclampsia, cases have been observed in which icterus, enlargement of the liver and general symptoms of ptomaine poisoning were found, indicating thaffailure in those functions of the liver which have to do with the production of the blood was present. It must be remembered that the kidneys are not the only organs whose 166 THE PATHOLOGY OF PREGNANCY. 167 failure to perform elimination properly produces eclampsia. The practitioner must not expect to find urine loaded with albumin and casts in all cases of eclampsia. Many of the fatal cases have but a small percentage of albumin and few casts in the urine. The kidneys of a large proportion of pregnant women are engorged during pregnancy, producing what is called "the kidney of pregnancy." Serum albumin and hyaline casts are not infre- quently found in the urine during pregnancy. In fact, cases in which the urine is loaded with casts and albumin not infrequently recover from eclampsia, while others, whose urine was almost free from albumin and casts, die with very little remission in the violence of their symptoms. It would seem that it is not the presence of albumin and casts, but that of ptomaines, which proves dangerous. The diagnosis of threatened toxaemia is to be made by a careful observation of the patient's condition. The physician should know whether the bowels move properly ; the quantity and char- acter of urine passed ; the condition of the skin, and, as far as possible, whether the lungs are bearing their share in elimination. Gentle exercise in the open air, with good ventilation in dwellings, is not to be neglected in preventing toxaemia. The premonitory symptoms of eclampsia are those of poison- ing of the nervous system; the cerebrum acts deficiently, the patient is slightly stupid, apathetic or irritable; the special senses are disordered : there are flashes of light or specks before the eyes ; there is diminished acutenessof hearing; there is sometimes disor- dered taste or smell. Frontal headache is often complained of, and a vague feeling of lassitude and disquietude is often present. The bodily functions are sometimes performed with a fair degree of efficiency, and, again, the action of the kidneys, intestines and skin is somewhat below the average. Just preceding the attack it is not uncommon for the cerebrum to be considerably be- numbed, so that a patient may enter a hospital on the verge of an eclamptic seizure, and afterward be unable to recall any circum- stances connected with her admission. The eclamptic seizure comprises tonic and clonic spasms. 1 63 MANUAL OF PRACTICAL OBSTETRICS. The expression of the patient's face becomes suddenly staring and unnatural, the muscular system is thrown into a tonic spasm, a deep breath is taken, followed by clonic spasms, often suffi- ciently powerful to shake a patient's bed and exhaust her greatly. The jaws are clinched, the tongue may be bitten between the teeth, and, as the stage of clonic spasms ceases, froth and mucus from the trachea and bronchi gather about the mouth and nos- trils. Following the clonic spasms, a period of coma supervenes, of greater or less duration. After this the patient may become conscious until the advent of the next eclamptic fit. As the spasms are repeated, the tremendous muscular activity of the clonic stage produces exhaustion and rapid decomposition of the muscle substance. The products of this decomposition, added to the poisonous materials already circulating in the pa- tient's blood, increase the violence and extent and duration of her spasms. The uterus is generally excited to activity, and uterine contractions bring on labor, which is frequently rapid and violent. The fixation of the diaphragm and distension of the lungs, during the stage of spasms and coma, favor pulmonary oedema. From the same causes cerebral congestion supervenes. The nervous system, excited and depressed by the poisonous materials circulating in the blood, becomes gradually exhausted, and paralysis of the heat centre is followed by a rise in tempera- ture. Paralysis of the sympathetic causes excessive cardiac ac- tion, with rapid pulse and subsequent exhaustion and heart-fail- ure. Arterial tension is increased by the irritation of the altered blood until the stage of paralysis and exhaustion is reached, and the arterial wall loses much of its contractile force. Cerebral oedema and effusion into the ventricles of the brain assist in overcoming the nervous system. Death results in deep coma, with progressive failure of the vital nerve centres. Other causes of death occurring during or after eclampsia are, exhaustion, septic infection and sudden heart-failure with development of heart-clot. TREATiMENT. The treatment of eclampsia resolves itself into prophylaxis, and the treatment of the patient during the convul- THE PATHOLOGY OF PREGNANCY. 169 sions. From what has bean said, it can readily be understood that the prophylactic treatment must be addressed to furthering and maintaining a proper elimination. It should be the invariable custom of the physician to examine the urine of patients at inter- vals of two or three weeks during pregnancy. Especial attention should also be given to the regular and proper action of the intes- tines and skin, and nutritious and easily assimilated diet should be advised, with the avoidance of unusual and prolonged exercise and exposure to damp and cold. The practitioner should remember that the presence or absence of albumin in the urine is not of great significance as regards the occurrence of eclampsia. The most valuable method of studying the condition of the kidneys is by a microscopic examination of the urinary sediment. Should granular or fatty casts be found and should they persist, and albu- min also be present, there can be no doubt but that the kidneys are at fault. The diet best adapted for patients threatened with eclampsia is milk. It is often difficult, however, to restrict patients to this only, as many soon acquire an intense disgust for this article of diet. Highly nitrogenous foods should be avoided, and also an excess of sugar and fat and any substance liable to derange the action of the liver and intestines. If the patient cannot be restricted to milk, soft-boiled eggs, fish, white meat of fowls, fruits, vegetables, stale bread and the use of an abundance of soft drinking water should be advised. To secure proper action of the intestines, it will often be neces- sary to prescribe laxatives. Salts should be avoided, as it has been ascertained that potassium salts especially act as irritants in the blood in these conditions and hence favor convulsions. Colo- cynth, senna, compound licorice powder, with the occasional use of small doses of calomel, are indicated. Glycerine and gluten suppositories and occasional enemata may "be employed to assist in keeping the bowels regular. The action of the skin should be maintained by frequent bathing in tepid or warm water. The fabric worn next to the skin should be woolen to promote a constant and free circulation of blood in the skin, thus tending 8 170 MANUAL OF PRACTICAL OBSTETRICS. to relieve the viscera from congestion. Alcoholic liquors should be avoided as beverages, and also the use of tea and coffee in excess, and any narcotic substance. The patient will avoid prolonged and fatiguing exertion, such as difficult journeys, and, if possible, should pass her pregnancy in a dry and equable climate. In proportion as the severity of the symptoms increases, the practitioner may employ more active measures to secure elimina- tion. The best of these consists in arousing the activity of the skin vigorously by the use of a hot bath. The patient should be in a tub of water at a temperature of 80 or 90, and the tempera- ture be then raised until the limit of endurance is nearly reached. While in the bath she should drink freely of hot water, and after leaving the bath she should lie wrapped in blankets for a couple of hours. There is no one drug of value as a preventer of eclampsia, and the temptation to prescribe sedatives and narcotics should be strenuously opposed, while the cause and pathology of the con- dition will give the practitioner an accurate guide for treatment in the indication to further and maintain elimination. The treatment of eclamptic convulsions consists first in so narcotizing the patient as to modify the violence of the convul- sions, thus preserving the nervous system from rapid destruction, and in securing prompt and thorough elimination. Two narcotics are of especial value, chloroform and chloral. Morphia is also often employed, and has been used with the best possible results. The administration of chloroform is of primary importance, as no other narcotic so promptly controls the convulsions. If possible, the task of giving chloroform should be intrusted to one person only, who should sit beside the patient, ready to administer the anaesthetic at the slightest indication of the convulsion. To pre- vent the patient from biting her tongue, a folded handkerchief or napkin should be placed between the jaws. A clean handkerchief or napkin may be used as an inhaler, and sufficient chloroform be poured upon it to secure a speedy and positive effect. Chloral may be given by rectal injection in doses of 30 or 40 grains, repeated at intervals of two or three hours, until from 60 to 90 THE PATHOLOGY OF PREGNANCY. 