OBSTETRICS.

CARE OF THE PERINEUM. (A. A. WHIPPLE, M. D., in The Clinique.) Much has been written in regard to the necessary care of the perineum during the passage of the head through the vulvar orifice, and many methods of prevention have been devised and recommended by obstetricians. In nearly every work on obstetrics the practitioner is advised to endeavor to prevent laceration by the maneuver that is usually described as "supporting the perineum." By this is meant laying the palm of the hand on the distended structures and pressing firmly upon them during the pain, with the view of mechanically preventing their tearing. Error may be traced to a misconception of what is required. This term conveys an erroneous idea, for certainly no one can prevent lacerations by support of the perineum. If the term relaxation were employed, we would have a more accurate idea of what should be aimed at; and if this is borne in mind, I think it cannot be questioned that nature may be usefully assisted at this stage of labor.

Among the many causes for perineal lacerations we find unfavorable position and size of the head; too early extension in occipito-anterior, and insufficient flexion in occipito-posterior positions; injudicious voluntary efforts; rigidity of the perineal tissues, the improper use of ergot; awkward handling with injudicious and hasty traction in forceps cases, to be a few of the many causes. But more than all is the want of judgment, mechanical skill, or good common sense on the part of the physi cian who presides over the delivery.

"With care you can lead an elephant by a hair, but you mustn't yank." Perineal rupture is not always an evidence of unskillful management, and yet it is clear to my mind that measures directed to the support of the perineum, without removal or arrest of the cause, must prove ineffective. Laceration of the perineum would be a rare accident were the rule to support it during the latter part of the second stage entirely dispensed with in obstetrical practice. The care of the perineum consists in omitting the inferferences that cause injury. Omit the improper use of ergot and manipulations that excite reflex forces; suspend the injudicious voluntary efforts at the proper time; correct the defects of posision, of flexion and extension. These suggestions refer to the removal, lessening and arrest of the causes, and not to the propping up of an attenuated and fragile tissue, while the forces or causes are continuously operating with increasing intensity.

In my opinion, the best way to prevent lacerations is to prevent a rapid termination of the second stage of labor, thus giving the perineal muscles and other tissues time and opportunity to relax. This can be accomplished in natural labor by retarding the advance of the head at the last moment, when the perineum is distended to its utmost, at the same time asking the mother to cease bearing down.

As this time draws near I usually explain to the patient what I wish her to do, and why. A short delay at this time gives the distended tissues opportunity to stretch, and the head will pass without tearing, when otherwise the combined voluntary and involuntary expulsive efforts will force it through, often at the expense of a ruptured perineum. By the use of forceps we can subserve the purposes of delay more effectually than without them. They are the most useful and beneficial instruments in the physician's armamentarium - instruments which, in skillful hands, and with proper care and judgment, can never do harm to mother or child, and will often be the only means of saving the life of one or the other, or both, or of sparing the mother the consequences of delayed delivery and excessive pressure of the soft parts. The operator, by the exercise of a moderate force of resistance, can slow the exit of the head, and thereby avoid injury.

To prevent serious lacerations of the perineum, some obstetricians have advised that one or more lateral incisions be made with a pair of blunt-pointed scissors or a probe-pointed bistoury. This may, no doubt, be done with safety, but I question its utility. It is said by those who look with favor upon this little operation, that an incised wound will heal more readily than a lacerated one. It is my opinion, however, that when a distended perineum ruptures, its structures are so thinned that the tear is always linear, and as a matter of fact, the edges of a tear are always as clean, and as closely in apposition, as if the cut had been made with a knife, and will heal perfectly if the edges are brought into contact and held there with sutures. I see no reason to anticipate a tear, and therefore believe we are not justified in resorting to perineal incisions when we do not know beforehand in any given case whether laceration will take place or not. The greater number will escape without rupture, and those that do not should be cleansed and the rent closed by sutures immediately.

The physician should never attend a woman in confinement and leave the room without first having learned, by actual observation with a good light, whether rupture has taken place or not. If you do, you will

sooner or later be surprised and humiliated by the nurse telling you that the woman is torn. It is careless practice, to say the least, to let the nurse be the first one to learn of this condition.-Arch. of Gyn.

TREATMENT OF THE PERINEUM DURING Labor.

(Lucy Waite, M. D., in Clinique.)-In the hospitals of Drs. Sparte and Braun, of Vienna, the modus operandi in vogue is as follows: The normal case of confinement is under the care of a midwife in training. It is her duty to watch the progress of the case, and, on the bulging of the perineum, the patient is drawn to the edge of the bed, and turned upon her left side. The limbs have been previously wrapped in sheets. An assistant sits on the edge of the bed and supports the right limb, so as to raise it up and off of the arm of the operator. The operator takes her position at the back of the patient, passing the left hand over the right limb and between the thighs, and presses back the oncoming head with the fingers of the left hand. The ball of the right hand covers the anus, the thumb being placed on one side of the perineum, and the fingers on the other. The central perineum is thus left in sight between the thumb and first finger, and is at no time subjected to pressure. In this position the head is under perfect control, lying between the two hands of the operator. With the right foot raised upon a stool or round of a chair, and the elbow of the right arm resting against the right knee, the operator is in a position to use to the best advantage all the strength he possesses. Given this position of both patient and operator, the delivery of the head without laceration of the perineum, in any case which can reasonably be called normal, becomes a matter of strength, patience, and judgment. The head is really delivered between the pains. During pains the head is crowded back by the fingers in the vagina, allowed to advance only enough to put the perineum slightly more on the stretch than after the last pain, and between the pains the head is pushed by the ball of the right hand very gently upward and forward, away from the pelvic floor, and under the pubic arch. The head is practically rolled out between the two hands.

