less safe than the simple devices described.

In cases of hydrocephalus, when the child presents by the

FIG. 103.




DECAPITATION; TIGHTENING A CORD AROUND THE NECK.

breech, the progress of birth will often cease with the efforts
to expel the head. It is desirable in such cases to drain the sub-
arachnoid spaces to lessen the size of the head ; an opening may
be made into the spinal column, the soft tissues having first been
incised to permit of easy access to the vertebrae.



SURGICAL TREATMENT OF COMPLICATED LABOR. 203

By evisceration is understood that form of embryotomy which
opens the abdominal or thoracic cavity of the foetus, allowing the
escape of blood and other fluids contained in these cavities, and



FIG. 104.



FIG. 105.




DECAPITATION WITH BRAUN'S HOOK.



BRAUN'S DECAPITATION
HOOK.



oftentimes the removal of the viscera themselves. This is usually
readily accomplished by incising the walls of the cavity. It is



204



MANUAL OF PRACTICAL OBSTETRICS.



sometimes best to eviscerate the thorax by opening the abdomen
below the diaphragm, rupturing the diaphragm, and extracting
the lungs and heart from the opening thus made.

Embryotomy requires especial caution as regards antisepsis.
It is well not only to cleanse instruments and hands, but also to
wash out a cavity opened, by an antiseptic solution. In cases
where the foetus has died it may contain in its body sources of

FIG. 106.




TARNIER'S BASIOTRIBE.

infection, and hence its tissues should be antisepticized at the
moment when the body is opened.

Craniotomy upon the after-coming head is sometimes indicated in
cases where the head becomes impacted at the moment of delivery
in breech presentation (Fig. 106). It is usually most convenient
to enter the skull through the foramen magnum, the head having
been brought as far down as possible by traction upon the trunk.
After the evacuation of the skull, delivery will be usually accom-
plished most easily by the use of the cephalotribe. It may some-
times be necessary to enter the skull through the roof of the foetal
mouth.

MINOR OBSTETRIC SURGERY IN DELAYED LABOR. In cases
where delay in labor occurs through rigidity of the os and cervix,



THE SURGICAL TREATMENT OF COMPLICATED LABOR. 205

dilation may be accomplished by stretching, with the fingers or
Barnes' rubber bags, or by majcing multiple shallow incisions in
the os and then dilating. Especial precautions regarding anti-
sepsis are required in these cases, for wounded surfaces in the os
and cervix become easily infected. By multiple incisions exten-
sive laceration of the cervix may often be prevented.



CHAPTER XXX.

THE PUERPERAL STATE.

THE accomplishment of labor marks the beginning of what
is known as the lying-in period, or puerperium, or the puer-
peral state. By this is understood the time in which the
woman is recovering from the effects of her labor. It will
be seen that no limit can be set in all cases for the puer-
peral period. Thus, the savage woman recovers from labor suffi-
ciently to resume her usual avocations in a few days, while her
civilized but weaker sister requires several months to fully recover
from parturition. The lying-in period applies especially to the
time during which the patient is in bed, but also the time elaps-
ing before the patient engages actively in her former pursuits.
The phenomena of the puerperal period are those connected with
the process by which the uterus and the entire genital tract are
reduced in size from their hypertrophied condition at labor to
their normal proportions. Together with this process, called
involution, the abdominal muscles of the patient, which have
been strained and distended during the pregnancy, assume their
former consistence and contractile power. The hypertrophies
which have existed in the secretory and glandular organs of
the patient gradually give place to the usual conditions obtain-
ing in these parts. Together with these changes, which may
be styled retrograde or absorptive changes, there occurs the
establishment of a new function, namely, lactation, or the secre-
tion of milk.

