THE FŒTUS.
The embryo first begins to be distinct about the _third_ week; is then
about two lines long, weighing one to two grains; is surrounded by an
amnion which lies loosely about it, and obviously proceeds from the
abdominal laminæ; it presents cerebral vesicles; there is the appearance
of an eye, several arteries are seen though not distinctly formed; the
abdominal cavity is open for a considerable extent in front.
About the _fifth_ week the embryo becomes more consistent; the head is
disproportionately large; rudimentary eyes are indicated by two black
spots; the abdomen is nearly closed, though at the umbilical aperture a
loop of intestine escapes; the abdominal members are present, and the
cord exists in a rudimentary condition; the embryo is nearly two-thirds
of an inch long and weighs about fifteen grains.
The successive changes in the development were, 1st, a germ membrane
visible immediately after the bursting of the vesicle; 2d, at some point
an aggregation of granules forming the cumulus of the blastoderma; 3d,
the embryo developed lying at this point, as it were upon the membranes,
which consist of three superimposed laminæ or layers; 4th, on the serous
layer arise the organs of animal life, the brain and spinal marrow,
organs of sense, skin, muscles, tendons, ligaments, cartilage, and bone;
on the mucous the organs of vegetative life, the intestinal canal,
lungs, liver, spleen, pancreas and other glands. The heart and vascular
system arise from the vascular layer (if this can be considered a
separate one).
About the second week, or perhaps the third, there is a mass of globules
loosely connected together forming the _primitive streak of Von Baer_,
and around this the _area vasculosa_ is developed. The globules of the
primitive streak, seem next to be developed into two laminæ dorsales,
which is the axis of the future embryo, and the origin of the spinal
column. That portion of the fluid that separates the _chorda dorsalis_
from the lamina dorsalis is the future spinal cord, and brain. Two other
lamina—_laminæ ventrales of Von Baer_—are in the mean time proceeding
from the axis of the embryo, one on each side; they grow laterally and
converge below the axis.
After the rudiments of organic life have been commenced in the central
portion of the serous layer, a fold of its peripheral portion arches
over the dorsal surface of the embryo so as to represent a sac, and is
composed of two membranes; the one next to the fœtus is the _amnion_,
the other is gradually separated from the amnion and joins the serous
lamina of the blastoderma; this is the _false amnion_ of Pander.
The heart is formed at this early period, and although there is no
septum between the ventricles, a vein may be seen entering into it, and
an artery passes out which divides into four branches to be distributed
and ramified in different portions of the fœtus.
The abdomen is yet an open cleft, in which (but projecting beyond it) is
the heart, which is of very large dimensions; behind the heart is the
liver, and under the liver the intestine which is attached by means of a
distinct mesentery. At this period (three weeks) the lungs are
constituted of five or six lobules, and two large glandular structures
may also be discerned along the vertebral column, which are called
Wolfian bodies; these anticipate the function of the kidneys. The
_alantois_ is seen arising from the lower part of the intestinal canal
on a little vesicle and extending so as to encircle the embryo.
During the second month the extremities are growing, and become more
projecting; the body is curved and the head bent downwards; there are
indications of the nostrils and a gaping oral aperture; the forehead is
more swelled because of the development of the hemispheres of the brain;
the spinal cord is cylindrical of nearly uniform thickness and
terminating in a blunt extremity—posteriorly it is open; the _medulla
oblongata_ makes a bend forwards at the top of the neck, and then
ascends perpendicularly into the capacious cranium.
The first centres of ossification appear about the seventh week on the
clavicle and lower jaw. At this time the kidneys and renal capsules
begin to appear. The only trace of muscular fibre is in the diaphragm.
The vertebral arches are not yet closed in, and the ribs appear like
little streaks; the liver is very large and granular. The stomach is
assuming somewhat of its normal form; the urinary bladder is enclosed,
but the anus is imperforate. At this time the embryo is about an inch in
length.
At two months the rudimentary organs of generation may be distinguished,
but their development does not clearly show the sex. The embryo is from
one and a half to two inches long and weighs near half an ounce, the
head forming two-thirds of the whole.
After this period the different parts are developed with tolerable
rapidity. At _ten weeks_ the embryo is about two and a half inches in
length. At the end of the _third month_ it is from five to six inches
long and weighs from three to four ounces. The thorax is closed at all
points but is only slightly developed; the cord contains no intestines,
and its spiral turns are evident; the nails are beginning to appear; the
sex is distinct, and the skin acquires some consistence. At the fourth
month the fœtus is six to eight inches in length, and weighs from seven
to eight ounces. A fœtus born at this period might live for an hour or
two. At _five months_ the length of the body, including head and feet,
is from eight to ten inches, and weighs from eight to eleven ounces; at
_six months_ the weight is about one pound, and the length is eleven to
twelve and a half inches.
At _seven months_ the fœtus is from twelve and a half to fourteen inches
long and weighs from three to five pounds. The hands and feet, including
the nails, are developed; all its parts are tolerably firm, and their
respective dimensions better proportioned than formerly. The scrotum
usually contains one or both testicles, they having descended through
the inguinal ring, from their original place near the vertebral column;
the eyelids are partly open; the skin is very red and covered with down.
Many children live and are reared that are born at seven months.
The length of a fœtus born at term is eighteen or nineteen inches,
though the utmost limit is more than two feet. The usual weight is from
six to seven pounds; children have been born, however, that were as much
as eighteen pounds in weight. I suspect that this will never occur
unless the term has been extended beyond the usual period.
AT TERM the fœtus that is twenty inches long will generally measure ten
and a half to eleven inches from the crown to the umbilicus. The
different parts are well developed and partly covered by a smegma called
the _vernix caseosa_; the head has attained the proper hardness, and the
scrotum usually contain the testicles. In female children the nymphæ are
generally covered entirely by the labia, the breasts project, and in
both sexes contain frequently a milky fluid.
As soon as the child that has been carried the full time is born it
usually cries, opens its eyes, and makes some struggling motions with
its limbs; it soon passes urine and feces, and readily takes the breast.
With occasional exceptions the position of the child is unaltered from
an early period of pregnancy to its termination, whether the head be
upwards or downwards. The arms are generally folded over the chest, the
knees drawn up to the abdomen; the back curved, and the head bent upon
the chest, so as to occupy as little space as possible. In ordinary
cases the head is directed downwards, and the face looks obliquely, so
that in the first and second position the back of the fœtus is turned
partly forwards, and the belly in the third and fourth. We are enabled
in many cases to ascertain the position of the fœtus in the uterus
before labor has commenced, by means of the stethescope, by noting
whether the pulsation is felt on one side or the other of the abdomen
and observing whether it is heard clearly or not.
The longitudinal diameter of the head is from 4 to 4½ inches, the
transverse from 3½ to 4, the vertical 3 to 3¾ inches. The transverse
diameter of the shoulders and thorax is 4¾ to 5½; the widest diameter of
the hips 4 to 5 inches. In general the measurements are a little less in
the female than in the male.
The head of the fœtus is large, and as it is less compressible at term
than other portions it merits a particular description; we should be
acquainted with all its characters, that we may recognize them and
thereby determine the position during labor.
The fœtal head is ovoidal in form, the large extremity being posterior.
Several bones enter into the formation of the cranium; they are, 1st,
the _frontal_ bone forming the forehead; in the fœtus even at term it is
usually divided; 2d, the two _parietal_ bones, one on each side of the
head, meeting on the median line at the top of the head; they help to
form the vault of the cranium; 3d, the occipital bone, forming the
posterior and part of the base of the skull; and 4th, the temporal
bones, one on the right and one on the left side below the parietal,
completing the lateral portions of the cranium and contributing to form
the base of it. The cranial bones are not united to each other by
sutures as they are in the adult, but are separated, the parietal bones
especially, by membranous intervals, the intervals being larger in some
children than in others. These intervals, or _sutures_ and
_fontanelles_, must be carefully studied.
The _sagittal suture_ is the antero-posterior one, and extends from the
root of the nose to the occipital bone. It is formed in front by the
interval that separates the frontal bone into two halves, and superiorly
by that between the two parietals. There is a suture which crosses this,
called the transverse or _coronal suture_, which is formed by the space
existing between the frontal and parietal bones. When the sagittal
suture arrives at the superior angle of the occipital bone, it seems to
part and give rise to two oblique lateral sutures which are called
_lambdoidal_; these are formed by the posterior borders of the parietal
bones and the superior one of the occipital.
Just at the point where the coronal and the lambdoidal sutures join the
sagittal one, two membranous spaces, larger than those just described,
are found; these have received the name of _fontanelles_.
In cases of head presentation during labor, one or the other of the
fontanelles may be felt by the attending practitioner, and this
indicates to him the position of the head and the presentation.
The _anterior fontanelle_ presents an extensive surface at the place
where the transverse crosses the sagittal suture. It is lozenge-shaped,
and is bounded by four bony angles.
The _posterior fontanelle_ is formed by the union of the two lambdoidal
sutures with the termination of the sagittal suture. It is smaller than
the anterior one, and is of a triangular form. It is bounded by the
occipital bone and the angles of the parietal bones. During labor the
bones may overlap each other so that the sutures cannot be felt, but the
prominences of the bony margins will aid the diagnosis.
THE PHYSIOLOGY OF FŒTAL LIFE.
The ovule, after it arrives in the uterine cavity, comes in contact at
all points with the mucous membrane of the uterus. Its nutrition at
first is organic by superficial imbibition; afterwards, probably the
villi of the chorion imbibe the fluids there secreted, and transmit them
into the space between the chorion and the amnion, thence it transcends
through the walls of the amnion, and a portion is conveyed into the
fœtus through the umbilical vesicle. After the placenta is formed there
may still be some absorption of some of the nutritive matters contained
in the liquor amnii through the skin of the fœtus, but its growth is
principally maintained by an assimilation of that which the radicles of
the umbilical vessels take up in the placenta. By means of the extensive
contact existing between the vascular apparatus of the two placentas, a
transudation probably takes place of some part of the maternal blood,
which is absorbed and mingled with the fœtal blood, and furnishes some
of the nutritive material.
When mingled with the fœtal blood, the nutritive elements supplied by
the mother are devoted to the development of the organs. It is supposed,
however, that they undergo changes in the large liver of the fœtus and
in its intestines.
There is no true respiration in the uterine cavity, but one function of
the placenta is to renew the blood of the fœtus from that of the mother,
in about the same way that the blood of fishes is ærated by the water
passing through the gills.
Whether in the earlier months absorption is carried on by the surface
alone, or whether a portion of the liquor amnii finds its way to the
stomach is difficult to decide, but, without doubt, a certain amount of
digestion is carried on.
The CIRCULATION of the blood in the fœtus cannot be understood without
referring to certain anatomical peculiarities that do not exist in the
adult. These characteristics depend on the absence of respiration, and
disappear when it is established.
1st. The septum between the auricles of the heart is imperfect, having
in its center a valvular oval aperture called the _foramen ovale_.
2d. The pulmonary artery, soon after its origin, gives off a branch, the
_ductus arteriosis_, which enters the aorta just below the arch. The
pulmonary arteries are very small.
3d. The _umbilical artery_ in the _fœtus_ is a large vascular trunk,
which is nearly obliterated in after life. The two umbilical arteries
run forwards and inwards along the lateral and superior parts of the
bladder, then curve forwards to the abdominal wall, along which they
ascend to the umbilicus, then pass along the cord to the placenta.
4th. The fœtus further differs from the adult in having an umbilical
vein, which comes from the placental tissue, traverses the length of the
cord, passes through the umbilical ring, is mostly distributed to the
liver, but has a supplemental vein situated at the thick edge of the
liver, and leading to the vena cava ascendens, called the _ductus
venosis_.
The general effect of all these peculiarities is to render the heart
virtually a single one; to provide for the quiescent state of the lungs,
and to modify the distribution of fresh blood.
THE COURSE OF THE BLOOD IN THE FŒTUS IS AS FOLLOWS: The blood
circulating in the umbilical vein is, on entering the fœtus, a part of
it discharged through the _ductus venosis_ into the vena cava; another
part is distributed to the liver, and is brought to the vena cava by the
hepatic veins, and then mingles also with that from the inferior
extremities, and then with that from the upper extremities as it passes
into the right auricle. A part of this is transmitted through the right
ventricle, and thence (except a supply for the nourishment of the lungs)
through the ductus arteriosis into the descending aorta. A second and
larger part passes through the foramen ovale into the left auricle, then
into the left ventricle and arch of the aorta, the branches of which
supply the head and upper extremities. The continued stream passes into
the descending aorta, mixing with that already described. The whole now
descends to the lower part of the aorta, where a portion is sent to the
inferior extremities, but a larger part is drawn into the umbilical
arteries, and is carried by them into the placenta.
After birth remarkable changes take place. Something in the
circumstances in which the child is placed stimulates respiration and
crying, by which means the lungs are inflated, and space is afforded to
the pulmonary circulation, which supercedes the use of the foramen ovale
and ductus arteriosis; the blood from the lower extremities cannot pass
through the umbilical arteries, and does pass through the ascending cava
into the right auricle and ventricle, then into the lungs, where it
undergoes analagous changes to those effected in the placenta, and is
distributed to the body generally. The fœtal openings are generally
obliterated in the course of a week, though the foramen ovale, or the
ductus venosis, may continue pervious for two or three weeks; but soon
the ductus venosis and the umbilical arteries are obliterated and the
adult circulation established.
PART III.
PREGNANCY AND PARTURITION.
CHAPTER I.
DIAGNOSIS OF PREGNANCY.
A few of the early signs of pregnancy are not made available to the
physician ordinarily when his opinion is demanded. A woman is naturally
unwilling that her physician, if he be a man, should make even a digital
examination, and this makes it more necessary that the nurse should know
all the rational signs.
One of these signs is the changed color of the mucous membrane of the
vagina and labia. This membrane is of a pale red color, but it becomes
of a violet hue during the time of menstruation, and if a woman becomes
pregnant, the violet or deep red color becomes continuous.
There is also, even in the commencement of pregnancy, a peculiar odor to
the secretion from the vagina and os uteri, which has been compared to
that of the vernix caseosa.
There is no sign of pregnancy by which we can always distinguish it in
its early stages; in some instances nearly all the rational signs are
absent. The general condition of a pregnant woman is changed in a
greater or less degree, but all are not changed alike.
Generally she is plethoric, the pulse is fuller and quicker; the
quantity of circulating fluid is augmented, the quality altered by the
increase of fibrine; but these changes are not always obvious. Well
marked sympathies are excited in various organs; the nervous system may
suffer especially; the woman’s temper and disposition may change; she
may become capricious, may have likes and dislikes in eating, especially
if her digestion is weak; there may be loss of appetite, heartburn,
increased flow of saliva, toothache, excitability of mind, sleepiness,
etc.; but even when many of these symptoms are present, even when the
liver and kidneys are affected, so that the skin is sallow or discolored
in patches, and irritability of the bladder causes much pain and
distress, these various signs may only furnish a sum of probabilities
amounting _almost_ to certainty.
In some cases of pregnancy the skin, instead of becoming sallow, is more
florid, with occasional eruptions on the face.
Some women become fat during pregnancy; others lose flesh; their faces,
in the early months, are pinched and pointed, and their features
altered.
_Milk in the breasts_, especially in the first pregnancy, is a sign
which is said to be reliable; but it is true of some women that, during
their period of menstruation, their breasts enlarge; there is a
sensation of fullness, with throbbing and tingling pain in them, and
that a milk fluid may be secreted; the same symptoms that are present
with others at the second month of pregnancy.
Another change is a more marked sign in the breasts. There is at first a
soft and moist state of the skin, and the little glandular follicles
around the nipples are bedewed with a secretion. This may often be seen
at the second month, and it may also be noticed that the veins of the
breast look more blue, and that the breasts themselves are firmer and
more knotty to the touch.
There are, however, other signs which are more to be depended on than
these that have been mentioned.
Females _cease to be regular during pregnancy_. A healthy married woman,
during the period of child-bearing, bases her prediction upon this sign,
and is seldom disappointed. But women are not all healthy; disease and
disorder of the womb, or other organs of the body, especially of the
lungs, may cause suppression of the catamenia; and, on the other hand,
the discharge may recur for several months after conception, or even
monthly during the period of utero gestation; and, in anomalous cases,
some young married women, who had hitherto been quite regular, ceased to
menstruate for several months without any known cause.
_Morning sickness_ is one of the earliest signs of pregnancy, as it
often occurs within two weeks. The nausea may be slight or it may be
very distressing; it may happen to be soon relieved, but it usually
continues for three or four months or longer. It varies also as regards
the time of day during which it continues to be bad; but if it recurs at
the regular time and in the regular manner, it is of great value as an
evidence of pregnancy, when combined with other symptoms.
