child's life, even if labor be successfully accomplished, is very
doubtful. Hence the mother's interest must be wholly para-
mount, and, before the foetus becomes impacted, embryotomy is
indicated. The most common of these conditions is that of dropsy
of the cerebral ventricles, with distention of the brain and its
coverings. This pathological state varies in severity from cases
associated with rhachitis, in which recovery ensues, to instances of
excessive distention of the brain and cranium, in which cerebral
functions and even the continuance of life are impossible.
The presence of a HYDROCEPHALIC SKULL is diagnosticated by
feeling a smooth, slightly elastic tumor without bony landmarks
DISORDERS OF THE FCETUS.
in place of the ordinarily ossified head. Examination under
anaesthesia with the greater portion of the hand will confirm the
absence of the sutures and fontanelles. Delayed or suspended
labor results from the presence of a hydrocephalic head of con-
siderable size. The mistake of applying the forceps to such a
head must be avoided ; the grasp of the instrument would be
insecure, and slipping and wounding of the mother's tissue would
result. The head must be lessened in size by evacuating a por-
tion of the fluid. When the distention of the head is not exces-
LABOR DELAYED BY HYDROCEPHALIC HEAD.
sive, a fine trocar may be employed, in the hope that when a
portion of the fluid has been removed, labor pains may compress
and expel the head. Where the head is so large that no such
result can be reasonably expected, it is best to perform craniot-
omy, empty the head of a considerable portion of the fluid, and
deliver it by the cranioclast (Fig. 125).
The hydrocephalic head not infrequently lodges in the fundus
276 MANUAL OF PRACTICAL OBSTETRICS.
of the uterus, the foetus assuming a breech presentation. In
these cases craniotomy on the after-coming head is the most
HYDROCEPHALUS AND BREECH PRESENTATION.
effective treatment. When the skull cannot be readily reached,
the spinal canal may be opened and fluid drained in that man-
ner (Fig. 126).
MONSTERS: FCETAL DEATH IN UTERO.
DEFICIENT development in various portions of the foetal body
causes deformities so unnatural in appearance that such a foatus is
called a monster. Single monsters (a single deformed foetus) are
often the blighted one of twins, the living, normal foetus having so
appropriated the tissue and pabulum of the other that but a portion
of the body has developed. Monsters may be conveniently divided
into those which can exist alone (autositic) and those which depend
upon the placental circulation of a second foetus, so that the mon-
ster's life ceases when the umbilical cord is cut (omphalositic).
Among the autositic monsters are the ectro-melic, with the ab-
sence of a limb; symelic, the limbs joined ; celosomatic, the abdom-
inal wall almost entirely deficient ; exencephalic, the cranial bones
lacking; pseudencephalic, brain and cranial bones but slightly
developed; anencephalic, with brain and skull lacking; cycloce-
phalic, eyes fused ; otocephalic, ears joined, face lacking. The
omphalositics are the portions of a blighted twin, the other normally
developed. They are deficient in cardiac formation (acardiac),
or have no head (acephalic), or lack a trunk (asomatic), or have
no well-defined shape (foetus amorphous) (Fig. 127).
Double monsters are most often joined twins, or a normal
foetus, with several limbs or parts of a second foetus joined to the
body of the first.
Although even double monsters are often delivered sponta-
neously, yet should impaction and delay in labor occur, ernbry-
otomy should be at once performed.
DIAGNOSIS AND TREATMENT OF FOETAL DEATH IN UTERO.
When foetal death occurs it may be diagnosticated by the cessa-
tion of heart sounds and movements. Progressive diminution in
the size of the mother's abdomen is also a symptom of diagnostic
MANUAL OF PRACTICAL OBSTETRICS.
importance. If no interference be practiced, a dead foetus is
usually expelled spontaneously in less than a month after the foetal
death. If retained, it may become soaked in amniotic fluid and the
serum of its own blood (macerated) ; or shrivelled (mummified) ; or
hardened (a lithopsedion). Putrefaction will not take place unless
air gains access to the foetus through rupture of the membranes.
When foetal death has been diagnosticated, labor should be in-
duced by a bougie. If the foetal membranes have been ruptured
and putrefaction be present, dilatation must be cautiously ef-
fected, the foetus removed and the uterus disinfected.
DISEASES OF THE NEW-BORN CHILD.