It is evident that the first set of changes mentioned, namely,
involution, results in the formation of a large amount of material
to be removed from the body. If organs have hypertrophied by
the multiplication of cellular elements and the aggregation of
tissues, a normal condition of these organs can only be reached
206



THE PUERPERAL STATE. 207

by eliminating the excess of material. Thus, the uterine muscle
and the enlarged and multiplied glands of the lining membrane
of the uterus are lessened in size by a process closely resembling
that of fatty degeneration. The material produced by this degen-
eration is, a portion of it, oxygenated in the patient's blood by
respiration, while the greater part of it is removed from the body
by the different emunctories. The presence in the blood of this
fatty material produces an increased amount of bodily heat,
resulting oftentimes in a slight and habitual rise of temperature
during the week or ten days of the puerperal period. Thus, the
average temperature of the healthy lying-in woman is often one
hundred degrees instead of ninety-eight and five-tenths. In some
cases, the patient seems to take care of this material without dis-
turbance of temperature and with, possibly, a different mode of
elimination. Together with the breaking down of hypertrophied
tissue there comes a process of multiplication of red blood cor-
puscles which restores to the blood its losses at labor.

When once the fatigue of labor has been surmounted, a
sense of physical comfort and an increase in appetite com-
monly occur, which persist through the puerperal period. The
lacerations in the genital tract heal during this time; deposits
of pigment upon the face or other portions of the body are
slowly absorbed and destroyed, and oftentimes a gain in weight
and an increase in the development of the woman follow parturi-
tion. While the breasts have become somewhat hypertrophied by
a turgid condition of the mammary glands during pregnancy, yet
the formation of breast-milk does not take place until a number
of hours, or possibly two or three days after delivery. The milk
may then come into the breasts, as it is sometimes said, " with a
rush." The breasts become distended, reddened from a general
hyperaemia, and frequently the neighboring lymphatics show a
temporary engorgement. The over-distended tissues of the peri-
neum and pelvic floor regain their elasticity to a considerable
extent. There always remains, however, a certain degree of
dilatation sufficient to make a diagnosis of a previous parturition
possible.



208 MANUAL OF PRACTICAL OBSTETRICS.

A peculiar condition of receptivity to certain infections seems
to obtain during the lying-in period. Thus, the exanthematous
diseases are more easily contracted by lying-in women than by
others. Septic infection from polluted air, or from unclean sur-
roundings, is also readily absorbed. While this may be explained
in part by the lacerated surfaces of the genital tract, infection
from a contaminated atmosphere is sufficiently common to illus-
trate the patient's receptive condition. The nervous system,
which has been so severely taxed during parturition, shows imme-
diately afterward an unstable state which renders the patient easily
disturbed by emotion. Thus any cerebral disturbance results in
a considerable derangement of temperature, or, oftentimes, in
serious interference with the function of lactation.

The treatment of the puerperal period consists in surrounding
the patient with such an environment that her dangers of infection
shall be reduced to a minimum, and that the processes of absorp-
tion and repair be disturbed as little as possible and furthered in
every way. Tranquillity and rest for the nervous system are also
of paramount importance. To secure proper protection against
infection for the lying-in patient, her room should be clean and
not connected with any channel leading to decomposing material.
Thus, it is better that there be in her apartment no pipe
leading to a cesspool, drain or sewer. Occasionally, heating
apparatus may become a source of danger, as illustrated in a hos-
pital where a nurse had carelessly thrown a napkin, stained with
the lochial discharge, into an unused furnace ; a flue from the
furnace opened near the bed of a patient recently confined, who
contracted septic infection from air conveyed through the flue
from the furnace below. More frequently, however, the immediate
environment of the patient may become a source of safety or of
danger. Thus, her bed and bedding should be absolutely clean ;
the effete material removed from her body by the intestines and
kidneys should be promptly disposed of, and the lochial discharge
should be absorbed in such a manner as to prevent its decom-
position. The air which the patient breathes should be pure,
fresh, and frequently renewed. Processes of excretion and invo-



THE PUERPERAL STATE. 209

lution are best furthered by promoting the action of the excre-
tory organs, and by favoring nutrition in every possible way.
Thus, it is an excellent custom to secure a thorough evacuation
of the intestines on the second or third day after labor, and the
bowels should move at least once in two days through the lying-in
period. The action of the kidneys should be encouraged by
water freely taken. The skin should be stimulated to perform its
function by a daily bath, followed by gentle massage. The ner-
vous system of the patient should be afforded rest by securing
absolute freedom from intrusion.

