Part 8

The paper concludes with a detailed statement of the _modus operandi_ and after-treatment in the modern Cæsarean operation. (A loop of the constrictor can usually be readily passed over the fundus and slipped down to the cervix while the uterus is still in the abdomen as we have shown.) (A Case of Cæsarean Section, N. Y. M. J., August 29, 1885.) Traction upon the constrictor perfectly occludes the short abdominal wound during the incision of the uterus, eventration taking place as the uterus collapses on removing the fœtus. The advantage, therefore, of extending the abdominal incision some inches above the umbilicus in all cases and turning out the uterus before opening it may be doubted. It is sometimes, however, impossible or difficult to apply the constrictor to the uterus in situ. Extraction of the fœtus by the head is certainly easier than delivery by the feet as advised by most writers.

The comparative results of induced labor, version, perforation and Cæsarean section in the Dresden Clinic have been recently considered in a series of papers by Leopold and his assistants, Korn, Lohman and Praeger.

The maternal mortality was as follows:

Induced premature labor 2.2 per cent. Version and extraction 4–8 per cent. Perforation 2–8 per cent. Cæsarean section 8–6 per cent.

The fœtal mortality was in

Premature labor 33.4 per cent. Version and extraction 41. per cent. Cæsarean section 13. per cent.

Leopold concludes that while Cæsarean section cannot yet be substituted in all cases for craniotomy, it is at least justifiable as an alternative when the following conditions are present or possible, viz.:

Complete asepsis.

The patient strong and not long in labor.

The fœtal heart-beats normal in rate and rhythm.

Strauch (Arch. f. Gyn.), analyzing the results in twenty-eight cases of induced premature labor arrives at like conclusions. While the mortality in cases of the mothers was _nil_, the fœtal mortality was fifty-five per cent. The rights of the fœtus demand a more frequent choice of Cæsarean section, the mortality of which by the modern method is thus far 11.8 per cent. for the mothers and 8 per cent. for the children.

Dr. Felice La Torre, of Paris, reaches the conclusion from extensive clinical research that craniotomy or premature labor is better than Cæsarean section, since the former saves all the mothers.

Krassowski (Arch. f. Gyn., B. 32 H. 2) reports five Porro and two Saenger operations saving six mothers and five children. K. uses thymol 1:1,000 for instruments, and the biniodide of mercury 1:4,000 for the hands, etc. He seals the abdominal wound with collodion to which biniodide of mercury has been added.

Zweifel reports six additional cases of the Cæsarean operation after Saenger, saving five mothers and all the children.

THE MECHANISM OF LABOR IN HEAD PRESENTATION.

Sutugin (Sammlung Klin. Vorträge, No. 310) makes an important contribution to the knowledge of this subject. The paper deals with an “almost wholly neglected factor in the mechanism of labor,” namely, the position of the fœtal trunk in utero, the mechanism of the trunk movements and their effect upon the positions of the head during labor. He first shows that the views commonly accepted with reference to the position of the fœtal trunk during pregnancy are in part erroneous. Observations by the author in six hundred and sixty cases, published in 1875, established the fact that before labor, in either right or left positions, the dorsum of the child is almost invariably turned to the mother’s back, the vertebral column of fœtus, as a rule, lying but little to one side or the other of the spinal column of the mother; and, furthermore, the changes of position during pregnancy, as from right to left, probably take place by rotation along the posterior wall of the uterus. On the occurrence of energetic uterine contractions, especially at the beginning of labor, the back of the child is sometimes rotated to the mother’s side. Kehrer has confirmed the conclusions of Sutugin in observations upon certain of the lower animals. It may be noted in passing that, according to Kehrer’s observations, gravity is a subordinate factor in determining the attitude of the fœtus in utero.