FAILURE of oxygenation of the foetal blood is a common dis-
order attending labor and persisting for a few hours during the
puerperal state. It is commonly known as ASPHYXIA, and is of two
degrees. The first is that in which the child's color is dark red,
the heart beats slowly, the mouth grasps the physician's finger, the
reaction to counter-irritants is present, respiratory movements are
present although feeble. This condition is often accompanied by
cerebral compression from haemorrhages on the surface of the
brain, following compression of the skull during labor. Where
haemorrhage is not present, efforts at resuscitation are commonly
The second stage of asphyxia is the "pallid asphyxia" of some
observers. The child's body is a bluish-white; the muscles re-
laxed ; feeble efforts at respiration or deglutition are present ; a
very feeble heart impulse can be observed. The eyes react but
slightly to light. In these cases treatment is often unavailing.
Children suffering from diseases which make the establishment of
respiration impossible through constitutional weakness often survive
labor for several hours or a day. Such children have gasping
respiration; are red in color; lie in a condition of stupor; moan
in an unconscious manner, and swallow nourishment with diffi-
culty. When an autopsy is made on such a child, a condition of
atelectasis is commonly found in the lungs. The portions into
which air has not entered sink in water, are dark red or violet in
color, show a smooth surface when cut, with no mucus on pressing
upon the cut bronchial tubes.
The treatment of asphyxia has been already stated under the
treatment of labor in breech presentation. Children who have
280 MANUAL OF PRACTICAL OBSTETRICS.
been resuscitated from asphyxia should be kept in an incubator
for several days, and require careful attention as regards the main-
tenance of the circulation and the promotion of nutrition.
SEPTIC INFECTION IN THE NEW-BORN CHILD. Septic infection
may find lodgment in the child's body through the umbilicus or
a mucous surface. Among the latter varieties of sepsis are septic
imflammation of the conjunctivae, of the mouth, and in female
children of the vulva. The first results in ophthalmia neonatorum.
The symptoms of ophthalmia of the new-born are redness and
swelling of the lids, with a muco-purulent secretion. If allowed
to go on, infiltration and sloughing of the cornea, with perfora-
tion and intra-ocular abscess, may destroy sight.
In proportion as antiseptic precautions are taken regarding the
condition of the mother's genital tract before labor and the avoid-
ance of infection during labor, ophthalmia disappears. When the
gonococcus, however, is present in the vagina before labor and
infects the eyes, the after-treatment is often unsuccessful. In
many hospitals a drop of a 2 per cent, solution of nitrate of silver is
dropped into the eyes, after douching them with boiled water. In
hospital practice this precaution gives excellent results. Where
the genital tract is known to be aseptic before delivery, it is un-
necessary. So soon as the disorder is recognized, if one eye only
is affected, the other should be closed and protected by an anti-
septic pad and bandage. The inflamed eye is then to be douched
with a saturated solution of boracic acid every hour or half hour,
in alternation with bichloride of mercury solution i to 8 or 10,-
ooo. This is best accomplished by placing the warmed solution
in a fountain syringe, using a medicine-dropper in place of the
usual nozzle. The child is placed across the nurse's lap, its arms
confined by a blanket, its inflamed eye lying lower than the other.
While the lids are gently separated with the fingers of one hand,
with the other the stream is directed from the nasal side of
the lids to the outer canthus. The fluid is conducted by a rubber
sheet into a receptacle and thus infection of the other eye is
avoided. The eyes should never be wiped or rubbed with bits
of cotton as is so often done. It is well to dilate the pupils with
DISEASES OF THE NEW-BORN CHILD. 281
atropia early in the case. Where swelling and redness are exces-
sive, compresses dipped in an iced solution of boracic acid may be
kept constantly upon the lids. The occasional application of a
solution of silver nitrate, 20 grs. to the ounce, is useful in severe
cases, if it can be done by a thoroughly competent person. The
infection of ophthalmia is very virulent, and great care must be
exercised by nurses and attendants to avoid the transmission of
Umbilical sepsis is marked by redness and swelling of the um-
bilical tissues, with fever. Occasionally the infection passes di-
rectly through the lymphatics into the general circulation, while
no local symptoms are present. Various micrococci may cause
umbilical sepsis, among them the germ of erysipelas.
The mouth may be invaded by various forms of bacteria. Most
common is a fungus called the sprue fungus, which forms white
patches upon the mucous membrane. It occasions considerable
irritation, and may be swallowed and disturb the intestinal func-
tions. It is best treated by allowing the child to swallow slowly
a teaspoonful or half teaspoonful of solution of boracic acid,
from 5 to 10 per cent, in strength, given with some palatable
vehicle, several times daily. Where boracic acid is used freely in
cleansing the nipple, the development of sprue (or thrush) is rare.