As regards the absorption of the lochia and the prevention
of absorption by wounded surfaces of the genital tract, anti-
septics are indicated. It has formerly been customary to re-
ceive the lochial discharge upon napkins, which were cleansed
when soiled, and used again. As our knowledge of antiseptics
has increased, this practice has, so far as possible, been super-
seded by the use of absorptive dressings, which are destroyed
when soiled. These dressings have the further use of occluding
the genital canal, and preventing the entrance of infectious
germs from the outside. Among the many occlusion and ab-
sorptive dressings employed may be mentioned sublimated jute
enclosed in cheese-cloth soaked in sublimated solution ; old,
soft linen, antisepticized in the same manner, and made into
absorptive pads, and, in the experience of the writer, a pad or
napkin made as follows : first, a strip of picked oakum or jute
three-fourths of an inch thick, sixteen inches long, five inches
wide. On each side of this, cheap cotton batting, sufficient to
cover and inclose the oakum. The whole is included in a piece
of cheese-cloth, eighteen inches long, twelve or thirteen wide.
The edges of the cheese-cloth are brought together and secured
loosely by cotton thread. The ends may be closed to advantage
in the same manner. This napkin is dipped in bichloride of
mercury, one to two thousand, and dried.

On an average, six or eight are required for the first three or
four days after confinement, and subsequently four daily. When
the material is bought in large quantities at wholesale, and these

9*



210 MANUAL OF PRACTICAL OBSTETRICS.

napkins are made by hospital nurses, the material itself, exclusive
of the labor and the bichloride of mercury used, costs one and
one-quarter cents for each napkin. When a small quantity
are made less than a hundred the napkins cost, also exclud-
ing labor and bichloride, about three cents each. When stained
through, the pad is removed, rolled up in a bit of old paper,
and burned.

The question as to the possibility of a patient infecting herself
with puerperal sepsis from the secretions or discharges of her own
body has occasioned much discussion. If auto-infection be pos-
sible, then the lochial discharge is extremely dangerous to the
patient, and should be thoroughly antisepticized. If, on the
other hand, the lochial discharge is dangerous only after it has
come in contact with the external atmosphere and undergone a
partial decomposition, then the lochial discharge does not need
to be antisepticized except after it has emerged from the body
into the external atmosphere. If an examination of the genital
tract of the mother be made after labor to determine presence or
absence of septic bacteria in her lochial discharge, it is found
that only where the lochia come in contact with the atmosphere
do septic germs exist. In the lower portion of the vagina are
found the lower orders of bacterial life. The interior of the
uterus in a normal case contains no septic germs whatever, and
hence requires no disinfection. The routine use, then, of vagi-
nal douches after labor is quite unnecessary, and often harmful,
because of the risk of infection which occurs whenever the human
body is entered by any instrument or appliance. Practically,
then, when a patient has not been infected before labor by
syphilis, gonorrhoea, or septic infection, she needs after labor
but a single vaginal douche. This should be given of bi-chlor-
ide of mercury one to five thousand. After this no douches are
needed, but the parts should be bathed with the same solution
after the renewal of each pad, and especially after the bladder
and rectum are emptied. It is well, in all cases where specific,
septic or catarrhal inflammation of the genital tract has occurred
before labor, to give the patient a preliminary douche of some



THE PUERPERAL STATE. 211

antiseptic when labor begins. Bi-chloride of mercury one to
five thousand is often employed. A preparation of green soap
and creolin, so combined as to contain from one to two per
cent, of creolin, has been used in the Philadelphia Hospital for
several years with advantage. The soap is especially efficient in
removing retained and partly decomposed secretions.

Especial precautions are necessary whenever occasion arises
for catheterizing the patient. The catheter should be kept in a
five per cent, solution of carbolic acid, or a one to one thousand
solution of bi-chloride of mercury. Before its introduction the
attendant should carefully cleanse the orifice of the meatus with a
bi-chloride solution one to five thousand. The catheter should
then be inserted without coming in contact with the patient's
bedding or surrounding portions of her body. After the bladder
has been emptied, the parts should again be cleansed in the same
way as before the insertion of the catheter. With these precau-
tions it is possible to avoid infection of the bladder, although,
without them, such infection and consequent inflammation are
very apt to occur.



