Obstetrics, normal and operative

Front matter

Qass.

Book

COPYRIGHT DEPOSIT

Preface

Ix the following pages I have endeavored to set down some of the results of a fairly extensive experience in the hospital, private, and consulting practice of obstetrics, and in the teaching of students, first of undergraduates at the Cornell University Medical College, and later of postgraduates at the Xew York Polyclinic.

In spite of the fact that there are many excellent text-books in the field, I have ventured to think that there is room for another, based upon a different plan. ]\Iost obstetrics works, it seems to me, contain too much irrelevant matter and too little about the practice of obstetrics. This is because they are constructed upon a plan which, while it has the authority i tradition and custom, does not conserve the interests of either practitioner cr student. It is discouraging to both, for example, to find so large a space devoted to developmental anomalies and fetal monstrosities that little or none is left for the superlatively important subject of fetal mortality in labor. It is to the last degree exasperating to find a long biography of the Chamberlen family, and to search in vain for information as to the method of employment of that marvel of mechanism, the axis-traction forceps.

Let us take another example. If in the course of a difficult version the operator finds it impossible to grasp a knee or foot, the difficulty may sometimes be obviated by the simple expedient of turning the patient upon her side. This is one of the most important facts in the whole range of clinical obstetrics, and yet, turning to some standard text-book, we find that it is either unknown or unnoticed, but observe at the same time that considerable space is devoted to the subject of the cause of menstruation.

I have omitted the traditional section on embryology, which has become a science in itself and can be adequately treated only in a separate work. Of course, I would not minimize its importance. A knowledge of physiology is absolutely necessary to the intelligent practice of medicine, but no one would now think of taking up a large part of a work upon the practice of medicine with a preliminary treatise on physiology. The section on anatomy has been omitted for a similar reason.

The theory of pure obstetrics, however, without a knowledee of which iv PREFACE

the practice of obstetrics can never reach the dignity it deserves, has not been neglected. I have tried to give briefly and plainly the essentials, i.e., about as much as the student ought to know, or is likely to remember. Enough also to serve, if desired, as a groundwork for further study.

This book contains many original photographs made especially for me at the Xew York City Hospital and elsewhere. These photographs seem to me to be unequalled, but perhaps I am a partial witness. For the privilege of reproducing, sometimes with slight modifications, certain illustrations, particularly Professor Fabre's collection of photographs showing the various forms of pelvic contraction, I am indebted to the publishing house of J. B. Bailliere et Fils, of Paris. Other illustrations have been borrowed, but always with due credit. I conceive it to be the duty of the author of a scientific work to give his readers the best illustrations he can get without reference to their source, provided, of course, due credit is always given. The purpose of such a work is not so much to extend the author's fame as a draughtsman, as to teach the reader what he wishes to know. Some original illustrations have no other merit than originality.

I have not attempted to write a dictionary of bibliographical reference, and I have tried to omit those things which are of historic or academic interest only, and those things which every one knows, in order to have space for those essentials of the practice of obstetrics which many do not seem to know.

Every text-book is to some extent a compilation, and it is well to acknowledge this at the outset. I trust, however, that this book will not be found wanting in the expression of individual opinion, and that where I have quoted much I have not failed to give due credit.

In conclusion I would extend greeting and congratulation to all those who, whether as practitioners or as specialists, are engaged in the arduous and trying work of obstetric practice. In no department of medicine are more positive results obtained. In none is there greater alleviation of suffering or saving of human life. This beneficent work is its own reward.

ACKNOWLEDGMENTS

CHAPTER I.— PREGNANCY, LABOR AND THE PUERPERIUM Changes in the Maternal Organism Resulting from Pregnancy i

