Krassowski (Arch. f. Gyn., B. 32 H. 2) reports five Porro and two Saenger operations saving six mothers and five children. K. uses thymol 1:1,000 for instruments, and the biniodide of mercury 1:4,000 for the hands, etc. He seals the abdominal wound with collodion to which biniodide of mercury has been added.
Zweifel reports six additional cases of the Cæsarean operation after Saenger, saving five mothers and all the children.
THE MECHANISM OF LABOR IN HEAD PRESENTATION.
Sutugin (Sammlung Klin. Vorträge, No. 310) makes an important contribution to the knowledge of this subject. The paper deals with an “almost wholly neglected factor in the mechanism of labor,” namely, the position of the fœtal trunk in utero, the mechanism of the trunk movements and their effect upon the positions of the head during labor. He first shows that the views commonly accepted with reference to the position of the fœtal trunk during pregnancy are in part erroneous. Observations by the author in six hundred and sixty cases, published in 1875, established the fact that before labor, in either right or left positions, the dorsum of the child is almost invariably turned to the mother’s back, the vertebral column of fœtus, as a rule, lying but little to one side or the other of the spinal column of the mother; and, furthermore, the changes of position during pregnancy, as from right to left, probably take place by rotation along the posterior wall of the uterus. On the occurrence of energetic uterine contractions, especially at the beginning of labor, the back of the child is sometimes rotated to the mother’s side. Kehrer has confirmed the conclusions of Sutugin in observations upon certain of the lower animals. It may be noted in passing that, according to Kehrer’s observations, gravity is a subordinate factor in determining the attitude of the fœtus in utero.
The author of the paper declares that, in a large number of cases examined during the last twelve years he has not in a single instance found the back of the child turned wholly forward during pregnancy, not even in first positions of the head. He has more recently made a study of the varying positions of the trunk during labor. Early in the labor, in first positions of the head, the trunk rotates so that the back of the child looks sideways, the shoulders lying in a plane parallel with the introitus. The breech rotates more slowly than the shoulders, the spinal column of the child thus assuming the form of a spiral during delivery. The fœtus, therefore, in its descent moves in a screw-like direction around its own axis, but the back of the child is not turned forward even during parturition, as authors generally have assumed. These views are born out by the frozen sections of Chiara, Waldeyer, and Shroeder. The rotation of the head is in part due to the rotation of the trunk, “the torsion of the axis of the fœtus,” and is not to be referred solely to the action of the pelvic planes. The author claims that a torsion of the uterus upon its axis similar to that of the child also occurs. With reference to the etiology of the torsion in case of uterus or fœtus, he ventures no explanation.
MANAGEMENT OF THE PLACENTAL STAGE OF LABOR.
Fehling (Sammlung Klin. Vorträge, No. 308) compares the views and practice of authorities in the treatment of the third stage of labor. The various methods of placental delivery that have been advocated by different writers are recounted. The reaction against Credé in favor of expectancy, first started by Dohrn and Ahlfeld, has resulted in proving the inferiority of the latter plan, and in a return to more active methods. In a large number of German clinics, the uterus is allowed to rest immediately after the expulsion of the child, without friction. When the placenta lies detached in the lower uterine segment, which is generally the case after fifteen or twenty minutes, nothing is to be gained by longer waiting. The author is favorably disposed toward the practice of Credé, which as he says, has never been shown by its adversaries to be capable of harm when properly conducted. With reference to the mechanism of placental separation, both theoretical considerations and clinical observations favor the views of Duncan, yet the question is not settled. Retained membranes may be removed with the aseptic hand. Yet Credé and Olshausen consider the retention of even the whole chorion free from danger, and clinical experience has shown better results by the expectant plan in case of retained membranes than by interference. These results, the author thinks, in the light of Döderlein’s researches, are explained by the fact that the hand may transport the peccant germs from the vagina into the uterus. The active plan, with a preliminary vaginal disinfection and a vigorous asepsis throughout, should yield better results than expectation. Interference with these precautions is, at least, justified in case of atony and hæmorrhage or fever, including, if need be, the use of the curette and subsequently ergot. Dührssen’s method of tamponing the uterus in post-partum hæmorrhage with iodoform gauze is favorably mentioned.
In the event of cervical tears causing troublesome hæmorrhage, Kaltenbach, Schroeder and Leopold practice immediate suture. The author thinks the vaginal tamponade is generally to be preferred. Yet, in certain cases the suture may also be required, or the application of the perchloride of iron on cotton pledgets to the bleeding surfaces.
Credé (Arch. f. Gyn., B. 32, H. 1) again discusses and defends his method of managing the placental delivery which he prefers to call the external method.
The duration of the third stage need not in the majority of normal labors exceed fifteen to thirty minutes. In many instances a more expectant plan of treatment is better. In occasional cases more rapid delivery is demanded in the interest of the mother. Since the method is free from danger when properly conducted, the expulsion of the placenta may be hastened within reasonable limits if for no other purpose than to save the time of the attendants and to spare the sufferings of the patient. He claims that the amount of blood-loss is diminished under his treatment of the placental stage, and that the membranes are not more frequently retained. Furthermore, he believes the retention of portions of the membranes or placenta to be harmless in an aseptic condition of the passages.