CHAPTER XXXI.

THE PUERPERAL STATE : LACTATION.

THE breasts of the mother also require attention during the
lying-in period to prevent the entrance of germs and the develop-
ment of mammary abscesses. During the latter months of preg-
nancy the patient should have washed the nipples thoroughly
with Castile soap and warm water, and if any cracks or abrasions
exist, an ointment of boracic acid, ten grains to the ounce of
some suitable fat, should be employed. At the time of labor it
is well to prevent congestion and over-distension of the breast,
and also to take precautions that some of the lower forms of bac-
teria, which easily infest the child's mouth, should not form upon
the nipple. The breasts may be advantageously supported and
compressed by several forms of breast bandages. Thus a broad
figure of 8 may be passed around the breasts and over the shoul-
ders. A breast-binder may be used which, in the experience of
the writer, has never occasioned inconvenience, and usually
proves a considerable comfort. This should be fitted by the
nurse at the time when the breasts become distended. A strip
of unbleached muslin or Canton flannel should be selected, large
enough to encircle the body, lapping over between the breasts,
and wide enough to go over the axillary line to the extremity
of the sternum. This may then be pinned about the patient, the
line of pinning being in the centre of the body between the
breasts. Opposite to the nipples two holes should be cut the size
of a silver quarter of a dollar, and these apertures should be
bound with strong tape, otherwise the weight of the breast will
force the gland through the bandage, tearing it asunder. An
aperture of this size will ordinarily enable an infant to nurse
without removing the bandage, but should it be desired to en-

212



THE PUERPERAL STATE: LACTATION. 213

large the aperture, this may be done to any extent required.
Shoulder-straps are then fitted, being fastened anteriorly to the
upper edge of the bandage, passing over the shoulder to the
upper edge of the bandage upon the other side and behind. By
tightening or loosening the shoulder-straps the breasts may be
gathered toward the median line, and raised toward the upper
portion of the body. In this way the patient will experience a
marked degree of comfort, and over-distension and threatened
engorgement may be prevented. Infection of the nipple and
of the breasts may be guarded against by cleansing the nipple
thoroughly after each nursing with a saturated solution of boracic
acid, to which a little glycerine has been added. Should cracks
or fissures occur, they may be painted, after being cleansed, with
compound tincture of benzoin.

It will be found advantageous to take precautions to avoid the
growth of bacteria in the mouth of the child. While septic
bacteria do not often gain access to the child's mouth, yet some
of the lower forms of these germs are very commonly found
there, and may infect the mother's nipple. It is well to cleanse
the child's mouth, after nursing, with a bit of soft old linen,
dipped in a saturated solution of boracic acid, to which a little
glycerine has been added. The breasts should be nursed, so far
as possible, in alternation. During the day, two hours is a
convenient interval for the child to nurse, and during the night,
twice between ten in the evening and six in the morning is
quite sufficient. If the nurse insists upon the child's feeding
regularly through the day, even waking it if necessary, it will
be much more likely to sleep at night, and will be well able
to do with less frequent nursing. No absolute rule can be
laid down regarding the amount which any child should take.
The child's appetite, if it be properly taken care of, is usually
the best guide. When a child nurses with great greediness,
some abnormality in digestion should be suspected, and sought
for, if possible. Such children are very apt to regurgitate very
frequently after nursing, and are often troubled with indigestion
and flatulence. The habit of greedy nursing may sometimes be



214 MANUAL OF PRACTICAL OBSTETRICS.

corrected if the mother will allow the nipple to rest between
two fingers of the hand which is supporting the breast. Pressure
upon the nipple in this manner will regulate the flow of milk,
and prevent too large an amount from entering the child's
stomach at once. On the other hand, a tardy secretion of milk
may occasion some anxiety for fear lest the infant suffer. If the
usual preliminary flow of colostrum is present, but little uneasiness
should be felt, although the discharge from the breast remains thin.
If the infant cries from hunger which cannot be appeased, one or
two meals of sterilized milk may be given during the twenty four
hours.

