rtff >>i I: IW Mfek>-.^ ft* •?•:%: fe : ^ i* v_ ... ■, ... ' . r nix -v 4AL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE K/ J \P\iK/ r ordinary abdominal dimensions, it is not very easy to see how it could assume this position. The same remarks apply to the presentation of the side, which does undoubtedly sometimes occur. Indicative of the first of these abnormal presentations, we will find it, upon examination, difficult to reach the presenting part. If we succeed, however, in touching it, the finger can detect the spinous processes in a line marking the presence and course of the spine. On either side may be felt the insertion of the ribs. In case of the side of the thorax presenting, we have the ribs, which may be traced in their length around the body. If it be the loins that offer to the touch, we may be able still to discover in the vicinity some of the lumbar ver- tebrae and the crest of the ilium. 144 PRACTICAL MIDWIFERY. Although it is admitted that the above named parts may present at the entrance of the upper strait, it is believed that only very exceptionally they constitute a permanent presenta- tion. If the foetus, through the abundance of the waters in which it floats, or any special restlessness or activity, take up such a posture, so long as it retains it, it is illy adapted to the cavity of the womb in which it is contained, and, therefore, produces abnormal pressure upon some portion of its walls. This, through reflex action, would excite uterine contraction, through which, according to the law we have cited when speaking of the " Mechanism of Labor," the fcetus would be obliged to adapt its position to the shape of the cavity in which it is contained. It has been abundantly proven by ob- servation, especially of the German obstetricians, as before remarked, that the child often spontaneously changes its posi- tion in the latter months of pregnancy. Even should this favorable change not occur until the accession of labor, the contractions of the womb in this process will be likely to bring about a presentation of the vertex or the breech instead of those parts of which we have just spoken. If we be engaged to attend a patient in labor, and from any peculiarity she may have noticed in her sensations or in the shape of the abdomen, we have reason to suspect any of these abnormal presentations, it will be well to ask permission to make an external examination of her person, and if we have reason to think anything may thereby be added to our knowl- edge, one also per vaginam. When the womb is not too much distended by fluid, or the walls of the abdomen not overloaded with adipose tissue, we may, by skillful palpation, be able to sat- isfy ourselves of the nature of the case. If we detect a crosswise position of the fcetus, we may administer Puis, which has been advised with considerable confidence in its efficacy, and to which we have before adverted. If a favorable change take place, whether owing to the medicine or not, it is all very well. But if we find, still carefully watching the patient, that at the near approach of labor no favorable alteration has occurred, we should attempt to change the position of the child by external manipulations such as will be elsewhere DEVIATIONS FROM NORMAL LABOR. 145 spoken of. If we succeed in this the patient should maintain the strictest quietude till after delivery. But if when we are called for the first to attend the case in labor, we find this unfavorable state of things, we should then attempt to change the presentation by bi-manual version—failing in this it re- mains that we should turn by the feet. c) Presentation of the Breech.—Presentation of the breech is next in frequency to that of the head. It is much more perilous to the child than the latter. There is considerable discrepancy of opinion, however, as to the ratio of infantile mortality when the breech presents. Dr. Churchill represents it as nearly one in three, while Dr. Play fair, one of the latest British authorities, thinks this entirely too high, and gives, as his estimate, about one in eleven. Doubtless the proportion of loss is smaller now than formerly, inasmuch as the manage- ment of such cases has greatly improved. To the mother it is generally believed there is no increased risk; but this can hardly be correct, since labor is not unfrequently protracted, and, therefore, the consequences of exhaustion proportionally imminent. The causes which determine the child to take up this posi- tion in the womb, so that, contrary to what usually occurs, the breech, at the time of labor, is found at the upper strait instead of the head, are involved in obscurity. Various theo- ries have been proposed to account for this anomaly in gesta- tion ; but to all of them insuperable objections may be offered. In our present state of knowledge, therefore, it is most wise, simply to accept the fact, especially as this will be sufficient for all practical purposes. It is important that we should, at an early stage of labor, recognize a breech presentation when such exists. Before the rupture of the membranes the diagnosis may be difficult, espe- cially as we should be careful in our explorations, lest we should prematurely discharge the waters, and thus lose the aid of a very powerful agent in dilating the os uteri. Such aid is very important here, as the breeoh, both from its form and want of solidity, ha3 but little distending power when com- pared with the head. 10 146 PRACTICAL MIDWIFERY. When the membranes are relaxed, in the absence of pain, or when they have already ruptured, the exploring finger will sooner or later impinge upon the point of the coccyx, and if carried up in contact with this part, its solid, irregular posterior surface will be felt. This may be regarded as diagnostic of a breech-presentation—as no other part yields the same sensation to the touch. Further exploration will reveal two soft pro- tuberances, the buttocks of the child, which may be distin- guished from the cheeks, the only parts for which they could be readily mistaken, by the difference of the underlying bones felt through the muscular structures, by the fissure between them differing from anything found in the face, by the anus in the centre of the fissure, a closed and puckered aperture, resisting the introduction of the finger, at least in the living child, and if the finger be forced within it, the absence of the jaw-bones and gums, which, one would think, would prevent the possibility of confounding it with the mouth. Palpation upon the abdomen of the mother will sometimes enable us to detect the head high up toward the ensiform cartilage, and she will sometimes tell us of her suspicions, from the sensation of a more than usually solid body pressing upon her stomach during the latter period of gestation. The stethoscope may also aid us in our diagnosis, as the sounds of the foetal heart will be heard much higher up than in cases of presentation of the head. The side of the mother upon which we hear the pulsations most distinctly, determines that to which the back of the child is turned, and enables us to decide upon its position as well as its presentation. Thus, if the pulsations are most distinctly heard anteriorly upon the left side, we may assume that the back of the foetus is turned in that direction. The breech, in the same manner as any other part of the child, may present in several different positions. Thus the back may be turned to the left side of the mother, and ante- riorly, constituting what may be called the left sacro-anterior position, which is by far the most frequent; or it may be turned to the right side anteriorly, the right sacro-anterior position—while each of these has its reverse, and there may exist intervening shades between them. DEVIATIONS FROM NORMAL LABOR. 147 We have already spoken in a general way of the mechanism of labor by the breech. As such labors, however, are not in- frequent, say one in fifty, and require the utmost care and no little skill to conduct them to a safe termination, at least as regards the child, we will go somewhat more into detail upon this subject. Before labor comes on, the child, as it were, sits in the womb, its head moderately flexed upon the thorax and its limbs upon its anterior plane. Sometimes the limbs are merely flexed at the hip-joints and lie extended their whole length upon the anterior surface of the child, or they are again flexed at the knees and the lower legs folded against the posterior surface of its thighs. In the latter case, before the breech is forced down, the lower legs may somewhat cross each other, as they do in presentations of the head ; but, be this as it may, as the breech descends they assume a position in front "and parallel with the sides of the child. The breech enters the superior strait, impelled by the force of the uterine contractions with its long diameter in corre- spondence with the transverse or oblique diameter of the pel- vis. It descends, but its descent is slow compared with that of the head. As it lacks the solidity of that part, and espe- cially if the child be small, it may not rotate so certainly as does the head in its descent. As rotation in this case involves, to some extent, the twisting of the body, and as the soft struc- tures yield to compression from opposing parts in the inner surface of the pelvis, rather than evade them, it may come down without shunning such opposition to its descent as the head would do, and thus not effecting complete rotation. Gen- erally, when the child is of good size, one hip or the other, according to the original position, will finally turn under the pubic arch. In this rotation of the hips, however, if it take place, the body and shoulders of the child do not participate. When the membranes give way, the presenting parts, the hips, are of such irregular conformation, that they do not close the orifice by compression, but permit the waters wholly to escape. The womb then clasps firmly the child, presses its limbs closely to its trunk, as well as flexes its head upon its 148 PRACTICAL MIDWIFERY. breast, and by this compression fits it the better for its transit through the pelvic canal, but, at the same time, prevents the upper parts from rotating in unison with that in advance. When one hip takes its position under or near the arch of the pubis, the other is thrown into the hollow of the sacrum, the anterior surface of which it traverses, and subsequently the perineum, which it gradually distends. The dilatation of the perineum, however, advances slowly under the distending power of the breech, owing to the softness and compressibility of the latter. In the case of primiparae this process may occupy hours. The thinned edge of the perineum sometimes falls into the fissure between the buttocks of the child, and thus, for a time, arrests both movement and distension. Ulti- mately, however, the posterior hip is born, and very shortly, or simultaneously with it, the anterior. If the body have not participated in the rotation of the hips, they then revolve upon the long axis of the foetus, effecting a kind of restitution. In the natural process the body then partially follows, and the shoulders present at the upper strait, the long or bis-acromial diameter corresponding with the transverse or oblique diameter of the pelvis. As the shoulders descend they rotate with rather more certainty than the hips, because by their greater width they more completely fill the pelvis, and by their greater solidity they are less liable to compression ; and, therefore, not accommodating themselves to resistance, they appreciate it, as it were, and move in the direction in which it is least met. The complete rotation of the breech is practically of less moment than that of the shoulders. For it is manifest that if the shoulders should come down to the lower strait in a trans- verse position, the head, from its natural relation to them, must offer at the upper strait with its occipito-frontal or prob- ably its occipito-mental diameter in correspondence with the antero-posterior diameter of the strait. There would in that case be such a want of adaptation that the head could not de- scend. The antero-posterior diameter of the superior strait measures only four inches—the occipito-frontal diameter of the child is also four inches—the occipito-mental five inches. But if the shoulders rotate so as to bring the anterior one under DEVIATIONS FROM NORMAL LABOR. 149 the arch of the pubis, then the head will present at the upper strait with its occipito-frontal or occipito-mental diameter in relation with the transverse diameter of the pelvis, h\ inches, so that it can readily pass. The head thus engaging descends, and finally rotates so as to bring its long diameter into accord with the antero-posterior, the longest diameter of the lower strait, and thus speedily follows the shoulders into the world. The management of labors by the breech is very important, in some cases very simple, in others very difficult. It is a general rule not to interfere so long as the presenting part is making suitable progress, unless the condition of the patient absolutely require it. To exert force upon the breech by means of the fingers or blunt hook fastened in the groin of the child, is apt to draw away the head as it were from the embrace of the womb and cause the chin to recede from the thorax, and carry up the arms from the breast. Better wait with patience upon the process of nature, minding as soon as the cord is within reach to draw it a little downward, and if possible place it to the side of the pelvis, where there appears to be the least danger of pressure. If the patient suffer intensely, chloroform may be administered, which will also conduce to relaxation of the maternal parts. When the breech is born and the body as far as the umbilicus, as the shoulders come down we should try to secure the rotation of the anterior one under the arch of the pubis, a position which it will generally spontaneously assume in obedience to the general law already stated. When these are born we should look after the head. This is the moment of peril. Delay in the descent of the breech, unless through compression of the cord, is usually unattended with danger, but detention of the head beyond a very few moments, is very apt to prove fatal to the child. When the labor is so far ad- vanced that the head offers at the superior strait, it has nearly left the womb, and is therefore almost out of reach of its ex- pulsive power. It is well at this juncture to arouse the ener- gies of the woman by exhorting her to bear down with all her force. We should at the same time introduce two fingers of the one hand, as soon as we can reach the face of the child, and place one on either side of the nose, with which we can by 150 PRACTICAL MIDWIFERY. pressure, flex and draw down the head, while we press upon the occiput with two fingers of the other hand. By such manoeu- vre the head will usually come down and the birth be safely terminated. If, however, the breech do not advance and the mother's powers are manifestly failing, here, as always in like circum- stances, it will be our duty to attend to her interests, regarding those of the child as secondary. Dr. Barnes advises us in such cases not to apply traction at the groin, but to bring down a foot—the one nearest to the pubis, as in so doing we decom- pose the wedge which the foetus represents, the breech forming the apex, and the head, shoulders and flexed limbs the base. Whether we should or should not make traction upon the foot when brought down would depend upon the necessities of the case. If the wedge thus decomposed and diminished in size seem disposed to pass readily, we may leave the further de- scent to the powers of nature, if they have not already become exhausted—if they have we should deliver. But after all the most important part is, so far at least as re- gards the child, the deliver}?- of the head quickly after it comes to engage in the pelvis. If the simple manoeuvre already de- scribed do not succeed, what shall we do, for there is no time for delay ? Most writers advise us to resort at once to the forceps —to have the instrument at hand and immediately introduce it, and extract the head. This is probably easier said than done. In the country, at least, we have seldom the assistance at hand that would be required to apply the forceps with ease and ex- pedition. The bystanders would require instruction, and while we should be giving this, the child would perish. From my own very limited experience in the use of the forceps in such cases, I cannot but think it is a bungling, ill adapted appliance. Various other expedients have been proposed by different ob- stetricians. It will be remembered it is force we want to expel the head, force which the womb is perhaps now no longer able to supply. If it can be rallied or rather assisted by the will of the mother calling into aid the powers of the accessory mu scles it will be well; unfortunately, however, as before intimated the head is nearly, if not entirely, beyond its reach. But DEVIATIONS FROM NORMAL LABOR. 151 another expedient proposed by Prof. Penrose, of which I am disposed to think very favorably, may be used in conjunction with her efforts. The principle is to supply the vis a tergo which the womb is supposed to be now no longer competent to furnish. "Apply your hand or hands," says he, " on the lower part of the abdomen, or an assistant can make the pressure for you, and press directly down upon the head ; you can by this proceeding apply any amount of vis a tergo, you can supplement entirely the lost force of the uterus and the lost force of the mother's efforts * * * * the rapid delivery of the head can always be easily and quickly secured by the bearing down efforts of the mother, aided or even replaced by the bearing down efforts of the attendant."—Obstet. Journ., Great Britain and Ireland, Amer. Supplement. We have not had occasion to test this method, but would not hesitate to do so with great confidence in its prospect of success if well executed. It would probably be advantageous to place the patient upon her back, with her hips near the edge of the bed. An assistant, or even an intelligent nurse might be instructed beforehand, to lay her hands, one upon each side of the womb, gently following it down as the body of the child recedes until the moment when the head alone is felt, ready to engage in the upper strait. Then at that instant a grasping, downward, pressing, pushing movement should be made upon the head through the fundus of the womb, and in the direction that common sense would dictate as most effectual to extrude the head. By assigning this duty to an assistant the ac- coucheur would be left at liberty to manage the body of the child, and might aid by moderate traction, for if the head be pressed downward by an external force, there would be little danger of extension taking place so as to interfere with its speedy delivery. We have thus dwelt upon the management of the after-com- ing head, because it is important not only in cases of sponta- neous breech presentation, but also in cases of artificial version by the feet. In all these it is scarcely necessary to repeat what may be readily inferred from what we have already said, that prompt delivery of the head is essential to the safety of the child. 152 PRACTICAL MIDWIFERY. We have already spoken of direct traction as a means of de- livering the after-coming head. We are usually restricted in our application of this means, by a dread of breaking the child's neck. It is doubtless a good rule to use no more tractile force than is necessary for the accomplishment*of our purpose. But from the experiments of Matthews Duncan (British Medical Journal, Dec 19,1874, p. 763), it appears that the neck of a dead child, at term, can sustain a weight of one hundred and five pounds before the spinal column gives way. In the case of the living infant, it is probable that muscular resistance would enable it to sustain a still greater force. But how great a force may be applied without doing serious injury, is still another question. In desperate cases, however, where ordinary force does not suffice, and where a few moments' delay will un- doubtedly sacrifice the life of the child, we will be justified in increasing very considerably the amount beyond what we com- monly use. Heads as well as pelves may differ so much in shape, that it is impossible, by any previous calculation, to determine exactly where they will nip, and it is very difficult in the hurry and excitement of the moment to discover what point is arrested, and exactly where arrest has taken place. If we will bear in mind, however, the general law laid down, and when the press- ure of the assistant from above is for a moment relaxed, if we will, by a wriggling movement, detach the head from its lock, then applying force in a somewhat similar manner, according to the illustration elsewhere given, viz., the drawing of a buckle through a compressed terret, it will move in the direc- tion of least resistance, and if the space be not entirely dispro- portionate to its size, it will speedily be born. It sometimes happens in presentations of the pelvic extremity of the child, that the thighs depart from their close approxima- tion to the abdomen, and the lower legs recede from the thighs, giving rise to what is termed a presentation of the feet. Again, the thighs may be extended, while the lower legs are still more or less closely applied to their posterior surface. This constitutes a presentation of the knees. These presenta- tions assume different positions as true presentations of the DEVIATIONS FROM NORMAL LABOR. 153 breech. It is unnecessary here to speak further of them, as they are only varieties of that of the breech, and the same prin- ciples we have already laid down equally apply to their man- agement. DEVIATED PRESENTATIONS OF THE HEAD. It occasionally happens, through obliquity of the uterus or other causes, that the head, instead of presenting fairly at the superior strait, rests upon the brim of the pelvis, and when acted upon by energetic contractions of the womb, is, according to the direction of the force, either restored to a normal pre- sentation or is made to deviate still further therefrom. When the former takes place the labor usually proceeds in the natural manner; when the latter, a presentation of the shoulder is apt to be the result. Such presentations, although generally be- lieved to arise from deviations of the head, may, it is thought, sometimes be original, and these are believed to be necessarily associated with obliquity of the uterus. In a large proportion of cases of shoulder presentation the arm prolapses, sometimes also simultaneously, the umbilical cord. The descent of the latter is generally, if not always fatal to the child, unless speedily remedied by appropriate measures. When the arm has come down, the hope of the presentation being corrected by the natural powers alone, through what is termed " sponta- neous version," that is, a replacing of the head or even substi- tuting the breech over the entrance into the cavity of the pel- vis, is very small. The os humoris of the foetus, although lack- ing the solidity of that of the adult, is sufficiently solid to act as a pin, in fastening down the shoulder in its assumed position. This may be illustrated by supposing a small piece of board having a wooden pin inserted into it, laid upon another, perfo- rated so as to let the pin pass through it. In such circum- stances no ordinary force can move the small board sidewise, for the pin passing through the other board prevents its motion. But if we suppose the pin replaced by something more flexible, as a piece of gum elastic of the same diameter, now although the small board may be made to move sidewise, by forcing it 154 PRACTICAL MIDWIFERY. to drag the gum elastic through the hole, it will require much more force to produce the result than if the gum elastic pin were not in the way of its movement. " In Nature we observe," says Dr. Barnes, " two chief shoul- der positions, and each of these has two varieties. In the first position, the head lies in the left sacro-iliac hollow. In the second position, the head lies in the right sacro-iliac hollow. Now, in either position, either the right or the left shoulder may present. Thus if the head is in the left ilium, the right shoulder will descend when the child's back is directed for- ward ; and the left shoulder will descend when the child's belly is directed forward. In the case of the second or right cephalo- iliac position, the right shoulder will descend, when the child's belly is turned forward, and the left shoulder when the child's back is turned forward." Although it cannot be denied that shoulder presentations under favorable circumstances may be converted into presenta- tions of the vertex, or even of the breech, such a fortunate change is too improbable to be worthy of much reliance in practice. It may do well enough for the doctor to sit expectant by, to see what dame Nature unassisted may be able to accom- plish, and if she succeed, to have it in his power to report a wonderful case, and encourage some one else to pursue the same course. But to do so is generally to do it at the risk of the patient's life. The shoulder will for the most part sink deeper and deeper into the cavity of the pelvis, and become more and more immovably fixed. The waters will gradually drain off and the womb tightly embrace the foetus on all sides—insinuate itself completely into its whole outline, and retain its hold even in the absence of pain. Unable to overcome the opposing re- sistance, the efforts of the uterus increase into fury, and' if not soon successfully aided, end only in rupture of the organ itself, or in complete and often fatal exhaustion of the patient. We remember two cases treated in this manner in which we were finally called in consultation. In the first the membranes rup- tured about one o'clock in the morning, and a presentation of the shoulder with prolapse of the arm and cord immediately manifested itself, attended also by very considerable flooding. DEVIATIONS FROM NORMAL LABOR. 155 I was called about nine or ten o'clock the same morning. The pains had entirely ceased, and the patient lay in an extremely prostrated condition. From the size of the prolapsed arm, there was reason to infer that that of the entire foetus was pro- portionate, an inference afterwards fully confirmed. The death of the child was, of course, considered as certain from the con- dition of the cord, already for a long time pulseless and col- lapsed ; the onl}T object in view, therefore, was to save the mother. As the waters were almost wholly drained off, the child closely embraced by the womb, and the shoulder forced deep into the cavity of the pelvis, while a stout arm occupied the vagina, cephalic version was out of the question, and podalic version was likely to be very difficult. Under these circum- stances I proposed to the attendant physician to deeply anaes- thetize the patient with chloroform, and then endeavor to effect turning by the feet, but that without this preliminary I did not wish to attempt it. Objections were at first made to the use of chloroform, as likely to increase the haemorrhage, as it is said to do, but these were finally waived upon assurances that it would not necessarily do so. The patient was then very tho- roughly brought under the influence of the anaesthetic, and turning and delivery effected with comparative ease; she did not, so far as I could perceive, move a muscle during the whole operation. The haemorrhage gradually yielded under the use of Apoc can. and Trillium pen., given in succession, and by the afternoon it had entirely subsided. A good, but necessa- rily, from the amount of haemorrhage, a somewhat slow reco- very followed. The second case alluded to above was not so fortunate. A little before or shortly after the arrival of the attendant (1 o'clock, p.m.), the waters were discharged and the arm immedi- ately prolapsed. A messenger was at once despatched for me to see the case in consultation, but unfortunately I had just gone several miles from home, in an opposite direction, and the messenger did not follow me. The pains immediately became strong, increasing still in force, till, as I was informed, from 5 p.m. onward till I arrived, they had reached a degree of agony such as the attendant thought he had never before witnessed. 156 PRACTICAL MIDWIFERY. Owing to my late reception of the message, it was not till 9 o'clock, p.m. I arrived at the bedside. The patient was of re- markably short build, and upon examination I found the shoulder so crowded down, that the hand could not be carried up so as to reach the feet. I first placed her in the knee-and- elbow posture, sustained by assistants, hoping that through the influence of gravitation the shoulder would somewhat recede, and make room for the hand to pass, but in this I was wholly disappointed. The patient was then again laid down, and chloroform administered to full * anaesthesia. The relaxing effect of this agent was such that upon a second attempt the hand was readily introduced, a foot seized, and delivery effected without any special difficulty. The child was of very large size, but of course still-born. No appreciable haemorrhage fol- lowed. The patient waked up as usual from the effects of the anaesthetic, and we entertained the hope that with the proper care she would do well. I remained about an hour after de- livery, and having conferred with the attendant in another room, as to the best mode of after-treatment, I was about put- ting on my coat to retire, when suddenly summoned to the bed- Bide, I found the patient dying. This seems to have been a case of death from shock through extreme and protracted suffering. She had, as I-learned, taken a large amount of morphia, by way of palliation, before my arrival. In order to secure the best results in the management of shoulder presentations, it is important we should recognize them as early as possible. If this can be done before the mem- branes have ruptured, we should endeavor to effect cephalic version, as directed in the chapter on " Turning." The neces- sity for version by the feet should, as far as possible, be avoided ; in fact should be had recourse to only as a last resort. If the child be of large size, and especially if the waters be discharged, it may, perhaps, be said to be generally fatal to its life. U nder the same circumstances, too, it is very hazardous to the mother. But however important it may be to recognize early a shoulder presentation, if such exist, it is not always easy before the rup- ture of the membranes. When upon a first examination the presentation cannot be DEVIATIONS FROM NORMAL LABOR. 157 felt, while yet we are satisfied that the woman is really in labor, we have reason to suspect there is something wrong, and should be upon our guard and keep a vigilant lookout. I have, how- ever, met with cases in which, at first, I could not touch the presentation, but after an hour or so it came within reach, and was as I desired. It is possible that in such cases the presen- tation had been changed by the powers of the womb from a faulty to a good one. If the membranes, however be lax, or there be present but a small amount of the amniotic fluid, we may, by a careful ex- amination, carrying up the finger as high as possible, even allowing the hand partially to follow it into the vagina, when this is practicable, be able to detect the shoulder presenting at the superior strait. The signs, by which it may be recog- nized, are the presence of the acromion process, the scapula, the spine of the scapula, the axilla, and when they are access- ible, the spinous processes of the vertebral column. We should notice, too, the relative position of these parts by which we may determine whether the fcetus lies with its anterior aspect toward the front of the mother, or the reverse. If we have not been able to satisfy ourselves of the presentation prior to the rupture of the membranes, we should immediately examine when this takes place. And now, as often happens in shoulder- presentations, if the arm prolapse, we must not jump to the conclusion that the shoulder is present at the upper strait, for the arm is sometimes extruded beside the head. The best advice we can give the student or young practitioner, to enable him to recognize the shoulder or any other part presenting, is to familiarize his sense of touch with these parts in the born, but quite newly born infant. Feel the shoulder in connection with the neighboring regions,—also the knee, the elbow, the hands, the feet. Repeat this until you know and remember exactly what sensation these different parts communicate to your sense of touch—until when you explore the shoulder you will know it is not the elbow or the knee; when you lay hold of the foot you will know it is not the hand. If once this ex- perience is acquired, it will be useless to tell the student that he may distinguish the foot from the hand because the former has a great toe, the latter has not. 158 PRACTICAL MIDWIFERY. Although, as we have intimated, slightly deviated presenta- tions of the head may be, and perhaps generally are, corrected by the natural powers alone, and even the shoulder, through the same powers, may depart from the upper strait and the vertex or breech take its place, we cannot always depend upon this result, and if it should fail to take place, the longer we delay, the more difficult will it be to avail ourselves of the re- sources of art. These rectifications, by nature alone, probably take place, for the most part, where the child is somewhat below the normal size. If then upon the rupture of the membranes, or better still, before this occurrence, we detect the shoulder at the superior strait, whether the arm be prolapsed or not, we should at once endeavor to correct the presentation. The fingers of one hand are introduced into the vagina, and an attempt made to push up the shoulder, and, if successful in this, we should endeavor, by the requisite manipulations, to coax the head to take its place. These attempts may generally be greatly aided by the other hand applied to the abdomen of the mother, and gentle force exerted through its walls upon the other extremity of the foetus in such a manner as common sense would suggest as most likely to lead to the accomplishment of our purpose. To give minute directions here, would be only to perplex, for if the practitioner has not sufficient common sense to perceive what forces he needs and in what direction to apply them, he would be unable to follow advice given in detail. If we can bring the head over the entrance into the pelvis and secure it there until it engages in the superior strait, we may safely entrust the labor to the natural powers. If we be unable to succeed by this simple method in correct- ing the faulty presentation, unless we are satisfied the child is very small, and the powers of the woman very vigorous, we should proceed at once, before the waters are wholly drained off and the womb contracted firmly upon the child, to turn by the feet. For minute instructions in the method of doing this successfully, the student is referred to the chapter upon that subject. (See Version or Turning). I would only further remark that, as may be learnt from DEVIATIONS FROM NORMAL LABOR. 159 the two cases given above, the previous administration of chlo- roform affords immense advantages in the operation of turning either by the head or by the feet. It should, when used as a preliminary measure to this operation, unless there be manifest counter-indications, be given until deep anaesthesia is produced. Let it be administered cautiously and slowly, so as to induce complete insensibility and that gradual and beautiful relaxa- tion of the tissues which, when judiciously given, it can accom- plish. If the chloroform even completely arrest the action of the womb, which it does not often do, it will so much the more contribute to our purpose. These assertions are not only fully accordant with my own experience, but sustained by the vastly greater experience of others—men of unquestioned eminence— whose testimony ought to be received, one would think, with- out cavil. I have noticed in several cases where I have been called in consultation, to one of which I have just adverted, where morphia had been freely given by the previous attendant for the relief of pain, that the effects of chloroform were not only more speedily induced, but the insensibility was more profound, and the relaxation of tissues more complete than where no such antecedent measures had been adopted. Since I noticed this phenomenon, I have learnt that M. Bernard has used mor- phia previous to the administration of chloroform in his vivi- sections, and the result was that his subjects became perfectly passive and relaxed, opposing no resistance to his operations. In cases where the waters have been long drained off and the womb closely embraces the child, and where turning seems still to be the proceedure most promising of good results, we might take advantage of the fact above stated, and, half an hour before we operate, administer a dose of morphia, either by the mouth or by subcutaneous injection. This we would follow by the administration of chloroform, to complete anaes- thesia before we attempt to turn. I would, however, subjoin the caution, that where great prostration exists, morphia should not be given, as it probably greatly adds to the shock, and pro- portionately increases the danger from that quarter. Under these circumstances chloroform should be given with great care, and its effects very carefully observed. 160 PRACTICAL MIDWIFERY. CHAPTER X. ACCIDENTS AND DISEASES INCIDENT TO LABOR AND THE PUERPERAL STATE. PROLAPSE OF THE CORD- This is one of the most fatal accidents, so far as the safety of the child is concerned, that occurs during labor. I need hardly say that this fatality is owing to the compression of the cord, arresting the circulation through its vessels, and thus causing asphyxia. The length of time necessary to produce this effect has been variously reckoned from two to ten minutes. The former is probably a shorter time than is generally required to cause the death of the infant, while the latter is, no doubt, considerably longer. I need not spend time in pointing out the diagnostic signs by which prolapse is detected. When the cord is felt pro- lapsed it is, or ought to be easily recognized—it is not easy to imagine how it can be mistaken for anything else that may occur, or anything else mistaken for it. There are, however, a few cases upon record in which a coil of intestine has been mistaken for the umbilical cord, and which mistake led to the most disastrous consequences. Dr. Tyler Smith, in his Annual Address to the Obstetrical Society of London, reports the following: "A midwife attended the patient, a very poor woman, during her labor, and she admit- ted having given Ergot before the birth of the child. Mr. Robinson was called at midnight to remove the placenta, going as a matter of charity. On examining he found what seemed to be a loop of funis in the vagina; passing his hand along it and through what he supposed to be the os uteri he felt a mass of about the size of the placenta which he drew down. Find- ing some difficulty, he divided the supposed funis in two ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 161 places, and then found to his horror that he had been dealino- .... ° with intestine. At the post-mortem and inquest it was shown that a laceration existed at the upper part of the vagina, through which the bowel had passed, and the placenta was still in utero with the funis broken short off. The real facts were, no doubt, that the laceration occurred during labor, probably from the Ergot, that the midwife tried to remove the placenta (there probably being spasmodic contraction of the os uteri in consequence of the Ergot), and in doing this tore the umbilical cord from its attachment. This was not mentioned to Mr. Robinson. The loop of intestine descended, as it often does in such cases, through the rent. Mr. Robinson, called at this peculiar juncture, fell into the trap." The unfor- tunate man was tried in a British court for homicide and con- victed. We hence see the importance, especially when aroused from our midnight slumbers, of taking sufficient time to learn the facts of the case and knowing precisely what we are going to do, before we act. This especially applies when called to cases which have been attended by ignorant midwives or ill-in- structed, inexperienced physicians, especially such as deal hap- hazard in enormous doses of Ergot. We should in such cases most cautiously feel our way, distinguishing everything we meet with, from everything else to which it bears resemblance, and never operate until we are fully satisfied as to what we are about to operate upon. We can hardly conceive, however, of such a mistake being made and leading to such mal-practice prior to the birth of the child. So long as the funis pulsates it may be distinguished from intestine by its pulsations alone, which are rapid and not synchronous with those of the mother. When it has ceased to pulsate, as it usually has when long pro- lapsed, we cannot avail ourselves of this characteristic. But the peculiar sensation imparted by the cord, when slightly compressed between the finger and thumb, would, I think, suf ficiently distinguish it from anything else. The young practi- tioner should familiarize himself with this sensation till he cannot possibly be mistaken. It is unnecessary to state the causes which have been assigned 11 162 PRACTICAL MIDWIFERY. as giving rise to this accident, inasmuch as they are generally irremediable in the case before us. Our business will be to ex- hort to that vigilance and alertness which will enable us to de- tect it immediately upon its occurrence, and adopt the best means for its relief. If we be convinced that the umbilical cord is presenting, before the rupture of the membranes, we should watch the case most assiduously, and make an examination immediately after the waters break. We shall then probably find the cord more or less prolapsed, and if so this will be the moment for decided action. Various expedients have been advised for remedying this .accident. Some direct us to carry up the cord with the fingers and hook it upon the chin of the child when the head presents, —others instruct us to hang the loop upon one of the limbs of the foetus. Some again would simply place the prolapsed portion within the womb and retain it there for a few subse- quent pains. Others advise us to turn or apply the forceps according to the presentation, or the distance to which the pre- senting part has sunk into the pelvis. The two latter expedients, one or the other, may be successful or even necessary in some cases, as, for instance, turning when the shoulder and arm pre- sent. The other methods are apt to fail from the fact, that the cord generally prolapses again and again, unless the pains be sufficiently vigorous and the pelvis sufficiently wide to bring the head rapidly down, so as to occupy the space to the exclu- sion of the funis, and terminate the labor very speedily. Dr. Thomas, of New York, in the year 1858 proposed a method of treatment which he termed the postural method, and which, in the large proportion of cases of this accident, is likely to take the precedence of all other modes of treatment. His plan consists in placing the woman upon her knees and elbows, her face resting upon a pillow. The prolapsed cord is then carried up into the womb with the fingers, and gravitation then acting in an opposite direction, it does not again descend. After retaining this posture for ten or fifteen minutes, that is till after the occurrence of a few pains, the patient is suffered to resume the usual obstetric position upon the left side. This ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 163 method is said to be very successful in saving the life of the child, and avoids all risks to the mother such as she necessarily incurs in the operation of turning, and even too hasty delivery with the forceps. This practice has been introduced into England with decided approbation. Dr. John Brunton, Sur- geon-Accoucheur to the Royal Maternity Charity, details a number of cases, in a late number of the Obstetrical Journal of Great Britain and Ireland, in which the plan succeeded admi- rably in his own practice, to which he adds several cases equally successful from that of Dr. Wilson, Professor of Obstet- rics in Anderson's University, Glasgow. If the presentation of the cord be recognized before the rup - ture of the membranes, it would be well to try this method. Should the membranes be slow to rupture spontaneously, the waters might be discharged by artificial means, as soon as the os uteri would be found sufficiently dilated. Thus the head might engage in the upper strait and prevent prolapse. ADHERENT PLACENTA. This may, perhaps, strictly speaking, not be properly termed an accident of labor, as it undoubtedly is a pre-existing condi- tion. But it is during labor it first becomes known to the obstetrician, and then first demands his attention. It seems proper, therefore, to treat of it in this place. We have already spoken of the delivery of the after-birth in normal labor, even when undetached at the birth of the child and for some time afterwards. But we have here reference to those cases, and those cases only, wherein the placenta is not only retained beyond the usual time, but abnormally or morbidly attached to the surface of the womb, resisting the ordinary attempts at separation. We will not here stop to inquire into the causes of this un- fortunate condition. No doubt they are varied. Some morbid state of the surface of the womb, or of the placenta, or of both, precedes and gives rise to this unnatural adhesion. This is, perhaps, most generally inflammatory action from injuries or other causes. 