A MANUAL of OBSTETRICS BY JOHN COOKE HIRST, M. D., F. A. C. S. Associate Professor of Gynecology and Obstetrics, Graduate School of Medicine, University of Pennsylvania; Associate in Obstetrics, School of Medicine, University of Pennsylvania; Obstetrician-in-Chief, St. Agnes Hospital; Gynecologist-in-Chief, Mount Sinai Hospital; Obstetrician and Gynecologist to the Philadelphia General Hospital; Consulting Obstetrician to Chambersburg, Pa. Hospital; Consulting Gynecologist to Taylor Hospital, Ridley Park, Pa; Fellow of American College of Surgeons; Fellow of the College of Physicians, Philadelphia. SECOND EDITION, ENTIRELY RESET WITH 229 ILLUSTRATIONS PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1924 Copyright, 1919, by W. B. Saunders Company. Revised, entirely reset, reprinted and recopyrighted September, 1924 Copyright, 1924, by W. B. Saunders Company MADE IN U. S. A. PRESS OF W. H. SAUNDERS COMPANY PHILADELPH 1 A TO THE CLASSES OF THE MEDICAL SCHOOL OF THE UNIVERSITY OF PENNSYLVANIA, PAST PRESENT AND FUTURE, THIS BOOK IS DEDICATED BY THEIR FELLOW-STUDENT, The Author. PREFACE TO THE SECOND EDITION The revision for this edition has been thorough, so much so that the entire book had to be reset. Considerable new matter has been added: notably the sugar tests for early pregnancy; Rubin test for artificial pneumoperito- neum to establish patency or closure of the fallopian tubes in sterility; glucose injections in toxemia of pregnancy; the detailed technic of the Potter method of podalic version; the detailed technic of cesarean section; the Kielland forceps; the newer methods of attempted disinfection of the blood stream in puerperal sepsis; puerperal psychoses; a thorough revision of the repair of lacerations, with presentation of the advantages and disadvantages of delayed and immediate repair; the tests for liver function in toxemia; placenta accreta; anesthesia in labor; and some sixty other additions where new facts or methods claimed proper attention. A new feature is the addition of touch pictures in the various positions of the head involved in forceps deliveries. These pictures show what is felt by the examining finger and just above is shown the corresponding position of the child's head and body in utero. This makes it easier to visualize the posi- tion involved, a condition absolutely necessary to the successful application of forceps. Every effort has been made to bring the Manual up to date, to make it of as much practical value as possible to the busy practitioner and to the medical student, and at the same time keep its size within the limits of greatest usefulness. Academic discussion and unproven theories have, therefore, been omitted or only slightly emphasized; the practical side-the side required in the physician's daily practice-has been given the greater prominence. 7 8 PREFACE TO THE SECOND EDITION It is hoped that in its present form it will justify its claim to be a reasonably complete presentation of the subject, and particularly adapted to the needs of the busy practitioner and student. John Cooke Hirst. 1823 Pine Street, Philadelphia, Pa., September, 1924. PREFACE This book is written as a companion to the author's Manual of Gynecology. It also presents, as far as possible on the printed page, the methods of teaching the subject he has used with satisfaction for the last twenty years. Throughout the book an effort has been made to present the subject clearly and concisely, and to avoid all unprofitable discussion. The methods of treatment and technic of operations advocated have all been tested in practice and have given satisfactory results. The scope of the book has been rather sharply limited. A minimum of embryology has been included. Diseases of the newborn child are included only in so far as they occur during the puerperium. The chapters on lacerations of the birth-canal and consequences of childbirth, while differing somewhat in scope, are necessarily very similar to the same chapters in the Manual of Gynecology. A new classification of deformities of the pelvis is presented, classifying them according to their most prominent deformity. This method has been found easier for the student to remember, and simplifies the discussion of their management. Especial care has been given to the description of the mechanism of labor, with a view to simplifying this, to the student, most puzzling subject. The illustrations in this chapter have been chosen with the idea of enabling him to visualize the different presentations, a thing most essential in the proper application of forceps. The longest chapter is that on the obstetric operations. Especial care has been given to a somewhat extensive descrip- 9 10 PREFACE tion of that most dangerous of all obstetric instruments, the forceps. The different operations are all detailed, with indi- cations, contra-indications and the steps of their performance. The entire subject of obstetric hemorrhage is to be found in one chapter, with precise directions as to management. This book, like the Manual of Gynecology, is presented with the hope that it will be found useful by both medical student and practitioner, whose time for voluminous reading is limited. John Cooke Hirst. CONTENTS CHAPTER I Page Anatomy of the Pelvis and Generative Organs. Congenital Anomalies of the Uterus 17 The Pelvis 17 Development of the Female Sexual Organs 21 Congenital Anomalies of the Uterus 30 CHAPTER II Menstruation. Ovulation. Sterility. Development of the Fetal Appendages. Fetal Characteristics 32 Menstruation 32 Ovulation . . 33 Sterility 37 Transuterine Pneumo-peritoneum 41 Development of the Fetal Appendages 43 CHAPTER III Physiology, Diagnosis, and Differential Diagnosis of Preg- nancy 56 Changes in Maternal Organism 56 The Symptoms of Pregnancy 59 Differential Diagnosis of Pregnancy from Conditions Simu- lating It 65 Methods of Precision in Diagnosis of Pregnancy 67 Management of Normal Pregnancy 75 CHAPTER IV Normal Labor (Eutocia) 78 Management of Normal Labor 80 CHAPTER V Normal Puerpf.rium 103 Management of Puerperium 105 11 12 CONTENTS CHAPTER VI Page Physiology and Management of the New-born Infant . . .114 Physiology of the New-born Infant 114 Management of the New-born Infant 115 CHAPTER VII The Mechanism of Labor 121 Vertex Presentation 125 Face Presentation 135 Brow Presentation 140 Presentation of the Greater Fontanel 143 Breech Presentation 143 Transverse Presentation 149 Mechanism of the Third Stage 153 CHAPTER VIII Diseases of the Ovum and Fetal Appendages. Intra-uterine Diseases of Fetus. Monsters 159 Abnormalities of the Amnion 159 Abnormalities of the Chorion 161 Abnormalities of the Umbilical Cord or Funis 165 Abnormalities of the Placenta 166 Abnormalities and Diseases of Deciduae 167 Diseases of the Fetus in Intra-uterine Life 168 Monsters 172 CHAPTER IX Pathology of Pregnancy 174 Diseases of the Vulva 174 Diseases of the Vagina 176 Diseases of the Cervix .178 Diseases of the Uterus 179 Non-toxic Diseases of the Alimentary Canal 183 Diseases of the Breasts 185 Diseases of the Circulatory System 185 Blood Diseases 187 Infectious Diseases 188 Injuries and Accidents 188 Surgical Operations During Pregnancy 188 Relaxation of the Pelvic Joints 188 Diseases of the Nervous System 188 CONTENTS 13 Page Diseases of the Respiratory System 189 Diseases of the Skin 190 Diseases of the Urinary System 190 The Toxemias of Pregnancy 198 CHAPTER X The Premature Termination oe Pregnancy (Abortion. Mis- carriage. Premature Labor.) Extra-uterine Pregnancy 218 Abortion 218 Extra-uterine Pregnancy......... 223 CHAPTER XI Dystocia 230 Inertia Uteri 230 Dystocia Due to Bony Pelvis 234 Dystocia Due to Maternal Soft Parts 256 Dystocia Due to Fetus and Its Appendages 263 Dystocia Due to Accidents in Labor 271 Dystocia Due to Disease. 275 CHAPTER XII Hemorrhage 277 Classification. . 277 Abortion 277 Placenta Praevia (Unavoidable Hemorrhage) 278 Premature Separation of a Normally Situated Placenta (Abruptio Placentae; Accidental Hemorrhage) 286 Postpartum Hemorrhage 290 Hemorrhage Due to Lacerations of the Birth-canal 295 Puerperal Hemorrhage (after Twenty-four Hours) 296 CHAPTER XIII Injuries oe the Birth-canai 298 Classification 298 Inj'uries to the Pelvis 299 Sprained or Loose Sacro-iliac Joint 299 Fracture of the Coccyx 299 Rupture of the Uterus 300 Lacerations of the Cervix 304 Lacerations of the Anterior Vaginal Wall 310 Tears of Posterior VaginalWall and Perineum 312 14 CONTENTS CHAPTER XIV Page Other Pathologic Sequelae of Child-birth 331 Erosion of the Cervix . . 331 Retrodisplacement of the Uterus 333 Pelvic Inflammation 343 Diastasis of the Recti 344 Floating Kidney 346 Ectopic Kidney 347 Fracture of Coccyx 349 Rectocele 351 Cystocele 351 Prolapse of the Uterus 353 Incontinence of Urine 358 Genital Fistulas 359 CHAPTER XV Diseases of the Puerperium 365 CHAPTER XVI Diseases of the Breasts 375 CHAPTER XVII Puerperal Sepsis 389 Treatment 393 Complications 402 CHAPTER XVIII Pathology of the New-born Infant 416 CHAPTER XIX Obstetric Operations 436 Preparation for, Technic and After-treatment of Obstetric Operations 436 Induction of Abortion 445 Induction of Labor 450 Artificial Dilatation of Parturient Cervix 456 The Forceps 466 Version 486 The Potter Version 489 CONTENTS 15 Page Extraction of the Breech 492 Extraction of the After-coming Head 494 Extraction When the Chin is Anterior 495 Embryotomy 495 Symphyseotomy 5°° Pubiotomy (Hebotomy; Hebosteotomy; Extramedian Sym- physeotomy) 5O1 Anterior Vaginal Hysterotomy (Hysterostomatomy; Vaginal Cesarean Section) 5°4 Cesarean Section 5°8 Index 521 A MANUAL OF OBSTETRICS CHAPTER I ANATOMY OF THE PELVIS AND GENERATIVE ORGANS. CONGENITAL ANOMALIES OF THE UTERUS THE PELVIS The pelvis is the bony ring through which the weight of the body is transmitted to the lower extremities. It is com- posed of four bones-the two innominate bones, the sacrum and the coccyx. The two innominate bones are joined to the sacrum posteriorly, and at the symphysis pubis anteriorly. The joints are very strong, but the sacro-iliac joints possess a certain degree of motion, which is of importance in labor. The anatomy of the pelvis need be considered here from the obstetric point of view only. The female pelvis differs mark- edly from the male, being of importance in childbearing. It is of greater breadth, of less depth, the pelvic inlet is larger, and the pubic arch much wider and lower. The pelvis is divided into two portions called the false and the true pelvis. The false pelvis is that portion lying above the promontory of the sacrum, the top of the symphysis and the ileopectineal line. It is bounded by the lumbar vertebrae, the iliac fossae, and the lower portion of the anterior abdominal wall. It is of little importance from an obstetric standpoint. The true pelvis is that portion of the pelvis lying below the ileopectineal line, or the linea terminalis, as it is called by some authors. It is the portion directly concerned in child- 2 17 18 ANATOMY OF PELVIS AND GENERATIVE ORGANS bearing. Its cavity may be described as an obliquely trun- cated, slightly curved cylinder. This description is not strictly accurate, as the pelvic canal is of different shapes at different levels, and it should be studied at typical points, to gain a correct idea of its size and shape. Pelvic Planes, Their Shapes and Measurements The planes at which the pelvis is studied ordinarily are four in number: Fig. 1.-The normal pelvic inlet, showing the chief diameters of the normal pelvis. (1) The plane of the inlet, or superior strait; (2) The plane of greatest expansion, or pelvic expansion; (3) The plane of greatest contraction, or pelvic contraction, and (4) The plane of the outlet, or inferior strait. THE PELVIS 19 The plane of the inlet or superior strait is bounded by the promontory of the sacrum, the ileopectineal line, and the top of the symphysis pubis. Its shape is cordiform, the promon- tory jutting forward, forming two bays on either side for the reception of the large vessels and nerves, where they are guarded from injury during labor. Its measurements are: a transverse diameter of 13.5 cm., measured at right angles to the conjugate, representing the greatest width; two oblique diameters of 12.75 cm. each, measured from one sacro-iliac junction to the ileopectineal eminence on the opposite side; and an anteroposterior diameter, the so-called true conjugate, of 11 cm., measured from the promontory of the sacrum to the middle of the internal surface of the symphysis inch below its upper edge. The plane of the greatest expansion is bounded by a line passing through the middle of the symphysis, the tops of the acetabula and between the second and third pieces of the sacrum. Its shape is almost circular, its anteroposterior diameter being slightly longer. Its measurements are: an anteroposterior diameter of 12.75 cm- and a transverse diameter of 12.50 cm. both representing the longest distance in either direction. On account of the sacrosciatic notches, it is not possible to take an oblique diameter. The plane of the greatest contraction is bounded by a line passing through the bottom of the symphysis, the spines of the ischium, and the third and fourth pieces of the sacrum. Its shape is elliptical, being 1 cm. longer anteroposteriorly than laterally, and its measurements are: an anteroposterior diameter of 11.50 cm., and a transverse diameter of 10.50 cm. The plane of the outlet, or inferior strait, is bounded by a line drawn through the tip of the coccyx, the tuberosities of the ischia and the lower margin of the pubic arch. Its shape is cordiform, due to the projection forward of the tip of the coccyx. Its measurements are: a transverse diameter of 11 cm. and an anteroposterior diameter of 9.5 cm. This last is not a constant figure, as in labor the coccyx normally swings 20 ANATOMY OF PELVIS AND GENERATIVE ORGANS back as the child's head passes over it, making the actual anteroposterior diameter extend from the tip of the sacrum, a distance of n cm. Pelvic direction means the direction or course of the pelvic canal. This can be expressed by a line drawn paral- lel to the curve of the sacrum, and equidistant at all points Fig. 2.-The planes of the inlet and outlet, with the axes of the pelvis. from the pelvic walls. This definition is not mathematically accurate, but is approximately so. The old formula express- ing the direction of the pelvic canal, known as the "curve of Carus," is very complicated and also inaccurate. Pelvic Inclination.-By this term is understood the angle which the planes of the superior and inferior straits form with the horizon. In the normal pelvis, with the woman in the erect posture, the promontory of the sacrum is about io cm. higher than the upper edge of the symphysis. The normal inclination can be approximated by holding a pelvis in such a way that the anterior superior spines of the ilium and the spines of the ischium are in the same vertical plane. The inclination of the inlet is ordinarily 55 degrees, and that of the outlet 10 degrees. The conjugato-symphyseal angle is the angle formed by the axis of the symphysis and the line representing the true conjugate. It is normally 105 degrees. DEVELOPMENT OF THE FEMALE SEXUAL ORGANS 21 The pelvic ligaments are not of great interest, except the obturator membranes and the sacrosciatic ligaments. The obturator membranes close the obturator foramina, and the sacrosciatic ligaments, closing the large sacrosciatic notches posteriorly, receive pressure from the long diameters of the child's head in labor, and assist in directing the presenting part forward under the symphysis. Pelvic Muscles.-The pelvic cavity is greatly encroached upon by the iliopsoas, obturator internus and pyriformis muscles. They act as cushions during labor, being gradually flattened out and thus protecting the child from injury. The transverse diameter of the pelvis, with the muscles in situ, is 8 cm., instead of 13.5 in the dried specimen. Pelvic floor is composed chiefly of the levator ani, the trans- versus perinei, superficial and deep, the bulbocavernosus, the anterior and posterior triangular ligaments, the coccygeus and the sphincter ani muscles. The levator ani is far the most important. It consists of two halves, passing back from the anterior pelvic wall and encircling the vagina and rectum. It is a muscular band as broad as the first two joints of the index-finger, and is the chief support of the rectum and posterior vaginal wall. The deep transversus perinei muscle is that portion of the levator ani which has a separate sheath and is inserted in the perineal body in the middle line. It lies between the superfi- cial and deep perineal fascias, or triangular ligament. The anterior triangular ligament is an extension of Colles' fascia. The bulbocavernosus lies in the labium majus, keeps the labia in apposition, and prevents gaping of the vulva. DEVELOPMENT OF THE FEMALE SEXUAL ORGANS The development of the genito-urinary system up to a certain point follows the same course in both sexes. It is developed from the Wolffian body, the Wolffian duct and the Mullerian ducts. In the female the Wolffian duct atrophies and the Mullerian ducts form the uterus, tubes and vagina, the 22 ANATOMY OF PELVIS AND GENERATIVE ORGANS ovaries being developed from the Wolffian body. The remains of the Wolffian duct are found in the ducts of Gartner, in the anterior vaginal wall. The anterior portions of the Mullerian ducts coalesce to form the tubes and the upper portion of the uterine body; The posterior portions of the ducts unite to form the lower part of the uterine body, the cervix and the vagina. The female genitalia are divided into (1) external and (2) internal organs. The external organs are: (1) Mons veneris, Fig. 3.-Diagram of the external genitalia. (2) the labia majora and minora, (3) the clitoris, (4) hymen, (5) the vagina, which may be properly included under this head. The internal organs are (1) the uterus, (2) the Fal- lopian tubes, (3) the ovaries. The following is a brief descrip- tion of these organs. The mons veneris is the name given to the fatty cushion resting upon the anterior surface of the symphysis, covered, DEVELOPMENT OF THE FEMALE SEXUAL ORGANS 23 in the adult, with a more or less profuse growth of hair. In the female the area covered by the hair is triangular, its base corresponding to the upper edge of the symphysis. The vulva is the name given to the structures lying beneath the mons veneris. Its direction is usually horizontal, when the woman is erect. It varies greatly in appearance, depend- ing particularly upon whether or not the woman has borne children. The labia majora are two elongated, rounded masses of fatty tissue covered by skin extending down on either side of the vulva. They are usually 7 to 8 cm. in length, 2 to 3 cm. wide and 1 to 1.5 cm. thick, becoming narrower and thinner at their lower extremities. They vary in appearance, depend- ing upon the amount of subcutaneous fat. In virgins and nulliparous women they are in close approximation, while in women who have borne children, they frequently gape widely. They are analogous to the scrotum in the male. The labia minora are two narrow, triangular folds of tissue, seen between the upper part of the labia majora, when these are separated. They converge anteriorly, surrounding the clitoris, while posteriorly they merge gradually into the labia majora. The clitoris is analogous to the penis in the male, but differs in having no corpus spongiosum and no urethra. It consists of a glans, a corpus and two crura, and is rarely more than 2 cm. long. Its glans is enclosed by the upper portion of the two labia minora. The vestibule is the almond-shaped area extending from the clitoris to the fourchet, bounded laterally by the labia minora. The portion between the fourchet and the vaginal opening is called the fossa navicularis, and is usually obliter- ated by childbirth. The vulvovaginal glands, or Bartholin's glands are two compound racemose glands, about the size of a small bean. They are situated under the constrictor vaginae, behind the lower portion of the labia majora. Their ducts, 2 cm. long, open on the sides of the vestibule, just outside of the vaginal 24 ANATOMY OF PELVIS AND GENERATIVE ORGANS opening. They are a frequent lurking place of gonorrhea. They are sometimes called the glands of Duverney, who first described them in the cow. The hymen is the membranous structure which more or less completely occludes the vaginal opening. It presents marked differences of shape and thickness. The most com- mon shape of the hymeneal opening is crescentic or circular. The most important of the other forms are the septate, the cribriform and the fimbriated hymen. It is usually ruptured at the first coitus, the ruptures being multiple and most often in the posterior portion. It is usually destroyed by childbirth, the atrophied remains being known as myrtiform caruncles. Very rarely it is imperforate. It may also persist unruptured after coitus or even child- birth. The vagina is a musculomembra- nous canal extending from the vulva to the uterus. It runs through the pelvic floor, and its walls are normally in close apposition. A cross-section of the vagina resembles the letter H. The vagina is about 8 cm. long anteriorly and io cm. long posteriorly. The shape of the anterior and posterior walls is triangular, the canal being broadest near the cervix. A prominent longitudinal ridge projects from both the anterior and posterior walls, known as the anterior and posterior vaginal columns. From this ridge, in women who have not borne children, extend numerous transverse folds, known as rugse. These disappear after repeated childbirth, and the vaginal walls are then frequently smooth. The vagina is lined by a mucosa composed of Fig. 4.-Section illustrat- ing the characteristic form of the vaginal cleft: Ua, Urethra; Va, vagina; L, levator ani; R, rectum. (Henle.') DEVELOPMENT OF THE FEMALE SEXUAL ORGANS 25 numerous layers of stratified squamous epithelium. The vag- inal mucosa contains no glands. In the embryo the vagina is composed of a solid mass of polygonal cells. The vaginal lumen is formed about the third month of fetal life, by the degeneration of these cells. The Uterus The uterus is a hollow muscular organ, partially covered with peritoneum. It lies in the pelvis, between the bladder and the rectum. Its axis is approximately at right angles to the vagina. It is pear-shaped, slightly flattened antero- posteriorly, and consists of a body and a neck or cervix. The Fig. 5.-Diagram of the uterus and vagina, and the structures of the broad ligament. {Kelly after Cullen.) uterus, in the adult female is about two and one-half inches long and weighs about two ounces. The uterus is composed of an inner epithelial layer, a middle muscular layer and, in its upper two-thirds an outer or peritoneal layer. The inner layer, which lines the cavity, is called the endometrium. It 26 ANATOMY OF PELVIS AND GENERATIVE ORGANS is a thin velvety membrane, i to 2 mm. in thickness, composed of a surface epithelium, a stroma of short spindle-cells, and small tubular glands, lined by columnar epithelium. The surface epithelium is a single layer of ciliated columnar epithelial cells. The stroma contains numerous blood and lymph channels. In the cervix are seen numerous ridges of mucous membrane, radiating from a central ridge, the figure being known as the arbor vita or plica palmata. Fig. 6.-The arteries of the uterus and ovaries: O, A., ovarian artery; b, artery of the round ligament; b', branch to the tube; c, c, c, branches to the ovary; d, continuation of main trunk; e, branch to the cornu; U.A., uterine artery; e, main trunk;/, bifurcation; g, vaginal branches; h, vaginal branch from the cervical artery. (Hyrtl.) The uterine muscle, or the myometrium, is composed of bundles of non-striated muscle fibers, united by connective tissue containing many elastic fibers. The arrangement of these bundles is still a matter of dispute. The uterine blood- vessels are very numerous, and pierce the uterine wall in all directions. DEVELOPMENT OF THE FEMALE SEXUAL ORGANS 27 The ligaments of the uterus are ten in number, viz.: 2 broad, 2 round, 2 uterosacral, 2 uterovesical and 2 cardinal. In the bases of the broad ligaments are two bands of dense connective tissue which are regarded as ligaments of the uterus-the cardinal ligaments. They are attached to the supravaginal portion of the cervix. The uterine ligaments are partly suspensory and partly act as guy ropes. The blood-vessels of the uterus are the uterine and ova- rian arteries, which anastomose and send numerous branches to the uterus. There is quite free communication between the Fig. 7.-Heavy black lines indicate reflection of peritoneum. Note the difference in the anterior and posterior uterine reduplication. vessels on the two sides of the uterus. The veins form large plexus around each uterine artery, form the uterine veins and empty into the hypogastric. The return blood from the ovary and upper part of the broad ligament is collected by veins which form a large plexus--the pampiniform plexus. The vessels from this form the ovarian veins and the ovarian veins empty, the left into the renal, the right into the vena cava. The Lymphatics of the Uterus.-The lymphatics of the uterus terminate in different glands. Those from the cervix 28 ANATOMY OF PELVIS AND GENERATIVE ORGANS empty into the hypogastric glands; those from the uterus into the deep lumbar glands, situated in front of the aorta, about the level of the kidney. The nerves of the uterus are derived partly from the third and fourth sacral nerves, but chiefly from the sympathetic system. The Fallopian Tubes The Fallopian tubes are two convoluted muscular canals extending from the uterine cornua through the upper portion of the broad ligaments. They are 12 to 14 cm. long, the left being slightly the longer. They are divided into the uterine portion, extending from the cornu to the upper angle of the uterine cavity; the isthmus, the narrow portion of the Fig. 8.-Diagram of the tube, ovary and broad ligament, and their structure. {After Stewart.) tube adjoining the uterus; the ampulla, or wider portion of the tube, and the fimbriated extremity or abdominal opening. These fimbriae are exuberant folds of the lining mucous mem- brane, and one of them-the ovarian fimbria-extends nearly or quite to the ovary. The tube is composed of an inner mucous, a middle muscular and an outer peritoneal layer. The lining mucous membrane is composed of a single layer of high columnar ciliated cells, resting upon a thin basement membrane. There is no sub- mucosa. The muscosa is arranged in folds which vary from a comparatively simple arrangement near the uterus to an DEVELOPMENT OF THE FEMALE SEXUAL ORGANS 29 extraordinarily complex one near the abdominal end. The cilia lash toward the uterine cavity. The muscular coat is composed of two layers of non-striated muscle, an inner circular and an outer longitudinal one. Some of the inner fibers run longitudially also. The caliber of the tube varies from the uterine end, which will admit a bristle, to the ampulla which admits a fine probe. The Ovaries The ovaries are two almond-shaped organs, slightly flat- tened, lying against a small depression in the posterior sur- face of the broad ligament, and attached to the ligament by the mestruarium. The ovary is of a mother-of-pearl color, 5 cm. long, 3 cm. broad and 1.5 cm. thick, weighing about 8 grams. The hilum of the ovary is that portion of the margin to which is attached the mesovarium. The external appearance of the ovary varies with the age of the woman. In young women its surface resembles mother- of-pearl, through which show a number of small vesicles- the graafian follicles. In older women the ovary is rough and corrugated, and it atrophies rapidly after the menopause. The ovary is divided into the medulla or central portion, which contains the blood-vessels, and the cortex, which con- tains the mature and immature follicles. An ordinary graafian follicle is a connective-tissue space in the cortex, containing a highly specialized cell-the ovum- and surrounded by a wreath of capillary blood-vessels. A mature graafian follicle consists of a connective-tissue covering-the theca folliculi; an epithelial lining-the mem- brana granulosa; the liquor folliculi and the ovum. The ripening of the graafian follicle will be discussed in the next chapter. The Corpus Luteum.--The ripe follicle ruptures through the stigma, which is a necrotic spot in the follicular wall, at 30 ANATOMY OF PELVIS AND GENERATIVE ORGANS its most prominent' part, usually opposite the ovum. The ovum, the discus proligerus (the heaped-up portion of the membrana granulosa, in which the ovum is embedded) and the liquor folliculi are discharged. The walls of the follicle collapse into folds, like a fan, and the point of rupture heals rapidly. The cavity, due to the activity of the lutein cells or fibroblasts, is filled in with connective tissue rich in blood- vessels. This structure is known as the corpus luteum. The connective tissue is gradually absorbed, till about a month after the rupture of the follicle nothing is left but a small scar on the surface of the ovary. The corpus luteum of pregnancy is an exaggeration of the corpus luteum of menstruation. It is much larger, occupying sometimes one-third of the ovary, and is visible throughout the entire pregnancy, being largest at the third month. The blood-supply of the ovary is derived chiefly from the ovarian artery. THE CONGENITAL ANOMALIES OF THE UTERUS The uterus, as has been said, develops from the perfect fusion of the two Mullerian ducts. Sometimes these ducts fail to unite, and from this failure result the various forms of congenital deformities of the uterus. They vary from almost complete absence of the uterus to the actual duplication of the uterus and vagina. The various deformities are: 1. Uterus didelphys, or duplex, resulting from a complete failure of fusion, and usually accompanied by double vagina. 2. Uterus unicornis, due to the development of one Mul- lerian duct and the atrophy of the other. 3. Uterus bicomis unicollis, a uterus with one cervix and two bodies, each with one tube and ovary. 4. Uterus cordiformis, presenting the conventional heart- shape. 5. Uterus incudiformis, or anvil-shaped uterus. THE CONGENITAL ANOMALIES OF THE UTERUS 31 6. Uterus septus, subseptus or biforis; various deformities of the uterine cavity, due to junction of the ducts but imper- fect union of the canals. Effect upon Pregnancy.-i. May proceed normally to term. 2. Frequently simulates extra-uterine pregnancy, if in rudimentary horn of a double uterus or in a uterus unicornis. 3. Abortion, due to failure of the uterus to enlarge. 4. Rupture of uterus. The three latter are the chief dangers of pregnancy in con- genital deformities. The pregnancy may go to term, which is the rule in the minor grades of deformity. Effect upon Labor.-The deformity most likely to cause trouble in labor is the double uterus, and the following are the chief dangers: 1. Obstruction to labor by the non-pregnant half. 2. Rupture of the uterus. 3. Inertia uteri. 4. Postpartum hemorrhage. 5. Putrefaction of decidua in the non-pregnant half, and consequent septic infection. Diagnosis can usually be made by careful bimanual exami- nation, under an anesthetic if necessary, but many cases are overlooked, as spontaneous labor occurs in the majority of cases. Treatment is inaction, unless the symptoms simulate extra- uterine pregnancy. This is not likely except in uterus uni- cornis or pregnancy in a rudimentary horn of a double uterus. In such a case the treatment is the same as for extra-uterine pregnancy-immediate laparotomy and removal of the gesta- tion sac. CHAPTER II MENSTRUATION. OVULATION. STERILITY. DE- VELOPMENT OF THE FETAL APPENDAGES. FETAL CHARACTERISTICS MENSTRUATION Menstruation is the name given to the periodic bloody discharge from the genitalia of women, occurring on an average of once in 28 days, during the period of their sexual activity; from about the fifteenth to the forty-fifth year. Cause.-The cause of menstruation is most obscure, depend- ing upon some nervous influence from the sympathetic nervous system, which causes a periodic congestion of the genital organs. Mechanism.-The anatomic changes in the genital organs during menstruation are well understood. The endometrium, about five days before the period, begins to swell, until at the time of the discharge, it is about 8 mm. thick, brownish- red and very soft. It is filled with delicate new-formed capil- laries. The bleeding occurs mainly by a diapedesis through the walls of these capillaries, and the escape of the blood between the cells of the surface epithelium, with very little or no destruction of tissue. The surface epithelium is not as a rule thrown off. The regeneration of the endometrium after the period takes about seven days. The so-called menstrual cycle of the endometrium is five days' preliminary swelling, four days of the period, seven days' regeneration and twelve days of quiescence. Time of Appearance and Cessation.-In this climate men- struation appears usually at the age of 14 to 15 years. The time of appearance is influenced by climate, mode of life, etc. 32 OVULATION 33 The warmer the climate, the earlier the onset of menstruation. It is not infrequent to observe a bloody discharge, simulating menstruation, from the genitalia of female infants. Precocious menstruation in very young children is not very uncommon, and is usually associated with precocious sexual development. Cessation or the Menopause.-The menses cease ordinarily about the forty-fifth year. Exceptions to this rule are fre- quent. They sometimes cease as early as the twenty-fifth year, and persist sometimes well into the fifties, and, rarely, even later. The interval between periods is usually 28 days. This varies greatly, and wide variations from the rule are not inconsistent with good health. The menstrual molimina is the name given to the local and reflex symptoms during menstruation-enlargement of the breasts, pain in breasts, headache, dizziness, backache, etc. The duration of the flow is normally three to five days. This again varies widely, many women menstruating for only two days and others for seven or more, and remaining perfectly healthy. The Character of the Flow.-The menstrual discharge comes mainly from the uterine mucous membrane and in slight part from the tubes. It is composed of blood, mucus, and epithelial cells. It is dark in color, alkaline, has a distinct odor, like marigold, due to the secretions of the sebaceous glands at the vaginal outlet, and should not clot. The amount of the flow has been estimated at from 4 to 6 ounces. Practically it is measured by the number of napkins needed for adequate protection. If more than three a day are required, during the height of the flow, the quantity is excessive. OVULATION Ovulation means the rupture of the ripe graafian follicle and the extrusion of the ovum. As the follicle ripens it retreats deeper into the ovary, along the line of least resistance. Dur- 3 34 MENSTRUATION, OVULATION, STERILITY ing the period of menstrual congestion, the follicle rapidly secretes liquor folliculi and projects like a blister from the surface of the ovary. It ruptures through the stigma, a necrotic spot in the follicle wall, usually opposite the ovum, and the ovum, discus proligerus, and liquor folliculi are extruded. The Connection between Menstruation and Ovulation.-In the majority of women menstruation and ovulation are prac- tically synchronous. They are not necessarily so, however, and either can occur independently of the other. The maturation of the ovum, or ripening, is the name given to the change in the ovum, more especially in the nucleus, by which it is prepared for fertilization. Only a brief outline can be given here. The changes are supposed to begin shortly before the follicle ruptures and to be completed during the journey of the ovum through the tube. The germinal vesicle gradually approaches the surface of the ovum, loses its membrane, and is, in a short time, trans- formed into a typical karyokinetic figure. This figure, by the usual changes, becomes spindle-shaped, and lies perpendicular to the surface of the ovum. The chromatin of the spindle is arranged in two star-shaped figures (the amphiaster stage) and extrudes portions of its substance in the form of small globules--the polar globules-usually two in number. These globules are cast off and disappear; the nucleus retreats into the interior of the ovum, and becomes the female pronucleus. The cause of these changes is not known. Their failure to occur is one of the accepted theories of the origin of dermoid cysts, it being supposed that the polar globules may unite with the female pronucleus and allow an imperfect degree of fetal development. The migration of the ovum is the method by which the ovum gains access to the tube and then to the uterine cavity. The cilia of the cells upon the fimbriated extremity of the tube lash toward the lumen of the tube, and cause a slight current in the thin layer of fluid lying between the pelvic organs. The OVULATION 35 ovum, when discharged, is taken up by this current, and wafted into the tube, and along the tube to the uterine cavity. The ovum is usually carried.in to the tube corresponding to the ovary from which it was discharged, but it may be carried into the opposite tube. (External transmigration of the ovum.) The seminal fluid containing the spermatozoa, is deposited during coitus in the vagina, in the so-called seminal lake be- hind and below the cervix. The seminal fluid is a yellowish- white, thick fluid, derived from the testicles, prostate and Cowper's glands. The quantity at each ejaculation is one to two drams. It contains water, phosphates, fats, spermatin and spermatozoa. The number of spermatozoa have been variously estimated from 6,500,000 to 226,000,000 to an ejaculation. The former number seems the more reasonable. The spermatozoa are about %oo °f an inch long, consist of a head, body and tail, and have extremely active motion. They are said to be able to travel one inch in seven and one- half minutes, and have, under favorable circumstances, re- markable vitality, having been found alive in the cervical canal of a woman eight days after copulation. They appear in the spermatic fluid about the fifteenth year of life and ordinarily disappear about the sixty-fifth year. The Reception of Spermatozoa into the Uterus.- It has been found that the uterus of animals, under electric stimulation of the sexual organs, descends into the pelvis, grows shorter but broader, thereby causing the os uteri to open. The uterus, when the stimulation was removed, returned to normal and the os closed. It is supposed that these changes result in causing the uterus to exert a sucking action, and to suck the seminal fluid directly into the uterine canal. It frequently happens that spermatozoa, deposited in the vagina or even upon the external genitalia, make their way, by their own mobility, into the uterus, and conception results. The meeting place of the spermatozoon and the ovum is generally accepted to be in the tube, at about the junction 36 MENSTRUATION, OVULATION, STERILITY of its middle and outer third. Only rarely does conception occur in the uterus itself, though it is possible at any point from the peritoneum to the internal os. Fertilization of the Ovum.-When the spermatozoon meets the ovum, its head penetrates the cell and the tail disappears. The head then becomes the male pronucleus, taking the place of the polar bodies cast off in the ripening of the ovum; fuses with the female pronucleus, and the development of the embryo is begun. The average date of conception is following the first men- strual period after marriage. A marriage is not considered sterile until eighteen months have passed without concep- tion, although women have not infrequently become pregnant after many years of apparent sterility. Early Changes in the Development of the Ovum.-The segmentation nucleus of the ovum, formed by the fusion of the female pronucleus and the head of the spermatozoon is converted, by karyokinetic changes, into a di-aster. The ovum is then divided into two cells; each of these divided into two, and so on until the ovum is a mass of cells; the so-called morula or mulberry mass. Fluid then appears in the mass, and forces the cells out toward the periphery, transforming the ovum into a vesicular structure, with a single layer of cells sur- rounding a central cavity filled with fluid-the blastodermic vesicle or blastula. At one pole of the blastula the cells are concentrated into a flattened disc called the blastoderm or embryonic area. This consists of two kinds of elements, form- ing two distinct layers under the outer layer of cells. These two layers are known respectively as the ectoderm and entoderm, the ectoderm being the outer. The embryonic area becomes slightly elevated and forms an opaque zone known as the em- bryonic shield. In the middle of this shield appears the primi- tive streak, which in section is found to be a cord of cells in which offshoots from the ectoderm and entoderm fuse, and from the junction of which there extends on either side a third layer-the mesoderm. STERILITY 37 As the mesoderm develops, it parts into two layers-the parietal and visceral layers-enclosing the celom or body cavity. The parietal layer unites with the ectoderm to form the somatopleura, from which is developed the lateral and anterior abdominal walls. The inner or visceral layer unites with the entoderm to form the splanchnopleura, from which is developed the digestive tract and its associated organs. The development of the embryo proper begins at the end of the second week. STERILITY In at least 40 per cent, of cases the fault lies with the male. In the female, the commonest causes are: (1) anteflexion Fig. 9.-Anteflexion of the uterus, usually associated with stenosis of the cervical canal, and infantile development. One of the commonest causes of sterility. and stenosis; (2) pelvic inflammation-endometritis or sal- pingitis; (3) retroversion of the uterus; (4) acquired stenosis of the cervix-the so-called one-child sterility-and (5) congenital lack of development or atresia of cervix, vagina or hymen, and psychic causes like vaginismus. It is not always possible to determine a cause upon examination. 38 MENSTRUATION, OVULATION, STERILITY Treatment.-Before any treatment of the wife is instituted, the husband should be examined to determine his power of procreation. Obvious physical vigor does not necessarily Fig. io.-Instruments for maintaining dilatation of the cervical canal, i. Sponge tent, expanding by the absorption of moisture. Impossible properly to sterilize. 2 Tupelo tent of porous wood. Open to same objection. 3. Stem pessary of hard rubber. 4. Wylie drain. 5. Schatz's two-bladed metranoikter. 6. B. C. Hirst's four-bladed modification of the Schatz. mean power to procreate. If the husband is pronounced capable, the patency of the wife's fallopian tubes must be STERILITY 39 tested by the Rubin method of transuterine pneumo-peri- toneum. Until this method, devised by I. C. Rubin, was presented, the only way of determining the patency of the tubes was the radical one of abdominal section and direct inspection. The apparatus consists of a pulsating meter connected with a mercury manometer. Attached to the outflow tube of the meter is a small cannula, provided with a rubber cork, to close the cervix securely. The test can be made without anesthesia, as a routine office procedure. Essentials of Safety.-(i) Any acute or sub-acute inflamma- tory pelvic precess must be definitely excluded; (2) The cannula and outlet tube of the meter-the only apparatus handled by the operator-must be boiled. Technic.-(1) The apparatus is set up as illustrated in Fig. 11. (2) The patient is arranged in the lithotomy position, and the cervix exposed through a bivalve speculum. (3) The cervix is carefully sponged off with lysol solu- tion, dried and painted with 7 per cent, tincture of iodine. (4) The gas is now turned on, at such a rate that four pulsations of the meter per minute are registered. At this rate, if the outlet tube is occluded, the mercury column in the manometer will take 15-20 seconds to record a pressure of 100 mm. A faster flow than this is undesirable. (5) The cannula is inserted in the cervix and the rubber cork held tight against the external os. (6) The manometer is watched and its rise recorded. (7) In normally patent tubes the column rises to about 80-100 mm., falls sharply to 40 or 50 and fluctuates there as long as the cannula is held in place. If the tubes are stenosed but not entirely non-patent the column will rise to 140 or 150 and then fall slightly and fluctuate at about that level. If the tubes are non-patent, the column rises steadily to 200 mm., beyond which point it is not wise to carry the test. Frequently the column will rise to 140 or 150, then suddenly fall, as though some substance had been blown out of the tube 40 MENSTRUATION, OVULATION, STERILITY and it's lumen cleared. Subsequent tests will show that the mercury will not again reach as high a level. Non-patency of the tubes cannot be established definitely in less than three tests, preferably at intervals, on different days. (8) The cannula is withdrawn and the speculum removed. Many modifications of this test have been presented, but none are as satisfactory as the original. Gas Used.-If only enough gas is to be used to establish patency, oxygen is satisfactory, and is furnished in low pres- sure cylinders that do not require a reducing valve. If large amounts of gas are to be introduced, carbon dioxide is better, because of its very rapid absorption. Auscultation of Tubes.-It is possible, by applying a stetho- scope over the lower abdomen, to hear the gas bubble through the fallopian tubes. By this method, it can be established that one is patent and the other non-patent. About 42 per cent, of the patients examined for sterility will be found to have non-patent tubes. Reactions.-(1) Pain.- This is not felt in the pelvis, but under the right scapula, when the patient sits or stands. The gas rises and finally collects between the liver and dia- phragm and by pushing the liver downward, pulls upon the falsiform ligament. The pain is never severe and is of short duration, especially if carbon dioxide is used. The presence of the gas may plainly be shown by x-ray plate or fluoroscope. (2) Infection is very unlikely except from poor technic or the use of the test in the presence of an existing infection. Air embolus is not to be feared. X-ray of the Pelvic Organs.-A very satisfactory plate of the pelvic organs may be secured by introducing 600 to 800 c.c. of oxygen and taking the plate with the patient in the Trende- lenburg position. Carbon dioxide is not suitable for this because it is absorbed too quickly. As each pulsation of the meter records the passage of 40 c.c. of gas, the quantity intro- duced can be accurately measured. STERILITY 41 Pregnancy after the Rubin Test.-A fairly accurate prog- nosis can be given of likely or unlikely pregnancy after this test, depending upon whether the tubes are found normal, ste- nosed or presumably non-patent. Pregnancy not infrequently Fig. ii.-The Rubin apparatus for artificial transuterine pneumo- peritoneum, to test the patency of the fallopian tubes. occurs soon after the test, before any other treatment could have much chance of effect. If the tubes are found non- patent, and are opened in the course of a subsequent abdominal section, the Rubin method offers valuable aid in maintaining patency. It can be applied as early as ten days after the operation. In all cases, pregnancy must be excluded before any intra-uterine manipulation is considered. 42 MENSTRUATION, OVULATION, STERILITY If the tubes are found non-patent, treatment will be of no avail. If the tubes are found stenosed, inaction is the best policy; any intrauterine manipulation is likely to cause suffi- cient local reaction to complete their closure. If the tubes are patent, it is best to dilate the cervical canal by Hegar's solid bougies, to overcome any stenosis. These dilators are better than the branched ones, for this purpose, as they cause less traumatism. Very little curettage is done-only at each cornu. Excessive or frequently repeated curettage brings about a superinvolution of the uterus which may render the sterility incurable. Unless some means is taken to maintain the dilatation, it is rarely efficient. A stem pessary is dangerous and liable to be followed by infection; the same may be said of the Wylie drain-an aluminum or hard rubber plug worn in the uterus for several weeks following the dilatation; the Schatz metranoikter-preferably the four-bladed modification of B. C. Hirst, further modified by van Dolsen, is the safest pro- cedure. This is left in place for twenty-four hours, is then removed and the uterus washed out. Cases of atresia are managed by the proper restoration of the patency of the canal; retroversion-if not adherent-may be remedied by a pessary or Fig. 12.-van Dolsen's modification of the metranoikter. DEVELOPMENT OF THE FETAL APPENDAGES 43 operation. Salpingitis requires abdominal or vaginal section to inspect and restore the patency of the fallopian tubes-a pro- cedure of doubtful efficiency. Lack of development-the so-called infantile uterus-requires dilatation without curet- tage, electrical stimulation by the galvanic, rapid faradic and sinusoidal current, and hypodermic injections-intramuscu- larly-of i mil corpus luteum extract, given daily in series of 12 doses, with an interval of two to three weeks between series. In sterility associated with obesity-the so-called dystro- phia adiposogenitalis-it is advisable to use hypodermics of i mil of soluble extract corpus luteum, given daily in series of 24 doses, with an interval of two or three months between series, and a tablet desiccated thyroid 2 grains, desiccated ovarian residue 2 grains, desiccated whole pituitary gland 1 grain, desiccated suprarenal gland 1 grain-given as one tablet four times daily for 2 months at a time. Electrical intra-uterine treatment is not without risk; any lapse in asepsis is likely to be followed by severe pelvic perito- nitis and permanent sterility, so the method must be employed with due regard to this danger. Sterility of long standing is sometimes relieved, spontane- ously and without treatment. Many patients never conceive, though no reason for their sterilty can be found. Artificial insemination is rarely successful and is not free from danger of infection. DEVELOPMENT OF THE FETAL APPENDAGES The Amnion, Chorion, Placenta, Umbilical Cord and Deciduae The amnion is developed from the somatopleura, the ecto- derm sending two reduplications backward, one from each side, over the dorsum of the embryo. These reduplications meet and fuse. Thus two cavities are formed-one within the fused membranes or the true amnion-the other, between the membranes and the outer covering of the embryo, or the 44 MENSTRUATION, OVULATION, STERILITY false amnion. The amnion consists of a layer of young connective tissue, covered, on its inner surface, with a single layer of flat endothelial cells. It forms at term the lining of the fetal surface of the placenta, the sheath of the umbilical cord and the inner layer of the membranes. Functions of the amnion Fig. 13.-Diagram showing completion of the amnion and formation of the chorion. {Dorland.) A, amnion; i, zona pellucida; 2, outer lamina of the epiblast after closure of the amniotic folds; P, allantois; U, umbilical vesicle. are: (i) To act as a covering of the child; (2) to furnish and contain the liquor amnii; (3) as a cushion to protect the child from shocks; (4) to dilate the cervix in labor. The liquor amnii is a slightly turbid, alkaline fluid, specific gravity 1010, and containing urea, albumen, sebaceous matter, lanugo, squamous epithelium, ammonium carbonate and uri- nary salts. It is greatest in amount at the sixth month of pregnancy-about 3 pints; at term the average amount is one and one-half pints. It is derived partly from the mother, and partly, by excretion of urine, from the fetus. The Chorion.-The formation of the chorion is probably one of the earliest changes that the human ovum undergoes. It is developed from the cell-wall of the ovum, and at first consists of two layers: an inner, thin layer of fine connective tissue and an outer composed of many layers of epithelial DEVELOPMENT OF THE FETAL APPENDAGES 45 cells-the trophoblast. When the ovum reaches the uterine cavity, and is embedded in the decidua, the chorion sends out many fine finger-like processes, called chorion villi. They are composed of a finger-like process of mucoid connective tissue, covered by two layers of cells. The inner layer is called the Langhans' layer and the outer, a band of protoplasm without marked cell divisions, and the nuclei running parallel Fig. 14.-Diagram of chorion villus. Fig. 15.-Six weeks' ovum, showing the chorion frondosum and chorion laeve. (De Lee.) to the surface, is known as the syncytium, and is instrumental later in starting the placental circulation. That part of the chorion in contact with the decidua serotina retains its villi, which later form the placenta, and is known as the chorion frondosum. The rest of the chorion loses its villi, fuses with the amnion and decidua reflexa to form the membranes, and is known as the chorion loeve. Until the third month, the villi of the chorion derive nutriment from the whole decidua serotina and reflexa; after the third month, from the serotina only. Each villus contains a loop of capillaries, derived from the vessels of the allantois. 46 MENSTRUATION, OVULATION, STERILITY The Placenta.-The ovum is attached to the decidua cover- ing the anterior or posterior wall of the uterus, usually near the fundus. About the sixth week of pregnancy the blood supply of the decidua serotina becomes more and more abun- dant, while that of the reflexa is diminished. Hence, the Fig. 16.-Normal placenta (maternal surface). (De Lee.) chorionic villi in relation with the serotina, receiving all the nourishment they need, begin to proliferate rapidly. Many of the villi penetrate deeply into the decidua. From these later, outgrowths or buds of syncytium are sent out, which open the maternal blood-channels in the decidua, so that blood is poured out around the villi; the blood is taken up by the villi, by a process of osmosis, and is carried by the capillaries in the villus, to the fetus. The placenta begins to functionate about the third month of pregnancy. DEVELOPMENT OF THE FETAL APPENDAGES 47 The Placenta at Full Term.-The placenta at term is a flattened circular organ about seven inches in diameter, one Fig. 17.-Normal placenta (fetal surface). (De Lee.) inch thick and weighing about one pound. The maternal surface, which was in contact with the decidua serotina, pre- sents a ragged, torn appearance, and is divided by depressions 48 MENSTRUATION, OVULATION, STERILITY into a number of parts, or cotyledons. The fetal surface is smooth and glistening, covered by amnion, and a mass of large, distended interlacing blood-vessels. The umbilical cord is inserted usually near, but not at, the center of the fetal surface. The membranes hang like a veil from the periphery of the placenta and are com- posed, as has been said, of the amnion, the chorion laeve, and the decidua re- flexa. The circular sinus of the placenta is the name given to a large vein which often skirts a considerable portion of the periphery of the placenta, rarely com- pletely encircling it. The Umbilical Cord or Funis.-About the twentieth day of pregnancy, there occurs a sac-like projection of the posterior end of the intestinal tract. This pro- jection grows outward until it reaches the periphery of the ovum, and contains bloodvessels. Within the allantois these vessels are reduced in number to two arteries and a vein. The arteries convey venous blood from the fetus to the mother; the vein arterial from the mother to the fetus. The vessels are embedded in a gelatinous substance called the jelly of Wharton. The Cord at Term.-The umbilical cord at term is about twenty inches long, one-half inch thick, and has a dull white moist appearance. In structure it may be roughly compared to a candle with two pieces of string wound around it. The wax of the candle represents the jelly of Wharton, the wick the umbilical vein and the pieces of string the umbilical arteries. The arteries are twisted eight to ten times around the cord, U.S. U.V U.A. Fig. 18.-Diagram of umbilical cord in cross-section. U.V., umbilical vein; U.A., umbilical arteries; U.S., remnant of umbilical stalk. DEVELOPMENT OF THE FETAL APPENDAGES 49 from right to left. The narrowest portion of the cord is usually at a point about two inches from the umbilicus of the child. The Decidua.-The decidua is the name given to the mucous membrane of the uterus, when it has undergone the changes dependent upon pregnancy. These changes begin very shortly after the fertilization of the ovum, although the exact time is uncertain. The endometrium becomes very much thickened, and its surface marked by deep furrows, giving it a very rough appearance. It is thickest about the fourth month of preg- nancy. From that time until term it gradually atrophies, except at the placental site. The stroma cells hypertrophy until they attain eight or ten times their original size. Microscopic Appearance.-Under the microscope the decidua is seen to be composed of two layers; a compact layer, made up of the hypertrophied stroma cells of the endometrium; and a spongy layer, containing the dilated uterine glands. The cells of the compact layer are round, oval or sometimes polygonal; epithelioid in type with large vesicular nuclei. The ducts of the uterine glands, in the early stage of the formation of decidua, are seen running through the compact layer to the surface, but these ducts finally disappear, and in the later months, no trace of them can be seen. The glands of the spongy layer are at first lined with the cylindrical epithe- lium typical of the uterine glands This gradually becomes cuboidal and a great part of it is cast off into the lumen of the gland and lost. A certain amount remains intact, and from it the endometrium is regenerated during the puerperium. The decidua is very richly supplied with blood, especially in the deeper layers. According to the functions of the decidua, it is usually considered under three heads: the decidua ver a, the decidua redexa, and the decidua serotina. The decidua vera is the name given to all the decidua lining the uterine cavity, except that portion to which the ovum is attached, and the portion reflected over the ovum. Its struc- ture has been described above. It atrophies after the fourth 4 50 MENSTRUATION, OVULATION, STERILITY or fifth month of pregnancy, so that at term it is only about 2 to 3 mm. thick. When the impregnated ovum enters the uterine cavity, it drops into one of the deep furrows in the decidua, usually near the fundus on the anterior or posterior Fig. 19.-Cross-section of uterus at the end of seventh week of preg- nancy, showing the relation of the decidua and other fetal structures. (Modified from Allen Thomson.) wall. It is covered in by the arching over of the sides of the furrow, and their agglutination. As the ovum develops, the decidua covering it is pushed out into the uterine cavity, forming a kind of capsule for the growing ovum, and is known as the decidua rejlexa. This portion of the decidua is greatest in amount at about the second month of pregnancy. About the fourth month, the decidua reflexa is brought, by the growth of the ovum, into intimate contact with the vera, fuses with it, and gradually degenerates and disappears. This FETUS AT DIFFERENT MONTHS 51 is the most widely accepted theory, but some observers, notably Peters, in describing what he believed represented a three days' human ovum, and Selenka, in his studies of monkeys, state that the ovum actually penetrates the surface epithelium and burrows down into the decidua vera. They claim that the decidua reflexa is merely that portion of the vera which covers the ovum and undergoes passive enlarge- ment as the ovum grows. The point is, however, still under discussion. The decidua serotina is the portion of the decidua lying imme- diately beneath the ovum, and which represents the placental site. It is often called placental decidua. It is the portion of the decidua richest in blood-vessels, which are very numerous, usually run a spiral course, and penetrate the entire thickness of the membrane. The placenta is attached to this portion of the decidua. During the third stage of labor, when the pla- centa is separated from the uterine wall, the line of separa- tion is usually between compact and spongy layers. The com- pact layer is cast off, adhering to the maternal surface of the placenta; from the spongy layer the endometrium is regener- ated during puerperium. THE FETUS AT DIFFERENT MONTHS IN ITS DEVELOPMENTS It is not intended to take up the characteristics of the embryo and fetus at each month of its development, but merely to consider briefly the more important points. First Month.-During the first two weeks the embryo con- sists largely of the yolk-sac. The embryonal period begins with the third week when the embryo is divided into head, body and tail. About the twenty-first day the limbs make their appearance as small buds. In the fourth week the em- bryo increases greatly in size, its head and tail are almost in contact, and its back markedly arched. It is about one-half an inch in length. 52 MENSTRUATION, OVULATION, STERILITY Third Month.-The embryo is about three and a half to four inches in length, and weighs about an ounce. Centers of ossification are found in the bones. The fingers and toes lose their web and become differentiated. The trunk is divided into thorax and abdomen by the appearance of the ribs. The sex is distinguishable by the presence or absence of a uterus, and the placenta commences its functions. Sixth Month.-The fetus is about twelve inches long and weighs one and one-half pounds. The subcutaneous fat is being developed and the skin beginning to lose its wrinkled appearance. The head is relatively very large. If born at this time it may live one to fifteen days. Seventh Month.-The fetus is fifteen inches long and weighs forty-one ounces. The body is covered with lanugo, and the pupillary membrane disappears. If born at this time, it may survive, but more often dies The old Hippocratean doc- trine, still generally believed among the laity, that a child born at the seventh month has a better chance of surviving than one born at the eighth, is erroneous. Eighth Month.-The fetus is sixteen inches long and weighs three and a half pounds. Of children born at this time 40 to 75 per cent, are saved. Ninth Month.-The fetus is eighteen inches long and weighs about four and one-half pounds. If born, will certainly live, if given ordinary care. These figures are based upon a duration of pregnancy of 40 weeks or 10 lunar months. The fetal circulation differs from the ordinary circulation in several important points. The blood is carried through the umbilical vein to the umbilicus, thence along the anterior abdominal wall to the outer surface of the liver. Here the vein divides into two, the larger emptying into the portal vein; the smaller, called the ductus venosus, into the ascending cava. From the ascending cava the blood goes to the right auricle. As the lungs are not functioning, the bulk of the blood passes into the left auricle, directed by the Eustachian valve through THE MATURE FETUS 53 the foramen ovale, an opening in the interauricular septum. From the left auricle it goes to the left ventricle and thence into the aorta, and thence primarily to the upper extremity of the fetus. As the lungs need only sufficient blood for their nutri- tion, an outlet is provided for the excess entering the right auricle and ventricle from the descending vena cava in the ductus arteriosus, a large branch opening into the aorta from the pulmonary artery. The aorta thus conveys mixed blood to the trunk and lower extremities. From each internal iliac a vessel, known as the hypogastric artery, ascends to the umbili- cus. These vessels become the umbilical arteries in the cord, and return the blood to the mother for oxygenation. THE MATURE FETUS The characteristics of the mature fetus are briefly: 1. Weight, 7 to 7.5 pounds. The weight of full-term chil- dren varies from an extreme of one pound to one of twenty- eight and three-quarters pounds, this latter being the child of the "Nova Scotia Giantess." Anything over twelve pounds is very rare. 2. Length, twenty inches. 3. Face plump and rosy and subcutaneous fat well de- veloped. 4. Languo disappeared. 5. Ver nix caseosa is abundant only on the flexor surface of the limbs and the back. 6. Finger-nails project beyond ends of fingers. 7. Bones of head are firm. 8. Child moves and cries vigorously. HEAD MEASUREMENTS Bitemporal . 8.0 cm. (315 in-) Biparietal • 9-5 cm. ( 3 64 in.) Occipitomental • 130 cm. (5-i2 in.) Occipitofrontal . n.75 cm. (4-56 in.) Trachelobregmatic • 9-5 cm. (3-74 in.) Suboccipitobregmatic • 9-5 cm. (3-74 in.) Circumference (occipitofrontal).. • 34-5 cm. (i3-5 in.) 54 MENSTRUATION, OVULATION, STERILITY The Centers of Ossification.-In the mature fetus the center of ossification in the lower epiphysis of the femur is 5 mm. in diameter. That in the upper epiphysis of the tibia is just appearing. In the humerus they do not appear for several months after birth. Fig. 20.-Child's head at term and diameters. The predetermination of sex is not possible. Various methods of controlling the sexes have been put forward, notably that of Schenk, of Vienna, but are we still in ignorance of the laws governing the production of sex. The proportion at birth is 106 boys to 100 girls. The boys have a slightly higher death rate than girls, so that at puberty the numbers are about equal. Multiple Fetation.-Twins occur once in about 120 preg- nancies (1-80 in Europe). Triplets occur once in 7910; quadruplets once in about 371,000 births. There are about 100 cases of quintuplets on record, and only one or two reliable cases of sextuplets. Accounts of more than six children at a birth, though frequently reported in the middle ages, must be considered apocryphal. Causes.-Heredity seems to play an important part. Roughly speaking multiple pregnancies result from: 1. Fertilization of two or more separate ova, when the children each have their own chorion, amnion and placenta THE MATURE FETUS 55 (which may be fused into one). They are not necessarily of the same sex. 2. The complete segmentation of one impregnated ovum into two or more parts. In this case the children have a common chorion and placenta, but each has its own amnion. They are always of the same sex, resemble each other closely, and are called homologous twins. Two other theories of the pro- duction of multiple pregnancies: (1) the penetration of the ovum by two or more spermatozoa and (2) the impregnation of ova escap- ing from different graafian follicles at different times {superfetation) do not meet with wide acceptance. Hydramnios is very common in twin pregnancies, affecting usually one sac only. It sometimes happens that one fetus is out- stripped in growth by its fellow. The weaker finally dies and is pressed flat against the uterine wall. When born it resembles a flattened mummified child, and is called a fetus papyraceus. It is not uncommon for twins to be markedly unequal in size and therefore apparently of different stages of development. This is probably the origin of the theory of superfetation. Fig. 21.-Child's head at term and diameters. CHAPTER III PHYSIOLOGY, DIAGNOSIS, AND DIFFERENTIAL DIAGNOSIS OF PREGNANCY CHANGES IN MATERNAL ORGANISM Abdominal Walls.-The abdominal walls during pregnancy are, in the later months, greatly overstretched, and conse- quently certain marks or scars called striae are formed. These striae are due to the fact that the deeper layers of the skin are not as elastic as the upper and break in many places instead of stretching. If the stretching of the abdominal wall is painful it can often be relieved by inunctions of cocoa butter or olive oil. The abdomen usually presents a marked pigmen- tation surrounding the umbilicus and extending in the middle line downward to the symphysis and upward half way to the xiphoid cartilage-the linea nigra. Breasts.-The changes in the breasts will be found in the section on the symptoms of pregnancy. Weight .-There is ordinarily an increase of about one- thirteenth of the body weight in pregnancy. Circulation.-The total quantity of blood is increased, but its constituent parts do not keep the same relation. The watery element is most markedly increased. This is sometimes called the physiologic hydremia or anemia of pregnancy. There is also a moderate leukocytosis, which is markedly increased in labor. Blood-pressure in Pregnancy.-The normal systolic blood- pressure in pregnancy is 118 to 125 mm. of mercury. It shows a tendency to rise slightly in the last four weeks. The diastolic pressure is not of so much importance, though too wide a divergence between systolic and diastolic should lead 56 CHANGES IN MATERNAL ORGANISMS 57 to suspicion of myocarditis and be watched accordingly. The mercury column sphygmomanometers like the Nicholson, or the dial instruments like the Tycos are the ones in most com- mon use. A record of the blood-pressure should be kept every two weeks until the last month and then every week. Urine.-The urine is usually increased in pregnancy, especially the watery elements. The total quantity of solids is about normal. Bladder.-The bladder shows, in the early months of preg- nancy considerable irritability, due to the pressure of the uterus upon it. As pregnancy advances, the bladder rises out of the pelvis with the uterus and becomes an abdominal organ. Its capacity is diminished, due to its position between the growing uterus and the anterior abdominal wall. Vagina.-Due to the increased blood-supply, the most char- acteristic changes are the purplish color and the more copious secretion. The elements composing the vaginal wall hypertro- phy. The vaginal secretion is intensely acid in reaction, due to Doderlein's bacillus, which secretes lactic acid. Normally the vagina contains no pathogenic bacteria. Cervix.-The cervix is somewhat hypertrophied, broader, softer, but its length is unaltered. The cervix is plugged dur- ing the whole of pregnancy with a plug of tough mucus. The Uterus.-The muscle fibers of the uterus increase enor- mously in size during pregnancy. The number of fibers is very slightly increased, if at all, so that the size of the uterus is due to a hypertrophy and not a hyperplasia. It increases from an organ having a length of two and one-half inches and a weight of two ounces (capacity of 16.5 mils or 1 cubic inch) to one twelve inches long and weighing two pounds (capacity 6600 mils or 400 cubic in.). The uterine walls are thickest up to the fourth month; from then on they become somewhat thinner, so that at term they are rarely more than to 1 cm. thick. During the first three months the uterus is sharply anteflexed. As pregnancy advances, this is gradually but never entirely corrected. The uterus is almost always rotated 58 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY toward the right, due to the pressure of the rectum and sig- moid flexure upon the left side. At term, the uterus reaches about half way from the umbilicus to the xiphoid, with the intestines massed above and behind it; the anterior uterine and abdominal walls are usually in contact. The blood-vessels of the uterus are greatly increased in caliber and are very tortuous. The lymphatics are greatly dilated; those below the mucous Fig. 22.-The relation of the intestines to the uterus at term. membrane particularly. From them lead tubes the size of goose-quills through the uterine muscle, which are collected under the peritoneal covering in an intricate plexus. The muscle fibers are irregularly arranged in three layers-an outer, middle and inner layer. The outer is mainly longitu- dinal; the middle forms a dense network containing the majority of the large vessels; the inner is circular and poorly developed except in the cervix and at the openings of the tubes. THE SYMPTOMS OF PREGNANCY 59 The ovaries and tubes undergo chiefly a great increase in vascularity. There is ordinarily no ovulation during preg- nancy; and the ovary from which the fertilized ovum was dis- charged is the site of the corpus luteum of pregnancy. The pelvic joints, especially the sacro-iliacs, are somewhat loosened. This is sometimes enough to interfere with walking and to require a binder for support. THE SYMPTOMS OF PREGNANCY The symptoms of pregnancy are divided into two classes: those noted by the patient herself, called subjective; and those elicited by the physician during his examination-the objec- tive symptoms. Subjective Symptoms.-The subjective symptoms, arranged approximately in their order of importance are: Cessation of Menstruation.-While this is the most impor- tant, it does not necessarily mean pregnancy. Its cessation independent of pregnancy is most commonly due to (i) Change of climate, (2) cold, (3) fear of or desire for impregnation, (4) anemia, (5) pelvic inflammation or tumors. On the other hand, menstruation may persist for three months or more after impregnation or rarely throughout the whole pregnancy. Nausea and Vomiting.-The nausea and vomiting of preg- nancy begins as a rule at about the sixth week. It lasts about six weeks and is usually more pronounced in the morn- ing, when the woman first arises, as the change from a hori- zontal to erect posture increases pelvic congestion. It may be increased by anything that produces pelvic congestion, irrespective of pregnancy, or a disordered stomach. Again it may be entirely absent. For details as to treatment see section on toxemia of preg- nancy. Change in the Size and Shape of the Abdomen.-The shape and size of the abdomen in the early months of pregnancy offers no help in the diagnosis of pregnancy. In the latter 60 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY months it steadily enlarges and assumes the pyriform shape characteristic of the pregnant uterus. This shape may be simulated by fat in the omentum and abdominal walls, ascites, fibroid tumor, ovarian cyst, overdistended bladdet and, rarely, tympanites. Changes in the Breasts and Genitalia.-These are due to in- creased blood-supply, and usually take the form of increased warmth or tingling sensation. The fullness of the breasts and the presence of colostrum may be noticed by the patient. The same sensations are not uncommon at each menstrual period. Quickening.-This name is given to the sensations experi- enced by the mother when the fetal movements are first felt. It was formerly erroneously thought to mark the time when life was imparted to the child. It occurs usually between the fourth and fifth month. The movements may be felt as early as the third month. They may not be noticed at all; or a woman earnestly de- siring maternity and believing herself pregnant may be con- scious of peristaltic movements of her intestines and mistake these movements for those of a fetus. Nervous Phenomena.--The chief disorders of the nervous system are a tendency to dizziness and fainting, a change in disposition, inordinate appetite or perversions of appetite and taste. The bladder is commonly irritable, and frequency of urina- tion is marked, but this is so common a complaint as to lose much of its value as a sign of early pregnancy. None of the subjective signs of pregnancy are positive signs; all of them can be simulated by other conditions, and they should be considered, not by themselves, but in con- nection with other evidences of pregnancy elicited by the physician in his examination. Objective Symptoms.-For convenience in study, the objec- tive signs of pregnancy are here grouped by localities. THE SYMPTOMS OF PREGNANCY 61 Face.-Occasionally there is marked brownish pigmentation of the forehead, temples and skin over the malar bones, amounting sometimes to positive disfigurement. It usually disappears promptly after delivery, but rarely is permanent. Fig. 23.-The breast near term, showing primary and secondary areola. (DeLee.) Breasts.-The breasts become (1) more prominent; (2) present a pigmentation of the areola, the color changing from pink to a reddish-brown or even dark brown; (3) the develop- ment of the secondary areola; a slightly irregular deposit of pigment outside of the primary areola; (4) enlarged veins are seen coursing over the breasts; (5) the skin becomes marked with striae; (6) the glands of Montgomery in the areola are prominent; (7) colostrum can be expressed from the nipple, especially in the later months. Abdomen.-The abdomen contour shows (1) the presence of a pyriform tumor; (2) the striae and linea nigra are usually well-marked; (3) at intervals the abdomen becomes hard, and 62 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY the uterus more prominent-the intermittent contraction or Braxton-Hicks' sign; (4) the head, body and extremities of the fetus can be mapped out; (5) the fetal movements can be felt and seen; (6) the fetal heart sounds can be heard and counted. The placental or uterine bruit can usually be heard and the funic souffle occasionally. The uterine bruit has no diagnostic significance, being often heard in tumors. Fig. 24.-The abdominal outline at full term. Vagina -These are the more important signs, especially in the early months of pregnancy, (i) Blue discoloration of the vaginal mucous membrane, becoming purple in the later months. (2) Frequently a band of bright scarlet around the fourchet. (3) Softening of the cervix. "When the cervix is as hard as the cartilage of one's nose, pregnancy is unlikely. When as soft as one's lips, pregnancy is likely" (Goodell). (4) Hypertrophy of the cervix-becoming broader. (5) Soft- ening of the lower uterine segment or Hegar's sign. (6) Jug- shaped enlargement of the uterus above the internal os. (7) The presence of the presenting part. (8) Ballottement-or the THE SYMPTOMS OF PREGNANCY 63 sensation imparted by the presenting part when it is lightly pushed, floats away in the liquor amnii, and then falls back upon the examining finger. This symptom can be simu- lated by a small ovarian cyst or uterine fibroid with a long pedicle. Fig. 25.-Striae on the abdomen. (De Lee.) The Signs of Pregnancy Prior to the Third Month Subjective Signs.-(1) Cessation of menses; (2) nausea; (3) changes in breasts: (4) nervous phenomena. Objective Signs.-Breasts: (1) enlarged; (2) engorged veins; (3) enlarged Montgomery's glands; (4) pigmented areola; (5) colostrum. 64 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY Abdomen.--None. Vagina.-(1) Scarlet discoloration; (2) blue discoloration; (3) soft cervix; (4) hypertrophied cervix; (5) Hegar's sign; (6) jug-shaped uterus. The Positive Signs of Pregnancy.-The only signs which can be called positive are: Fig. 26.-The shape and size of the non-pregnant uterus. (Budin.) Fig. 27.-The shape and size of the uterus altered by early preg- nancy. (Budin.) 1. Fetal Heart Sounds.-A double sound, beating at the rate of 120 to 160 to the minute. It sounds much like the ticking of a watch under a pillow. A single beat is most likely the pulsation of the mother's aorta, transmitted through the uterus. It can be differentiated by noting that it is a single sound, and is synchronous with the mother's heart beats. 2. Fetal Movements.-These are of two kinds: the sharp tap of the extremities and the heave o£ the child's back. The twitching of the abdominal muscles must not be mistaken for them. DIFFERENTIAL DIAGNOSIS OF PREGNANCY 65 3. Braxton Hicks' sign or the intermittent contractions of the uterus, at intervals of 10 to 15 minutes. They can be felt; the abdomen becomes hard during a contraction and the outline of the uterus much more prominent. They can be simulated by the contractions of a greatly overdistended bladder, and also by the contractions of the uterus over a large single submucous fibroid, but these conditions are so uncommon that it is justifiable to include this sign among the positive signs of pregnancy. 4. The x-ray can usually be depended upon to show a satisfactory shadow of the fetal skeleton, after the sixth Fig. 28.-Hegar's sign of pregnancy. month of pregnancy. Not infrequently, however, even at full term, the shadow is doubtful or entirely absent. DIFFERENTIAL DIAGNOSIS OF PREGNANCY FROM CONDITIONS SIMULATING IT The conditions most likely to be mistaked for pregnancy are: (i) Fibroid tumor; (2) ovarian cyst; (3) ascites; (4) omen- tal and abdominal fat; (5) tympanites and (6) overdistended bladder. 5 66 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY Fibroid Tumor.-The special symptoms by which a fibroid can be recognized are: (1) More often menorrhagia than amenorrhea. (2) A very bold and often irregular outline to the abdominal tumor. (3) On palpation the tumor is hard and knobby. (4) Absence of fetal heart sounds and movements. The outline of a fetal body is frequently simulated by the knobs of a fibroid in an astonishing manner. Fig. 29.-Testing the actual outline of the abdomen by eliminating the superficial fat. Ovarian Cyst.-(i) An oval instead of pyriform abdominal tumor. (2) Often vicarious menstruation or persistence of men- struation. (3) Absence of the objective signs of pregnancy, though the subjective may be perfectly simulated. (4) By vaginal examination the uterus is found small, hard and often pushed far to one side. METHODS OF PRECISION IN DIAGNOSIS OF PREGNANCY 67 Ascites can usually be diagnosed by the dullness in flanks and tympany in the center of the abdomen; the characteristic flattened abdomen with prominent flanks when the patient is recumbent, and the absence of the objective signs of pregnancy. Omental and abdominal fat can be diagnosed by noting the thickness of the abdominal wall; by the doughy consis- tency of the abdominal tumor and by the absence of the ob- jective signs of pregnancy. Tympanites is diagnosed by the tympany over the entire abdomen, even upon deep percussion, and the absence of all objective symptoms of pregnancy, especially by vaginal ex- amination. It must be remembered that tympanites may exist with pregnancy if, as sometimes happens, the intestines prolapse between the uterus and abdominal wall and become distended. Overdistended Bladder.-Here the catheter gives an un- failing means of diagnosis. The bladder may be enormously distended; one in the author's service at the Philadelphia General Hospital contained 170 ounces. In any case of doubt, an examination under an anesthetic may be necessary. It must be remembered that pregnancy can exist with any of the above conditions, and that the diag- nosis of early pregnancy complicated by any one of them is often extremely difficult, and can only be made by a careful, detailed search for the objective symptoms of pregnancy. The subjective symptoms can be so closely simulated as to render them useless for diagnostic purposes. METHODS OF PRECISION IN DIAGNOSIS OF PREGNANCY (i) Abderhalden Test.-The serologic diagnosis of preg- nancy. A fresh piece of human placenta is washed and boiled. It is covered with the blood serum (io mils) of the woman to be tested, placed in a dialysation tube, which is then hung in a vessel of distilled water. After dialysation has progressed for sixteen hours, in the incubator, the dialysate is tested for 68 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY protein derivatives by ninhydrin. If they are present, a blue color appears. The technic is difficult; the results uncertain. Eighty-five per cent, of women give a positive reaction at the menstrual period, and a positive reaction can often be obtained in the blood of a man. (2) Placentin Test.-The injection of a placental extract intradermically should be followed by a local reaction some- what similar to the von Pirquet reaction in tuberculosis. This has a high percentage of error, and is useless except in primiparae. (3) X-ray.-The fetal skeleton is transparent to the rays prior to the sixth month of pregnancy. Hence this method is not available in the early diagnosis. (4) Artificial Renal Glycosuria.-There is in early pregnancy, a marked reduction of sugar tolerance. If glucose or cane sugar be administered to a patient supposedly pregnant, glycosuria will be produced if the pregnancy really exists, whereas the same amount of sugar in a patient not pregnant would show no reaction in the urine. A similar reaction can be produced by the injection of phloridzin, without the ingestion of sugar. This low sugar tolerance occurs only in the first three months of pregnancy; it then rapidly disappears and can be elicited in later pregnancy only exceptionally. In early pregnancy, however, about 95 per cent, of accurate positive results are claimed. Phloridzin Test.-The injection of 0.01 gm. of phloridzin will produce glycosuria in anyone, irrespective of pregnancy. For the diagnosis of pregnancy, the technic is as follows: (1) The patient should take no food, before the test, and should report in the morning, with stomach empty. (2) She is instructed to empty the bladder by voluntary urination, and this urine is preserved and marked No. 1. (3) She then drinks six ounces of water or tea without milk or sugar. (4) She is then given by deep intramuscular hypodermic injection, 0.002 gm. (%00 grain) of phloridzin in 1 mil water, METHODS OF PRECISION IN DIAGNOSIS OF PREGNANCY 69 with o.ooi gm. grain) of betaeucain or novocain. This can be obtained in sterile i mil ampules. Before this injection is given, however, the first specimen of urine is tested by Nylander's solution. If it reduces the solution, the phloridzin test is not continued. (5) The patient is instructed to pass urine one half hour, one hour, and one and one-half hours after the injection. These specimens are marked 2, 3, and 4. (6) They are tested with Nylander's solution and if a posi- tive reduction is obtained, the patient is probably pregnant. (7) Antipyrine, salicylates, saccharin, chloral, camphor, chloroform, pituitrin and adrenalin often give a positive Ny- lander test and none of them should have been used. (Kam- nitzer and Joseph, quoted by Hellman.) Administration of Glucose by Mouth.-Glucose is a normal constituent of the blood stream in a concentration of 0.09 to 0.11 per cent. If 100 grams of glucose be given a normal per- son, the blood sugar concentration rises temporarily to 0.19 per cent, or over, without the appearance of sugar in the urine. In early pregnancy, however, sugar appears with a blood sugar percentage of much under 0.19 per cent. The method of the test is as follows: (1) The patient reports for the test with an empty stomach. (2) The urine is passed and examined for sugar. A specimen of blood is taken, for blood chemistry. (3) She is given 100-150 grams of glucose dissolved in 500 mils of tea. As this dose is often nauseating, she is required to remain prone for forty-five minutes. (4) After forty-five minutes, the bladder is catheterized and the urine examined for sugar; and again at one hour and one and one-half hours. (5) As soon as sugar is found in the urine (usually after the first hour) a second blood specimen is taken. (6) Fehling's solution is used for the urine examination and it is essential to examine three specimens as detailed above, as the appearance of sugar is often delayed. 70 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY (7) The appearance of glycosuria with a percentage of blood sugar below 0.19 is considered diagnostic of pregnancy (quoted from Welz and Van Nest). Cane Sugar by Mouth.-This is based upon the same pre- mise as the glucose test but is much simpler, more practical and less uncomfortable for the patient. It is the best test for general practice. Technic.-(1) The patient reports for the test, with stomach empty. (2) She voids a preliminary specimen of urine, which is tested for sugar by Fehling's reagent. (3) She is given 100-125 grams of granulated table sugar, dissolved in two glasses of water, acidulated with lemon juice. (4) One hour later, the bladder is catheterized, and a speci- men of blood is also taken for blood sugar. The urine is examined by Fehling's qualitative test; and the blood sugar percentage is calculated. (5) A positive sugar test in the urine, associated with blood, surgar percentage of below 0.19 is regarded as indicative of pregnancy. Correct diagnosis can be expected in about 95 per cent, of cases. The cane sugar used is everywhere available, and is much less nauseating than the glucose. (Quoted from Long and J. C. Hirst, 2nd.) All these tests are ineffective after the tenth week of preg- nancy. After that time the lowered threshold for the leakage of blood sugar through the kidney rapidly disappears. In about 5 per cent, of cases, sugar (milk sugar; levulose) will be found in the urine. This of course invalidates the sugar test for pregnancy, unless the urine be polarized both before and after the sugar is given by mouth. Duration of pregnancy is 273 days, if counted from impreg- nation of the ovum of the last period; or 252 days if counted from impregnation of the ovum of the missed period. Labor occurs on an average of 269 days after a single fruitful coitus, but the junction of the ovum and spermatozoon is not imme- diate. METHODS OF PRECISION IN DIAGNOSIS OF PREGNANCY 71 Pregnancy is prolonged over 300 days in 6 per cent, of women. Sometimes as long as 320 days or longer. The law of legitimacy (Napoleonic Code) recognizes the legitimacy of the child born 181 to 302 days after possible legitimate conception. Missed labor is the occurrence of a few pains at the expected term and then their subsidence and inaction for a variable period. Estimation of the date of labor is usually done by counting back three months from the date of the last normal menstrual period, and adding seven days. This gives approximately the date of labor. In April and September six days; in December and January five days and in February four days are to be added. When the menstrual history is uncertain or when the patient has conceived during lactation we can arrive at an approximate idea from (1) the height of the fundus uteri; (2) the date of quickening (four and one-half to five months).; and (3) the occurrence of subsidence of the uterus (one to two weeks before term). The height of the fundus at the different months is: Fourth month-just above the symphysis. Fifth month-half way from symphysis to umbilicus. Sixth month-at the umbilicus. Seventh month-four fingers breadth above the umbilicus. Eighth month-half way from the umbilicus to the xiphoid. Ninth month-at the xiphoid cartilage. Tenth month-descends to the location at the eighth month, when the presenting part enters the superior strait. Signs of Patient being at Full Term.-History.-She de- scribes the'occurrence of subsidence of the uterus, with con- siderable increase of pressure in the pelvis, backache and irritability of the bladder. Abdominal Examination-The fundus uteri is one-half way from the umbilicus to the xiphoid; the child's back is about twelve inches long, and the head has obviously entered the superior pelvic strait. 72 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY Vaginal Examination.-The child's head is low down and well engaged in the superior strait; the cervix is somewhat shortened and possibly has begun to dilate, admitting one finger. A vaginal examination at this time is very likely to be followed by slight bleeding. Fig. 30.-Silhouettes of a patient before and after subsidence of the uterus, or lightening, has occurred. (De Lee.) All these signs indicate that labor is fairly imminent, and have their greatest importance in primiparse. Examinations Necessary in Pregnancy.-In a normal preg- nancy the patient should be examined at least three times. The first examination is made at the time she consults the physician, to engage him for her confinement. It should con- sist of a careful search for the symptoms of pregnancy, that the correct diagnosis be established; a further vaginal exami- nation to determine whether there exist any deformity or anomaly likely to make the labor difficult; a careful measure- ment of the maternal pelvis and an examination of the patient's heart and lungs. The second examination should be made four weeks before term. It should be directed chiefly toward ascertaining the size of the child and proportionate relations of the presenting part to the pelvic inlet. In this way can be recognized any over- METHODS OF PRECISION IN DIAGNOSIS OF PREGNANCY 73 growth of the infant, and labor can then be induced from two to four weeks before term. This third examination is ordinarily made two weeks before term. In this the position of the child should be carefully mapped out. The method of making the diagnosis' will be given here; the reasons for and frequency of the different pres- entations belong to the section on the mechanism of labor. The patient is arranged flat on her back on a bed or suitable examining table; her clothing should be arranged to expose the abdomen and a sheet should then be thrown over her, so that there is no unnecessary exposure. The abdominal examina- tion should be made through this sheet. The most easily palpable portion of the fetus is the back. Its position is diagnosed by making pressure with the finger tips on one side of the abdomen, gradually moving them across to the other side in a series of tapping movements. The back can be felt giving a broad, even sense of resistance on one side, in contrast to the softer cystic feel of the rest of the uterus. The extremities can usually be felt in the upper portion of the uterus, on the side opposite that on which the back was found. The examining hand outstretched makes a series of rubbing movements over that portion of the uterus, and the extremities are felt as hard cylindric bodies which move away from the examining hand as it displaces them or as the child itself changes their position. The head is the presenting part in 95 per cent, of all cases, and can be felt above the superior strait. For this examination the physician stands by the patient's side, facing her feet. His finger-tips are placed upon the abdominal wall just above Poupart's ligament, on either side, the middle finger corre- sponding to the middle of t'he ligament. Pressure is then made gently in a direction downward and inward, and the head can be felt between the finger-tips. A fairly accurate idea of its size can be gained in this way, and also its relative size to the pelvic inlet, by trying to force the head into the pelvis. 74 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY Auscultation.-By auscultation can be heard the fetal heart sounds, the fetal movements, the uterine and funic souffles. The fetal heart sound have already been described. They are heard most plainly over the fetal back. In a left occipito- anterior position of a vertex presentation they are heard most plainly at a point one inch below and one inch to the left of the umbilicus. In right occipito-anterior positions, one inch below and to the right of the umbilicus. In right or left occipitoposterior position, on a line one inch below the umbili- cus in the right or left flank. In breech presentations above the umbilicus and in transverse presentations just above the symphysis. Diagnosis of Prior Pregnancy.-The signs usually left by a prior pregnancy are: 1. Breasts pendulous, areola darkened and often striae. 2. Abdominal walls flaccid and marked by striae. 3. Frequently diastasis of the rectus muscles. 4. Destruction of the hymen and presence of myrtiform caruncles. 5. Possibly laceration or relaxation of perineum. 6. Vaginal walls smooth and rugae lost. 7. Cervix cylindric instead of conic. 8. Possibly cervical lacerations. 9. Change in external os from a circular opening to a trans- verse slit. These are of importance in medicolegal work. Diagnosis of Death of Fetus.-Usually, upon the death of the fetus, spontaneous abortion occurs. In early pregnancy the disappearance of the subjective signs; the appearance of milk in the breasts; the failure of the abdomen to enlarge when measured from week to week are important presumptive signs. In late pregnancy, the failure of the abdomen to enlarge; the disappearance of fetal heart sounds and fetal movements that had previously been heard, seen and felt would indicate the death of the child. MANAGEMENT OF NORMAL PREGNANCY 75 When the membranes are not ruptured the product of con- ception does not putrefy; it macerates, and may be retained for months. In all cases of doubt, assume that the child is alive. The child can die in utero and be retained for long periods, without sign of toxemia or sepsis in the mother. Predetermination of Sex.-Is not possible, except in a breech presentation in labor. The normal ratio is 106 boys to 100 girls at birth. The death-rate in boys is higher than girls, so that at puberty the proportion of sexes is reversed. Pseudocyesis or spurious pregnancy is the name given to a condition in which the patient firmly believes that she is pregnant. It is most often seen in women intensely anxious for or in dread of maternity, or in those whom an abdominal enlargement from some cause, most often obesity associated with amenorrhea, has led them to suspect pregnancy. Usu- ally a positive assurance that she is not pregnant is sufficient to convince the patient, but occasionally even the most positive statement will fail to disabuse her of the idea. MANAGEMENT OF NORMAL PREGNANCY The following are the more important rules for the manage- ment of pregnancy: (1) Come to the office every two weeks for taking of blood pressure, until the last month. Then come once a week. (2) Send specimen of urine every two weeks, until the last month, then once a week. Send this the week you do not come yourself. (3) Report at once any persistent headache, failing vision, black specks before the eyes, pain in upper abdomen or a notice- able decrease in the amountof urine passed, bringing a specimen of urine with you. (4) Report at once any unusual constipation or indigestion. (5) It is vital for you to be regular in your visits to the office. 76 PHYSIOLOGY AND DIAGNOSIS OF PREGNANCY (6) Dress warmly, do not wear corsets tight. In the last two months a Maternity corset is desirable. (7) Take regular exercise in fresh air and sunlight, best by walking and stop short of fatigue. Avoid all violent forms such as golf, swimming, tennis or long auto rides. (8) Bathe only in teptid water, avoiding both hot and cold baths. (9) Keep bowels well open. (10) Do not go out in wet weather without rubbers. (11) Avoid lifting weights, either from the floor or a shelf. (12) For the last two months apply witchhazel to nipples night and morning. Then rub in albolene, using pledgets of cotton for both applications. (13) Diet.-Eat meat only once a day. In last two months three times a week only. Eat plenty of green vegetables and stewed fruit. During last month reduce diet generally, especially sweets and fats. Avoid overeating at any time. Drink at least six glasses of water a day. (14) Report at once any unusual swelling of feet, or ankles, hands, face or eyelids, or any other abnormal symptoms. (15) Do not take advice about your condition from friends or relatives. Ask your physician, and do not take patent medi- cines. (16) Brush teeth twice daily with chalk and orris tooth pow- der and follow with milk of magnesia. (17) Should you begin to have regular pains, during which the abdomen becomes hard, and especially if there is a dis- charge of watery fluid or slight blood discharge, report at once. (18) Come to office eight weeks after delivery, for your final examination. Coitus in pregnancy is unwise at any time. It is most dangerous in the first three months, and, particularly, in the last six weeks. The chief dangers are abortion; aggravation of the nausea and vomiting in early pregnancy, often causing it to become pernicious; infection, at any time in pregnancy, but particularly in the last few weeks, and in the last month MANAGEMENT OF NORMAL PREGNANCY 77 premature separation of the placenta. It is wisest to explain the risks to the patient and her husband, and advise against the practice entirely. The risk is'least in the middle three months of pregnancy, except at the time that would ordinarily have been a menstrual period. CHAPTER IV NORMAL LABOR- EUTOCIA Causes of Labor.-The onset of labor is due to a combina- tion of causes, the chief of which are: 1. Maturity of the the last month of preg- nancy the attachments of the child to the uterus are loosened, by a process of fatty degeneration, so that at term it is practi- cally a foreign body in the uterus, and as such, stimulates the uterus to contract. This process is analogous to the ripening of fruit on a tree; its attachments becoming so loosened that a slight jar is sufficient to sever them. 2. Periodicity.-The average date of labor corresponds to what would have been the tenth menstrual period, dating from conception; a time at which the uterine muscle is exceptionally irritable and liable to contract upon slight provocation. 3. Overdistention of the Uterus.--Like all hollow muscular organs, the uterus will tolerate distention up to a certain point; then it is stimulated to contract. This point is reached at about the tenth lunar month of pregnancy. 4. Habit.-A rather indefinite cause, meaning that, as for numberless generations, women have brought forth their children at about the fortieth week of gestation, the uterus is influenced by habit to begin its contractions at this time. 5. Anaphylaxis theory, supposedly due to a sudden trans- mission of fetal serum through the placenta into the maternal circulation, and by anaphylactic reaction causing the uterus to contract; a rather doubtful premise. The symptoms of imminent or beginning labor are: 1. Subsidence of the uterus, occurring from one to two weeks before term. It is due to the contractions of the uterine and 78 THE STAGES OF LABOR 79 abdominal muscles forcing the presenting part into the supe- rior strait, and is a premonitory, not an actual, sign of labor. 2. Characteristic labor pains, which occur at intervals of ten to fifteen minutes. They are centered chiefly in the sa- crum, radiating from there toward the anterior portion of the abdomen, last for about a minute, and during the pain the abdomen becomes hard and the uterine outline more prominent. 3. The show or discharge of the plug of mucus, slightly tinged with blood, which has occluded the cervical canal throughout pregnancy. 4. Dilatation of the Cervix with Obliteration of its Length.- This is the most valuable and important of the symptoms of beginning labor. The degree of dilatation, as labor ad- vances, can be roughly estimated by the number of fingers that can be inserted in the canal, or by comparing the size of the canal with coins of different denominations (half-dollar, dollar, etc.). The Stages of Labor.-Labor is divided into three stages, called first, second and third stages. The first stage is from the beginning of labor to the complete dilatation of the cervix; the second stage from the complete dilatation of the cervix to the birth of the child; the third stage from the birth of the child to the expulsion of the placenta and membranes. The duration of the first stage varies considerably, depend- ing upon the age of the patient, whether she is a primipara or multipara, the presentation of the child, etc. In primiparae, the length of the first stage is ordinarily twelve hours. The length of the second stage is, on the average from four to five hours in a primipara and about half that in a multipara. The length of the third stage is about twenty to thirty minutes. The third stage is very much shortened if pituitrin has been given during the second stage. The total length of labor in a vertex presentation in primiparae is about eighteen hours, although twenty-four hours is not at all unusual. In breech presentations, on account of the inordinately long first stage, a labor of thirty-six to forty-eight hours is common. 80 NORMAL LABOR-EUTOCIA THE MANAGEMENT OF NORMAL LABOR In receiving a call to attend a case of labor, the physician should respond promptly. The armamentarium necessary is largely a matter of personal preference, but the following articles, with those provided by the patient herself, will be found sufficient for an ordinary case: One obstetric bag (18 to 20 inches long). Nail brush. Eight ounces tincture green soap. One bottle antiseptic tablets. Two ounces liq. cresolis comp, (lysol). One tube carbolized vaselin or K. Y. Jelly. One obstetric forceps (Simpson). One outlet forceps (Hale-Sawyer). Hemostats and scissors. Needles and needleholder (for immediate repair, if done). Glass tubes {not envelopes) of number 1 and 3 chromic catgut. Silkworm gut. Hypodermic syringe and tablets. Two pairs of rubber gloves. Gown. Ether and chloroform. Pituitrin and aseptic ergot (for hypodermic use;. Two double tenacula. One placental forceps. One jar of uterine packing. One tube of tape for tying cord. A small vial of 1 per cent, solution of nitrate of silver, or of 25 per cent, argyrol, for the child's eyes. Both these solutions should be made up fresh at frequent intervals. The articles provided by the patient are: One dozen towels, freshly laundered and preferably sterilized. Six sheets. Protective bed-pads, either nursery cloth (one yard square) or newspapers sewed up in cheesecloth. Preferably the former. THE MANAGEMENT OF NORMAL LABOR 81 Rubber sheeting 1.5 X 2 yards. Ten yards sterile gauze. Two pounds absorbent cotton. Abdominal and breast binders. Flannel binders 6X18 inches for baby. Talcum powder. Four dozen safety pins. Douche and bed-pan. Fountain syringe. Bath thermometer. Rectal tube. Soft rubber catheter, size number 17 F. Two or 3 basins. This list can be amplified considerably, according to per- sonal preference, but can hardly, without sacrifice of efficiency, be reduced. Examinations.-The examinations necessary to determine the condition of the patient are best carried out in the follow- ing order: The physician questions the patient concerning the pains; how long they last; the interval between them; their character and severity, etc. Having ascertained these points, the abdominal examination is next made. For this the patient lies flat on her back on the bed, her clothes rolled up above the level of the fundus, the bed clothes turned down to about the upper one-third of her thighs and a sheet thrown over her so that there is no exposure. Through this sheet the fetal body can be palpated, the fetal heart sounds heard, as well as if the abdomen were bare. The next examination is the vaginal examination. Vaginal Examination.