171 grains have been taken. Morphia may be administered hypoder- mically in doses of one-fourth or one-half a grain, and in com- bination with atropia when a tendency to respiratory failure is present. The subduing the violence of the paroxysms, however, will be useless to save the life of the patient unless prompt elimination is secured. This is best done by the employment of the hot bath in the following way : the patient is raised upon the sheet on which she lies, and both are placed in a tub of water at a tem- perature of 90. Sufficient ground mustard to redden the patient's skin should be thrown into the water, and the temperature of the bath should be raised rapidly until the tolerance of those whose hands are in the bath has been reached. If symptoms of heart- failure present themselves, digitalis may be given hypodermically while the patient is in the bath. Ordinarily, fifteen or twenty minutes will suffice to keep the patient in the bath. The patient's skin should also be rubbed, and when the skin is thoroughly reddened she should be taken from the bath upon the sheet, a blanket wrapped hastily about her, and laid upon a bed covered with a rubber blanket. Woolen blankets should then be added in abundance, with hot cans at the feet and about the thighs ; after a few moments the patient's forehead will be seen to be moistened by perspiration, which will usually become profuse in a short time. Meanwhile, a rectal injection of chloral may be given, and morphia used hypodermically if needed. To secure elimination in desperate cases, a drop of croton-oil mixed with olive-oil may be placed upon the tongue. It will usually be better, however, if the patient can swallow, to employ calomel as a diuretic and also as a purgative. For this purpose, ten grains of calomel with an equal quantity of soda should be swallowed as soon as possible. This dose should not be repeated but once in thirty-six hours. It may be followed an hour after- ward by a laxative injection. The practitioner, meanwhile, should observe carefully the patient's pulse and temperature. If she be threatened with heart -failure, digitalis and ammonia may be given by hypodermic injection. If the pulse continues to 172 MANUAL OF PRACTICAL OBSTETRICS. rise, remaining above 100, the prognosis becomes correspond- ingly grave as the case proceeds. It is not unusual to observe a temperature of 103 or 104 F. in these cases, usually falling under the influence of the hot bath. If stimulants are required, whis- key and milk, two ounces of each, may be warmed and given by rectal injection. In apoplectiform cases where plethora is excessive, bleeding may be practiced with marked temporary benefit. No permanent improvement can be expected, as this expedient will not exercise more than a temporary influence upon the patient. The effect of eclamptic convulsions is usually to bring on labor. If the convulsions be violent the uterine muscle often shares in the general muscular activity. Labor is sometimes rapid and precipitate. When the practitioner finds that labor has commenced, he will do well to further its completion. Thus, when dilatation is sufficient, the forceps may often be used to advantage, or version may terminate the labor. If, however, dilatation is not complete, and no signs of labor are present, no effort should be made to forcibly dilate the cervix and empty the uterus. Such a procedure would simply add to the reflex excita- bility of the general nervous system, and further a fatal result for the mother and child. After labor the convulsions may con- tinue, although this is exceptional and not the rule. The prognosis of eclampsia has improved since our knowledge of the pathology of the affection has become more accurate. While formerly more than one-third of all eclamptic patients died (33^ per cent.), under treatment planned upon indications furnished by the pathology of the affection, but one-thirteenth (7^ per cent.) died. Eclampsia occurring during the first stage of labor is more fatal than that which comes on before labor has begun. The death of the child before labor begins improves the mother's chances, probably by removing a source of uterine irritation in foetal movements and the waste products of foetal digestion. In eclamptic patients an occasional error may arise through the existence of hysteria complicating nephritis. Thus, in a THE PATHOLOGY OF PREGNANCY. 173 recent case in which nephritis was well 'marked, the patient was observed to have paroxysms simulating eclamptic seizures. A few moments' careful observation detected the evident counter- feit. It is interesting to observe that although this patient had well-marked nephritis, she never had a genuine eclamptic seizure. Epilepsy may simulate eclampsia very closely. The examina- tion of the urine and the results of treatment will usually enable the obstetrician to make a differential diagnosis. The prognosis for the child in eclamptic cases is rendered unfavorable through the usual rapidity and precipitateness of the labor. In spite of all this, however, children are frequently born and live after labor occurring during eclamptic convulsions. A mother who has had eclampsia should not nurse her child. NEPHRITIS OCCURRING DURING PREGNANCY. While toxaemia and eclampsia are . well recognized conditions, it has been customary to ascribe all eclampsia to kidney failure. This is but partially true, and nephritis during pregnancy is to be recognized as an affection distinct from toxaemia and eclampsia, although predisposing to them. The causes producing nephritis in the non-pregnant operate more readily during pregnancy, from the burdened condition of the mother's emunctories owing to the demands of the foetal economy ; exposure to wet and cold, poor and improper food and the causes which produce an altered and irritating blood, resulting in arterial disease and ultimately kidney failure, commonly cause nephritis. The symptoms are those usually observed, casts and albumin in the urine, with cedema, lessened amount of urine and uraemia. A point of especial interest to the obstetrician is the relation which nephritis caused by disease of the arterioles of the kidney bears to the life of the fcetus. While the pathology of the condition is not perfectly demonstrated, yet observation seems to show that while the arterioles of the mother's kidneys are becoming gradually occluded by diseased products, a similar change is going on in the small vessels of the placenta. This process gradually occludes areas in the placenta, thus robbing the foetus of portions of its 174 MANUAL OF PRACTICAL OBSTETRICS. blood supply and gradually causing death by asphyxia. In the interests of mother and child, a time must come when the induc- tion of labor is justified in the interests of both. Women having well marked nephritis are not apt to recover perfectly after labor and are more liable to eclampsia ; the foetus of such a mother often dies in the uterus before labor comes on, or perishes soon after birth. It is difficult to determine the exact time at which to induce labor, and this can be known only from an accurate and prolonged observation of the case. But it is certainly true, in the present stage of our knowledge, that pregnancy should be inter- rupted in a patient having well-marked symptoms of nephritis which do not abate on treatment. The treatment of nephritis during pregnancy does not differ from that in the non-pregnant. The warm and hot bath ; proper hygiene ; laxatives which produce free, watery stools ; the use of pure, soft drinking water are the ground work of treatment. It should be remembered that it is not the