The perineum is thus stretched, line by line, and the head must be large and the perineum indeed tough which cannot be managed in this way, if sufficient time is taken.

There are cases which even skilled fingers cannot successfully manipulate, and the house surgeon immediately performs episiotomy. This is done by one cut made to the side from within out, from one-half

to an inch, according to the judgment of the operator. The immediate operation is made, in all cases, and the patient leaves the hospital with a sound perineum. No anesthetics are used in normal cases, and no lubricants of any kind. In fact, it would be impossible to manipulate the perineum in this way if the parts were more slippery than they must be under the natural lubricating fluids secreted at this time. A large reduction in the per cent. of lacerations is claimed for this method; twelve per cent in all cases, as opposed to fifteen to forty per cent, under other methods.

When the forceps are used in head presentations, the patient is delivered on the back, the same general method being used, the forceps taking the place of the left hand.-Ibid.

RETENTION OF PORTIONS OF MEMBRANES AND PLACENTA IN PREMATURE AND NORMAL LABOR. (Dr. Martini in Munich Med. Wochenschr.) -He first discusses the causes of retention of the membranes and placenta, differing from the well-known explanation of the expulsion after separation of the membranes and placenta. This physiological process may be disturbed by the uterus, the placenta, the retro-placental hematoma and the membranes; finally he says the separation does not occur gradually, but rapidly. He based his opinions on eighty cases.

The most frequent causes of retention of the appendages of the ovum, in the largest expectant treatment of the placental period (in the Munich clinic two hours is the average time waited until expression of the placenta) are, from Martini's observations:

First. Hemorrhages from the uterus before complete separation of the membranes.

Second. Early expulsion of the placenta.

Third.

Fourth.

Intrauterine death of the fetus.

Abnormal adherence of the placenta.

Influence of Retained Portions upon course of confinement is answered by Martin from his eighty cases. Although 57.5 per cent. of the women had fever, yet retained portions of the membranes had seldom any influence upon the temperature during confinement. In 76.3 per cent. of his cases he can certainly exclude any such influence; in eighteen cases a relation between the fever was not to be excluded, yet only in five cases could such an influence with certainty be excluded, in the other thirteen women other diseases were probable. Retained decidual tissues had no influence upon confinement; on the contrary mac

eration of the fetus appears to have an important influence upon the temperature, as in ten such cases six had fever. In twenty-five cases there were fetid lochia; in twenty-four hemorrhages in consequence of retained placenta - or ovum-remnants; in fifteen cases lochia, late and bloody, were present. As regards involution of the uterus, the material allows of no decided judgment. The rule was that retained pieces were spontaneously expelled; only in eight cases was intrauterine interference necessary. It followed five times immediately after delivery, two separations of placenta, twice at the seventh and once at the eighth day. Of these seven cases, one expired from entrance of air into the uterine veins, four had high, two slight, fever, and only in one case was the temperature subfebrile.

The results do not speak for the great dangerousness of the retention of portions of the placenta and ovum during confinement, but on the contrary, for the great danger of intrauterine interference for the removal of the portions; hence, Martini recommends expectant treatment in retention of portions of the ovum. If unfavorable symptoms appear, The confinement must be

then there will be time enough to interfere. carefully watched; the vagina should be washed out in case of illy smelling lochia; slow involution of the uterus by massage, hot douches and ergot. Sensitiveness of the abdomen and fever by ice and internal remedies, especially baths. Only in cases where hemorrhages threaten life should intrauterine interference be made.-Arch. of Gyn.

REMOVAL OF RETAINED PORTIONS OF MEMBRANES AFTER DELIVERY (A. A. HENSKE, M. D., in Med. Chips.)-I do not desire to discuss in detail the causes of retention of portions of the memoranes in normal labor. They are, as far as we know: 1. Irregular or incomplete contraction of the uterus; 2. Too early or improper manual removal of the placenta ; 3. Pathological changes of the histological structures of the membranes themselves. The consequences of such retention of portions of the membranes are different from those of the retention of portions of the placenta. Here we have nearly always hemorrhage and insufficien: contraction of the uterus as the result. In cases of retention of parts of the membranes only, we never have hemorrhage resulting. If there is hemorrhage, then the hemorrhage and the retention are due to the same cause-insufficient contraction. Only when blood-clots are retained in the membranes, and a so-called fibrinous polypus thus formed, we may subsequently have hemorrhage. But another question arises, Does the decomposition of