-For this the patient is best arranged lying upon her side, usually the one toward which the fetal back looks. Her buttocks are at the edge of the bed; her thighs well flexed on the abdomen and legs on the thighs. A sheet is then thrown over her, falling well over the edge of the bed. While the patient is being thus arranged by the nurse or 6 82 NORMAL LABOR EUTOCIA other attendant, the physician can be cleaning his hands. A safe plan of hand cleansing is the following: 1. The hands should be smooth and the nails trimmed short. 2. They are scrubbed with a nail brush, green soap and hot water for ten minutes, by the clock, using hot running water. 3. The soap is rinsed off and the hands scrubbed for one minute in alcohol (95 per cent.). 4. A pair of rubber gloves, sterilized by boiling, is then put on, and the examination made. Fig. 31.-Patient prepared for the doctor's external examination. The sheet covering the abdomen is omitted, to show clearly the arrange- ment of the other coverings. (De Lee.) The nurse lifts up the sheet covering the patient, exposing the patient's genitalia. She then lifts up the upper buttock so that the vulvar orifice is exposed. The physician, with a pledget of cotton soaked in lysol solution, i dram to 2 pints (the use of bichlorid solutions in labor is dangerous to the baby's eyes, as some of the fluid is sure to remain in the vagina), wipes off the vulva in a direction toward the anus, and inserts his gloved finger directly by the sense of sight, into the vagina. The old practice of groping under the sheet for the vulvar orifice is extremely dirty and should never be done. THE MANAGEMENT OF NORMAL LABOR 83 The attending physician should always bear in mind that from the standpoint of infection, a delivery is on a par with a Fig. 30.-Patient prepared for the internal examination, lying on her back. (De Lee.) major surgical operation and should be conducted with the same care. 84 NORMAL LABOR-EUTOCIA What is learned by vaginal examination: 1. The condition of the perineum (rigid or relaxed). 2. The condition of the vaginal walls. 3. The size of the pelvic cavity. 4. The condition of the cervix (hard or soft). 5. The length and thickness of the cervix and the size of the external os. 6. The condition of the membranes (intact or ruptured). 7. The character, size and position of the presenting part. Fig. 33.-General arrangement of the delivery room, with patient arranged for vaginal examination, lying on her side. For the sake of clearness, the sheet covering her is omitted. (De Lee.) Rectal examination has been suggested, and quite exten- sively employed, as a substitute for vaginal examination. The risk of infection is much less, and the method is to be preferred in cases where proper aseptic technic is impossible. The difficulties of diagnosis are easily overcome, and the method has much to commend it. It should always be done in cases where the patient is undergoing a test of labor, with a possible cesarean section in view. The Frequency of Examinations.-They should be limited to the smallest possible number. One during the first stage and THE MANAGEMENT OF NORMAL LABOR 85 one or two during the second stage are usually sufficient. The hand cleansing described above should be carefully carried out before each examination. Even for the rectal examination a sterile glove should be worn. When it has been ascertained that the patient is in labor, the first thing to be done is to clean out the lower bowel by an enema. A cathartic should not be used, as it is unnecessary to Fig. 34.-Diagram of room arranged for normal confinement. (De Lee.) empty anything but the lower bowel. The patient should take a full bath, if her personal hygiene is open to criticism, and should in any case put on clean underclothes and night dress. During the early part of her labor she may be allowed to move about the room if she desires, and should be put to bed when the external os has reached the size of a silver dollar. From this time on she should not be allowed out of bed. The pubic hair should be shaved or clipped. Depilatory pastes (barium sulphid and starch) are not reliable and often very irritating. 86 NORMAL LABOR-EUTOCIA Preparation of Room and Bed.-The room in which the labor takes place should not contain any unnecessary hangings. It should be sunny and well ventilated, and ample provision should be made for artificial light, at night. The bed should not be low. It is prepared for the labor by covering the central portion of the mattress with a piece of rubber sheeting about a yard wide and two yards long. An Fig. 35.-Arrangement of bed for a delivery. ordinary sheet next covers the whole mattress. On top of this is a second rubber sheet, of the same size as the first, covered by a drawsheet slightly wider than the rubber. On top of this is the absorbent obstetric pad, best made of a piece of nursery cloth one yard square, which has been boiled and dried. It is secured to the mattress by safety pins. At the head of the bed should be a table covered by a sheet. On this table are arranged (1) a basin of 1 dram to 2 pints lysol solution containing numbers of large pledgets or squares of cotton; (2) dozen clean towels; (3) a small basin of boracic acid solution, 10 grains to the ounce, containing some squares of lint; (4) carbolized vaselin or other lubricant; THE MANAGEMENT OF NORMAL LABOR 87 (5) a small basin containing the tape for the cord, soaking in lysol solution; (6) scissors for the cord, sterilized by boiling. A chair is placed at the side of the bed, and a waste bucket, for waste material, at the foot of the chair. Arrangements should be made for an abundant supply of boiled water, by boiling three pitchers in a clothes boiler full of water, filling the pitchers from this water and allowing them to cool. By mixing this water with a fresh supply of hot boiled water sterile water at any desired temperature can be obtained. The bottled distilled water sold in drug stores answers perfectly for the cold water. Management of First Stage During the first stage of labor, very little activity on the part of the physician is required. The patient should be put to bed when the external os is the size of a dollar. It is not safe for the physician to be away from his patient, if the pains are coming as often as every five minutes. Signs of danger to child in labor are a fetal heart beat sinking to 100 or below (except during a pain) and discharge of meconium into the liquor amnii (except in a breech presentation). The fetal heart rate should be counted at frequent intervals during labor. The cessation of fetal move- ments in labor is common, and usually without significance. Nausea and vomiting in labor, especially in the first stage, is not uncommon. It is due usually to nervous reaction, and need cause no alarm. If the first stage has been unduly protracted and food has been withheld, it may be due to hunger. If so a light meal is beneficial. Management of Second Stage When the dilatation of the cervix is complete, the pains change in character. They are closer together, more severe, and during each pain the patient strains with all her might, 88 NORMAL LABOR EUTOCIA bringing into play the abdominal muscles. In this stage the physician can materially aid his patient. Anesthetics.-The need for an anesthetic is usually first seen during the second stage. The methods employed are: 1. Ether.-This is not given continuously, but only for a few breaths at the beginning of each pain. When the pain begins, a few drops of ether are poured on a piece of gauze, placed over the patient's face, and she is told to breathe deeply. When the pain passes off, the gauze is removed, and replaced at the beginning of the next pain. This has the merit of safety to recommend it. 2. Chloroform.-This is said to be safer during pregnancy and labor than at any other time. The method of adminis- tration is the same as ether, but smaller quantities are required. 3. Scopolamin and Morphin (Twilight Sleep) was first recom- mended by Steinbuchel in 1902. Krdnig and Gauss have given this its greatest prominence. They recommend an initial dose of % gr. of Morphin Sulphate and gr. Scopolamin Hydrobromid. Forty-five minutes later a second hypodermic injection of gr- Scopolamin is given. Subsequent doses, as required, are given of Scopolamin gr. V200, the test being the patient's memory of objects shown her. If she can- not remember an article she has been shown fifteen minutes previously, the narcosis is deep enough for the moment. The room must be darkened, the patient's eyes bandaged and her ears stuffed with cotton, and all noise eliminated. "Twilight Sleep" is very far from the lay conception of painless labor but is simply a loss of memory of what has occurred. It is not free from complications. Inertia uteri; postpartum hemor- rhage; a high proportion of forceps deliveries; asphyxia of the child; and at times severe mania. This method should be used only in hospitals, where all the essentials of technic can be carried out, and not in private homes. It requires the constant attention of the physician, from the onset to termination of labor. It is most applicable THE MANAGEMENT OF NORMAL LABOR 89 to the nervous primipara. It does not displace the need and advantage of complete surgical narcosis, by ether or chloro- form, at the time of expulsion of the child. In a modified form, however, with smaller doses, it does afford great relief in the long drawn out first stage in primiparae. Narcophen, the drug first recommended by Kronig and Gauss, is a proprietary narcotin-morphin-meconate. 4. Nitrous oxid and oxygen is safe and often acts splendidly. There is a high percentage of failure, however. It is begun during the second stage, and given only for four to six breaths at the beginning of each pain. Two to three per cent, of oxy- gen is the usual amount, but many patients require pure nitrous oxid. There is danger of asphyxia to the baby if the mother becomes cyanosed. The method is also expensive, as consider- able gas is needed, and it requires a trained anesthetist for its proper administration. 5. Spinal anesthesia has up to now proved too evanescent and unreliable. There has been no way in which the duration of anesthesia could be controlled. Recently Dr. J. Ralston Wells of Philadelphia has perfected a technic by which, using a special preparation of cocaine, the dose can accurately be measured and the length of anesthesia predetermined and controlled. This feature will make it possible to employ spinal anesthesia, with proper precautions, in the later second stage of labor. 6. Injection of the sacral hiatus and sacral nerve blocking with J4oo novocain solutionis of little value. The anesthesia secured is short, and at the best incomplete. 7. Rectal oil and ether anesthesia has given fair results. One ounce of ether and 3 ounces of olive oil are given by rectum, with the patient in the Sims position, and run in slowly through a large catheter. The method is one of analgesia rather than anesthesia, and has the disadvantage of occasional intense irritation and prompt expulsion of the solution. Puller.-To aid the patient's abdominal muscles in their effort to expel the child, a puller is often employed. This is a 90 NORMAL LABOR-EUTOCIA sheet rolled on its long axis, to form a rope, which is securely tied to the foot of the bed, best at one corner and not in the middle. A pillow is placed against the foot board of the bed, for the patient to brace her feet against. She is given the end of the sheet and told to pull and strain during the pain. The use of the puller is discontinued when the perineum begins to bulge. Rupture of Membranes.-The question of rupture of the membranes usually arises at this time. Unless they rupture spontaneously, a safe rule to follow is not to rupture them in a primipara unless they appear at the vulva, and in a multipara only when the dilatation of the cervix is complete. They are ruptured with a single blade of a tenaculum or pinched through with a pair of placental forceps. It is often difficult, when wearing rubber gloves, to distinguish the membranes from the scalp. The scalp wrinkles during a pain, the membranes bulge; the scalp is rough, the membranes smooth; the scalp usually has hffir, the membranes not. If the liquor amni which escapes is stained by meconium, extra watch upon the fetal heart is necessary. It may be necessary to wait until the membranes bulge during a pain, to make sure whether they are ruptured. Expressed Fecal Matter.-In the latter portion of the second stage, small masses of fecal matter are often extruded from the anus during a pain. They should be wiped away with a pledget of cotton soaked in lysol solution 5 i to Oii, wiping away from the vulva, and the pledget of cotton thrown in the waste bucket at the side of the bed. Bulging of the Perineum.--When the head has descended to the pelvic floor and the rotation is complete, it is seen that during a pain the anus dilates slightly and the perineum bulges outward. At this time the physician should take his place at his patient's side, as her delivery is imminent. Full bladder in labor is of common occurrence, and is easily recognized by the soft, cystic mass of the bladder under the lower abdominal wall. It is annoying to the patient and THE MANAGEMENT OF NORMAL LABOR 91 attended with some risk of injury to the bladder in the late second stage. If the patient cannot void urine, she should be catheterized with a soft rubber catheter. A glass catheter should not be used. Even if the head is far down, the catheter can be passed into the bladder if the forefinger of one hand is placed between the head and the symphysis pubis, and with this finger the catheter guided upward and forward into the bladder. Position of Patient for Delivery.-The patient is best de- livered lying on her side, her buttocks close to the edge of the bed, her thighs flexed upon her abdomen and her legs upon her thighs. The legs are separated by a pillow, rolled to form a cylinder, placed between the patient's legs from the knees down. The sheet covering her is looped up around her upper buttock and the opening thus made surrounded by sterile towels. The choice between this position and the ordinary lithotomy one is largely a matter of personal preference. Leg-cramps in labor are frequent and most annoying. They affect most often the muscles of the calf, and next the thigh. By holding the leg up, at an angle of 30 degrees, fully extended, and pressing the foot forcibly upward, the cramp can quickly be relieved. Distention of the Vulva.-As the head descends, the vulva gapes slightly during each pain. The child's scalp is visible. After the pain the head usually recedes somewhat, descending slightly further at the next pain. Protection of the Perineum.-The perineum stretches until it is apparently as thin as paper and is obviously in danger of rupture. Some of the strain can be taken off it by retarding the advance of the head with one hand, and with the other, protected by a towel, pushing the head away from the perineum up under the symphysis. If the patient shows a tendency to strain at this time, the action of her abdominal muscles can be inhibited by having her breathe rapidly with her mouth open. The head can thus be gradually guided over the perineum, giving the maternal tissues time to stretch. 92 NORMAL LABOR-EUTOCIA Episiotomy.- When the vulvar ring is overdistended by the head, and laceration seems imminent, a ragged tear can be avoided by incising the perineal body, so as to have a cut with clean-cut edges. The incision can be made in one of three directions: i. Vertical (straight toward the anus).-This is the easiest to repair and is the best under ordinary circumstances. If Fig. 36.-Patient arranged for delivery on her side. The perineum is distended and the scalp visible between the labia. The rate of advance of the head can be controlled by pressure of the hands. {American Text-Book of Obstetrics.') there is great disproportion between the head and outlet, or if the space between the posterior commissure of the vulva and the anus is unusually short, the vertical incision is to be avoided, because of the danger of tear of the sphincter ani. 2. Oblique.-Extending from the posterior commissure of the vulva downward and outward. This is the line of choice if THE MANAGEMENT OF NORMAL LABOR 93 the cut has to be an extensive one, or if the space between the vulva and anus is short. 3. Transverse.-At right angles to the vulvar cleft. This is usually to be avoided as it gives no more room than the oblique, is very hard satisfactorily to repair, and leaves the perineum excessively tender for months afterward. The best scissors for the purpose is the Collins ab- dominal scissors, and the incision is as short as con- sistent with the desired result. The tear is repaired with interrupted stitches of over-chromicized {never plain) catgut, or silkworm- gut, just as any other ex- ternal laceration, care being taken to leave no dead space. After the head is bom the first thing to do is to feel around the neck for the cord. If the cord is felt, it must be freed by hooking the finger under it and by pulling, making a loop which can be slipped over the child's head. If this is impossible, the cord can be cut between two hemostats. The child's face, directly after delivery, is rather startlingly cyanosed, due to the fact that it is the only portion of the child free from pressure. This color does not indicate any haste in delivery, as the child is not in immediate danger of asphyxia. After a moment the head is seen to turn to one side, following the rotation of the shoulders internally. The head is then grasped between the physician's hands and gentle traction, Fig. 37.-The three varieties of epi- siotomy. (De Lee.) 94 NORMAL LABOR-EUTOCIA preferably during a uterine contraction, is made, at first back- ward toward the anus, to engage the anterior shoulder under the symphysis, and then forward, so that the posterior shoulder glides out over the perineum. By slight backward traction the anterior shoulder is then delivered, and the rest of the child's body slips out without difficulty. Strong traction is harmful. Fig. 38.-Delivery of the posterior shoulder. (De Lee.) Should any difficulty be experienced in the delivery of the shoulders, traction should never be made by hooking the finger in the child's axilla. This nearly always results in a fractured humerus or injury to the brachial plexus and is mentioned only to be condemned. Slow, steady and gentle traction on the head, assisted by the patient's own voluntary straining efforts and uterine contraction is the only method to be used in delivery of the shoulders. Nurse's Duties.-The nurse should, as soon as the head is born, wipe off the child's eyes with lint soaked in boracic acid solution. If there is any reason to suspect gonorrhea in the mother, the baby's eyes are flushed out with 25 per cent, argyrol solution, or the Crede method of instilling a few drops of 1 per cent, nitrate of silver in each eye is employed. The THE MANAGEMENT OF NORMAL LABOR 95 nurse then gives the mother a teaspoonful of fluid extract of ergot, or preferably a hypodermic of two ampules of aseptic ergot, given deep to avoid a persistent brown stain, and grasps the fundus through the anterior abdominal wall, and by gently kneading, sees that it is kept firmly contracted. Baby after Birth.-When the baby is born, it usually gasps and begins to cry lustily. If it does not the physician should Fig. 39.-Tying the umbilical cord. The cord is tied inch from the skin margin. The material is narrow tape. (De Lee.) hold it upside down, clean out its mouth by hooking his little finger back of the pharynx, to remove the mucus which is probably blocking the trachea. Then by slapping its back and buttocks sharply, respiration will usually be started. When it is breathing satisfactorily, it is placed upon its right side, with its head above the level of its mother's buttocks to favor the closure of the foramen ovale and to keep it out of the maternal discharges. Tying and Cutting the Cord.-Unless there is some reason for hurry, the cord is not tied until pulsation in it has ceased. It is tied with a piece of sterile tape, tying first a surgeon's double knot at a point about one-finger's breadth from the 96 NORMAL LABOR-EUTOCIA child's abdomen. The free ends of the tape are brought around the cord and are tied in a single and then a slip knot at a point opposite the knot first tied. The cord is cut by bringing it up between the physician's fingers, to protect the child's fingers and toes from injury and cutting with scissors at about one-half inch above the ligature. The placental end of the cord is allowed to drain, to reduce the bulk of the pla- Fig. 40.-Cutting the umbilical cord. The cord is severed J4 inch from the ligature. {De Lee.) centa, and facilitate its delivery. The baby is then wrapped in a blanket and placed out of the way, best in its own crib. Management of the Third Stage Delivery of the Placenta.-The placenta is detached from the uterine wall by the contraction of its site, springing off from the uterine wall, as soon as it has been compressed to a mass about one-half its original size by the uterine contraction. This process takes as a rule from fifteen to twenty minutes, THE MANAGEMENT OF NORMAL LABOR 97 and should not be hurried. The time required is much shorter when pituitrin has been used. The placenta, after its separa- tion is forced down into the lower dilated portion of the uterus, and often requires artificial assistance to secure it's expulsion. The Crede method of expelling the placenta is the one usually employed, and consists in grasping the uterine body so that the fingers lie behind it, the fundus rests in the palm of the hand Fig. 41.-Crede's method of expression of placenta. The position of the thumb is important. and the thumb lies in front and slightly toward the right side. The uterus is stimulated to contract by gentle friction. As soon as it is felt to contract, it is tightly squeezed between the fingers and thumb and forced downward into the pelvis. This squeezes the placenta out of the vagina as a stone is squeezed out of a cherry. The placenta emerges like an inverted umbrella, with the membranes trailing after it, and is caught in a basin pressed against the patient's buttocks, just below the vulvar orifice. 7 98 NORMAL LABOR EUTOCIA The membranes, which are caught and held by the firmly contracted uterus, are next extracted by grasping them with the thumb and forefinger, protected by gauze; pulling gently first toward the symphysis and then toward the peri- neum, at the same time stopping the kneading of the fundus, to allow the uterus to relax its grip. After a very few moments the membranes slip out of the vagina. The placenta and membranes should next be examined to determine whether they are intact, or whether pieces of either have been left in the uterus. If any part of the placenta is missing it should be extracted from the uterus. The hand or instruments should never be inserted into the uterus to recover part of the mem- branes unless more than half of them be missing. Missing parts of the membranes are ordinarily spontaneously extruded from the uterus; missing pieces of placenta are usually adherent to the uterine wall and will cause long continued and sometimes serious bleeding unless extracted. A large piece of placental tissue expelled a few days after delivery, although the placenta was examined and found intact, is a placenta succenturiata or accessory placenta. Care of the Patient Directly after Delivery.-As soon as the placenta and membranes have been extracted, the patient may be examined to determine if any lacerations exist. Any repair needed can be done at this time, if so desired. If the repair is done, the suture material should be either silkworm gut or over-chromicized number 3 catgut. The plain or ordi- nary catgut is absorbed much too soon. When the repair is completed the care then devolves upon the nurse. She slips the soiled pads, sheets and rubber protective sheeting off the bed, sq that the patient will lie upon the clean sheets, already spread under the temporary labor bed. The genitalia are washed off with lysol solution, and the abdominal pad, binder and vulvar pad are adjusted. The abdominal pad is intended to (1) fill the space in the abdomen left vacant by the contracted uterus and (2) to act as a mild irritant to the uterus and thus maintain its contrac- THE MANAGEMENT OF NORMAL LABOR 99 tion. It is best made of one or two folded towels, and is placed so that its lower edge is just above the fundus uteri. It must not be lower than this, to avoid exerting pressure directly upon the anterior uterine wall. The abdominal binder is of unbleached muslin; long enough to reach about once and a quarter around the patient's body, and wide enough to extend from the floating ribs to the trochanters. It is put on snugly, and fastened by safety pins down the center and tightened by darts at each side. The incorporation of a wide strap to hold the vulvar pad in place- like a T-bandage, is of great use in preventing the binder from riding up. The vulvar pads are made of a sausage-shaped envelope of gauze stuffed with cotton. The day's supply is made up in the morning by the nurse who should carefully clean her hands, and they should be changed about six times in the twenty- four hours. These pads are also supplied by many wholesale drug houses, conveniently packed and autoclave sterilized. Postpartum Chill.-Very often, shortly after the delivery of the placenta, the patient complains bitterly of cold, and shakes violently. It looks alarming, but is of no moment and of short duration. It is a vasomotor disturbance, said to be due to the sudden diminution in heat by cessation of the violent muscular effort in labor, and to the loss of heat by perspiration. It requires no treatment other than warm covering, hot-water bags and an assurance of safety to the patient and particularly to her family. Many patients will exhibit fever, as high as ioi° immediately after labor. This is purely reaction, and will subside within 24 hours. The Infant after Delivery.-After the mother has been attended to the nurse turns her attention to the baby. To remove the vernix caseosa with which it is covered, it should be greased with olive oil (lard is often used and answers the purpose very well) and carefully washed with a good soap, water at a temperature of 90° F. (tested by a bath thermometer and not by guess). It should be washed in the nurse's lap and 100 NORMAL LABOR-EUTOCIA not put into a tub until the end of the first week to avoid wetting the cord and its dressing. The cord is then retied and dressed. The nurse unties the slip-knot in the ligature of the cord, pulls the ligature tight and ties it securely in a square knot. The cord is dressed by taking a square piece of gauze and cutting it down the middle for one-half its length. The cord is then brought up through the slit in the gauze and covered by folding one-half of the gauze over it. The flannel abdominal band is next wrapped around the child's abdomen, and is secured by basting over the ends with needle and thread. The child is dressed and put in its own crib and should not be in bed with its mother. The following routine orders for the care of a normal case, may be of use to the student. Routine After-care of Obstetric Cases 1. Apply abdominal pad above uterus, and hold by abdomi- nal binder, tightly applied. Binder should be wide enough to extend from lower ribs to the upper one-third of thighs. Keep binder well tightened, and pin the pad to the binder. 2. After forty-eight hours apply Murphy breast binder as well, nipples being always covered with sterile gauze. 3. If nipples are sore, use witch-hazel p. r. n. 4. Catheterize every 12 hours, if necessary. 5. After 48 hours give bottle flat citrate of magnesia (without the gas) and the other half six hours later. 6. If nipples are fissured, use Phenix rubber nipple shield, and apply after nursing equal parts of castor oil and subnitrate of bismuth. This should be washed off with boric acid before each nursing. 7. Regularly, before and after nursing, wash nipples with boric acid solution (10 grains to the ounce) and after nursing dry and rub in a few drops of sterile sweet oil. Use pledgets of sterile cotton. THE MANAGEMENT OF NORMAL LABOR 101 8. Diet.-Soft for first two days; light for next three days; full diet after fifth day. Give no strawberries or raw tomatoes. 9. Patient on back for first twelve hours, then may turn on side. 10. As few visitors as possible. 11. If breasts need massage, use oil on fingers, and be gentle. 12. When breasts are painful from excess of milk, massage gently, and keep breast binder firm, with ice-bags on outside of binder, if very painful. Routine Care of Baby 1. Oil with sweet oil or lard. 2. Give first bath after mother is attended to. 3. Dress cord with sterile gauze, and do not disturb dress- ing till cord falls off, unless it comes away very easily. 4. Use boric acid or borated talcum as a dusting powder. If after cord is off, the stump is not dry, use salicylic acid 1, starch 6, as a powder. 5. Wash eyes with boric acid (10 grains to ounce) daily. 6. Keep in crib or basket, and not in bed with its mother. 7. Put to breast every 8 hours for first forty-eight hours. If it seems hungry, give condensed milk 1 dram, boiled water 12 drams after it has tried to nurse. 8. When milk comes in, nurse every 3 hours from 7 A.M. to 10 P.M. Then at 2 A.M. again. This must be regular, if asleep, wake it up. 9. If jaundiced, give calomel gr. every hour for ten doses, followed in two hours by dram each of castor oil and sweet oil. 10. After each nursing, wash mouth with piece of gauze or lint, with 10 grains to the ounce boric acid solution. 11. Bathe once daily. Water 90° F. If buttocks chafed, use sweet oil rubs, and no water. 12. If it nurses too fast, give % ounce cool water just before each nursing. 102 NORMAL LABOR-EUTOCIA 13. Do not pick up, or nurse irregularly if it cries. It should be left alone in its crib as much as possible. 14. If urine colored red, or red stain on diaper, give water between feedings. 15. Weigh three times a week for the first month, then on Wednesdays and Sundays, and keep record of the weight. 16. Feeding intervals vary somewhat, with different babies. Whatever interval is adopted, be regular. The physician should wait in the house for at least an hour after the delivery, on account of the possibility of postpartum hemorrhage. CHAPTER V NORMAL PUERPERIUM Puerperium.-The puerperium is the name given to the period of convalescence from child-birth, during which the different organs and systems of the woman's body are restored to their normal state. The duration of the puerperium is normally six to eight weeks. Involution of the uterus is one of the most striking changes that take place during this period. It is the process by which the uterus is restored to its normal size. The precise manner in which this change is effected is still a matter of dispute, but it is generally believed to be a fatty degeneration and ab- sorption of the redundant portion of the muscle fibers of the uterus (the portion added during pregnancy), and not the total destruction of the old fibers with the formation of new ones. Involution of the Endometrium.-The regeneration of the endometrium proceeds from the glandular layer of the de- ciduae, and is due to a process of active growth and develop- ment. Both the glands and the interglandular stroma share in this development. It is complete at about the eighth to tenth week after confinement. The rate of involution of the uterus is judged by the position that the fundus uteri occupies on successive days after delivery. Directly after delivery it is just below the umbilicus; twenty- four hours later it has risen to a finger's breadth above the umbilicus. From this point the uterus steadily decreases in size until the fundus disappears behind the symphysis on the tenth to fourteenth day. This disappearance on the tenth day or shortly thereafter has given rise to the erroneous idea 103 104 NORMAL PUERPERIUM that the ninth day marks a critical period in the woman's convalescence. The uterus is often temporarily displaced high up and to the right by a distended bladder. The lochia is the discharge from the uterus after delivery and during the puerperium. It is of three kinds. (1) The lochia rubra, lasting from four to five days and consisting Fig. 42.-Height of uterus postpartum, the bladder empty: L, After labor; 1, first day; 2, second day, etc. (De Lee.) chiefly of blood; (2) the lochia serosa lasting one to two days and consisting of serous oozing from the granulation tissue in the parturient tract; (3) the lochia alba lasting another seven to ten days and consisting of a purulent secretion from these granulating surfaces, and the regenerating endometrium. The total quantity of the lochia has been estimated at three and one-quarter pounds, but it is usually measured by the number MANAGEMENT OF THE PUERPERIUM 105 of vulvar pads required. These pads should be changed, dur- ing the first week, six times per twenty-four hours Changes in Breasts.-The breast is a compound racemose gland; the milk-ducts from the different lobules are gradually collected into lacteal ducts, some fifteen or twenty in number, which open at the nipple, each by its separate opening. The epithelium of the ducts is continuous with that of the skin over them. The lacteal ducts are lined with squamous epithelium; the small ducts in the lobules with columnar epithelium. The fluid secreted by the breasts during pregnancy and for the first forty-eight hours after labor is thin, opalescent and possesses slight nutritive and markedly laxative qualities, due to its high proteid content. At the end of forty-eight hours the breasts rapidly enlarge, are engorged, tender and painful to pressure. On slight pressure the milk will run out of the nipples. Characteristics of Human Milk.-It is white, opaque, has a specific gravity of 1025, a sweetish taste, and contains proteins 1.75 per cent., fat 4 per cent., sugar of milk 7 per cent., ash 0.5 per cent., and water 85 per cent. Its reaction is alkaline and it ordinarily contains no micro-organisms. Quantity of Milk.-The quantity of milk secreted by the breasts for the first week is about fourteen fluid ounces in twenty-four hours. After the fourth week it is about two pints in twenty-four hours. It increases gradually up to the sixth or seventh month, when the quantity is three pints in twenty-four hours. After the eighth month the quantity gradually decreases. In many women, the quantity of milk is often very much less than this, it being common for them to have to discontinue nursing their infants as early as the second month. MANAGEMENT OF THE PUERPERIUM Position of Patient in Bed.-For the first six hours the patient should lie flat on her back, without a pillow, to lessen 106 NORMAL PUERPERIUM the danger of cerebral anemia. For the first twelve hours she should remain flat on her back if possible. Thereafter she may turn on either side. During the second week, it is wise to have her lie flat on her abdomen for two periods of one hour each, daily, to favor forward position of the uterus. At the end of the second week, or possibly a few days sooner if the fundus uteri has reached the symphysis, she is shifted from her bed to a lounge or easy chair, sitting up as long at a time as she can without fatigue. During the fourth week she is walking about the room and the floor on which the room is situated, but does not go downstairs. At the end of the fourth week she goes downstairs for the first time. Temperature and Pulse.-The temperature should be taken at least four times a day. The recently delivered woman is subject to variations of temperature for very slight cause, and a temperature of less than ioo° F. can ordinarily be disregarded. The pulse is slow and full, usually 60 to 70 beats a minute. After-pains.-The uterus, having been firmly contracted under the influence of ergot and external stimulation, relaxes somewhat a few hours after labor. This relaxation allows a little blood to ooze out of the vessels at the placental site. The blood collects until it forms a clot large enough to stimulate the uterus to contract again, to secure its expulsion. This contraction is painful and to it the name after-pain is given. After-pains are more common in multiparae than in primiparae. The common statement of the patient that the pains are worse than labor pains is an exaggeration. The diagnosis is easily made by noticing the cramp-like paroxysmal pain, often followed by the expulsion of the clot, and by noting that during the pain the uterus is firmly contracted. There is no fever nor abdominal rigidity. The treatment is the administration of a teaspoonful of a mixture containing equal parts of fluidextract of ergot and paregoric, every three hours for three or four doses. If the MANAGEMENT OF THE PUERPERIUM 107 pains are very severe, they may be controlled by ergot by the mouth and morphin gr. J-g hypodermically. This is rarely necessary. Rarely the paregoric in this mixture will affect the baby, through the milk. Aspirin gr. 5, every four hours for two or three doses will avoid this danger and will satisfactorily control the pains. Diet.-For the first two days the patient needs compara- tively little food, and her diet is best limited to liquids such as milk, broths, clear soups, etc., with the addition of toast and some kind of cereal; one cup of tea a day may be permitted if desired. During the third and fourth days, the milk secre- tion has begun and the diet should be increased by the addition of milk toast, eggs (poached, soft boiled or scrambled) stewed oysters and similar articles. During the fifth and sixth days the diet is still further increased by adding white meat of chicken, tenderloin of beef, mutton chops, mashed potatoes and the more easily digested vegetables. After the sixth day the patient is allowed an ordinary light diet of three meals a day, meat at one of them, and should be advised to drink at least four glasses of milk a day, in addition to her ordinary diet. Visitors.-The visitors to the lying-in rooms should be, if possible, restricted to the immediate family; all others should be excluded, for the first week at least. Care of Genitalia.-The genitalia should be washed off with lysol (5 i to Oii) solution when the vulvar pads are changed- four to six times a day. Abdominal Binder and Vulvar Pads.-The nurse should see that the abdominal binder fits smoothly and snugly. It must be tightened frequently. The abdominal pad may be dis- carded after the fourth day. The vulvar pads must be changed four to six times a day. A necessary but unpleasant part of the physician's daily visit is the routine inspection of the vulvar pads which the nurse will have saved for him. They should be examined by sight and 108 NORMAL PUERPERIUM smell, as frequently the first indication of infection is the brown color and foul smell of the lochia. The lochia rubra have normally the odor of fresh blood or raw meat. Urination.-The recently delivered woman frequently has retention of urine for a considerable time (24 to 48 hours) after her labor. Before labor, the bladder is pressed upon by the uterus, and can expand in one direction only-upward. After labor this pressure is relieved, it expands in all directions and holds a considerable quantity of urine before the patient feels any desire to urinate. This is the commonest cause of retention of urine after labor. Another cause is the edema of the anterior vaginal wall and urethra, caused by the pressure of the child's head in labor, forming a mechanical obstruction. The treatment is to wait for twenty-four or even thirty-six hours after labor if necessary before resorting to the use of the catheter. If catheterization is once begun, it should be done every twelve hours until the patient is able to void her own urine. The urine after labor is increased in amount, but all its solids except the chlorides are decreased. Bowels.-A parturient woman is usually constipated and requires the routine use of laxatives. Forty-eight hours after delivery, an active cathartic should be given (castor oil one ounce, or magnesium citrate bottle or 6 ounces, or magnesium sulphate ounce), followed, if necessary, by an enema. As the nursing mother cannot take fluid charged with carbonic acid gas, the magnesium citrate should be given flat. A daily movement of the bowels should be secured by the use of some suitable laxative as cascara gtt. xxx in syrup of figs 1 dram, at 9 P.M., followed the next morning by an enema, if necessary. Profuse sweating after delivery is not uncommon. It lasts as a rule throughout the first week and does not give cause for alarm. The watery elements of the body are all increased during pregnancy, and this sweating is one of nature's methods MANAGEMENT OF THE PUERPERIUM 109 of correcting the hydremia of pregnancy. It requires no treatment. Management of the Breasts.-The breasts require little attention until the milk secretion begins. This appears at the end of forty-eight hours, when the milk usually comes in rapidly, and the breasts become markedly engorged. They should be emptied by encouraging the child to nurse regularly every three hours. The excess of milk, if the child cannot empty the breast, must be drained off with the breast-pump and massage, and the breasts supported by a breast binder. Fig. 43.-The Murphy breast binder. {De Lee.) The Murphy binder is the best. The nipples must be care- fully washed off after each nursing with boracic acid solution, and a few drops of sweet oil rubbed in the nipple and areola with a piece of absorbent cotton. The nurse and patient should both be cautioned against handling the nipples with their fingers. The nipples, under the binder, are kept covered with sterile gauze. Visits.-The physician should see his patient again within twelve hours after her labor. He should visit her once a day for the first two weeks, every other day during the third and once or twice during the fourth week. She should be in- structed to report at the office at the end of six weeks for her final examination. 110 NORMAL PUERPERIUM Return of menses after delivery is not subject to a hard and fast rule. Usually during the puerperium and lactation there is a four- to six-month period in which there is no men- struation. During this period the uterus is super-involuted (lactation atrophy) and this fact is one of nature's efforts to limit too rapid a repetition of pregnancy. Menstruation may return, however, at any date and is liable to be profuse and prolonged for the first few periods. Its return, contrary to popular superstition, has no disastrous effect upon the mother's milk and is not a sign for weaning the child. Should the mother, while nursing, become pregnant again, the child should be weaned, because the nursing is liable to cause the mother to miscarry, and the child is certain to be under- nourished, as pregnancy seriously affects the quality of the milk, if it does not suddenly abolish the secretion. Examinations necessary in the puerperium are three in number. The first is made 4 or 5 days after labor, and is for the diagnosis of lacerations. This examination, necessary only in cases when repair has been for some reason delayed, should be carried out with the patient across the bed with her feet on two chairs, or better in the lithotomy position on a table. Lacerations cannot be satisfactorily inspected and many severe ones will be overlooked if the patient, during the examination, lies in her ordinary position in bed. The cervix should be inspected through a bivalve speculum. The labia should be separated with pledgets of cotton and any tears in the vagina can be easily seen and their character and extent noted. More detailed instructions for the conduct of these examinations will be found in the chapter on lacera- tions of the birth-canal. The order of examination should be: 1. Inspection of the cervix through a bivalve speculum. 2. Palpation of the muscle of urogenital trigonum (see injuries of birth-canal). 3. Palpation of levator ani, deep transversus and super- ficial transversus perinei. 4. Palpation of sphincter ani. MANAGEMENT OF THE PUREPERIUM 111 Surgical anesthesia and timely episiotomy at the time of expulsion will limit most tears of the vaginal canal. This episiotomy wound is of course repaired at once. If there are extensive intravaginal lacerations, their satisfactory repair directly after labor is almost impossible, and the repair had better be delayed until the seventh day, when all necessary plastic work can be done. Should the patient have fever, the repair is postponed until the temperature is normal for five to seven days. The detailed technic of diagnosis and repair is given in the chapter on injuries of the birth-canal. The second examination is made during the third week, to determine the position of the uterus. If the uterus is found retroverted, it is replaced and the patient instructed to assume the knee-chest position twice a day for as long at a time as she can without fatigue, up to half an hour. She should be told to separate the labia slightly with her fingers when in the knee-chest position or insert the sterile nozzle of a fountain syringe, to allow air to balloon out the vagina. No form of pessary is satisfactory or even desirable at this time. The knee-chest position consists in the patient kneeling upon the edge of the bed, keeping the thighs perpendicular and the pelvis as high as possible. She then leans forward, turning her head to one side, until her chest touches the bed. Some practice is required before it can be maintained properly. The third or final examination is made at the end of the sixth or eighth week. It consists of the careful investigation of the following: 1. The inspection of the vulvar orifice, as the patient is in the lithotomy position, for gaping. 2. The testing of the levator ani muscle, by inserting the index finger up to the second joint, and making pressure, downward and outward toward the tuberosity of the ischium. If the muscle is torn, the finger sinks in a cleft. The finger should then be swept from one ramus of the pubis to the other, to see if the muscle forms an unbroken horseshoe curve. 112 NORMAL PUERPERIUM The testing of the sphincter ani and remaining muscles. 3. The condition of the cervix by digital examination, which is unreliable and must be supplemented by examination through a speculum. 4. The size and position of the uterus by placing two fingers of the examining hand in front of the cervix and by making pressure with the other hand on the abdomen just above the symphysis, the uterine body, if in good position, can be grasped between the two hands. This, at this time, is the most important single point in the examination. 5. The examination of the tubes and ovaries by using hand corresponding to the side examined. Placing the fingers in the lateral vaginal vaults, and with the other hand pressing downward and inward above Poupart's ligament on either side the tubes and ovaries can usually be felt. This requires some dexterity, and the beginner must usually content himself with noting whether the vaginal vaults are soft and yielding or hard and resistant. If soft, there is probably no inflam- matory reaction; if hard, inflammation probably exists. 6. The examination of the cervix through a bivalve speculum. 7. The examination of the abdominal wall for diastasis of the rectus muscles. Placing the hand so that the ulnar side makes pressure in the middle line of the abdomen, the patient is asked to strain as if about to sit up. If diastasis exists, the separated muscles can easily be felt. 8. The Examination of the Kidneys for Position.-The patient is examined in a semirecumbent position and requested to relax her abdominal muscles as much as possible. One hand is then placed in the patient's lumbar region, just below the last rib. The other hand makes pressure just below the float- ing ribs on the abdominal surface, and if the kidney is low, it can be grasped between the hands. It is necessary for the abdominal hand to palpate as low as the pelvic brim, as the kidney sometimes descends this far. q. The testing of the coccyx for fracture. The patient is placed in the Sims' position. The forefinger of one hand, MANAGEMENT OF THE PUERPERIUM 113 protected by a finger-cot, is inserted in the rectum, and the coccyx grasped between this finger and the thumb in the anal fold. The coccyx possesses a certain normal mobility antero- posteriorly. If it can be moved laterally, if the movement gives the patient pain and if a sharp angle can be made by separating the upper and lower portions of the bone, it is injured. When injured it is most commonly through the joint between the first and second pieces, and rarely through the bone itself. io. The rectum and anus are inspected and palpated for fissure and hemorrhoids, both internal and external. 8 CHAPTER VI PHYSIOLOGY AND MANAGEMENT OF THE NEW- BORN INFANT PHYSIOLOGY OF THE NEW-BORN INFANT Weight.-This is normally 7 to pounds at birth. Varia- tions from this rule are common. Weights of nine and ten pounds are not infrequent; anything over twelve pounds being very rare. A baby usually loses about one-half pound during the first week, it regains this during the second week, and should then gain in weight at the rate of one and one-half pounds a month until about the fourth month, and one pound a month thereafter. Pulse.-The pulse of a new-born baby is usually 140 to 160 to the minute. Respirations are at a rate of forty-four a minute, sinking after about the fourth month to thirty-five. Respiration is begun by (1) shock of the colder air on the child's skin; (2) accumulation of CO2 in the blood, causing it to gasp. Temperature.-The temperature directly after birth is slightly elevated. By the next day it has sunk to normal, and then runs an irregular course, being greatly influenced by very slight causes. There is usually a slight rise, when the child begins to receive milk from the breasts. Urine.-The urine is albuminous, of low specific gravity and deficient in coloring matter. It does not stain the diapers and is voided in small quantities and frequently. The total quantity of urine increases from an average of 18 mils on the first day to 220 mils on the eighth day. Bottle-fed babies pass 50 to 75 per cent, more than breast-fed. 114 MANAGEMENT OE NEW-BORN CHILD 115 The small amount of moisture on the diaper and the lack of staining often cause a report that the child has passed no urine. Similarly, "bloody" urine is due to uric acid and is a signal for more water. Bowels.-For the first two days, the bowel movements are dark green in color, consisting of meconium; after the second day when the child begins to receive its nourishment, they gradually become canary yellow, liquid and reasonably free from curds. They move three to four times a day. Stomach.-The stomach is placed high up on the left side. Its long axis is vertical, which explains the frequent regurgita- tion of milk. Its capacity is about one ounce at birth, increases an ounce a month up to the sixth month, and thereafter somewhat more slowly. The eyes are nearly always a sort of slate blue in color. The eyesight is hypermetropic. The blood contains six to seven million red cells to the cubic millimeter, the red cells are more spherical and for the first ten days, often nucleated. White cells are more numerous than in the adult (up to 23,000), and the hemoglobin per- centage is 120 (compared to 93 per cent, in the mother's blood). MANAGEMENT OF THE NEW-BORN CHILD Bath.-Its first bath is given shortly after labor, the water being at a temperature of 90° F. (as tested by a thermometer). The child is greased with olive oil or lard, to remove the vernix caseosa, and is washed in the nurse's lap. The infant is bathed daily, about the middle of the day, the water at 90° F. and is not put into the tub until the end of the first week. Cord.-The cord is dressed with sterile gauze, and an ab- dominal binder. There is no choice in the different materials recommended for the dressing of the cord, as long as the material is sterile. The same is true of dusting powders; a satisfactory one is one part of salicylic acid to six of starch. The cord undergoes mummification and drops off about the 116 PHYSIOLOGY OF THE NEW-BORN INFANT fifth day. The stump retracts within the umbilical ring, and heals in a very few days. If umbilical discharge persists, cleanliness and a dusting powder are all that are required. Clothing.-All the skirts and dresses worn by the baby should be made on waists, to hang from the shoulders, and nothing should depend upon being fastened around the child's waist for its support, except the flannel abdominal band. Feeding.-For the first two days, the child is put to the breast every eight hours. When it is thirty-six hours old it will usually awaken to the fact that it has an appetite, and will cry vigorously from hunger. The mother has no milk until after forty-eight hours, so the interval should be bridged by making a mixture of one part of condensed milk and twelve parts of boiled water, and giving the baby an ounce or so of this every three or four hours. Its use should be discontinued when the mother's milk begins. After the second day, the nursing intervals should be every three hours during the day from 7 A.M. to io P.M. and once during the night at 2 A.M. These intervals should be closely adhered to, if possible. The importance of training the baby to regular habits cannot be overestimated. Too frequent nursing increases the proportion of solid elements in the milk, and makes it difficult to digest. Too infrequent nursing increases the watery elements, and deprives the milk of its nutritive qualities. The length of time babies should nurse is, on the average, ten to never more than twenty minutes. Diapers.-The diapers should be changed often, as the child urinates frequently and if the wet diaper is allowed to remain in place, severe chafing will result. The baby's buttocks must be washed off and dried, and also dusted with a good dusting powder (borated talcum) whenever it is found that the diaper is wet. This is most conveniently done after the nursing. If chafing appears, soap and water cleansing should be stopped, and the child cleansed with sterile oil. Care of the Child's Mouth.-The baby's mouth should be carefully cleansed after nursing with small squares of lint wet MANAGEMENT OF NEW-BORN CHILD 117 with a io gr. to the ounce boracic acid solution, or with sterile water to prevent the occurrence of stomatitis and thrush. Resting place should be its own basket or crib. On account of the danger of overlying, it should not be in bed with its mother. Airing.-The baby may be taken out after the first month in summer, and the third month in winter, in fine weather, for a short time. Care of Premature Infants.-The difficulties to be over- come are those of low temperature and undeveloped diges- tive apparatus. The following procedures overcome them, in so far as it is possible. 1. Child is not dressed but wrapped in gauze and cotton or wool. The diaper is placed under its buttocks, and changed when required. 2. The child is placed in a deep basket, well filled with pillows and blankets, and lined with hot water bottles. If steam heat is available, the basket should be pushed close to the radiator. A temperature of 90° should be maintained as constantly as possible. 3. The child is fed by drawing the mother's milk with a breast-pump, diluting it one-half with sterile water, and ounce of this mixture given every hour, with a medicine drop- per. Gavage through a tube is not practical. 4. The child is rubbed once daily with warm sweet oil and is not otherwise washed. Prognosis.-At six months, a very small percentage are saved; at six and one-half months, 20 per cent.; at seven months, 40 per cent.; at seven and one-half months, 75 per cent.; at eight months and thereafter 90 to 95 per cent. Artificial Feeding of Infants.-There are two methods avail- able: (1) a wet-nurse and (2) modification of cow's milk. Wet-nurse.-The qualifications are (1) she should have a child of nearly the same age as the one to be nursed; (2) she should have neither syphilis nor tuberculosis; (3) her milk 118 PHYSIOLOGY OF THE NEW-BORN INFANT should be of good quality, as is best evidenced by the appear- ance of her own child; (4) she should be from respectable surroundings. In this country it is often difficult to secure wet-nurses, even though bureaus to supply them exist in many of the large cities. Modification of Cow's Milk ANALYSIS Cow's Milk 1. White. 2. Acid. 3. Septic. 4. Curds heavy. 5. Fat 4 per cent. Sugar 6 per cent. Casein 3.5 to 4 per cent. Human Milk 1. Yellowish. 2. Alkaline usually. 3. Practically sterile. 4. Curds light and flocculent. 5. Fat 4 per cent. Sugar 7 per cent. Casein 1.75 per cent. The chief difference is thus seen to be in the casein contents. Goat's milk is much more like human milk, but in this country is difficult to procure. The capacity of the child's stomach is about one ounce at birth and increases roughly one ounce for each month of age; the feeding interval is at first every three hours and is length- ened, as the child grows, to three and one-half and four hours. The total amount of food varies from ten ounces in twenty- four hours at birth to forty ounces by the end of the first year. Each child is an individual problem; hence no short synopsis of feeding can be given. For details of feeding, the student is referred to works on diseases of children, in all of which the subject is fully discussed. It is not desirable, in a manual on obstetrics, to enter into too great details of artificial feeding in infants. The problem is often presented however, during the puerperium and the following method is so simple and has given the author such satisfaction that he includes it here. The method is devised by Dr. Charles W. West, of Philadelphia, and possesses all necessary attributes of accuracy, simplicity and flexibility. MANAGEMENT OF NEW-BORN CHILD 119 The percentage of fat, proteid, sugar, and the total quantity required are first decided upon. Then the necessary quantity of milk, water and sugar are determined by the following formula. The formula is based upon the use of a 4 per cent, milk. Formula. Proteid -- X 32 = number of ounces of top milk dipped out, Proteid ' . . , n 4- X quantity = amount of top milk withdrawn to be used, Quantity . ... , ... -- X (Sugar - proteid) = number ounces of dextn- maltose or milk-sugar, Quantity minus the number ounces milk used = number ounces of barley-water. EXAMPLE It is desired to make up 24 ounces of a mixture containing 1 per cent, proteid; 6 per cent, sugar; 3 per cent. fat. M X 32 = 10% or 11 (practically) ounces of top milk to be withdrawn, /-( X 24 = 6 ounces of this top milk to be used, 2Moo X 5 = 12%oo = (JM) ounces of milk-sugar, 24 - 6 = 18 ounces of barley water. DIRECTIONS FOR THIS MIXTURE, GIVEN TO THE MOTHER OR NURSE From a quart jar (not shaken up) of 4 per cent, milk, dip off, with a Chapin dipper, the top 11 ounces, and pour into a clean vessel. Of this 11 ounces, 6 ounces are again dipped off, and to this added ounces of milk sugar and 18 ounces of barley water. It is always easiest to work out the quantities in multiples of 12 ounces. The above example gives 10 bottles of 2 ounces each with 2 extra for possible breakage. 120 PHYSIOLOGY OF THE NEW-BORN INFANT Pasteurization of Milk.-An easy method is the following: 1. Prepare the number of bottles required for twenty- four hours, in the morning. 2. Stopper with cotton and place in a vessel deep enough to contain them. The bottles should be warmed to prevent cracking, and a rack to hold them is very convenient. 3. Pour on actively boiling water up to the level of the milk. 4. Put on cover and stand aside for thirty minutes. 5. Keep the bottles on ice until used, and warm each one just before giving to the baby. This gives the milk a temperature of 170° F. for twenty minutes. The bottles are filled to the brim with cold water just after using, and are scalded out before being refilled the next day. The nipples should be bought as blanks, scalded and kept in a covered quart Mason jar of boric acid solution. The holes are made with a hot needle; the proper size hole yielding two or three drops a second. CHAPTER VII THE MECHANISM OF LABOR Presentation.-By presentation is meant the part of the fetus which presents at the pelvic inlet. Position.-The position of the presenting part describes the relation that the most prominent portion of the presenting part bears to the mother's acetabula or sacro-iliac junctions. The methods of naming presentations are numerous. The most widely used method is the following: Each presentation is named from its most prominent por- tion: The vertex is named from the occiput; the face and brow from the chin; the breech from the sacrum. There are .four positions of each presentation. If, to use the vertex as a model, the occiput points toward the mother's left acetabulum, the position is left occipito-anterior, or L. 0. A., as it is ordinarily abbreviated. If it points toward the right acetabulum, it is a right occipito-anterior, or R. O. A. If toward the right or left sacro-iliac junction, it is right or left occipito-posterior; R. O. P. or L. O. P. In a face presentation we then have right or left mento-anterior or posterior; in a breech presentation, right or left sacro- anterior or posterior. The method applies to all presentations. Most Frequent Presentation.-The position of the child in utero is longitudinal in 99.5 per cent, of all cases. The head is the most common extremity to present. It is the heaviest Fig. 44.-The four quadrants of the pelvic inlet. Used in naming the different presenta- tions. (De Lee.) 121 122 THE MECHANISM OE LABOR portion of the child and naturally tends to gravitate downward, and supposedly aided by the fact that the child voluntarily assumes the position, to give its extremities more room in the upper portion of the uterus. The commonest portion of the head to present is the vertex. The vertex is roughly that portion of the child's head between the anterior and posterior fontanels. From the anterior fontanel to the root of the nose is the sinciput; from the posterior fontanel to the suboccipital protuberance is the occiput. As the longer half of the child's head is in front of the spinal column, as shown diagram- matically by two bars, one representing the axis of the spinal column and the other the head, any pressure exerted on the head will depress the longer bar and flex the head. The commonest position of a vertex presentation is the left occipito-anterior. In this position the head is in the right oblique diameter, which is the longest unobstructed diameter of the pelvis. On account of the normal left lateral torsion of the uterus, the back is turned anteriorly, and the child is further supposed to adapt its abdominal surface to the pro- jection forward of the lumbar spinal column, which turns its back forward and its occiput toward the left acetabulum. If the back is to the right, the occiput usually points toward the right sacro-iliac junction, because the chin is turned forward by lateral torsion of the uterus. L. O. A. is about 70 per cent, and R. O. P. nearly 30 per cent, of vertex presentations. Recently Potter states that of his patients, nearly all of whom are delivered by version as soon as dilatation of the cervix is complete, 70 per cent, show primary posterior posi- tions of the occiput. He claims that early and complete examination-with the hand in the lower uterine segment, enables him to make more satisfactory diagnoses than is pos- sible otherwise. Possible presentations of the head are: (1) vertex; (2) anterior fontanel; (3) brow; (4) face; (5) ear; (6) parietal eminence. FORCES INVOLVED 123 Forces Involved.-The forces involved in the mechanism of labor are the forces of expulsion and of resistance. The forces of expulsion are the abdominal muscles and muscles of the upper uterine segment. The lower uterine segment is the portion of the uterus that is dilated to allow the passage of the child. The boundary line between the seg- ments, usually at or slightly above the level of the internal os, is a perceptible ridge and is called the contraction ring of Bandl. The degree of force exerted by the combined uterine and abdominal muscles has been estimated to be from seven- teen to fifty-five pounds (one estimate as high as 88 pounds). The uterine muscle exerts its force upon the uterine contents by diminishing the area of the uterine cavity and thus forcing the fetal body in the direction of least resistance. The forces of resistance are: (i) the bony walls of the pelvis; (2) the lower uterine segment and cervix; (3) the vagina and (4) the vulva; (5) the child's head and body. The pelvis offers only slight resistance to the passage of the child of normal size. The lower uterine segment and cervix are dilated normally by a pouch of the membranes containing liquor amnii pushed down in front of the head, and exerting equal hydrostatic pressure in all directions. The membranes are assisted by the longitudinal fibers of the uterus, which help to pull the cervix up over the presenting part; by the separation of the muscle-bundles in the cervix, and finally by the fact that the cervix becomes paralyzed and then stretches mechanically. The fetal head and body are classed as one of the forces of resistance. The head is the largest and, in labor, most important part of the fetus. The bones of the head are divided from each other by sutures; the two frontal bones being separated by the frontal suture, the two parietal by the sagittal suture; the frontal from the two parietal by the coronal suture and the two parietal from the occipital by the lambdoidal suture. At the junction of the coronal, sagittal and frontal sutures there is a lozenge or kite-shaped space called the anterior fontanel; at the junction of the sagittal and lamb- 124 THE MECHANISM OF LABOR Fig. 45.-Method of palpating head in the diagnosis of position. Fig. 46.-Position of heart sounds. They are heard in these positions with greatest intensity, in the different presentations, as noted. VERTEX PRESENTATIONS 125 doidal sutures is found a small triangular space, the posterior fontanel. The sutures and fontanels allow a certain amount of mobility to the cranial bones. By overlapping of the bones, the head is materially reduced in size during labor, particularly in cases of contracted pelvis, and the posterior fontanel almost disappears. Diagnosis of position is made by (i) abdominal palpation- to note the position of the back, head and extremities; (2) abdominal auscultation-to note the position of the heart sounds; (3) vaginal examination-to note the character and relations of the presenting part and, if a vertex, the relation of the sagittal suture to the oblique diameter of the pelvis and the position of the large and small fontanels; (4) to a limited extent by the x-ray. Position of Heart Sounds.-In L. 0. A. they are heard plainest one inch below and one inch to the left of the umbili- cus; in L. O. P. one inch below the umbilicus and well over in the left flank. In R. O. A. one inch below and one inch to the right of the umbilicus; in R. O. P. one inch below and well over in the right flank. In breech presentation, on a trans- verse line about three fingers above the umbilicus; in transverse presentations; on a transverse line midway between the umbilicus and symphysis. The x-ray will show whether the position of the child is head or breech presentation, or transverse. It will not show the various positions of vertex or breech presentation with any accuracy. VERTEX PRESENTATIONS Diagnosis of L. O. A.-Abdominal examination shows the back to the left; the head below; the heart sounds heard plain- est one inch below and to the left of the umbilicus. Vaginal examination shows the dome of the vertex present- ing; the sagittal suture in the right oblique diameter; the small triangular fontanel anterior near the left acetabulum; the large diamond-shaped fontanel back near the right sacro- 126 THE MECHANISM OF LABOR Fig. 48.-Left occipito-posterior position of a vertex presentation. (De Lee.) Fig. 47.-Left occipito-anterior position of a vertex presentation. (De Lee.) VERTEX PRESENTATIONS 127 Fig. 50.--Right occi-pito-anterior position of a vertex presentation. (De Lee.) Fig. 49.-Right occipito-posterior position of a vertex presentation. (De Lee.) 128 THE MECHANISM OF LABOR Fig. 52.-Right occipito-anterior position of a vertex presentation. {Dorland.) Fig. 51.--Left occipito-anterior position of a vertex presentation. {Dorland.) VERTEX PRESENTATIONS 129 Fig. 54.-Right occipito-posterior position of a vertex presentation. (Dorland.) Fig. 53.-Left occipito-posterior position of a vertex presentation. (Dorland.) 9 130 THE MECHANISM OF LABOR iliac joint. It is difficult to feel these details unless the cervix is fairly well dilated. Diagnosis of L. O. P.-Abdominal examination shows the back to the left, the head below; the heart sounds one inch below the umbilicus and in the left flank. Vaginal examination shows the dome of the vertex present- ing; the sagittal suture in the left oblique diameter; the small fontanel posterior near the left sacro-iliac joint; the large fontanel anterior near the right acetabulum. Diagnosis of R. O. P.-Abdominal examination shows the back to the right; the head below; the heart sounds heard one inch below the umbilicus and well over in the right flank. Vaginal examination shows the dome of the vertex pre- senting; the sagittal suture in the right oblique diameter; the small fontanel back near the right sacro-iliac; the large fonta- nel forward near the left acetabulum. Diagnosis of R. O. A.-Abdominal examination shows the back to the right; the head below; the heart sounds heard one inch below and one inch to the right of the umbilicus. Vaginal examination shows the dome of the vertex present- ing; the sagittal suture in the left oblique diameter; the large fontanel back near the left sacro-iliac joint; the small fontanel forward near the right acetabulum. When during labor there is a large caput succedaneum and the sutures and fontanels are masked by it, it may be a help in diagnosis to feel high up for the child's ear, or even palpate the head by inserting the whole hand in the vagina. This is done under anesthesia, as a preliminary to a forceps delivery; it is never needed in a spontaneous delivery. In case of doubt, when a diagnosis cannot be made with certainty, few mistakes will be made if the head is assumed to be in the right oblique diameter of the pelvis, and the forceps applied accordingly. The Mechanism of a Vertex Presentation.-The mechanism of a vertex presentation can best be described in ten steps. It is essentially, the same in all positions of a vertex. VERTEX PRESENTATIONS 131 1. Flexion and moulding of the head, occurring from the time of subsidence of the uterus to the actual onset of labor. Its purpose is to fit the head accurately in the pelvic inlet. 2. Ftirther flexion and moulding, at the beginning of the first stage of labor, is a continuation of the first step. 3. Lateral inclination, or more accurately, posterior incli- nation of the head, to accommodate it to the new direction it has to take, to descend the birth canal. The axis of the pelvic canal does not continue in the same line as the axis of the uterus, but takes a direction at first downward and backward. Fig. 55.-Touch picture. Normal anterior rotation of the occiput. 4. Obliteration of the length of the cervix and the dilatation of its canal, by the amniotic sac. 5. Descent of the head to the pelvic floor, by extension of the fetal spine. The body does not follow this movement, so that the hips remain at as high a level as they were before. The child's back, which during the early stage of labor is rounded, is simply straightened out. 6. Anterior Rotation of the Occiput.-When the most de- pendent portion of the head (in a vertex presentation, the occiput) strikes the pelvic floor, it follows the direction of least resistance and rotates downward, forward and inward, until it occupies a position under the symphysis. The movement is the same in all positions of a vertex presentation, except that in posterior positions the occiput has a greater distance to rotate, and the labor is consequently longer. An anterior 132 THE MECHANISM OF LABOR position rotates through 45 degrees; a posterior position through 135 degrees. 7. Birth of the head, partly by actual propulsion along the canal and partly by extension of the head, to allow the face to be born over the perineum while the occiput is arrested under and anterior to the symphysis. 8. Restitution- When the head rotates, the shoulders do not follow the movement, and the neck is thus somewhat twisted. When the head is born the twist in the neck is corrected and this is called restitution. It is a theoretical movement and is rarely noticeable, except in posterior positions. 9. External rotation of the head externally following the rotation of the shoulders internally as the anterior shoulder encounters the resistance of the pelvic floor and is rotated downward, forward and inward under the symphysis. 10. Birth of the Shoulders.-The anterior shoulder appears first under the symphysis, emerges half way and is then ar- rested. The posterior shoulder slips out over the perineum, and then the anterior shoulder is entirely born, and the rest of the child's body follows rapidly. Most Common Abnormalities of Mechanism in a Vertex Presentation.-The mechanism of a vertex presentation has few abnormalities, the most important being: 1. Engagement of the head in the transverse diameter, instead of the oblique, in contracted pelves. This diameter, if the iliopsoas and iliacus muscles are flattened out by pressure, affords greater room for the head. 2. Imperfect flexion, in contracted pelvis, to allow the engage- ment of the smaller bitemporal diameter in the contracted conjugate, instead of the larger biparietal diameter. 3. Exaggerated lateral inclination, in flat pelves. The angle at which the axis of the pelvic canal meets the axis of the uterus is increased, and the head has a sharper corner to turn. 4. Slow dilatation of the cervix, from rigidity or in contracted pelves. VERTEX PRESENTATIONS 133 5. The head passes the promontory one-half at a time. This is seen in flat pelves, and is a direct consequence of exaggerated inclination. The head is arrested with the parietal eminences caught on the promontory and symphysis. As the lateral inclination increases, the posterior parietal eminence rides up and allows the anterior to slip past the upper edge of the symphysis. As the symphysis, below its upper edge, shelves out, this allows the whole head to move forward enough to let the posterior parietal eminence slip past the promontory, and the head to enter the pelvic canal. Fig. 56.-Touch picture. Occiput rotated into the hollow of the sacrum. 6. Posterior Rotation of the Occiput.-In about 1.5 to 2 per cent, of cases, the occiput, instead of rotating forward under the symphysis, goes backward into the hollow of the sacrum. Cause.-1. Obstacles to forward rotation such as a large head which fits tightly in the pelvis, or a hand prolapsed down beside the head, acting as a wedge to prevent forward rotation. 2. Contracted pelves, especially in the transverse diameter. 3. Lack of resistance, such as a lacerated perineum, justomajor pelvis or small fetal head. 4. Imperfect flexion, allowing the chin to strike the pelvic floor, and be rotated anteriorly, thus throwing the occiput posteriorly. Effect.-1. Greatly prolongs labor. 134 THE MECHANISM OF LABOR 2. Greatly increased fetal mortality (9 per cent.). 3. Greatly increased danger of laceration of the perin- eum. Management.-Prevent its occurrence if possible, by the application of forceps to twist the head around, or the use of one blade of the forceps as a lever to pry the head around. If the accident occurs, spontaneous delivery is possible, but the application of forceps is usually required. The forceps is applied without rotation of the blades, laterally to the child's head, the sagittal suture runs anteroposteriorly, the large fontanel under the symphysis. When the forceps is adjusted, traction is made by constantly raising the handles until the child's brow appears under the symphysis. The handles are then lowered, to extract the face; and then raised again, to extract the occiput. Episiotomy (oblique) is usually required, to save undue laceration of the perineum. No attempt should be made to rotate the occiput anteriorly, under the symphysis, because of the excessive twisting of the child's neck. 7. Delayed Anterior Rotation of the Occiput.-Causes.- 1. Excessive size of head. 2. Errors in flexion. 3. Compound presentations, where the hand acts as a wedge. - 4. Inertia uteri. Management.-If the labor is unduly prolonged, and exami- nation shows the head still to be in the oblique diameter, the best treatment is the application of forceps. The complication is most likely to occur in R. O. P. The forceps is applied in this position, the head drawn down on the perineum, and then rotated anteriorly by the forceps as rotator. The forceps (then nearly upside down) is removed, reapplied as in R. O. A. and the delivery completed. This is the Scanzoni maneuver, and is, except in a primipara, better than the manual FACE PRESENTATION 135 rotation either on the perineum or at the pelvic brim. If this maneuver is used in a primipara, there is con- siderable danger of severe laceration, often into the bladder. In posterior positions of the vertex, forceps delivery is required in about 15 per cent. In many cases it will be found difficult or impossible to draw the head down the canal, without the application of more force than is justifiable. In these cases, podalic version is indicated. FACE PRESENTATION Frequency.--Face presentation occurs about once in two hundred and fifty to three hundred cases. Cause.-A face- presentation is usually due to some cause preventing proper flexion of the head, such as tumors or Right mento-posterior. Left mento-anterior. Fig. 57.-The two commonest positions of a face presentation. (De Lee.) enlargement of the neck, coiling of the cord around the neck, marked enlargement of the thorax, etc. Diagnosis.-The diagnosis of a face presentation is made as follows: i. By Abdominal Examination.-The child is found pre- senting by the head, the bulk of the head to one side of the 136 THE MECHANISM OF LABOR median line; a deep groove can be felt between the child's occiput and back, and the heart sounds are heard most plainly over the child's abdominal surface. 2. By Vaginal Examination.-The absence of the dome of the vertex, filling the upper pelvic canal is most striking. Fig. 58.-What the examining finger feels in a face presentation, left mento-anterior position. (Dorland.) The presenting part is high up; the smooth surface of the fore- head forms a marked contrast to the irregular outline of the rest of the face; when the os is dilated, the characteristic features of the face can be felt-the orbital ridges and eye- sockets, the nose, the point of the chin and the mouth with the hard line of the gums. If the patient has been in labor for some time, the features of the child's face are often obscured FACE PRESENTATION 137 by edema, and the diagnosis must rest upon the discovery of the mouth. It is recognized as the mouth by the hard line of the gums within it, and by the fact that if the finger be inserted, the child, if alive, will suck upon it. The diagnosis of position of a face presentation is made by noting the position of the chin. If near the left acetabulum, the position is L. M. A. (left mento-anterior); if near the left sacro-iliac, L. M. P.; if near the right sacro-iliac, R. M. P.; if near the right acetabulum, R. M. A. A common error in diagnosis is to mistake a breech for a face presentation. Mechanism.-A face presentation almost invariably begins as a brow presentation, but becomes a face presentation as soon as labor sets in, and the head becomes fully extended. The chin is the most prominent part, and is, in a normal case, rotated anteriorly when it meets the resistance of the pelvic floor. Hence the four positions of a face presentation are named the left mento-anterior or posterior, and the right mento-anterior or posterior. The left mento-anterior is the most common. Face presentation is dangerous to both mother and child. By steps, in a strictly normal case, the mechanism is as follows: 1. Gradual extension and moulding of the head, in the two weeks preceding labor. 2. Further extension and moulding, when labor sets in. 3. Lateral inclination of the head. 4. Dilatation of the cervical canal. 5. Descent of the head to the pelvic floor. 6. Anterior rotation of the chin, which meets the resistance of the pelvic floor, and is turned downward, forward and inward, until it rests beneath the symphysis. 7. Birth of the head, by propulsion along the canal and by partial flexion. 8. Restitution. 9. External rotation. 10. Birth of the shoulders and body, in the way already described under vertex presentation. 138 THE MECHANISM OF LABOR A face presentation with the chin anterior, is a possible labor and can perform spontaneously all the steps noted above. A face presentation with the chin posterior is an impossible labor, and cannot, without active interference, proceed beyond the point where normally the chin should rotate anteriorly. Abnormalities in Mechanism.-The commonest abnor- mality in mechanism is the delay or entire failure of rotation of the chin under the symphysis, or its rotation into the hollow of the sacrum. To secure this rotation it is necessary for the Fig. 59.-Face presentation, chin posterior in hollow of sacrum. (Smellie.) (Smellie.) chin to encounter the resistance of the pelvic floor. If the chin is posterior to the midtransverse line of the pelvis, on account of the disproportion between the length of the child's neck (1.5 inches) and the lateral depth of the pelvis (3.5 inches) the chin is often unable to descend far enough before the thorax begins to enter the pelvis and prevent further progress. The chin must perform this forward movement for the head to be born. As the uterine contractions continue, they attempt to force the upper portion of the trunk, with the posterior half of the child's head into the pelvis. As these portions of the child have a total diameter of 18 cm. (7.25 inches), it is obviously impossible to crowd them into the pelvic inlet, which has a diameter of only 11 cm. (4.25 inches), and the labor is in- superably obstructed. FACE PRESENTATION 139 Prognosis of Face Presentation.-Mother.-Deep perineal lacerations are common, because of the large diameter of the head (the mento-occipital) engaged as the head is born. The maternal mortality, including cases that have been mismanaged is 6 per cent., but with intelligent treatment should be very much less. Child.-The fetal mortality, from the prolongation of labor and the undue pressure upon the child's head is 15 per cent. Management-If the patient is seen early in labor, and the chin is found to be well forward of the transverse diameter of the pelvis, the labor will in all probability terminate spontaneously and require no interference, but only careful watching, with more frequent examination than in a vertex presentation. If the chin is posterior, and this occurs almost as frequently as anterior positions, an attempt should be made, if seen early, to convert the face into a vertex presentation, by flexing the head either by external manipulation (Schatz's method) or by external and internal manipulations combined (Baudelocque's method). If the labor is well advanced, an attempt should be made to secure anterior rotation of the chin by supplying the resistance usually afforded by the pelvic floor. This can be done by pressing upon the chin and posterior cheek with two fingers; by using a single blade of the forceps as a lever, which is less tiresome and more convenient than the fingers; or by applying forceps to the head and compelling rotation by twisting the head in the necessary direction. If the chin is anterior to the transverse diameter, the for- ceps may be used as tractor as well as rotator. If the chin is posterior, the head should never be pulled upon with forceps. If all efforts at rotation fail, it may be possible, under ether, to push the head out of the pelvis (if it is not too firmly im- pacted) and by performing podalic version, deliver the child. Management of Impacted Face Presentations.-If the patient is seen late in labor, when posterior rotation of the chin has already occurred, and the child's face firmly wedged in the pelvic canal, the problem is a difficult one. First it 140 THE MECHANISM OF LABOR should be ascertained if the child is alive or dead. If dead, craniotomy offers a simple solution. If alive, and the head is not too firmly wedged in (as it probably is) an attempt should be made to convert it into a vertex presentation and then extract with forceps. This attempt will probably fail. If the uterus is not firmly moulded around the child's body and tetanically contracted, podalic version may be done; but this is usually a most dangerous procedure. If the case is not a proper one for it, and few of them are, a ruptured uterus will almost certainly result. An impacted face presentation, with a live baby, calls usually for either pubiotomy or low cervical cesarean section; the latter being the better and safer method. In all cases of face presentation delivered by the vagina, deep oblique episiotomy is required, to control in extent the otherwise unvoidable lacerations. However, by this time the child is so firmly impacted that no change in its position can be made with safety; it is usually dead from the excessive pressure, and if its death can be in- dubitably confirmed, craniotomy is the method of delivery. BROW PRESENTATION In brow presentation the head occupies a position midway between flexion and extension, thus presenting the largest diameters of the head to engage in the superior strait. It is the most unfavorable of all head presentations for both mother and child. Frequency.-A persistent brow presentation occurs once in 1750 labors. As every face presentation begins as a brow, and as a brow presentation is not infrequently converted into a vertex, primary brow presentation must be much more frequent than the figures would indicate. Cause.-The same causes account for both face and brow presentations. BROW PRESENTATION 141 Diagnosis.-The points upon which the diagnosis rests are practically the same as for a face presentation, with one excep- tion. It is not ordinarily possible to feel the chin and mouth; as by the time these are palpable, the presentation has become a face. Fig. 6o.-Left mento-posterior position of a brow presentation. {Dorland.) Mechanism.-The positions of a brow presentation are named from the positions of the chin, and the steps of the mechanism, when possible, are exactly those of a face presen- tation. Abnormalities in Mechanism.-The head is more tightly wedged into the pelvis than in a face presentation, on account of the larger fetal diameters involved. For this reason delay 142 THE MECHANISM OF LABOR in rotation of the chin is the rule, and an insuperably ob- structed labor from failure of or posterior rotation of the chin is common. Prognosis.-The fetal mortality is 30 per cent. The ma- ternal mortality depends upon intelligent management. It Fig. 6i.-Right mento-posterior position of a brow presentation. (Dorland.) has been estimated at io per cent., but should be, in competent hands, almost negligible. Management.-The management is that of a face presenta- tion. It is not likely that rotation can be secured, even by using the forceps as rotator, and if the head is not firmly engaged, podalic version will give the best results. If the head BREECH PRESENTATION 143 is firmly impacted the management is the same as that of an impacted face presentation. PRESENTATION OF THE GREATER FONTANEL Presentation of the greater or anterior fontanel is a rare occurrence. Its mechanism is practically that of a face presentation. The largest diameters of the head are involved, and extensive lacerations of the cervix and pelvic floor are very frequent. Treatment.-It should be converted into a vertex presenta- tion if possible, by pressing the brow upward with two fingers of one hand in the vagina, while counterpressure downward is made upon the occiput through the abdominal walls, with the other hand. If this fails podalic version and not forceps is the proper treatment. BREECH PRESENTATION Frequency.-Breech presentations occur in about 3.3 per cent, of all labors. They are more frequent in multiparae than in primiparae; and more frequent in multiple than in single pregnancies. Cause.-The causes of breech presentations are usually irregularities in the shape of the fetus or of the uterus, such as dilatation of the lower uterine segment, or hydrocephalus. Their occurrence is favored by any obstruction to the normal engagement of the head, such as a contracted pelvis, a pelvic tumor, or placenta perina. Diagnosis.-Abdominal Examination.-The head can usually be felt in the upper portion of the uterus; the back occupies one side of the uterine cavity and the extremities the other; the presenting part is small, easily compressible and the fetal heart sounds are heard most often above the umbilicus. By vaginal examination the presenting part is small and high up; the dome-like projection of the child's head, felt in vertex presentations is absent, and by careful examination 144 THE MECHANISM OF LABOR the features of the breech may be made out; the tip of the sacrum, the buttocks and the genitalia. If the membranes are ruptured, the finger is often stained with meconium. One or both feet are often felt alongside of or even below the breech. It is not uncommon for a breech to be mistaken for a face presentation. It is not uncommon for a breech presentation to change into a head presentation. This is most likely to happen during the last month of pregnancy, and has been Right sacro-posterior. Fig. 62.-The commonest positions of a breech presentation. {De Lee.) Left sacro-anterior. reported as occurring even during labor; of course before the presenting part has become engaged. A breech presentation, with presentation of one or both feet, is sometimes called a "footling." Mechanism.-The most prominent part of the breech is the sacrum. Hence the positions of a breech presentation are right or left sacro-anterior or posterior: R. S. A.; L. S. A.; R. S. P.; L. S. P. The flexion and moulding of the presenting part, seen in vertex presentations, is absent in a breech, be- cause the presenting part is so small and easily compressible that it does not have to accommodate itself to the shape of the pelvic inlet. The first step in the mechanism is 1. Lateral inclination of the breech. 2. Dilatation of the cervix. BREECH PRESENTATION 145 3. Descent of the hips to the pelvic floor. 4. Anterior rotation of the sacrum. 5. Birth of the hips. 6. Engagement of the shoulders in one of the oblique diameters, usually the right, and descent of the shoulders. Fig. 63.-What the examining finger feels in a left sacro-anterior posi- tion of a breech presentation. Both feet palpable. {De Lee.) 7. Anterior rotation and birth of the shoulders. 8. Engagement of the head in the oblique diameter opposite to that in which the shoulders engaged. 9. Anterior rotation of the occiput and birth of the head by the chin, face, forehead and anterior fontanel passing succes- sively over the pelvic floor. Abnormalities in Mechanism.-Slow Dilatation of the Cervix. The breech is small, easily compressed, and an inefficient excitor of uterine contractions. It is not unusual for this step to take twenty-four to thirty-six hours. Imperfect Rotation.-On account of the small size of the breech, the anterior hip often meets with resistance insuffi- cient to rotate it forward under the symphysis and the hips emerge from the vulva in an oblique position. IO 146 THE MECHANISM OF LABOR Posterior rotation of the occiput is a rare abnormality and will be discussed in the management of a breech. Prognosis.-Breech labors are often very long, on account of the slow dilatation of the cervix. The fetal mortality is 30 per cent., and prolapse of the cord is much more common than in vertex presentations. Prolapse of the cord is a serious complication in a vertex presentation; in a breech it is rarely serious, as the risk of compression is slight. Passage of meconium is a serious feature of any labor except a breech. It usually signifies impending death for the child. In a breech presentation it is due largely to mechanical compres- sion, and has usually no serious feature. In all cases it must be remembered that a breech presentation, presenting spontaneously at the outlet, rarely offers any difficulty in delivery. A breech presentation pulled down prematurely, however, in an attempt to hasten delivery, before the cervix is completely dilated, often causes formidable diffi- culty in the extraction of the after coming head. Management.-If the case is seen before labor has begun, it may be converted, by external version, into a vertex pres- entation, to give the child the increased chance of safe de- livery. The attempt to do this will often fail. If labor has set in, it should not be interfered with until the child's body has emerged up to the umbilicus. A long finger-like process of the membranes often projects through the dilating cervix, and should not be ruptured, on account of the danger of pro- lapse of the cord. When the hips appear at the vulvar orifice the patient is brought across the bed, and placed in the lithotomy position, with her hips well over the edge of the bed. The body of the child, as it appears, is grasped with both hands, and pulled down toward the floor. This usually throws the arms up over the head. The arms are next extracted by grasping the feet in one hand and carrying the child's body up and to one side. The opposite arm is then extracted by inserting two fingers in the vagina, locating the arm, and by pressure on the forearm {not the upper arm) sweeping it across BREECH PRESENTATION 147 the child's face. The body is then carried to the other side and the other arm extracted. The head is delivered by the Wigand method of placing the child across the forearm with the middle finger in its mouth, to maintain the flexion of the head. The body is then carried up over the mother's ab- domen, in the so-called curve of Cants, aided by suprapubic pressure upon the occiput with the free hand. It will often be found desirable to deliver the shoulders anteriorly under the symphysis, in the manner described by Potter. The child, it as emerges, is rotated so that the abdomen is up. As soon as the feet emerge, the body is again Fig. 64.-Delivery of after-coming head. The arrow shows the direction the body is carried. rotated so that one shoulder is anterior and the scapula appears under the symphysis. The arm then drops out, with very slight pressure at the elbow. The body is then rotated through 180 degrees, so that the other scapula appears under the symphysis and the other arm is gently extracted. When the child's body is pulled down toward the floor, one or rarely both of the arms may be caught behind the neck, below the occiput. This is the nuchal position of the arm, and it is often necessary to fracture the humerus to dislodge it. The other methods of delivering the after-coming head will be described in the chapter on obstetric operations. 148 THE MECHANISM OF LABOR Posterior rotation of the occiput should not occur, if the atten- dant has been careful to rotate the back anteriorly while pulling upon the body after the hips have appeared. If it occurs, its management depends upon whether the chin is free, or caught Fig. 65.--The nuchal position of the arm. {Dorland.') under the symphysis. If it is free, the child's body is carried straight down toward the floor; if it is caught under the sym- physis the body is carried up over the mother's abdomen. In any cases of breech presentation, no time should be wasted after the body is born past the umbilicus. From the time the umbilicus is born until the delivery is complete, the cord is subjected to serious compression. Hence, haste in the termination of the labor is essential. The maneu- vers described should be performed as rapidly as is consistent with safety, until the child's face is exposed through the vulvar ring, and its nose and mouth visible. From this time on, haste is not essential, as the child can breathe, and the slow TRANSVERSE PRESENTATION 149 delivery of the large, posterior portion of the head will mini- mize the severe lacerations which commonly attend too rapidly completing this step in the delivery. In certain cases of breech presentation in primiparse, with justominor pelves, whose measurements in themselves do not necessarily demand it, cesarean section must be considered as a means of delivery. Particularly is this true of elderly primiparae or when the child is oversized. The head cannot be fitted in the pelvis; it must come through hurriedly, ex- tended and unmoulded, and when the decision to deliver by vagina is once acted on, it is not possible, after the body is de- livered, to change and try something else. All these factors must be considered, and in certain cases cesarean section will unquestionably appeal to the physician as the best means, for both mother and child, as in a justominor pelvis whose measurements, were the case one of head presentation in which a test of labor could be carried out, would not justify a section. It is a good rule never to attend a breech presentation, or a case requiring version without having the forceps boiled and ready for use, in case any difficulty is found in delivering the after-coming head. In many cases, episiotomy will avert extensive or even com- plete perineal lacerations. TRANSVERSE PRESENTATION Frequency.-Once in about two hundred cases. Cause.-Transverse presentations are seen in women with abnormal relaxation of the abdominal walls; deformities of the pelvis such as kyphosis; distention of the uterine cavity due to a fibroid tumor and rarely in cases of hydramnios or hydro- cephalus. They are much more frequent in multiparse than in primiparae. Diagnosis.-The abdomen is much wider than normal, and the long axis of the uterus runs transversely. The head 150 THE MECHANISM OF LABOR occupies one iliac fossa and the breech the other; the shoulder usually presents, and the heart sounds are heard most plainly Fig. 66.-Shoulder presentation, right acromio-anterior. {Dorland.) Fig. 67.-What the examining finger feels in a shoulder presentation. {De Lee.) in the middle line below the umbilicus. By vaginal examina- tion the presenting part is high up, and by careful palpation TRANSVERSE PRESENTATION 151 it is sometimes possible to make out the characteristics of the shoulder. It is easy to mistake the fold between arm and body for the gluteal fold in a breech. In a transverse position it is usually possible to feel the ribs. Position.-It is usually asserted that a transverse presenta- tion has not the four positions given to the other presentations. A plan has been proposed, but not widely accepted, to name four positions of a transverse presentation from the acromion process. Hence left-acromio-anterior, etc. Fig. 68.-Spontaneous evolution of a shoulder presentation. (One-sixth natural size, redrawn from Kustner.) Mechanism.-Strictly speaking, a transverse presentation has no mechanism. When labor sets in, the shoulder presents, an arm usually prolapses and all progress ceases. Presenta- tions of the umbilicus or back are possible, but rare. If such a case were left to itself, the lower uterine segment would 152 THE MECHANISM OF LABOR become overdistended, the contraction ring rise higher and higher until the uterus ruptured. Spontaneous delivery is possible in one of three ways: (1) Evolution into a vertex. (2) Spontaneous evolution into a breech presentation. (3) Spontaneous delivery as a shoulder presentation, with the body doubled up (corpore reduplicate). This is most likely to happen in premature children, but the author has seen two cases at full term; one where the child weighed eight and one-half pounds. Prognosis.-Unless the labor is terminated by artificial means, is bad. If the case is neglected, rupture of the uterus is to be expected. Management.-If the case is seen before labor, it is possible, if the membranes are intact, and the abdominal walls not rigid, to transform the presentation into a breech or vertex. If seen during labor, podalic version is the better treatment. It is difficult to give a definite rule for guidance as to the safety of podalic version in labor. Ordinarily if the membranes have been ruptured, with active pains, for over two hours, or if there is a visible contraction ring, and the uterus is moulded tightly around the child's body, the danger of rupture of the uterus is too great to justify version. Except in the greatest emergency, version should not be attempted without an anesthetic. Management of Impacted Shoulder Presentations.-When podalic version is impossible. The first step is the determina- tion of the life or death of the child. It may be possible to auscult the heart sounds on the abdomen, but usually the hand must be inserted in the uterus, to palpate the cord. If the cord is beating, and well above 100, cesarean section is indicated. A prolapsed arm need not contraindicate the operation; the arm can be washed, painted with tincture of iodin, put back in the vagina, and the vagina cleansed, painted with tincture of iodin and packed. If the child is dead, decapitation is the only thing to be considered. MECHANISM OF THE THIRD STAGE 153 Bandl's Contraction Ring.-In any case of obstructed labor, and particularly in impacted shoulder presentations, the lower uterine segment is much overdistended. The dividing line between the contracting upper portion of the uterus and the overdistended paralyzed lower portion is marked by a depres- sion usually running obliquely across the abdomen. It is always palpable and often visible. This is Bandl's contraction Fig. 69.-Impacted shoulder presentation, with prolapse of the arm, and high Bandl's contraction ring. An impossible labor. (Chiari.) ring, and the nearer it is to the umbilicus, the greater the danger of rupture of the uterus. The upper margin of an overdistended bladder in labor must not be mistaken for it. MECHANISM OF THE THIRD STAGE Separation and Delivery of the Placenta Separation of the Placenta.-The placenta is detached from the uterine wall by a diminution of its site. The structure of the placenta is much like a sponge, and can be compressed up to a certain point. When that point is reached, uterine con- traction continues and the placenta is peeled off the uterine wall, and is expelled from the uterine cavity into the lower uterine segment and vagina. The process takes fifteen to thirty minutes. When pituitrin has been given during labor, this time is often shortened to three or four minutes. When the 154 Tills MECHANISM OF LABOR placenta is detached and ready for expression, the fundus usually rises to slightly higher level. Delivery of the Placenta.-When the placenta is loose, it is expressed by the Crede method. It is delivered like an inverted umbrella, or sometimes edgewise, with its membranes trailing up into the vagina and lower uterine segment. Management/-As the placenta emerges it is caught in the hand. The hand holding the uterus then relaxes its grip, and the membranes are extracted by gentle traction on them, using the placenta as a handle. The practice of making a rope of the membranes by twisting them is too likely to leave some behind. If it becomes necessary to pull on the mem- branes themselves, sterile gauze should be used, as they are too slippery to be held in the gloved fingers. When the placenta and membranes have been extracted, they should be examined for missing portions. Any missing part of the placenta should be extracted; if anything less than one-half of the membranes remain behind, the missing portion will usually be passed spontaneously within twenty-four hours. Severe bleeding only should indicate the extraction of small missing portions of the membranes. Sometimes, when the placenta has been examined and found whole, a large piece of placenta will be passed a few days later. This is usually a placenta succenturiata, or accessory lobule, which was not detached with the main organ. Abnormalities in Mechanism.-The placenta may be either retained or adherent. If retained, all that is necessary to secure its delivery is the proper application of the Crede method. Occasionally it is held in place by atmospheric pressure, and the Crede method fails to dislodge it. In such cases, the finger may be hooked over the edge of the placenta, and the air let in behind it, when its expulsion will be easily secured. A retained placenta is not attended with bleeding, while an adherent placenta usually bleeds profusely. It should be a rule not to give the dose of ergot by hypodermic until the placenta is delivered. If the placenta is adherent, as is shown usually by MECHANISM OF THE THIRD STAGE 155 Fig. 70.-Retained placenta, with large blood clot in upper portion of uterus. {Redrawn from Polak.) Fig. 71.-Method of manipulation for artificial separation of the adher- ent placenta. (Dickinson.) 156 THE MECHANISM OF LABOR the bleeding, the large size of the uterus and the complete failure of the Crede method, it must be extracted manually. Unless the bleeding justifies it, manual extraction should not be considered until after one hour after delivery. After careful cleansing not only of the hand, protected by a rubber glove, Fig. 72.-Adherent placenta. {Polak.') but of the vulva and vagina, the whole hand is inserted in the vagina, following the cord up into the uterus. The fingers are inserted under the edge of the placenta, and it is gradually and gently peeled off the uterine wall. If any adhesions, too dense to be separated in this manner, are felt, they may be pinched through with the thumb and forefinger. The loosen- ing of the placenta is materially aided by compression by the MECHANISM OF THE THIRD STAGE 157 free hand upon the fundus, through the abdominal wall. When the placenta is entirely detached, no effort is made to extract it, but the uterus is stimulated to contract by kneading it with the free hand on the abdomen, and is made to expel the hand and placenta together. If the placenta is forcibly Fig. 73.