amount of serum albumin in the urine which indicates danger, but casts and kidney debris, and hence careful microscopic examination of the urine is more valuable than chemical tests. CHAPTER XXVI. INFECTIOUS AND CARDIAC DISEASE DURING PREGNANCY. THE ACUTE INFECTIONS OCCURRING DURING PREGNANCY. Great interest has attached to the acute infections since bacteriology has thrown new light upon the causation of such maladies. The question naturally suggests itself, can the germs causing the acute infections pass through the villi of the chorion and the inter-villous placental septa and infect the foetus as well ? At the present time an affirmative answer can be given to this question as regards typhoid infection, malaria, pneumonia, syphilis, tuberculosis and gonorrhoea. It is also stated that cholera and yellow fever are transmitted from mother to child, the latter in such a manner as to convey immunity from subse- quent attacks upon the foetus which survives, while in the uterus, an attack of the disease. The exanthematous infections are conveyed to the foetus, variola, measles, scarlatina, and erysipelas frequently causing foetal death, before or after delivery. It seems to have been demonstrated that pregnancy neither exempts or exposes a woman to the acute infections. She incurs greater dangers than the non-pregnant from abortion, from haemorrhage and from the fact that in some of the infections mentioned, as variola, scarlatina and erysipelas, the micrococci which cause puerperal pyaemia frequently develop in company with the germs of the original infection, and hence puerperal sepsis is added as a complication. The symptoms of these diseases in pregnancy do not essentially differ from those in the non-pregnant. The symptoms of abortion are likely to be added to those of the original infection, and should not fail to attract the physician's attention. As 175 176 MANUAL OF PRACTICAL OBSTETRICS. regards prognosis, if the patient's temperature does not remain long at or above 104 F. her chances and those of the foetus are not desperate so far as fever is concerned. The occurrence of abortion is unfavorable ; a premature labor is not especially dangerous. The prognosis of abortion or premature labor occur- ring during an acute infection will be greatly influenced by the observance or disregard of antiseptic precautions. As there is, in these cases, especial danger of the development of micrococci, so there is indicated especial precaution. If haemorrhage be prevented, the patient's strength be conserved, and sepsis does not complicate the case, a better prognosis can be given than would otherwise be justifiable. The treatment of the acute infections during pregnancy is that proper in the non-pregnant, with especial attention to the reduction of temperature. No theory or method of treatment appropriate in such cases is contra indicated because of preg- nancy, but whatever will best further the mother's interests will be best for the child. Quinine may be given freely during malarial infection without fear of producing abortion. When abortion or labor has begun, quinine, in common with many tonics acting upon the nervous system, is most efficient in strengthening the contraction of the uterus. It will rarely cause abortion or labor before such a process has actually commenced. Stimulants may be used as freely as needed with the best results. Abortion should not be intentionally produced, as it increases the mother's dangers. In variola and syphilis, preventive medication may be em- ployed advantageously for the interest of the foetus. Vaccina- tion should be performed so soon as variola is suspected, and pregnancy is no counter indication to vaccination in all cases. The prompt use of mercury 'in recent syphilitic infection is demanded in the interests of the foetus. Preventive inocula- tions with tuberculin do not as yet give promise of success in threatened foetal tuberculosis. Gonorrhoeal infection during pregnancy demands prompt treatment. The vagina should be thoroughly douched with a solution of bi-chloride of mercury, INFECTIOUS AND CARDIAC DISEASE DURING PREGNANCY. 177 one to one thousand, followed by boiled water. lodoform is then to be thoroughly applied to the mucous membrane, a tam- pon of iodoform gauze, which distends the vagina moderately, is especially useful. Injections may be given to advantage through a cylindrical speculum. The early destruction of the gonococci is desirable, as they tend to nest in the folds of the vaginal mu- cous membrane, and thus infect the mucous surfaces of the foetus during labor. They also threaten the mother with infection of the urinary tract. Continued gonorrhoeal inflammation during pregnancy causes in many cases adherence of the foetal mem- branes to the cervix and os ; at labor premature rupture of the membranes results, and a tedious and difficult labor may follow. CARDIAC DISORDERS DURING PREGNANCY. The physiological changes occurring in normal pregnancy tend to exaggerate a dis- eased condition of the heart before pregnancy. The tax put upon the mother's circulatory system by the needs for foetal nu- trition favors, in advanced cardiac lesions, failure in nutrition in the hypertrophied heart muscle and dilatation occurs, increasing to a dangerous degree during labor. If the valvular lesion be slight, compensation may be maintained, and no immediate harm follow pregnancy and labor. Repeated pregnancies and labor should be avoided; in fact, women with well-marked car- diac lesions should not become pregnant. During pregnancy violent exertion must be avoided, and chilling the surface of the body. The clothing should be perfectly loose ; the skin, bowels, kidneys and lungs should be kept in proper activity. The nutrition of the heart muscle is to be maintained by attention to nutrition, with the use of cardiac tonics. The sensation of breathlessness, which so often annoys pregnant women, should be explained to the patient, and should not be allowed to cause undue apprehension. The* physician will inform himself by physical examination of the actual condition present. At labor the patient's dyspnoea is best relieved by the hypodermic use of ether, atropia, strophanthus or digitalis and strychnia, with inhalations of chloroform or ether. If possible, oxygen should be in readiness for inhalation. Labor may be judiciously 178 MANUAL OF PRACTICAL OBSTETRICS. expedited by forceps or version. Haemorrhage is to be feared, and possible thrombosis after delivery. The relief afforded by anaesthetics in cases of labor with advanced valvular lesions is surprising and immediate. In common with other disorders, cardiac lesions are not incurred by pregnancy, but are aggravated by it. Endocarditis, caused by rheumatism, is most frequent, atheroma and aneurism are less commonly observed than in men. The occurrence of failure of nutrition in the heart muscle, with beginning dilatation, may justify the production of abor- tion. CHAPTER XXVII. AFFECTIONS OF THE GENITO-URINARY ORGANS OCCURRING DURING PREGNANCY. THE condition of pregnancy predisposes to inflammation of the mucous membrane of the vagina and cervix. Simple engorge- ment, with increased secretion of mucus, is almost a constant condition of the vaginal mucous membrane. Unless precautions are taken to insure cleanliness, micrococci will breed in the de- composed secretions, and inflammation and ulceration will result. The symptoms of such conditions are vaginal discharges, and pain and irritation upon micturition and walking. Treatment should be addressed first to destroying micrococci and next to maintaining a condition of cleanliness by vaginal injections. Bichloride of mercury, i to 5000 or 2000, will be useful at first, to be followed later by injections of boric acid or alum in dilute solutions. The treatment of gonorrhoea has been considered under the acute infections. When micrococci invade the bladder, a trying complication of pregnancy, and one likely to occasion trouble after labor, is present. Urethritis, cystitis, pyelitis and suppurating kidney have all followed this accident. When pus is found in the urine the bladder should be douched twice daily with creoline solution, a teaspoonful to the pint of warm water. Internally salol may be given, 10 grains three times daily, or boracic acid 15 to 20 grains three times daily. Milk diet, if possible, with rest in bed and careful disinfection of the vagina, will also be of advantage. It is of interest to note that cystitis of moderate degree may be