_A dark brown areola_ around the nipple may usually be noticed at the
end of the second month; this is a distinguishing sign, especially if it
be a first pregnancy. A month or two later, the dark color is more
obvious, and it is darker in persons with dark hair, etc. It may be
described as being a dark circle, somewhat swollen, or with a puffy
turgescence, both of the nipple and the surrounding disk; the surface of
the areola studded over and rendered unequal by the prominence of the
glandular follicles, the integument covering the part soft and moist;
sometimes small mottled patches, of a whitish color, scattered over the
outer surface of the areola, and for about an inch all around it.
These marks are quite plain at the fifth month, and at six months a
number of silvery _streaks_ may be observed.
_Quickening_ is one of the most important signs of pregnancy, and occurs
about the fourth or fifth month; not because the child is then first
alive, but because the womb then rises higher in the abdomen, and
because the child has reached a further state of development. Quickening
is a proof that the woman is near half her time gone; though it may
happen that the sensation is observed as early as the third or fourth
month, instead of at four and a half months. In some cases women do not
know the time when they quicken, as only a slight sensation is felt;
this some compare to the fluttering of a bird. But a lady may at that
time be faint, or giddy, or sick, though there seemed to be nothing more
than a mere pulsation. Subsequently, however, the movements become
stronger and more frequent. The motions of the child may be felt by a
third person on placing the hand on the woman’s abdomen, especially if
the person’s hand be cold. I have known one case in which, by placing my
hand on the woman’s abdomen, I caused motions which simulated active
movements of the child, although there was no fœtus present.
INCREASED SIZE AND HARDNESS OF THE ABDOMEN is characteristic of
pregnancy. Enlargement of the abdomen may be from flatulence, but such
enlargement is not persistent; the belly is large one hour and small the
next, and on pressing the bowels firmly, a rumbling of wind may be
heard, which perhaps may move about, and on percussing (tapping) the
part, a hollow sound may be elicited, as from a drum. A large abdomen
may be due to fat, but there is a soft and doughy feeling that is
characteristic of fat. On the contrary, in pregnancy, hardness, solidity
and resistance to pressure characterize the gravid uterus, and the
enlargement is not only persistent, but gradually increasing. It is true
that when a very fat woman is pregnant, percussion or palpation of the
abdomen may be fruitless, and any certain diagnosis cannot be made, but
in most cases, if we are careful to observe these conditions, and also
whether there is a distended bladder and rectum, the diagnosis can be
made after the fourth or fifth month.
To make an examination by percussion and palpation, let the female lie
down, with the head raised and the thighs flexed on the abdomen; then
examine with both hands, especially near the pubis. Pressure with the
ends of all the fingers, gradually moving them upward, will enable us to
detect the womb, if it rise above the symphasis, and also the size and
height of the fundus.
_Ballottement_, or _repercussion_, is used as a means of deciding upon
the presence of a fœtus; a means that is most available about the fifth
and sixth month. The female examined should be in an upright position,
or if she be in bed, her shoulders should be raised. We are directed to
introduce the forefinger into the vagina and touch the cervix uteri, or,
rather, in front of the neck upon the walls of the uterus; then slightly
jerking upward by slightly flexing the first joint of the finger;
observe if something recede from it and fall again in a moment. The
ballottement is said to be a sensation “analagous to that produced by
placing a ball of marble in a bladder full of water and then striking
the bladder with the finger just under where the ball rests, when the
latter is thrown up and falls from its own weight upon the finger that
displaced it.”
When the vaginal touch is practiced, while one finger remains in the
vagina, palpation of the uterus with the other hand may assist in the
diagnosis by depressing the uterus, or by holding it firmly in place.
Then the jerk of the finger upon the head of the fœtus causes it to
float upwards a little in the liquor amnii and descend.
AUSCULTATION is used to decide many cases of doubtful pregnancy. The
pulsations of the fœtal heart are generally perceptible by the fifth
month. The examination may be made by applying the naked ear to the
abdomen of the mother, she being placed on her back in the bed with her
head raised.
The _fœtal pulsations_ are frequent, generally from 120 to 140 a minute.
The _uterine souffle_ or bellows murmur may often be heard as early as
the fourth month; it is synchronous with the mother’s pulse; its seat is
said to be the uterus, and some believe that it indicates the position
of the placenta. This sound and the _pulsation of the umbilical cord_
are not very important diagnostic signs, and the same may be said of the
presence of _kiestiene_ in the urine, which may, however, be detected as
early as the third month.
Some of the ailments that attend pregnancy I will now merely mention:
There may be irritability and a disposition to inflammation; violent and
obstinate vomiting; indigestion and depraved appetite, heartburn,
costiveness, hemorrhoids, liver spots or blotches, especially about the
face; diarrhœa or dysentery; strangury, with a frequent inclination to
void the urine; leucorrhœa; varicose veins in the legs, thigh and
abdomen; inquietude, and sleeplessness; dropsy, or an œdematous
condition of the lower extremities; prurigo vulva; either of these may
be more or less troublesome, but can hardly be regarded as diagnostic
signs. Some remedies for these will be mentioned hereafter. (F. 69, 72,
75, 81, 131, 173, 206, 220).
The abdominal walls are often distended beyond what the woman is able to
bear without inconvenience, as the skin may become inflamed and crack.
It is much more common that the true skin beneath the epidermis cracks,
and, although the outside is not altered, there often remains upon the
abdomen of women who have had children a number of small marks, or
little whitish streaks.
CHAPTER II.
ABORTION.
If a premature expulsion of the fœtus occur before the end of the
seventh month, it is called an _abortion_, or _miscarriage_; subsequent
to this period, premature labor.
The cause of abortion may be in the ovum or in the mother, and it is
more liable to occur at the beginning of each month corresponding to the
menstrual period. The maternal causes may arise from the condition of
the mother or may be accidental; may be anything that injuriously
affects the mind or body. Debility of constitution, consumption,
leucorrhœa, uterine irritation, febrile complaints, and obstinate
constipation may be causes, but some women who are weak or sick retain
the ovum with wonderful tenacity. Blows, falls, violent concussions,
excessive or sudden exertions, straining, severe coughing, taking long
walks, riding on horseback, or over rough roads in a carriage, a long
railway journey, fright, sudden shocks, anger, joy, sorrow, good or bad
news suddenly told, taking a wrong step in ascending or descending
stairs, lifting heavy weights, violent drastic purgatives, calomel,
dancing, and tight lacing may excite the uterus to action and effect the
expulsion of its contents.
It is an unfortunate thing for a woman if she miscarry with her first
and second child, for it often becomes a habit. Having once miscarried,
she is more likely to miscarry again, and by repeated miscarriages her
constitution is broken, and the chances of her ever having a living
child become very small.
A woman may experience some _threatening or warning symptoms of
miscarriage_ for one or two days before those of labor supervene. There
is usually a feeling of languor or weariness, of lassitude and
depression of spirits, and a sense of uneasiness, and then, after these
premonitory symptoms have lasted for some time, there may be a discharge
of mucus or blood from the vagina. The show may increase to flooding,
and soon there may be pain, at first slight and irregular, afterwards of
a grinding character, and subsequently severe, irregular, and bearing
down. At this stage we may be quite certain that the pains will continue
to recur until the fœtus at least, if not the afterbirth, have passed
into the vagina.
The progress in different cases is, however, quite dissimilar. In the
beginning of pregnancy the expulsion of the ovum might closely follow
the accident that caused it. For example, a woman might slip in
descending a staircase and fall violently on her seat, causing immediate
expulsion of the ovum, with a large quantity of fluid blood. There are
some women who have acquired the habit of aborting, and the ovum passes
out of the womb with scarcely any pain, little or no hemorrhage, and the
woman speedily recovers. But it will very seldom happen, after the first
six weeks, that there is not some interval between the accident and the
consequent abortion, and that there is not considerable and protracted
pain.
If the cause of the abortion affects the mother instead of the ovum, she
generally experiences, at the time of the accident, a sharp pain about
the loins or abdomen, which may continue slightly for several days, and
then be renewed, with violent uterine contractions, and some serous and
then bloody discharges from the vagina.
The progress of a miscarriage is not as regular as a labor at full term.
In many cases there are shiverings succeeded by fever for a day or more
preceding the hemorrhage. Severe indisposition may continue for several
days. There may be not only considerable uterine pain, but much pain in
the bladder and loins; a sense of sinking in the epigastrium, of weight
near the vulva and anus, and an ineffectual desire to urinate.
Such symptoms continue a longer or shorter time, and then usually the
fœtus alone is expelled, the placenta being retained. The latter is
generally detached after a time, or it may (if within the first three
months) be discharged and pass out in a dissolved condition, with the
lochia. Very alarming hemorrhage may precede and accompany abortion;
this makes the case one of danger at the time, and may permanently
affect the health of the woman afterwards. The flooding may continue
after the expulsion of the ovum; but I have always found that in such
cases there was a portion of the placenta that was detached, and that
might be removed, though not perhaps without some difficulty. A good
physician should always be called in cases of continued flooding.
The patient ought always to preserve any and every substance discharged,
that it may be showed to the physician. He should make a digital
examination, and he usually finds the os uteri to be partially dilated,
and a portion of the placenta hanging in the orifice. It has always been
my practice to see that all was removed before leaving my patient, and I
have known very dangerous hemorrhage to occur where this rule was not
observed. The placenta can generally be seized by two fingers and
removed; but if persevering efforts are necessary, they should not be
relinquished until the safety of the mother is assured, which cannot be
while the ovum, or membranes, or placenta remain in the uterus separated
from their connections.
But it should always be considered especially important to PREVENT THE
ABORTION. If a woman is prone to miscarry, she ought, as soon as she is
pregnant, to lie down a great part of the day; she must keep her mind
calm and unruffled, and must live on plain diet; she should retire early
to rest, and _she must have a separate sleeping apartment_. She should
avoid taking active physic, but keep her bowels open by diet or by the
mildest aperients, or, possibly, daily enemata. Gentle exercise may be
taken, alternated with frequent rest. Cold ablutions are proper every
morning, but the body should be rubbed afterwards with a coarse towel.
The most usual time for a woman to miscarry is from the eighth to the
thirteenth week, but if a woman have a particular time, which to her is
the usual period, whenever that time approaches she should be unusually
careful. Let her lie down more than she usually does; let her avoid
exciting amusements. She might try to keep her bowels open by the
external application of castor oil, or by the mildest aperients, or by
hot water enemata.
If slight hemorrhage and trifling pains come on, we should seek to
arrest the abortion by giving perhaps grain doses of opium every four or
five hours. If the hemorrhage is severe, a drachm dose of fluid extract
of ergot may be given, and a large draught of cinnamon tea; perhaps a
quarter of a grated nutmeg, and, in extreme cases, a spoonful of brandy
with it.
But let it be understood that in all such cases a physician should be
called as soon as possible; and while waiting for him the patient ought
to lie on a hair mattress; a vaginal injection of hot water may be
given; she should have but scant clothing upon the bed; her room should
be well ventilated, and if she is faint from the loss of blood, a little
aromatic ammonia may be given.
CHAPTER III.
PARTURITION.
FALSE PAINS occur most frequently in a first pregnancy, but most
pregnant women have occasional pains, and these become more violent
within three weeks of the full time. They may be owing to a disordered
stomach, as well as to the action of the uterus; but they usually come
on at night, and are liable to be mistaken for labor pains. They are,
however, unattended with show; they often change from place to place,
perhaps going successively to the hips, loins, lower extremities and
abdomen; they come on at irregular intervals, and are at one time
violent, at another feeble, and they occasion no dilation of the os
uteri; but true pains come on with some regularity, and usually increase
in severity. False pains are from various causes, such as fatigue of any
kind, especially too long standing, sudden and violent motions of the
body, costiveness or diarrhœa, general feverishness, agitation of the
mind, or a spasmodic action of the abdominal muscles. It is necessary to
adopt the means used for the relief of the pains to the apparent cause,
and generally to give an opiate proportioned to the degree of pain, or
to repeat in small quantities at proper intervals till the patient shall
be composed.
PERIOD OF GESTATION.
The duration of pregnancy is not always absolutely a certain number of
days. The usual term is ten lunar months, or nine calendar months and
one week. If we could have correct records of all cases we should
probably find that half the cases of pregnancy terminated in labor in
the fortieth week, but that in a few instances the term was prolonged to
the forty-fifth week and that in as many cases women were delivered of
fully developed children as early as the thirty-seventh week.
A woman may make her count pretty correctly as follows: She should first
note the last day of her being unwell. Let forty weeks from that day be
marked in an almanac, and she may expect her labor to come on near that
time.
It may happen that a woman who never has her menses while she is
suckling, may become pregnant and not have a date to count from; but she
ought in that case to reckon from the time that she quickens. Although
quickening takes place at various periods, she may then consider herself
nearly half gone in her pregnancy, and calculate that in four and a half
months she will be delivered.
A woman may have a show for one or two monthly periods after her
gestation commences, but the discharge may be distinguished from the
regular menstrual fluid by its being either small in quantity, or by its
clotting, and generally by its lasting but a few hours. The woman should
reckon from the time when she had her last regular menstruation.
PARTURITION.
NATURAL LABOR. The uterine functions are characterized by periodicity.
If an abortion occurs that is not the result of an accident, it is
generally at what would have been, but for conception, a monthly period,
and even injuries are more likely to produce their bad effects at that
particular time. So the normal period for parturition corresponds to a
menstrual period, and generally labor may be looked for at about the
tenth period after the last appearance of the catamenia. We can hardly
tell why it so uniformly happens at that particular time; the process is
analagous to the falling of ripe fruit—it drops because the fruit is
fully matured.
It is not in accordance with the plan of this work to dwell at all upon
any other than what is called natural labor, but I shall include in this
class all such as are terminated by the natural powers, whether they be
head, face, breach, or foot presentations.
By PRESENTATION, I mean that part that presents itself at the brim of
the pelvis, so that the accoucheur’s finger impinges upon it as the end
is passed into the center of the os uteri.
The DIAGNOSIS of the different presentations is made by the touch. The
head may be known by the hardness and roundness, and more certainly by
the fontanelles and sutures; the breach by its general softness, and by
the tuberosity of the haunch bone; by the cleft between the buttocks,
the scrotum or the vulva, and the anus; the knee by the hardness and
roundness of the bone; the foot by its form, its being at right angles
with the leg, the nearly equal length of the toes, the narrow heel,
etc.; and the face by the inequalities of the presenting part. (These
inequalities cannot at first be felt; upon touching it we first perhaps
detect the brow, then, as labor progresses, we may feel the nose, mouth,
etc.) The head presents in about 98 cases out of 100.
PHYSIOLOGICAL PHENOMENA OF LABOR.
According to the division made by standard authors on parturition, its
first stage extends from the beginning of labor to the complete
dilatation of the os uteri; the second terminates by the birth of the
child, and the third by the expulsion of the placenta.
During the last two or three weeks of the term, the uterus sinks lower
in the pelvis, and seems to spread out laterally; the lungs and stomach
are not so much compressed, and respiration and digestion, if difficult,
become more easy, and often the patient becomes more cheerful and
active. The precursory symptoms of labor vary in intensity in different
women; but it may be observed pretty generally that there is more
activity and disposition to movement for one day preceding the real
labor.
But during the last few days of the gestation there are contractions of
the uterus, which, though short and distant, and not attended with much
pain, are effective in dilating the cervix, and preparing for the
subsequent labors.
The subsidence of the lower end of the uterus into the pelvis, however,
causes many unpleasant symptoms. The pressure upon the bladder renders a
frequent evacuation of its contents necessary; there is often an
ineffectual desire to urinate, and sometimes strangury. There is often a
sense of weight about the anus, an irritable state of the bowels,
occasional griping pains, and a desire to go to stool when but little is
passed, and sometimes diarrhœa. The œdema and varices of the lower
extremities augment, the hemorrhoidal vessels swell up, and the piles
are larger. These precursory symptoms are manifested more in primapara
than in others. To some, walking becomes at this time impossible.
There are during the last month, and especially toward the close of it,
painless uterine contractions; there may be at first a sort of squeezing
sensation with it. But about twenty-four hours previous to the
commencement of actual labor, these contractions are accompanied with
some pain and are periodical, recurring perhaps every twenty or thirty
minutes. If an examination be made of the os tincæ at the COMMENCEMENT
OF LABOR it will be found that the rounded collar of the os is already
effaced. The pains then suddenly become acute, and it can be observed
that the uterus contracts if we notice its greater hardness and
roundness during a pain. The os uteri if somewhat dilated closes
partially with each contracting, and it can be observed that its margins
are growing thinner though tense and resistant at the time of the pain.
The contractions distend the membranes; these are first pressed _on_ the
neck, then _into_ it, then as soon as the dilatation is sufficiently
advanced engage in it in the form of the segment of a sphere, whose
dimensions progressively increase with the dilatations.
There is now and perhaps has been for several hours a glairy discharge
from the vagina, which becomes streaked with blood, there are perhaps
shiverings or rigors (not accompanied with a cold skin), the pains
increase in force and frequency, the pulse is hard, full, and rather
frequent, the countenance is flushed, often there is vomiting, and the
patient is prone to despond and be discouraged.