The author of the paper declares that, in a large number of cases examined during the last twelve years he has not in a single instance found the back of the child turned wholly forward during pregnancy, not even in first positions of the head. He has more recently made a study of the varying positions of the trunk during labor. Early in the labor, in first positions of the head, the trunk rotates so that the back of the child looks sideways, the shoulders lying in a plane parallel with the introitus. The breech rotates more slowly than the shoulders, the spinal column of the child thus assuming the form of a spiral during delivery. The fœtus, therefore, in its descent moves in a screw-like direction around its own axis, but the back of the child is not turned forward even during parturition, as authors generally have assumed. These views are born out by the frozen sections of Chiara, Waldeyer, and Shroeder. The rotation of the head is in part due to the rotation of the trunk, “the torsion of the axis of the fœtus,” and is not to be referred solely to the action of the pelvic planes. The author claims that a torsion of the uterus upon its axis similar to that of the child also occurs. With reference to the etiology of the torsion in case of uterus or fœtus, he ventures no explanation.

MANAGEMENT OF THE PLACENTAL STAGE OF LABOR.

Fehling (Sammlung Klin. Vorträge, No. 308) compares the views and practice of authorities in the treatment of the third stage of labor. The various methods of placental delivery that have been advocated by different writers are recounted. The reaction against Credé in favor of expectancy, first started by Dohrn and Ahlfeld, has resulted in proving the inferiority of the latter plan, and in a return to more active methods. In a large number of German clinics, the uterus is allowed to rest immediately after the expulsion of the child, without friction. When the placenta lies detached in the lower uterine segment, which is generally the case after fifteen or twenty minutes, nothing is to be gained by longer waiting. The author is favorably disposed toward the practice of Credé, which as he says, has never been shown by its adversaries to be capable of harm when properly conducted. With reference to the mechanism of placental separation, both theoretical considerations and clinical observations favor the views of Duncan, yet the question is not settled. Retained membranes may be removed with the aseptic hand. Yet Credé and Olshausen consider the retention of even the whole chorion free from danger, and clinical experience has shown better results by the expectant plan in case of retained membranes than by interference. These results, the author thinks, in the light of Döderlein’s researches, are explained by the fact that the hand may transport the peccant germs from the vagina into the uterus. The active plan, with a preliminary vaginal disinfection and a vigorous asepsis throughout, should yield better results than expectation. Interference with these precautions is, at least, justified in case of atony and hæmorrhage or fever, including, if need be, the use of the curette and subsequently ergot. Dührssen’s method of tamponing the uterus in post-partum hæmorrhage with iodoform gauze is favorably mentioned.

In the event of cervical tears causing troublesome hæmorrhage, Kaltenbach, Schroeder and Leopold practice immediate suture. The author thinks the vaginal tamponade is generally to be preferred. Yet, in certain cases the suture may also be required, or the application of the perchloride of iron on cotton pledgets to the bleeding surfaces.

Credé (Arch. f. Gyn., B. 32, H. 1) again discusses and defends his method of managing the placental delivery which he prefers to call the external method.

The duration of the third stage need not in the majority of normal labors exceed fifteen to thirty minutes. In many instances a more expectant plan of treatment is better. In occasional cases more rapid delivery is demanded in the interest of the mother. Since the method is free from danger when properly conducted, the expulsion of the placenta may be hastened within reasonable limits if for no other purpose than to save the time of the attendants and to spare the sufferings of the patient. He claims that the amount of blood-loss is diminished under his treatment of the placental stage, and that the membranes are not more frequently retained. Furthermore, he believes the retention of portions of the membranes or placenta to be harmless in an aseptic condition of the passages.

The method of Credé, briefly restated, is as follows: First apply gentle, painless friction in a circular direction over the anterior wall of the uterus, laying the hand flat upon the abdomen. Bring the axis of the uterus in conformity with the axis of the pelvic inlet. If the placenta is not expelled after three or four pains assist the next contraction, at its acme only, by compressing the upper segment, grasping the fundus with the thumb in front and the fingers behind, at the same time using gentle downward pressure. Use slight friction only but no compression during the intervals between the pains nor even during the contraction except at its height. Success usually attends the eighth or tenth pain.