present with an acid urine in the case of women. In pyelitis, catheterization of the ureters is of value to determine which 179 180 MANUAL OF PRACTICAL OBSTETRICS. kidney is affected : in severe and prolonged cases lumbar incision and drainage of the kidney are indicated. Displacement of the uterus and vagina are among the complica- tions of pregnancy. Prolapse of the vaginal walls is usually the result of repeated parturitions, with a relaxed condition of the tissues. Prolapse of the uterus may occur early in pregnancy, accom- panied by endocervicitis ; although previous distension of the vagina during labor is an exciting cause, it may be observed in primagravida. Its symptoms are sensations of weight and drag- ging, the presence of a tumor, with interference with the functions of the bladder and rectum. Abortion may result if the case be neglected, with septic infection following it. Replacement of the prolapsed organ and its retention in its normal position can usually be effected by manipulation. An antiseptic tampon is a convenient and efficient agent for retaining the uterus in its normal position. Surgeons' lint, in strips three inches wide, smeared with an antiseptic ointment, is a useful material for tampon. Hard and elastic pessaries are not contra- indicated in these cases. In extensive prolapse of the vaginal walls, with laceration and erosion of the cervix, colporrhaphy and trachelorrhaphy may be performed without fear of abortion, if undue violence be avoided and antiseptic precautions be taken to secure union by first intention. RETRO-DISPLACEMENT OF THE PREGNANT UTERUS It is not uncommon for the uterus to tip backward early in pregnancy. The frequency of backward displacements in the non-pregnant, tight clothing and corsets worn during pregnancy, and relaxation of the supports of the uterus as its weight increases, have all been alleged as causes of this condition. Between the third and fourth month, when the uterus rises out of the pelvis, such a displacement is usually spontaneously corrected ; if inflammation and adhesions exist, binding the uterus down, abortion or death of the foetus and impaction of the uterus in the hollow of the sacrum will result. The symptoms of retro-displacement of the pregnant uterus are Plat Davis' Obstetrics > u- (U -p p o I-l Cfl M (U Cfl Fi o iH X 0) AFFECTIONS OF THE GENITO-URINARY ORGANS. l8l frequent and irritating micturition, constipation, and pain over the sacral and gluteal regions. Digital examination will confirm the physician's suspicions. The treatment of this complication of pregnancy, in mild cases, consists in emptying the bladder and rectum, anteverting the uterus by pressure with the fingers in the vagina or rectum, and fitting a pessary, either of hard rubber or some softer material, to retain the uterus in position. In replacing the uterus, violent manipulation must be avoided ; if the patient be placed in the knee-chest posture the uterus will generally go easily into place. A support will not be needed after the fourth month, when the uterus has risen above the pelvic brim. In impaction of the pregnant uterus in the hollow of the sacrum, persistent but gentle efforts are needed to dislodge it from its abnormal position. The cervix may be grasped by a tenaculum forceps and drawn downward and backward, while with the fingers of the other hand an effort is made to dislodge the fundus. If the uterus cannot be replaced, its size must be lessened by producing abortion ; this is best accomplished by introducing a sound, rupturing the membranes. When the uterus is bound down by adhesions, impacted in the hollow of the sacrum, and death and decomposition of the foetus ensue, the condition is one of gravity. The obstetrician is then obliged to forcibly break up such adhesions, replace the uterus and empty and disinfect its cavity. The uterus has been extirpated through the vagina for the relief of this condition, with success. ANTERIOR DISPLACEMENT OF THE PREGNANT UTERUS. In women whose abdominal walls are ill developed, weakened by many pregnancies, and in pregnant women having contracted pelves so small that the uterus cannot enter the pelvic cavity, exaggerated ante-version of the pregnant uterus has been observed. Its symptoms are interference with the function of the bladder, first frequent micturition, then infrequent difficult micturition, and finally the retention of the contents of the bladder with almost constant dribbling of urine. The abdomen protrudes as the uterus grows larger, until the German term of "hanging 1 82 MANUAL OF PRACTICAL OBSTETRICS. belly" seems appropriate. Pain and "dragging" are felt in the sacral region. The diagnosis of the condition is readily made by examination after the bladder has been emptied by a catheter. In early pregnancy a ring pessary will usually correct the malposition ; later in pregnancy a broad abdominal band will be found use- ful. RELAXATION OF THE PELVIC JOINTS is an occasional complication of pregnancy. Although these joints become more vascular, and contain more synovial fluid than in the non pregnant, it is rare for their mobility to become excessive. The pubic joint is most affected in these cases, and can be felt to move freely when the patient steps. Walking may become impossible, and stand- ing be scarcely endured. There is no one cause which seems responsible for this condition, and hence no treatment except mechanical devices for partly immobilizing the joint is of avail. The application of a broad, well fitting bandage of strong material, passing around the entire pelvis from the trochanters above the crests of the ilia, is usually efficient. A plaster-of- Paris bandage has been necessary in severe cases, and in others rest in bed. THE NERVOUS SYSTEM. Pregnancy affects the nervous sys- tem, often profoundly. The reflexes are exaggerated; the tro- phic and secretory nerves are more active, and more easily excited. The brain shares in the generally sensitive condition of the patient, and the pregnant woman is often easily frightened, irritable and usually apprehensive. A generally stimulating effect is observed with others, and such women feel better than when not pregnant. Such patients have better appetite and digestion than before pregnancy. The sensitive condition of the sympathetic nervous system causes cardiac palpitation, dys- pnoea, flushing of the features and often perspiration on very slight provocation. Salivation, discoloration of the skin about the face and often the genital organs, and, in many cases, excessive nausea and vomiting, are all to be referred to hyperaesthesia of the various portions of the nervous system, caused by pregnancy. Plate YIH. Da vis' Obstetrics - s E <= E .2 o a in O Cfl C O rH 03 i_ O u -M n\ IK' Oh.stetries Transverse Rupture of the Anterior Cervical Wall. ( Spiegelberg ) THE ACCIDENTS OF LABOR ENDANGERING THE MOTHER. 241 deep chloroform anaesthesia, this anaesthetic being superior to ether for such cases. The injection of morphia is also of value, and the hot bath or hot applications have been found useful. Brandy may be given by hypodermic injection in free doses. If the foetus is dead, it should be delivered in the manner least likely to injure the mother; embryotomy will usually be advantageous. FIG. 113. VERSION IN THREATENED RUPTURE OF THE UTERUS. If the foetus lives, version or forceps will be chosen, as the pre- sentation and dilatation of the birth canal may indicate j ver- sion before uterine rupture and under deep anaesthesia being a most valuable expedient (Fig. 113). 