She is less agitated after the pain subsides, though it does not cease
entirely. During the interval the margins of the os again become supple,
the membrane that was tense while the pain lasted becomes flaccid, and
the child’s head can be more plainly felt. As the contractions are
repeated the os uteri dilates more and more until it is completely
opened and no part of its margin can be touched; though very frequently
from some obliquity of the uterus, the margin on one side can be
observed pushed down before the head of the child, while that on the
other side cannot be reached. In ordinary cases the membranes are
ruptured and the waters escape at the commencement of the second stage,
and the time occupied by the first stage is nearly three-fourths that
for the whole labor. But the duration of the stages as well as the time
occupied by the parturition is exceedingly variable, and the same may be
said in regard to the duration and character of the pain.
We may observe here that pain is nearly inseparable from the
contractions of the uterus, so that in common language the two
expressions are used indifferently; but using the word in its ordinary
sense the pain in the first stage of labor is different from that in the
second. What are called grinding pains characterize the first part of
labor, and although they differ in different individuals, they are
pretty generally so severe as to cause the patient to cry out. As soon
as the labor advances to _the second stage_ there is a change in the
character of the pains. They are more frequent and longer and the
intervals shorter; but though the suffering may be greater the cry is
more suppressed, the bearing down is carried to a greater degree, and
each pain is succeeded by a calm more perfect than that in the first
stage. Should the interval be rather long some patients get a little
sleep between the pains, but if there has not been a bursting of the
waters previously there is generally now a pain sufficiently hard to
break the membrane.
Either in the first or last part, or during the whole of the labor, the
woman says that the pain is in her back, it being in the lumber and
dorsal region; the grinding pain she speaks of as being forward, they
seem however to go through from the umbilicus to the sacrum. In cases
where there is rigidity of the uterine orifice, there is I believe pain
especially in the back; and when the os becomes fully dilated, the pains
are bearing down; the patient at the accession of a pain holds her
breath, and seizing hold of something with her hands, brings the muscles
of the back and abdomen and extremities to aid the expulsive efforts of
the uterus. I do not doubt that this straining of the mother at this
time is advantageous; these efforts of the mother should not be
encouraged, however, at the first part of the labor, because then they
do no good, nor at the very last, as combined efforts then may rupture
the perineum.
As the head advances through the pelvic cavity the pressure upon the
nerves which pass through it gives rise to cramps in the thighs and
legs.
As the head passes into the vagina the walls become flabby and the canal
seems to enlarge and elongate and to be prepared to yield to the
pressure of the head. If an internal examination be made the head will
be perceived filling the cavity, descending with each pain and receding
at its conclusion—the advance ordinarily exceeding the recession, though
sometimes the gain is not perceptible. When the head rests on the
perineum, that offers some resistance, which seems to stimulate the
uterus and abdominal muscles to greater efforts and more forcible
contractions.
If it be a first labor there may be at this point a little delay in its
progress. But the fœtal head being forced down by the rapidly recurring
pains so presses against the floor of the pelvis that it yields and
becomes bulging in front, and distended, though there still is recession
as the pain intermits. But adequate force is called into action; each
pain gains upon the advance made by its predecessor; the vulva partially
opens, and at each pain they open more and more; the resistance of the
parts is finally overcome. After the perineum has given the head its
proper direction in its transit, there usually comes a hard pain—forcing
a loud cry from the woman—another pain succeeds immediately, which
expels the head altogether from the parts; then after a short rest the
uterine power is again exerted to expel the body of the child.
There may be an interval of a few minutes before the pains return with
sufficient force to expel the shoulders, but the child is in no
particular danger; it is best to wait awhile, the nurse in the meantime
making pressure with her hand over the uterus, before any traction is
made on the head or shoulders. If the body is very large, however, it
may be well soon to draw a little on the head or to reach with one
finger into the axilla and to bring down the lower shoulders; then the
rest will be delivered without any difficulty.
The intense suffering of the mother is now exchanged for perfect joy or
ease; there is at once a transition from extreme misery to total freedom
from pain, though the labor is not yet completed. Ordinarily a few pains
return before many minutes, and complete the last stage of labor—the
expulsion of the placenta. Sometimes the contractions that expel the
child, expel also the membranes and placenta; but more generally they
are only partially detached or they may be adherent and not easily
removed.
After the birth of the child, and the tying of the naval string, it is
proper to apply the hand upon the abdomen of the mother to ascertain
whether there be another child, and whether the uterus be contracting
properly. I advise that an effort should be made immediately to remove
the afterbirth and secundines, making firm pressure over the womb; this
will generally stimulate the uterus to make good contractions, and may
assist in pressing out the placenta. I do not advise that a midwife
should pull upon the cord, but it is my practice to press the fingers of
my right hand well into the vagina, and as soon as possible grasp a
little of the placenta; my left hand at the same time pulling slightly
on the cord, and thus by combined effort removing the afterbirth pretty
quickly.
I have never had much trouble about retained or adherent placenta in
cases where I myself officiated in the delivery, and I attribute my good
fortune in this respect to the fact that I do not tie the placental
portion of the cord, preferring to let some blood discharge from the
afterbirth, thus diminishing its size, and then if necessary I direct
that considerable effort be made in the way of squeezing and pressure
and friction over the uterus.
It is true that if nothing is done a pain will usually come on within
twenty minutes that will expel the afterbirth very effectually including
all the membranes, and considerable clots of blood; but I apprehend that
in many cases during this delay there is an hour-glass contraction of
the womb comes on, which retains the placenta and prevents its proper
separation.
But before attending to the placenta, the necessary attention should be
paid to the child. A little cold water sprinkled on it will usually make
the child cry, if it does not breath immediately after it is born, and
this makes the change in it from uterine to breathing life. The child
may then be separated from the mother by cutting the cord. After the
removal of the child it is proper to endeavor to deliver the afterbirth,
though it may not be necessary at first to do anything more than to use
friction over the uterus with moderate pressure, which may be gradually
increased.
CHAPTER IV.
MECHANICAL PHENOMENA OF LABOR.
The cavity of the uterus and that of the pelvis form a continuous
PASSAGE through which the child must be forced in its exit from the womb
at birth. The uterus possesses the character of muscularity and is the
main agent in the expulsion of the child. By its own muscular action the
cavity of the uterus is diminished and pressure made on the fœtus,
forcing it down towards the orifice, distending the cervix, and dilating
the passage. During the second stage of labor the power of the uterus is
aided by the voluntary muscles of the abdomen and by the depression of
the diaphragm.
The character of the passage will be brought to mind by recalling what
was heretofore said of the diameter of the pelvis. It will be remembered
that the usual antero-posterior diameter of the brim does not exceed 4½
inches while the transverse is 5¼ inches, and that at the lower outlet
the antero-posterior diameter is about 5 inches and the transverse about
4 inches.
The FIRST OBSTACLE which the child meets in its progress is the cervex
uteri. This being composed partly of muscular fibre which acts somewhat
as a sphincter, and partly of elastic celular tissue, holds the
sphincter in the tissue with a tenacity which is not easily overcome.
But repeated muscular contractions of the womb force down the bag of
waters, which forms a sort of wedge, and this is forced down and into
the os uteri, compelling it to open.
There are also muscular fibres in the uterus which have a longitudinal
as well as some that have a circular course, and the action of the
former tend after a time to retract the os, over the fœtal head.
The _second obstacle_ is the bony brim of the pelvis into which the head
of the fœtus cannot pass until its long diameter is adapted to certain
diameters of the pelvis. The diameter of the bony pelvis is diminished
over one-fourth of an inch by the soft parts upon it, but the oblique
diameter of the pelvis will admit the long diameter of the head of the
child, which does not often exceed 4½ inches. The head usually presents
in this way, and passes in a somewhat spiral manner until it arrives at
the outlet where the diameters are adjusted to each other. The head is,
however, too large to pass, even in this way, were it not that it admits
of a degree of compression to facilitate the entrance and progress
through; this moulding is effected by the continued pains. The head of
the child which presents at the brim with the occiput towards the left
acetabulum rotates during the passage, so that the occiput at its exit
is directly under the symphasis pubis; the cause of the rotation is
found in the form and direction of the passage and in the shape and size
of the fœtal head.
This presentation and position is the most common one, though either of
the following is liable to occur. By naming the position we indicate
just how a presenting part lies, or is turned. We adopt the following
classification, which accords with several good authors:
PRESENTATIONS AND POSITIONS.
PRESENTATIONS. │NO. POSITION. NAME OF POSITION.
A—Vertex or head │ 1 Occiput to left Left occipito-iliac
│ acetabulum. anterior.
│ 2 Occiput to right Right occipito-iliac
│ acetabulum. anterior.
│ 3 Occiput to Symphasis Occipito pubic.
│ pubis.
│ 4 Occiput to r. R. occipito-iliac
│ sacro-iliac junc. posterior.
│ 5 Occiput to l. L. occipito-iliac
│ sacro-iliac junc. posterior.
│ 6 Occiput to promon’y of Occipito sacral.
│ sacrum
B—Breach, including │ 1 Sacrum to left Left sacro-iliac
inferior │ acetabulum. anterior.
extremities. │
│ 2 Sacrum to right Right sacro-iliac
│ acetabulum. anterior.
│ 3 Sacrum to symphasis Sacro pubic.
│ pubis.
│ 4 Sacrum to r. Left sacro-iliac
│ sacro-iliac posterior.
│ junction.
│ 5 Sacrum to l. Right sacro-iliac
│ sacro-iliac posterior.
│ junction.
│ 6 Sacrum to promont’y of Sacro sacral.
│ sacrum.
C—Body, including shoulders, elbow and hand.
D—Face, including six varieties.
The right occipito-iliac posterior (A 4) position is not a very uncommon
one, but that variety which is described and named as the left
occipito-iliac anterior (A 1), in which the occiput is directed in front
and to the left, is most frequent. These and other vertex presentations
may be recognized even in the commencement of labor through the vaginal
walls, the head being known by its rounded spheroidal surface.
Supposing that we have a case of the kind that is most common (A 1), and
that labor has begun, we may introduce the finger through the os uteri
and we encounter a rounded, smooth and resistant surface, which is the
anterior part of the head, and then by directing the finger upwards and
backwards it will come in contact with the sagittal suture.
If the direction of the suture is oblique, and if it runs from before
backwards and from the left towards the right, the position must be
either the left anterior or the right posterior occipito-iliac one. (A 1
or A 4).
To complete the diagnosis we follow with the finger the sagittal suture
until it reaches the fontanelle, and this determines the position. If
the posterior fontanelle is found to the left and in front, and the
anterior one is to the right and behind, the position is A 1, or the
left antero-occipito-iliac one. The back of the fœtus is turned forwards
and towards the left side, while its face and anterior plane is turned
backwards and towards the right, and the occipito-frontal diameter of
the child’s head corresponds to the oblique diameter of the pelvic brim.
As the labor progresses and the head is forced down in the pelvis, it is
also more strongly flexed on the chest and the occiput is pressed down
in the excavation. With the occiput thus presenting, it traverses all
the space between the superior and inferior straits until it reaches the
floor of the pelvis; there it makes what is sometimes called the pivot
turn—it executes a movement of rotation, which carries the occiput
behind the symphasis pubis and the forehead towards the hollow of the
sacrum; then the head being pressed forwards and stretching the
perineum, the forehead and face being disengaged from it, emerge; then
after the perfect expulsion of the head it again rotates, the occiput
turns somewhat to the left thigh and the face towards the right thigh.
In the beginning of labor the shoulders are turned so as to correspond
to the oblique diameter of the pelvic cavity, but they pass through the
pelvis in a transverse position. After they reach the inferior strait,
the body rotates so that the right shoulder of the child turns towards
the left side of the mother and the wide diameter of the shoulders is
accommodated to the wide diameter of the strait, and the rotation of the
head, which is free externally, is secondary to the rotation of the
shoulders.
In the EXPULSION OF THE BODY the right shoulder, or subpubic one, is the
first one to appear in the vulvar fissure, but the left or posterior one
may be disengaged at the commissure of the perineum before the right one
is delivered; the remainder of the trunk is expelled very soon,
describing a prolonged spiral course in its passage.
A child originally in the RIGHT POSTERIOR-ILIAC position becomes
converted towards the last of the labor into an occipito pubic or
anterior one, and the labor terminates as it does in A 1, when the
occiput was originally in front. It is the left shoulder, however, which
gets behind the arch of the pubis, and the occiput is directed towards
the _right_ thigh after the head emerges.
In some instances, though rarely, the child originally in A 4 position
remains with the occiput behind to the termination of the labor. In such
cases the forehead comes under the pubis and remains there for a time,
while the occiput traverses the whole circle of the perineum; then the
whole head and face is immediately delivered.
It is not deemed necessary to describe here the mechanism of labor in
the more unusual varieties which are so very numerous.
As regards PROGNOSIS, head presentations are the most favorable of all,
and those in which the occiput looks anteriorly in the beginning of
labor are more favorable than those in which it is turned posteriorly.
In occipito-posterior positions the labor is more tedious than when the
occiput is in front, and the expulsion becomes particularly difficult
when the head maintains its original position and does not rotate or
take the pivot turn.
Upon the fœtal head after it is delivered there is almost always a
protuberance to be found—a tumefaction, more or less considerable upon
some point of the vertex; its greater size indicating a longer
continuance of the labor, and its seat indicating in what position the
child was born. This tumor is almost always located on one of the
posterior superior angles of the parietal bones, and shows that the
occiput escaped under the pubic arch. During the labor the whole head is
strongly compressed except at one point on the vertex, which therefore
becomes the seat of a sero-sanguinolent infiltration. This tumor
disappears usually within forty-eight hours; if it does not, it may
properly be punctured. It may contain either serum, or serum and blood,
or grumous blood.
CHAPTER V.
DIAGNOSIS OF ARTIFICIAL LABOR.
When the expulsion of the fœtus takes place from the efforts of nature
alone, the labor is called by some authors spontaneous or natural, but
when art is obliged to interfere it is called artificial. It would be
very useful to us if we could always decide in the commencement of labor
whether the assistance of art would be required, and I will group
together in a few pages such instructions as I am able to give on this
important subject.
The nurse or midwife will not very generally be able to decide any point
by auscultation, but she as well as the physician may judge from the
appearance of the woman, from her past history, from palpation of the
abdomen, and from vaginal touch. She should accustom herself to judging
by all these means, that she may be able to decide early whether the
help of an accoucheur will be _imperatively_ needed.
No one can decide certainly from simply seeing a patient in the
beginning of labor, whether her labor will be natural and spontaneous,
or artificial; but I have many times when first looking at a lady, if
her complexion was fair, and her form good, but rather tall, predicted
that her accouchement would proceed regularly and favorably. But in
forming our opinion we need to know something of the previous health and
present ailments of the patient, and, if a multipara, the character of
former labors. If nausea and vomiting or any other ailment has reduced
her strength so that she is exceedingly weak, this may give rise to some
reasonable apprehension; but I have known a woman that could scarcely
retain a morsel of food on her stomach for seven or eight months, that
had become very weak indeed and exceedingly emaciated, who yet endured
her labor well and soon recovered. The general rule is, that the more
perfect the woman’s health is, the better she is fitted for child
bearing, but if her general health and strength is reduced below its
proper standard by some previous or accompanying disease, such for
example as consumption, she may endure the labor very well, and succumb
to the disease afterwards.
Pregnant women are liable to be attacked with epidemic, endemic, and
sporadic diseases. Eruptive fevers, etc., may attack parturient women,
and if they do, the disease and labor in every case will have a
reciprocal influence on each other—the disease will complicate the case.
Influenza or intermittent fever may attack a woman at any period of
gestation, and there may be no serious results. Cholera, small pox,
typhoid fever, scarlet fever, measles, pneumonia, and jaundice are
liable to cause abortion, and there is danger of fatal results, or
either of them would be a dangerous complication at the time of labor.
Syphilis would be a cause of abortion or premature labor, and any
disease which allows the mother to carry the child the full term may
reduce and weaken her. Glandular engorgements and scrofulous ulcers
improve during gestation, but if the woman is suffering from a fracture,
the bones will not unite very well. Tumors in the abdomen and pelvis may
be an obstacle to delivery, and ulcerations of the cervix may also be
harmful and protract the labor, as also may constipation, dropsy, and
albuminuria.
The latter may not be detected without an analysis of the urine, but
dropsy will be obvious as soon as it exists. The evidences of tumors and
ulcerations are found by palpation and the touch—sometimes by the use of
the speculum.
After learning the present appearance and the former history of the
patient it may be necessary to examine further perhaps by palpation.
By PALPATION we may sometimes (but not always) distinguish the head of
the child, and perhaps tell to which side its back is turned. When
making the examination let the patient lie on her back, make gentle
pressure when the pains are off and the abdomen is relaxed; press the
ends of your fingers above the body of the pubis; by pressing downwards
you may perhaps feel the head if it has descended into the pelvis. You
will need to press the abdomen carefully all over to ascertain if there
are tumors, and also to ascertain if the body or some other part
presents at the cervix uteri.