SCARLET FEVER: ITS RELATION TO PUERPERAL FEVER

Boxall (Br. Gyn. J.) in sixteen cases of scarlet fever in childbed found septic manifestations in but one. In forty lying-in patients exposed to the scarlatinal poison the puerperium was entirely normal. Three hundred patients or more were admitted to the hospital during the epidemic of scarlatina therein, yet a comparison of the morbidity during this time with that which immediately preceded the outbreak showed that the prevalence of scarlet fever in the hospital exerted no appreciable effect upon the course of the puerperium in patients who escaped scarlatina.

Galabin (Br. M. J.) thinks there is strong evidence of the bacterial relation of puerperal sepsis to scarlet fever. Septicæmia does not represent a distinct entity like scarlatina. Cheyne found the common microbes of suppuration in the blood of scarlet fever patients not infrequently.

MITRAL STENOSIS AND THE THIRD STAGE OF LABOR.

Dr. D. B. Hart (E. M. J., Feb. 1888,) reports eight cases of this complication with seven deaths. With reference to the etiology Dr. Hart thinks the progress of the cardiac lesion is greatly accelerated by the increased amount of work imposed upon the crippled heart during pregnancy. At the beginning of labor, therefore, we may get failure of compensation, dilated heart and engorgement of the lungs. At the close of the labor, if free hæmorrhage does not occur, the extra blood before accommodated in the utero-placental sinuses is returned to the right heart. Death is therefore liable to occur in the third stage from over distention of the right heart.

Dr. Ballantyne (E. M. J., March, 1888,) adds two more cases to the above record, both terminating fatally. Sphygmograms obtained in these cases show that the period immediately following the expulsion of the placenta is the one of greatest danger, and they are entirely consistent with Hart’s theory of the cause of death.

TREATMENT OF ABORTION.

Fry (Am. Obs. J., June, 1888,) advocates the use of the galvanic current as a substitute for the curette for the removal of retained fragments of the secundines. He uses a current of sixty to ninety milliamperes with the anode in the uterus. The application is continued from six to ten minutes and repeated on alternate days. The placental tissue, owing to its relatively low vitality, is destroyed without injury to the uterus itself. Separation and expulsion follow. Hæmorrhage is relieved by the well known hæmostatic action of the positive electrode. Dr. Fry also claims antiseptic properties for the positive pole since here are liberated oxygen and chlorine in a nascent state and also acids.

Goodell thinks the curette an inefficient instrument for the evacuation of the uterine cavity and liable to injure the uterus. He advocates polypus forceps. Parrish finds the curette deceptive. He uses the finger. Longaker prefers the finger. [A Sims’ speculum, a dull curette and a strong, straight uterine dressing forceps, with its joint two and a half inches from its distal end need never fail. The finger is awkward, difficult, painful, and sometimes requires preliminary dilation of the cervix. It cannot, moreover, be so easily sterilized, and even though clean primarily is liable to carry septic organisms from the vagina. Injuries to the uterus are for the most part the fault of imperfect asepsis.]

PLACENTA PRÆVIA.

Obermann (Arch. f. Gyn., B. 32 H. 1.) discusses the treatment of placenta prævia by version with the results obtained in sixty-four cases at the Leipsic clinic. The method, which has become known as Hofmeier’s method, he states as follows:

Perform bimanual version with deliberate extraction in case of much hæmorrhage. The podalic extremity of the child makes an effectual tampon. Massage of the uterus during extraction is advised to aid expulsion. Iodoform gauze tampon may be used in case of hæmorrhage in the early months. The colpeurynter is recommended in case of hæmorrhage with a closed cervix. Alcoholic stimulants are given early and often.

The results in the sixty-four cases were eighty-nine per cent. of the mothers and forty-seven per cent. of the children saved.

Nordmann, of Dresden, condemns early resort to operative procedures as a routine measure, a more expectant plan of treatment being competent in a certain proportion of cases.