242 MANUAL OF PRACTICAL OBSTETRICS. Foetal mortality in threatened and actual uterine rupture is very high. Long continued pressure by the upper uterine seg- ment, and the inspiration of blood and abdominal fluids, where the foetus escapes into the abdomen, usually kill the foetus by asphyxia. Its chance for life is so slight that it is commonly disregarded in the presence of the great danger which threatens the mother, except in very favorable cases. INVERSION OF THE UTERUS. By traction upon the placenta through the cord, by sudden violent pressure upon the fundus, and by spontaneous, but forcible uterine contractions, the womb may be inverted or turned wrong side outward. This accident is most apt to happen to weak and exhausted patients, in cases where the uterus has been over-distended during pregnancy and labor, or in women whose muscular development is deficient. Symptoms of inversion of the uterus are pain, shock and haem- orrhage and the appearance of a uterine tumor in the vagina. This tumor may vary in size, from a mass the size of a large orange in cases where the fundus only is inverted, to a tumor as large as a man's two fists hanging between the thighs. The diagnosis of an inverted uterus is not always easy. A prolapsed and inverted bladder and a fibroid polyp of the uterus may simu- late the inverted uterus. Should the placenta be adherent, it will be at once evident that the tumor is the uterus. A diag- nosis in these cases is to be made by a careful examination. The bladder must be emptied by a catheter ; bimanual examination will reveal the absence of the uterus above the pubes, and an attempt to pass a sound into the uterus will demonstrate the na- ture of the accident (Fig. 114). Uterine inversion is one of the most serious accidents of labor. Death from exhaustion soon after labor, or from sepsis if the pa- tient survives the accident, commonly results when inversion is complete. The treatment of this condition consists in restoring the uterus to its normal condition. Pressure by the antisepti- cized hand, the uterine tissue being protected by a pad of anti- septic gauze, should be immediately made upon the fundus, in the pelvic axis. While force must be exercised, it should be THE ACCIDENTS OF LABOR ENDANGERING THE MOTHER. 243 done in a gentle, steady manner, and should be continued for from five to fifteen minutes at a time, with counter pressure over the pubes. The patient's general condition demands attention in these cases; antiseptic douches are of value in promoting reposition and preventing sepsis, and pain should be mitigated by the injection of morphia and atropia, and shock combated by the injection of brandy or ether. If the physician be called to a neglected case of inversion of FIG. 114. INVERSION OF THE UTERUS. a Upper vaginal wall. b The inverted uterus. the uterus in which septic infection is threatened by an infected uterus, its removal will afford the patient her best chance for life. LACERATION OF THE CERVIX UTERI occurs in the majority of first labors, but is slight in extent. Under precautions to avoid 244 MANUAL OF PRACTICAL OBSTETRICS. septic infection, such lacerations heal without suture. In cases of rapid delivery, and in spontaneous, precipitate labors, lacera- tion extending to the attachment of the vagina may occur, causing haemorrhage, which demands treatment. Immediate suture is the proper treatment for such an accident. One suture of stout silk, catgut or silver wire on each side will commonly result in good union. If the patient is too exhausted to permit of suturing, iodoform gauze tampons may be used to check haemorrhage. CHAPTER XXXVII. LACERATION OF THE PERINEUM AND PELVIC FLOOR. LACERATION of the perineum and pelvic floor requires the prompt attention of the physician. This accident occurs more frequently than many practitioners will admit, as its confession implies a want of skill in the minds of many. If all lacerations which extend beyond the fourchette, or posterior commissure, be called laceration of the perineum, many of the marvellous records of hundreds of cases without a laceration would disappear. Clini- cally, all lacerations which extend beyond the fourchette should be sutured whenever possible. In hospital practice this can be readily accomplished ; in private practice the physician is often led to omit suture and depend upon spontaneous union under cleanliness. It is true that union often results in laceration of moderate extent without suture, but such treatment is not the most scientific and thorough. It is the rule among careful obstet- ricians to suture all lacerations half an inch in length, including the posterior commissure, and certainly no great mistake can be made by following this rule. If free haemorrhage exists, a tampon of gauze may be applied, and the obstetrician will wait for several hours until it ceases. He may also wait for daylight and to secure rest for his patient to advantage. In lacerations not extending to the rectum, silk or silver wire may be used to advantage for suture material. In lacerations to or through the bowel, catgut will be needed in addition to the other. A curved needle upon a handle is pre- ferred by some ; others use the ordinary curved surgeon's needle, in needle forceps. The patient is brought to the edge of a bed or table, her feet in chairs or supported by assistants. Except in immediate suture, or where but one or two stitches are required, 245 246 MANUAL OF PRACTICAL OBSTETRICS. anaesthesia is necessary for an accurate closure. The operator will require needles, needle-holder, or needle on fixed handle, scissors, a pair of tenaculum forceps or a tenaculum, a pair of haemos- tatic forceps and suture ma- terial. A vaginal douche of a gallon of bichloride solu- tion, i to 5000, at a tempera- ture of 100 F., may first be given. Antiseptic precau- tions having been taken with the operator's hands and in- struments, a simple lacera- tion, as shown in Fig. 115, is to be closed with silk or silver wire, by passing the sutures beneath the entire wound from the lower end upwards. The letter a repre- sents the highest point of the laceration. In Fig. 116 the same laceration has been al- tered in its shape by drawing the point a upwards with a tenaculum forceps, for con- venience in approximation. It is frequently the case, in primiparge especially, that in addition to a central tear in the perineum, lacerations are found extending up into the vaginal tissues on one or both sides. In Figs. 117 and LACERATION OF THE PERINEUM AND PELVIC FLOOR. 247 FIG. 118. FIG. 119. 118 such lacerations and their closure are illustrated by diagrams, the point a being the highest point in the true perineal laceration. In Fig. 119 the method of closing a laceration extending into the bowel and upwards into the vagina on each side is illustrated. The bowel is closed from within out- wards by stitches of fine catgut, and the laceration is thus converted into one illustrated in Fig. 120, and closed by silk or silver as there re- presented. When an obstetrician has become experienced in the use of catgut, and possesses catgut of good quality, he may close perineal lacerations by the continuous catgut suture as shown in Figs. 121 and 122. Where primary union does not result after the closure of perineal injuries, in eight or ten days after operation the patient may be anaes- thetized, the granulating surfaces scraped with a curette and closed by suture. If thoroughly done this procedure rarely fails. The after treatment of these cases consists in careful antisepsis. Three or four douches to the perineum and lower portion of the vagina should be given in twenty-four hours of bichloride solution, i to 8000, or creolin. i per cent. Antiseptic pads or napkins should be kept on the vulva. The use of the catheter should be avoided, and the parts cleansed after each urination in- stead. Loose bowel movements should be obtained after the third or fourth day. It is an unnecessary precaution to bind the legs FIG. 120. 248 MANUAL OF PRACTICAL OBSTETRICS. FlG. 121. together in rational, reasonable patients. If the sutures do not annoy the patient they may remain ten days, when union results. In extensive laceration they may be left two weeks. The patient should remain recumbent for at least two weeks after the laceration is closed. SUDDEN DEATH DURING LABOR is caused by the formation of a clot in the heart, by the entrance of air into the circulation through the uterine sinuses, and by sudden shock and syncope occurring after uterine rupture. The symptoms of threat- ened death are those of cardiac syn- cope, faint rapid pulse or sudden cessation of the pulse, pallor of the features, sudden mental alarm and distress, with rapid unconsciousness. The most prompt stimula- tion for the heart and brain is demanded. Hypodermic injec- o tions of ether, raising the foot of the bed several feet, atropia, ammonia and brandy or whiskey by hypodermic injection, and LACERATION OF THE PERINEUM AND PELVIC FLOOR. 