If _auscultation_ is used we may determine positively the position of
the fœtus by observing just where the sounds of the fœtal heart may be
most plainly heard.
The VAGINAL TOUCH is the usual mode of determining whether there is an
unfavorable presentation of the child, as well as whether there is
deformity of the pelvis, tumors in the vagina, ulcerations, &c.
When the head presents in the commencement of labor, if the fundus of
the uterus is not too much inclined forwards, and there is no deformity
of the pelvis, the os may easily be reached, and the hard round head of
the child be felt without difficulty. Should a hard presenting part not
be felt either through the dilated os or the walls of the uterus, it may
be because there is a breech or body presentation, or there may be
twins, or there may be an unusual amount of water in the uterus, or the
child may have hydrocephalus—in either of these cases it might not be
possible to decide immediately about the presentation and position.
FACE PRESENTATIONS cannot be detected very early in the labor. Before
the membranes are ruptured the head is high and difficult of access.
When it is reached the forehead is first encountered, afterwards we may
feel the nose and mouth. It is unfortunate for us that we cannot usually
distinguish a face presentation in the early stage of labor. It is not
so important that we make an early diagnosis of presentation of the
breech, as there is no danger to the mother involved in the latter.
PRESENTATION OF THE BODY should always be detected early, at least as
soon as the membranes are ruptured. The abdomen of the mother is much
longer in the transverse diameter than is usual, and the head of the
child may sometimes be felt in the iliac fossa. The form of the mother’s
abdomen is irregular as the fœtus lies curved on itself. When we are
able to touch the fœtus, if the shoulder presents, we first feel a small
bony projection, the acromion point of the shoulder; then other points,
including the acute angle of the shoulder blade. We should ascertain as
soon as possible on which side the head lies, and also the posterior
plane of the child.
Sometimes the hand comes down in the vagina or even appears at the
vulva; if it does we may know by that (and by slipping the finger of our
hand up into the axillary space) just how the child lies. If the back of
the child’s hand is turned towards the mother’s right thigh the head is
to the right, and if to the left thigh, to the left. The little finger
being towards the coccyx indicates that the child’s back is towards the
mother’s loins, and the same finger being towards the pubis is evidence
that this is in front. It is quite important that these points should be
noted.
There are various causes of tedious, difficult and obstructed labor, and
in each case we are obliged to depend principally upon the touch for
diagnosis. In some instances the difficulty will be obvious as soon as
we attempt to make an examination. A NARROW and UNDILATABLE VAGINA will
be easily recognized, but this will rarely be found a serious obstacle
to the passage of the child; as the labor proceeds the vagina seems
naturally to dilate and to be more softened and relaxed.
Cases have been reported where there was a _scirrhus tumor_ or cancer
connected with the neck of the uterus, even during labor; happily such
cases are rare. The scirrhus would be felt hard and unyielding. A tumor
of any kind connected with the os uteri, the vagina or the rectum may
obstruct the descent of the child’s head more or less according to its
size and mobility. Of course they can be detected.
A VAGINAL CYSTOCELE ought always to be rectified. It sometimes happens
that the bladder is caught by the head of the child in its descent into
the cavity of the pelvis and pushed before it, and it can be seen as a
soft red tumor between the vulva. The finger can be passed posterior to
it, but not anterior, and the catheter cannot be passed in the usual
direction.
A few cases are on record where a _stone_ (calculus) in the bladder was
pushed down before the fœtal head. A careful examination will show that
the tumor is covered by the bladder; its hardness will indicate its
nature.
A COLLECTION OF HARDENED FECES IN THE RECTUM is detected without
difficulty. It will be of an irregular form, hard and inelastic.
SWELLING OF THE SOFT PARTS may cause obstruction. If the child’s head is
detained for a long time pressing upon the brim of the pelvis, it may
obstruct the circulation and diminish the capacity of the passage. In
such cases there is unusual heat and dryness in the parts.
When a nurse or midwife makes an examination by touching, she needs to
continue it through several pains, and to repeat it again soon to know
if there is any progress to the labor. If the progress is very slow this
may be from various causes, some of which I will now simply name. It may
be because the uterus is very much distended, and this renders the pains
inefficient; there may be partial and irregular contractions of the
uterus, weakness of constitution, fever or local inflammation, a want of
irritability in the constitution, a deformity of the pelvis and spine,
or doubts and fears on the part of the patient may diminish the action
of the uterus. The labor may be slow because it is the first one, or
because the membranes were ruptured too early, or because the woman is
advanced in years at the time of having her first confinement. The
uterus may be pitched over obliquely, there may be extreme rigidity of
the os uteri, extreme rigidity of the soft parts of the mother, a
contracted or small pelvis, the head of the child may be large and
ossified so as to be unyielding. One or both arms may come down by the
side of the head of the child; on the part of the mother there may be a
distended bladder from inability to void the urine, there may be
cicatrices (scars) or adhesions of the vagina, and in some cases it has
happened that an enlarged ovary has dropped down into the pelvis, or a
portion of intestine containing scybala or hardened feces obstructs the
passage, or the os uteri is very minute, or imperforate, or totally
absent.
Some of these cases may demand the interference of art in the first
stage of labor, but delay at that time involves very little danger; as a
rule neither the mother nor child is in danger (except when there is
hemorrhage or convulsions) on account of labor before the membranes are
broken. If the nurse can ascertain the cause of the delay and finds that
time is what is especially needed, she must exercise patience herself
and encourage her patient to do so.
It is hardly possible to predict beforehand in what cases convulsions
will occur, but if there is much headache in the commencement of labor
and if there has been considerable albumen in the urine of the patient,
we have especial reason to apprehend trouble of that kind.
The history of the case is important in forming an opinion as to whether
there may be severe hemorrhage. Some women are naturally predisposed to
flowing.
PART IV.
SKILLED NURSING AND MIDWIFERY.
CHAPTER I.
PRELIMINARY INSTRUCTION TO THE NURSE MIDWIFE.
It is my design in giving the following instructions to prepare the
student of this work to be a skilled or skillful nurse, not to be simply
a midwife; to act in conjunction with, not in opposition to, physicians;
to conform to, and not to violate laws which regulate the practice of
medicine; to officiate in cases of easy, natural labor sometimes, but
never in cases requiring the use of instruments; to be prepared to act
in emergencies until the doctor can come and take the case; not to treat
the case when the services of a physician can be obtained and is desired
or needed; in short to act intelligently in all cases in which women now
act perhaps blindly, hurriedly and ignorantly.
The present state of feeling among our people, and especially among the
medical profession in this country, would not sanction an effort to
educate women solely as midwives.
But there is a general feeling or sentiment that every young lady ought
to have that kind of education which may render her useful; that she
should be prepared in some way to minister to the desires, wants and
needs of her fellow creatures, and that some part of that knowledge or
skill should be of that kind which would be available if these persons
were thrown on their own resources; hence I would have some of you to
be, not only nurses of the sick, but skilled nurses of lying-in women.
And should some young lady after studying this work, decide to pursue
the study of medicine thoroughly and become a physician, the knowledge
here obtained would be available.
PRELIMINARY INSTRUCTIONS.
1. Do not stop short of a thorough knowledge of this book, every part of
it.
2. Endeavor here to get a knowledge of midwifery that will qualify you
to attend ordinary cases of _natural_ labor, and enable you sometimes to
give medicine when needed, and when there are no physicians in
attendance; but understand that there are many times when the only
proper thing for you to do is to send for a physician or experienced
accoucheur.
3. Do not hesitate to seek knowledge and experience and instruction from
any source where you think that you can obtain it. Physicians will be
willing to aid you, and I think the time is coming when he will regard
the educated nurse as his friend, and not as his natural enemy.
4. I do not think it best that you should call yourself a midwife,
because if you do it will excite misapprehension and prejudice. Seek in
every way to be skillful as a nurse, and seek to have a corresponding
reputation.
5. Do not undervalue your position, if you have the wisdom and courage
and perseverance necessary to prepare you to minister to your sex in
their time of greatest suffering and trial. Do not doubt that your
mission is an honorable one. And even if you do not minister very often
to the sick in labor, except as the right arm of the medical man, you
may help to raise the standard qualifications of the nurses of our land.
Do not suppose that I am complaining harshly of our present supply of
nurses. Women have shown a wonderful adaptability to the needs and
exigencies of their suffering friends in nursing and caring for them.
And it is because they are so ready to receive instruction that I
endeavor here to furnish good instruction for them.
6. Do not suppose that your knowledge obtained by study is sufficient to
enable you to act as midwife (except in an emergency), unless your
studies are supplemented by observation, as mother nurse, &c.
7. Do not be unwilling to minister to women who are poor. The young
physician is willing to do something in this way to gain experience and
for the sake of humanity, and this will be your opportunity to gain
experience without coming in competition with rivals.
8. The nurse as well as the medical man, must study the phenomena of
labor at the bedside of the patient. No one can be qualified by mere
reading for the duties of a midwife, and no woman that is diligent and
observing can attend a case of labor without some addition to her
knowledge.
INSTRUCTION TO THE NURSE MIDWIFE.
When I use the term nurse midwife I mean a nurse that has some knowledge
of midwifery, that can be called to attend to women near the time that
she expects to be confined, and that can remain in attendance for two
weeks or more if it is desired or necessary. Sometimes a woman would, if
possible, have a skilled nurse with her a week or more before
confinement, especially because she would thereby avoid sending for the
physician unnecessarily, and because she would be less likely to detain
him for a long period of time.
If the nurse midwife understands her business she will in some cases do
better for the woman than a physician in the commencement of labor. For
instance, suppose that a doctor is called a distance of five miles and
away from his home and his other patients, and when he examines the case
the pains seem to be of the character of false labor pains. He knows
that the real good of the patient might require that she should take an
opiate, but the doctor would be unwilling to give it lest it might
protract a real labor, and subject all parties to the inconveniences of
a prolonged labor including unnecessary visits of the doctor. The nurse
who can remain with the patient, if the labor should not be concluded in
several days, would be more likely to do just what the good of the woman
requires. And in such a case a skilled nurse would be peculiarly
acceptable to a physician if he chanced to be called, because he would
be much more at liberty to leave his patient if it seemed necessary to
do so.
When a nurse midwife is called to attend a case, she should carry with
her besides disinfectants, a male catheter, some laudanum or other
opiate, quinine, and extract ergot, in order to be prepared for
emergencies. Ordinary cases may require no medicine, but some cases do.
CHAPTER II.
THE NATURAL LABOR.
A NATURAL LABOR has been described as one “in which the head presents,
and descends regularly into the pelvis; where the progress is
uncomplicated, and concluded by the natural powers within twenty-four
hours, (each stage being of due proportion), with safety to the mother
and child, and in which the placenta is expelled in due time.”
A skillful, careful examination in the commencement of labor will enable
you perhaps to decide whether the labor will be natural or otherwise.
But it may be your duty first to know if your patient is in ordinary
health, or if she have any fever or organic disease, and you should
enquire about the bodily functions generally, the condition of the
pulse, skin, &c. Before making a digital examination you should notice
the character of the pains, their frequency, force and regularity, the
amount of voluntary effort, the character of the outcry, &c. From these
enquiries you probably will be able to decide whether she is suffering
from real labor, or false pains.
She will, however, probably not object to a digital examination and your
opinion will be founded principally upon that. The modern practice is to
wash the hands in antiseptic soap or some solution before making an
examination.
We are directed by most writers to have the patient lie upon her left
side near the edge of the bed when we examine her. The fore finger of
the right hand (sometimes the left) after being well oiled or soaped
should be passed along the perineum into the vaginal orifice, and is to
be pressed upward and backward towards the promontory of the sacrum
until the os uteri or the presenting part is found. Sometimes this is
not reached without an effort. When reached endeavor to find the fœtal
head or to determine what is the presenting part—feel sufficiently to
distinguish the lips of the os uteri from the presenting portion of the
fœtus. Do not be hasty in making the examination; wait till you examine
sufficiently to know if the child is forced down; observe both during
the time of a pain and during an interval, and observe if the pains
dilate the os. Sometimes during a natural labor there may be a severe
pain, and when the pain is hardest, the os contracts. By waiting to take
a number of pains you will learn if there is real progress. When
examining, note the calibre, heat and moisture of the vagina; the
general condition of the cervix; the dilatability of the os uteri and
the actual dilatation by the bag of waters or the fœtal head during a
pain. If the head presents you can best learn the particular position
when the pain is off; and after the membranes are ruptured you can
decide better than previously. Ordinarily the sagittal suture can be
felt, and perhaps both fontanelles, but you must not be discouraged at
all if you cannot determine the exact position. Doctors ordinarily do
not deem it necessary.
If you can decide that it is a head presentation and that the woman is
undoubtedly in labor, you may probably decide that the labor will be
natural, and you may properly tell the friends so, adding perhaps, that
it will depend upon the character of the ensuing pains whether the labor
will be protracted or short.
Various circumstances of which you are possibly not yet cognizant may
make your case of labor a tedious or difficult one. You have decided,
perhaps, that there is no obstruction to the passage of the child, no
deformity of the pelvis, scirrhus or other tumors in the vagina, no
cystocele, no prolapsed ovary, and that there is not a rigid perineum or
imperforate vagina. If there is, you need to have a medical man present,
but should none be obtained you will need to repeat your examination
from time to time. Observe if each pain presses down the bag of waters
and dilates the mouth of the womb, and if the soft parts are in a
relaxed state, and if there is a show. Even if the appearances are thus
promising, the labor may be slow and tedious from various causes.
1. Possibly hardened feces maybe in the rectum; if they are you may be
assured of the fact when you make a digital examination, as they seem
like tumors posterior to the vagina. The remedies are physic, enemas,
rest—possibly opium.
2. Inefficient pains may be due to a bladder distended with urine. When
this is suspected we should observe whether there is abdominal swelling
(not tympanitic) low down; pain on pressure which gives rise to a desire
to urinate; a constant desire to pass water though the patient has just
performed the act, or a dribbling of water from the parts. If the
bladder cannot otherwise be relieved a catheter should be used, and as a
precaution to avoid wetting the bedclothes it is well to have a catheter
made long enough by affixing a piece of India rubber tubing to the end
of it to reach a vessel at the side of the bed. Never use force in
passing a catheter in. It is very seldom that it is necessary to use it
at all during labor.
3. If there is a hernial protrusion of the bowel, or a calculus of the
bladder falling down in the passage you will probably have a medical man
to officiate. But I may say that if there is need of your doing anything
to replace them, or if it is necessary to return a prolapsed bladder,
you can best do it when your patient is in the knee-chest position.
4. The lack of expulsive power is sometimes due to the want of sleep. If
the first stage, that of dilatation, is prolonged the subsequent uterine
contractions seem to want efficiency. In such cases if the patient can
have a dose of opium or morphine administered to induce sleep it acts
favorably. Where there is nervous excitement particularly, the
efficiency of the pains are increased if we give opium and first procure
a period of rest.
5. The uterus may be greatly distended and its expulsory power thereby
weakened. In such cases there may be a suspension of the action of the
uterus for several hours although the labor before that had made
considerable progress. If pains of labor are feeble or slow or
suspended, no harm can come to the mother or child (in such cases)
except that the mother is compelled to bear them for a longer time. The
only remedy that I would suggest is that the distention be relieved by
the rupture of the membranes and discharge of water. If more efficient
pains did not come on, then I would give a dose of morphine, which would
either increase the pains, or give a period of rest.
6. Sometimes there are vehement and cramp-like pains in the abdomen
producing no effect that is good and adequate, caused by partial
irregular or spasmodic contractions of the uterus—usually what are
called hour-glass contractions. If the bowels have been evacuated and
there is no improvement, I would give one-fourth grain of morphine which
will enable the woman to go through her labor more easily, and perhaps
quite as quickly.
7. It is generally believed that a cord being very short and being
around the neck of the child may protract a labor. I do not deny that
this may possibly occur, and when the child’s head is born, and I find
that there is a coil of the funis on its neck I loosen it.
8. Weakness of the constitution when the general health of the woman is
below the natural proper standard may be a cause why the uterine
contractions are not severe. But in such cases the parts are not rigid,
and nothing more than a dose of four or five grains of quinine is needed
to make the pains effectual.
9. A want of irritability in the constitution frequently observed in fat
and inactive women, or in those who are exceedingly timid, will
sometimes be a cause of slow and lingering labor. Fear often lessens the
energy of all the powers of the constitution, and diminishes or wholly
suppresses for a time the action of all the parts concerned in
parturition. Attendants should endeavor to inspire such patients with
activity and resolution, and remove all fear from their minds. These
cases are not dangerous but I have often found it necessary in this kind
of cases to apply forceps. The skilled nurse might perhaps give eight or
ten grains of quinine, if no physician has charge of the case.
10. Every woman is expected to suffer greater pain and to have a more
tedious labor with her first child, and if a woman be advanced in age at
the time of having her first child the difficulty attending her labor
may be somewhat greater. A longer time may be required for the
completion of the labor than in ordinary cases, but I do not advise
giving any medicine unless it is perhaps a dose of quinine. There may be
a little more need of assistance by instruments, &c.