Local Changes i

The Uterine Musculature 5

The Growth of the Uterus 9

Shape and Position of Uterus 9

Uterine Inclination and Torsion 10

Relations of the Uterus 12

Cervix and Adnexa 12

Vagina, Vulva, Perineum and Pelvic Floor 16

Pelvic Joints , 16

Abdomin-\l Walls 17

Gener.\l Changes 18

Heart and Circulatory Apparatus 18

Blood 19

Respiratory Apparatus 20

Alimentary Canal 20

Glandular System 21

Urine and Urinary Tract 22

Skin 23

Mind and Nervous System 24

Bones 24

Nutrition and Metabolism 25

CHAPTER n.— THE DIAGNOSIS AND CLINICAL PHENOMENA OF

PREGNANCY

Importance of the Subject 27

Relative Value of Symptoms 28

Symptoms of First Half of Pregnancy 28

Importance of Early Bimanual Examination 32

Results of Inspection, Palpation and Vaginal Examination 32

Changes in the Uterus 32

Changes in the Breasts 42

Symptoms of the Second Half of Pregnancy 43

Positive Signs 43

Duration of Pregnancy 44

To Determine Whether the Foetus is Alive 46

The Diagnosis of Multiparity 47

Serodiagnosis of Pregnancy 48

Pseudocyesis 50

CHAPTER VI.— THE PHYSIOLOGY AND MECHANISM OF LABOR Anatomy of the Pelvis 94

Differences Between Male and Female Pelves 99

The Pelvis of Infancy and Childhood 100

The Fet.\l Head 100

The Physiology and Cause of Labor 107

Innervation of the Uterus 109

Dilatation of the Cervix no

The " Bag of Waters " 112

Placental Expulsion 116

Mechanism in Anterior Positions of the Occiput 117

CHAPTER VIL— THE DIAGNOSIS AND CLINICAL PHENOMENA OF

LABOR

Premonitory Symptoms 128

How to Know When Labor Has Begun 128

The Contractions of Labor 130

Why They are Accompanied by Pain 133

Atypical Labor 136

CHAPTER VIIL— THE MANAGEMENT OF LABOR

Preparation 138

Physician's Outfit 139

At the Home of the Patient 141

The Patient Herself 142

The Prevention of Infection 143

Technic of Vaginal Examination i^i

Conduct of the First Stage 154

General Hygiene i^^

Anesthesia 156

"Twilight Sleep" 1^7

Conduct of the Second Stage 162

Care of the Perineum 163

Delivery of the Shoulders 168

Physical and Moral Support 168

Attention to the Fcetus 170

Ligation and Care of the Cord lyi

Prophylaxis of Gonorrhgeal Ophthalmia iy2

Conduct of the Third Stage ][ 172

Prevention of Hemorrhage 174

Complete Expulsion of Placenta and Membranes 174

CONTENTS ix

CHAPTER IX.— THE PHYSIOLOGY AND CLINICAL HISTORY OF THE PUERPERIUM

Involutiox of the L'terus 182

Characteristics of the Postpartum Uterus 183

Involution of Cervix and Vagina 187

Clinical Course of the Puerferium 189

CHAPTER X.— THE MANAGEMENT OF THE PUERPERIUM

Rest and Sleep 194

Prevention of Infection 195

After-Pains 197

Catheter and Vaginal Douche 199

Temperature and Plxse 201

Breasts and Nipples 203

Care of the New-born Child 206

Posture of Patient in Bed 208

When May She Leave Her Bed 209

CHAPTER XL— MULTIPLE PREGNANCY AND LABOR

Definition, Frequency, Etiology 212

Development 212

Diagnosis 215

Clinical History 217

Treatment in Pregnancy and Labor 218

Part II

PATHOLOGY OF PREGNANCY AND LABOR CHAPTER XIL— LOCAL DISORDERS OF THE MOTHER

Inflammations of the Genital Tract 223

Uterine and Other Tumors 229

Malpositions of the Uterus 240

Structural Anomalies of Uterus 246

Atresia 250

CHAPTER XIIL— GENERAL DISORDERS OF THE MOTHER

Toxaemia of Pregnancy 253

Eclampsia 260

Vomiting of Pregnancy 273

Acute Yellow Atrophy of the Liver 280

Chorea Gravidarum 281

CHAPTER XIV.— INTERCURRENT AFFECTIONS

Chronic Infectious Diseases , 283

Syphilis 283

Tuberculosis 289

Acute Infectious Diseases 291

Circulatory System 295

Respiratory System 298

Urinary Tract 299

Gastro-intestinal Disturbances 304

Nervous System 305

Cutaneous 307

Surgical Operations in Pregnancy 307

X CONTEXTS

CHAPTER XV.— THE PRE^IATURE INTERRUPTION OF PREGNANCY Clinical History and Management of Abortion and Premature Labor. . . 308

CHAPTER XVI.— EXTRA-UTERINE PREGNANCY

Clinical History and Diagnosis 324

Treatment 33^

CHAPTER XVII.— ANO.MALIES OF THE FCETUS AND ITS APPENDAGES

Hydrocephalus 334

Anenceph.\lus 337

Abnormalities of the Placenta • 338

Anom.\lies of the Cord 344

Diseases of the Chorion 346

Diseases of the Amnion 350

CHAPTER XVIII.— ANO^IALIES OF THE EXPELLENT FORCES

Uterine Inertia 354

Rigidity of the Cervix 356

Excessive Uterine Retraction 365

Tetanic Contraction of Uterus 365

Precipitate Labor 366

CHAPTER XIX.— MALPOSITIONS AND MALPRESENTATIONS OF

THE FCETUS

Posterior Positions of the Occiput 368

Transverse Presentations 375

Breech, Face and Brow Presentations 385

CHAPTER XX.— FETAL MORTALITY IN LABOR

Causes, Diagnosis, Prevention and Treatment of Fetal Asphyxia 404

Prolapse of the Cord. 426

CHAPTER XXL— LACERATIONS OF THE GENITAL TRACT DURING LABOR Repair of Perineal Lacerations

HiEMATOMA 444

Tears of Vagina and Cervix 4^.5

Rupture of Uterus 446

Inversion of Uterus 4^^

CHAPTER XXII.— THE PUERPERAL HE^IORRHAGES Postpartum

Cervical 47 1

Late ^ 473

Placenta Pr.evia 474

Accidental 483

CHAPTER XXIIL— CONTRACTED PELVIS

Etiology 488

Classification 4^0

Pelvimetry ^lo

Clinical Course of Labor ^25

Choice Between Forceps Operation and Version 530

CONTENTS xi