249 where oxygen is available the inhalation of this gas are all de- manded with the greatest promptness. Manipulations to accom- plish delivery must cease, and attention be given to resuscitating the patient. Unfortunately many of these cases perish before more than one effort can be made to save them. The possibility of heart-clot and the entrance of air through the placental site should be borne in mind in cases of post-partum hemorrhage, and such patients should not be allowed to sit up and should be prevented from sudden exertion so far as possible. In removing a placenta in these cases, as little violence as possible should be exerted, and uterine contractions maintained by pressure and massage over the uterus. THROMBOSIS OF THE VEINS ABOUT THE VULVA AND VAGINA is an accident of labor which may result from violence during de- livery or without apparent cause. The appearance of a bluish- red tumor near the labium, with the complaint of pain on the part of the patient, enables the physician to recognize the acci- dent. If labor can be completed without rupturing the tissues which cover the thrombus, care should be exercised that the ex- ternal air does not find entrance. If bleeding goes on and the thrombus is accompanied by the extravasation of blood into the cellular tissue through the rupture of capillary vessels, the tumor should be laid open under careful antiseptic precautions, the clot turned out and the cavity packed with antiseptic gauze. Labor should then be completed, and a compress and antiseptic napkin worn after delivery. The after-treatment of such a cavity con- sists in its thorough -disinfection, and securing healing from the bottom by the continued use of the tampon. When labor is completed without rupture, an antiseptic pad and pressure by a T bandage will favor the absorption of the clot. In difficult delivery by forceps or version and extraction the PUBIC JOINT has been RUPTURED. This accident is marked by sudden pain, and yielding of the joint which is appreciated by the physician. It may or may not be accompanied by laceration of the tissues beneath the pubes. If the joint surfaces do not be- come infected by sepsis compression, by plaster-of- Paris bandage, 250 MANUAL OF PRACTICAL OBSTETRICS. or by a firm binder is sufficient. Suppurating arthritis has fol- lowed injury to the pubic joint during labor, making it necessary to drain and disinfect the articulation. Recovery, with firm union, usually results in these cases. In sudden death during labor the physician's duty to the un- born child is a subject of interest and importance. Immediate delivery is the indication, to be accomplished as the circum- stances of the case will best permit. If the genital canal is dilated and the head or breech presents the forceps may be found effi- cient. In multiparae, where the foetus is not favorably situated for the application of forceps, version has been successful. Where the genital canal is undilated, the extraction of the child by Csesarean section is indicated where the pregnancy is suffi- ciently advanced to give reason to hope that the foetus can sur- vive. CHAPTER XXXVIII. PUERPERAL SEPSIS (PUERPERAL FEVER). THE most important, because the most deadly complication of labor and the puerperal state is septic infection. At the present day it is quite needless to raise the question as to the nature of puerperal fever. The exact mode of its origin may not be clearly proven, but the fact that it is an infection, produced by an infecting agent which can be communicated, rests upon grounds beyond question. By puerperal fever we do not refer merely to rises in temperature occurring after labor; such fevers will be considered later. But prolonged variation in pulse and temperature of con- siderable degree, accompanied by constitutional symptoms which denote the presence of an actively poisonous agent, and by anatomi- cal lesions, necrotic in character, form together a clinical picture formerly named puerperal fever, better known as puerperal sep- tic infection. This disorder is identical with septic infection occurring in any recently wounded patient, whether a man crushed by machinery whose wounds become infected during handling by a careless surgeon, or a woman whose torn perineum is infected during labor by the dirty fingers of her attendants. This infection is produced by the action of living ferments, which directly destroy the tissue or plug up the circulatory channels of the body, or indirectly poison the patient by producing toxic alkaloids which are absorbed. The question arises as to whether these infecting germs are always communicated from without, or whether they may be found independently in the patient's body; in other words, whether puerperal infection is ever auto-genetic. While it is true that the body of the healthy woman never contains and can never develop these germs, it is also true that in the course of. 251 252 MANUAL OF PRACTICAL OBSTETRICS. diseases previously communicated to the patient, poisonous agents are introduced which gain access to the wounds in the genital tract made during labor, and produce puerperal sepsis by infect- ing these wounds. Thus the germs of gonorrhoea, syphilis or cancer may be present in the body before pregnancy; and, find- ing access directly to the circulation through the wounds of labor, may produce sepsis. The symptoms of puerperal sepsis will be best understood if we remember that the infecting germs may gain access through the lymphatics of freshly made wounds in the vagina and vulva, or go directly into the circulation through the open sinuses at the placental site. In the first instance vulvitis and vaginitis, with the formation of a puerperal ulcer, develop, in three or four days, from contact of a dirty hand or instrument in the vagina after labor. In the second mode of septic infection, the infected hand of a careless obstetrician, who performs version or separates and delivers an adherent placenta, lodges infecting germs in the uterine wall, where the placenta was attached, and direct infection through open sinuses results. The course of puerperal sepsis can best be comprehended by recalling the anatomy of the lymphatics of the genital tract, as the infection usually follows the course of these channels. The lymphatics of the vulva and lower fourth of the vagina commu- nicate with the superficial inguinal glands, and thence through the saphenous opening to the deep inguinal glands or along the deep blood-vessels, finally entering the abdominal cavity. An infection planted in the vulva or lower portion of the vagina may finally spread to the peritoneum. Considerable time would be required, however, for this result to occur, and the usual symptoms of vulvitis and vaginitis, with puerperal ulcers at the posterior commissure, would have given ample warning of threat- ened danger. From the cervix uteri and upper three- fourths of the vagina, the lymphatics communicate with the deep iliac and sacral glands. Hence a focus of infection in the uterine cervix or in the upper part of the vagina readily infects the peritoneum. PUERPERAL SEPSIS (PUERPERAL FEVER). 253 In the uterine cavity lymphatic spaces are numerous in the uterine decidua, communicating with lymphatic channels in the serous covering of the uterus. From this surface lymphatics pass through the broad ligaments to the glands situated deeply on the posterior wall of the abdomen, in the lumbar region. It can readily be seen, then, how direct infection of the uterine decidua speedily causes peritonitis. The least dangerous form of puerperal sepsis is vulvitis and vaginitis, resulting from infection of the vulva and lower fourth of the vagina. It is most common in women who have torn perinea or fissures in the mucous membrane at the opening of the vulva. In forty-eight to sixty hours after labor, the patient's temperature rises to 101 F., or 102; slight pain, burning, smarting on micturition are felt about the vulva ; a rigor may be experienced by nervous patients. The pulse is 100 to 120. On examination the labia are swollen, the mucous membrane reddened ; at the posterior commissure abraded or lacerated sur- faces are found, covered by a yellowish or faintly greyish deposit. The lochia may cease for a short time, to be slightly purulent and offensive later. If the perineum has been sutured, the surfaces will not be healing by first intention, but the edges of the wound will be separated by pus, and the stitches will have loos- ened slightly. The treatment of this condition consists in douching the vulva and lower portion only of the vagina with bichloride of mercury solution, i to 5000, douches to be given four times in twenty-four hours. Half a gallon should be used for a douche, at a temper- ature of 100 F. The physician should thoroughly apply to ulcerated or fissured surfaces peroxide of hydrogen upon absorbent cotton, or tincture of iodine and a saturated solution of carbolic acid in glycerine equal