11. An oblique position of the os uteri, it being projected on one side
or the other of the center of the superior strait, or so far backwards
that it cannot be felt for several hours after labor has begun, is a
cause of delay. The presenting part may be found pressing against the
walls of the pelvis at one point, instead of keeping its course in the
center of the pelvic cavity. You should endeavor to place the patient so
as to remedy this condition. When the presenting part is found to one
side, it will be found that the fundus of the womb is lying to the
opposite side; this should be remedied by a proper support of the
abdominal tumor or by holding it up by the hands. For example, if the os
uteri be projected to the left side, she ought to rest on the right side
and have a pillow placed under her body; some physicians would prefer
that she lay on the left side, but without the pillow under her.
12. Extreme rigidity of the os uteri is a cause of tedious and very
painful labors. It sometimes happens that the os is dilatable, but the
pains are not sufficiently expulsive. Perhaps at the same time the os is
found far back towards the promontory of the sacrum, and the head
appears not to be driven directly into the os so as to aid in its
dilatation, but rather presses against the anterior wall of the cervix.
In such a case the end of the finger can be hooked into the anterior lip
of the os uteri so as to aid in the dilatation, and also to help correct
the displacement of the os. In other cases we may help dilate the os by
a firm and gentle sweep of the finger around the advancing part of the
child’s head within the os. But we cannot always do this, because we may
be afraid of rupturing the membranes prematurely. If the membranes have
been already ruptured, we may act more boldly, but we must never make
any great efforts to dilate it artificially lest we excite inflammation.
In many cases it is best to give ¼ gr. of morphine, and inform the
suffering woman that she cannot possibly get through her labor in a
short time, but if you can give her an hours’ rest, the os, which is
rigid, will be more relaxed and pains more effectual.
13. In first labors there is sometimes unusual rigidity of the soft
parts, which are external. Where the perineum is rigid it may require
several hours continuance of the pains before it is sufficiently
stretched to allow the head of the child to pass. But the difficulty can
hardly be relieved by our interposition. We should generally wait the
due time, as we must also if the os coccygis is anchylosed with the
sacrum.
14. The head of the child may be comparatively large when the pelvis is
of the ordinary form and size. This may be a cause of delay though it
may perhaps cause nothing more than prolonged, tedious labor. In such
cases you have time to send for a doctor, even if he lives at a
distance. After the woman has been a long time in labor he will think it
best to apply the forceps.
You will be importuned in cases of slow and tedious labor to administer
ergot, but any one who knows the action of the drug would never give it
in any of the following cases: 1. Where the os is not well dilated. 2.
When any mechanical obstacle exists to the passage of the child, or when
there is a tendency to convulsions, and _you_ should never give ergot
except for hemorrhage; and when you have much reason to fear it, you may
in such cases give one or two twenty drop doses of the fluid extract
very near the termination of labor. Quinine may be given as an oxytocic
with safety. Morphine is liable to render the pains weak for a time, but
it often increases their efficiency.
I will now enumerate your duties when you act as accoucheur.
1. Ascertain if the lady is really in labor. Make a digital examination.
If the os is high up so as to be reached with difficulty, slightly
patulous and rigid, and the pains are felt in front, there is reason to
believe that the labor has not yet commenced—that she only has false
labor pains. At this time attend to the bowels; give perhaps paregoric
or morphine to relieve her of what is to her useless and exhausting
agony, and enjoin rest. You may at this time properly give her an enema
containing ¼ of a grain of morphine or fifteen grains of chloral
dissolved in gruel or starch or mucilage.
2. When you make an examination and find that the pains are efficient in
producing a dilatation of the os uteri, that the parts are soft and
relaxed, if there is a secretion called the show, if there is a
favorable presentation, and the labor is making some progress, the
patient should be told of all that is favorable in the case.
3. Be careful in making early examinations to, first, if possible, reach
the os with the finger. When your finger presses against the cervix it
will hurt her considerably more than it will when it presses against the
presenting part of the child. 2. Avoid rupturing the membranes. 3.
Notice if there is anything observable to hinder the progress of the
labor. 4. Note any progress of the labor.
4. If everything is favorable, assure the patient of the fact; if you
have doubts and fears upon some point, you need not express all your
fear, but do not delay to send for a physician.
5. You may in the early stage of labor, permit the patient to move about
as she wishes, and she may rest on the sofa when tired. She may have her
usual diet, but not any stimulants.
6. From time to time make an examination. If the os is dilatable you
need not fear that the membranes may then be ruptured. Learn as fully as
possible the presentation and position, and if you press your finger
against the child’s head you may thereby reinforce weak pains.
7. Do not annoy the patient by pressing upon the back or anywhere during
a pain if she requests you not to, but when she does not object you can
make such pressure as will reinforce the action of the abdominal
muscles. When she is lying on her back with her shoulders elevated so
that she is in an almost vertical position, you can stand beside her
with your back towards her head, and make the necessary palpation by
pressing with your hands on her abdomen, one of them on each side. Do
this only when there is no tenderness, when the os is dilated, when
there is a normal pelvic canal and a low position of the presenting
part. Seek in thus pressing to move the uterus to the axis of the pelvic
brim, then with the palms of your hands to the sides or fundus of the
uterus press gradually downward, increasing the pressure for six or
eight seconds, and then gradually diminishing. You may repeat this as
often as she has a pain, and with an increasing force, and if the
patient assents, you may make such pressure unremitting.
8. When the os uteri is fully dilated or soft and dilatable, the
membranes may be broken by pressing with the end of your finger against
it, or if this does not suffice, the finger nail previously nicked may
open it.
9. When free hemorrhage occurs prior to delivery, it may depend upon
placenta previa; that is, upon the placenta being attached very near or
over the mouth of the womb; in such a case obtain a physician to take
charge of the case if possible. You may yourself give half a teaspoonful
of extract of ergot in the emergency.
10. During the progress of the labor you must always remember that the
unassisted, natural powers are in most instances fully sufficient to
bring the labor to a safe termination, and whatever you do should be of
the kind that is not harmful. The important thing for the attendants to
possess is gentleness and patience, and it is a good thing for the
patient if she can be kept tranquil and cheerful.
11. A little light food may be offered the patient at any time during
labor.
12. During the first stage of labor the patient must not strain or bear
down to the pains, but it is my practice when I examine my patient and
find that the head has not yet entered the pelvis, at the same time that
the touch stimulates the uterus to contract, I direct the patient to
bear down during each pain. After the head is fully engaged in the
bones, no stimulus to pain is needed; however, as the bearing down pains
come on, she should be advised to strain or press down.
13. Towards the last, when she is in great pain, if she be inclined to
cry out, let her do so; never reprove her.
14. I approve of giving chloroform in some cases, but I do not advise
the skilled nurse to give it except when a physician is present to
direct its use.
15. During the latter part of the labor the only assistance you can
render the woman is to support the back, and to give her something to
pull upon if she is so inclined. A sheet tied to the foot of the bed may
be useful for this purpose. At the very last, bearing down efforts
should be discouraged.
16. When the head is about to be expelled we always fear there may be
slight or severe lacerations of the perineum. Do not in any way hasten
the expulsion, even if there should be a number of pains in which a part
of the head presents externally during the pain, and then recedes when
the pain goes off. I have not always been able to prevent laceration,
but the following directions are the best that I can give: Endeavor to
have the patient extend her legs, and do not have her knees drawn up
close to the body at the last. When the perineum is put on the stretch,
place the thumb and forefinger of the right hand on either side of the
perineum, and press so as to aid the stretching or distention. When the
perineum is distended and protruding you may cover the hand with a soft
napkin and apply it across the perineum, also by the sides of the vulva,
and make firm, moderate pressure during the pain. Endeavor to have the
pressure equable around the head of the child.
17. When the head is expelled an attendant should make steady gentle
pressure upon the uterus and follow it down, keeping her hand firmly
upon it for several minutes, perhaps for half an hour, or if you have
given a little attention to the child, you yourself may put your hand on
the contracted uterus and firmly knead it for ten minutes.
18. It is not necessary to extract the body immediately after the
expulsion of the head. It is better to wait three or four minutes for
the return of a pain before making any traction.
19. Although a little traction can be made on the head, it is a better
way while an attendant presses on the uterus, and while you hold on to
the child’s head with one hand, insert a finger of the other hand into
the axilla, (under the child’s arm) and gently extract the body.
20. The child may be born apparently asphyxiated—its face swollen—and of
a dark livid color, and at first make only feeble and gasping efforts at
respiration; if there is the least beating of the heart can be
perceived, there is fair hopes of its recovery. The cord should at once
be tied and the child removed from the mother. If one or two slaps on
its body does not make it cry, try immediately artificial respiration by
the Sylvester method perhaps, not omitting at first and afterwards to
throw a little cold water on its body. If these efforts fail I would try
to induce respiration by placing my hand over its nostrils and blowing
into its mouth, and immediately afterwards compressing its lungs.
21. As soon as the child cries, as it most generally will as soon as it
is born, proceed to tie and separate the cord. Tie the cord tight, so
that it is thoroughly compressed and the vessels obliterated, applying
the ligature about one and a half inches from the child, and then cut
the cord one inch further from the child. The child can be rolled in
flannel and removed, and you can attend to the mother and to the removal
of the afterbirth.
22. In only a very few cases I have had post partem hemorrhage or
adherent placenta to trouble me, and I commend to you the method that I
have used for the removal of the placenta. I do not tie the cord until
circulation has ceased in it. I then sever it, and usually two or three
ounces of blood may flow from it. This I suffer to run into some vessel
to avoid soiling the bed uselessly, and then wind the cord around my
right hand so that I can hold it. If I cannot have an attendant to make
proper pressure on the uterus, I immediately endeavor to compress it as
much as I possibly can with my left hand, but I make very little
traction on the cord. I usually instruct some one else to make strong
and firm pressure upon the uterus, and I pass two fingers of one hand
into the vagina, and learn thereby when the placenta descends, and if
necessary assist in its removal. Although we should never hurry in
removing the afterbirth, I believe that it always is easily removed if
we make the effort very soon after the child is born, and if it is
necessary for you to pass your hand into the uterus you can do so then
better than at any other time. Judging from my own experience in cases
of retained placenta, if you pass your hand along the cord into the
uterus, you will find that an hour-glass contraction retains the
afterbirth (whether adherent or not) in the fundus. You will have to
press your fingers through the constricted portion and grasp it, and you
can remove it steadily and slowly, but not stopping to give it “one or
two turns in the vagina.”
23. POST PARTEM HEMORRHAGE is liable to occur; when it does, obtain a
physician as soon as you can, but some things must be done immediately.
1. Some one must grasp and compress the womb continually. 2. Remove the
pillows and raise the foot of the bed so that the patient’s body lies
higher than her head. 3. If you have it, give a small teaspoonful of
extract of ergot, or twenty drops spirits turpentine or (F. 96.) 4.
Examine to know if possible, the source of the hemorrhage; if it comes
from the vagina or perineum where there is laceration, it is not very
dangerous. Inject hot water of the temperature of 115° into the uterus,
and apply a dry cotton cloth, heated as hot as possible, to the abdomen
externally. 5. Before using the injections remove all clots from the
vagina. 6. Quinine and stimulants may be exhibited if there is sinking,
and ice may be applied to the abdomen and to the internal surface of the
uterus, if the bleeding continues. I will here direct another thing
which is very effectual, and which might be used at first in preference
to anything else. 7. After removing the clots take a handkerchief or
piece of muslin, saturated with vinegar, in your hand, pass it entirely
into the uterus, and let it remain there 15 or 20 minutes, and your hand
also. Your hand will compress the open blood vessels, and keep a clot in
the mouth of them, and the vinegar will act as the best astringent that
can be used. In one case of violent flooding I simply _held my hand
still_ in the uterus for five minutes, and the flow ceased. After the
hemorrhage subsides you must be careful not to raise the patient’s head
above the level suddenly; her life may be put in jeopardy by suddenly
raising her so that she sits up.
AFTER PAINS are very seldom severe in primapara cases, and they are less
likely to be severe if the proper manipulations have compelled the womb
to close completely, expelling all clots, &c. But sometimes there is a
peculiar irritability or neuralgic condition of the womb which gives
rise to excruciating pains. Ordinarily you may use Tully’s powder. (F.
123, 93, 95, 107.)
RETENTION OF URINE in some cases necessitates repeated visits of the
physician, and he will appreciate a nurse who can introduce the
catheter. If the patient cannot at first void the urine, perhaps the
application of a hot wet sponge over the pubis may enable her to do so.
But it may be necessary to introduce a catheter two or three times a day
until she regains her power over her bladder, or until the swelling of
the urethra subsides.
It is well for the nurse to know that owing to the distensible state of
the abdominal parietes, the patient will lay twelve or fourteen hours,
perhaps, after the child is born, without manifesting a desire to void
the urine, though her bladder may be very full, and you should remind
her of the necessity of passing the water, lest it produce cystitis. In
some instances the urethra and neck of the bladder are extremely
irritable, causing strangury, and there may be some difficulty in
passing the catheter, but the urine must be evacuated, and afterwards it
may be necessary to use ergot, laxatives, opiates and fomentations. (F.
125, 126, 162.)
CHAPTER III.
CONVALESCENCE.
VARIATIONS FROM ORDINARY CONVALESCENCE will, under ordinary
circumstances, receive necessary attention from the physician, but the
skilled nurse should know as much about them as possible, and I here
make a brief reference to some of them.
The NERVOUS SHOCK, caused by the last pains of labor, in some cases is
very severe. This is indicated not only by the exhaustion, but by the
countenance which is expressive of suffering, anxiety and oppression.
The pulse may be very slow or unusually rapid, the breathing may be
panting. Opium is the best remedy, and this may be given in small doses
repeated, or a teaspoonful of paragoric may be given, also aromatic
ammonia, and 3 or 4 drops of spirits of camphor.
The STATE OF THE PULSE after a natural labor soon comes down to near the
ordinary standard; if it remains above a hundred it is because there is
some special cause. It will be quick if there are very hard afterpains,
a tendency to flooding, diarrhœa or disturbance of the stomach, and it
is quickened also when lactation commences.
The LOCHIAL DISCHARGE ordinarily continues about three weeks, at first
of pure blood mixed with coagula, and if good uterine contraction has
not been secured, coagula may be expelled for several days after the
delivery. Sometimes there is a SUDDEN DECREASE OF THE LOCHIA, perhaps on
the fifth and sixth day, and at the same time an increased bulk of the
womb, and increased frequency of the pulse. Apply hot fomentations to
the abdomen, and probably some clots will be expelled, but at the same
time give purgative enemata; and if there is abdominal tenderness give
an aromatic purgative and laudanum. (F. 108, 122). There are remarkable
differences in the QUANTITY, QUALITY AND ODOR OF THE LOCHIA without any
morbid affection of the uterus or vagina. But when the lochia are acrid,
the vagina, labia and external parts become excoriated, and smarting or
itching is caused. Try extreme cleanliness, frequent bathing, lead
lotions, black wash, vaginal injections of warm water, and F. 153, 154.
If the discharge ceases a few hours after birth, or if it continues the
usual time, but in very small quantity, or if it is prolonged beyond the
usual period, or if it is excessive at first, and if at the same time
all the other symptoms are favorable, there is not occasion for much
medicine, though it may be necessary to give the patient a better diet,
possibly some tonics. (F. 174, 175). It sometimes occurs that the lochia
is suddenly discharged in double quantity after the patient is permitted
to sit up or walk about. In such cases enjoin extra rest.
If the red discharge continues longer than usual, or if it return after
yellow or greenish discharges, you should be on your guard against
HEMORRHAGE. Enjoin rest in a horizontal position under light clothing.
Occasionally the LOCHIA HAVE A VERY FETID ODOR. It is not very rare to
observe a very disagreeable odor in the lochia without any bad results,
but this often indicates the retention and putrefaction of coagula or a
small portion of the placenta or membranes. Syringe out the vagina
freely night and morning with Labaraques solution or some other
antiseptic wash, (F. 153) and once or twice a day with warm milk and
water. A weak solution of carbolic acid 1 in 50 may be used, and it may
be proper to throw it into the uterus.
The SECRETION OF MILK generally becomes established in about forty-eight
hours, and very often on the third day the breasts become turgid, hot
and painful. There may, or may not, be some general disturbance, fever,
chills, &c., but if there is it will usually be relieved after the milk
is drawn out. It is customary on the morning of the third day to secure
an action of the bowels, and this generally allays the vascular action
if it is excessive. But very trivial causes may set up INFLAMMATION OF
THE BREAST, and this is always liable to end in suppuration, which may
be long continued and distressing.