-Hour-glass contraction of uterus, imprisoning placenta. (Bumm.) extracted, it may act like the piston in a cylinder, and by suction cause inversion of the uterus. Hour-glass Uterus.-'When after a reasonable wait, one hour or more, attempts at manual extraction of the placenta are made, it will sometimes be found to be retained by a tight contraction of the uterine muscle below it. This gives the uterus the shape of an hour-glass. The contracted ring 158 THE MECHANISM OF LABOR must be dilated manually, the placenta separated, if neces- sary, and the contraction of the uterus allowed to expel the hand and placenta. Intractable Adherent Placenta.-Very rarely it will be found impossible to separate the placenta from the uterine wall, without using more force than is justifiable. In these cases, the uterus and vagina should be packed, for twenty-four hours, with sterile gauze. On the removal of the gauze, the placenta usually follows it spontaneously, or can be easily expressed. Prognosis.-The greatest dangers are hemorrhage and sepsis, which may be minimized by prompt treatment and cleanliness. Placenta Acer eta (or Increta).-Rarely the placenta is im- movably attached to the uterine wall. The decidua serotina is atrophied or absent; the villi of the placenta invade the uterine wall and the placenta becomes practically an integral part of the uterus. The uterine wall is very thin and easily ruptured. On attempt at manual removal, the hemorrhage is always alarming. If, after 24 hours of packing, there is no noticeable loosening of the placenta, abdominal hysterectomy will usually be required to avoid death from hemorrhage. Complete manual removal of a placenta accreta is impossible. CHAPTER VIII DISEASES OF THE OVUM AND FETAL APPEN- DAGES. INTRA-UTERINE DISEASES OF THE FETUS. MONSTERS ABNORMALITIES OF THE AMNION The amnion may be the seat of inflammation, and, as a consequence, may adhere to the newly forming skin of the embryo. As the cavity distends, these adhesions are stretched out into long bands-the amniotic bands. Occasionally an extremity of the fetus is caught between two of these bands and amputated. They occur usually with oligohydramnios. Other deformities of the fetus-anencephalus, exomphalos, etc., have been attributed to them. Abnormalities of the Amniotic Fluid The fluid may be whitish or opaque; green or brown if meco- nium is present; or reddish, as in the case of a macerated fetus. It may putrefy, if the fetus is dead; this has occurred, however, with a living child. Abnormalities in Secretion.-Excessive secretion or hydram- nios is not uncommon. A severe degree of hydramnios occurs once in about 150 pregnancies; minor grades much more fre- quently; a quantity in excess of two liters must be considered excessive. Thirty liters has been reported. Cause.-Most frequently the fluid is derived from the fetus, although it may come from the mother alone, or from both mother and fetus. It may be due to 1. Abnormally active kidneys of the fetus. 2. Abnormally active skin. 159 160 DISEASES OF THE OVUM AND FETAL APPENDAGES 3. Abnormal pressure in the blood-vessels of the cord or the fetal surface of the placenta. About half the cases of hydramnios have no demonstrable cause. Symptoms.--(1) Excessive size of the uterus, especially in the latter months of pregnancy; (2) muffling of the fetal heart sounds and movements; (3) globular shape of the uterus. The uterus sometimes reaches an enormous size without marked in- convenience to the patient. About 2 per cent, of the cases are acute, when the symptoms are (1) intense pain, from the sudden distention of the uterus; (2) dyspnea; (3) cyanosis; (4) often excessive vomiting; (5) fever; in addition to the symptoms mentioned above. Diagnosis.--The history of pregnancy and careful search for the above symptoms should clear up the diagnosis. Preg- nancy with ascites; with ovarian cyst; with overdistention of the bladder or with twins have all been mistaken for hydramnios. Treatment.-Usually inaction unless the distention is extreme and the patient's respiration and heart action embar- rassed. In such a case, the membranes should be ruptured, either with the finger, or with some instrument passed along the finger as a guide. In either case the opening made should be partially closed by the fingers, to prevent a too rapid rush of fluid and prolapse of the cord. This treatment will usually induce labor. It is sometimes possible to reduce the amount of fluid by sweating. The treatment is best carried out by means of the portable cabinets, heated by steam. Hot packs are not efficient. Two sweat baths a day, of thirty minutes each, are given. The method is always worth a trial, though failures are frequent. Oligohydramnios or deficiency of liquor amnii is rare. Occasionally the liquid is almost absent, only a few drams of clear viscid fluid remaining. The etiology is not well under- stood. The diagnosis is difficult and treatment is of course impossible. ABNORMALITIES OF THE CHORION 161 ABNORMALITIES OF THE CHORION Hydatid Mole Synonyms.-Hydatidiform mole, vesicular mole, myxoma chorii and cystic degeneration of the chorion villi. The chorion villi are transformed into small, pedunculated cysts, filled Fig. 74.-Cystic degeneration of the chorion villi, or hydatid mole. (Bumm.) with a clear viscid fluid, varying in size from a pinhead to a small walnut. Its name refers to its fancied resemblance to a bunch of grapes. It involves usually the entire chorion, but may be limited to a small portion of the membrane. The cause of hydatid mole has been much discussed, but Marchand has shown that the essential feature is found in the epithelial covering of the villus, which proliferates, pene- trates the villus and probably causes the degeneration of the stroma with disappearance of the blood-vessels of the terminal villi. The fluid contents are attributed to edema. Recent II 162 DISEASES OF THE OVUM AND FETAL APPENDAGES investigations have shown that there is a curious connection between the corpus luteum and the ovum. As long as the corpus luteum is healthy, the ovum remains so. If the corpus luteum is destroyed, the ovum is blighted. If the corpus luteum becomes cystic, a hydatid mole often develops in the ovum, and if in the corpus luteum there occurs an unrestrained proliferation of the lutein cells, there is a corresponding pro- liferation of syncytium in the ovum and a chorionepithelioma results. Frequency.-Hydatid mole is rare, ocurring once in about 2500 pregnancies. It is most frequent after the age of thirty- five, though seen at all ages. It appears early in pregnancy, rarely after the third month. Symptoms.-The symptoms of hydatid mole often simulate an ordinary threatened abortion. There is quite profuse bleed- ing, associated with the signs of pregnancy. There is at first a rapid increase in the size of the uterus, and then a cessation of development. Thus in the earlier months, the uterus may be much larger than would be expected from the date of preg- nancy; in the later months, much smaller than the normal. There is usually a severe toxemia, marked by depression, jaun- dice and vomiting. Hydatid mole is too frequently associated with nephritis, for the association to be a coincidence. There often occurs a discharge of one or more of the chorionic vesicles. The diagnosis rests upon the detection of these vesicles in the discharge, or on feeling the grape-like masses with the finger introduced through the cervical canal. It is not uncommon for the entire mass to be expelled suddenly, with few premonitory symptoms. Treatment.-As soon as the diagnosis is made, the uterus should be evacuated by dilating the cervix, preferably to the size of a dollar, and with pressure on the fundus attempting to express the mass. Usually placental forceps will be required to complete the extraction. Care must be taken to prevent perforation of the uterus. If the hemorrhage is profuse, it may be necessary to tampon the vagina until the cervix is ABNORMALITIES OF THE CHORION 163 sufficiently dilated. The earlier in its history the mole is evacuated the more severe is the bleeding. Moles removed at what should be near term can usually be managed with very Fig. 75.-Section of uterus containing a hydatidiform mole (Bumm): a, Vesicles extending into blood-sinuses in uterine wall; b, openings of maternal blood-sinuses; c, os internum; d, cervix; e, vesicles extending into uterine wall; f, uterine veins and degenerated chorionic villi. moderate bleeding. Those early in pregnancy are complicated by very severe bleeding, necessitating the prompt packing of the uterus and vagina, and administration of aseptic ergot 164 DISEASES OF THE OVUM AND FETAL APPENDAGES (two ampules) and pituitrin (one ampule) hypodermically. Twenty-four hours later the evacuation of the uterus can be proceeded with, though several attempts must often be made before the uterus is emptied. After the expulsion of the mole, the patient should be carefully watched at intervals of a month or two through a period of several years, to detect as early as possible a developing chorionepithelioma. If such a patient begins to bleed irregularly, the interior of the uterus must be carefully explored and the scrapings examined microscopically. Dangers are hemorrhage; perforation of the uterus, either by manipulations in extracting the mole or spontaneously; septic infection; and the possible sequence of chorionepithelioma. Chorionepithelioma (Deciduoma Malignum, Syncytial Cancer) This is a most malignant growth, following labor, abortion or frequently hydatid mole. About one-half of the reported cases of chorionepithelioma have been preceded by hydatid mole. It results from unrestrained proliferation of the syncy- tium, and gives most rapid metastases all over the body, but particularly to the lungs, vagina and brain. The nodules are soft, spongy and purplish in color. Microscopically they con- sist mainly of masses of syncytial cells and large blood spaces. It may occur coincident with normal pregnancy or hydatid mole, or at any interval up to several years thereafter. Symptoms are usually irregular bleeding from the uterus occurring after the puerperium is completed, accompanied by a foul smelling discharge. In many cases the appearance of metastases in the vagina was the first symptom detected. The uterus is large and soft and the os patulous. The diagnosis rests upon the microscopic examination of a portion of the tissue. Treatment.-Combined total hysterectomy as soon as the diagnosis is made. abnormalities of the umbilical cord 165 Prognosis.-If detected early and promptly treated by panhysterectomy, recurrence is unlikely. If seen in the stage when vaginal or other metastases have appeared, the out- come is dubious. Radium has not been successful in con- trolling the original growth or the metastases. Operation is always advisable, however, as metastases have been reported to disappear. It may occasionally be extruded like a miscarri- age, and spontaneous cure result. It is usually the most rapidly growing and spreading of all the malignant tumors. Fibromyxomatous Degeneration of the Chorion This is a condition that may simulate hydatid mole. The mass is solid instead of cystic and is most often confined to a small portion of the chorion, at the placental site. It is usually detected in the placenta after labor. ABNORMALITIES OF THE UMBILICAL CORD OR FUNIS Length.-The cord may be much longer than normal, up to 198 centimeters (77 inches), or may be very short (3.5 centimeters-one and one-third inches). A long cord is likely to be coiled around the neck or extremities of the child and frequently prolapses during labor; a short one may delay the advance of the child in labor, or may cause a premature separation of the placenta. Loops of the Cord.-The cord is frequently twisted around the neck or extremities of the child, the loops being rarely drawn taut. Occasionally they result in the child's death. Knots of the Cord.-These are of two kinds, the false and true. False knots are due to a localized hypertrophy of the jelly of Wharton; true knots are actual knots, sometimes of a most complicated character. They are rarely drawn taut, but sometimes the vessels are compressed, the circulation is cut off and the child dies of suffocation. 166 DISEASES OF THE OVUM AND FETAL APPENDAGES Tumors of the cord are rare, and are usually myxomata or myxosarcomata, and occasionally small cysts, due to the local- ized liquefaction of the jelly of Wharton, are found. Umbilical hernia, due to an arrest of development of the abdominal wall around the umbilical ring, is frequent. Abnormalities in Insertion.-The insertion of the cord is usually near the center of the placenta, but not in the exact center. It is not infrequently inserted at the margin of the placenta, or even at some distance from the edge, on the mem- branes, the so-called velamentous insertion. ABNORMALITIES OF THE PLACENTA Number.-The placenta of a single child may be divided into lobes, which simulate separate organs. There may be small accessory placentae-placenta succenturiate-which are often retained after expulsion of the main organ. In multiple pregnancies, each child has usually its own placenta, except in unioval pregnancies. Situation.-Normally the placenta is situated in the upper portion of the uterus. It is sometimes attached near or over the internal os-placenta previa (q.v.); or surrounds the entire membranes-placenta membranacea. Size and Weight.-The normal placenta is about seven inches in diameter and weighs about one pound. These dimensions are often increased or even doubled. Infarcts occur in every placenta. They appear as whitish patches of varying extent. They are of no clinical importance unless of a size sufficient seriously to interfere with the pla- cental circulation, when abortion may result. Inflammation of the placenta is occasionally seen, usually gonorrheal in origin, and is secondary to inflammation of the decidua. Syphilis.-The placenta shows a great hypertrophy and distortion of the villi, due to infiltration by small round cells. The degree of involvement depends on the date of the mother's ABNORMALITIES OF THE DECIDUAE 167 infection. If she is syphilitic before conception, the entire placenta is involved; if she is infected late in pregnancy, it may appear entirely normal. A syphilitic placenta is usually whitish or pinkish in color, and if the child is expelled near term, is considerably larger than normal. Syphilis is by far the most common cause of repeated, noninduced abortions and miscarriages. Tumors of the placenta are rare. They are benign or malig- nant. The commonest benign tumor is fibromyxoma; the malignant is chorionepithelioma. ABNORMALITIES AND DISEASES OF THE DECIDUAE Inflammation is not uncommon, being usually secondary to slight degrees of endometritis. Severe endometritis is neces- sarily associated with sterility. The inflamed decidua is greatly thickened, either localized or diffuse, and may present polypoid growths or small cysts. The rupture of these cystic decidual glands, with the sudden gush of fluid from the vagina, is one of the causes of hydrorrhea gravidarum. Acute primary inflammation of the decidua, due to direct infection or to one of the exanthemata, sometimes occurs. Hydrorrhea gravidarum is the name given to a constant or periodic flow of a serous or seropurulent liquid, resembling liquor amnii, from the vagina of pregnant women. Its causes are rupture of the membranes, hydrosalpinx, edema of the uterine walls or inflammation of the decidual glands. The quantity may be a pint or more. It usually occurs after the sixth month of pregnancy and is likely to induce premature labor. The patient should be warned of this possibility. No treatment for hydrorrhea gravidarum is of any avail. Subchorial hematoma is rare. It is due to an extravasation of blood between the decidua and chorion, in cases of poly- poid inflammation of the decidua. The nourishment of the embryo is usually cut off, and pregnancy is terminated. 168 DISEASES OF THE OVUM AND FETAL APPENDAGES DISEASES OF THE FETUS IN INTRA-UTERINE LIFE Syphilis.-This is the most frequent cause (83 per cent.) of habitual fetal death in the latter months of pregnancy. The fetus contracts the disease in one of three ways; by a syphilitic father, the mother remaining free from infection; by a syphilitic mother at the time of conception and by the mother contracting syphilis subsequent to her impregnation. It is possible for a mother to give birth to a syphilitic child, though she herself shows no clinical signs of syphilis; she may have a negative Wassermann reaction. Fig. 76.-Excoriations and blebs in the face of a syphilitic child. (De Lee.} Congenital syphilis may descend from grandparents to grand- child, the intermediate generation being free from symptoms and having negative Wassermann reaction. Symptoms.-If the child is born alive, the most reliable signs are: its wizened appearance, like a little old man with a cold in his head; blebs and bullae on its body; protuberant abdomen; coryza which is irritating and produces two lines of excoriation running down its upper lip; possibly linear scars of healed ulcers around its mouth or anus-the so-called rhagades-and the harsh, dry and brittle skin. The blood and cerebrospinal fluid will give a positive Wassermann reaction and spirochetae pallidae may be found in the fetal tissues, placenta and cord. In a dead child, the most reliable signs are: Wegner's sign of fatty degeneration of the epiphyses of the long bones, most DESEASES OF FETUS IN INTRA-UTERINE LIFE 169 marked in the upper epiphysis of the femur; overgrowth of the liver, overgrowth of the spleen, and cirrhosis of the lungs -the so-called white pneumonia. Wegner's sign is the most reliable of all. The epiphyses in a normal child show as sharply drawn, bluish-white lines, about 1 mm. wide; in a syphilitic child the epiphyses show as broad jagged yellowish lines, three or four times their normal breadth. This line is plainly visible in an x-ray plate. Fig. 77.-Wegner's sign of syphilis, in the femur of a syphilitic fetus. (E. P. Davis.) Infection.-A child with marked syphilis whose mother shows no sign of syphilis, may nurse from her without danger of infecting her, but would almost certainly infect any other woman (Colles' law). On the other hand a syhilitic woman may nurse her apparently healthy child without fear of its contracting the disease (Profeta's law). Prognosis is poor. Ninety-three per cent, of children born with obvious syphilis die in the first year; of the remainder not 170 DISEASES OF THE OVUM AND FETAL APPENDAGES many live to puberty. Of those who do survive the majority are ill-developed, ill-nourished and subject to complications such as ascites, hydrocephalus, and persistent skin eruptions. Dentition is delayed and shows the well-known Hutchinson's teeth. Treatment.-If a patient presents herself with a history of repeated stillbirths, considerable tact is required to establish a diagnosis of syphilis. Wassermann tests should be made of the blood of both husband and wife, if possible. If the wife is not already pregnant, appropriate treatment should be given to both, if both give positive reactions. If the wife is already pregnant, and her Wassermann reaction is positive, she alone need be treated, as far as the results to this pregnancy are con- cerned. It must be remembered that the intravenous use of salvarsan or neo-salvarsan in pregnant women is more likely to be followed by severe reactions, and that treatment must be supplemented by mercury and iodids. Pregnant women also respond to doses smaller than those required in non-pregnant. It is exceedingly difficult to get most patients to carry out faithfully a course of inunctions, though this is the best method of administration. If proper treatment is instituted either before pregnancy or early in pregnancy (prior to the third month) it is probable that the child will apparently be healthy and show no clinical signs of syphilis though its Wassermann will probably be positive, especially of the spinal fluid. Treatment of Syphilis in the New-born Child.-Daily inunc- tions of io to 20 grains of mercurial ointment is the best and easiest treatment. Instead of this grain of mercury and chalk, or grain of calomel may be given four times daily. The intravenous use of salvarsan to the.child is difficult of performance, and dangerous. It is also unsafe to rely upon the curative qualities of the milk of the mother who has received salvarsan. The child should be handled only with rubber gloves, and the person caring for it should be warned of the infectious nature of the disease. It should never be allowed to nurse from a wet-nurse. DISEASES OF FETUS IN INTRA-UTERINE LIFE 171 Infectious Diseases and the Exanthemata.-It is rare for a woman contracting any of the infectious diseases during preg- nancy to transmit the disease to her child. Ordinarily the placenta seems to act as a bar or filter, beyond which the infection does not extend. All these diseases are attended with a considerably increased risk of a premature termination of pregnancy. If a woman contracts any of the exanthemata and recovers without miscarriage, the child is said to be immune to future attacks. Noninfectious diseases of the fetus, such as rickets, cystic elephantiasis, congenital polycystic kidney, congenital ana- sarca, etc., are rare, and such children ordinarily do not survive. Often the fetal size is so increased that spontaneous delivery is impossible. Injuries to the fetus such as fractures of the bones, disloca- tions, traumatism from stabs or wounds follow sometimes violence to the mother. Habitual fetal death is due to many causes, chief among them syphilis (83 per cent.), displacements or deformity of the uterus, inflammation in or about the uterus, chronic disease of the mother and the so-called habitual death, where no definite cause can be assigned. The diagnosis is made by exclusion and the treatment must be directed to the cause. In habitual death without demonstrable cause, which most often occurs in the latter weeks of pregnancy, a living child may be born by the induction of labor previous to the time at which the fetus has died in previous pregnancies. In these cases it is wise to carry out in future pregnancies, the routine treatment for syphi- lis, even though its presence cannot be proven. Effect of Maternal Death upon the Fetus.-The child usu- ally dies at the same time, but it is said to have survived as long as two hours (Tarnier). Effect of Fetal Death upon the Mother.-If the child dies early in pregnancy, an abortion will ordinarily result. If it does not, the diagnosis may be difficult. The signs of preg- 172 DISEASES OF THE OVUM AND FETAL APPENDAGES nancy will usually subside, milk may appear in the breasts, and the abdomen fails to enlarge progressively. The changes that take place in the fetus after death, unless it is expelled from the uterus are: (i) maceration; (2) putre- faction; (only if the membranes are ruptured); (3) saponifica- tion (adipocere-an ammoniacal soap); (4) calcification (lithopedion); (5) mummification; (6) total or partial absorp- tion (this only in the first three months of gestation). If the diagnosis can be established, the uterus should be emptied. If the fetus dies late in pregnancy, the fetal movements cease, the heart sounds cannot be heard, and, if the pregnancy does not terminate at once, milk may appear in the breasts. If the membranes are not ruptured the child will macerate, but not putrefy. If there is doubt about the diagnosis, the preg- nancy should not be interfered with, as it is entirely possible for the physician to fail to appreciate the fetal movements or hear the fetal heart sounds, and still the child to be alive. If the child dies during labor, in cases where the choice of some operative procedure depends upon the decision, under proper precautions the hand can be introduced into the uterus and the cord palpated, to determine the presence or absence of pulsations. Maternal impressions seem to affect the psychic develop- ment of the fetus and not the physical. Severe shock and fright have influenced the child's mentality, but that shocks, dreams, horrible sights, etc., so affect the child as to produce physical deformity is open to grave question. Maternal fever does not affect adversely the fetus, unless it is raised suddenly, as in sunstroke, or to excessive heights. A temperature up to 105° or 106° F., attained slowly, doesnot necessarily affect the child, even if long continued. MONSTERS There are two classes of monsters: i. Single. 2. Double or multiple. MONSTERS 173 Causes of single monsters: i. Defective-when all or part of an organ is missing. 2. Deformed-when the organ is wrongly formed or displaced. 3. Excessive development-where an organ is enlarged or doubled. 4. Due to intra-uterine disease-the effects of amniotic bands, such as amputations. Syphilis plays a prominent part in the causation of single monsters. The double monsters are named from the site of their union: Sternopagus (sternum); xiphopagus (the ensiform cartilage-the Siamese twins); craniopagus (head); ischiopagus (breech) etc. The diagnosis and management of monsters is difficult and each case is a separate problem. The x-ray is often of great value in establishing a diagnosis. CHAPTER IX PATHOLOGY OF PREGNANCY DISEASES OF THE VULVA Edema of the vulva is not uncommon. It is due to pres- sure upon the pelvic veins, or kidney insufficiency, and oc- casionally to local infection. It may affect one or both labia, and is more common in the latter months of pregnancy. The treatment should be directed to the cause, if cause can be found, with hot fomentations locally. If the condition does not yield to treatment, the labia may be punctured, in several places, with a thin-bladed knife or needle. This may termi- nate pregnancy, but is occasionally followed by gangrene of the labia and the danger of infection is great. Vegetations or veneral warts (condylomata) are of two kinds: (i) Flat; (2) pointed. The flat are due to syphilis, and occur in groups of three or more, on the inner surfaces of the labia and around the anus. They are associated with mucous patches and other signs of syphilis. Pointed condylomata are due to dirt, parasites or gonorrhea. They are branched papillomata, occur over the labia and perineum, and often extend to the vagina or even cervix. They are usually partially macerated by a serous irritating discharge. Treatment.-Pointed condylomata should be removed by the cautery about two weeks short of term, as they are liable, especially if extending into the vagina, to be crushed in labor and cause septic infection. The removal will probably bring on labor, and should be done under general anesthesia, unless the warts are small and few in number. Flat condylomata should not be touched locally, as if removed, they always 174 DISEASES OF THE VULVA 175 recur more extensively than before. They will respond to constitutional treatment for syphilis. Pruritus is due to diabetes, irritating leukorrhea, dirt and parasites or neurosis. The itching is intense. The treat- ment should consist in relieving the cause, and local applica- tions of very hot water, strong solutions of nitrate of silver, (20 to 40 gr. to the ounce) or of carbolic acid, or menthol ointment 5 per cent. The most satisfactory local application has been the follow- ing lotion: Acid carbolic gr.xlv Acid boric 3iss Pulv. zinc oxid 5iii Glycerin 3i Aquae camphorae q. s. ad 3 vi M. Sig. To be applied frequently with absorbent cotton. In neurotic pruritus no treatment may be of avail and preg- nancy may have to be terminated. Rarely the neurotic type of pruritus may persist after delivery, and require surgical interference. This is never necessary in the other forms. It consists in (1) amputation of the labia, which is unsatisfactory because of the persistent itching of the scar, so that the patient is as uncomfortable as before; or (2) resection of the five pairs of sensory nerves; (1),genital branch of genitocrural; (2) ilio- inguinal; (3) inferior pudendal; (4) perineal branches of the pudic; (5) dorsal nerve of the clitoris. X-ray treatments are efficient in many cases, and give a high percentage of cures. Radium is disappointing. Varices of the labia are occasionally very large. Fatal hemorrhage has occurred. They should be protected from injury, as hemorrhage is always dangerous, and must be con- trolled by pressure of a vulvar pad or ligature. The patient should be instructed how to apply pressure, with a gauze pad, to check the bleeding temporarily, if the vein ruptures. 176 PATHOLOGY OF PREGNANCY If a vein ruptures subcutaneously, an enormous labial hematoma will form. -As the increase in size is rapid and constant, it must be opened by a large incision, the clots turned out and the bleeding checked by ligature, suture and packing. The operation is always difficult and tedious and at times is quite formidable. Cancer of the vulva is very rare in pregnancy. The age of the patient is usually beyond that of child-bearing. If it occurs, it should be operated on at once regardless of the preg- nancy, and the scar subsequently treated with x-ray or radium. The prognosis is bad. Lupus vulvae is also very rare. The patients usually suffer severely, and the only treatment is the energetic use of x-ray. DISEASES OF THE VAGINA Gonorrhea in Pregnancy.-This infection is never to be regarded lightly. It can invade the decidua and cause severe local inflammation and abortion. During pregnancy the danger of primary acute pyosalpinx is not great, though an old infection may be lighted up to acute severity. Venereal warts of the cervix, vagina and vulva are common consequences of gonorrheal infection, as are also abscesses of Skene's or Bartho- lin's glands. The leukorrheal discharge accompanying granular vaginitis is always annoying and often intensely irritating. The child's eyes are very often infected during birth. After labor, the gonococci may invade the uterus, tubes, pelvic or general peritoneal cavity or even the blood stream and cause severe infection. They more often, however, by lowering the patient's local resistance, act as forerunners of a streptococcic infection. The treatment of these conditions is considered in the various sections in which they belong. Vaginitis is usually of the granular variety, due to gonorrhea. An irritating leukorrhea, with the reddened granular appear- ance of the vagina, are the most prominent symptoms. Ven- ereal warts on the cervix and vulva, may be associated with it. DISEASES OF THE VAGINA 177 Treatment should be avoided, if possible, on account of the danger of miscarriage. The best treatment is the local appli- cation, through a skeleton speculum, of 30 per cent, carbolic acid in glycerin, or of a 40 grain to the fluid-ounce solution of silver nitrate. If carbolic acid is used, the vulva and buttocks should be well greased with vaselin. Routine douching is not Fig. 78.-Granular vaginitis in pregnancy. advisable. The patient should be warned of the possibility of miscarriage, due to the irritating nature of the treatment. An emphysematozis vaginitis, due to the bacillus emphysema- tosus vaginae is sometimes seen. It follows colpohyperplasia cystica, when the fluid in the cyst is replaced by gas (tri- methy lamin). Varices occur as in the vulva and require the same treat- ment. Suburethral hypertrophy of the vaginal mucosa is common. It is of no importance, but sometimes is of such extent as to 12 178 PATHOLOGY OF PREGNANCY simulate cystocele. It usually requires no treatment, but can be excised if annoying to the patient. Suburethral abscess is due to infection from Skene's glands. It looks not unlike a cystocele, but is hard and brawny in feel, and pressure causes pus to exude from the urethra. It is drained like any other abscess. Vaginal cysts are of two kinds: (1) Lymphatic cysts- which may occur anywhere; and (2) cysts of Gartner's duct in the anterior vaginal wall. They are occasionally so large as to obstruct delivery and to require puncture. Parasitic infection, or mycosis vaginae is seen in white patches, like thrush. It is due to the Leptothrix vaginalis and is easily curable by mild antiseptic douches, such as 10 gr. to the ounce of boric acid. Vaginal cancer requires immediate operation, regardless of pregnancy. If too advanced for operation, cesarean section, two weeks short of term, will be required. Vaginal hernia is exceedingly rare. It is most commonly lateral or posterior. DISEASES OF THE CERVIX Diseases of the cervix are usually inflammatory in character, and often cause exaggerated or pernicious vomiting. The inflamed and eroded cervix frequently bleeds irregularly, simulating persistent menstruation. An inflamed cervix is treated on the same principles as granular vaginitis, with 40 grains to the ounce of nitrate of silver, or the solid stick applied through a bivalve speculum. Cancer of the cervix complicating pregnancy is rare. If it occurs, the prognosis is extremely unfavorable. The majority of patients abort. If pregnancy goes to term, the mortality from hemorrhage or septic infection is nearly 50 per cent., if the patient is allowed to fall in labor. If cancer is discovered early in pregnancy, the uterus should be removed DISEASES OF THE UTERUS 179 at once; if late in pregnancy a cesarean section followed by abdominal panhysterectomy is the proper treatment. Cervical polyps do not complicate pregnancy except by bleeding. They are easily seen through a speculum, and removed by torsion. Cervical condylomata are rarer than vaginal. There is great risk of their being crushed in labor, and causing septic infection. They should be removed by cautery in the last two weeks of pregnancy. Anesthesia is usually necessary. DISEASES OF THE UTERUS Displacements.-The uterus may be displaced backward (retroversion); forward (anteflexion); laterally; may be pro- lapsed; may form part of a hernia. Retroversion or retroflexion of the pregnant uterus results most often from pregnancy occurring in a uterus already re- troverted. The organ may fall backward after impregnation. Retroflexion is the more common. Symptoms.-The most prominent symptom is dysuria, from the mechanical obstruction of the urethra by pressure of the cervix against the symphysis. Later the overflow of reten- tion may develop. Other symptoms are backache, headache, persistent pelvic pain and possibly bleeding. The occurrence of any of these symptoms in a pregnant woman indicates an immediate vaginal examination. Diagnosis.-With two fingers of one hand in the vagina, in front of the cervix, which is abnormally high, pressure with the other hand on the abdomen above the symphysis fails to elicit the rounded bulk of the uterus. If the fingers of the hand in the vagina are moved behind the cervix, the body of the uterus is felt lying in the hollow of the sacrum and filling the pelvis. Terminations.-Most commonly, spontaneous reposition by contraction of the longitudinal muscle fibers of the anterior wall, at about the third month of pregnancy. Next in frequency, abortion; incarceration or wedging of the uterus in 180 PATHOLOGY OF PREGNANCY the true pelvis followed possibly by inflammation and gan- grene. Rarely the pregnancy may go to term, by the over- stretching or sacculation of the anterior uterine wall. Treatment.-While spontaneous reposition is the most common termination, it is not safe to wait for it to occur, on account of the danger of incarceration. The patient should Fig. 79.--Incarcerated retroverted uterus, with distention of the bladder. be placed in the lithotomy position and catheterized. A long stiff silk or linen catheter is needed, sterilized by soaking in cold i-iooo bichlorid of mercury solution or 1-20 carbolic acid. Soft rubber or glass catheters are useless. A male prostatic catheter may be needed, or even paracentesis may have to be done. It is impossible to replace the uterus until the bladder is emptied. The physician places two fingers of one hand in the vagina and behind the cervix and makes pressure upward and slightly to one side, to escape the promontory of the DISEASES OF THE UTERUS 181 sacrum, until the fundus can be reached through the abdominal wall by the fingers of the other hand and pulled forward. If this fails, the knee-chest posture and a repositor should be tried, to push the uterus forward. This method is materially aided by fastening a tenaculum on the anterior lip of the cervix and pulling down while the fundus is pushed up by the reposi- tor. Anesthetics are often necessary. If the attempt is successful, the uterus must be supported by a pessary, until it Fig. 8o.-Front and side views of Patterson's abdominal support. is too large to slip back into its old position-about the fourth month. If the uterus cannot be replaced, there is a choice between abdominal section and reposition, or the termination of pregnancy. Incarceration- If the uterus is incarcerated it may be impossible to catheterize the patient. A long stiff silk or linen catheter must be used and if the attempt fails, supra- pubic puncture of the bladder is justifiable. It may then be possible to replace the uterus; if not, it must be emptied. If the pregnancy goes to term by sacculation of the anterior uterine wall, the cervix is pulled high up above the symphysis, 182 PATHOLOGY OF PREGNANCY there is no continuity of the uterine and pelvic canals, the presenting part cannot enter the superior strait and the anterior uterine wall is dangerously thinned out. The uterus will often rupture early in labor; inertia is the rule. The safest method of delivery is cesarean section a week before term. Podalic version is not safe, because of the thin uterine wall. Anteflexion of the uterus is physiologic and usually gradu- Fig. 8i.-Posterior displacement of the cervix at term. (Dickinson.) ally corrects itself as pregnancy progresses. The uterus may protrude between the recti muscles and in that case must be supported by an abdominal binder. If the anteflexion is the result of an operation for suspension of the uterus, it may be serious. The adhesions either break spontaneously or preg- nancy may proceed to term by a sacculation of the posterior uterine wall. Lateral displacements are not serious and in pregnancy rarely require more than the use of longitudinal pads and an abdominal binder. NONTOXIC DISEASES OF ALIMENTARY CANAL 183 Prolapse almost invariably occurs from pregnancy in a uterus already prolapsed, or it may be due to the increased weight of the uterus. All or part of the cervix usually pro- jects from the vagina, when the woman is erect, and in the early months the whole organ may protrude. Terminations.-Complete or partial reposition, which is the most frequent and occurs about the third month; abortion or incarceration. Treatment.-The uterus must be replaced, and a suitable support worn; the best being the ball-and-stem pessary, sup- ported by straps from an abdominal belt or Goddard's alumi- num ring pessary. Soft rubber implements, intended to remain in the vagina, should never be used on account of the foul discharge they cause. If the uterus is incarcerated, pregnancy must usually be terminated. Posterior displacement of the cervix is seen only in primi- parae. The anterior portion of the lower uterine segment is overstretched, and the cervix will be felt far posterior, and high up near the promontory of the sacrum. In the ordinary examination, no cervix or cervical canal can be felt; it is neces- sary to reach high up behind the head to feel it. It is of no importance in pregnancy. In labor, it may cause serious delay, due to the failure of the cervix to dilate. If the fore- finger is hooked in the canal, and traction made during a pain, the difficulty is quickly overcome. Rheumatism of the myometrium sometimes occurs, marked by violent abdominal pain, without variation in the pulse or temperature. The administration of salicylates clears up the diagnosis, and affords relief inside of twelve hours. NONTOXIC DISEASES OF THE ALIMENTARY CANAL Appendicitis in pregnancy is more serious. The following conclusions are advised: i. If a patient has had appendicitis, and becomes pregnant, operation should be recommended. 184 PATHOLOGY OF PREGNANCY 2. In. appendicitis in pregnancy, operation and not palliative treatment should be followed. 3. The later in pregnancy the attack, the more likely it is to be fulminant. 4. The later in pregnancy the attack, until the sixth month, the higher up and nearer to the umbilicus is the incision. After the sixth month, the incision is median. 5. Operations in early pregnancy do not endanger the fetus. 6. If it is necessary to operate after the sixth month, the uterus will have to be turned out of the abdominal cavity, and emptied by a cesarean section before being replaced. This is particularly needed in drainage cases, and often hysterectomy as well. Caries of teeth, due chiefly to the acid saliva, is common. The remedy is an alkaline mouth wash, and if any dental work is required, it should be of a temporary character, and prolonged sessions in a dentist chair avoided. Only local anesthesia should be used. Nitrous oxide is to be avoided. Gingivitis and pyorrhea are aggravated by pregnancy. Mouth washes containing astringents, local sponging with tincture of ipecac and hypodermic injections of emetin give the best results. Constipation should be relieved by mild laxatives. Calomel particularly should be avoided. The best combination is one of cascara and phenolphthalein, the dose varied as required. Diarrhea is best checked by paregoric one dram, chalk mixture two drams and bismuth subnitrate five grains. Hemorrhoids are common and distressing. The best re- sults are obtained from the use of the bidet, and the following prescription: 1$. Cocain hydrochlor gr xx Ointment of nutgall Ointment of belladonna aa oz 1 Sig. Apply three or four times daily, inside the rectum, after the hemorrhoids are replaced. DISEASES OF THE CIRCULATORY SYSTEM 185 The bowels are kept loose and straining at stool is to be avoided. Liver degenerations belong really to toxemia. In the toxemia of early pregnancy with hyperemesis the degeneration of the liver begins in the center of the lobule; in the toxemia of late pregnancy, with eclampsia, the degeneration begins in the periphery. Ptyalism.-The saliva is alkaline, and is secreted in large quantities (as high as 51 ounces daily). The cause is obscure; a neurosis or possibly auto-intoxication. It may depend, as seems to do in part the nausea of pregnancy, upon the failure of absorption of the corpus luteum of pregnancy. It is seen mostly in the first four months of pregnancy. Treatment is disappointing. Belladonna, atropin, astringent mouth washes may be employed. Hypodermic injections of 1 mil daily of corpus luteum extract has succeeded in relieving, but not curing, two cases of the author's. Vomiting will be considered under toxemia of pregnancy. DISEASES OF THE BREASTS Nipples should be hardened for nursing by astringent appli- cations such as glycerite of tannin; alcohol; or witch-hazel. If they become fissured, protection by a nipple shield and an ointment of bismuth subnitrate and albolene, equal parts, will usually give prompt relief. Tumors.-Adenomata usually grow rapidly during preg- nancy. Carcinomata occur rarely, as the patients are usually past childbearing age. When cancer complicates pregnancy, it is always aggravated by it. DISEASES OF THE CIRCULATORY SYSTEM Heart.-Systolic murmurs at the base and accentuation of the second aortic sound are not uncommon in pregnancy, and are usually without significance. 186 PATHOLOGY OF PREGNANCY The commonest variety of real heart-disease is mitral regurgita- tion; combined mitral disease coming next. These two form the over-whelming majority of heart lesions in pregnancy. Valvular disease is less to be feared than myocarditis, which is fortunately rare. An abnormally wide divergence between the systolic and diastolic blood-pressure usually indicates myocarditis, and the patient should be watched accordingly. Contra-indications to Pregnancy.-A heart with valvular lesions, well compensated, and particularly in young, otherwise healthy women, does not, with proper treatment, contra- indicate pregnancy. A heart with decompensation will almost certainly fail in pregnancy or labor. Danger during pregnancy are broken compensation; dyspnea from pulmonary congestion; serous transudations in the pleura, requiring paracentesis; acute dilatation of the heart. Second- arily albuminuria, nephritis, and occasionally symptoms of Graves' disease. Danger during labor is chiefly acute dilatation of the heart. Decompensation may also appear first in labor. Treatment in pregnancy consists in expectancy under careful medical supervision. Ascending doses of tincture of digitalis or strophanthus, beginning with a dose of five drops three times daily and increasing a drop a dose at intervals of about two weeks. Moderate exercise with frequent intervals of rest. Frequent examination of the urine, and if much dyspnea, morphin and atropin hypodermically. Labor should be in- duced four weeks before term, if there are any symptoms of decompensation; or two weeks before term in any case. Treatment in Labor.-Stimulation with digipuratum hypo- dermically (one ampule every three hours) during the course of labor, and every six hours for three days following (or tinc- ture of digitalis m. x. by mouth); delivery with forceps when the expulsive pains of the second stage begin, with as light ether anesthesia as possible. In many cases, when the strain of labor is greatly to be feared, cesarean section one week before term is the safest method. BLOOD DISEASES 187 In decompensation, rapid delivery without anesthesia, and active stimulation. In acute dilatation of the heart, immediate delivery, active stimulation (i ampule of digipuratum; or i mil digalen; or 30 minims of camphorated oil), oxygen, a tight abdominal binder-all except the binder to be given during the process of delivery and continued afterward. In all cases make preparations for any complications beforehand. Prognosis.-The most critical time is just after delivery. Sudden collapse several hours afterward is not uncommon. The mortality is variously stated at from 6 to 80 per cent. The lower figure is more nearly correct. A tendency to moderate bleeding after delivery should not be checked, as it is usually beneficial. The danger to the child is great, stillbirths averaging 50 per cent. Graves' disease is liable to be serious in pregnancy, though sometimes improved by it. If toxemic symptoms develop, the case is always more serious. The treatment is the same as for heart lesions, except that rapid delivery is usually not needed. If an anesthetic is required, ether is the only one to be considered. Varicose veins occur chiefly in the legs, thighs and labia majora. They are unmistakable, and usually cause consider- able discomfort. Dangers are rupture with hemorrhage (dangerous), thrombosis and infection (from scratching). Treatment during pregnancy requires an elastic stocking or bandage, for the varices of the legs. Those of the labia require no treatment. The patient should be instructed how to control the bleeding by pressure, in case of rupture. Rest is essential and if there is much inflammation dilute leadwater and alcohol, equal parts, is the best application. BLOOD DISEASES Pernicious anemia and leukemia often originate in preg- nancy and are always aggravated by it. Purpura is usually fatal and always kills the child. 188 PATHOLOGY OF PREGNANCY INFECTIOUS DISEASES All the infectious diseases are made worse by pregnancy and abortion or miscarriage is to be expected in about 50 per cent, of cases. INJURIES AND ACCIDENTS Any severe shock is liable to cause abortion, and falls during the last three months of pregnancy not infrequently cause rupture of the uterus or premature separation of the placenta. SURGICAL OPERATIONS DURING PREGNANCY Operations not involving the uterus, tubes, ovaries or lower genital tract can be performed with little if any additional risk. The risk of miscarriage is increased somewhat in all operations, especially those noted above. Dental operations should be curtailed as much as possible, and in all operations gas anesthesia is to be avoided. In general it is wiser not to operate in pregnancy though the patient should not be subjected to any undue risk, merely to avoid an operation. RELAXATION OF THE PELVIC JOINTS Relaxation of the pelvic joints, especially the sacro-iliacs, is to a certain extent present in every pregnancy. Occasion- ally it is enough to cause severe backache, difficulty in walking or even entire inability to walk. Mild cases can be managed by lacing the lower third of the corset tightly over the hips. Severe cases require a binder or adhesive straps. It usually persists for several months after delivery, and requires similar support. DISEASES OF THE NERVOUS SYSTEM - Chorea in pregnancy is a recurrence of an old chorea and is serious. Sixty per cent, of the cases occur in primiparae. The disease is greatly aggravated by pregnancy and it has a DISEASES OE THE RESPIRATORY SYSTEM 189 mortality of 18 per cent. Blood examination shows marked eosinophilia. The mild cases usually yield to bromids, arsenic and iron; the severe ones require anesthesia for temporary control, and the prompt interruption of pregnancy. Epilepsy is not influenced by pregnancy, except that often the convulsions cease during pregnancy, only to reappear after delivery. Insanity.-Frequency 1-400 cases. Types.-1. Mania (homicidal). 2. Melancholia (suicidal). 3. Mental confusion. Time of occurrence most frequently in the puerperium; next during lactation, and least frequently in pregnancy. This does not take account of the temporary delirium often seen in labor. Treatment is best carried out in an asylum and based upon good hygiene and full diet. The tendency to homicide (of the infant) and suicide must never be forgotten, and the patient watched accordingly. Neuralgia is most frequent in the sacral plexus, often causes considerable lameness, and is obstinate to treat. It will usually remain until after delivery. Other local neuralgias are most often symptoms of toxemia, and treated accordingly. DISEASE OF THE RESPIRATORY SYSTEM Tuberculosis in pregnancy is always serious. An existing infection is made worse; a latent one often made active. The superstition among the laity that tuberculosis is benefitted by pregnancy is erroneous. A patient with phthisis should be warned against pregnancy; and the presence of active phthisis in a pregnant woman in early pregnancy is a justifi- able indication for the premature termination of pregnancy. Epistaxis is common and often serious enough to require packing of the nares. Often it will not cease until pregnancy is terminated. 190 PATHOLOGY OF PREGNANCY Asthma is unfavorably influenced by pregnancy. Hemoptysis is not always due to phthisis. It is seen in the "cardiac nerve storms" of pregnant women, and in these controlled by chloral and bromids. It may also be due to inflamed or hypertrophied tonsils, adenoids or bad teeth. DISEASES OF THE SKIN Pruritus may be general or confined to the genitalia. Pruritus vulvae is due to: (i) dirt or parasites; (2) irritating leukorrhea; (3) diabetes; (4) neurosis. If a cause can be found and relieved, the itching will cease spontaneously. If it is neurotic, local applications of carbolic acid of 1 per cent.; menthol ointment gr. 30 to oz. 1; oil of bitter almonds; nitrate of silver gr. 10 to oz. 1 may be used. Often the ter- mination of pregnancy will be required. In diffuse pruritus (prurigo gestationis) the itching is due to liver toxemia. The treatment is to eliminate nitrogenous foods, keep bowels open with saline laxatives and to admin- ister bile in the form of oxgall. In cases where the skin is harsh and dry, inunctions of cocoa butter or olive oil is a useful addition (quoted from J. C. Hirst, 2nd). Pigmentation of the skin is often persistent throughout pregnancy, but usually disappears after labor. If not, lemon juice is the best local application. Brittle or loose finger nails annoy the patient, and cause much pain. Treatment is disappointing, chiefly tonics and oil applied locally. Recovery is spontaneous after delivery. Impetigo, herpes and molluscum fibrosum are all aggra- vated by pregnancy, and often first appear in pregnancy. Tumors complicating pregnancy will be described in the chapter on dystocia due to maternal soft parts. DISEASES OF THE URINARY SYSTEM The urine in pregnancy is always increased, and often to great excess. The polyuria ceases after delivery and no treat- DISEASES OF THE URINARY SYSTEM 191 ment is needed. If the quantity is diminished, the cause should be investigated at once. Albuminuria will be described under the toxemia of preg- nancy. Sugar is next in importance to albumen. It is usually lactose and is unattended by systemic symptoms. True glycosuria is rare and if present is greatly aggravated by pregnancy, although diabetes mellitus may, in certain cases, regularly appear in each pregnancy and disappear after delivery. Sugar appears in the urine in about 3.5 per cent, of all cases. The differential diagnosis between lactose and glucose can be made by polarization. Hematuria is usually due to vesical hemorrhoids, papilloma, stone or acute cystitis and will disappear after labor. The bleeding is usually not profuse enough to require treatment. Diseases of the Bladder Irritability is common and due to congestion, pressure from a displaced uterus or neurosis. If a displacement is found and corrected, the irritability will cease. For other cases the best prescription is one containing sodium bromid, gr. io, potassium citrate, gr. 5, tincture of belladonna, gtt. 5, liquor potassii citratis, drams 2 to each dose, four times daily. Incontinence is usually that of overflow, and due to a displaced uterus. Reposition of the uterus and the use of the catheter will relieve it. Cystitis is aggravated by pregnancy. It is treated by daily irrigations with boric acid solution and the instillation of one ounce of 25 per cent, argyrol solution, or 10 per cent, silvol solution, to be retained as long as possible. It is not infre- quent for infected urine to regurgitate from the bladder into the ureter and pelvis of the kidney and cause pyelitis. Stone in the bladder is very rare, but when it occurs should be removed before labor, to prevent a fistula. 192 PATHOLOGY OF PREGNANCY Diseases of the Kidney Nephritis will be described under toxemia of pregnancy. Dislocation of the kidney is almost always the right. Un- less it is so low as to be in the pelvis (usually the congenital ectopic kidney) or twists on its ureter to give acute hydro- nephrosis, it is of little moment. If acute hydronephrosis develops, catheterization of the ureter is indicated. If this fails to give relief, induction of labor is required. The removal of one kidney does not usually influence unfavorably any subsequent pregnancy. Pyelitis in pregnancy is common. It may occur any time in pregnancy, but is most common in middle trimester. Pre- disposing causes are the tendency to hydro-ureter and hydro- nephrosis due to a movable kidney or direct pressure on the ureter against the pelvic brim, by the bulk of the pregnant uterus. The actual infecting agents are: (i) Bacillus aerogenes mycosum (differing from the colon bacillus in being nonmotile); (2) colon bacillus; (3) pneumococcus; (4) gonococcus; (5) staphylococcus; (6) streptococcus (in puerperium). Symptoms.-1. High fever; (2) leukocytosis; (3) pain in loin and referred down ureter; (4) pyuria. Diagnosis by the above symptoms and, if necessary, cystos- copy and the inspection of the eroded ureteral orifice. Cloudy urine can be seen issuing from it. Differential Diagnosis.-The commonest mistake is to con- fuse this with appendicitis. The diagnosis should offer no difficulty. Treatment.-Palliative.-(1) Rest in bed on side opposite the affected one; (2) ice-bag to affected loin; (3) large amounts of water; (4) milk diet; (5) urinary antiseptics (salol, urotro- pin, helmitol); (6) bladder irrigations, to help ureteral peristal- sis and aid drainage. Radical.-Cystoscopy; catheterization of affected ureter, washing out of pelvis of kidney with boric acid solution, followed by 25 per cent, argyrol or 10 per cent, silvol or DISEASES OE THE URINARY SYSTEM 193 neo-silvol solution. This, possibly repeated, will cure most cases. If it does not, induction of labor will be required. Unless neglected, nephrotomy and drainage or nephrectomy will rarely if ever, be required.. Fig. 82.-Method of withdrawing contents of an ampule, for hypo- dermic injection. The ampule is held upside down, the needle inserted in the neck, and the syringe is pushed up by forefinger of right hand. Causes of right-sided pain in women are: (i) Cholecystitis or gall-stones; (2) fecal impaction in hepatic flexure of colon; (3) floating kidney with hydronephrosis; (4) kidney stone; (5) ureteral stone; (6) pyelitis; (7) appendicitis; (8) salpingitis; 13 194 PATHOLOGY OF PREGNANCY (9) extra-uterine pregnancy; (10) ovarian cyst twisted on pedicle; (n) varicose veins in broad ligament. Functional Tests for Kidney Activity.-Indigocarmin.-If 1 mil of indigocarmin is injected in the thigh; blue urine should be seen, through the cystoscope, to emerge from the ureters in about twelve and a half minutes. Delay usually indicates improper function, though exceptions are numerous. If the dye is injected intravenously, which is perfectly safe, blue urine should appear in to 4 minutes. For intravenous injection, 10 mils of a of 1% solution of indigocarmin are used. The solution must be efficiently sterilized. Phenolsulphonephthalein.-Two to four mils of phenol- sulphonephthalein are injected deep in the patient's thigh. She is catheterized immediately before the injection; again in one hour and ten minutes and again in one hour. The last two specimens are saved. Their color is compared with the color in the colorimeter vials. About 60 per cent, is the normal excretion in two hours. Less indicates improper function, although wide variations are seen with few or no symptoms. Cystoscopy Methods.-(i) Air distention of bladder and direct vision. (2) Water distention of the bladder with indirect (inverted) vision. The method of choice in most cases. The air-dis- tention method requires either the knee-chest or very high Trendelenburg position; often an anesthetic; and, due to the interference with breathing, is impracticable late in pregnancy. Directions for Use of Air Distention Cystoscope.-1. The patient is arranged in the high Trendelenburg or knee-chest position. 2. Urethra cleansed, cocainized with 4 per cent, cocain solution and dilated with either conic or cylindric sound. 3. The cystoscope is inserted, with obturator in place; obturator withdrawn and light turned on. DISEASES OF THE URINARY SYSTEM 195 4. The urine, as it collects, is aspirated by suction with a catheter and bulb. The habit of drying the bladder with gauze strips is pernicious. It is too likely to injure the vesical mucosa. Directions for Use of the Water Distention Cysto- scope.- 1. Patient lithotomy po- sition, no ether. 2. Cleanse urethral orifice, and if very small, use small urethral sound (22). 3. Have cystoscope and catheters sterilized by formalin vapor, or by soak- ing in 1-100 formalin solu- tion. 4. With soft rubber catheter, of good caliber, drain the bladder of urine, using as a lubricant 10 per cent, cocain in glycerine. If the urine is cloudy, the bladder should be irrigated until the fluid returns clear. 5. Fill bladder through catheter with cold sterile water, and withdraw catheter; hot water softens the ureteral catheters. Use enough water to cause patient slight discomfort. Too little water in bladder is the commonest cause of trouble in cystoscopy. 6. Lubricate the cystoscope tip with the cocain and glycer- ine solution, insert gently in bladder, turn upside down (except in direct vision scopes) attach light cord and turn on light. Fig. 83 .-Sterilizing plant for cys- toscopes and catheters. Loose for- maldehyd powder in bottom of jar. Efficient and inexpensive. 196 PATHOLOGY OF PREGNANCY y. Do not use too much light, as the lamp is easily burned out. 8. Locate ureters by turning cystoscope at angle of 45 degrees to perpendicular, on each side of bladder. The inter- ureteric fold can usually be seen easily. At each end is the ureter, like a red slit. The ureteral mouth can be seen to spout urine at intervals of about 15 seconds. 9. If the ureteral openings cannot be found, indigocarmin can be in- jected intravenously. Within two and one-half to four minutes blue urine will spout from the ureters. 10. To catheterize ureter, when located, focus it at about 5 o'clock (right) or 7 o'clock (left) using the field as a clock face. Push catheter down till visible past lens. Guide it in proper direction with the hinged flap worked from the handle of scope and push in mouth of ureter. When in, put flap down flat again and then push catheter up to pelvis of kidney. 11. To push catheter in, grasp it with fingers as near where it enters the cystoscope channel as possible. Other- wise it will bend. 12. Never catheterize a healthy ureter from an infected bladder. 13. To wash out pelvis of kidney use a hypodermic syringe and boric acid solution and then silvol or neo- silvol 10 to 15 per cent. The pelvis of the kidney should hold 10 to 15 mils but be guided by patient's com- plaint of pain, and never persist after pain starts and never use force in injecting the fluid. Fig. 84.-Type of syringe for irrigating kidney. It has a capacity of 5 mils. DISEASES OE THE URINARY SYSTEM 197 14. To remove cystoscope turn off light, be sure guiding flap is flat down and remove. 15. To leave catheters in, push up as far as possible, allow- ing them to curl up in bladder. Leave only inch of catheter beyond eyepiece of cystoscope. Then remove cystoscope as in number 14. When catheters appear at urethral orifice, hold them and pull cystoscope away from them. Fix them to thighs with adhesive tape, let drain into bottles and be sure before removing the cystoscope that you know which is right and which left. 16. After using dry cystoscope with gauze, dry catheters by wiping off and keep them with aluminum wire stylets in them. Fig. 85.-The trigone of the bladder with the ureteral orifices and the interureteric fold. Methods of Collecting Urine from Ureters Separately 1. Ureteral catheterization. 2. Segregation. Ureteral catheterization is much the best. It occasionally gives pain afterward, due to irritation of the ureter or passage of a small clot, but this is short lived and of no moment. Segregation is the formation of an artificial division in the bladder and the exhaustion of the urine from each side of the partition by suction. It is not satisfactory and only used when ureteral catheterization is not practicable. The instru- ments used are: 198 PATHOLOGY OF PREGNANCY 1. Harris' method, where pressure by a bar against the anterior vaginal wall is used to make the partition. 2. Cathelin's or Luys' methods, where the partition is formed of rubber, integral with the instrument inside the bladder. Luys' instrument is the most satisfactory. Fig. 86.-The urine segregator of Luys. Uses of a Ureteral Catheter.-i. To collect urine; (2) to diagnose stricture of ureter; (3) to diagnose stone in ureter (wax-covered tip); (4) to irrigate pelvis of kidney; (5) for x-ray work, to show position and course of ureter; (6) to make ureter prominent, in operations for cancer. THE TOXEMIAS OF PREGNANCY Kinds.-The early-seen in the first four months of preg- nancy, characterized by normal or subnormal blood-pressure; moderate or severe vomiting; and rarely any kidney break- down. The late-seen in the last five months of pregnancy; charac- terized by high blood-pressure; albuminuria; eye disturbance; convulsions, but rarely vomiting except incidentally. In both early and late toxemia, the most serious cases are those with liver degeneration. THE TOXEMIAS OF EARLY PREGNANCY 199 Theories as to Cause.-Early Toxemia.-(1) Toxins due to syncytial hyperplasia; (2) failure of absorption of corpus luteum; the corpus luteum of pregnancy increasing in size until the third month and then the cessation of nausea and beginning absorption of the corpus luteum occurring synchronously. Late Toxemia.-(1) Errors in fetal metabolism, causing a retention in the maternal system of a toxin which causes anemia of kidney with fatty infiltration (so-called kidney of pregnancy); (2) direct effects of increased intra-abdominal pressure; as in twins, hydramnios, etc. The Toxemia of Early Pregnancy VOMITING Vomiting may be: (i) physiologic; (2) exaggerated or (3) pernicious. The normal vomiting of pregnancy is most marked in the morning, though it may recur at irregular intervals through- out the day. It is annoying rather than distressing and the routine treatment is: (1) Light diet; (2) sodium bromid gr. 15 in camphor water, drams 2, four times daily; (3) hypo- dermic intramuscular injections of 1 mil soluble extract of corpus luteum once daily. The exaggerated vomiting of pregnancy is marked increase over the normal. It is not uncommonly reflex, and search should be made for: (1) eroded cervix and (2), retroversion of the uterus-the two commonest causes of reflex vomiting, before instituting any treatment. Otherwise the treatment is as above. The Use of Corpus Luteum Extract in Vomiting of Preg- nancy.-This is based upon the author's theory that every woman is constantly absorbing corpus luteum. When she becomes pregnant the corpus luteum of pregnancy does not absorb at once, but increases in size. When the remains of the preceding corpus luteum have disappeared, the vomiting begins, due to the absence of further material. Synchronously with 200 PATHOLOGY OF PREGNANCY the resumption -of absorption of the corpus luteum of preg- nancy, at the third month, the nausea disappears. It is believed that this is not a coincidence, but cause and effect. The soluble extract is given intramuscularly in doses of i mil every other day to i mil twice daily, depending upon the severity of the attack. Each mil equals 20 mg. of the dried substance. No effect is usually noted until after the fourth dose, when relief comes suddenly. Twelve doses are given in all, on the average. The author's results so far have been distinctly encouraging. Mouth administration is not satis- factory, as the action of the corpus luteum extract is unfavor- ably influenced by digestion. In severe cases, the extract can be given intravenously in doses of 2 mils (ampules.) Anaphylaxis is not to be feared. Any reaction is rare and is simply urticaria of short duration. Pernicious Vomiting or Hyperemesis Gravidarum.-Kinds. 1. Neurotic. 2. Reflex-from anything causing pelvic congestion. Most commonly from (1) erosion of the cervix and (2) backward displacement of the uterus. 3. Toxemic. Frequency.-It is more common in, or at least more fre- quently reported from, the United States and France than from Germany or England. About 65 per cent, of cases occur in multipart, and it is distinctly more dangerous in multi- par ae than in primiparae. Pathologic Changes.-These are most marked in the liver and kidneys. Fatal cases, on autopsy, show diffuse hemorrhagic hepatitis; acute fatty degeneration in the center of the lobules, and even extensive necrosis of the liver. The kidneys show changes varying from the kidney of pregnancy (anemia with fatty infiltration) to acute parenchymatous nephritis with grave degeneration. Symptoms.-(1) Excessive and almost incessant vomiting and retching, irrespective of whether the stomach contains food or not; (2) elevation of pulse and temperature; (3) THE TOXEMIAS OF EARLY PREGNANCY 201 drying of all the mucous membranes; (4) jaundice; (5) emacia- tion. The rapid development of these symptoms usually points toward a toxemic type of vomiting; their slow develop- ment rather toward a reflex or even neurotic type. The high ammonia content of the urine (up to 40 per cent.) with low urea has been demonstrated to be due not to toxemia, but to an acidosis from starvation. Treatment. 1. Hygienic Treatment.-This consists in giving the patient the best possible surroundings; insistence upon hospital care is much to be preferred. All causes of pelvic congestion, such as coitus, should be eliminated. Any craving for unusual articles of food may be gratified, provided the articles craved are reasonably digestible. Complete rest in bed, quiet, and freedom from visitors must be insisted upon. Gynecologic Treatment.-Any condition in the pelvis which might cause vomiting from reflex irritation must be corrected. Erosion of the cervix should be treated with 8 per cent. (40 grains to the ounce) nitrate of silver solution, repeated in two days. A retroverted uterus should be replaced, in the knee- chest posture and a pessary inserted. Medical Treatment. 1. Feeding.-The stomach should be given an entire rest, except where special cravings exist, and all food given by the rectum. The best enemas are: liquid peptonoids or predigested beef two ounces and salt solution (0.7 per cent.) or sugar solution (glucose one and one-half ounces to two pints) two ounces, given every four hours. A nutritive enema should never exceed six ounces, and four is better. Peptonized milk or peptonized beef-tea or broth may be substituted, but the predigestion should be carried thirty to forty-five minutes. Feeding by the duodenal tube and bucket, to make sure that food is ingested and carried past the pylorus, has been advised but is of doubtful utility. Twice daily a high enema of salt or sugar solution one pint should be given to relieve the thirst. Intravenous Injections of Glucose Solution.-This is based upon the carbohydrate deficiency in the maternal organism, 202 PATHOLOGY OF PREGNANCY and the depletion of the reserve of glycogen in the liver to supply the demands of the growing fetus. Forty-five grams of chemically pure glucose is dissolved in 300 mils of water and sterilized by the autoclave for 30 minutes or by boiling over a water bath. The solution must be filtered before sterilization. Any loss of water in sterilization is made up by addition of sterile water to make the original volume of 300 mils. The solution is injected slowly, taking about 30 minutes, into the vein, and repeated daily. The glucose is stored in the liver as glycogen, aids in restoring the damaged liver cells and causes their rapid regeneration. Drugs.-Opium (gr. 1 extract) by suppository twice daily; bromids one dram in solution in each nutritive enema, chloral thirty grains in three ounces mucilage of acacia by enema, repeated once; adrenalin solution 1-1000, twenty drops three times daily by the mouth or five drops hypodermically. The local anesthetics like cocain, B-eucain, menthol, etc. have little effect, and all the depressant drugs, like morphin and bromids, tend later to increase the vomiting. Serum Treatment.-The administration of thirty to fifty mils of serum from a woman who has established tolerance to vomiting, on the principle that it contains some antitoxin, has met with slight if any success. The difficulties in obtain- ing a sufficient supply are obvious. Intravenous injection of corpus luteum extract has given decided favorable results, and is of distinct value. Two mils of the soluble extract are injected intravenously daily, or in bad cases twice daily, to a total of 16 to 24 mils. If no good effect is noted from this amount, it is useless to continue. Obstetric Treatment.-It is difficult to lay down a dogmatic rule as to when pregnancy is to be interrupted. If rectal feeding, and other treatment for one week has failed to control the vomiting; if the pulse runs persistently over no; and if there develop hematemesis, jaundice, fever or marked albu- minuria, the termination of pregnancy is required, but only after consultation. THE TOXEMIAS OF PREGNANCY 203 Prognosis.-With proper treatment and the timely inter- ruption of pregnancy, the mortality should be low. The chief danger is in waiting too long before interfering. Acute Yellow Atrophy of the Liver In severe cases of both early and late toxemia, degeneration of the liver is not uncommon. It is more common in the late toxemia, but by no means unknown in the early. Cause is unknown. Chloroform, arsenic, mercury and phosphorus poisoning cause lesions exactly similar. Pathology.-The liver is diminished in weight, shrunken and often less than one half its original size. On section it is chrome yellow in color. The center of the lobule is the seat of marked degeneration, the cells showing necrosis and fatty degeneration. The amino-acid content of the blood is greatly increased. Symptoms.-These come on slowly during early or late toxemia but rarely are sudden and fulminant. There is jaundice; vomiting of coffee ground material; diminished urine, which is always high colored and often bloody; increas- ing torpidity and coma, though violent convulsions sometimes occur. Fever is usually absent, until just before death when it may rise suddenly and the blood pressure, unless renal insufficiency develops, is usually normal or only slightly raised. Prognosis is bad. Treatment is essentially that outlined for pernicious vomiting or eclampsia, depending upon whether the patient is in early or late pregnancy. Intravenous glucose solutions have here their greatest value. Test for Liver Function.-In cases of toxemia, where the liver function has been seriously impaired, the phenol-tetra- chlorphthalein test is valuable as a guide to the amount of impairment. Five milligrams of the dyeper kilo of body weight are injected intravenously. Normally this amount very rapidly disappears from the blood stream. In normal human beings, 204 PATHOLOGY OF PREGNANCY within fifteen minutes of the injection, 2 to 6 percent, is present in the plasma, and complete disappearance of the dye takes place within forty to sixty minutes. In cases where the liver function is impaired, high percentages are found for many hours after the injection. This test is of value in differen- tiating the toxic from the non-toxic types of vomiting in early pregnancy, and the hepatic from the nephritic toxemia of late pregnancy. The Late Toxemia of Pregnancy Types.-There are two distinct varieties; the nephritic-• in which the kidneys fail-and the hepatic-in which the liver undergoes degeneration. The degeneration of the liver in the late toxemia of pregnancy begins in the periphery of the Fig. 87.-The Nicholson blood-pressure apparatus, with mercury column. lobule and spreads toward the center-the exact opposite of the same degeneration in the early toxemia The hepatic type of the late toxemia is much the more dangerous. Blood-pressure.-The earliest, most constant sign of toxe- mia in the latter half of pregnancy is a high and rising blood- pressure. The pressure may be taken with either a mercury THE TOXEMIAS .OF PREGNANCY 205 column or dial sphygmomanometer, the former being the better. The systolic pressure may be obtained by observing the oscillation of the column or needle, auscultation over the brachial artery at the elbow, or palpation of the radial pulse. The systolic pressure is the most important, although it is wise always to read the diastolic as well, as too great a diver- gence between them is often an indication of myocarditis. The normal blood-pressure in pregnancy should average 118 to 125 mm., tending to rise slightly in the last month. A pres- sure of 125 to 150, unaccompanied by other symptoms need cause no alarm, but pressure over 150, with a tendency to rise still higher, indicates prompt and active treatment. Albuminuria.-If a trace of albumen be regarded as positive, 75 per cent., at least of pregnant women will show it. A measurable amount of albumen will be found in approxi- mately 6 per cent. In 10 per cent, of toxemic patients, the con- stitutional symptoms of headache, failing vision, somnolence, and epigastric pain will antedate the appearance of albumen. The presence of albumen is best detected by boiling or nitric acid (Heller's test). As a small amount of albumen is not necessarily a cause for alarm, the more delicate tests are neither necessary nor desirable. For quantitative tests, Esbach's picric acid method answers every purpose. Urea estimation is unreliable. It is said that the normal urea output should be 16 to 24 grams a day. If this falls below ten grams, the outlook is said to be serious. This has not been borne out in practice, and the urea estimation in the toxemia of late pregnancy is not of great clinical value. For office work, the Doremus ureometer answers every purpose. It is employed as follows: The normal amount of urea excreted in pregnancy is said to be from 1.5 to 2 per cent. (16 to 24 grams per diem). The Doremus apparatus consists of a two branched tube set upon a stand, the larger branch having a U bend, terminating in a large bulb. The smaller branch is separated from the larger 206 PATHOLOGY OF PREGNANCY by a stopcock. The large branch is filled with a 40 per cent, solution of caustic soda, to which 1 mil of bromin is added, forming a fresh solution of sodium hypobromite. The small branch is filled with urine and 1 mil is allowed to run through slowly, by turn- ing the stopcock. The urea is decom- posed, nitrogen is set free, and gathers at the top of the tube. The amount of nitrogen formed is read off from the scale marked up on the tube, each division representing 0.001 gram of urea to the mil of urine. The total amount in twenty-four hours can thus be cal- culated. Nitrogen Partition.-This is repre- sented by two rather intricate laboratory calculations. First the relation of urea to the other nitrogens. Normally urea is about four-fifths of the total nitrogen in the urine; in toxemia it is said to be reduced to one-half or less. Secondly the ratio of ammonia nitro- gen to the total nitrogen content of the urine. This is normally 3 to 5 per cent, but may rise, in toxemia, to as high as 50 per cent. These tests are for the trained chemist, and their value to the practical physician is almost negligible. Urea and Urea Nitrogen in the Blood.-In many cases the urea and urea nitrogen count of the blood is of the greatest diagnostic importance, particularly those cases showing kidney breakdown in the early half of pregnancy, in whom a previous nephritis has been proved or is suspected. The normal amount of urea in the blood is between .02 and .035 per cent. In nephritis .05 to .07 per cent, are common and in uremia up to .2 per cent, is not uncommon. This is important in determining the need for terminating pregnancy. Fig. 88.-D o r e m u s ureometer. THE TOXEMIAS OF PREGNANCY 207 Cases showing more than .1 per cent, will usually terminate fatally. Pathologic changes in the kidney are: (1) The kidney of pregnancy-anemia of the kidney with fatty infiltration-and (2) acute or chronic nephritis. Kidney of pregnancy is rarely seen in the early months of pregnancy; nephritis may appear at any time. The following differential diagnosis is more theoretical than practical. DIFFERENTIAL DIAGNOSIS BETWEEN KIDNEY OF PREGNANCY AND TRUE NEPHRITIS Kidney of Pregnancy 1. No previous history of kidney trouble. 2. Appears late in pregnancy. 3. Urine increased at first but liable to sudden diminution; low speci- fic gravity. 4. Albumin present and liable to sudden increase. 5. Casts late if at all. 6. Albuminuric retinitis absent. 7. Clears up after delivery. 8. Fatal cases show anemia of kidney and fatty infiltration. Nephritis 1. May be present. 2. Appears early. 3. Same as in kidney of pregnancy. 4. Same as in kidney of pregnancy. 5. Casts early and abundant. 6. Albuminuric retinitis often present. 7. Likely to persist after delivery. 8. Fatal cases show inflammatory changes and degeneration. Treatment of Albuminuria in Pregnancy.-When albumen is discovered, in measurable amounts, in the urine of a preg- nant woman, the urine should be filtered and re-examined, to exclude contamination by leukorrheal discharge. Catheteri- zation is not necessary. If the albumen still is found, the following treatment is instituted. (1) Reduce the diet, eliminating the nitrogenous food, such as red meats, peas, beans, corn and tomatoes. (2) Prescribe large amounts (12 to 15 glasses daily), of water. 208 PATHOLOGY OF PREGNANCY (3) Basham's mixture two drams four times daily. (4) Bowels kept loose enough for two semiliquid move- ments a day. (5) Make quantitative test for albumen in the urine every other day. (6) Take readings of blood-pressure every other day. (7) Reduce exercise, and avoid exposure to cold or wet. If in spite of this treatment the urine diminishes in quantity; or the albumen increases; or casts appear; or the blood-pres- sure continues to rise: (1) The patient should be put to bed. (2) Her diet should be milk only-or milk soups, milk toast, etc., to vary the monotony. (3) The bowels kept liquid by citrate of magnesia-given flat-or magnesium sulphate or similar hydragogue cathartic. (4) She should be sweated for half an hour twice daily by a hot pack or better by a steam bath, given in a portable cabinet. (5) Examinations of urine and blood-pressure should be daily. A hot pack is given by wrapping each leg in a blanket wrung out of very hot water, the body in a third, and on top of this piling dry coverings. It can be made more efficient by putting under the dry blankets, six bricks, heated uncomfortably hot to the hand, each brick wrapped in an alcohol soaked towel. The hot pack is not nearly so efficient as the steam or vapor bath. Steam or Vapor Bath.-Special cabinets are on the market for this and are best used. An efficient substitute can be made by taking half of three barrel hoops, and binding them at intervals to a curtain pole or broom stick. This framework is put over the patient, who is lying in bed between blankets, and a tent is built over her with blankets, leaving only her head exposed, and made as airtight as possible. Steam from a kettle of boiling water is led under this, by a rubber tube- the tube being tied to the ridge-pole of the tent in such a posi- tion that the patient cannot be scalded. This is a most effi- THE TOXEMIAS OF PREGNANCY 209 cient method, and should always be used in preference to the hot pack. If, in spite of this treatment, the patient does not improve, pregnancy should be terminated on the following indications: f 1) Sudden or steady increase in albumen. (2) Sudden or steady decrease in urine. (3) Sudden or steady rise in blood-pressure. (4) The appearance of the premonitory signs of eclampsia -headache, failing vision with black specks before the eyes (muscae volitantes); epigastric pains; restlessness. The appearance of defective vision, black specks before the eyes, or blindness always indicates the prompt interrup- tion of pregnancy. If neglected, the patient, if she survives, may be permanently blind. Prognosis.-In the majority of cases the toxemia either clears up entirely or eclampsia can be averted by the timely interruption of pregnancy. If a patient has had to be treated during her pregnancy in the manner just described, and has recovered without the interruption of pregnancy, labor should be induced two weeks ahead of time to avoid a fulminant recurrence, and in the interval she should be closely watched. ECLAMPSIA Causes of Convulsions.-Most frequently due to toxemia. Other causes are hysteria, epilepsy, brain tumor and in 5 per cent, of cases reflex from the gastro-intestinal tract (indiges- tion, fecal impaction or tapeworm). The name eclampsia has by usage been restricted to mean those convulsions due to toxemia. Cause of Eclampsia.-The exact cause is unknown. It is supposed to be due to toxins of fetal source contaminating the maternal blood. What these toxins are is not known. They affect the liver and kidneys of the mother. The theories of toxins from the thyroid, parathyroid, suprarenal bodies and pituitary and mammary glands have as yet no proof to support 14 210 PATHOLOGY OF PREGNANCY them. The actual convulsions are said to be due to acute cerebral anemia, or direct irritation of the central nervous system. Frequency.-Eclampsia occurs once in about three hundred pregnancies. It is most frequent in primiparae, in multiple and in illegitimate pregnancies. The convulsions begin most frequently in labor, next in pregnancy and least frequently in the puerperium. The outlook is most favorable if convulsions appear before delivery and cease after delivery; not so favorable if convul- sions appear before delivery and persist afterward; and least favorable when the convulsions do not appear until after delivery, although some published statistics seem to contradict this latter statement. Number of convulsions does not necessarily indicate the severity of the attack. Cases have been fatal with only one convulsion, and others have recovered after more than two hundred and fifty. Blood-pressure is almost invariably high; the average being 190 mm. In two cases the author has seen pressures of over 420 and 400 respectively (both with recovery). It is said that true eclamptic convulsions can occur with a low blood-pressure (130 or less) but as 5 per cent, of the cases of convulsions are of gastro-intestinal origin, they may be of this type. Premonitory signs are: (1) High blood-pressure; (2) failing vision with muscae volitantes; (3) headache; (4) epigastric pain ( a very constant symptom); (5) somnolence, or more often restlessness. Occasionally all premonitory signs are absent, the convulsions occurring without warning of any kind. The eclamptic attack begins with a stare; there is then a progressive clonic convulsion of the face, neck, arms, body but rarely legs; consciousness is lost with each seizure for increasing periods, until finally coma is unbroken; the temperature rises (a beginning fall is often the first sign of improvement). The convulsions last about thirty to sixty seconds and look much more alarming than they really are. THE TOXEMIAS OF PREGNANCY 211 Labor often begins spontaneously when the convulsions appear, due in all probability partly to the cyanosis (excess of CO>) accompanying the convulsions and partly to the active treatment employed. In the absence of any obstruction to delivery, labor is usually more rapid than normal. The patient may seem conscious between the convulsions, and answer questions, but she will have no recollection of any- thing that occurs. Differential diagnosis of eclampsia from hysteria or epi- lepsy or apoplexy is easily made. The chief points of difference are high blood-pressure, albuminuria, absence of localized palsies or convulsions, and the tendency of the eclamptic to bite her tongue. If the urine of an eclamptic patient is boiled, it will usually turn almost or entirely solid. Prognosis.-The average mortality of eclampsia, for the mother is close to 20 per cent. One quarter of the deaths in childbirth are due to eclampsia. Small series with a lower mortality have been reported. Great rapidity of the pulse and high fever occur in the worst cases only. Prognosis should always be guarded, as apparently favorable cases often suc- cumb. The most unfavorable cases are those showing jaundice and other evidence of liver degeneration. In favorable cases the kidneys usually clear up entirely. The quantity of urine first increases, often to one hundred ounces or more in twenty- four hours; then the casts, if any, disappear; then the albumen; and the last step is the return of blood-pressure to normal. The mortality to the child is about 50 per cent. Causes of Death.-(1) Edema of lungs or brain; (2) apo- plexy; (3) uremia; (4) acute yellow atrophy of liver; (5) heart- failure. Pathological Findings.-Nephritis with degeneration of epithelium; liver degeneration varying from minute capillary thrombi to extensive fatty degeneration; emboli of liver-cells in all important organs; emboli of giant polynuclear cells from the placental villi to the lungs. 212 PATHOLOGY OF PREGNANCY Treatment.-Preventive treatment is that described under the treatment of albuminuria. Active Treatment.-Every case of eclampsia should be treated as a severe one, and no precautions should be omitted in deference to the apparently mild case. It is not uncommon for convulsions to cease, after a short while, and then to recur with unusual violence after the lapse of a few hours. Anesthesia.--The only anesthetics available are ether and chloroform. Their only value is in the prevention of convul- sions, as during a convulsion the patient does not breathe and cannot inhale them; or in operative measures to secure delivery -although here the patient is frequently so comatose that no anesthesia is necessary. Chloroform may, by prolonged administration, produce the same liver degeneration as eclamp- sia; ether is a usually severe irritant to the kidneys. When required, however, ether is the safer. Reduction of blood-pressure may be secured by: (i) Hypoder- mic injection of 15 minims of fluidextract of veratrum viride and repetition of a dose of five minims every hour until the pulse softens; (2) nitroglycerin gr. %o hypodermically and repeat in an hour-of very questionable value; (3) inhalations of amyl nitrite-also doubtful; (4) rupture of the membranes, producing an average fall of 90 mm. but not to be done prior to the eighth month, unless it is desired to induce labor; (5) venesection-removing 16 to 20 ounces-probably the most valuable of all. Purgation and sweating also tend to reduce blood-pressure, but this action is merely incidental to their chief one of elimination. Reduction of blood-pressure with amelioration of the other symptoms is a favorable sign; reduc- tion of blood-pressure with aggravation of the other symptoms is a sign of impending death. Hypodermoclysis.-A pint of sterile water (not salt solution, on account of the deleterious action of salt on the kidneys) may be injected under the breast every eight hours. It aids greatly in the establishment of free sweating, but the second dose should not be given unless in the interval free sweating THE TOXEMIAS OF PREGNANCY 213 and purging has begun, or there is danger of edema of the lungs. Administration of the fluid intravenously is not ad- visable, nor administration by high enema. Gavage of large amounts of water through a stomach tube (one to one and one- half liters every four hours) is a better plan, if the patient can be made to retain it. Purgation.-This is best done by washing out the stomach and introducing through the tube two ounces of castor oil and four drops of croton oil. This mixture should be warmed, so that it will run freely through the tube. Croton oil four drops in a teaspoonful of sweet oil, given on the back of the tongue, is liable to be vomited promptly. The oil given through the stomach tube is rarely vomited. If the patient can swallow, two drams of concentrated magne- sium sulphate solution may be given every fifteen minutes, until the bowels begin to move. Huge doses are usually required, eight or ten ounces being not unusual. Elaterium gr. J4, repeated every hour until the bowels move, may be substituted, but does not act as well. Sweating is best done by the vapor bath (steam cabinet) as described in the treatment of albuminuria. The bath is given for thirty minutes in every four hours (four hours from the beginning of one bath to the beginning of the next). An ice-cap is placed upon the patient's head, and if she is able to swallow, a glass or two of water during the bath aids materially in starting the sweating. A hot pack is not nearly so efficient as the vapor bath. If used, the interval is the same. Sweating by drugs, such as pilocarpin, is to be condemned. Venesection is one of the most valuable methods of treatment. It should be reserved for those cases whose blood-pressure is over 150. The extreme restlessness, and cerebral edema, yield more quickly to venesection than any single method of treat- ment, and it is not uncommon for the convulsions to cease, or be markedly diminished in frequency, immediately after the bleeding. Sixteen to twenty ounces should be taken, and 214 PATHOLOGY OF PREGNANCY repetition of the bleeding is indicated by subsequent rise in blood-pressure. Supplementary bleeding should not exceed eight ounces. Induction of labor, is ordinarily not required, other than rupture of the membranes if the patient is past the eighth month. The violence of the purging and sweating are usually enough to start labor spontaneously. Should anything more than rupture of the membranes be desired, bougies or a boiled rectal tube should be passed through the cervix, and no prolonged or violent operative procedures be attempted. Outline of Routine Treatment.-The following routine treatment for the average case will be found useful, and will not often need variation: Fig. 89.-Prevention of tongue injury by use of a gag, made of a twisted handkerchief, used like a bit, and tied behind the neck. (1) Prevent the patient from biting her tongue by a suitable gag-a handkerchief or towel passed between the teeth like a bit and bridle is the best. (2) Restrain during the convulsions. (3) Avert convulsion if possible, by a few breaths of ether, when the convulsion is seen to be imminent. THE TOXEMIAS OF PREGNANCY 215 (4) Wash out the stomach, and through the stomach-tube pour, warmed, two ounces of castor oil and four drops of croton oil, or give two drams of saturated solution of magnesium sul- phate every fifteen minutes until bowels move. (5) Reduce blood-pressure by rupture of membranes, if past eighth month, or venesection (16 to 20 ounces) if pressure is over 150 mm. (6) Sweat for thirty minutes in each four hours, in a steam cabinet or hot pack. (7) Give one pint of sterile water under breast. Do not repeat unless patient sweats freely. (8) Ordinarily let the labor alone and do not attempt rapid delivery. Treatment Other Than Routine. Morphin.-This, known as the Veit or Stroganov treatment, has an element of danger. It is well borne in parenchymatous nephritis, and very badly borne in interstitial nephritis. As 10 per cent, of eclamptics show interstitial nephritis, the risk is too great to be disregarded. If it is used, morphin is given hypodermically, without atropin, in doses of % grain, repeated every hour for two or three doses. Veit has given three grains in six hours, and four and one-half grains in twenty-four hours. The morphin also hinders free elimination. It should be reserved for those cases whose convulsions are extremely violent and not controlled by venesection, or the cases of extreme restlessness and mania. Intravenous injection of glucose solution as described in the treatment of pernicious vomiting is valuable as a means of preventing liver degeneration. Pilocarpin.-This, known as the Edinboro treatment, is to be condemned except under special indications. Its use strongly predisposes to edema of the lungs, and it has the highest mortality of any treatment for eclampsia. It may be used, in a single dose of grain hypodermically, in those patients, who do not respond to other treatment, in the hope that sweating may thus be started. 2l6 PATHOLOGY OF PREGNANCY Chloral thirty to sixty grains are given at a dose, and as much as three drams in twenty-four hours. It is given in mucilage of acacia-three ounces-by enema. It has a record of 3.5 per cent, mortality in 114 cases, a record that entitles it to serious consideration. Typhoid and parathyroid extract, the use of which is based upon animal experimentation, have not given much, if any success, and are not worth while. Hirudin has been recommended, intravenously, to prevent if possible the capillary thromboses of the liver and kidneys. It is of doubtful value, and has the serious objection of pre-, disposing to postpartum hemorrhage, from the reduced coagu- lability of the blood. Other methods recommended are: (1) Lumbar puncture; (2) decapsulation of kidneys; (3) pumping or even amputation of the breasts-based upon the erroneous theory of a mammary cause for the convulsions. All these methods are more or less fantastic, and have not received more than passing notice. Lumbar puncture, however, has a distinct value in patients with severe headache and failing vision, and relieves these symptoms promptly. It is in no way curative. Forcible delivery (accouchement force). Ample statistics are available to prove that forcible delivery, without previous elimination, has a mortality twice as high as the more conserva- tive plan of elimination and spontaneous delivery. These patients are bad surgical risks and suffer severely from surgical shock. After twenty-four or forty-eight hours of elimination, operative delivery can be carried out much more safely than would have been possible without such elimination. Methods.-If the patient is in labor, the cervix well dilated and the head engaged, delivery by forceps is indicated. Po- dalic version is an alternative method. The main problem is found in the patients not in labor, without effacement of the cervix. Here hydrostatic or instrumental dilatation of the cervix with delivery by forceps or version give the least risk, provided sufficient time is taken for delivery. Vaginal THE TOXEMIAS OF PREGNANCY 217 cesarean section (anterior vaginal hysterotomy) offers a rapid method, but one with considerable danger of tearing the blad- der, if it is employed after seven and a half months. Abdominal cesarean section is indicated in any case where there exists any obstacle to easy delivery, or where the patient's condition is such that very rapid delivery is essential with a minimum of shock. Stimulation.-Many eclamptics with normal delivery and very many with forcible delivery require stimulation. A satisfactory routine method is: (i) Digalen io drops or digipuratum i ampule hypodermically every three hours; (2) strychnia sulph. gr. hypodermically every three hours alternating with digitalis; (3) camphorated oil hypodermically 20 minims and repeat every two hours if needed; (4) external heat by hot-water bags or by electric cabinet. CHAPTER X THE PREMATURE TERMINATION OF PREGNANCY (ABORTION. MISCARRIAGE. PREMATURE LABOR). EXTRA-UTERINE PREGNANCY When the expulsion of the ovum occurs prior to the fourth month, it is called abortion; from the fourth to the seventh month, miscarriage; and from the seventh month to term, premature labor. ABORTION Frequency.-The frequency of abortion is about 20 per cent, or one to every four or five completed pregnancies. The most common period is between the second and third months. Causes^-The cause of an isolated case of abortion is often difficult to determine, but it is usually due to overexertion or some physical shock. The commonest causes of repeated abortions are: (1) Syphilis, responsible for about 85 per cent.; (2) backward displacement of the uterus; (3) pelvic inflamma- tion-most commonly endometritis; (4) irritable uterus-one extraordinarily sensitive to external shock; (5) chorea. Many other causes could be cited responsible for isolated cases, but the vast majority are accounted for by the above. Some women, on the other hand, present the greatest resistance to shocks or causes ample to produce abortion; even the roughest treatment or severe accidents fail to disturb their pregnancy. Classification.-Abortion may be threatened or inevitable; the inevitable may be complete or incomplete. Symptoms of Threatened Abortion.-Cramp-like pains in the lower abdomen and hemorrhage. The hemorrhage is usually • in the form of clots and is rarely excessive. On examination, the patient presents the confirmatory signs of 2l8 ABORTION 219 pregnancy and blood is issuing from the cervix. The expulsion of the ovum may be immediate or it may be delayed for many days or even weeks. A negative sugar tolerance test is strong presumptive evidence that the ovum is dead. Diagnosis of threatened abortion is made upon the above symptoms. They may be closely simulated by efforts of the uterus to expel a fibroid polyp. Treatment of threatened abor- tion is absolute rest in bed, no local treatment such as douches; avoidance of active cathartics; opium suppositories, gr. i, twice daily and a teaspoonful of the fluidextract of viburnum pruni- folium three times a day. If this latter is nauseating, gr. v of the solid extract of viburnum pruni- folium may be substituted, in addition to the opium in the suppositories. If the symptoms subside, the patient should be kept in bed for a week after all bleeding has ceased, to guard against recurrence. If actual abortion does not take place, the threatening symptoms will usually begin to subside within forty-eight hours of the beginning of treatment. Diagnosis of Inevitable Abortion.-Continued pain, con- tinued hemorrhage, dilatation of the cervix and the presenta- tion of portions of the ovum mean usually inevitable abortion. Tarnier's sign is due to the dilatation of the cervix. As the cervix dilates from above downward, the cervico-uterine angle, where the uterine body bulges sharply outward at the level of the internal os, becomes a more gentle curve. This is apparent even before there is any dilatation of the external os. When an abortion is seen to be inevitable, and the os is not much dilated, but bleeding is free, the bleeding may be checked by packing the vagina tightly with sterile or iodoform gauze. Fig. 90.-Tarnier's sign of in- evitable abortion. 220 THE PREMATURE TERMINATION OF PREGNANCY When the gauze is removed twelve hours later, the ovum will often be found adhering to the upper layers of the gauze or presenting through the cervix, whence it can be easily removed by placental forceps. If it is not discharged, the treatment may be expectant or active. Expectant Treatment.-The patient is given fluidextract of ergot, thirty drops, three times daily, but this is liable to cause retention instead of expulsion of the ovum, by contracting the cervix as well. Pituitrin ampule hypodermically and repeated in two hours if needed is better. If a foul odor to the discharge appears or free bleeding begins, the waiting plan must be abandoned and the uterus evacuated. As a rule the expectant treatment is not to be re- commended. In only 13 per cent, is the expulsion of the ovum complete, and the other 87 per cent, will in the end require the instru- mental evacuation of the uterus. Active Treatment.-When the os is sufficiently dilated, the ovum can be evacuated by the finger (possible only when the ovum is in the cervix or lower uterine segment) or by Emmet curetment forceps. If the bleeding is profuse and the os not sufficiently dilated, it may be controlled by packing, or the cervical canal may be instrumentally dilated and the ovum extracted. The curet is rarely needed, and if used should be a dull one. Extreme gentleness is needed to avoid perforation of the uterus. In nulliparae, an anesthetic is usually required; but the dilatation and evacuation may usually be done in PiG. 91.-Packing for abortion. ABORTION 221 multiparae without anesthesia. In either case, it is much easier with the patient on a table than across the bed. If the patient has lost a great deal of blood, it is wiser to pack the uterus and vagina for twelve or twenty-four hours, and in all cases the Fig. 92.-Cervical abortion, the ovum still in the reflexa and the placenta drawn out, but adherent at its base. This is the only type of abortion where the ovum can be removed with the finger. (De Lee.) patient should be given one dram of fluidextract of ergot by mouth or one ampule of aseptic ergot hypodermically, when the operation is completed. The uterus should be irrigated 222 THE PREMATURE TERMINATION OF PREGNANCY after the evacuation and again after the packing has been removed. , After-treatment.-The patient is kept in bed for ten days. Diet is light and the bowels should be kept well opened. No douching is necessary unless the patient is infected, when she is treated as any ordinary case of puerperal infection. The infection is of two types-the spontaneous abortion due to sapremia: the criminal abortion either sapremic or more likely streptococcic and hence much more serious. The simple evacuation of the uterus and one or two intra-uterine douches will cure the former, the latter is always serious and sometimes fatal. Diagnosis of Complete or Incomplete Abortion.-If the mass expelled from the uterus has been saved for the physician's inspection, it should be floated out in water and examined to determine how much of the chorion if any, is missing. This is often impossible. In these cases the diagnosis must rest upon the degree of dilatation of the internal os. If this is closed we may assume that abortion is complete or only threatened and in either case the patient can be treated expectantly. If the os is open, and the uterine cavity can be easily palpated, abortion is incomplete and the evacuation of the uterus is indicated. In doubtful cases, the appearance of lactation may be of value in clearing up the diagnosis. While the bleeding of threatened abortion is not dangerous, the bleeding from an incomplete abortion may be very serious and even fatal. These cases of incomplete abortion should have the uterus and vagina packed after the evacuation, if the bleeding has been severe, as a precautionary measure. Missed Abortion.-Rarely an abortion is threatened, the fetus dies, the symptoms subside and the ovum is retained in the uterus for a varying period, even years. No treatment is indicated unless the symptoms of abortion recur or the patient shows signs of infection, when the uterus must be emptied. As in the minds of many patients the word abortion is synony- mous with criminal abortion, they will often resent the use of EXTRA-UTERINE PREGNANCY 223 the word. In all cases it is better to speak of the condition as miscarriage, as that is the term with which they are familiar. MISCARRIAGE Miscarriage differs from abortion in the time of occurrence (fourth to seventh month); the product of conception is rarely thrown off entire, but usually the membranes rupture, the fetus is born and the placenta is likely to be retained. The pain is greater and more like true labor pain and the bleeding less. The classification, the symptoms and the treatment of threatened miscarriage are the same as abortion. For remov- ing the tightly adherent placenta from the uterus, the hand is often better than curet or placental forceps. Occasionally the ovum is cast off entire, without rupture of the membranes. PREMATURE LABOR Premature labor is caused by many of the causes of abortion and is the rule in multiple pregnancies. It differs in no way from labor at term except that it is shorter and easier, and that there is greater likelihood of adherent placenta. It is managed as labor at term. EXTRA-UTERINE PREGNANCY (ECTOPIC GESTATION, TUBAL GESTATION, TUBAL PREGNANCY) This means the arrest and development of the fertilized ovum at some point other than the uterine cavity, most often in the outer third of the fallopian tube. The ovum may lodge anywhere from the peritoneal cavity to the interstitial portion of the fallopian tube, in the uterine cornu. Classifications.