parts, followed by the free use of iodo- form or boracic acid as a dusting powder. It is well to thor- oughly unload the bowels by calomel, gr. 2*^, and soda, gr. 10, followed by a saline or an abundant hot enema. Abdominal pain is best relieved by placing upon the abdomen a flannel wrung out of hot water, on which spirits of turpentine have been 254 MANUAL OF PRACTICAL OBSTETRICS. freely sprinkled. If stitches have been introduced, they should be at once removed, and ununited surfaces freely disinfected. The patient's diet should be of the most nutritious and digestible character, and alcohol should be given early to debilitated pa- tients. In cases where the infection begins at the uterus or upper por- tion of the vagina, the rapid spread of septic germs soon produces inflammation of the tissues about the uterus, and of the peritoneum which covers it. The first is /d, j; lotetfeaved for Notes, a^o rinary Amalyus . TUrd F, x.oo Holland. The Urine, Common Poisons, and Milk Analysis, Chemical and Microscopical. For Laboratory Use. Fourth i - : -- . :-:- i-- : .; OoA,tj Van Hiys. Urine Analysis. OIK. Ooth, 2.00 VToIirs Applied Medical Chemistry. By Lawrence Wolff. CHILDREN. Goodhart and Starr. The Diseases of Children. Second Edition. By J. F. Goodhart, H.D., Physiciaa * the Ertdiaa Hospital far CaOdtea; Assiccaat Physiciaa to Gay's Hospital, Loodoo. Revised aad Edited by Louis Starr, M.O., CSsical Professor of Diseases ofChfldrea ia tie Hospital of the UaHw- siry of Peamsylvaaia; Physiciaa to the ChOdrea's Hospital, Phibtdelnhia. C"r-" ; - ; -e snay Prescriptions aad Forambe, t^nfi.alag to the U. S. Phanaacopoeia, Kreetioos far aukiaf; Artificial Hmaaa Milk, far the Artificial Destioa of Mitt, etc. - . - ., doth, >oo; Leather, 3-3- H,:- : I ,v, :;; : : .- :-*-- . Prafessor of Diseases of Childi.ajiea8i> : . ; -. ,. .-- Ocdi, i-oo; 8 STUDENTS' TEXT-BOOKS AND MANUALS. Children: Continued. Starr. Diseases of the Digestive Organs in Infancy and Childhood. With chapters on the Investigation of Disease, and on the General Management of Children. By Louis Starr, M.D., Clinical Professor of Diseases of Children in the Univer- sity of Pennsylvania. Illus. Second Edition. Cloth, 2.25 DENTISTRY. Fillebrown. Operative Dentistry. 330 Illus. Cloth, 2.50 Flagg's Plastics and Plastic Filling. 4th Ed. Cloth, 4.00 Gorgas. Dental Medicine. A Manual of Materia Medica and Therapeutics. Fourth Edition. Cloth, 3.50 Harris. Principles and Practice of Dentistry. Including Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery and Mechanism. Twelfth Edition. Revised and enlarged by Professor Gorgas. 1028 Illustrations. Cloth, 7.00; Leather, 8.00 Richardson's Mechanical Dentistry. Fifth Edition. 569 Illustrations. 8vo. Cloth, 4.50; Leather, 5.50 Sewill. Dental Surgery. 200 Illustrations. 3d Ed. Clo., 3.00 Taft's Operative Dentistry. Dental Students and Practitioners. Fourth Edition. 100 Illustrations. Cloth, 4.25 ; Leather, 5.00 Talbot. Irregularities of the Teeth, and their Treatment. Illustrated. 8vo. Second Edition. Cloth, 3.00 Tomes' Dental Anatomy. Third Ed. 191 Illus. Cloth, 4.00 Tomes' Dental Surgery. 3d Edition. Revised. 292 Illus. 772 Pages. Cloth, 5.00 Warren. Compend of Dental Pathology and Dental Medi- cine. Illustrated. Cloth, i.oo; Interleaved, 1.25 DICTIONARIES. Gould's New Medical Dictionary. Containing the Definition and Pronunciation of all words in Medicine, with many useful Tables etc. J Dark Leather, 3.25 ; % Mor., Thumb Index 4.25 Harris' Dictionary of Dentistry. Fifth Edition. Completely revised and brought up to date by Prof. Gorgas. Cloth, 5.00; Leather, 6.00 Cleaveland's Pronouncing Pocket Medical Lexicon. 3151 Edition. Giving correct Pronunciation and Definition. Very small pocket size. Cloth, red edges .75 ; pocket-book style, i.oo Longley's Pocket Dictionary. The Student's Medical Lexicon, giving Definition and Pronunciation of all Terms used in Medi- cine, with an Appendix giving Poisons and Their Antidotes, Abbreviations used in Prescriptions, Metric Scale of Doses, etc. 24mo. Cloth, i.oo; pocket-book style, 1.35 83~ See pages 2 to 5 for list of Students' Manual*. STUDENTS' TEXT-BOOKS AND MANUALS. EYE. Hartridge on Refraction. 4th Edition. Cloth, 2.00 Hartridge on the Ophthalmoscope. Nearly Ready. Meyer. Diseases of the Eye. A complete Manual for Stu- dents and Physicians. 270 Illustrations and two Colored Plates. 8vo. Cloth, 4.50; Leather, 5.50 Swanzy. Diseases of the Eye and their Treatment. 158 Illustrations. Third Edition. Cloth, 300 Fox and Gould. Compend of Diseases of the Eye and Refraction. 2d Ed. Enlarged. 71 Illus. 39 Formulae. Cloth, i.oo ; Interleaved for Notes, 1.25 ELECTRICITY. Bigelow. Plain Talks on Medical Electricity and Batteries. Illustrated. With a Glossary of Electrical Terms. Cloth, i.oo Mason's Compend of Medical and Surgical Electricity. With numerous Illustrations. i2ino. Cloth, i.oo HYGIENE. Parkes' (Ed. A.) Practical Hygiene. Seventh Edition, en- larged. Illustrated. 8vo. Cloth, 4.50 Parkes' (L. C.) Manual of Hygiene and Public Health. Second Edition, izmo. Cloth, 2.50 Wilson's Handbook of Hygiene and Sanitary Science. Seventh Edition. Revised and Illustrated. In Press. MATERIA MEDICA AND THERAPEUTICS. Potter's Compend of Materia Medica, Therapeutics and Prescription Writing. Fifth Edition, revised and improved. See Page 15. Cloth, i.oo; Interleaved for Notes, 1.25 Biddle's Materia Medica. Eleventh Edition. By the late John B. Biddle, M.D., Prof, of Materia Medica in Jefferson Col- lege, Philadelphia. Revised by Clement Biddle, M.D., and Henry Morris, M.D. 8vo., illustrated. Cloth, 4-25: Leather, 5.00 Potter. Handbook of Materia Medica, Pharmacy and Therapeutics. Including Action of Medicines, Special Thera- peutics, Pharmacology, etc. By Saml. O. L. Potter, M.D., M R.C.P. (Lond.), Professor of the Practice of Medicine in Cooper Medical College, San Francisco. Third Edition. 8vo. Cloth, 4.00; Leather, 5.00 Waring. Therapeutics. With an Index of Diseases and Remedies. 4 th Edition. Revised. Cloth, 3.00; Leather, 3.50 *? See pages 14 and /j for list of t Q*i- Contends t 10 STUDENTS' TEXT-BOOKS AND MANUALS. MEDICAL JURISPRUDENCE. Reese. A Text-book of Medical Jurisprudence and Toxi- cology. By John J. Reese, M.D., Professor of Medical Juris- prudence and Toxicology in the Medical Department of the University of Pennsylvania ; President of the Medical Juris- prudence Society of Philadelphia ; Physician to St. Joseph's Hospital ; Corresponding Member of The New York Medico- legal Society. Third Edition. Cloth, 3.00; Leather, 3.50 OBSTETRICS AND GYNAECOLOGY. Davis. A Manual of Obstetrics. Colored Plates, and 150 other Illustrations. Ready in October, i8()l, Byford. Diseases of Women. The Practice of Medicine and Surgery, as applied to the Diseases and Accidents Incident to Women. By W. H. Byford, A.M., M.D., Professor of Gynaecology in Rush Medical College and of Obstetrics in the Woman's Med- ical College, etc., and Henry T. Byford, M.D., Surgeon to the Woman's Hospital of Chicago. Fourth Edition. Revised and Enlarged. 306 Illustrations, over 100 of which are original. Octavo. 832 pages. Cloth, 5^x3 ; Leather, 6.00 Cazeaux and Tarnier's Midwifery. With Appendix, by Munde. The Theory and Practice of Obstetrics ; including the Diseases of Pregnancy and Parturition, Obstetrical Operations, etc. Eighth American, from the Eighth French and First Italian Edition. Edited by Robert J. Hess, M.D., Physician to the Northern Dispensary, Philadelphia, with an appendix by Paul F. Munde, M.D., Professor of Gynaecology at the N. Y. Polyclinic. Illustrated by Chromo-Lithographs, and other Full- page Plates, seven of which are beautifully colored, and numerous Wood Engravings. One Vol., 8vo. Cloth, 5.00; Leather, 6.00 Lewers' Diseases of 'Women. A Practical Text-Book. 139 Illustrations. Second Edition. Cloth, 2.50 Parvin's Winckel's Diseases of Women. Second Edition. Including a Section on Diseases of the Bladder and Urethra. 150 Illus. Revised. See page 3. Cloth, 3.00; Leather, 3.50 Morris. Compend of Gynaecology. Illustrated. Cloth, i.oo Winckel's Obstetrics. A Text-book on Midwifery, includ- ing the Diseases of Childbed. By Dr. F. Winckel, Professor of Gynaecology, and Director of the Royal University Clinic for Women, in Munich. Authorized Translation, by J. Clifton Edgar, M.D., Lecturer on Obstetrics, University Medical Col- lege, New York, with nearly 200 handsome illustrations, the majority of which are original. Svo. Cloth, 6.00 ; Leather, 7.00 Landis' Compend of Obstetrics. Illustrated. 