In diphtheritic inflammation of the vagina at labor, the diph-
theritic virus may become transferred to the child's mouth, and
set up a like process in the fauces.
The child may inspire septic material from the vagina during
complicated labor, in which asphyxia is threatened and respiratory
movements occur. Inspiration pneumonia follows, and is often
Malignant jaundice, tetanus, acute haemoglobinuria of the
newborn are the results of infection by agents not yet clearly
known : the results of these infections are fatal, treatment being
simply palliative. Haemoglobinuria is associated with cyanosis,
jaundice and hemorrhages from various organs; the disease is
called by Winckel, hsemoglubinuria. The bacillus of tetanus
usually finds entrance through the umbilicus.
282 MANUAL OF PRACTICAL OBSTETRICS.
THE UMBILICUS may be also the seat of haemorrhage after the
ligation and cutting of the cord. This may arise from fungous
granulations or from a brittle condition of the blood vessels. If
pressure by an antiseptic pad fails to stop such haemorrhage, two
needles may be passed at right angles beneath the bleeding tissues
and a figure-of-eight ligature applied.
Besides the caput succedaneum, which disappears in a few days
after labor, CEPHALH^EMATOMA may be present. This is a tumor
formed by the extravasation of blood between the periosteum and
cranial bones, usually situated on or near a parietal bone, and
varying in size from a walnut to an apple. The blood is dark,
like syrup. The tumor is not painful, and has a tense, hard edge.
If the tumor be opened, the blood reaccumulates.
Cephalhaematoma may also be internal, the blood being situ-
ated between the bone and internal periosteum. External cephal-
haematoma is rarely dangerous ; when internal it is accompanied
by the symptoms and dangers which mark cerebral compression.
Cephalhaematoma may be left to be absorbed spontaneously,
or incised, emptied and compressed. If incised it should be
done six or eight days after the tumor is discovered. If antiseptic
precautions be observed, incision may be practiced with impunity.
THE BLOOD of the newborn infant may become so disordered
that passive haemorrhage from the mucous surfaces may threaten
the child's life. When the blood is very fluid and very dark in
color the condition is known as melaena neonatorum. Such dis-
organization of the blood is invariably fatal.
SYPHILIS and RHACHITIS are among the most important of the
constitutional and deforming diseases of the foetus. The former
is known by the pallid, clay-colored complexion of the foetus ;
the coryza which is present at birth in many cases, and the pem-
phigoid eruption which appears a few days after birth over the
whole body. If the body of such a foetus be examined, the liver
and spleen are found enlarged, perhaps containing gummata.
The lungs are the seat of a fibroid pneumonia ; the bones exhibit
a reddish-yellow streak just above the epiphyses (Fig. 128), which
is caused by the proliferation and fatty degeneration of syphilitic,
DISEASES OF THE NEW-BORN CHILD.
cellular tissue. The nostrils of such a foetus are thick ; its limbs
poorly developed ; its tissues ill- nourished.
The rhachitic foetus has the projecting forehead, the enlarged
epiphyses of the long bones, the "beads" along the ribs where
FCETAL BONE, SYPHILIS, SHOWING SYPHILITIC LINE.
they join the sternum, the projecting sternum and spinal curva-
ture which so often mark this disease.
Syphilis may be treated by calomel, gr. ^, with soda ; by
inunction of mercurial ointment or the hypodermic injection of
bichloride of mercury, yfo of a grain in solution. Syphilitic
eruptions and sores may be dusted with calomel. Cod-liver oil
is indicated in both syphilis and rickets.
THE following memoranda and formulae have been found of
practical interest and value :
ANTISEPTICS. Bichloride of mercury is best used for cleansing
the hands of the obstetrician and the external genitals of the
patient. It has caused poisoning in vaginal douches, i to 5000.
It should not be employed for intra-uterine douches, as fatal
poisoning may readily follow such use. Bichloride is usually sold
in tablets. When these cannot be obtained, the following pow-
ders will be found convenient :
Bichloride of mercury grs. 10
Tartaric acid grs. 49
Cochineal gr. i
One powder dissolved in one pint of water makes a solution,
i to 1000. When a solution of bichloride is turbid, common
salt may be added to favor complete solution. In strength of i
to 2000 it may be used for cleansing the hands and external
parts; in i to 5000 to i in 10.000 for vaginal douches. Bichlo-
ride solution, i to 1000, is useful to cleanse rubber articles. Symp-
toms of bichloride poisoning are salivation, sore teeth and gums,
mucous, bloody diarrhoea, rapid pulse, prostration, coma, death.