Robt. Barnes (Br. Med. Jour., March 3d, 1887) sums up his views substantially as follows: The hæmorrhage in placenta prævia proceeds from so much of the lower zone of the uterus as is laid bare by separation of the placenta during canalization. This comprises all that portion of the uterus that lies below the equator of the fœtal head. When canalization is complete the hæmorrhage is almost invariably arrested spontaneously by retraction of the lower zone thus freed. Until canalization is completed flooding is liable to persist, but after that process is accomplished the case becomes practically a natural labor. The too prevalent idea that the hæmorrhage is unavoidable and must go on till delivery is erroneous and mischievous. Enough placental attachment usually remains after complete dilatation to preserve the life of the child. The fœtal life is not necessarily compromised except in certain extreme cases of complete central placenta prævia. His views of treatment follow as a corollary. Expedite the first stage, avoiding violence or precipitation. His caoutchouc bags accomplish this indication and control hæmorrhage. Detach the placenta with the finger from the zone below the equator of the head, thus permitting retraction and arrest of flooding. Rupture of the membranes and the use of the binder meet the indications in certain cases. The vaginal plug may be used in occasional instances if carefully watched. The os uteri moderately expanded and the placenta separated from the lower zone, hæmorrhage having ceased, wait. With sufficient dilatation, deliver, if necessary, by forceps, version, or craniotomy. Dr. Murphy’s success by this plan has been unexampled. [Dr. Barnes does injustice to version in placenta prævia, since he appears to assume that immediate extraction and violence to both mother and child are a necessary part of the procedure. The success of that plan he attributes in great part to the fact that, in carrying out the operation of turning, the placenta had probably been detached from the lower zone. These criticisms certainly cannot apply in case of external or bipolar version. With reference to Barnes’ bags, it is safe to say, “the German teachers” are not the only practitioners who have found them, in many cases, more or less impracticable.]

OBSTETRIC SEPSIS AND ANTISEPSIS.

Auvard, writing to the Annals of Gynec., April, 1888, says, while before the days of antiseptics it was better for a woman to be delivered in the street than in a hospital, the hospital ward is now less dangerous than the isolated lying-in chamber of the out-patient obstetric service. He points out the importance of improving the resisting power by use of tonics before the labor, in debilitated patients. In Auvard’s practice every woman takes a thorough bath at the beginning of labor. The whole vulvar and vaginal surfaces and cervical canal are sterilized before expulsion begins, before obstetric wounds are developed. Asepsis before and during the birth is more effectual than the use of antiseptics at the close of labor and renders the latter unnecessary.

Sublimate soap and the sublimate solution, with which this soap makes a lather, are well rubbed into the surfaces to be cleansed by aid of the fingers. The dangers of sublimate poisoning do not obtain while the surfaces are intact.

In the event of septic developments during the puerperal period he thinks sublimate irrigation insufficient for genital antisepsis. The vulva and vagina should be scrubbed by aid of the fingers with the sublimate soap and solution. The uterus should be scraped with the curette. Auvard has devised for this purpose a curette with a hollow stem through which a stream of the antiseptic solution is kept flowing during its use. [The mercurial salts may be replaced with a 1:1000 hydronaphthol solution for use within the passages after labor, though the danger from the former antiseptic may be greatly diminished by washing away the mercurial with a final injection of plain boiled water.]

AUTO-INFECTION IN CHILDBED.

Ahlfeld (Cent. f. Gyn., No. 52,) shows that it is not always safe to presume upon the impossibility of self-infection, and reports two cases in point. In rare cases infection may arise from organisms primarily present in the genitalia. [This goes to fortify Auvard’s position.]

OCCURRENCE OF GERMS IN THE DISCHARGES FROM THE UTERUS AND VAGINA DURING THE PUERPERAL PERIOD.

Döderlein (Arch. f. Gyn., B. xxxi., H. 3,) finds in a series of carefully conducted observations, that in normal cases the uterine discharges contain no germs, while in the same patients numerous varieties of germ life abound in the vagina. Pathogenic organisms may occur in the vagina apart from any internal examination. These germs may gain access to the uterus of themselves when not carried by intra-uterine instrumentation or manipulation. These conclusions are confirmed by Kaltenbach.

The uterine lochia of women suffering from puerperal sepsis in any form invariably contain germs, the streptococcus pyogenes being constantly present.

SUBLIMATE SOLUTION.