The MAMMARY INFLAMMATION may follow exposure to cold, a blow or other
injury on the breast, some temporary engorgement of the lacteal tubes,
or sudden and depressing mental emotions, and it often follows from
fissures and erosions of the nipples. To prevent the formation of an
abscess, endeavor to remove the engorgement of the lacteal ducts by
gentle hand friction with oil or F. 209, 202. Moderate the inflammation
by giving five drops of the extract Phytolacca decandra (Poke root)
every two hours—give saline cathartics, minute doses of aconite, and
perhaps a large dose of quinine. Keep the patient in bed and have the
affected breast supported by a suspensory bandage. Apply hot
fomentations containing a solution of carbolic acid, or poultices
containing it, and the breasts may be smeared with belladonna extract
rubbed down with glycerine; or belladonna liniment or ointment may be
applied (F. 201). Belladonna plasters or diachylon plasters may be
useful. Give 15 grains bromide potassa.
WHEN PUS HAS FORMED notwithstanding efforts made to cure the
inflammation, as soon as it is near the surface so that it can be
detected by the fluctuation, the abscess should be opened. During the
last few years careful surgeons have been unwilling to make any incision
or lance even an ordinary abscess without employing some antiseptic
method, such perhaps as the following:
The patient’s skin where the incision is to be made, is first to be
washed in 1 to 1000 bichloride of mercury solution—hands and instruments
employed in the work must touch nothing that is not sterilized; hands
must be washed in the same solution before operating—sponges that are
used must be cleaned and stored in a 1 to 20 carbolic acid solution, and
instruments must be soaked in the same for 15 minutes before being used,
and some apply a large wad of bichloride of cotton or gauze to catch the
exuded pus.
The following is Lister’s antiseptic method which he first directed, to
prevent the introduction of air containing living germs:
“A solution of one part of crystalized carbolic acid in four parts
of boiled linseed oil having been prepared, a piece of rag from four
to six inches square is dipped into the oily mixture and laid upon
the skin where the incision is to be made. The lower edge of the rag
being then raised a scalpel or bistoury dipped in the oil is plunged
into the abscess and an opening about three-quarters of an inch in
length is made, and the instant the knife is withdrawn the rag is
dropped upon the skin as an antiseptic curtain, beneath which the
pus flows out into a vessel placed to receive it, and all the pus
should be pressed out as near as may be. For a dressing afterward
Playfair recommends the following: About six teaspoonfuls of the
above mentioned solution of carbolic acid in linseed oil is mixed up
with common whiting to the consistence of firm paste; this is spread
upon a piece of tin foil about six inches square, so as to form a
layer about a quarter of an inch thick; the tin-foil thus spread
with putty is placed upon the skin, so that the middle of it
corresponds to the position of the incision, the antiseptic rag used
in making the incision being removed the instant before. The
tin-foil is then fixed securely by adhesive straps, the lower edge
being left free for the escape of the discharge into a folded towel
placed over it, and secured by a bandage. The dressing is changed
once in twenty-four hours, as a general rule, and must be
methodically done. A second similar piece of tin-foil having been
spread with the putty, a piece of rag is dipped in the oily solution
and placed on the incision the moment the first tin is removed. This
prevents mischief during the cleaning of the skin with a dry cloth,
and pressing out the discharge from the cavity.”
The same author directs methodical strapping of the breast with
adhesive plaster, in cases of long continued suppuration, and he
adds that “much attention must be paid to general treatment, and
abundance of nourishing food, appropriate stimulants and such
medicine as iron and quinine will be indicated.”
I give on the authority of another the following as good treatment for
SORE NIPPLES:
“1. Keep everything that will irritate, whether clothing or
medicine, away from the nipple, and have the excess of milk drawn
from the breast in the easiest way possible. 2. Keep the excoriated
nipple thickly covered with sub-nitrate of bismuth. 3. When the
nipples are cracked at the base keep the cracks filled with bismuth,
and put on a round piece of adhesive plaster starred in the centre,
and just large enough to slip over the nipple and extend around its
base an inch or more every way. When this is loosened it must be
reapplied.” (F. 231, 243).
There are certain accidents of parturition so grave in their nature, and
attended by symptoms so alarming and urgent that no nurse would attempt
to treat the patient except under the direction of a physician. I only
refer to them because it is believed that some of these serious cases
might have been prevented by early proper action on the part of the
midwife or other attendant.
INVERSION OF THE UTERUS sometimes occurs, though but rarely. If it is in
the practice of a midwife, and if she be at the time pulling on the
cord, that will be assigned as the cause of the accident. Inversion
consists essentially in the enlarged and empty uterus being either
partially or entirely turned inside out. The immediate symptoms are
those of shock or collapse—fainting, small, rapid and feeble pulse,
possibly convulsions, or vomiting, and a cold, clammy skin. The
countenance becomes deadly pale, the voice weak, and other symptoms
indicates sudden exhaustion or sinking. In cases of partial inversion
the symptoms are not so striking. Hemorrhage to a large amount,
frequently but not always occurs. In more than half the cases no
mechanical cause can be traced, but as it is sometimes attributed to
pulling on the cord, to pressure with the hand on the fundus, and also
to the patient straining forcibly, these combined causes should be
avoided. When the symptoms named are present, you can give the patient
some aromatic ammonia or other stimulant; always obtain a physician as
soon as possible.
PUERPERAL MANIA is nearly always preceded by restlessness, want of
sleep, and other premonitory symptoms. When the mania first comes on
there is usually causeless dislike to those around her, and as the child
may be the object of suspicion, the nurse must be extremely careful that
the patient does not have an opportunity to seriously injure it. The
course of treatment must be mainly directed to the maintenance of the
strength of the patient, and the two things most needful are a
sufficient quantity of suitable food and sleep. Possibly your efforts in
this direction before the disease is fully developed, may ward off the
disease.
PUERPERAL SEPTICEMIA was formerly called puerperal fever; as its nature
is now better understood than formerly, we hope to do more than was
formerly done to prevent it. This fever is now very generally believed
to be produced by the absorption of septic matter into the system,
through some tear or laceration in the generative tract such as exists
after labor.
This septic matter may be from within the patient such as coagula, or
membrane, or placenta partly decomposed; or from without as might be on
the hands of physician and nurse, or in the air from cases of
erysipelas, &c., or in some way from puerperal patients.
The notion that puerperal fever and septicemia is produced by BACTERIA
has now become an established doctrine, and has given rise to a rational
treatment based thereon, especially for their prevention.
As prophylactic means may be mentioned, the use of a carbolic solution 1
in 30 which the practitioner or nurse applies before touching any case,
the use of carbolized oil 1 in 8 for lubricating the fingers, catheter,
forceps, &c.; syringing out the vagina with diluted Condy’s fluid, rigid
attention to cleanliness in napkins, &c. The nurse should use
antiseptics to only a very limited extent without the advice of a
physician.
CHAPTER IV.
CARE OF INFANT CHILDREN.
Infants sometimes require treatment for ailments either slight or severe
when the advice of a physician cannot be obtained.
The NAVAL is sometimes a little sore after the naval string comes away.
It may be dressed by putting a little simple cerate or vaseline or
carbolized cosmoline on lint or a linen rag, and applying it to the part
affected every morning, and a bread poultice every night until it is
quite healed.
A RUPTURE OF THE NAVAL is sometimes caused by much crying, and it may be
occasioned by the nurse pulling on the cord to remove it before it will
readily separate from the infant’s body.
The best treatment is a piece of adhesive plaster as large as the top of
a tumbler, with a properly adjusted pad made of several folds of muslin
fastened on the plaster, which will keep the bowels from protruding. The
bandage or belly band can be put on over this.
If the infant have a GROIN RUPTURE the only proper treatment is to keep
on it day and night if it cry much, a well fitting truss. In applying
the truss be careful to return the rupture thoroughly, and endeavor to
have it well adjusted or it will chafe and will not effectually cure.
If the child is TONGUE TIED so that it cannot apply its tongue to the
nipple to suck, the frenum may be cut, but it will not be necessary to
make more than a small nick or a slight cut in it.
MILK IN THE BREASTS OF NEW BORN INFANTS, or a serous fluid resembling
it, is often found, and sometimes there is considerable swelling both of
the breasts of male and female children. It is not the better way to
apply plasters or to squeeze or press them, but the milk may be drawn
out by putting an open top thimble over the nipple and drawing on it.
CHAFINGS may be caused by inattention to cleanliness. Fat babies are
subject to them, and when there is disorder of the bowels or kidneys
they cannot at all times be prevented. Thoroughly sponge the parts with
tepid rain water, allowing the water from a well filled sponge to stream
over them, then carefully dry with a soft towel, and perhaps dust over
them sub-nitrate of bismuth. (F. 202.)
DIARRHŒA and DYSENTERY and also COSTIVENESS are among the ailments with
which infants may be afflicted. I wish to be particular in giving
directions, that these may generally be avoided, but I must again repeat
that the nurse should never be influenced by my advice to do any thing
contrary to the directions of the attending physician.
To avoid the subsequent necessity of giving medicine you must be very
careful in their administration at first. It is indeed necessary that
the meconium should be purged off at first, but nature in general
provides such physic as is required, and if the child is applied to the
mother’s breast, it obtains in the colostrum such medicine as it needs.
Where the infant cannot obtain anything from the breast a gentle
aperient may be given, and I name the following as being suitable:
either molasses and water, raw sugar, a solution of manna in warm water,
a teaspoonful of sweet oil, or of simple syrup of rhubarb, or in more
obstinate cases, of castor oil, or one-fourth teaspoonful compound
licorice powder, (F. 108.) but you must never give a drastic purgative,
and you must not repeat the aperient if the discharges become yellow and
natural. A young infant ought to have from three to six motions in the
twenty-four hours, the color ought to be of a bright yellow or orange,
and of the consistency of mustard as ordinarily prepared for the table,
and there ought not to be any lumps or curds in its motions. A mother or
nurse ought to be very observant of the state of the bladder and
bowels—should inspect motions daily and see that they are not slimy, or
curdled, or green. If they are she should be very careful, especially in
regard to what the mother eats and drinks. If the bowels are costive she
must avoid the frequent repetition of opening medicine, however gentle
and well selected the aperients may be. They interfere with digestion,
often irritate the bowels, and render them more costive. For the sake of
the child as well as herself, the mother may vary her diet considerably
after the first week, she may eat boiled and stewed, broiled and roast
meats, mutton, lamb, and beef, fish, game, and chickens, potatoes,
turnips, spinach, celery, peas, beans, figs, bananas, prunes, baked
apples, &c. (F. 45 to 60.) The bowels of the child that nurses generally
(not always) keep pace with those of the mother, and she must endeavor
both for her own sake and that of the child, to keep her bowels loose by
means of diet. If necessary she must take physic. (F. 107, 108, 109.)
If the constipated child nurses the mother and the mother constantly
pays proper attention to her own health, and especially to her diet, the
child will very seldom require physic. Indeed I would not give active
physic when the child seemed well, if it did not have a passage oftener
than once a week. If it has cow’s milk or other food besides the
mother’s milk, do not boil the milk and you can add to the cow’s milk,
corn starch, or the following: Make a thin mush by boiling a small
quantity at a time of unbolted wheat flour in water and straining it
through a sieve while hot. The child may sometimes be fed with this
alone, a little sweetened. Molasses may be given freely, or molasses and
soda. The child should be watched, and if there is occasional
costiveness, and at the time any indisposition, make a suppository of
common soap about an inch in length and a quarter of an inch thick, dip
it in water and pass it into the rectum. Or give an injection of less
than a gill of water with perhaps a teaspoonful of molasses and a pinch
of salt. But I would avoid the practice of giving an enema daily, as
tending to get up a bad habit in the system. Should the costiveness have
provoked fever, induced pain, or excited convulsions, active physic may
be given, either castor oil, magnesia, calomel, or F. 108. But be sure
that costiveness is not brought on by giving paregoric or other opiates,
and let a child drink freely of pure cold and fresh water. The water may
be boiled to destroy germs, and then cooled in a refrigerator; it should
always be boiled before being used when there is an epidemic of bowel
complaint prevailing.
In DYSENTERY there is a specific inflammation and ulceration of the
mucous membrane of the colon, especially of the lower part, and of the
rectum—there is generally some fever, frequent and bloody stools,
tenesmus, and griping pains. Sometimes it attacks an infant or a
delicate child, there being at first for several days diarrhœa, the
motions being slimy and frothy like frogspawn, afterward entirely mucous
and blood. The child is dreadfully griped, strains violently, and
screams, and twists about every time it has a motion, and there is
vomiting and great prostration.
You should in treating the child at the breast still keep him to it, and
give it no other food. If the mother’s milk is not good, procure if
possible a healthy wet nurse. If the child must be fed give it cow’s
milk from one healthy cow—fresh from the cow—small quantities at a time
and frequently, mixed with gum arabic water. In the commencement a warm
bath may be used, or as a substitute you may wrap the child in a blanket
that has been previously wrung out of hot water; over this put a dry
blanket and keep the child thus enveloped for twenty or thirty minutes.
Formula 74 and 99 may be used, but the dose for a young child must be
small to accord with its age.
CHOLERA INFANTUM is more prevalent in the United States than in any
other country. The continued heat of summer is a predisposing cause, and
improprieties in diet and clothing, worms, premature weaning, and
teething are exciting causes.
You may treat this disease in the initial stage by giving F. 80, and
also for a child a year old, injections of a gill of warm water in which
a teaspoonful of common salt has been dissolved, allowing the patient
three or four times a draught of warm water, as much as it desires to
drink. Perhaps the drink will be immediately vomited, but it will at
least remove irritating matter from the stomach. The injection, too, may
operate immediately, but it may bring with it a fecal or bilious
discharge, and if several times repeated, its effects will be salutary.
A muslin cloth heated almost to scorching and applied once or twice dry
to the neck, may stop vomiting, and draughts applied to the extremities
may also be of much benefit. After using injections of warm soft water,
anodyne injections may be given three or four times a day; but cases of
this kind are too serious for any nurse or mother to treat, if the
services of a physician can be obtained; and I will only mention one or
two things more. When the extremities are cold put the child for a few
minutes in a warm bath of mustard water, and then employ friction to the
skin.
I have found chicken tea made by boiling the chicken very soon after it
is killed, very useful in checking the vomiting and curing the child.
Of course a physician will be obtained in these serious cases if
possible.
RETENTION OF URINE in the newly born infant if slight is easily removed
by giving two or three drops of spirits of nitre once an hour in a
little sweetened water, or if obstinate it may be aided by castor oil
and the warm bath. A little pumpkin seed or parsley root tea also
succeeds remarkably well.
APTHÆ is usually called the baby’s sore mouth. It generally begins on
the inner part of the lower lip or corner of the mouth, as a small white
speck which resembles a coagulum of milk. These aphthous white pustules
soon appear over the inside of the cheeks and on the tongue and gums.
The eruption is very white and looks as if whey or curds were spread
over the mouth, which is hot and painful, and the disease sometimes
does, and at other times does not cause fever. I regard this complaint
as being one of the germ diseases, although the fact has not yet been
demonstrated. The children fed upon farinaceous food are most liable to
this disease, and during its continuance, if the child is not at the
breast it should be kept entirely to the milk of one cow. Medicine
should be given with regard to the stomach and bowels. If the passages
from the bowels are green, magnesia is a proper kind of physic, and when
there is diarrhœa use formula 80, 77, 81.
GENUINE JAUNDICE may attack a young child, but this is to be
distinguished from those cases where there is only a generally diffused
YELLOW COLOR OF THE SKIN. In the latter class of cases there are no
symptoms indicating any serious disease; the yellowness may continue for
several days, and this disappears without the aid of any medicine and
without leaving any evil behind. But in jaundice the whites of the eyes
and the tears are tinged yellow, and, besides, the feces are paler than
they should be, the urine is yellow, and other serious symptoms are
added. If the bowels be costive, or irritated to frequent efforts, if
the abdomen swells and becomes tense, if the child is uneasy and
inclined to vomit, if it refuse the breast and frequently moans as if in
pain, if it emaciate rapidly, jaundice in a bad form is present, and
there is probable disease of the liver. Call the doctor.
I need not continue my instructions any farther in regard to the
diseases of infancy, as you are expected to act as far as you can under
the directions of a physician. But I must again advise you as to how you
are to treat your medical advisor. Give him your entire confidence. Be
truthful and candid with him. Have no reservations; give him a plain
statement of the symptoms. Be prepared to state the exact time the child
showed any illness. Tell him if the child had a chill; if there be any
eruption on the skin, note the quantity and appearance of the urine, the
number, color, &c., of the stools—all the symptoms of the disease.
Strictly obey the doctor’s orders in diet, in medicine, in everything,
and never omit any of his suggestions. If the case be severe, never call
a second physician without first consulting and advising with the one
first chosen; speak in the presence of children with respect and
reverence of the doctor, and endeavor to have them like him. Send for
the doctor when practicable early in the morning, as the daylight is
most favorable for making the examination, but if the illness come in
the night do not delay on that account; if you do not know what to do,
it is better that the doctor be called early than late.
CHAPTER V.
CASES OF DIFFICULT LABOR.