-The kinds of extra-uterine pregnancy are the (a) tubal; (Z>) ovarian and (c) abdominal which may be primary or secondary; and combinations, such as the tubo- uterine or interstitial or cornual pregnancy; tubo-ovarian preg- nancy, etc. 224 THE PREMATURE TERMINATION OF PREGNANCY Cause.-The cause of extra-uterine pregnancy is anything which prevents the normal progress of the ovum along the tube to the uterine cavity; usually adhesions in or around the tube or the loss of the cilia of the tubal mucous membrane, due to a preexistent salpingitis. Often no cause can be demonstrated. Frequency is said to be one in 500 cases, and most often between twenty and thirty years. Tubal pregnancy is by far the commonest. Ovarian pregnancy is exceedingly rare. Primary abdominal pregnancy is also very rare but secondary abdominal pregnancy, where the embryo was originally in the tube, but escaped into the abdominal cavity and there con- Fig. 93.-The possible sites of extra-uterine pregnancy: 1, Cornual or interstitial; 2, tubal in the isthmus; 3, tubal; 4, and 5 ampullar. Ovarian and primary abdominal pregnancy are exceedingly rare. (Gilliam.') tinned its development for some time, has often occurred. In such a case the child may die at the time of its extrusion into the abdominal cavity, and be retained as a lithopedion for an indefinite time (56 years in one case); or it may partially absorb and the bones ulcerate through into the bowel or bladder; or it may continue its development until term, or past it, and be delivered alive by abdominal section. Development.-In the tube the ovum behaves much as it does in the uterus. It burrows into the mucosa; this is imper- EXTRA-UTERINE PREGNANCY 225 fectly transformed into decidua and the chorion and amnion develop as in normal pregnancy. Decidua is also formed in the uterine cavity, not as thick as in normal pregnancy. This decidua after the death or removal of the embryo is cast off, but sometimes must be removed by curetment, as it may become necrotic and cause sapremia, or may be a cause of bleeding. Terminations.-Most commonly tubal abortion, or extrusion of the ovum through the dilated fimbriated extremity of the tube, with more or less severe hemorrhage, at about the sixth to tenth week of pregnancy. Next in frequency, erosion of the tubal wall (the so-called rupture) with severe internal hemor- rhage; erosion of the tube with hemorrhage into the layers of the broad ligament; the conversion of the fetus into a lithope- dion or calcification of the fetus; rarely death of the embryo and complete resolution. A tubo-uterine or interstitial pregnancy may make its way into the uterine cavity and progress normally to term and very rarely a tubal pregnancy may develop to term. Tubal pregnancy not infrequently occurs twice in the same individual. Rarely combined extra-uterine and intra- uterine pregnancy have been found. If the ovum lodges at or near the uterine cornu, there is less disturbance of menstru- ation than if it lodges near the ampulla. Early rupture, accom- panied by much more severe bleeding, is to be expected in such a case. Clinical History and Symptoms.-The patient has usually had children before, but the last some years previously. She misses one or two periods, which then return as irregular bleed- ing. At the same time occurs violent stabbing pain in the lower abdomen, severe enough to make her faint, and when she recovers consciousness, she is nauseated. The pain recurs in paroxysms, increasing in frequency and severity, but the interval between them is free from pain. Finally after one of these attacks of pain, the symptoms of internal hemorrhage appear. Frequently, however, this entire history may be negative, and the first symptom is a violent attack of pain with is 226 THE PREMATURE TERMINATION OF PREGNANCY the signs of internal hemorrhage. There is often a discharge of decidua, from the uterus, described by the patient as "a piece of flesh, different from a blood-clot;" but no ovum is dis- charged, except in the rare instances when there is a combined intra- and extra-uterine pregnancy. There is a slight eleva- tion of temperature averaging 99.5° F. and a leukocytosis of 12,000 to 14,000. On vaginal examination, the patient pre- sents confirmatory signs of pregnancy, the uterus not so large as one would expect to find it, and behind it a pelvic mass, extremely sensitive to the touch. The average time of rupture or tubal abortion is from the sixth to tenth week. Cullen's sign of a greenish blue discoloration around the umbilicus is of some value, if there has been free intraperitoneal hemorrhage. It is best seen in a darkened room, with a flashlight. While strongly suggestive of intraabdominal bleeding, it is not con- clusive, as it has been observed in acute salpingitis with peritonitis. Diagnosis and Differential Diagnosis.-The diagnosis between the different varieties of extra-uterine pregnancy is made by operation, as the clinical history and symptoms of the tubal, ovarian and abdominal varieties, are practically identical. The differential diagnosis from conditions closely resembling it may be of extreme difficulty. Two conditions that are prac- tically indistinguishable from it are: (1) hemorrhage from a ruptured varicose vein in the broad ligament and (2) severe hemorrhage from the wall of a ruptured graafian follicle. Others in which a mistake is excusable are: (3) Acute salpingitis with or without coincident intra-uterine pregnancy; (4) ovarian cyst twisted on its pedicle; (5) appendicitis with or without coincident intra-uterine pregnancy. In salpingitis there should be a leukorrheal discharge; higher fever; higher leukocyte count; no decidua passed; less sensitive mass; occasionally bilateral. The twisted ovarian cyst would be spherical in shape; lower temperature (shock); lower leukocyte count, no decidua. In appendicitis the point of tenderness would be over McBurney's point; higher fever, EXTRA-UTERINE PREGNANCY 227 higher leukocyte count, no decidua; absence of a pelvic mass. The difference is not so clear in practice. Acetonuria, said to be pathognomonic of internal hemorrhage, has been proved of no value as a diagnostic aid, being frequently found in pyosalpinx. If the ovum is alive, a positive sugar tolerance test is of value. In all cases in which a diagnosis of extra- uterine pregnancy is justifiable, the diagnosis should be made and acted upon. All the above require abdominal operation, and the only mistake is that of a possibly unnecessary hurried operation. A common but unjustifiable error in diagnosis is to mistake extra-uterine pregnancy for an incomplete abortion. In cases of abdominal pregnancy, past the sixth month of development, the x-ray will often afford a means of clearing up the diagnosis between extra-uterine pregnancy and other abdominal tumors. Opening the posterior vaginal vault as a means of diagnosis is unjustifiable. The risk of infection is formidable. Treatment is abdominal section as soon as the diagnosis is made. The vaginal route is not advisable. After as complete a preparation as possible under the circumstances, the abdomen is opened in the middle line, under general or local anesthesia. When the peritoneum is reached, its color is dark slate, if the tube is ruptured, from the clotted blood underneath. When the peritoneum is opened, the blood gushes forth in large quantity. No attention should be paid to it. The affected tube and ovary should be brought up into the wound, ligated and removed. The blood-clots are removed from the abdomen best by irrigation with sterile water or salt solution. The abdomen is closed without drainage. Rapidity of operation is essential. The need for rapidity is over, however, as soon as the blood supply of the affected tube has been controlled. Any intravenous stimulation or transfusion can be done on the table, during the operation. Stimulation with drugs should be withheld until the source of bleeding is controlled. The expec- tant plan of treatment, of waiting until the patient has recov- 228 THE PREMATURE TERMINATION OF PREGNANCY ered from shock before operation, is not to be recommended. Occasionally these patients will not rally from shock but will bleed to death, and nothing is gained by delaying operation. This is the rule in cases when the ovum has lodged near the uterine cornu. When the pregnancy has progressed, as it occasionally does, to the latter months, the danger of rupture is small and the operator is justified in waiting till the child is viable. If the child is alive, in these cases, often extreme difficulty will be found in controlling the bleeding from the placental site, and packing will usually be required. In cases where the child is dead and has been long retained, the placenta, blood- clots and decidua are very putrescible, and drainage is uni- formly required. When the tube has ruptured into the layers of the broad ligament, and the patient has recovered from the immediate shock, the resulting hematoma is best evacuated by incision through the vaginal vault. Active stimulation is the rule in all bad cases. Salt solution or gum acacia solution intravenously (2500 mils or more) is required. The common mistake is in giving too little. Intravenous transfusion of blood 500 to 750 mils; digalen ttjj or digipuratum (1) ampule every three hours hypodermically; strychnin sulph., gr. every three hours hypodermically; oxygen for a few hours if very desperate; and external heat with bandaged extremities. Prognosis.-Without operation 66 per cent, succumb to internal hemorrhage. Of the remaining 34 per cent, a large proportion are invalids or ultimately lose their lives from com- plications directly a result of the extra-uterine pregnancy (suppurating pelvic hematoma, etc.). With abdominal sec- tion, the mortality should be very small (1 per cent, or less), if seen in time, and few, if any, cases are too desperate for operation. A few cases will first rally and then die of acute anemia, in spite of stimulation. Pregnancy in one horn of an uterus unicornis or bicornis sometimes occurs. It cannot usually be diagnosed from tubal pregnancy and its complications and treatment are the EXTRA-UTERINE PREGNANCY 220 same. It will probably rupture at the cornu of the uterus, but later in pregnancy than the tubal variety. The ovum may be expelled through the cervix, as in ordinary abortion. A true cornual pregnancy may either rupture at the third or fourth month, or more likely spontaneously move into the uterine cavity and continue to term. It is not wise to remove both fallopian tubes unless both are diseased. While repeated ectopic is a risk, if the other tube be left, many more patients will become normally pregnant and be delivered at term. CHAPTER XI DYSTOCIA A difficult labor may be either delayed or obstructed. The commonest causes of delayed labor are: (1) Inertia uteri; (2) rigid cervix; (3) breech presentations; (4) twins; (5) occiput posterior positions. The commonest causes of obstructed labor are: (1) Contracted pelvis; (2) overgrowth of fetus; (3) hydro- cephalus; (4) obstruction due to pelvic tumors; (5) transverse or other malposition of child. The management of these con- ditions are considered in their appropriate places. Anomalies in forces of expulsion may be deficiency or excess of expulsive force. INERTIA UTERI Inertia uteri or deficient expulsive force is common. The causes are: (i) Fatigue; (2) overdistention of uterus by hydramnios or twins; (3) faulty innervation of uterine muscle; (4) many previous labors; and sometimes (5) fear of the physi- cal pain of the contractions. Time of Occurrence.-May occur at any time during the labor, but is most frequent during the first stage and next at the end of second stage, the so-called terminal inertia. Diagnosis is usually easy. The uterine contractions become less frequent and shorter, the uterus is not as hard as it normally should be; the patient's suffering is obviously slight, and there is no advance in labor. The dilatation of the cervix is slow or does not progress at all, and the presenting part remains stationary. Differential Diagnosis.-Inertia uteri must be distinguished from overdistention of the lower uterine segment, in a case of obstructed labor. In the latter, the lower portion of the uterus 230 INERTIA UTERI 231 does not contract at all; there is a high contraction ring which should be visible on the abdomen; in bad cases the upper, con- tracted portion of the uterus can be distinctly felt above the contraction ring; and a careful pelvic examination will usually reveal the cause of the obstruction. A mistaken diagnosis will usually mean the patient's death from a ruptured uterus. Treatment of inertia depends upon the cause, and no single plan of treatment will answer in all cases. If due to fatigue, a hypodermic injection of % gr. of morphin will usually give the needed rest. Morphin, or morphin and scopolamin, is safe for the child only in the first stage of labor. More often, however, the uterus requires stimulation, the methods being: (i) Kneading the uterus with the hand; (2) bougies or bags; (3) the application of forceps; (4) stimulation by drugs. Kneading the uterus with the hand is of little use, being fatiguing to the doctor and patient and of no value except just at the very last of the second stage. The insertion of two bougies or a boiled rectal tube into the cervix and lower uterine segment is often difficult, on account of the position and engagement of the presenting part. If successful, the value depends upon the bougies acting as a foreign body and thus exciting the uterus to contraction. The application of forceps requires dilatation of the cervix of about three fingers, and rupture of the membranes. The head is pulled down enough to irritate the cervix and thus cause uterine contractions, and no attempt is made to deliver the head. Also a method of doubtful utility, and one posses- sing dangerous possibilities, if abused. Drugs are the most valuable means of stimulating uterine contractions. Those used are quinin, ergot, alcohol and pitui- trin. Quinin is unreliable and in patients who have an idio- syncrasy against it is liable to cause severe postpartum hemor- rhage. There are some women in whom a dose of quinin will cause the menstrual flow to appear. These women cannot take quinin in labor. It is used in a single large dose of ten to twelve grains. Small doses are useless. 232 DYSTOCIA Ergot is never given as long as the child is in the uterine cavity except between the birth of the two children in twins. In twins, the birth-canal has already been dilated by the passage of the first child, and the interval between the two children is, or should be, so short that no contraction need be feared. The ergot is given here as a preventive of postpartum hemorrhage, and not to excite expulsive pains. Otherwise it is more liable to cause further delay by stimulation of the circular fibers of the cervix, as well as the longitudinal fibers of the uterine muscle. Alcohol is given as brandy, one-half ounce, whiskey one- half ounce, or sherry two ounces, with a few crackers or piece of toast, to guard against the nausea often produced by alcohol upon an empty stomach. It is unreliable as to action and is often vomited. Pituitrin.-The best of all the oxytoxics is pituitrin (pitui- tary extract, hypophysin), a solution of the active principle of the posterior lobe of the hypophysis cerebri. It was first used extensively in 1909, though in limited use a few years prior to this. It is given deeply intramuscularly and not sub- cutaneously, in doses of not over one half mil; less is better. It is a powerful stimulant to all unstriped muscle, and if used recklessly is a most dangerous drug. Its action on the uterine muscle is of greatest intensity when the patient is already in labor; it is not so intense when used to induce labor; and as an abortifacient it is entirely unreliable. If used according to the following directions, its use should be followed by gratifying success. 1. It should be given in primiparae only when the head has passed through the cervix. 2. It should be given in multiparse only when the cervix is thoroughly effaced, fairly dilated and easily dilatable. 3. It should never be given to any patient, if there is any obstacle to an easy delivery. 4. Three, four or five minim doses should be the rule. The full ampule of one mil should never be given before delivery except in cesarean sections. INERTIA UTERI 233 5. It should be given deeply intramuscularly, preferably in the deltoid, and not subcutaneously or above all not intra- venously. 6. Overdose is liable to be followed by relaxation of the uterus and postpartum hemorrhage. More than 1 mil, as a total amount, should not be used in any labor. 7. In syphilitic patients, the danger of rupture of the uterus is greatly increased, and pituitrin should not be used at all. 8. Stronger solutions are on the market, for use after surgi- cal operations. This "surgical" pituitrin should be avoided in obstetrical work. 9. If inertia occurs early in first stage of labor, before the os is well dilated, 3 doses of 3 minims each, an hour apart, often act very well. Accidents from its use have been: (1) Rupture of the uterus; (2) fetal asphyxia from violent uterine contraction; (3) post- partum hemorrhage; (4) premature separation of placenta; (5) extensive laceration from precipitate delivery. Other means of stimulating uterine contractions are: (1) Simple soapsuds enema; (2) separation of the membranes around the internal os; (3) rupture of the membranes (advis- able in multiparae only). Recently there has been put on the market a stronger prepa- ration of pituitrin, intended to combat intestinal paresis after abdominal operations. It is labeled Pituitrin S. and should never be used in obstetric work, unless the obstetric preparation, labeled Pituitrin O is not available. It must be used in correspondingly smaller doses. The full dose of 1 mil should never be given. Terminal inertia, occurring when the head is on the peri- neum, is managed by kneading the fundus, a hypodermic of mil of pituitrin or by the application of forceps; the short Sawyer forceps being here better than the heavier Simpson instrument. Terminal inertia is often due to weakness of the abdominal muscles, or the unwillingness of the patient to use the abdominal muscles, on account of the pain. In either case 234 DYSTOCIA it can be corrected by the use of the Sawyer forceps, with moderate or complete anesthesia. Excessive uterine force may result in extensive lacerations to the mother; injury to the child by expulsion with the mother in the erect posture, when the cord will probably be ruptured; and in precipitate labor. Treatment.-Take away the puller, retard the advance of the child's head over the perineum by direct pressure, and inhibit use of abdominal muscles by having patient breathe rapidly with open mouth. DYSTOCIA DUE TO BONY PELVIS Deformities of the Pelvis Frequency.--From 5 to 20 per cent, of women have some degree of contracted pelvis, but in only 3 to 5 per cent, is this contraction serious enough to cause trouble in labor. Ordi- narily pelves whose internal conjugate is over 9.5 cm. will cause no serious delay in delivery. Methods of diagnosis are: (1) Some obvious visible de- formity, which is often not present; (2) pelvimetry; (3) the sr-rays, which will show characteristics of some deformed pelves but are unreliable for measurements. Pelvimetry is of two classes: (1) External and (2) internal. The normal pelvic measurements are: External Measurements.-(1) Anterior superior spines of ilia-26 cm.; (2) crests of ilia-29 cm.; (3) trochanters-- 31 cm.; (4) external obliques-from one posterior superior spine of ilium to opposite anterior superior spine-22 cm. The oblique diameters are named from behind; (5) external conjugate or Baudelocque's diameter-from the depression below the spinous process of the last lumbar vertebra to the middle of the symphysis, meh below its upper margin- 20.25 cm. (Michaelis' diameter begins at the tip of the spinous process and is 21.5 cm.); (6) transverse of the outlet-between the tuberosities of the ischium-11 cm.; (7) the sagittal DYSTOCIA DUE TO BONY PELVIS 235 diameters of the outlet-begin at a line corresponding to the transverse of the outlet and from there to the bottom of the symphysis for the anterior (5.5 to 6 cm.) and to the tip of the sacrum for the posterior (9.95 cm.). They are of impor- tance in the management of pelves contracted transversely at the outlet; (8) the circumference of the pelvis-from the Fig. 94.-Normal pelvic inlet. (De Lee.) depression below the spinous process of the last lumbar ver- tebra over the crest of the ilium to the middle of the symphysis and doubled-90 cm. Internal Measurements.-(9) The internal conjugate diagonal -from the promontory of the sacrum to the bottom of the symphysis-12.75 cmd (IO) the true conjugate or conjugata vera -from the promontory of the sacrum to the inner surface of the symphysis; inch below its upper edge-11 cm. This is the most important single diameter of the pelvis. Any pelvis two or more centimeters short in an important diameter, is said to be contracted. All these measurements, except the sagittal diameters, are most conveniently taken with the ordinary calipers. The sagittal diameters require a special instrument; and the circumference, a tape measure. 236 DYSTOCIA Relation of external to internal conjugate is that it forms a fairly reliable guide to when it is necessary to measure the internal conjugate, but it does not tell how small the internal conjugate is. The rule ordinarily applied in practice is: If the external conjugate is below 16 cm. the internal conjugate is seriously contracted; from 16 to 18 cm. there will be serious Fig. 95.-The digital method of measuring the internal conjugate diag- onal. From this the true conjugate is calculated by the method described in the text. (Dickinson.) contraction in about half the cases; from 18 to only a small proportion will have an internal contraction; and above 2oJ4> there is almost sure to be no internal contraction. There- fore below 18 cm., the internal conjugate should always be measured; above 18 cm. it is hardly necessary. However, too much importance must not be attached to the external measurements alone. Methods of measuring the internal conjugate are the manual and the instrumental. Technic of Manual Method.--The patient is placed in the lithotomy position, and the external genitalia are carefully cleansed. An anesthetic is sometimes required, if patient is DYSTOCIA DUE TO BONY PELVIS 237 very nervous. Two fingers of one hand are inserted in the vagina, and the tip of the middle finger is placed against the promontory. The place where the subpubic ligament touches the hand is then marked, the fingers withdrawn, and the distance between that point and the tip of the middle finger is measured with a pair of calipers or a tape measure. This distance is the internal conjugate diagonal. From it the true conjugate is estimated by subtracting 1.75 cm. in every form of pelvis except the rachitic, and the generally contracted flat nonrachitic, where 2 cm. are subtracted. This method is very accurate, on the average, and is the method most often em- ployed. If it is difficult to reach the promontory with the examining finger, serious contraction need not be feared. The Instrumental Method.-Of the many instruments devised for the direct measurement of the internal conjugate, the best for general use is B. C. Hirst's pelvimeter. With this instru- ment the distance is taken between the promontory of the sacrum and the outer surface of the symphysis pubis, just below its upper edge. Then the thickness of the symphysis is measured and the second measurement subtracted from the first. The Neumann-Ehrenfest pelvigraph plots out a chart of the pelvis upon a piece of paper, as does the perimeter in plotting out the eye-ground. The Neumann-Ehrenfest kleiseometer measures the pelvic inclination. They are adapted for use in the hands of specialists only, and are too complicated and difficult to manipulate for use in general practice. The Sagittal Diameters and Their Measurements.-The sagittal diameters are the practical anteroposterior measure- ments of the pelvic outlet. The anteroposterior diameter in the dried specimen runs in a straight line from the bottom of the symphysis to the tip of the sacrum. The sagittals run from the bottom of the symphysis to a base line representing the line between the tuberosities of the ischium, and thence to the tip of the sacrum. To measure the sagittals, the patient is arranged in the dorsal position. A special pelvimeter may be used but is entirely 238 DYSTOCIA unnecessary. The necessary base line is established by a tape measure stretched between the tuberosities of the ischium and held there by an assistant. With ordinary calipers, the distance from the center of this line to the bottom of the symphysis is measured and averages five and a half to six centimeters. This is the anterior sagittal. From the center of the line to the tip of the sacrum is the posterior sagittal and averages ten centimeters (9.95). The index of the outlet based upon the sagittal diameters can be calculated by an ingenious formula devised by Dr. C. D. Daniels, of Philadelphia. If the altitude of a triangle Fig. 96.-Planes of sagittal diameters of outlet. is multiplied by its base and the result divided by two, the approximate area of the triangle is found. In this case the altitude is the posterior sagittal diameter; the base is the dis- tance between the two tuberosities of the ischium. There- fore, in a normal pelvis, the area of the triangle whose altitude is the posterior sagittal diameter, is 55 sq. cm. Altitude X base roXn no_ 2 - 2 - 2 - DYSTOCIA DUE TO BONY PELVIS 239 Fig. 97.-Normal sagittal diameters of the pelvic outlet. Fig. 98.-Importance of sagittal diameter. Though the contraction transversely is extreme, the long posterior sagittal permits delivery. Fig. 99.-Importance of sagittal diameter. Though the transverse of outlet is 6 cm., the short posterior sagittal will not permit of delivery. 240 DYSTOCIA This figure (55) is taken as the normal, and called the index of the outlet. If this index is 55 to 33, as a rule spontaneous delivery may be expected; if 33 to 28 considerable difficulty will be experienced and below 28 the difficulty is liable to be insup- erable. These figures are as yet more or less dogmatically taken, and numerous exceptions to the working of the rule will be found. Antepartum Fetometry.-All pelvic measurements are rela- tive to the size of the child. The process of testing the relative size of the child's head to the pelvic inlet is called antepartum fetometry. (1) Mullers' Method.-With patient on her back, try to push head into pelvis, by pressure from above. (2) B. C. Hirst Modification of Muller.-If the head, when pushed down by the Muller method, will not enter the superior strait, note the relation of the anterior parietal eminence to the symphysis; if it does not project beyond the symphysis, spontaneous delivery is possible. (3) Perret's Method.-The occipitofrontal diameter of the child's head is measured, through the mother's abdominal wall. A fold of the abdominal wall is pinched up and meas- ured, and this subtracted from the first measurement, to find the biparietal diameter. (4) Stone's Method.-The occipitofrontal diameter is meas- ured. No allowance is made for the thickness of the abdominal wall. In heads with an occipitofrontal diameter of 11 cm. or less, 2 cm. is subtracted to find the biparietal; if over 11 cm., 5 cm. is subtracted. (5) Ahlfeld's measurements, based upon a belief that the biparietal diameters of the head bear a definite relation to the length of the child. To measure the length one tip of the cali- pers is placed upon the abdomen over the child's breech, the other tip in the vagina, against the vertex. This measurement is regarded as equal to one half the child's length and the rela- tion of the size of the head is calculated: Length 50 cm. - DYSTOCIA DUE TO BONY PELVIS 241 biparietal diameter of 9 cm.; 49 cm. = 8.72 cm.; 48 cm. = 8.56 cm.; 47 cm. = 8.44 cm.; 46 cm. = 8.34 cm. Pelvic inclination is increased in all flat pelves (a flat pelvis is one where the chief contraction is anteroposterior at the inlet) especially the rachitic. It is diminished or lost in: (1) Kypho- sis; (2) spondylolisthesis. Frequency of Deformed Pelves.-The commonest deform- ity of the pelvis is the simple flat. Next the justominor, and third the rachitic. The most common serious deformity is the rachitic. Classification of Deformed Pelves.-The following classi- fication of deformities of the pelvis has been found easy for the student to remember and is sufficiently accurate for all practical purposes. It is arranged in groups, based upon the predominating deformity, so each group has essentially the same effect upon the mechanism of labor and is managed by the same general rules. I. Pelves Whose Chief Deformity is Anterior Posterior Contraction at the Inlet. 1. Simple flat. 2. Justominor. 3. Generally contracted flat, nonrachitic. 4. Rachitic. 5. Spondylolisthesis. 6. Osteomalacia (malacosteon). 7. Kyphoscoliosis. II. Pelves Whose Chief Deformity is Contraction of Trans- verse Diameters, Especially at the Outlet. 1. Kyphosis. 2. Fetal funnel-shaped. 3. Robert. III. Pelves Whose Chief Deformity is Oblique Contraction: 1. Nagele. 2. Unilateral deformity (coxalgia, disease of one leg, clubfoot, etc.). 16 242 DYSTOCIA IV. Atypical Pelves. 1. Justomajor. 2. Split pelvis. 3. Assimilation pelvis. 4. Lordosis. 5. Fractures (old) of pelvis. V. New Growths. 1. Exostoses. 2. Osteosarcoma. 3. Enchondroma. Diagnosis and Management of Deformed Pelves.-For convenience in study, the pelves will be considered in groups, according to their chief deformity. I. PELVES WHOSE CHIEF DEFORMITY IS CONTRACTION OF THE CONJUGATA VERA Simple Flat Pelvis.-The commonest and least serious de- formity of the pelvis. Fig. i op .-The characteristic measurement of a simple flat pelvis. {De Lee.) Cause.-Indefinite. Has been ascribed to arrested rickets, overwork, carrying heavy weights, or too early sitting or walking in childhood. DYSTOCIA DUE TO BONY PELVIS 243 Characteristics.-The sacrum is pushed downward and for- ward, but not rotated on its transverse axis. All the antero- posterior diameters are shortened, but the transverse and oblique are practically normal. There is sometimes a second or accessory promontory. The conjugate is very rarely less than 8 cm. Effects on the mechanism of labor are that the head is (i) imperfectly flexed; (2) engaged in the transverse diameter of the pelvis; (3) there is exaggerated lateral inclination; (4) the dilatation of the cervix is slower than normal. These are the effects upon the mechanism of any flat pelvis, where a short conjugate is the chief obstruction. Effect upon Labor.-Rarely serious, as the conjugate is rarely below 8 cm. Justominor or Generally Equally Contracted Pelvis.-This is the second in frequency among the white races. Cause.-Arrested development. Characteristics.-Is usually seen in women of small stature. The hips are abnormally narrow; the bones are lighter than normal; the joints are not as firm as normal; all measurements are proportionately reduced, except the circumference of the pelvis, which is far below normal. Varieties.-(1) Juvenile; (2) masculine; (3) dwarf (pelvis nana). The first is the usual type. The other two are rare. Effect upon Mechanism of Labor.-Slight, except to give excessive flexion and often transverse engagement of the head. Effect upon Labor.-iNot usually serious. In the applica- tion of forceps, great care must be used, in traction, to avoid fracture of the pelvic joints. Generally Contracted Flat (Non-rachitic) Pelvis.-Cause.- Same as simple flat. Characteristics.-Practically a combination of the simple flat justominor pelves. All the diameters are reduced, but the conjugate is disproportionately small. Effect upon mechanism is that of any flat pelvis. (See simple flat.) 244 DYSTOCIA Normal Justo-minor Flat Rachitic Robert Naegele Malacosteon Fig. ioi.-Various shapes of the pelvic inlet. (Bumm.) DYSTOCIA DUE TO BONY PELVIS 245 Effect upon labor is more serious than either of the foregoing. Rachitic Pelvis (Rickets).-The third in frequency of de- formities of the pelvis; the most common of the types in which serious difficulty is met in labor, and the most frequent deform- ity in the colored race. Varieties.-(i) Generally contracted flat; (2) generally equally contracted; (3) simple flat. The first one is much the commonest. There is described a pseudo-osteomalacic type of rachitic pelvis, the most serious form, but so rare as to be a negligible factor. Cause.-Rickets in early childhood; the downward pressure of the weight of the trunk, and the upward and inward pres- sure of the femora. Characteristics.-The sacrum is pushed downward and for- ward, rotated on its transverse axis and sharply bent in the middle; the posterior spines are closer than normal; the anterior superior spines are flared wider apart; the acetabulae are further anterior; the normal curvature of the innominate bones is increased; the conjugatosymphyseal angle is increased; pelvic inclination is markedly increased; and the pubic arch is abnormally wide. The lozenge or rhomboid of Michaelis, formed by lines joining the depression below the spinous proc- ess of the last lumbar vertebra, the two dimples below the posterior superior spines of the ilia and the beginning of the intergluteal fold (the tip of the sacrum) is changed from its usual diamond shape into a kite or triangular figure. Diagnosis.-The patient is often a negress, has a waddling gait, and is short, pigeon-breasted, sway-backed and bow- legged. All the pelvic measurements are decreased, but the conjugate is disproportionately small. The distance between the spines of the ilia is often as great as or greater than the crests. The rhomboid or lozenge of Michaelis is changed to a kite-shaped or triangular figure. Sway-back is marked. The pubic arch is wide, and usually all the obstruction is at the pelvic inlet. The sacrum is felt to be sharply curved, the 246 DYSTOCIA promontory is easily reached, and in calculating the internal from the diagonal conjugate, 2 cm. must be subtracted. A false or double promontory, from the forward displacement of the first sacral vertebra, is not unusual. Fig. 102.-The rhomboid or lozenge of Michaelis, as seen in a normal pelvis. (Boim.) Fig. 103.-The lozenge of Michaelis as seen in a rachitic pelvis. (Bumm.) Effect upon the Mechanism of Labor.-That of a flat pelvis. (See simple flat.) Effect upon Labor.-This is usually most serious, as the conjugate is sometimes as small as 5 cm. Osteomalacia is rare in this country, not uncommon in parts of Europe, notably Austria and Italy and common also in China. DYSTOCIA DUE TO BONY PELVIS 247 Cause.-A rarefying osteitis, seen in adult life, with absorp- tion of the lime salts and consequent softening of the bones. Due usually to unhygienic surroundings and improper food. Characteristics.-The bones, in advanced cases, are of leathery consistency. The sacrum is pushed far down in the pelvic canal. The innominate bones are pushed in by the femora. The symphysis projects forward like a beak. By vaginal examination, the general contraction of the pelvic cavity and sometimes its almost entire obliteration can be recognized, and the pubic arch is extremely narrow. The rt-ray shows well the shape of the pelvis. Symptoms and Diagnosis.-The attack begins usually by rheumatoid pains in pregnancy, associated with a progressive loss in height. The pain is worse on any exertion, but relieved by rest in bed. Then the patient has to walk by throwing each leg outward in a half circle, to avoid striking her internal malleoli together as she walks-the osteomalacic gait. The labors she may have during the progress of the disease, which is slow, are increasingly difficult, and finally cesarean section is required. Effect on the Mechanism of Labor.-When possible at all, that of a flat pelvis. Effect upon Labor.-Makes delivery more and more difficult as the disease progresses, finally requiring cesarean section. Management.-At first, forceps are sufficient; later crani- otomy and finally cesarean section are necessary. When cesarean section is done, the Porro operation is the better, as the disease is sometimes arrested by the increased deposition of lime salts in the bones that follows removal of the ovaries and uterus. It is possible, however, to deliver a patient with forceps whose measurements, applied to any other pelvis, would make the delivery impossible, as the bones will give enough to allow passage of the child. Spondylolisthesis is a pelvis in which the last lumbar vertebra has slipped downward and forward over the anterior 248 DYSTOCIA face of the sacrum, by elongation and secondary fracture of its arches. It is comparatively rare. Characteristics.-The last lumbar vertebra is displaced over anterior face of sacrum. The sacrum is pushed backward, and its tip projects into pelvic canal. Pelvic inclination is diminished. The pelvis is somewhat funnel-shaped and the pubic arch is narrow. The measurements chiefly contracted are the conjugate, the anteroposterior and transverse diameters of the outlet. Diagnosis.-The patient has a saddle-back, from prominence of innominate bones. The measurements involved are those stated above. The external conjugate may be normal, but the internal is seriously encroached upon. The patient's abdomen is markedly shortened. The spinous process of last lumbar vertebra is prominent. The internal conjugate is measured from the most prominent part of the projecting vertebra. Effect upon Mechanism of Labor.-When possible that of a flat pelvis. Effect upon Labor.-Usually insuperable obstruction. Kyphoscoliosis.--In this pelvis the humpback is situated in the dorsal region, is more rounded than angular, and is usually due to rickets. The lateral curvature is usually to the right. Characteristics.-The characteristics of the rachitic pelvis," with asymmetry. Management of Labor in All Flat Pelves.-To avoid repeti- tion, the management of labor in all pelves where the conjugate is the diameter most seriously involved, will be considered here. It is impossible to lay down rules to fit every case, but the following rules will be found reasonably accurate. If the patient is first seen before labor: If the conjugate is between n and 9.5 cm., ordinarily no interference is indicated; between 9.5 cm. and 8 cm., the induction of premature labor, two to four weeks short of term, with probably the use of forceps or version will usually give the best results; from 8 to 7 cm., induction of premature labor, with forceps, and if after a moderate trial (twenty minutes maximum) the forceps fail, pubiotomy, sym- DYSTOCIA DUE TO BONY PELVIS 249 physeotomy or cesarean section is required; below 7 cm. cesarean section seven days before term is best. If the patient is first seen during labor: With a conjugate from 11 to 9.5 cm. spontaneous delivery is the rule, and nothing Fig. 104.-The Walcher position. (Bumm.) more than forceps will be required; from 9.5 to 8 cm., choice between axis-traction forceps or version, usually the former, provided the head does not engage spontaneously, and the more serious procedures are necessary when the forceps have failed; from 8 to cm. axis-traction forceps may be cautiously 250 DYSTOCIA tried, but if they fail, pubiotomy or cesarean section is required; below 7 cm. only cesarean section should be considered. It must be understood that the axis-traction instrument markedly increases the danger to the child, and if it is used at all, it must be with due recognition of this fact. All cases, where there is a reasonable probability of spontaneous delivery, should be given a test of labor, to see what they can do for themselves. It is astonishing what flexion and moulding will do, in many cases. A primipara can be safely allowed to go for twenty-four hours; a multipara for twelve only (on account of the greater danger of rupture of the uterus). Should either patient show signs of exhaustion, or danger signals for the baby appear, earlier interference would be indicated. The above measurements apply only to cases where the child's head is of normal size. An overgrown child will com- plicate matters exceedingly. A careful estimation of the size of the child's head compared to the pelvic inlet should always be made. If, when the head is pressed firmly against the pelvic inlet, one parietal bone juts out beyond the symphysis, the obstruction is serious, and will very probably require cesarean section, even though the pelvic measurements seem not to warrant it. Craniotomy, in contracted pelves, is justifiable only if the child is dead. The Walcher position is of advantage in the lesser grades of contraction, down to about 8 cm. It consists in placing the patient upon an improvised operating table (such as a kitchen table), her buttocks projecting just beyond the edge of the table, and her feet hanging down toward but not touching the floor. The ordinary bed is too low to be of service. This maneuver is said to add as much as i cm. to the conjugate. If forceps are to be used, they must be applied before the legs are let down. In pelves whose conjugate is less than 8 cm., the method is of no value. DYSTOCIA DUE TO BONY PELVIS 251 II. PELVES WHOSE CHIEF CONTRACTION IS TRANSVERSELY AT THE OUTLET Kyphosis.-In a typical case, the kyphosis is situated in the lumbosacral region, is angular and due to tubercular caries of bodies of vertebra. Characteristics.--The sacrum is pushed backward. Pelvic inclination is lost. The tip of the sacrum is projected forward into the pubic canal. The pelvis is contracted transversely. The pubic arch is narrowed and often asymmetrical. The conjugate is often increased in length. In very marked cases, the spinal column overhangs the pelvic inlet, and renders impossible any engagement of the head-the pelvis obtecta. Diagnosis.-The humpback is obvious. The patient stands with knees bent, due to lost pelvic inclination. The conjugate is increased, while the transverse measurements, especially of the outlet, are markedly contracted. The anterior and posterior sagittal diameters of the outlet are of the greatest importance. For spontaneous or forceps delivery, the pos- terior sagittal diameter must be at least 7.5 cm., as on account of the narrowed arch, all of the anterior sagittal diameter is not available. As the transverse diameter of the outlet de- creases, the posterior sagittal must increase to allow of delivery. The pubic arch is narrowed and often asymmetrical. The patient's abdomen is shortened, and when she is near term, markedly pendulous. Effect upon the Mechanism of Labor.-Transverse presenta- tion is common, but usually spontaneously corrected, the child finally presenting by the head. The head is often slow to engage, due to the pendulous uterus. Posterior rotation of the occiput is very frequent and should not be corrected, as there is more room for the delivery of the larger posterior portion of the head in the posterior sagittal diameter. In these cases episiotomy will nearly always be required. There is more or less complete obstruction at the outlet. Effect upon Labor.-May be serious, depending upon the transverse diameter of the outlet. 252 DYSTOCIA Management.-If the distance between the tuberosities of the ischium is 8.5 cm. or over, spontaneous delivery is prac- tically sure. If it is between 8.5 cm. and 6 cm., the induction of labor four weeks short of term and the use of forceps will probably be successful. Should forceps fail, symphyseotomy or pubiotomy make the "delivery easy. With a diameter below 6 cm. cesarean section is best. It should always be determined whether the outlet is symmetric or not, as the asymmetric type is the more serious. Version is to be avoided, as the results to the child are bad, from difficulty in delivery of the head. Craniotomy is indicated only when the child is dead. Fig. 105.-The pelvic inlet in a fetal funnel-shaped pelvis. (£>e Lee.) Fetal Funnel-shaped Pelvis.-Cause.-Anomaly of develop- ment. Characteristics.-The pelvis is abnormally narrow and deep. The pelvic walls converge as they approach the outlet. The measurements of the inlet are normal, those of the outlet contracted, especially transversely. The pubic arch is extremely narrow. Effect upon the Mechanism of Labor.-Imperfect flexion; backward rotation of the occiput; serious lacerations of the perineum, unless episiotomy be done to avoid them, due to the head being forced backward at the outlet. DYSTOCIA DUE TO BONY PELVIS 253 Effect on Labor.-Delays are common, forceps often required, and the obstruction may prove insuperable. Management.-In minor grades, forceps are required, but injury of the soft parts often results. A transverse diameter of the outlet of 7.5 to 6 cm. is best managed by symphyse- otomy or pubiotomy; below 6 cm. cesarean section is neces- sary. Craniotomy is justifiable only when the child is dead, and version should not be attempted. Posterior rotation of the occiput is the rule, and should not be corrected, for the same reason as in kyphosis. Robert Pelvis.-The rarest type of pelvis. Cause.-Failure of development of the alae of the sacrum on both sides. Characteristics.-The pelvic cavity is almost obliterated, from the uterine transverse contraction. The sacrum is very narrow. Effect on Mechanism.-No mechanism is possible. Effect on Labor.-Insuperably obstructed. Management.-Cesarean section. III. PELVES WHOSE CHIEF DEFORMITY IS OBLIQUE Naegele Pelvis.-This is rare. Cause.-Failure of development of the ala of the sacrum on one side. Characteristics.-The pelvic inlet is obliquely oval. The atrophied joint is usually ankylosed. The sacrum is narrow and rotated toward the atrophied side. The innominate bone on diseased side runs almost straight to the symphysis. The other innominate bone is more curved than normal. The pubic arch is narrow and asymmetric. The diagnosis requires careful measurements, as there is usually no limping or other obvious deformity, but the x-ray shows it plainly. Effect upon the Mechanism of Labor.-That usually of a flat pelvis except that the head is extremely flexed, and the 254 DYSTOCIA rotation is imperfect, and engages in the longest oblique diameter of the pelvis. Effect on Labor.-This is serious and nearly all require major operative procedures. Management.-Induction of labor four weeks short of term has given the best results, but only in cases where the distance from the bottom of the symphysis to the healthy sacro-iliac joint is not less than 8.5 cm. In other cases, cesarean section has been most successful. Forceps and version are not of value. Oblique Deformity Due to Absence or Disease of One Extremity (Coxalgia, Loss of One Leg, Club-foot, etc.).--This produces a moderate oblique deformity on the sound side, due to the weight of the body being constantly thrown on that side. It is not a serious deformity, the difference between the oblique diameters being rarely more than 1.5 or 2 cm., and with a child of normal size, no obstruction to labor need be expected. IV. ATYPICAL PELVES Justomajor Pelvis.-(Generally equally enlarged.) Cause.-Usually excessive stature, but may be seen in women below normal height. Characteristics.-All measurements proportionately larger than normal. Bones larger and heavier. Impossible to reach the promontory with examining finger. Effect on Mechanism.-None except possibly abnormalities in rotation, due to insufficient resistance. Effect on Labor.-Predisposes to precipitate delivery; there may be delay from resistance of soft parts. Split pelvis is a very rare form. It is due to failure of development of the symphysis and is associated with exstrophy of the bladder. The obturator foramina are open. It has no effect upon labor, except that the thighs have to be supported, to prevent fracture of the sacro-iliac joints, from undue separa- tion of the bones. DYSTOCIA DUE TO BONY PELVIS 255 Fractures of the pelvis do not usually cause trouble unless union with marked deformity has occurred. In such cases, the obstruction may be insuperable. Atrophy, caries and necrosis have the same effect as im- properly united fractures. Synostosis or immovable pelvic joints result in loss of the slight normal elasticity of the pelvis, and do not cause serious obstruction. Lordosis is extremely rare, as a primary condition. When not secondary to some pelvic deformity, the pelvic inclination is tremendously increased, and labor is complicated by failure of the head to engage in the pelvic canal. Assimilation pelvis is the term used to describe the pelvis in which the transverse processes of the last lumbar vertebra are transformed into structures similar to the lateral masses of the sacral vertebrae. Thus the last lumbar vertebra assumes the function of the first sacral vertebra and the sacrum consists of 6 instead of 5 pieces. Rarely the first sacral vertebra takes the characteristics of a lumbar vertebra and becomes part of the lumbar spine. In the first case, the pelvis is increased in depth; in the latter, decreased but in both cases without marked influence on the course of labor. Luxation of both femora causes extreme lordosis, a widen- ing of the pelvis, particularly at the outlet, the conjugate is somewhat contracted, but rarely is less than 9 cm.; hence the obstruction to labor is slight. Fig. i06.-Cong e n i t a 1 luxation of both femora. This patient also had multiple arthritis deformans. (Phila. Gen. Hospital.) 256 DYSTOCIA V. TUMORS OF THE PELVIC BONES New growths are either: (i) Exostoses; (2) enchondroma and osteosarcoma. Exostoses are of two classes: (1) Spines (acanthopelys or pelvis spinosa) and (2) knobs. Cause.-Sometimes due to rickets, but most cases have no demonstrable cause. Situation most commonly over sacro-iliac joints, next over symphysis, and last all around the pelvic brim. Diagnosis by deep pelvic examination. Unless attention is directed to them by some external deformity, they are likely to be overlooked. Management.-The knobs do not ordinarily cause much trouble in labor. The spines will perforate the uterus during labor, and for that reason cesarean section is the safest method of delivery. Enchondromata and osteosarcomata are usually in the hollow of the sacrum, cause an insuperable obstruction, and require cesarean section. By a careless examination, their rounded mass might be mistaken for the child's head. DYSTOCIA DUE TO THE MATERNAL SOFT PARTS Edema of vulva is commonly due to pressure, rarely to kidney insufficiency. Its chief importance in labor is the danger of laceration of the perineum, and the likelihood of infection or possibly gangrene. The treatment is the appli- cation of hot water or puncturing the most dependent portion of the labia with a thin-bladed knife, under aseptic precautions. Varicose veins of the vulva are dangerous on account of the hemorrhage, if they are torn. If they rupture subcutane- ously, they cause a huge labial hematoma. The hemorrhage is always profuse, requiring suture or ligature. The patient should be instructed how to apply pressure, in emergency. Abscess of Bartholin's gland is often a cause of puerperal sepsis. The abscess should be opened early in labor, the DYSTOCIA DUE TO THE MATERNAL SOFT PARTS 257 cavity curetted, swabbed with carbolic acid and packed. The excision of the gland entire is not advisable at this time, on account of the free bleeding. Anus vestibularis, or a rectovaginal fistula, complicating labor adds considerably to the risk of infection. If possible, it should be closed with a purse-string suture just before the head comes down on the perineum, the suture being removed immediately after delivery. Tumors of the vagina or vulva are usually either fibroids (elephantiasis) or cysts. They are not often of a size to com- plicate labor, but if they are they must be removed if solid and punctured if cystic, and the child delivered by forceps. Overdistended bladder may interfere with the engagement of the head, become incarcerated, and a vesicovaginal fistula result. Forceps, particularly, should never be applied with a full bladder. Catheterization with a long stiff silk or soft rubber catheter of good caliber will obviate any difficulty. Overdistended rectum many interfere with delivery of the head, but an enema will correct the condition. Cystocele and rectocele complicate labor only if they become incarcerated and edematous from pressure. If so, forceps is the remedy. Usually labor is extraordinarily easy, after the head has passed through the cervix, due to lack of resistance. Atresia of the vagina is never complete or pregnancy would be impossible. There is always a sinus, however small and tortuous, communicating with the cervix. The canal can usually be dilated by metal or hydrostatic dilators, with or without deep longitudinal incisions. In some cases, especially those due to extensive cicatrices from previous inflammation, cesarean section may be required. Septa of the vagina are most often transverse, and if an obstruction to delivery, can be divided between two ligatures. If longitudinal, they are cut in several places, and the slight hemorrhage controlled by sutures. 17 258 DYSTOCIA Rigid perineum is common in primiparae, particularly after the age of thirty-five; it is also often due in multiparae to previous plastic operations. If the head is stationary on the perineum for more than one hour, forceps is indicated. The short Sawyer forceps is usually sufficient. More than one hour's delay is dangerous, both on account of the pressure on the child's head and the danger to the mother, from straining, of acute dilatation of the heart. Atresia of the cervix is most commonly caused by improp- erly performed repair of laceration. The opening of the cervical canal is often situated far to one side, near the vaginal vault. The site of the normal orifice can always be seen or felt, and a small opening should be made in the center. The further dilatation of the canal proceeds rapidly. If there is much cicatricial infiltration, multiple incisions of the cervix may be required. Rigidity of the cervix is common, to a greater or lesser degree, to all primiparae. It is not often excessive before the age of thirty-five. It is due also, in multiparae, to scars of previous operations for repair of tears, or cicatricial infiltra- tion, specific or malignant. The symptoms are slow dilatation of the cervix, and the thick resistant band of cervical tissue which can be felt. If neglected, the thick edematous cervix will sometimes tear completely off-the so-called annular detachment. The treatment consists in first allowing plenty of time, provided the cervix does not become edematous. Usu- ally it is not necessary to resort to artificial means of dilatation. Every effort should be made to preserve the membranes. If dilatation is not spontaneous, it may be secured by manual dilatation; hydrostatic dilatation or even multiple incisions, should milder methods not answer. The dilatation of the cervix by the application of forceps and traction is not to be recommended, due to the high fetal mortality. Version is also to be avoided in cases of rigid cervix. If the cervix becomes edematous, and is fairly well dilated it is often possible to complete dilatation by pushing the cervix back over the DYSTOCIA DUE TO THE MATERNAL SOFT PARTS 259 head, during the pains. All unnecessary or prolonged manipu- lations should be avoided, on account of the danger of infection. In extreme cases, vaginal cesarean section or deep multiple incisions may be required, though in these cases the danger to the bladder must be remembered. Cancer of the cervix complicating pregnancy and labor is rare. When it occurs, the disease is considerably aggravated. The chief dangers are hemorrhage (from lacerations) and sepsis. The treatment is: (i) cauterization of the sloughing cervix; (2) abdominal cesarean section; (3) panhysterectomy (which is considerably complicated by hemorrhage). The prognosis, due to the widely dilated vessels and lymph spaces, is bad. Displacement of the Uterus.-Anterior due to a diastasis of the rectus muscles, and an extreme anteversion of the uterus. The patient's abdomen is very pendulous &nd the diagnosis is obvious. The anteversion of the uterus prevents the engagement of the presenting part in the pelvic inlet. An abdominal binder restoring the uterus to proper position will correct the dif- ficulty and labor will proceed naturally. Backward.-Pregnancy can go to term in a retroverted uterus only by extreme overdistention and thinning of the anterior uterine wall (sacculation). The very thin anterior wall can be palpated, and the fetal body and extremities are very distinct. Vaginal examination will show the thick posterior wall of the uterus, adherent in the pelvis. Spontaneous delivery is not possible, as the thin anterior wall has not sufficient contractile power. Rupture of the uterus is to be feared. Dilatation of the cervix and forceps (not version) is the best form of treatment. Cesarean section may be required, if the wall is very thin. The uterus and vagina must always be packed after delivery, as the danger of postpartum hemorrhage is great. Prolapse does not usually complicate labor. If the cervix becomes edematous, forceps and countertraction on the cervix is required. 260 DYSTOCIA Posterior Displacement of the Cervix.-In many primiparae, the anterior portion of the lower uterine segment is overdis- tended by pressure of the head from above, and the cervix is drawn up posteriorly, usually effaced, near the promontory of the sacrum. In the ordinary vaginal examination, the patient appears to have no cervix. In labor the dilatation of the cervix is greatly retarded, or even arrested. The manage- ment is easy. Feel high up near the promontory for the ex- ternal os, hook the forefinger in the os, and pull down during a pain. Three or four tractive efforts are usually all that are needed, provided the cervix is effaced and pains active. Labor in double uterus is often complicated by inertia and postpartum hemorrhage. It is usually necessary to termi- nate the labor by forceps, and often to pack the uterus and vagina for profuse bleeding. A puzzling feature is the feeling of an undilated cervix in labor, if the non-pregnant half of the genital can be entered by the examining finger. Fibroid Tumors of the Uterus.-For convenience, the com- plication of fibroids in pregnancy, labor and puerperium will be considered here. Fibroid tumors are often a cause of sterility, and it is com- paratively rare to see them in pregnancy or labor. When they co-exist with pregnancy they complicate the pregnancy by: (i) Rapid growth, due to the increased blood-supply; (2) abortion; (3) hemorrhage; (4) excessive pain; (5) malpres- entation of the child (transverse, etc.). The complication in labor depends upon the situation of the fibroid and its size. If it is situated above the pelvic brim, and does not become incarcerated in the pelvis, it will not be an obstruction and the only complications are those due to its presence, such as placenta praevia, inertia, malposition of the child or rupture of the uterus. If it is impacted in the pelvis, it is very likely to cause serious obstruction, although a fibroid which no amount of pushing could dislodge from the pelvis is not unlikely to be pulled up above the brim by the continued uterine contractions, if sufficient time be given. DYSTOCIA DUE TO THE MATERNAL SOFT PARTS 261 Fibroids complicate the puer perium by: (1) Postpartum or puerperal hemorrhage, and infection. Management.--Fibroid tumors in pregnancy do not often require treatment. For excessive pain or bleeding or very rapid growth they may have to be removed, but as this almost invariably means the termination of pregnancy, they should be let alone if possible. Zw labor, the treatment depends upon the position and size. If above the pelvic brim, they usually require no treatment. If impacted in the pelvis, and a reasonable wait has not secured Fig. 107.-The use of a chair in bed, to secure the Trendelenburg position. (De Lee.) their spontaneous dislodgment, the patient should be placed in the Trendelenburg posture, etherized, the fibroid pushed out of the pelvis, if possible, and the child delivered with forceps. In this case, care must be taken to see that the for- ceps are applied to the head and not to the fibroid-a mistake not difficult to make. If it is impossible to push the fibroid out of the pelvis, abdominal cesarean section is required, followed by myomectomy or hysterectomy-the former if possible. 262 DYSTOCIA In the puerperium, a fibroid should be let alone, unless there is excessive bleeding or fever. In either case its removal, by hysterectomy or myomectomy, is indicated. Prognosis.-As only the worst cases are as a rule reported, mortality figures are misleading. The danger to the mother is slight, except in cases requiring surgical interference, where the mortality runs between and 5 per cent. The child under- goes more risk, due to the dangers of labor but the risk is not over 15 to 20 per cent. Ovarian cysts complicate pregnancy by a rapid growth, excessive pain or by twist on the pedicle. The abodmen is usually excessively distended, and this is the chief discomfort in pregnancy. The other complications are rare. Cysts complicate labor depending on their size and position. If the cyst is in the upper abdomen, it does not cause obstruc- tion. In the pelvis, it is usually a complete obstruction, unless it ruptures from pressure. The puerperium may be complicated by: (1) Twist on the pedicle; (2) intracystic bleeding; (3) infection; (4) intestinal obstruction. Management.-If the cyst is discovered prior to the sixth month of pregnancy, it is wise to remove it. This can be done without a greater percentage of miscarriage than normal (25 per cent.) and the great danger of twist on the pedicle is avoided. If seen after the sixth month, the patient should be allowed to go to term, unless abdominal distention is unbear- able or the cyst twists on its pedicle. In labor-in the upper abdomen no treatment is needed. For cysts impacted in the pelvis, spontaneous dislodgment does not occur. Choice of treatment lies between: (1) Vaginal section and removal of the cyst; (2) tapping; (3) abdominal cesarean section. Vaginal section is not to be recommended, because of its difficulty and the danger of infection. Tapping is bad, because: (1) The cyst may be multilocular and hence imperfectly emptied; (2) hemorrhage; (3) sepsis; (4) the possibility of DYSTOCIA DUE TO FETUS AND ITS APPENDAGES 263 its being a dermoid and the consequent risk of peritonitis. Abdominal cesarean section with removal of the cyst is the best treatment. Another reason against tapping or vaginal section is that the cystic mass may be an enormous pyonephrosis. The author has seen three such cases, requiring most formidable abdominal operations for their relief. In the puerperium, a cyst is most likely to twist upon its pedicle. It should therefore be removed forty-eight hours after delivery, to forestall this and all other accidents. Prognosis.-Maternal mortality has averaged 6 to 30 per cent., depending upon operative or expectant treatment. Fetal mortality is about 25 per cent. These figures should be very much reduced with intelligent management. Effect of Age on Labor.-Labor is easiest between the ages of eighteen to twenty-five. Added years bring usually rigid cervix, inertia, eclampsia, abnormal presentations and the much greater likelihood of lacerations. There are exceptions to the rule, but nearly always labor after the age of thirty-five is a serious affair, and spontaneous delivery is the exception. DYSTOCIA DUE TO THE FETUS AND ITS APPENDAGES Overgrowth is not uncommon. The heaviest child on record weighed pounds-its mother being a circus freak, seven feet, nine and one-half inches tall (the Nova Scotia giantess). Weights of twenty-five, twenty-three, twenty-two pounds and less have been reported. Any child weighing over eleven pounds is almost sure to cause severe dystocia. Causes.-(1) Prolongation of pregnancy; (2) multiparity (successive children increasing in size); (3) large parents; (4) overeating during pregnancy. Diagnosis.--Unless the child is gigantic, overdistention of the abdomen is not the rule. This symptom with a lack of fluctuation will exclude hydramnios, and twins can be diag- 264 DYSTOCIA nosed with considerable certainty by the x-ray. Antepar- tum fetometry will show the size and hardness of the fetal head, and especially its relation to the pelvic inlet, the size of which is known. The diagnosis is not always easy. Difficulties.-(i) The large and usually hard head is often easier to deliver than the shoulders. With these comes the greatest difficulty. Many children die in labor, from asphyxia or injuries. Birth palsies involving the cervical nerves and brachial plexus are common. Management.-If the patient is seen before labor, difficulty can often be avoided by antepartum fetometry and induction of premature labor. If a patient has a history of very large children, she should never be allowed to go beyond term or even to full term. If the head will enter the pelvic inlet, it can usually be delivered by forceps, or even spontaneously; the difficulty with the shoulders may be met by trying to rotate them into a favorable diameter; bringing down the arm and shoulder easiest to reach by hooking the forefinger in the axilla, even fracturing the arm if necessary; traction on the neck by a towel placed around it rather than traction on the head; cleido- tomy (cutting one or both clavicles) and finally episiotomy to save the perineum. It is sometimes necessary to morcellate a gigantic child, but this is a formidable procedure. If the head will not enter the superior strait, cesarean section is required. Version, for an overgrown child, should not be considered, even in multiparse. Premature ossification of the cranium robs the cranial bones of their normal power of overlapping and moulding. If the head will enter the pelvic inlet, it can be delivered with forceps. If not, cesarean section is required. Hydrocephalus is not uncommon. The most common cause is syphilis-though many cases occur without demon- strable cause. It is often associated with other malformations, most commonly spina bifida. DYSTOCIA DUE TO FETUS AND ITS APPENDAGES 265 Effect on Pregnancy.-The child frequently dies, hence pregnancy is often prematurely interrupted. About one- third of the cases present by breech. Spontaneous rupture of the uterus is not infrequent. Fig. 108.-Section through a large hydrocephalic fetus, showing how the head can dangerously overdistend the lower uterine segment. (Tarnier.) Effect upon Labor.-A small hydrocephalus may be delivered spontaneously. Even a very large head, if not tense, may mould and descend the canal. During labor the head may rupture and the fluid be discharged. Most commonly, how- 266 DYSTOCIA ever, hydrocephalus presents an insuperable bar to spontane- ous delivery. Diagnosis.-If the head is large: the cystic feel; the parch- ment-like cranial bones (craniotabes); the wide sutures and fontanels make the diagnosis easy. In moderate cases it may be necessary to insert the hand in the lower uterine seg- ment, under anesthesia, and palpate the head as a whole. If a woman is in labor over two hours in the second stage with active pains, no engagement of the head and no obvious reason for the non-engagement, hydrocephalus must be suspected. Differential Diagnosis.-From the macerated soft head of a dead child. This latter is not much if at all enlarged, and the liquor amnii discharged when the membranes are ruptured, is red. Treatment.-If the child is born spontaneously,, it will usually die shortly. If it is deemed a fair risk, the spinal canal may be drained through the body of one of the lumbar vertebrae, by a canula, into the retroperitoneal space. Even fairly large heads may be so drained, and with further experi- ence as to the permanent results, cesarean section may have a place in the treatment of hydrocephalus. Usually, however, the child cannot be considered, and craniotomy is required. The head may be punctured and labor allowed to terminate naturally, or the child may be extracted with the cranioclast (see obstetric operations). If it is presenting by the breech, the aftercoming head may be tapped through the foramen mag- num, roof of the mouth or behind the ear-ordinary long, sharp-pointed curved scissors are sufficient armamentarium. If the child has a spina bifida, the cranium may be drained through the spinal canal. Twin labors are usually uncomplicated, but 25 per cent, show some abnormality. The greatest danger in pregnancy is eclampsia (ten times as frequent); the greatest dangers in labor: (1) inertia uteri; (2) malpresentation; (3) impaction or locking of heads; the greatest danger after delivery is post- partum hemorrhage. DYSTOCIA DUE TO FETUS AND ITS APPENDAGES 267 Presentation.-Most common is both heads (49 per cent.); next head and breech (32 per cent.). Interval between delivery should be only a few minutes, but not more than one hour. A longer interval is due to mis- management. Size of twins is usually slightly under the normal, and they are rarely exactly of the same weight. Six pounds and five and a half is about the average. Date of Labor.-On account of the overdistention of the uterus, twins are commonly born two or three weeks ahead of the calculated date. Diagnosis.-A much overdistended uterus, without marked globular shape or fluctuation, should point to twins. It may be possible to outline two fetal bodies or heads; to hear two fetal heart beats of different rates. The x-ray will ordinarily show the two skeletons. The condition is often overlooked, and the diagnosis only made after the birth of the first child, when it is found that the uterus does not contract down, but remains near its original size. Management is like that of a normal labor except that as soon as the first child is born, the cord should be cut between two ligatures; the patient should be given a dose of ergot by mouth or, better, aseptic ergot hypodermically, and the position of the second child determined at once. If this is not ab- normal, the physician may wait for half an hour, or, more sensibly, rupture the second sac and deliver the child by version. As the birth canal is dilated and the child usually small, this is an easy matter. It is wiser to repeat the dose of ergot after the birth of the placenta, and to remain with the patient for at least two hours after delivery, on account of the danger of postpartum hemorrhage. The bulk of the placenta may make its extraction more difficult than the normal but with a little patience, manual extraction is not required. Prognosis.-The fetal mortality is high; the maternal mor- bidity greater than in single births. Hydramnios of one sac is 268 DYSTOCIA not uncommon. One of the children is often developed at the expense of the other, and the weaker does not survive. Multiple births follow the same general rules as twins. Trip- lets are always considerably premature, and while all three may survive, the death of one at least is to be expected. Quadruplets are still more premature and their survival is unlikely. Five and six have occurred, but so rarely as to make their consideration negligible. Malpresentations.-Most of them have been discussed in the chapter on mechanism of labor. Compound presentations are common-most frequently head and hand; the hand may act as a wedge to prevent rotation, and it will be necessary to push it out of the way and apply forceps. Presentations of the umbilicus are managed like a transverse presentation, except that if the child is dead, evisceration is required. Abdominal enlargements of the fetus, overdistended bladder, ascites, general ana- sarca, polycystic kidneys-all require puncture of the ab- domen and, except the bladder, evisceration as well. Monsters are a law unto themselves. Loosely joined monsters (like the Siamese twins) may be born spon- taneously; operative interfer- ence is almost always required, either dismemberment or cesarean section. The commonest of all monsters-anence- phalus-is always born spontaneously. Prolapse of the umbilical cord (funis) is not uncommon; the commonest time for it to occur is just after the membranes rupture. Hence it should be the rule to examine a patient at this time. It occurs once in about four hundred cases. Fig. i 09.-Prolapse of the umbilical cord. {Dorland.) DYSTOCIA DUE TO FETUS AND ITS APPENDAGES 269 Degree of Prolapse.-(i) Occult, where the cord lies between the head and pelvic wall, but beyond the reach of ordinary examinations. This is one factor that explains stillbirth in normal easy delivery or in easy forceps operations. (2) Forelying-palpable through the os, but inside the membranes. (3) Complete prolapse into the vagina or even outside the vulva. Etiology.-Most commonly seen in flat pelves, where the head does not accurately fill the pelvic inlet. Also in malpres- entations, marginal placenta praevia and breech presentations (in these latter it is not serious). Dangers.-To the mother, none; to the child, grave danger of asphyxia. The most dangerous position of the cord is anterior. The mortality to the child is forty to fifty per cent, in the artificially delivered cases; eighty per cent, in those delivered spontaneously. Diagnosis.-If nothing can be felt by a vaginal examination, and the heart beats are found to sink to 50 or 60 a minute during the pain and rebound to normal afterward, occult prolapse should be suspected, and if this slowing of the fetal heart is repeated, with every pain, rapid delivery, as soon as dilatation permits, is necessary to save the child. There should be no difficulty in diagnosis in either forelying or com- plete prolapse. The pulsating cord can be felt and in the latter case, often seen. Only the veriest tyro will mistake it for prolapse of the intestines, in ruptured uterus, although that mistake has often been made Lack of pulsation in the cord does not always mean that the child is dead. Treatment.-In forelying cord, the patient is placed in either the Trendelenburg posture (over a chair upended on the bed) or the knee-chest position, and kept there until dilatation is complete. As long as the membranes are unruptured, danger to the child is slight. When dilatation is complete (and it can be hurried by hydrostatic dilatation of the cervix) the child should be delivered, or at least drawn down well into the pelvic canal, with forceps, with the patient still in the Trendelenburg posture. Then she can be placed flat in bed. 270 DYSTOCIA Complete prolapse is best treated by thoroughly cleansing the cord and replacing it either manually or with a repositor (manually is much the best). The patient is placed in the Trendelenburg posture, and the cervix dilated either manually or with a metreurynter (bag). The child is delivered by for- ceps or version, with the patient still in the Trendelenburg position. If the cervix is not fully dilated, version should not be attempted, as it may be necessary to extract the child as soon as the version is performed. Anesthesia is always necessary. Cesarean section is only chosen where the desire of the parents for a living child outweighs any risk to the mother. If the child is dead, spontaneous delivery should be awaited, unless some condition on the mother's part demands more rapid delivery. In such a case craniotomy (and not forceps or version) is the method to be chosen. Rupture of the cord is due to: (i) Precipitate delivery in the erect posture, where the cord may tear loose from the umbilical ring, or more commonly break about inch from the child's abdomen; (2) it may be broken by efforts to free it from around the neck. A ruptured cord does not usually bleed excessively. If there is a stump, it should be tied. If the cord has been torn out of the ring, the bleeding may be temporarily controlled by pres- sure. Then the retracted stump is pulled out of the umbilical ring with a tenaculum, transfixed with a sterile safety-pin and tied under the pin. Transfixion of the abdominal walls above and below the umbilicus is not to be recommended. Long Cord.-An excessively long cord may be a source of danger from its tendency to prolapse, or to become tangled around the neck and extremities and secondarily compressed. Short Cord.-May be actually short, or artificially shortened by coiling. To avoid difficulty, the cord must be at least 25 cm. long, to reach from the placental site to the vulva. Symptoms.-If in the second stage of labor, the child's head recedes after each pain, if the patient complains of a dragging DYSTOCIA DUE TO ACCIDENTS IN LABOR 271 sensation, even acute pain, over the placental site, and if there is a marked slowing of the fetal heart during each pain, a short cord may be suspected. Dangers.-(i) Asphyxia; (2) rupture of cord; (3) premature detachment of the placenta; (4) inversion of the uterus. Treatment.-If the child's heart shows dangerous slowing, rapid delivery and the clamping and cutting of the cord, when it can be reached, as soon as the head is born. Early Rupture of the Membranes (Dry Labor).-If the mem- branes are prematurely ruptured, labor does not always begin. If it occurs early in pregnancy the patient may go to term. Ordinarily, labor begins within three or four days. It is an undesirable accident, especially in primiparae. The dilatation of the cervix is slower, is much more painful; artificial dilatation is often necessary. There is danger of sepsis from excessive manipulation. Forceps delivery is much more likely to be needed. As soon as the cervix begins to be edematous, interference is indicated. Late Rupture of the Membranes.--Rarely the membranes are so tough as to retard the advance of the head. Artificial rupture, when dilatation of the cervix is complete is the only treatment required. Occasionally the head is born with the membranes covering it-forming a "caul." The head must be freed at once to guard against asphyxia. DYSTOCIA DUE TO ACCIDENTS IN LABOR Fracture of the pelvis, rupture of the uterus and lacera- tions are all considered under the chapter on injuries of the birth-canal. Hematoma may occur anywhere from the broad ligament to the vulva, most commonly in one labium majus and the perineum. Internal hematomata will usually be diagnosed by ordinary bimanual examination. They are globular, and will nearly always undergo spontaneous absorption. They may rupture at any time, with severe and possibly fatal hemorrhage. 272 DYSTOCIA They are due to the spontaneous subcutaneous rupture of a varicose vein, or to traumatism. Hematomata of the vulva are sausage shaped, purple in color, and the diagnosis is easy. Unless they become in- fected or persistently increase in size, they should be let alone. If opened, the incision should be large and the cavity packed tight. Any bleeding vessel should be tied but the bleeding is usually a general free oozing. Inversion of the uterus is the rarest of all accidents in labor. It may occur either before or after the delivery of the placenta. Fig. i io.-Mesial section of a case of inversion of the uterus. (Swan.) It is commoner in primiparae, and may occur as late as fifteen days after delivery. It may be complete, or incomplete (partial). Causes.-(i) Ill-directed efforts at manual separation and extraction of adherent placenta; (2) spontaneously from the weight of the placenta adherent to the fundus, coincident with relaxation of the uterus; (3) traction on the cord, to extract the placenta; (4) traction of a short cord, just after delivery. DYSTOCIA DUE TO ACCIDENTS IN LABOR 273 Symptoms.-(i) Sudden, profound shock after delivery; (2) the inverted uterus fills up the vagina, to the vulvar orifice or even projects from the vulva; (3) the cervix can be felt surrounding the upper portion of the uterus, like a collar; (4) the bulk of the fundus cannot be felt by abdominal palpation; (5) a deep groove can be felt extending across what remains of the fundus; (6) no uterine cavity can be demonstrated by a sound. Rectal examination may be used to feel the absence of a uterine body. Fig. hi.-Steps in reducing an inverted uterus. Differential diagnosis from a fibroid polyp should be easy. In this case the body of the uterus can be felt, the distinguish- ing groove is absent; the uterine cavity can be demonstrated. Treatment.-Occasionally spontaneous reposition occurs, but should not be awaited. It never occurs in a complete inver- sion. No delay should be caused by waiting for the patient to recover from shock. The sooner reposition is attempted, the easier it is. If the placenta is still attached, it should be removed. The whole hand is inserted in the vagina, and pres- 18 274 DYSTOCIA sure made upward, forward and to one side, to escape the promontory. Pressure is made near the cervix and never on the bulk of the uterus. If the cervix is torn on one side, pres- sure should be made on that side. The uterus is thus gradu- ally curled back into shape. When replaced, the uterus and vagina should be packed with gauze, to prevent recurrence, which is removed in twenty-four hours. If reposition is delayed, it may be necessary to cut the cervix to permit the uterus being replaced. This should never be necessary if reposition is begun at once. The cervix is cut posteriorly, the uterus replaced, the cervical cut repaired and the uterus and vagina packed to prevent recurrence. Prognosis.-The mortality from shock, hemorrhage, and sepsis is high, Reported series giving 25 to 80 per cent. Syncope.-Fainting after labor is not uncommon, and is most often due to fatigue, sudden change in intra-abdominal pressure and profound 'nervous impressions. Unless due to hemorrhage or embolism, and associated with air-hunger, it need not cause alarm. Sudden death during and after labor is caused by em- bolism, hemorrhage, rupture of the uterus, shock from inver- sion of the uterus, and acute dilatation of the heart. If it occurs during labor, the child rarely survives more than a few minutes. Living children have been delivered as long as two hours after the mother's death. In case of sudden death, immediate postmortem cesarean section is required, and the law will sustain the physician, irrespective of family consent. It is not necessary to listen for the fetal heart sounds. Postmortem delivery sometimes occurs. It is due to ac- cumulation of gases of decomposition, and not to uterine con- tractions. It has given rise to unfounded suspicion of burial alive. Rupture of larynx and trachea, from excessive straining, has occurred. It is not serious, and the resulting emphysema is not dangerous. Immediate delivery, by forceps or version, is indicated. DYSTOCIA DUE TO DISEASE 275 DYSTOCIA DUE TO DISEASE Eclampsia is fully considered under the toxemia of preg- nancy. * Valvular disease of heart, even if compensated, is a serious matter in labor. Mitral disease is the most serious. The patient should be given tincture digitalis, minims io or digalen, minims 5 or digipuratum, one ampule hypodermically, every three hours during the course of labor; strychnin sulphate, gr. Jqjo every four hours during labor; all straining should be avoided, and the labor terminated with forceps, under light anesthesia, as soon as the cervix is sufficiently dilated. Cesarean section is justified if the condition of the patient's heart is such that any marked straining would be dangerous. Should signs of broken compensation appear-cyanosis, dyspnea, rapid and irregular pulse-rapid dilatation of the cervix and delivery by forceps or version is required. Moder- ate bleeding after delivery is not to be checked, as it is benefi- cial, often avoiding the need for venesection. The latter must always be considered, as the most dangerous time is directly after delivery, due to the extra amount of blood thrown back into the circulation, with the cessation of the function of the placenta. If no signs of broken compensation appear, the prognosis is favorable; otherwise there is considerable danger, and these patients require close watching and are not safe for some weeks after delivery. Pleural effusions are common in the puerperium. Acute dilatation of the heart, from straining, is always to be feared when the head is arrested at the vulvar outlet. Should the head not advance for one-half hour after the scalp becomes visible, forceps are indicated. The symptoms of acute dilatation are: (1) Shock; (2) cyanosis; (3) dyspnea; (4) rapid and irregular pulse; (5) enlargement of the area of the heart. The treatment is immediate delivery, by forceps without anesthesia, and active stimulation with digitalin or digipura- 276 DYSTOCIA turn (i ampule), strychnin, camphorated oil, pituitrin, and oxygen. Tuberculosis of the lungs is not a cause of dystocia, except for the greater likelihood of pulmonary hemorrhage during the straining of the second stage. Delivery during pneumonia, typhoid fever or other adynamic diseases is likely to be accompanied by profound shock, and steps must be taken to avoid or combat the shock. CHAPTER XII HEMORRHAGE CLASSIFICATION I. Antepartum or in Pregnancy.-(i) Abortion; (2) pla- centa praevia: (3) premature separation of normally situated placenta, (4) Rupture of varicose veins. II. Intrapartum or in Labor.-(1) Placenta praevia; (2) premature separation of normally situated placenta; (3) lacerations (including rupture of the uterus); (4) rupture of hematoma or varicose veins. III. Postpartum (First Twenty-four Hours after Delivery). (1) Relaxation of the uterus; (2) lacerations; (3) retained or adherent placenta; (4) rupture of hematoma; (5) inversion of uterus. IV. Puerperal (after Twenty-four Hours).-(1) Relaxation of the uterus (more rarely); (2) retained placenta, membranes or blood-clots; (3) dislodged clots at placental site; (4) dis- placements of the uterus; (5) puerperal hematomata; (6) tumors, benign or malignant. ABORTION Abortion has been discussed under the "premature termina- tion of pregnancy," but for the sake of clearness, the control of the hemorrhage from abortion will be reviewed briefly. Threatened abortion causes bleeding that is never dangerous. It can be controlled by rest, and not by packing the vagina, as the latter tends to make the abortion inevitable. The bleeding from inevitable abortion is checked by packing the vagina alone, if the os is not dilated. If dilated, any pro- 277 278 HEMORRHAGE truding or presenting portions of the ovum should be removed, and both uterus and vagina packed for twelve to twenty-four hours. The bleeding from incomplete abortion may be very serious. If the patient's condition permits it, the uterus is emptied and both uterus and vagina packed for twelve to twenty-four hours. If her condition is too serious for imme- diate interference, pack both uterus and vagina and remove the remains of the ovum, with the packing, twenty-four hours later, after she has reacted from her primary shock. PLACENTA PRJEVIA (UNAVOIDABLE HEMORRHAGE) Placenta praevia is the development, wholly or in part, of the placenta in the lower uterine segment-the dilatable por- tion of the uterus in labor. Frequency.-On an average once in 1000 cases (series vary from 1-1500 to 1-300 cases), and ten times as frequently in multiparae as in primiparae. It is more common, naturally, in hospital than in private practice. Causes.-Low attachment of the ovum, due probably to a pre-existing endometritis, at or near thfe internal os uteri. Varieties.-(1) Central (the most dangerous, but occurring in less than one-fifth of the cases) where the center of the placenta is approximately over the internal os; (2) partial (the most frequent of the serious forms) where the os is entirely covered, the placenta attached on both sides, but the bulk of the placenta is to the right (usually); (3) marginal, where a flap of placenta extends over the os, but is not attached on the far side; (4) lateral, where the edge of the placenta comes nearly or quite to the edge of the canal. Marginal and lateral placenta praevia are the commonest varieties, and the least serious. Symptoms.-(1) Sudden, causeless, painless, profuse bleed- ing, occurring at any time in pregnancy, from the third month on, but most frequently in the seventh and eighth months. The bleeding tends, naturally, to increase as the patient nears PLACENTA PRAZVIA (UNAVOIDABLE HEMORRHAGE) 279 term. A continuous, slight dribbling of blood is called stillicidium sanguinis. The more nearly central the placenta, the more severe and the earlier the onset of the bleeding, as a rule. (2) Usually the cervix is soft and boggy, and the os is some- what dilated. Central Partial Marginal Lateral Fig. 112.-Varieties of placenta praevia. (3) Through the os can be felt the rough maternal surface of the placenta. Differential diagnosis from premature separation of a normally situated placenta. 280 HEMORRHAGE Placenta Premia 1. Begins any time in pregnancy. 2. No pain. 3. Uterus does not become tense. 4. External hemorrhage profuse. 5. Symptoms proportionate to loss of blood. 6. Os patulous or dilated. 7. Placenta can be felt. 8. Fetal movements and heart- sounds usually unchanged. Premature Separation 1. Begins in last month or early labor. 2. Pain at placental site, later be- coming general. 3. Uterus tense. 4. External hemorrhage usually slight. 5. Symptoms more severe than loss of blood would explain. 6. Os not dilated, unless in labor. 7. Placenta cannot be felt. 8. Fetal heart-sounds and move- ments usually disappear. Prognosis.-The frequency of abortion or miscarriage is about 60 per cent. Usually slight hemorrhage in labor is more severely felt by the patient, due to the blood already lost in pregnancy. The maternal mortality averages about eight or ten per cent; the fetal mortality about fifty-five to sixty per cent. The chief dangers to the mother are hemorrhage and sepsis-the latter from manipulations required in delivery and the accessibility of the placental site. Treatments-Prior to the seventh month of pregnancy, the bleeding is so rarely serious, that it is justifiable to adopt an expectant policy, but only where the patient is so situated that she can be reached without delay, should serious hemorrhage begin. A patient with placenta praevia is safe only in a hospital, and is not safe in her own home. Prior to the seventh month, if moderate bleeding occurs, it can usually be checked by putting the patient to bed, at com- plete rest. If severe bleeding occurs, and the os is not dilated it can be checked by a firm vaginal tampon, of sterile gauze. Technic of Packing.-(i) The patient is placed across the bed, with her hips over the edge, her feet on two chairs. (2) The perineum is retracted with a Sims' speculum. (3) The vagina is packed firmly with sterile gauze, preferably in a long strip, packed in as tightly as possible, especially in the PLACENTA PRJEVIA (UNAVOIDABLE HEMORRHAGE) 281 upper part of the vagina. (4) A large thick square of sterile gauze is placed over the vulva, and is held in place by a T bandage. Treatment at Seventh Month.-The danger of fatal hemor- rhage is now so great-the child being also viable-that Fig. 113.-Case of placenta praevia with vagina properly packed with gauze. (Dickinson.) induction of labor is advisable. In central and partial placenta praevia the technic is as follows: (1) The patient is placed in the lithotomy position on an operating table and anesthetized. (2) The physician prepares himself as carefully as to hands, gown and gloves as for a major operation. 282 HEMORRHAGE (3) Insert one hand in the vagina, after thorough vaginal cleansing with tincture of green soap, hot water, lysoi solution (one dram to two pints). (4) Dilate the cervix manually, inserting one finger after another until the cervix can be stretched over the knuckles. (5) Feel on the patient's left side for the edge of the placenta, rupture the membranes, grasp the anterior leg, perform podalic Fig. i i 4.-The control of hemorrhage in placenta prsevia by impaction of the breech, after podalic version. (De Lee.) version, and pull the leg down until the knee is outside the vulva (showing that the breech is impacted in the cervix). (6) Withdraw the anesthetic, and wait one to two hours for further dilatation, delivering the child as an ordinary breech presentation. Unless the physician is confident of his ability to perform the dilatation and version quickly, he had better not attempt it, as until the breech is impacted in the cervix, the hemorrhage is very profuse. Usually all bleeding ceases when the breech is impacted, but the patient must be closely watched PLACENTA PRAEVIA (UNAVOIDABLE HEMORRHAGE) 283 for signs of shock, as sometimes the bleeding continues internally and may require immediate delivery. Too rapid extraction of the child may rupture the lower uterine segment, and this rupture, spontaneously, is not rare. An alternative method is the use of a large rubber bag, to secure the dilatation of the cervix necessary for version. This Fig. i 15.-The use of a Voorhees bag in controlling the bleeding in placenta praevia. (£>e Lee.) slower dilatation is often safer than the more rapid manual method and is less likely to cause extensive tears. Marginal and lateral placenta praevia so rarely cause bleed- ing at this time, that they need not be considered here. Management of Placenta Praevia at or near Full Term.- If central or partial placenta praevia have not given symptoms before this, the first hemorrhage is always sudden and very profuse. It may be temporarily checked by vaginal packing, as already described. When the physician has had time to 284 HEMORRHAGE make adequate preparations, he may proceed in one of several ways. (1) Allow the child's head to push the packing out, if the patient is in labor. This is the Wigand treatment, and is reason- ably safe for the mother but not for the child. (2) When all preparations are made, proceed as described in the induction of labor, at the seventh month, although this is now a much more formidable procedure, and should not be attempted except in multiparae. Much longer time is required for safe delivery than at the seventh month and the danger of severe laceration of the cervix and lower uterine segment is much greater. (3) The metreurynter or rubber bag, distended with sterile water and placed either inside or outside the membranes. The former is better. The method is difficult of application in either central or partial placenta praevia. Gentle traction (one-half pound) is made on the tube until the bag slips through the cervix. (4) The forceps, after the cervix is sufficiently dilated. Can rarely, if ever, be used in central or partial cases. (5) Vaginal cesarean section has a number of advocates, but the operation is difficult, the bleeding is very severe, and the operation is one for experts in a well-equipped hospital only. (6) Abdominal cesarean section has a well-defined field. It should never be necessary in lateral or marginal cases. It is indicated in central placenta praevia in both primiparae and multiparae; in partial placenta praevia in primiparae; and in any case where an obstacle exists (contracted pelvis, very rigid cervix, etc.) to an easy vaginal delivery, abdominal cesarean section should be the method of choice, but never extraperitoneal cesarean section, on account of the hemorrhage attending the incision in the lower uterine segment. Treatment of Marginal or Lateral Placenta Praevia.- Many cases give such slight bleeding that they require no treatment. If bleeding is severe enough to cause alarm, it PLACENTA PRJSVIA (UNAVOIDABLE HEMORRHAGE) 285 is nearly always in labor, when the cervix is fairly well dilated, and can be controlled as follows: (1) Simple rupture of the membranes, to allow the head to descend and make pressure, is often enough. (2) The metreurynter, placed inside the membranes and distended with sterile water. (3) Forceps. (4) Podalic version-in multipart only. Stimulation.-In ordinary cases, no stimulation is required before delivery, but during delivery, especially by podalic version it may be needed. Hypodermoclysis of 500-1000 mils of salt solution; intravenous injection of a similar amount, or 2 per cent, gum acacia solution or transfusion (preferably by the sodium citrate method) of 250-750 mils is best, because the patient needs fluid in the circulation to replace the blood lost, rather than hypodermic stimulation. In very severe cases it may be required to pack the vagina, for temporary control of bleeding, and to perform transfusion (500 mils) before any attempt at delivery can be made. After delivery, nearly all cases require stimulation-hypodermoclysis, intravenous injec- tion of salt solution, transfusion, hypodermics of digalen Tlfio or digipuratum 1 ampule every three hours; strychnin sulphat. gr. Mo every three hours; nitroglycerin gr. Moo every three hours; bandaging extremities and external heat, and after reac- tion has set in, a hypodermic of M grain of morphin, to control the restlessness of the acute anemia. Control of Bleeding after Delivery.-Because the placental site is in the lower uterine segment-the dilated and parlyzed portion-the greatest danger after delivery is postpartum hemorrhage. The contraction of the upper portion of the uterus has little influence upon the source of the bleeding. Hence ergot and pituitrin cannot be depended upon to control bleeding. Every case of placenta praevia, except those delivered by abdominal cesarean section, should have the uterus and va- gina tightly packed with gauze (further supported by a large pad of gauze externally ana a T binder) for at least twenty- 286 HEMORRHAGE four hours after delivery. No matter how favorable the ap- pearance of the case after delivery, the precaution should not be neglected. Very moderate postpartum hemorrhage, in addi- tion to the blood already lost before and during delivery, may be fatal. PREMATURE SEPARATION OF A NORMALLY SITUATED PLACENTA (ABRUPTIO PLACENTAS); ACCIDENTAL HEMORRHAGE Separation of the placenta, either partial or complete, at its normal site is considerably less common than placenta praevia. Its frequency, in cases serious enough to demand attention, is about 1-2000 cases. A B Fig. 116.-Premature detachment of a normally situated placenta. (American Text-book of Obstetrics.) Causes.-(i) Traumatism: falls; coitus in the last month of pregnancy; jolting of a carriage or automobile; traction of a short cord. (2) High maternal blood-pressure in toxemia. (3) Placental or decidual disease. Cases often occur without PREMATURE SEPARATION OF NORMAL PLACENTA 287 any demonstrable cause, and the accident is more frequent in multiparae. Pathology.-The separation of the placenta alone is not the full extent of the injury. The uterus, and often the tubes and ovaries also, changes to a purplish copper color, due to exten- sive intramuscular hemorrhage, causing dissociation of the muscle bundles and almost complete loss of contractile power. This condition is certainly present in all severe cases, and is at times complicated by small longitudinal fissures in the surface of the uterus, probably dependent upon the excessive distention. Fatal intraperitoneal hemorrhage can result from these fissures. Degree.-Either upper or lower edge of the placenta may be separated, or the central portion be detached, with a large hematoma behind it, or rarely the entire organ may be separated. The bleeding may be (i) frank-escaping externally, but never without some retention in the uterine cavity-or (2) concealed-by the center or upper edge of the placenta being detached; or by the cervix being blocked by the presenting part or a clot; and very rarely by the blood flowing into the amniotic sac through a high rupture of the membranes. The bleeding is at first concealed and secondarily only frank. Only about half the cases show any external bleeding. Symptoms.-Mild cases may give only slight pain, no signs of bleeding and the condition is recognized only by the expul- sion of considerable masses of blood-clot after the placenta is expressed. The typical severe case'begins in the last month of pregnancy or in early labor. There is first severe pain over the placental site, rapidly becoming diffuse over- the entire uterus. The uterus is increasingly tense. If the patient is in labor, the pains become less effective, and are finally masked altogether by the intense constant pain of the distended uterus. The patient begins to show the signs of internal bleeding- air-hunger, rapid pulse, ringing in the ears, pallor and sweating. There is moderate external bleeding in about half the cases, not sufficient in amount to explain the visible effects of hemorrhage. 288 HEMORRHAGE It may be possible to feel the bulging of the uterus caused by the retroplacental clot. Differential Diagnosis.-(1) Diagnosis from placenta premia has been given under that head. (2) Rupture of the uterus occurs late in labor, the membranes are ruptured, shock is Fig. 117.-Mesial section of a case of premature detachment of the placenta, showing the large amount of blood retained in the uterine cavity. (Pinard and Varnier.) immediate, and the presenting part recedes, even into the peritoneal cavity. Rupture of the circular sinus of the placenta cannot be diagnosed from premature separation of the placenta, and requires the same treatment. Prognosis.-With complete detachment of the placenta the mortality for the mother is 50 per cent.; for the child 95 per cent. Partial detachment will give more favorable results, greatly dependent upon the promptness of treatment and the PREMATURE SEPARATION OF NORMAL PLACENTA 289 skill of the physician. Postpartum hemorrhage is frequent, due to the loss of contractile power of the uterus, from intra- muscular hemorrhage. Because of the failure of the uterus to contract, abdominal cesarean section often demands hysterec- tomy as well. Treatment.-Vaginal packing is useless in controlling the hemorrhage. The chief indication is to deliver the patient as rapidly as consistent with a minimum of shock. If the cervix is not dilated, but is soft and dilatable, manual dila- tation and podalic version or forceps will give the best results. In primiparae with a rigid cervix or in any case where an ob- stacle exists to an easy vaginal delivery, abdominal cesarean section must be considered. It may be necessary to remove the uterus to control the persistent bleeding. In choosing a plan of treatment, it must be remebered that the uterine mus- cle may be extensively infiltrated with blood and its contractile power lost. This can only be ascertained by abdominal section and as the bleeding can be controlled only by removal of the uterus, cesarean section and hysterectomy may be forced upon the operator. Vaginal cesarean section is more difficult but in multiparse at least is indicated where the cervix is the main obstacle to delivery. Ergot and pituitrin have been recommended, but are both unsafe until after the child is delivered. Rupture of the membranes in partial cases, excites the uterus to effective contractions and hastens the dilatation of the cervix. If dilatation of the cervix has been performed, and forceps applied, and the head will not come through the cervix, further action is governed by the patient's condition. If not alarming, time can be taken for intermittent traction with the forceps; if she is in imminent danger, craniotomy is indi- cated. Stimulation.-All cases of premature detachment of the placenta will require the same stimulation as placenta praevia. After delivery, the uterus and vagina must be packed, in every 19 290 HEMORRHAGE case, as a preventive of postpartum hemorrhage. No packing can be used before delivery. Hemorrhage from rupture of the uterus is controlled in one of two ways, depending upon whether the rupture of the uterus is complete or incomplete. Complete rupture of the uterus requires abdominal section and hysterectomy below the site of the tear. Incomplete rupture is nearly always anterior, under the bladder. The bleeding can be perfectly controlled by packing the lower uterine segment and the vagina with sterile or iodo- form gauze. Hemorrhage from rupture of a hematoma requires packing only, unless the hematoma is in the layers of the broad liga- ment. This is associated with rupture of the uterus, in most cases, and requires the same treatment. POSTPARTUM HEMORRHAGE Postpartum hemorrhage is the name given to any hemor- rhage occurring within twenty-four hours after the delivery of the placenta, but by usage restricted to that due to either: (i) Relaxation of the uterus or (2) lacerations of the birth- canal. The pregnant woman is fortified against a loss of blood by an oversupply, so that a loss of blood, serious to a non-pregnant woman, is borne without symptoms. She is normally pro- tected against bleeding after delivery by: (1) The high fibrin content of the blood (favoring rapid clotting) and (2) the firm contraction of the uterine muscle. The average loss of blood is eight to ten ounces (300 gm.). Anything up to one pint (500 gm.) is borne without symptoms, and anything over one pint may be considered pathologic although a loss of a quart (1000 gm.) is usually well borne. Causes of Relaxation of the Uterus.-(1) Fatigue from a long labor; (2) overstretching of the muscle, due to hydramnios POSTPARTUM HEMORRHAGE 291 or twins; (3) too much pituitrin in labor; (4) anesthesia (chloro- form or ether); (5) premature extraction of the placenta; (6) retention of portions of placenta or membranes. (7) It is much more common in high altitudes, and also in the tropics. Symptoms.-(1) Expulsion of blood, in jets, of a few ounces every few seconds, and more rarely a continuous flow. (2) The uterus is soft, relaxed, enlarged and distended with clots, and is difficult to outline by palpation through the abdominal wall. The contrast to the firm, well-outlined uterus is very marked. (3) If the loss of blood is sufficient, the constitu- tional signs of hemorrhage appear-pallor, rapid pulse, leaky skin and air-hunger (yawning or sighing). Rarely there is a very profuse outpour of blood, from which the patient may die in a few minutes. Diagnosis.