164 PRACTICAL MIDWIFERY. It would seem that some women are peculiarly liable to this accident. I knew a young lady several years ago who, in her first labor, I was told, retained the placenta for several days, as it had resisted the usual attempts at removal. It was, how- ever, finally extruded " en masse," and she recovered without any specially untoward symptoms. At her next confinement she experienced the same trouble. I was called to see her nearly twenty-four hours after delivery. A young physician, previous to this, had made unsuccessful efforts to extract the placenta, and had abandoned the case as beyond his skill. With great difficulty I succeeded in introducing the hand into the womb, but the latter wTas so forcibly contracted, that I was unable to use my hand satisfactorily, even by way of explora- tion. I could only ascertain that the placenta seemed to be firmly adherent in its whole extent, except a small portion of its lower margin, which may have been detached in the pre- vious attempts at removal. Having no reliable assistant to keep the patient anaesthetized, and believing the operation im- practicable without chloroform, I postponed further proceed- ings until I could secure these advantages. It was late, and I was under the necessity of returning home, over several miles of road in the worst possible condition. My plan was to fully anaesthetize the patient, dilate the os uteri with the colpeuryn- ter—we had not yet heard of Barnes' dilators—introduce the hand and tenderly remove as much as possible of the placenta. Unfortunately in my absence violent haemorrhage took place, and another physician, who was much nearer, was called in. I was also summoned, but when I arrived the patient was pulseless and speechless, and as pale as a corpse. Haemorrhage was still going on. The case being a desperate one—life nearly extinct—the patient incapable of giving a single symptom or answering the simplest question, I resorted at once to injection of a weak solution of perchloride of iron. Haemorrhage almost instantly ceased. I remained with the patient during the night. Pulse gradually returned, and by the next day she had considerably rallied, but still, I thought, too feeble to carry out the plan above indicated. In my absence she began to show signs of septicaemia, which did not yield to any remedies em- ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 165 ployed, and of which she died in the course of two or three days. Pieces of the placenta picked off by the physician who first visited her during the haemorrhage, were examined by me and found to lack the usual structure of placenta, more resembling in texture the fibrous muscular portions of beef, an abnormality which I had surmised from my imperfect ex- ploration. There had been, as I understood in this case, but little haemorrhage up to the time I first saw it, and this coincides with the very extensive adhesion which I supposed to exist, for it is manifest that the mouths of more vessels will be left patulous if there be a pretty extensive separation of the pla- cental mass, than under the opposite circumstances. The uterus maintained its contraction when I last saw the patient before the haemorrhage occurred; that accident, therefore, especially in so violent a form, was to me unexpected. Prob- ably further separation of the placenta and relaxation of the womb had simultaneously taken place. When I saw her after the occurrence of the haemorrhage, the degree of contraction of the os uteri was such and her exhaustion so extreme that I could not then ascertain the then present condition of the pla- centa. The intimate adhesion of the placenta, which we here con- template, cannot be fully ascertained until we introduce the hand and attempt to remove it. In order to effect this we proceed, at first, as we would in the simpler forms of adhesion, where, from inertia, we are sometimes obliged to assist nature, namely, endeavor to find a detached portion somewhere around the edge of the mass. If found, insert the points of the fingers of the left hand under this, with the dorsal surface turned toward the inner surface of the womb. Give the fingers a swinging motion from side to side, thus gently separating the placenta from the womb. I need hardly say the finger-nails should be pared short and smoothed at the ends. In this manner, as far as possible, detach all that can be easily de- tached, until the more firmly adherent portion is, as it were, isolated. Then spreading fingers so as to embrace the whole mass, compress it toward, and so as to embrace, the still adher- 166 PRACTICAL MIDWIFERY. ent portion. Then, with a wrenching movement and slight pressure, turn the mass so as to cause it to separate. This manoeuvre will probably bring away as much as can be separated without risk of wounding the surface of the womb. The hand, however, may be again introduced and the surface examined, and if portions loose, or partially detached, be found there, they can be removed. In this operation, and all similar ones, the womb should be sustained and properly manipulated by the outside hand. In all such cases we should, for several days, be on the look- out for post partum secondary haemorrhage, of which we will fully speak further on. It is still an undecided question how far we should proceed in our efforts at the removal of morbidly adherent placentae. On the one hand, if any considerable portion be left behind, we run the risk of haemorrhage and septicaemia—on the other, we may so wound the uterine structures as to give rise to fatal inflammation of that organ. We should carefully consider the specialities of the case, and accordingly take our risks. Whichever of these we select, we should do all we possibly can to prevent the anticipated evil by way of prophylaxis. HEMORRHAGE. This is one of the most common, and not unfrequently one of the most alarming accidents of labor which it is the lot of the obstetrician to encounter. Its occurrence is often sudden, and it may be unexpected, and its violence sometimes so great as to threaten the speedy extinction of life, or at least extreme pros- tration, followed by a very tedious and unsatisfactory conva- lescence. This introductory statement will at once show how import- ant it is that the young practitioner should be fully prepared to meet such emergency with calmness and self possession, which can be done only by his having at his command the re- sources of our art, to be brought promptly into requisition, ac- cording to the varying character of the cases with which he may meet. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 167 a) Ante-partum Accidental Haemorrhage.—We have already spoken of the haemorrhage sometimes accidentally oc- curring during the course of pregnancy, as well as that antece- dent and subsequent to abortion. We now propose to consider the forms of the same accident which take place in connection with labor, premature or at full term. By the former, as before defined, we mean that which happens after the viability of the foetus, but before the usual term ; by the latter, that occurring at the close of normal gestation. In order to avoid as far as possible repeating what the student has elsewhere learnt, we assume that through works on anatomy he has become fully acquainted with the structure of the parts concerned in repro- duction, and from those upon physiology, the functions of the various organs thus concerned. It will be necessary, therefore, in this place only to remind him of the vascular connection be- tween the placenta and the womb. Through the vessels of the latter, blood is carried into the former, from the organism of the mother, to perform the function, however that may be done, necessary to the nourishment and growth of the fcetus during its intra-uterine life. These vessels are large in proportion to the amount required for this purpose, and the afflux to the parts is influenced by the constant demands of the growing child. The quantity of blood therefore at all times circulating through these vessels is very considerable. It will be thus apparent that when they are severed, from any cause whatever, and re- main patulous, haemorrhage must ensue. This sometimes hap- pens in the course of labor otherwise normal, from a premature detachment of a portion of the placenta. The ordinary means provided by nature for the prevention of haemorrhage from the open utero-placental vessels, is their closure by the contraction of the womb; but this cannot fully take place while the foetus as well as its appendages, is still retained within its cavity. When, however, the placenta is attached at a distance from the os uteri, as it usually is, this form of haemorrhage is seldom such as to be attended with serious consequences, or even to cause alarm. If sufficiently copious to require attention we may administer Apoc. cann., four grains of the first dec. tritu- ration of the bark of the root, in four tablespooufuls of water, 168 PRACTICAL MIDWIFERY. giving a teaspoonful every few minutes. Trillium pen., a few drops of the mother tincture, in a like quantity of water, to be given as above. Per-sulphate of iron diluted with water will probably answer a good purpose. Also Ergot may be thought of, especially if the character of the pains correspond with the pathogenesis of that drug. If these or other remedies, appa- rently indicated, fail to arrest the flow, if the os uteri be pretty fully dilated or dilatable, we may rupture the membranes and discharge the liquor amnii. The womb, then, especially if in vigorous action, will contract upon its contents, and thus at least close the mouths of the bleeding vessels, and arrest or modify the haemorrhage. Another source of haemorrhage during labor, is the occasional presence of a uterine polypus. This is a rare occurrence, but should not on that account be passed without notice. Some authors advise, when it can be brought within reach, to ligate and remove it. The method of doing this will be found de- scribed in works professedly upon uterine surgery. This ope- ration, when performed during the puerperal condition, is not without danger, and when the tumor does not interfere with delivery, it is perhaps best to treat the haemorrhage as above, and for the present let it alone. Haemorrhage during labor may occasionally arise from ulcer- ation of the os uteri. The distension to which this part of the womb is subjected during the process of parturition, if ulcera- tion has previously existed, almost necessarily ruptures the small vessels traversing its surface, which of course pour out their contents. Haemorrhage from this source is not likely to be alarming—much less fatal. If detected, and thought worthy of attention, perhaps the best method of holding it in check would be to carry up a pledget of lint, moistened with a solu- tion of Per-chloride or Per-sulphate of iron, into contact with the os, and let it remain there till displaced by the force of the womb. The strength of the solution may be properly regu- lated by adding gradually to water the solution of the salt as generally sold, until it produces a very decidedly styptic taste when applied to the tongue. Laceration of the os uteri and vagina are also named as ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 169 sources of haemorrhage. Although the accident, when it oc- curs, takes place during labor, the consequent haemorrhage is not likely to manifest itself till that process has been com- pleted. When it happens, it will probably be most effectually controlled by the application of a styptic, as above directed. b.) Placenta Praevia—Unavoidable Haemorrhage.—But by far the most important source of haemorrhage during labor is the implantation of the placenta wholly or partially over the os internum or cervix uteri. This is called " placenta praevia," and, in the opinion of some, always gives rise to haemorrhage of a more or less alarming character, and from this supposed cer- tainty of its occurrence, it has usually been termed " unavoid- able haemorrhage." " Although a haemorrhage," says Cazeaux, " is usually con- ceded to be inevitable under such circumstances, yet it may not appear even during the labor; and the dilatation of the os uteri may be effected without the loss of a drop of blood. This ab- sence of discharge is doubtless a rare circumstance ; but its au- thenticity at the present day, is well established by numerous cases ; authors only differing as to the explanation given of it." So rare indeed, however, is such exemption, that it should not in the least influence our precautions in practice. In cases of placenta praevia, the haemorrhage usually mani- fests itself a few weeks before the close of gestation. On its first appearance it is not always violent; perhaps not generally so. If the patient keep quiet it usually subsides spontaneously, but is apt to recur again and again, up to the time of delivery. When we are called to a case of flooding, toward the close of gestation, and are not able to trace the accident to any violence, such as a fall, lifting heavy weights, or any kind of over-exer- tion, we have reason to suspect the existence of placenta praevia. Our suspicions will be confirmed, if a second occurrence take place in like manner, without any assignable cause. If an ex- amination be now made, and the os uteri be sufficiently patu- lous to admit the point of the finger, a spongy mass will be felt overlying it. The theory formerly entertained to explain these precursory haemorrhages was the following. It was thought that the os 170 PRACTICAL MIDWIFERY. internum began to dilate some time before labor, preparatory to that process, and as the placenta, firmly attached to the lower segment of the womb, could not stretch, so as to accom- modate itself to the altered condition of the seat of its attach- ment, its connection with the womb was gradually severed, and consequently the utero-placental vessels ruptured, and hence they poured out their contents. This theory is now by the more advanced authors regarded as untenable, inasmuch as it is believed that dilatation .begins at the os externum and ad- vances upwards, and not the reverse of this, wrhich the theory contemplates. In his work on Obstetric Operations, Dr. Barnes gives us a diagram representing the womb as divided into three zones, as he terms them. The upper he calls the fundal zone—the mid- dle, the meridional zone—and the lower the cervical zone. When the placenta is seated upon the latter, haemorrhage must ensue prior to labor, because, as he affirms, this region does not dilate in proportion to the growing demands of that organ, and during labor, because this portion of the womb must dilate, re- cede from the os, its centre, and fall back in all directions, to afford an opening for the child to pass, and hence, as it recedes, must detach itself from the placenta in situ upon it, and, of course, open the uterine vessels, over which the latter had been superimposed. In this process, however, the cervical zone, as it recedes towards the middle, or meridional zone, and is, as it were, lost in it, closes its own vessels, and thereby arrests hae- morrhage from their mouths. The theory of Dr. Barnes to account for the first accessions of haemorrhage, it seems to me, is liable to objections. Perhaps all we are justified in saying confidently of these early attacks is, that they are owing to partial separations of the placenta from its attachment to the internal surface of the womb, caus- ing an opening to a greater or less extent of the utero-placen- tal vessels, which consequently pour out their contents. What causes this severance is not so plain. Possibly, as the placenta is here implanted upon a less congenial soil than it would have found in the higher regions of the womb, its attachment may be less firm, and therefore more liable to be disturbed by slight ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 171 causes. Thus unfavorably situated it may possibly undergo changes itself, in the latter months of pregnancy, increasing the instability of its hold upon the uterine surface. Under these circumstances, slight forces may effect separation more or less extensive. It is now well ascertained, as we have stated in the chapter upon the Signs of Pregnancy, that the womb, during gestation, is constantly subject to contractions at short inter- vals. Even these, under favoring circumstances, may cause utero-placental separation, and give rise to haemorrhage. But whatever doubts we may have of the correctness of Dr. Barnes' theory of the precursory haemorrhages in cases of placenta praevia, his explanation of the cause of that during labor is en- tirely satisfactory, and seems unquestionable. Fortunately placenta praevia rarely occurs, but when met with constitutes a very dangerous complication of labor. Its infrequency of occurrence itself, furnishes a reason why the practitioner should thoroughly acquaint himself with every- thing necessary to its successi'ul management. Various methods have been from time to time proposed for the treatment of this accident, most of which it must be con- fessed have been very unsuccessful. A large proportion of the infants have been lost, and not a few of the mothers. We were told by the older authors, that when called to a case of placenta praevia, we should moderate the attendant haemorrhage by cold applications, or if necessary hold it in check for a time, by the use of the tampon, until the os uteri is sufficiently dilated, or in urgent cases even hasten its dila- tation by moderate force, pass up the hand peeling off the pla- centa on one side, rupture the membranes as far up as possible, seize a foot, turn and deliver. This method, now perhaps pretty generally abandoned, at least as to its indiscriminate application, is open to many objections, and its want of success proved it practically to be a very bad one. The os uteri, not- withstanding the haemorrhage, is not unfrequently slow to di- late, being, as it were, sealed up by the superimposed placenta. Hence, while waiting for the completion of this process, the patient may perish from the loss of blood. Again, turning by the old method subjects the child to considerable risk, and the 172 PRACTICAL MIDWIFERY. shock from suddenly emptying the womb may very likely prove fatal to the mother, already reduced to the lowest grade of prostration, through great and repeated losses of blood. Under such circumstances the womb should never be suddenly emptied. Another method, first proposed I believe by Dr. Radford, was to insert a finger into the os uteri and peel off the placenta entirely from its attachment to the womb. It was said that the haemorrhage then ceased, and the labor might be allowed its own time for completion. This was a step in the right direc- tion ; for, although all was not done that was intended, that, at least, was often done which was required. That is, although it was intended to remove the entire placenta, this was really not effected; for, as Dr. Barnes has shown, the finger could not reach the entire insertion of the placenta. It was, how- ever, detached from the lower segment or zone of the womb, and this, as we shall see, was all that was necessary to arrest the haemorrhage. It should be remembered that no single method of treatment is applicable to all cases with which we may meet. Having familiarized ourselves with the great principles upon which all rational and safe practice must be founded, we should modify our treatment according to the dictates of science and common sense, so as to suit each individual case. When consulted for haemorrhage, prior to the actual com- mencement of labor, we may use such measures as are else- where laid down to arrest it temporarily. Perfect rest in a cool room, Apoc. can., Trillium pend., Viburnum, Erigeron can., Thlaspi bursa-pastoris, selected according to symptoms, are likely to answer our purpose. We should watch the case closely, and if the patient seem seriously endangered from re- peated losses of blood, we should conscientiously consider the propriety of inducing premature labor. If this be decided upon, we may find that introducing and inflating, or filling with water, the colpeurynter, carried up to the os uteri, may be the means not only of temporarily arresting haemorrhage, if such be present, but of bringing on efficient labor pains. Should this simple measure not succeed in accomplishing our ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 173 purpose, we should adopt such means as are pointed out in our chapter upon the induction of premature labor, that may be found suited to the case. In attending a case, whether of induced or spontaneous labor, if the os uteri do not dilate we may use Barnes' dilators one after the other in succession. When the os uteri is suffi- ciently dilated to admit of the operation, if haemorrhage is still going on, we should puncture the membrane through the pla- centa with a male catheter, and slowly draw off the liquor amnii. This will especially be proper if we have fully satis- fied ourselves that the head presents—if otherwise, and podalic version of the child seem likely to be demanded, the measure may be more questionable. When the waters are discharged the womb will probably contract more vigorously, and forcing down the head upon the placenta, will apply it as a compress upon the bleeding vessels. If the pains be not sufficiently vig- orous, give Ergot in small doses, repeated at very short inter- vals, so as to be able to control its effects. If haemorrhage, how- ever, still continue, introduce the finger and detach the pla- centa all around, as far as it can be reached. This will remove an obstacle to the full dilatation of the os uteri, arid favor the retrocession of the lower segment of the womb, and enable it to fall back upon the meridional region. We have seen that in so doing its patulous vessels are closed, and haemorrhage conse- quently ceases. If the action of the womb be now energetic, either spontaneously or in response to Ergot, and the presenta- tion normal, the labor may be left to the natural powers to ter- minate. If, however, flooding still continue, it might be well to inject, by means of a flexible gum catheter, attached to a Davidson's syringe, a warm, slightly styptic solution of persul- phate of iron, between the detached portion of the placenta and the uterine surface. In most cases where the above measures are resorted to, the haemorrhage will cease, and there will be no need of haste. But if flooding still continue, and we cannot excite the womb to the requisite action—or if there be an abnormal presentation, we must render such aid as may be required according to the principles elsewhere laid down. Turning should be avoided, 174 PRACTICAL MIDWIFERY. if possible, or if indispensable, should be executed by the bi- polar method, if that be applicable. The forceps, recommended by some, is objectionable on account of the difficulty of applica- tion in such cases, and the loss of blood likely to take place during the operation ; but notwithstanding this, there may be instances where the use of this instrument is indispensable. I have no doubt there are cases of placenta praevia which may be safely managed, in reference at least to the mother, without further interference than to secure the dilatation of the os uteri, where nature fails, unaided, to effect this, and to keep up the vigorous action of the womb when this fails. Nor do I think such management always imperils the life of the child beyond its usual risks in such a state of things. At all events, the life of the child is here a secondary consideration, as it is likely to be born feeble and anaemic, and therefore not very likely to pass through the usual perils of infancy. Many years ago I had the sad misfortune to lose a very in- teresting young woman, in her third or fourth labor, in conse- quence of the complication now under notice. She had suffered repeated haemorrhages before I was called finally for her relief. Following the directions of the then best authorities, I turned and delivered the child alive and with the utmost ease. Al- though, at the time, I thought the patient's pulse fully justi- fied the measure, she collapsed, and I found it impossible to rally her, so that she died apparently from shock within an hour. From what I noticed about the moment I commenced the ope- ration, I afterwards thought, had I let her alone, she would have delivered herself without my interference. Some years afterwards, a case came under my treatment which I had no* doubt was one of placenta praevia, although I had not made a vaginal examination. I had prescribed for haemorrhage, occurring perhaps a month before her expected confinement, for which she could assign no cause. She was re- quested to let me know, if any, even the slightest recurrence should take place. Her husband called on me, ^perhaps two weeks after, to say that his wife had been flooding since the day before ; that she had no pains (which I afterwards found to be incorrect), that the abdominal enlargement had so much sub- ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 175 sided since the former haemorrhage, that she thought she must have been mistaken as to her condition. As I was about to leave home, I gave him Apoc. can. pretty strong, to be taken at short intervals, and if the haemorrhage did not shortly cease, he should by all means let me know. I sat up till after midnight, expecting and prepared to treat a case of placenta praevia. I was called up by 1 o'clock, a. m., by a messenger, who could tell me nothing of the case, but on my arrival I found the child had been still-born, before the messen- ger had been dispatched; from appearance had probably been dead since the former flooding. I found the membranes rup- tured just at their junction with the placenta. The secundines had been expelled with the child. The patient told me that not finding the medicine relieve the flooding, she had taken the doses in rapid succession, each of which seemed to increase her pains, till the whole contents of the womb were at once extruded.* She made a good recovery. We need scarcely add that when the child and the after- birth are delivered, we should be careful to secure firm and persistent contraction. Give Bell, if symptoms of cerebral congestion ensue. POST-PARTUM HEMORRHAGE. Haemorrhage may occur immediately after the birth of the child, and before the delivery of the secundines, even where there has been nothing abnormal in the implantation of the placenta. This is generally owing to the presence of the after- birth, by which the womb is prevented from contracting, so as to close the mouths of the bleeding vessels. The placenta may be wholly or partially detached from the uterine surface. In either case, there are vessels patulous and pouring out their contents. They will continue to do so till the womb contracts and closes their open mouths, or these latter are temporarily plugged by coagula formed within them. This latter may hap- * When iii such cases, there is unreasonable delay in the passage of the head through the pelvis, the forceps may perhaps be available—at lenst should be thought of. 176 PRACTICAL MIDWIFERY. pen through partial stagnation of the circulation brought on by decrease of the heart's action through loss of blood. The arrest from this cause is, however, usually only temporary, so long as uterine contraction has not been fully effected. As soon as the heart rallies, and the circulation resumes in any considerable degree its force, the clots opposing a barrier to haemorrhage are liable to give way, and alarming flooding again to set in. In this state of things, we should as soon as possible empty the womb of its remaining contents. We need not here repeat the instructions elsewhere given for the delivery of the after- birth. It is, however, particularly important in this case, to second the tractile efforts of the hand within the internal organs, by the other hand placed over the womb externally, exerting a bearing down force, not only for the purpose of facili- tating delivery, but to induce the womb to contract as its con- tents recede. This external pressure should be maintained for some time, until it is ascertained that there is no disposition to relaxation. When the secundines are delivered and uterine contraction secured, haemorrhage usually ceases permanently. This will not, however, always be the case. Sometimes, the womb again relaxes, and the flooding recurs with great violence. It is therefore important that the accoucheur should remain for some time with his patient, and before he leaves give particu- lar instructions to the nurse how to proceed, in case such an unfortunate occurrence should take place in his absence. If the womb do not contract when the after-birth is removed and flooding still continue, and if the usual compressing ma- nipulations do not succeed, or if danger be imminent, it is ad- vised to carry one hand up the vagina and elevate the lower segment of the womb, while the other hand applied externally forces down the fundus, so as to bring together the upper and lower regions of that organ, thus closing its cavity, and conse- quently the open mouths of the vessels. Where there is a dis- position to relaxation of the womb after it has contracted, most writers advise the application of a compress over that organ, secured by a binder. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 177 Dr. Hyatt, of North Carolina, claims to have frequently arrested post-partum haemorrhage, either before or after the delivery of the secundines, in the following simple manner. " An india-rubber balloon, which may be bought at any toy- shop, is tied over the end of a Davidson-syringe nozzle and passed into the cavity of the flaccid uterus. It is then distended by warm or cold water; by this means we bring pressure to bear directly upon the mouths of the bleeding vessels, which effectually seals them, and renders further haemorrhage impos- sible." If water be used in the above operation, we would by all means advise to use it warm, as we cannot but think that cold applications to the interior of the uterus shortly after de- livery are, to say the least, extremely hazardous ; not so much as regards immediate consequences, as those more remote. Ac- cording to very respectable testimony,* the injection of water as warm as can well be borne (110°) into the uterus, is itself one of the most efficient means of arresting haemorrhage. In this latter operation, the pipe of the syringe should be carried up within the womb till near the fundus. It appears from an article published in the Archives de Tokologie, for May, 1876, that Dr. Chassagny had resorted to an expedient for the arrest of haemorrhage essentially the same as that of Dr. Hyatt given above; the latter gentleman, however, claims priority in its use. If the above expedient be resorted to, we would suggest that after the india-rubber is sufficiently distended, the bulb of the syringe be detached and the finger of the accoucheur gently applied to the end of the tube, so that the water may be retained and gradually escape as the womb contracts. Flooding will occasionally set in violently, as above inti- mated, some time after the delivery of the after-birth, even when the womb has seemed to be well contracted. Of course * Dr. Athill and others. Dr. A., in a paper read before the Obstetrical Society of Dublin, details some interesting and successful experiments with the above expedient in the Rotunda Hospital of that city. He says he was induced " to try it in consequence of a letter written by Dr. Whitwell of San Francisco to Dr. Foley, of Boston, who is at present studying in this hospital." 12 178 PRACTICAL MIDWIFERY. relaxation in such cases has again taken place. Such an event, alternate contraction and relaxation, is believed, sometimes at least, to be foreshadowed by the character of the pains during labor. When the uterine contractions set in suddenly, soon attain their height, and then quickly subside, we may look for a want of permanent contraction after the parturient process is ended. In such cases we should endeavor to forestall this un- fortunate circumstance, by the administration of remedies during labor. I have found small doses of Ergot given toward the close of labor, generally secure speedy and permanent con- traction, and at the same time greatly diminish subsequent suf- fering from after-pains. We need hardly repeat the injunction that when the prognostic indication just mentioned is encoun- tered during labor, the attendant should be specially watchful of the case, and remain as long as possible with his patient after her delivery. Another premonition of flooding, to which we have before called attention, is an unusual quickness of the pulse. When this is observed to continue after the excitement of labor has somewhat subsided, we should be upon the look-out for flood- ing and provide accordingly. I met with this symptom once in a young woman after the birth of her first child, and sus- pecting haemorrhage, I remained in the house for an unusual length of time, but finding no abnormal discharge, I was just about to leave, when I was suddenly summoned to the bedside of the patient. Perhaps the most alarming haemorrhage I have ever witnessed, followed. It yielded at the time, to the meas- ures employed, and the womb seemed to contract in a normal manner. The following night, however, I was again sum- moned on account of its recurrence in a very violent form. It again yielded, but the patient some days afterward seemed to be affected by septicaemic poisoning, and appeared likely to make a very bad recovery. After using several remedies with negative results, I gave Ars. alb., 2d dec, with excellent effect. Unusual quickness of the pulse, with some haemorrhage, and symptoms of shock should lead us to suspect laceration of the perineum. Post partum flooding may generally be attributed to want of ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 179 complete and persistent contraction of the womb. This, as we have intimated, is sometimes due to mechanical obstruction, such as retained placenta, in whole or in part, and even clots formed within the uterine cavity may have the same effect. But this deficiency of contractile power may be owing to one or more, of several remote causes, having primarily no relation to that just stated. Sometimes it may be traced to pre-existing disease, giving rise to general debility, of which the womb, as other organs, partakes. Again it may be owing to exhaustion of the uterine power, from severe and protracted labor. It may, moreover, be caused by a too rapid delivery, a too sudden emp- tying of the uterus, so that its walls cannot follow up the re- ceding contents. Besides Very sudden delivery is usually at- tended by more or less of shock, in which the womb, in com- mon with the whole organism partakes. When want of con- traction follows the administration of chloroform, it is pretty uniformly laid to the charge of that agent, and haemorrhage, in the opinion of some who have never used it, is almost an un- failing result. We will, hereafter, express our opinion upon this subject, and need not anticipate in this place. The action of the causes we have just referred to, sometimes give rise to a mechanical one, which, in its turn, tends to increase and pro- long the haemorrhagic condition. When the womb fails to contract, immediately after the extrusion of the after-birth, the blood, pouring into its cavity, forms clots, which in turn inter- fere with its complete closure, until it acquires sufficient force to expel them as foreign bodies. Generally, in regard to the evils attending childbirth, it is better, if we can, to forestall and prevent them, than to suffer them to become developed, even though we should be success- ful in relieving them. Much may be done in this way in re- gard to post-partum haemorrhage. It is a good rule, as we have already said in the chapter on the Management of Labor, and here repeat for the sake of em- phasizing it—it is a good rule, when the head of the child is born, to have an assistant, well instructed in the duty, to place the hand over the uterine tumor, and with firm pressure, to follow down the receding body as it passes into the world. 