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certainly conscientious and was not in the rear rank as regards ability for there are undoubtedly many who differ from him only in not knowing when this accident does occur. Some of our best authorities make the broad assertion that rupture of the female perinæum during labor should never occur, and the more you study this subject at the bed-side during delivery the more nearly you will agree with them provided you follow a logical course in preventing injury. The one thing needful is to prevent rapid delivery and allow the parts time to dilate. Your patient beseeches you to help her and repeatedly asks if it will take much more time. Your sympathies are wrought upon but you must remember the test of your skill is not the time required but the condition of your patient afterward. If you have prevented injury no more time has been consumed than her case required; if this has not been done you have allowed the head to be born too soon or suddenly. Different methods of treatment have been advanced to prevent injury. The one which has probably been the most widely promulgated is that of supporting the perinæum with the hand. As ordinarily practiced or in whatever manner accomplished this is one of the surest means of causing rupture. Instead of allowing the tissue to stretch over the advancing head pressure is made upon both surfaces, the fibres become bruised and weakened and will most surely tear. In so far as this course tends to prevent the too rapid advance of the head and to crowd it forward against and in front of the pubis it accomplishes good and this probably explains why it has been so generally resorted to, but
any such pressure must not be made over the perinæum or in any way directly against the mother. A few have advised making an incision on the sides so that any giving way will occur here and be in a location where it will heal by granulation; even this less objectionable injury should be avoided. One writer has said in effect if you cannot keep your hands off you may press with the thumb and fingers spread out over the child's head. This is correct except that you should always have your fingers against the head and in position to retard rapid expulsion should it be likely to occur. Any pressure exerted should be directly against the child's head and never upon the tissue of the mother. In no case should you allow the head to be expelled during pain. When the head is about to pass all voluntary exertion on the part of the mother should be stopped; she must not pull with her hands, hold her breath or in any way make downward pressure. Until so much of the head protrudes that it is likely to come through you may let it advance, then you should control its advance with one, or both hands, placed against the child's head and pressing forward against the pubis and backward if necessary, allowing the head to come through slowly. Now that the head has passed without causing any injury, your whole duty is by no means done for it undoubtedly frequently happens that injury is done by the shoulders and body. After examining to see if the cord is around the child's neck you should next ascertain the position of the shoulders and arms. If the arm is doubled across the chest it should be delivered by introducing two fingers, before the shoulders begin to advance, and drawing it gently forward at the same time swinging it to one side, care being taken not to press against the perinæum. If the arms lie beside the body you can often reach the one which is in front or next to the pubis and by swinging it in front of the body it can be delivered without using much force. If this can be accomplished without pressure or any unnatural motion of the child's arm it should be done, as it greatly lessens the diameter by bringing out one shoulder at a time. Until all of the child is expelled the portion which is born should be supported and carried forward over the pubis that it may not press upon the perinæum; this is very important, for if you have ever drawn a board over a fence you have had an illustration of the strain which is put upon the parts when this is done.
The use of the forceps is frequently the cause of laceration. The habit of giving an anæsthetic and using force while the patient is insensible cannot be too thoroughly condemned. If properly used and sufficient time is allowed, your patient need suffer no more than would be the case where delivery took place without their aid. The os uteri should have become fully dilated before the forceps are resorted to, and you must always avoid pressure upon the tissues or making a fulcrum of any part. The perinæum is the part which most frequently suffers when instruments are resorted too, and yet if you will follow the advice above given you 'have a very thorough means of preventing the too rapid advance of the head while it is passing through the external parts.
It has long been my habit where it becomes necessary to apply the forceps, to remove them as soon as the object for which they were applied has been accomplished. If the patient has not become exhausted so that the force of the uterine contractions is gone, it will seldom be necessary to allow them to remain, while the head passes, and it is perhaps safer to remove them.