It not infrequently happens that some abnormal condition
of the mother's milk exists, which causes it to disagree with the
infant. A gross inspection of such milk would result in finding
it thinner than normal, and bearing the appearances of a fluid
deficient in the amount of fat. An accurate idea of the compo-
sition of such milk can only be obtained by subjecting it to an
examination with a lactometer, and also to microscopic examina-
tion. As the physician cannot always have a lactometer at his
disposal, he will do well to rely largely upon his microscope.
Normal milk, when viewed under the microscope, presents a
number of rounded bodies which are the milk globules. They
are of fairly uniform size, and are smooth and not granular in
appearance. In the first milk or colostrum which forms, there are
found numerous young epithelial cells, which are derived from
the gland tubules of the breast. As the secretion of milk becomes
established, these colostrum corpuscles, as they are often called,
disappear, and in their place the field of the microscope is found
to contain the rounded, smooth, corpuscular body which forms
the essential element in milk. The fully developed milk-globule
is a cell composed of an albuminoid outer wall or envelope, con-
taining a small amount of fat. When digestion occurs, the
albuminoid envelope is digested and dissolved, and the fat is
directly absorbed in the lacteals. If a microscopic examination
be made of the stomach of an animal digesting milk, the fat of
the milk may be observed in a state of granular degeneration



THE PUERPERAL STATE: LACTATION. 215

in the tubules of the stomach and intestines. It is then under-
going the process of absorption. If the physician, upon
examining a sample of milk, finds many colostrum corpuscles
present, and that the number of milk-globules is deficient ; that
they are not of a fairly uniform size, and seem not to be present
in abundance in the field, he may reasonably infer that the milk
is deficient in quality. If, furthermore, he should observe blood-
corpuscles, pus-cells and bacteria in the milk, he should at once
reject it for use, as being infected with some form of puerperal
infection. Should the mother be suffering from tuberculosis of
the breast, the tubercle bacilli can be detected in the milk.

Much discussion has been aroused regarding the influence of
the mother's diet upon the secretion and quality of her milk. It
has been a common practice to interdict such articles of food as
are supposed to "sour" the milk. Such, for example, are acids
and food cooked or dressed with an acid. Salad and pickles were
considered as highly objectionable food for a nursing mother.
Further studies on the mother's digestion have shown that what-
ever agrees with her personally, and whatever is digested well, as
a rule produces milk for her child. The food of the nursing
mother should be easily digested, abundant in quantity, palatable,
and, if possible, enjoyable. Certain articles of food tend to
increase materially the flow of milk ; such are milk itself, when
taken freely by the mother ; beets, vegetables containing sugar ;
chocolate and cocoa are beverages tending to increase the secre-
tion of milk. Beer and porter, in many cases, and water, are
also beverages of practical value.

Patients differ greatly in regard to the perfect performance of
the function of lactation. Drugs given to promote the secretion
and flow of milk are useful only as they are general tonics.
There is no specific of practical and continued value in these
cases. The care of the breasts during the period when lactation
is about to be established is a matter of considerable importance.
Not only should the nipple be kept thoroughly cleansed, as has
been described, but the settling and accumulation of milk in any
portion of the breast should be prevented by gentle friction and



21 6 .MANUAL OF PRACTICAL OBSTETRICS.

massage over those portions of the gland where the milk-ducts
are distended and hardened. More important, however, is the
use of the bandage as has been described.

Certain drugs are excreted very rapidly through the mother's
milk. Such are potassium iodide, the iodides, chlorides and
certain drugs affecting the central nervous system profoundly.
It has been supposed that opium, when taken by the mother,
passed soon into the milk, and thence to the child. While
this is undoubtedly partially true, yet there is reason to be-
lieve that it passes less readily into the milk than has been sup-
posed. Quinine, when given to the mother, affects the child
through the milk, and many purgative medicines have the same
effect.



CHAPTER XXXII.

ARTIFICIAL FEEDING OF INFANTS.

IT not infrequently happens that the function oflactation fails;
this may arise from deficient vigor on the part of the mother without
any one local or specific disease. It also follows the acute infec-
tions of whatever sort, of which septic infection is the most familiar
example. Malformation of the breasts and occlusion of the ducts
of the nipple are also causes. A sudden and severe shock to the
nervous system of the mother may produce cessation of lactation.