-If a patient is bleeding profusely after delivery and the uterus, by abdominal examination, is hard and firm, the bleeding is almost surely due to laceration. If the labor has not been an instrumental one, or one in which other forci- ble means of delivery have been used; or if pituitrin has not been given, the bleeding from lacerations is rarely if ever serious, a*nd will cease spontaneously in a very few minutes. If the uterus is soft and boggy and ill-defined, the bleeding is due to relaxation. The pulse is not a fair guide to the severity of the hemorrhage. It may remain slow and full, even with a serious hemorrhage, and then suddenly disappear. Treatment.-The routine treatment of postpartum hemor- rhage from relaxation of the uterus is as follows: (1) Remember that most of these cases are easily controlled and do not get alarmed. (2) Give intramuscularly 1 ampule of pituitrin and 2 of aseptic ergot (or 30 minims of ergone). (3) Remove the abdominal binder, if applied, and knead the uterus briskly. Most cases will be controlled by these means alone. If anything further is required: 292 HEMORRHAGE (4) Make sure the uterine cavity is empty of blood-clots, placenta or membranes, by inserting the aseptic gloved hand and exploring, at the same time rotating the hand some- what roughly, to stimulate the muscle to contract. (.5) Bimanual compression of the uterus, by one hand in the vagina and one on the abdomen. (6) Very hot intra-uterine douche of sterile water, 120° F. (7) Pack the uterus and vagina with sterile gauze. Fig. 118.-Correct packing of the uterus and vagina for postpartum hemorrhage. (Bumm.) Technic of Packing.-(i) Patient is arranged across the bed, with her feet on two chairs, and her hips over the edge of the bed. (2) She is carefully cleansed, and the cervix caught by 2 double tenacula and pulled down. POSTPARTUM HEMORRHAGE 293 (3) With Emmet curetment forceps, a long strip of sterile gauze is carried into the uterus, up to the fundus. The gauze is then packed in, in layers, until the uterine cavity is full. (4) The vagina is packed with similar strip and the packing is held in by a vulvar pad and T bandage. Piece of Placenta' Internal os Exter. -nal os Fig. i i 9.-Faulty packing of uterus and vagina for control of postpar- tum hemorrhage. (Bumm.) (5) The entire packing can be removed after twelve hours; it should be withdrawn slowly, over a period of fifteen or twenty minutes, and it is rarely necessary to repack. Packing is the surest method of controlling the bleeding, but is not to be used unnecessarily, because of the danger of sepsis, though this is slight if the technic is properly carried out. Styptics, like Monsel's solution, should not be used. The resulting clots are firm and putrescible, and sepsis is likely. Ice to the abdomen or vinegar carried in the uterine cavity on sterile gauze have been superseded by more modern methods. Very obstinate cases are sometimes checked by firmly packing 294 HEMORRHAGE the uterus, and closing the cervix over the pack by temporary sutures, removed in twenty-four hours. It is doubtful if this method has any advantage over the combined uterine and vaginal packing, held in by a T bandage. Otherwise uncontrollable cases have been stopped by the Momburg belt-a, five-foot length of rubber tubing placed around the abdomen, above the fundus uteri, and pulled tight enough to stop the femoral pulse. This method has some danger of shock, is excessively painful, and may injure the intestines or kidneys by pressure. It has no advantage over the much easier and more rational compression of the aorta by the clenched fist. Faradism of the uterine muscle by a portable electric battery has some advocates, but is not worth while. It takes some time, which can ill be afforded, to connect the apparatus, and there is great risk of infection, as the uterine pole is in the uterine cavity. No physician should attend a labor case without having the necessary implements for packing the uterus, sterile gauze for packing, the apparatus for intravenous injection of salt solu- tion, and a properly equipped hypodermic set. Stimulatation.-Most of the cases will be controlled before there is any need for stimulation. If needed, however, the same stimulation as in placenta praevia is indicated. The patient must not be left until her condition is satisfactory, and danger of bleeding past. Prognosis.-Death from hemorrhage due to relaxation of the uterus is rare. Severe postpartum hemorrhage occurs in about 2 per cent, of labors, but fatal cases not oftener than one in 5000 labors. A greater danger is septic infection from too enthusiastic intra-uterine manipulations, with questionable asepsis. Lactation is often delayed, and subinvolution of the uterus is common. HOMORRHAGE DUE TO LACERATIONS 295 HEMORRHAGE DUE TO LACERATIONS OF THE BIRTH-CANAL Profuse bleeding with a firmly contracted uterus means, usually, laceration. This is particularly likely in cases of hurried, instrumental delivery, and is rare in spontaneous deliveries, that were not precipitate. The hemorrhage from lacerations is usually free for a few moments, and then ceases spontaneously. It may be very serious, however, and some- times fatal. The site of the injury is most commonly on the anterior vaginal wall, near the clitoris and urethra; next in the cervix, and least commonly, in the perineum. Diagnosis.-The patient is placed across the bed with her feet on two chairs, her hips over the edge of the bed. She is carefully cleansed externally, and the area around the clitoris and urethra is inspected for tears; the cervix is examined through a bivalve speculum or pulled down with tenacula, and the posterior vaginal wall inspected, with the bivalve speculum or a Sims' speculum holding up the anterior vaginal wall. Treatment.-If the hemorrhage is not too profuse, make gentle pressure with a gauze sponge, for a few minutes, and it will usually cease. If it is alarming, the method of treat- ment depends upon its source. Anterior Vaginal Wall, Clitoris and Urethra.-A continuous catgut stitch, making pressure with a sponge to control the blood temporarily, will close the wound, and permanently stop the bleeding. Cervix.-This is the site of the most serious tears, and the source of the most dangerous bleeding. If forceps have been applied, prior to complete dilatation and effacement of the cervix, the tear may extend through the cervical muscle into the lateral vaginal vault, the broad ligament or the connective tissue behind the bladder-really a rupture of the uterus. This bleeding from severe tears can best be controlled by packing, renewed at intervals of twenty-four hours. If the cervix is 296 HEMORRHAGE torn laterally, the bleeding may be controlled by sutures or better by packing around the cervix on the injured side, well up into the vaginal vault, with sterile gauze-the so-called ring tampon. In the perineum, the bleeding is most likely from a single vessel, which can be tied. If it is a general ooze, vaginal pack- ing with a vulvar pad and T binder for a few hours, will check it. Bleeding from retained or adherent placenta is easily checked by the expression or extraction of the placenta, and the dose of ergot should not be repeated until the placenta is delivered. Bleeding from inversion of the uterus cannot be checked until the uterus is replaced. It is not enough to be serious; the profound shock seen in these cases is due to the inversion, and is out of all proportion to the amount of blood lost. PUERPERAL HEMORRHAGE (AFTER TWENTY-FOUR HOURS) Relaxation of the uterus is uncommon at this time but may occur as late as four weeks after delivery. The bleeding is controlled as already described under postpartum hemorrhage, except that these late hemorrhages from relaxation almost invariably require packing of the uterus and vagina. Retained portions of the placenta or membranes do not always cause bleeding. When they do, the bleeding is likely to be moderate in amount, and serious only through its long con- tinuance. Any persistent moderate bleeding after delivery, without obvious cause, should indicate exploration of the uterine cavity. Even if the placenta was examined after its expulsion, and found entire, a placenta succenturiata may have been retained. When the membranes are retained, spontane- ous expulsion within forty-eight hours is the rule, and they rarely justify efforts to extract them. Copious discharge of blood-stained serum, with occasional clots, nearly always indi- cates blood-clots in the upper vagina or uterus, and requires exploration of the uterine cavity. The bleeding from all these PUERPERAL HEMORRHAGE (AFTER TWENTY-FOUR HOURS) 297 causes ceases promptly when the offending tissue is removed. Dislodged clots at the placental site nearly always follow sudden exertion, such as getting up too soon. The bleeding is very sudden and profuse, and this cause can be inferred if there is a history of exertion followed by profuse bleeding from a well-contracted uterus. Prompt packing of the uterus and vagina will control it. Backward displacement of the uterus, when involution has proceeded far enough to allow it to slip behind the promontory, will cause annoying slow bleeding. The condition is easily diagnosed by bimanual examination, and the uterus should be replaced, with the patient in the knee-chest position. Atony of the uterus, causing moderate bleeding without demonstrable cause, and the uterine cavity being found empty on exploration, is best checked by ergot thirty drops three times daily, with a hypodermic of pituitrin ampule twice daily (for 2 days). Fibroids sometimes cause serious bleeding. If the tumor is a polyp, it should be snared or twisted off. If intramural, and styptics as described under atony do not check the bleeding, hysterectomy or myomectomy may be necessary. Fibroids always prolong the bloody lochia, but serious hemorrhage is most likely in a case of polyp. Cancer or chorionepithelioma are rare but possible causes of bleeding. The uterus is explored, the evacuated material examined microscopically, and, if malignant, panhysterectomy is indicated. CHAPTER XIII INJURIES OF THE BIRTH-CANAL CLASSIFICATION I. Injuries to the Pelvis.-(i) Fracture or separation of the symphysis; (2) fracture or separation or sprain of sacro-iliac joints; (3) fracture of ramus of pubes; (4) fracture of coccyx. II. Rupture of the Uterus.-(1) Complete (communicating with the peritoneal cavity); (2) incomplete (the peritoneum still intact). III. Lacerations of the Cervix.-(1) Unilateral (open or submucous); (2) bilateral (open or submucous); (3) stellate (open or submucous); (4) annular detachment. IV. Lacerations of Anterior Vaginal Wall.-(1) Clean cuts of mucous membrane; (2) open or submucous tears of muscle of urogenital trigonum. V. Lacerations of the Perineum.-(1) Tears of levator ani; (2) tears of deep trans versus perinei; (3) tears of anterior and posterior layers of triangular ligament; (4) tears of the bulbo- cavernosus; (5) tears of the superficial trans versus perinei; (6) tears of sphincter ani (complete tear). Further divisions into: (1) Complete tear (involving sphincter ani); (2) incomplete (not involving sphincter); (3) central perforation of the peri- neum; (4) laceration and abrasion of labia. VI. Fistulae.-(1) Vesicovaginal (on anterior vaginal wall); (2) ureterovaginal (in vaginal fornix); (3) rectovaginal (on posterior vaginal wall). 298 FRACTURE OF THE COCCYX 299 INJURIES TO THE PELVIS These are almost always the result of attempts at forcible delivery, and are most common in justominor pelves, where forceps have been used too forcibly. Fracture of the symphy- sis, sacro-iliacs or ramus are rare. The symphysis is almost always the site of injury. Usually an audible snap can be heard, or the sudden giving way of the pelvis distinctly felt. The gap in the bone can be palpated. Delivery should be completed with as little violence as possible, and the pelvis immobilized by a canvas binder or better broad strips of adhe- sive plaster. The after-care is difficult, but is made somewhat easier by having the patient on a Bradford frame-a sort of extra cot placed on the bed, the floor of which is made of broad strips of canvas, laced to the frame. In injuries to the symphysis, the subpubic ligament often is not torn. This masks the accident, which is only discovered when the patient is unable to walk when she gets out of bed. A hematoma commonly forms over the site of the injury, and these two factors should point to injury of the symphysis, if it was not diagnosed at the time of its occurrence. Fractures of the pelvic joints or bones are serious, especially if there has been a secondary laceration into the vagina. The great danger is infection. SPRAINED OR LOOSE SACRO-ILIAC JOINT A sprained or loose sacro-iliac joint gives the patient extreme discomfort when she begins to resume her normal activities. There is intense backache, over the affected joint, worse on walking or standing. The treatment is a binder or corset, designed to immobilize the hips. Recovery is slow, usually over four to six months. FRACTURE OF THE COCCYX This is seen most commonly in elderly primiparae, with justominor pelves. It is not serious in labor, and hence will 300 INJURIES OF THE BIRTH-CANAL be considered in the chapter on pathologic sequelae of child- birth. RUPTURE OF THE UTERUS Frequency.-About 1 in 2500 cases. About eight times as frequent in multiparae, and the years of greatest frequency are thirty to forty. Obesity and syphilis both predispose to uterine rupture. Varieties.-(1) Complete, where the peritoneum is torn through and the uterine cavity communicates with the peri- toneal cavity. (2) Incomplete, where the peritoneum is uninjured. Fig. 120.-Complete rupture of the uterus. (Auvard.) Causes.-Predisposing causes are: (i) Repeated overdis- tention of the uterus, such as many previous pregnancies, poly- hydramnios or twins; (2) previous cesarean sections or other operations involving the uterine wall; (3) diseased uterine muscle (from old inflammation); (4) congenital ill-develop- ment of uterus; (5) fibroid tumors; (6) placenta praevia. II. Exciting causes are: (1) Overdistention of the lower uterine segment in neglected obstructed labor; (2) perforation by hands or instruments; (3) ill-advised attempts at podalic RUPTURE OF THE UTERUS 301 version; (4) administration of ergot or pituitrin, if any obstacle to delivery exists. Site of Rupture.-Most commonly in the lower uterine seg- ment, running transversely, with usually an L-shaped exten- sion into the broad ligament or vagina. Spontaneous rupture may occur in the upper portion of the uterus (as after previous cesarean section) or transversely across the fundus. In primi- parae, the cervix may tear anteriorly up to or through the vesico- uterine reflection of peritoneum. The tear is usually very ragged and irregular, the edges edematous and infiltrated with blood. Incomplete rupture is most often anteriorly through the cervix to the vesico-uterine peritoneum, or laterally into the layers of the broad ligament. Symptoms.-Premonitory.-(1) Long-continued labor with no advance of head, or with malpresentation; (2) overdisten- tion of the lower uterine segment; (3) high position of Bandl's contraction ring; (4) just before rupture, the appearance of an area of great tenderness to palpation, over the lower uterine segment. Bandl's contraction ring is the sharply defined muscular ridge or line between the contracting upper portion of the uterus and the dilated, paralyzed, overdistended lower portion of the uterus. It is plainly visible and palpable, running obliquely across the lower abdomen. Bandl's contraction ring normally marks the site of the coronary vein of the uterine wall, or the beginning of the firm attachment of the peritoneum; it is the boundary between the contracting and dilatable por- tions of the uterus. The nearer the contraction ring is to the umbilicus, the more imminent the danger of rupture of the uterus. Symptoms of Rupture.-(1) Sudden sharp stabbing pain; (2) shock; (3) usually surprisingly little external bleeding; though the intraperitoneal hemorrhage may be very profuse; (4) cessation of labor pains; (5) recession of the presenting part; (6) possible escape of the fetus into the abdominal cavity; (7) intra-uterine examination, in this case or after the child is 302 INJURIES OF THE BIRTH-CANAL extracted, will reveal the rent, with or without prolapse of the intestines into the uterine cavity. Rarely the uterus may rupture spontaneously or be ruptured in the performance of version, with almost total absence of symptoms, and the injury be discovered only when the placenta is expressed. Intra-uterine examination is the only means of diagnosis in such a case, and should be done routinely in all cases of version. At times the uterus will rupture in the last month of preg- nancy, through the scar of a previous cesarean section, with practically no symptoms. Fig. i2i.-A full bladder in labor. The line marking the fundus of the bladder is strikingly like the high contraction ring of Bandl. {De Lee.) Diagnosis from premature separation of the placenta should not be difficult. Rupture occurs late in labor; separation early. Rupture of the uterus has the premonitory signs detailed above, they are absent in separation. In rupture the uterus is usually diminished in size; in separation, increased. The tear is palpable in rupture, and none can be felt in separa- tion. The outline of the abdomen, with a moderately dis- tended bladder looks not unlike a high contraction ring, but the absence of all serious symptoms, fluctuation over the bladder and the catheter should clear up the diagnosis at once. The most serious error that can be made is to mistake the over- distended lower uterine segment for the sluggish uterus in inertia, and attempt to stimulate the muscle to further con- traction, by pituitrin or ergot. A careful consideration of the RUPTURE OF THE UTERUS 303 premonitory symptoms should make such a mistake impossible. Rupture of the uterus is possible with few if any symptoms at the time of rupture. Spontaneous recovery may result (very rarely) or an abdominal abscess or peritonitis develop. In any case when the physician has reason to suspect rupture of the uterus, a careful exploration of the uterine cavity should be made after delivery, to prevent overlooking such an injury, until septic peritonitis appears and makes any treatment useless. Prognosis.-Ruptures of the anterior wall or fundus are more serious than those of the posterior wall. Incomplete rupture is naturally safer than complete. Hysterectomy and drainage except in incomplete cases, is much safer than expectancy with irrigation and drainage. The maternal mor- tality is 50 to 75 per cent., depending upon the form and promptness of treatment; the child usually dies at the time of rupture. Treatment.-Preventive treatment, to correct the abnormal- ity responsible for the obstruction to delivery, is of course the obvious way of avoiding the accident-and most cases of uterine rupture are avoidable. The dictum of "once a cesa- rean, always a cesarean" is not borne out in practice. The great majority of such patients can, if the obstruction to delivery is not absolute, deliver themselves spontaneously under proper management. The treatment of the rupture depends on whether the rupture is complete or incomplete, its situation, and the length of time that has elapsed since rupture. The sooner a patient is operated upon, the better the prognosis. The child is first extracted, if it has not passed into the abdominal cavity. The methods are forceps (not version, as this will increase the extent of the tear), or cranio- tomy. If the child is in the abdominal cavity, it is removed by abdominal section. Incomplete ruptures are best treated by daily packing with iodoform or sterile gauze. Great gentleness is necessary in the examination to determine whether a tear is complete or incomplete, as it is easy to tear through the peritoneum. 304 INJURIES OF THE BIRTH-CANAL Complete ruptures are treated by abdominal section with removal of child and placenta, and hysterectomy below the site of the tear, with extraperitoneal fixtation and drainage of the stump of the cervix (marsupialization). It may be possible to sew up the rent, and leave the uterus in situ, but this is rare. The edges are so ragged and the danger of leakage so great, especially at the angle, that the attempt is rarely justifiable. If a patient should have a rupture of the uterus, and recover spontaneously, or if the rent has been sewed up and the uterus left in situ, she should be delivered by cesarean section in any future pregnancy, before she falls in labor, as a second rupture is almost sure to occur. LACERATIONS OF THE CERVIX Frequency.-Some injury occurs in every labor, but healing in moderate cases is usually spontaneous. Of every hundred patients who suffer a torn perineum, about thirty-three will have a cervical tear sufficient to require repair. Predisposing Causes.-(i) Elderly primiparae; (2) rigidity; (3) scar tissue due to previous repair; (4) premature rupture of the membranes; (5) forceps before the os is suffi- ciently dilated; (6) precipitate delivery; (7) pituitrin given before dilatation is complete; (8) manual or instrumental dilatation. Site.-The commonest tear is unequally bilateral; next unilateral, (3) stellate and (4) rarely annular detachment, where the entire cervix tears off. Symptoms and Diagnosis.-Hemorrhage after delivery with a firmly contracted uterus usually means a torn cervix. The cervix may be examined through a bivalve speculum or pulled down to the vulvar orifice with tenacula. A satisfactory model of bivalve speculum is the Collin. It is simple and has only one screw to adjust. It is sterilized by boiling. LACERATIONS OF THE CERVIX 305 Method of Insertion of Speculum.-The patient is arranged across the bed, her feet on two chairs and her hips over the edge of the bed. The vulva is carefully cleansed with cotton and lysol solution (one dram to two pints). The physician Tear in contraction ring. Dangerous in placenta praevia Tear in vaginal vault Rupture of cervix Usual cervical tear 'Clitoris tear Lateral vaginal tear Usual perineal tear, second degree Posterior vaginal tear or split Lateral fornix tear Fig. 122.-Diagram of most frequent tears in the parturient canal. {De Lee.) ' determines the position of the cervix by examination with one finger. The speculum, oiled, is inserted edgewise, turned transversely and pushed in the vagina in the direction deter- mined by the examining finger. This is usually downward at an angle of about 45 degrees, toward the bed or table on which the patient is lying. The blades are then separated, and if the direction of insertion is correct, the cervix should appear between the blades. If only the anterior vaginal wall 20 306 INJURIES OF THE BIRTH-CANAL Fig. 123. Patient draped for vaginal examination in the dorsal and lithotomy position. Fig. 124.-a, Collin's bivalve speculum, b, Sims speculum, c, Wire bi- valve speculum, for exposure of the cervix and vaginal walls. LACERATIONS OF THE CERVIX 307 is seen, the blades are allowed to collapse, the speculum is half withdrawn, and re-inserted at a steeper angle. All motions should be gentle, and of course rubber gloves are worn. When the speculum is correctly placed, the extent of the cervical tear can be seen. Fig. 125.-Bivalve speculum in position with blades open. The cervix appears between the blades. To remove the speculum, it is withdrawn open for about an inch (so that the cervix will not be pinched) the blades are allowed to collapse, and the speculum is withdrawn, turning it edgewise again. Time of repair may be immediate or delayed. The im- mediate repair has certain disadvantages. (1) The cervix is swollen and edematous and the stitches are likely not to hold: (2) the risk of sepsis is increased; (3) the difficulty of the operation is considerably more than when done a week later; (4) spontaneous healing will often occur, if the cervix is left undisturbed. Consequences of Nonrepair.-(1) The bloody lochia are prolonged and more profuse; (2) subinvolution is more com- 308 INJURIES OF THE BIRTH-CANAL mon; (3) retroversion (due to the weight of the subinvoluted uterus) is more common; (4) leukorrhea; (5) erosion of the Fig. 126.-The commonest mistake in the use of a bivalve speculum. The instrument has been inserted at too slight an angle, and nothing except the anterior vaginal vault appears between the blades. Advantages of the Delayed Repair.-The diagnosis of extent of the tear is certain, sepsis is not to be feared, better approximation of the edges can be obtained and good results are more certain. The operation is done one week after delivery, provided there is no fever. If the temperature is elevated above 99.5° F. repair is postponed until it has been steadily normal for a week. Disadvantages of the Delayed Repair.-(1) It means anes- thesia and a formal operation just when the patient is beginning to feel comfortable after her ordeal; (2) anesthesia often affects injuriously her milk secretion. Technic.-(1) The patient is anesthetized and prepared as for any vaginal operation. (2) The anterior and posterior lips of the cervix are caught with tenacula, pulled down and separated. LACERATIONS OF THE CERVIX 309 (3) The edges of the denudation are marked out, as in the Emmet trachelorrhaphy, care being taken to limit the denuda- tion to the area of the laceration and not to encroach upon the cervical canal. The shape of the denudation is triangular, on each lip. 3 Fig. 127.-1. Unilateral laceration of the cervix. 2. Bilateral lacera- tion of the cervix. 3. Stellate laceration of the cervix. As seen through a speculum. I 2 (4) Interrupted stitches, of number 3 forty-day chromic catgut, are placed beginning on the mucous membrane of the vaginal aspect of the anterior lip, emerging close to the mucous membrane of the cervical canal, entering again close to edge of the mucous membrane of the canal on the posterior lip, and emerging on the vaginal aspect of the posterior lip opposite the point of entrance on the anterior lip. Three or four sutures to a side are required. (5) The stitches are tied, after all are inserted. (6) When all are tied the cervical canal should have a caliber of the forefinger. Too tight closure will mean dysmenorrhea later. If the tear is unilateral, only one side is repaired; if 310 INJURIES OE THE BIRTH-CANAL stellate, each line of tear is repaired separately. Annular detachment requires no treatment, other than the removal of any irregular tabs of cervical tissue that may remain. Catgut (forty-day chromic number 3) is preferable to silk- worm-gut, as it does not have to be removed. 2 I Fig. 128.-i. The method of denudation and placing the stitches for Emmet's trachelorrhaphy. 2. The repair completed. LACERATIONS OF THE ANTERIOR VAGINAL WALL Clean cuts of the mucous membrane have no consequences, except hemorrhage directly after labor. If the bleeding warrants it, they are closed at once by a continuous stitch. If not, they heal spontaneously, if kept clean. Muscle of the Urogenital Trigonum.-This is the analogous muscle to the compressor urethrae in the male. It arises at the junction of the symphysis and descending ramus of the pubis, and runs diagonally back through the anterior vaginal wall. It divides and joins its fellow from the opposite side above and below the urethra, inserting into the fascia of the anterior vaginal wall. It is the only direct muscular support possessed by the lower third of the anterior vaginal wall, to which it is a levator, and is a compressor urethrae. A tear of this muscle is one of the factors in the production of a cystocele, and also accounts for many cases of incontinence of urine after delivery. LACERATIONS OF THE ANTERIOR VAGINAL WALL 311 Diagnosis of Injury.-With the patient in the dorsal position, the forefinger of one hand is inserted in the vagina, and pressure SYMPHYSIS ANTERIOR PROCESSES OF MUSCLE ORIGIN OF UROGENITAL MUSCLE URETHRA POSTERIOR PROCESSES OF MUSCLE VAGINA ANUS made straight up, to either side of the urethra, against the lower edge of the pubic bone. If the muscle is torn, the finger Fig. 129.-Anatomy of urogenital muscle. Fig. 130.-Repair of the muscle and fascia of the urogenital trigonum. presses against the sharp edge of the bone. If it is not torn, a flat ribbon of muscular tissue and fascia is felt between the finger and the bone. On inspection, the lower portion of the anterior vaginal wall bulges downward, if the muscle is torn. 312 INJURIES OF THE BIRTH-CANAL Repair.-This injury cannot be repaired directly after delivery, due to excessive bleeding. It can be done at the end of the first week, if this method of repair is elected. Fever delays this until the temperature has been normal for a week. Technic.- (1) Dorsal posture, usual preparation and anes- thesia. (2) The anterior vaginal wall is caught by a double tena- culum, just to the outer side of the urethra. (3) A second tenaculum catches the labium on the same side, at the same level. (4) When these are separated, a triangular sulcus is seen on the lateral aspect of the anterior vaginal wall, with the point toward the cervix. (5) This sulcus is denuded and the muscle repaired with a continuous tier stitch of number 1 forty-day chromic catgut. Interrupted suture can be used, but continuous is quicker and better. TEARS OF THE POSTERIOR VAGINAL WALL AND PERINEUM The great majority of patients have some degree of perineal tear. The degrees of tear are variously classified, the more common division being: (i) First degree tears, involving only the tissues of the perineal body in the middle line; (2) second degree tears, involving the levator ani; (3) third degree tears, involving the sphincter ani. Lacerations of the vulva and labia are really only abrasions. They are rarely deep, and unless attended by bleeding, do not require sutures. Tears of the Vagina, Pelvic Floor and Perineum.-The structures injured are: (1) Levator ani (the main muscular support of the pelvic floor); (2) deep transversus perinei-torn in the middle line, and retracting to either side; (3) the fascia anterior and posterior to the deep transversus perinei-the anterior and posterior layers of the triangular ligament; (4) the superficial transversus perinei; (5) the bulbocavernosus; (6) TEARS OF POSTERIOR VAGINAL WALL AND PERINEUM 313 the sphincter ani, if the tear extends that far in the middle line; (7) Colles' fascia, extending in from the fascia lata of the thigh. Tears of the levator ani are two kinds: (1) Forceps cuts, which may be anywhere in the course of the muscle and are usually a more or less complete division at right angles to the fibers and (2) spontaneous tears, in which the muscle tears loose from its tendinous attachment to the descending ramus of the pubes, and tears obliquely downward across the fibers of the muscle, but not through them, so that the tear opens out as a book is opened. This muscle is the main support of the pelvic floor, and its injuries are attended by the well known effects of such a tear: sense of loss of support, rectocele, and later prolapse of the uterus. The tear may be either open or submucous; the open tears are easy to see and feel, the submucous tears are often over- looked and result later in the misnamed "relaxation of the pelvic floor." Causes of Perineal Tears.-(1) Spontaneous delivery. (2) Forceps (almost invariably cause a tear). (3) Hurried de- livery. (4) Posterior shoulder of child will often make or extend a laceration. (5) Contracted pelvis-the narrow pubic arch forcing the head posteriorly. (6) Occipitoposterior positions. (7) Edema from prolonged labor. (8) Rigidity. In patients who have been properly repaired, it is common for the perineal body to give way, in subsequent labors, but injuries of the levator are much less common than in primiparae. Diagnosis of laceration of the perineum is best made four or five days after delivery. It is impossible correctly to diag- nose the full extent of injury to the pelvic floor directly after labor. Tests.-The patient is placed across the bed, in the dorsal position. (2) She is asked to strain, when the degree of gaping of the labia is noted. (3) After careful cleansing of the vulva, the labia are separated, when any obvious tear can be seen. (4) The thickness of the perineal body is palpated by one 314 INJURIES OF THE BIRTH-CANAL gloved finger in the vagina and the thumb outside, on the perineum. This will disclose injury to the bulbocavernosus, superficial and deep transversus perinei muscles. (5) The levator ani is tested as follows: The forefinger is inserted in the vagina, up to the second joint, and pressed downward and Fig. 13 i.-Proper way to arrange a patient across the bed for vaginal examination. There is plenty of room, and the chairs are out of the way. outward, to note a cleft, if any, in the muscle. The forefinger is swept from one pubic ramus to the other, to note whether the muscle forms an unbroken horseshoe curve. With the forefinger in the vagina and the thumb outside, the thickness of the levator is palpated. (6) The sphincter ani is always tested last, by feeling the complete circumference of the muscle with the forefinger in the rectum and the thumb outside. It is easy to Overlook a submucous tear of the sphincter, and a serious mistake to do so. Mere inspection of the perineum is no guide to the extent of injury present. TEARS OF POSTERIOR VAGINAL WALL AND PERINEUM 315 Central Tear of the Perineum.-In very rigid perinei, when overdistended by the head, a circular perforation sometimes appears midway between the posterior commissure of the vulva and the anus. This should be at once opened through into the vagina by scissors, followed by a double episiotomy. Unless so treated, the head is likely to emerge from the rectum, with disastrous results to the sphincter. Fig. 132.-Wrong way to arrange a patient across the bed for vaginal examination. The chairs are so close together that there is no room for examination. Symptoms of Tear through the Sphincter Ani (Complete Tear).-(i) Incontinence of gas and feces (which may mean only overstretching of the sphincter); (2) the sphincter forms a slightly curved line across the posterior border of the anus; (3) its ends are marked by two visible dimples or pits; (4) the folds of skin, or rugae, normally surrounding the anus are gone anteriorly and deepened posteriorly; (5) if the sphincter be palpated with one finger in the rectum, the gap in the ring muscle can be felt plainly. 316 INJURIES OF THE BIRTH-CANAL Time of Repair.-By delivering a patient by central or oblique episiotomy, as the vulvar ring begins to distend, and the short Hale-Sawyer forceps under complete anesthesia, practically all tears of the levator ani can be prevented. This episiotomy wound can be repaired immediately, by interrupted sutures, and the pelvic floor restored to practi- Fig. 133.-Testing levator ani muscle. The forefinger is inserted in the vagina up to the second joint; the thumb is midway between the tuberosity of the ischium and the anus. cally normal, though this method prevents any consideration being given to any other laceration, of the cervix or anterior or posterior vaginal walls, that may exist, until after the puerperium is completed. Perineal injuries may be repaired according to one of two plans: (i) Immediately after delivery or (2) by the delayed repair done on the seventh day after delivery. The immediate repair is the one most commonly done, but is open to certain grave objections: (1) Accurate diagnosis of the extent of the tear is difficult or impossible; (2) the bruised and edematous tissues are not good material for repair; (3) there is some danger of infection; (4) unless properly done these repairs are often only a skin closure; (5) sloughing of the stitches and partial failure are common, necessitating a second operation later. These disadvantages can be obviated by doing the repair on the seventh day, provided the patient has no fever, in which case the repair is postponed until the temperature has been TEARS OF POSTERIOR VAGINAL WALL AND PERINEUM 317 normal for a week. This method is undeniably efficient, and restores a patient to a condition as nearly normal as is possible, but it also has certain disadvantages: (1) It means a formal anesthesia and plastic operation just at the time the patient is beginning to feel comfortable; (2) it is attended with very considerable after-discomfort. (3) It often influences unfavorably her milk secretion. By carrying it out, however, all injuries can be repaired, which is not possible by any other method. Treatment Preventive.-Avoidance of undue haste in delivery; pro- tection of the perineum by retarding the head; lack of haste Fig. 134.-Method of testing the sphincter ani for laceration. in forceps delivery; using small forceps (Hale-Sawyer) wherever possible; timely episiotomy; avoidance of large doses or indis- criminate use of pituitrin. By observance of these details, many, but by no means all, lacerations can be avoided or at least limited in extent. 318 INJURIES OF THE BIRTH-CANAL Technic of Repair.-Immediate.-No matter what the physician's preference may be, this should never be under- taken if the vulva and vagina are badly bruised; if there is reason to believe that there is beginning infection; if the patient is excessively exhausted or if she is an eclamptic; or if the laceration dates from a previous labor. It is advisable to place but not tie the sutures before the placenta is delivered, and the old practice, recently revived, of putting sutures in the perineum before delivery of the head, and removing them, if not needed, after delivery, is illogical. Anesthesia is said not to be needed, because the overstretched tissues are not sensitive. The patient's actions, while the repair is in progress, will cause the physician grave doubts as to the accuracy of this statement. Technic of Immediate Repair.-(i) The patient is arranged across the bed, with her feet on two chairs, and her hips over the edge of the bed. (2) The vulva is carefully cleansed with cotton and lysol solution (one dram to two pints). (3) If much blood is trickling down from above, a large gauze or cotton sponge may be inserted in the vagina, against the cervix, and removed after the stitches are in place, but before they are tied. (4) The labia are separated and the extent of the injury inspected. This is materially aided by retraction of the anterior vaginal wall by an assistant. (5) Visible open tears of the levator may be sutured with a continuous number 3 chromicized catgut stitch. (6) The perineal body is repaired by interrupted stitches of number 3 chromic catgut or silkworm-gut, placed so that the entire depth of the tear is included, and not the skin of the perineum only. Episiotomy wounds are sutured in the same way. Plain catgut is not to be used, as it disappears too soon. Silk and linen thread have the disadvantage of cutting through the tis- sues. The after-care of these repairs is as described under the TEARS OF POSTERIOR VAGINAL WALL AND PERINEUM 319 delayed repair of the perineum. The silkworm-gut sutures are removed on the twelfth day. The catgut ones will disappear spontaneously. If the sphincter ani is torn, it is advisable to rejoin its ends at once, repairing also any tear above it in the recto-vaginal septum, by interrupted number 3 chromic catgut sutures. If the tissues are much bruised, it is wiser to do no further repair, as sloughing is sure to result. The sphincter will probably heal kindly and any subsequent repair is thereby made much easier. For all external sutures (those to be tied on the external perineal skin), silkworm gut is the best material. Even chromicized number 3 catgut is liable to premature absorp- tion with complete or partial failure of the repair. Plain catgut, or sizes smaller than number 3 should never be used. Technic of the Delayed Repair of the Perineum. Preparation for Operation. Day before Operation.-4 P. M. Shave pubes completely. 9 P. M. Magnesium sulphate ounce, or citrate of magnesia, flat, 8 ounces. Day of Operation.-Early in morning, cup of beef tea, no other breakfast. Clear lower bowel out thoroughly by repeated enemas, so that last enema is given at least two hours before operation. Continue enemas until water returns clear. Two hours before operation give paregoric 2 teaspoonfuls. Catheterize just before etherization. Give morphin sulph. gr. atropin sulph. gr. X50, one-half hour before anesthesia. Local preparation done on the table. The technic of the Emmet, Hegar, and B. C. Hirst opera- tions is as follows: Emmet Operation.-(1) The patient is in the dorsal position, the vagina carefully cleansed with tincture of green soap, hot water and lysol solution. (2) As nearly all lochial discharge at this time contains pathogenic organisms, the uterus should be washed out with lysol solution, and a large pledget of cotton soaked in lysol 320 INJURIES OF THE BIRTH-CANAL solution placed against the cervix. This must always be removed as soon as the operation is completed. (3) Each labium is caught with a bullet forceps just below the lowest myrtiform caruncle (above which is the duct of Bartholin's gland) or more conveniently the labia are separated with the Gelpi self-retaining perineal retractor. Fig. 135.-The Gelpi self-retaining perineal retractor, for use in plastic operations. It is especially useful where one has only one assistant. (4) The tip of the rectocele is caught with a volsellum (the tip is the portion nearest the cervix, in the midline, which •without tension can be brought down to the posterior com- missure of the vulva). (5) The lateral sulci are denuded in one piece or in strips. (6) The central perineal triangle is denuded, and if any granulation tissue is present, it is curetted off with the edge of a knife. (7) The lateral sulcus wounds are closed by continuous or interrupted sutures of number 3 chromic catgut, or interrupted sutures of silkworm-gut. Catgut stitches are tied, silkworm- gut are secured with perforated shot, as it makes their removal easier. (8) The crown stitches of number 3 chromic catgut or silk- worm-gut are inserted. The stitch passes through one labium, just below the tenaculum, emerges in the sulcus just below the last sulcus stitch, transfixes the tip of the rectocele, and passes TEARS OF POSTERIOR VAGINAL WALL AND PERINEUM 321 through the other labium to emerge on the skin perineum, just opposite its point of insertion. Two or three of these stitches are required. Fig. 136.-The Emmet perineorrhaphy. {After Stewart.) Fig. 137.-Diagram of the Emmet perineal repair, a. Denuded area; b, area not denuded; c, interrupted stitches in sulcus; d, continuous stitches in sulcus; e, crown stitches. The Emmet operation is not always a satisfactory one, as it takes no account of the anatomic lines of laceration, but answers very well if the laceration is of moderate extent. 21 322 INJURIES OF THE BIRTH-CANAL Fig. 138.-The Emmet and Hegar denudations compared, a, Lowest myrtiform caruncle, the same in both operations; b, tip of rectocele; c, highest point in Hegar operation on posterior vaginal wall; d, lines of Emmet denudation; e, lines of Hegar denudation. The solid lines show the shape of the Emmet denudation; the dotted lines that of the Hegar. Fig. 139. Fig. 140. Fig. 139.-Denudation in the Hegar operation, and suture of the rectocele above the levator ani. a, Myrtiform caruncles; b, denuded area; everything included in triangle is denuded; c, stitch puckering up tip of triangle. Fig. 140.-Hegar operation, second stage, a, Myrtiform caruncles; b, denuded area; c, puckered up tip of triangle; e, interrupted stitches of levator ani; f, interrupted suture of perineal body. TEARS OF POSTERIOR VAGINAL WALL AND PERINEUM 323 Hegar Operation.-(i) The patient is prepared as for the Emmet operation. (2) The labia are caught, as in the Emmet operation. (3) A point in the middle of the posterior vaginal wall, about two-thirds of the way from the vulva to cervix, is caught with a volsellum. (4) The large single triangle formed by these three instru- ments is denuded, care being taken to avoid wounding the rectum, an accident likely to occur unless great care is exercised. Any granulation tissue in the area to be denuded is curetted off. (5) Transverse interrupted stitches are placed across this triangle from the apex downward. The upper ones may be of number 3 chromic catgut, the lower three vaginal and the perineal stitches should be silkworm- gut, because they are under considerable tension. (6) The perineal stitches are placed, beginning with the one nearest the anus, so as to close the wound in the perineal body, entering from and emerging in the perineal skin. The Hegar operation regards the normal perineal anatomy and its injuries still less than the Emmet operation, but is usually satisfactory in its end results, especially in old lacera- tions, dating from a previous labor, with a large rectocele. Technic of the B. C. Hirst Perineorrhaphy.-(1) The patient is prepared as for the Emmet operation. (2) The labia and tip of the rectocele are caught as in the Emmet operation. Fig. 141.-The Hegar perineorrhaphy. 324 INJURIES OF THE BIRTH-CANAL (3) The sulci and central triangles are denuded as in the Emmet operation. (4) The fascia covering the levator ani is incised, on each side, in a line parallel to and just beneath the edge of the sulcus denudation, and the actual tear in the muscle exposed. The tear in the levator ani is closed on each side, inside the sheath of the muscle, by a continuous stitch of number 1 chromic catgut. (5) Two interrupted stitches are placed through the sheath and end of the deep transversus perinei muscle, but are not tied. The stitches pass through the sheath and muscle of one side, pick up the perineal body floor in the middle line, between the anterior and posterior layers of the triangular ligament, and through the sheath and muscle of the opposite side. (6) The posterior layer of the triangular ligament is closed over the bulging rectum, it being through the tear in this ligament that the rectocele protrudes. (7) The lateral sulci are closed as in the Emmet operation, by a continuous stitch. (8) The tip of the retocele is fastened down to the posterior column of the vagina, inside the posterior commissure of the vulva, where it originally belongs. (9) The tension of the Gelpi retractor is relaxed, and the two stitches securing the deep transversus perinei are tied. (10) The tears of Colles' fascia, bulbocavernosus, superficial transverse perinei and anterior layer of the triangular ligament, all in the perineal body, are closed by interrupted stitches placed so that, when tied, the knots will be covered in when the perineal skin is closed. (11) The perineal skin is closed. All catgut used is number 1 chromic catgut, of forty-day durability, except in the skin sutures, where overchromicized number 1 gut is used. This operation is designed to correct the lacerations in the planes in which they occur, and to effect a normal anatomical restoration. TEARS OF POSTERIOR VAGINAL WALL AND PERINEUM 325 It is not usually advisable to put in any vaginal packing, as it tends to dam back the lochia. No perineal operation should be attempted from a written description. For its understanding, actual demonstrations are necessary. Routine After-care of Plastics.-1. Morphin sulph. gr. atropin sulph. gr. Hso, 6th hour p.r.n. 2. Water p.r.n. first twenty-four hours. 3. Irrigate perineal stitches with sterile water four times daily, and also after each urination or bowel .CysTocele Connect. Tissue' Bridge Dimple Sphincter Fig. 142.-A typical complete tear of the perineum through the sphincter ani. {After Graves.) movement, and keep sterile vulvar pad in place after irrigation. Inspect stitches frequently. 4. If stitches become soiled, clean with cotton on applicator and peroxide of hydrogen. Moderate cutting may be disregarded. 5. Vaginal douche sterile water every day after third day. 6. Simple enema once or twice in second twenty-four hours. 7. End forty- eight hours, calomel gr. % every hour for six doses. Six 326 INJURIES OF THE BIRTH-CANAL hours later magnesium sulphate one-half ounce. 8. Soft diet after first twelve hours, light diet fifth day, full diet seventh day. 9. Catheterize eighth hour p.r.n. 10. Take out vaginal packing in twenty-four hours, if any inserted, and note its removal on the chart. 11. As a routine laxative use compound cathartic pills, one at bed time. If too active, give only half a pill. If griping, use A.B.S. and C. pill. Operation for Complete Tear.-Repair of a complete tear should never be attempted as long as there is any edema, sloughing, unhealthy granulation, or fever. Failure is sure if this precaution is disregarded. If a complete, or any other perineal tear shows sloughing or edema, restoration to heathy Fig. 143.-Arrows indicate direction of traction. Stretching the sphinc- ter ani in a complete tear operation. condition is more quickly attained by thrice daily douches of sterile water, and application of weak solutions of nitrate of silver (gr. x to oz. j.) to any place showing persistent false membrane. Preparation for repair of complete tear is the same as any plastic operation, except that several days must be devoted to getting the bowels to move freely, before the operation is attempted. Technic.-(i) The patient is arranged and cleansed as for any plastic operation. TEARS OF POSTERIOR VAGINAL WALL AND PERINEUM 327 (2) The sphincter is stretched by grasping between the thumbs and forefingers, and stretched for a full minute. Fig. 144.-Diagram for complete tear operation, a, Lateral sulci in vagina (denuded); b, rectocele (not denuded); c, sphincter pits; the empty ends of the sphincter sheath; d, tip of tear in rectovaginal septum; c, sphincter ani, retracted in its sheath. (3) The labia and tip of rectocele are caught as in the Emmet operation. Fig. 145.-Bringing up the ends of the sphincter ani. The ends of the muscle are retracted in the sheath, J4 to )4 inch below the surface of the denudation. (After Crossen.) (4) An incision is made from one sphincter pit, around the tear in the rectovaginal septum, to the other sphincter pit. 328 INJURIES OF THE BIRTH-CANAL (5) The rectovaginal septum is split, between the vagina and rectum, so as to secure an ample margin of raw tissue, without unnecessary sacrifice of any portion. (6) The tear in the rectovaginal septum is repaired by interrupted silkworm-gut stitches, put in from the rectal side, so that the knots, when tied, will be in the rectum. Inter- rupted chromic catgut stitches with the knots buried in the perineal body may be used, but with a greater likelihood of rectoperineal fistula. (7) The ends of the sphincter are pulled out of the pits into which they had retracted, by single tenacula, and cleared of any granulation tissue which may cover them. Fig. 146.-The stitches of the complete tear operation, a, The tip of the tear in the rectovaginal septum; b, the sphincter ani; c, denuded area around the tear in the rectovaginal septum; d, end of sphincter, dug out of its pit. 1. Interrupted suture closing apex of tear in rectovaginal septum. 2. Interrupted suture, through sphincter and sheath. Only one of each kind is shown. Two interrupted stitches of number i chromic catgut are passed through the ends of the muscle, so that when tied the knots will be buried in the perineal body. These are for approximation only. Two silkworm-gut stitches are passed through the sphincter and sheath, beginning at the muco- cutaneous junction at the anus on one side, and emerging at a corresponding point on the opposite side. These are for TEARS OF POSTERIOR VAGINAL WALL AND PERINEUM 329 approximation and tension. With this plan, further tension stitches are unnecessary. (8) All the rectal stitches are tied from above downward. (9) The rest of the perineal injury is repaired as may be required by the extent of the tear, disregarding the rectal feature of the tear. In complete tears it is most common for the levator to escape injury, and the tear is confined to the perineal body in the middle line. After-treatment is the same as any plastic except for the care of the bowels. The safest plan is to keep the bowels locked by paregoric, one teaspoonful twice daily, for five days after operation. During this time the patient's diet is restricted to liquids as broths, albumin water, soups, etc. leaving as little bowel residue as possible. Milk is excluded. On the morning of the fifth day the patient is given one ounce castor oil. At the time of a desire for movement, she is given, through a catheter, an enema of four ounces of warm sweet oil, to be retained for one-half hour if possible. After this first movement, her diet is increased and she is given sufficient laxatives to secure at least two semi-liquid movements a day. The stitches are removed on the sixteenth day, best in the knee-chest posture through a rectal speculum, cautiously opened, and the bowels must be kept liquid for at least a month and soft for two or three months thereafter. The commonest cause of failure, next to infection, is neglect of the bowels, especially after the stitches have been removed. Infection is likely to result in either complete failure or rectovaginal or rectoperineal fistulae. These latter rarely if ever heal spontaneously, and must be closed by a second operation. In this or any other plastic it is unnecessary to keep the knees bound together, unless the patient is unruly or delirious, and she may turn on either side after forty-eight hours. Factors Essential to Success in Complete Tear Operations. (1) Choice of proper time and condition for operations. (2) Stretching of sphincter. (3) Exposure and cleansing of ends of sphincter. (4) Permanent suture material (silkworm- 330 INJURIES OF THE BIRTH-CANAL gut). (5) Pass sutures deep enough to catch sheath of sphinc- ter. (6) Leave stitches in at least sixteen days. (7) Keep bowels semi-liquid as described. If the bowels should become Fig. 147.-The sphincter repaired. {After Crossen.) locked, the first movement must be secured under oil enemata, and in all probability by breaking up the fecal mass by the gloved finger, inserted in the anus and morcellating the mass by pushing back toward the sacrum and never forward. With proper management, and if necessary, timely episiot- omy, a required sphincter will usually withstand subsequent delivery without giving way. Genital fistulae, being, as a rule, late complications, are best considered in the next chapter, in the pathologic sequelae of child-birth. CHAPTER XIV OTHER PATHOLOGIC SEQUELS OF CHILD-BIRTH The commoner pathologic sequelae of child-birth, injuriously affecting the patient's health are: (i) Lacerations of the birth-canal. (2) Erosion of the cervix (not due to laceration). (3) Retrodisplacement of the uterus. (4) Pelvic inflammation. (5) Diastasis of the recti. (6) Floating kidney. (7) Fractured coccyx. (8) Rectocele. (9) Cystocele. (10) Prolapse of the uterus. (11) Incon- tinence of urine. (12) Genital fistulae. (13) Hemorrhoids. Many of the operations required in the treatment of the pathological sequelae of child-birth are here described by principle only and not by detailed steps of technic. They are all done at periods remote from delivery, and hence are properly included in works on gynecology, and have no direct bearing on the obstetric question. This applies especially to the operative treatment of backward displacement of the uterus. Lacerations are described in the preceding chapter. EROSION OF THE CERVIX Erosion of the cervix is commonly miscalled ulcer. It is not ulceration, but a prolapse of the deep-red columnar epithe- lium of the cervical canal over the squamous epithelium of the anterior and posterior lips of the cervix. Its appearance is red and angry. It bleeds easily to the touch, but is not ulceration in the sense that destruction of tissue accompanies it. The causes are: (i) Laceration. (2) Gonorrhea. (3) Non-specific infection of the cervical or endometrial glands. 331 332 OTHER PATHOLOGIC SEQUELAE OF CHILD-BIRTH It is occasionally seen in virgins, and in these cases often no cause can be found. Symptoms.-The symptoms of erosion are a profuse, stringy mucopurulent leukorrhea. Diagnosis is made by inspection through a bivalve speculum. It is not possible accurately to diagnose erosion by digital examination. The anterior or posterior lips of the cervix are the site of ap- parent ulceration, red, and bleed easily when touched with an instrument. When the blades of the bivalve specu- lum are widely opened, it is common for the lips of the normal cervix to be separated so that the mucous membrane of the cervical canal is visible. When the speculum is slightly withdrawn, the lips fall together and the apparent erosion disappears. When erosion really exists, it does not disappear when the speculum is withdrawn. Treatment.-Erosion due to lacera- tion of the cervix will not disappear permanently until the laceration is repaired. Erosion due to gonorrheal infection is incurable, as long as the disease persists. From both these causes, erosion is merely a symptom which disappears as soon as the primary cause is removed. The best routine treatment for erosion of the cervix, not due to one of the above causes, is to expose the cervix, through a bivalve speculum, pour in the speculum enough 40 gr. to the ounce nitrate of silver solution to cover the cervix completely, allow it to remain for five minutes, sponge out the excess and remove the speculum. If the solution causes unpleasant stinging, it can be neutralized by a douche of normal salt solution (one dram to the pint). This application, repeated once or twice, at intervals of forty-eight hours, is usually all that is required. As an alter- Pig. 148. - Bilateral laceration of the cervix, with marked eversion and erosion. RETRODISPLACEMENT OF THE UTERUS 333 native method, the eroded area can be touched with a solid stick nitrate of silver, until thoroughly whitened. This is repeated, if needed, in eight or ten days. If a vaginal douche is deemed advisable, the following will be found satisfactory: Carbolic acid 2 drams, zinc sulphate 1 ounce, dried alum 3 ounces. Two teaspoonfuls of this powder to two quarts of hot water. The directions to the patient for taking a douche are: 1. Always in recumbent posture, preferably in bath tub. 2. Use fountain syringe and never a forced flow. 3. Boil syringe and nozzle, and use boiled water. 4. Use only mild antiseptics, such as boric acid; permanga- nate 1-3000, and not bichlorid or carbolic acid. 5. Have water comfortably hot. Never cold. 6. Have syringe not more than two feet above body. 7. Control flow, so that four quarts will take fifteen minutes to flow through. 8. Use nozzle with blind end, and openings in side. 9. Do not use hot douche just before, during, or just after period. Sometimes a severe erosion will require amputation of the cervix. This is only to be done when all other means have failed. As little as possible of the cervix should be removed, because of the tendency to subsequent miscarriage. It is well to have all these persistent erosions examined micro- scopically for possible malignancy. RETRODISPLACEMENT OF THE UTERUS Retrodisplacement of the uterus is of two kinds: Retroversion where the uterus is turned backward without distortion of its longitudinal axis; retroflexion where the uterus is sharply bent backward. Symptoms.-(i) Persistent backache, low down, relieved by lying in bed, disappearing in the morning and gradually increasing all day. If the uterus is adherent, the backache may be constant; (2) persistent vertical or occipital headache; 334 OTHER PATHOLOGIC SEQUELS OF CHILD-BIRTH (3) moderate pain in both groins (torsion of the broad liga- ments); (4) dysmenorrhea or menorrhagia, also irregularity, with a tendency to frequency of the periods. Many cases are attended by no symptoms at all, the retroversion being dis- covered in the course of examination for other complaints. Diagnosis.-The position of the cervix is no guide to the position of the icterus. Two fingers of one hand are inserted Fig. 149.-Normal position of the uterus. (Ashton.) in the vagina, the tips of the fingers being in the anterior vaginal vault. With counterpressure on the abdomen, the uterine body should be felt between the fingers. If it is not, the fingers in the vagina are placed behind the cervix, and the uterine body may be felt in the hollow of the sacrum. In cases of doubt the position of the uterus may be determined by a uterine sound, but the danger of injury and infection is so great that the method cannot be recommended. In all doubtful cases, an anesthetic may be necessary. A diagnosis should never be made unless the bladder is empty. Treatment.-This depends upon: (i) The time when the patient is seen; (2) the presence or absence of adhesions; RETRODISPLACEMENT OF THE UTERUS 335 (3) the social class of the patient, as the palliative treatment with a pessary requires care and attention a working woman is not able to afford. Fig. 150.-Normal position of the uterus, seen from above. Fig. 151.-Diagram illustrating the three degrees of retroversion of the uterus. The third degree is often called complete retroversion. (After Skene.) If the retroversion is discovered at the final examination, six weeks after child-birth, the uterus may be replaced and kept in place by a pessary. This is the only time a pessary 336 OTHER PATHOLOGIC SEQUELA! OF CHILD-BIRTH Fig. 152.-The different steps in bimanual reposition of a retroverted uterus. This is only possible when the patient is thin, relaxed, and the uterus is not adherent. RETRODISPLACEMENT OF THE UTERUS 337 may effect a cure. The chance of success is about 40 per cent. At all other times, the pessary is merely a crutch and will not cure. Reposition of the Uterus.-The patient is arranged in the dorsal position. Two fingers of one hand are placed in the vagina, the tips of the fingers behind the cervix. The uterine body is lifted up as far as possible, and the other hand, on the abdomen, attempts to hook the fingers behind the fundus and pull it forward. This is only possible when a patient is thin, the abdomen relaxed, and the uterus free from adhesions. A double tenaculum, on the anterior cervical lip, is often use- Fig. 153.-Knee-chest elevated position. {Ashton.) ful. If this attempt fails, the patient is put in the knee-chest posture, the perineum retracted by a Sims speculum, and the uterus pried up by a repositor in the posterior vaginal vault, aided by a tenaculum on the cervix. If this fails, the attempt should be repeated under an anesthetic. The reposition of the uterus by a sound or catheter in the uterine cavity is efficient but dangerous, and should not be used unless proper aseptic precautions are observed. If the uterus can be replaced at all, one of the methods described will be successful. 22 338 OTHER PATHOLOGIC SEQUELAE OF CHILD-BIRTH Retention of the Uterus in Position.-If the uterus is free from adhesions; if there is good perineal support; if the uterus can be replaced, and if the patient does not have to do hard manual labor, a pessary will keep the organ in proper position. Hodge Smith Thomas Fig. 154.-The three types of retroversion pessary in common use. Kinds of Pessary.-The kinds in most common use are: (1) Hodge; (2) Albert Smith modification of the Hodge, and Fig. 155.-Method of beginning the insertion of a pessary. (3) Thomas. The Smith and Thomas pessaries are the best; the Hodge is usually uncomfortable, except in cases where there is a moderate lack of perineal support. Insertion of a Pessary-(1) The patient is in the dorsal posi- tion; (2) the uterus is in proper position; (3) the pessary is RETRODISPLACEMENT OF THE UTERUS 339 grasped by the lower bar and greased (glycerin); (4) the fore- finger of one hand presses down in one vaginal sulcus; (5) the pessary is inserted obliquely in this sulcus, and upside down, for about one-half its length; (6) the pessary is turned right side up; (7) the forefinger of the other hand makes pressure on the upper bar of the pessary, carrying it up and behind the cervix (never in front of the cervix). Qualifications for Proper Pessary.-(1) No portion of it is visible when inserted (if so, it is too long, and can be shortened Fig. 156.--The pessary in position. (After Skene.) by increasing the curvature); (2) it should reach from the pos- terior vaginal vault to the anterior vaginal wall, at the level of the internal urinary meatus; (3) there should be room to pass the finger all around it; (4) it should be the smallest that will satisfactorily support the uterus; (5) it should cause no pain; (6) it does interfere with coitus; (7) in cases of retro- flexion the Thomas pessary is used to span the angle of flexion. It is not always possible to find at the first trial a pessary satsifactory in all respects. The instrument must be fitted to 340 OTHER PATHOLOGIC SEQUEL 2E OF CHILD-BIRTH each case. The shape of the pessary can be varied by immers- ing in boiling water; moulding it to the desired shape, and then plunging in cold water to harden it. After-treatment.-The patient is told to report in two weeks, or sooner if she is uncomfortable. She then reports every four weeks for three months. At each visit, the pessary is removed by hooking the forefinger from below, under the lower bar; the vaginal vaults are inspected through a bivalve speculum for possible erosion or irritation, and if none is found, the pessary is reinserted. After three months, an attempt is made to do without the pessary, for two weeks; if the uterus is found in good position, and again four weeks later, the patient may be discharged as cured. If the displacement recurs, the pessary is again inserted for three months, with examination as before. If then, after the pessary has been worn for six months, the uterus will not stay in place without support, the patient is given her choice between the constant wearing of a pessary or operation. During the period of trial, the patient may undergo a course of pelvic massage and Swedish movements, designed to strengthen the pelvic muscles and ligaments, but of doubtful value. The long-continued wearing of a pessary is not desirable. It requires constant watching, the pressure of it is irritating, it tends to aggravate any neurosis of the patient, and to convince the patient that she requires constant medical attention. Frequent vaginal douching while the pessary is worn is not advisable; a douche of salt solution twice a week is ample. A pessary is not indicated in a patient who has to work; it is contra-indicated in an adherent retroversion, in perineal lacerations and only the Thomas pessary should be used in cases of retroflexion. Adherent retroversion may sometimes be managed by placing the patient in the knee-chest posture, retracting the perineum with a Sims speculum, and packing in the posterior vaginal vault small wool tampons, making as much pressure as the patient can endure. The vagina is then packed with other RETRODISPLACEMENT OF THE UTERUS 341 tampons to hold the upper ones in place. A strict count should be kept of the number inserted. They are removed in forty- eight hours, the vagina douched, and a fresh lot inserted. This treatment, kept up over six or eight weeks, will sometimes replace a uterus which at first was densely adherent. It is uncomfortable and requires patience, but as a means of avoiding operation is worth a trial. Operative Treatment of Retrodisplacement.-Many operations have been devised, but those in most common use are the following: Fig. 157.--The suspension stitch in ventro-suspension of the uterus. Two of these are placed close together. Pig. 158.-A. lateral view of the operation of ventro-suspension of the uterus completed. Notice how the bladder is cramped for room. {After Crossen.) (i) The Alexander (Alexander-Adams-Alquie-Edebohls) the principle of which is the shortening of the round ligaments in the inguinal canal. It has the disadvantage of not permit- ting inspection of the pelvic organs for adhesions, or the appendix, unless the internal rings be opened. This can easily be done, however. It has a limited field, as there must be no suspicion of pelvic adhesions, and the patient must not be fat. It has, when properly done, very few failures and with- stands subsequent child-birth well. 342 OTHER PATHOLOGIC SEQUELAE OF CHILD-BIRTH (2) The Pfannenstiel transverse incision, combined with the Alexander operation. This permits the inspection of the appendages, the removal of the appendix, and also utilizes the round ligaments for support of the uterus. It is appli- cable to any case, and has the good features of the Alexander operation without its limitations. Fig. 159.--The Baldy operation for retroversion; seen from above and from behind. {After Graves.) It has sone objectionable features: (i) Danger of injury to the bladder, in opening the peritoneum, as the wound is very near the symphysis; (2) difficulty in removing a badly ad- herent appendix, because of limited room; (3) deep-seated hematomata due to extensive separation of muscle under the fascia, are not uncommon and cause prolonged drainage; (4) it is technically difficult, or impossible, if the patient is fat. (3) Ventrosuspension of the uterus to the anterior abdomi- nal wall. It will not withstand future child-bearing, though effective until the patient has another child. (4) Baldy operation of bringing the round ligaments through the broad ligaments, under the ovarian ligaments, and sewing the loops together behind the uterus. (The Webster opera- tion is the same, except that the loops of the round ligament are not drawn together behind the uterus.) PELVIC INFLAMMATION 343 (5) Gilliam operation, where the round ligaments are brought through the rectus muscle and peritoneum, to either side of the abdominal incision at its lower end, and the loops of the ligaments sewed together and to the rectus. It does not leave the uterus in normal position. (The Mayo operation is a modification of this; the round ligaments being caught at the internal ring, and pulled over to the midline, in the inci- sion, between the fascia and the muscles.) (6) Coffey operation, where the round ligaments are folded down the anterior face of the uterus to the vesical attachment and back again to the cornu, and secured by sutures. This will not withstand subsequent child-birth. All the vaginal operations for retroversion are attended by difficulty in subsequent child-birth, and are not to be recom- mended in women of child-bearing age. The indications for operative treatment are: (1) adherent retroversion, where attempts at reposition have failed; (2) where the pessary has failed to cure, and further wearing of the instrument undesirable; (3) working women, unable to afford the time, attention and semi-invalidism required by the pessary. PELVIC INFLAMMATION Under this head are considered the moderate infections of the parametrial connective tissue, not including those requiring operation. These latter will be found under the complications of puerperal sepsis. Symptoms.-(i) Pelvic pain, worse on the left side usually, markedly increased by being much on feet, or by constipation; (2) usually bladder irritability; (3) moderate fever (100°) and moderate leukocytosis (16000); (4) the uterus is fixed, the cervix cannot be moved by the examining finger without pain; (5) the bases of both broad ligaments and to a lesser degree, the connective tissue of Douglas pouch and the vesico- uterine space, are indurated; (6) there is no other palpable pelvic mass. 344 OTHER PATHOLOGIC SEQUEL2E OF CHILD-BIRTH Treatment.-(i) Hot vaginal douching, three times daily, using mild astringents or antiseptics, never powerful ones. The water should be as hot as the patient can stand, usually i2o°F., and the directions already given should be observed; (2) application of tincture of iodin (7 per cent.) to the vaginal vaults twice or three times a week; (3) boroglycerid (25 per cent, boric acid in glycerin) or ichthyol (50 per cent, ichthyol in glycerin) on wool tampons, three times a week, the tampons being removed after twenty-four hours, and the douching carried out only when the tampons are not in place. Boro- glycerid is preferable to ichthyol, as it does not stain the cloth- ing. (4) Bowels kept well open, with magnesium citrate. Any case not yielding to the above, will probably require surgi- cal interference. In all these cases, however, patience is a virtue. By wait- ing, in many cases even extensive pelvic exudates will entirely disappear. DIASTASIS OF THE RECTI In the last three months of every pregnancy the abdominal recti are gradually separated by the pressure of the enlarging uterus. In cases of hydramnios or multiple pregnancy, where the abdomen is overdistended, the separation may be extreme. If an abdominal binder is worn and kept properly tight during the puerperal convalescence, the muscles gradually assume their normal parallel course, and the support of the anterior abdominal wall is not markedly diminished. Where the abdominal binder is not worn, or discarded too soon, or not kept properly tight, permanent separation, with consequent splanchnoptosis and pendulous adbomen will result. The effects of a' diastasis are chiefly those of splanchnoptosis and practically a ventral hernia. The patient, if the diastasis is marked, is incapacitated. Diagnosis is easy. The abdominal skin is flaccid and wrin- kled; coils of intestine can plainly be seen moving under the thin DIASTASIS OF THE RECTI 345 skin and fascia; when the patient strains the center of the abdomen rises like a dome, and the edges of the separated muscles can be felt. Treatment.-A separation of less than four fingers in breadth can usually be disregarded, as the symptoms are so moderate that no relief is needed. Greater separation than this gives symptoms whose severity are in direct ratio to the degree of separation. A moderate case can be relieved, temporarily at least, by an abdominal binder, preferably one which supports the abdomen as well as compresses. A straight-front corset will give good support; adhesive straps will give temporary relief. Massage and electricity are not likely to have any beneficial effect. Exercises tending to strengthen the abdominal muscles often help the moderate cases greatly, but are useless where the separation is over four or five fingers. All these methods are merely temporary (except possibly after the first labor) and cannot be used in women obliged to do hard work. In these patients, the Webster operation will effect a cure. The principle is a long incision from the ensiform to the pubes, dissecting back the skin and fat on each side to the retracted muscles. In this process the peritoneal cavity is usually opened as the umbilicus is cut across. The small opening is closed at once, and the rest of the operation is extraperitoneal. The sheaths of the separated recti are sewed together, without opening them, in the middle line, using interrupted chromic catgut number 2 for tension sutures and continuous number 1 chromic catgut stitch for approximation. The tissue lying between the muscles is allowed to arrange itself behind the suture line, and is not excised. The excess of the skin is trimmed off, and if desired, a new umbilicus can be made, by a purse-string suture inverting the skin edge, at the proper point. This operation withstands subsequent labor provided it does not occur too soon after the operation (two years at least) and proper attention is given to the abdominal binder during the puerperium. 346 OTHER PATHOLOGIC SEQUEL.® OF CHILD-BIRTH FLOATING KIDNEY Causes.-(i) Loss of the supporting fatty capsule; (2) drag on kidney by movable cecum or colon; (3) secondarily only the relaxation of the lower abdomen by the distention of pregnancy. Symptoms.-In most cases, symptoms are absent. Only a small percentage (5 to 8 per cent.) require any relief. A dull dragging pain in the loin (nearly always the right) associated with a "sense of looseness" in the corresponding side of the Fig. 160.-Nephrorrhaphy. Shows the method of passing the fixation sutures. {Ashton, after Edebohls.) abdomen. The discomfort is not transmitted down the ureter, as it is likely to be in stone. Sudden, sharp attacks of pain, due to the twist in the ureter with temporary hydronephrosis, are common. Often a large quantity of urine is passed, following such an attack of pain. The severity of the symptoms does not depend upon the degree of looseness, and coincident appen- dicitis is frequent, due to congestion of the appendiceal veins by pressure of the kidney on the mesenteric veins (Edebohls). Diagnosis.-The patient is arranged flat on her back, with knees flexed on the abdomen. It is impossible, except in thin individuals, to feel the normally placed kidney. The left hand is placed flat under the left flank, and pressed upward, while the right hand makes counter pressure on the abdomen, just below the costal margin, The patient takes a deep breath ECTOPIC KIDNEY 347 and then exhales quickly. The smooth, elastic body of the kidney is unmistakable. As the kidney is often low, the exami- nation should extend as far down as the pelvic brim. In doubt- ful cases, the pelvis of the kidney may be injected with sodium iodide solution and an x-ray will show its position. Treatment is required only when definite symptoms demand relief. Muscular exercise, full diet and a properly fitting abdominal binder, with a pad, will relieve the moderate cases. Where Dietl's crises of pain occur, however, or in very low and very movable kidneys, operation is required. The principle is decap- sulation of the kidney, with suspen- sion by stitches through the capsule against the cut edge of the quadratus lumborum, outside the erector spinse just below the last rib. The kidney should not be fixed too high, above the last rib, as it is likely to rotate over the points of support. The kidney thus fixed, is always palpable, and the patient should be informed of this fact, to avoid errors of diagnosis in any future examinations. Fig. 161.-The type of adhesion and the position of the kidney (upper pole at the last rib) as secured by the Edebohls' nephror- rhaphy. (After Edebohls.) ECTOPIC KIDNEY Ectopic kidney is the congenitally low kidney, at, near or even below the pelvic brim. The vessels come from the internal iliacs, and the ureter is short, hence the reposition to its normal position is impossible. Diagnosis can be made definitely by catheterizing the ureters with x-ray catheters and x-ray 348 OTHER PATHOLOGIC SEQUELAE OF CHILD-BIRTH picture and by pyelography. The condition is of no importance except in labor, but should be excluded before any attempt at reposition of the kidney is made. Fig. 162.-Congenital ectopic kidney. FRACTURE OF COCCYX Fractured coccyx is most common in justominor pelves, especially where forceps have been used, and in elderly pri- miparae. The injury may occur spontaneously. It is most commonly a rupture of the joint between the first and second pieces of the coccyx. Mechanism.-The mechanism of a fracture of the coccyx, resulting in permanent mobility, is first a fall, where the coccyx is driven in the pelvic canal, rupturing the posterior longi- tudinal ligaments, and causing the coccyx to project much further than normal into the pelvic canal. In labor, the head FRACUTRE OF COCCYX 349 pushes the coccyx in the opposite direction, causing a rupture of the anterior longitudinal ligament, and a separation of the joint between the first and second pieces. Terminations.-(1) The coccyx may ankylose inward (into the pelvic canal) when spontaneous cure results, until the next Fig. 163.-Separating the fragments of a broken coccyx. labor breaks it again; (2) ankylosis backward, in a straight line, so that the patient sits upon the tip of it, like a nail; (3) permanent painful mobility, coccygodynia-much the com- monest. The first requires no treatment, the others require removal of the bone. Causes of Coccygeal Pain.-Pain is not always due to injury of the bone. The causes of coccygeal pain are: (1) Injury; (2) reflex (from retroversion of the uterus); (3) rheumatic; (4) neurotic. It should be an invariable rule never to remove the coccyx unless injury can be demonstrated. Symptoms of Painful Mobility.-(1) The patient complains of pain at the end of the spine on walking, sitting or particu- larly on defecation; (2) she has difficulty in arising from a chair; (3) she sits on one buttock, and cannot remain long in one position. 350 OTHER PATHOLOGIC SEQUELAE OF CHILD-BIRTH Diagnosis.-With the patient in the Sims (left lateral) posture, one forefinger, protected by a finger-cot or glove, is inserted in the rectum and the coccyx grasped between this finger and the thumb outside. There is normal anteroposte- rior motion of about 1.5 cm. If the coccyx can be moved laterally; if the movement causes pain, and if by pressure a step can be made between the upper and lower fragments, the bone is injured. X-ray does not show the injury. Treatment.-At least six months after labor should be allowed, for possible spontaneous ankylosis. A mild oint- ment (1 or 2 per cent, iodin) may be used externally over the Fig. 164.-The line of amputation in coccygectomy. The last piece of the sacrum has tubercles but no lateral alae; the first piece of the coccyx has lateral alae but no tubercles. The line of amputation lies between them. bone, chiefly as a placebo. If spontaneous cure is not affected, or if the coccyx ankyloses backward, its removal is indicated. The coccyx is exposed by an incision over it, as far from the anus as possible. The bone is dissected loose from its attach- ments with scissors, care being taken not to wound the rectum, which is close underneath. The dissection is carried above the lateral alse on the first piece of the coccyx, and the bone amputated with a Gigli saw between these alae and the tubercles marking the last piece of the sacrum. It is important that all the coccyx be removed; amputation through the ruptured joint will not relieve the symptoms. The median sacral artery is tied, the deep wound drained with a few strands of silkworm-gut (horsehair drain) and closed with interrupted stitches of silkworm-gut, so CYSTOCELE 351 that all dead space is obliterated. Serious infection may result if the wound is improperly closed. It is dressed with gauze and collodion, and kept as clean as possible. The stitches are removed in two weeks. RECTOCELE Rectocele is caused by a bulging forward of the anterior wall of the rectum, covered by the posterior vaginal wall, through a tear in the fascia between the levator ani and deep transversus perinei muscles, and the triangular ligament. The patient will usually mistake the condition for prolapse of the uterus. Diagnosis.-With the patient in the dorsal position, the labia are separated, and she is asked to strain. The bulging forward of the rectocele is obvious. Treatment.-Proper repair of the perineal floor and body, as described under lacerations of the birth-canal. CYSTOCELE Cystocele is a bulging downward of the bladder and anterior vaginal wall. Causes.-(i) Laceration of the muscle of the urogenital trigonum; (2) diastasis of the anterior vaginal fascia; (3) elongation of the uterovesical and cardinal ligaments. The most important predisposing cause of a cystocele is traction by forceps, particularly axis-traction forceps, before the head has passed through the cervix, and improper direc- tion of pull on the forceps at any stage (outward instead of downward until the head is under the pubic arch). The injury does not appear until several months or even many years after labor. Its proper correction in all cases is one of the as yet unsolved problems in gynecology. Symptoms.-(1) The patient complains of some protrusion from the vulva, which she is likely to call the uterus; (2) vesical irritation, from decomposition of urine in the pouch below the urethra. 352 OTHER PATHOLOGIC SEQUELAE OF CHILD-BIRTH Diagnosis.-With the patient in the dorsal position, the labia separated, she is asked to strain. The protrusion of the anterior vaginal wall is apparent. It is not advisable to test the position of the bladder by the insertion through the urethra of a sound. There is great danger of injury to the vesical mucosa. A suburethral abscess, from Skene's glands, looks not unlike a cystocele, but the absence of bulging on straining, the brawny feel and pus exuding from the urethra on pressure should make the diagnosis easy. Treatment.-Palliative by the globe, ball-and-stem, Schatz, Menge or Gehrung pessaries. The palliative treatment is never curative, and is simply a crutch. Fig. 165.-Operations for cystocele. From left to right: 1. Stoltz purse string operation. 2. Old oval denudation. 3. Martin operation. 4. B. C. Hirst operation, a, Urethra; b, cervix; c, denuded area; d, stitch. Operative Treatment.-There is no single operation appli- cable to all cases. The age of the patient, the degree of cysto- cele, and the method of its production must be considered. The Watkins-Freund-Wertheim operation of interposition of the uterus under the bladder, by opening the anterior vaginal vault, is the surest cure, but is not to be done where any further child-bearing is to be expected, unless the patient is artificially sterilized, by resection of the fallopian tubes at the uterine cornu. It is the only method to be depended upon in very large cystoceles, particularly those occurring very soon after delivery by axis-traction forceps. The Martin operation of oval denudation and tier suture of number i chromic catgut answers very well in moderate cases, PROLAPSE OF THE UTERUS 353 provided the denudation is carried far enough out to each side to include the retracted fascia. The Goffe operation of opening the anterior vaginal vault and suspending the bladder to the fundus uteri and upper portions of the broad ligaments, is successful in bad cases where further labors are to be expected. The B. C. Hirst operation of exposing the retracted fascia by a T incision and dissection of the vaginal wall, freeing the bladder laterally and from below by cutting the uterovesical ligaments, and sewing the fascial edges together under the bladder is for moderate cases only. In very severe cases, it may be necessary to open the abdo- Fig. 166.-The position of the uterus and its relation to the bladder after the Watkins-Wertheim operation of interposition. (After Crossen.') men and sew the bladder fan-shaped to the anterior abdominal wall. By one of these methods, practically any case can be managed, but no single method answers for every case. PROLAPSE OF THE UTERUS While the great majority of cases result from the injuries of child-birth, there are other causes: (i) Sudden severe muscular effort; (2) constant muscular shocks (as in a chronic cough); 23 354 OTHER PATHOLOGIC SEQUELAE OF CHILD-BIRTH (3) rupture of an ovarian cyst (the weight of the fluid in the lower abdomen acting as a mechanical cause). Too early rising after labor, with the resumption of hard work, associated with unrepaired lacerations is the commonest cause of prolapse. A predisposing factor is forceps delivery through a partially dilated or partly effaced cervix, axis-trac- tion forceps, or improper direction of pull in any forceps operation. Fig. 167.-Prolapse of the uterus and rectum. {Author's case, Phila- delphia General Hospital.) Symptoms.-(i) Loss of support, felt worst toward evening, when the patient has been on her feet all day; relieved by rest in bed; (2) complaint of protrusion through the labia of the cervix or other portion of the uterus (depending upon the degree of prolapse). The degree of prolapse is named from the position occupied by the cervix, when the patient is in the erect posture. A prolapse in which the uterine body emerges from the vulva, is called complete, or procidentia uteri. PROLAPSE OF THE UTERUS 355 Diagnosis is easy. The cervix, or more of the uterus, is seen to protrude between the labia. It is important not to make an examination when the patient has been some time in bed or just after the removal of a pessary, as the true degree of prolapse may not be apparent. Cystocele is almost always marked, and usually forms the greater part of the protruding mass. The vaginal mucosa is usually thickened and rough, and may be the site of extensive ulceration. Treatment.--Palliative treatment is never curative. It is indicated only in patients in whom there is a contra-indication Fig. 168.-The Goddard pessary for prolapse, cheap and efficient, but requires a bandage around the waist for support. to operation. It consists in support by some form of pessary. Those in common use are: (i) The globe or ball pessary-a hard rubber ball of sufficient size, held in place by a perineal napkin. (2) The soft rubber ring-looking like . a large cruller-mentioned only to be condemned. It becomes very foul after a short time. (3) The ball-and-stem pessary, held in place by an abdominal belt and perineal straps-cumber- some but effective. (4) The Goddard pessary-an aluminum ring, held in place by a semicircular wire support, fastened to a bandage around the patient's waist-cheap and effective. (5) The Menge pessary-a heavy hard rubber ring with a detachable bulb fastened at right angles, to prevent the ring from turning sideways and dropping out-better than any of the preceding. (6) The Schatz doorknob pessary, similar in 356 OTHER PATHOLOGIC SEQUELS OF CHILD-BIRTH action to the Menge, but not so efficient. Any patient wear- ing a pessary for prolapse must be kept under constant super- vision, as the pessary is likely to prove irritating, and should be inspected at least once a month. Fig. 169.-The Menge pessary for prolapse. Showing its position when inserted. Operative treatment depends upon the type of prolapse. That seen in nulliparous women is almost always a simple hypertrophic elongation of the cervix, which amputation of the cervix alone will cure. Usually the operative measures required are: (i) Amputation of the cervix; (2) dilatation and curettage (done after the amputation because the cervix PROLAPSE OF THE UTERUS 357 is usually too long for effective dilatation; (3) interposition operation for cystocele; (4) extensive perineorrhaphy. If these procedures be properly carried out, any abdominal operation for prolapse is unnecessary. A common mistake is to perform vaginal hysterectomy. This should never be done unless there is uterine carcinoma and should be followed by plastic work on the anterior and posterior vaginal walls, to prevent inversion of the vagina, which will surely follow if this be neglected. Neither vaginal hysterectomy nor ventro- fixation of the uterus will cure prolapse of the uterus, unless combined with extensive vaginal repair. Fig. 170.-Schatz's door-knob pessary for prolapse of the uterus. Not quite so efficient as the Menge, but based upon the same principle. If the vaginal mucosa is ulcerated, the ulcers should be treated with nitrate of silver (40 gr. to the ounce) and boro- glycerid tampons, and allowed to heal before any operation is attempted. Most operations for prolapse are done at an age when further child-bearing is unlikely. In young women, however, laceration is likely to recur at any future delivery, but proper repair at that time will usually prevent any recur- rence of the prolapse. 358 OTHER PATHOLOGIC SEQUELAE OF CHILD-BIRTH INCONTINENCE OF URINE Incontinence of urine after delivery is due to: (i) Paralysis of the vesical sphincter; (2) overflow from retention; (3) laceration of the urogenital muscle (compressor urethrae); (4) fistula; (5) retroversion of the uterus. The symptoms are obvious. There is leakage of urine, either constantly or upon any exertion. The diagnosis of the cause may be difficult. The incon- tinence of overflow is easily overcome by the catheter (soft rubber or silk and not glass). That due to fistula can be managed only by the closure of the fistula. Incontinence only upon sudden muscular effort is almost always due to laceration of the muscle of the urogenital trigonum, the repair of which will be found described in the chapter on injuries of the birth-canal. If none of these causes are responsible, the cause is paralysis of the vesical sphincter. Moderate cases tend to recover spontaneously. Cases of long standing are exceedingly difficult to treat. Large doses of strychnin (gr. j/20 f°ur times a day) over a long period and the slow inter- rupted faradic current, one pole in the urethra and the other on the abdomen, applied for 45 minutes every day will often hasten a cure. If a reasonable trial fails, injections of paraffin (melting point no° F.) are often successful. The injections are made in the tissues between the anterior vaginal wall and the vesical neck, over the internal urinary meatus. It is best to make them like a dumb-bell, the knobs in either side of the vesical neck, and the transverse bar across it. The effect is that due to slight pressure. In otherwise intractable cases, surgical methods are: (1) Shortening the vesical sphincter: (2) extensive cystocele operation; (3) interposition operation. They should be tried in this order. If the uterus be retroverted, reposition will often control the incontinence. GENITAL FISTULA 359 GENITAL FISTULA The causes of genital fistulas are: (1) Sloughing from continued pressure in obstructed labor-now rare, due to better management; (2) lacerations from violent delivery or slipping forceps; (3) abscess; (4) tuberculosis; (5) syphilis; (6) cancer-in its later stages. Kinds.-A long list of fistulae may be made by connecting in every possible way the bladder, vagina, rectum, ureter, intestine, uterus and urethra. By far the commonest are, in order: (1) Vesicovaginal; (2) Rectovaginal; (3) Uretero- vaginal; (4) Vesicocervicovaginal. Fig. 171.-Fistula: of the genital organs: a, Vesicouterine fistula; b, vesicocervical fistula; c, vesicovaginal fistula; d, urethrovaginal fistula; e, rectovaginal fistulaperineovaginal fistula. (Beigel.) Diagnosis of Vesicovaginal Fistula.-The patient complains of constant dribbling of urine; usually excoriation of the labia and thighs, and, if the fistula is of long standing, cicatricial contractions of the vagina. In very small fistulae there may be leakage only in certain positions, or when the bladder is full. Almost always there is a complicating cystitis. The demon- 360 OTHER PATHOLOGIC SEQUELAE OF CHILD-BIRTH stration of a fistula may not be easy. Large ones can usually be seen at once, but a small fistula may be so hidden by a fold of the vaginal mucosa, that it is difficult or impossible to see. If the fistula cannot be seen (usually near the cervix and toward one vaginal vault) when the vagina is expanded by a bivalve speculum, other means of diagnosis must be used, (i) Searching with a probe-a rather clumsy method; (2) cystoscopy, as the bladder end of the fistula is usually easy to see, and a probe or ureteral catheter can then be passed through it; (3) injection into the bladder of colored fluid, when its point of leakage can be seen. The best fluid is sterile milk, and four ounces is enough. If the fistula is so small that leakage only occurs in the erect posture, the bladder may be injected with 2 per cent, methylene-blue solution, pledgets of cotton placed in the vagina and the patient allowed to walk about for a few minutes. The pledget of cotton marking the site of the fistula will be stained blue. By these injections, incontinence due to paralysis of the vesical sphincter may be excluded. Treatment of Vesicovaginal Fistula.-No attempt should be made to repair the fistula until puerperal involution is com- plete. Two or three months after labor is the most favorable time. Very small fistulae may be made to heal by cauteriza- tion with nitric acid or a red-hot probe or electric needle. This method is not safe, as it may cause the fistula to enlarge instead of heal. Usually, the steps of repair are: (1) For at least a week before operation, the bladder should be flushed with boric acid solution, twice daily; (2) for the operation, the patient is anesthetized, placed in the dorsal (or Sims') position, and prepared locally as for a plastic; (3) the fistula is located, and denudation is made around it, down to but not through the vesical mucosa; (4) the edge of the fistula is split, so as to separate it from the anterior vaginal wall; (5) the bladder wall is closed with interrupted number 1 chromic catgut or linen thread stitches; (6) the vaginal mucosa and fascia is closed over the bladder wall by interrupted stitches of linen GENITAL FTSTULJE 361 thread. The denudation should be so planned that as little tension on the stitches as possible will result; (7) the bladder is kept from overflowing by a permanent mushroom catheter, or better by catheterization every four hours, as the permanent catheter is likely to cause troublesome cystitis. Fig. 172.-The simplest form of operation for vesicovaginal fistula. Fig. 173.-The flap-splitting operation for vesicovaginal fistula. The linen stitches are removed in two weeks. Complete success is not common at the first trial, and re-operations are common. If the vagina is the seat of cicatricial contraction, the bands must be cut, the vagina dilated with glass plugs and the normal elasticity restored as far as possible, before any repair is attempted. Syphilitic, tubercular and cancerous fistulae should not be touched surgically as they are impossible to repair. In syphilis, if the Wassermann reaction changes under treatment from positive to negative and remains so for six months, there is some chance of success in the repair of a fistula; the other two are hopeless. Very large fistulae, so large 362 OTHER PATHOLOGIC SEQUELAE OF CHILD-BIRTH that no flaps can be made by dissection and undermining of the edges may be treated in one of three ways: (i) Opening the anterior vaginal vault, anteverting the uterus, and sewing the uterine body, as a plug, in the opening in the bladder; (2) complete closure of the vagina-colpocleisis-so that the blad- der and vagina form one cavity. This is so often followed by ascending infection of the ureters, pyelonephrosis and fatal sepsis, that its use seems unjustifiable; (3) implantation of the ureters into the bowel. This is open to the same objections as colpocleisis. Diagnosis of Rectovaginal Fistulae.-The patient complains of passing fecal matter and gas through the vagina. The same symptoms occur in tear of the sphincter, and the patient is unable to distinguish between them. The fistula is usually easy to see, and is most often just inside the vagina or on the perineum. Milk may be injected and its point of exit noted. Treatment of Rectovaginal Fistulae.-Repair is much easier and more certain of success than in vesical fistula. An oval denudation is made around the fistula down to but not includ- ing the rectal mucosa. The edge of the fistula is split, to separate the rectal wall. The opening in the rectum is closed with number 1 chromic catgut, interrupted stitches, and the vagina] wall closed over it. The bowels are kept loose from the start, two movements a day being required. Before any attempt is made to close an apparent recto- vaginal fistulae, anus vestibularis must be excluded. In these cases the anus opens just inside the vaginal orifice, and has all the appearance of a fistula. A little care in diagnosis will prevent this mistake. Here also syphilitic, tubercular, and cancerous fistulae cannot be repaired. The same reservation as to syphilis applies here as in vesicovaginal fistulae. Diagnosis of Ureterovaginal Fistulae.-Constant dribbling of urine irrespective of the patient's position, but in amounts smaller than would be expected if a vesicovaginal fistula. No opening from the bladder can be found, but the fistula, or at GENITAL 363 least the source of the urine, can usually be seen in one vaginal vault. These fistulae are most common in high forceps deliveries, or in rapid delivery of a breech or in version. Such a history may help in directing attention to the site of the fistula. If the fistula cannot be seen, a hypodermic injection of indigo-carmin (2 mils) is given. Then by placing a cotton pledget near the supposed site, the blue stain on the cotton will serve to locate it. Treatment of Ureterovaginal Fistulae.-Either implantation of the ureter into the bladder by the vaginal route-colpo- ureterocystostomy, or by the abdominal route-laparo- ureterocystostomy. Implantation of the ureter in the bowel is sure to cause ascending infection and pyelitis and is not to be recommended. Vesicocervicovaginal fistula, from violence in forceps deliveries or too rapid extraction of the child after version or in a breech presentation, is one of the most difficult of fistulae to treat. The urine can be seen emerging from the cervix. The only way to close the opening is to dissect the anterior vaginal wall from the bladder, free the bladder by cutting the uterovesical ligaments, and closing the fistula in the bladder, which is thus exposed, by interrupted sutures of linen thread. It is, fortunately, rare. It is difficult to lay down any set rules for operation for a condition in which each case is a separate problem. The method of closing genital fistulae must be adapted to the needs of the individual case. The foregoing is merely an outline of typical cases. Hemorrhoids.-Due to the excessive vascularity of this region in pregnancy and the tendency to chronic constipation, hemorrhoids are exceedingly common. They vary in size from small isolated piles to huge masses simulating prolapse of the rectum. They are particularly likely to occur if old, unrepaired tears of the perineum exist. They cause as a rule considerable discomfort and are excessively prone to become the seat of thrombosis and local infection. For temporary 364 OTHER PATHOLOGIC SEQUEL2E OF CHILD-BIRTH relief pushing them back above the grasp of the sphincter, keeping the bowels fairly loose, so there is no straining for a movement and the local application, both externally and internally, of an ointment containing cocain hydrochlorid gr. 15; ointment of nutgall and ointment of belladonna each one-half ounce, will, if persisted in, give considerable comfort. If the hemorrhoids are extensive, however, or thrombosed, it will usually be necessary to remove them. CHAPTER XV DISEASES OF THE PUERPERIUM Anemia (puerperal) is usually not a true anemia, but simply a delayed return to normal from the hydremia and leukocytosis of pregnancy. Ordinarily the involution of the blood is prac- tically complete within two weeks after delivery, but may be delayed by severe illness in pregnancy, hemorrhage, nephritis or sepsis. The most useful treatment is: (i) Full diet with high protein food (meat, meat soups, etc.); (2) Blaud's pills 5 gr. four times daily; or (3) iron pyrophosphate, gr. v, arsenious acid gr. strychnin sulphate, gr. four times a day; (4) Fowler's solution 5 drops 3 times a day and increasing. In severe cases or those in which pernicious anemia seems immi- nent, blood transfusion (250 to 500 mils) is indicated. The Exanthemata and Acute Intercurrent Diseases.-A puerperal patient is more susceptible to infection from any con- tagious disease; the disease is likely to be more severe than normal; the mortality is higher than usual. Scarlet fever is rare. The point of infection is either the throat or wounds in the genital canal. This latter is the more common, and the incubation period is five to seven days, although it is sometimes shortened to twenty-four or forty- eight hours. The symptoms are the same as ordinary scarlet fever except that (1) the disease appears almost always in the first three days of the puerperium; (2) throat symptoms are slight; (3) the rash is likely to be dark red; (4) nephritis is much more common. The prognosis is about the same as under ordinary circumstances, with a very slightly higher mortality. Treatment is the same as ordinary scarlet fever; special watchfulness for nephritis and prohibition of nursing the baby being the chief points of difference. 365 366 DISEASES OF THE PUERPERIUM Measles is also rare. When it attacks a pregnant woman, abortion is very common. In the puerperium the danger is considerable; hemorrhage from the uterus is common, and the chief and most dangerous complication is pneumonia. Small-pox is much more severe in the puerperium, but fortunately rare. Erysipelas is frequently seen as a complication of puerperal sepsis, and sepsis is often caused by erysipelas-the micro- organism of septicemia and erysipelas (the streptococcus pyogenes) being practically identical. Facial erysipelas is rare. When erysipelas occurs in pregnancy, the site is rarely if ever the genitals; when it occurs in the puerperium it is nearly always in the genitalia. Symptoms.-If remote from the genitalia, the fever, red skin, brawny skin, obvious sepsis are distinctive. In the genitalia, it is impossible to diagnose from ordinary strepto- coccic infection, unless the source of infection be known. Treatment.-Remote from the genitalia, the same as ordinary erysipelas. Genital erysipelas is treated as puerperal sepsis. Prognosis.-Remote from the genitalia, the prognosis is good, unless the case be of the rapidly spreading type. In the genital infection, the mortality is 50 per cent. Diphtheria.-In the throat, it is an accidental complication. In the genitalia, the diagnosis can be made bacteriologically only. The exudate does not differ in appearance from that seen in ordinary streptococcic infection, but yields readily to antitoxin. Malaria is somewhat modified by the puerperium. It predisposes to hemorrhage; the milk often disappears, to reappear after the chills and fever have ceased; the fever is first continuous, then intermittent, but does not become normal between intermissions. The third day after delivery is the commonest date of onset. Diagnosis.-By finding the protozoa in the blood. Treatment.