To recapitulate then, do not make too frequent or too long continued examinations, especially during the first stage of labor. Allow the membranes to remain intact as long as possible. Do not interfere except perhaps to gently correct some malposition. Rigidity of the os will usually yield if time is allowed. Where convulsions or some equally urgent complication arises, making it necessary that you hasten delivery you should imitate the natural course of labor, and allow time for the parts to dilate. The prevention of lacerations will consist in not interfering until the head is likely to pass, and then interfering actively to prevent the too early or forcible expulsion of the child.
BY DR. MARGARET CALDWELL, OF WAUKESHA.
This disease is recognized by different authors as, Acute Purulent Oedema, Peri-uterine Inflammation, Peri-metritis and Parametritis according to the location of the disease, but is generally known by the simple name of Pelvic Cellulitis.
To understand this subject it is necessary to remember that the pelvis contains the pelvic organs which consist of the ovaries, uterus, vagina, rectum and bladder, with the uterine ligaments, two anterior, two posterior and two broad, the two latter containing between their folds the fallopian tubes, ovarian and round ligaments. The three pairs, anterior, posterior and broad are composed of folds of peritoneum, enclosing a certain amount of cellular tissue. Very little muscular tissue is to be found in the pelvic cavity outside of the organs themselves. The spaces between the organs are filled up with . a greater or less quantity of cellular tissue which not only steadies them but prevents any damage being done them by the transmission of ordinary jars given the body. Patients who attempt to move about upon their feet after the exudation has taken place, and those suffering from the chronic form complain more of the jar each step gives the pelvic and abdominal organs, than of any other symptom. The blood-vessels and nerves which supply the pelvic organs, pass through this tissue and assume a very tortuous course, to allow nature, for instance in pregnancy, to carry them far beyond their ordinary position. Pelvic Cellulitis is an inflammation of this cellular tissue, and I think always of some of the ligaments and consequently of a portion of peritoneum. According to the severity of the case, the inflammation will or will not extend into the pelvic organs or pelvic peritoneum.
Cellulitis is a disease attacking females usually during menstrual
life, but cases have occurred before puberty and after the menopause, and may occur in the puerperal or non-puerperal condition. It is undecided as to whether the disease is of septic origin, or travels through the uterus and tubes into the ovarian region, or through the muscular walls of the uterus into the connective tissue, or is carried by means of the lymphatics.
From the many agencies which may cause it, it seems as if each theory was correct. Emmet thinks a low grade of phlebitis may exist for an indefinite period of time, and its existence in the cellular tissue is the most rational explanation which can be offered for this sudden complication. If we accept this theory we may place as the primary cause the fact that females entering upon womanhood are allowed to change their girlish attire for that of a young lady, putting on tight clothing, corsets and numberless bands around the waist which change the position of the viscera, preventing a proper venous circulation in the abdominal organs, thereby permanently enlarging the pelvic veins. In the puerperal condition we have abortions, laceration of the cervix and too frequent digital examination during labor, or what is often termed, meddlesome mid-wifery. In other cases we have gonorrhea, hematocele, rupture of cysts, excessive use of the sewing machine as proven by a return of the trouble in nearly all chronic cases by its use, a severe application to the endometrium in some cases, or coition too soon after certain forms of uterine treatment, or allowing a patient to ride or walk too soon after certain kinds of application, a too thorough examination or one performed too roughly. Il-fitting pessaries are a fruitful source, hence the disfavor in which they are held by physicians whose mechanical genius is not equal to the proper moulding of them. Preventing conception either by the cold douche immediately following coition, or the wearing of so-called preventives producing mechanical irritation.
One of the worst cases I have met occurred in a patient who was wearing a Hodge pessary and who adjusted one of these socalled preventives, as did her husband who was acquainted with the fact.
When the cellular tissue becomes inflamed, the free flow of venous blood is prevented, the uterus becomes engorged, and an exudation takes place through its mucous surface. This mucosanious discharge is often of sufficient quantity to make the patient