Treatment consists in stopping the use of the bichloride, using a
mouth wash of equal parts of potassium chlorate and boracic acid
in solution, and giving opium and stimulants for the diarrhoea.
CARBOLIC ACID AND CREOLIN are valuable in 2 per cent, so-
lutions for intra-uterine douches and to cleanse metal instruments.
Glycerine should be added to carbolic solutions to insure solu-
bility. Creolin forms a ready emulsion with water. In 30 drops
to the pint of warm water it makes an excellent vesical douche in
cystitis. Its odor is disagreeable to many ; it stains linen and
white rubber articles ; it is very irritating to the skin of some
patients. Severe pain is sometimes complained of after the use
of creolin solutions 2 per cent., but inflammation rarely follows in
Carbolic acid and creolin cause smoky urine in cases of poison-
ing, with dysuria and toxaemia, terminating in coma and death.
Aside from stopping the use of the poisonous substance, but little
can be done in treating these cases.
BORACIC ACID is an excellent antiseptic for use on the mother's
nipple, in the child's mouth and eyes, and in 6o-grain supposi-
tories within the uterus. Saturated solutions may be used, with
the addition of 5^2 of glycerine to the ^. In powder, boracic
acid is useful as a dressing for the umbilicus, and in dusting the
folds of the skin in children disposed to eczema.
THYMOL, i to 1,000, is an excellent intra-uterine douche.
IODOFORM may be used in suppositories within the uterus in the
following formula :
lodoform grs. 300
Starch ; . . aa gr. 30
In 3 suppositories, or the quantity of iodoform may be grs. 180,
each suppository containing 60 grains.
lodoform may be used to dust the umbilicus and cord ; it may
be combined with bismuth subnitrate, equal parts.
DRESSINGS FOR THE UMBILICAL CORD. Powdered salicylic
acid, i part ; powdered starch, 5 parts ; powdered boracic acid ;
iodoform and bismuth equal parts.
A mass of absorbent cotton large enough to receive the cord
and cover it, is sprinkled freely with one of the above powders ;
the cord is enfolded in the cotton, turned upwards and to the
left of the umbilicus and the belly-band pinned over it.
The following OINTMENT will be found useful in healing SORE
Powdered boracic acid grs. 10
Cold cream ^i
Powdered boracic acid grs. 10
Cosmoline aa 5^
Or powdered zinc oxide or bismuth subnitrate in the same pro-
portion, with these bases.
DIRECTION FOR MAKING A BREAST-BINDER OR COMPRESSION
BANDAGE. It is twenty-nine inches long by eight wide ; three
and a half inches from either extremity, and in the centre of the
bandage two holes have been cut the size of a quarter of a dollar,
the edges of which are carefully overseamed to prevent the aper-
tures from tearing out, the distance between them being the dis-
tance measured between the nipples. At the upper edge of the
bandage, five inches from the end, two shoulder-straps are at-
tached, two inches wide. The bandage is so applied that it pins
over the centre of the chest between the breasts, the apertures
giving room for the nipples, through which the child may nurse.
The shoulder-straps come over the shoulders and may cross in
front, or be pinned without crossing, to the upper edge of the
bandage after it has been fastened about the body. The pur-
pose of this bandage is to draw the breasts upward and inward,
thus relieving the pain caused by engorgement. This bandage
may be made of Canton flannel or of firm muslin as desired.
THE ABDOMINAL BINDER. A strip of hemmed muslin 12
inches wide, from 24 to 30 inches long.
LAXATIVES. For use during pregnancy the compound licorice
powder is excellent; also the compound rhubarb pill of the
U. S. P. Women threatened with eclampsia do well with the
compound colocynth pill.
After labor Fordyce Barker's post partum pill is useful :
Ext. coldcynth comp gr. 20
Ext. hyoscyam gr. 15
Pulv. aloes socot gr. 10
Ext. nucis vom gr. 5
Ipecacuanha aa gr. i
In 1 2 pills. Two may be taken at a dose.
If the tongue be furred and coated, calomel, grs. 2^, and
sodium bicarbonate, gr. 10, may be taken, followed in eight or
ten hours by a seidlitz powder and a copious rectal injection.
ANAESTHETICS are to be chosen in obstetric cases as follows :
Chloroform, in normal labor as an anodyne until the moment
of delivery, when complete anaesthesia is desired. In threatened
uterine rupture, where uterine tetanus is present, chloroform to
complete anaesthesia is indicated. To relax a tightly contracted
uterus to permit the removal of a retained placenta, chloroform
is indicated ; for the low forceps operation and for version.