I wish to give you so much instruction in regard to cases of difficult
labor that you may at least be prepared to decide in any case when the
services of a physician is indispensably necessary, to decide whether
the parturition in a given case is a natural one that does not need any
assistance, or an unnatural one requiring the assistance of the art of
midwifery, scientific or manual, for the relief of irregularities and
difficulties. In general I shall adopt Churchill’s divisions and
definitions as I think they are very concise and correct.
TEDIOUS LABOR.
“DEFINITION. The head of the child presents and the labor is terminated
without manual or instrumental assistance, but it is prolonged beyond
twenty-four hours from causes which occasion delay in the first stage.”
Prolongation of labor is of comparatively small consequence when the
membranes are still intact, as they serve to protect the soft parts of
the mother as well as the body of the child from injurious pressure, but
the mere lengthening of the labor may become a serious thing when the
head has entered the pelvis, when the uterus is strongly excited by
reflex stimulation, and when the maternal soft parts as well as the
fœtus and cord are exposed to severe pressure. When we find no evil
resulting from the delay we need not interfere, but when we can remove
the cause of it we are bound to do so.
In tedious labors the woman becomes fatigued, the loss of sleep is much
felt, her spirits become depressed, and the stomach is more or less
disturbed, but when the other bodily functions are performed regularly,
the skin is cool, the pulse quiet, the tongue clean and moist, there is
no headache, and the pains recur tolerably regularly, the condition of
the patient is favorable, though the pains are inefficient and vary in
their duration and frequency. There is usually loud outcry during the
pain in the first stage of labor, but there is often sufficient
remission of the suffering for the woman to get some quiet sleep, and
generally there is progress to the labor.
INEFFICIENT ACTION OF THE UTERUS occurs most commonly in women confined
for the first time, and sometimes we can ascribe it to no cause but
constitutional peculiarity, or a deranged state of the digestive organs,
or mental depression; in other cases it may be caused by irritation of
the os and cervex uteri.
The skilled nurse may properly send for a medical man, though he is not
indispensably necessary in such cases. The best thing which she can give
in such cases is a quarter grain dose of morphine to suspend the pains
and induce sleep, or if this is not thought best it may be proper to
give physic or stimulating enemata. Never give ergot to increase the
pains, but it may be proper to give several grains of quinine. However,
giving medicine must be left as much as possible to the physician.
EXCESSIVE AMOUNT OF LIQUOR AMNII with undue distention of the uterus in
some cases renders the pains inefficient. The unusually large size, and
the fluctuation of the abdominal tumor may be obvious, but although an
accoucheur might deem it advisable to evacuate the waters, the skilled
nurse who could not be certain that there was a favorable presentation,
should not do it. She must exercise patience herself and encourage the
patient to do so, and time will probably do the work, though it is
better to commit the case to a doctor.
AN UNDILATABLE OS UTERI, which remains rigid although the pains are
severe, may sometimes be felt with its edges thin and stretched over the
head, and sometimes thick and tough. In the majority of cases patience
and time may overcome the obstacle, but as it is best in some cases to
give chloroform, chloral, &c., and in some instances to use local means
to relax or dilate the os, the physician should be sent for. The nurse
may properly give the patient a hip bath.
PREMATURE ESCAPE OF THE LIQUOR AMNII and OBLIQUITY OF THE UTERUS are
both causes of tedious labor, but not cause for apprehension or special
interference. I have already given some hints in regard to the treatment
of the latter class of cases.
THE POSTERIOR LIP OF THE CERVIX UTERI IN SOME INSTANCES IS RETRACTED
WHILE THE ANTERIOR IS DRAWN TIGHTLY OVER THE CROWN OF THE HEAD. In such
cases it has been my practice to draw with my finger the anterior lip
forward, and during the time of the pain to press my finger against the
head of the child. I do this believing that the anterior lip is caught
between the head and symphasis pubis, and that it will be better
retracted while support is given to the head.
POWERLESS LABOR.
“DEFINITION. The labor is prolonged in the second stage by causes which
act on the uterine powers primarily or secondarily, rendering the pains
feeble and inefficient or totally suppressing them.” In consequence of
the stage at which the delay takes place, certain symptoms arise which
render speedy delivery imperative.
The second stage may continue twenty hours or more without any bad
symptoms, but usually if it exceeds twelve hours some of the following
symptoms may be observed: The pains become irregular as to recurrence
and force—perhaps become weaker—there may be rigors or shiverings—the
vomiting may be distressing—there may be constant restlessness and
fever—the vagina and uterus may be hot and tender to the touch—and the
pressure of the child’s head may prevent the evacuation of the bladder.
The same causes (weak constitution, mental emotion, disease, &c.), which
in the first stage rendered the labor tedious without bad symptoms, now
occasion these and perhaps even more alarming indications. If an
experienced accoucheur now arrives to take charge of the case he will be
likely to apply the forceps, but it would have been better if he had
been there and applied them sooner, before the patient had undergone so
much suffering; and the midwife who attends a woman in the first stage
of the labor should ascertain if any of the following causes of
powerless labor exists: Is there a weak constitution or one exhausted by
disease? Is it a first labor and the woman of advanced age? Has the
patient had very many children? Is there excess of liquor amnii? Is
there malposition of the uterus? No midwife should undertake to manage
such a case alone.
OBSTRUCTED LABOR.
“DEFINITION. The progress of the labor is impeded by some mechanical
obstruction in the passages connected with the soft parts, which by
causing delay in the second stage leads to the developement of symptoms
of powerless labor.”
The symptoms that arise and that cause anxiety are the same as in a case
of powerless labor, except that while in the latter kind the pains are
feeble, in the case of obstructed labor the pains may be vigorous and
severe but ineffective in consequence of obstacles. I may say, however,
that these obstacles have not been often met with in my practice. Since
I commenced the practice of midwifery three thousand cases of pregnancy
have been under my observation for treatment, and I have not yet met
with any of the following causes of obstructed labor: Occlusion of the
os uteri, cancer of the os uteri, undilatable vagina, tumors in the
pelvis, or diseased ovary, stone in the bladder, imperforate hymen,
hernial protrusion into the vagina, or blood effusions, or swelling of
the soft parts. I have met with one case of excessive œdematous effusion
of the vulva, which I relieved by puncturing the skin; one case of
cystocele which I relieved by first drawing the water and then returning
the bladder, before the head of the child descended into the pelvis; one
case of ovarian tumor that was not at that time in the pelvis; one case
of small fibrous tumor on the neck of the uterus, which did not much
obstruct the labor; and numerous cases where hardened feces in the
rectum was an obstacle until they were removed by the use of enemata. In
cases of obstructed labor the skilled nurse will show her wisdom by
detecting the obstructions and sending for an accoucheur.
DEFORMED PELVIS.
“DEFINITION. The progress of the labor impeded by abnormal deviations in
the form of the pelvis, giving rise to delay in the second stage, or
rendering the descent of the child impossible without assistance, or
altogether impracticable. The symptoms are those of powerless labor.”
The EQUALLY ENLARGED PELVIS, enlarged in all its parts, is not often met
with, and is of no obstetric importance. If in any case this condition
is diagnosed preceding or during labor, the patient should be watched by
the nurse lest labor close so precipitately that the child falls to the
ground.
THE EQUALLY CONTRACTED PELVIS—equally contracted in all its diameters,
generally renders the labor difficult and tedious but not impracticable,
by the natural powers. Other distortions such as has often been caused
by rickets, &c., offer great obstruction to the passage of the child. In
some cases a modification of the position of the child allows it to
descend, but in many cases it is necessary to interfere and terminate
the labor artificially. The nurse should not wait for unfavorable
symptoms to appear before she sends for a man that is able to use the
forceps, &c.
MALPOSITION AND MALPRESENTATION OF THE CHILD.
Unnatural or abnormal labor may be caused by some peculiarity on the
part of the child, in the position or presentation. These cases demand
the services of the skilled accoucheur, and I do not intend to hint that
the nurse should ever attempt to do what an educated physician should be
called to do in these cases.
FACE PRESENTATIONS sometimes retard the labor so much in the second
stage as to give rise to unfavorable symptoms. In cases where the action
of the uterus is so energetic as to finally expel the child, the
sufferings of the mother are severe and prolonged. I have in my practice
met with four cases, three of which were delivered by the natural
powers, the children living; in one case craniotomy was performed. The
mothers all lived. The diagnoses of face presentations is not easy at an
early stage of labor. The finger first touches the forehead, which may
be mistaken for the vertex. When the membranes are ruptured we may be
able to make out the presentation. We may distinguish the edges of the
orbits, the prominence of the nose, the mouth, &c. The bridge of the
nose is the best guide, it being prominent, firm, and unlike any part of
the breech or vertex. The face becomes tumefied during the labor, and
the cheeks pressed together to resemble the nates, and it may be
mistaken for a breech presentation. But in either presentation the
proper course for the nurse is to leave the case alone in the
expectation that the natural efforts will be sufficient to complete
delivery. The child when born has a frightful appearance from the
swelling and discoloration of one cheek, &c., but the injuries pass away
in a day or two.
THE FOREHEAD TOWARDS THE ARCH OF THE PELVIS at the time of delivery is
not favorable, but unless the pelvis is proportionately small no
interference is necessary.
The BREECH may present at the brim in different positions, and the
breech is distinguished by its roundness and softness, by the cleft
between the buttocks, by the arms and by the organs of generation. In
some cases the labor is concluded as quickly as if the head descended,
in others it is more tedious. The results as regards the mother are as
favorable as in head presentations. The danger to the child is in direct
proportion to the length of time between the birth of the body and that
of the head.
When the body is expelled so far as the umbilicus, the danger to the
child commences, for at this time the cord may be pressed between the
body of the child and the pelvic walls. A loop of the cord should be
pulled down, and if it freely pulsates the child can probably be
delivered alive. Generally a judicious traction on the part of the
accoucheur, combined with firm pressure through the abdomen applied by
an assistant, will effect delivery of the head before the delay has had
time to prove injurious to the child. If the arms of the child are above
at the side of the head, the doctor will bring one down by passing a
finger over the shoulder as near as possible to the elbow, and then
drawing it across the face and chest until it arrives at the external
orifice, but all this time it is the part of the nurse to continue to
make effective pressure upon the abdomen of the mother—also while he
delivers the shoulders—and while he perhaps introduces two fingers into
the vagina of the mother to reach the upper jaw of the child and make
pressure upon it, so as to depress the chin and facilitate the expulsion
of the head.
PRESENTATION OF THE KNEES and PRESENTATION OF THE FEET is identical in
its progress with breech cases, and the treatment of breech cases
applies to footling presentations, but it is best to avoid pulling on
the foot or feet that come down, as it is safer for the child if the
lower part of the body is delivered quite slowly. Even if the nurse
should in an emergency deliver the child, she should help principally by
pressure on the mother’s abdomen.
The only rule that I would have the skilled nurse adopt in regard to
these cases, is that it is necessary that she should discover as early
as possible if the labor is not a natural one, and if it is unnatural,
should obtain the services of a physician as soon as possible. The same
rule applies to cases of placenta previa hemorrhage, but I shall have
more to say of these hereafter. A case of compound presentation where
the hand and arm presents with the head, or in which the feet and hands,
or one of each present together, also imperatively demand the services
of an experienced accoucheur without delay. The nurse will be impotent
to give any efficient help until the doctor arrives.
Presentation of the SUPERIOR EXTREMITIES will receive from me a full and
complete description, because I believe that under certain circumstances
the nurse should be prepared to operate by turning. As this radical
opinion may perhaps be opposed by my medical brethren, I offer the
following reasons for it which I consider a sufficient justification.
1. Cases of this class commence with the ordinary symptoms of labor;
their peculiar character cannot usually be distinguished until the os is
well dilated, and this is the only favorable time to perform the
operation of turning.
2. Although in cities and villages generally, a physician’s services can
in most instances be immediately obtained, in the country it is not
always practicable to obtain them within an hour or two of time.
3. Such knowledge as is necessary for the performance of this operation
may be obtained from such description and instruction as can be given in
books.
4. There are some women who possess the necessary traits of character,
the complete exercise of their faculties, with the perfect coolness
which is demanded of the operator in such a case.
5. I do not advocate trusting the operation to a nurse when the services
of an accoucheur can possibly be obtained within the proper time.
6. The services of a physician, if obtained one or two hours after the
arm is first thrust down in the vagina, may not be of any use because
the time for turning is passed.
7. The operation of turning, performed by a properly instructed nurse,
does not involve the least danger to the mother or child.
8. The only danger connected with this operation arises from the size of
the hand of the operator, and the woman’s hand is small.
9. It is a historical fact that at one period practitioners overrated
the performance of turning, and extended its use to unsuitable cases,
and after the invention of the forceps, they fell into an opposite
error. It is possible that we may be in error if we hold that the nurse
cannot be instructed to perform the operation of turning.
10. I do not advise that the nurse should ever attempt to turn in those
cases in which the membranes have been long ruptured—the shoulder and
arm pressed down into the pelvis, and the uterus contracted around the
body of the child. I once succeeded in a case that two experienced
physicians had tried in vain for several hours to turn, and I never had
very much difficulty in turning, but there have been many cases where
excellent operators could not succeed in turning.
In cases of PRESENTATION OF SHOULDER, ARM OR TRUNK, delivery by the
natural powers is quite exceptional, though the natural powers have
occasionally succeeded in expelling the child. The safety of the mother
and child depend upon the early detection of the abnormal position of
the fœtus, and upon their receiving proper treatment before labor has
been long in progress.
The position of the child is one intermediate between the long and
transverse diameters. It may lie with its back towards the abdomen of
the mother or with the back towards the spine of the mother, and the
head of the child may be towards the right or the left of the mother.
The existence of a shoulder presentation is not commonly suspected until
the first examination is made during labor. Suspicion will arise from
finding on examination that we are not able to reach the presenting
part, and that the os uteri does not dilate as usual, and that when it
becomes dilated the bag of membranes protrude of a conical form, but
this is common to all malpresentations. When the shoulder has descended
a little it is recognized as a round, smooth prominence, rounder than
the elbow, and we may be able to reach the axilla, &c. The elbow may be
recognized by the sharp prominence of the bone, and the hand can be
distinguished from the foot by the fingers being wider apart and more
readily separated from each other than the toes, and by the thumb which
can be carried across the palm. The situation of the thumb and the
aspect of the palm of the hand will mark whether it is the right hand or
the left.
As soon as the nurse ascertains or suspects from an external palpation
or a vaginal examination, that it is a cross birth she should send for
the doctor, who ought to be there as soon as the membranes are ruptured,
and the nurse must not be very persistent in making examinations lest
she rupture the membranes prematurely. She may perhaps give a small dose
of morphine, but I would not advise that she give chloroform as it is
not necessary.
The right time to turn the child is when the os uteri is dilated, either
before or immediately after the rupture of the membranes, and if a
doctor cannot be soon obtained, it is better that a skilled nurse should
turn the child, and if she is properly instructed, she should do it
carefully and slowly, but without any fear and confidently. She can
assure the patient that she will be able in a short time to relieve her
sufferings.
In England the ordinary position for turning is on the left side. I
prefer that the patient be placed across the bed on her back with her
legs drawn up and supported by assistants. I now describe my own mode of
operating.
I bare my right arm and hand (sometimes the left), lubricating it
freely. If the waters have only recently escaped, and the os be dilated,
the operation is performed with ease, especially after we have
determined the position of the child.
I press the fingers together in the form of a cone, the thumb between
the fingers—slowly and carefully press them into the vagina in an
interval between the pains, and constantly and slowly press the hand in,
only when the contractions of the uterus remit; never using any force,
gently pass the fingers into the os; gently open the fingers a little
occasionally to dilate the os sufficiently, and when it is expanded pass
the hand into the uterus, make out the presentation accurately, so as to
keep my hand to the abdomen of the child; always keep the hand still
during a pain; when there is an interval between the pains, carefully
search for the feet; when one of the feet is found, clasp the leg at the
knee with one finger; flex the leg at the knee so that the finger has a
good hold of it, draw it down in the absence of a pain; as the knee
approaches the os when it is drawn down over the abdomen of the child,
the shoulders and head recede towards the fundus, and when the head has
reached the fundus and the knee is brought through the os, the case is
converted into a knee presentation, and I deliver slowly but without
needless delay—making a little traction during each pain, the management
being conducted as in feet presentations, and the whole process being
assisted by pressure made on the uterus by my left hand, or by the hand
of an assistant.
Possibly these directions will be better understood if I use the
language of another who directs:
1. That the patient be placed on her left side near the edge of the bed.
2. The os externum is then to be dilated with the fingers reduced into a
conical form, acting with a semi rotary motion of the hand.
3. When the hand is passed through the os externum it must be slowly
conducted to the os uteri. We may perforate the membranes with the
finger if they are not broken.
4. The hand must then be passed along the thighs and legs of the child
until we come to the feet. If both the feet lie together we must grasp
them firmly with one hand, but if they are distant from each other we
may deliver by one foot.