180 PRACTICAL MIDWIFERY. Nor should the hold be relaxed even when the body is born, but firm pressure maintained until the accoucheur himself is free to take charge. This simple expedient itself, we have thought, does much to secure contraction of the womb, the early expulsion of the secundines, and subsequent immunity from haemorrhage. But while we regard firm and persistent contractions of the womb the great prophylactic against haemorrhage, and the only reliable means of its permanent arrest, when it has taken place, the homoeopathic obstetrician is by no means restricted to me- chanical manipulations to produce this condition. On the con- trary, there may be existing at the time, a morbid condition of the uterus which may completely baffle all such efforts, and yield only to a well selected remedy truly homoeopathic to that condition. The young practitioner should therefore thoroughly study the pathogenesis of all remedies likely to be available under these trying circumstances. This he should do, not at the bedside of the patient, and from a book carried in his pocket, to be used if necessity require; but in his private study, and previously and thoroughly—and then we have no objection to the book in his pocket as a reminder. There is, perhaps, no situation in which the young obstetric practitioner can be placed, more trying, than to have in charge, without the aid of older counsel, a case of violent uterine hae- morrhage. On the one hand he feels his own reputation at risk—on the other the life of his patient. Fortunately, how- ever, these cases do not so often result fatally, through their immediate consequences, as one would expect. Perhaps the secondary effects are, upon the whole, more to be dreaded than the primary. But we reiterate, let the young practitioner al- ways be prepared to do the utmost to speedily arrest an unna- tural effusion of blood. The following are a few of the remedies particularly deserv- ing attention in post-partum haemorrhage, viz.: Apoc. can. Bell., Crocus, Ipecac, China, Secale, Trillium, Ergeron. There are still others worthy of study in this relation. We have however, I believe, never gone beyond this list in the use of medicines, and have as yet lost no lives. In violent cases we ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 181 have almost always resorted to medication in conjunction with the mechanical measures just recommended. When there is good reason to believe that clots have accu- mulated in the uterus, so as to prevent its contraction, efforts should be made to procure their expulsion. If firm pressure upon the organ do not effect this object, we may try Puis., and if this do not succeed, perhaps Ergot will answer our purpose. These remedies, however, should not be given at random : the one or the other must be selected according to the circum- stances of the case, and which it would be useless for us to imagine and then depict—it must be taken as it occurs. If Ergot be given, it must be given in repeated doses of such strength as will ensure vigorous contraction, or else satisfy us that it is incapable of reaching the case. When the womb, from its size, as felt through the abdominal walls, is believed to contain a large amount of coagulated blood, while yet the os and vagina are sufficiently dilated or dilatable, we are advised to introduce the hand and turn out the clots. This expedient may be necessary if haemorrhage is still going on, and we have reason to believe that the measures we have already laid down may not succeed sufficiently soon in effecting their expulsion. It must be remembered that co- agulated blood, if present in large amount, must be removed, if we would secure safe contraction of the womb. It has been advised to raise and seat the patient upon the chamber-vessel to effect this object, and we have known this measure to suc- ceed. If haemorrhage continue after the expulsion of the clots, we may try the injection of warm water. Should we meet with a case of violent haemorrhage which should resist such of the foregoing expedients as might be se- lected, and, indeed, any others we might adopt, and seemed to be progressing toward a fatal termination so rapidly that some- thing more effectual must be done or the life of the patient be lost, an important question arises, shall we or shall we not use an injection of a solution of the per-chloride or per-sulphate of iron? I am fully aware that Homoeopathic physicians entertain strong prejudices against such measures, and I may truly add, 182 PRACTICAL MIDWIFERY. I am myself one of that number. Some very positively affirm that they have met with no cases that did not yield to homoeo- pathic remedies, and I readily concede that they have been very fortunate. I will, moreover, add that I myself have met with very few. But yet every one who has had an extended experience must admit that cases do occur wherein a fatal result is so alarmingly imminent, that it is evident something must be efficiently done in a few moments, or the case will be lost. The patient is unable to give her subjective symptoms—can answer no questions—nay is absolutely speechless and almost pulseless, while flooding is still going on. Under these un- favorable circumstances, and ordinarily no little trepidation, whatever remedies may be really available, the physician has a very poor chance to select. Unfortunately we are sometimes compelled, as the best we can do, to choose between two evils, and it is certainly the part of wisdom to choose the less. A solution of the perchloride of iron of very moderate strength, injected into the womb, has, in all cases reported, so far as my researches extend, immediately arrested haemor- rhage. This arrest, so far as I have noticed, has been perma- nent. In the very few cases in which I have resorted to this measure, such has certainly been the result. Avery important question then arises, namely, are the ordinary or necessary consequences of the practice, such as to determine its rejection in every case of flooding, however violent or hopeless ? The haemostatic action of the remedy is probably two-fold. By its irritating property it stimulates the womb to contract, and by its power as a styptic it coagulates the blood within the mouths of the bleeding vessels, and constringes the con- gested capillaries from which blood may be welling out into the cavity of the womb. From these two actions of the drug arise whatever dangers may necessarily follow its use. We will, for a moment, examine them. In the first place, as an irritant acting upon the internal surface of the womb, highly congested, and in a state of exalted nervous impressibility, it must be confessed there is some reason to dread serious inflam- mation (endometritis). Practically, however, if we mav de- pend upon the reports of those most frequently resorting to ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 183 such injections, this does not often happen. Again, through the same property of the per-chloride, there is danger to be ap- prehended from another quarter. The injected fluid may pos- sibly, through the Fallopian tubes, find its way into the peri- toneal cavity, and excite severe, if not fatal, peritonitis. This risk may, however, be in a great measure avoided by using but little force in throwing up the fluid and providing for its easy return through the vagina. Its constringing power, moreover, probably sets up a barrier to its entrance. Through the styptic properties of the drug, danger may be apprehended from the size and quality of the coagula formed within the womb. Whatever amount of blood may be present there, when the solution of the perchloride is injected, if this latter be in sufficient quantity and of sufficient strength, will be co- agulated and form very solid clots. The uterus, weakened by the loss of blood from the general system, may be unable, at least for a considerable time, to expel these from its cavity. Their solidity, and perhaps adherence, may oppose an addi- tional obstacle to this result. Hence a ground of apprehension of septicaemia from their decomposition. The danger, how- ever, from this source is probably not so great as might be supposed. The decomposition of the clots is most likely de- layed by the very agent that produced them, the per-chloride itself, at least to some extent, acting as an anti-septic Besides injections will arrest haemorrhage effectually, when of a far less degree of concentration, than those generally employed, and thus their danger, whatever it may be, may be lessened, both in regard to their irritating properties, and their tendency to form solid clots, by extreme coagulation of the fibrine of the blood. So far as I have resorted to this measure for arresting flooding, I have used a solution merely of sufficient strength to produce a decidedly styptic impression when applied to the tongue, and yet the flow was instantaneously arrested. The propriety of using injections of perchloride or per-sul- phate of iron, has been very fully discussed by the different obstetrical societies of Great Britain. The weight of authority in these learned bodies, seems to be in favor of its employment, but rather as a last resort than as an ordinary expedient. From 184 PRACTICAL MIDWIFERY. a very limited experience with it, fortunately so, it is certainly only as such I would have recourse to it. But as " drowning men catch at a straw," I would rather employ it with all its risks, whatever they may be, than to be obliged in a few mo- ments to lay my hand upon a pallid corpse. I would only add that the per-sulphate is perhaps, in most respects, preferable to the per-chloride, and is probably homoeopathic to haemorrhage. Finally, there is one other condition of haemorrhage to which I think the foregoing expedient may be applicable, but these too only when other means have failed, and death seems slowly but surely advancing to seize his prey. Violent and exhaust- ing flooding has already occurred, prostrating the patient to the lowest condition compatible with the continuance of life. We have given remedies which seemed to check the flow, but still there is from hour to hour and from day to day a con- tinued drain, which nothing seems to arrest, and which is manifestly extinguishing the little spark of life which yet re- mains. In such cases, we should carefully examine both with the finger, and if necessary with the speculum, to ascertain if possible whence the haemorrhage proceeds. It will likely be found to be from some laceration or abrasion, or it may be from a growth. If the latter, its removal at the time may be attended with too great risk to attempt, and in either case the injection as above will most probably, at least temporarily arrest the flow, gain time, and enable the patient to rally. There is a form of haemorrhage differing in no essential char- acteristic from those we have just considered, except that its occurrence is not announced by the usual unmistakable signs. The blood accumulates in the womb sometimes in large amount, but does not flow out by the vagina, and therefore the accident may not be detected until even dangerous effusion has taken place. This has been called, not with very great propriety, internal haemorrhage, simply because it is not attended by the usual external manifestations, while strictly speaking, all uterine haemorrage is internal. It is important that the accoucheur should early detect this secret process, since owing to the expansibility of the womb just after delivery, a vast amount of blood may accumulate within its cavity. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 185 After the child is born and the after-birth removed, or even before this latter is accomplished, if the pulse be found quick, the womb but little or not at all contracted, or on the contrary it may be rather enlarged, if upon examination no external haemorrhage or very little appears, if no laceration of the pe- rineum be detected (if such exist there will be haemorrhage), if the patient manifest signs of shock, suffers from difficulty of respiration and is thirsty, we have reason to believe that in- ternal haemorrhage is going on. The indication is to remove the accumulation within the womb and compel it to contract. AVe have already given in detail the means to be employed for effecting contraction, and if we can secure this, we secure at the same time the expulsion of the blood contained within. But if we cannot induce the womb to contract and expel its contents without unnecessarily wasting precious time, it is proper we should introduce the hand and turn out the clots, and then renew our efforts to secure contraction. We need not hesitate to turn out the blood, whatever may be its quantity, for it is already thrown out of the circulation, and can there- fore do nothing toward sustaining life. On the other hand, by its presence it prevents contraction, and thereby invites still fur- ther loss. If great exhaustion have taken place, use stimulants very cautiously. The subsequent treatment of such cases dif- fers in no important respect from that already given, only we should be especially watchful to keep up permanent contraction. It occasionally happens, that shortly after delivery, even where no premonitions have been noticed, a frightful haemor- rhage sets in, rapidly undermining the vital powers, and not unfrequently terminating in sudden and unexpected death. I have not myself been so unfortunate as to meet with a case of this kind, but have repeatedly known them to occur. Such cases are always attended with extreme danger, from the sud- denness and violence of the onset, from the perturbation they usually excite in the attendant and friends of the patient, as well as too often the absence of the appliances necessary suc- cessfully to meet the urgent indications. A method of arresting uterine haemorrhage has lately been proposed, which I think, when it is available, would answer 186 PRACTICAL MIDWIFERY. well in cases such as above described. I am sorry I am unable to give the name of the individual by whom it was first prac- ticed and recommended to the profession. It consists in apply- ing pressure upon the aorta upon the principle of the tourni- quet. This is effected in several different ways, according to the requirements of the case in hand. If the woman, for instance, be of relaxed muscular fibre, attenuated abdominal walls, and the internal viscera easily movable, the womb and bowels may be partially pushed aside, and the points of the fingers thrust deep into the tissues until they press upon the great aorta with sufficient force to arrest the haemorrhage. Their position and pressure should be thus maintained till there is no longer dis- position to recurrence. When the womb cannot be easily turned aside, and where it presents considerable solidity, it may, like the pad of the tourniquet, be pressed upon the artery by force applied externally. Again, pressure may be exerted upon the vessel through the posterior wall of the uterus by the hand in- troduced into that organ. Manipulations performed by one hand in the rectum, and the other applied externally, or within the womb, have also been recommended. The advantages of this method, when applicable, are the celerity with which it may be applied and the promptness of its effects. It requires nothing but what is always at hand. These advantages are very important, as the cases we have in view admit of no delay. A short time spent in looking up appliances, and life is extinct. However, strong our confidence in well selected medicaments, there is no time for them to act, scarcely enough to administer them. On the other hand, where there is extreme tenderness of the abdominal walls, as there not unfrequently is, the patient would scarcely bear the requisite amount of pressure to be effective. Again when the abdominal parietes are very thick, either from heavy and dense muscular fibre, or the presence of much adipose tissue, or when the omentum is loaded with fat, it will not be easy to make sufficient pressure upon the vessel to answer our purpose. I need hardly add that the point selected in the course of the aorta, to which to apply pressure, should be sufficiently ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 187 high to arrest the current in the direction of the womb, nor need I say that the method, if successfully executed, will have a doubly beneficial effect, first, by arresting the unneeded flow to the womb, and, secondly, by sending an additional amount of blood to the brain, which is, perhaps, already suffering from anaemia. A very interesting paper will be found upon this subject in the Obstetrical Journal of Great Britain and Ireland, Vol. VI., No. 11, p. 701, by G. de Gorrequer Griffith, L.P.C.P. d) Post Partum Secondary Haemorrhage.—It has long been a matter of surprise to me that obstetrical writers have devoted so little space to the subject indicated by the above title. Its importance certainly merits more attention than has thus far been accorded to it. Of all the writers, to whose works I have had access, Dr. Barnes, in his " Obstetric Opera- tions," does it most justice, and here, as everywhere, is very instructive. Under the head of " Secondary Puerperal Haemor- rhage," however, he treats of several forms which have not their origin within the uterine cavity, as, for instance, those arising from laceration or abrasion of the cervix, laceration of the vagina, perineum, etc. It is our present design, however, to speak only of haemorrhage having its source in the internal surface of the womb, and such as occurs not earlier after de- livery than the second or third day, and may take place at a much later period. This form of haemorrhage is peculiarly dangerous from at- tendant circumstances, and from the pathological condition upon which it often depends. When haemorrhage occurs shortly after birth, some symptoms usually herald its approach, " Coming events cast their shadows before," and the prudent accoucheur remains with his patient, provided with the best means at his disposal, to ward off approaching danger. Not so, however, when secondary haemorrhage takes place. Its occurrence, perhaps, is not anticipated; the patient is alone with the nurse or the members of her family, it may be unsuspectingly enjoying quiet sleep, so necessary to her res- toration, when waking suddenly, she finds herself immersed 188 PRACTICAL MIDWIFERY. in a pool of her own blood. The doctor is hastily sent for, but he lives miles away, and is, perhaps, not at home when the messenger arrives. Thus, before anything is efficiently done, the patient has become exanguious and pulseless, and if of a feeble constitution, may have sunk below the rallying point. Another source of peculiar danger is found in the liability of the blood-clots resulting from the haemorrhage to become putrid within the womb, and thus give rise to septicaemia, often in its worst form. It has seemed to me that the womb has less power to expel foreign bodies after secondary haemorrhage, such as we here contemplate, than after that which may occur shortly subsequent to delivery. The blood-vessels, too, being so thoroughly depleted of their normal contents, the more readily absorb any fluid within their reach, be it noxious or otherwise. There are also morbid conditions sometimes co-existent with this form of haemorrhage, which may indeed have contributed to its occurrence, and which, at least, add to its danger. There may, for instance, have been pre-existing circumscribed inflam- mation of the internal surface of the womb. It may have constituted a factor in the production of haemorrhage; but be this as it may, when it has taken place, it very considerably augments the danger of its results. The patient then not only suffers exhaustion from the loss of blood, but from the depress- ing, consuming effects of local inflammation. The citadel of life is thus assaulted at different points, and, in consequence, is, too often, doomed to fall. If, moreover, it be true, as some have supposed, that second- ary haemorrhage sometimes has its origin in a peculiar dyscra- sia of the blood itself, in consequence of which it is thinned in its consistence, or its coagulability is diminished, or both, for they are likely to be associated, it is manifest that the arrest of the flow by Nature's usual method would be more difficult, and the consequent danger of the result increased. The im- paired state of health, too, necessarily concomitant with such a dyscrasia of the blood, would render the patient far less likely to rally from the extreme exhaustion of profuse haemor- rhage. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 189 Fortunately cases of secondary post partum haemorrhage are comparatively rare, for it mostly depends upon causes which the careful practitioner may avoid. We will at present under- take to enumerate but a few of the more prominent of these, and subsequently endeavor to indicate, as far as we can, both prophylaxis and remedy. Among the most fruitful sources of this form of haemorrhage may be mentioned, portions of the placenta or even membranes left behind within the womb. If these portions be detached and escape the hand of the operator, so as to be retained, they are, perhaps, less likely to produce this disastrous result than if left undetached. In the former case they merely act as a for- eign body, and as such may indeed produce irritation upon the internal surface of the womb, and, consequently, invite an un- wonted afflux of blood to the part and thus encourage haemor- rhage. But in the latter they furnish an outlet by which the vessels of the womb pour out their contents into the cavity of that organ. Besides, if any considerable portion of the pla- centa remain, by its bulk it prevents the uniform contraction of the womb, and, consequently, the perfect closure of the mouths of the maternal vessels, so essential to safety from haemorrhage. When speaking of Adhesion of the Placenta, we have re- ferred to the difficulty occasionally encountered in our attempts to remove the entire mass, and of the great risk of haemorrhage where we fail to effect this. We need not here repeat what we have said, but will speak only of the treatment of the haemorrhage which, sooner or later, is likely to occur in these unfortunate cases. And here I would refer the reader to the remedies spoken of when treating of haemorrhage in a former chapter of this work. These remedies are available also here. But secondary haemor- rhage from the cause we are now speaking of, generally occurs, as we have already said, in our absence, and often to an extent, before we reach the bedside of the patient, that she is unable to give the subjective symptoms of her case. The flow perhaps still continues, and it is manifest, unless soon arrested, the pa- tient's life must be sacrificed. In such case I would not hesi- 190 PRACTICAL MIDWIFERY. tate to inject, as an extreme resort, the perchloride or persul- phate of iron, diluted very considerably below the degree of concentration used by Dr. Barnes, or as I have elsewhere said, just strong enough to produce a decidedly styptic impression when applied to the tongue. Another cause of secondary post partum haemorrhage we would notice, is the retention of blood-clots within the uterine cavity. From various causes it sometimes happens that the uterus does not firmly contract after delivery, and blood still oozing from the patulous mouths of the vessels, forms a coagu- lum which the deficient powers of that organ are unable to ex- pel. This coagulum may increase in size by continued accre- tions, and thus in turn prevent the further contraction of the womb, and the firm closure of the mouths of its vessels, and in the meanwhile acting as a foreign body produce irritation. This will cause an increased flow of blood to the womb, while under its distending force, the imperfect closure of the vessels may give way and more or less alarming haemorrhage ensue. To forestall and prevent the accident from this source, we should, of course, by a resort to the means elsewhere pointed out, secure perfect contraction of the womb before leaving the patient after delivery, and from time to time see that such con- traction is maintained. When clots are suspected to exist in the womb shortly after delivery, and which that organ seems unable to expel, obstetrical writers, as we have before said, ad- vise us to introduce the hand and turn them out. This could not be done, however, when secondary post partum haemorrhage occurs, inasmuch as the os uteri would then be closed, so as not to admit the hand without violence. But even then, Secale may so stimulate the womb, as to secure the action necessary to expel any clots it may have retained for want of vigor. Mental emotions sometimes give rise to secondary haemor- rhage. This is brought about indirectly through their influ- ence upon the heart. We may suppose, in such cases, that the mouths of the maternal vessels are not yet firmly closed and when from fright or other emotion, the heart is excited to un- wonted action, the increased impetus given to the blood causes it to break through the imperfect barriers, at the mouths of the ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 191 uterine vessels, opposing its exit. Common sense prescribes as the best prophylaxis against accidents from this cause, that the patient, especially if she be of a nervous temperament, should be scrupulously secluded from all sources of emotion or excite- ment. Derangement of innervation, which controls the contractile powers of the womb, giving rise to irregular, unsymmetrical contraction of that organ after delivery, constitutes another source of secondary haemorrhage. The womb, when its power is intact, usually assumes a globular form—on the other hand, when impaired in the manner referred to, the form assumed may be cylindrical or otherwise abnormal. Such contraction, but an imperfect safeguard against haemorrhage even at the first, is apt to relax in a few days, and may be followed by pro- fuse flooding. To correct this defective contraction, and thereby forestall its consequences, we would have confidence in minute doses of Ergot, if the difficulty have not been caused by abuse of that drug. Another derangement of innervation or nervous function giving rise to secondary haemorrhage, may yet be mentioned. It is that in consequence of which an equilibrium of the circu- lation is no longer maintained. There is undue afflux of blood, first to one organ or part, then to another. The womb is liable in its turn to become the seat of this afflux, and the conse- quence sometimes is profuse, and even fatal haemorrhage. The following case will illustrate this rather rare phenome- non. It occurred perhaps more than twenty years ago. A young woman of low stature, primipara, was in labor for at least three days, owing at first to deficiency of uterine contrac- tions, and afterwards, in the second stage, to the unusually large size of the child. She was delivered without instrumental interference, and made a reasonably good recovery up to the tenth day, when, according to custom, she began to sit up out of bed. Her mother then, unfortunately gave her some rice pudding at her dinner, prepared with milk—the latter an ar- ticle which had always disagreed with her. This imprudence brought on violent cholera morbus, and the irritation extended to the womb—already susceptible from its contused condition 192 PRACTICAL MIDWIFERY. in consequence of an unusually hard and protracted labor. The vomiting and diarrhoea subsided under treatment, but in the course of two or three days her face at one time would become so congested as to be almost of a purple color—then the lungs would be so oppressed as to cause extreme dyspnoea, while the face would become pale. Finally the afflux of blood was deter- mined to the womb, followed by a haemorrhage which at once brought her to death's door. This occurred in the night; I was not present, but an experienced physician and his son, who had been called to my aid, were with her. She expired the following evening. We have before observed that the physician, especially in the country, is seldom present during the most violent stage of the haemorrh'age of which we speak. Should he be, and the same accompanying symptoms present themselves as in the haemorrhage occurring just after delivery, the remedies indi- cated in the one case, as we have before said, would be also proper in the other. But in the majority of cases we should simply witness the violent gush of blood and the rapid sinking of the vital powers, demanding the immediate arrest of the flow, if we would save the life of our patient, or prevent her sinking into that depth of prostration from which too often there is no return. Here the various expedients for producing contraction of the womb, if that be found relaxed, as is mostly the case, immediately suggest themselves, and most of them need not interfere with the most skilful medication simultane- ously carried on. It is an excellent plan for country practition- ers to instruct a nurse or other woman, in every neighborhood, within the bounds of his practice, how to use the more simple of these expedients, such as kneading and compression of the womb by means of the hand or by pad and binder, or even the introduction of the tampon. By so doing the temporary arrest of the haemorrhage would often be secured, the ruinous loss of blood prevented, and I verily believe lives, in many instances, saved, which are now lost for want of such knowledge. If the physician be present, other means failing, he may have recourse to the introduction and inflation of the gum elastic toy balloon elsewhere spoken of. It may be remarked ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 193 here, that we cannot expect in these cases, so much from appli- ances calculated to promote uterine contraction, as in haemor- rhages occurring earlier after delivery, as the contractile power of the womb at this late period and under existing circum- stances may generally be supposed to be very deficient. Before closing my remarks on haemorrhage, do I owe an apology for having so largely recommended mechanical, chem- ical and physiological appliances ? If so, it has ever been my wish " to give a reason for the faith that is in me," such as ought to be sufficient to satisfy every candid mind. Some, I know, profess to treat successfully all haemorrhages by simple medication—by remedies, perhaps, of the forty or hundred thousandth dilution. As I wish publicly to question no man's assertion, although there is, perhaps, no truth better established than that such assertions are sometimes incorrect, I would simply say that all are not equally skillful in selecting remedies and, of course, not equally successful in their employment. I have already spoken of the difficulty, in many instances, in ascertaining symptoms such as would guide us in the correct selection of a remedy if, in the case before us, uch there be. I readily admit that a diseased condition may be an important factor in haemorrhage; but when this is the case, that disease is, perhaps, mostly of a chronic character, and not likely to respond to a remedy with sufficient promptness to save the patient's life. This should be the great object of the physician's aim, no matter by what means attained. If called to a man whose femoral artery had been severed and his life blood flowing rapidly away, the idea of medication would probably hardly occur to us. Common sense would suggest other means of arrest. The case of a woman flooding after labor is not so unlike to this, as not to suggest^similar means of relief. I must say, however, that by far the larger number of haemorrhages I have encountered, have ceased after medical treatment and the simpler adjuvant means, and when I am convinced that medicine alone will answer in every case, I will be among the first to use it to the exclusion of all other means. 13 194 PRACTICAL MIDWIFERY. LACERATION OF THE PERINEUM. This, although not reckoned amongst the more dangerous accidents of parturition, should nevertheless be guarded against with the utmost assiduity, on account of the distressing con- sequences it sometimes entails. It is, however, not without danger, as, in its worst forms at least, it exposes an extensive raw surface to the action of the discharges, and, by absorption, may give rise to fatal septicaemia. In order to prevent this accident, when that is possible, we should, in the first place, inquire into the causes usually con- cerned in producing so unfortunate a result. Of these authors have enumerated the following as the principal, viz. : 1. Neglect to support the part while the head is passing. 2. Injudicious or improperly directed support, which is re- garded by most as worse than no support at all. 3. Rigidity of the perineum, on account of which it fails to yield under the pressure of the head. This is most likely to occur in primiparae, and especially those somewhat advanced in life when they give birth to their first child. 4. Extreme uterine action propelling the head violently against the perineum, without giving it sufficient time to yield. 5. Large size of the head of the child requiring extreme distension before it can pass the outlet. 6. Fatty degeneration of the musc.ular structures composing the organ in question. 7. The sudden extension of the limbs of the patient from their usual flexed position, just as the head is held within and about to pass the vulva. 8. Misdirection of the head from defective formation of the parts, whereby, instead of being propelled forward toward the outlet, it takes a direction backward toward the coccyx, thus spending its force upon the posterior part of the perineum. In reviewing the alleged causes of the accident under con- sideration, we are compelled to say, in regard to the first, that we doubt extremely whether support of the perineum be neces- sary, except possibly in very rare and they, perhaps, unrecog- ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 195 nizable cases, and whether in nearly all it does not tend to bring about the very accident it was intended to prevent. When we contemplate the wonderful provision the Creator has made for carrying the process of parturition through its earlier stages, we can hardly suppose he has left it so defect- ively provided for at its close, as so much to need our bung- ling aid, that it cannot be safely completed without it. But throwing aside the argument from analogy, if we, for a moment, reflect upon the manner in which lacerations usually take place, we will, I think, equally arrive at the conclusion that support can do nothing to prevent them—nay, may even favor them, by interfering with the normal yielding of the tissues. Lacer- ations usually commeuce at the posterior commissure, and are caused by the wedge force of the head, which tends to sepa- rate laterally the labia. When the rupture begins at the com- missure, it ruus backwards under the influence of this lateral force, following the raphe or a line near and parallel to it. But this force is not acting in a direction opposed to that of press- ure or support, and, therefore, capable of being controlled or modified by it, but in a line across or at right angles to that of the support, and, therefore, entirely beyond its power to hold in check. I can conceive of no form of laceration, except, perhaps, the central, that could be prevented by perineal sup- port, as usually advised. I should, perhaps, say that we are directed by authors generally, to lay the ends of the fingers upon or near the point of the coccyx and let the whole length of the palm lie in a forward direction upon the perineum. This method of support may, to some extent, counteract cen- tral laceration, that is, where the head perforates the perineum midway between the posterior commissure and the anus ; but this form of the accident is extremely rare. Even this might be more effectually prevented by other means. When there is extreme distension of the perineum and labia, the outlet refusing to dilate with sufficient rapidity to let the head pass, while the child is propelled by a powerful " vis a tergo " from the energetic action of the womb, I am inclined to think something might be done to prevent laceration, by applying both hands, so as, with gentle firmness, to embrace 196 PRACTICAL MIDWIFERY. the tumor formed by the head, as covered by the structures of the mother, a little way back from the circle formed by the distended labia, and drawing the structures somewhat forward. The hands, thus applied, would act as a hoop or band to sup- port the endangered tissues. Dr. Goodell advises us, where we apprehend laceration, to insert a finger of the left hand into the anus, to draw the tissues forward, while several fingers of the right hand are firmly applied in front of the head, to retard its advance. We need hardly say this would be most repugnant to patient and physician. It must, however, be admitted that authors are, as yet, divided upon the necessity or utility of perineal support dur- ing the last throes of labor. The older writers generally strongly advocate its use, and even among the most recent ones there are those who still insist upon its importance. Dr. Thomas More Madden, of Dublin, in a paper contained in the May number, 1872, of the American Journal of Obstetrics (on Lacerations of the Perineum, Sphincter Ani, etc.), has tabu- lated a series of cases which had come under his observation— a large proportion of which he attributes to neglect of the perineum, and, of course, maintains the utility of its support. On the other hand, Leishman, in his work on the " Mechanism of Parturition," denounces it. The latter claims that the acci- dent has not happened in his hands more frequently than in the hands of others of greater experience and ability than him- self, who uniformly resort to perineal support. Dr. Grailey Hewitt, a high authority, contends that not only is the prac- tice quite unnecessary, but very often it is absolutely mischiev- ous. Dr. Meadows, a quite late writer, in his " Manual of Midwifery," says: " My own opinion is, that when the head has had fair time gradually to stretch the perineum and sur- rounding structures, there is no need whatever for this, to say the least, most unpleasant proceeding." He admits, however, that in the opposite state of things support may be of use. But while we would reject the neglect of support as a fre- quent cause of lacerations, and propose a very simple preventive for those arising from that which is termed injudicious, ::amely, to omit support altogether, rigidity of the perineum as a fruit- ful source of the accident, deserves more serious attention. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 197 It was the custom of the older allopathic physicians in such cases to resort to blood-letting, tartar emetic, and the like. These remedies are objectionable, if for no other reason, because they reduce the strength of the patient, and thus disqualify her for her important functions, to say nothing of the extreme discomfort which they produce. In other words, although these may to some extent relax the perineum and diminish its resistance, they at the same time lessen the uterine power in a perhaps still greater ratio, and although the danger of lacera- tion may be reduced, the length and discomfort of the labor are likely to be greatly increased. The use of lobelia, which has been more recently recommended, if pushed to the point of nausea, comes under the same category and is open to the same objections. If it be found to produce relaxation short of its nauseating and debilitating effects, as I believe some assert that it does, it may prove a very useful remedy in this state of things. I have used the tincture of Gelseminum as I thought with favorable results, but my experience with it has not been sufficiently extended to enable me to speak positively in its favor. Warm sitz-baths are likely to do good, and as I cannot conceive of any bad results likely to follow their use, unless in cases where they might encourage haemorrhage, they might be resorted to when more powerful means are not available. In- unction with lard and prolonged rubbing, as advised by Dr. Clay, may be tried. When, however, the uterine action is very moderate, or even defective, no harm, so long as this state of things exists, can result from rigidity of the perineum. Under the moderate ac- tion of the womb it is likely sooner or later to yield. When the head comes to rest upon this structure, and the rather feeble action of the uterus seems unable to overcome its resistance, I would recommend the manipulation I have fully described when speaking of " Retarded Labor." But it is when rigidity of the perineum co-exists with violent uterine action, that we are to expect danger of laceration of the perineum and surrounding structures. Here, fortunately, we have one of the most efficient and reliable of remedies for the correction of both these evils. Singly, so far as danger to the 198 PRACTICAL MIDWIFERY. perineum is concerned, they are not much to be dreaded—com- bined they should always excite our apprehensions. The re- medy to which I refer is chloroform. This, if judiciously and understandingly administered, not only moderates excessive ute- rine action, but softens and relaxes all the maternal structures which are concerned in parturition, the perineum included. One of the great advantages of chloroform is that it holds in check reflex action, just at the moment when the parts are most in danger of laceration. Who has not noticed that, in sensi- tive women, when the head is just ready to emerge, the sensa- tion caused by its pressure calls forth such violent, involuntary efforts, that it must pass, though all opposing structures should be driven before it. Chloroform saves all this. Under its in- fluence we have observed the head to be retained for some mo- ments, even within the embrace of the distended labia, the pa- tient being wholly unconscious of its presence there. In order, however, to secure such results, it is necessary that the effects of the chloroform be deepened toward the close of labor to al- most complete anaesthesia. This may be done, we think, in all suitable cases, with almost entire immunity from danger. Whether there be any homoeopathic remedy capable of miti- gating the excessive pains of labor, I am not, from any experi- ence of my own, able to decide. I know it is claimed that there are such, but whether they succeed in the hour of trial is quite another matter. If the severity of the pains arise from a dis- eased condition, then it is probable such remedies may be found. If, for instance, as M. Beau professes to believe, the pains of labor are, for the most part, a lumbo-abdominal neuralgia, I would expect some relief from the arsenite of copper. Yet we must not confound the pain with the action of the uterus. They usually co-exist, but are not the same thing—they are separable. It is possible for the most energetic action to go on, while there is comparatively little pain—the remedy there- fore which may control the pain does not necessarily diminish the violent contractions of the womb. The preventive measures we have already detailed apply also to those cases where there is danger of laceration from other causes, which we enumerated at the outsetting, but have not ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 199 considered seriatim in the course of this chapter. If the head, from malformation, be directed backward upon the perineum, assistance may be afforded by proper manipulation tending to carry it forward toward the outlet. Again to prevent the accident from sudden extension of the limbs when the head is about to emerge, an assistant should take hold of and firmly support and elevate the upper knee (the right), and in the absence of such aid, a large roll of some- thing light and soft should be placed between the limbs. But supposing after all our precautions, or before our arrival at the bedside of the patient, laceration may have taken place, what is then to be done ? This is certainly a most important question, and before answering it, we must take into account the extent of the injury. Prof. Tarnier, the anuotator of Cazeaux, divides these lacer- ations into three grades, incomplete, central and complete. " Thej* are incomplete, when beginning from the vulva they do not involve the sphincter of the anus ; central when the rupture occurs between the vulva and anus, without involving either of these openings; complete when the vulva, perineum and sphincter ani are torn, together with the recto-vaginal partition to a greater or less height." Prof. Tarnier maintains that in both the incomplete and central varieties of the accident, it is best to abstain from all operations as not only unnecessary, but possibly injurious. Dr. Madden, of the Dublin Lying-in Hos- pital, advises quilled sutures of silver wire or carbolized catgut to be introduced immediately after the accident has occurred, and to be removed in forty-eight hours. This is his practice in all forms of serious rupture. He insists much upon the early removal of the sutures, and believes that adhesion has generally taken place in that short time. According to Prof. Tarnier even complete laceration will often heal without oper- ation, but in such cases there can be no doubt but Dr. Madden's course is the most prudent, unless the condition of the patient's health should make it advisable to postpone the operation. When the sphincter ani is not involved, and we decide to omit the sutures, the knees should be kept in close proximity either by the will of the patient or secured by a bandage. A small 200 PRACTICAL MIDWIFERY. compress saturated with a solution of tincture of calendula, or carbolic acid, when the discharges smell badly, should be firmly applied to the wound, and retained by means of a T bandage, care being taken that the compress should not be so large as to wedge the parts asunder. The most strict regard to cleanliness should be observed. The patient should not be allowed to walk about till the healing process is completed, or nearly so. There is reason to believe that this accident often occurs to considerable extent, when it is either not detected by the at- tendant, or if known to exist the patient is not informed. These cases, if such there be, recover spontaneously more or less perfectly. When attending a case of labor, if the uterine action have been very intense, the perineum rigid, the head somewhat sud- denly extruded, and shortly after the child is born the patient manifests symptoms of severe shock, such as an extremely quick and feeble pulse, dyspnoea, a sensation of sinking, etc., there is reason to apprehend that an accident of this kind may have happened, even though it may not before have been de- tected. Careful examination should at once be instituted, and if rupture have taken place, such measures should be promptly adopted as the nature and extent of the injury may seem to demand. In the first place we should resort to means to relieve the patient from the shock of injury. If there be haemorrhage from the wound or womb, we should use means to arrest it as speedily as possible. For uterine post-partum haemorrhage we have as remedies, Apocynum cannabinum, Trillium pendulum, Erigeron and others whose special indications should be care- fully recalled. For that occurring from the laceration, the best remedy will be to bring the edges of the wound together, and secure them in contact by a compress, retained by a suitable bandage. The compress should not cover the outlet, otherwise the usual dis- charge from the womb will be prevented and accumulation take place. For the extreme prostration, camphor may be given by olfaction, or if it be very alarming, stimulants, as wine or brandy, may be administered, being careful to avoid excess- ive reaction. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 201 TOXJEMIC PUERPERAL DISEASE. Within this term we include all those forms of puerperal disease which, in the present state of our knowledge, we re- gard as arising from an agent acting upon and changing the character of the blood of the patient; whether this agent may have had its origin in septic matter generated within her tis- sues or be derived from without; and, in the latter case, with- out regard to its particular source. During labor there are doubtless few, if any, cases in which the parts concerned entirely escape injury. They are subject to contusions, abrasions and lacerations, some or all of which would doubtless very generally be found if the necessary ex- aminations were made. They sometimes, as we all know, take place to a very serious extent. These injuries are liable to be followed in the puerperal woman, as in others, by traumatic inflammation. Under favorable circumstances, however, this may pursue a mild course and reach a fortunate termination, differing in no essential particular from that arising from wounds in general. As this affection does not fall within the limits of the subject which will now engage our attention, we will take no further notice of it. We will only here remark that all abrasions and lacerations—all breach of continuity of surface whatever, afford an open door for the entrance of septic matter, which may be brought into contact with them, until they are protected by the reparative process. But the course of inflammation occurring in the puerperal woman is, unfortunately, not uniformly favorable. It is not always followed by speedy subsidence and healthy repair of the injury. It frequently assumes a much more serious char- acter. From the prostrated, adynamic condition, which often follows labor, sometimes even precedes it, inflammation, result- ing from injury, may assume a low grade, tending to sloughing and the discharge of a putrid, sanious fluid (itself, perhaps, the result of a previously acting blood poison), which, by absorp- tion, is capable of still further contaminating the blood and thus giving rise to all the alarming phenomena and too often fatal consequences of toxaemic disease. Nor is this the only 202 PRACTICAL MIDWIFERY. source of blood poison originating within the organs of the woman. On the contrary, blood clots retained within the womb or vagina, portions of the placenta, or even the lochial discharge, when putrid, may act in a similar manner. There seem to be two factors necessary to the production of toxaemic puerperal disease. The one is found in the peculiar susceptibility of the puerperal woman;—the other in some agent capable of acting, at least in her present condition, as a blood poison. Wherein this susceptibility consists, has by no means been demonstrated to the satisfaction of all. Some have supposed that it has its origin simply in the prostration succeeding labor. If, by prostration, be meant merely the re- duction of nervous or muscular power which follows all ordi- nary cases of labor, the theory is inadequate to an explanation of the phenomenon. But may we not suppose that when any cause, of whatever nature, so reduces the vital forces so that the catalytic action concerned in carrying on the processes of life is, for the time being, held in abeyance, that of the mor- bific agent, namely the hlood poison, gains the ascendency and developes the disease in question, especially as the condition of the blood, peculiar to pregnancy and the puerperal state, abounding in albumen, may render it more liable to its action. It is probably this latter circumstance which so modifies the operation of the morbific agent as to produce what we recog- nize as puerperal toxaemic disease. Some maintain that it is through breaches of continuity in the tissues of the woman alone that septic poison can be ad- mitted, at least in sufficient amount to produce disease. But as blood poison in other cases can gain admission by other avenues, so as to produce its full effect, perhaps we are not as yet prepared to deny the possibility of this happening in the case of the parturient woman. When the vital powers of puerperal women remain in suffi- cient vigor after labor to rapidly repair injuries sustained dur- ing that process, before or by the time septic matter is formed, an efficient barrier is set up against it, and absorption, to any considerable extent, at least, is prevented. In the opposite state of things, however, septic matter may be taken up, but ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 203 even then, unless in overpowering quantity, serious disease may not result. The powers of the organism may still exist in suf- ficient force to resist and ultimately expel the blood poison. i But if, through the action of some one or more of the ordinary debilitating causes, including mental emotions, atmospheric and telluric influences, etc., the activity of the catalytic force concerned in carrying on the vital processes of the system, be so reduced that it is no longer capable of holding in check the similar force which the blood-poison tends to exert, then the latter becomes predominant and disease triumphs over healthy vitality, the blood is'-touched corruptibly," and all the phe- nomena of toxaemic disease are developed. Billroth, I believe, claims to have demonstrated that absorp- tion cannot be effected by wounds, except in a recent state, or when the fluid to be absorbed has the power of dissolving their protective covering, so as to present a fresh surface. Be this as it may, it is certain that absorption to the extent of producing serious disease does not always take place when putrid matter is contained within the genital organs of the woman. We often meet with cases where blood-clots are expelled from the womb in a state of decomposition, as evidenced by their odor, and when the lochia is highly offensive, and yet there is but little, if any, departure from normal convalescence. Even re- tained placenta is sometimes thrown off in a very putrid con- dition, and yet the patient afterwards makes a reasonably good recovery. But when the placenta is for some time retained, or when bloodclots undergo putrefaction within the womb, toxaemia, in some of its forms, not unfrequently results. This is especially liable to happen when exhausting haemorrhage has taken place, as it often does when any portion of the placenta remains un- detached within the womb. The danger of this result is here increased by twofold causes. In the first place, the vessels being emptied of their normal contents, fluids within reach of the absorbents are greedily taken up. At the same time the powers of the system to resist the deleterious action of morbific agents are greatly depressed, through the debilitating effects upon vital action by the loss of blood. 204 PRACTICAL MIDWIFERY. But the agent employed in the production of toxaemia does not always originate within the patient herself. On the con- trary it is often derived from other sources. It may be intro- duced into her organism by contact, through the physician or nurse. When the attendant has had in charge a patient labor- ing under this disease, especially if he have had occasion to make vaginal examinations, he may readily convey the poison to another by his hands. It would seem that this effect may be produced where the utmost care has been taken to cleanse the hands, and even to throw off the clothes worn when in the presence of a patient suffering from toxaemic disease. The case of Dr. Rutter, of Philadelphia, is often cited, whose practice, notwithstanding the utmost precautions on his part, was so constantly followed by the disease, that he retired for weeks into the country, but, upon his return, met with a repetition of the same disasters.* The contagion of certain other diseases is believed by many to be capable of producing puerperal toxaemia in the lying-in woman. Such is that of malignant erysipelas, typhus and ty- phoid fevers. So frequently is what is usually termed child- bed fever encountered during an epidemic of erysipelas, that they are by some considered essentially the same disease, only modified by different circumstances. Such conclusion we think hardly sustained by general observation. It would seem that puerperal women may have attacks of genuine erysipelas, in which all the distinctive symptoms of that disease are fully de- veloped, unaccompanied by the peculiar symptoms of puerperal toxaemia, and without the fatality of that disease. The same may be said of scarlet fever. It would seem, nevertheless, pretty certain that the conta- gious emanations, whatever they may be, from malignant ery- sipelas, are capable of producing the disease under considera- tion, in those who may be in a condition favorable to that re- sult. Indeed, the disease known as malignant erysipelas, may be but a form of what is termed pyaemia, and which is but a * I have seen it stated that Dr. Rutter suffered from ozoena, and it was surmised that this might have been the source of the trouble. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 205 modification of toxaemic disease, and therefore more nearly re- lated to puerperal toxaemia than to ordinary erysipelas. It cannot be denied that the same morbific agent may pro- duce different morbid phenomena in different individuals, ac- cording to their peculiar susceptibilities. Several persons, for instance, are caught out in a drenching shower. Their suscep- tibilities to disease are different, we are unable to say why or wherein this difference consists. One perhaps suffers, in conse- qence, from acute bronchitis, one from pneumonia, one from diarrhoea, another from dysentery, another from neuralgia, another from rheumatism, and some perhaps escape uninjured. Here the morbific agent is the same, the subjects apparently similar, but the results very different. We observe something like this also in the proving of our drugs, in the different symptoms evolved by different provers. An epidemic of puerperal fever lately occurring in the Phila- delphia Hospital has been reported, which could not be attri- buted to the contagion of erysipelas, for no case of that disease had for some time previous been in any of the wards, but which is said to have manifested the tendency to produce ery- sipelas in those not liable to puerperal fever. It is from this apparent relationship between the two diseases, namely, erysip- elas and puerperal toxaemia, that, as before intimated, some have supposed the latter to be merely a modified form of the former. This relationship has, however, been strenuously de- nied by others ; and it is but proper to say that preconceived theories may have led to incorrect observations or false deduc- tions. The truth probably is, that any morbific agent capable of acting as a blood-poison, may give rise to the phenomena constituting puerperal toxaemia, in one whose peculiar condi- tion, or, so to speak, present temporary idiosyncrasy, disposes her to take on that kind of diseased action. The poison of typhus and typhoid fevers have also been named amongst the causes capable of producing the disease of which we are now speaking. If so, it must be owing to the peculiar susceptibility of the patient. Within the last eighteen months I attended a well marked and severe case of typhoid fever in a man whose wife, when he was at the worst stage of 206 PRACTICAL MIDWIFERY. his sickness, gave birth to a child in the same room in which he lay, and remained there during her confinement. The room was by no means well ventilated, and I feared for the result. She was, however, in an unusually short time out of bed, and engaged again in her attentions to her husband. Her conva. lescence was perfect, and so far as I know, without a single un- toward symptom. Some weeks afterwards she exhibited, in a very marked degree, the usual precursory symptoms of typhoid fever, and I felt almost certain she would go down with that disease. I gave her immediately Baptisia tine, as a prophylac- tic, and to my surprise, in the course of a very few days she was entirely well. In this case we may believe that the im- pression was made upon her system by the poison, either during the puerperal state or before her confinement, for when she left her bed her husband was already convalescent. The precise nature of the change wrought in the circulating fluid in puerperal toxaemia, through the agency of the blood poison, has not yet, so far as I know, been precisely deter- mined. " In many respects," says Dr. Meadows, " it resembles that found in severe cases of typhoid fever. There is a de- crease in the number of red blood cells, and an increase in the white cells, the fibrine is also increased, at least at first, but the solids generally are diminished. The extractive matter is in- creased, as is also the amount of lactic acid and fat. Moreover, there are also traces of bile-pigment, and Mr. Moore says that he discovered a ' black precipitate ' in the blood of a person who had died of this disease, and that there was ' a peculiarly offen- sive odor arising from it.' " The foregoing is probably but an imperfect account of the change which takes place in the blood, under the influence of the poison, rendering it not only unfit for the support of life, but causing it to produce destruction of tissue, or at least to suffer it to take place, almost in any part of the organism to which it circulates, and even in some instances to extinguish the vital spark before any appreciable organic lesion has supervened. Nor can we suppose that it is merely the quantity of poison absorbed by the blood that, by its admixture, renders that fluid unfit to perform its normal functions. The amount primarily ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 207 absorbed is often no doubt exceedingly small. But in these cases " a little leaven leaveneth the whole lump." The precise manner in which this is effected has not as yet been demon- strated to the satisfaction of all. Some have supposed the process to be similar to, if not identical with fermentation. Hence they have been encouraged to use as antidotes to blood- poisoning, those agents which are known to prevent or arrest that process. For instance, sulphurous acid prevents fermen- tation, at least for a considerable time, in freshly prepared cider. Hence the sulphites have been used to prevent or arrest the ravages of blood poison. But whatever hopes artificial ex- periments may have held out, these have been disappointed so far as I know, when these agents have been employed in clinical cases. It is a well established fact in chemistry that certain sub- stances, by their mere presence, disturb the stability of com- pounds, and cause their elements to enter into new combinations, while these substances themselves undergo no change. " When a mixture of oxygen and hydrogen is exposed to the action of spongy platinum, the gases combine to form water; when alco- hol is dropped on platinum black, under exposure to air, the alcohol is oxydated and converted into acetic acid." In these cases the platinum itself undergoes no change, but determines changes in the condition of the substances with which it is in contact. This peculiar action or modification of force, as yet unexplained, has been called Catalysis, from the Greek words, xura downwards, and i™ I loosen. As yet we employ this term as we do x or y in algebra, to denote an unknown quantity. But whatever may be the nature of this action, it seems to me probable that that of the poison upon the blood may be similar to, if not identical with it; that through its catalytic power, it may cause such changes in the constitution of the blood that it remains no longer the vital fluid, conveying life and health and nutriment to every part, but becomes a lethal agent, set- ting up disease even in the very channels through which it cir- culates, and producing disorganizations and death in all the parts to which it is conveyed, and which, in its healthy state, it had built up and supported. 208 PRACTICAL MIDWIFERY. If this view be correct, we think it furnishes a satisfactory explanation of the astounding fact that toxaemic puerperal dis- ease may originate from contact of the hands of the physician with the genital organs of the patient, even when the former are supposed to have been thoroughly cleansed. A single atom of septic matter may so act upon the secretions as to convert them into poison to be taken up by the absorbents, and ulti- mately corrupt the whole mass of blood. Strange as this may seem, it is scarcely more so than that a single spark carelessly dropped in the dried grass of the prairie, should kindle a fire capable of spreading over and devastating vast regions of country. Without regard to the source whence the toxaemic poison may be derived, the resulting disease differs greatly in different subjects, in its symptoms, course and pathological lesions. In one case, the uterus will appear to have been almost exclu- sively the'seat of diseased action; in others, and more fre- quently it will be found to have invaded other organs, as the peritoneum, Fallopian tubes, broad ligaments and ovaries. Distant organs, as the lungs and liver, may be and not unfre- quently are involved in the morbid process. All this goes to demonstrate the all-pervading nature of the poison, whose dele- terious action may be traced wherever the contaminated fluid circulates. The pathological lesions differ not only in their lo- cality, but also in their kind. In one case may be found only the vestiges apparently of ordinary inflammation, while in another will be detected purulent deposits. From some difference in the symptoms of the disease in different cases during its course, and in pathological lesions detected after death, some writers have supposed several distinct toxaemic puerperal diseases to exist, to which the terms septicaemia, pyaemia and puerperal fever have been respectively applied. In the present state of our knowledge, however, it seems to me probable that these varieties are mainly owing to differences of idiosyncrasy, for the time being, in the patient, or other inappreciable circum- stances, which modify the result. The opposite opinion has not, as yet at least, been demonstrated with anything like sat- isfactory clearness, as it is yet as far as ever from meeting with ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 209 general acceptance. We have, therefore, as announced at the commencement of this chapter, preferred to treat of this Protean disease under a generic term, including all the varieties, rather than as several distinct affections. This is the more allowable, because in Homoeopathic practice we select the remedy accord- ing to the symptoms which present themselves, and not accord- ing to any arbitrary nosological classification or name, nor yet according to any supposed local pathological lesions which may exist, but which generally cannot be demonstrated till remedial measures are no longer of any avail. As the sources of toxaemic disease are so varied, and the pa- thological lesions discovered after death so different, it is rea- sonable to suppose that the symptoms which announce its ap- proach and characterize its course will be equally diverse. It will be well, therefore, before we proceed to speak of treatment, to give such a general view of these, as will at least enable the practitioner to anticipate the coming storm, or when it has ac- tually arrived, to appreciate its extent, violence and probable results. Of the various lesions found after death, the following pro- portions are given by Dr. Simpson: " Of 500 fatal cases of puer- peral fever, recent inflammatory changes were noted in the interior of the uterus in 372 cases; in the veins of the uterus, 349 ; in the peritoneum, 321; in the lungs and pleura, 202; in the lymphatics, 129; in the ovaries, 78 ; in the cellular tissues and muscles, 46 ; in veins other than uterine, 40; in the brain and its membranes, 23 ; in the spleen, 21; in the vagina and pudenda, 19 ; in the bones and joints, 18 ; in the kidneys, 17; in the stomach and bowels, 13; in the pericardium, 12; in the mamma, 7 ; in the Fallopian tubes, 5 ; in the bladder, 4; in the parotid gland and heart substance, 3^each; in the endo- cardium, 2; and in the iris, tonsils, larynx and trachea, 1 each." In cases in which the peritoneum is first or mainly invaded in the onset of the disease, the patient complains of unusual soreness in the lower abdominal region, and tenderness under pressure. This is usually accompanied by pain more or less intense, and of a continuous character. This latter circum- 14 210 PRACTICAL MIDWIFERY. stance will serve to distinguish from the after pains, which are intermittent. Those of " false peritonitis " are perhaps gene- rally still more acute, and are ameliorated by occupying the patient's attention. These pains go on, however, increasing in severity, and are greatly aggravated by motion and by tension of the abdominal muscles. To avoid the latter the patient as- sumes the dorsal position, with the limbs drawn up. There is said to be a peculiar pain about the umbilicus, with a sensation as if it were drawn inwards. General constitutional disturb- ance soon follows ; there are distinct rigors, greatly increased pulse, varying from 120 to 160 beats per minute, small and wiry. The skin becomes hot and dry, the breathing short, the abdominal*muscles taking but little part in the process of res- piration. The tongue becomes dry and coated, red at the tip, but brown further back. The abdomen is often tympanitic, and as the disease advances, swollen from effusion of fluid "within the peritoneal sac. There are nausea and vomiting of mucus or bile, and sometimes of a dark fluid resembling coffee grounds, and even of fcecal matter. The lochia may be unaf- fected, diminished, or even increased. The bowels are some- times constipated, or there may be even profuse diarrhoea. The urine is thick, scanty, and high colored. In fatal cases, low muttering delirium sometimes sets in, the expression of the features is anxious, the pulse becomes still more frequent and sometimes scarcely perceptible, till death, from exhaustion, closes the scene. When the uterus is first involved, that organ is found to be enlarged and extremely tender under pressure. The symptoms are said usually to set in shortly after delivery, but we believe we remember one case wherein they did not at least become strongly pronounced till several days afterwards. There are severe rigors, accompanied by intense headache, general con- stitutional disturbance of a highly inflammatory character. Lochia usually suppressed. The inflammatory action often extends to the peritoneum, and the symptoms become modified accordingly. When the uterine appendages are primarily involved, the pain and tenderness will be more circumscribed, and its seat will indicate the particular organ invaded. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 211 When the veins of the uterus are inflamed, constituting what is termed uterine phlebitis, the onset is sudden and usually oc- curs a few hours after delivery. Here, again, there are rigors, followed by headache, suppression of the lochia and milk, fever, thirst, dry brown tongue, vomiting, etc The foregoing description will furnish a general outline of the disease. Different cases will be found to vary considerably in their symptoms, and different epidemics so much so, as almost to seem to be distinct diseases. This variation may depend upon modifications of the morbific agent acting as a blood poison, or upon some distinctive peculiarity inherent in differ- ent patients. An epidemic recently occurred in a Philadelphia hospital, in which a remarkable indifference on the part of the patients as to their condition and prospects characterized the disease. But whatever shades of difference we may observe, there will still be manifest a general family resemblance that will enable us to decide as to the real nature of the case before us. We must not forget, however, that the protean form of the disease itself, admonishes us of the necessity of individualizing each particular case, as it is presented to us; that we must not ex- pect to find any specific of universal applicability, nor even certainly suited to any considerable number of consecutive cases. Still, however, in any given epidemic, a remedy which we find efficacious in the outsetting of the disease, is likely to prove generally useful throughout its course. Before speaking of the details of treatment which is too often unavailing in this terrible disease, we will endeavor to point out such measures as are generally successful in its pre- vention. Prophylaxis, where practicable, is always better than cure, and especially so in case of the malady which now en- gages our attention, which too often has progressed so far, or assumed such a degree of virulence before we are called in, as to baffle all our efforts. We have already intimated that liability to this disease pro- bably consists in depressed vitality. If this view be correct, then an important prophylactic measure will be to see after our patient before her confinement, and adopt such measures, if ne- 212 PRACTICAL MIDWIFERY. cessary, as will bring her up to that period in the best possible state of health. She should be in a condition which we term vigorous, all the vital functions actively performed, and even the mind in the best possible tone, active and cheerful. This object will be more or less attainable in different cases, and alas 1 in some not attainable at all. I need not attempt to enu- merate the various means adapted to the object just stated. They will be suggested to the intelligent physician by the va- rious circumstances of his patients, and valuable hints, I trust, be found in this and other works upon midwifery. Before confinement, the physician should at least assist and advise in the selection of the lying-in room, so that as far as possible it may be well adapted to ventilation, proper and uni- form temperature, etc. As we have elsewhere advised, it will be well, as a general practice, where tedious labor is antici- pated from rigidity of the soft structures, to require the patient to take Actea racemosa or Macrotin, for some days before labor, or such other remedies as he may think indicated, for the purpose of relaxation. When labor comes on it should be conducted upon principles already laid down, so as to avoid, as far as possible, all unneces- sary extreme suffering, abrasions, lacerations, contusions and mechanical injuries of every kind. Extreme exhaustion should by all means be avoided by timely resort to such means of assistance as the principles of our art require. After delivery, firm and persistent contraction of the womb should be secured, so as to expel blood-clots, or leave no room for their accumula- tion. I have thought Ergot, given in small doses in the course of labor, promoted this object. Dr. Goodell advises placing the patient frequently over the chamber-vessel, after delivery, as an efficient means for the expulsion of clots, to which I have elsewhere adverted. When the patient is properly put to bed after delivery, as be- fore advised, a few drops of the tincture of Arnica, diffused in a tumbler of water, should be administered in teaspoonful doses, once in two hours, and if contusions are manifest externally, a stronger preparation should be applied. Dr. Zwingenbero-, translated by Dr. Lilienthal, in the Hahnemannian Monthly, for ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 213 July, 1875, asserts that it is his uniform practice to prescribe Arnica internally and externally, to women immediately after delivery, and since he has adopted this mode of treatment, says he has met with no cases of puerperal fever. The translator avers that this has also been his experience, and I would add, it has been mine. The Arnica probably tends to this result by accelerating the healing of wounded structures before septic matter is formed, and thus presenting a barrier to its absorp- tion when it is produced, and probably too, as a powerful homoeopathic antiseptic. After what we have already said, it would seem hardly neces- sary to warn the practitioner to avoid communicating the dis- ease through any careless neglect of precautions on his part. If he have been so unfortunate as to have had a case of the dis- ease, especially if his duties have required him to bring his hands in contact with the person, and more particularly with the discharges of the patient, he had better, if possible, for the time being turn over his obstetric practice to another. The same precaution would be proper if he have had recently a bad case of erysipelas. But if this cannot be done, the utmost care should be taken to disinfect his hands, his person and his clothing, or rather to entirely change the latter. Dr. Wynn Williams speaks very highly of iodine as a disinfecting agent, in reference to septicaemia—he uses it for cleansing the hands with great confidence—for disinfecting the clothing—for wash- ing out the genital organs, etc. He affirms he has never had a case of puerperal fever since adopting its use, which he has ex- tended over a space of twenty years. Possibly bromine would be equally or more efficacious. Toxaemic puerperal disease frequently occurs, especially in large cities, in epidemic form. Of the nature of the epidemic influence we have no certain knowledge. It is truly " the pes- tilence that walketh in darkness." Of the part it plays in the production of the disease, we are equally ignorant. Possibly, after all, it may act only as a predisposing cause, by reducing the vital force below the standard necessary successfully to re- sist the encroachment of the blood-poison ; the latter, derived from some of the ordinary sources, serving, under these favor- 214 PRACTICAL MIDWIFERY. ing circumstances, as the proximate or exciting cause of the disease. If this be so, although direct prophylactic measures may be unavailing against the action of the epidemic influence itself, those we have already proposed may still, to some ex- tent, prevent its ultimate effects. But a most important question here presents itself—can we by the specific action of a remedy administered, forestall that of the blood-poison, and thereby prevent this terrible disease from becoming developed ? Have we or have we not, medicinal an- tidotes to the morbific agent which in this as in other zymotic diseases, so often works destruction in despite of all our reme- dial measures ? It has long seemed to me that a vast field of research, in reference to this class of diseases, lies before us, holding out the most tempting rewards to the successful ex- plorer. It is plain to every one that when the blood "becomes so con- taminated, so changed in its constitution and character as no longer to be adequate to the support of life, death is inevitable. To forestall and prevent this consummation should therefore be the great object of the physician, if he would save life. So far as we know, however, we cannot arrest this lethal process by throwing into the circulation an agent which is capable of seizing and destroying germs of blood poison, or of causing the elimination of the altered blood corpuscles, while it leaves be- hind the still unchanged portion to perform its function in sus- taining life. Such power of selection in any medicinal agent is not to be expected. If we would therefore accomplish the object above stated, we must look for something that will act upon an entirely different principle. Far-sighted men seem to discern a dawning light in this di- rection. At a meeting of the London Obstetrical Society, held April 7th, 1875, Dr. Richardson, in concluding his remarks, holds the following noble and suggestive language : " My im- pression is," says he, " that in the course of time we shall ar- rive at the discovery of certain agents which will immediately stop the action of septicaemous poison by their direct physical effect upon the blood, and their influence in holding oxygen in combination with the blood. I have recently referred in ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 215 another society to the effect of quinine in this respect, but that is a bungling crude method of dealing with an agent that will act in such proportions as the ten thousandth or the hundred thousandth part of a grain, so as to produce disturbance within the organism. So, dealing with this matter of antiseptics, I should say that if antiseptics, as they are called, that is bodies which prevent putrefaction, are advanced as a means of curing these particular diseases arising from septicaemous poisons, their action is not because they are antiseptics (because other agents which are not antiseptics possess a similar property), but for the simple reason that they act upon a given principle, and many of them act altogether in accord physically, and I might almost add chemically in neutralizing the specific action of these poisonous agents; I mean antiseptics do not act by de- stroying germs or organic forms, but they act definitely by in- terfering with the poisonous action of the septicaemous material which produces the fatal disease. I predict that in ten years hence, in this society, we shall see a means of preventing these diseases from septicaemous poisonings as clearly as we now see the means of producing them by the introduction of these poisons in the form of inoculated matter in small-pox by vaccination." Looking back, we find in the Medical Examiner for Novem- ber, 1848, a reference to quinine as a prophylactic of puerperal fever. Several experiments with that drug are given, from which it would seem that the opinion advanced by the writer is not at least altogether unfounded. Dr. Goodell, in detailing his treatment of lying-in patients, which he claims to have been unusually successful, and remarkable for its exemption from childbed fever, when that disease was prevailing around him, speaks prominently of using quinine as a prophylactic, but explains its efficacy upon a principle different from that which I have in view and wish to elucidate. Recent observatons made upon the action of quinine, would lead us, I think, to the conclusion that it produces changes in the constitution of the blood. The disease resulting from the protracted use of this drug, usually called cinchonism, seems to be in reality a blood disease, and has, as an essential element, 216 PRACTICAL MIDWIFERY. an altered condition of that fluid. This effect, too, appears to be produced independent of any change which the quinine itself undergoes ; for the latter seems to be eliminated by the emunctories, unchanged and in about the same quantity that had been taken. Now, if these statements be correct, it would appear that whatever change the quinine may effect upon the blood, is effected not by adding any portion or element of itself to that fluid, nor by abstracting any principle by way of com- bination with itself from it, but simply by catalysis or action of presence, through which force its constitution is altered, its elements more or less extensively entering into new arrange- ments. Now, if septicaemous poisons act upon the blood by catalysis, as we have attempted to show is probably their mode of action, then there may be, and probably is, a similarity between the latter and that of quinine, and consequently the one is anti- dotal of and Homoeopathic to the other. If we be thus far correct, we would go still further, and say that according to the principle just stated, the whole class of remedies which act by catalysis upon the blood lie before us from which we may hopefully select for the prevention and even cure of toxaemic puerperal disease, as well as zymotic dis- eases generally. Similarity of catalytic action between the remedy and the morbific agent is equivalent to antagonism; the one suspends or sets aside the action of the other. Probably, too, the greater the similarity in the particular mode of the catalytic action of the remedy and the morbific agent, the more certainly effectual will the remedy be. Further, too, it may possibly be found that high attenuations of the remedy > if well selected, will most certainly arrest and hold in check the changes in the blood set up by the lethal agent, which acts often in a highly attenuated form. Of this, however, I do not speak from any experience, but simply the analogy of the case. The power of the catalytic force of one agent to arrest or suspend that of another, is recognized by Prof. Dalton in his work on Human Physiology. In answering the question " How it is that the gastric juice which digests so readily all albumi- nous substances should not destroy the walls of the stomach itself, ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 217 which are composed of similar material," he gives the following reply. " The true explanation, however, we believe, lies in this— that the process of digestion is not a simple solution, but a catalytic transformation of the elementary substances, produced by contact with the pepsine of the gastric juice. We know that all the organic substances in the living tissues are con- stantly undergoing, in the process of nutrition, a series of cata- lytic changes, which are characteristic of the vital operations, and which are determined by the organized materials with which they are in contact, and by all the other conditions present in the living organism. These changes therefore of nutrition, of secretion, etc., necessarily exclude for the time all other catalyses, and take the precedence of them. In the same way, any dead organic matter exposed to warmth, air and moist- ure, putrefies, but if immersed in gastric juice, at the same tem- perature, the putrefactive changes are stopped or altogether prevented, because the catalytic actions, excited by the gastric juice, take precedence of those which constitute putrefaction. For a similar reason, the organic ingredients of the gastric juice, which acts readily on dead animal matter, has no effect on the living tissues of the stomach, because they are already subject to other catalytic influences, which exclude those of digestion as well as those of putrefaction." I fondly hope that further researches upon the action of reme- dies by catalysis upon the blood, will enable us to forestall and prevent the developement of the dreaded disease which now engages our attention. Every woman in child-bed we may re- gard as possibly liable to an attack, and especially so if cases have recently occurred in the same vicinity. We have thus, so to speak, the " probabilities " signalled to us in advance, that we may look out for, and provide against the coming storm. Nor is it only as prophylactic agents I anticipate much from the class of remedies known as antiseptics, which will probably generally be found to act by catalysis upon the blood. They will, most likely, constitute our best curative agents, when the disease is developed, by arresting the process which rapidly tends to render the blood unfit for the support of life. Short of this point and before irreparable lesions have taken place, 218 PRACTICAL MIDWIFERY. they will doubtless often save the patient—beyond it, no reme- dial measures of course will avail. But while it is our first duty to employ all suitable means to prevent the accession of toxaemic puerperal disease, indeed all puerperal disease, it is no less incumbent upon us closely to watch the patient, from day to day, so that should an attack unfortunately occur, we may have an opportunity of treating it in its earliest stage. To this end we should not only visit the patient as often as may be necessary, but strictly enjoin upon her to inform us immediately when any symptoms arise different from those of ordinary convalescence. Lest we should seem to require the practitioner to enter into this fearful contest in armor to which he is not accustomed, before closing we will endeavor to give him as well, the treat- ment which has at least the sanction of some authority—how generally successful we are unable to say. When the attack sets in with highly inflammatory symp- toms, such as high fever following a severe chill, full bounding pulse, etc., Aconite should be given in repeated doses, and of sufficient strength to allay the fever and reduce the pulse. A few drops of the strong tincture in a tumbler of water, a tea- spoonful every hour, or for awhile even more frequently, till some improvement in these symptoms takes place, or another remedy seems demanded. Some advise the high attenuations of Aconite, a dose every half hour or fifteen minutes, till im- provement, then suspend its use. In some instances Veratrum viride may be preferable; the symptoms, of course, must deter- mine the choice. If the disease be ushered in by a severe chill, with disposi- tion to its periodical recurrence, I would advise Sulphate of quinine, 1st dec, 1 gr., to be repeated, at least for some time, every hour, or even at shorter intervals. When there is severe congestive pain in the head, especially if accompanied by a vio- lent bearing down sensation in the uterine region, Belladonna should be given. If there be evidence of rapid change taking place in the blood, from the catalytic force of the blood poison, Arsen. a., 3d dec. should be given and persevered in. This condition may be recognized by the great tendency to prostra- ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 219 tion, fetor of the breath, sordes upon the teeth, disposition to passive haemorrhage, etc. When there is extreme prostration, muttering delirium, grasping at flocks, involuntary stools, etc, Chin, ars., 1st cent., is recommended by Dr. Baehr. In this condi- tion Crotalus may* also be thought of—also Muriatic ac. Rhus tox. may be useful where there is a disposition to epistaxis, pains characteristic of the drug, and a low typhoid condition. Some- times it may be well to compare the symptoms of Ergot with those of the case before us. When we are called to see the case early, before the action of the blood poison has gained much headway, I would have considerable confidence in Bap- tisia, which might, if thought best, be alternated with some other remedy, which we should think more specifically indi- cated. Indeed I would strongly advise Baptisia to be given from the beginning, in doses equivalent to one drop of the mother tincture, at intervals, such as the urgency of the case would seem to demand. Baptisia is more specially indicated when the uterine discharges are foetid. Where there is consi- derable tympanitis, eructations, fetid diarrhoea, diminished se- cretion of urine, tendency to passive haemorrhage, especially from the bowels, Terebinthina will often be found an excellent remedy. The " spirits" of turpentine may be given upon sugar or in emulsion, in doses equivalent to one, two or three drop doses, at first every hour or two hours, afterward length- ening intervals according to the usual conditions prescribed. The same remedy may at the same time be externally applied to the abdominal region by means of stupes. It has been stated in the Scientific American, that Drs. Berg- man and Schmiedeberg have claimed that they have succeeded in isolating the poison generated by the putrefactive process of animal matter, in the form of what they denominate the sul- phate of sepsin. If this be so, this article will probably be found of great value in treating the more malignant forms of puerperal toxaemic disease. So hopeful am I of the success of those remedies that act directly upon the blood, in the prevention and cure of this dreadful disease, that I would strongly recommend the perse- vering use of not only those already named, but of others of the 220 PRACTICAL MIDWIFERY. same class; not indeed given indiscriminately, but carefully selected as may be, with our present imperfect knowledge of their true pathogenetic effects. Nor would I administer them exclusively by the mouth; but when there was reason to be- lieve that the absorbent powers of the alimentary canal were impaired, I would give them by inhalation, and even by sub- cutaneous injection. So general is the outlook of thoughtful men in the direction I have above indicated, for a more reliable means of treating puerperal and zymotic diseases generally, that I cannot think their hopes will prove altogether fallacious. No one, however, has, as yet, so far as I have known, fully comprehended the great principle—the homoeopathic principle involved; and if that which we have above stated be the correct one, we are not as yet in possession of the exact kind of pathogenetic and patho- logical knowledge necessary to apply it always with the great- est possible certainty and success. But let us, by means of the microscope and chemical analysis, ascertain the precise nature of the changes wrought upon the blood by any given disease, and also of those produced by our remedies, and if this can be done, we have then, in military phrase, the key to the whole position. We do not, of course, mean to say that other symp- toms, both subjective and objective may not be called in to our aid to the same end. PUERPERAL CONVULSIONS. This term should, in strict propriety, be used to denote such forms of convulsions only, in the production of which the puer- peral state is an essential factor. Under it, however, are gene- rally included by writers upon obstetrics, all convulsions which befall the parturient woman, shortly before, during, or imme- diately after labor, however these may vary in their symptoms or differ as to the causes from which they arise. Using the term as a generic one, they distinguish the different forms by specific names. Hence we have Hysterical Puerperal Convul- sions, Apoplectic Puerperal Convulsions, and Epileptic Puer- peral Convulsions, meaning by the last Eclampsia or Puerperal Convulsions, properly so called. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 221 The cause of this disease has been a subject of laborious in- vestigation, but notwithstanding the labor expended in the re- search, no opinion has as yet been advanced acceptable to all. The case is still " sub judice," and likely for some time at least so to remain. It would seem, however, that one essential element in the production of eclampsia, or true puerperal convulsions, is that peculiar state of the nervous system of the woman, sometimes at least, induced by utero-gestation. Such condition does not, however, in all cases follow pregnancy, else when the same proximate causes come into play, all puerperal women would be attacked with eclampsia, which we know is not so. For in- stance, one will be thrown into violent convulsions when the head strongly presses upon, or is in the act of passing the cervix uteri, while another during that process experiences no par- ticular inconvenience. Nor does this difference depend wholly upon an original or radical difference of constitution or organi- zation ; for the same woman may suffer from convulsions during one labor, while in another, apparently in the same circum- stances, she will be exempt. It seems probable, however, that women of a naturally irri- table nervous system, are more likely to acquire during preg- nancy this susceptibility to eclampsia than those of an opposite organization. When this peculiar irritability exists, any cause producing a strong impression upon the nervous system, either central or peripheral, may give rise to convulsions. Thus, perhaps, over- distension of the uterus by the presence of twins, or an abnor- mal amount of liquor amnii, pressure of the fcetal head upon the os uteri, over-distension of the bladder with urine, or of the rectum with faeces, congestion of the brain from the blood being forced upon it by the efforts of labor, or its return inter- fered with from any cause whatever. Even strong mental emotions may cause a sudden invasion of convulsions. Much has of late been said about urea retained in the blood through disordered function of the kidneys, as a cause of puer- peral convulsions. This state of things has been inferred from the presence of albumen in the urine, for when this is detected, 222 PRACTICAL MIDWIFERY. it is said that upon analysis that fluid is found to contain less than the normal quantity of urea, while at the same time the blood contains more. Associated with an albuminous urine, will often coexist oedema of the feet, lower limbs, arms and face of the patient. These symptoms were supposed to fore- shadow an attack of eclampsia, upon the occurrence of labor. Although convulsions, according to the experience of obstetri- cians not unfrequently occur when albuminous urine has been previously detected, and there has been cedematous swelling of the feet, face etc., of the patient, yet this does by no means al- ways happen. I remember the case of a woman who engaged me to attend her in confinement just one day before labor set in, whose feet were so swollen as to bulge over the tops of her shoes, which she then wore much larger than her usual size, while her face and arms were equally cedematous. She had a tedious labor, and was ultimately delivered with the forceps, the head being taken at the upper strait, and yet no convulsions super- vened. I had not an opportunity to examine the urine, and cannot therefore say whether it contained albumen or not, but it is most likely it did. It should be remarked, however, that in this case, being apprehensive of an attack of eclampsia, and noticing at one time during the course of the labor some twitch- ing of the muscles of the face, which I thought rather ominous, I gave her a few doses of the tincture of Gelseminum, and soon these convulsive movements ceased, and shortly were, for the time, forgotten. Another case, however, perhaps still more to the point, was that of a woman who sent me a message that she desired to see me, without stating her object. Living at some distance, and not supposing the matter of "much importance, I did not see her until some time afterwards. She then told me she had been very much swollen in her limbs and face, but that the swelling had passed away spontaneously. I was called upon to attend her in labor, but could not reach her until the child was born. There had been no convulsions, nor so far as I could learn, even the remotest indication of their approach. Convulsions of the severest character often occur when the urine has been for some time before labor daily examined, and not a trace of albumen detected, and when there had been no cedematous swelling of the limbs or face of the patient. • ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 223 If, however, albumen be not present before the eclampsic attack, especially if this be severe or prolonged, it is apt to ap- pear in the urine shortly afterwards. From these facts, it seems not unlikely that the two phenomena, viz., eclampsic convulsions, and the appearance of albumen in the urine, and an abnormal amount of urea in the blood are effects, the off- spring of a common cause, rather than that they sustain to each other the relation of cause and effect. It has been thought that the same morbific agent which induces convulsions may also derange the functions of the kidneys, giving rise to the appearance of albumen in the urine, and at the same time par- tially arresting the elimination of urea from the blood. Frankenhauser, of Jena, has published a work referred to by Dr. Barker, entitled " On the Nerves of the Uterus," illustrated by plates, in which he claims to have demonstrated a direct connection between the nerves of the uterus and the renal gan- glia. From this discovery he infers that the condition of the kidneys, often associated with convulsions, is merely sympa- thetic with the irritation of the uterus. " He believes that the sudden occurrence of the eclampsic attack, following all exter- nal sources of irritation (as pressure of the fcetal head upon the cervix, digital examinations, etc.), and from emotional causes, goes to prove that the nervous system, and not the vascular system, is the starting point of puerperal convulsions, and that the changes observed in the kidneys of women dying from con- vulsions, are too trivial and transitory, to indicate a long con- tinued congestion ; and further, in confirmation of these views, are to be added the undeniable cases of convulsions when no albuminuria has existed." A similar idea was promulgated by Dr. Tyler Smith, namely, " that the albuminuria may depend upon sympathetic irritation of the kidneys by the gravid ute- rus, similar to the irritation of the salivary glands, the mam- mae, the thyroid, etc., and not upon mere pressure " (Dr. Bar- ker's Puerperal Diseases). Still it may be true that the abnormal amount of urea said to be contained in the blood, cotemporaneously with the exist- ence of albumen in the urine, may be a factor in the production of puerperal convulsions. Whatever irritates the brain, and I 224 PRACTICAL MIDWIFERY. through it the spinal cord, may contribute to such result: for it is maintained that upon whatever point the irritation may primarily act, its action must be communicated to the spinal cord before convulsions can take place. Although the puerperal condition must be regarded as an essential element in the production of eclampsia, there is never- theless a vast difference in the liability of puerperal women to this fearful accident. A very large proportion of the cases oc- curring are those of primiparae. In women in their first gesta- tion we may suppose there exists a more exalted sensibility of the nervous system than in such as have borne several children. There are also sources of irritation which in future pregnancies are much less powerful. For instance, in the case of primiparae the abdominal walls resist more strongly the distending force of the womb. The same perhaps may be said in regard to the walls of the uterus itself—that this organ accommodates itself in a less friendly way, to the necessities of its new condition, than it will do in future pregnancies. Statistics seem to show that young unmarried girls are peculiarly liable to puerperal convulsions. In their case, in addition to the causes just enu- merated, the moral emotions come into play. A sense of shame, degradation, and sometimes the loss of all once held dear—a compulsory descent from respectability it may be, to prospec- tive ruin, adds fearfully to their risks. It is thought by some that women of minute stature are more liable to convulsions than those of larger size. If this be true, and we have met with no confirmation of it in our own expe- rience, it is accounted for upon the same principles we have laid down in the case of first pregnancies. Some again have supposed that epileptic patients are more subject to eclampsic seizures than others. On the contrary, however, statistics seem to show that in such patients, pregnancy often arrests for the time epileptic paroxysms, which again recur and assume their accustomed regularity after delivery. It is probable, however, that women who from early life, through the influence of slight causes, are thrown into convulsions, not epileptic, but mani- festly of a purely nervous character, will be more subject to puerperal convulsions than others, whose nervows systems are ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 225 naturally less impressible. It has, moreover, been said that women who have once suffered from this malady are likely to experience a recurrence of it in their subsequent labors. This may be so in regard to the class of patients we have last no- ticed, but, generally, it probably does not hold good. We know a lady now resident in the city of Baltimore, the mother of se- veral children, whose first labor was ushered in by severe con- vulsions, which continued in less and less frequently recurring paroxysms for several days. Her second labor was attended by the same complication, but subsequent ones were normal. Puerperal convulsions of the severest form are sometimes ushered in suddenly without any premonitory symptoms. Dr. Lilienthal records the case of a lady far advanced in preg- nancy (Hahnemannian Monthly), who, very shortly before her seizure, walked to the door with some friends about leaving her house, and was suddenly attacked by what proved to be fatal eclampsia. Sometimes the attendant, while taking his ease, and unauxiously waiting upon the progress of what he regards as a natural labor, is suddenly called by the nurse to the bedside, to witness the unmistakable commencement of severe convulsions. In this, however, as in other affairs of life, very often " Coming events cast their shadows before," and precursory symptoms manifest themselves, which should always put the accoucheur upon his guard. These are given in such faithful and minute detail by Dr. Barker, in his recently published Lectures on " Puerperal Diseases," that I cannot do better than to transfer his description to these pages. " The first and most frequent of these symptoms is headache, some- times dull and continuous, and in other cases throbbing and recurrent. It is occasionally intermittent for days or weeks, until a few hours before the attack, when it becomes constant. It is frequently attended with vertigo, on making any move- ment of the head." " The symptom next in frequency and still more significant of danger, is impairment of vision. This, like the headache, is frequently temporary at first, afterward becoming permanent. 15 226 PRACTICAL MIDWIFERY. In some the sight, which had previously been good, appears to be suddenly lost," " In connection with either or both of the symptoms I have just described, I should mention oedema, particularly of the face, coexisting with oedema of the extremities. It occasion- ally happens that this symptom exists alone, and even this in so slight a degree as not to be observed, unless carefully sought for, when the two other symptoms are wholly absent. Under these circumstances, it becomes an imperative duty to carefully and frequently examine the urine and test it for albumen." " Whether albumen be or be not found in the urine, or even when the other symptoms I have just described are absent, if a pregnant or parturient woman suddenly complains of sparks before her eyes, or dimness of sight, or ringing in her ears, or difficulty in articulation, or suddenly becomes nervous, irritable, and complains of a severe pain in the head, the danger from con- vulsions is imminent." Although any of these symptoms appearing in a patient near the time of confinement, or indeed at any period in the course of utero-gestation, should put us upon our guard, we have known most of them to exist, either singly or in groups, and eventually to pass away spontaneously without the superven- tion of convulsions. Those detailed in the last paragraph of the extract we have made, may I think justly be regarded as by far the most threatening. Puerperal convulsions may take place before, during, or after labor. We remember the case of an unmarried girl who had a fatal attack about her seventh month. She had endeavored to conceal her pregnancy, and did not give any account of the prodromic symptoms she might have experienced. The con- vulsions first manifested themselves early in the morning, and the mother spoke of her as having been up in the .night and showing signs of strange bewilderment. She, I believe, never spoke from the commencement of the attack. The description of the onset of the paroxysm is so graphi- cally given by the author from whom I have just quoted, that I trust I shall be excused for making a further quotation from his work just named. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 227 The patient " becomes pale, with a fixed expression of her countenance, and a general immobility of her whole system. This lasts but a moment, when the eyelids begin to twinkle, the eyeballs to turn in their sockets, under the upper lid, so that only the white of the eye is seen ; the angles of the mouth are drawn, producing a horrid grimace, which Baron Dubois has aptly compared to the countenance of the satyrs of the fable. The angle of the mouth being drawn up on one side, the face turns to the same shoulder; then the muscles of the face begin rapidly to contract, and this contraction almost im- mediately extends to the muscles of the trunk and the extremi- ties. The neck swTells, the jugular veins stand out prominently, and the carotids beat violently. The fists are doubled, gene- rally with the thumb of one or both hands compressed in the palm by the fingers. Sometimes one arm is raised as if in an attitude to ward off a blow. The muscles of the throat and larynx strong]}' contract and cause a momentary suspension of respiration; the face is intensely congested, and of a purple hue. This condition of tonic convulsion does not continue, ordinarily, more than twenty or thirty seconds, when it is fol- lowed by the clonic convulsive movements. Rapid, jerking movements of the muscles of the face, body and extremities now succeed the muscular rigidity. A short, noisy, broken inspiration, with stertorous expiration, is attended witli the escape from the mouth of a white foam, sometimes bloody from lacerations of the tongue. The patient can neither feel, see nor hear. The circulation is soon influenced by the respiratory troubles. The spasmodic contraction of the diaphragm and the other thoracic muscles interrupt decarbonization and oxy- genation ; the pulse which was at first hard and strong, now becomes rapid and feeble, capillary circulation is arrested, which causes a purple hue, particularly noticeable on the hands. To- ward the end of the paroxysm, all these symptoms progres- sively disappear. The spasmodic movements of the muscles become less frequent and less violent until they entirely cease, the respiration and circulation become regular, the superficial congestions disappear, and the surface recovers its natural color. This period of clonic convulsions lasts from two or three 228 PRACTICAL MIDWIFERY. minutes to twenty. The tonic convulsions are really much more dangerous to life, and when patients die in the convul- sion, it is in this period, the death being probably due to asphyxia." The Prognosis of eclampsia is always uncertain, at least in the severer forms of the malady. Although comparatively a rare occurrence, it is not only one of the most alarming, but also one of the most fatal that attend pregnancy or the puer- peral state. It may terminate in complete recovery, the pa- tient having no recollection of what has transpired, or it may give rise to other diseases, such as puerperal mania, paralysis of members, idiocy, loss of memory, amaurosis, etc., or it may terminate in death, either directly during tonic spasm, perhaps as above stated through asphyxia, or, as more frequently hap- pens, during the soporose stage, induced through oppression of the brain, by congestion or effusion. Fatal haemorrhage has been known to succeed convulsions, through paralysis of the womb preventing its firm contraction. A favorable termina- tion may be expected when the paroxysms become more distant and less severe, when a good degree of consciousness is restored between them, when there seems to be but little cerebral op- pression, or if this have existed, when it is manifestly subsid- ing. On the contrary, short and imperfect intervals between paroxysms of great severity, deep unconsciousness between the convulsions, stertorous breathing, and other indications point- ing to great cerebral oppression, portend a fatal issue. The prognosis will be specially unfavorable, if the attack has hap- pened before delivery, and there has been no amelioration as regards the frequency and severity of the paroxysms after that has been accomplished. Such being the nature of this formidable malady, its success- ful treatment is manifestly a subject of great importance. We will, however, premise before going further, that here, as in many other cases with which the physician meets, prevention is, sometimes, easier than cure. When at all practicable, there- fore, it should at least be attempted. If we succeed in prevent- ing the occurrence of the malady, we of course avoid the uncer- tainties always attendant upon treatment when it has once taken place. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 229 When our services are engaged beforehand for attendance upon a patient in confinement, we should always call upon her and ascertain exactly the state of her health. And although convulsions and albuminuria by no means seem to be insepara- bly connected, yet the existence of albumen in the urine is sometimes a symptom of that derangement of vital function which appears to be a factor in the production of eclampsia. It will be well, therefore, to test the urine of the patient, espe- cially if there be swelling of the feet, arms and. face, or, indeed, Of either. This cedematous swelling is believed to be often associated with albuminous urine. The remedy upon which I have most relied in correcting this condition, especially if the swelling be prominent, is Arsen. alb., say thrice daily. If the urine be very scanty, Apis mel. may be given, either in alter- nation with the Arsenic or alone. If the patient complain of pain and burning, after voiding her urine, Equisetum hiemale will probably be of service. Where the albumen is very abun- dant, perhaps Merc. corr. will be found useful. Phosphor, may be thought of, if other symptoms be present pointing to it. Where there may be anticipated difficulty from unyielding structures, and especially if there be choreic twitchings, I would by all means give the tincture of the Actea rac, say six drops in water, thrice daily, for ten or fourteen days before expected confinement. AVhen the patient complains of fullness and pain in the head, especially on stooping, Bellad. should be given—if the pain be greatly aggravated by motion, Glonoine should be thought of. If nervousness and wakefulness are troublesome, these should be treated as before directed (see chapter on Dis- orders of Pregnancy). In short, whatever derangement of health we may find in the patient, it should be carefully treated according to the symptoms. As far as possible every source of irritation, whether material or moral should be removed. Anxiety and despondency should be counteracted by present- ing encouragement drawn from the proper sources, and the pa- tient should be led to feel that whosesoever sympathy she may lack, she has fully that of her attendant. To bring the patient up to the time of trial in good health and a cheerful state of mind, has a wonderfully prophylactic effect, not only as regards 230 PRACTICAL MIDWIFERY. the calamity under consideration, but others also. Even the "unfortunate" should share our sympathy. We should re- member that while far from condoning their crime, we are called upon, not to sit in judgment upon their conduct, but to relieve their sufferings, and save their lives, that they may go their way and sin no more. We should call to mind the ex- ample of Him who was infinitely purer than the best of us, whose withering rebuke dispersed the bloodthirsty conscience- stricken crowd—" Let him that is without sin among you, cast the first stone at her." But it will sometimes lie beyond our power to use proplw- lactic measures to avert convulsions. As we have already said, they will sometimes suddenly manifest themselves without premonition, and without suspicion, on our part or perhaps even that of the patient, of their approach. Or we may be called, or at least reach the bedside after they have fairly begun. All we can then do is to resort to remedial measures, such as our knowledge and skill may suggest. In the first place, if we are present when the attack sets in, our duty is to secure the patient as far as possible from injuring herself during her spasms. Something should, if possible, be placed and kept between her teeth, in order to prevent her from biting her tongue. A piece of cork will perhaps answer best, if present—if not, a very solid roll of linen or muslin. She should be so restrained as to prevent her from bruising her limbs by violent movements, but not held so firmly as to en- tirely prevent mobility. We should, if possible, ascertain the focus of irritation which has given rise to the spasms. We should endeavor to discover whether the bowel may not be overloaded with faecal matter, or the bladder distended with urine. The former, if it exist, should be immediately relieved by injections of tepid water, and the latter by the introduction of the catheter, as soon at least as this can be done. Most persons in their ordinary condition aud hearth, experi- ence little or no inconvenience from either of these causes, un- less in extreme cases, or very long continued ; but we must bear in mind the very greatly increased impressibility of the ner- vous system of the puerperal woman. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 231 Should any other source of irritation be discovered, whether material or moral, it should at once, as far as possible, be ob- viated. Even the presence of persons in the chamber toward whom the patient may be supposed to entertain any feeling of antipathy, should not be permitted. Our motto here should be, emphatically, " Tolle causam." If labor have already set in, we should examine the condi- tion of the os uteri, and if there be sufficient dilatation to jus- tify the procedure, and especially if there be reason to believe that the convulsions are dependent upon irritation of the womb from the presence of the fcetus, we should deliver either by means of the forceps, or by turning, according as the one or the other -of these resources may be most plainly indicated. • If the head be already engaged in the upper strait, or have descended into the cavity of the pelvis—especially if the os be well di- lated, the forceps will come into play, but on the contrary, if the head be high and the os imperfectly dilated, turning will be the proper resort. It may, perhaps, be stated generally, that when convulsions occur during labor, to empty the womb as speedily as can be done with safety, is one of the first indica- tions to be fulfilled. Till this is done remedies are not likely to succeed, but nevertheless should be diligently used. It fre- quently happens, however, that the mouth of the womb is most rigidly contracted, and obstinately refuses to yield to the ordi- nary resources of nature, and too often also those of art. We must not, then, rudely lacerate this organ for the sake of effect- ing speedy delivery, but resort to such other measures for the present as may best serve to mitigate the spasms, and ultimately secure dilatation. If there seem to be symptoms indicating congestion, especially of the head, Bellad. may be given, pro- vided the patient can be induced to swallow. Pellets or powders may be thrown far back into the mouth, if she con- tinue too unconscious to take them in the usual manner. This remedj' very often corresponds to the most prominent symp- toms of eclampsia, and that it has " moreover a special affinity to the condition of a parturient female, is not only shown by our Materia Medica, in spite of the incoherent arrangement of its symptoms, but may likewise be learned from any recog- nized toxicological treatise." 232 PRACTICAL MIDWIFERY. Gelseminum is a remedy of great promise in the treatment of puerperal convulsions. Its pathogenesis can be best learnt in Hale's New Remedies, also in Burt's Characteristic Materia Medica. From the effects of this remedy I myself have wit- nessed, I know of none in which I would place greater confi- dence. I would give it in drop doses of the mother tincture, repeated according to urgency. . Dr. Hempel speaks very favor- ably of Bromide of Potassium in large doses. I have had no experience with this drug; but would be disposed to try it should others, with which I am more familiar, disappoint me. Where there is rigidity of the os uteri, I would place consid- erable reliance upon Actaea racemosa ; not only from its relax- ing effects upon that organ, but on account of its curative powers over chorea, a spasmodic affection sometimes arising from irritation of the womb. By all means try it where the os uteri is very rigid. Hydrate of chloral is very highly spoken of by allopathic authors, and should not, on that account, be rejected. But a great difficulty, in administering medicines satisfac- torily by the mouth, arises from the spasmodic nature of the disease, and, in severe cases, from deep and long continued un- consciousness. Where this opposes an insuperable barrier, they may be given by enema, or, perhaps better, by subcutaneous injection. In cases where the paroxysms are severe, return frequently, where we are anxiously desirous of emptying the womb, but the os is undilated and undilatable, and especially where other remedies, carefully selected, have been of little or no avail, Chloroform affords us an admirable resource. When properly managed, it not only controls reflex action and holds in abey- ance the convulsive attacks, but it proves the very best agent for relaxing the os and thereby rendering delivery not only practicable, but safe. As it is administered by inhalation, its salutory effects are independent of the consciousness of the patient, so long as she still respires. The inhalation should be conducted carefully and in the manner I have elsewhere advised (see chapter XII); but, at the same time, with suffi- cient boldness, to produce the anaesthetic effects of the a^ent. ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 233 Its administration should be suspended when the paroxysm comes on, till this has subsided and the patient has taken in sufficient fresh air to relieve the asphyxia. I am aware I subject myself, at least with some, who, per- haps, claim to cure all cases by other means, to the charge of departing from Homoeopathic practice in this advice. In the first place I am not so certain that it is a departure from sound Homoeopathy. I am strongly inclined to believe that Chloro- form exercises a specific curative power over, at least, some forms of convulsions. Its action upon the nerves of sensation is certainly similar to that of the morbific agent, inasmuch as both produce anaesthesia. Chloroform is also said to have caused convulsions. I well remember a case which, I admit, is not wholly conclusive, as the conclusion is reached only through analogy ; but which is certainly strongly suggestive. It happened in the very early days of the use of chloroform as an anaesthetic, as some then thought, and still think, as a lethal agent. A young male cat had been dropped upon my premises, I suppose, perhaps, because he was regarded as an incurable invalid. He was subject to what appeared to be very severe epileptic convulsions of frequent recurrence. His paroxysms were ushered in by the most piteous howling, and then violent clonic spasms, followed by tonic, which in a few seconds closed the fit. When his paroxysm ceased, he walked slowly awa}', and seemed to feel very badly. He had become much emaciated. It occurred to me I would kill him with Chloroform, which, from the high reputation of the drug in that direction, I thought would be an easy performance. I took the opportunity when he was in a severe paroxysm, and administered the chloroform upon a sponge and without stint. The convulsions soon ceased and the patient lay still, as if in death. He soon, however, showed by his movements that he was not dead. I repeated the process—and that again and again, until I became convinced that however well adapted to homicide, chloroform is not the best agent for felicide. I therefore dismissed the patient to die at his leisure. But, to my astonishment, I never saw the cat have another paroxysm of convulsions—I believe he had none, and he soon took on 234 PRACTICAL MIDAVIFERY. flesh, and became apparently perfectly healthy, and remained so about my premises for several years. The objection, too, that the amount of Chloroform required, and that if successfully used, is commonly given, is at vari- ance with the ordinary course of Homoeopathic practice, I consider of no weight. If it be even fully settled that some remedies, such as Arsenic, Silicea, Sulphur, etc., act best in high attenuations, it is certainly bad logic, in our present state of knowledge, to conclude that the same is true of all other medicinal agents. The utility of Chloroform, given as directed above, is, I think, fully established by the experience of others. Our Allopathic brethren claim to have reduced their mortality through its agency about fifty per cent. We are hardly justi- fied, I think, in the conclusion that this difference is owing to the substitution of chloroform in the place of more homicidal measures. The following case, treated but a few months since, I think of sufficient interest to justify me in the recital. I was called upon to attend in labor a young lady in her first confinement, whom I had known before to be of exceed- ingly nervous temperament, and subject to spinal irritation. She lived at a distance of several miles, so that, although en- gaged some time before her labor, I did not see her, but re- quested particularly by letter that if any cedematous swelling of her person should occur, I might be informed of it. I was assured there was none. When I first reached her bedside she complained of severe headache, and seemed to be very nervous. I gave her some remedy, I think Coffea. Shortly after I heard no more of pain in the head; but as labor advanced, and she began to suffer severely, she begged of me to give her chloroform. Her re- quest was granted, and she passed very handsomely under the influence of the anaesthetic The womb continued in very vig- orous action, although she was wholly insensible to pain, and toward the close of labor its powerful contractions were almost continuous, as if under the influence of Ergot, although none had been given. The labor terminated rather sooner than I had expected, and the child, constitutionally a feeble one, was ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 235 still-born, either, I presume, from premature detachment of the placenta or compression of the cord. The patient waked up as usual and made no particular complaint. I saw her next day toward evening, and found she had been suffering through a considerable part of the day from intense pain in the head. I left Bell, with a strict injunction to let me know if anything more unfavorable should occur. I was waked about two o'clock the following night by a messenger, who could only inform me that the patient was " much worse ; " but could not tell in what particular way. I went with him a distance of about nine miles, and the night being rainy and exceedingly dark, a good deal of time was spent on the road. When I arrived I found the patient had been in frightful convulsions since about nine o'clock—it was now about four in the morning. The paroxyms recurred about every twenty minutes—the pulse, which had been the evening before full and remarkably slow, had now become very small and quick. After some preliminary measures, I commenced administer- ing chloroform in the intervals of the paroxysms, by inhala- tion, and as soon as I was able to effect it, threw up one drachm of the same in water as an enema. This was retained, how- ever, but a short time. Simultaneously with these measures, I commenced giving by teaspoonful doses a solution of six to ten drops of Veratrum viride in a tumbler say two-thirds full of water, every fifteen or twenty minutes. In the intervals of her seizures, the patient, although entirely unconscious, swal- lowed any liquid put into her mouth with a spoon. After commencing this treatment, the next recurrence was at an interval of one hour—then two hours—then three hours, which was the final one. I visited the patient next morning, and found her doing well, but utterly oblivious of all that had happened the day before ; had at first forgotten about her late confinement, and had even expressed some uncertainty about her marriage. She, however, fully regained her faculties, which were very good, and made a satisfactory recovery. Upon my return from my last visit to this patient (Sunday), I was informed that two other similar cases had occurred during 236 PRACTICAL MIDWIFERY. the past week within a few miles, both primiparae, both under allopathic treatment, and both had died. I found this report upon careful inquiry to be strictly correct. Finallj', we as a school have thrown away the lancet, and we hope, but for very exceptional cases, forever. Are there any imaginable circumstances in the treatment of puerperal convulsions that might still suggest the propriety of its em- ployment? I confess I speak here with hesitancy, for having set out for the Promised Land, although its full enjoyment may yet be distant, I feel no inclination to return to the flesh- pots of Egypt. Even our Allopathic brethren have to a great extent lost their confidence in bleeding in this disease, and have nearly discarded its use. Still there are cases reported of the convul- sions finally ceasing immediately after venesection. If unmis- takeable evidence exist of strong congestion in the brain, when as yet we have reason to hope that rupture of the vessels has not taken place, nor effusion considerably advanced, when the pulse is full and strong, or on the other hand, as may be most likely, oppressed and feeble, and when death already threatens the patient unless relief be procured from some quarter—as yet unexplored—let us try the lancet. FALSE OR SPURIOUS PERITONITIS. This is the name given by authors to an affection of child- bed, which if it occur at all,.usually takes place within a few days, mostly a few hours after delivery. It is characterised by an excessively severe pain originating in some spot in the ab- dominal region, but if it continue for some time, seems to spread over a larger space. It is important in several of its aspects, although not necessarily a dangerous affection. In the first place, it bears sufficient resemblance in its symptoms to incipient peritonitis to excite great alarm on the part of the patient and her friends, which is of itself an evil much to be dreaded. In the hands of the allopathic practitioner, a mis- take of this kind might lead to fatal results; for should he re- sort to the lancet and freely abstract blood, the mischief in ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 237 some cases would be irreparable. With us, who ought to be guided in our practice by the symptoms, not by the name, it is true there is no such danger, but still it is proper we should apprehend the true nature of the case. False peritonitis, as it is with no great propriety of language called, is not an inflammatory affection, but probably altogether neurotic. It is not improbable, however, that severe cases ne- glected or improperly treated, may sometimes induce or run into true peritonitis. The older writers upon midwifery took no notice of the affection. According to Dr. Meadows, Dr. Gooch was the first to describe it and point out the suitable treatment. I remem- ber to have met with several cases in my own practice before I met with any description of it in the authors to which I had access. I quote the following from Dr. Meadows' " Manual of Mid- wifery." kt It occurs," says he, " mostly in women of delicate and nervous habits, and is frequently met with in hysterical persons. The pain is often of the most excruciating character, and is greatly aggravated by any movement of the body. So distressing is the pain, that persons will sometimes become almost frenzied with it; they are quite incapable of bearing even the slightest touch with the hand or the weight of the bed- clothes on the body ; but that which marks its strongly nervous or hysterical character, and serves at once to distinguish it from the truly inflammatory pain is, that if the patient's attention be distracted by conversation or other means from the seat of pain, pressure, even to a considerable extent, if gradually and cautiously applied, will be borne not only without complaint, but apparently without her knowledge; but no sooner is her attention again drawn to it, than the same exquisite sensitive- ness again reveals itself, and she screams out lustily even at the approach of pressure. Again, if by soothing words and promi- ses of cautious proceeding we induce her to let us apply the hand upon the abdomen so gently that it does not even rest its weight upon it, we shall find that we may now gradually in- crease the pressure until by degrees it becomes considerable, not only without her feeling any increase of pain, but with 238 PRACTICAL MIDWIFERY. complete relief, the pressure of the hand as it were appearing to benumb the pain. If we withdraw the hand in the same gradual manner, no pain will be induced, but if we remove it suddenly, a spasm of the muscles with intense pain is immedi- ately excited." (Ptigby.) " With all this, there is often a great show of constitutional disturbance, though it is all of the same evanescent character; the tongue becomes dry, the pulse quick, small and jerking, the skin is hot, but mostly covered with perspiration, and the mental excitement is often very great." The patient too will often tell us she has had a chill. This probably has been of a nervous character, like that which not unfrequently occurs shortly after delivery. According to the observation of authors who speak of this affection, it is most frequently encountered in the case of women of previously feeble health and nervous irritability. One of the worst cases I have met was that of a woman who before and since has suffered severe attacks of hay asthma. As regards the treatment of this affection, I have always found Acetate of morphia to give very prompt relief. ' One grain in ten teaspoonfuls of water thoroughly dissolved, a tea- spoonful every half hour till relief is experienced, then discon- tinue remedy. Patients generally reported relief after the second or third dose, without experiencing in any degree the narcotic effects of the drug. How much smaller doses might answer the same purpose, I am unable to sa}'; I have succeeded with the above, and have been satisfied. I have also used, at the suggestion of Dr. Ludlam, Atropia 3d dec. with excellent results. One or the other of these medi- cines has promptly relieved all the cases I have met, and I think will relieve generally, with few if any exceptions, if resorted to in time and under the requisite concomitant circumstances. MASTITIS, OR INFLAMMATION OF THE MAMMARY GLANDS. This affection often occurs to the nursing woman, and most frequently shortly after delivery. We therefore speak of it as ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 239 one of the diseases of the puerperal state. It may, however, take place at any time during lactation. The immediate cause giving rise to inflammation of the breasts, is obstruction to the flow of milk along the lactiferous tubes, and consequently to its discharge by the nipples. En- gorgement hence ensues, and if not soon relieved, inflammation speedily follows. This obstruction may arise from various causes—from neglect to draw the milk, through which the milk tubes become distended, and crowd and compress each other. Or it may owe its origin to undue congestion of the blood-vessels, with which the substance of the mammary glands is abundantly supplied. This congestion may arise from chills or exposure to cold, perhaps strong mental emo- tions, or any causes that disturb the equilibrium of healthy in- nervation. The breasts during lactation, especially in its earlier periods, are in a state of unwonted activity, both ner- vous and vascular, and therefore readily receive the impression of any morbific agent, upon whatever part of the organism its primary impact may fall. There are commonly reckoned by authors three varieties of mastitis, viz., the sub-cutaneous, affecting the areolar tissue, beneath the skin ; the glandular, seated in the substance of the gland itself, and the sub-glandular, in the cellular tissue be- meath the gland. As inflammatory processes do not very scru- pulously observe the limits prescribed by classification, these varieties not unfrequently overstep their assigned bounds, so that more than one of them may be encountered in the same breast, either at the same time or in close succession. The first named variety, if alone, is in its course the shortest and least injurious to the functions of the organ, either for the time or subsequently. The second and third, unless well man- aged in the outsetting, are of long duration, and give rise to untold suffering, and often render the breast incapable of per- forming its functions after recovery. The best treatment of this disease, as of many others to which the puerperal woman is liable, is the prophylactic. When inflammation of the mammary gland sets in, unless treated very earl}', it is extremely liable to go on to suppura- 240 PRACTICAL MIDWIFERY. tion. If it occur after the physician has ceased from his daily attentions to his patient, she is apt to be subjected to a trial of the many infallible cures known to the nurse or friends in charge. When he is recalled it is usually too late to prevent suppuration. Enumerating prophylactic measures and going back to the remotest of them, we would advise, as we have elsewhere done, and which we need not fully repeat in this place, especially in women pregnant for the first time, to pay early attention to the condition of the nipples. This should be done for some time before confinement. We have thought that the administration of Arnica at the close of labor, as is our uniform practice, has a tendency to pre- vent mastitis, especially the phlegmonous or sub-cutaneous va- riety of that disease. Its efficac}^ in the case of common boils, is, I believe, pretty generally conceded. After delivery, a great object will be to keep the breasts as perfectly exhausted as possible. To this end, the child, if healthy, should be earl}' accustomed to suck. It should not be unnecessarily fed before the secretion of milk, and especially upon panada and other articles, entirely unsuited to its diges- tive powers, which impair its health and of course diminish its appetite and disposition to take the breast freely. When the milk cannot, for any reason, be fully drawn by the child, re- course must be had, if necessary to prevent engorgement, to the gentlest and least irritating means accessible, and the best of these is the mouth of the nurse, and next to this the exhausted bottle. These measures need be carried so far only as to pre- vent excessive and painful accumulation of milk. It has generally been advised, when a circumscribed hardness takes place in any part of the gland, which the women usually call " caking," that the nurse, standing behind the patient, if the latter be sitting up, having her hands lubricated with some soft oil, should gently rub the breast forward toward the nip- ple, very slightly increasing the pressure as the patient becomes accustomed to it. Of late, however, such interference is dis- countenanced by the " highest authorities." We are very apt to oscillate from one extreme to another, and very often pass ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 241 the truth lying midway between. When there is simple en- gorgement or congestion, and the inflammatory process, pro- perly so called, has not yet set injudiciously applied pressure in the form of gentle friction may, I think, sometimes be of service. Still it is perhaps better not to leave to the indiscre- tion of the nurse the employment of a measure which if inju- diciously applied, may do much harm. At a meeting of the Obstetrical Society of London, held on the 6th of January, 1875, a paper was read by Dr. W. Bath- urst Woodman, " On the prevention of Mammary Abscesses by the Application of the Principle of Rest." An interesting discussion on the subject of the paper ensued, in which some of the most distinguished members of the society took part. The author iuferred from the rarity of mammary abscess in the case of cats, dogs and other animals deprived of or ab- sented from their young, and which are subjected to no inter- ference, that the disease in the human female is rather hastened than prevented by the usual measures employed for prevention. The author does not tell us how much these animals suffer be- fore they escape, and how much that suffering might be dimin- ished by judicious appliances. In the case of mares, which generally escape abscess, the "nimia deligentia" is only too often resorted to. It is highly probable the inferior animals are naturally less liable to abscess than the human female. These eminent gentlemen pretty generally agreed that it was all important to secure perfect rest to the sufterino- oro-an and to abstain from the usual interference such as frictions external applications, etc. They recommend the use of the suspensory bandage to relieve dragging and weight. Some advised the application of the Belladonna plaster. Dr. Ash- burton Thompson advised minim doses of Tincture of aconite every hour, by which he had succeeded in cutting short in- flammations of the breast, which there was no doubt would have run on to suppuration—frequently, indeed, in three cases out of four. In cases of still-birth he had hitherto found ab- stention from fluids sufficient in every case to avoid every kind of mammary disturbance. Dr. Braxton Hicks thought the principle of rest had been 16 242 PRACTICAL MIDWIFERY. gradually coming upon us for years, friction only being re- sorted to among the poor and ill-educated. Surgery at the present day was all tending to quietude, manipulations only led to suppuration, and often produced the extra amount of stimulation required to set it up. Dr. Murray observed that the application of a Belladonna plaster was of great service, keeping the arm at the same time fastened to the side. In some instances a slight process of friction upwards was productive of good. The foregoing are, it is true, allopathic authorities; but I am not unmindful of the words of the great Roman poet, "fas est ab hoste doceri." That injudicious interference is injurious in the case of mas- titis, and where is it not ? is manifest from the fact that, so far as I can remember, I can think of no case where the procedures of ignorant women were freely resorted to, that did not end in suppuration, often very extensive, and not unfrequently involv- ing both glands. The patient throughout the puerperal period should care- fully avoid all imprudent exposures to currents of air or a chilling atmosphere, or dampness. Owing to the cutaneous surface being usually moist with perspiration, she readily chills, and the injurious effect is often reflected upon the breasts. After leaving her bed these organs should be Care- fully guarded against cold, but, on the other hand, should not be kept too warm. After the child commences to suck, every precaution should be taken to avoid sore nipples. If these become tender, she should procure a gum elastic nipple shield before abrasion takes place. The nipples should be carefully washed after each nursing of the child. If, notwithstanding all precau- tions, they become abraded, ulcerated or chapped, the suitable remedies, elsewhere laid down, should at once be had re- course to. Mammary abscess is usually ushered in by a chill more or less severe. This is followed by fever and headache. The mammary gland or a portion of it becomes hard, and to the touch presents the sensation of a lump. Pain sets in and gradually increases until it deprives the patient of sleep, im- ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 243 pairs or destroys appetite, and, if unchecked, completely unfits her for every duty and all enjoyment. When called in the stage of chilliness and fever, Aconite should be given at short intervals, say every half hour, until perspiration sets in, the patient keeping closely in bed. The weight of the breast should be relieved by adhesive straps or a properly adjusted suspensory bandage. Gentle but not ex- cessive pressure may be applied, avoiding such a degree as to increase pain or suffering. Bryonia is indicated by hardness and distension of the breasts, shooting pains, dry skin, thirst, etc Belladonna should be given when there is engorgement, redness of the skin covering the breast resembling erysipelas, headache, etc We have seen few cases go on to suppuration where Bell, was perseveringly given. This remedy is thought by some to be better suited to threatening of mammary abscess at the time of weaning the child than shortly after labor. Extract of Belladonna, softened or diluted with glycerine, and spread upon the surface of the breast, will be found an excel- lent application in glandular mastitis. It may be applied by- means of a cloth, having a hole cut in to fit the nipple. Phytolacca decandra (poke weed) has been much praised by some as a remedy for mastitis. It has been used in domestic practice, and has been pretty generally thought to possess curative powers in this disease. Dr. Hale, in his " New Rem- edies," speaks highly of it. I have occasionally used it; but my experience with it has not been sufficiently extensive nor my results sufficiently positive to speak very decidedly in its favor. I would suppose it perhaps indicated where there is aching of the limbs and a general feeling of malaise. Phosphorus is a remedy of great value in this complaint. Where the symptoms were not very acute in the outsetting, consisting of hardness and soreness of a portion of the gland, threatening a worse state of things if neglected, I have thought Phosphorus, perseveriugly used, has, in my hands, been of great benefit. Sooner or later the hardness has generally passed away and the soreness subsided, the gland returning to its nor- mal condition. I have generally applied a solution of a few 244 PRACTICAL MIDWIFERY. drops of the saturated alcoholic tincture to the breast exter- nally, by means of flannel cloths, or lint saturated with the so- lution and covered with oiled silk, to preserve moisture, at the same time giving it internally. Where hardness remains after the use of other remedies, or where suppuration is imminent, Mercurius will be found use- ful. In the last named condition, Hepar sulphuris may be of use. Where mammary abscess has taken place, been badly man- aged and assumed a chronic form, there being often several fistulous openings, discharging pus or serous fluid, Silicea will often prove an excellent remedy. I have seen such cases so emaciated by long continued suffering as to present the appear- ance of one in the advanced stages of consumption, who in a few weeks, under the persistent use of Silicea, so changed their aspect as to be scarcely recognizable. It has been disputed whether poultices should be applied to gathering breasts, at least before the breaking of the abscess. If I were to express an opinion, it would be this—avoid poul- tices until it is pretty certain that suppuration is inevitable— then apply them in a very simple form, until, at least, the bursting or opening of the abscess. Again there is a difference of opinion as to whether we should open the abscess with the lancet, or in all cases leave it to open spontaneously. Truth is seldom found in extremes. Rules laid down, to be applied to all cases, are necessarily often misapplied. My practice has been to avoid plunging the lan- cet deeply into the gland, especially near the nipple. Many of these abscesses, if encouraged by the use of Mercurius, will, in due time, open themselves and thus save the pain and other evils of a cutting operation. But when the matter has ap- proached near the surface, that nothing but the skin needs to be cut, where this latter does not seem to give way, and espe- cially if discoloration over a considerable surface appears likely to take place, and if in addition to this the patient is suffering much pain, I do not hesitate to use the lancet and make a free opening for the exit of the pus. The incision, especially if near the nipple, should be made in a line as if radiating from ACCIDENTS AND DISEASES INCIDENT TO LABOR, ETC. 245 that point. In this way there is less risk of severing the milk ducts; always, however, if possible, avoid an incision within the limits of the areola. It is scarcely necessary to add, after what I have already said, that the opening should be made with a bistoury or abscess lancet, and not with the spring lan- cet, used in phlebotomy, as has often been barbarously done. Some women have the greatest horror of this operation, partly from their consciousness of the excessive tenderness of the part, and, perhaps, principally from nervousness induced by loss of sleep and extreme protracted suffering. In such cases there can be no valid objection against the use of an anaesthetic, pushed to inseusibility. If we decide upon this, perhaps ether had better be selected, as the effect of fear is ex- tremely paralyzing to the action of the heart; this effect, added to that of chloroform, might produce disastrous conse- quences. Ether has, at present, at least a less formidable repu- tation, as a destroyer of life, than chloroform, and should it produce this unfortunate result, it would be more readily ex- cused than its competitor. Quite lately it has been asserted that an application of a so- lution of carbolic acid in glycerine, I think two parts of the former to one of the lattter, will temporarily destroy the sen- sibility of the skin. The application should be made five min- utes before incision is attempted. When pus is formed in the cellular tissue beneath the gland, as evidenced by chills, extreme enlargement of the breast, in- distinct fluctuation, etc., the puncture should be made at the most dependent point beneath the margin of the organ, at which the matter can be conveniently reached. In this variety of mammary abscess, when the pus is left to find its own exit, it not unfrequently discharges at several different points, form- ing as many fistulous openings into the substance beneath the gland. When matter accumulates and is long pent up in the sub-glandular cellular tissue, it compresses the gland and brings on disease of its substance, often resulting in abscess of that organ itself, and greatly complicating the case. Before closing this chapter, we will transcribe what Mr. Lis- ter has written upon the treatment of abscess, according to his antiseptic plan:— 246 PRACTICAL MIDWIFERY. " A solution of one part of crystallized carbolic acid in four parts of boiled linseed oil having been prepared, a piece of rag, from four to six inches square, is dipped into the oily mixture and laid upon the skin where the incision is to be made. The lower end of the rag being then raised, while the upper end is kept from slipping by an assistant, a common scalpel or bis- toury, dipped in the oil, is plunged into the cavity of the ab- scess, and an opening, about three-quarters of an inch in length, is made, and the instant the knife is withdrawn the rag is dropped upon the skin as an antiseptic curtain, beneath which the pus flows out into a vessel placed to receive it. The cav- ity of the abscess is firmly pressed, so as to force out all exist- ing pus as nearly as may be (the old fear of doing mischief by rough treatment of the pyogenic membrane being quite ill- founded); and if there be much oozing of blood, or if there be considerable thickness of parts between the abscess and the surface, a piece of lint, dipped in the antiseptic oil, is intro- duced into the incision, to check bleeding and prevent primary adhesion, which is, otherwise, very apt to occur. The intro- duction of the lint is effected as rapidly as may be, and under the protection of the antiseptic rag. Thus the evacuation of the original contents is accomplished with perfect security from the introduction of living germs. This, however, would be of no avail, unless an antiseptic dressing could be applied that would effectually prevent the decomposition of the stream of pus constantly flowing out beneath it. After numerous dis- appointments I have succeeded with the following, which may be relied upon as absolutely trustworthy. About six teaspoon- fuls of the above mentioned solution of carbolic acid in lin- seed oil are mixed up with common whiting (carbonate of lime) to the consistence of firm paste, which is in fact glazier's putty, with the addition of a little carbolic acid. This is spread upon a piece of common tin-foil, about six inches square, so as to form a layer, about a quarter of an inch thick. The tin-foil, thus spread with putty, is placed upon the skin, so that the middle of it corresponds to the position of the incision, the antiseptic rag, used in opening the abscess, being removed the instant before. The tin-foil is then fixed securely by adhesive ACCIDENTS AND. DISEASES INCIDENT TO LABOR, ETC. 247 plaster, the lowest edge being left free for the escape of the discharge into a folded towel placed over it and secured by a bandage. The dressing is changed, as a general rule, once in twenty-four hours; but if the abscess be a very large one, it is prudent to see the patient twelve hours after it has been opened, when, if the towel should be much stained with discharge, the dressing should be changed, to avoid subjecting its antiseptic virtues to too severe a test. But after the first twenty-four hours a single daily dressing is sufficient. The changing of the dressing must be methodically done as follows. A second similar piece of tin-foil having been spread with putty, a piece of rag is dipped in the oily solution and placed on the incision the moment the first tin is removed. This guards against the possibility of mischief occurring during the cleansing of the skin with a dry cloth and pressing out any discharge which may exist in the cavity. If a plug of lint was introduced when the abscess was opened, it is removed under cover of the antiseptic rag, which is taken off at the moment when the new tin is to be applied. The same process is continued daily until the sinus closes." When a considerable cavity is formed in the breast and the pus is fully evacuated, very gentle, equable pressure, sustained by the dressing, will contribute very much to speedy and per- manent repair. It is of the utmost importance that an abscess, when formed, should be properly treated, but, as before intimated, it is still more important to prevent its occurrence, which may usually be done by timely and judicious homoeopathic treatment. 248 PRACTICAL MIDWIFERY. CHAPTER XI. OBSTETRIC OPERATIONS. FORCEPS. The precise time when the forceps was first employed, has not been well ascertained. It is. generally believed that Dr. Paul Chamberlen was the inventor of the instrument. For some time, however, he kept it a secret, and used it privately, as is supposed prior to the year 1647. It was not, however, generally known till long after that time. The forceps devised by Chamberlen, of which the late Prof. C. D. Meigs possessed and exhibited to his classes what he supposed to be an exact fac-simile, was extremely rude. Perhaps no instrument has passed through a greater number of modifications up to the present time; a circumstance which shows its estimated im- portance, and the desire cnerished by the most eminent obstet- ricians, to fully evolve its powers and facilitate its employment. It would be incompatible with the prescribed limits and scope of this work, to enter into afull description of the differ- ent forms of the instrument now in use. The usual method of attempting to convey a correct idea of these by means of wood-cuts, for the most part results in failure ; as .it is, an at- tempt to depict solids upon a plain surface, which can be suc- cessfully done only by a very exact observance of shading and perspective, such as we can hardly expect to find in illustrations accompanying books on midwifery. A far better idea can be gained by examining the instruments themselves, usually kept on hand by cutlers, who generally can exhibit the most ap- proved forms used by the most prominent practitioners. The most important requisites of a good forceps are the following: 1. That it be as light in all its parts as is consistent with the requisite amount of strength. OBSTETRIC OPERATIONS 249 2. That the blades should be no wider than may be necessary to avoid too concentrated pressure upon a circumscribed por- tion of the cranium, and to secure a safe hold upon the head. If too wide, the difficulty of introduction is materially in- creased, while at the same time their mobility when within the pelvis is diminished. 3. That it should have sufficient length to grasp the head when necessary, at or above the superior strait. 4. That its cranial curve should be such that the inner sur- face of the blade may, when applied, come into as extensive contact as possible with the foetal head, and not rest merely upon a few points, while the pelvic curve should be so modi- fied as to endanger as little as possible the tissues of the mother by undue compression or laceration. 5. The fenestrae or openings in the blades should be as large as possible, consistent with the requisite strength, so that the scalp of the child protruding through them, may serve to pro- tect the maternal structures from undue direct pressure by the instrument. The blades of the forceps perhaps still most commonly used in Great Britain have but one curve, namely, the cranial. This instrument is generally designated as the straight forceps. It is well suited for seizing and extracting the head when at the lower strait, but exceedingly awkward when it is necessary to take it above or at the entrance of the pelvis, or even when high in the cavity. On the continent of Europe and in this country, another curve is superadded to the above, termed the pelvic curve, which, when the instrument is introduced, cor- responds with the curve of the sacrum. The latter instrument is, however, at present, meeting with more favor in the British isles than formerly. In the United States, so far as I know, it is almost exclusively used. In very nearly all cases likely to occur, it is vastly preferable to the strait forceps. I can think of no exception, unless it be when we desire to rotate the head in mento-posterior presentations of the face. Several distinct methods of locking or fastening the blades together after they have been introduced, have been adopted. In the forms in use with us, the blades cross each other in their 250 PRACTICAL MIDWIFERY. introduction, and are afterwards brought together and secured by what is called the English or the German lock. The former consists in a mortise in the shank of each blade, by which one passes into the other when brought together; the latter has a mortise in the one shank, and a thumb screw in the other. When approximated, the thumb screw is received into the mortise, and with a few turns of the former the lock is secured. The long forceps in use with us, so far as I have observed, is furnished with the German lock; the short, or Davis' or Meigs' forceps has the British. Another form of the instrument, said to be an admirable one, is that used by Prof. Lazarewitch, of Charkoff, Russia. In this forceps, the blades lock without crossing. They are simply opposed to each other and kept in place by a little button in the handle. It is claimed that the introduction of this in- strument is easier than that of those requiring the crossing of the blades ; that it is of no consequence which of the blades may be first introduced; that dangerous compression is pre- vented, and that from the arrangement and position of the lock there is no risk of pinching the maternal structures. These are advantages, it is true, but they may be all likewise secured by proper attention, with the instruments in common use. Every practitioner who is in the habit of frequently resorting to the use of the forceps, usually has his own decided prefer- ence. This preference often depends upon other circumstan- ces than the real merit of the forceps. The influence of former instructors, long habit, and often mere accident, may determine his choice. For my own part, I set out with the use of Davis' forceps, influenced no doubt by the eminent professor whose lectures I had attended, and whose dexterity would have enabled him to succeed with almost any instrument. After a few years practice, however, I abandoned Davis' forceps, and substituted that of Dr. Hodge, which I still consider a much superior instrument, and so far as I am able to judge, the best in use among us. I prefer Dr. Hodge's to Davis', because the former is long, while the latter is short, and not so well adapted to cases where the head has to be taken at a consider- able height. The blades of Davis' forceps are wide and diffi- OBSTETRIC OPERATIONS. 251 cult of introduction, especially in primiparae, or when there is rigidity of the parts; whereas the blades of Hodge's, which are perhaps as narrow as is consistent with their purpose, admit of easy introduction and of being readily moved when within, so as to bring them into the desired position. Davis' forceps is furnished with the British lock, which although possessing the advantages of some yielding mobility, is not perhaps en- tirely secure, while Hodge's instrument is fastened with the German lock, which can be so adjusted as to admit of all neces- sary motion, while at the same time there is no danger of the branches becoming unlocked in the course of an operation. Whatever instrument we adopt, it is probably better to ad- here to its use alone, at least in all ordinary cases. It may be well enough to have another in reserve for very special occa- sions. But by restricting ourselves to the use of a single in- strument, we develope more fully its powers, become more familiar with all its applications, and probably, on the whole, obtain better results than we should do by having several in use at the same time. The occasions or emergencies requiring the employment of the forceps are elsewhere treated of in this work. It will be our business in this chapter, therefore, simply to point out the mode of using this invaluable instrument, and designate the proper moment for its employment, when this is deemed neces- sary. When we have decided upon the expediency of an operation, we should inform the patient and her friends of our decision, explain to her our reasons, especially if she be intelligent, and quiet her apprehensions by assuring her that she does not incur any serious risk by submitting to our wishes. If she be already under the influence of chloroform, this procedure would of course be unnecessary. But many women while in possession of consciousness, have an insurmountable horror of the " use of instruments." When we consider how frequent is their abuse, this is not at all wonderful. The acquiescence of the patient being secured, the next thing to be attended to, is her position preparatory to the opera- tion. An important question is, what should this be? British 252 PRACTICAL MIDWIFERY. obstetricians prefer what is called the usual obstetric posi- tion—that is, to lie as in ordinary labor, upon the left side, the knees drawn up, and the legs flexed at something like a right angle upon the thighs. They claim for this position that it disturbs the patient less, as she requires no removal or additional adjustment, and is therefore less excited or alarmed, than if more formal preparations were made. This may be true in whole or in part, but it is more than doubtful whether these supposed advantages are not much more than counterbalanced. In this position she must necessarily have her hips drawn very near the edge of the bed, so as to lie, one would think, in a very constrained and uncomfortable posture. The operator, too, must labor under disadvantage, for want of ready access to his patient. Of course habit would, in some measure, remedy this ; but I cannot refrain from the belief that the selection of this position is not so much from any real ad- vantages it possesses, as from hereditary or national predilection. The forceps may be applied by an expert operator in almost any posture of the patient, but when there is no urgent contra-indi- cation, we may as well as not avail ourselves of the advantages of position, as it may thus be much more agreeable to ourselves and much less dangerous to the patient. For my own part, I greatly prefer to have the patient placed across the bed, and upon her back, her hips drawn quite near the edge, for this will cause her no discomfort, as she will have the whole width of the bed to support her. Two chairs are placed beside the bed, front to front, but sufficiently far apart to allow the ope- rator to stand between them. The limbs of the patient, pro- jecting beyond the bed, are flexed at the knee, and a foot placed upon each chair. Some light covering is thrown over each limb for protection, and a sheet or quilt from the bed should be drawn over her person, to prevent exposure. An assistant on each side takes charge of the limbs, by firmly taking hold of the knee with one hand, and of the foot or ankle with the other. The body of the patient should be slightly elevated by bolsters, etc., placed underneath, and steadied, if possible, by a strong and reliable assistant—the nurse, if present, will often do very well. The blades of the forceps should now be warmed OBSTETRIC OPERATIONS. 253 by immersing them in tepid water, hastily wiped dry, and anointed externally with olive oil or a little fresh lard. If there be no contra-indications to the use of chloroform, or no serious objections on the part of the patient or her friends, I would advise that she be rendered insensible before the intro- duction of the blades of the forceps. She will thereby gene- rally retain her position more steadily, and of course avoid the danger of injury from the instrument through violent move- ments. She will also escape suffering both from the introduc- tion of the blades and from extraction, a matter of no small importance, at least to herself, and what is perhaps no less to be desired, will retain no horror of instrumental delivery, to harass her with the dread of a like catastrophe in future labors. Another advantage of chloroform is, that it suspends to a con- siderable extent reflex action, and by thus partially holding in check the action of the womb, so far as dependent upon that cause, often greatly facilitates the introduction of the blades. Formerly it was my practice to introduce and lock the blades before I administered chloroform, and pressing upon the handles, to ascertain by questioning the patient whether I had included any of her structures in the grasp of the instrument. But for some years past I have abandoned that precaution as unnecessary, and thus far have had no reason to repent of this course. I have, however, been the more careful to avoid such accident when the patient was not in condition to apprise me of its occurrence. While I am myself most thoroughly convinced of the great utility of chloroform in forceps operations, I am aware of the many objections brought against it, even by respectable mem- bers of the profession, and especially by those who have never tried it. I will not here stop to answer any of these; it is enough for me if I can annul, or even diminish the sufferings of my patients without doing any present or prospective injury. I envy no man his feelings, who can coolly witness the agony of an instrumental labor, such as it at least sometimes is, when by dismissing his prejudices or his fears, he could save this fearful penalty of maternity. At the same time I would say to the young practitioner, be cautious. 254 PRACTICAL MIDWIFERY. The next step is the introduction of the blades. How is this to be done ? According to authors and teachers generally, the answer to this question is long, complicated, and often not very intelligible. The truth is, the same unvarying rules have not been universally accepted and taught. With most, however, the object has been to apply the blades to the sides of the head of the child whatever might be its position, and however high or low it might be in the pelvis, even (if we understand them rightly), above the superior strait. That very eminent Ameri- can obstetrician, Dr. Hugh L. Hodge, admits of no exception to this rule, but when the head is locked at the lower strait by the bi-parietal diameter. In this case, he will allow the blades to rest respectively upon the occiput and forehead ; and we may add, it is very difficult to conceive how in that circumstance they could be applied in any other way. To attain the object above stated, namely, to apply the blades to the sides of the head, whatever its position or wherever its place in the pelvis, would manifestly be often difficult, and sometimes practically impossible. Hence the rules laid down to accomplish this object are numerous, some- times obscure, or even unintelligible, and not unfrequently as given by different authors, contradictory. We have reason too to believe that young and inexpert practitioners in their eu- deavor to recall and follow these rules at the bedside, frequently do serious injury to mother or child, or both. We will endeavor here to indicate a simpler and, as we humbly believe, a better method; a method which may be said to reduce the numerous rules for the application of the forceps to a single one, or rather to substitute a single one in the place of all others. We should first, as usually enjoined, ascertain ps nearly as possible the position of the head. I say head, for if any other part present, the forceps has nothing to do with it. This can- not always be certainly determined, but generally it may be. If we can reach the occiput in nearly all cases, it differs suffi- ciently from the forehead to distinguish it from that part, and of course to enable us to determine to which side it is turned. The direction of the sagittal suture and the position of the OBSTETRIC OPERATIONS. 255 fontanelles are generally relied upon as guides in enabling us to decide this point. A little reflection will lead the student to see how he may avail himself of these to ascertain the position of the head. If, however, we cannot determine the exact position, an approximation to it is all that is absolutely necessary. We will suppose all things ready, as we have before indi- cated, that the woman is arranged in the posture for which we have expressed our preference, which we need not again describe, and that it is Dr. Hodge's long forceps that we are about to use. We first oil the index and middle fingers of the right hand, carefully insinuate them into the genital fissure, carry them up in contact with that region of the foetal head, which is turned to the left side of the mother. If the head have not entirely escaped* from the womb, we must carefully lift, as it were, the still encircling lip from the child's head, so as to leave room for the blade to pass between them. We must continue to support the attenuated section of the os uteri upon the dorsal side of the fingers until the instrument is in- troduced within. We then with the left hand take hold of the blade, which, from its shape, we readily determine should occupy the left side of the pelvis. In Hodge's forceps, this is the one that carries the thumb-screw. It is held very much in the manner we usually hold a pen. The handle is held slant- ing and nearly over and parallel with the right groin of the woman; while the point of the blade is inserted along the palmar surface of the insinuated fingers, and in close contact with the fcetal head. The object now is to carry up the instrument so that the point follows the convexity of the cranium, until it has reached the situation where it is to be left. While this movement is being executed, the handle, at first nearly par- allel with the right groin of the patient, is carried over to- wards her left thigh and depressed so as to rest considerably below it, and if not held in the hand of an assistant, is sup- ported by the posterior commissure. It is better to leave it * Unless the os uteri be well relaxed and very dilatable, we should not attempt to pass the forceps within it. It will be better to wait under ordi- nary circumstances till the head has fully passed from the womb. 256 PRACTICAL MIDWIFERY. thus than to commit it to the care of an inexpert agitated nurse, or like person, who may be present. When the left blade is carried up to its place, the right is introduced above it in a similar manner, the hands changing office, and the operation being reversed. It must be remem- bered that no force whatever is to be used in this stage of the operation. The blades should be held so lightly that force is impossible without taking a firmer grasp. If the point be arrested in its progress, we may be sure it is going wrong, and instead of compelling it to advance, the blade should be par- tially or wholly withdrawn, and a second attempt made. We should be careful to make the point of the instrument closely hug the head; it cannot go wrong while following the sphe- ricity of the foetal cranium. We should always desist from our attempts at introduction during a pain. The blades thus introduced along the sides of the pelvis, no matter where the head may be, whether at the superior strait, in the cavity, or at the lower strait, will lie the one upon the one extremity of it, and the other upon the opposite. If at the superior strait, the one will rest upon the occiput and the other upon the os frontis, or frontal bone, or nearly so. If it have descended into the cavity, it is likely to be grasped more obliquely ; and again, if the head have already reached the lower strait and completed its rotation movement, the blades of the instrument will lie upon its sides. When we have succeeded in introducing the blades of the forceps, the next step in the operation is to procure an easy lock; that is to bring the handles into such proximity and correspondence that the thumb-screw on the one can be intro- duced into the mortise or notch in the other. Here, again, no violence must be used to effect this object. If we do not at first succeed, we must with all gentleness so alter the position of the blades by partial withdrawal of them, or such other movements as common sense suggests as likely to effect the object. No specific rules can be given that will apply to all cases, and if the operator have not sufficient ingenuity to see what manipulation is likely to assist him to the attainment of his purpose, he had better abstain from the operation alto- OBSTETRIC OPERATIONS. 257 gether. If, however, the blades be well carried up, and the handles well pushed back toward the posterior commissure, an easy lock will very generally be readily procured. The observ- ance of this latter expedient is very essential to success. When the mortise fairly embraces the stem of the screw, a few turns are given to the latter, just sufficient to prevent the blades from separating, without making the lock too tight or unyield- ing. The next step in the operation is extraction. To effect this, we grasp the handle of the forceps with the right hand, in order to apply the requisite force, while a couple of the fingers of the left may be applied to the top of the child's head. Here, again, we must carefully abstain from all unne- cessary violence. In grasping the handles of the long forceps, we must remember they have great leverage power. When merely extraction is the object, without compression, it will be sufficient to seize the instrument near the lock, so that very little compressive force will be exerted. We need not violently squeeze the head to keep the instrument from losing its hold or slipping. If the blades be well carried up, in ordinary cases, they will not slip; the maternal parts will retain them in place. Perhaps they are more likely to slip when violently compressed than when gently held. We must remember, too, that we are supposed, generally at least, to have in our grasp the head of a living child, the continuance of whose life de- pends upon our skill and care. If the head be taken at the superior strait, the extracting force should at first be applied, as nearly as we can, in the di- rection of the axis of that strait, and varied as the head ap- proaches the outlet. A good rule will be to apply the force in the direction which the handle of the forceps, left free to move, may point. This will be determined by the head mov- ing in the direction of least resistance. The instrument should be so held and traction so applied that the handle may rise, and the whole instrument rotate in our hand, if the advancing head dispose it so to do. What we have to do, is to apply the vis a fronte, and leave the head to select its course according to the law laid down in the chapter upon the mechanism of labor. 17 258 PRACTICAL MIDWIFERY. Some advise a simple extracting force, contending that the forceps is or should be regarded as a simple tractor. Others, and I think with better reason, maintain that the instrument is not only a tractor but a lever, and that its leverage power should also be subsidized in delivery. While authors generally admit that the forceps is competent to act as a lever, the exact nature of its leverage power seems not to be so clearly under- stood. It has been represented as a double lever, the lock or thumb-screw being the fulcrum upon which each blade or sep- arate lever turns. This view is correct, if we regard only its compressive power. When used simply as a compressor, each blade acts as an independent lever, and the force of each is in a direction exactly opposite to that of the other. These forces, however, do not directly tend to effect delivery, but only indi- rectly, if at all, by shortening one diameter of the foetal head. It is only when the oscillatory movement is given to the handle, that the leverage power of the instrument is called into play so as directly to contribute to the delivery of the head. Here each blade becomes alternately a lever and a tractor, and each of the sides of the pelvis of the mother alternately the fulcrum. When the handle of the instrument is made to sweep round toward the right thigh of the woman, the blade upon that side acts for the moment as a lever carrying the head somewhat forward, and the internal surface of that side of the pelvis is the fulcrum; while the blade on the opposite side performs the function of a tractor, tending thereby also to ad- vance the head. When the movement is reversed, precisely the opposite action ensues. Any one may demonstrate to him- self the alternate traction power of the blades by grasping his hand in the forceps, and then executing the oscillatory move- ment of the handle. When the head is small and has been arrested only through want of uterine power, direct traction alone may be sufficient. But when any considerable resistance is to be overcome, we should unite a gentle oscillating movement of the handle from thigh to thigh, and thus combine the leverage power of the instrument with its traction force. This movement serves, as it were, to tide the head over any obstruction created by the OBSTETRIC OPERATIONS. 