Ether is to be preferred for Csesarean section ; amputation of
the uterus ; craniotomy ; the high forceps application ; for sutur-
ing the perineum.
Bromide of ethyl and the alcohol, chloroform and ether mix-
ture, alcohol i, chloroform 2, ether 3, have been used, but pos-
sesses no practical advantages over ether and chloroform.
THE DIAGNOSIS OF CONTRACTED PELVIS. The following
measurements are to be made :
Between the ant. sup. spines of the ilia.
Between the crests of the ilia.
The external conjugate, from beneath the spine of the last
lumbar vertebra to the pubic joint, anterior aspect.
The internal, true conjugate, from the sacral promontory to the
posterior surface of the pubic joint.
Between the tuberosities of the ischia.
From the post. sup. spine of the ilium of one side to the ant.
sup. spine of the other.
The following clinical data are given by Diihrssen, as indicating
the presence of pelvic deformity :
Curved and prominent extremities.
Pendulous abdomen during a first pregnancy.
History of previous difficult labor.
Premature rupture of the membranes.
Prolapse of the cord or foetal limbs.
Failure of the head to enter the pelvis.
Abnormal position and presentation of the child.
The various presentations of the head in contracted pelves are :
In flat pelvis, the anterior fontanelle sinks deeply, a parietal bone
presenting ; in symmetrically-contracted pelves, the posterior fon-
tanelle and vertex sink deeply ; in flat, rhachitic pelves, present-
ation of parietal bone and deep position of the smaller fonta-
nelle. These various positions are those most favorable in the
respective kinds of contracted pelves.
CONTENTS OF BABY BASKET. This basket should include the
baby's toilet articles : simple rice powder, a little pot of white
vaseline or cold cream, white Castile or spermaceti soap, and
such other articles as an experienced nurse or mother may deem
necessary. We append a list of an outfit which has been found
of practical use : brush and comb ; skein of white twisted em-
broidery silk ; soft fine sponge ; bottle of white vaseline ; sharp
pair of pointed scissors; powder-box and puff, with talc powder;
pin-cushion ; small and large safety-pins; pure castile soap; pair
of socks ; some old, fine linen ; flannel or knitted band ; flannel
shirt, a petticoat and night-gown for infant ; an afghan or piece
of extra flannel, in which to wrap child ; also piece of flannel, or
old blanket, to receive it in ; in addition the baby will require
eight day dresses, eight night gowns, eight white skirts, four day
flannel skirts, four night flannel skirts, four pairs of day socks,
four pairs of night socks, six flannel shirts, six flannel bands,
three dozen small soft linen diapers, three dozen larger cotton
ones, at least two little knitted sacques.
The following description of A CROCHETTED BABY-BAND is taken
from "Babyhood," Vol. III., p. 33: "Single zephyr in ridge
stitch ; that is, half stitch, in which, going back and forth, only
the back half of the stitches in the lower row are picked up.
Begin on a chain of fifty and crochet forty-eight ridges, hence
ninety-six rows. Join by a row of plain stitches, and at top by
a picot edging (five chains and a tight stitch back into the
INFANTILE COLIC. Prevented by proper diet of mother and
systematic nursing of infant.
Relieved by peppermint water, gtt. x-xv, in a little sweetened
hot water. If constipation exists, it can usually be relieved by
Sodii Phosphas, gr. v-x, three times daily, given in hot water.
A spice plaster, or hot flannel over the abdomen, is also useful.
A BDOMINAL binder 286 Application of the forceps 94
Abnormal condition of mother's Area germinativa 14
milk 214 Artificial feeding of infants 217
Abnormal insertion of the placenta. . . 222 Asphyxia 279
Abnormal labor, treatment of, in head- Asphyxiated child, resuscitation of . . 114
presentation 88 Attitude of the feetus 57
Abnormalities of labor in head-presenta- Auto-transfusion 227
tions 71 Axial groove 14
Abnormalities of the umbilical cord . . 270 Axis of the birth -canal 38
Abortion 149 Axis-traction 98
Abortion, criminal 155
Abortion, habit of 151 T) ABY-BASKET, contents of . ... 288
Abortion, therapeutic 155 ' Bandage, compression 286
Accidents of labor endangering the Band), contraction-ring of 238
mother 238 Basket, baby, contents of 288
Acid, boracic 285 Binder, abdominal 286
Acid, carbolic 284 Binder, breast 286
Acute infections during pregnancy . . 175 Birth, foetus at 29
Adherence of the placenta and mem- Birth-canal 34
branes 267 Birth-canal, axis of 38