5. Before we begin to extract we must be sure that we do not mistake a
hand for a foot. The feet must be brought down with a slow, waving
motion into the pelvis, when we are to wait till the uterus contracts,
still retaining them in the hand.
6. The feet are to be brought down with each return of the pain, and the
labor may be finished partly by the efforts of the mother and partly by
art.
7. If the toes are turned towards the pubis the back of the child is
towards the back of the mother which is an unfavorable position.
8. If the toes are towards the sacrum, the back of the child is towards
the abdomen of the mother, and this position is advantageous when the
head comes to be extracted.
9. When the feet of the child has passed through the os externum, wrap
them in a cloth and holding them firm wait till there is a pain, during
the continuance of which gently draw down the feet. When the pain ceases
we must rest, we merely assisting the efforts of the patient.
10. When the child is brought so low that the funis reaches the os
externum, a small portion of it is to be brought out to slacken it, and
from this time the operation is to be finished as speedily as it can be
with safety, but if the circulation of the funis be undisturbed, there
is no occasion for haste as the child is in safety.
11. If the child should stick at the shoulders the arms must be
successively brought down.
12. When both the arms are brought down the body of the child must be
supported upon our left arm and hand, the fingers on each side of the
neck, and if the head should not come easily away, we must introduce the
forefinger of one hand into the mouth of the child to render the
position of the head more convenient for passing.
12. When a child has been extracted by the feet, the placenta usually
separates very easily, but in the management we are to be guided by the
general rules.
13. In these cases the child usually needs to be resuscitated, and the
nurse should arrange so that hot and cold water may be at hand if
required.
In these descriptions of the operation I have mentioned both the back
and side as good positions for the mother, because some accoucheurs
prefer one position and some the other. Some prefer to have the patient
on the hands and knees. But if the nurse have the instructions here
given well in her mind, she can operate in either position. If she
ascertains at first how the child lies she may sometime reach its
abdomen better if she introduces her left hand, but the main point is to
proceed slowly and carefully. She should be careful in passing in her
hand to change the direction of it in accordance with the pelvic axis,
and should not use much force at any time. The danger to the mother is
very small indeed; the danger to the child arises, as in breech
presentations, from the compression of the funis, which commences about
the time the buttocks appear at the os externum. But the safety is only
when the operation is performed at the proper time. The nurse must never
operate if the services of a physician can be obtained at that time, but
when it is necessary she may proceed to turn, doing it slowly and
properly, but fearlessly and confidently. If the doctor that is sent for
is informed before he arrives that it is a case of hand presentation, he
will come dreading the difficulties that he may encounter, and if he can
have the satisfaction of knowing when he comes that the woman is safely
delivered, he will be exceedingly glad.
CHAPTER VI.
CONCLUDING INSTRUCTIONS IN MIDWIFERY.
What I shall say of PLURAL BIRTHS, and MONSTERS, of CHILDREN AFFECTED
WITH HYDROCEPHALUS, OR ASCITES, of EXCESSIVE SIZE OF THE FŒTUS, of
DEFECTS IN THE FORMATION OF THE FŒTUS, of PROLAPSE OF THE FUNIS, &c.,
will be compressed in a few words. I am not instructing the nurse to
attempt to conduct a case of even natural labor without having a
physician if he can be obtained, but she should consider the services of
a trained practitioner _imperatively_ necessary in these unusual cases.
In either instance there may be a safe delivery by the natural powers
alone, and the nurse may act in an emergency, but it would not be
consistent with the plan of this work for me to describe in detail the
various operations that are sometimes performed in these several cases,
or to give instructions in the use of instruments, which I advise the
nurse never to use.
In regard to those instances where it seems as if it would be necessary
to use instruments, I quote the following rules adopted by accoucheurs:
1. Meddlesome midwifery is always bad. 2. In no case need we interfere
when the obstacles to be overcome can be overcome in a reasonable time
by nature or without an operation. 3. Cases in which instruments are to
be used are exceptions to the general rule, and no instrument should be
used in a clandestine manner. 4. We should not have such an aversion to
the use of instruments that we too long delay that assistance we have
the power of affording with them.
PLACENTAL PRESENTATION.
PLACENTA PREVIA will never be treated by the nurse, but she should know
its nature, know that it is this that causes unavoidable hemorrhage, and
she should not fail to obtain a skillful physician early, to attend the
case. The flooding is the necessary consequence of the dilatation of the
os uteri, by which the connection between the placenta and uterus is
separated, and the more the labor advances, the greater the disruption,
and the more excessive the hemorrhage.
The woman usually passes through the early part of pregnancy without any
sign that denotes the peculiar attachment, but the placenta can easily
be distinguished from the membranes or coagulated blood as soon as the
os uteri is a little opened. When a hemorrhage comes on from this cause
the patient is never free from danger till she be delivered. Often the
medical man is obliged to free the patient from imminent danger by
artificial delivery, but I can conceive of no circumstance in which a
_nurse_ would be justified in turning for unavoidable hemorrhage.
Before, during, and after the delivery, the appliances used in other
cases of hemorrhage may be used with some advantage, but I would hardly
advise the nurse to do any thing before the doctor arrives.
ACCIDENTAL HEMORRHAGE.
That form of FLOODING that arises from a partial and accidental
separation of the placenta which occupies its usual position, must here
be briefly referred to, as the nurse may be called on to do something in
an emergency. The immediate cause of the flow is the separation of some
portion of the placenta from the womb, and the laceration of the
vessels. The hemorrhage is at first internal, is accompanied with dull
pain at the spot where it takes place, it generally becomes external, it
may or may not be attended with the discharge of coagula from the os
uteri, and when the discharge commences it varies in quantity from a few
ounces to an amount that is alarming. It is generally necessary to make
a digital examination, to distinguish the accidental from the
unavoidable hemorrhage.
Until the doctor arrives the patient should be kept in bed on a hard
mattrass and very lightly covered with bed clothes. The temperature of
the room should be kept very low, and nothing but cold water allowed.
The danger from hemorrhages that occur at or near the full period of
utero gestation, may often be estimated by the absence or degree of
pain, as well as from the quantity of the discharge. Hemorrhages are
much more dangerous with sudden than with slow discharges of blood, and
women are always in greater danger when they are not accompanied with
pain. Puerperal convulsions, whether of the hysteric, epileptiform, or
apoplectic variety will always demand and almost always receive the
prompt attention of the physician.
While the nurse is waiting for the doctor to arrive she might possibly
administer a cathartic, thirty grains of bromide of potash, and an
enema, but as a general rule she should not give anything. She might
insert a wedge or roll of linen between the teeth to prevent injury to
the tongue, and she should remove every thing out of the way, by
striking against which, the patient might hurt herself.
PART V.
ÆTIOLOGY, SYMPTOMOTOLOGY, MEDICATION, NURSING.
CHAPTER I.
CAUSES OF DISEASE.
The causes of disease are spoken of by authors as predisposing, and
exciting. By proximate cause of disease is meant the cause of the
symptoms present; this cannot appropriately be dwelt upon here.
By exciting cause is meant the immediate cause of a disease, and the
distinction from predisposing cause arises from the fact that when two
persons are exposed to something injurious to the health, they may not
be equally affected.
It has been said that if twenty persons undergo hardship and exposure
from shipwreck, the effect of the wet and cold may be in one to cause
catarrh, in another rheumatism, in a third pleurisy, in a fourth
opthalmia, in another inflammation of the bowels, and fifteen may escape
without any illness at all. A predisposing cause is defined to be
anything whatever, which has had such an influence on the body as to
have rendered it unusually susceptible to the exciting cause of the
particular disease. In most cases the distinction is obvious, but it is
sometimes difficult to say of a given cause whether it ought to be
ranked among the predisposing or the exciting causes.
Disease is often warded off notwithstanding the presence of the exciting
cause, when we ascertain and prevent the predisposing cause of it, and
it may sometimes be averted in despite of strong predisposition, if we
know and can guard against the agencies by which it is capable of being
excited.
When we enumerate causes of disease we see among them many that under
ordinary circumstances minister to life, health, and enjoyment; and I
can hardly refer at all to the varying circumstances under which they
become the medium of pain, disease and death. These circumstances are so
various, so many of them are apt to be put in operation at the same
time, and so little power have we of excluding them one after the other,
so as to ascertain the exact efficiency of each, that our observation
respecting their actual effects are open to much fallacy.
We cannot for instance in a given case estimate accurately the effect of
impurities in the atmosphere such as organic and inorganic dust, nor the
effect of differences in degree of its natural qualities such as
extremes of heat and cold, sudden variations of temperature, excessive
moisture or dryness, different electric conditions, differences of
pressure, a deficiency of light, and the amount of ozone, &c.
OF HEAT AND COLD AS EXTERNAL AGENCIES CAUSING DISEASE.
The range of temperature compatible with human life is very great; men
live in the hottest and the coldest climates, where the earth produces
any sustenance for them. It requires more care to preserve life under
intense cold than under intense heat. Tropical climates are thickly
peopled where the thermometer ranges from 80° to 100° for a long time
together. In arctic countries on the other hand where the thermometer
sinks to 40° or 50° below zero, we still find inhabitants, but they are
few and thinly scattered. It is probable that at a degree of temperature
a little greater than that of the equator or a little less than that of
the poles men would perish.
Man is capable of existing under certain circumstances for a short time,
and enduring a much higher degree of heat than the general atmosphere
attains in the hottest portions of the earth, but there are generally
some deleterious effects from hot climates or continued hot weather.
The effect of HEAT is to stimulate the organic functions of the body,
but when considerable heat is applied for some time together its effect
is to cause languor and lassitude, want of energy, a disinclination for
exertion both bodily and mental; it has a depressing effect generally
upon the animal functions or the nervous system, and there are some
forms of disease that are distinctly traceable to heat as a cause.
We all know the effect of hot weather in causing perspiration, and when
the operation of high temperature is continued for some time it has a
marked influence upon the liver, increasing the quantity of bile that is
secreted, and altering its sensible qualities; this is sometimes
followed by inflammation of the liver.
In this country those attacks of vomiting and diarrhœa which are so
common towards the latter end of summer or in autumn are the effects of
a succession of hot days. In tropical climates the morbific effects of
external heat are still more conspicuous, tending to violent disorders
of the stomach and intestines, and also to acute inflammation of the
liver and to acute abscesses in that organ.
In these cases the heated atmosphere unduly stimulating the secreting
function of the liver creates the predisposition to the disease, while
the exciting cause of the inflammation may be exposure to cold.
There may be deleterious effects from exposure to cold where the climate
is quite hot. For instance a man may after the heat occasioned by the
employments of the day, undress and lie opposite a window, his shirt wet
with perspiration, to enjoy the sea breeze at night, and though the
thermometer may be as high as 80° he may have a sensation of cold. If
there is real chilliness it may be deleterious.
Heat sometimes acts as an _exciting_ cause of disease—it produces
sunstroke, or it may produce an eruptive disease such as prickly heat,
&c.
The effect of extreme COLD (I use the term cold in the popular
acceptation), when its application is continued, is that of a sedative
upon the organic functions. Though at first causing pain in the
extremities, if continued it causes sleep or overpowering drowsiness.
Before this complete stupor comes on there may be a blunting of the
sensations and confusing of the intellect, giving to the person exposed
to it, the appearance of one intoxicated. When persons in this state are
suffered to sleep, and the operation of the cold continues, they become
less and less sensible to external impressions until death closes the
scene.
But the effect of cold upon the body within certain limits of intensity
and duration is that of a tonic. When its refrigerating and sedative
properties can be sufficiently counteracted by exercise and warm
clothing, cold is stimulating, refreshing, and invigorating to mind and
body, it clears and sharpens the faculties, bestows alacrity and
cheerfulness of spirits, and may become a curative agent.
Yet exposure to cold is one of the most common causes of various
complaints. As a rule it is true that there is danger from sudden
vicissitudes of temperature, although the proposition requires
limitation. No peril need attend a change from a hot to a cold
temperature if the power to evolve heat inherent in the system be entire
and active and persistent, not lessened by any of those circumstances
which have the effect of weakening it, such as local disease, and
fatigue. Cold is dangerous, not especially when the body is hot, but
when it is cooling after being heated. At such times taking a large
draught of cold water, or cooling the body suddenly some other way might
cause death immediately; if not, an inflammation of some internal part
of the body might arise.
Every thing that has the effect of weakening the system and so
diminishing the power of evolving heat, favors the morbific effect of
cold, and is a predisposing cause of disease. The most common of these
debilitating circumstances are fasting, evacuations, fatigue, a last
night’s debauch, excess in venery, long watching, much study, and rest
or inaction immediately after it, or after great exercise.
The faculty of evolving heat is weak in old persons and in the newly
born, and these are often the victims of the power of cold.
The bad effects of cold depend very much upon the duration of the
sensation. Even slight feelings of chilliness, if long protracted, are
apt to terminate in some form of disease.
Cold is more likely to prove injurious when it is applied by a wind or
currant of air, and the injurious operation of cold is augmented when it
is accompanied with moisture—wetness is the worst way in which cold can
be applied. The contact of wet or damp clothes with the skin, both
increase and prolong the sensation of cold. A foggy atmosphere is more
prejudicial than a clear one of the same temperature. While we are
asleep, also, our power of resisting the effects of cold is diminished.
The power of habit enables a person to resist the effect of cold, and we
may sometimes turn our knowledge of it to good account in gradually
fortifying the system against the influence of cold that cannot be
avoided. But we must not, while we fear to render our children
effeminate by over care and much clothing, run into the opposite extreme
and endanger their health by exposure. The process of hardening is
doubly dangerous when it is attempted with children who were originally
delicate, and should never be tried on any child or any person who is
unsound, who shows any signs of present or approaching disease, or any
marked predisposition to future, and especially to scrofulous disease.
An abiding sense of chilliness must never be permitted even when we are
endeavoring to accustom a child to cold. If they can be kept in the cold
air, and at the same time be kept feeling warm either by exercise,
diversion of the mind, or by clothing, the result as regards the health
is good.
The cold bath, and especially the shower bath, is a good means of
fortifying the body against cold air. When we take a cold bath in the
morning, if the sense of cold does not remain long, and is followed by a
glow of warmth, the bath is sure to do good. If, however, after the bath
we suffer headache, and continue to be chilly and languid or
uncomfortable, it should at once be given up as useless and dangerous.
EFFECTS OF THE SEASON UPON HEALTH.
In this country, generally, catarrh and coughs and pectoral complaints
of all kinds, are most apt to prevail in the winter and spring months,
while bowel complaints are more numerous and distressing in the summer.
The mucous membranes of the air passages sympathize with the skin under
the agency of external cold; those of the stomach and intestines under
that of heat.
The thoracic disorders which commence or grow worse in the winter are
often fatal, and there are various other maladies that are aggravated by
cold, so that the mortality of winter is greater than that of summer.
Bowel complaints are more prevalent at the latter part of summer or
early fall, when moderately cold days succeed a long period of hot
weather, the high diurnal temperature being the predisposing cause, and
the cold exciting or bringing on the disease.
I shall not refer to other causes of disease except to say that if two
persons marry each other who have a hereditary predisposition to
disease, their children, if they have any, will probably not be healthy.
CHAPTER II.
SYMPTOMS OF DISEASE, WITH INSTRUCTION TO NURSES.
Symptoms are the signs by which we know that disease is present. Every
circumstance happening in the body of the sick person capable of being
perceived by himself or others, which can be made to assist our judgment
concerning the seat or nature of the disease, its probable course and
termination or its proper treatment, is a sign or symptom.
These phenomena are the evidence upon which the whole art of the
physician proceeds. It is important that the nurse should know how to
note the symptoms, not only that she may know how and report to the
doctor changes that occur in his absence, but that she may be able also
to minister to those who are suddenly attacked with sickness, and to
judge whether in cases of slight indisposition it is necessary to send
for a physician.
By arranging and comparing symptoms, and by noting the circumstances
under which they occur, the physician can distinguish the disease, and
learn what are the indications of treatment—this belongs especially to
him. But it is very important that a nurse should know how to note all
changes as they occur, and sometimes it is best she should keep a
written record of them. An important point in a trained or skillful
nurse is that of her ability to observe accurately and describe
intelligently what comes under notice in the absence of the physician.
She should cultivate the habit of strict observation, and simple and
truthful statement—neither deficient, exaggerated, or perverted, stating
facts and not opinions.
Symptoms or phenomena which accompany disease may be _subjective_, those
which are evident only to the patient, or _objective_ which are
observable by others. Both sorts of symptoms shed mutual light on each
other, and as the statements of the patient are not always trustworthy,
the nurse should be careful not to let anything pass unseen that can by
vigilance be noted.
The following directions will help the nurse to cultivate the habit of
observing symptoms:
Try to learn all you can of the previous history of the case; you will
sometimes get information which the patient would not be likely to
communicate to the doctor in person.
Note the patient’s apparent age with any indications of disguised age,
signs of weakness—whether corpulent or bloated; note any deformities,
swellings or wounds, and notice the attitudes and expression of the
countenance.