-Quinin in larger doses than usual--forty to seventy-five grains a day. The quinin does not affect the milk. PNEUMONIA 367 Arthritis is due to acute rheumatism, puerperal sepsis or gonorrhea. If rheumatic, large doses of salicylates are required. If a complication of sepsis, it is usually in the knee, ankle or shoulder, in that order of frequency. The course is long, three to four months, suppuration is likely, ankylosis occurs in at least 60 per cent. If gonorrheal, the commonest joint is the ankle, the risk of ankylosis 20 per cent. In septic arthritis: (1) Immobilization of joint; (2) paint skin with iodin; (3) apply saturated magnesium sulphate dressing; (4) ice-bag over the dressing; (5) open if suppuration occurs; (6) passive motion as soon as the acute symptoms are over-to guard against ankylosis. In gonorrheal arthritis, the treatment is the same, with in addition large doses of gonococcus vaccine, either stock or autogenous; 1000 million bacteria are given at a dose, repeated daily for several doses. Gonorrheal arthritis is very rare in women, except after child-birth or miscarriage. Gonorrhea is always aggravated by pregnancy, the child's eyes are often infected, and severe sepsis, from a mixed infec- tion, is not uncommon in the puerperium. There is often a rapid development of a pyosalpinx, often bilateral, and the previous gonorrheal infection, by lowering the patient's resis- tance, makes a streptococcic infection more likely and, when it does occur, much more severe. Treatment in the puerperium is the same as gonorrhea in general except for the greater likelihood of surgical complications. Pneumonia is much more serious in the puerperium. It is most frequent in pregnancy, but as it so often causes premature termination of pregnancy, it is frequently seen in the puerpe- rium as well. While the induction of labor would seem rational, it is dangerous, and to be avoided. Shock is to be feared, and the later in pregnancy, the more grave the prognosis. The treatment is the same as ordinary pneumonia, except for combating the shock after delivery, and the greater need for stimulation in the puerperium. 368 DISEASES OE THE PUERPERIUM Fever may be infectious or non-infectious. The commonest causes of non-infectious fever are: (i) Engorgement of the breasts; (2) exposure to cold showing itself in other ways than engorgement of the breasts; (3) constipation (4); syphilis (this being an extremely irregular fever, with wide variations in a short time). The common mistake, of ascribing every case of fever in the puerperium to septic infection, should be avoided. Granulation Tissue after Repair of Perineum.-It is com- mon to have a patient complain of pain after repair, due to exuberant granulation tissue along the suture line. Inspection will show the cause of pain, and one or two applications of solid stick nitrate of silver will permanently remove it. Hematoma is an interstitial effusion of blood, varying in size and shape, situated anywhere from the broad ligament to the vulva, but most commonly in one labium majus. In the labium it is sausage-shaped; elsewhere in the canal it is likely to be globular. Cause usually spontaneous rupture of a vessel with sub- cutaneous effusion of blood, usually during the second stage of labor. It may be due to injury by forceps, or excessive tractive efforts (here in the broad ligament). Symptoms.-(1) Sharp pain in the second stage of labor, like that of tearing tissue; (2) pain often exaggerated as the hema- toma increases in size; (3) appearance of a purple swelling, usually in one labium; (4) hematoma in the vagina or cervix appearing like a large but adherent blood-clot; (5) hema- toma in the broad ligament diagnosed by bimanual examina- tion, as a globular mass; (6) physical signs of loss of blood, though these are rare unless the hematoma has ruptured. Diagnosis should be easy. It has .been mistaken for blood- clot, varicose veins, or inverted uterus. Termination.-(1) Spontaneous rupture, with excessive and sometimes fatal hemorrhage; (2) suppuration; (3) resolution. If a vaginal hematoma suppurates, fistulae are common. Treatment depends upon the situation. RETAINED PLACENTA OR MEMBRANES 369 Labial Hematoma.-(i) Rest; (2) moderate perineal pres- sure; (3) cold; (4) no opening unless it suppurates. The hematoma should not be opened while it is increasing in size, unless the patient shows alarming signs of hemorrhage. When opened, it should be done freely, any visible vessel tied and the cavity packed with iodoform gauze; the gauze changed and the cavity irrigated daily. Vaginal Hematoma.-(1) Pressure by means of a rubber bag (colpeurynter) filled with ice water, changed frequently; (2) if possible to avoid, no opening while the tumor is increasing in size; (3) if any suppuration, or if resolution delayed, open and pack with iodoform gauze. Occasionally a deep lateral tear in the vagina will open into the ischio-rectal fossa, and a huge hematoma develop, extending well out over the buttocks laterally and posteriorly. Cervical hematoma same as vaginal. Broad ligament hematoma should be given time to undergo resolution, as it will if no large vessel is injured. If the patient shows physical signs of loss of blood; if the hematoma increases in size; or if it ruptures, abdominal section is required. These hematomata should never be approached through the vagina. It may be necessary to do hysterectomy to control the bleeding. Puerperal hemorrhage is due, most commonly, to (1) Retained placenta and membranes (secundines); (2) dis- placement of the uterus; (3) dislodged clots at the placental site; (4) retention of blood-clots; (5) tumors, either benign (fibroid) or malignant (carcinoma uteri or chorionepithe- lioma). Hemorrhage from relaxation of the uterus is very rare after the first twenty-four hours after labor. Retained Placenta or Membranes.-The placenta and membranes should be carefully examined, directly after their delivery, to see if any portions of them are missing. Any missing portion of the placenta is removed at once, preferably by the hand protected by a sterile glove, and after careful cleansing of the patient. Usually retained portions of the 24 370 DISEASES OF THE PUERPERIUM membranes do not justify interference to remove them; they are passed spontaneously within forty-eight hours. A placenta succenturiata may be retained, even though examination of the placenta shows no portion to be missing, or bleeding may be caused by hypertrophied angiomatous decidua. At any time except during the twenty-four hours immediately following delivery, evacuation of the uterus is best done with Emmet curettement forceps and, for decidua, a broad blunt curet, and not with the hand. Displacement of the uterus causes moderate oozing, usually beginning after the tenth day, when the uterus is sufficiently involuted to drop past the promontory. Reposition of the uterus, in the knee-chest posture, will control the bleeding. Dislodged clots at the placental site cause sharp bleeding, almost always following sudden exertion. It is the most dangerous of all puerperal hemorrhage, and requires packing of the uterus and vagina to control it. Retention of blood-clots causes a discharge of small clots and bloody serum, rather than actual hemorrhage. The fundus uteri is usually much higher than normal, and compres- sion of the uterus will usually cause clots to be discharged from the vagina. Flushing with sterile water is the best means of removing the clots. Thirty drops of fluidextract of ergot three times daily, by mouth, for two days, will prevent their re-occurrence. Fibroid tumors, causing bleeding in the puerperium, demand removal. Chorionepithelioma, diagnosed by microscopic examination of the scrapings from the uterine cavity, demands immediate panhysterectomy. Puerperal Psychoses.-Moderate or severe affections of the patient's mental condition are not very uncommon. They are due to:-(i) Infection; (2) Unstable nervous system, chiefly in patients with a hereditary taint; (3) auto-intoxication as in eclampsia. They vary from slight dispositional changes to wild mania and insanity. They are characterized by great excitement, RELAXATION OF THE PELVIC JOINTS 371 frequent hallucinations and, during the maniacal stage, marked homicidal tendencies, particularly towards the baby. Later the maniacal stage wanes, the patient becomes depressed and often suicidal. The prognosis is favorable in cases fol- lowing eclampsia; less so in cases following infection and least of all in cases with a hereditary taint. Recovery is rapid after eclampsia, in a few weeks all symptoms disappear. After infection convalescence is very tedious and often lasts three to nine months; the longer the course the poorer the chance for recovery. In cases with hereditary taint, the condition is often permanent. There is in all cases a mortality of io to 15 per cent., due of course more to the underlying sepsis or eclampsia than to the mental affection itself. If, after the causal condition is remedied, there is not prompt improvement, further treatment is best carried out in an institution. Relaxation of the pelvic joints not infrequently persists after labor. The joints may be simply abnormally mobile, or injured by forceps, or the seat of active inflammation and suppuration-the latter frequently a complication of injury. Diagnosis.-(1) Difficult locomotion and great pain on attempting to change position or to walk. (2) Walking is usually difficult or impossible. (3) By examination, in the erect posture, the abnormal mobility of the joints is noticeable. (4) X-ray picture may show separation or inflammation, and is always worth taking. (5) Suppuration is shown by redness of skin, induration and pain. Suppuration in the symphysis is not dangerous; in the sacro-iliac joints it is a serious and often fatal complication. Treatment.-(1) Immobilization in bed, with a canvas binder laced so as to immobilize the pelvis. (2) Reinforce- ment by sand-bags is a help to the binder. (3) If the canvas binder is not satisfactory, broad adhesive straps may be used. (4) Convalescence is slow-eight to twelve weeks as a rule. (5) If there is inflammation and suppuration of the joints, early opening and drainage is required. 372 DISEASES OF THE PUERPERIUM Sacral Neuritis.-In justominor pelves, where the pro- jection of the promontory is slight, the trunks of the sacral plexus are subject to undue pressure. The pain usually begins in labor, and often is so severe as to require anesthesia and forceps delivery. After labor it persists as extreme hyper- esthesia, often accompanied by partial or complete motor paralysis of the legs tone or both). Pressure in the sacral plexus (by rectal examination) causes marked increase in the pain. As only one oblique diameter of the pelvis is occupied by the longest head diameter, these cases are limited usually to one leg. In all cases, especially where both legs are involved, injury to the sacro-iliac joints rather than the sacral nerves must be suspected and eliminated. Treatment is rest, immobilization of legs by sand-bags, and, after the acute stage has passed, passive movements, massage and electricity. Prognosis is favorable, but convalescence is slow. Subinvolution of the uterus is a retarding of the normal involution of the uterus. The cause is anything that interferes with the normal reduction of blood supply by interfering with the contraction of the uterus; such as: (i) Retained secundines; (2) lacera- tions of the cervix; (3) hypertrophied decidua; (4) puerperal sepsis; (5) backward displacement of the uterus. The diagnosis is easy. The fundus can be palpated at a level higher than it should occupy, considering the time after delivery. Directly after delivery the fundus is felt one finger's breadth below the umbilicus; twenty-four hours later it is one finger's breadth above the umbilicus (due to slight relaxation after the effect of ergot has worn off); it then steadily descends until it disappears behind the symphysis in the tenth to four- teenth day. Involution is complete in six to eight weeks on the average. Treatment is to remove the cause, when the involution will take care of itself. Involution is more rapid in women who are given ergot and pituitrin after delivery, but continued use of TYMPANITES 373 ergot does not correspondingly hasten involution; therefore its routine use, after the initial dose to minimize the risk of postpartum hemorrhage, is not to be recommended. Superinvolution of the uterus is the too rapid or exaggerated reduction in the size of the organ. It is not common. The cause is obscure. It has been ascribed to pelvic inflam- mation, hemorrhage, hyperlactation, rapidly repeated preg- nancies and many other reasons. There is a moderate form, common in lactation, but occasionally going to extreme diminution in size, called lactation atrophy. The uterine walls are thin, easily perforated and any curettage done in a nursing patient should be done with caution. Treatment.-Spontaneous resolution or return to normal size is the rule. Recovery may be hastened by electrical stimulation, or by hypodermics of i mil corpus luteum extract daily for several weeks, given deep intramuscularly. Tympanites.-Excessive distention of the abdomen after delivery is not uncommon. It is one of the main difficulties in the after-treatment of cesarean section. It is due to a paresis of the bowel, without peritonitis. There is no fever, and the pulse is not affected. The condition is not one to cause alarm, provided the pulse is not affected. The best routine treatment is: (x) Abdominal binder; (2) five grains of calomel dry on back of tongue; (3) two hours afterward, grain of elaterium by mouth; (4) two hours later mag- nesium sulphate, ounce 1; (5) if no movement occurs within six hours of the dose of magnesium sulphate, give high com- pound enema of magnesium sulphate oz., turpentine oz., glycerin 1 oz., water up to 1 pint; (6) give routinely pituitrin ampule hypodermically twice daily for three days-eserin sulphate hypodermically gr. |4o every four hours-strychnin sulphate gr. |4o hypodermically t.i.d. In severe cases the bowel may be distended with water and the slow faradic current applied-one pole in the rectum and the other on the abdomen. 374 DISEASES OF THE PUERPERIUM In the worst cases the bowel may be punctured, apparently with safety, though this should very rarely be needed. The routine use of the rectal tube and, as an alternate, high enemas of alum i oz. to two pints of water may be given. Hemorrhoids often become edematous or acutely congested during the puerperium, and cause great pain. The quickest relief is stretching of the sphincter, if the hemorrhoids are pinched by it, under nitrous oxid anesthesia; followed by an ointment of cocain gr. 15, ointment of nutgall oz., ointment of belladonna oz. Urine after Delivery.-There is a tendency to retention, due partly to a paresis of the bladder wall and partly to edema of the urethra from pressure. By waiting twenty-four hours, if possible, the use of the catheter may usually be avoided. The patient may be passing urine, however, and the bladder still be badly overdistended. The lower abdomen should be pal- pated, routinely, to detect any distention of the bladder. The total amount of urine per day is increased by about 50 per cent., especially in the first week of the puerperium. Albumen is common. Sugar is usually lactose and therefore negligible, though commonly found. Hematuria is not uncommon, during the first few days of the puerperium, from pressure on the neck of the bladder in labor. If it persists, especially with frequency or tenesmus, cysto- scopy is indicated to exclude stone or papilloma. Incontinence of urine has been described in the pathologic sequelae of child-birth. CHAPTER XVI DISEASES OF THE BREASTS Absence.-The breasts are never microscopically absent. While there may be no evidence of any gland tissue, it is said that traces may always be found, by microscopic examination. This is of course of no clinical importance. Hypertrophy is rather rare. The breasts are usually asym- metrical, the condition is most often (80 per cent.) seen in women under twenty-five years of age. The breasts may be very large-one of sixty-four pounds being reported. The enlargement is usually a fibrous tissue growth, and a profuse flow of milk is not the rule. Nursing the child has been a cause of reduction in size of the glands, hence it is not contraindicated. Supernumerary breasts (polymastia) are not uncommon. In the embryo of six weeks, there is a line of cells running from the axilla to the groin-the crista lactea. From the thoracic portion of this the breasts are developed. The extension of the crista lactea into the axilla is the most frequent site of accessory breasts, though they may be situated anywhere. Each gland may have its own nipple and secrete milk during lactation. These extra glands are usually small, and up to io have been reported. The "swollen gland in the axilla" complained of by so many patients after delivery, is simply an accessory breast. Abnormalities of the Nipple.-The most important of the abnormalities of the nipple are: (i) Fissured or cracked nipple; (2) inverted; (3) stunted; (4) hollow; (5) mulberry; (6) conical; (7) mushroom. 375 376 DISEASES OF THE BREASTS Fissured nipple may occur in pregnancy, from lack of cleanliness or rubbing of clothing. It is most common during lactation, in primiparse, in blonde or red-haired women rather than brunettes, and in any defor- mity of the nipple itself. If the condition occurs in pregnancy, cleanliness and protection by a nipple shield will usually suffice. Symptoms.-(i) Intense pain on nursing and (2) a visible crack in the skin. This fissure usually runs around the base Fig. 174.-Faulty development of the nipple. (Dickinson.) of the nipple, at its lower border, but may occur as a vertical fissure dividing the nipple or as an ulcer anywhere on its surface. If not easily visible, a reading magnifying glass should be used to search for it. In any case of painful nursing, a fissure should be looked for, at once. The fissure often bleeds when the child is nursed, and if this blood is swallowed by the child, it will appear in the stools-pseudomelena. Treatment.-If the nipples are sore in pregnancy, and no actual fissure is visible, they should be kept scrupulously FISSURED NIPPLE 377 clean, protected by a nipple shield and witch-hazel applied to them twice daily. If the fissure appears during lactation, scrupulous cleanliness is imperative. The nipple is protected during nursing by a nipple shield. The nipple is washed off with boric acid solu- tion before and after each nursing. After nursing it is dried and an ointment of equal parts of subnitrate of bismuth and castor oil is applied. All these applica- tions are made with sterile cotton pledgets. The nipples are then covered with sterile gauze and a Murphy breast binder applied. Alternative applications are compound tincture of benzoin, applied to the fissure itself; ichthyol i dram in i ounce each of glycerin and olive oil; solid stick nitrate of silver to the fissure. It is not safe for the child to nurse without the protection shield until forty-eight hours after the fissure has apparently healed. Should the fissure refuse to heal, or the child be unable to nurse from the shield, a teterelle may be used. This is a form of breast pump in which the mother, by a rubber tube and mouth piece, makes the necessary suction to draw the milk into the pump, and the child withdraws it by a separate orifice and tube. It is sold as the number 3 Phoenix Fig. 175.-Nipple-shield. (Phoenix.) Fig. 176.-Soft-rubber nip- ple-shield called "Infantibus" will be tolerated in cases of sensitive nipples when the "Phoenix" and others cannot be endured. (J. P. C. Griffith.) 378 DISEASES OF THE BREASTS breast pump. If this will not work satisfactorily, the child must be weaned. Care of Nipple Shields.-Shields must be washed and scalded directly after use, and kept in a closed jar of boracic acid solu- tion (gr. x-oz. i.) so that they are completely covered by the solution. The shield is removed from the solution with dressing forceps, and rinsed in cool sterile water just before use. The boracic acid solution is changed daily. Danger of fissured nipple is chiefly infection and breast abscess. Inverted nipple is an arrest of development. Long-con- tinued use of the breast pump in pregnancy, with moderate suction, will help somewhat, suction being applied for 15 to 20 minutes night and morning. The condition is usually obstinate. Massage with the fingers is somewhat dangerous, due to bruising and infection. The breast pump is more efficient and safer. Inverted nipples are difficult to keep clean; dur- ing lactation, they are likely to fissure, and it is impossible for the child to nurse without a nipple-shield or a teterelle (number 3 Phoenix pump). Stunted nipple is important only in that it is difficult for the child to nurse. Systematic use of moderate suction with a breast pump throughout pregnancy, will often cause improve- ment, but the nipple-shield is usually required during the nursing period. Hollow nipples are merely a form of inverted, have the same disadvantages and are treated in the same way. Mulberry nipples are exceedingly likely to fissure and require care to prevent this complication. If a fissure occurs, it is treated as already described. Conical nipples make it somewhat difficult for the child to nurse, but the difficulty is not a serious one, and a nipple-shield is rarely required. Fig. 177.-Phoenix breast pump. The rubber bulb should be half collapsed only and the edge of the bell greased with vaseline before applying. DEFICIENT SECRETION 379 Mushroom nipples have the same disadvantages as mulberry- fissure-though to a less degree. Anomalies in the Milk Secretion.-The only fluid in the breasts for forty-eight hours after delivery is a thin, milky fluid, with a high fat and protein content, called colostrum. The milk usually appears suddenly, about forty-eight hours after delivery, accompanied by considerable painful engorge- ment of the breasts and often a slight rise of temperature- "milk fever." No attempt, other than gentle massage, should be made to control this engorgement, as it is only temporary. The amount of milk secreted in twenty-four hours is normally 14 ounces by the end of the seventh day; two pints by the end of the fourth week; three pints by the end of the sixth month. From this time on, the quantity tends to decrease. Milk may be found in the breasts entirely independent of the puerperium, in any condition which causes pelvic congestion. In many women, it is found at every menstrual period. The onset of lactation may be greatly delayed, even for several months after delivery. Deficient Secretion (Oligogalactia).-The milk may be entirely absent (agalactia), but this is very rare. The com- monest causes of deficient secretion are: (.1) Lack of develop- ment of breasts; (2) toxemia of pregnancy (eclampsia); (3) sepsis; (4) hemorrhage; (5) heredity. It is common in very young and in elderly primiparse. It is not uncommon, when one child has died and lactation is prematurely interrupted, for secretion to be deficient after a subsequent delivery. The amount of milk does not depend upon the size of the breast. Excessive nervousness or sudden mental shock, fright or anger affect the quality of the milk more than the quantity. The return of menstruation is usually without effect upon the milk. Pregnancy during lactation may cause an abrupt disappear- ance of the milk. Treatment.-No single plan of treatment is of a avail in all cases. Often after sepsis, severe hemorrhage or eclampsia, the secretion of milk will be resumed spontaneously, and in 380 DISEASES OF THE BREASTS sufficient quantities. If four meals a day, one quart of milk extra between meals and a wineglass of malt or porter with the meals will not cause a sufficient increase, the child must be weaned. Breast feeding and bottle alternating is not advisable except for short periods. There is no proven galactagogue. Corpus luteum extract, extract of the involuting endometrium, pituitrin, whole pituitary gland and placental hormone have all been advised for the purpose, but none are as yet established. Often the milk supply improves greatly after the patient gets out of bed and especially after she is able to exercise in the open air. Excessive Secretion (Polygalactia).-This is very common. It is usual during the first week, and unless excessive, requires no treatment at this time other than massage after nursing, to get rid of the excess. If the excess persists the treatment is: (i) Massage after nursing; (2) hydragogue cathartics (magne- sium sulphate; magnesium citrate) in sufficient amounts to give two liquid movements a day; (3) breast binder (Murphy) constantly; (4) scanty diet and especially diminution of fluid elements in diet; (5) regular nursing. Hyperlactation is a voluntary prolongation of the period of lactation, the normal length of the period being eight to nine months. It is much more common in the poorer classes. The effect is bad for both; the mother becomes weak and anemic, thin, has pain in the breasts and back, and is generally neuras- thenic. The uterus becomes much superinvoluted (lactation atrophy), and if the conditions are not corrected the atrophy becomes to a great extent permanent. Tuberculosis is likely to become active. The effect on the child is malnutrition, delayed dentition and rickets. Treatment is to wean the child and prescribe full diet, rest, iron tonics and outdoor life for the mother. Galactorrhea is a constant flow of milk from the breasts, irrespective of nursing, persisting after the child is weaned. The cause is unknown but neurosis plays a part. The flow is usually moderate (few ounces a day) but may be as much as ENGORGEMENT OF THE BREAST 381 several quarts daily. The patient's health is not affected, as a rule, other than the natural annoyance of the condition, but she may show all the appearance of a serious wasting disease (tabes lactea). Treatment is difficult, (r) Thorough massage of breasts; (2) constant tight breast binder; (3) restriction of diet, espe- cially fluids; (4) potassium iodid or potassium acetate gr. x four times a day; (5) hydragogue catharsis. The breast binder should be disturbed as little as possible, as constant compression is the most valuable factor. Strap- ping of the breasts with adhesive straps may be more effective. The condition resists treatment stubbornly. Drying up milk after child's death is the same as the treat- ment for galactorrhea. Here the binder must be disturbed as little as possible, as massage tends to keep up the secretion. Usually in forty-eight hours most of the discomfort is past. Galactocele is a cyst, filled with milk, due to the occlusion of a milk-duct. It is usually small and of no importance, but if large and painful, it should be drained with a hypodermic syringe, and the area compressed by a pad and adhesive straps, to prevent refilling of the cavity. Qualitative Anomalies of the Milk.-A meat diet increases the fat and casein, but decreases the sugar. A vegetable diet increases the sugar, but diminishes the casein and fat. The commonest anomaly is deficiency of fat and excess of casein, a condition difficult to remedy by diet. Profound emotion, anger, fright, all affect the milk unfavor- ably. Some germs, notably those of tuberculosis, pass through the milk. Yellow milk is usually due to a failure of emulsifica- tion of the fats; blue, red and green milk are the result of bacterial activity. Abscess of the areola is due to infection of Montgomery's glands. It is treated like any other small boil, by opening and drainage. Engorgement of the Breast.-The engorgement may be general or local (caked breast). Engorgement is the rule when 382 DISEASES OF THE BREASTS the milk first appears. At other times the commonest cause is cold. Symptoms.-(1) Sudden fever (the commonest cause of a sudden rise of temperature during lactation is engorgement of the breasts); (2) breasts are heavy, tense, hot and tender; (3) engorged lacteals can be palpated. Treatment.-(1) Hydragogue catharsis; (2) massage, prefer- ably catching the milk in sterile gauze and notin a breast pump; ICE- BAGS COTTON THIN Ring s. OF COTTON ROLLED TOWEL ■THIN BINDER BODY Fig. 178.-Schematic section of body, showing relation of ice-bags to breasts. {De Lee.) (3) breast binder; (4) cold, by means of two ice-bags to each breast constantly or (5) heat by hot cloths for twenty minutes in every two hours. Cold is the more efficient. It may be applied by the Leiter coiled rubber tube, with ice-water flowing through it. The apparatus needs constant watching, as air- locks tend to form, and stop the flow of water, and is not as efficient as ice bags. A local engorgement with induration without suppuration is called "caked breast." Massage is a mistake, as it is often a forerunner of a breast abscess. The best treatment is to apply ice-bags, but otherwise to leave the breast alone. MASTITIS 383 Technic of Massage.-Above all, massage must be gentle. It cannot be hurried; at least twenty minutes being required to empty the breast. The operator's hands must be thoroughly scrubbed and liberally anointed with sterile oil. The skin of the breast must be thoroughly cleansed. There are four series of movements: (i) Gentle circular movement from the periphery toward the nipple; (2) breast supported and inner segment massaged toward nipple; (3) same reversed for outer segment, (4) bimanual rotary compression, from periphery to nipple. The milk should be caught in sterile gauze, as it comes from the nipple. Breast pump should not be used. All movements must be gentle, and the force gradually increased only as the breast softens. The massage should never be pain- ful: bruising of the breast is a prolific cause of a breast abscess. Mastitis (Breast Abscess).-Inflammation of the breast may occur in the areola, the subcutaneous connective tissue, the gland itself and the connective tissue under the breast. The commonest type is infection of the gland, with secondary involvement of the connective tissue. The bacteria respon- sible are usually Staphylococcus albus or aureus, much less often the Streptococcus pyogenes, pneumococcus, colon bacillus or Oidium albicans. Cause.-Dirt in handling, whether from hands, cloths, water, clothes or various applications, is the cliief cause. The wide- spread superstition among the poor that saliva is the best application for a fissured nipple is responsible for many cases. The skin of the areola and nipple always contain pathogenic germs, and these may develop powers of invasion, through the ducts (this will explain the cases due to bruising in massage). The child may be the source of infection, if it has thrush or stomatitis. Symptoms.-A chill and moderate of fever (103°), most commonly from the tenth to twentieth day of the puerperium. The breast is painful, and one or more indurated areas can be felt. The commonest portion affected is the outer lower quadrant. The temperature and pain usually subside within 384 DISEASES OE THE BREASTS thirty-six hours; if they continue, suppuration is to be expected. Treatment.-(i) If the breast is engorged, massage is indi- cated, otherwise not. In any case it must be gentle; (2) purgation with hydragogue cathartics; (3) breast binder; (4) ice-bag over affected area: (5) applications of saturated magnesium sulphate solution or dilute leadwater and alcohol (two ounces leadwater to three ounces of alcohol); (6) strap- -Intramammary abscess {pointing Superficially) . z 'Subcutaneous "Submammary abscess Subareolar abscess Iritramammary abscess (Deep in the substance ofthebrcastj Fig. 179.-Location of pus in a breast abscess. {After Deaver.) ping with adhesive straps, if the extra pressure is not too painful. This treatment is to be used only before suppuration is evident, and is often spoken as the " abortive treatment." Bier's local hyperemia, by suction cups, is painful and ineffec- tual. It is used with suction for four minute periods, with equal periods of rest, for forty-five minutes once daily. The results do not justify its use. Breast abscess is a common sequel of mastitis. As the area involved in the suppurative process is, at first, small, but tends BREAST ABSCESS 385 rapidly to infiltrate the entire breast, it is important to recog- nize the presence of pus as soon as possible. A breast ab- scess is nearly always multilocular and fluctuation is not to be awaited. The pus is located above, usually in, or under the gland. Fig. 180.-Drainage tubes in a breast abscess. Symptoms at first are indefinite. Pus my be expected with the following signs: (i) A dusky red or purple color of the skin over the indurated area; (2) edema of the skin over the indurated area; (3) fever of an irregular septic type; (4) leukocytosis (18000 to 22000 on the average). Differential diagnosis may be needed, in rare instances, from carcinoma of the breast, tuberculosis of the breast or actino- mycosis. There is a type of carcinoma of rapid growth, first appearing in late pregnancy or early puerperium, called 25 386 DISEASES OF THE BREASTS mastitis carcinosa. This, as well as tuberculosis or actinomy- cosis, requires microscopic sections of an excised portion, for accurate diagnosis. Treatment.-Early opening of a breast abscess is imperative, before wide destruction of the gland has taken place. The technic is as follows: (i) General anesthesia; (2) local sur- face cleansing as for any operation; (3) with a thin-bladed knife, make multiple stab wounds, about one quarter inch long, opening every area where pus is suspected, and wiping off blade of the knife with alcohol pad, after each incision. These incisions are to be made radiating from the nipple, so as not to cut across a milk-duct; they should be entirely with- in or without the areola, and not across the border (as in healing the pigment will follow the scar); the incisions should be so planned that when the patient is out of bed, all drainage tubes will run down hill, and not straight across the breast; and it is desir- able to confine all incisions, if possible, to the lower half of the breast; (4) a long hemostat is inserted through each opening, and the septa between the locules of pus broken down, so as to make as nearly as possible a unilocular abscess; (5) each opening is flushed out with sterile water, run from a fountain syringe by gravity; (6) each pair of openings is then connected by fenestrated rubber drainage tubing, about the size of a lead pencil. The tubing is pulled from one opening to the other by the hemostat or clamp. Care is taken not to run the tubes superficially (as they will slough out and make ugly scars) or under the nipple; (7) safety pins are passed through each end of each tube; (8) the tubes are flushed with sterile water, to be sure they are patent; (9) the breast is dressed with Fig. 181.-Pigment of the areola following incisions. {Richmondson.) POSTMAMMARY ABSCESS 387 bunched gauze and a breast binder. Bandages or straps are a nuisance. The Bier hyperemia treatment is a failure in the ordinary breast abscess. It is fairly effective in small single abscesses, but a much easier, quicker and less painful way to cure a small unilocular abscess is to make a single small incision over the most prominent part of the swelling, wash out the pus, and inject a io per cent, solution of silvol. If the systemic symp- toms of a breast abscess are severe, and the pus is streptococcic, intravenous injection of 100 mils of antistreptococcic serum is often of great value. The usual time of healing of a breast abscess, properly opened and drained, is five to six weeks. After-treatment.-The drainage tubes are flushed, once daily, with sterile water, run by gravity from a fountain syringe with a medicine dropper attached to the tube. Only if the tubes are blocked is a piston syringe used to force water through them, and as soon as they are clear, the fountain syringe is substituted. No attempt is made to remove the tubes for at least two weeks, and then the shortest is removed first, and the others at two- or three-day intervals; the sinuses are packed lightly with gauze, from each end, and flushed daily. Small secondary superficial collections frequently need opening during the convalescence. Unless the nipple ducts have been blocked, lactation in subsequent confinements is surprisingly little interfered with. Postmammary abscess (submammary abscess) is a collection of pus in the connective tissue under the breast, just over the pectoral muscles. It is rare, and serious. Symptoms.-One breast is more prominent than the other, the whole gland being lifted off the chest. There are no symp- toms of inflammation in the breast itself, and very little pain on pressure. Systemic symptoms of sepsis are severe, fever high and leukocytosis 25,000 or more. Diagnosis is best made by aspiration with a hypodermic syringe. The needle should be of fairly large caliber, as the pus is usually thick. 388 DISEASES OF THE BREASTS Treatment.-An opening is made at the most dependent portion, a counter opening diametrically opposite, and through- and-through drainage established by a fenestrated rubber tube. The aftercare is that of ordinary breast abscess. Tumors of the breast, usually adenomata, often grow rapidly in pregnancy, and in lactation become so engorged and painful that their removal is often demanded. They should, however, be let alone, if the symptoms are not such as to make their removal imperative. When removed, they should always be examined microscopically. If malignant, tubercular, or actinomycotic, the whole breast must be removed. CHAPTER XVII PUERPERAL SEPSIS Historical.-Puerperal infection has occurred from the earliest times. It is mentioned in the works of Hippocrates, Galen and many of the old writers. In 1676 Willis wrote a treatise on "febris puerperarum" and the first work in English on puerperal fever was by Strother in 1718. Its contagious nature was recognized over 150 years ago and clearly emphasized by Oliver Wendell Holmes in 1843. The cornerstone of antisepsis in obstetrics was laid by Semmelweis, in the maternity department of the Vienna General Hospital, in 1846-7. By compelling the students in attendance to wash their hands in chlorin water before making any vaginal examination, the death rate sank from 11.4 per cent, in 1846 to 1.25 per cent, in 1848. Cause.-The genital canal of the infant at birth is normally sterile. The genital canal of a healthy adult is sterile above the internal os. The patient is protected from infection by: (1) The acid vaginal secretion (due to lactic acid, secreted by Dbderlein's bacillus); (2) leukocytosis and phagocytosis; (3) the mucous plug in the cervix; (4) during and after labor the addi- tional safeguards of the descent of the liquor amnii, the child's body and the lochia; (5) the diminished virulence of any patho- genic bacteria resident in the vagina. Microorganisms are easily introduced from the vulvar and perineal skin, by vaginal examination, or by unclean hands or instruments. No pathogenic germs are found in normal vaginal secretions; in abnormal secretions, occurring in 33 to 40 per cent, of patients, staphylococci, streptococci, colon bacilli, gonococci and many other varieties appear, 389 390 PUERPERAL SEPSIS Routine douching of the vagina is not to be depended on as a prophylactic measure, as it destroys the natural safeguard of acid secretion, and does not destroy the pathogenic germs. Kinds of Sepsis.-(i) Septicemia (streptococcic infection) due to the absorption of bacterial toxins, or the actual invasion of pyogenic organisms into the blood current; (2) sapremia, due to the absorption of toxins from putrid material retained in the uterus. Sapremia is the least serious, and easiest cured. Pyemia is another name for streptococcic blood infection. Bacteria at Fault in Septicemia.-Any pathogenic germ is capable, theoretically at least, of causing puerperal sepsis. The commonest are: (1) Streptococcus pyogenes, in about 94 per cent.; (2) staphylococcus of some form, usually aureus; (3) colon bacilli; (4) gonococci (usually associated with strepto- cocci or staphylococci). It is rare to find, in cultures, a single strain. Usually the cases are mixed infections, as many as fifteen different bacteria being found in a single case. Streptococci are usually hemolytic, as may be also many others, even the colon bacillus. Invasion of the blood stream by bacteria, so that cultures of the blood show positive growths, is a serious sequel. Strep- tococci are usually the offending germs; the most fatal of all blood stream invasions is due however to the staphylococcus aureus. In many severe cases of infection, the blood stream remains sterile. In these, the pathogenic bacteria are being poured into the system through the lymphatic channels. Method of Introduction into the Genital Tract.-(1) Hands of physician or midwife-by far the commonest mode; (2) much more rarely the nurse; (3) dirty instruments; (4) water, (5) pads; (6) clothing; (7) bed clothing; (8) bath water-- hence tub baths should be replaced by showers, in hospitals at least; (0) auto-infection-when the pathogenic germs are already resident, and increase in virulence after labor. This undoubtedly occurs, but infrequently, and should not be assumed until all other modes have been excluded. The possi- DIFFERENTIAL DIAGNOSIS FROM OTHER ADYNAMIC DISEASES 391 bility of sepsis from dust-laden air cannot be forgotten. Many cases have been reported in which this cause was apparently proved. How Bacteria Behave.-(i) Dbderlein's bacillus is destroyed and the vaginal secretion becomes alkaline; (2) the pathogenic germs tend to spread up the genital canal; (3) a trail of false membrane is left behind, covering every wound or abrasion in the genital tract; (4) mixed infections are usually more serious; (5) most germs tend to spread through the uterine and broad ligament lymphatics to the peritoneum (except the gono- coccus and colon bacillus, which show preference for the uterine and tubal mucosa); (6) the higher up in the genital canal the starting point of infection, the less is the patient's resistance. Saprophytes usually attack the hypertrophied decidua, which is peculiarly putrescible. The most common site of primary strep- tococcic infection is the endometrium, from which it spreads in every direction. Symptoms and Diagnosis.-General symptoms are: (1) A rise of temperature, usually taking several days to reach its maximum, and preceded often by a chill. Rarely the tempera- ture rises abruptly; (2) increased pulse; (3) anorexia, heavy breath and coated tongue; (4) in the worst cases a septic diarrhea and erythematous blotching of the skin. In any case where temperature and pulse are elevated, and no other cause can be found, puerperal sepsis should be suspected. Local symptoms are: (1) Foul discharge. This is not con- stant. A very foul discharge without any evidence of infec- tion may be due to decomposition of lochia in the upper part of the vagina; the worst cases of hemolytic streptococcic infection often have no discharge at all; (2) redness and edema of the labia; (3) false membrane over the normal mucosa or any abrasion; (4) cessation or diminution of the lochia; (5) subinvolution of the uterus; (6) later the development of inflammatory exudate in the bases of the broad ligaments. Differential diagnosis from other adynamic diseases is made: (1) From malaria by the finding of the protozoa in the 392 PUERPERAL SEPSIS blood; (2) from typhoid fever, by the Widal reaction, although a positive Widal is sometimes seen in streptococcic infection; (3) bronchopneumonia is a not uncommon complication of the puerperium, and much like sepsis until the characteristic signs appear in the chest. Blood Picture in Sepsis.-(1) Marked leukocytosis; (2) eosinophiles at first are absent, and their return a favorable sign; (3) high percentage of polymorphonuclear cells; (4) a reduction in the number of lobes in the polymorphonuclear cells (often spoken of as "the blood picture pushed toward the left"). A low leukocyte count, with grave systemic symptoms is an unfavorable sign. Methods of Precision in Diagnosis.-(1) Leukocyte and blood count as above; (2) uterine cultures; (3) blood cultures. Uterine cultures are best made with the Doderlein tube as modified by W. R. Nicholson. The cervix is exposed through a bivalve speculum, the glass tube with its sheath is inserted past the internal os, the glass tube pushed out through the sheath into the uterine cavity. By suction with a piston syringe and rubber tube attached to the end of the glass tube, the latter is filled with the uterine discharge. The glass tube is withdrawn into the sheath, and the two withdrawn as one. The glass tube is sealed with sealing wax at both ends, and sent to the laboratory for culture. A still simpler method is Littles' tube, which depends for suction upon a plug of rubber bands, pulled through the tube by the thread with which they are tied. The method is unreliable, 75 per cent, at least of puerpera show a positive result, and in many cases of streptococcic blood infection, the uterine culture may be negative. Blood Cultures.-A spot on the skin over the median basilic vein is carefully sterilized and the vein made prominent by a tourniquet-10 to 20 mils of blood are withdrawn by a sterile glass hypodermic syringe, and cultured. Strict aseptic technic and good laboratory technic are essen- tial. Contamination shows in about one-third of the cases, TREATMENT 393 but the method is more reliable than uterine cultures. What- ever value may exist in uterine cultures is lost entirely after the seventh day of the puerperium. The virulence of strepto- cocci is in direct ratio to their hemolytic power. Fig. 182.-Nicholson's modification of the Doderlein tube. In any case of doubt it is wise to treat the case as one of sepsis, until the correct diagnosis can be established. TREATMENT Preventive Treatment.-(i) Room should be, if possible, sunny and well ventilated. A communicating bath room is a desirable feature, the old superstition as to sewer gas being 394 PUERPERAL SEPSIS thoroughly discredited-providing the plumbing is good and of the modern type. Unneccessary furniture and hangings should be taken out, and no food, unemptied bed-pan or commode should be left for any length of time. The bed is protected by rubber sheeting, and extra pads of squares (i yard square) of nursery cloth (boiled and dried) are provided. The mattress and bed-clothing should be fresh and clean. Patient.-She is told to take a full bath (preferably shower) at the onset of labor, particular care being given to the genital region. The pubic hair is clipped close or shaved. Depila- tory pastes (barium sulphid i, starch 3) are unreliable and often intensely irritating. Should she have any abnormal vaginal discharge, the vagina is thoroughly ' cleansed by pledgets of cotton and tincture of green soap, followed by a douche of lysol solution dram to 2 pints), followed by sterile water (the lysol, if any be retained in the vagina, being an irritant to the child's eyes). Otherwise douching is unnecessary, and often harmful. Care is taken to see that every portion of placenta and membranes is evacuated, in the third stage. During the puerperium, the vulva and perineum are irri- gated at least six times daily, to remove blood-clots and lochia. Physician should wear an operating suit, gown and sterile gloves. His hands should be carefully scrubbed and the gloves sterilized just before each examination. If the gloves are boiled, they should be boiled flat, wrapped in a towel or gauze, and never rolled in a ball. Autoclave sterilized dry gloves are preferable, but not always procurable. He should not attend contagious diseases and also obstetric cases. Nurse is subject to the same general rules as the physician. Her hands should be clean, her uniform fresh, and she must wear sterile rubber gloves in catheterizing, douching, or caring for the patient's bresats. Water should be boiled for at least half an hour before use, and no dependence should be placed in antiseptic solutions made with unboiled water. TREATMENT 395 Instruments are boiled for fifteen minutes before use. If injured by boiling (like bougies) they are soaked for at least one hour in cold 1-500 bichlorid, or 1-10 carbolic acid, or 2 per cent, formalin solution. Bougies particularly, or any other implement that will float, must be wrapped in gauze before being immersed in the solution. Vulvar pads are made of sterile cotton and gauze. The nurse each morning makes up, with sterile hands, the day's supply, which are then scrupulously protected from contami- nation, and removed from the wrapping as required. They are changed six times daily for the first week, then four times daily. Cotton pledgets are made by cutting the rolled cotton into squares about six inches square. Pledgets used for cleansing the vulva are of course used but once, and always in the direc- tion from vulva to anus. Clothing worn by the patient should be absolutely clean and freshly laundered. Antiseptic solutions in labor are likely to prove irritating to the child's eyes. The best of them is lysol dram to 1 dram to the quart); the most dangerous, bichlorid of mercury. They should always be made with boiled water. Vaginal examinations should be limited to as few as possible. The patient is arranged on her back or side, with suitable exposure of the vulva. She is carefully cleansed, and the examining finger, gloved and anointed with sterile lubricant, inserted by the sense of sight. Rectal examinations are especially advisable in patients under- going a test of labor, with a view of possible operative interfer- ence. They are to be made with the same care as vaginal examinations. In any forceps operation, special care as to cleansing and as far as possible the avoidance of bruising must be employed. For podalic version, the arm should be covered by a sterile rubber glove and gauntlet. It is not possible to perform version with a short glove and long-sleeved gown. 396 PUERPERAL SEPSIS Curative treatment may be local or general. The local curative treatment consists of a thorough disinfection of the genital tract by curet, placental forceps and douche. The teaching that the uterus and genital tract should be let severely alone is not satisfactory. Meddlesome interference is to be avoided, of course, but there is considerable value in a cautious, properly executed disinfection of the uterine cavity. Technic: (i) No anesthetic is needed, but the procedure must always be done on a table, and never in bed. (2) The patient is placed in the lithotomy position, and her knees held by a sheet leg- holder (see chapter on operations in private houses). (3) The vulva and vagina are thoroughly scrubbed with cotton pledgets and tincture of green soap, and douched with lysol solution (1 dram to the quart). (4) The anterior lip of the cervix is caught with a double tenaculum. (5) The uterus is thoroughly explored with Emmet curettement forceps, and all loose material extracted. (6) The uterus is gently scraped with a broad dull curet, re-explored with placental forceps, until no more organized material is extracted. The curet is best confined to those cases where the uterus is thickly lined with necrotic decidua, which is difficult if not impossible to remove except by curettage. In all other cases, the placental forceps alone are sufficient. (7) The uterus is douched with lysol solution, and packed only if there is free bleeding. (8) The packing, if any, is removed in twenty-four hours and the uterus douched again. (9) One thorough cleans- ing with placental forceps is sufficient, subsequent treatment being daily douching, until the temperature has been normal for forty-eight hours. Douche- The best composition for an intra-uterine douche is one of the following: (1) Tincture of iodin (7 per cent.) 4 drams, alcohol (ethyl-95 per cent., never methyl or wood alcohol) 8 ounces, sterile water up to four pints; or (2) for- malin (40 per cent.) 30 drops, glycerin 2 ounces, water 1 pint; or (3) lysol solution 1 dram to 2 pints. The temperature of the douche should be iio°-ii5° F. The patient is placed in TREATMENT 397 the dorsal position, cleansed, the cervix exposed through a bivalve speculum, the intra-uterine catheter (best the large Bozemann) inserted by sight, and the solution allowed to flow by gravity, with not more than two feet head. The douche bag or can and catheter are boiled and the solutions made up with sterile water. One intra-uterine douche a day is enough. Contra-indication to disinfection of the genital canal is phlebitis. If it could be known that the patient had phlebitis and that the uterus was empty, no cleansing would be needed. But as this diagnosis is made only by exclusion, one disinfection is per- missible. If the fever rises sharply, however, after the cleans- ing, no further intra-uterine treatment of any kind should be given. Objections are: (i) Danger of carrying infection into the cervi- cal muscle, by the tenaculum-negligible; (2) danger of break- ing down the protective wall of leukocytes under the decidua and favoring the spread of infection-negligible if proper gentle- ness is used; (3) danger of perforation of the uterus-undeniable, but small if proper skill be used, and the operation done on a table and not on the bed. Also the method should be much more gentle than the exploration of the non-pregnant uterus. Perforation of the uterus is a dangerous accident, in a septic uterus. If the instrument suddenly slips in much further than usual, and no resistance can be felt, all further attempt should be abandoned. Above all, do not douche. The safest plan is to open the posterior vaginal vault, pack with gauze and put patient in the Fowler position. Hysterectomy is not required unless the perforation is large enough to permit the extrusion of a knuckle of bowel. General Treatment.-(1) Diet is chiefly concentrated liquids, milk, broth, soups, and alcohol up to the point of tolerance. (2) Drugs are chiefly heart stimulants. As long as the pulse is under no, none are needed. Digipuratum 1 ampule t.i.d. or digalen itjj.x.t.i.d., or digitalin gr. ffn t.i.d., all hypodermi- cally--or tincture of digitalis tt^.x.t.i.d. by mouth; strychnin sulphate gr. hypodermically t.i.d. In emergencies, caffein, 398 PUERPERAL SEPSIS sodium benzoate, camphorated oil, nitroglycerin and oxygen. Artificial hyperleucocytosis is, theoretically at least, advis- able. (i) Protonuclein gr. v four times daily by mouth is of very doubtful value; (2) hypodermic injection of two drams of a 2 per cent, watery solution of nuclein twice daily; (3) a fixation abscess by hypodermic injection of one dram of tur- pentine under the skin of the abdominal wall; (4) sodium nucleinate injections, twice daily. Serum therapy is often brilliantly successful and always, even in apparently unfavorable cases, worth a trial. Like any other serum it must be given early, and in sufficient doses. Much the best method of administration is intravenous, 150 to 250 mils of antistreptococcic serum at a dose, repeated once daily for a total of 500 to 750 mils. In all cases, the patient must be desensitized, at the first injection, by injecting 5 mils of serum only, waiting for 30 to 60 minutes and if there is no unfavorable reaction, then injecting the remaining 145 mils. This is necessary at the first dose only. If this pre- caution be neglected, serious or fatal anaphylaxis may be the result. An alternative method is to give the serum in doses of 80 to 100 mils into the areolar tissue under the breasts, repeated three times daily, but this is not nearly so efficient as intrave- nous administration. The serum must be fresh; it will not stand distant transportation, and, in the proper doses, is expensive. If antistreptococcic serum is not available, or is inefficient, five to seven ounces of normal human blood-serum may be given intravenously, once daily, but this is still largely experimental. Bacterins are much less efficient than serum. Autogenous vaccines are better than stock, and should be given in huge doses, 1000 to 2000 million. Streptococcic infection is least amenable to vaccines; gonorrheal infection, especially aithritis, is often favorably influenced. Chemical disinfection of the blood stream has been attempted in many different ways, none of which has so far justified its theoretical promise. TREATMENT 399 (1) N eo-salvarsan in doses of 0.4 gm. intravenously at inter- vals of three days seems to be of considerable value in the chronic cases of long standing. It is of no value in the acute stages of the infection. It is given with precisely the same technic as in syphilis. (2) Mercurochrome has been used by Piper in the proportion of 30 mils of a 1 per cent, solution for the first 100 pounds of body weight with an additional 5 mils for each additional 30 pounds body weight. The solution is made with sterile distilled water. It is injected intravenously and very slowly, with the solution kept as near roo° F. as possible. The injections can be repeated but never as long as there is any trace of the dye in the urine or feces. The amount used represents approximately a 1-16,000 dilution with blood. There is always a violent reaction of vomiting, diarrhea, severe chill and rapid rise of fever to 105. As a dosage of 5 mg. per kilo is nonlethal and one of 10 mg. is lethal, it can be seen that there is a very small leeway of dosage, and there is always the danger of a fatal reaction. (3) Colloidal silver, intravenously as 5 mils of a 2 per cent, watery solution of collargol, protargol or argyrol, given daily for several days, gave promise for awhile, but has not justified the promise. There is danger here of severe reaction. The idea of chemical disinfection of the blood is by no means new, many substances (nitrate of silver, bichloride of mercury, formaldehyde, foreign protein, etc.) have been used and dis- carded and only the newer developments are mentioned above. Salt solution is better given by slow infusion into the rectum than by either hypodermoclysis or intravenous. Thirty to forty drops to the minute are instilled. If the rectum becomes intolerant, the injection is stopped and continued only inter- mittently, with intervals of several hours. Blood transfusion is often of the greatest value, as a means of furnishing serum of fresh bacteriolytic power or to combat the secondary anemia of long continued sepsis. It can be given as a single massive transfusion of 750-1000 mils or by repeated small transfusions of 50-100 mils. It is particularly valuable in 400 PUERPERAL SEPSIS hemolytic streptococcic blood stream infection, though by no means a specific. The patient's and donor's blood must of course be carefully typed. There is more danger of anaphy- lactic reaction after repeated small transfusions, even with proper typing, than after the single massive dose. Operative Treatment of Puerperal Sepsis by Abdominal Section.-Indications for abdominal section are: (i) Localized suppurative peritonitis; (2) diffused suppurative peritonitis; (3) suppurative salpingitis or oophoritis; (4) suppurative metritis, when pointing toward the peritoneal cavity (cornual abscess most commonly); (5) suppurative cellulitis (largely exploratory); (6) infected abdominal tumors. Abdominal section is indicated when, in the course of septic fever, there appears a palpable abdominal mass; provided this mass is not in the base of the broad ligaments, in which case 90 per cent, undergo spontaneous resolution. The mass is most likely to be a cornual abscess and sal- pingitis with the adherent intestine and omentum. Contra-indications are: (1) Sapremia; (2) phlebitis; (3) septic endometritis; (4) lymphangitis; (5) pyemia. Exploratory section is done only to determine whether a mass, presumably containing pus, is intraperitoneal or extraperitoneal. Hysterectomy, partial or complete, is often indicated. The need for it is not seen until the abdomen is opened. Indica- tions are: (1) Ruptured uterus; (2) suppurative metritis; (3) gangrenous fibroids; (4) widespread infection of uterus and broad ligaments. Special Technic.-Abdominal sections for sepsis differ from the ordinary sections in the following points: (1) Rapidity of operation; (2) only sufficient ligatures are used to stop the bleeding; (3) the broad ligaments are allowed to gape and are not sewed over; (4) vessels are tied separately, as much as possible; (5) the upper abdominal cavity is protected by gauze sponges; (6) practically every case is drained. Drainage.-(1) Just before the abdomen is closed the pelvis is sponged as clean as possible; (2) a curved glass drainage tube TREATMENT 401 about the size of the forefinger is put in the bottom of Douglas' pouch. The curved is better than the straight tube, because it can be brought out nearer the symphysis, and hence lessens the danger of incisional hernia; (3) under and around the tube is packed a gauze strip, usually four layers one and one-half inches wide (made by folding a six-inch bandage), so that the entire pelvis is filled and all the intestines held above the pelvic Fig. 183.-Abdominal drainage by glass tube and gauze; the most efficient type of drainage in septic conditions in the pelvis. brim. The end of the gauze is brought out along the tube; (4) the protective sponges are now removed and the abdomen closed around the tube and gauze. A rubber tube, caliber of the forefinger with walls sufficiently thick to give fair rigidity, answers as well as the glass tube and is free from danger of breakage. The vaginal method of drainage (through a tube in Douglas pouch) is not safe, in septic cases, and should be avoided. After-care.-(1) Every twenty-four hours the glass tube is sucked out by a piston syringe and catheter, for the first five days. The amount of fluid will diminish from about an ounce the first day to a couple of drams on the fifth; (2) the patient 26 402 PUERPERAL SEPSIS is kept in the Fowler position and the Murphy drip (glucose one and a half ounces, sodium bicarbonate one and one-half ounces, water two pints, forty drops a minute, temperature kept near no0) is used; (3) all these patients need rather active stimulation, particularly in the second twenty-four hours; (4) on the fifth day the glass tube is removed; (5) beginning on the sixth day, the gauze is removed, taking out about one quarter of the total amount each day, so that by the tenth or eleventh day, it is all out; (6) as soon as the last of the gauze is out, a rubber tube is inserted in the sinus left by the gauze as deep as it will go, and a safety-pin put through the outer end; (7) through this tube the pelvis is flushed daily with sterile water, run in by gravity, and the tube shortened as it is pushed out from below; (8) the usual convalescence lasts four to six weeks. Except for these points, the after-care is that of the ordinary section. Resection of the pelvic veins in sepsis is, as a rule, not justi- fiable. The mortality of the operation has been, in various reported series of cases, 49 to 84 per cent. Much better results can be obtained by other means. COMPLICATIONS OF PUERPERAL SEPSIS Endocolpitis or inflammation of the vagina, is shown usually by a thick gray-green false membrane. The best treatment is four hot vaginal douches daily, of sterile water. The routine use of antiseptic solutions is not to be depended on, as they diminish the resistance of the body cells, and do not destroy the micro-organisms. Endometritis has the same necrotic membrane, but due to necrotic decidua. Under it is the protective layer of leukocytes which, if thick enough, confines the process to the uterine cavity. Treatment is daily intra-uterine douches of sterile water. One douche daily is sufficient. Salpingitis and Oophoritis.-An ovarian abscess is more common than salpingitis, and also much more virulent. The COMPLICATIONS OF PUERPERAL SEPSIS 403 septic tube differs from the gonorrheal in that it is unilateral, fever much higher, leukocytosis higher, broad ligaments thick, abdominal end of tube open. A primary pyosalpinx in the puerperium is rare. It is not uncommon for a pus tube that antedates pregnancy to be the seat of a fresh outbreak in the puerperium. Due to the large uterus, it is not always possible to feel a mass by vaginal examination, as the tubes are higher up, beyond the reach of the examining fingers. Treatment.-Operation should be delayed, if possible, to allow of localization. By liquid diet, moderate purgation, ice-bag to lower abdomen constantly, and four hot sterile water vaginal douches a day, it is often possible to check the acute stage. A gonorrheal tube is much more likely to be favorably influenced than a septic, and particularly a primary septic, one. If there is no improvement in forty-eight hours, it is usually unwise to delay operation. Metritis.-Infection may spread into the uterine muscle from the endometrium, and involve small areas only, or almost the entire muscular layer. When the infection reaches the peritoneum it causes firm adhesions of the uterus to any neigh- boring structures (the colon, small bowel, or omentum). The course is slow, but suppuration is the rule, and unless the abscess drains spontaneously into the uterine cavity, fatal peritonitis is to be expected. Diagnosis is difficult. The uterus is fixed, enlarged, tender and often irregular, but unless an abscess breaks into the uterine cavity during the examination, the only way to estab- lish the diagnosis with certainty is by exploratory section. There is often'a palpable abdominal mass, which is not the abscess, but the adherent bowel and omentum, and this adhesion may occur without suppuration. Treatment.-Ice-bag to the lower abdomen; four hot vaginal douches daily, and moderate stimulation. The abscess some- times drains into the uterine cavity and spontaneous recovery results. This is not to be expected, however, when there is a palpable abdominal mass, as the pus, if any be present, is 404 PUERPERAL SEPSIS then under the peritoneal coat of the uterus or even outside the uterus, walled off by the adhesions. These cases demand Fig. 184.-The areas involved in pelvic cellulitis. 1. Broad ligaments. 2. Base of broad ligaments and lateral vaginal fornices. 3. Ischiorectal fossae. abdominal section, with complete or partial hysterectomy. If the abscess is a single one, at the cornu, it is possible to open and drain it, without sacrifice of any part of the uterus, but this is the ex- ception. Pelvic cellulitis is infection of the pelvic connective tissue of Douglas' pouch, the uterovesical space or the bases of the broad ligaments. The source of infection is through the lym- phatics of the lower uterine segment and cervix, particularly if the cervix is torn. There is at first edema of the connective tissue, then extensive cellular infiltration with absorption of the edema, leaving the cellular elements as a stony hard exudate. If there has not been much cellular prolifera- tion, all induration may spontaneously disappear when the edema is absorbed, but this is not common. Fig. 185.- Diagram to illustrate the differ- ence in indurated areas in peritonitis and cel- lulitis. Practically this is of little value, as the two are so often co- existent. Complications op puerperal sepsis 405 Theoretically the greatest induration in cellulitis should be laterally to the cervix, and in pelvic peritonitis anterior pos- teriorly, but the two are so commonly associated that any attempts at differential diagnosis are futile. Fig. 186.-Opening a pelvic abscess through Douglas' pouch. Diagnosis.-The cervix feels as if fixed in plaster-of-Paris, and'entirely immobile. The pelvis is filled by a stony exudate, and the cervix is pushed often far anteriorly or to one side. The exudate may be confined to the base of one broad ligament only. Treatment.-In the stage of infiltration, before suppuration takes place, the treatment is palliative. As long as there is no bulging downward of the posterior or lateral vaginal vaults, it may safely be assumed that there is no suppuration. (1) Hot vaginal douches of sterile water at 120° F., daily; (2) ice-bag or ice coil to lower abdomen constantly; (3) bowels open; (4) liquid or soft diet; (5) moderate stimulation. Tam- pons are painful to the patient, do no good in these acute infec- tions and are therefore to be avoided. Pelvic abscess occurs in about 10 per cent, of cases of cellulitis. 406 PUERPERAL SEPSIS Symptoms.-(1) Fever of a septic type; (2). high leukocytosis (20,000-30,000); (3) bulging downward of the vaginal vault. The pus tends to burrow downward between the vagina and rectum, and the posterior vaginal vault becomes convex instead of concave. The induration is too great for detection of fluctuation. Operation is indicated when the bulging of the vaginal vault appears. Fig. 187.-AT drainage tube and the forceps used to insert it. The tube must be of large caliber and the straight tube extends completely through the cross arm. Fig. i88.-The tube grasped in the forceps, ready for insertion. Posterior Pelvic Puncture.-Technic.-(i) General anesthesia, careful vaginal scrubbing and patient in the dorsal position; (2) catch posterior lip of the cervix with double tenaculum; (3) make a semicircular incision through the mucosa marking the vaginal attachment to the cervix posteriorly; (4) long-han- dled, sharp-pointed scissors are plunged in through this incision, keeping strictly to the middle line and as close as possible to the uterus, and withdrawn open, to stretch the opening as far as COMPLICATIONS OF PUERPERAL SEPSIS 407 possible; (5) it is usually wise further to dilate the opening with branched uterine dilators, to ensure free drainage; (6) the cavity is explored with the forefinger (scissors are not used because of danger of wounding the ureter, uterine arteries or intestine); (7) the cavity is flushed out with sterile water; (8) if evacuation of pus has been free, the cavity is drained Fig. 189.-Drainage of a pelvic abscess, with a T rubber drainage tube. with a T-tube-if not much pus but considerable cheesy exudate is found, the cavity is packed with gauze for forty- eight hours, to break down the exudate, and is then drained with a T-tube; (9) the T-tube is cut off flush with the vulvar orifice; (10) the pelvis is irrigated daily, with sterile water through the T-tube; (11) the tube is removed when the dis- charge has practically ceased, and the hole in the vaginal vault allowed to close, without packing. Phlebitis.-The veins of the uterus and broad ligaments are infected from the placental site. The clots in the sinuses at the placental site are infected, the process extends to the veins of the pampiniform plexus and the uterine and ovarian veins. The infected thrombus may extend into the iliac veins, a piece be broken off and carried to the lung. Peritonitis in phlebitis is very rare; pulmonary embolism and pyemia are not uncom- 408 PUERPERAL SEPSIS mon. The thrombotic process is not always confined to the pelvis, but may occur in remote areas-mesentery, lung or brain. Symptoms.-(i) Long-continued septic symptoms, without signs of localization, point to phlebitis; (2) any attempt to disinfect or irrigate the uterus is followed by a sharp rise in temperature; (3) often, but not always, tenderness to palpa- tion in the vaginal vaults; (4) involution of the uterus pro- gresses normally. It is not uncommon for all symptoms to disappear, remain absent for several days and then return as severe as ever. These relapses may be many times repeated. Dangers.-(1) Phlegmasia alba dolens (milk-leg) is almost sure to occur; (2) pyemia; (3) pulmonary embolus. Treatment.-(1) Absolute rest in bed, until the temperature has been uninterruptedly normal for ten days; (2) stimulation, particularly alcohol, to the point of tolerance; (3) one disinfec- tion of the uterine cavity, which will probably be followed by a temporary rise in temperature. The one cleansing is justi- fiable, to avoid leaving necrotic endometrium in the uterine cavity, but it should not be repeated, on account of the danger of embolism; (4) the operative treatment, by tying and excising, the ovarian, hypogastric or iliac veins, has given a mortality so much higher than the treatment outlined above, that it is unjustifiable. Prognosis is guardedly favorable. There will be some mortality from pyemia and pulmonary embolism. Pyemia.-Symptoms.-(1) Long-continued septic symp- toms; (2) repeated chills; (3) positive blood cultures; (4) metas- tatic abscesses, but no pelvic localization. Treatment.-(1) Forced concentrated liquid diet; (2) alcohol to point of tolerance; (3) digitalin gr. Xo and strychnin sul- phate gr. hypodermically four times daily as long as pulse is over no; (4) 250 mils of antistreptococcic serum intravenously, in one dose, and repeated in forty-eight hours if the symptoms justify it; (5) active stimulation-digipuratum COMPLICATIONS OF PUERPERAL SEPSIS 409 i ampule hypodermically every three hours; strychnin sulphate gr. hypodermically; nitroglycerin gr. hypodermically; camphorated oil minims 30 hypodermically; oxygen and external heat, if sudden collapse occurs. Neo-salvarsan and blood transfusion are both of value in pyemia and must be considered. Prognosis.-Pyemia is always serious, causing most of the deaths from puerperal sepsis. The convalescence is very prolonged; metastatic abscesses may occur anywhere-in the joints, vital organs, even the eyeball. Meningitis is common and always fatal. Phlegmasia alba dolens or milk-leg is a very common- almost a constant-sequel of phlebitis. The left leg is the more commonly affected-rarely the infection is bilateral. The name milk-leg comes from the milky white appearance of the skin or from the old belief that all localization of infec- tion was due to metastasis of the milk-lactation being usually interrupted by the fever. Kinds.-(1) Cellulitic, due to infection of the connective tissue of the thigh; (2) thrombosis of the iliac and deep femoral veins-much the more common (98 per cent.). The theory of venous stasis being the cause of phlegmasia is hardly tenable. Symptoms.-(1) On the tenth to thirtieth day after delivery, the patient complains of severe pain in the calf of one leg, usually the left, and also in the corresponding groin; (2) the leg is almost immovable, and any movement gives intense pain; (3) the leg swells rapidly, the skin is tense and milk white, and usually pits deeply on pressure; (4) there is moder- ate fever, lasting for a short time, and subsiding long before the swelling shows any signs of decrease; (5) there is usually tenderness along the whole course of the femoral vein, which can be felt as a tender cord; (6) the swelling may begin in the groin and extend to the labium ma jus on the affected side; (7) the patient shows the usual signs of sepsis-depression, gastric disturbance, nausea and flushed cheeks. 410 PUERPERAL SEPSIS In the cellulitic variety, the infection extends to the con- nective tissue of the thigh from the pelvic connective tissue, through the obturator foramina. Treatment- (i) Absolute rest in bed; (2) elevation of the leg, on pillows or in a fracture-box, at an angle of forty-five degrees. This does more to relieve the pain than any single point in the treatment; (3) evaporating lotions (leadwater two ounces, alcohol three ounces; or dilute leadwater and laudanum; or saturated solution of magnesium sulphate) covering the whole leg; (4) paint course of vein with 5 per cent, tincture of iodin or 50 per cent, ichthyol in glycerin- of doubtful value; (5) full diet and moderate stimulation; (6) no local massage; (7) the symptom urgently demanding relief is the pain in the groin. Ice-bag to the groin, more rarely a hot-water bottle, elevation of the leg and codein gr. or morphin sulphate gr. hypodermically will give the greatest relief, though the use of opiates should be restricted. When the patient is out of bed, after the temperature has been normal for ten days, the swelling of the leg will often increase. This should be controlled by an elastic stocking, and no massage should be given for three months at least, and then very cautiously. Dangers.-(1) Pulmonary embolus; (2) pyemia; (3) gangrene. Prognosis is guardedly favorable. The patient must remain in bed until the temperature has been uninterruptedly normal for ten days, as the greatest danger is pulmonary embolus, from too early getting up. Recovery may be complete, but convalescence is usually prolonged, and a temporary or per- manent lameness may result, about which the patient should be warned. Gangrene will demand prompt amputation, and is a very serious complication, as it is probably progressive. Extensive thromboses, even to the inferior vena cava, are not uncommon. In the cellulitic type, if long continued, elephan- tiasis is not unlikely, and suppuration is common. The most favorable termination is complete resolution, but is rarely attained. The next most favorable, and the commonest, COMPLICATIONS OF PUERPERAL SEPSIS 411 is organization of the thrombus, obliteration of the vein, and compensatory collateral circulation through the epigastric and gluteal veins, with frequent slight disability. Pulmonary embolism is the greatest danger in phlegmasia. It is not likely to occur if the patient is kept quiet for a suffi- cient length of time. The clot may come from the femoral, iliac or uterine veins. A piece is broken off and carried by the circulation to the right auricle, right ventricle and pulmonary artery. Small emboli cause anemic infarcts and pleuro- pneumonia, and are not likely to be fatal, though a succession of them may be. The patient complains, without previous warning, of a severe pain in the chest and dyspnea. Her color is bad, she is obviously shocked, the heart is dilated and the pulse rapid, irregular and weak. If the embolus is a small one, active stimulation and oxygen will cause reaction in a short time. If the embolus is large the symptoms are all much more severe, and death is either instantaneous or so rapid that no time is given for any treatment. Pelvic peritonitis is caused most often by an extension of septic endometritis, either through the uterine lymphatics or through the open ends of the fallopian tubes. Leakage from the tubes is the result usually of muscular exertion and while resulting peritonitis is sharp, it is usually of short duration, and may be due simply to the irritating nature of the fluid. Symptoms.-(i) Moderate fever, usually considerably higher by rectum than by mouth; (2) great muscular resistance of the abdominal wall; (3) patient lies with knees drawn up; (4) peristalsis audible; (5) moderate leukocytosis; (6) pelvic exudate. Treatment.-Both palliative and operative is that of celluli- tis, with which it is usually associated. Pelvic peritonitis is more likely to require abdominal section than is cellulitis, but suppuration is less common. Prognosis.-The majority recover with complete resolution of the exudate, without operation. 412 PUERPERAL SEPSIS Diffuse peritonitis is the most fatal of all the complications of sepsis. Practically all septic deaths occur from this or from chronic pyemia. Causes.-(i) Extension from the pelvis; (2) rupture of an abscess in the uterine wall, usually at the cornu; (3) rupture or perforation of the uterus; (4) necrotic tumors. Symptoms- (1) Moderate fever, higher by rectum; (2) great muscular rigidity of abdominal walls; (3) peristalsis absent; (4) abdominal distention; (5) rapid, running, wiry pulse; (6) puckered anxious face, with gray pallor; (7) often, but not always, uncontrollable vomiting. All the local abdom- inal symptoms may be lacking, and a patient die within twenty-four hours of the onset of symptoms, from a fulminant peritonitis. Treatment.-The only chance, though a very slight one, lies in early abdominal section; removal of the cause of the peritonitis, if it can be found; thorough flushing of the abdomen with salt solution; best possible drainage, by rubber tubing through the abdomen, flanks and posterior vaginal vault. The operation must be rapidly done as the patient is a poor surgical risk. The intestines are found lightly glued together, are red and covered with yellowish-green lymph, and bathed in a thin pus. Localized abscesses between adherent coils of intestines are frequent and should be discovered and the coils separated. After the operation the patient is put in the Fowler position, with continuous enteroclysis, and very free stimulation. Prognosis:-Almost all die within twenty-four to forty-eight hours. There is often a deceptive improvement shortly after operation, due to the temporary removal of the toxic fluid by drainage. Within twelve hours the patient sinks rapidly. Very rarely, a patient with diffuse streptococcic peritonitis will be saved, so the operation is always worth doing. Sapremia is the form of sepsis, due to the absorption of the products of decomposition, from putrid pieces of placenta, membranes, blood-clot or decidua retained in the uterine COMPLICATIONS OF PUERPERAL SEPSIS 413 cavity. It is, of all forms of sepsis, the easiest to cure. It appears usually in the first three to five days of the puer- perium, but may occur as late as the fourth week. Symptoms.-(i) Elevation of pulse and temperature, without chill; (2) subinvolution of the uterus; (3) foul brown discharge; (4) blood culture sterile; (5) no symptoms of localization. Treatment.-A thorough disinfection of the uterine cavity, as described under the local curative treatment of sepsis. The curet should be avoided as much as possible, though its gentle use will remove masses of decidua too flat and too tightly adherent to be removed by the placental forceps. Usually one disinfection is enough, and the symptoms promptly disappear. Sudden cessation of the lochia is due to: (1) Very actively contracting uterus (only in primiparae); (2) cervical canal obstructed by blood-clot or piece of placenta; (3) backward, rarely forward, flexion of the uterus (usually with sudden high fever--104° to 105°); (4) sepsis. The condition is a symptom only and is treated by removal of its cause. Arthritis is seen only in pyemia or gonorrhea. It is always a serious complication. Pyemia attacks most often the knee and shoulder, though no joint is exempt; gonorrhea most often the ankles, wrists and fingers. Pyemic arthritis should be opened and drained early, but the complication is usually fatal. Gonorrheal arthritis is treated as already described, by immobilization and vaccines, with a 20 per cent, risk of suppuration and ankylosis. Septic proctitis is due to infected enema nozzles, or to a pelvic abcess rupturing into the rectum, and is treated by irrigation. Septic cystitis and pyelitis is caused most often by dirty catheters. Infection may result from lymphatic or blood- current metastasis. A common predisposing cause to cystitis is prolonged pressure of the child's head in labor. Symptoms of Cystitis.-(1) Several days after labor there develops frequent and painful urination; (2) vesical tenesmus; 414 PUERPERAL SEPSIS (3) moderate fever; (4) tenderness on palpation over the bladder; (5) cloudy foul urine, with ropy mucopurulent sediment. Diagnosis may be confirmed by cystoscopy, when the blad- der-wall is seen to be red, the vessels engorged and prominent, strings of mucopus hanging from the bladder-wall and pos- sibly ulceration. Treatment.-(1) Prompt irrigation and disinfection of the bladder to prevent, if possible, an ascending ureteritis and pyelitis. (2) Rest in bed; (3) milk diet; (4) large amounts of water-fifteen to twenty glasses a day; (5) cystogen, or salol, or urotropin gr. x four times daily; (6) daily bladder irrigation with boric acid solution ten grains to the ounce, by a catheter and funnel; (7) injection, after the irrigation, with one ounce of 25 per cent, argyrol, or 25 per cent, pro- targol, 1 per cent, hegonon, or 10 per cent, silvol solution, to be retained as long as possible. Usually in three or four days all the acute symptoms have subsided. Pyelitis may be suspected if: (1) Patient has a chill; (2) considerably higher fever; (3) pain in back and loin, referred along course of ureter; (4) leukocytosis of 20,000 or over. The diagnosis is established by cystoscopy, when the mouth of the ureter can be seen to be eroded, and urine full of pus may be obtained by ureteral catheterization. Treatment.-(1) The affected ureter is catheterized, the catheter passed as high toward the kidney as possible, and the pelvis of the kidney irrigated with ten grains to the ounce boric acid solution, followed by 1 per cent, hegonon or 10 per cent, silvol solution. Unless a two-way ureteral catheter is used, dangerous pressure in the pelvis may be exerted, and the fluid must be injected very gently. Injection should cease at once if the patient complains of any increased pain in the back. The capacity of the kidney pelvis is 5 to 8 mils. If the infection is not streptococcic, this treatment is fol- lowed by prompt improvement. COMPLICATIONS OF PUERPERAL SEPSIS 415 Streptococcic pyelitis is very serious, almost sure to require nephrotomy and drainage, and the majority are fatal. Tetanus is rare in the puerperium. The commonest source of infection is dirty water used for douching. The symptoms and treatment do not differ from tetanus in general, and the mortality is 90 per cent. Ischiorectal abscess is an uncommon complication. It is due usually to infection from a deep tear of the vagina, or suppuration of a hematoma. The diagnosis is easy, the mass easily outlined by rectal examination, and free early incision and drainage are indicated. CHAPTER XVIII PATHOLOGY OF THE NEW-BORN INFANT Asphyxia.-The causes of respiration in the new-born are: (i) Stimulation of all muscles, including those of respiration, to reflex action, by the sudden lowering of temperature from about ioo° F. to room temperature at 70° F.; (2) accumulation of carbon dioxid in the blood, due to cessation of placental circulation, at first stimulates, but later paralyzes the respira- tory centers. Causes of Asphyxia.-(1) Prolonged pressure on the umbili- cal cord; (2) prolonged pressure on the head; (3) efforts at intra- uterine respiration, usually dependent upon the first two men- tioned; (4) traction on the neck, in breech deliveries; (5) accidents to or diseases of mother, such as hemorrhage, and toxemia; (6) congenital deformities of the child. Kinds of Asphyxia.-(1) Asphyxia livida-the earlier and less serious; (2) asphyxia pallida. Diagnosis is easy. The child is livid or pallid, depending upon the stage of asphyxia; the heart beats very slowly-60 or less per minute; no efforts at voluntary respiration are made. Treatment is preventive and curative. During labor any preventable cause of asphyxia should be removed. The heart sounds should be listened for at fre- quent intervals and if a progressive slowing takes place, forceps is usually indicated. At first there is a marked acceleration of the rate, but this is of short duration and the progressive slowing is the symptom most often observed. Curative Treatment.-(1) Hold child upside down, by its feet, clean mucus out of mouth and throat by little finger, or better by aspiration of the mucus by suction through a 416 ASPHYXIA 417 catheter with glass reservoir attached; (2) spank sharply. The child will begin to breathe sometimes before it cries, and when respiration is established it should be let alone, and not mauled until it cries. The stages of recovery are: (1) Quicken- ing of the heart rate; (2) gasping irregularly; (3) regular volun- tary respirations; (4) crying. Fig. 190.-Infant lungmotor. If prompt results are not attained, some form of artificial respiration should be used. Pouring ether on the child's chest or immersing it in cold and hot water alternately are both ineffective, and not worth wasting time over. Methods of Artificial Respiration.-(i) Best of all is one of the mechanical devices, such as the lungmotor or pulmotor. This latter should be set to work at the rate of the normal child's breathing-45 to the minute. (2) Mouth-to-moulh insufflation, where the child is placed on a table with its chest elevated. The face is covered with gauze, and the attendant blows gently through this gauze into the child's open mouth, and compresses its chest to expel the air. Also at the rate of 45 to the minute. 27 418 PATHOLOGY OF THE NEW-BORN INFANT (3) Schultze or Swinging Method.-The child is wrapped in a towel and held facing away from the physician. It is swung up over the left shoulder and then down again between the knees-calisthenics of doubtful value. a Fig. 191.-Schultze's method of artificial respiration, a, First motion; b, second motion. (From Cragin, " The Practice of Obstetrics.'") (4) Marshall Hall Method.-Rolling the child from side to side in a towel-doubtful. (5) Dew or Byrd method, doubling up the body, holding upside down to allow mucus to run out of throat and straight- ening out again-reasonably efficient. (6) Laborde Intermittent Tongue Traction.-Inefficient. (7) Sylvester Method.-Using the arms by traction, to inflate the chest is not efficient, as the infant's pectoral muscles are too weak to elevate the chest wall. ASPHYXIA 419 (8) Catheterization of the larynx is advisable only when there is some obvious obstruction. Any method used should be conducted gently and without violence, to avoid injury to the child. Fig. 192.-Dew's method of artificial respiration. (From Cragin, "The Practice of Obstetrics.'') If there is no response to efforts at resuscitation within half an hour, the case is hopeless. If the child responds, even slightly, efforts may have to be continued for hours. 420 PATHOLOGY OF THE NEW-BORN INFANT In cases where there is progressive slowing of the heart, in spite of all efforts of resuscitation, deep hypodermic injec- tion of io drops of i-iooo adrenalin solution is worth a trial. It has been given even into the heart muscle itself. Prognosis.-In asphyxia, the child will often die within forty- eight hours after resuscitation. The greater the difficulty in revival, the more likely it is to die. Inspiration pneumonia is a common and serious sequel. Intracranial hemorrhage is not uncommon. After-treatment.-(i) Have child carefully watched for high temperature, rapid and feeble heart, rapid respiration and cyanosis; (2) keep child warm by hot water bottles; (3) give mustard bath three times daily for first three or four days; (4) give drop tincture of digitalis, 5 drops of brandy in 1 dram of hot water every four hours, for the first four days. Atelectasis is due to failure of the lungs to distend with air, due to some obstruction or malformation of the air passages. The child is born apparently in asphyxia pallida, is not revived, and the actual diagnosis made only by postmortem. There is no treatment. Chafing of the skin, particularly of the buttocks, is very common. Treatment: is (1) Cleanliness; (2) avoid soap and water and use only olive oil; (3) powder with talcum after oil is dried as much as possible; (4) frequent changing of diapers. Exposure to direct sunlight for several hours daily is distinctly beneficial. Acne is very common, occurs all over the body, and is treated in the same way. Colic is seen in nearly every baby, at some time. It always indicates attention to the diet, and is due, most commonly, to an excess of proteid or fat in the milk. It may be caused by the child nursing too fast at first. If so, giving ounce of water just before nursing will be of benefit. Temporary Relief.-(1) Enema of two ounces of soapy water, given with a soft rubber ear syringe, with soft rubber nozzle; (2) five drops of brandy in 1 dram of hot water; (3) CONGENITAL DEFORMITIES 421 pepsin gr. i in i dram of hot water; (4) hot peppermint water 1 dram. Constipation in babies is often mechanical only, due to the persistence of the rectal valves, the sharp angulation of the sigmoid, the tight sphincter and the weak abdominal muscles. If the movements, when passed, are soft and well digested, the constipation is mechanical and best relieved by the use of the soap stick, and not enema, as the latter forms a habit. When movements are formed and hard, more fat is needed in the child's diet. This may be secured by (1) olive oil dram twice daily by mouth), or oil rubs or, in bottle fed babies, by a change in the formula. Moderate constipation is often relieved by milk of magnesia, 20 drops three or four times a day, but for immediate results, particularly if the movements are green, castor and sweet oil, each 30 drops, are best. Diarrhea.-Four to six movements a day are not necessarily abnormal. Severe diarrhea is due to errors in diet or milk infection. Treatment.-(1) Castor oil 1 dram, not repeated inside of forty-eight hours; (2) colonic irrigation, if movements are irritating; (3) bismuth subnitrate gr. ii, precipitated chalk gr. v four times daily, given in suspension in water, with a medicine dropper. Congenital Deformities.-(1) Hare-lip.-May be repaired in the first few days of life. (2) Tongue-tie.-Interferes with nursing. The child is made to cry, in a good light. The frenum is snipped with blunt pointed scissors and with the finger torn down to the base of the tongue. (3) Cleft-palate.--The child can only nurse from a bottle with a flap of rubber over the nipple, to form a temporary, artificial roof to its mouth. Fig. 193.-Nipple with rubber flap, to be used in cases of cleft palate. (De Lee.) 422 PATHOLOGY OF THE NEW-BORN INFANT Due to recent developments in the surgery of this deformity, operation can now be done in the first few days of life with great success, and there is no need of postponing it, from fear of failure or complications. (4) Polydactylism.-Extra fingers and toes are ligated with fine silk and amputated, unless they are obviously firmly attached. Usually they are only bits of flesh. (5) Umbilical hernia is best treated by a convex button held in the ring by. adhesive straps, or by adhesive straps pinching the abdominal wall tightly enough to close the ring. Several months' treatment is necessary. In severe cases, where a large section of the abdominal wall is lacking, and the intestines covered only by peritoneum (exomphalos; celosoma), operation is necessary, but the prog- nosis is bad. (6) Spina bifida is seen most often complicated by hydro- cephalus. The defect should be closed by excision of the sac and interrupted catgut sutures. If hydrocephalus develops, the spinal canal can be drained by a canula through the body of the last lumbar vertebra, into the postperitoneal space. (7) Phimosis.-Every male baby has a tight, adherent prepuce. It is best stretched with small hooks (strabismus hooks) about the tenth day; the adhesions broken up, the glans oiled and prepuce brought back over it. Daily thereafter the skin is retracted, and for the first week the glans is oiled, to prevent the recurrence of adhesions. Circumcision is not necessary, if the prepuce can be retracted, though there is no objection to its early performance. (8) Paraphimosis is rare, except with hypospadias. When it occurs, without hypospadias, the tight ring must be cut. (9) Imperforate rectum is the most serious of all the deformi- ties. A crucial incision is made over the site of the anus, by blunt dissection the pouch of rectum is reached, pulled down, opened and sewed to the skin. The prognosis in these cases is good. If the rectum cannot be reached through the peri- HEMOPHILIA 423 neum, an inguinal colostomy is required, and in these cases the prognosis is bad. Anus vestibularis is occasionally seen in female children, and should be sought for, if the normal anus is missing, before any operation is performed. (io) Club-foot.-Every baby can lie with its legs fully extended and clap the soles of its feet together. This must not be mistaken for club-foot. If the foot is really clubbed, some benefit can be gained by plaster cast, until proper orthopedic measures can be instituted. Convulsions may occur as a result of: (i) cerebral injury in labor; (2) gastrointestinal irritation; (3) constipation; (4) without demonstrable cause. The treatment is: (1) one dram castor oil; (2) colonic irriga- tion with cool salt solution; (3) mustard bath (technic described under inspiration pneumonia); (4) stop food for two or three feedings; (5) remove cause of convulsions, if any can be found. Intra-cranial hemorrhage, from birth injury, is a common cause, and until this can be eliminated, the prognosis of a case of convulsions must be guarded. Hemophilia of the new-born shows itself most often as melena (intestinal bleeding). Hemophilia is said to be trans- mitted through the female (who does not show it) to the male (who does not transmit it). There are many exceptions to this in practice. It is most common in premature children, but may occur in those born at full term. The child may bleed from any portion of the body, but most often the blood is found in the stools. Care should be taken to see that the blood passed is not swallowed by nursing from a fissured nipple. Treatment.-In true melena styptics are of no value. Ten to 20 mils of normal horse serum should be injected daily, until the bleeding ceases. Any kind of serum, or even whole human blood may be injected. Injections of gelatin are dangerous, because of the danger of tetanus and anthrax. Transfusion is effectual, but no better than serum or whole blood injections, 424 PATHOLOGY OF THE NEW-BORN INFANT and much more difficult to do. Transfusion is best done into the superior longitudinal sinus, at the posterior angle of the anterior fontanel. Icterus neonatorum (jaundice) is of two kinds: (i) Hepatog- enous, which is common in all children, due to failure of drainage of bile from the very small common duct. The pigmentation disappears in a few days. Treatment is calomel gr. every hour for ten doses followed by 30 drops each of castor and sweet oil. Treatment does not hasten the disappearance of the jaundice, and is really unnecessary. It is now thought that the jaundice has nothing to do with the liver, but is due to the breaking down of large numbers of red blood corpuscles soon after birth and therefore is hematog- enous. This theory has not yet been proved. In any case, the ordinary jaundice of the new-born is not serious, and need cause no concern. (2) Hematogenous (Buhl's or Winckel's disease) due to a blood-current infection with hemolytic streptococci, and acute yellow atrophy of the liver. It is always rapidly fatal. The difference is obvious. In the first the child may be deeply pigmented, but shows no evidence of illness. In the second the child is gravely ill, with great prostration and high fever. Injuries of the New-born.-Fractures of the skull are nearly always the result of forceps deliveries. They are most common in the occipital bone, and next in the parietals, depending upon the position of the forceps and the force used in delivery. They are often compound, associated with intracranial hemorrhage and more or less severe injury to the brain itself. Most cases are stillborn; nearly all the others die shortly after birth either from asphyxia or cerebral hemorrhage. Convul- sions are a common sequel, and are due to cerebral hemorrhage. Treatment is stimulation by mustard baths, hypodermics of strychnin sulphate gr. j*4oo and atropin sulphate gr. Xsoo, but is not of much avail. Recovery very rarely occurs. Intracranial hemorrhage occurs usually in cases where some violence is needed in delivery, as in forceps, or axistraction INJURIES OF THE NEW-BORN 425 forceps or in breech presentations where there is difficulty in delivery of the after coming head. It may occur, however, in spontaneous labors, where no difficulty has been encountered. The clot is usually subdural and bilateral. Symptoms usually appear on the second day and are restless- ness, crying, muscle twitching, tremor of lower jaw especially, nystagmus, irregular pupils and later convulsions and coma. Fig. 194.-Spoon-shaped depression of the skull, due to pressure of the promontory of the sacrum. (Z>e Lee.) The pulse is rapid, respirations poor and shallow, the fonta- nelles are tense and there is usually some fever. These symp- toms are progressive, and vary in intensity with the amount of hemorrhage. Treatment is symptomatic and the prognosis is very doubtful. Most cases with marked symptoms die in spite of any treatment, and those who survive often have an unfavorable later history, with some form of spastic paralysis. Spoon-shaped depression of the skull is due to pressure of the promontory of the sacrum or to improperly applied forceps. It occurs in one or both parietals and is simply a dent in the 426 PATHOLOGY OF THE NEW-BORN INFANT bone. It is not accompanied by fracture, the child shows no symptoms, and if let alone, the depression disappears in one or two years. Treatment is unnecessary. Fracture of the arm is usually a separation of epiphysis and diaphysis, or a green stick fracture of the shaft of the humerus, the result of extraction of the arm in delivery of a breech presentation. Treatment.-Fix the arm in the Velpeau position, with a small pad of cotton in the axilla, and hold the arm in position by means of an undershirt, with only one sleeve (for the sound side), laced down the front. Healing is complete in about three weeks; bandages, plaster-cast or adhesive straps are not necessary. Fracture of the clavicle occurs most often in breech presen- tation, in delivery of the head. It can occur in head presenta- tions, when the anterior shoulder is pulled under the symphysis, and can be entirely spontaneous. In every case, the clavicle should be palpated for possible injury, or the fracture may be overlooked until the child shows disability in one arm. The dressing is the same as for a fractured arm. Limitation of motion only, and not fixation is aimed at in the dressings. Fracture of the leg, seen only in podalic version or in breech presentation, is treated by extension and fixation. The acci- dent is rare. Decapitation is sometimes seen in breech presentations, where, in efforts to extract the head, the neck is broken and the head pulled off. This accident can be avoided, if fracture of the neck occurs and the neck begins to stretch alarmingly, by craniotomy and extraction, before the head is entirely pulled off. If the head is detached, and loose in the uterine cavity, craniotomy is the method of extraction and never cesarean section. Caput succedaneum is the local edema of that portion of the scalp which corresponds to the opening of the dilating cervix. It is usually associated with considerable distortion of the head, by excessive moulding. It is present at birth, INJURIES OF THE NEW-BORN 427 does not fluctuate, is brawny and tough to the feel, and disap- pears, with the distortion of the head, in twenty-four to forty- eight hours. No treatment is required. Cephalhematoma is a localized subpericranial hemorrhage, confined to one or both parietal bones, and is always due to Fig. 195.-Caput succedaneum. (De Lee.} injury-either forceps, or the pressure of the promontory or spines of the ischium. There is sometimes a linear fracture of the skull with it. It appears after birth, is soft and fluctu- ating and at the edge of the swelling the sensation is that of a depressed fracture. As the clot stimulates activity of the peri- osteum, there is often crackling over the swelling. Cephal- hematomata disappear spontaneously in two to eight weeks, and should never be opened, unless they suppurate or increase uninterruptedly in size. The danger of operation is menin- gitis, as the thin skull offers little resistance to infection. Sloughs of Scalp.-Prolonged pressure will often cause the scalp to slough over a small area, frequently with devitaliza- tion of the bone and formation of a small sequestrum. Treat- 428 PATHOLOGY OF THE NEW-BORN INFANT Fig. 196.-Double cephalhematoma. (£. P. Davis.) Fig. 197.-Facial paralysis (Bell's palsy) due to forceps pressure in delivery. {Budin.) INJURIES OF THE NEW-BORN 429 ment is surgical cleanliness, and the removal of the sequestrum, if it forms, but healing is slow. Bruising of the face, forehead, and neck with actual abrasion of the skin and the formation of hematomata, is not uncom- mon. It is a sequel of forceps delivery and is treated by cleanliness, boric acid ointment (gr. xx to one ounce) and cold compresses. Fig. 198.-Erb's palsy, due to'injury of the cervical roots of the brachial plexus. (E. P. Davis.) Birth palsies may affect parts supplied by any nerve on which there has been pressure or excessive traction. Facial paralysis (Bell's palsy) may be unilateral or (rarely) bilateral. It is due most often to pressure by the forceps, where the nerve leaves the stylomastoid foramen, but has occurred in spontaneous labors, or after the head has been delivered, in efforts to deliver the shoulders. The paralysis is of short duration as a rule, but may persist for long periods. Spontaneous recovery, without treatment, is the rule. 430 PATHOLOGY OF THE NEW-BORN INFANT Erb's paralysis is clue to injury of the fifth and sixth motor roots of the brachial plexus, nearly always by traction efforts in delivery of the after-coming head, or by forceps blades. It can be the result of a fractured clavicle. The arm hangs flaccid, the hand rotated inward and the thumb pointing back. Sensation is preserved, but motion lost, and muscles rapidly atrophy. Prognosis is not good. Paralysis resulting from forceps crushing is less serious than that due to traction on the after- coming head, as in the latter the nerve roots may be torn loose from the spinal cord. Unless great improvement is seen within a month, recovery is unlikely. Treatment.-Largely preventive, in avoiding undue violence in extraction. An x-ray picture is desirable, to show possible fractures or dislocations of the clavicle or humerus. Elec- tricity and massage will aid, if the nerve roots are not destroyed. Transplantation of nerves has been tried, with some success. Rupture of the sternocleidomastoid muscle sometimes occurs as a result of efforts to deliver the after-coming head. A local hematoma forms, which is easily palpable, and later the entire muscle is tender and rigid. Spontaneous recovery, without treatment, is the rule. Infection of the new-born may effect the lungs or the umbilicus. That of the lungs is called inspiration pneumonia; it is not a true pneumonia but a septic pneumonitis. Inspiration Pneumonia.-Causes.-(i) Inspiration of mucus, as in threatened asphyxia; (2) mouth-to-mouth insufflation in attempts to revive an asphyxiated child. Symptoms.-(1) High fever (105 or over) appearing on the second or third day; (2) very rapid respiration (80 to 120); (3) cough, variable but often incessant; (4) cyanosis; (5) inability to nurse and restlessness. Diagnosis is made from the symptoms more than physi- cal signs. Only a small area of the lung may be involved, MASTITIS 431 there is rarely demonstrable dulness, and there is no sputum. If a child shows a high fever within forty-eight hours of birth, especially if there has been a difficult delivery and asphyxia, the cause is almost always inspiration pneumonia. Treatment.-(i) Artificial feeding, by mother's milk drawn in a number 3 Phoenix breast pump and fed to the child with a medicine dropper. The child cannot usually nurse from the breast; (2) mustard bath for fifteen minutes every three hours; (3) brandy five drops, tincture of digitalis drop, every four hours; (4) keep child undressed, wrapped in blankets, and disturb as little as possible, except for the necessary treatment; (5) in severe cases, antistreptococcic serum, 20 mils hypo- dermically, once daily. Prognosis is grave. Relapses are common, and the mor- tality is 33 to 40 per cent. Mustard Bath.