4th edition, enlarged. Cloth, i.oo; Interleaved for Notes, 1.25 Galabin's Midwifery. By A. Lewis Galabin, M.D., F.R.C.P. 227 Illustrations. See page 3. Cloth, 3.00; Leather, 3.50 Rigby's Obstetric Memoranda. 4th Edition. Cloth, .50 <9~ See pages 2 to 5 for list of New Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 11 PATHOLOGY. HISTOLOGY. BIOLOGY. Bowlby. Surgical Pathology and Morbid Anatomy, for Students. 135 Illustrations, 121110. Cloth, 2.00 Davis' Elementary Biology. Illustrated. Cloth, 4.00 Gilliam's Essentials of Pathology. A Handbook for Student*. 47 Illustrations. I2mo. Cloth, a.o *** The object of this book is to unfold to the beginner the funda- mentals of pathology in a plain, practical way, and by bringing them within easy comprehension to increase his interest in the study of the subject. Gibbes' Practical Histology and Pathology. Third Edition. Enlarged. 121110. Cloth, 1.75 Virchow's Post-Mortem Examinations, sd Ed. Cloth, i.oo PHYSICAL DIAGNOSIS. Fenwick. Student's Guide to Physical Diagnosis. 7th Edition. 117 Illustrations. I2mo. Cloth, 2.25 Tyson's Physical Diagnosis. Illustrated. To be ready, October, I&QI. PHYSIOLOGY. pages. 321 carefully printed Illustrations. With a Full Glossary and Index. See Page 3. Cloth, 3.00; Leather, 3.50 Brubaker's Compend of Physiology. Illustrated. Sixth Edition. Cloth, i.oo; Interleaved for Notes, 1.25 Stirling. Practical Physiology, including Chemical and Ex- perimental Physiology. 142 Illustrations. Cloth, 2.25 Kirke's Physiology. New mh Ed. Thoroughly Revised and Enlarged. 502 Illustrations. Cloth, 4.00; Leather, 5.00 Landois' Human Physiology. Including Histology and Micro- scopical Anatomy, and with special reference to Practical Medi- cine. Third Edition. Translated and Edited by Prof. Stirling. 692 Illustrations. Cloth, 6.50; Leather, 7.50 " With this Text-book at his command, no student could fail in his examination." Lancet. Sanderson's Physiological Laboratory. Being Practical Ex- ercises for the Student. 350 Illustrations. 8vo. Cloth, 5.00 PRACTICE. Taylor. Practice of Medicine. A Manual. By Frederick Taylor, M.D., Physician to, and Lecturer on Medicine at, Guy's Hospital, London ; Physician to Evelina Hospital for Sick Chil- dren, and Examiner in Materia Medica and Pharmaceutical Chemistry, University of London. Cloth, 4.00; Leather, 5.00 ee pages 14 and IS for list of t Quix- Commends t 12 STUDENTS' TEXT-BOOKS AND MANUALS. Practice : Continued. Roberts' Practice. New Revised Edition. A Handbook of the Theory and Practice of Medicine. By Frederick T. Roberts, M.D. ; M.R.C.P., Professor of Clinical Medicine and Therapeutics in University College Hospital, London. Seventh Edition. Octavo. Cloth, 5.50 ; Sheep, 6.50 Hughes. Compend of the Practice of Medicine. 4th Edi- tion. Two parts, each, Cloth, i.oo; Interleaved for Notes, 1.25 PART i. Continued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc., and General Diseases, etc. PART n. Diseases of the Respiratory System, Circulatory System and Nervous System; Diseases of the Blood, etc. Physicians' Edition. Fourth Edition. Including a Section on Skin Diseases. With Index, i vol. Full Morocco, Gilt, 2.50 From John A. Robinson, M.D., Assistant to Chair of Clinical Medicine, now Lecturer on Materia Medico., Rush Medical Col- lege, Chicago. " Meets with my hearty approbation as a substitute for the ordinary note books almost universally used by medical students. :d by i ucid, It is concise, accurate, well arranged and lucid, . . . just the thing for students to use while studying physical diagnosis and the more practical departments of medicine." PRESCRIPTION BOOKS. Wythe's Dose and Symptom Book. Containing the Doses and Uses of all the principal Articles of the Materia Medica, etc. Seventeenth Edition. Completely Revised and Rewritten. Just Ready. 32010. Cloth, i.oo; Pocket-book style, 1.25 Pereira's Physician's Prescription Book. Containing Lists of Terms, Phrases, Contractions and Abbreviations used in Prescriptions Explanatory Notes, Grammatical Construction of Prescriptions, etc., etc. By Professor Jonathan Pereira, M.D. Sixteenth Edition. 32010. Cloth, i.oo; Pocket-book style, 1.25 PHARMACY. Stewart's Compend of Pharmacy. Based upon Remington's Text-Book of Pharmacy. Third Edition, Revised. With new Tables, Index, Etc. Cloth, i.oo; Interleaved for Notes, 1.25 Robinson. Latin Grammar of Pharmacy and Medicine. By H. D. Robinson, PH.D., Professor of Latin Language and Literature, University of Kansas, Lawrence. With an Intro- duction by L. E. Sayre, PH.G., Professor of Pharmacy in, and Dean of, the Dept. of Pharmacy, University of Kansas. I2mo. Cloth, 2.00 SKIN DISEASES. Anderson, (McCall) Skin Diseases. A complete Text-Book, with Colored Plates and numerous Wood Engravings. 8vo. Cloth, 4.50; Leather, 5.50 Van Harlingen on Skin Diseases. A Handbook of the Dis- eases of the Skin, their Diagnosis and Treatment (arranged alpha- betically). By Arthur Van Harlingen, M.D., Clinical Lecturer on Dermatology, Jefferson Medical College ; Prof, of Diseases of the Skin in the Philadelphia Polyclinic. 2d Edition. Enlarged. With colored and other plates and illustrations. 12010. Cloth, 2.50 ee pages i to 5 for list of New Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 13 SURGERY AND BANDAGING. Moullin's Surgery, A new Text-Book. 500 Illustrations, 200 of which are original. Cloth, 7.00; Leather, 8.00 Jacobson. Operations in Surgery. A Systematic Handbook for Physicians, Students and Hospital Surgeons. By W. H. A. Jacobson, B.A., Oxon. F.R.C.S. Eng. ; Ass't Surgeon Guy's Hos- pital ; Surgeon at Royal Hospital for Children and Women, etc. 199 Illustrations. 1006 pages. 8vo. Cloth. 5.00; Leather, 6.00 Heath's Minor Surgery, and Bandaging. Ninth Edition. 142 Illustrations. 60 Formulae and Diet Lists. Cloth, 2.00 Horowitz's Compend of Surgery, Minor Surgery and Bandaging, Amputations, Fractures, Dislocations, Surgical Diseases, and the Latest Antiseptic Rules, etc., with Differential Diagnosis and Treatment. By ORVILLB HOKWITZ, B.S., M.D., Demonstrator of Surgery, Jefferson Medical College. 4th edition. Enlarged and Rearranged. 136 Illustrations and 84 Formulae. i2mo. Cloth, i.oo ; Interleaved for the addition of Notes, 1.25 *** The new Section on Bandaging and Surgical Dressings, con- sists of 32 Pages and 41 Illustrations. Every Bandage of any importance is figured. This, with the Section on Ligation of Arteries, forms an ample Text-book for the Surgical Laboratory. Walsham. Manual of Practical Surgery. For Students and Physicians. By WM. J. WALSHAM, M.D., P.R c.s., Asst. Surg. to, and Dem. of Practical Surg. in, St. Bartholomew's Hospital, Surgeon to Metropolitan Free Hospital, London. With 236 Engravings. See Page a. Cloth, 3.00; Leather, 3.50 URINE, URINARY ORGANS, ETC. Holland. The Urine, and Common Poisons and The Milk. Chemical and Microscopical, for Laboratory Use. Illus- trated. Fourth Edition. I2mo. Interleaved. Cloth, i.oo Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- trations. i2mo. 572 pages. Cloth, 2.75 Marshall and Smith. On the Urine. The Chemical Analysis of the Urine. By John Marshall, M.D., Chemical Laboratory, Univ. of Penna ; and Prof. E. F. Smith, PH.D. Col. Plates. Cloth, i.oo Tyson. On the Urine. A Practical Guide to the Examination of Urine. With Colored Plates and Wood Engravings. 7th Ed. Enlarged, izmo. Cloth, 1.50 Van Niiys, Urine Analysis. Illus. Cloth, 2.00 VENEREAL DISEASES. Hill and Cooper. Student's Manual of Venereal Disease!, with Formulae. Fourth Edition. i2mo. Cloth, i.o e pages 14 and rj for list of .' Qw*-Comj>t*d* t JUST PUBLISHED. GOULD'S NEW MEDICAL DICTIONARY COMPACT. GOiNGISE. PRACTICAL. ACCURATE. COMPREHENSIVE UP TO DATE. It contains Tables of the Arteries, Bacilli, Gan- glia, LeucomaTnes, Micrococci, Muscles, Nerves, Plexuses, Ptomaines, etc., etc., that will be found of great use to the student. Small octavo, 520 pages, Half-Dark Leather, . $3.25 With Thumb Index, Half Morocco, marbled edges, 4.25 From J. M. DACOSTA, M. D., Professor of Practice and Clinical Medicine, Jefferson Medical College, Philadelphia. "I find it an excellent work, doing credit to the learning and discrimination of the author." *** Sample Pages free. 1 University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hilgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which it was borrowed. Biomef DEC 1 4 1994 rf. WQ100 D25lm 1891 )avis, Edward P Manuel of practical obstetrics. MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664