259 dragging down before it of the soft structures lining the par- turient canal of the mother. When the head fits tightly, these structures are liable to be torn or otherwise injured by a simple, straightforward extracting force; whereas, by an os- cillating or pendulum movement, when the head is thrown, say to the right side, the corrugated tissues on the left are per- mitted by their resiliency to fall back. .Again, when the head is thrown to the left side, it as it were oversteps the tissues which had just partially receded upon that side, and allows those upon the other to fall back in like manner, and so on alternately, till the head has passed. Practically, all experi- enced operators know how much, in difficult cases, gentle and skillful oscillation contributes to the ease of delivery. There should be no haste, at least in ordinary cases. " Time enough if safe enough," should be our motto. Sometimes, when only gentle aid is required, in addition to the natural powers, we may act very deliberately, relaxing our hold in the inter- vals of the pains, and adding our assistance only as they recur. But often a more speedy delivery will be proper, always, how- ever, occasionally intermitting our efforts, in imitation of the na- tural process of labor. iSTo general rule applicable to all cases can be laid down. When the resistance to be overcome is great, we should act deliberately, giving time for the moulding of the head, and the dilatation of the soft structures, through which it must pass. The compressing power of the pelvis of the mother, acting through the vis a tergo of the uterine force, or the vis a fronte furnished by the forceps, is much better than any compression by the violent grasp of the handle of the instrument, which, while it shortens one diameter of the head, lengthens another, and that the very one we desire to shorten.* On the contrary the compressing, moulding force of the pelvis, diminishes those diameters which encounter resistance, and lengthens only that which meets with little or none, namely, that corresponding with the axis of the parturient canal. * It must be remembered that the contents of the cranium completely fill its cavity, and therefore when they are forced by compression from one diameter, they must distend the head in the direction of the diameter, at right angles to it. This may be illustrated by compressing a bladder filled with water. 260 PRACTICAL MIDWIFERY. As the extracting force is continued, provided the head ad- vance, the handle gradually rises, as the presenting part sweeps over the curve of Carus, until it becomes, in some instances, nearly parallel with the abdomen of the mother. This move- ment should not be resisted, but rather encouraged. When the top of the head reaches the perineum, and that or- gan begins to be put upon the stretch, great care is to be taken to prevent its laceration. This is avoided, not so much by fur- nishing any imaginary support, as by operating slowly and cau- tiously, so as to give it sufficient time to distend. Some advise the disengaging of the forceps, when the head rests upon the perineum, and the leaving of the delivery thenceforward to the natural powers. But it is to be remembered that in many cases requiring the forceps, the natural powers are for the time in abeyance, and if the head be abandoned there, it will remain there indefinitely. We much prefer completing the work we have begun, and not removing the instrument until we have fully delivered the head. As soon as the head is born, the in- strument should of course be disengaged; and any further assistance that may be necessary should be furnished by the hands alone. A finger hooked in the axilla of the arm turned toward the sacrum, will give the requisite aid for the delivery of the shoulders. We have thus far spoken of the introduction of the blades of the forceps along the sides of the pelvis, without any special re- gard to the situation or position of the head. When the head is yet above the superior strait, or just enter- ing the brim, its occipito-frontal diameter more or less nearly corresponds with the transverse diameter of the pelvis. Conse- quently if seized with the forceps introduced along the sides of the pelvis, in this situation, one blade will rest upon the back part and one in front. Fears, therefore, may be entertained lest the instrument should bruise and disfigure the features of the face. Practically, however, with care there is little danger of this. It will be remembered that as the head presents at the superior strait, it is strongly flexed upon the thorax, and be- comes still more so as it dips into the brim. This flexion too, is no doubt still further increased by the compressing force of OBSTETRIC OPERATIONS. 261 the forceps. While one blade, therefore, rests upon the occi- put, the other expends its force upon the os frontis, or frontal bone of the cranium, and not upon the face. We have noticed but one exception to this, of which we have elsewhere spoken at some length. In this case there was a fluctuating tumor im- mediately beneath the chin of the child, entirely filling the space between the chin and thorax, and completely preventing permanent flexion. The head failed to descend, or even fairly to enter the superior strait. The forceps was applied before rotation, if possible at all, could have taken place, and delivery waseffected without any unusual difficulty. A slight inden- tation, which passed away in a very few days, was found close to the root of the nose ; the skin was neither cut nor abraded. But if even under the like unfavorable circumstances, the blade situated in front of the head should rest upon the face, so little compressive force is usually needed, that we may avoid doing any serious, permanent injury. Again, it may perhaps be doubted whether the head brought down in this manner, can pass the inferior strait without effect- ing the movement of rotation. That it can, has been again and again practically demonstrated. Prof. Tarnier, the anno- tator of Cazeaux' Midwifery, admits that it may be sometimes so delivered ; we believe from practical experience and obser- vation that it may be generally so, and that without serious in- jury to either mother or child, unless the latter be unusually large, or the pelvis of the former abnormally small. Some as- sert that the head not unfrequently rotates with the forceps — some that it occasionally rotates within the forceps. We have certainly experienced the former, and think we have met with at least one case of the latter. It is moreover probable that when the instrument is held with sufficient delicacy, the former movement will usually take place when the occipito-frontal diameter of the head is too long to pass the transverse diame- ter of the lower strait. When the head rotates with the for- ceps, known by the twisting of the handle in the hand of the operator, it is better to disengage and re-apply the instrument. We will probably then be able to apply the blades to the sides of the child's head ; or if the latter be not sufficiently rotated 262 PRACTICAL MIDWIFERY. Tor this, we may attempt to complete the rotation with a blade of the forceps, at least so far as to accomplish this object. Again, when there is reason to suspect that the head when seized by its long diameter at the brim, cannot pass the lower strait without rotation, it will be best, when we have brought it do\vn within the cavity of the pelvis, to detach the forceps, rotate the head with a blade of the instrument, the fingers or the lever, and then reapply. This manoeuvre may not always be practicable, but generally is. We can then deliver, having the long diameter of the head to correspond with the long di- ameter of the inferior strait. When the head has already descended considerably into' the cavity, and rotation has partially taken place before we apply the forceps, the obliquity may be such, that introducing the blades along the sides of the pelvis, as we have above indi- cated, they do not settle in sufficiently exact opposition to, or in parallelism with each other, to rest steadily upon the cranium, or to admit of an easy lock. When this is the case, they had better both be withdrawn, and complete rotation effected as above directed. This done, their reapplication will be easy and satisfactory. If the head have already reached the inferior strait, or be resting upon the floor of the pelvis when we are required to operate, the introduction is easy, inasmuch as to carry the blades up the sides of the pelvis, is to place them upon the sides of the foetal head. This of course assumes that rotation is completed, and the occiput or forehead turned under the arch of the pubis. But very slight extracting force is here ne- cessary, the wedge and leverage power of the instrument being often sufficient to effect delivery. As soon as the operation is completed, the patient, unless in a state of extreme exhaustion, should be replaced comfortably in bed, and special care taken to remove all wet clothing from contact with her person. This should be done not by at once stripping off her clothes, but by withdrawing wet and soiled garments, and interposing between them and her skin dry and warm skirts. She should be strictly enjoined to avoid all con- versation, excitement and exertion of every kind. As has been OBSTETRIC OPERATIONS. 263 advised at the close of normal labor, a few drops of the tincture of arnica should be diffused in half a tumbler of wafer, ot which a teaspoonful may be given every two hours. It is not uncommon, after instrumental delivery, for the patient to be unable to pass her water. This should be par- ticularly attended to. If she have been much exhausted, it would be well to introduce the catheter and evacuate the urine, without requiring her to make the effort to pass it herself. Most women, at least shortly after delivery, are unable to pass their water without assuming a more or less erect position. This should be avoided if possible, immediately after all severe labors as flooding or syncope or both may be the result. Before closing this chapter, it may be well, although we have repeatedly, in the course of this work, adverted to this subject, to speak somewhat more fully and connectedly of the precise moment when this operation, when deemed proper or imperative, should be undertaken. British practitioners formerly advised us not to apply the forceps until an ear could be felt—that is, till the head was low in the pelvis. This precept seemed to be given irrespective of the suffering or exhaustion of the patient. Its strict observ- ance necessarily led to a frequent resort to craniotomy. Again, it was thought by some that the head must in all cases have passed entirely out of the mouth of the womb before we should interfere. Some again fixed the time for resort to the forceps by the number of hours the head had been stationary in the pelvis, or resting upon the perineum. They attempted to de- monstrate the evils resulting from a too early use of the instru- ment, by pointing to cases of contusion, inflammation and sloughing of the vagina and neighboring structures. We now, however, believe that these distressing accidents more fre- quently arise from too long delay, than from precipitancy. When the head is strongly driven against these tender parts by a womb vigorously endeavoring to overcome resistance, or when they are pressed by the cranium which has become wedged within them, although the uterine powers may have failed and ceased to act, the circulation is arrested, and this, aided by the prostrated vitality of the patient, leads to a low 264 PRACTICAL MIDWIFERY. grade of inflammation—call it what you please—and perhaps subsequent sloughing. To determine the exact time when interference is proper, we should be guided by the condition and necessities of the patient, It matters not whether according to the old classification the labor be natural or preternatural, if we find the powers failing or unequal to the task, and the case be one admitting the appli- cation of the forceps, it is our solemn duty to render assistance through its aid. We must not stand as idle spectators of the struggle, nor content ourselves with the hope so, that the powers of nature will ultimately prevail; we must become forth- with parties in the contest, and ensure their safe and speedy triumph. We will derive aid in arriving at a correct conclusion, by a just appreciation of the health, strength and powers of endur- ance of our patient. In the case of constitutionally feeble women, or those who have been debilitated by pre-existing dis- ease, and whose natural resources there is reason to fear will be inadequate to the task, at least without leading to extreme and dangerous exhaustion, it will be well to apply the forceps at a comparatively early period of the labor. In such patients, it is of the utmost importance to husband their resources. When intensely prostrated, they often become the prey of some fatal accident or puerperal disease; or if they recover, it is through a tedious convalescence, and perhaps regain at best but imper- fect health. In such cases the forceps may be introduced, not with a view to immediate extraction, but to aid the patient at the recurrence of each successive pain. Extracting force may be applied at the commencement of a uterine contraction, and the grasp relaxed when the pain passes off. The womb is thus relieved of much of its task, and, as it were, encouraged to increased effort. In a word, we should carefully watch the condition of the patient as labor progresses, and hold ourselves ready to dis- charge our duty whenever her failing powers hang out the sig- nal of distress. " The forceps," said the late Dr. C. D. Meigs, " is the child's instrument," but it should also be remembered it is the mother's, too. OBSTETRIC OPERATIONS. 265 • Thus much in relation to the safety of the mother, but that of the child no less, demands our attention. Unreasonable de- lay may also jeopardize the life of the latter, at least under cer- tain circumstances. It is well, therefore, to know what these circumstances are, and when a regard for the safety of the child should enter into our calculation in determining the proper moment for resorting to the forceps. It is surprising how often the child, after long delay, and even when subjected to the powerful action of the womb, will cry vigorously as soon as it is born. It would seem, therefore, that delay alone is not necessarily fatal to its life. So long as the action of the womb is intermitting—a quies- cence of considerable length occurring between the pains, the foetus will bear a great amount of pressure without fatal in- jury. But when the pains are not only violent but continuous, as if provoked by Ergot, there is great danger to the child from their direct effect upon the brain, as well as from com- pression of the cord and premature detachment of the placenta, accidents which under these circumstances are liable to occur. AVhen such is the case a resort to the forceps, where there is no imperative contra-indication, should be seriously thought of. When at any point in its descent the head ceases to advance, but recedes somewhat in the interval of the pains, there is no special reason for apprehension, even though the womb be act- ing with great vigor. On the contrary, if the head remain sta- tionary, do not in any degree fall back when the pain subsides; delay is then dangerous, and may be fatal to the life of the child. When, in connection with any of the foregoing circum- stances (or, indeed, independent of them), the fcetal heart-beats are manifestly growing feebler, and the accustomed fcetal move- ments less distinctly felt by the mother, danger is to be appre- hended, and it becomes our duty to act accordingly. Within the last few years a resort to the forceps has become much more common than formerly. This has arisen in part from the happier results obtained in the application of the in- strument, owing to its greater perfection, and greater skill and simplicity in its application. The fact, too, that many of the 266 PRACTICAL MIDWIFERY. disasters once charged to the premature use of the forceps, are now shown to have been due to culpable delay, has done much to remove the unreasonable prejudice that long existed against an operation so conservative of maternal and infantile life. It may be, however, we are at this moment in danger of drifting upon the opposite extreme. While, therefore, we advocate the free and intelligent use of this noble instrument, we would so- lemnly warn, especially young practitioners, to guard against its too frequent and unnecessary employment in obedience to a mere whim of fashion. VERSION. The term version, or turning, is applied to that operation by which one part of the fcetus is substituted for another, with a view to greater advantage in delivery. There are two varieties of this operation, respectively called cephalic version and po- dalic version. The former supplants the existing presentation by bringing the head to the entrance of the superior strait, the latter the pelvic extremity of the child, that is, the breech, the knees, or the feet. When cephalic version is practicable and not contra-indi- cated by co-existing circumstances, it is preferable to podalic, inasmuch as delivery by the head is usually safer to both mother and child than delivery by the feet. And first., we will speak of cephalic version. This method of turning has at different times in the history of midwifery been proposed and advocated, but has again as often sunk into neglect. Lately, however, since what is called the bi-manual method of operating has been more distinctly described and successfully practiced, it has once more come into favor, and is more likely now to retain its reputation than heretofore. Cephalic version is generally applicable to those cases where the head, although not corresponding to the entrance into the upper strait, is nearer to it than is the pelvic extremity of the child, where the waters either have not been evacuated at all, or have been but partially drained off, and where the present- ing part is still movable. Before proceeding to operate, it will OBSTETRIC OPERATIONS. 267 of course be necessary to ascertain the presentation of the fcetus, that is what part is nearest the entrance of the superior strait, and, as it were, waiting to engage in it, and against which the finger first impinges, when it is within reach, in making the examination. We should, moreover, if possible, satisfy ourselves of the position of the presenting part, or its relation to the pelvis of the mother. Having ascertained these particulars, the next thing to consider is the proper position of the patient, in order to facilitate the operation. She may con- tinue to lie upon the left side as usual, her hips being placed as near as possible to the edge of the bed, her right leg being elevated and supported by an assistant, with one hand placed under the knee and the other grasping the ankle. This will re- move obstruction out of the way of the right hand of the accouch- eur as he employs it in external manipulations. The head of the patient had better be directed toward the middle of the bed, so that the operating arm be not unnecessarily bent or twisted, and all pillows and supports removed, so that the pelvis, shoulders and head be as nearly as possible upon the same level. If, however, the case is likely to prove difficult, the position upon the back, similar to that we have advised for the forceps operation, is to be preferred. The objection that it gives additional trouble and disconcerts the patient, is not a very valid one, when weighed against real advantages. When the woman is very weak, however-, or very nervous and apt to be alarmed by what might seem to her more formidable prepa-^ tions, this arrangement, unless considered very important, had better be dispensed with. Before proceeding to turn by this or any method, the os uteri should be so far dilated as to admit the introduction of two or three fingers and dilatable—that is, soft to the touch, so as to afford assurance that it will readily yield to distending force. We will suppose the case to be a presentation of the shoulder, the membranes are either intact or have been lately ruptured, and the presenting part is not deeply forced down into the pelvis, but still movable at the brim. The patient may or may not be under the influence of chloroform, although this agent is a most important adjuvant in both varieties of version, as it generally secures steadiness 268 PRACTICAL MIDWIFERY. on the part of the patient, a very great advantage. The ac- coucheur should strip off his coat, roll his sleeves above the elbows, anoint thoroughly the dorsal surface of the fingers and hand, and it may be well to introduce a piece of lard between the labia. Two or three fingers of the left hand are then gently insinuated into the vagina and carried up to the presenting part. Some difficulty may be experienced in the introduction from the labia being as it were inverted and pushed up by the fingers. This may be corrected with the fingers of the right hand parting the labia by a movement such as we use in sepa- rating the eyelids. In order to have the entire command of the presenting part, it will probably be necessary to carry the entire hand into the vagina, and this should be accomplished in the most gentle manner. We may succeed better by taking advantage of the presence of a pain if the patient be not anaesthetized, as her natural suffering will divert her attention from that caused by the introduction of the hand. When the presenting part is reached and well under the control of the fingers, it should be gradually pushed up, in the absence of pain, the head reached, and by a coaxing motion of the fingers drawn toward the entrance of the pelvis, while the right hand applied externally, operates upon the opposite pole of the fcetus, and in an opposite direction, that is, toward the fundus of the womb. This method is called bi-manual, because both hands are employed working to each other's aid, the one inter- nally and the other externally; bi-polar, because both poles or ends of the fcetus are simultaneously acted upon. When the head is brought fairly over the entrance into the pelvis, it should be retained there, if there be no reason to hasten delivery, until through the force of the womb it begins to engage in the upper strait, when the labor may be aban- doned to the natural powers. But if for any sufficient reason it be deemed necessary to expedite delivery, the forceps must be applied, subject to the same rules governing their applica- tion, in a spontaneous or natural vertex presentation. Cephalic version may also occasionally be effected, when the foetus lies somewhat transversely and the head is too high to be felt by the ordinary examination per vaginam. In the first OBSTETRIC OPERATIONS. 269 place, the patient, laid upon her back, should be fully anaesthe- tized with chloroform, and the position of the head ascertained by palpation. One hand then is externally applied above the head, and by a sliding movement, gently presses it down toward the entrance of the superior strait, while the other hand acts in a similar manner upon the other end or pole of the foetus, and in the opposite direction. When the head is brought suffi- ciently low to be within reach, the fingers of the left or right hand, as best suited, may be introduced into the vagina, carried up and made to play upon the cranium, so as, with the aid of the external hand still operating, to bring it over the entrance into the pelvis. When this is effected, the head should be re- tained in this position and the membranes ruptured, when, as the waters flow off, it will engage in the upper strait, and the labor, if there be no indication requiring prompt delivery, may be left thenceforward to the powers of nature. Cephalic version, however, although greatly facilitated and extended by the introduction of the bi-polar method, accredited to Dr. Braxton Hicks, but probably practiced long before there was any written account of it, must always be limited in its application, and in very many cases requiring version, alto- gether impracticable. Where this fails, podalic version must be our resort. As we have in the course of this work generally pointed out the indications requiring turning, it will be sufficient here to state that this latter variety of the operation should be had re- course to only when the former is deemed inapplicable, or upon trial has failed. Podalic version is justly regarded as a serious operation, both as regards the mother and the child, and should not therefore be adopted, unless the circumstances imperatively require it. When we have decided that a case demands podalic version, the next point upon which we wish to satisfy ourselves is how shall we perform it ? In giving this information to the student we will first speak of the preliminary measures to be adopted, in order to ensure convenience in operating, safety and success. It is generally advised, first to empty the bladder by means 270 PRACTICAL MIDWIFERY. of the catheter, and the rectum by administering an enema. If, however, we have required the patient, as we should do, fre- quently to pass her water during the progress of labor, the cath- eter may be dispensed with. In like manner, if the bowels have been freely evacuated shortly before labor set in, it is not likely that any accumulation has taken place demanding our interference. Under the opposite circumstances, the above pre- cautious had better be regarded. The position of the patient preparatory to the operation is another matter of importance. I have generally permitted her to retain that ordinarily recommended for natural labor, namely, upon the left side. It has the advantage, whatever that may be, of requiring but little change in the surroundings of the patient, and therefore avoids excitement or alarm. In difficult cases, however, I prefer the dorsal position, with the hips drawn near the edge of the bed, as advised for the applica- tion of the forceps. It is necessary when the patient lies upon the left side, that the right leg should be elevated, and so held by the hands of an assistant. The bi-polar method is sometimes applicable also to podalic version. When this can be successfully employed, it much di- minishes the risks to the mother, inasmuch as it is not neces- sary, in order to execute it, to carry the hand into the womb. It may, moreover, be commenced while there is yet less dilata- tion of the os uteri than would be necessary were we obliged at once to insinuate the whole hand through that aperture. The bi-polar method, where it is not manifestly impracticable, should always first be tried. The left hand should be well oiled upon its dorsal surface and a lump of lard introduced between the vulvae. It is bet- ter, as a general rule, to divest ourselves of the coat, and turn up the shirt sleeves above the elbows, although this precaution may not always be necessary. If there be present no circumstance requiring speedy de- livery, we may wait till the mouth of the womb is pretty fully dilated. If otherwise, if it be sufficiently so to admit one fin- ger, we may commence the operation, by artificially promoting dilatation, either with the fingers or by introducing Doctor OBSTETRIC OPERATIONS. 271 Barnes' gum elastic dilators. When we can insinuate three fingers, we may begin to turn. The fingers of the hand to be introduced are collected in the form of a cone, and tenderly carried up till, if necessary, the whole hand is within the vagina. The direction in which the occiput is turned must be well ascertained, and then by a dex- terous, gentle motion of the fingers, the head is to be propelhd_ in that direction, while the right hand applied externally, upon the opposite pole of the foetus, is made to operate in the oppo- site direction. By this conjoined operation of the two hands, the head is made to ascend upon the one side, while the breech is caused to descend upon the other. The right hand, exter- nally, is shortly applied to the ascending head of the child, while the left hand internally comes in contact with the knees, descending upon the side of the womb, opposite to that along which the head has ascended. If the fcetus float in a large amount of amniotic fluid, it is not likely to remain stationary in the position in which it has been placed through the force exerted upon it by the hands of the accoucheur. It is better, therefore, if the membranes have not before been ruptured, when a knee comes within reach of the fingers of the left hand, to make an opening, and permit the waters, at least partially, to drain off. . This will give stability to the fcetus, and probably enable the practitioner to hook down a knee. Either knee may be taken. Dr. Barnes prefers the more distant one, but if this be not easily caught, he does not think it worth while to lose time in searching. Traction upon the knee aided still by the co-operation of the hand upon the outside, will complete version, and bring the pelvic extremity of the child to occupy the lower portion of the womb. The next step in the operation of delivery by podalic ver- sion or turning by the feet is extraction ; f»r be it remembered, turning is one thing and extraction is another and a very differ- ent thing. We may turn, and when this is executed leave the future process to be completed by the natural powers, or we may supersede them by art. Generally, however, the same considerations that prompt us to turn, also demand delivery with as little delay as possible. 272 PRACTICAL MIDWIFERY. When, therefore, a knee is secured, we proceed to bring down the limb and apply sufficient traction, slowly and care- fully, to cause the body of the child to descend. In doing this we must be careful simply to supply force, as far as possible in the axis of the superior strait. We are not to think of turn- ing the child one way or the other, according to our views of the course it ought to take. We should hold the limb so loosely in our hand that it may revolve if so disposed, or allow the hand to be so passive, as to turn with the revolving limb. If simple force be supplied, we may rest assured that the body acted upon, if it move at all, will move in the direction of least resistance ; and that direction here is the proper one. When the body of the child is born as far as, or a little past the umbilicus, we must see to the cord—prevent it if possible from being exposed to pressure. In order to effect this object, we should draw down a considerable loop of it, and remove the remainder so far as we can, to such situation as will give it most room, or place two fingers thrown slightly apart, one on each side of it, so as to form a channel between, in which the cord may securely repose. The next difficulty to be encountered is with the arms. These members are usually inclined inwards and are folded in front of the child. When traction is made upon the body, they are liable to be displaced and carried upward through friction upon the maternal parts. Hence they sometimes oppose a very formidable resistance to the further progress of delivery. If the child be small however, or the maternal passage wide, or both, these conditions coexist, even this accident may cause no trouble and the child be wholly born without any difficulty. If otherwise, however, it will be necessary to bring down the arms by the side of the child. In order to do this successfully and safely, it is necessary to bear in mind the construction of the joints, in what way they naturally bend, and carefully avoid forcing them to bend in an opposite direction. The hand should be passed up over the shoulder of the child and carried along the humerus until it reaches the elbow. The arm is then tenderly straightened by drawing it over the face OBSTETRIC OPERATIONS. 273 and breast and bringing it down by the side of the child. In the choice of the arm first to be operated on, Dr. Barnes ad- vises us to take the one we can move with the greatest ease, for if this be brought down it leaves more space for the adjust ment of the other. After the arms are brought down the next difficulty to be encountered, is the delivery of the head. In the chapter upon breech presentations we have spoken so fully of the delivery of the after-coming head, that it is unnecessary to repeat what we have there said, or to add anything in this place. Turning by the feet, while the membranes are still intact, or even where the waters are but partially drawn off, usually pre- sents no very great difficulty, even where the bi-polar method fails and we are obliged to carry a hand up into the womb and bring down a foot. To perform this the left hand and arm are well anointed with lard, the former only on its dorsal aspect. The fingers, gathered in the form of a cone, are very tenderly insinuated into the os uteri, the membranes ruptured, if still entire, and the whole hand carried up within the womb until a foot is felt, and grasped. But it is not a matter of indiffer- ence which foot we seize. If the arm be prolapsed, we may know from examination whether it is the right or left. This determined, we take the foot of the opposite side, for this, when acted upon, will cause the most easy and natural rota- tion of the body of the child and ascent of the prolapsed arm. In general that foot should be taken which will rotate and turn the child with least violence to the articulations, prevent the unfolding of the limbs from their natural intra-uterine position, and that will most tend to throw the forehead into the hollow of the sacrum in the progress of delivery. In in- troducing the hand, we should advance only in the absence of pain, and if the uterine contractions be powerful, we should flatten the hand upon the surface of the child, until the pain subsides. When we have selected and seized the proper foot, we commence traction, operating during the pains, and sus- pending our efforts while they are absent. There should be no hurry—no violence. The hand not employed in traction, should be applied externally, to support the womb, and to as- 18 274 PRACTICAL MIDWIFERY. sist in completing version, by pressing up the head. When version is completed, it should aid the extracting force, by downward pressure. It is surprising with what facility turn- ing is effected while the waters are retained, and if the mem- branes are first ruptured when the hand is carried up to oper- ate, so completely is the aperture plugged by the arm that very little of the fluid escapes. The delivery of the child here is of course the same as when a foot is brought down by the bi-polar method. But while the operation, as above described, is sufficiently simple, we are often called upon to perform it under very differ- ent circumstances. The patient may have been long in labor, the amniotic fluid dribbling away for many hours, so that we find the womb tightly embracing the child on all sides, indeed insinuating itself into all the sinuosities of the fcetus. Turn- ing, when the waters are thus almost completely evacuated, is, to use the language of the late Prof. C. D. Meigs, "a horrible operation." We have said, in speaking of cephalic version, the patient may be under the influence of an anaesthetic or not, as pre- ferred by herself or deemed proper by her attendant. But in the case here supposed, deep anaesthesia is of the utmost im- portance. Indeed the success of the operation sometimes de- pends wholly upon this resource. I have succeeded in cases of this kind by the aid of chloroform, where, I believe, turn- ing would have been impossible without it. But in order to be certain of its salutary effects, we must continue the inhala- tion until we secure complete insensibility to pain, which is usually attended by complete relaxation. We will sometimes find the presenting part, the shoulder for instance, so completely forced down and blocking up the passage that all attempts at introducing the hand are baffled. But after deep anaesthesia is induced, we are surprised at the ease with which we overcome what was before an insurmount- able obstacle. It is in these cases of the utmost importance that we use all gentleness and care in carrying up the hand, in desisting from efforts during pain, especially if the pains be violent, as they usually are, until the womb becomes quiescent OBSTETRIC OPERATIONS. 275 through exhaustion. The turning of the child is now effected with great difficulty, and it is, therefore, important we should operate slowly, giving the tissues abundant time to yield. Every step of the process should be taken with the utmost care and precaution. Where there is no necessity for an immediate operation, and especially when we have no assistant present capable of ad- ministering the chloroform, so as to steadily keep up its effects, I would advise, as I have done when speaking of Deviated Presentations of the Head, to give the patient one-fourth of a grain of morphia, and wait for its effects before commencing the inhalation. If she be suffering very severe pain, the dose may be repeated or a somewhat larger amount given at first. When the patient is previously under the influence of mor- phia, a smaller quantity of chloroform is required, and the effect is much more profound and persistent. Indeed, through the combined aid of these two agents, I have turned and de- livered in the most difficult cases, while the patient did not utter a moan nor move a limb throughout the whole operation. If morphia be previously given, it is important that the de- livery should be conducted slowly, to avoid shock, the dangers of which, I think, are probably increased by the administra- tion of that drug. Indeed, under circumstances wherein we have reason to apprehend severe shock, morphia had probably better be omitted. Hydrate of chloral, 15 grains, repeated at intervals of twenty minutes, may, in that case, be preferably used ; but I think morphia unsurpassed in its power to relax spasm, and bring such cases completely under our control. I know this practice will be strongly objected to by some as unhomceopathic. But I apprehend these cases lie outside the homoeopathic law, and even that, nothing to its discredit. I no less believe in the truth of the law of similars, because I know it is not applicable to the setting of a broken limb, or the reduction of a dislocated joint. Our aim is here to bring the impossible within the limits of possibility, and to save our patient from horrible suffering; and if we can devise any means to accomplish these purposes without entailing upon her lasting injury, it is our duty as men, and especially as 276 PRACTICAL MIDWIFERY. physicians, to adopt such means, asking no questions and solic- iting no man's approbation. CRANIOTOMY. Under circumstances to which we have repeatedly alluded in the course of this work, craniotomy, or the opening of the head of the child, becomes an unavoidable necessity if we would save the life of the mother. To decide when such ne- cessity exists is always a painful and solemn duty, unless we have sufficient reason to believe the child is no longer living, when of course the safety of the parent is the only object of concern. Otherwise, nothing but the saving of the life of the mother can justify us in taking away that of the child. The operation when fully performed, consists of two steps or stages, namely, perforation and extraction. The instruments employed for these purposes have been various. For perforation, Smellie's scissors has perhaps been most extensively used. It consists of two blades jointed to- gether similarly to the blades of the instrument after which it is named. These are made very strong, with cutting edges upon the back, and when brought together form a sharp point at the ends well adapted to perforate the skull. An instrument invented by M. Blot is preferred by many to the foregoing, and is perhaps likely to supersede it. It is constructed pretty much upon the same principle as Smellie's scissors. Both these in- struments may be found with the cutlers, where an accurate idea of their form and peculiarities may be had. When we have decided upon the necessity of this horrible operation, the first thing to be done is to place the patient in a convenient position, so as not only to render her as comfort- able as possible, but so that we can have the most ready access to her, and be the least hampered in the performance of our duty. She may be placed either upon the left side or the back, but generally, the latter is much the best. Her fears, if she be conscious, should be as far as possible removed by assurances that she incurs but little personal risk in submitting to the ope- ration. If there be no cogent reason to the contrary, she had OBSTETRIC OPERATIONS. 