-(1) Three bedroom pitchers (about four gallons) of water at a temperature of 105° F., poured in the baby's bathtub; (2) add one tablespoonful of mustard flour; (3) hold child in this bath, immersed up to its neck, with head supported along nurse's arm, for fifteen minutes. The skin should be gently rubbed during the bath; (4) wrap in warmed blankets, and do not dry for one-half hour. Umbilical infection (omphalitis) is shown by a pouting umbilical stump, covered with a gray-green slough, and a red area around the umbilicus. The child has a high fever, and is obviously very ill. The treatment is surgical cleanliness, stimulation (brandy nv v., tincture digitalis njj-every three hours) and antistreptococcic serum 20 mils hypodermi- cally once daily. There is danger of septic infection of the blood current. Mastitis.-The breasts of both sexes, but more frequently the male, become engorged or inflamed in the first three weeks after birth. Colostrum is present from the end of the first to the third week. The breast is hard, painful, the skin red, and occasionally an abscess forms. PATHOLOGY OP THE NEW-BORN INFANT 432 Treatment.-(i) Avoidance of massage or squeezing, in an attempt to empty the glands; (2) application of leadwater two ounces, 95 per cent, alcohol three ounces; (3) oiling of skin, to relieve tension; (4) early operation, if suppuration occurs. Menstruation.-A bloody discharge from the genitalia of female children is not rare. The discharge is typical of true menstruation, but lasts only two or three days. In precocious development, however, regular menstruation has been estab- lished as early as the seventh month of infancy. No treatment is required. Mouth Infections.-A phthae are small, pearly vesicles seen in the mouth, on the gums and lips. Thrush is a coalescence of white spots, surrounded by an areola of reddened mucous membrane. The infecting agent is the saccharomyces albicans. Treatment for both is washing the mouth, gums and lips with 10 grains to the ounce boric acid solution, every three hours and also after each nursing. Ophthalmia neonatorum is infection of the child's eyes, usually, but by no means always, due to the gonococcus. Antiseptic solutions used in labor may produce an ophthalmia indistinguishable, except bacteriologically, from gonorrheal. A benign subacute conjunctivitis is often seen, affecting usually one eye, which answers promptly to irrigation by boric acid solution (gr. x to oz. j), and does not require energetic treatment. True ophthalmia begins usually forty-eight hours after birth. The eyelids are very edematous, and a copious yellow discharge oozes from between them. Gonococci can be found in the discharge. The conjunctiva looks like red velvet, and the cornea later loses its epithelium and is often ulcerated. Treatment.-If the mother is suspected of having, or known to have, gonorrhea, the vagina should be thoroughly cleansed with tincture of green soap and hot water, during the first stage of labor, and the cleansing is repeated once or twice SNUFFLES 433 until the head is on the perineum. As soon as the child is born, the eyes are washed with boric acid solution, and two drops of a i per cent, nitrate of silver solution (gr. v to one ounce) are dropped in each eye, with a medicine dropper, being careful to separate the lids and not to try and put the point of the medicine dropper between them (Credo method). If ophthalmia develops, the curative treatment is: Irriga- tion of the eyes, every two hours, day and night, with io gr. to one ounce boric acid solution; (2) cold compresses on the lids constantly; (3) twice daily instil 25 per cent, argyrol solution, or 10 per cent, silvol solution, with a medicine dropper; (4) once daily, 1 per cent nitrate of silver solution is instilled; (5) if only one eye is affected, bandage the other, to protect it; (6) watch carefully for corneal ulcer. Technic of Irrigation of the Eyes.-(1) Wrap child up to its neck in a thin blanket; (2) place two chairs facing each other; (3) sit in one chair, place child's body on the other and take its head between your knees; (3) as both hands are free, sepa- rate eyelids with one hand and inject boric acid solution with the other; (4) it is best to use a stream of solution from a saturated cotton pledget, rather than a medicine dropper, as there is then no danger of injury to the eye. Caution.-As the discharge from the eye is exceedingly infectious, and if any should get in the eyes of the person caring for the child serious ophthalmia and probably blindness would result, great care in handling should be observed. These cases are best handled only with rubber gloves. Prognosis.-Recovery is the rule, with careful treatment, without corneal opacity. Syphilis of the infant has been sufficiently considered under diseases of the fetus. Snuffles (coryza) are due usually to cold from drafts. The child's crib should be properly protected, and it should wear a cap until nature has provided sufficient hair. A coryza that is excoriating and shows crusts and irritation around the nos- trils is probably syphilitic and is treated accordingly. 28 434 PATHOLOGY OF THE NEW-BORN INFANT Hemorrhage from the umbilicus (omphalorrhagia) may occur before or after the cord has dropped off. If it occurs before the stump has dropped off, the first ligature is too loose and a second is needed. Bleeding from the umbilical ulcer is often serious. If the vessel or vessels can be seen, they may be ligated, but this is usually not practicable. A stump sufficient to tie can nearly always be pulled out of the umbilical ring, by a tenaculum, transfixed with a sterile safety-pin, and tied under the pin. If this is impossible, a pad of sterile gauze, shaped like a pyra- mid is placed in the umbilical ring, with the point of the pyra- mid down, and held by adhesive straps. As a last resort the abdominal wall may be transfixed below or above the umbili- cus, with large straight needles, and a figure-of-8 ligature tied around the needles. Horse serum is invaluable, if the bleeding is due to hemophilia or the blood is deficient in clotting power. Locally, styptics like Monsel's solution, powdered adrenalin or bismuth may be tried, but all usually without permanent effect. Omphalorrhea is a constant, or periodic, seropurulent dis- charge from the umbilicus, due to a patent urachus. Umbilical fungus is a red, strawberry mass of granulation tissue, projecting from the umbilicus. If it is cauterized with solid stick nitrate of silver, it will usually disappear. Twenty per cent, require amputation, however. If the stump of the cord persists and does not drop off, it too must be amputated. Sudden death of the child may be due to: (i) Patulous foramen ovale or other congenital heart lesion; (2) thymus gland hypertrophy; (3) cerebral injuries in birth; (4) overlying by mother in bed. These are the most common causes. Patulous foramen ovale causes what is usually called a "blue baby." The prognosis of this, as in other congenital heart lesions, is fairly good. Compensation is often established during the first month of life; if the condition persists, the child is delicate and must be managed with great care; many will die suddenly in the early weeks of life. MEDICINES IN THE NEW-BORN 435 Medicines in the New-born.-Mercury is better borne than any other drug, and can be given in large doses. Calomel gr. in divided doses of each; mercurial ointment gr. x by inunction are examples. Opium is not borne at all, even as paregoric, of which three drops have been fatal. Even the paregoric and ergot mixture given to the mother for the control of after-pains, (5ss of each to the dose-every 4 hours) has caused evidence of opium poisoning in the nursing infant. Other drugs are given in doses proportionate to the age of the child. The fewer drugs given to any new-born infant, the better. CHAPTER XIX OBSTETRIC OPERATIONS PREPARATION FOR, TECHNIC AND AFTER-TREATMENT OF OBSTETRIC OPERATIONS The preparation for obstetric operations is the same as for any plastic (for vaginal delivery) or abdominal section, with the rather important exception that most of these operations are of an emergency character, and the time for preparation is, therefore, limited. When time permits, the following prepa- ration will be found satisfactory. Preparation for Abdominal Section Day before Operation.--Urine examination, blood count and full bath. 4 P. M. Scrub abdomen and upper of thighs for ten minutes by the clock, using soft bristle brush (face brush) or gauze; after first two minutes shave completely. Rinse off soapsuds, and scrub for one minute in alcohol (95 per cent.) using fresh brush, rinse off again with sterile water, dry with sterile towel, and apply dry sterile gauze dressing with binder, covering abdomen and upper of thighs, and bandaged so that it cannot ride up. Light supper. 9 P. M. Magnesium sulphate ounce, or magnesium citrate flat 6 ounces. If nervous, veronal 10 grains. Day of Operation.-Early in morning, cup of beef tea, no- other breakfast. Two hours before operation repeat scrubbing of day before, except that shaving is omitted, and after alcohol, apply dres- sing of dry sterile gauze, held in place by same kind of binder. An hour and a half before operation cleanse lower bowel by simple enema so that last enema returns clear. 436 PREPARATION, TECHNIC AND AFTER-TREATMENT 437 Three quarters of an hour before operation give hypodermic of morphin sulphate gr. , atropin sulphate gr. 5 o • The mor- phin is best omitted in Cesarean section, the atropin alone being given. Catheterize just before etherization, and never trust to voiding. The nurse who does the scrubbing must prepare her hands and wear sterile gown and sterile gloves, as for an operation. On the table, the abdominal skin is painted with 4 per cent, picric acid in 95 per cent, alcohol, and then dried by a gauze sponge. Rubber dam used in all sections, covering the abdominal skin, and operation is done through a slit in the dam, which is sewed in the wound. In emergency cases, where time is limited, or where abdomen is very sensitive, cover abdomen, after shaving, with gauze, dripping wet with tincture of green soap, and cover with binder; after two hours, take off gauze, wipe abdomen with alcohol 95 per cent., paint with 4 per cent, picric acid solution as above, dry, and put in gauze dressing and binder. Preparation for vaginal delivery or any other vaginal manipulations, such as induction of labor, etc. 1. The pubic hair should be shaved. 2. The rectum and lower bowel should be evacuated by repeated enemas, till the water returns clear. 3. The patient is arranged in the dorsal lithotomy position, preferably on an operating table, or one improvised from a kitchen table. 4. The vulva and vagina are thoroughly cleansed with cotton, tincture of green soap and sterile hot water, and if any antiseptic vaginal douche is given, it should be followed by a douche of st-erile water, because of danger of the antiseptic fluid causing ophthalmia in the baby. 5. This cleansing is always better done under the anesthetic, especially in primiparae. If no anesthetic is used, as in the induction of labor, the vulva is carefully scrubbed and the vagina cleansed as above, in a multipara, or douched in a primipara. Proper cleansing in a primipara is almost impossible without anesthesia. 438 OBSTETRIC OPERATIONS 6. Just before anesthetization, the patient should be cathe- terized, and never trusted to void. It is most essential in forceps operations that the bladder be empty. Preparation of Private Houses for Operations.-As most of the obstetric work in general practice is done in the patient's home, the following instructions will prove of value. They are designed to meet the requirements of gynecologic opera- tions as well as obstetric. It is perfectly feasible to arrange private houses for opera- tions so that the lack of hospital facilities need not be seriously felt. An abdominal operation is, of course, more easily done and the patient more easily cared for in a hospital than at the patient's home, but even this type of operation can be ade- quately cared for at home, provided the preparation is suffici- ently well made. Ordinary operations, especially plastics for the repair of the injuries of child-birth, are satisfactorily done in the patient's home. A trained nurse, or one at least accustomed to the care of surgical cases and with a working knowledge of asepsis, is most desirable, but not indispensable, provided the physician is willing to give minute instructions as to the care required and to attend to such details as catheterization himself. The Choice of a Room.-If possible, the room should be one adjoining the patient's bedroom, and preferably not the patient's own room. The patient is thus spared the sight of the necessary preparation. The paramount question is one of light, and the opera ting-table should be so placed as to get the maximum amount, hence, near the window. The window can be screened against outside observation by cover- ing it with a single piece of gauze or by pinning together the curtains, provided they are of a material which will transmit the light without too much diminution, or even by soaping or whitewashing the panes of glass. Except for an abdominal operation it is not necessary to strip the room or take up the carpets or rugs. The floor can be protected by newspapers, thickly laid, and over these a sheet, wrung out of a i-iooo PREPARATION, TECHNIC AND AFTER-TREATMENT 439 bichlorid solution, should be spread and should be damp when the operation is begun. Any unnecessary hangings ought to be removed and the furniture moved to a part of the room where it will be out of the way and covered with sheets. The walls in the immediate vicinity of the operating- table should be protected by sheets held up by the glass-headed pins known as Moore's push-pins, and not by tacks. The pins leave no scar, as tacks do, especially in wall-paper and plaster. The Operating Table.-This should preferably be one of the models of portable, collapsible operating-tables, but this is by no means a necessity. A kitchen table with sufficient strength of legs answers every purpose. If this is used, the top must be thoroughly scrubbed and then thickly padded, as the thinly padded table is a prolific cause of backache after operations. In many operations, notably perineal opera- tions, a Kelly pad is a desirable addition; but one that will answer every purpose can be improvised by rolling up rubber sheeting at the sides and back, or even newspapers covered by towels or sheets. The special tables are provided with stirrups and leg-holders for the lithotomy position, when this position is desired. The kitchen table can be equipped with either the Edebohls' portable leg-supports, which clamp on the edge of the table, or, much better, by a rolled sheet tied about one knee, passed back over one shoulder and out under the other (so that pressure does not come altogether on the patient's neck) and fastened above the other knee. The knots should be on the outside of the legs. This makes the best leg-holder I know. If the Edebohls' supports are used, it will be found necessary to tighten the screws with a wrench (no one's fingers are strong enough), for, if the patient should strain, the leverage is enormous. If a chair or stool is needed, a piano-stool draped with a sheet is most satisfactory, but a plain chair (not too low) will answer. The end of the Kelly pad, or its substitute, should drain into a bucket or slop-jar which has been well scalded out. 440 OBSTETRIC OPERATIONS The special operating-tables have apparatus for the Trende- lenburg position; the kitchen table can be equally well equipped by raising the two legs on blocks or bricks, or even, if the extreme position is desired, on the seats of two chairs. The whole table is best draped in a sheet, although this is not essential. Fig. 199.-Lithotomy position with limbs supported by a sheet-sling. (De Lee.) Instrument- and Dressing-tables.-Two of these are required, one on either side of the operating-table. As these tables often have polished tops, adequate protection must be pro- vided. This is best done by covering the top thickly with newspapers, placing on these a large tin tray and covering all with a sheet,' draped so that it will touch the floor on all sides. This is to protect the legs and sides. Douche-bag.-This is needed in all perineal operations, and a more efficient means of splashing the wall-paper than an PREPARATION, TECHNIC AND AFTER-TREATMENT 441 improperly hung douche-bag can hardly be devised. A suit- able hook is provided, preferably in the window-frame. An open towel is placed over this hook so that the center of the towel is over the hook. The bag is hung on the hook and the towel allowed to drape down over it. This has proved an adequate protection. The douche-bag and tube are, of course, prepared by boiling. Instruments.-It is best to boil these where the physician and nurse can keep an eye on them. A large alcohol lamp and a copper tray sterilizer or basin will be satisfactory. If an alcohol lamp is placed in the bath-tub, and the instruments are sterilized there, it will guard against the danger of upsetting them and possibly a conflagration. If the instruments are sterilized over the kitchen stove, servants must be warned not to touch them. I have seen a servant dig the various instruments out of the sterilizer with a stove-lid lifter and speculate on their uses. Dressings.-For all ordinary operations the commercially sterilized gauze and cotton are entirely satisfactory. For abdominal operations the dressings should preferably be steam sterilized either in an. autoclave or even in a Rochester steam sterilizer. If the latter is used, the final sterilization should be completed just before the operation. It is not possible ade- quately to dry dressings so sterilized, and it is better to have them warm and wet than cold and clammy. Sheets and towels can be adequately prepared by freshly laundering them and then ironing with an iron hot enough to come just short of scorching them. The time-honored custom of baking in the oven of the kitchen range is useless. Such dressings are not sterile unless so scorched as to be unfit for use. For gauze sponges, I have always found the commercially sterilized gauze safe. Basins.-Unless the physician carries his own nest of basins, he must depend on the household supply. Three at least are needed and they must be boiled. Rinsing or wiping them out with an antiseptic solution is not sufficient. 442 OBSTETRIC OPERATIONS Scrubbing.-The best arrangement for scrubbing up and sterilizing the hands can be made in the bath-room. Running water and previously boiled nail-brushes are used, and to obviate stooping over, the dishes of soap, alcohol, etc., can be arranged on a bread-board placed over one end of the tub and resting on the sides of the tub. Rubber Gloves.-Steam sterilized and, hence, dry gloves are best, but this is not always practicable. Boiling is a method always available and is satisfactory. The gloves must be boiled wrapped in gauze or a towel, and should always be boiled flat so that the water can enter them. The custom of boiling gloves rolled up in a ball is a pernicious one, as the inside of these gloves is never sterile and most of the outside is open to grave suspicion. Sterile Water.-The night before operation a clothes-boiler is filled with water. In it are placed three pitchers and a dipper with a hooked handle. These are boiled for half an hour. The pitchers are hooked out of the water with the handle of the dipper and filled, and then towels are tied over their tops and they are set aside to cool over night. The next morning the clothes-boiler full of water and the dipper are boiled again. Thus by mixing the cold water that has stood over night with the hot water boiled just before the operation a supply ample for most operations is secured. In emergencies, the bottled water sold at all drug stores is adequate for the cold sterile water, except in abdominal operations. The water in the pitchers can be cooled in a reasonably short time by pouring cold water over the outside of the pitchers. Supplies Required.-The supplies needed for an ordinary operation are as follows: six sheets; twelve towels; 8 ounces of 95 per cent, alcohol; 8 ounces tincture of green soap; i pound of absorbent cotton (two half-pound rolls); one 5-yard roll of sterile gauze; one i-yard jar of iodoform gauze; one bottle of mercuric chlorid tablets; one 2-ounce bottle of glycerin as a lubricant for putting on wet gloves; two pound cans PREPARATION, TECHNIC AND AFTER-TREATMENT 443 of ether, unopened; one i-yard package of sterile gauze (for the etherizer, to avoid opening the larger package). I have this list printed on cards, and one is sent to the patient's house to guard against details being forgotten. Nurse's Kit.-I find it useful to provide the nurse who does the preparing of houses with a bag equipped with what has been found needful. This bag is small and easily carried, but con- tains eleven basins, twelve brushes, twelve pairs of rubber gloves; all the catgut used in the operation (from eight to ten boxes being carried); a Kelly pad; douche-bag; razor for shaving patients (especially in perineal operations); gown and uniform; the glass pins (three dozen) used for protective sheets, and a roll of safety-pins. It is perhaps unnecessary to point out that all visible dis- turbances caused by these preparations should be cleared away, and all soiled linen and sponges and water disposed of as soon as possible. This is particularly desirable when every- thing has been prepared in the patient's room. No signs should be left for the patient to see on recovery from the anesthetic. Preparation of the Doctor's Person and Hands.-The atten- dant on an obstetric case should wear a sterile operating suit, and not his ordinary every-day clothes; a sterile short sleeved gown (preferable to the long-sleeved gown, because certain operations (version-for instance) are impossible with a long sleeved gown-as the arm will not enter the vagina further than the end of the cuff of the glove unless arm and gown are covered by a long gauntlet glove); and sterile (either wet or dry) rubber gloves. Preparation of the Hands.-The hands should be cleansed as carefully as if no gloves were to be worn. The following method will be found satisfactory: (i) The nails are to be kept short, and smoothly trimmed. (2) Scrub for ten minutes (by the clock) with tincture of green soap, running hot water and a fairly stiff nail-brush, being careful to devote an equal amount of attention to each hand. 444 OBSTETRIC OPERATIONS (3) Scrub for one minute in 95 per cent, of alcohol, using a fresh brush. (4) If dry gloves are to be worn, the hands are dried on a sterile towel and powdered with sterile talcum. If wet gloves are used, no drying of the hands is needed. There is a greater chance of infection in obstetric cases than any other surgical case. The nearer an obstetric case is managed like a major surgical operation the better will be the immediate and remote results. Routine After-care of Abdominal Sections.-These direc- tions must be considered together with the normal routine care of any normal delivery, in a patient delivered by adominal section (cesarean section, pubiotomy or symphyseotomy). 1. Elevate head of bed on blocks twelve inches. 2. Morphin sulph. gr. % 1 . . . . 1,1/ sixth hour p. r. n. The less the Atrophm sulph. gr. >150 j better. 3. Water p. r. n. in ounce quantities as soon as nausea ceases. 4. Catheterize sixth hour p. r. n. 5. If wound sealed with collodion, take off outer dressing after six hours and put icebag over wound. Keep ice-bag on for first 3 days. 6. After twenty-four hours feed by albumen water, broth, or milk and limewater equal parts, 1 to 2 ounces every hour. 7. After twenty-four hours give enema: milk of asafetida oz. 6, Hoffmann's anodyne dram 1, water q. s. ad. 1 pint. 8. If much nausea, wash out stomach by giving 2 glasses of water with one dram of sodium bicarbonate to each glass. If this does not stop it, wash out with tube. 9. After forty-eight hours give calomel gr. every hour for six doses, followed in two hours by magnesium citrate 6 ounces. 10. After bowels move give soft diet, fifth day give light diet, seventh day give full diet. 11. If much distention, give eserin salicylate gr. )4o hypo- dermically fourth hour, and pituitrin ampule twice daily hypodermically. INDUCTION OF ABORTION 445 12. If urine output is low, give spartein sulphate gr. 1, hypo- dermically sixth hour and force water. 13. Collodion dressing off eighth day, and wound dressed thereafter every other day with dry sterile gauze. 14. As a routine laxative use compound cathartic pills, one at bed time. If too active give only half a pill. If grip- ing use A. B. S. & C. pill. The routine after-care after operative vaginal delivery is that of a normal delivery. If any stitches have been inserted, they are cared for as follows: 1. Irrigate perineal stitches with sterile water four times daily, and also after each urination or bowel movement, and keep sterile vulvar pad in place after irrigation. 2. If stitches soiled, clean with cotton on applicator and peroxid of hydrogen. 3. Vaginal douche sterile water every day after fifth day. 4. Stitches inserted directly after delivery can safely be removed on the tenth day. INDUCTION OF ABORTION Induction of abortion is the premature termination of preg- nancy prior to the sixth month of pregnancy, (or the date of viability of the child). Indications.-(i) Pernicious vomiting, where all other means of control have failed, and further delay means the death of both mother and fetus; (2) severe kidney breakdown, in early pregnancy, most likely due to a pre-existing nephritis; (3) placenta praevia, with severe hemorrhage; (4) severe con- stitutional disease, such as heart disease or tuberculosis, threat- ening the life of the mother; (5) pernicious anemia. It is wise never to induce abortion without a consultation, so that the responsibility may be shared and criticism avoided. Technic of Operation.-The method of operation varies with the date of pregnancy. The administration of abortifacient drugs, like tansy, pennyroyal, etc., is of no value. All these 446 OBSTETRIC OPERATIONS drugs are active poisons, and if given in large doses cause a severe and sometimes fatal gastro-enteritis and toxic nephritis. Pituitrin is useless. Fig. 200.-B. C. Hirst's double tenaculum for the cervix. Fig. 201.-Emmet's curet forceps. Up to the third, or possibly the fourth, month of gestation, the technic is as follows: 1. The patient is shaved and prepared locally as for any vaginal operation. 2. A general anesthetic is advisable, but as many of these patients are poor surgical risks, local anesthesia may be required. INDUCTION OF ABORTION 447 3. The patient is arranged in the dorsal position on an oper- ating or kitchen table, and not in bed. 4. The anterior lip of the cervix is caught with a double tenaculum, and the tenaculum is held by an assistant. 5. With branched dilators, the cervical canal is dilated to about one and a quarter inches trans- verse diameter, or about the size of the thumb. 6. An Emmet curet forceps is inserted in the uterus, the ovum broken up and whatever portions can be easily removed are pulled out. This step should cease as soon as the bleeding becomes free. 7. The uterus is washed out with sterile water, through a Bozemann two-way uterine douche-nozzle. 8. The uterus and vagina are packed with sterile or iodoform gauze. 9. The patient is returned to bed. 10. Twenty-four hours later the patient is again placed on the operating table, without an- esthesia. The packing is re- moved. The anterior lip of the cervix is caught with a double tenaculum. The remains of the ovum are removed from the uterine cavity with Emmet curet forceps, and the uterus washed out. 11. Repacking is not necessary, nor is curettement needed to remove the decidua. Fig. 202.-Ovum forceps to be used when the embryo is too large to be broken up easily with the Emmet curet forceps; they require considerable dilatation of the cervix. 448 OBSTETRIC OPERATIONS 12. The patient .is kept in bed for seven to ten days. It is not possible to evacuate the uterus at one sitting, without an unjustifiable loss of blood. These patients are usually bad surgical subjects, and the less prolonged the operation the better. Local Anesthesia.-Unless the patient is unruly, the opera- tion can be performed under local anesthesia. The solution used is 1-400 novocain solution, with ten drops of 1-1000 adrenalin solution to each fluid ounce of the mixture. A syringe of 10 mil capacity is most convenient, and the points of injection are: (1) Directly anterior to the cervix, at the Fig. 203.-Points of entrance of the needle in infiltration of the cervix in local anesthesia by novocain or other solutions, preliminary to dilatation or anterior vaginal hysterotomy, a, The cervix; b, anterior infiltration under the bladder; c, c, lateral infiltration; d, d, infiltration of the cervical muscle, parallel to the cervical canal; e, posterior infiltration. The crosses are the points of insertion of the needle. junction of the vaginal mucosa; (2) directly posterior to the cervix; (3) to each side of the cervix, in the lateral vaginal vaults; (4) if the cervix be considered as a clock face, straight into the cervical muscle at three and nine o'clock, parallel to the cervical canal. The solution is practically non-toxic, and large amounts can be used with impunity. When novocain cannot be secured, /3-eucain 4 per cent, or cocain 2 per cent, will be satisfactory, but must be used sparingly. Packing.-The most convenient packing is made from a six- inch gauze bandage, six yards long. The bandage is folded from each edge to the middle and then down the middle again, INDUCTION OF ABORTION 449 thus giving four layers thick, one an-d one-half inches wide, with no free raveling edge. The six yards of packing are packed in a glass tube or jar, autoclave sterilized, and used directly from the tube or jar. Plain gauze is satisfactory and much cheaper than iodoform. After-treatment is that of any plastic operation. (1) Rest in bed seven to ten days; (2) light diet; (3) bowels moved in Fig. 204.-Uterine or vaginal packing; yards of four thicknes gauze; inches wide; put up in the ordinary i yard iodoform gauze jar and autoclave sterilized. forty-eight hours by magnesium citrate six to twelve ounces, and thereafter daily laxative if needed; (4) vaginal douche of sterile water daily after the third day. Complications are (1) Hemorrhage; (2) septic infection; (3) perforation of the uterus. Hemorrhage is not likely to be severe and can be controlled at any time by uterine packing. Septic infection is not likely unless the case is already infected, or portions of the ovum left behind. The uterus is cleaned out, and douched daily, as per directions given in the local treatment of puerperal sepsis. 29 450 OBSTETRIC OPERATIONS Perforation of the uterus is not likely unless an attempt be made to evacuate the uterus, with the patient ip bed; or too much force used with the instruments. Should the uterus be perforated (recognized by the placental forceps suddenly slipping far in, with no resistance) all further attempts at evacuation should be, for the present, discontinued. The uterus is packed, the patient put to bed in the Fowler position, and no attempt made to remove the remainder of the ovum until after twenty-four hours. Then the uterus can be evacu- ated, but not douched. Abdominal section unnecessary, if this plan be followed. Hemorrhage is usually not to be feared. The method of induction of abortion described above is not possible, after the fourth month, because the fetus is then too resistant to be broken up easily. If pregnancy must be termi- nated between the fourth and sixth months, two plans are open: (i) One of the methods of inducing labor; (2) anterior vaginal hysterotomy (usually miscalled vaginal cesarean section). Both these will be described under their proper headings. INDUCTION OF LABOR The induction of labor is most common after the seventh month of pregnancy. From the fourth month on, the same indications apply as for the induction of abortion. After the child becomes viable, the indications are: (i) Contracted pelvis, provided the contraction is not of sufficient degree to demand induction of labor more than two or, at the very most, three weeks before term; (2) toxemia of pregnancy (kidney insufficiency or premonitory signs of eclampsia); (3) prolonga- tion of pregnancy (more than two weeks beyond term, provided the physical signs point to maturity of the child); (4)grave disease of the mother (tuberculosis or valvular heart disease with broken compensation); (5) habitual death of the fetus, shortly before full term; (6) placenta praevia (by one of the methods described under the head of placenta praevia). INDUCTION OF LABOR 451 Methods I. Drugs.-When a patient is at or very near term, it is possible to induce labor by means of drugs. It is worth a trial, is efficient in about 60 per cent, of cases and only at term. As a means of inducing premature labor, it is useless. If the first trial fails, it is often successful if repeated in forty-eight hours. Technic.-(i) If possible, give ten drops of tincture of nux vomica four times daily for four days previous to the day selected for induction. (2) On day selected, give calomel gr. every hour for eight doses. (3) When last dose of calomel is given, give one ounce of castor oil. (4) At time of first movement from oil, give ten grains of quinin. (5) Twenty minutes later, give 3 minims of pituitrin hypodermically; one hour later another 3 minims; one hour later another 3 minims. The second and third doses are not given if the pains are active. The method is not entirely free from danger, due to the stormy action, occasionally, of the pituitrin. This should never be given, if after the oil and quinin, the patient has begun to have labor pains. II. Krause's Method.-Flexible bougies inserted in the uterus. This method is one of the safest for the general practitioner, but is only about 80 per cent, efficient. If proper asepsis be observed, no harm can be done. The method is difficult or impossible of performance if the head be firmly engaged. Technic.-(1) The patient is arranged in the dorsal position, on a table (and not in bed), and prepared locally as for any vaginal operation. Careful scrubbing of the vagina is essential to safety. (2) An anesthetic is ordinarily not required. (3) The anterior lip of the cervix is caught with a double tenac- ulum, and held by an assistant. (4) The operator places two fingers of his left hand in the vagina, and the tips of these fingers in the cervix. If necessary, the required dilatation may be secured, almost painlessly, by branched dilators. (5) Along the groove between the fingers, are passed, one after the other, 452 OBSTETRIC OPERATIONS two number 17 (or number 6 American) French flexible silk and wax bougies. They should go straight (without coiling) between the membranes and posterior uterine wall, until only one inch is outside the cervix. (6) The vagina is packed with gauze, to hold the bougies in. (7) The patient is put back to bed. The bougies are sterilized in cold 1-500 bichlorid or 1-20 carbolic or 10 per cent, formalin. They are wrapped in gauze before being placed in the solution, as they will float, and should never be coiled up. They cannot be boiled. They must remain in the solution for at least one hour before being used. They should be limber enough to bend easily when tested, but not so limp as to be difficult of insertion; if too stiff they are liable to puncture the membranes. It is com- mon to have them tunnel under the edge of the placenta, with fairly free hemorrhage for a few minutes. The bleeding ceases quickly and is of no moment. Labor pains may be expected in half an hour to twelve hours. Usually pains begin within four to six hours, and 80 per cent, of patients are delivered within twenty-four hours from the time of induction. The bougies can be removed as soon as the cervix is well dilated and labor firmly established. If after twenty- four hours, no labor pains have been instituted, it is wiser to remove the bougies, dilate the cervix and proceed as detailed in the fifth method, described below. The commonest cause of failure is that the bougies have coiled in the cervix, instead of passing straight up between the membranes and the uterine wall. III. Boiled Rectal Tube Coiled in the Cervix.-This has the merit of being least likely of all methods to puncture the mem- branes, or do other damage, if properly used. It is not as efficient as the bougies, because it always coils up in the cervix. The method of procedure is precisely like that of the bougies, except that the tube coils in the cervix. The use of a stylet, to stiffen the tube, is not safe. The tube is INDUCTION OF LABOR 453 sterilized by boiling, and should preferably be a new one for each case. IV. Rubber bags (metreurynter) inserted in the cervix and distended with sterile water. This method is one of the most difficult in which to preserve asepsis in performance. The insertion of the bag requires considerable handling, especially as it often slips out of place and has to be reinserted several times. The efficiency is about that of the bougies (80 per cent.). The bag is supposed to dilate the cervix by hydro- static pressure, and therefore approximate nature's method. There is this important difference, however. In labor the pressure of the amniotic sac is intermittent; the pressure of the bag is constant. This constant pressure, while it dilates the cervix, causes it to become edematous, and as the bag only secures, at the most, two-thirds dilatation, the remainder is done by the presenting part, and almost always at the expense of a bilateral tear of the edematous cervix. Of the various bags described in the section on dilatation of the cervix, only two are adapted to induction of labor. These are the Voorhees conical bag, and the B. C. Hirst hour-glass or spool bag. These bags are made of canvas, covered with rubber. They become hard and brittle after a short time, and must then be thrown away. If, after use, they are dehydrated by filling with alcohol, their life may be somewhat prolonged. The disadvantages of the Voorhees bag are that it disappears entirely within the cervix and often displaces the presenting part, which may not return to the superior strait in a favorable position; it also elongates the cervix, when the required traction is made upon the filling tube. The Hirst bag does not project far enough beyond the internal os to dislodge the presenting part; the hour-glass bag is for the effaced cervix and the spool bag for the uneffaced. The medium size of either bag is best adapted for general use. Technic.-(i) The patient is arranged as for any vaginal operation, on a table, and carefully cleansed. 454 OBSTETRIC OPERATIONS (2) In primiparae anesthesia is always required, and is desirable in multiparae. (3) The bag is tested, by being filled with sterile water. If it does not leak, the quantity of water required completely to distend it is noted. It is then rolled in its long axis, like a cigar, grasped in placental forceps, and lubricated with sterile glycerin. (4) The cervix is caught with a double tenaculum and dilated with branched dilators to about the size of three fingers, or 7 c.m. transverse measurement. (5) Two fingers of the left hand are placed in the cervical canal, and the bag inserted into the cervix, along the fingers as a guide, by a rotary motion. (6) The placental forceps are removed, and the bag held in the cervix between the two fingers. (7) An assistant, with a metal piston syringe, fills the bag with as nearly as possible the previously determined quantity of sterile water. Air should never be used. (8) A hemostat is clamped on the tube, two knots are tied tightly in the tube, about three inches apart and the hemo- stat removed. (9) With the Voorhees bag, the tube is left outside, and the nurse instructed to pull gently on it, for one minute, every fifteen minutes, until the bag slips through the cervix. A weight of to 2 pounds may be attached to the tube and the pull made mild but continuous. With the Hirst bag, the tube is tucked in the vagina, and held in by packing. (10) The patient must remain in bed. The bags are sterilized by boiling. The Voorhees bag, when inserted, disappears above the internal os. It always dislodges the presenting part, and may cause serious dystocia by transforming a vertex presen- tation into a face or a shoulder. The Hirst hour-glass bag is inserted so that the constriction of the bag corresponds to the external os, when the cervix is effaced. If the cervix is not effaced, the spool bag must be INDUCTION OF LABOR 455 used, the shank of the spool corresponding to the cervical canal. It will be found necessary to add water to the Hirst bags about every half hour, as the yielding cervix permits more pressure. The bag should be kept fairly tense, and removed after four hours. By this time everything possible in the way of dilatation will have been accomplished, and unnecessary edema of the cervix avoided. In fact, labor pains often begin as soon as the bag is removed. V. Dilatation of the Cervix, Bougies and Bag.-This is the most certain and rapidly effective of all the methods. It is also a formal operation and presupposes skill in the handling of instruments, and proper equipment. About 98 per cent, of patients are delivered within eighteen hours. Technic.-(1) The patient is arranged in the dorsal position, carefully cleansed, and always anesthetized. (2) The anterior lip of the cervix is caught with a double tenaculum. (3) By branched dilators, the cervix is dilated to a transverse measurement of 7 c.m. (4) Two sterile bougies are inserted, in the manner already described. (5) A Hirst hour-glass or spool bag is inserted in the manner already described. (6) The vagina is packed with gauze and the patient returned to bed. The bag is removed in four hours and the vaginal packing changed. The bougies are left in until labor is firmly established. VI. Packing cervix with gauze is often done, but is not as efficient as any of the other methods. Pains do not usually appear until after twelve hours, and the method is effective only at term, with labor imminent. The gauze is packed loosely above the cervix and tightly in the cervix and vagina, under strict aseptic precautions, and removed when labor pains seem well established. If, after a trial of these methods, the patient does not fall in labor, or if the mother's condition is such that further 456 OBSTETRIC OPERATIONS delay is inadvisable, the following methods of accouchement force are available. (1) Dilatation of the cervix with forceps extraction. (2) Dilatation of the cervix with podalic version. (3) Vaginal cesarean section. (4) Pomeroy bag (dangerous and powerful) and forceps or version. All these methods are described under their appropriate headings. None of the above-described methods are available in placenta preevia. The technic of induction of labor in this complication is described in the chapter on hemorrhage due to placenta praevia. ARTIFICIAL DILATATION OF THE PARTURIENT CERVIX Indications.-(i) Rigidity of the cervix. (2) Any complication requiring rapid delivery. (3) Asa step in the induction of labor. In this operation a great damage may be done. It is neces- sary to choose a method with a minimum of danger of lacera- tion, or in the more violent methods, to avoid laceration if possible. A lacerated cervix opens an avenue of infection into the bases of the broad ligaments, and severe or fatal sepsis may result. The danger of laceration is greatest when the cervix is not effaced, and the more complete the efface- ment of the cervix, the easier and more complete is the dilata- tion obtained. I. Branched or Metal Dilators.-(a) Hegar's bougies are a set of metal bougies varying from the size of a lead-pencil to that of the middle of the forearm. They are inserted into the cervix one after the other, in successive sizes, until the desired degree of dilatation is reached. The cervix is caught with a double tenaculum and held by an assistant. The armamen- tarium is clumsy, heavy, hard to transport, and the method has nothing to recommend it over others to be described. Methods ARTIFICIAL DILATATION OF PARTURIENT CERVIX 457 (6) Two-bladed Branched Dilators.-The original Gau dilator has been modified by R. C. Norris, and later by the author. The instrument has blades long enough to reach through almost any cervix, even if not effaced, and the dilating force is evenly applied by a wheel-and-screw thread. It has a maximum separation of the blades of 7.5 cm., which is the Fig. 205.-Three sizes of Hegar's dilators. There are twenty-four sizes. {De Lee.) limit of safe dilatation with a two-bladed dilator. In a pri- mipara, an anesthetic is required, in a multipara none is needed. Technic.-(i) The patient is arranged in the dorsal position and the vagina carefully cleansed. 458 OBSTETRIC OPERATIONS (2) The anterior lip of the cervix is caught with a double tenaculum and held by an assistant. (3) The dilator is inserted beyond the internal os and the blades slowly separated by the screw-wheel. About twelve minutes are required safely to dilate the cervix in a primipara to the full extent of 7.5 cm.; about half this time in a multipara. Fig. 206.-Actual caliber of the smallest and one of the larger Hegar bougies, showing the amount of dilatation procurable. {American Text- book of Obstetrics.) (4) When the full dilatation is reached, the dilator is col- lapsed and removed. If further dilatation is required at once, it is best secured by one of the hydrostatic methods, as dilata- tion beyond 7.5 cm. with the branched dilators is sure to result in severe laceration, particularly if the cervix is not effaced. (c) Four-bladed branched dilators are all powerful instru- ments, and should be used only with caution. Any greater dilatation than 5 cm. is sure to be followed by extensive lacer- ations. All these four-bladed dilators are capable of securing a dilatation of 10 or 11 cm., but this is only done with serious injury to the mother, even if the cervix be effaced. The best known are the Bossi and the Dewees. The latter is the less dangerous of the two, as its blades are broader and free from the knife edge flare of the Bossi blades. The technic is the same as the two-bladed dilator; but the instrument is incomparably more powerful, and much more ARTIFICIAL DILATATION OF PARTURIENT CERVIX 459 dangerous. Nothing is gained by using the more complicated multiple bladed dilators, as the danger of laceration is not diminished by the many extra points of contact. It is safe to dilate to 7.5 cm. with a two-bladed and 5 cm. with a four- Fig. 207.-Author's dilator, closed and open. It is designed to permit a transverse dilatation of 7.5 cm., the limit of safety. The shank of the screw wheel shows the amount of separation of the blades. bladed dilator, provided the dilatation is done slowly. Beyond these limits, severe lacerations are certain. II. Manual methods are very hard physical work, unless the cervix is effaced, soft and already fairly well dilated. Unless 460 OBSTETRIC OPERATIONS the cervix is effaced, satisfactory manual dilatation is almost impossible and there is great danger of laceration. Indications.-(i) Placenta praevia, as a step in delivery by podalic version. (2) Any need for rapid delivery, after the cervix is effaced and the os already fairly well dilated. Contra-indications.-Ordinarily, rigid cervix, where the freedom from injury depends on slower methods of dilatation. The manual methods are rapid, and to be used only when time is a factor and speed in dilatation is essential. Methods.-1. Harris method where one hand only is used. This is the method to be chosen in placenta praevia, or other indication for podalic version. Technic.-(1) The patient is in the dorsal position, carefully cleansed and anesthetized. (2) The entire hand is inserted in the vagina. (3) The thumb and forefinger are inserted in the cervical canal, separated enough to introduce the third finger; then the fourth and finally the little finger. (4) The stretching of the cervix is then finished over the knuckles. The method is a powerful one, likely to be followed by laceration. 2. The Edgar method is the better, except in placenta praevia, where the hand of the Harris method acts as a sort of tampon to minimize the bleeding. The Edgar method is a powerful one, the cervix can be rapidly dilated but it is much more effi- cient if the cervix be effaced. Technic.-(1) The patient is in the dorsal position, carefully cleansed and anesthetized. (2) Two fingers of the right hand, with the back of hand up, are inserted in the vagina, hooked in the cervix posteriorly (at six o'clock on the clock face) and the cervix pulled down. (3) Two fingers of the left hand, with back of hand down, are inserted and hooked in the cervix anteriorly (at twelve o'clock on the clock face). ARTIFICIAL DILATATION OF PARTURIENT CERVIX 461 (4) By using the wrists and back of hands as a fulcrum, the cervix is dilated with the fingers, making pressure first at six and twelve o'clock, and then at three and nine o'clock. After the cervix is half dilated, pressure can only be made anteroposteriorly, as if it is attempted to make pressure laterally, the fingers will slip out of the cervix. Lacerations are common, but on the whole, this is the quick- est method of dilating the cervix, with a minimum of injury, provided the cervix is effaced. In both these methods there is more risk of infection than with branched dilators, unless rigid asepsis be observed. They involve considerable handling, but are very efficient. III. Packing the cervix with gauze, so that labor pains may come on and soften and efface the cervix, as a preliminary to more rapid dilatation is only useful when the cervix is so rigid that any attempt to dilate it would be sure to cause lacerations. The method can only be used when the necessary time can be allowed (12 to 18 hours at least), for pains to come on and effect the desired effacement. IV. Hydrostatic Methods.-The use of a dilatable rubber bag, distended with water under pressure, would seem at first the ideal way to dilate the cervix. Theoretically, it approxi- mates more closely than any other, the natural method, with the amniotic sac. Practically it has disadvantages: (1) The pressure is constant, instead of intermittent, and the cervix is always made edematous, so that the final one-third of the dilatation is done at the expense of tearing; (2) the bags require considerable handling to insert them, with the attendant risk of septic infection; (3) they are liable to slip out of the cervix, and require repeated reinsertion; (4) they are prone to leak and thus become useless: (5) those that extend into the uterus, like the Voorhees, tend to displace the presenting part and cause serious errors of presentation; (6) if left in place several hours, they become foul, and therefore dangerous. Their use is indicated where there is need for fairly rapid, even dilatation of the cervix, but where immediate delivery is not essential. 462 OBSTETRIC OPERATIONS All bags are sterilized by boiling, tested before use to detect leaks, their capacity is noted, and they are rolled on their long axes and lubricated with sterile glycerin, and inserted in the cervix held in the grasp of a pair of placental or Champetier de Ribes forceps. All patients are in the dorsal position and cleansed with extra care. Anesthesia is necessary in all primiparae, and not as a rule in multiparae. The cervix must be naturally or artificially dilated to admit about three fingers, before the bag can be inserted. The bag is inserted by putting two fingers of the left hand in the cervix (steadied by a doubled tenaculum in the hands of an assistant), and the bag, grasped in placental for- ceps, screwed rather than pushed in the cervix. The placental forceps are removed, the bag held in place between the two fingers in the cervix, while being filled. Sterile water is used to fill them, never air. The filling syringe is best a metal piston syringe, with a capacity of 150 mils. These points apply to all bags and are stated here to avoid repetition. Technic.-1. Barnes or violin-shaped bag is now practically obsolete. It is inserted so that the external os corresponds to the indentation on the sides of the bag. 2. Voorhees conical bag is used mostly in the induction of labor. The medium size is the most useful. (1) The cervix is grasped with a double tenaculum and held by an assistant. (2) The bag is inserted in the cervix, and held in place with the fingers until too well distended to slip out. It is filled fairly tense with sterile water or lysol solution {never air) and two knots are tied in the tube, one inch apart, to hold the water in. Water will leak past a single knot. (3) The vagina is packed with gauze around the tube, but the tube itself hangs outside the vulva. (4) The patient is put back to bed and the nurse instructed to pull on the tube for one minute every ten minutes until it comes through the cervix, when it is allowed to collapse and is ARTIFICIAL DILATATION OF PARTURIENT CERVIX 463 Fig. 208.-Various types of balloon dilators; a, b, Voorhees'; c, Car Braun's colpeurynter; d, Barnes'; e, Hirst's; f, Champetier de Ribes'; g, air pessary; h, Pomeroy's; i, bougie (end is closed.) (De Lee.) 464 OBSTETRIC OPERATIONS removed. This traction tends to-elongate the cervix, instead of effacing it, and the method has the danger of laceration common to all bags. 3. Hirst hour-glass or spool bags are the best of all the bags for moderate dilatation. The hour-glass bag is used when the cervix is effaced, the spool bag when it is not effaced. The medium size, with a transverse diameter of three inches, is the best for general use. The method of insertion is that of the Voorhees bag, but this bag does not disappear inside the cervix, and the uterine portion does not project far enough into the uterine cavity seriously to affect the position of the presenting part. It is inserted so that the external os corresponds to the constriction in the hour-glass bag, or the cervical canal to the shank of the spool in the spool-shaped bag. It is filled with water until tense, and extra water must be added every half hour. This can be avoided by attaching the bag to a water bottle and this in turn to a blood-pressure apparatus. The pres- sure in this case is kept at 180 m.m.; and in either case the bag is removed in four to six hours. Its only disadvantage is that it slips out of the cervix rather easily and must be watched, and it shares, with all the bags, the danger of laceration during the completion of the dilatation. 4. The Tarnier balloon and the Braun metreurynter are spherical, and more used for making pressure in the vagina in cases of prolapsed cord, while waiting for normal dilatation of the cervix, than as cervical dilators. When used for the latter purpose, they slip entirely inside the cervix, dislodge the presenting part far more than the Voorhees bag, and have no superior dilating power. 5. Champetier de Ribes bag is an enormous conical bag, with a limit of dilatation greater than the normal complete dilatation. It is inserted in the cervix, fully distended with water, and then gradually pulled through the cervix. It has no advantage over the lighter Voorhees bag, which was mod- eled on it, and has the disadvantage of excessive size. 465 ARTIFICIAL DILATATION OF PARTURIENT CERVIX 6. The Pomeroy bag is a large double bag, consisting of a cervical and vaginal portion, and designed to dilate the entire genital canal, from internal os to vulva. It is inserted in the cervix, and held in place while the cervical (upper) bag is filled to hold it in place. The larger vaginal bag is then filled, and both outlet tubes clamped with hemostats. In twenty to thirty minutes, if extra water be added to keep up the tension as the cervix yields, the cervix can be completely dilated and the child extracted with forceps or by version. It is a very powerful instrument, can inflict extensive lacera- tions, and its use should be confined to multiparse with an effaced cervix, and preferably in a breech presentation. In primiparae the danger of lacerations is too great to justify its use, except in emergencies. After-care of Bags.-After use, the bags should be washed with soap and water, the cavity rinsed out with plain water, followed by alcohol. The outside of the bag is dried and pow- dered. They are kept in boxes in an even cold temperature. By this their life may be prolonged, but, at best, they must be discarded after six or eight months. They cannot be repaired, once they begin to leak or crack. V. Forceps.-To put forceps on the child's head, through a partly dilated cervix, and by traction on the head complete the dilatation is bad obstetrics. The only justification is when there is urgent need for immediate delivery, as in fail- ing compensation or acute dilatation of the heart. It is frequently necessary, however, to apply forceps, when the cervix is three-quarters dilated and well effaced. Here the head should be held steady and the cervix pushed back over it. The only difficulty will be with the anterior lip, which should be cut if it does not yield easily. This method is much safer for the child, than to effect the dilatation solely by traction. VI. Incision of the cervix is indicated in: (i) extreme rigidity; (2) urgent need for rapid delivery. 30 466 OBSTETRIC OPERATIONS Methods.-(1) Anterior vaginal hysterotomy (vaginal cesa- rean section), described in its proper place; (2) Duhrssen's multiple incisions; (3) single incision of the edematous anterior cervical lip, which does not yield easily, though dilatation be rather far advanced. Duhrssen's incisions are made up to the vaginal vault, with blunt-pointed scissors. Bandage scissors are very useful for the purpose. If the cervix be con- sidered as a clock face, the incisions are at two, four, eight and ten o'clock. The child is extracted by forceps (version is always risky unless the cervix be fully dilated) and the placenta expressed. Bleeding is usually profuse, but can be controlled by one stitch at the upper angle of each cut, but unless the patient's condition forbids it, complete suture of the wounds is advisable, using interrupted sutures of number 3 forty-day chromic catgut. The condition of the cervix governs largely the choice of methods of delivery, and the choice of the proper method requires considerable skill and experience. The slower methods are always safer, provided the condition of the patient permits the necessary delay. THE FORCEPS Historical.-The invention of the obstetric forceps is generally credited to Peter Chamberlen, and the date about 1616. The instrument was kept as a family secret in the Chamberlen family, and four different models were finally found in the Chamberlen house in Essex, in 1813. About 1750, Smellie in England and Levret in France independently devised a similar instrument. The Simpson forceps in use today is a direct descendant of Smellie's; the Hodge forceps, from Levret's. The forceps consists of two blades, called right and left, referring to their position in the maternal pelvis. Each blade has a handle and attached finger piece for traction. The blades are fenestrated. The instrument has a cephalic curve, THE FORCEPS 467 Fig. 209.-The Simpson forceps. Fig. 210.-The light Simpson forceps with short handle. A better, safer instrument and the best for general use. Fig. 21 i.-The short Hale-Sawyer forceps for use at the pelvic outlet. This instrument is not designed for traction, but simply to lift the head over the perineum. 468 OBSTETRIC OPERATIONS to fit the sides of the child's head, and a pelvic curve, to fit the curve of the sacrum. The best forceps for general use is the Simpson. This can be used at any point in the pelvic canal. For the pelvic outlet, where a very light forceps answers every need, the Hale- Sawyer is most useful. For application of the axis-traction principle, the best is the Dewees axis-traction forceps. These Fig. 212.-Application of forceps. three answer every requirement for any point of application. The Kielland forceps, revolutionary in several details, has no pelvic curve, a shifting lock on the shaft, and is still on trial in this country, though quite warmly endorsed abroad. The chief claim is that it makes a high application much easier and more accurate. Functions of the Forceps.-(i) As a tractor, its chief func- tion. (2) As a rotator, dangerous to the maternal soft parts unless the head is on the perineum and under the pubic arch. It is not justifiable to rotate the head with forceps until it has reached this position. (3) As a lever, a use not justifiable. Pendulum motion of the head does not occur in the normal mechanism of labor, and the head should not be wrenched from side to side with forceps. THE FORCEPS 469 (4) As a Compressor.-A certain amount of compression is inevitable in every forceps delivery. It is reduced to a mini- mum by a folded towel placed between the forceps handles. Deliberate compression to reduce the bulk of the head is only done at a great risk of cerebral hemorrhage or fracture of the skull. Position of Application.-(1) To the "floating head," when the head is not yet engaged in the pelvic inlet. Except in cases urgently needing delivery and as a sequel to artificial dilatation of the cervix, this position of application should never be considered. (2) High application, where the head has engaged in the pelvis but is not yet past the superior strait. (3) Mid plane application, where the head has passed about half way between the pelvic inlet and outlet. This is the most frequent application. (4) Low or outlet application, where the head is on the peri- neum and at the pelvic outlet. Indications for Forceps.-(1) Uterine inertia; (2) rigid perineum; (3) moderate contraction of the pelvis, where delivery is possible; (4) moderate overgrowth of child, where delivery is possible; (5) any condition requiring rapid delivery, where the cervical dilatation is sufficient; (6) where the child's heart sounds become progressively slower. Good general rules are the following: (1) Where with fairly active pains, progress ceases in the second stage of labor, for over two hours; (2) where the child's heart reaches no or less, at two estimations several minutes apart, and not during a pain; (3) any complication in the second stage of labor, threatening the life of either mother or child, and demanding prompt delivery. Contra-indications are just as important as, or even more important than, the indications. (1) The cervix must be completely dilated, or so nearly so that the completion of dilatation offers no difficulty. There is no better way of causing severe lacerations, with subsequent 470 OBSTETRIC OPERATIONS cystocele and prolapse of the uterus, than traction with forceps applied through a partially dilated cervix. (2) The membranes must be ruptured. (3) The head must be engaged in the pelvis. There are exceptions to this, notably placenta praevia, when the head can be pulled down to act as a tampon to check the bleeding. (4) There must not be impossible disproportion between the head and the pelvic cavity. (5) Forceps must not be used where there is an impossible presentation, such as face or brow presentation with the chin posterior. (6) The forceps must not be used in hydrocephalus. (7) A dead child should not be delivered with forceps. Craniotomy is better for the mother. But in all cases of doubt, use the forceps. Conditions for the Use of the Forceps.-(1) Delivery must be possible, and not obstructed by too great a disproportion between the child's head and the pelvic canal, nor by an impossible presentation. (2) If possible, an accurate diagnosis of the position of the head must be made, by noting the relation of the sagittal suture to the oblique diameters of the pelvis, and the position of the anterior and posterior fontanels. In case of doubt, feeling for the child's ear often clears up the diagnosis of position. (3) The cervix must be completely dilated, or very nearly so. (4) The membranes must be ruptured. (5) The bladder must be empty. (6) The forceps must be applied according to the diagnosis of position. (7) In cases of contracted pelvis, the forceps may be used as a test instrument, to see if the head can come through. Methods of Application.-(1) Cephalic-to the sides of the child's head, after an accurate diagnosis of position has been made. This is always to be done if possible, and in this THE FORCEPS 471 position the forceps inflicts a minimum of injury. The for- ceps when applied should grasp the head just anterior to each ear, the fenestra corresponding to the child's cheek. (2) Pelvic application-where the forceps is applied to the head, in the transverse diameter of the pelvis, regardless of the position of the head. This is to be avoided, if possible, as the forceps is liable to slip and the child is sure to be injured. Pelvic application is correct in occiput in the hollow of the sacrum and where the head is distending the perineum with the occiput anterior, as in these cases the two applications Fig. 213.-Forceps properly applied to the sides of the child's head, with the occiput anterior and posterior. coincide. The forceps must always be applied with the "front" (the side of concavity of the pelvic curve) away from the perineum. Otherwise when the head rotates, the forceps will be upside down, and when the handles are elevated, the tips of the blades will cut into the rectum. Preparation of Patient and Preliminary Steps.-The patient is best arranged on a kitchen or operating table, in the dorsal position, with the knees held back by a twisted sheet leg- holder. The ordinary bed is too low for a proper direction of 472 OBSTETRIC OPERATIONS traction, unless the operator sits on the floor. The table minimizes the difficulty of the operation. Forceps should never be applied without consent. An anesthetic is always to be used, unless the patient's condition forbids its use (heart or respiratory disease) or in a multipara with a relaxed perineum, where only the short outlet forceps is to be used. The pubes and vulva are shaved, and the vulva and vagina thoroughly cleansed with tincture of green soap, hot water and cotton or gauze, as for any vaginal operation. The bladder and rectum must be empty. Except for the outlet application, the dorsal position is much the best. Outlet forceps can be applied in the lateral position. The forceps must be boiled, and the common fault of sterilizing only the blades and not the handles is to be avoided. Just before insertion both surfaces of the blade are lubricated with sterile glycerin. General Technic of Application of Forceps.-(1) Consent should always be obtained; (2) the left blade is always (or nearly always) inserted first; (3) that blade is rotated which corresponds to the oblique diameter of the pelvis in which lies the sagittal suture; (4) the patient must be catheterized. Left Occipito-anterior Position of a Vertex Presentation.- Diagnosis.-(i) The head is presenting; (2) the sagittal suture is in the right oblique diameter; (3) the large fontanel is posterior, on the patient's right, near the right sacro-iliac junction; (4) the small fontanel is anterior, on the patient's left, near the descending ramus of the pubes. Application.-(1) Two fingers of the right hand are placed in the vagina; (2) the fingers are passed far enough back to feel, if possible, the rim of the cervix; (3) the left blade of the forceps is grasped, like a pen, in the left hand; (4) the blade is inserted, with the handle held high up, and allowed to enter the vagina almost by its own weight. As it enters the handle sinks. The blade is slightly rotated outward (away from the Application of Forceps in the Different Positions THE FORCEPS 473 middle line) so as to lie flat along the curve of the sacrum, and passed into position between the cervix and the child's head; (5) two fingers of the left hand now replace those of the right hand in the vagina, and the right blade is grasped in the Fig. 214.-Left occipito-anterior position of a vertex presentation. (Dorland.) right hand and inserted similarly to the left and almost on top of it; (6) the right blade is rotated, by the two fingers inside the vagina and not by the handle, across the child's face into position on the right side of its head; (7) the handles will move back in position. If they will not quite lock, the handles are slightly depressed, and the right blade then 474 OBSTETRIC OPERATIONS slips a little farther around; (8) a folded towel is placed between the handles to prevent compression of the head, and the ends of the towel wrapped around the handles, to protect the operator's hands; (9) traction must be made moderately, in a direction obliquely downward, using only the biceps and Fig. 215.-The grip on the forceps. The lower hand is for traction and the upper partly for traction and partly to detect slipping. not all the force the operator is capable of; (io) pull in a way simulating labor pains, for a minute and then a rest of one or two minutes, allowing the forceps to spring apart; (n) traction is made by the first and middle fingers of the right hand over the shoulders on the handles, and not at the lock. The other fingers of the right hand maintain the proper compression around the handles. The left hand is fixed over the right, with the middle finger outstretched and the tip against the THE FORCEPS 475 child's scalp, to detect slipping of the forceps; (12) when the head is under the pelvic arch, the forceps' handles begin to move upward. From this point the handles describe a curve corresponding to that of the pelvic canal. The operator changes his position, to the side of the patient, and merely lifts on the forceps, and does not pull outward. The perineum is protected by the free hand, as in a normal labor, and if much Fig. 216.-The proper grip on the forceps, when the head is under the pubic arch, and distending the perineum. At this point, no outward traction is made. (De Lee.) overstretched, episiotomy is useful. This part of the delivery must not be hurried, and as the head is born, the forceps handles should be lying flat on the mother's abdomen. The rest of the delivery is like a normal labor. Right Occipito-posterior of the Vertex.-Diagnosis- (i) The head is presenting; (2) the sagittal suture is in the right oblique diameter; (3) the large fontanel is anterior, to the patient's left; (4) the small fontanel is posterior, near the patient's right sacro-iliac junction. 476 OBSTETRIC OPERATIONS Application of the Forceps.--(1) Two fingers of the right hand are placed in the vagina, if possible the tips between the cervix and the child's head; (2) the left blade of the forceps is grasped and inserted as in L. O. A. and passes into position along the right side of the child's head; (3) the right blade is Fig. 217.-Right occipito-posterior position of a vertex presentation. (DorZand.) inserted as in L. 0. A. and rotated, by the fingers internally, over the occiput into position along the left side of the child's head; (4) the same method of traction is employed as in L. O. A. except that the head is brought down on the pelvic floor in its original posterior position, and no attempt is made to rotate it as it comes down; (5) the head is now rotated, by THE FORCEPS 477 the forceps, to the anterior position; (6) as the forceps is now upside down, it must be removed and reinserted as described in the next paragraph for R. 0. A. The blades can be shifted without removal, but this is difficult and it is safer to remove and reapply them; (7) the rest of the delivery is then completed as described in L. 0. A. Fig. 2i8.-Right occipito-anterior position of a vertex presentation. (DorZawd.) Right Occipito-anterior Position of a Vertex.-Diagnosis.- (i) The head is presenting; (2) the sagittal suture is in the left oblique diameter of the pelvis; (3) the large fontanel is pos- terior, near the mother's left sacro-iliac junction; (4) the small fontanel is anterior, on the mother's right. 478 OBSTETRIC OPERATIONS Application.-(1) Two fingers of the right hand are inserted as already described; (2) the left blade is inserted into position along the sacrum and must then be rotated to its final position alongside the left side of the child's head (anteriorly); (3) the right blade is then inserted, and occupies its proper position without rotation; (4) the delivery is then completed as described in L. 0. A. Fig. 219.-Left occipito-posterior position of a vertex presentation. (Dorland.) Left Occipito-posterior Position of a Vertex.-Diagnosis - (i) The head is presenting; (2) the sagittal suture is in the left oblique diameter; (3) the large fontanel is anterior, to the mother's right; (4) the small fontanel is posterior, toward the mother's left sacro-iliac. THE FORCEPS 479 Application.-(i) Two fingers of the right hand are inserted as already described; (2) the left blade is inserted posteriorly and then rotated to its proper position anteriorly, across the child's occiput, to the right side of the head; (3) the right blade is inserted, and occupies its proper place without rotation; (4) the head is pulled down as in L. O. A. but comes down with the occiput posteriorly until it is under the pubic arch; (5) the head is then rotated anteriorly, which turns the forceps upside down; (6) it is removed and reapplied as for L. O. A. and the delivery completed. Occiput in the Hollow of the Sacrum.-Diagnosis.-(1) The head is presenting, and well down on the perineum; (2) the sagittal suture runs anteroposterior; (3) the large fontanel is anterior, under the symphysis; (4) the small fontanel is posterior, in the hollow of the sacrum. Fig. 220.-Touch picture. Occiput rotated into the hollow of the sacrum. Application.-(i) The left blade is inserted and falls natu- rally into position alongside the right side of the child's head; (2) the right blade is inserted and falls naturally into position along the left side of the child's head; (3) the forceps is trans- verse to the pelvis, yet the application is a cephalic one; (4) traction is made with the handles raised until the child's brow appears under the symphysis; (5) the operator stands to one side and depresses the handles until the face is born, support- ing the perineum with his free hand; (6) the handles are then raised, and the occiput delivered. This position puts great 480 OBSTETRIC OPERATIONS strain on the perineum. Episiotomy is always needed to pre- vent severe laceration. Unless sure of the previous position, the head should not be rotated anteriorly, but delivered as it lies, although anterior rotation and delivery entails a much less severe strain on the perineum. Forceps with the Head at the Pelvic Outlet and Properly Rotated.-Here the head is low down, the sagittal suture runs anteroposteriorly with the small fontanel anterior and the large one far posteriorly. Only the small Hale-Sawyer forceps should be used. It is applied, the left blade first, and the blades slip naturally into position alongside the child's head, so that when applied, the forceps is transverse. This is also a position where the cephalic and pelvic applications of forceps coincide. No traction is required; the head is shelled out of the pelvic canal by an upward movement of the handles, in a continuation of the curve of the pelvic canal. All out- ward traction is to be avoided, as it will only do harm. Doubtful Positions.-When the patient has been long in labor, there is usually such a large caput succedaneum that accurate diagnosis of position is very difficult or impossible. In such cases the hand may be inserted in the vagina and the entire head palpated. Feeling for the ear and noting its direction of facing will sometimes be of help. If no diagnosis of position can be made, and the forceps must be used, the instrument should be applied in the right oblique diameter, as most presentations are in this diameter. Removal of Forceps.-When it becomes necessary to remove the forceps, two fingers of one hand should always be between the blade and the vaginal wall. The dull blade can cut the distended vaginal wall deeply, if this precaution is neglected. Points of Safety and Danger in the Use of Forceps.- (i) An accurate diagnosis of position must be made, and the forceps applied accordingly. Forceps of any kind should never be used until the bladder has been emptied by a catheter. The urethra will always be somewhat elongated, and a silk or linen or fairly large caliber THE FORCEPS 481 soft rubber catheter is to be employed. Even if the head is very low down, the patient can always be catheterized by placing the finger of one hand between the head and the anterior vaginal wall, and with this finger guiding the catheter upward and slightly forward into the bladder. It should never be trusted to the patient to void; the catheter is the only safe plan, and neglect of this may result disastrously. (2) No traction must be made unless the blades will lock. (3) Difficulty will sometimes be met in rotation of the blades, because the tip of the blade strikes the child's shoulder. This difficulty must be overcome by the fingers pressing on the blade internally, and never by forcing it around by the handle. (4) A folded towel must always be between the handles, when traction is made, to prevent undue compression. (5) Traction must be made simulating labor pains, allowing the blades to spring apart between pulls. (6) The forceps must never be wrenched from side to side, nor must the handles be raised until the head is on the perineum. No movement is permissible that does not occur in the normal mechanism of labor. (7) If the cervix is not completely dilated, the head must be held stationary with the forceps and the cervix pushed back over the head. Traction on an imperfectly dilated cervix is one of the best ways to tear it, produce cystocele and later prolapse of the uterus. (8) Never continue pulling on the forceps, if it begins to slip. Reapply it properly or use another model, as if the forceps slips off, severe injury to the pelvic floor, bladder or rectum is certain. (9) As the forceps causes partial correction of the normal flexion of the head, larger diameters are involved in its passage through the birth-canal, and laceration is much more likely than in a normal labor. (10) Traction is made in a direction obliquely downward, until the head is on the perineum. For this the operator must be seated-on a chair if the patient is on an operating 31 482 OBSTETRIC OPERATIONS table; on the floor if she is on the usual low bed. Only the force of the biceps should be used. To brace the feet and pull with all one's strength is brutal and murderous. When the head is on the perineum, and the handles begin to turn up of their own accord, he must stand, to one side of the patient, and the forceps grasped at the lock with the little finger between the shanks of the forceps. All outward traction is now abandoned; the head is lifted over the perineum and the forceps handles carried toward the patient's abdomen. (n) When properly applied, on the average size head, the handles should be almost together. Wide separation of the handles indicates improper application or a very large head. As the head is born, the occipital protuberance should be just under the mother's urethra, and the forceps perfectly transverse. (12) Plenty of time must be taken. In a primipara, the usual time for delivery in a mid forceps operation is thirty to forty-five minutes. (13) Heavy forceps should never be used when the light Sawyer one will do. At the outlet, unless the head is rotated in the hollow of the sacrum, only the Sawyer forceps may be used. (14) The Sawyer forceps may be used with the patient lying on her side. The dorsal position is best for all other applications. (15) Episiotomy is practically always necessary, in primiparae at least. The oblique cut is usually better than the median, as there is less risk of injuring the sphincter, although it is slightly more difficult to repair. (16) The child's heart sounds should be watched in all for- ceps deliveries, as it may be necessary to hurry delivery if progressive slowing of the heart shows asphyxia. Forceps in Abnormal Presentations.-(1) In face presenta- tions, the forceps had better be used as a rotator only. In posterior positions of the face, traction should never be made; in anterior positions traction is permissible, but risky, as sudden slipping is common. THE FORCEPS 483 (2) In brow presentation, the management is the same as in face presentation. (3) In breech presentation, the forceps may be used to extract the breech, but there are better methods. The forceps is liable to slip off, severely injure the mother, and fracture of one or both of the child's femora or of its pelvis are common. (4) Forceps may be required to extract the after-coming head. The child's body and arms are held up, the forceps applied to the sides of the head, and the head delivered by carrying the handles upward. Severe perineal injury is likely, unless episiotomy is done, but it is sometimes impossible to deliver the head in any other way. The Sawyer forceps should be used if possible, and the need for hurry in delivery is past when the face is born. Prognosis of Forceps Operations.-For the mother the great- est dangers are severe laceration, hemorrhage and infection. The higher the application the greater the likelihood of injury. The cervix is often badly torn, cuts of the anterior vaginal wall, even involving the bladder, are not rare. The pelvic floor is nearly always more or less torn. The traction often causes rapid development of a cystocele or prolapse, even when no injury has been evident at the time of delivery. The sym- physis may separate, or the sacro-iliac joints be sprained, particularly in justo-minor pelves. Fracture of the coccyx is common. If the forceps slips all these accidents are intensified. For the Child.-Asphyxia; compression of the skull with intra-cranial hemorrhage; actual fracture of the skull; injuries to the eyes (bruising cataract, retinal hemorrhage, exophthal- mos); injury to nerves causing ptosis or Bell's palsy; bruising and cuts anywhere on the scalp or face; cephalhematoma. Children born with forceps are much more liable to asphyxia and inspiration pneumonia. The forceps, properly applied, causes the risk to the baby to be at least trebled, over a normal labor. Improperly applied and used, it is murderous. Axis-traction Forceps.-The principle of the axis-traction forceps is to make traction on the head downward and back- 484 OBSTETRIC OPERATIONS ward at the superior strait, coincident with the axis of the pelvic canal. Models.-(i) The American forceps-Dewees-much the best of all; (2) the French model, the Tarnier; probably the Fig. 221.-The Tarnier axis-traction forceps. (American Text-book of Obstetrics.) Fig. 222.-The Dewees axis-traction forceps. The least dangerous of these instruments. one in most common use, but a bad instrument; (3) the Ger- man model-the Breus and (4) the English or Milne-Murray. THE FORCEPS 485 The axis-traction instrument is very powerful, and great damage can be done by its unskilled use. The Dewees forceps has a fixed handle, and the traction is thereby applied at a proper angle. All the others depend upon bars attached half way up the blades, and unless the traction be applied with the rods widely divergent from the blades and handles, it is impossible even to approximate the proper line of traction. The forceps should never be used unless the patient is on kitchen or operating table, and the Dewees instrument is the one least likely to do severe damage. Indications- (i) To complete engagement of the head in pelvis whose conjugate at the brim is not less than 8 c.m.; (2) in a case of hurried delivery, where the child must be extracted quickly. Application.-In contracted pelvis, the head is trying to engage in the inlet, and lies transverse. If the forceps is applied transversely, one blade lies squarely over the child's face. This is not recommended. It is not practicable to apply the blades to the sides of the head, as by this the axis- traction principle is lost. They must be applied obliquely- one over the malar bone and the other to one side of the occiput. To do this, the blade must be rotated that cor- responds to the oblique diameter in which the head will lie, after it enters the pelvis, always assuming that the occiput rotates anteriorly. For instance, if the head is transverse and the occiput to the left, the head will lie in the right oblique diameter after it enters the pelvis, and the right blade is the one rotated. After the forceps is in position and locked, traction is made, simulating labor pains, for not more than a total of four or five traction efforts. If this shows no advance, nothing is gained by continuing. The forceps should be removed and the patient delivered by version, cesarean sec- tion or pubiotomy. During traction, the perineum, with all except the Dewees instrument, must be protected by a Sims' speculum. 486 OBSTETRIC OPERATIONS If engagement of the head is completed, three courses are open: (1) Remove the axis-traction instrument and substitute the less powerful Simpson forceps-much the better plan. (2) Complete the delivery with the axis-traction instrument without the rods or traction bar. (3) Remove the forceps and allow the patient to deliver herself-decidedly a bad procedure. It is questionable whether the use of axis-traction forceps to secure engagement of the head is ever a justifiable procedure. If the head cannot be engaged by proper traction-downward, of the Simpson forceps, it is unlikely that the greater force of the axis-traction forceps will succeed without injury to the child or to the maternal structures. The instrument, even the Dewees, is too powerful for safety, and its use is becoming, fortunately, less frequent. A head which will not spontaneously enter the pelvic canal, should not be dragged in. In this type of case, the Kielland forceps is advocated. Due to the shifting lock, the blades can be applied to the sides of the child's head at different levels-a condition made necessary by the exaggerated lateral inclination of the head. It is claimed that the blades of the Kielland forceps will make possible the engagement of the head when no other forceps can be made to hold. It is not advisable to try to use a makeshift instrument, with holes bored in the blades through which tapes are threaded, to make the necessary traction. VERSION This procedure means the changing of the position of the fetus from an unfavorable to a more favorable one, or for purposes of delivery. It varies from a simple correction of flexion or position of the head to a complete reversal of the child (from head to breech or vice versa). VERSION 487 Indications.-(i) Occipitoposterior positions, to be rotated anteriorly at the superior strait; (2) face or brow presentations to be changed into a vertex; (3) breech presentations, to be converted into head presentations, by external manipulations alone; (4) transverse presentations, brought down by the breech (podalic version); (5) contracted pelves, with conjugate not under 8 cm., as an operation of choice; (6) any case requir- ing rapid delivery, where the cervix is dilated sufficiently, or is easily dilatable (such as placenta praevia). Strictly speaking, version is turning of the child, so that the pole opposite the one originally presenting is brought down. Contra-indications.-(1) A tetanically contracted uterus with a high contraction ring; (2) very firm engagement of the presenting part; (3) an impossible pelvis; (4) a gigantic child; (5) long-ruptured membranes, usually coincident with a tetanically contracted uterus; (6) an undilated cervix (for podalic version). Methods.-(1) Postural, where errors of flexion may some- times be corrected by the position of the patient; (2) external manipulation alone; (3) internal manipulation alone; (4) combined external and internal manipulation. Version is said to be cephalic, when the head is brought down, or podalic, when the foot is brought down. Technic.-(1) Errors of rotation (persistent occipitopos- terior) or errors of presentation (face or brow) may be corrected by arranging the patient in the dorsal position, preferably on a table, and under deep anesthesia. After proper preparation, the whole hand is inserted in the vagina, and aided by the free hand on the patient's abdomen, the head is pushed out of the pelvis and rotated into the desired position. For this complete dilatation of the cervix is essential, as the head will not remain in its new position unless pulled in the superior strait with forceps. The method is urgently needed in mento- posterior position of a face or brow; otherwise it is a matter of election, to be done only when difficulty is feared. 488 OBSTETRIC OPERATIONS Cephalic version is most often required to change a breech to a vertex presentation. It is only possible before labor has begun, and with unruptured membranes and a uterus not prone to contract upon handling. It is done by external abdominal manipulation, pushing up the breech as the head is pulled down. Failures are common, and when successful, longitudinal pads and a binder are required to prevent, if possible, a return of the child to its original position. Postural version is used to correct, if possible, errors of flexion, as in brow and face presentations. By turning the patient to one side or the other, it is possible, but not likely, that the presentation may be converted into a vertex. Podalic version is most frequently indicated in transverse presentations. If the arm be prolapsed, it must be carefully cleansed and returned to the vagina. Before attempting podalic version, the cord should be palpated, to see if the child is alive or dead. If dead, decapitation is the proper procedure and not version. Podalic version must never be done if the lower uterine segment is overdistended, with a high contraction ring, and the uterus tightly moulded around the child's body. Rupture of the uterus is sure, if version be done in such a case, and not unlikely even in a case apparently favorable. Technic.-(i) The patient is arranged on a table, properly cleansed, and anesthetized. In all cases, the operator should wear long gauntlet gloves, reaching to the elbow. (2) The prolapsed arm, if any, is cleansed and returned to the vagina. A fillet may be placed around the wrist and the arm thus prevented from returning into the uterine cavity. (3) The hand which midway between pronation and supi- nation corresponds with its palmar surface to the child's abdomen, is inserted into the uterine cavity. (4) The anterior foot is sought and by traction on the foot and ankle, the child's body is turned around. In this proce- dure, it is important to see that the child is not brought down astride of its cord. It is not usual to bring down both feet. One gives ample hold for traction; it is unnecessary to make THE POTTER VERSION 489 prolonged uterine search for the other foot. Bringing down the anterior foot secures anterior rotation of the breech, and the other leg makes extra bulk for further dilatation of the cervix. But if the cervix is completely dilated, bringing down both feet often makes the delivery easier. (5) As soon as the knee is outside the vulva, the operation of podalic version is completed. The case is then managed like an ordinary breech. (6) Traction on the leg should be cautious and gentle. It is easy to fracture the child's femur. After every podalic version, the uterus should be examined for possible rupture, and it must be remembered that podalic version is not a safe method of delivery for the child, even when the cervix is com- pletely dilated. THE POTTER VERSION Dr. I. W. Potter of Buffalo advocates a technic for version widely different from the preceding. He, in an enormous experi- ence, advocates it as a routine method of delivery in every case, claiming thereby fewer injuries to the maternal soft parts, abolition of the second stage of labor and greater safety for the child. Whatever the final judgment may be as to its use as a routine method of delivery, the technic evolved is admirable. Technic.-(i) The patient is arranged, on a table, in a modified Walcher position, anesthetized to the stage of surgical anesthesia and the bladder emptied of all urine. (2) The tissues of the vagina and pelvic floor are ironed out by firm stroking, from above downward, by one finger, then two, three and four fingers, and finally the whole hand. Tincture of green soap is freely used as a lubricant. (3) The cervix, which must be obliterated and soft, is still further stretched with the fingers. (4) The left hand is then carried into the uterus and the mem- branes separated from the uterine wall, quite high up, avoiding, however, the placental area. 490 OBSTETRIC OPERATIONS (5) The child's position, size and relation to the pelvic cavity is now definitely established, by the hand in the uterus. (6) The membranes are ruptured high up, and a towel wrapped around the operator's wrist, to catch all fluids. Fig. 223.-Modified Watcher position used in Potter version, when assistants are available. (Potter.) (7) The child's arms are then folded over its chest. This is to prevent their being carried up above the head when the body is being extracted. (8) Both feet are grasped between the first and middle finger of the left hand, and by gentle traction, assisted by an upward push, by the external hand, on the head in the iliac fossa, the feet are brought down to the vulva. (9) By gentle traction the body is then brought into the vagina, and the buttocks emerge from the vulva, the child's abdomen being anterior, under the symphysis. (10) The body is now rotated, in the direction which it tends to assume, until the anterior shoulder can be brought under the symphysis and the scapula emerges. The corresponding arm then drops out unaided. THE POTTER VERSION 491 (11) The body is rotated, by the operator's grasp on its chest, through 180 degrees, until the other shoulder is exposed under the symphysis and delivered in the same way. (12) The child's head is then delivered as in any breech pres- entation, slowly and gently, by the operator carrying the body upward, with two fingers in the child's mouth to maintain flexion (and not as tractors). Fig. 224.-Modified Walcher position used in Potter version, when no assistants are available. (Potter.} Essentials of Technic.-(i) The cervix must be completely obliterated and dilated, or so soft that complete dilatation is easily attained. (2) The left hand is always used, regardless of the child's position. (3) After proper skin preparation, the operator's hand and forearm is encased in a long gauntlet glove. Short gloves cannot be worn. 492 OBSTETRIC OPERATIONS (4) Surgical anesthesia is necessary. (5) The modified Walcher position, with thighs slightly separated and almost parallel to the trunk, is essential. (6) There is no need of haste or violence at any stage of the operation. Differences in Technic, Compared to the Older Operation. (1) Modified Walcher position. (2) Traction on both feet. (3) Delivery of abdomen anterior, under the symphysis. (4) Delivery of shoulders anterior, under the symphysis. (5) Preliminary ironing out of the vagina and perineum. (6) High rupture of the membranes, to retain as much liquor amni as possible. (7) Folding the child's arms across its chest. EXTRACTION OF THE BREECH Indications.-(i) Where ample time has been allowed, and the breech is not yet on the pelvic floor, and progress has been arrested; (2) any condition in mother or child indicat- ing hurried delivery. It must be remembered that complete effacement, dilatation and paralysis of the cervix is essential for the safe delivery of the after-coming head. Delivery in a breech is a much more simple procedure when it has not been interfered with prematurely. Methods.-I. Decomposition, where one leg is pulled down and used as a handle for traction. Technic of Decomposition.-(1) The patient is arranged across the bed, with his hips over the edge of the bed, or better on a table. (2) For primiparae, anesthesia is necessary. (3) After proper cleansing, one hand is inserted along the child's body, and the anterior foot is sought. The leg is bent at the knee and by traction the foot is delivered across the child's abdomen and pulled outside of the vulva, until the EXTRACTION OF THE BREECH 493 knee is born. The second leg is left alone, to add to the bulk of the breech, for efficient dilatation of the cervix. (4) Too active traction is likely to fracture the femur. Decomposition is not possible if the breech is far down the pelvic canal. It is, when possible, much the best method, except when the child is dead. II. Manual Method.-Applied in two ways: (1) Under anes- thesia, the whole hand is inserted in the vagina, the child's breech is grasped with the index finger over the crest of one ilium, the ring finger over the crest of the other ilium and the middle finger outstretched along its spine. The position is very fatiguing and the method is of doubtful utility. (2) One index finger is hooked in the child's groin, and trac- tion is made, as with a hook. The direction of pressure should be toward the child's abdomen, and away from the femur, to lessen the danger of fracture. During traction, the wrist is supported with the other hand closed around it. As the opera- tion is very tiring, the hands may be changed from time to time. III. The Fillet.-This is a bandage, four or six inches wide, passed between the thighs, over the back and down again between the thighs. The pressure must never be on the abdo- men. It is a most efficient method, when once applied, but is exceedingly awkward to apply. The bandage is passed either with the hands, which is very difficult, or with a fillet carrier, like an enormous aneurysm needle. A fillet carrier with a sliding tip, like a Bellocq's canula, makes the applica- tion much easier, but in any case it is impossible without anesthesia. IV. The forceps may be applied to the breech, but this is done with considerable risk of slipping, and danger of fracture of the pelvis or femur. If the forceps holds, the method is efficient. V. Blunt hook is best confined to dead children or those where all other means to extract the breech have failed. It is a heavy steel hook, which is passed over the thigh at the groin, and by which the breech is drawn out. It is exceedingly 494 OBSTETRIC OPERATIONS efficient, but there is considerable risk of perforating the groin, and almost a certainty of fracturing the femur. EXTRACTION OF THE AFTER-COMING HEAD (1) Wigand Method.-Child astride of forearm, forefinger in mouth to maintain flexion, the child is carried up over the mother's abdomen, aided by suprapubic pressure on the head. (2) Mauriceau Method.-Same as the Wigand except that the pressure on the head is infrapubic, under the symphysis, with the middle finger against the child's occiput. Care must be taken not to get the finger under the edge of the symphysis or a broken phalanx may result when the body of the child is carried upward. (3) Prague Method.-The child is grasped by the feet, in one hand, and the fingers of the other hand placed over the neck. By using the whole body as a lever, the child is turned up over the mother's abdomen. This is a very powerful method, and likely to result in considerable perineal laceration. (4) Forceps.-The body and arms are held up by an assis- tant. The forceps applied and the head shelled out by elevat- ing the handles and not by traction. The forceps should always be ready for use, in any case of breech presentation or version, as it may be impossible to dislodge the head without it. (5) Deventer Method.-The child is pulled straight down toward the floor, without previously disengaging the arms. This method is only possible in premature children, or in women with very large pelvis and relaxed pelvic floor. In all these methods, force must not be used. There is danger of rupturing the cervical roots of the brachial plexus, fracture of the clavicle, fracture of the neck or even detachment of the head from the body. If moderate traction does not suffice, and the forceps will not dislodge the head, craniotomy is required. Nothing is gained by excessive traction, as the child is sure to be badly injured or killed. If sufficient force EMBRYOTOMY 495 has been used to fracture the spinal column, and the neck sud- denly begins to stretch alarmingly, all traction should cease and craniotomy be done. Otherwise the head will be pulled off -an accident for which there is no excuse, except in a dead, macerated child. If the head is detached, the neck should be caught firmly with a volsellum and the head delivered by craniotomy. EXTRACTION WHEN THE CHIN IS ANTERIOR If the chin is anterior, which rarely happens, the body is carried up if the chin is above the symphysis and the head extended; is carried down if the chin is under the symphysis with the head flexed. EMBRYOTOMY Embryotomy is a generic term, describing several different mutilating operations on the child. These are: (1) crani- otomy; (2) decapitation; (3) amputation of extremities; (4) evisceration; (5) cleidotomy. The indications for all these naturally differ considerably. Craniotomy Indications.-(i) Where the child is dead, with or without a contracted pelvis; (2) impacted face presentation with the chin posterior (here the child is usually dead; if not, pubiotomy or extraperitoneal cesarean section is better); (3) hydrocephalus; (4) on the living child, it may be considered as a means of delivery when any other means is not available, but should be very rarely needed. Technic.-(1) The patient is arranged in the dorsal position on a table, prepared as for any vaginal operation, and fully anesthetized. (2) The child's scalp is caught firmly with a heavy volsellum, by which an assistant steadies the head. 496 OBSTETRIC OPERATIONS (3) The skull is perforated through a fontanel, suture or bone, by means of a long-handled, sharp-pointed scissors. There are many special perforators made, the best of which is the Blot, but they are expensive and not as efficient as the scissors. Care must be taken to see that the perforating instrument enters the cranium, and is not deflected by the skull. This is much more likely to happen with the perforator than with scissors. (4) The hole in the cranium is then dilated with an ordinary Wathen uterine dilator, to get room to insert the cranioclast. It is not necessary nor advisable to waste time washing out the brain. This will come out as the head is pulled upon. (5) The Braun cranioclast is next inserted, the solid blade inside the skull, screwed moderately tight, so as to get a firm hold, and the head delivered as with ordinary forceps. If the Pig. 225.-Braun's cranioclast. {American Text-book of Obstetrics.) instrument is screwed too tight, it will bite pieces out of the skull like a ticket punch, and if this occurs several times, it adds considerably to the difficulty by not leaving enough for a firm hold. Above all, it must be so applied that the cervix is not included in its hold (6) As soon as the head is delivered, the cranioclast is removed, and the perforator inserted into the medulla at the foramen magnum. This is important particularly in hydrocephalus, as the child might breathe or even cry after birth. (7) The rest of the body is then delivered as in any normal labor. If great difficulty be experienced with the shoulders, EMBRYOTOMY 497 a blunt hook may be used in the axilla, or one or both clavicles cut. (8) If craniotomy is done in a contracted pelvis, or if the child be very large, the cranioclast may not be able to extract the head. In this case, it must be crushed by a cephalotribe, of which the best is the Tarnier. The central spike is inserted in the head, and the heavy forceps applied transversely. The head is then crushed and delivered. This instrument is expen- sive and not likely to be found outside of maternity hospitals. A fairly good substitute is the Tarnier axis-traction forceps, with the blades screwed as close together as possible. If the cranioclast tears off once or twice, sharp spicules of bone are likely to protrude from the wound in the cranium. These should be looked for and removed, before the head is brought down. If the cranioclast fails, and no cephalotribe is available, the head may be delivered by two heavy volsella, taking firm grips of the bone and scalp, and applied one alter- nately above the other as the head is brought down. Craniotomy is sometimes needed in the after-coming head. In this case the skull is perforated through the roof of the mouth or through the foramen magnum. Witfi the head open, it can be delivered with forceps as it collapses. In these cases the body must never be cut away from the head, as the body is a very convenient handle, and if the head is freed, it usually retreats in the uterine cavity; the necessary craniotomy is thereby made much more difficult. If this has happened, the stump of the neck is caught with a volsellum, the head thereby steadied, the skull perforated where it can be most easily reached, and the cranioclast inserted. The head is then extracted by combined pull on the volsellum and cranioclast, so that the neck is brought down first, to avoid tearing of the uterus and vagina by sharp edges of bone. After every craniotomy, the uterus should be washed out, on account of the amount of handling necessary, and examined for possible injury. 32 498 OBSTETRIC OPERATIONS Decapitation Indications.-Shoulder presentation, impacted, with high contraction ring and a dead child. If the child is alive, and in good condition, and the contraction ring is so high that podalic version is not to be considered, cesarean section should be done. The diagnosis of the child's condition is made by palpation of the cord, under proper aseptic precautions. Technic.