Laplace has shown the importance of acidulating sublimate solutions for general antiseptic use. Neutral solutions on mingling with blood or other albuminous fluids become more or less inert by the precipitation of the albuminate of mercury. That precipitate is not formed in the presence of hydrochloric or tartaric acids. The proportion for sterilizing wounds should be five parts of the acid to one of the sublimate in one thousand of water. [Biniodide solutions require no acid. This is one of the many advantages of the mercuric iodide over the bichloride for antiseptic use. In a series of experiments made for the purpose of determining the reaction of biniodide solutions on albuminous fluids we found that neutral solutions of the biniodide of mercury yield no precipitate with albuminous fluids. No reaction was obtained with a biniodide solution acidulated with hydrochloric acid in the proportion of five parts to the thousand. The addition of organic acids, such as acetic, citric or tartaric, as is well known, causes a precipitate of albuminate of mercury. There is no chemical incompatibility between sublimate soap and biniodide solutions.]

TRICHLORIDE OF IODINE.

One of the new antiseptic agents is iodine trichloride. In contact with organic bodies it gives off iodine and chlorine in the nascent state. The final products, moreover, hydrochloric and iodic acids, are well known oxidizing agents. The strength of solution used is one part in 1,000 or one in 500 parts of water. Such a solution is equivalent in sterilizing power to a 1:1,000 or 2,000 sublimate solution. [One disadvantage of this antiseptic is the powerful corrosive action of nascent chlorine and iodine upon metal instruments.]

DANGERS OF ANTISEPTICS.

Senger (Br. M. J., May 19, 1888,) has proved by experiments on dogs and rabbits that the antiseptic agents commonly employed are liable to cause degeneration of the kidneys. He injected into perfectly healthy animals corrosive sublimate, carbolic acid, etc., in one-twelfth the quantity necessary to kill them. Then on extirpation of one kidney he found in all cases, on microscopical examination, glomerulo-nephritis. He also found fatty degeneration of the liver, spleen, the heart-muscle, etc. The various antiseptic agents were found to be injurious in different degrees, corrosive sublimate being the most dangerous, then the others in the following order: iodoform, carbolic acid, salicylic acid, boric acid. These observations especially enforce the importance of avoiding the use of antiseptics in the abdominal cavity, or in other large cavities under conditions favorable to absorption. Sterilized water or a five per cent. chloride of sodium solution should be substituted for use in the peritoneum. Senger has shown that the salt solution in no way injures the organs, and that it possesses moderate antiseptic power, killing the streptococcus pyogenes aureus in twenty-eight minutes.

EFFECT OF ERGOT ON THE INVOLUTION OF THE UTERUS.

Drs. G. G. Herman and C. O. Fowler (Br. M. J., Feb. 11, 1888,) discuss this question, basing their conclusions on the results noted in fifty-eight cases treated with ergot for a fortnight after delivery, and sixty-eight in which a single dose only of ergot was given at the close of labor. In the cases continuously ergotized the diminution of the uterus in size was more rapid than in those who received but a single dose. On the duration of the lochial discharge no appreciable effect was observed from the use of ergot.

Dr. Boxall has made similar observations on two parallel series of cases of one hundred each. Every alternate patient was given a mixture containing ext. ergot. ammon., ♏︎ xv., t.i.d., during the first three days after labor. Dr. B. concludes from the experience of these cases that the practice of giving ergot as described tends to prevent the formation of clots, to hasten their expulsion, and to diminish the frequency, intensity and duration of after-pains. That if omitted at first and given afterwards ergot tends to promote the expulsion of clots and to relieve after-pains.

ANÆSTHESIA WITH CHLOROFORM AND OXYGEN.

Dr. Kreutzmann (Cent. f. Gyn.) recommends a mixture of oxygen and chloroform vapors as an anæsthetic in obstetric and surgical practice. The mixture may be made by passing freshly prepared and pure oxygen through chloroform on its way to the inhaler. Neudörfer injects a small quantity of chloroform into a balloon filled with oxygen, administering through a face piece. It is claimed for this method, that anæsthesia is at once established after a few deep inspirations without the least excitement, and that there are no disagreeable after-effects, the patient awaking promptly on ceasing the anæsthetic as from a refreshing sleep.

* * * * *