277 better be fully anaesthetized and well steadied by reliable as- sistants. All things being properly adjusted, we proceed as follows: If we select for perforation the instrument of Smellie or Blot, we take it in the right hand, while two fingers of the left are passed up the vagina till they reach the head—we must be sure that it is the head we feel. A spot should be selected where the perforator may be placed most nearly at right angles to the surface of the cranial bone, in order to diminish the chance of slipping. The point of the instrument is then carried up in contact with the inserted fingers and protected by them, until it reaches the selected spot upon which it is firmly im- planted, and then by a rotating movement it is forced through the skull. The sensation imparted to the hand will inform us of this event. The handles are then opened and the instru- ment rotated so as to enlarge the opening sufficiently for the contents of the cranium to be discharged. When this is done, the head collapses and may usually be extracted by one of the instruments in use for the purpose. That which has hitherto been most commonly used is called the crotchet, a most dan- gerous instrument. It is in the form of a hook, the point of which is flattened, and the shaft terminated by a handle cross- ing it at right angles like that of a tooth key. The hook is fastened by its point upon the skull, either outside or within the perforation, and in either case is liable to slip and do great injury to the soft structures of the woman. If this instrument be used at all, the point should be very carefully guarded in the act of extraction by the fingers, which are themselves very liable to be wounded. A still better ad- vice is to discard the crotchet altogether. The late Dr. C. D. Meigs of Philadelphia has proposed two pairs of forceps, known as Meigs' Craniotomy Forceps, which answer an excellent purpose. They resemble pincers with long handles, the one bent in the mandibles, the other straight. The latter, when the skull is quite soft, may be used to perfo- rate, the former to extract. I have performed the operation very satisfactorily as follows: I select as a perforator an instrument resembling a chisel; this 278 PRACTICAL MIDWIFERY. implement itself will answer the purpose very well, if a better be not at hand. If used, the corners and edge should be some- what blunted to avoid cutting the maternal parts. A better instrument however may be imagined by supposing the chisel terminated in a flat angular point, with edges sharp enough to penetrate the cranium under moderate force, but not to cut the soft structures of the mother, with which it may accidentally come in contact. The instrument is forced through the skull by a direct, not rotating movement, and thus makes in the scalp an incised, not lacerated wound. If the instrument do not readily penetrate, a slight stroke or tap with a small ham- mer upon the end of the handle, while the point is securely held in place, will accomplish this object. The instrument is then rotated, and will thus enlarge the opening in the skull to more than the width of its blade, which may be half an inch or more, while all the debris of bone will remain within the scalp, inasmuch as the wound in the latter is a simple gash, the lips of which when parted, tend immediately to fall to- gether and enclose the crushed bone underneath. We then take Meigs' bent forceps and carefully guiding the upper man- dible inside the cranium, and the lower between that bone and the scalp, seizing a portion of the skull, we remove it, carefully guarding it with the fingers as it is withdrawn, so as not to wound the mother's tissues with its sharp edges. We should be careful not to tear away the scalp in this operation, but simply to remove the underlying bone. When we have suffi- ciently enlarged the opening to give free exit to the brain, which should be thoroughly broken up by the perforating in- strument before it is withdrawn, we should then take a firm hold upon the margin of the perforated bone, the mandibles being adjusted as above directed, and carefully extract in the axis of the parturient canal. While we make extraction, the inserted fingers should be still kept near the point of the in- strument, so that should the portion of bone fastened upon break off, we may prevent it from wounding the passage. This accident is not likely to happen, but had nevertheless better be guarded against. When the scalp is thus left intact except the mere incision at first made by the perforator, it is manifest OBSTETRIC OPERATIONS. 279 its edges will overlap the edges of the cranial bone, and pre- vent them, in extraction, from lacerating the maternal tissues. The use of the speculum has been advised in the operation of craniotomy, but it seems to me it would be very much in the way, and after all contribute no important aid. Any one who cannot trust his sense of touch, had better employ another to operate for him. The operation is most simple when the top of the head can be selected for the opening, but this cannot always be done. With proper care and dexterity other parts may be perforated and the operation successfully performed. CEPHALOTRIPSY. This operation contemplates the reduction of the size of the foetal head by the crushing of the cranial bones, in order to effect delivery in cases where the deformity of the pelvis is too great to admit of it, with safety, by craniotomy alone. Although some allusions seem to indicate that an indistinct idea of the operation was entertained long ago, practically it is of recent date. As the hint was probably first taken from the action of the obstetric forceps, which in early days no doubt too often and unintentionally served as a cephalotribe, cepha- lotripsj^ must have been introduced subsequently to the inven- tion of the former instrument. The obstetric forceps of Cou- touly, Assalini, Delepech and Lauverjat acted as powerful compressors, and used as such would readily suggest the idea of a stronger instrument to be applied to the crushing and the further reducing of the size of the fcetal cranium. The credit of inventing the cephalotribe (the name given to the instrument used in the operation, of which we now speak) is attributed to A. Baudeloque, nephew to the celebrated ob- stetrician of the same name. Its construction is similar to that of the obstetric forceps, but the blades are narrower and stronger than those of that instrument, and usually destitute of the pelvic curve, and possessing the cranial, only in a slight degree. Various contrivances have been adopted for applying the com- pressive force. Some modification of the screw power has been 280 PRACTICAL MIDWIFERY. the most common. A screw is passed from one handle through the other, and worked by a lever in the form of a windlass. It is manifest this would exert immense power in approxi- mating the handles, and act with a proportionate force in the crushing of the head. The instrument as above described is a heavy and clumsy one, of difficult application, and in some respects lacking in efficiency when applied. M. Cazeaux enumerates the follow- ing defects, viz.: " 1. It is too straight to accommodate itself to the curvature of the pelvis, and it is therefore applied with difficulty to the side of the head. 2. As the clams are nearly plain, they open like a pair of scissors, and do not encase the head as the concave blades of the ordinary forceps do; conse- quently they are liable to slip, and thus give rise to serious accidents. 3. Tractions made by it are very often ineffectual, even when well applied to the head; because it necessarily draws in a direction different from the axis of the superior strait, owing to the absence of curvatures in the edges of the blades." Influenced by these serious objections, M. Cazeaux procured a forceps with a curvature, as he says, slightly exceeding that of Levret's, which he considered more easy of application, and more safe and effective in traction. To this he also applied the screw arrangement to secure the crushing force. Where the screw and windlass are used it is important their mecha- nism should be such as to admit of easy application and detach- ment; otherwise by their weight and inconvenient extension, they render the instrument difficult and even dangerous in manipulation. We have thought the following modification of the cephalo- tribe might be a convenient one, as it certainly would be more simple than that in common use. Let a pair of forceps be made similar to those of Cazeaux above described, sufficiently strong in all its parts, and with handles so short as to be con- venient in introduction, but sufficiently strong to bear any re- quired amount of force. At the distal end of each of these handles let there be an arrangement for connecting an exten- sion long enough to secure any desired amount of leverage, OBSTETRIC OPERATIONS. 281 simply by the application of the hand. This, perhaps, might be effected by making a socket in the end of the handle similar to that we sometimes find in one leg of mathematical compasses or dividers, when it is desirable occasionally to substitute one leg for another. The extension piece could be slipped into the socket after the instrument was introduced and locked, and firmly secured by a small thumb screw inserted in the side. This arrangement, it is thought, would avoid the inconvenience and danger to the patient in the introduction, arising from the handling of a heavj- instrument, and the force being applied directly by the hand, the operator could more accu- rately feel through the instrument, and be more fully conscious of the effect produced. It would also be more manageable in applying traction, and more readily withdrawn, for reapplica- tion, or detached when the operation was finished. Generally, when it can be done, the head should be perfo- rated, as in ordinary craniotomy, before the application of the cephalotribe. This allows the escape of the cranial contents under compression, and avoids, in great measure, the bulging of the head in the diameter at right angles to that compressed, and also the risk of rupturing the scalp, and thus allowing spi- culae of bones to protrude. Even with this precaution it has been shown that the bulging takes place to some extent, but far less than if the precaution be omitted. As the head is generally grasped in the transverse diameter of the pelvis, that most lengthened by compression would be the one correspond- ing with the antero-posterior of the mother, and which is the one usually shortened in deformity. According to experiments of Hersent, all the diameters except the one included in the blades are lengthened under pressure on an average of about seven-sixteenths of an inch; when the cephalotribe is applied without previous craniotomy, but where the latter had first been performed, although there was still extension, it did not exceed from one-sixteenth to three-sixteemhs of an inch. Authorities differ (and in what do they not differ), as to the extreme limit of contraction of the pelvis rendering the suc- cessful application of the cephalotribe impossible. The inven- tor of the instrument claimed that it might be easily and effi- 282 PRACTICAL MIDWIFERY. ciently applied in cases where the antero-posterior diameter of the upper strait measures more than one inch and eleven six- teenths of one inch. Hersent fixed the extreme limit at two and a half inches, while perhaps the majority of accoucheurs maintain that the operation may be successfully performed with a diameter of two inches, unless the child be very large. Dr. Barnes believed the instrument could be applied and the head crushed with a diameter of one inch and a half. It should be borne in mind, however, that as we approach the extreme limit of the possibility of cephalotripsy, the opera- tion becomes more and more perilous to the mother, from the difficulty of applying the instrument and the consequent irrita- tion set up in the parts, from repeated unsuccessful attempts. The danger may nearly or quite equal that of the Caesarean section, without the partially redeeming trait of the possible, sometimes probable, saving of the child. In these extreme cases, therefore, it may be regarded only as a last resort, short of Caesarean section, having as its brightest prospect the rather uncertain salvation of the mother, but the certain loss of the child. In the application of the cephalotribe, we should be guided by the same general principles which we have already laid down, when speaking of the use of the obstetric forceps. As in these cases, however, the necessity of the operation arises from pelvic deformity, that very circumstance greatly increases the difficulty of its performance, and that, just in proportion to its extent. It is therefore important the greatest care should be taken in the introduction of the blades. We should carry up the hand as far as possible to guide their course, and to ex- plore the obstructions that may exist, and scrupulously abstain from all undue force or violence. An assistant should always steady the head by pressure over the hypogastric region. As the instrument is heavy and the blades more pointed than those of the obstetric forceps, if they be incautiously propelled, they may easily inflict injury upon the maternal structures. If we fail at once to get the blades into their proper places, so as to lock, we had better withdraw one or both, and make another attempt. Sometimes it is advised to reverse the order of their OBSTETRIC OPERATIONS. 283 introduction—sometimes when the first blade has been easily brought to its place, and the course of the second seems to be obstructed, it is thought best to carry the second up over the first, or rather, along the surface of the same hand that served to guide the first, to be properly adjusted after it is fairly with- in. It is recommended by some, after the blades are intro- duced, to push back the handles as far as possible towards the perineum, because it is alleged that in deformed pelves the pro- montory of the sacrum projects so far towards the os pubis as to push the head forward against the anterior abdominal wall of the mother, so that if this precaution be not used, the vault of the cranium alone will be crushed. In some cases this ad- vice may be good, but is not applicable to all. Care should be taken to pass the blades as high as possible, so that thej' may include in their grasp the base of the skull, as it is all important in order to effect delivery that this should be thoroughly compressed. When the instrument is properly adjusted the next step is to applj' the compressing force, whether this be by screw power or otherwise. This force should be very gradually ap- plied, so as not to destroy the integrity of the scalp nor cause spiculae of bone to project through it. We should be satisfied that the head is completely crushed, and the contents of the cranium as nearly as possible evacuated. Of the former we may form an opinion by the amount of crepitation under the force of the instrument, whether this be heard or felt, and of the latter by the amount of cerebral matter evacuated through the opening previously made in the scull. If we have reason to believe that the head is not completely crushed by the first application of the instrument, we should withdraw and reapply it, being careful to prevent its falling into the groove made by the first compression. An examination should be made with the finger to ascertain whether there are any spiculae project- ing through the opening previously made in the scull, and if so, remove them. If the perforation have been made in the manner we have indicated in the chapter on craniatomy, there is not likely to be any trouble from this source. When the operation of crushing is completed, unless the de- 284 PRACTICAL MIDWIFERY. formity be very great, and consequently the passage very nar- row, we usually apply extractive force. The cephalotribe, as commonly made, on account of the slight curvature of its blades, is not so good a tractor as the obstetric forceps. As before observed it is apt to lose its hold and slip. This occur- rence may be ascertained by the sensation imparted to the hand. It may be readjusted and another trial made. As the head is usually seized in the transverse diameter of the pelvis of the mother, and its diameter therefore more or less elongated in the direction of the antero-posterior of the pelvis, extraction often becomes difficult. To obviate this, it is advised to rotate the instrument, so as to bring the lengthened diameter of the head in accord with the transverse diameter of the pelvis; and when the head is thus brought down into the cavity to rotate again, so as to suit the changed diameters of the pelvis. If, however, simple extraction force be applied with gentle oscillating movement, it is probable, in obedience to the law again and again referred to in this work, the diame- ters of the head will spontaneously accommodate themselves to those of the pel vis. When the upper strait is very much narrowed through de- formity, the head within the grasp of the instrument cannot be brought down. In such cases, after the crushing is thor- oughly completed, it is better to leave the future process to the powers of the womb, provided they be vigorously in action. The head now made soft and yielding, will be gradually moulded to the shape of the abnormal pelvis, and pass the superior strait, either spontaneously or with such gentle aid as the exigencies of the case may demand, and a little ingenuity suggest. If the size of the after coming parts create difficulty, the instru- ment may, in turn, be applied to them so as to facilitate delivery. In very difficult cases some authors advise repeated crushing operations, with an interval of several hours between, as less dangerous than prolonged efforts at the same time. In the interval the patient is strengthened by taking appropriate nourishment. I apprehend the danger here would, in many cases be, the hopeless exhaustion of the woman through pro- longed suffering. This might perhaps be in some degree OBSTETRIC OPERATIONS. 285 counteracted by the judicious use of chloroform or of morphia, to such extent as to temporarily arrest uterine action and pro- cure sleep—the great objection to the latter would be the prob- able increase of the risk of severe shock. M. Pajot, of Paris, details his method of practicing the oper- ation substantially as follows. After thoroughly, but carefully crushing the head, he endeavors to make the reduced diameter thereof to correspond with the contracted diameter of the pel- vis, by rotating the instrument to the right or left, as may be most easy, while it still retains the head firmly in its grasp. If he find such rotation difficult to accomplish, he desists from further attempts, and carefully withdraws the instrument with- out making the least traction. The force of the womb, he finds will usually, and often in an incredibly short time, mould the altered head to suit the passage it has to traverse, at the same time imparting to it the movement of rotation so difficult to effect by means of the instrument. When necessary, he repeats the operation of crushing, at an interval of two, three or four hours, according to the woman's condition, as determined by the symptoms, allowing two or three introductions of the instrument for each time. It is at- tempted to support the strength of the patient in the mean- while with light nourishment. M. Pajot purposely avoids traction upon the head by means of the cephalotribe, and styles his method " cdphalotripsie repete sans tractions." The foregoing method would, no doubt, in most cases effect delivery, if the patient should live long enough for that pur- pose ; but it is not so certain what would afterwards become of her. It will be consolatory to know that this horrible and revolt- ing operation is seldom necessary with American women, and especially in practice in rural districts. We do not often meet with a pelvis requiring the head to be reduced in size, in order to effect delivery, unless the cranial bones be unusually ossified or the head of the child abnormally large. Even in such cases the large proportion can be successfully and safely managed by the skillful and dextrous use of craniotomy instruments alone. Cephalotripsy should, therefore, be regarded as a last resort 286 PRACTICAL MIDWIFERY. this side the Caesarean section, and applied only to those cases in reference to which it may justly be asked: What better can be done ? INDUCTION OF PREMATURE LABOR. This operation, as the name imports, contemplates the effect- ing of delivery before the normal close of utero gestation. It is performed in the interest of the mother, of the child or simultaneously of both. It is a procedure of comparatively recent date; and although it is impossible to say with cer- tainty when the first trial of it may have been made, it was not until 1756 that it met with professional approbation. Den- man tells us that in that year a congress of the most eminent physicians met in London to discuss its merits, and who sanc- tioned its legitimacy and utility. From that time it has grown slowly but steadily in professional favor. At the present day, perhaps, no enlightened physician doubts its propriety under circumstances demanding the kind of relief which it, when properly performed, undoubtedly affords. In general terms, this operation is indicated where the cir- cumstances of the mother or child are such as to expose either or both to imminent risk to life by the continuance of gesta- tion to full term, but which there is a reasonable prospect of averting or greatly diminishing by the induction of premature labor. But to speak more particularly, it is indicated in cases of pelvic deformity of such degree, as to render impossible the birth of a living child of ordinary size, at term, when such might be born by anticipating, by a few weeks, the normal period of delivery. To quote from Prof. Thomas: " It is difficult to say what degree of deformity calls for the procedure, but in general terms, it may be stated that wherever it is estimated, or, as is far better, where it is proved that a child at full term cannot be delivered by instrumental or manual means, premature de- livery is called for. Still, speaking generally, the normal length of the shortest diameter of the pelvis is four inches; OBSTETRIC OPERATIONS. 287 between this and three inches is the domain of the forceps ; between three inches and two and a half, that of version; be- tween two and a half and two, that of craniotomy ; and under two inches that of the Caesarian section. I shall not argue as to the propriety of preferring premature delivery to the terrible risks attendant upon the graver of these procedures, for all will admit it." Again we may regard as fit subjects for premature delivery those cases wherein obstruction to the birth of a full grown child is created by tumors, such as ovarian growths, cancerous tumors and the like. In some such cases a child after it has reached viability may be safely delivered by premature labor, which would be necessarily sacrificed if allowed to go on to full term ; while at the same time the life of the mother might also be sacrificed. We occasionally meet with cases where the death of the fcetus in former pregnancies has occurred at a given period toward the close of gestation. In such we may resort to the induction of premature labor so as to forestall this accident.* In order to accomplish this, it will be necessary, near the time assigned by the mother as the period of the death of the child on former occasions, to watch carefully its condition as sig- nalled by the usual signs of approaching dissolution, such as violent and uneasy movements, weakening of the heart's action, etc. When we notice these prognostications, if the child be of viable age, it will generally be best to propose pre- mature delivery. If the pregnancy, however, has not advanced so far as to afford reasonable hope of saving the life of the child, it is perhaps scarcely necessary to interfere. There will sometimes be considerable difficulty in determining this matter. In order to fix as nearly as possible the exact point in the pro- gress of utero-gestation, Dr. Barnes advises us to " reckon the pregnancy from the day after the last cessation of the menstrual period, the most probable time of conception." There are cases, however, where conception has taken place in the absence of the usual catamenial manifestations, and here we have no * See " Disorders of Pregnancy." 288 PRACTICAL MIDWIFERY. other aid to a correct conclusion but the unreliable one afforded by the time of quickening. As to the viability of the child, Prof. Thomas asserts : " Little hope should be entertained if the delivery be brought on at, or just after the seventh month ; almost none should be indulged in before the seventh month, while a child delivered at or after the eighth month, provided its vital forces have not been depreciated by the abnormal state which has necessitated delivery, has, with proper management, almost as good a pros- pect of life as one arrived at full term." " The end of the eighth month, i. e. the ninth menstrual epoch, is the most favorable time for the induction of prema- ture labor." This operation is moreover indicated when the pregnant woman has become the subject of some disease inherent in her condition, which if unrelieved seriously threatens her life, as well as that of the foetus, if utero-gestation be permitted to proceed to term, and which all known remedial measures have been unavailing to arrest. Another condition is that there be reasonable ground of hope that the timely induction of prema- ture labor may save the life of mother or child or of both. In this class are included cases of excessive and intractable vomit- ing, causing extreme prostration and emaciation, aggravated uraemia, etc. The number of such cases I humbly trust will be greatly diminished under homoeopathic treatment, as our mild specific remedies will be found to reach many of them which have heretofore been abandoned by the old school as ir- remediable by medicinal agents. There is in the children of some women a tendency to ex- treme ossification of the cranium before birth. Such cases at full term, unless the pelvis be very roomy, or the head very small, necessitate delivery by craniotomy, and of course the loss of fcetal life, or Caesarean section, exposing the mother to imminent peril. By anticipating natural labor by two or three weeks, it is believed the child in such cases may usually be saved, while the mother herself is exposed to less risk than she is in delivery at term. Finally, there are cases of placenta praevia, where the haem- OBSTETRIC OPERATIONS. 289 orrhage sets in early, several weeks before the normal close of utero-gestation, is at times violent, or persistent as a constant drain, reducing the strength of the patient to such an extent as to render it extremely doubtful as to her safety, if premature delivery be not effected. Here not only is the life of the mother seriously imperilled, but scarcely less that of the child. By the induction of labor before the mother's strength is hopelessly prostrated, or the child rendered feeble and anaemic by the loss of its accustomed supply, both may perhaps be saved. As the induction of premature labor is an operation of great responsibility, it should never be undertaken without the most serious and conscientious consideration. Under no circumstances is it without risk, and sometimes it may be said to be very hazardous. In most cases, however, where circumstances are favorable, when resorted to in time, and properly performed, it may be regarded as scarcely attended with more danger than natural labor. We should always previously inform the patient of its nature, design, and probable advantages, and at the same time not conceal from her what we may suppose, in her particu- lar case, to be its risks. If at all practicable, we should have our decision sustained by the opinion and approbation of at least one professional friend of good reputation. The methods employed for the induction of premature de- livery have been and still are very varied. While different cases may require different modes of management, the selec- tion of the best, the most efficient and safest means is of the utmost importance. Certain medicinal agents taken into the circulation and through it, acting upon the nerves, controlling the functions of the womb, are capable of bringing on contractions of that organ and effecting the expulsion of its contents. Such is the Secale cornutum, or Ergot of rye. This has been used for the purpose under discussion, and effectively, but given in the large doses customary, where uterine contractions are produced, they are usually so violent and unremitting as to endanger rupture of the womb, or the death of the child or both. It is to be re- membered that at the time when it is sought to effect prema- ture delivery, the organs are in a state of unpreparedness, the 19 290 PRACTICAL MIDWIFERY. os uteri undilated and undilatable, and hence not disposed to respond in a kindly way to the force pressing the presenting pait violently upon it. Ergot has therefore been abandoned, on account of its violent action, and the dangers to mother and child arising therefrom. I am not certain that it might not be available, given in small and oft repeated doses, as I have else- where advised for other purposes, while at the same time Ac- taea racemosa might be given in alternation with it, which would serve to relax the structures, and in some measure obvi- ate the difficulties arising from their rigidity. This is, how- ever, only a suggestion ; I. have no personal experience in such a mode of treatment, nor have I seen any case reported as thus treated. Puncturing the membranes, so as gradually to drain off the liquor amnii, will, in most cases, sooner or later bring on labor pains. This method is however considered dangerous to the child, as when the waters are evacuated the womb contracts forcibly upon it, and being usually more feeble than at full term, it is more liable to injury. We lose, moreover, the advantage of the wedge power furnished by the bag of waters in dilating the os uteri, and this remaining undilated, is another source of danger to the child and suffering to the mother. In effecting premature delivery, the more nearly we can imi- tate natural labor, the more satisfactorily and safely we will accomplish our object. What then takes place in natural labor, and in what order of sequence ? First, the os uteri gradually relaxes, then labor pains set in, the bag of waters is formed, protrudes through the os, and by its distending power, aided by other forces, accomplishes complete dilatation, the mem- branes rupture, the presenting part enters the upper strait, de- scends through the pelvis, and the child is born. Now to imitate this process, in the first place let us effect partial dilatation of the os uteri. This may be done by intro- ducing a laminaria tent. Possibly a tent made in suitable form, of dried slippery elm bark, might be safer, and act as well. To bring on labor pains, we push up a gum elastic cath- eter, with the usual wire stilet within, to be withdrawn when the catheter is in place. Instead of the catheter we may use a OBSTETRIC OPERATIONS. 291 gum elastic bougie, which is, perhaps, preferable. It should be very gently pushed up several inches between the uterus and the membranes, very carefully avoiding the rupture of the lat- ter, and also keeping clear of the site of the placenta. The bougie should be left in this situation for several hours, if ne- cessary, till labor pains come on. In the meanwhile we may go on with the dilatation of the os by the introduction and ex- pansion of Barnes' dilators, of which we have elsewhere spoken. When the os is fairly dilated, if necessary, we may give small, repeated doses of Ergot, and in due time rupture the mem- branes. This latter measure should be resorted to for bringing on the pains, if the introduction of the bougie do not. The conduct of the labor thenceforward is the same as if at full term. We have already spoken of the viability of the child. As to the time we should select for the operation, when circumstances admit of choice, one general remark may be made. We should always allow the child to attain to as great an age as is consist- ent with the particular object we have in view. The nearer the natural close of utero-gestation it can be safely delivered, the greater is its chance for continued life. Infants prematurely born require especial care. Dr. Thomas advises them to be kept in an atmosphere of 95° Fah., until they are capable of generating the amount of heat necessary to sus- tain life. When other means of maintaining warmth are not at hand, bottles containing warm water should be laid around them. They should be carefully fed upon diluted milk, or, better still, that drawn from the breast of a healthy wet-nurse, till the mother herself is prepared to suckle them. CESAREAN SECTION. This operation has for its object the extraction of the child through an incision artificially made, in the abdominal and uterine wall of the mother. It takes its name from Claudius Caesar and Julius Caesar, both of whom, according to tradition, were delivered in this way—the evidence of its truth, however, is now somewhat misty. The fatality of this operation to the 292 PRACTICAL MIDWIFERY. mother is, up to the present time, very great, viz.: according to statistics collected by Dr. Clay, of Manchester, about 1 to 2^. It therefore should be regarded only as a last resort, where the mother is living. The circumstances under which the Caesarean section becomes a legitimate operation are very few. It may, in the first place, be had recourse to, when a woman far advanced in pregnancy, from any cause dies suddenly, there being reason to believe that the child within her womb is still alive ; or, even if she die by the slower process of disease, when there is a reasonable hope of saving the child by the operation. This, however, in the latter case, is probably seldom accomplished, as the time con- sumed in procuring the attendance of the operator, will be generally fatal to the life of the child, even if that be not ex- tinct at the moment of the mother's death. Even though the surgeon should be present, the friends of the woman must be sufficiently assured of her death, before any attempt is made to operate, and this delay would perhaps usually be sufficient to defeat the purpose. The objection to turning in these cases is the undilated condition of the passages, except where the pa- tient expired in the act of parturition. In case of the living woman, the operation is justifiable only in such circumstances where delivery cannot be effected by any other means, without subjecting the patient to equal or greater risks than those known to appertain to the Caesarean section. I hold the mother should never be exposed to great risks simply to save the life of the child, at least unless she, in the full pos- session of her reason, so elect. The mortality attendant upon the Caesarean section is prob- ably greatly increased by the circumstances under which it is usually performed. From the extreme abhorrence which every one, unless perhaps a special operator, must feel towards the operation, it is likely to be postponed to the latest moment, and until the patient is exhausted by the agonies of a fruitless labor, and therefore in a condition unfit to endure a severe operation of any kind. Hence it is advised, where it is known before- hand, that a necessity for such an operation exists, to perform it before the advent of labor. This advice is undoubtedly OBSTETRIC OPERATIONS. 293 rational, but would, in many cases, be exceedingly difficult to follow. If delayed till labor sets in, and it be fully determined that it is absolutely necessary, as giving the mother and the child the only chance for life, the sooner it is resorted to the better for both. Dr. Clay tells us that " the operation is justifi- able with an antero-posterior diameter of an inch and a half and three inches transverse, or under, or almost perfect obliter- ation of the passage by osseous growths." As preliminaries to the operation the bowels should be well evacuated by the most gentle means, avoiding all drastic pur- gation. Inspissated ox gall is highly spoken of, as not only clearing out the bowels effectually, but removing flatulency. The urine should be fully evacuated, either by the natural efforts of the patient or by the gum elastic catheter. The po- sition of the placenta should be carefully ascertained, so as to avoid its site, if possible, in making the incision in the womb. The temperature of the apartment should be raised to 75° F. and maintained at that during the operation, having the air also moistened by the evaporation of water. It is hardly necessary to say the patient should be fully anaesthetized before the operation is commenced. To this, however, some object, on account of the liability to vomiting, which, under proper management, is not likely to occur. The incision should be made as nearly as possible in the linea alba, so as to avoid wounding the epigastric arteries, and thereby causing haemorrhage. It should commence a little above the umbilicus and be carried a few inches below, cutting around and not through the umbilicus. The skin and muscu- lar fibres are carefully cut through, until the peritoneum is reached, which is known by its peculiar shining appearance. A small opening is made in this membrane, which may be done by pinching up a portion of it with forceps or by a very cautious stroke with the point of the scalpel. It is then divided to the length of the incision in the external layers, by means of a director, or inserting the fingers of the left hand underneath, to elevate it, and serve as a guide to the probe pointed bistoury employed in severing it. An assistant then, with one hand on each side of the incision, pushes for- 294 PRACTICAL MIDWIFERY. ward the womb, in which an incision is made, corresponding in situation and length with that in the abdominal walls, avoiding the fundal region and the placenta, if possible. When the incision is made into the womb, the assistant should insert a finger into each end of the wound, and thus draw up the organ tightly against the abdominal walls, so as to prevent blood and the liquor amnii from escaping into the abdominal or peritoneal cavity. The membranes are then punctured and divided, and the child is carefully removed, the head and shoulders, if practicable, being delivered first. The placenta and membranes are then extracted and the womb left to con- tract as speedily as possible. If it do not contract spontane- ously, gentle pressure is applied. It should be ascertained, by digital examination per vaginam or by passing up a catheter, that the os is patulous, so that the lochia may escape. It is not agreed whether it is better to close the uterine wound by sutures or leave that to be effected by its own contractile pow- ers. Probably it had better be secured by animal sutures, such as carbolized cat-gut, cut short, or silver wire. The ob- jection to the former is their liability to open prematurely when continuously exposed to moisture. If silver wire be used, after twisting, the points should be so bent as not to irri- tate the tissues with which they may come in contact. Spen- cer Wells used a continuous silk thread, one end of which he brought out through the os and vagina, so as to permit its re- moval. It is advised not to close the abdominal wound until the risk of haemorrhage is past. All blood and discharges should first be removed, by means of moist warm sponges, from among the abdominal viscera. This precaution cannot be too scrupulously attended to, as, if it be neglected, these matters necessarily become putrid, and almost certainly create septicaemia. The edges of the abdominal wound are carefully approxi- mated and secured by pins or silver wires passed deeply through the tissues ; some say, including the peritoneum itself. These pins or sutures are inserted about an inch apart, begin- ning above and passing downward. As to including the peri- toneum, there is a difference of opinion. Dr. John L. Atlee, OBSTETRIC OPERATIONS. 295 in his ovariotomy cases, does not include that membrane. The idea that approximation of its edges is effected by including it in the sutures, is probablj- fallacious; for the edges of so thin a membrane are not likely, by the operation, to be brought into close juxtaposition through any considerable por- tion of their extent. Then, on the other hand, the pressure of the pins or wire would be likely to produce irritation, and, perhaps, light up inflammation. When the wound is closed, it is covered with folded lint, which is secured by adhesive straps and a suitable bandage, prevented from slipping up, by attachments passed around the thigh. The bladder should be relieved, as often as necessary, with the catheter, and the bowels kept perfectly at rest. Arnica, in water, should be given as after labor, alternated with Ars. a.3, and continued. All the symptoms that may arise, should have their appropriate remedy. The diet should be of the lightest possible character. In case of great pros- tration, beef tea or essence of meat may be given, in quantities, however, strictly regulated by the exigencies of the case. Dr. Robert P. Harris, member of the Philadelphia Obstetri- cal Society, etc., has lately published {American Journal of the Medical Sciences, for April, 1878,) an interesting article upon the Operation of Gastro-Hysterotomy, " viewed in the light of American experience and success." He has collected seventy- two cases, of the operation performed in America, which he gives in more or less in detail. The conclusions, at which he arrives, are the following: That the success of American sur- geons has heretofore been greater than that of the European, especially than that of the surgeons of Great Britain. The failure in the latter country he attributes rather to the faulty habits of the women than to any want of dexterity or skill on the part of the surgeons themselves. The beer drinking propensity of the people he thinks an important factor in the ill-success. The doctor very rationally insists upon early operation, where it is found to be necessary, and, when thus performed, believes it more conducive to the safety of the mother, in cases of extreme contraction of the pelvis, than craniotomy or embryulcia, supposing these to be at all practicable. 296 PRACTICAL MIDWIFERY. The statistics of Dr. Harris seem to favor the employment of sutures in closing the uterine wound. He collected twelve cases in which they have been used, with five recoveries; whereas the general result of his observations is, thirty-five saved and thirty seven lost. CHAPTER XII. ANESTHESIA IN LABOR. As frequent reference is made in this work to the use of anaesthetics in the conduct of labor, it may be proper to devote a chapter specially to this subject. Here, however, it will be our object, not so much to direct attention to the indications which, in our opinion, call for their employment, as to answer some of the objections preferred against their use, in any cir- cumstances whatever, and then indicate the method by which they may be most safely and efficiently administered. I have already, and elsewhere, pointed out the indications demanding their employment. Let me, moreover, premise, that my re- marks, unless otherwise distinctly stated, are intended to apply to Chloroform, the only agent worthy the entire confi- dence of the obstetric practitioner. Ether, so much lauded in surgery (especially when largely mixed with chloroform), scarcely deserves a moment's consideration here. I do not advocate the indiscriminate employment of anaes- thetics in labor. Where it is natural, the patient courageous and strong, where she suffers no unusual amount of pain, and where, moreover, no special indications are present, it would be a sakeless procedure to administer chloroform or any other anaesthetic. Such patients would usually object to it them- selves. But, on the contrary, where there is intense suffering, from any cause whatever, and where insensibility or a relaxed ANESTHESIA IN LABOR. 297 condition of the tissues is desirable, this agent comes into phi}', and usually fully meets the expectations of both patient and attendant. One of the most urgent objections brought against the use of chloroform, in labor, has been its supposed immediate dan- ger. This objection, of course, falls to the ground, when it is shown that no su'.''-■ fc W . '-*£"...;.V;' :;>;v': SNiDicnw jo Aavaan ivnouvn SNoiasw jo Aavaan tvnoilvn 3Ni3ia3w jo Aavaan ivnoij NATIONAL IIBRARY Of MEDICINE NATIONAL LIBRAPV on u[i)if yV ^*CI !■—^w^si V^V /V^V i VA NLM005812648