-(i) The patient is arranged on a table, in the dorsal position, properly cleansed and anesthetized. (2) If the arm is prolapsed, it is cleansed, wrapped in wet sterile gauze, a fillet is put around the wrist and the arm is not replaced in the vagina. (3) The entire hand is placed in the vagina, and two fingers locate the neck. (4) The head can be amputated by a Braun hook, sharp on the inside, or a Ramsbotham sharp sickle-shaped knife, or a wire saw. These methods are not necessary; much the best way is as follows: A piece of heavy string (fish line) or umbilical tape, three feet long, is boiled. A small loop is made in one end, and this loop slipped over the end of the middle finger. The whole hand is inserted, the fingers carried over the neck from behind, reaching as far around the neck as possible. The finger is then worked out of the loop, leaving the string in situ. The fingers then reach around the neck from in front, the loop is caught and the string pulled around the neck and outside the vulva. The neck is now sawed through, with the greatest ease and rapidity, the spinal column offering no obstacle. This method is infinitely quicker, easier and neater than any other. (5) When the head is severed, the body is delivered first by traction on the prolapsed arm. It is impossible to deliver the head first, and no attempt should be made to do it. (6) The whole hand is inserted in the uterus, the head grasped by putting two fingers down the mouth, the thumb on the stump of the neck. The head is brought through the inlet in an oblique diameter, aided by suprapubic pressure, rotated EMBRYOTOMY 499 anteriorly and delivered. If the pelvis is contracted, the head may have to be crushed, but this is very rarely necessary. After the placenta is extracted, the uterus should be examined for possible rupture, and the cavity thoroughly douched with lysol solution, 1 dram to 2 pints, on account of the excessive handling. Amputation of Extremities This is necessary only in monsters. The arms and legs are removed with scissors, until the bulk of the child is reduced sufficiently to permit its delivery. Evisceration This is required only in monstrosities or in unusual presen- tations, such as abdominal, where the child is dead. The abdomen and chest are opened with scissors, the thoracic and abdominal contents removed manually, the back broken and the child delivered if necessary by morcellation. Cleidotomy Cleidotomy or cutting of the clavicles is not often required. Indications.-(i) Impacted shoulders, in very large chil- dren, after delivery of the head; (2) after craniotomy; (3) in anencephalic monsters, who often make up, in breadth of shoulders, what they lack in head. Technic.-(1) The head is pulled downward, to put the neck on a stretch, but if the child is alive, not sufficiently to endanger the cervical roots of the brachial plexus; (2) the anterior clavi- cle is located and with scissors is cut about its middle. It is rarely necessary to cut both; (3) after delivery, the skin wound is sutured and the case treated as one of fractured clavicle. Theoretically there is some danger of injury to the cervical roots of the brachial plexus and the subclavian artery. Prac- 500 OBSTETRIC OPERATIONS tically, as the shoulders are compressed in the pelvic canal, the clavicles are bowed outward, away from the vessels and nerves, so the danger is not great, with reasonable care. Symphyseotomy (often called Sigault's operation) is the cutting of the symphysis, to allow expansion of the pelvis and vaginal delivery of the child. Its one time popularity was due to the high mortality of cesarean section, in the pre- antiseptic days, and has been waning since the improvement in the methods in cesarean section. The operation is contra- indicated in pelves whose conjugate is less than 7.5 cm. at the brim. If section of the pelvis be desired, pubiotomy is better. Indications.-(1) As an elective operation in contracted pelves whose conjugate is not less than 7.5 cm.; (2) in trans- versely contracted pelves whose transverse of the outlet is not less than 6 cm.; (3) in cases of impacted face presentations with the chin posterior, where the child is alive. Technic.-(1) The patient is prepared both for abdominal section and plastic operation, arranged in the dorsal position and anesthetized. (2) A small incision is made just above the symphysis (Italian method and the best) or over the joint (French). (3) The pubic attachment of the recti is then cut trans- versely, enough to get one finger behind the symphysis. (4) A metal catheter is passed into the urethra and by downward pressure the urethra is held out of the way. (5) A curved Galbiati knife is passed under the symphysis and the joint severed. Usually the subpubic ligament must be severed separately. (6) The very free hemorrhage, from the crus clitoridis, is checked by packing the wound with sterile gauze. (7) The patient's pelvis is supported by assistants, and the child's head is drawn slowly through the pelvis by forceps, or the case is left to nature. The latter is the safer plan. SYMPHYSEOTOMY PUBIOTOMY 501 (8) As soon as the child is delivered, the patient's thighs are brought together. (9) The wound is explored with the finger, after the packing is removed, to see that the bladder is not nipped between the edges of the cut bone. (10) It is not necessary to wire the symphysis. (n) The wound is closed with silkworm-gut sutures, and the pelvis supported by a broad adhesive strap, encircling it. After-care.-The after-care is difficult and troublesome. The patient's pelvis is kept immobilized by adhesive straps or a laced canvas binder, and she must lie on a mattress free from sagging, or on a Bradford frame. Dangers.-(1) Hemorrhage, from the vesical plexus and the crus clitoridis; (2) injuries to the bladder and sacro-iliac joints during delivery; (3) non-union of symphysis; (4) infection of wound. After the vaginal work has been completed, the symphyseal wound is handled only with fresh sterile instruments and fresh gloves. PUBIOTOMY (HEBOTOMY; HEBOSTEOTOMY; EXTRAMEDIAN SYMPHYSEOTOMY) If the pelvis is to be cut, this is the better operation. The principle is cutting the pubis, midway between the symphysis and obturator foramen, on the side on which the child's occiput is, and preferably allowing nature to finish delivery, rather than terminate the labor by forceps. Indications.-(i) As an elective operation in contracted pelves, whose diameters are not less than 7.5 cm. conjugate or 6 cm. transverse of the outlet; (2) impacted face, with chin posterior, and a live child. Technic.-(1) The patient is prepared as for abdominal section, and also for vaginal delivery, arranged in the dorsal position, and anesthetized. (2) A small incision is made just outside the pubic spine, on the side on which is the child's occiput. 502 OBSTETRIC OPERATIONS (3) A large Doderlein needle, with a hook instead of a point, is passed around the bone, hugging it as closely as possible. Here delivery is possible, due to the long posterior sagittal diameter. Pig. 226.-Line of section in symphyseotomy and pubiotomy and the type of pelvis in which these operations are indicated. (4) The labium on the same side is pulled as far as possible across the vulva, to allow the point of the needle to emerge PUBIOTOMY 503 as far as possible from the vulvar orifice. The skin is nicked and the needle emerges. (5) A Gigli wire saw is attached to the needle, and pulled back along the track through which the needle passed. (6) The bone is sawed through, with the saw as near in a straight line as possible (to prevent breaking). At this point there is profuse bleeding from the crus clitoridis, and the wound may have to be packed and vaginal counterpressure applied by a gauze sponge held in a clamp. (7) The bones separate immediately about 2 cm.; as the head passes through the pelvis this increases to 4 cm. or over. (8) The head may be delivered with forceps, or allowed to descend naturally, this latter plan minimizing the risk of tearing through into the vagina. The patient's pfelvis must be supported in either case, to avoid injury to the sacro-iliac joints. Version is to be avoided. (9) As soon as the child and placenta are extracted, the patient's thighs are approximated; with fresh gloves the small wounds are sutured and dressed, and the pelvis is immobilized with adhesive straps. Catheterization will show injury to the bladder, if any. (10) The after-treatment is that of symphyseotomy. Dangers.-(1) Hemorrhage, from the crus clitoridis; (2) extensive hematomata, which are prone to become infected; (3) lacerations through into the vagina, during delivery-a serious accident because of the danger of infection; (4) injuries to the bladder, causing urinary infiltration of the prevesical space; (5) injury to sacro-iliac joints. The patient is usually able to leave her bed and walk in the fourth week-much sooner than in symphyseotomy. Prognosis.-An average maternal morbidity (fever, hema- turia, etc.) of 40 per cent. A maternal mortality of 4.9 per cent, and a fetal mortality of 10 per cent. After symphyse- otomy there is usually some permanent enlargement of the pelvis. This does not occur after pubiotomy, and the callus formation has proved a further obstruction in subsequent 504 OBSTETRIC OPERATIONS labors. Symphyseotomy may not be done twice. Pubi- otomy can be repeated but preferably not on the same side, and cesarean section is better. ANTERIOR VAGINAL HYSTEROTOMY (HYSTEROSTOMATOMY; VAGINAL CESAREAN SECTION) Principle.-Incision of the cervix and lower uterine segment, anteriorly in the middle line, through the internal os, after adequate separation and adequate protection of the bladder. Time of Operation.-Unnecessary prior to the third month; dangerous after seven and one-half months, because of the risk of tearing the bladder, but between three and seven and one-half months, it is the best operation rapidly to empty the uterus, with a minimum of shock. Indications.-(i) Any condition requiring rapid delivery between the third and seventh months of pregnancy, especially where the cervix is uneffaced and undilated; (2) intractable rigidity of the cervix. Anesthesia is preferably general. In any case up to the fifth or sixth month, local infiltration anesthesia answers per- fectly, but after this date, the traction on the child to secure delivery in such as to make general anesthesia desirable. If the patient's condition contra-indicates general anesthesia, local anesthesia will prove satisfactory at any time. The local anesthetic is best to 1 per cent. (1-400) novocain solution, to each ounce of which 10 drops of 1-1000 adrenalin solution has been added. This solution can be used in large quantities as it is practically non-toxic. Failing this solution, 2 per cent. /3-eucain or 1 per cent, cocain solution may be used, but much more sparingly. One per cent, apothesine solution gives excellent results and is practically non-toxic. The best syringe is a Record or all-glass Luer syringe, of 10 mil capacity, sterilized by boiling. The points of injection are: (1) An- teriorly under the bladder; (2) to either side of the cervix (at three and nine o'clock); (3) straight into the cervical mus- ANTERIOR VAGINAL HYSTEROTOMY 505 cle, parallel to the canal, at three and nine o'clock. The operation may be begun two or three minutes after the injec- tions are completed. Technic. An operating table, good light, proper instruments and ample assistance are essential. Failing these, the opera- tion is better not undertaken, above all not in placenta praevia. (1) The patient is arranged in the dorsal position on a table, carefully cleansed, and anesthetized. Fig. 227.--First incision, in the vaginal mucosa, to separate the bladder. The first step in anterior vaginal hysterotomy. {Peterson.) (2) The cervix is caught at each side with a lion-jawed volsellum, and the perineum retracted by a weighted Auvard speculum. (3) A longitudinal incision is made, on the anterior vaginal wall, through the mucosa, from near the urethral orifice to the vaginal attachment at the cervix. A transverse incision is made across the anterior lip of the cervix, at the attachment of the vaginal mucosa, meeting the lower end of the longitu- dinal cut at right angles, like an inverted T. (4) The mucosa is caught at each side, with a hemostat at the angle formed by the two incisions, and is dissected off the bladder. 506 OBSTETRIC OPERATIONS (5) The uterovesical ligament is cut, and the bladder is pushed up, by blunt dissection by the forefinger, protected by sterile gauze, until the peritoneal reflection is reached. (6) A vaginal retractor is then passed under the bladder, to protect it, taking care not to push the point high enough to break through into the peritoneal cavity. (7) The cervix is now pulled strongly downward, by the volsella attached to it, and is incised by straight heavy scissors, in the middle line, through the internal os. It is essential that the incision be in the middle line and it is very easy to deviate to one side, unless care be used. RETRACTOR UNDER BLADDER amniOTiC .SAC 'CUT CERVIX Fig. 228.-Vaginal cesarean section. The site of the incision in the cervix. (8) The child is now extracted by placental forceps, ovum forceps, miniature Simpson or full size forceps, depending upon the date of pregnancy. As soon as the cervix is cut, the an- terior retractor is in the way and should be removed, especially if the pregnancy has passed the fifth month. (9) The placenta is extracted, and the patient is given, hypo- dermically, two ampules of aseptic ergot and one ampule of pituitrin. (10) The uterus is washed out with sterile water. ANTERIOR VAGINAL HYSTEROTOMY 507 (u) The uterine cavity is packed with a gauze strip, even though at the time it seems firmly contracted and not to need packing. (12) The cervical wound is closed, by interrupted stitches of number 3 chromic catgut. The first stitch is placed about the middle of the wound, and using this as a traction stitch, the higher stitches are put in, and then those in the lower half of the wound. The vaginal retractor under the bladder is again needed, until the upper half of the cervical wound is closed. Care must be taken not to pass any stitch through the packing. (13) The vaginal mucosa is now sewed back in place, where it belongs. The portion of the longitudinal incision just above the cervix is not sutured, but left open for drainage, and a small strip of packing put under the bladder. If this precaution be neglected, an enormous hematoma may form. (14) The vagina is packed with sterile gauze, and the patient returned to bed. (15) A note is made on the chart that three pieces of packing are to be removed and accounted for. (16) Twenty-four hours later, the packing is removed, and the uterus washed out with sterile water. If the placenta has been removed entire, there should be no occasion to explore the uterus with placental forceps. In case of doubt, this should be done. (17) The after-care and convalescence is that of the ordinary plastic operation. A contra-indication to this operation is placenta praevia, due to the danger of hemorrhage and infection. In any case the operation is not an easy one and is not to be undertaken lightly. If done after the seventh month of pregnancy, the danger to the bladder is very great, and the vesicovaginal fistula is always at a situation most awkward to repair. After the seventh month of pregnancy, it is necessary to separate the vaginal wall posteriorly and incise the cervix through its posterior lip and wall, as well as anteriorly, to secure sufficient room to deliver the child. Unless the lowest stitch in the cervix is put in at 508 OBSTETRIC OPERATIONS right angles to the others, an everted, eroded cervix may result. There is as a rule no danger of rupture of the lower uterine segment in subsequent delivery. CESAREAN SECTION Historical.-The operation probably owes its name to the latin "cedere"-to cut, and not to the reputed birth of Julius Caesar. It was done supposedly for the first time successfully about 1500 A. D. by a Swiss swinegelder, on his own wife. The first deliberate operation by a surgeon was in 1610. As the operation is frequently performed among savage races, it is unquestionably much older than the dates given above. Prior to Porro (1877) and Sanger (1882) the mortality was so great that it was only done as a last resort. Indications are of two classes: I. Absolute-(1) a pelvis con- tracted below 7 cm. at the brim or 6.5 cm. transversely at the outlet; (2) absolute obstruction by a tumor in the pelvis; (3) gigantic child; (4) extensive cicatrices or carcinoma of the cervix, vagina or rectum. II. Relative-where a choice of methods exists, but where cesarean section seems to give the best chance for both mother and child. Perhaps the best example of this is a patient with a contracted pelvis with a conjugate of 8 cm., who has had one or two stillborn children by other methods, or a case of placenta praevia. A breech presentation in a contracted pelvis adds consider- ably to the difficulty of delivery, and cesarean section will be needed with measurements that would not necessarily require it in a head presentation. To meet the different indications presented, more than one technic is necessary. At least five different methods, exclud- ing the misnamed vaginal cesarean section, are required. The five are as follows: (1) The old classical cesarean, with the long incision and eventration of the uterus before opening it; (2) the more modern short high incision, opening the uterus in CESAREAN SECTION 509 situ, and then closing the uterine wound outside the abdomen; (3) one of the many varieties of extraperitoneal cesarean sec- tion; (4) the Porro operation, sewing over the uterine cervical stump and dropping it after hysterectomy; (5) the Porro operation, in which the stump is closed, and then marsupialized by fixing it extraperitoneally in the lower angle of the abdominal wound and drained. These technics meet the indications presented, in a way impossible if only one method of performing the operation is used. In operations of election, the best time is one week before term. Preparation of the Patient.-In cases of elective operation, the abdominal skin is as carefully prepared as for any other section. Most of the cases are emergencies, however, and a satisfactory skin preparation is thoroughly to shave, and then cover the abdominal skin with a thick poultice of tincture of green soap, held on by a binder. This is left on until the patient is on the table, then removed and the skin further cleansed with alcohol, painted with 4 per cent, picric acid in 95 per cent, alcohol and covered with rubber dam, through which latter the skin incision is made. The dam answers the same purpose as the surgeon's gloves. In all cases, except those who have not recently been ex- amined and who are not in labor, the vagina is cleansed and packed with sterile gauze. This gauze is removed when the operation is completed, otherwise it dams back the blood and may be a cause of postpartum hemorrhage, from retention of clots. Technic of Cesarean Section I. The Old Classical Operation.-This is the easiest and hence the best for the occasional or inexperienced operator. It has certain grave disadvantages: (i) The greater likelihood of hernia, in the very long wound; (2) the greater chance of adhesion of the uterine wound to the abdominal; (3) the greater chance of contamination of the peritoneal cavity, 510 OBSTETRIC OPERATIONS especially after the uterus is emptied and while the uterine wound is being closed. It is one of the methods to be considered in a clean case, but is not a safe method in a case where contamination is suspected, due to repeated examinations or futile attempts at delivery. Technic.-(i) The patient's skin is prepared as for any abdominal operation and in addition, the vagina is cleansed and packed with sterile gauze. (2) As soon as the operation is begun, the patient receives, by deep hypodermic, 2 ampules of aseptic ergot, and 1 ampule (1 mil) of pituitrin, given in that order. (3) A long incision is made, extending from half-way between the umbilicus and xiphoid to near the symphysis, and the uterus delivered outside the abdominal cavity. (4) Large gauze pads, with tapes attached, are packed behind, to either side and in front of the uterus, to safeguard the peritoneal cavity from contamination. (5) An assistant, with both hands outspread, compresses the abdominal wall around the lower uterine segment. This is not to control hemorrhage, but to prevent blood and liquor amnii entering the peritoneal cavity. To compress the broad ligament to control bleeding is a mistake, as it tends to favor subsequent relaxation. (6) The uterus is incised in the middle line, anteriorly. The placenta, if exposed by the incision, is disregarded. The child is seized by one leg and delivered. The cord is clamped in two places and cut, the child being held meanwhile head downward. The child is then handed to an assistant to be revived, if needed, and the cord tied. (7) The placenta is delivered manually, and the membranes freed by gentle traction. (8) The first layer of sutures is begun by inserting a curved needle, threaded with a long strand of number 2 chromic cat- gut, through the uterine wall above the wound and emerging in the upper angle of the wound, just above the endometrium. The cut muscle is then closed in two layers, by a continuous CESAREAN SECTION 511 tier stitch, care being taken not to penetrate the endometrium. When the upper angle of the wound is reached, in the return, the needle penetrates the wall and emerges above the wound, opposite the point of insertion; the stitch is then tied. Thus no knot is buried in the wound. 3 Fig. 229.-The closure of the uterine wound, to illustrate the tier stitch of the uterine muscle and the peritoneal stitch. The material is number 2 chromic catgut of 40-day durability. 1 2 (9) The peritoneal covering of the uterus is closed, by a continuous stitch of number 2 chromic catgut, threaded on a straight needle, sewing from above downward, and on return- ing the needle is inserted between the insertions made on the downward trip. This stitch is also tied above the uterine wound, the complete stitch appearing like a laced-up shoe. (10) The uterus is returned to the abdominal cavity; any clots are sponged out of the peritoneum (usually only a small amount, if any, near the bladder), and the abdominal wound closed and dressed in the ordinary way. 512 OBSTETRIC OPERATIONS II. The Sanger Operation with the Short High Incision.- This is the best operation for the unquestionably clean case; especially for operations of election. It has the very great advantage of preventing the coincidence of the uterine and abdominal wounds, and therefore minimizing the dangers of adhesions. The short wound is much less likely to be the site of a hernia. It is slightly more difficult than the old classical operation. The only contra-indication to it in a clean case would be a case of placenta praevia, where it is vital to prevent all possible loss of blood during the operation, as here the broad ligament cannot be compressed while the uterus is being opened, as in the case of the long incision. Otherwise it is by all odds the best operation for the clean case. Technic.-(i) The patient's abdomen and vagina are pre- pared as previously described, and the same dose of ergot and pituitrin is given when the operation is begun. (2) A short central incision is made, one-third above and two-thirds below the umbilicus, just long enough to permit the delivery of the head. (3) An assistant compresses the abdominal walls around the uterus, in situ, making greater pressure from the patient's right toward her left side. This is to overcome the normal lateral torsion of the uterus, and if it is not done, the uterine incision will be too near the left broad ligament, with consider- ably more hemorrhage. (4) The uterus is incised and the child delivered and treated as previously described. (5) As the head is being delivered, the assistant hooks his forefinger in the upper angle of the uterine wound, and pulls the uterus out of the abdomen, and then packs off with gauze behind to either side and in front. (6) The placenta and membranes are then delivered as previously described. (7) The uterine wound is closed exactly as in the previous operation, the uterus returned to the peritoneal cavity, and all clots sponged out. CESAREAN SECTION 513 (8) The abdominal wound is closed and dressed as usual. III. The Extraperitoneal Cesarean Section (Laparo-elytrot- omy).-It is well known that the chief danger of cesarean section is the risk of peritonitis in the case which has been repeatedly examined and handled, before the operation is undertaken. The attempt to avoid this risk led to many ways of doing the operation extraperitoneally. Some twenty-five modifications have so far been devised. The original extra- peritoneal operation, because of the formidable infections that often followed, has been abandoned. The modifications are all transperitoneal and all that can be claimed for them is that the risk of infection of the upper abdomen is minimized. The term low cervical cesarean section best describes them. The ideal indication for the operation is the case which has been in labor for a considerable time, whose lower uterine segment is therefore well thinned out; who has been repeatedly examined; whose child is in good condition but who is not obviously infected; one whose previous aseptic management is open to suspicion, but not one where infection is a practical certainty. It has certain disadvantages: (i) It is the most difficult technically, of all the cesareans; (2) it is not to be attempted before the patient is in labor, as the lower uterine segment is not thinned out; (3) above all, it is not the opera- tion for placenta praevia. This is because of the excessive bleeding. These objections apply more or less to all the methods of extraperitoneal cesarean, but particularly to the one whose technic is here described. Technic.-(1) The patient's abdomen and vaginal canal are prepared as previously described, and the doses of ergot and pituitrin given. (2) A central incision is made, from two inches below the umbilicus to the symphysis. (3) The peritoneum of the lower uterine segment is picked up about one inch below its firm attachment to the uterus and split transversely from one round ligament to the other. 33 514 OBSTETRIC OPERATIONS (4) A cofferdam of gauze is placed across the lower abdomen, just above the peritoneal attachment of the lower uterine segment. (5) The bladder is forced down as far as possible, and the short upper flap dissected up. (6) A broad bladed retractor is placed behind the bladder in the lower angle of the wound. (7) A short wound is made in the lower uterine segment, in the middle line, as far down behind the bladder as possible. (8) With bandage scissors the lower uterine segment is slit up, nearly to the firm peritoneal attachment. (9) The child's face is rotated into the wound, by a finger in its mouth. (10) The head is delivered with forceps put on upside down. During the delivery the bladder retrac* noved, to avoid tearing of the bladder. (n) The child's cord is clamped (12) The placenta may now be .. . nanually, or left to separate while the stitches are being i ?rtcd. (13) The uterine wound is closed by six or eight interrupted sutures of No. 2 chromic catgut, embracing the whole thickness of the wall. The upper and lower stitches are put in first, to act as traction sutures. None are as yet tied. (14) A continuous stitch of No. 2 chromic catgut then accurately closes the wound, and the tension stitches are tied. (15) A second No. 2 chromic catgut continuous stitch inverts the edges, so that all previous stitches are buried. (16) The upper peritoneal flap is tacked down by a few stitches. (17) The bladder flap is brought up and sewed, by a continu- ous stitch, above the first flap. Thus the uterine wound is securely sealed extraperitoneally. (18) The peritoneum is cleansed, the cofferdam of gauze removed and the abdominal wound closed as usual. Due to the suture line in the lower uterine segment, which prevents it from collapsing as it does after normal labor, the CESAREAN SECTION 515 fundus for a few days after labor is held up rather high. This is only for a short time and the rate of involution proceeds normally thereafter. The uterine and abdominal wounds coincide for a small part of their extent only, and adhesions are unlikely. During the whole operation, none of the abdominal organs except the uterus are visible, and the smooth- ness of the convalescence of these cases will surprise one who sees it for the first time. It is like that of a normal labor case. The field of the operation is usually limited to cases in labor, who have been examined repeatedly, but in its field it is a very useful procedure. Some operators, notably De Lee, use it in all cases in preference to any other technic. IV. The Porro Operation, with Dropped Stump.-This is the operation for clean cases complicated by fibroid tumor or other complication making the removal of the uterus desir- able, but not in a case where infection is suspected. It is also not a method for sterilization of the patient where such a procedure is justifiable. Technic.-(i) Up to the point where the uterus would ordinarily be closed, the technic is precisely the same as in the first method described. (2) The edges of the uterine wound are clamped together and the uterus removed by clamping both broad ligaments, cutting down to the uterine arteries; clamping and cutting them; separating the bladder anteriorly and amputating the uterus below the internal os. All this is precisely the same as the ordinary supravaginal hysterectomy, complicated by con- siderably more bleeding. (3) The cervical stump is tightly closed over the cervical canal, using both interrupted and continuous number 3 chro- mic catgut, as it is vital to prevent leakage. This step of the operation is done as soon as the uterus is removed. (4) The broad ligaments and uterine arteries are next tied, and the peritoneum closed over the stump, across the pelvis. (5) The abdomen is then closed as usual. 516 OBSTETRIC OPERATIONS This is not a frequently needed operation. Five per cent, of cesareans would be a liberal estimate of the need for it. V. The Porro Operation with Marsupialization and Extraperitoneal Fixation and Drainage of the Cervical Stump.-This is also an operation of limited field. Its two chief indications are: (i) A case undoubtedly infected before operation, but in whom craniotomy is not to be considered, on account of the child's condition; (2) ruptured uterus. Technic.-This is precisely the same as in the operation immediately preceding, except that when the stump has been carefully closed, it is brought up in the lower angle of the abdominal wound. The parietal peritoneum of the wound is then sewed around it in such a way as to prevent communica- tion with the general peritoneal cavity. The abdominal wound is then closed, except for the pouch at the lower angle, at the bottom of which is the cervical stump. This pouch is packed with gauze and drained and allowed to close by granulation. This operation is rarely needed, but when indicated, it greatly increases the patient's chance of recovery. Sterilization of Patients.-This should never be done, except with written consent of both husband and wife. Verbal con- sent is not sufficient, as patients have been known to change their minds, and it is well to have the written proof of consent. The dictum of "once a cesarean always a cesarean" is not borne out by facts. Rupture of the uterine scar in subse- quent pregnancies has occurred in not more than 3 per cent, of cases, and is due usually to poor closure and infection. A clean cesarean wound will safely withstand subsequent labor. When it is desired to sterilize a patient, it is best done by the excision of the tubes at the uterine cornua, the removal of the inner inch of the tube, and the closure of the cornua, burying the stump of the tube between the layers of the broad ligament. Mere ligation of the tubes is not sufficient. All cesarean sections, whose recovery has been uncomplicated, can sit up after the fourteenth day. CESAREAN SECTION 517 Complications During and After Operation.-(i) Hemor- rhage.- The bleeding during the operation is usually no more than after a normal labor. If it seems excessive, it should be remembered that the greatest possible irritation of the uterine muscle is the insertion of the necessary sutures. The suturing should therefore be begun without delay. In emergency, the bleeding can be controlled by compression of the broad liga- ments, but this is rarely needed. Postpartum hemorrhage is not greatly to be feared; the only cases in the series on which these conclusions are based were three in which no hypodermics of ergot were used. In all three of these, the bleeding was controlled by uterine packing. I should not hesitate to pack or irrigate a uterus sewed up as herein described. (2) Infection.-This is the most serious complication, as it nearly always takes the form of peritonitis. The danger can be minimized by careful selection of the type of operation performed, and should peritonitis develop, the Fowler position, stimulation and drainage are the only means of combating it. (3) Distention.-It is not uncommon to see considerable abdominal distention after a cesarean section. Peristalsis is active but the condition requires energetic treatment, not so much on account of any danger, but of the extreme discomfort. Hypodermics of eserin salicylate gr. strychnin sulph. gr. I/30 every four hours; hypodermic of ampule of pituitrin twice daily; high enema of alum oz. 1 to the quart; the rectal tube left in place several hours at a time; and, if there is much gastric tympany, lavage. This routine will correct the trouble within forty-eight hours as a rule. It is important to avoid the use of morphine after operation as much as possi- ble, as it tends to increase distention. (4) Fever.-Especially in primiparae, there may be a rise of temperature to 102 or over about the fourth or fifth day, accompanied by some foul odor to the lochia. This is due to a lack of vaginal drainage, and usually not to any retention of clots in the uterus. A daily vaginal douche of sterile water is 518 OBSTETRIC OPERATIONS all that is required. I would not hesitate to irrigate the uterus in these cases, if it should be required, but it is very rarely necessary. Anesthetic.-Should not be nitrous oxid. Ether or chloro- form are preferable. The gas is dangerous to the child. The operation can be done under local or spinal anesthesia, but this is undesirable. So little time is needed for the operation, that the short anesthetic period is without risk. It is also very unwise to give morphin in a cesarean section, before the operation. It enormously increases the risk of postpartum hemorrhage. Child.-It is always advisable to have a trained assistant to conduct the revival of the baby. These babies often show the effects of the anesthetic to the mother and require considerable attention. Particularly is this true when previous attempts at delivery have been made, with extra periods of anesthesia and possible injury to the child. It is common to see these babies born in asphyxia livida, and they require careful handling. The operation by no means guarantees safety for the child, when all these factors are taken into consideration. Repeated cesarean sections are common. As many as ten have been successfully done on the same patient. This fact must be considered, before the question of sterilization of the patient is decided upon. Prognosis.-In good hands, the maternal mortality should not exceed 5 per cent., in all cases, favorable and unfavorable. Because of the neglected case, the fetal mortality is consider- ably higher, though in favorable cases, where no attempt, or at the most, conservative attempts, at previous delivery have been made, it should be very small. The author's experience with the different technics described above has been 302 operations with seven maternal deaths, or 2.32 per cent. Postmortem Cesarean Section.-The fetus will live from five to twenty minutes after the death of its mother, living longer if the mother's death comes very suddenly. In pro- longed illness, with slow death, the child often dies first. If CESAREAN SECTION 519 the child is viable (past the 28th week) the abdomen should be opened at once and no time lost listening for heart sounds. Legally, the consent of the family is not required, but should be obtained if possible. In the dying patient, operation should take place before death, if the child's heart sounds show distress. Rupture of the Uterine Wound in Subsequent Pregnancy or Labor.-"Once a caesarean always a caesarean" is not borne out in practice. The risk of rupture of the uterine wound is about 3 per cent. If the indication for the operation is a permanent one, of course caesarean section will be required for any subsequent delivery. If its indication is accidental-as in placenta previa-the wound will usually safely withstand a subsequent labor, unless the convalescence from the first operation was complicated by infection. The lower uterine segment wound described in extra-peritoneal caesarean section will withstand subsequent labor without trouble. Occasionally the uterine wound will spontaneously rupture in subsequent pregnancy, in the last month, without cause, pain, or symptoms and the unruptured membranes will protrude through the rent. In any case when the uterus ruptures after a caesarean section, whether in or before labor, no attempts should be made to close the wound and leave the uterus in situ. Hysterectomy and marsupialization of the stump will be required. INDEX Abderhalden test of pregnancy, 67 Abdomen, changes in size and shape, in pregnancy, 59 in pregnancy, 61 Abdominal binder, 99 in puerperium, 107 distention after cesarean section, 5i7 • enlargements of fetus, obstruc- tion of labor by, 268 fat, pregnancy and, differentia- tion, 67 pad, 98 section in puerperal sepsis, 400 preparation for, 436 routine after-care, 444 walls, examination of, in puer- perium, 112 in pregnancy, 56 Abortion, 218, 277 causes, 218 classification, 218 complete, diagnosis, 222 frequency, 218 incomplete, diagnosis, 222 hemorrhage from, 278 induction of, 445 after-treatment, 449 complications, 449 indications, 445 local anesthesia for, 448 packing after, 448 perforation of uterus in, 450 technic, 445 inevitable, active treatment, 220 after-treatment, 222 diagnosis, 219 expectant treatment, 220 hemorrhage from, 277 Tarnier's sign in, 219 missed, 222 packing uterus for, 220 threatened, diagnosis, 219 Abortion, threatened, hemorrhage from, 277 symptoms, 218 treatment, 219 tubal, 225 Abruptio placentae, 286 Abscess, fixation, in puerperal sepsis, 398 ischiorectal, in puerperal sepsis, 4i5 of areola, 381 of Bartholin's gland, obstruction of labor by, 256 of breast, abortive treatment, 384 after-treatment, 387 Bier's treatment, 384, 387 cause, 383 differential diagnosis, 385 symptoms, 383 treatment, 384, 386 pelvic, in puerperal sepsis, 405 posterior pelvic puncture for, 406 postmammary, 387 submammary, 387 suburethral in pregnancy, 178 Absence of breasts, 375 Accidental hemorrhage, 286 Accidents in labor, dystocia due to, 271 in pregnancy, 188 Accouchement force in eclampsia, 216 Acetonuria in extra-uterine preg- nancy, 227 Acne in new-born, 420 Adenoma of breast in pregnancy, 185 Adherent placenta, hemorrhage from, 296 After-care, routine, 100 After-coming head, extraction, 494 forceps to extract, 483 521 522 INDEX After-pains in puerperium, 106 Agalactia, 379 Age, effect of, on labor, 263 Ahlfeld's method of antepartum fe tome try, 240 Airing of new-born infant, 117 Albuminuria in pregnancy, 205 hot pack in, 208 steam or vapor bath in, 208 treatment, 207 Alcohol in inertia uteri, 232 Alexander operation in retroversion of uterus, 341 Alimentary canal, nontoxic dis- eases of, in pregnancy, 183 Amnion, 43 abnormalities of, 159 false, 44 functions, 44 true, 43 Amniotic bands, 159 abnormalities of, 159 deficiency of, 160 excessive secretion of, 159 Amputation of extremities of fetus, 499 Anaphylaxis theory of labor, 78 Anemia of pregnancy, 56 puerperal, 365 Anencephalus, 268 Anesthesia for anterior vaginal hysterotomy, 504 in cesarean section, 518 in eclampsia, 212 in labor, 88 local, for induction of abortion, 448 Angle, conjugato-symphyseal angle, 20 Anteflexion of uterus in pregnancy, 182 Antepartum fetometry, 240 hemorrhage, 277 Anus, imperforate in new-born, 422 vestibularis, 362 in newborn, 422 obstruction of labor by, 257 Anvil-shaped uterus, 30 Aphthae in new-born, 432 Apoplexy, eclampsia and, differen- tiation, 211 Appendicitis in pregnancy, 183 Arbor vitae, 26 Areola, abscess of, 381 Arm, fracture of, in new-born, 426 Arteries of uterus, 27 Arthritis in puerperal sepsis, 413 puerperal, 367 Artificial feeding of new-born, 117 renal glycosuria test of preg- nancy, 68 respiration, 417 Byrd method, 418 catheterization of larynx, 419 Dew method, 418 Laborde method, 418 lungmotor for, 417 Marshall Hall method, 418 mouth-to-mouth method, 417 Schultze method, 418 swinging method, 418 Sylvester method, 418 Ascites, pregnancy and, differen- tiation, 67 Asphyxia livida, 416 neonatorum, 416 causes, 416 curative treatment, 416 diagnosis, 416 prognosis, 420 treatment, 416 of new-born infant, 416 pallida, 416 Assimilation pelvis, 255 Asthma in pregnancy, 190 Atelectasis in new-born, 420 Atony of uterus, puerperal hemor- rhage from, 297 Atresia of cervix, obstruction of labor by, 258 of vagina obstruction of labor by, 257 Atrophy of liver, acute yellow, in pregnancy, 203 of pelvis, 255 Atypical pelvis, 2 54 Auscultation in pregnancy, 74 Axis-traction forceps, 483 application, 485 Dewees', 468, 484 indications, 485 Tarnier's, 484 Baby after birth, 95 after delivery, 99 blue, 434 routine care, 101 Bacteria in puerperal sepsis, 390 Bacterins in puerperal sepsis, 398 INDEX 523 Bags for dilating cervix, care of, 465 rubber, for inducing labor, 453 Baldy operation in retroversion of uterus, 342 Ballottement in pregnancy, 62 Bandl's contraction ring, 153, 301 Barnes' bag for dilating cervix, 462 Bartholin's glands, 23 abscess of, obstruction of labor by, 256 Basins for home operation, 441 Bathing new-born infant, 115 Baudelocque's diameter of pelvis, 234 Bed, preparation of, for labor, 86 Bell's palsy in new-born, 428 Bier's hyperemia in breast abscess, 384, 387 Binder, abdominal, 99 Birth paralysis in new-born, 428 Birth-canal, injuries, in labor, 298 lacerations of, hemorrhage from, .295 diagnosis, 295 treatment, 295 Births, multiple, 268 Bladder, diseases of, in pregnancy, 191 full, in labor, 90 in pregnancy, 57 overdistended, obstruction of labor by, 257 pregnancy and, differentiation, 67 stone in, in pregnancy, 191 Blastoderm, 36 Blastodermic vesicle, 36 Blastula, 36 Bleeding, intestinal, in new-born, 423 Blood, diseases of, in pregnancy, 187 of new-born infant, 115 picture in puerperal sepsis, 392 transfusion in puerperal sepsis, 399 urea in, in pregnancy, 206 nitrogen in, in pregnancy, 206 Blood-clots, retention, in puerpe- rium, 370 Blood-pressure in eclampsia, 210 reduction, 212 in pregnancy, 56 in toxemia of pregnancy, 204 Blood-supply of ovary, 30 Blood-vessels of uterus, 27 in pregnancy, 58 Blue baby, 434 Blunt hook for breech extraction, 493 Bones, pelvic, tumors of, 256 Bony pelvis, dystocia due to, 234 Bougies, Hegar's, for dilating cer- vix, 456 Bowels, care of, in puerperium, 108 of new-born infant, 115 Braun's cranioclast, 496 metreurynter for dilating cervix, 464 Braxton Hicks' sign of pregnancy, 65 Breast, adenoma of, in pregnancy, 185 binder, Murphy, 109 cancer of, in pregnancy, 185 engorgement of, 381 Breasts, abscess of, 383. See also Abscess of breast. absence of, 375 caked, 381, 382 care of, in puerperium, 109 changes in, in pregnancy, 60 in puerperium, 105 diseases of, 375 in pregnancy, 185 hypertrophy of, 375 in pregnancy, 56, 61 massage of, technic, 383 supernumerary, 375 tumors of, 388 Breech extraction, 492 decomposition method, 492 indications, 492 manual method, 493 with blunt hook, 493 with fillet, 493 with forceps, 493 presentation, 143 abnormalities in mechanism, i45 cause, 143 diagnosis, 143 forceps in, 483 frequency, 143 management, 146 mechanism, 144 prognosis, 146 Brittle or loose finger nails in pregnancy, 190 524 INDEX Broad ligament hematoma in puer- perium, 369 Brow presentation, 140 abnormalities in mechanism, 141 cause, 140 forceps in, 483 frequency, 140 management, 142 mechanism, 141 prognosis, 142 Buds of syncytium, 46 Buhl's disease in new-born, 424 Byrd method of artificial respira- tion, 418 Caked breast, 381, 382 Cancer of breast in pregnancy, 185 of cervix in pregnancy, 178 obstruction of labor by, 259 of uterus, puerperal hemorrhage from, 297 of vagina in pregnancy, 178 of vulva in pregnancy, 176 syncytial, 164 Cane sugar test for pregnancy, 70 Caput succedaneum in new-born, 426 Caries of pelvis, 255 of teeth in pregnancy, 184 Caruncles, myrtiform, 24 Carus, curve of, 20 Cathelin's method of segregation of urine, 198 Catheter, ureteral, uses of, 198 Catheterization of larynx, artificial respiration by, 419 ureteral, in pregnancy, 197 Caul, 271 Cellulitis, pelvic, in puerperal sepsis, 404 Cephalhematoma in new-born, 427 . . Cephalic application of forceps, 470 version, 487, 488 Cervical hematoma in puerperium, 369 polyps in pregnancy, 179 Cervix, atresia of, obstruction of labor by, 258 cancer of, in pregnancy, 178 obstruction of labor by, 259 condyloma of, in pregnancy, 179 dilatation of, 456 Edgar's manual method, 460 Cervix, dilatation of, for inducing labor, 455 Harris' manual method, 460 hydrostatic methods, 461 incision of cervix for, 465 indications, 456 manual method, 459 methods, 456 with Barnes' bag, 462 with branched or metal dila- tors, 456 with Braun's metreurynter, 464 with Champetier de Kibes' bag, 464 with forceps, 465 with four-bladed branched dilators, 458 with gauze packing, 461 with Hegar's bougies, 456 with Hirst's bag, 464 with obliteration of length, in labor, 79 with Pomeroy bag, 465 with Tarnier's balloon, 464 with two-bladed branched dilators, 457 with Voorhees' bag, 462 diseases of, in pregnancy, 178 erosion of, 331 diagnosis, 332 symptoms, 332 treatment, 332 examination of, in puerperium, 112 in pregnancy, 57 incision of, for dilatation, 465 laceration of, hemorrhage from, 295 in labor, 304. See also Lacera- tions of cervix in labor. packing with gauze, for inducing labor, 455 posterior displacement, in preg- nancy, 183 rectal tube in, for inducing labor, . 45? rigidity of, obstruction of labor by, 258 Cesarean section, abdominal dis- tention after, 517 absolute indications, 508 anesthesia in, 518 care of child after, 518 complications, 517 INDEX 525 Cesarean section, extraperitoneal, 5i3 fever after, 517 for prolapse of umbilical cord, 270 hemorrhage in, 517 historical, 508 in placenta praevia, 284 infection in, 517 old classical, 509 Porro method with dropped stump, 515 with marsupialization of cervical stump, 516 postmortem, 518 preparation of patient, 509 prognosis, 518 relative indications, 508 repeated, 518 rupture of uterine wound in subsequent pregnancy, 519 Sanger method with short high incision, 512 sterilization of patient after, 5l6. technic, 509 vaginal, 504 Chafing of skin in new-born, 420 Champetier de Ribes' bag for dilating cervix, 464 Child, dangers to, in forceps oper- ations, 483 Child-birth. See Labor. Chill, postpartum, 99 Chloral in eclampsia, 216 Chloroform in labor, 88 Chorea in pregnancy, 188 Chorion, 44 abnormalities of, 161 fibromyxomatous degeneration of, 165 frondosum, 45 laeve, 45 villi, 45 cystic degeneration of, 161 Chorionepithelioma, 164 prognosis, 165 puerperal hemorrhage from, 297 symptoms, 164 treatment, 164 Circulation, fetal, 52 in pregnancy, 56 Circulatory system, diseases of, in pregnancy, 185 Clavicle, fracture of, in new-born, 426 Cleft-palate in new-born, 421 Cleidotomy, 499 Clitoris, 23 laceration of, hemorrhage from, 295 Clothing of new-born infant, 116 Club-foot, 254 in new-born, 423 Coccygeal pain, causes, 349 Coccygectomy, 350 Coccygodynia, 349 Coccyx, examination of, in puer- perium, 112 fracture of, 349. See also Fractures of coccyx. Coffey operation in retroversion of uterus, 343 Coitus in pregnancy, 76 Colic in new-born, 420 Colles' law in syphilis, 169 Collin's bivalve speculum, 306 Colloidal silver in puerperal sepsis, 399 Conception, average date, 36 Condyloma in pregnancy, 174 of cervix in pregnancy, 179 Conical nipples, 378 Conjugato-symphyseal angle, 20 Constipation in new-born, 421 in pregnancy, 184 Contraction ring, Bandl's, 153, 301 Convulsions in eclampsia, causes, 209 number, 210 in new-born infant, 423 Corpus luteum, 29, 30 extract in vomiting of preg- nancy, 199 intravenously, in hyperem- esis graviderum, 202 Coryza in new-born, 433 Cotyledons, 48 Cow's milk, analysis, 118 modification of, 118 Coxalgia, 254 Cramps, leg-, in labor, 91 Cranioclast, Braun's, 496 Craniotabes, 266 Craniotomy, 250, 495 indications, 495 technic, 495 Cranium, premature ossification of, obstruction of labor by, 264 526 INDEX Crede's method of delivering pla- centa, 154 of expelling placenta, 97 of preventing ophthalmia neonatorum, 94, 433 Crista lactea, 375 Cullen's sign in extra-uterine preg- nancy, 226 Curve of Carus, 20 Cycle, menstrual, 32 Cyst, ovarian, in labor, 262 in pregnancy, 262 in puerperium, 262, 263 pregnancy and, differentiation, 66 Cystic degeneration of chorion villi, 161 Cystitis in pregnancy, 191 septic, in puerperal sepsis, 413 Cystocele, 351 causes, 351 diagnosis, 352 Goffe operation for, 353 Hirst (B. C.) operation for, 353 Martin operation for, 352 obstruction of labor by, 257 operative treatment, 352 palliative treatment, 352 symptoms, 351 treatment, 352 Watkins-Freund-W e r t h e i m operation for, 352 Cystoscope, air distention, direc- tions for use of, 194 water distention, directions for use of, 195 Cystoscopy in pregnancy, 194 methods, 194 Cysts, vaginal in pregnancy, 178 Death, fetal, habitual, 171 in eclampsia, causes, 211 of fetus, diagnosis, 74 sudden during and after labor, 274 Decapitation of fetus, 498 of new-born, 426 Decidua, 49 compact layer, 49 microscopic appearance, 49 placental, 51 reflexa, 50 serotina, 51 spongy layer, 49 vera, 49 Deciduae, abnormalities, 167 diseases, 167 inflammation, 167 Deciduoma malignum, 164 Decomposition method of breech extraction, 492 Deformities, congenital, of new- born, 421 of pelvis, 234, 241. See also Pelvis, deformities. Degeneration of liver in pregnancy, 185 Delivery, care of patient after, 98 position of patient for, 91 postmortem, 274 return of menstruation after, no Deventer method for extraction of after-coming head, 494 Dew method of artificial respira- tion, 418 Dewees' axis traction forceps, 468, 484 Diapers, 116 Diarrhea in new-born, 421 in pregnancy, 184 Diastasis of recti, 344 muscles, 344 diagnosis, 344 Webster's operation for, 345 Diet in pregnancy, 76 in puerperal sepsis, 397 in puerperium, 101, 107 Dilatation, artificial, of parturient cervix, 456. See also Cervix, dilatation of. Dilators, four-bladed branched, for dilatation of cervix, 458 Hegar's, 457 J. C. Hirst's, 459 two-bladed branched, for dilata- tion of cervix, 457 Diphtheria, puerperal, 366 Dislocation of kidney in pregnancy, 192 Dislodged clots at placental site, 37° Displacements of uterus in preg- nancy, 179 obstruction of labor by, 259 Distention of vulva in labor, 91 Doderlein tube, Nicholson's modi- fication, 393 Doremus ureometer, use of, 205 Douche-bag for home operation, 440 INDEX 527 Dressings for home operation, 441 Dressing-table for home operation, 440 Drug method of inducing labor, 451 Drugs in inertia uteri, 231 Dry labor, 271 Ductus arteriosus, 53 venosus, 52 Dystocia, 230 due to accidents in labor, 271 due to bony pelvis, 234 due to disease, 275 due to fetus and appendages, 263 due to maternal soft parts, 256 Dysuria in pregnancy, 179 Eclampsia, 209 active treatment, 212 anesthesia in, 212 apoplexy and, differentiation, 211 attack, 210 blood-pressure in, 210 reduction, 212 causes, 209 of death in, 211 chloral in, 216 convulsions in, causes, 209 number, 210 Edinboro treatment in, 215 epilepsy and, differentiation, 211 forcible delivery in, 216 frequency, 210 glucose solution in, 215 hirudin in, 216 hot pack in, 213 hypodermoclysis in, 212 hysteria and, differentiation, 211 induction of labor in, 214 methods of delivery in, 216 morphin in, 215 pathological findings in, 211 pilocarpin in, 215 premonitory signs, 210 prognosis, 211 purgation in, 213 routine treatment, 214 stimulation in, 217 Stroganov treatment, 215 sweating in, 213 thyroid and parathyroid extract in, 216 treatment, 212 Veit treatment, 215 venesection in, 213 Ectoderm, 36 Ectopic gestation, 223 kidney, 347 Edema of vulva in pregnancy, 174 obstruction of labor by, 256 Edgar's manual method of dilating cervix, 460 Edinboro treatment in eclampsia, 215 Embolism, pulmonary, in phleg- masia alba dolens, 411 Embryonic area, 36 Embryotomy, 495 Emergency cases, preparation for operation in, 437 Emmet's curet forceps, 446 operation for lacerations of peri- neum in labor, 319 Enchondroma of pelvis, 256 Endocolpitis in puerperal sepsis, 402 Endometritis in puerperal sepsis, 402 Endometrium, involution of, 103 Engorgement of breast, 381 Entoderm, 36 Epilepsy, eclampsia and, differen- tiation, 211 in pregnancy, 189 Episiotomy, 92 Epistaxis in pregnancy, 189 Erb's paralysis in new-born, 428 Ergot in inertia uteri, 232 in premature separation of pla- centa, 289 Erosion of cervix, 331 diagnosis, 332 symptoms, 332 treatment, 332 Erysipelas, puerperal, 366 Ether in labor, 88 Eutocia, 78 Evisceration of fetus, 499 Examination in labor, 81 in puerperium, no necessary in pregnancy, 72 Exanthemata in fetus, 171 in puerperium, 365 Exostoses of pelvis, 256 Expulsion, forces of, anomalies of, 230 Extramedian symphyseotomy, 501 Extraperitoneal cesarean section, 5i3 528 INDEX Extra-uterine pregnancy, 223 acetonuria in, 227 cause, 224 classification, 223 clinical history, 225 Cullen's sign in, 226 development, 224 diagnosis, 226 differential, 226, frequency, 224 prognosis, 228 symptoms, 225 terminations, 225 treatment, 227 Extremities of fetus, amputation of, 499 Eyes of new-born infant, 115 Face, bruises of, in new-born, 428 in pregnancy, 61 presentation, 135 abnormalities of mechanism, 138 diagnosis, 135 forceps in, 482 impacted, management, 139 management, 139 mechanism, 137 prognosis, 139 Facial paralysis in new-born, 428 Fallopian tubes, 28 ampulla, 28 caliber, 29 fimbriated extremity, 28 in pregnancy, 59 isthmus, 28 muscular coat, 29 uterine portion, 28 False amnion, 44 pelvis, 17 Fat, abdominal, pregnancy and, differentiation, 67 omental, pregnancy and, differ- entiation, 67 Fecal matter, expressed, in labor, 90 Feeding new-born infant, 116 Femora, luxation of, 255 Fertilization of ovum, 36 Fetal appendages, development, 43 funnel-shaped pelvis, 252 heart sounds in pregnancy, 64 movements in pregnancy, 64 Fetation, multiple, 54 causes, 54 Fetometry, antepartum, 240 Fetus, abdominal enlargements of, obstruction of labor by, 268 amputation of extremities, 499 and appendages, dystocia due to, 263 changes in after death, 172 circulation of, 52 death of, diagnosis, 74 effect upon mother, 171 decapitation of, 498 development, 51 at eight month, 52 at first month, 51 at ninth month, 52 at seventh month, 52 at sixth month, 52 at third month, 52 diseases in intra-uterine life, 168 effect of maternal death upon, 171 fever on, 172 impressions on, 172 evisceration of, 499 exanthemata in, 171 habitual death of, 171 head measurements, 53 infectious diseases in, 171 injuries to, 171 mature, 53 noninfectious diseases in, 171 ossification centers, 54 overgrowth of, obstruction of labor by, 263 papyraceus, 55 syphilis of, 168. See also Syph- ilis of fetus. Fever after cesarean section, 517 milk, 379 puerperal, 368 Fibroid tumors of uterus in labor, 260 in pregnancy, 260 in puerperium, 370 hemorrhage from, 297 obstruction of labor by, 260 pregnancy and, differentiation, 66 Fibromyxomatous degeneration of chorion, 165 Fillet for breech extraction, 493 Finger nails, brittle or loose, in pregnancy, 190 Fissured nipples, 376 Fistula, genital, 359 varieties, 359 INDEX 529 Fistula, rectovaginal, diagnosis of, 362 obstruction of labor by, 257 treatment of, 362 ureterovaginal, diagnosis of, 362 treatment of, 363 vesicocervicovaginal, 363 vesicovaginal, diagnosis of, 359 treatment of, 360 Fixation abscess in puerperal sep- sis, 398 Flat pelvis, generally contracted, 243 management of labor in, 248 simple, 242 Floating kidney, 346 causes, 346 diagnosis, 346 nephrorrhaphy for, 346 symptoms, 346 treatment, 347 Floor, pelvic, 21 Follicle, graafian, 29 Foramen ovale, 53 patulous, in new-born, 434 Forceps, 466 application, in different positions, 469, 472 in inertia uteri, 231 to floating head, 469 axis-traction, 483 application, 485 Dewees', 468, 484 indications, 485 Tarnier's, 484 cephalic applications, 470 conditions for use, 470 contra-indications, 469 Dewees' axis-traction, 468, 484 dilating cervix with, 465 Emmet's curet, 446 for breech extraction, 493 for extracting after-coming head, 494 functions, 468 Hale-Sawyer, 467, 468 high application, 469 history, 466 in abnormal presentations, 482 in breech presentation, 483 in brow presentation, 483 in doubtful positions, 480 in face presentations, 482 in left occipito-anterior position of vertex presentation, 472 34 Forceps in left occipito-posterior position of vertex presentation 478 in placenta praevia, 284 in right occipito-anterior position of vertex, 477 occipito-posterior position of vertex, 475 indications, 469 Kielland's, 468, 486 low application, 469 methods of application, 470 midplane application, 469 operations, dangers to child in, 483 to mother in, 483 prognosis, 483 outlet application, 469 ovum, 447 pelvic application, 471 points of safety and danger in use, 480 preliminary steps to use of, 471 preparation of patient for use, 47i removal, 480 Simpson's, 467, 468 Tarnier's axis-traction, 484 to extract after-coming head, 483 with head at pelvic outlet, properly rotated, 480 with occiput in hollow of sacrum, 479 Forces of expulsion, anomalies of, 230 Forehead, bruises of, in new-born, 428 Fractures of arm in new-born, 426 of clavicle in new-born, 426 of coccyx, 349 coccygectomy in, 350 in labor, 299 mechanism, 349 symptoms of painful mobility, 349 terminations, 349 treatment, 350 of leg in new-born, 426 of pelvis, 255 of skull in new-born, 424 Fungus, umbilical, in new-born, 434 Funis, 48, 268. See also Umbilical cord. Funnel-shaped pelvis, fetal, 252 530 INDEX Galactocele, 381 Galactorrhea, 380 treatment, 381 Gelpi self-retaining perineal retrac- tor, 320 Genital fistulas, 359 varieties, 359 organs,careof,in puerperium, 107 Genitalia, changes in, in pregnancy, 60 Gestation, ectopic, 223 tubal, 223 Gilliam operation, in retroversion of uterus, 343 Gingivitis in pregnancy, 184 Glands, Bartholin's, 23 vulvovaginal, 23 Glucose solution in eclampsia, 215 intravenously, in hyperemesis gravidarum, 201 test for pregnancy, 69 Glycosuria, artificial renal, test of pregnancy, 68 Goddard pessary in prolapse of uterus, 355 Goffe operation for cystocele, 353 Gonorrhea in pregnancy, 176 puerperal, 367 Gonorrheal arthritis in puerperal sepsis, 413 puerperal, 367 Goodell's sign of pregnancy, 62 Graafian follicle, 29 Granulation tissue after repair of perineum, 368 Graves' disease in pregnancy, 187 Habit theory of labor, 78 Habitual fetal death, 171 Hale-Sawyer forceps, 467, 468 Hands, sterilization of, for home operation, 443 Harelip in new-born, 421 Harris' manual method of dilating cervix, 460 method of segregation of urine, 198 Head, after-coming, extraction, 494 when chin is anterior, 495 forceps to extract, 483 at pelvic outlet, properly rotated, forceps in, 480 measurements of fetus, 53 Heart, acute dilatation of, in labor, 275 Heart disease in pregnancy, 185 valvular, in labor, 275 Hebosteotomy, 501 Hebotomy, 501 Hegar's bougies for dilating cervix, .456 dilators, 457 operation for lacerations of peri- neum in labor, 323 sign of pregnancy, 62, 65 Heller's test for albuminuria in pregnancy, 205 Hematogenous jaundice in new- born, 424 Hematoma, obstruction of labor by, 271 puerperal, 368 rupture of, hemorrhage from, treatment, 290 subchorial, 167 Hematuria in pregnancy, 191 in puerperium, 374 Hemophilia in new-born, 423 Hemoptysis in pregnancy, 190 Hemorrhage, 277 accidental, 286 antepartum, 277 classification, 277 from adherent placenta, 296 from incomplete abortion, 278 from inevitable abortion, 277 from inversion of uterus, 296 from lacerations of anterior vaginal wall, 295 of birth-canal, 295 diagnosis, 295 treatment, 295 of cervix, 295 of clitoris, 295 of perineum, 296 of urethra, 295 from retained placenta, 296 from rupture of hematoma, treatment, 290 of uterus, treatment, 290 from threatened abortion, 277 from umbilicus in new-born, 434 in cesarean section, 517 in labor, 277 in placenta praevia, 278 control after delivery, 285 in pregnancy, 277 intrapartum, 277 postpartum, 277, 290 from relaxation of uterus, 290 INDEX 531 Hemorrhage, postpartum, Mom- burg belt for, 294 prognosis, 294 stimulation in, 294 symptoms, 291 technic of packing in, 292 treatment, 291 puerperal, 277, 296, 369 from atony of uterus, 297 from backward displacement of uterus, 297 from cancer or chorionepithe- lioma, 297 from dislodged clots at placen- tal site, 297 from fibroids, 297 from relaxation of uterus, 296 unavoidable, 278 Hemorrhoids, 363 in pregnancy, 184 in puerperium, 374 Hepatogenous jaundice in new- born, 424 Hernia, umbilical, 166 in new-born, 422 vaginal, in pregnancy, 178 Herpes in pregnancy, 190 Hilum of ovary, 29 Hirst's (B. C.)' bag for dilating cervix, 464 double tenaculum, 446 modification of Muller's method of antepartum fetometry, 240 operation for cystocele, 353 for lacerations of perineum in labor, 323 pelvimeter, 237 Hirst's (J. C.) dilators, 459 Hirudin in eclampsia, 216 Hollow nipples, 378 Home, operation in, 438 basins for, 441 choice of room, 438 douche-bag for, 440 dressings for, 441 dressing-table for, 440 instruments for, 441 instrument-table for, 440 nurse's kit for, 443 operating table for, 439 preparation of doctor's person and hands, 443 of patient for, 438 rubber gloves for, 442 Home, operation in, scrubbing faci- lities needed for, 442 sterile water for, 442 sterilization of hands in, 443 supplies required, 442 Homologous twins, 55 Hot pack in albuminuria of preg- nancy, 208 in eclampsia, 213 Hour-glass uterus, 157 Hydatid mole, 161 cause, 161 frequency, 162 symptoms, 162 synonyms, 161 treatment, 162 Hydatidiform mole, 161 Hydramnios, 55, 159 cause, 159 diagnosis, 160 symptoms, 160 treatment, 160 Hydremia of pregnancy, 56 Hydrocephalus, effect on preg- nancy, 265 obstruction of labor by, 264, 265 Hydrorrhea gravidarum, 167 Hydrostatic methods of dilating cervix, 461 Hymen, 24 Hyperemesis gravidarum, 200 drugs in, 202 frequency, 200 intravenous injections of cor- pus luteum extract in, 202 of glucose solution in, 201 pathologic changes in, 200 prognosis, 203 serum treatment, 202 symptoms, 200 treatment, 201 varieties, 200 Hyperemia, Bier's, in breast abscess, 384, 387 Hyperlactation, 380 Hyperleucocytosis, artificial, in puerperal sepsis, 398 Hypertrophy of breasts, 375 Hypodermoclysis in eclampsia, 212 Hysteria, eclampsia and, differen- tiation, 211 Hysterostomatomy, 504 Hysterotomy, anterior vaginal, 504 anesthesia for, 504 532 INDEX Hysterotomy, anterior vaginal, contra-indication, 507 indications, 504 technic, 505 time for operation, 504 Icterus neonatorum, 424 Ileopectineal line, 17 Immovable pelvic joints, 255 Imperforate anus in new-born, 422 Impetigo in pregnancy, 190 Incomplete abortion, hemorrhage from, 278 Incontinence of urine, 358 in pregnancy, 191 in puerperium, 374 Indigocarmin test of kidney activ- ity in pregnancy, 194 Induction of abortion, 445. See also Abortion, induction of. of labor, 450. See also Labor, induction of. Inertia uteri, 230 alcohol in, 232 application of forceps in, 231 causes, 230 diagnosis, 230 differential, 230 drugs in, 231 ergot in, 232 excessive uterine force in, 234 kneading uterus in, 231 overdistention of lower uterine segment and, differentiation, • _ 230 pituitrin in, 232 quinin in, 231 terminal, 233 time of occurrence, 230 treatment, 271 Inevitable abortion, hemorrhage from, 277 Infection in cesarean section, 517 Infectious diseases in pregnancy, 188 Inflammation of deciduae, 167 of placenta, 166 pelvic, 343 symptoms, 343 treatment, 344 Injuries during pregnancy, 188 of new-born, 424 Insanity in pregnancy, 189 Inspiration pneumonia in new- born, 430 Instruments for home operation, 44i Instrument-table for home opera- tion, 440 Intestinal bleeding in new-born, 423 Intrapartum hemorrhage, 277 Intra-uterine douche in puerperal sepsis, 396 Inversion of uterus, hemorrhage from, 296 in labor, 272 causes, 272 differential diagnosis, 272 prognosis, 273 symptoms, 272 treatment, 272 Inverted nipple, 378 Involution of endometrium, 103 of uterus, 103 Ischiorectal abscess in puerperal sepsis, 415 Jaundice in new-born infant, 424 Jelly of Wharton, 48 Joints, pelvic, in pregnancy, 59 Justomajor pelvis, 254 Justominor pelvis, 243 Kidney activity, functional tests, in pregnancy, 194 indigocarmin test for, in preg- nancy, 194 phenolsulphonephthalein test of, in pregnancy, 194 diseases of, in pregnancy, 192 dislocation of, in pregnancy, 192 ectopic, 347 examination of, in puerperium, 112 floating, 346. See also Floating kidney. of pregnancy, 199 nephritis and, differential diag- nosis, 207 pathologic changes in, in preg- nancy, 207 Kielland's forceps, 468, 486 Kleiseometer, Neumann-Ehrenfest, 152 Knee-chest position, 337 in puerperium, in Krause's method of inducing labor, 45i INDEX 533 Kyphoscoliosis, 248 Kyphoscoliotic pelvis, 248 Kyphosis, 251 Kyphotic pelvis, 251 Labia, hematoma of, puerperal, 369 lacerations of, in labor, 312 majora, 23 minora, 23 varices of, in pregnancy, 175 Labor, acute dilatation of heart in, 275 anaphylaxis theory, 78 anesthesia in, 88 armamentarium for, 80 articles provided by patient for, 80 Banal's contraction ring in, 153 beginning, symptoms of, 78 bulging of perineum in, 90 causes, 78 chloroform in, 88 delayed, causes, 230 dilatation of cervix with obliter- ation of length in, 79 distention of vulva in, 91 dry, 271 effect of age on, 263 of congenital anomalies of uterus on, 31 estimation of date, 71 ether in, 88 examinations in, 81 frequency, 84 expressed fecal matter in, 90 first stage, 79 management of, 87 forces involved in, 123 of expulsion in, 123 of resistance in, 123 fracture of coccyx in, 299 full bladder in, 90 hemorrhage in, 277 imminent, symptofhs of, 78 in pneumonia, 276 in typhoid fever, 276 induction of, 450 dilatation of cervix for, 455 drug method, 451 in eclampsia, 214 Krause's method, 451 metreurynter for, 453 packing cervix with gauze for, 455 rubber bags for, 453 Labor, induction of, with rectal tube coiled in cervix, 452 injection of sacral hiatus in, 89 injuries of pelvis in, 299 of sacro-iliac joint in, 299 inversion of uterus in, 272 lacerations of anterior vaginal wall in, 310 of cervix in, 304. See also Lacerations of cervix in labor. of labia in, 312 of levator ani in, 313 of pelvic floor in, 312 of perineum in, 312. See also Lacerations of perineum. of vagina in, 312 of vulva in, 312 late rupture of membranes in, 271 leg-cramps in, 91 long cord complicating, 270 management of, in flat pelves, 248 mechanism, 121 of third stage, 153 missed, 71 nausea and vomiting in, 87 nitrous oxid and oxygen in, 89 normal, 78 management of, 80 nurse's duties in, 94 obstructed, causes, 230 obstruction, by abdominal en- largements of fetus, 268 by abscess of Bartholin's gland, 256 by accidents, 271 by anus vestibularis, 257 by atresia of cervix, 258 of vagina, 257 by cancer of cervix, 259 by cystocele, 257 by displacement of uterus, 259 by double uterus, 260 by early rupture of mem- branes, 271 by edema of vulva, 256 by hematoma, 271 by hydrocephalus, 264, 265 by monsters, 268 by overdistended bladder, 257 rectum, 257 by overgrowth of fetus, 263 by posterior displacement of cervix, 260 by prolapse of uterus, 259 534 INDEX Labor, obstruction, by rectocele, 257 by rectovaginal fistula, 257 by rigid perineum, 258 by rigidity of cervix, 258 by septa of vagina, 257 by tumors of vagina, 257 of vulva, 257 by varicose veins of vulva, 256 ovarian cysts in, 262 pains, 79 pathologic sequelae, 331 periodicity as cause, 78 position of patient for delivery in, 91 of presenting part, 121 premature, 223 preparation of bed for, 86 of room for, 86 protection of perineum in, 91 puller in, 89 rectal examination in, 84 oil and ether anesthesia in, 89 rupture of larynx and trachea in, 274 of membranes in, 90 of umbilical cord during, 270 of uterus in, 300. See also Uterus, rupture. scopolamin and morphin in, 88 second stage, 79 management of, 87 separation of placenta, 153 short umbilical cord compli- cating, 270 show in, 79 signs of danger to child in, 87 spinal anesthesia in, 89 stages, 79 subsidence of uterus in, 78 sudden death during and after, 2 74 syncope in, 273 third stage, 79 management, 96, 153 tuberculosis of lungs in, 276 twilight sleep in, 88 twin, 266 date, 267 diagnosis, 267 interval between delivery, 267 management, 267 presentation in, 267 prognosis, 267 size of twins, 267 vaginal examination in, 81 valvular heart disease in, 275 Laborde method of artificial respi- ration, 418 Lacerations of anterior vaginal wall, hemorrhage from, 295 in labor, 310 of birth-canal, hemorrhage from, .295 diagnosis, 295 treatment, 295 of cervix, hemorrhage from, 295 in labor, 304 advantages of delayed re- pair, 308 consequences of nonrepair, . 3°7 diagnosis, 304 disadvantages of delayed repair, 308 frequency, 304 method of insertion of specu- lum, 305 predisposing causes, 304 site, 304 symptoms, 304 time of repair, 307 of clitoris, hemorrhage from, 295. of labia in labor, 312 of levator ani in labor, 313 of pelvic floor in labor, 312 of perineum, hemorrhage from, 296 in labor, 312 causes, 313 central, 315 complete, repair of, 326 after-treatment, 329 factors essential to suc- cess in, 329 delayed repair, technic, 319 diagnosis, 313 Emmet operation in, 319 Hegar's operation in, 323 Hirst's (B. C.) operation in, 323 . immediate repair, technic, 3i8 routine operations for, after- care, 325 preventive treatment, 317 tests for, 313 time of repair, 316 through sphincter ani, symp- toms, 315 INDEX 535 Lacerations of posterior vaginal wall in labor, 312 of urethra, hemorrhage from, 295 of vagina in labor, 312 of vulva in labor, 312 Laparo-elytrotomy, 513 Larynx, catheterization of, arti- ficial respiration by, 419 rupture of, in labor, 274 Leg, fractures of, in new-born, 426 Leg-cramps in labor, 91 Leukemia in pregnancy, 187 Levator ani, lacerations of, in labor, 3i3 Ligaments of uterus, 27 pelvic, 21 Linea nigra, 56 terminalis, 17 Liquor amnii, 44 Lithotomy position, 440 Liver, acute yellow atrophy of, in pregnancy, 203 degenerations in pregnancy, 185 function in pregnancy, test for, 203 Lochia, 104 alba, 104 rubra, 104 serosa, 104 sudden cessation, in puerperal sepsis, 413 Lordosis, 255 Lordotic pelvis, 255 Lulpus vulvae in pregnancy, 176 Lungmotor, 417 Lungs, tuberculosis of, in labor, 276 Luxation of femora, 255 Luys' method of segregation of urine, 198 Lymphatics of uterus, 27 in pregnancy, 58 Malacostion pelvis, 244 Malaria, puerperal, 366 Manual method of breech extrac- tion, 459, 493 Marshall Hall method of artificial respiration, 418 Martin operation for cystocele, 352 Massage of breasts, technic, 383 Mastitis, 383 carcinosa, 386 in new-born, 431 Maternal death, effect on fetus, 171 fever, effect of, on fetus, 172 Maternal impressions, effect of, on fetus, 172 Maturation of ovum, 34 Mature fetus, 53 Mauriceau's method of delivering after-coming head, 494 Mayo operation in retroversion of uterus, 343 Measles, puerperal, 366 Melena in new-born, 423 Membranes, extraction of, 98 rupture of, in labor, 90 Menge pessary in prolapse of uterus, 355 Menopause, 33 Menstrual cycle, 32 Menstruation, 33 amount of flow, 33 and ovulation, connection, 34 cause, 33 cessation of, in pregnancy, 59 character of flow, 33 cycle, 32 in new-born, 432 interval between periods, 33 mechanism, 32 molimina, 33 return after delivery, no time of appearance, 32 of cessation, 32, 33 Mercurochrome in puerperal sepsis, 399 Mesoderm, 36 Mesovarium, 29 Metranoikter, Schatz, 42 Van Dolsen's modification, 42 Metreurynter, Braun's, for dilating cervix, 464 for inducing labor, 453 in placenta praevia, 284 Metritis in puerperal sepsis, 403 Michaelis' diameter of pelvis, 234 Migration of ovum, 34 Milk, cow's, analysis, 118 modification of, 118 fever, 379 human, characteristics, 105 quantity, 105 pasteurization of, 120 qualitative anomalies, 381 secretion, anomalies in, 379 deficient, 379 drying up after child's death, 38i_ excessive, 280 536 INDEX Milk secretion, voluntary prolonga- tion, 380 Milk-leg in puerperal sepsis, 409 Miscarriage, 223 Missed labor, 71 Mitral regurgitation in pregnancy, 186 Mole, hydatid, 161. See also Hydatid mole. Molimina, menstrual, 33 Molluscum fibrosum in pregnancy, 190 Momburg belt for postpartum hemorrhage, 294 Mons veneris, 22 Monsters, 172 obstruction of labor by, 268 Morphin in eclampsia, 215 Morula, 36 Mother, dangers to, in forceps operations, 483 effect of fetal death upon, 171 Mouth, care of, in new-born infant, 116 infections in new-born, 432 Mouth-to-mouth method of arti- ficial respiration, 417 Mulberry mass, 36 nipples, 378 Mullers' method of antepartum fetometry, 240 Hirst's modification, 240 Multiple births, 268 fetation, 54 causes, 54 Murphy breast binder, 109 Muscle fibers of uterus in preg- nancy, 58 Muscles, pelvic, 21 Mushroom nipples, 379 Mycosis vagina: in pregnancy, 178 Myometrium, 26 rheumatism of, in pregnancy, 183 Myrtiform caruncles, 24 Myxoma chorii, 161 Nagele pelvis, 244, 253 Nausea in labor, 87 in pregnancy, 59 Neck, bruises of, in new-born, 428 Necrosis of pelvis, 255 Neo-salvarsan in puerperal sepsis, 399 Nephritis, kidney of pregnancy and, differential diagnosis, 207 Nephrorrhaphy for floating kid- ney, 346 Nerves of uterus, 28 Nervous phenomena in pregnancy, 60 system, diseases of, in pregnancy, 188 Neumann-Ehrenfest pelvigraph, 237 Neuralgia in pregnancy, 189 Neuritis, sacral, puerperal, 372 New growths of pelvis, 256 New-born, infant, acne in, 420 anus vestibularis in, 422 aphthae in, 432 artificial feeding, 117 asphyxia of, 416 atelectasis in, 420 bathing, 115 Bell's paralysis in, 428 birth paralyses in, 428 blood of, 115 bowels of, 115 bruising of face, forehead, and neck in, 428 Buhl's disease in, 424 caput succedaneum in, 426 care of cord, 115 of mouth, 116 cephalhematoma in, 427 chafing of skin in, 420 cleft-palate in, 421 clothing of, 116 club-foot in, 423 colic in, 420 congenital deformities in, 421 constipation in, 421 convulsions in, 423 coryza in, 433 decapitation of, 426 diapers, 116 diarrhea in, 421 Erb's paralysis in, 428 eyes in, 115 facial paralysis in, 428 feeding, 116 fracture of arm in, 426 of clavicle in, 426 of leg in, 426 of skull in, 424 harelip in, 421 hematogenous jaundice in, 424 hemophilia in, 423 hepatogenous jaundice in, 424 icterus in, 424 INDEX 537 New-born, infant, imperforate anus in, 422 infection of, 430 injuries, 424 inspiration pneumonia in, 430 intestinal bleeding in, 423 jaundice in, 424 management of, 115 mastitis in, 431 melena in, 423 menstruation in, 432 mouth infections in, 432 omphalitis in, 431 omphalorrhagia in, 434 omphalorrhea in, 434 ophthalmia in, 432 paraphimosis in, 422 pathology, 416 patulous foramen ovale in, 434 phimosis in, 422 physiology of, 114 premature, care of, 117 pulse, 114 resnirations, 114 resting place for, 117 rupture of sternocleidomastoid muscle in, 429 sloughs of scalp in, 427 snuffles in, 433 spina bifida in, 422 spoon-shaped depression of skull in, 425 stomach in, 115 sudden death of, 434 syphilis in, 433 treatment, 170 temperature, 114 thrush in, 432 tolerance to drugs, 435 tongue-tie in, 421 umbilical fungus in, 434 hemorrhage in, 434 hernia in, 422 infection in, 431 urine of, 114 weight, 114 wet-nurse for, 117 Winckel's disease in, 424 Nicholson's blood-pressure appa- ratus, 204 modification of Dbderlein tube, 391 Nipples, abnormalities, 375 care of, in pregnancy, 185 in puerperium, 109 Nipples, conical, 378 fissured, 376 hollow, 378 inverted, 378 mulberry, 378 mushroom, 379 shields, 377 care of, 378 stunted, 378 Nitrogen partition in pregnancy, 206 Nitrous oxid and oxygen in labor, 89 Non-rachitic pelvis, 243 Nurse's duties in labor, 94 kit for home operation, 443 Obesity, sterility associated with, 43 Obstetric operations, 436 Occipito-anterior position of vertex, left, diagnosis, 472 forceps in, 472 right, diagnosis, 477 forceps in, 477 Occipito-posterior position of ver- tex, left, diagnosis, 478 forcens in, 478 right, diagnosis, 475 forceps in, 475 Occiput in hollow of sacrum, diagnosis, 479 forceps in, 479 Oligogalactia, 379 Oligohydramnios, 160 Omental fat, pregnancy and, differ- entiation, 67 Omphalitis in new-born, 431 Omphalorrhagia in new-born, 434 Omphalorrhea in new-born, 434 Oophoritis in puerperal sepsis, 402 Operating table for home oper- ation, 439 Operation, abdominal. See Ab- dominal section. in private house, 438 See also Home, operation in. Ophthalmia neonatorum, 432 benign, 432 caution in, 433 Crede's method of prevention, 433 treatment, 94 method of irrigation in, 433 prognosis, 433 treatment, 432 true, 432 538 INDEX Ossification centers of fetus, 54 of cranium, premature, obstruc- tion of labor by, 264 Osteomalacia, 246 Osteomalacic pelvis, 246 Osteosarcoma of pelvis, 256 Ovarian cyst, pregnancy and, differentiation, 66 cysts in labor, 262 in pregnancy, 262 in puerperium, 262, 263 Ovaries, examination of, in puer- perium, 112 in pregnancy, 59 Ovary, 29 blood-supply, 30 cortex, 29 external appearance, 29 hilum, 29 medulla, 29 Overdistended bladder, obstruc- tion of labor by, 257 pregnancy and, differentiation, 67 rectum, obstruction of labor by, 257 Overgrowth of fetus, obstruction of labor by, 263 Ovulation, 33 and menstruation, connection, 34 Ovum and spermatozoon, meeting place, 35 early changes in development, 36 fertilization of, 36 forceps, 447 maturation of, 34 maturity of, as cause of labor, 78 migration of, 34 Packing after induction of abor- tion, 448 cervix with gauze for dilatation, 461 Pain, coccygeal, causes, 349 right-sided, in pregnancy, causes, 193 Pains, labor, 79 Pampiniform plexus, 27 Paralysis, Bell's, in new-born, 428 Erb's, in new-born, 428 facial, in new-born, 428 Paraphimosis in new-born, 422 Parasitic infection in pregnancy, 178 Parathyroid extract in eclampsia, 216 Pasteurization of milk, 120 Patulous foramen ovale in new- born, 434 Pelvic abscess in puerperal sepsis, 4°5. posterior pelvic puncture for, 406 application of forceps, 471 bones, tumors of, 356 cellulitis in puerperal sepsis, 404 direction, 20 floor, 21 lacerations of, in labor, 312 inclination, 20, 241 inflammation, 343 symptoms, 343 treatment, 344 inlet, normal, 235 joints, immovable, 255 in pregnancy, 59 relaxation of, in pregnancy, 188 in puerperium, 371 ligaments, 21 muscles, 21 peritonitis in puerperal sepsis, 411 planes, 18 puncture, posterior, for abscess in puerperal sepsis, 406 Pelvigraph, Neumann-Ehrenfest, 237 Pelvimeter, Hirst's, 237 Pelvimetry, 234 Pelvis, anatomy, 17 assimilation, 255 atrophy of, 255 atypical, 254 Baudelocque's diameter, 234 bony, dystocia due to, 234 caries of, 255 conjugate, internal, measure- ment, instrumental, 237 manual method, 236 true, measurement, 235 deformities, 234 classification, 241 contraction of conjugata vera, 242 frequency, 234, 241 methods of diagnosis, 234 dwarf, 243 enchondroma of, 256 INDEX 539 Pelvis, exostoses of, 256 false, 17 fetal, funnel-shaped, 252 flat, 244 generally contracted, 243 management of labor in, 248 fractures of, 255 generally contracted flat, 243 equally contracted, 243 injuries of, in labor, 299 justomajor, 254 justominor, 243, 244 juvenile, 243 kyphoscoliotic, 248 kyphotic, 251 lordotic, 255 malacosteon, 244 masculine, 243 measurements, 234 external, 234 internal, 235 Michaelis' diameter, 234 Nagele, 244, 253 nana, 243' necrosis of, 255 new growths of, 256 non-rachitic, 243 normal, 244 measurements, 234 oblique, 253 deformity due to absence or disease of one extremity, 254 . osteomalacic, 246 osteosarcoma of, 256 outlet, index, 238 plane of greatest contraction, 19 expansion, 19 of inlet, 19 of outlet, 19 pseudo-osteomalacic, 245 rachitic, 244, 245 Robert, 244, 253 sagittal diameters, measurement, 237 of outlet, 235 simple flat, 242 split, 254 _ spondylolisthetic, 247 transverse contraction at outlet, 251 true, 17 Perforation of uterus in induction of abortion, 450 in puerperal sepsis, 397 Perineorrhaphy, Emmet's method, 3i9 Hegar's method, 323 Hirst's (B. C.) method, 323 routine after-care, 325 Perineum, bulging of, in labor, 90 laceration of, hemorrhage from, 296 in labor, 312. See also Lacera- tions of perineum. protection of, in labor, 91 rigid, obstruction of labor by, 258 Periodicity as cause of labor, 78 Peritonitis, diffuse, in puerperal sepsis, 412 pelvic, in puerperal sepsis, 411 Pernicious anemia in pregnancy, l8.7. vomiting of pregnancy, 200 Perret's method of antepartum fetometry, 240 Pessary, Goddard, in prolapse of uterus, 3'55 Hodge, 338. in retroversion of uterus, 338 after-treatment, 340 qualifications, 339 Menge, in prolapse of uterus, 355 Schatz, in prolapse of uterus, 355 Smith, 338 stem, 42 Thomas, 338 Pfannenstiel incision in retro- version of uterus, 342 Phenolsulphonephthalein test of kidney activity in pregnancy, 194 Phenol-tetrachlorphthalein test for liver function in pregnancy, 203 Phimosis in new-born, 422 Phlebitis in puerperal sepsis, 407 Phlegmasia alba dolens, 409 cellulitic, 409 dangers, 410 prognosis, 410 pulmonary embolism in, 411 symptoms, 409 thrombotic, 409 treatment, 410 Phloridzin-test of pregnancy, 68 Physician's visits during puer- perium, 109 Pigmentation of skin in pregnancy, 190 Pilocarpin in eclampsia, 215 540 INDEX Pituitrin in inertia uteri, 232 in premature separation of pla- centa, 289 Placenta, 46 abnormalities, 154, 166 accessory lobule, 154 accreta, 158 adherent, 154 at full term, 47 hemorrhage from, 296 intractable, 158 delivery of, 96, 154 Crede method, 97 fetal surface, 48 increta, 158 infarcts, 166 inflammation of, 166 management, 154 maternal surface, 47 membranacea, 166 number, 166 prEevia, 166, 278 abdominal cesarean section in, 284 causes, 278 central, 278 treatment at seventh month, 281 diagnosis, differential, 279 forceps in, 284 frequency, 278 hemorrhage in, 278 control after delivery, 285 lateral, 278 treatment, 284 marginal, 278 treatment, 284 metreurynter in, 284 partial, 278 treatment at seventh month, 281 premature separation of pla- centa and, differentiation, 280 prognosis, 280 stillicidium sanguinis in, 279 stimulation in, 285 symptoms, 278 technic of packing in, 280 treatment, 280 at full term, 283 at seventh month, 281 vaginal cesarean section in, 284 varieties, 278 Wigand treatment, 284 Placenta, premature separation, 286 causes, 286 degree, 287 differential diagnosis, 288 ergot in, 289 pathology, 287 pituitrin in, 289 placenta praevia and, differ- entiation, 280 prognosis, 288 stimulation, 289 symptoms, 287 treatment, 289 retention of, 154, 369 hemorrhage from, 296 separation of, 153 situation, 166 size and weight, 166 succenturiata, 154 syphilis of, 166 tumors of, 167 Placental decidua, 51 membranes, 48 site, dislodged clots at in puer- perium, hemorrhage from, 297 Placentin test of pregnancy, 68 Planes, pelvic, 18 Plexus, pampiniform, 27 Plicae palmatse, 26 Pneumonia, inspiration, in new- born, 430 labor in, 276 puerperal, 367 white, in syphilis of fetus, 169 Podalic version, 488 Polydactylism in new-born, 420 Polygalactia, 380 Polymastia, 375 Polyps, cervical, in pregnancy, 179 Polyuria in pregnancy, 190 Pomeroy bag for dilating cervix, 465 Porro method of cesarean section with dropped stump, • 5IS with marsupialization of cervical stump, 516 Position, 121 diagnosis, 125 knee-chest, 337 lithotomy, 440 of fetus, diagnosis, 125 of heart sounds, 125 Postmammary abscess, 387 INDEX 541 Postmortem delivery, 274 Postpartum chill, 99 hemorrage 277, 290. See also Hemorrhage, postpartum. Postural version, 488 Potter version, 489 differences in technic com- pared to older operation, 492 technic, 489 essentials of, 491 Prague method of extracting after- coming head, 494 Predetermination of sex, 54 Pregnancy, Abderhalden test, 67 abdomen in, 61 abdominal fat and, differentia- tion, 67 walls in, 56 accidents in, 188 acute yellow atrophy of liver in, 203 adenoma of breasts in, 185 after Rubin test for sterility, 41 albuminuria in, 205 hot pack in, 208 steam or vapor bath in, 208 treatment, 207 anemia of, 56 anteflexion of uterus in, 182 appendicitis in, 183 artificial renal glycosuria test, 68 ascites and, differentiation, 67 asthma in, 190 auscultation in, 74 ballottement in, 62 bladder in, 57 blood-pressure in, 56 Braxton Hicks' sign, 65 breasts in, 56, 61 brittle or loose finger nails in, 190 cancer of breast in, 185 of cervix in, 178 of vulva in, 176 cane sugar test, 70 care of nipples in, 185 caries of teeth in, 184 cervical polyps in, 179 cervix in, 57 cessation of menstruation in, 59 changes in breasts in, 60 in genitalia in, 60 size and shape of abdomen in, 59. chorea in, 188 Pregnancy, circulation in, 56 coitus in, 76 condyloma of cervix in, 179 condylomata in, 174 constipation in, 184 contra-indications to, 186 cystitis in, 191 cystoscopy in, 194 methods, 194 diagnosis, 56 differential, 56, 65 methods, 67 diarrhea in, 184 diet in, 76 diseases of bladder in, 191 of blood in, 187 of breasts in, 185 of cervix in, 178 of circulatory system in, 185 of kidney in, 192 of nervous system in, 188 of respiratory system in, 189 of skin in, 190 of urinary system in, 190 of uterus in, 179 of vagina in, 176 dislocation of kidney in, 192 displacements of uterus in, 179 duration, 70 dysuria in, 179 eclampsia in, 209. See also Eclampsia. edema of vulva in, 174 effect of congenital anomalies of uterus on, 31 of hydrocephalus on, 265 epilepsy in, 189 epistaxis in, 189 examinations necessary in, 72 extra-uterine, 223. See also Extra-uterine pregnancy. face in, 61 fallopian tubes in, 59 fetal heart sounds in, 64 movements in, 64 fibroid tumor and, differ- entiation, 66 of uterus in, 261 gingivitis in, 184 . glucose test, 69 gonorrhea in, 176 Goodell's sign, 62 Graves' disease in, 187 heart disease in, 185 hematuria in, 191 542 INDEX Pregnancy, hemoptysis in, 190 hemorrhage in, 277 hemorrhoids in, 184 herpes in, 190 hydremia of, 56 impetigo in, 190 incontinence of urine in, 191 indigocarmin test of kidney activity in, 194 infectious diseases in, 188 injuries in, 188 insanity in, 189 kidney of, nephritis and, differ- ential diagnosis, 207 late toxemia of, 204 blood-pressure in, 204 hepatic, 204 nephritic, 204 lateral displacements of uterus in, 182 leukemia in, 187 liver degenerations in, 185 function in, test for, 203 lupus vulva; in, 176 mitral regurgitation in, 186 molluscum fibrosum in, 190 mycosis vaginae in, 178 nausea and vomiting in, 59 nervous phenomena in, 60 neuralgia in, 189 nitrogen partition in, 206 nontoxic diseases of alimentary canal in, 183 normal, management of, 75 omental fat and, differentiation, 67. ovarian cyst and, differentiation, 66 . cysts in, 262 ovaries in, 59 overdistended bladder and, differentiation, 67 parasitic infection in, 178 pathologic changes in kidney in, 207 pathology of, 174 pelvic joints in, 59 pernicious anemia in, 187 phenolsulphonephthalein test of kidney activity in, 194 phloridzin test, 68 physiology, 56 pigmentation of skin in, 190 placentin test, 68 polyuria in, 190 Pregnancy, posterior displacement of cervix in, 183 predetermination of sex, 75 prior, diagnosis of, 74 prolapse of uterus in, 183 pruritus in, 175 vulvae in, 190 ptyalism in, 185 purpura in, 187 pyelitis in, 192 pyorrhea in, 184 quickening in, 60 relaxation of pelvic joints in, 188 rheumatism of myometrium in, . i83 . right-sided pain in, causes, 193 segregation of urine in, 197 signs of, 59, 63. See also Signs of pregnancy. spurious, 75 stone in bladder in, 191 suburethral abscess in, 178 hypertrophy of vaginal mucosa in, 177 sugar in urine in, 191 surgical operations during, 188 symptoms, 59 objective, 60 subjective, 59 toxemias of, 198 early, 198, 199 late, 198, 204 theories as to cause, 199 tubal, 223 tuberculosis in, 189 tumors complicating, 190 tympanites and, differentiation, 67 urea estimation in, 205 in blood in, 206 nitrogen in blood in, 206 ureteral catheterization in, 197 urine in, 57 uterus in, 57 vagina in, 57, 62 vaginal cancer in, 178 cysts in, 178 hernia in, 178 vaginitis in, 176 varices of labia in, 175 of vulva in, 177 varicose veins in, 187 venereal warts in, 174 vomiting in, 59, 199 See also vomiting of pregnancy. INDEX 543 Pregnancy, weight in, 56 x-ray in diagnosis, 65, 68 Pregnant uterus, retroversion of, !79 diagnosis, 179 incarceration in, 181 symptoms, 179 terminations, 179 treatment, 180 Premature infant, care of, 117 labor, 223 ossification of cranium, obstruc- tion of labor by, 264 separation of placenta, 286 placenta praevia and, differ- entiation, 280 Presentation, 121 breech, 143 abnormalities in mechanism, 145 cause, 143 diagnosis, 143 frequency, 143 management, 146 mechanism, 144 prognosis, 146 brow, 140 abnormalities in mechanism, 141 cause, 140 diagnosis, 141 frequency, 140 management, 142 mechanism, 141 prognosis, 142 face, 135 abnormalities of mechanism, diagnosis, 135 impacted, management, 139 management, 139 mechanism, 137 prognosis, 139 footling, 144 head, possible, 122 L. O. A., diagnosis, 125 L. O. P., diagnosis, 130 most frequent, 121 of greater fontanel, 143 R. O. A., diagnosis, 130 R. O. P., diagnosis, 130 shoulder, impacted, manage- ment, 152 transverse, 149 cause, 149 Presentation, transverse, diagnosis, 149 frequency, 149 management, 152 mechanism, 151 position, 151 prognosis, 152 varieties, 121 vertex, 125 anterior rotation of occiput in, 131 delayed, 134 commonest position, 122 mechanism, 130 most common abnormalities of, 132 posterior rotation of occiput in, 133 Scanzoni maneuver in, 134 Proctitis, septic, in puerperal sepsis, T43 Profeta's law in syphilis, 169 Prolapse of umbilical cord, 268 See also Umbilical cord, pro- lapse. of uterus, 353 diagnosis, 355 Goddard pessary in, 355 in pregnancy, 183 Menge pessary in, 355 operative treatment, 356 Schatz pessary in, 355 symptoms, 354 treatment, 355 Pruritus in pregnancy, 175 vulvae in pregnancy, 190 Pseudocyesis, 75 Psychoses, puerperal, 370 Ptyalism in pregnancy, 185 Pubiotomy, 501 dangers, 503 indications, 501 prognosis, 503 technic, 501 Puerperal hemorrhage, 296. See also Hemorrhage, puerperal. sapremia, 390 sepsis, abdominal hysterectomy in, 400 section in, 400 antiseptic solutions in, 395 arthritis in, 413 artificial hyperleucocytosis in, 398. bacteria in, 390 544 INDEX Puerperal sepsis, bacterins in, 398 blood cultures in, 392 picture in, 392 transfusion in, 399 cause, 389 chemical disinfection of blood stream in, 398 colloidal silver in, 399 complications, 402 contra-indications to disin- fection of genital canal in, 397 to operation in, 400 cotton pledgets in, 395 curative treatment, 396 diagnosis, 391 differential, 391 methods, 392 diet in, 397 diffuse peritonitis in, 412 drugs in, 397 endocolpitis in, 402 endometritis in, 402 exploratory operation in, 400 fixation abscess in, 398 gonorrheal arthritis in, 413 historical, 389 intra-uterine douche in, 396 ischiorectal abscess in, 415 kinds, 390 mercurochrome in, 399 method of introduction into genital tract, 390 metritis in, 403 milk-leg in, 409 neo-salvarsan in, 399 nurse's precautions against, 394 . . oophoritis in, 402 operation in, 400 drainage, 400 exploratory, 400 patient in, 394 patient's clothing in, 395 pelvic abscess in, 405 posterior pelvic puncture for, 406 cellulitis in, 404 peritonitis in, 411 perforation of uterus in, 397 phlebitis in, 407 phlegmasia alba dolens in, 409 physician's precautions against, 394 Puerperal sepsis, precautions re- garding instruments in, 395 preventive treatment, 393 pyemia in, 408 pyemic arthritis in, 413 rectal examination in, 395 resection of pelvic veins in, 402 salpingitis in, 402 salt solution in, 399 sapremia in, 412 septic cystitis in, 413 proctitis in, 413 pyelitis in, 413, 414 serum therapy in, 398 sudden cessation of lochia in, 4i3 symptoms, 391 tetanus in, 415 treatment, 393 uterine cultures in diagnosis, 392 vaginal examinations in, 395 vulvar pads in, 395 water in, 394 septicemia, 390 Puerperium, 100 abdominal binder in, 107 acute intercurrent diseases in, 365 after-pains in, 106 anemia in, 365 arthritis in, 367 breast changes in, 105 care of bowels in, 108 of breasts, 109 of genital organs in, 107 diet in, 101, 107 diphtheria in, 366 diseases of, 365 dislodged clots at placental site in, 370 hemorrhage from, 297 displacement of uterus in, 370 erysipelas in, 366 examinations in, no of abdominal walls, 112 of cervix in, 112 of coccyx in, 112 of kidneys in,112 of ovaries in, 112 of uterus, in, 112 exanthemata in, 365 fever in, 368 fibroid tumors of uterus in, 261 37o INDEX 545 Puerperium, gonorrhea in, 367 hematoma in, 368 hematuria in, 374 hemorrhage in, 277, 369 hemorrhoids in, 374 incontinence of urine in, 374 knee-chest position in, in malaria in, 366 management, 105 measles in, 366 normal, 103 ovarian cyst in, 262, 263 physician's visits in, 109 pneumonia in, 367 position of patient in bed, 105 profuse sweating in, 108 psychoses in, 370 pulse in, 106 relaxation of pelvic joints in, 371 retention of blood-clots in, 370 of urine in, 108, 374 routine after-care, 100 sacral neuritis in, 372 scarlet fever in, 365 small-pox in, 366 subinvolution of uterus in, 372, 373 temperature in, 106 tympanites in, 373 urination during, 108 visitors in, 107 vulvar pads in, 107 Puller in labor, 89 Pulmonary embolism in phlegmasia alba dolens, 411 Pulmotor, 417 Purgation in eclampsia, 213 Purpura in pregnancy, 187 Pyelitis in pregnancy, 192 septic, in puerperal sepsis, 413, 4i4 Pyemia in puerperal sepsis, 408 Pyemic arthritis in puerperal sepsis, 4i3 Pyorrhea in pregnancy, 184 Quadruplets, 54 Quickening in pregnancy, 60 Quinin in inertia uteri, 231 Quintuplets, 54 Rachitic pelvis, 245 Rectal examination in labor, 84 in puerperal sepsis, 395 35 Rectal oil and ether anesthesia in labor, 89 tube in cervix for inducing labor, 452 Recti muscles, diastasis of, 344 diagnosis, 344 Webster's operation for, 345 Rectocele, 351 obstruction of labor by, 257 Rectovaginal fistula, diagnosis, 362 obstruction of labor by, 257 treatment, 362 Rectum, overdistended, obstruc- tion of labor by, 257 Relaxation of pelvic joints in puerperium, 371 of uterus, postpartum hemor- rhage from, 290 puerperal hemorrhage from, 296 Renal glycosuria, artificial, test for pregnancy, 68 Respiration, artificial, 417. See also Artificial respiration. Respiratory system, diseases of, in pregnancy, 189 Retention of placenta, 369 hemorrhage from, 296 of urine in puerperium, 108 Retrodisplacement of uterus, 333 Retroflexion of pregnant uterus, 179 of uterus, 333 Retroversion of pregnant uterus, j79 diagnosis, 179 incarceration in, 181 symptoms, 179 terminations, 179 treatment, 180 of uterus, 333 adherent, 340 Alexander operation in, 341 Baldy operation in, 342 Coffey operation in, 343 diagnosis, 334 Gilliam operation in, 343 Mayo operation in, 343 operative treatment, 341 pessary in, 338 after-treatment, 340 qualifications, 339 Pfannenstiel incision in, 342 reposition in, 337 retention in position, 338 546 INDEX Retroversion of uterus, symptoms, 333 treatment, 334 ventrosuspension in, 342 Rheumatism of myometrium in pregnancy, 183 Rickets, 245 Right-sided pain in pregnancy, causes, 193 Rigid perineum, obstruction of labor by, 258 Robert pelvis, 244, 253 Room for private house operation, 438 preparation of, for labor, 86 Routine after-care, 100 care of baby, 101 Rubber bags for inducing labor, 453 gloves for home operation, 442 Rubin's apparatus for artificial transuterine pneumoperito- neum, 41 test for sterility, 39 pregnancy after, 41 Rugae of vaginal wall, 24 Rupture of hematoma, hemorrhage from, treatment, 290 of membranes in labor, 90 of sternocleidomastoid muscle in new-born, 429 of umbilical cord, 270 of uterus, 300. See also Uterus, rupture. Sacral hiatus, injection of, in labor, 89 neuritis, puerperal, 372 Sacro-iliac joint, injuries, in labor, 299 Sacrum, occiput in hollow of, forceps in, 479 Salpingitis in puerperal sepsis, 402 Salt solution in puerperal sepsis, 399 Sanger method of Cesarean section with short high incision, 512 Sapremia in puerperal sepsis, 412 puerperal, 390 Scalp, sloughs of, in new-born, 427 Scanzoni maneuver in vertex pres- entation, 146 Scarlet fever in puerperium, 365 Schatz metranoikter, 42 pessary in prolapse of uterus, 355 Schultze method of artificial respi- ration, 418 Scopolamin and morphin in labor, 88 Scrubbing facilities needed for home operation, 442 Segregation of urine in pregnancy, 197 Seminal fluid, 35 lake, 35 Sepsis, puerperal, 389. See also Puerperal sepsis. Septa of vagina, obstruction of labor by, 257 Septic arthritis, puerperal, 367 cystitis in puerperal sepsis, 413 proctitis in puerperal sepsis, 413 pyelitis in puerperal sepsis, 413, 4U _ Septicemia, puerperal, 390 Serum therapy in puerperal sepsis, 398 Sex, predetermination of, 54, 75 Sextuplets, 54 Sexual organs, females, develop- ment, 21 Shields for nipples, 377 care of, 378 Shoulder presentation, impacted, management, 152 Show in labor, 79 Sigault's operation, 500 Signs of pregnancy, 59, 63 at full term, 71 Braxton Hicks', 65 Goodell's, 62 Hegar's, 62, 65 objective, 63 positive, 64 prior to third month, 63 subjective, 63 x-ray, 65 Silver, colloidal, in puerperal sepsis, .399 Simple flat pelvis, 242 Simpson's forceps, 467, 468 Sims' speculum, 306 Skin, chafing of, in new-born, 420 disease of, in pregnancy, 190 pigmentation of, in pregnancy, 190 Skull, fractures of, in new-born, 424 spoon-shaped depression, in new- born, 425 INDEX 547 Sleep, twilight, 88 Sloughs of scalp in new-born, 427 Small-pox, puerperal, 366 Smith pessary, 338 Snuffles in new-born, 433 Somatopleura, 37 Speculum, Collin's bivalve, 306 Sims', 306 Spermatozoa, 35 reception into uterus, 35 Spermatozoon and ovum, meeting place, 35 Spina bifida in new-born, 422 Spinal anesthesia in labor, 89 Splanchnopleura, 37 Split pelvis, 254 Spondylolisthesis, 247 Spondylolisthetic pelvis, 247 Spoon-shaped depression of skull in new-born, 425 Spurious pregnancy, 75 Stem pessary, 42 Sterile water for home operation, 442 Sterility, 37 associated with obesity, 43 Rubin's test for, 39 pregnancy after, 41 treatment, 37 Sterilization of hands for home operation, 443 of woman, method, 516 Sternocleidomastoid muscle, rup- ture of, in new-born, 429 Stigma, 29, 34 Stillicidium sanguinis, 279 Stomach of new-born infant, 115 Stone in bladder in pregnancy, 191 Stone's method of antepartum fetometry, 240 Stroganov treatment of eclampsia, 215 Stunted nipple, 378 Subchorial hematoma, 167 Subinvolution of uterus in puer- perium, 372 Submammary abscess, 387 Suburethral abscess in pregnancy, 178 hypertrophy of vaginal mucosa in pregnancy, 177 Sugar in urine in pregnancy, 191 Superfetation, 55 Superinvolution of uterus in puer- perium, 373 Supernumerary breasts, 375 Surgical operations during preg- nancy, 188 Sweating in eclampsia, 213 profuse, in puerperium, 108 Swinging method of artificial respi- ration, 418 Sylvester method of artificial respiration, 418 Symphyseotomy, 500 after-care, 501 dangers, 501 extramedian, 501 indications, 500 technic, 500 Syncope in labor, 273 Syncytial cancer, 164 Syncytium, 45 buds, 46 Synostosis, 255 Syphilis in new-born, 433 treatment, 170 of fetus, 168 infection in, 169 prognosis, 169 symptoms, 168 treatment, 170 Wegner's sign in, 169 white pneumonia in, 169 of placenta, 166 Tarnier's, axis-traction forceps, 484 balloon for dilating cervix, 464 sign in inevitable abortion, 219 Teeth, caries of, in pregnancy, 184 Temperature of new-born infant, 114 Tenaculum, double, B. C. Hirst's, 446 Test, Abderhalden, of pregnancy, 67 artificial renal glycosuria, of pregnancy, 68 glucose, for pregnancy, 69 phloridzin, of pregnancy, 68 placentin, of pregnancy, 68 Rubin, of sterility, 39 Tetanus in puerperal sepsis, 415 Teterelle, 377 Theca folliculi, 29 Thomas pessary, 338 Threatened abortion, hemorrhage from, 277 548 INDEX Thrush in new-born, 432 Thyroid extract in eclampsia, 216 Tongue-tie in new-born, 421 Toxemias of pregnancy, 198 early, 198, 199 late, 198, 204 blood-pressure in, 204 hepatic, 204 nephritic, 204 theories as to cause, 199 Trachea, rupture of, in labor, 274 Transverse presentation, 149 cause, 149 diagnosis, 149 frequency, 149 management, 152 mechanism, 151 position, 151 prognosis, 152 Triplets, 54 Trophoblast, 45 True amnion, 43 pelvis, 17 Tubal abortion, 225 gestation, 223 pregnancy, 223 Tuberculosis in pregnancy, 189 of lungs in labor, 276 Tubes, Fallopian, 28 Tumors complicating pregnancy, 190 fibroid, pregnancy and, differen- tiation, 66 of breast, 388 of pelvic bones, 256 of placenta, 167 of umbilical cord, 166 of uterus, fibroid, in pregnancy, 261 in puerperium, 261, 370 obstruction of labor by, 260 of vagina, obstruction of labor by, 257 of vulva, obstruction of labor by, 257 Twilight sleep, 88 Twins, 54 homologous, 55 labor in, 266. See also Labor, twin. Tympanites in puerperium, 373 pregnancy and, differentiation, 67 Typhoid fever, labor in, 276 Umbilical cord, 48 abnormalities in insertion, 166 abnormalities of, 165 at term, 48 care of, 115 knots, 165 length, 165 long, 270 loops, 165 prolapse, 268 cesarean section for, 270 complete, 269 dangers, 269 degree, 269 diagnosis, 269 etiology, 269 treatment, 269 rupture of, 270 short, 270 tumors of, 166 tying and cutting, 95 fungus in new-born, 434 hemorrhage of new-born, 434 hernia, 166 in new-born, 422 infection in new-born, 431 Unavoidable hemorrhage, 278 Urea estimation in pregnancy, 205 in blood in pregnancy, 206 nitrogen in blood in pregnancy, 206 Ureometer, Doremus, use of, 205 Ureteral catheter, uses of, 198 catheterization in pregnancy, 197 Ureterovaginal fistula, diagnosis, 362 treatment, 363 Urethra, laceration of, hemorrhage from, 295 Urinary system, diseases of preg- nancy in, 190 Urination during puerperium, 108 Urine, incontinence of, 358 in pregnancy, 191 in puerperium, 374 in pregnancy, 57 methods of collecting from ureters separately, 197 of new-born infant, 114 retention, in puerperium, 108, 374 segregation of, in pregnancy, 197 sugar in, in pregnancy, 191 INDEX 549 Urogenital trigonum, lacerations of muscle of, in labor, .31° diagnosis, 311 repair, 312 Uterus, 25 anteflexion of, in pregnancy, 182 anvil-shaped, 30 arteries of, 27 atony of, puerperal hemorrhage from, 297 backward displacement, puer- peral hemorrhage from, 297 bicornis unicollis, 30 biforis, 31 blood-vessels of, 27 cancer of, puerperal hemorrhage from, 297 congenital anomalies, 30 diagnosis, 31 effect on labor, 31 on pregnancy, 31 treatment, 31 cordiformis, 30 didelphys, 30 diseases of, in pregnancy, 179 displacements, in puerperium, 37o in pregnancy, 179 obstruction of labor by, 259 double, obstruction of labor by, 260 duplex, 30 examination of, in puerperium, 111,112 fibroid tumors, in pregnancy, 261 in puerperium, 261, 370 obstruction of labor by, 260 puerperal hemorrhage from, 297 hour-glass, 157 in pregnancy, 57 incudiformis, 30 inversion of, hemorrhage from, 296 in labor, 272 involution of, 103 kneading in inertia uteri, 231 lateral displacements of, in preg- nancy, 182 ligaments of, 27 lymphatics of, 27 muscle of, 26 nerves of, 28 Uterus, overdistention of, labor from, 78 packing, for abortion, 220 perforation of, in induction of abortion, 450 in puerperal sepsis, 397 pregnant. See Pregnant uterus. prolapse of, 353. See also Pro- lapse of uterus. reception of spermatozoa into, 35 relaxation of, postpartum hemor- rhage from, 290 puerperal hemorrhage from, 296 retrodisplacement of, 333 retroflexion of, 333 retroversion of, 333. See also Retroversion of uterus. rupture, 300 causes, 300 complete, treatment, 304 diagnosis, 302 frequency, 300 hemorrhage from, treatment, 290 in subsequent pregnancy after cesarean section, 519 incomplete, treatment, 303 prognosis, 303 site, 301 symptoms, 301 treatment, 303 varieties, 300 septus, 31 subinvolution of, in puerperium, 372 subseptus, 31 subsidence of, in labor, 78 superinvolution of, in puer- perium, 373 unicornis, 30 veins of, 27 Vagina, 24 atresia of, obstruction of labor by, 257 cancer of, in pregnancy, 178 diseases of, in pregnancy, 176 hematoma of, puerperal, 369 hernia of, in pregnancy, 178 in pregnancy, 57, 62 lacerations of, in labor, 312 septa of, obstruction of labor by, 257 550 INDEX Vagina, tumors of, obstruction of labor by, 257 Vaginal cesarean section, 504 cysts in pregnancy, 178 delivery, operative, routine after- care, 445 preparation of patient for, 437 examination in labor, 81 in puerperal sepsis, 395 mucosa, suburethral hypertrophy of, in pregnancy, 177 wall, anterior, laceration of hemorrhage from, 295 in labor, 310 posterior, lacerations of, in labor, 312 rugae of, 24 Vaginitis in pregnancy, 176 Valvular heart disease in labor, 275 Van Dolsen's modification of metranoikter, 42 Vapor bath in albuminuria of pregnancy, 208 Varices of labia in pregnancy, 175 of vulva in pregnancy, 177 Varicose veins in pregnancy, 187 of vulva, obstruction of labor by, 256 Veins of uterus, 27 varicose, in pregnancy, 187 Veit treatment of eclampsia, 215 Velamentous insertion of umbilical cord, 166 Venereal warts in pregnancy, 174 Venesection in eclampsia, 213 Ventrosuspension in retroversion of uterus, 342 Version, 486 cephalic, 487, 488 contra-indications, 487 indications, 487 methods, 487 podalic, 487 postural, 488 Potter, 489 differences in technic com- pared to older operation, 492 technic, 489 essentials of, 491 Vertex presentation anterior rota- tion of occiput in, 131 delayed, 134 commonest position, 122 mechanism, 130 Vertex presentation, mechanism, most common abnormalities, 132 posterior rotation of occiput in, 133 Scanzoni maneuver in, 134 Vesicle, blastodermic, 36 Vesicocervicovaginal fistula, diag- nosis, 363 Vesicovaginal fistula, diagnosis, 359 treatment, 360 Vesicular mole, 161 Vestibule, 23 Villi, chorion, 45 Visitors in puerperium, 107 Vomiting in labor, 87 in pregnancy, 59, 199 corpus luteum extract in, 199 exaggerated, 199 normal, 199 pernicious, 200 Voorhees' bag for dilating cervix, 462 Vulva, 23 cancer of, in pregnancy, 176 diseases of, in pregnancy, 174 distention of, in labor, 91 edema of, obstruction of labor by, 256 hematoma of, 272 lacerations of, in labor, 312 lupus of, in pregnancy, 176 tumors of, obstruction of labor by, 257 varices of, in pregnancy, 177 varicose veins of, obstruction of labor by, 256 vegetations of, in pregnancy, 174 Vulvar pads, 99 in puerperal sepsis, 395 in puerperium, 107 Vulvovaginal glands, 23 Walcher position, 250 Warts, venereal, in pregnancy, 174 Watkins-Freund-Wertheim opera- tion for cystocele, 352 Webster's operation for diastasis of recti muscles, 345 Wegner's sign in syphilis of fetus, 168 Weight in pregnancy, 56 Wet-nurse for new-born infant, 117 Wharton, jelly of, 48 White pneumonia in syphilis of fetus, 169 INDEX 551 Wigand's method of delivering after-coming head, 494 treatment in placenta praevia, 284 Winckel's disease in new-born, 424 X-ray in diagnosis of pregnancy, 65, 68 Yellow atrophy of liver, acute, in pregnancy, 203